Hartmanns solution and canulars

[Martyn]

Apologies Martyn, answered in a hurry, figures wrong way round. 50 mls 20% dex is appropriate peripherally.

lol, yeah I hear ya mate. I've got so many number flying round my head, i constantly have to recheck stuff I've done 1000's of times. I think it's the same for most of us.

I am hitting it from a different angle though. I'm a secondary care provider, rather than first responder and it changes things a bit. Most of my patients have central lines. We also keep all our patients on insulin infusions regardles of diabetic or not - as it's been proven that a rigorously controlled BM significantly improves ICU outcomes. We check sugars at least every 4 hours. Even so, somone will occasionally pull a hypo. But then we have the luxury of being able to glance over the charts and look at the trends. We can easily see whats gone in that might've affected the sugars (usually a too aggressive insulin regieme)and make a good judgement call about what to give. With the additional luxury of central access, we usually do push 20mls or so of 50% into them. If for some reason we dont have central access, then I'd need a good reason to push anything over 10% into a peripheral vien. In a hospital environment, there simply isnt the need to take chances with viens and cannulas, so we always play on the safe side of the fence. First response changes the rules significantly though. If you are miles from anywhere with limited resources, a vague history and only one cannula, you do what you need to do.

Hartmans is an excellent treatment when working without U&Es, but it's not really bushcraft...is it?

no, not really.

 

[pibbleb]

Scuba Pete

With all due repect, if you did that to a minor, as in you suggest in your original post, the hospital would be abliged to inform Social Services and you could be prosecuted by them for assualt.

This would certainly involve the police and at the very least having a social worker pretty much move in at the very worst, prison.

Any which way it wouldn't be very pleasant. As has already been posted I would suggest that there would be no need for the fluids anyway. If you are not doing refresher courses regularly how will you be aware of new protacols, for example most medics don't actually give fluids anyway anymore. The resus style has recently changed etc.

Theseare all protocols that medical professionals have to revise and be assessed on at least once a year.

Sorry, but if you are that worried about it and you don't think your phone is going to be up to the job then get a radio!

I'm happy to be corrected, but I'm pretty sure that this is all correct.

Pib

 

[Martyn]

As far as I can tell stotRE was asking about a FAK for him and his family. If he feels he has the experience and training to use an IV then I see no problem with that at all. You may not think there ever would be a time when you would use and IV, but you do not know what stotRE gets up to.

I can. His wife and children have rights. They are not his to do with as he sees fit. If it's irresponsible to practice on the public, it's irresponsible to practice on them too.

I am trained in first aid, at work and also through diving, I am a rescue diver. We were always told never to give medication. I would not dream of doing so to a stranger, but my family is another matter. If my Childs life were hanging in the balance I would not hesitate to use all the resources and knowledge at my disposal.

See above.

The best and most responsible thing you could do for them, is to phone for professional help. There are very, very few places in the UK where professionals are out of reach and in most places, a fully trained paramedic service is only minutes away. Your job as a first aider, is to bridge the gap for those few minutes. Do whatever you can, but do no more than you should. Your responsibilities as a father dont change that one bit.

You are not going to get sued by your family, and even if that were the case I would gladly proceed if I were sure it would save a life.

See, how can you be sure? Being sure requires and awfull lot of training and experience. I'm not confident I would be sure and I do have a lot of training and experience. Best guess perhaps, but not sure. I wouldnt risk my family's life with my own backyard medicine. You might find you wife might sue you if you kill your child through reckless administration of unecessary medications. More to the point, could you live with it yourself?

If you are 1000's of miles from help, in the jungles of Borneo or the battlefields of Afghanistan, then the rules change. But not in South East London, or even the highlands of Scotland.

 

[Martyn]

Scuba Pete

With all due repect, if you did that to a minor, as in you suggest in your original post, the hospital would be abliged to inform Social Services and you could be prosecuted by them for assualt.

...if the child (or wife) died as a result, the prosecution would be for manslaughter.

 

[pibbleb]

Yes you're right, I was trying not to be overly heavy, but yes the outcome would not be pleasant either.

Sorry this isn't my area of law so sorry if off track!

Pib

 

[leon-1]

Most military applications for this are in reaction to extreme situations, traumatic amputation, primary and secondary projectile injuries. The first thing in these cases is basically to keep volume high, hence squaddies use hartmanns as a volume expander.

In rare occasions they may use the likes of haemacell (long time since i did my courses so excuse spelling) as a plasma expander, this is generally discouraged in the forces as it can affect checking of blood type.

Effectively, if you come to a casualty that is screaming his head off because he has shrapnel wounds to his reproductive organs and is missing a foot upto midshin because he has stepped on a mine, you will wish to reduce the flow of blood and force liquid into his body as circulatory body fluid.

You will try and get in as many lines with the largest sized cannula that you can get your sticky little paws on (grey or brown if you can get them), there is a good chance you will also have a couple of guys squeezing flexi packs to force the fluids into the casualty quickly enough depending on what has been damaged.

You will take a record of everything you have put into the body, if you have given morphine you will have it marked how much and when. The next job would be evac to secondary care. All of this happens in a couple of minutes.

All you are trying to do is to keep the casualty alive long enough so that the RAMC can continue to patch them up at an aid station / Field Hospital.

You are not supposed to use tourniquet as they are banned throughout the whole of northwest europe, that includes in the armed forces.

 

[Phil562]

You are not supposed to use tourniquet as they are banned throughout the whole of northwest europe, that includes in the armed forces.

Not quite correct

 

[Wayne]

Every year medics and lay people get arrested for going too far with their first aid practice. People with mental illness pretending to be paramedics without the training. Medics making choices beyond there experience.

The 1840's good sammaritan act means in the UK you are unlikely to be successfully sued for performing first aid that you are trained and competant to perform. Some first aiders i know ride shot gun with paramedics regulary. I have taught fully qualified nurses first aid in the woods and they have failed miserably without the technical back up of a hospital setting.

Please remember that although many people feel happy and confident to perform advanced intervention it doesnt mean they should.

In the UK as Martyn states First Aiders should not be performing any invasive interventions. In a hostile environment we have a different duty of care and could legally administer drug therapy. I would suggest registering with a company like CEGA and purchasing a sat phone. Then you can call a fully qualified doctor with experince of the conditions your working in and you act as the eyes and hands of the medic.

I am hoping to provide fist aid cover for a expedition next year and i wouldnt dream of sticking a needle in a childs arm without parental consent under medical supervision.

There is always a temptation to do a little training and run off to some far corner of the world and massage your ego treating all manner of infections that would get you arrested over here.

I certainly wouldnt want someone with 5 days training sticking nedles into my wife or child.

 

[Martyn]

Most military applications for this are in reaction to extreme situations, traumatic amputation, primary and secondary projectile injuries. The first thing in these cases is basically to keep volume high, hence squaddies use hartmanns as a volume expander.

That's what I'm trying to say leon.

For battlefield scenarions, you can generalise a set of guidelines that are fairly broad and applicable to most situations. Most of your patients are otherwise, fit, healthy, young males, with a fairly standardised set of typical injuries. It's possible to draw up generalised protocols that will help save most lives in most circumstances. It easy to teach, fairly quick (by comparison) and fairly robust. You probably wont do much harm to many people in that circumstance by following the standard procedures - an acceptable risk under battlefield conditions.

What you cant do, is take those protocols and apply them to a civillian population, where you have large degrees of variance in age, health, injury and medical history. Your chances of doing harm are significantly increased. Although in most cases, the same procedures would still be applicable, for civillian care, they need to be on the money, all the time. That means an exponentially greater level of training, just to cover those times when it'd be "the wrong thing to do".

 

[leon-1]

That's what I'm trying to say leon.

For battlefield scenarions, you can generalise a set of guidelines that are fairly broad and applicable to most situations. Most of your patients are otherwise, fit, healthy, young males, with a fairly standardised set of typical injuries. It's possible to draw up generalised protocols that will help save most lives in most circumstances. It easy to teach, fairly quick (by comparison) and fairly robust. You probably wont do much harm to many people in that circumstance by following the standard procedures - an acceptable risk under battlefield conditions.

What you cant do, is take those protocols and apply them to a civillian population, where you have large degrees of variance in age, health, injury and medical history. Your chances of doing harm are significantly increased. Although in most cases, the same procedures would still be applicable, for civillian care, they need to be on the money, all the time. That means an exponentially greater level of training, just to cover those times when it'd be "the wrong thing to do".

I am not disagreeing with you mate, in fact I wholly agree with what you are saying.

I also agree with the method of training, you are immediate and first line, there is no reason in nearly all cases for the training to go beyond "this is a drip and this is how you stick it in someone"

There are a lot of things which you can do in the forces that you can get away with, but you are taught that you would not be allowed to get away with them on civvy street. In fact in some cases you are told specifically not to use this or that method if dealing with civilian casualties even if it may save thier lives.

So I appreciate exactly where you are coming from

 

[Martyn]

I have taught fully qualified nurses first aid in the woods and they have failed miserably without the technical back up of a hospital setting.

Please remember that although many people feel happy and confident to perform advanced intervention it doesnt mean they should.

Exactly.

A radiologist isnt a surgeon, a surgeon isnt an anaesthetist, an anaesthetist isnt a GP, a GP isnt a paramedic, a paramedic isnt a nurse and a nurse isnt a doctor.

Although there is a huge amount of overlap of knowledge in all cases, each profession has it's specialties and each professional is obligated and duty bound to recognise the limitations of their scope. There is some lattitude in all cases, but that usually is to cover for emergencies and unforseen eventualities. If you practice outside of your speciality under normative circumstances, you are on very thin ice, both legally and ethically.

Doesnt matter how many soldiers you cannulated on the battlefield, outside of that specific shpere, you are not competant to practice unless you hold legal status to do so.

I wouldn't dream of cannulating someone in a first aid situation, even though i do both venous and arterial cannulation as part of my normal practice.

 

[Doc]

I am registered as a doctor with the General Medical Council, and I also have training in, and practical experience of, pre-hospital care.

Legally, Hartman's, isotonic saline and other iv fluids are classified as prescription only medicines (POM). It is a criminal offence under the Medicines Act to administer these to a third party, unless it has been prescribed or you are acting under a patient group direction. People have been prosecuted for this. It is criminal, not civil law, so decisions to prosecute are made by the Crown Prosecution Service/Procurator Fiscal, and not by the patient.

Immediate Care is constantly changing (look at the ALS protocols) and if you are not currently in practice it is hard to stay up to date. For example, aggressive fluid resuscitation (as used to be practiced) may actually be harmful and current guidelines advise with-holding iv fluids where there is a palpable radial (in some cases, central) pulse. (1) (2)

Children are not small adults and there are differences in management.

The guidelines also state: 'Only staff who have had special training in techniques called advanced life support and pre-hospital care should give IV fluids to injured people before they reach hospital. These staff are usually paramedics or doctors. '

Even when iv fluids are given they should not delay evacuation.

It might be worth considering having iv fluids if your military training is up to date and you are on a serious far-from-help expedition outside the UK but I would agree with the others that in the UK the risks outweigh the benefits.

(1) Journal R Army Med Corps 2004 150 96-101
Fluid Resuscitation in Pre-Hospital Trauma Care: A consensus View (which incidentally advises Saline, not Hartmans)
(2) NICE Guideline http://www.nice.org.uk/page.aspx?o=ta074

 

[Scuba Pete]

I understand all of your points, I take them on board. I did not realize it was a prescription drug. I was not thinking of a particular drug, or procedure.

I did not mean to imply that I could just do anything to my family, without fear of prosecution.

I think you misunderstood me, I never mentioned the UK, and neither did stotRE. I was talking about life or death situations where no help was available, be it anywhere in the world.

I did not mean I would do this to a member of the public or to my family if help was available, of course I would contact medical personnel if I could.

If a family member was about to die, with no chance of outside help I would not hesitate in performing a procedure that I knew (e.g. Army training) might help.

You may not agree with this, that is your right. To be honest at that point I would not care one bit about the law, or the fact I might get arrested or even go to prison. If I saved my child’s life, it would be price I would be willing to pay.

I cant imagine any court would convict you for saving/trying to save your child that would have died anyway, just because you don’t have a medical qualification.

You mentioned how could you live with yourself, well if I stood there and watched my child die, knowing that I might have saved them, and I did not because I might get arrested. I could never live with that.

I hope I have made myself a bit clearer, sorry for any confusion.

Pete

 

[Martyn]

I hope I have made myself a bit clearer, sorry for any confusion.

Pete

Yes you have Pete, thankyou and I do understand your feeling on the matter.

In Britain, there is almost always paramedic/medical assistance a phone call and a few minutes away. If you are genuinely stuck away from contact, then as you say, the gloves are off - and no one should hold you accountable for doing what you can. But other than that rare and extreme circumstance, your first, best choice is to use the phone.

 

[wingstoo]

Doesnt matter how many soldiers you cannulated on the battlefield, outside of that specific shpere, you are not competant to practice unless you hold legal status to do so.

I would say that although he was competant to do this the Law says he mustn't, not that he isn't competant because the law says he isn't.

I would be quite happy for a competant person to treat me whether or not the law said so or not, especially in a scenario where he was there and a legally authorised person wasn't and I was leaking heavily, I would also use a tournaquet on a wound if it stopped me bleeding out when I had a chance, far easier than sticking your thumb on the wound,and I have two in my first aid kit, just in case, so long as proper protocol is used they are life savers.


LS

 

[pibbleb]

Scuba

I hope you don't think people were having a pop, as I'm sure they weren't and I'm certainly clear on where you're coming from.

Just offering some friendly, and a little concerned, advise. I have to say though that I don't know if I could be levelled headed enough to treat mmy own loved ones in this way, if I knew how!

Pib

P.S. is the issue here not whether a military medic is qualified, either literally or not, to pump someone full of fluids but whether they should?

I agree if I'm pumped full of lead :BlueTeamE I'd want a military medic to patch me up! That said how dangerous is spoon making in the woods. Anyone got a link for body armour?

 

[Scuba Pete]

Yes I agree. That’s one thing I like about the UK, there is always help when you need it. Handy if you need the coastguard for a diver with DCS.

Personally I don’t have training in IV medicine etc, so I wont be setting up drips anytime soon.

He he don’t worry, I stick to my first aid training, if I ever meet any of you laying in the street, I promise I wont get out my leatherman and do any surgery.

I remember on my course we were told that you should avoid helping people in the street. If you are trained in FA and you make a mistake, then you can get into trouble. At work I am covered but in public I am not. It’s funny, if you had no training and made the same mistake then nothing would happen to you.

It’s a shame the world has come to this.

Pete

 

[Doc]

Fair enough, Pete- as you say it is entirely context dependent. That is why the army has trained StotRE to do these things when there is no-one else available. I was only wanting to clarify a few things in my post and avoid anyone getting into trouble.

No-one should withold treatment that they KNOW is required through fear of the law. However, it is not always absolutely clearcut what is the best thing to do, especially without recent and in-depth training.

 

[Doc]

Yes I agree. That’s one thing I like about the UK, there is always help when you need it. Handy if you need the coastguard for a diver with DCS.

At least you would recognise decompression sickness. Many GPs would not. I have never seen a case, and I trained at Aberdeen, where they taught a good bit of diving medicine.

 

[Doc]

I should also add that pre-hospital fluids for trauma is a controversial area in medicine, and guidelines may well change in the light of ongoing research.

If you are not currently in practice, you could find that what you were taught even a few years ago is now regarded as obsolete. And if the patient dies.......