Gross Neglegence?

[SA_Medic]

Let me give a description of the events then I ask you for your thoughts.

I received the call via our Control room asking me to do the inter-hospital transfer of a 2month old, premature (born 2months prem) baby from. We could not get more details as this child was laying at one of the local government hospitals. So off we go, ready to transfer this child to one of the private hospitals. The only thing we know for sure is that the father of the child wants us to transfer him. The current treating doctor sees no reason for the transfer. Normally we will not oblige something like this as it's against company policy to transfer a patient without the treating doctor doing the necessary paper work.

Upon arrival at the paediatric ward, we are greeted by a somewhat uncaring nurse. I do the normal "Hello Sister, how are you?" bit only to be pointed in the direction of the doctor with a grunt. This is when I feel the air temperature, and decide it might be a good idea to zip up my jacket. The doctor walks me into a room filled with about 20 babies, I might as well have walked into a freaking freezer! I get to the side of the bed and find a small, blue skinned little boy on CPAP. The doctor start talking and explains the child was born two months prem, two months ago and admitted a week ago with pneumonia. I look at the IV and all I can see is a Saline on a dail-a-flow. No meds, no antibiotics. Just that one IV.

Asking the Doctor if what meds the child had I am told the Saline. I ask again, just to make sure I ask specifically. "Has the patient received any medication?" To which I am told:"No, just the saline". I connect my monitor to check vitals and find the following:

HR: 67

Sats: 56% (on CPAP)

To this I ask the DR if the child has always been this brady. The reply will shock you:"He's sleeping, so it's normal". At this point I feel like killing this DR but, decide to rather do what I am paid to do. I sedated the child and tubed him, with the bagging the HR goes up to 120 and the stats increases to 93% where it sticks. I can't get it any higher, so we leave and transport to the receiving hospital. I inform the control centre to let them know that we are inbound and need an ICU bed and no longer a normal bed as arranged. At the receiving hospital, they take chest x-rays which reveals a complete collapsed left lung....

How would you deal with this?

[itku2er]

Not much more you could have done with that, seems though that I do agree with your first thought of knocking DR in the head. Sounds like he needs a long vacation. I do not know how your hospitals are run over there so If you could please enlighten me to the difference between a private hospital and government ran one I would be happy. Maybe the DR was just too stressed out to really care who knows but still this is a babies life he should have been more caring.

[mobey]

You pretty well gotta take the proper channels.

Start with your supervisor, then Med Director.... etc etc.

You can always have a closed door with the charge nurse too...

[SA_Medic]

Government hospitals are completely government owned, run and funded. These hospitals in most cases would be on of those places where I would grab my IV stand and ride it to a PVT facility. Mostly due to slack staff and shortage of equipment.

Private hospitals as exactly that. Privately owned and funded by the medical insurance of those that get admitted. The doctor's here are mostly GPs and Specialists (who coincidently does hours at the Govt Hosp) with the nursing staff being old Govt employees wanting a cleaner facility to work in as well as higher salaries. Although, not always the sharpest knives in the drawer either....

[chbare]

Damn South Africans and you're nursing sisters. I did a double take when I first experienced that term.

One thing we must appreciate is that a delta exists between EMS in the US, Canada, & South Africa. Additionally, a rather large disparity can exist between government and private facilities as already stated. Therefore, it will be difficult for me to say what should and can happen at the level of policies and procedures as they pertain to EMS versus different South African hospitals. Additionally, as I understand the concept of "medical direction" does not exist as we know it in South Africa. SA EMS providers specifically B-Techs and the like are not necessarily strictly bound to a "medical director" per se. Please correct me if I am totally off.

Therefore, I will focus on the medical care:

Do you have any additional information?

Where there labs, radiographic findings, and any history and physical exam information you could provide us? A two month premature infant in respiratory distress can literally have a plethora of problems. The pneumothorax could have been caused by multiple concepts as well What about your assessment? Head to toe assessment, lung sounds, abdominal assessment, heart tones, information for the family?

Take care,

chbare.

Edited October 18, 2009 by chbare

[Kaisu]

Gross negligence? Unfreakin'believable! How is it that a paramedic with his/her training knows more about normal vitals in a newborn than an MD? I thought I had bad experiences with one of the hospitals where I run in, but a situation like that occurring here would bring the house down on that doctor, his staff, his hospital, etc.

Can you explain this? Are you much better educated than the average medic where you run? Where are you anyway? Perhaps you can tell us more about how a situation like this develops.

PS. really appreciate the insight into your neck of the woods.

[VentMedic]

It would depend on the type of PNA as to whether antibiotics would be warranted.

When you say collapsed lung, do you mean atelectasis or a pneumothorax?

Did you point out absent breath sounds on the collapsed side or what this already know and they were using CPAP to re-exapand the lung?

Did you note the PMI which should have been done as part of your assessment?

Did you transport the baby on CPAP? If so, what machine did you use? Is it possible that if the collapse was a pneumothorax, could you have caused it in transti?

Heart sounds? Did the baby still have a PDA and was your pulse ox pre or post ductal?

Congenital heart defects?

What was the prognosis of the baby?

Any other anomalies? Was this baby even considered viable at birth due to other defects?

Did the doctor inform the parents of the chances of severe deficits and was trying to coax them toward a non aggressive route? We often see family members who can not deal with the word "futile" and will often request an ambulance privately to move their loved one to the ED of another hospital since no other doctors will accept a transfer. Often the other hospital will tell them the same thing.

You have not provided enough information about the baby for any conclusions to be drawn.

However, I will tell you a little story about one of the reasons why Paramedic students are no longer allowed in our neonatal ICU. We had a little baby that looked cute and normal but had anomalies that were not compatible with life. The decision was made with the parents involved to terminate life support. The Paramedic student went to the parents and told them we committed murder by not giving the baby a chance.

Thus, if you came in with a "save the world" attitude, you would probably get more than a cold reception. Sometimes nature will still win.

[Kaisu]

goldarnit Vent! Everytime you post something you remind me of how dumb I am. I love it!

One of the things that I really miss about working in a hospital based system is finding out the outcomes. It is frustrating and infuriating to work in this field and have very little information as to whether what we are doing works or not. Everybody has an opinion and we in the field often have very little data to figure out what is right and what isn't.

Our role in the health care field is crucial yet so limited.

I personally would NOT have transported that child. The idea that I was taking a baby out of a controlled hospital environment and INTUBATING would be way too much to ask of me with the limited education I currently possess as a paramedic. Outside of my comfort zone and out of my scope of practice as well. Child sounds far from stable and requires a car with at the very least, a pediatric specialist to assume care enroute.

[fiznat]

I think whenever you start throwing around words like negligence in regards to a more highly trained provider, you'd better have a rock solid case. There is a whole lot we paramedics don't know about really sick infants, and honestly, PALS doesn't always cut the mustard in the ICU setting. It doesn't sound to me like you have all the information you need to question a physician's care so directly. It is quite possible you even did this kid some harm, sticking a laryngoscope down the throat of an already brady patient and then possibly blowing out a lung with overzealous bagging. I imagine the MD you turned care over to could have been equally critical of your work.

Believe me I've seen what I believe to be incompetent doctors (especially at the VA) too, and I'm not suggesting that you did the wrong thing here. Still, I've found it is usually better in the end to be humble and try and learn from a situation than focus all my energy on the criticism of others.

Edited October 18, 2009 by fiznat

[chbare]

I am going to give SA the benefit of the doubt here. Knowing what I know about some of the government run facilities in South Africa.

Take care,

chbare.