Monday, December 22, 2008

California Supreme Court Redefines Good Samaritan

I was fairly shocked to learn the normally reasonable California Supreme Court  botch a case regarding Good Samaritan laws. An individual--who had been drinking and smoking marijuana--rendered aid at a motor vehicle accident pulling the driver from the allegedly smoking car. The driver suffered traumatic injuries to her liver, requiring surgery, and to her spine. Secondary to either the accident or the extrication, the driver suffered paraplegia and brought a negligence suit against the individual who had extricated her from the vehicle.

At trial, the original court agreed the defendant was covered under the Good Samaritan laws, as would be expected, however, on appeal this decision was overturned. The appeals court found that the statute covers only "emergency medical care" (ed: original emphasis) and not the actions taken by the defendant. Eventually the appeals reached the state supreme court, and the court found in favor of the plaintiff agreeing with the appeals court's finding that the care provided by the defendant--removing the plaintiff from her vehicle--was inconsistant with the language and intent of the applicable Good Samaritan statutes.


Somehow, somewhere, the California Supreme Court has forgotten that removing your patient from harms way is the first step in patient care. Well okay, it comes after your safety, your partner's safety, and any bystander's safety (scene safe? BSI?). Still, if a patient is in a burning car, the first thing to do is remove the patient from the burning car. You cannot be expected to provide emergency medical care if the scene is not safe for you, your partner, or your patient. It stands to reason then, that the most fundamental form of Basic Life Support is removing your patient from danger.

What the California Supreme Court has done with their overly pedantic finding is to redefine a Good Samaritan and to change the rules of the game. The defendant in this case probably should be sued for negligence given all of the other facts in the case, however, they shouldn't be exempt from Good Samaritan laws merely because of a language technicality. People are already hesitant enough to provide bystander care with how lawsuit happy our society is, and now people in California have even less of a reason to provide care. Hopefully the legislature will iron this issue out in the new year.

Thursday, December 18, 2008

Wound Care and Non-Adherent Dressings

On our ambulance, the two least used forms of dressings are occlusive dressings and non-adherent dressings. It is easy to explain why we don't use occlusive dressings (ed: sucking chest wounds, while popular on ER, are NOT the mainstay of our site EMS), but it is a little bit harder to explain why we don't use non-adherent dressings often.

Typical wound care for an EMT-Basic consists of slapping a stack of 2x2, 3x3, or 4x4 gauze pads on the wound while applying direct pressure. If we have other things to do we'll ask the patient to hold the gauze, or tape it down. I can't ever recall ever using a non-adherent dressing or being asked for one; moreover, our wound care protocols do not give mention to them. Interestingly enough, before yesterday I probably would have been unable to give an indication for a non-adherent dressing without a little bit of thought.

Nothing could teach me the primary indication of a non-adherent dressing better than when I injured my knee yesterday. Just two small gouges, nothing big. I irrigated and debrided the wound, applied a 2x2" gauze, and secured the bandage with 1" cloth tape.

When I went to take a look at the wound that night, I was somewhat suprised to find the gauze had become part of the clot. I was even more supprised at the level of pain I was confronted with while removing the gauze-clot. The woven gauze had to be removed one strand at a time, even after applying warm water. It was at this point I had an epiphany.

My jump bag contains 4x4" non-adherent dressings that, surmising from their name, would not adhere to my wound like the gauze had. Sure enough, after cutting down the dressing to form a smaller 2x2" form, I applied the non-adherent dressing under a 2x2" gauze dressing, and taped the new and improved bandage down. Removal this morning was pain free, and further more I did not have to break any clots that had formed!

It only takes 5 seconds of googling to find that everyone from studies, to nurses, to patients emphatically support non-adherent dressings for wound care. Thanks to a personal lesson in pain, my own protocol for wound care will now include a non-adherent dressing for any wound (which will produce an exudate) upon which a dry sterile dressing will sit.