Week 9 – Question of the Week: How far are you prepared to stray from your area of expertise?

Week 9: 2011-05-05

Today I’m asking our professionals to comment on the following question:

At TEOTWAWKI, how far are you prepared to stray from your area of expertise?

Would a veterinarian be willing to perform an appendectomy?  As an EMT do you feel prepared to treat pneumonia?  Is a geriatrician happy to deliver a newborn?  Please answer from the perspective of your own training and additional experience.

Readers are welcome to post responses, questions, and comments below.

Check back soon and see what our panel of over 120 professionals has to say.

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About Cynthia J. Koelker, MD

CYNTHIA J KOELKER , MD is a board-certified family physician with over twenty years of clinical experience. A member of American Mensa, Dr. Koelker holds degrees in biology, humanities, medicine, and music from M.I.T., Case Western Reserve University School of Medicine, and the University of Akron. She served in the National Health Service Corps to finance her medical education.
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7 Responses to Week 9 – Question of the Week: How far are you prepared to stray from your area of expertise?

  1. KF says:

    I use a paradigm reversal when I’m asked this question.

    Would I allow someone with NO credible professional medical skills, or past medical practice experience to perform an emergent invasive procedure on ME in a TEOTWAWKI situation?

    If I’m conscious, and can remain so, throughout the procedure, perhaps.

    It is all dependent on the measure of risk to the person and also the significance of that person’s role to that Group.

    Risk of a permanent injury, or perhaps non-use of a limb?
    Risk of Death? If I die, then the group is down one more medical professional. It may be a necessary risk.

    If I am the one called to perform a procedure of which I have No hands-on previous experience, and it is me, or no one else,
    my best on-site judgement will make the difficult call depending on the risk to the person and the consequences to my unskilled actions.

    I ask myself a series of personal qualifying questions.
    An algorithm of sorts. Depending on the answer to each of the following questions, either continue, or stop.

    How far away from the normal standard of emergent care is this invasive procedure that needs to be performed: in either anatomical complexity and/or required skill/s?

    Is there a realistic expected positive outcome in doing this?
    Can I perform this procedure alone?
    Do I have any assistance available?
    Do I have the supplies I need to perform this procedure on hand? Do I have medications for an anesthetic block on hand?
    Do I have medications to prevent any post procedure infection complications and any analgesia, if required?
    Am I psychologically and emotionally able to accept an untoward outcome, or even death of the person as a result of my actions?


    • KF says:

      Addendum: on childbirthing.

      Childbirth is a natural order process that can be handled in a TEOTWAWKI situation, just like it has been handled for centuries before “modern hospital obstetrics”; at home, with the assistance of a midwife and a doula.

      On this subject, is a timely written article by Enola Gay, at
      Paratus Familia. Her daughter is presently studying the art of midwifery.

      Here is a small excerpt from the post. Read the entire article.

      “You can begin preparing for the TEOTWAWKI inspired population explosion now by putting together basic necessities for labor and delivery.”

      Basic Birth Kit

      * Cord clamps or sterile shoe laces
      * Iodine or herbal umbilical cord care (for umbilical cord stump)
      * Washable Chucks (incontinence pads)
      * Blankets and hats for baby
      * Hot water bottle (for warming baby)
      * Surgical gloves (in your size)
      * Bulb syringe (for clearing baby’s nose and mouth)
      * Thermometer
      * Cinnamon Tincture (for helping mom stop bleeding)
      * Hot water (for cleaning up mom and baby – and everything else)
      * Postpartum menstrual pads (preferably washable)
      * Cloth diapers

      “Many other things could be added, and of course, you will want to have more than just enough for one delivery.”

      Enola Gay


      • KF says:

        Here are some textbook references that would be great resources on childbirthing methods for your personal library.

        * Heart and Hands by Elizabeth Davis
        * Myles Textbook for Midwives
        * Husband-Coached Childbirth – Robert A. Bradley, MD, / Hathaways. Bantam Books, current edition (2008).
        * Natural Childbirth the Bradley® Way – Susan McCutcheon, AAHCC, Plume/Penguin, current edition.
        * Children at Birth – Marjie and Jay Hathaway, AAHCC, Academy Publications, current edition.
        * Assistant Coach’s Manual – Susan Bek, AAHCC, Marjie Hathaway, AAHCC, Academy Publications, current edition.
        * Womanly Art of Breastfeeding – La Leche League International. Must be current edition.

      • Doc Cindy says:

        I was fortunate enough to have my third child at home – SO much more pleasant than a hospital experience. We used no special equipment, but did have plenty of clean water and towels, and all the usual American baby paraphernalia. Can’t remember if we used a knife or scissors to cut the cord, but either will do.

        The C-section rate will drop, perhaps to zero, and I wonder if other complications will be any higher. We have medicalized a normal condition that can be handled at home most of the time. I do wonder, though, what would have happened with my fourth child, whose big head got stuck on the way out, before a C-section . . .

        • Chris MD says:

          Cindy, simple answer is that we return to the old days when death in childbearing was relatively common. It was a normal practice for the local priest to give last rites to women in labor for much of European history. Our big-headed babies put their mothers at huge risk in delivery. Unquestionably our current c-section rate is ridiculous (at our hospital we’ve taken to calling them vaginal bypass surgeries), but without that as an option, there will be many, many maternal deaths. Of course, in such a situation, we would probably go back to trauma and sepsis being leading causes of death and average life span drop to the 40’s or so.

  2. Craig says:

    Well, that is a tough call. In a true [end-of-life-as-we-know-it scenario] I am sure I will go beyond my limits as an EMT/DMT. After all, if you are actually put into that unfortunate situation, where someone is going to die without intervention, and no other intervention is possible, then yes, I will attempt a life-saving procedure. I have stocked numerous reference materials as well as OTCs and prescription medications; I am lacking, however, in anesthesia capabilities as well as locals. So, I would not look forward to such an occasion nor would I welcome the prospect. After all, I would not want to be in that position of “the operation was a success….but the patient died.” Hence, if you’re prepping, have a crew capable of achieving such things, have an area in your area of operations (AO) dedicated to life-sustaining procedures, and protect those doctors/surgeons/nurses as if your life depends on it, because, well, it does.

  3. Chris MD says:

    Well, I am a pediatrician in general practice, but with a misspent youth in a PICU fellowship. In my office we already do simple laceration repairs, casting, foreign body removals (eyes, ears, nose, skin) as well as drainage of abscesses. I have given a fair amount of thought to this topic as I prep my “deep aid kit.” I have decided that I would be comfortable stretching my limits a bit, but not too very far. I’ll not be doing any abdominal surgery (lack of copious supplies of IV anitbiotics pretty much rule that out anyway). Some basic midwifery, but no C-sections. As such, I have included a lot of lidocaine in my kit, but no anesthetic agents. Deep on sutures and topical antibiotics, not so much on IV. Splints, slings, gauze and tape. I am thinking survival / advanced first aid type level. In a true TEOTWAWKI situation, might rethink this to some degree, but I do take the whole “First do no harm” thing seriously.

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