Gross Neglegence?

[VentMedic]

Hey guys, I also want to emphasize SA is talking about care in an environment so far removed from what we know in the United States, that making a comparison is nearly impossible. If you have never experienced the horrors of some of these places, you really cannot adequately appreciate the profound differences. Therefore, I am not sure I would go so far as to call the doctor in question incompetent as much as simply not having access to resources? Then again, the patient was placed on CPAP, so the hospital in question had access to this resource.

I tend to agree with Vent that the prognosis for this kiddo is quite poor. I understand what you mean SA, I was forced to leave patients to die a miserable death during my time over seas because of lack of resources, qualified providers, and cultural beliefs that punish even the most innocent kids.

Take care,

chbare.

Infant CPAP can be achieved through several different machines that are up to 40 y/o.

The fact that there are no facilities that can care for a medical needs child is why I am leaning towards the physician nudging the parents towards a more realistic decision. That would also explain the noninvasive ventilation and slow to treat. He was probably hoping nature would take its course but then the parents may have panicked. Even if they find a nursing home hundreds of miles away, the baby will be alone as the parents would have to move on with their lives. The baby will be prone to many more infections and any of them at any time can end his life. This is a tough road even in the U.S. as we often end up placing a child up to 300 miles from his parents. Often the parents divorce and the other siblings will be alienated so all attention and resources can be spent on one child who will endure a life of physical pain and illness while attached to technology that may be barely adequate at best. And yes, that also applies to the U.S. So if this happens here in the U.S., I can not imagine what the baby and his parents have to look forward to in the future. Sometimes saving a life may not always be in the best interest of that baby.

When we do end of life on some patients, the physicians remove themselves from the area so there can be no option of the family begging for life support to be returned. We also don't tell the families RTs intubate. We have had families call for a private ambulance when their loved one is made comfort care. They pay to have their family member transported to an ED at another hospital. We also hear for days through the EMS/ambulance grapevine about what a horrible hospital our facility is. But, they don't know the facts. Nor do they know that the person died at the other facility. The only difference is they were deprived of the comfort measures we had instituted to make their death easier.

[Aussieaid]

SA Medic I commend you on giving this baby a chance at survival. If it survives it is only because you saved it. I am appalled at the neglect and care that this baby received even allowing for the lack of resources you have to deal with over there. I have cared for kids in third world countries with some medically ignorant people but what you describe is beyond ignorant. I have also been amazed at what some people can do with very limited resources and just a decent level of medical knowledge.

Correct me if I am wrong but from what you have told us this was a preterm baby who is now at a term newborn corrected age. The only medical condition that you have described is the current pneumonia and possibly a PDA. You have given no other indications that this baby is a special needs baby outside the fact of it's prematurity. The more premature the baby the higher the risk of the PDA not closing and it just may have to be treated either medically or surgically to close it. No big deal if that is the only cardiac anomaly. A premature baby is also at higher risk than term babies for lung problems and infections. The baby had been doing well enough prior to the current PNA (pneumonia) to survive almost 2 months at home. If there was no other medical conditions then there is absolutely no reason that this baby could not have survived PNA especially if it was correctly and promptly treated.

This baby was literally about to die when you got to it SA and the fact that you were able to keep it alive and improve it's sats to the mid 90's leads me to believe that it was simply dying from neglect. I simply cannot commend you enough!

This baby needed to start with:

1) IV maintenance fluids with dextrose. (The baby was life-threateningly dehydrated and literally starving and that can happen in less than 24 hrs in an infant this young let alone having been on a saline lock for a week!) Did you do a glucose test on the baby? I'm sure it was probably almost non-existent if you had done one. I bet it was severely hypoglycemic as well as acidotic.

2) To be intubated. The baby was lethargic (practically comatose) and would not have been able to maintain it's own airway.

3) Mechanical ventilation. The CPAP was totally not even working and was not helping the baby at all (severe retractions, hypoxia, cyanosis). This baby was moments away from coding as evidenced by the severe bradycardia.

4) This baby should have been on empiric antibiotics to start with (considering it is more commonly caused by bacteria than pneumonia). Neonates and even more, premature babies are highly susceptible to infection and they become septic if you even look at them funny. In the NICU's babies are started on antibiotics at the slightest sign of an infection and they don't wait for the lab results to come back before they start them - it could be too late by then). Easier to stop unnecessary antibiotics than to try and stop a rampant infection.

5) Fluid boluses. See number 1.

6) Baby should have been on an infant warming table at least or if not available should have been kept warm with warm room and wrapped warmly in blankets at least. Babies cannot regulate their temperature and they have even less control when they are ill. Septic babies become hypothermic very quickly and that contributes significantly to their downward spiral.

7) Transferred to a higher level of care. Obviously they had no clue of how to treat this baby (or any babies for that matter).

These are just to start with! I am totally in empathy with you SA and find my blood is boiling at the neglect and lack of care that this helpless baby received to the point that it was literally about to die. There is no excuse for this total lack of basic medical care. I don't know what channels you have to be able to address this but I agree that it warrants further investigation and follow up. How many other babies have died because of this abhorrent lack of regard for basic medical care and unbelievable ignorance?

I am sorry for the rant but I cannot give SA enough kudos for saving this baby's life (even if it dies most likely as a direct result of the neglect) and giving it a tiny chance of survival after the horrors that it has managed to live through. Because of how sick this baby was allowed to become before it got help it has that much less chance of surviving now. My heart goes out to the parents who had to watch their baby dying before their eyes and feeling powerless to help it. I think I would have walked out of the hospital with it and directly to the private hospital myself.

Yes, I don't have all the details but everything you have said points to neglect and ignorance. Nothing you mentioned leads me to believe that this was a baby with a condition that is incompatible with life. There was also no kind of care let alone end-of-life comfort care.

In my books you are a true hero SA.

[VentMedic]

Yes, I don't have all the details but everything you have said points to neglect and ignorance. Nothing you mentioned leads me to believe that this was a baby with a condition that is incompatible with life. There was also no kind of care let alone end-of-life comfort care.

In my books you are a true hero SA.

Quality of life should come to reason here. You do not know anything about that baby's birth but the doctor does. You do not know what the prognosis of the child was or what was discussed with the parents.

There are many issues that must be considered here which may already have been by the doctor and the parents. Unfortunately parents do not always agree with doctors in an emotional state.

Being heroic and creating a lifetime of pain and suffering for a baby and his parents versus allowing reality of nature to proceed are factors considered everyday in neonatal units around the world.

While he did the technical apects of resuscitation and did what he thought was best, certain questions should have been asked of the physician AND the family prior to transport. One question would be what are their expectations? Giving a family false hope is just at tragic.

This may sound harsh but even though this is a baby, one has to face some hard realities when dealing with emotions and weigh all the facts. This family may now watch their child die many more times while hooked up to life support. I hope I am wrong but this family is in for a lot of hardship and that includes the baby.

[Aussieaid]

Vent medic, I understand what you are saying about quality of life and allowing nature to take it's course especially when a baby has defects incompatible with any kind of quality of life. I also understand how families don't get that sometimes there is nothing you can do and how they have a hard time letting go. I worked in a PICU for quite a few years and was frequently frustrated and heartbroken watching unnecessary suffering.

From everything SA has posted this is a completely different scenario.

1) The unit with babies on it was freezing cold requiring SA to zip up his jacket. First rule of infants is maintaining a euthermic environment.

2) The Dr did not even know normal infant vital signs (HR in the 50-60's and he calls it a "normal sleeping baby rate"!)

3) Why have a saline lock in if the baby is just there for palliative care? Also why have the baby on CPAP at all especially as his hypoxia proved to be easily resolved with proper treatment.

4) The Dr mentioned nothing about any other medical conditions other than the prematurity and pneumonia.

These are indications of lack of even basic care or knowledge. Sounds like all the babies are there for "palliative" care!

Pneumonia and even basic ventilation are often available in larger hospitals even in third world countries. Obviously these are available where SA was as it was at the private hospital 5 minutes away. If your hospital doesn't have the capability then send them on don't hold on to them for a week and do absolutely nothing for them.

From what SA has told us (and I am basing all my opinions just on what he has said the same as everyone else) this baby had a treatable medical condition which was not treated and even worse was caused harm. Everything he has said has led me to believe that this is a case of severe malpractice over palliative care.

Also the parents wanted the baby transferred because they weren't happy with care. If they are willing to pay the cost of taking the baby to a private hospital and perhaps get a second opinion there then the Dr has no right to refuse to allow the kid to be transferred. Wouldn't you be happy to let them go and not have to be troubled with a "difficult" family? The receiving hospital had obviously accepted the baby and they had more resources and at least a PICU where the baby needed to be. I get the impression he refused because he knew his ignorance and neglect would be found out. Obviously there was a discussion with the Dr but the parents wishes were simply ignored and nothing leads me to believe what was being done or not done was in the best interests of the baby.

I am all for allowing a child to die a peaceful death if it has a poor prognosis but I don't believe in letting a baby die from treatable conditions because of ignorance and neglect. Pneumonia, dehydration, starvation, hypoxia, bradycardia were all treatable in this baby. Yes some babies die from pneumonia but you won't know if it was curable if you don't at least treat it.

Disclaimer: All my opinions have been formed based solely on the information provided. If we are given further information that negates my conclusions I am more than happy to recant my opinion.

[VentMedic]

From everything SA has posted this is a completely different scenario.

He also admitted he did not know all the facts or the prognosis. The doctor may also have thought if was futile to reason with anyone at that point about the prognosis as now the Paramedics have arrived to override any points of reason.

There is just too little information here. No labs, birth history or history of the parents are available. 1.2 kg for a baby at what should be term term gestation now is not good. We haven't even gotten into other issues such as HIV status or mental status of the baby before the PNA. You are only addressing the obvious without knowing any other details. "A" treatable condition and the bigger picture may be two very different views.

Thus, with so little information, I would have to give the doctor some benefit of the doubt that this baby could have been a "do not accelerate care" issue and the parents had second thoughts. The CPAP can provide some comfort to the parents as the gasping breaths are not as prominent.

We have many babeis that our technology and expertise "saved". However, they will never be off the technology nor will most even live close to their parents. The children go to the guardianship of the state and the parents my at first try to make the several hundred mile trip frequently and then it is just for the birthday and maybe a holiday. Before long the baby is alone as the parents have found they must move on with their lives which no one faults them for that. And again, this is the U.S. system. Possibly your healthcare system is better and can warehouse everyone but realistically, just becaue we can does not always mean we should.

I however do understand a Paramedic may not be able to make any ethical choices even if there is a doctor there to tell them otherwise. They may have to follow their own protocols. Thus that is why in the U.S. we do have specialty Neo and Pedi transport teams. It is rare we (specialty team) have walked away from a baby or a child at another hospital since we don't fly unless someone has determine the baby or child to be viable. However, at the hospital we may find a different story and after some COMMUNICATION between the physicians and the family, we do leave with an empty isolette.

Edited October 20, 2009 by VentMedic

[Aussieaid]

I will just agree to disagree. (It is after all a free country ). I understand the point you are trying to make but it seems that you are coming up with a hypothetical scenario that is not supported by any of the limited information given. The conclusion I reached was based off the information we did get. The Doctor was given the opportunity to give a medical history and did not give any other information except that the baby was 2 months premature and had been in the hospital for a week with pneumonia for which he had not been treated. I can't imagine a Dr not telling a paramedic that the pt is on palliative care or is a DNR no matter how little information they give. It seems to me that SA was attempting to find out more information on the pt but was not receiving it from the Dr not that he was "overriding any points of reason".

I don't know how it works in Africa but in the States a parent still has to give consent (unless there is a court order) to not escalate care or make the baby DNR status. It does not sound like the parents changed their mind but were unhappy with the lack of care altogether which is why they wanted him transferred. (Based on what SA has given us although it is hard to know since they had a language barrier).

The infant's weight is definitely concerning and there absolutely could be some underlying health problems especially as it was 2 months premature. There are any number of non-lethal conditions that can cause a baby to be in the lower growth percentiles and some could have been from the pregnancy and possibly even a cause of the prematurity. But the baby has also been sick for over a week and is severelydehydrated and starving. A baby can lose >10-15% body weight with dehydration in less than 24 hours so if this baby was on the small side to start with and now has not been able to eat or drink with no IV fluids for over a week he has most likely lost a way larger percentage of his body weight.

In this case I am willing to give SA the benefit of the doubt over the Dr who does not even know what a normal infant HR should be. SA has been polite, professional and does not come across as unknowledgable in this thread. The Dr does come across as ignorant even though I admit that we only have one side of the story.

I am not disagreeing with your thoughts on lack of quality of life and babies/people being saved who should be let go. I understand that whole concept very well after many years in PICU's. I am just not seeing that that is the scenario in this case rather that it is a case of blatant neglect. I have seen any number of medically mismanaged cases (by all walks of health care) and am under no illusion that Dr's are perfect (or paramedics). A jury can only make judgements based on the evidence given no matter what other hypothetical scenarios there could be and that is all I am doing in this case.

SA, it would be interesting to hear if you have any further information or follow-up on this case.

[VentMedic]

I am just not seeing that that is the scenario in this case rather that it is a case of blatant neglect. I have seen any number of medically mismanaged cases (by all walks of health care) and am under no illusion that Dr's are perfect (or paramedics). A jury can only make judgements based on the evidence given no matter what other hypothetical scenarios there could be and that is all I am doing in this case.

Again the information is not there. We do not know the course of treatment this baby had just prior to this event or at any part of his life. We do not know what course of action the parents has agreed to prior to calling the ambulance when death may have been near. The parents of a preemie learn quickly about medicine. This was NOT this baby's first day in a hospital.

But, many in EMS are reluctant to agree about death when it comes to children. This is why we get Paramedics coming to the ED hysterically wanting us to do a miracle on a cold dead baby who died from SIDS. At the scene they will give the parents all sorts of hope. Some must work every child regardless of lack of life signs because of protocol and others because they can not deal with the death of a child.

[RavEMTGun]

A truly educational and enlightening thread, if a bit sad.

[SA_Medic]

While I take all views into consideration and understand the views of everyone here. I do not agree with some of the postings related to this case. The sad reality here is that the government hospitals are severely under resourced as is the government / city run ambulances. Small things such as c-collars, vacuum mattresses, even transport incubators are non existent. If at all possible, I would have taken photo's or a video or something to show you that state of this and other government run hospitals in Africa. I am by no means trying to make excuses for what I have done (whether it be right or wrong). What I am saying is assuming that this baby has had any type of decent medical care while spending the week in the hospital or that the doctor has in anyway communicated with the parents what is being done would be very very optimistic to say the very least.

I have learned the hard way to expect your worst nightmare come true when you get called to transport any patient from the government run hospitals in Africa. More often than not, the patient was taken there by the family on loaded onto the back of the police pick up truck (the government ambulance service isn't available). The casualty department (don't even try and think your trauma units) has seen the patient, decided they are not up to working today and this patient will be fetched by us shortly so they just don't do anything. Neither quality nor value of life is taken serious here. For most medical staff in these facilities it's a salary, nothing more and nothing less.

In a recent newspaper article (I will try and find it) this same gvt hosp made the news for not seeing to a 2year old child resulting in the death of the child. As explained by the paper "The child was put to bed by her mother, the mother went into another room of the house and heard the child cry. When she entered the room she found a cobra on the bed with the child having been bitten on the head. A neighbour killed the snake, loaded the child and mother into a taxi (no ambulance available) and rushed them to said hospital. Upon arrival they explained the situation to casualty staff and showed them the snake. The mother was told to join the queue of 30+ people and wait their turn. When the child started haemorrhaging from the ears and nose, casualty doctors realised the child was sicker than they though. However, it was to late and the child died".

Value of life is my foremost and only concern in this country. Unless there's a specific DNR I will give my patient (regardless of age) the benefit of the doubt. If you have not learned in the first 3 years of this business that doing your best with every patient might just change their life, then you never will. Sure there's cases where a resus has to be called which I do and cases where starting a resus is plain and simple not even a viable option any more. However, if for any reason I feel the patient might still have a chance, I will give him / her that chance. I did not spend the money nor time on becoming a Paramedic and all the other abbreviations to stand "play God over life or death". I did this because I wanted to be a paramedic and wanted to give all people the chance at life *let the flaming begin*. Cliché as it might sound, but that's my view on this patient and every other patient I have and will see in the future.

I will post an update on this case later today as I am going to the hospital for a follow up.

[VentMedic]

Value of life is my foremost and only concern in this country. Unless there's a specific DNR I will give my patient (regardless of age) the benefit of the doubt. If you have not learned in the first 3 years of this business that doing your best with every patient might just change their life, then you never will. Sure there's cases where a resus has to be called which I do and cases where starting a resus is plain and simple not even a viable option any more. However, if for any reason I feel the patient might still have a chance, I will give him / her that chance. I did not spend the money nor time on becoming a Paramedic and all the other abbreviations to stand "play God over life or death". I did this because I wanted to be a paramedic and wanted to give all people the chance at life *let the flaming begin*. Cliché as it might sound, but that's my view on this patient and every other patient I have and will see in the future.

Nobody is doubting your ability as a Paramedic. But, you titled the thread as "Gross Negligence?" and seemed to want us to agree that doctor was grossly negligent. I can not condemn a doctor without knowing what was his intent and that of the parents throughout this baby's life. Parents do change their minds when it comes to life and death decision with DNRs being revoked at the last minute. However, that is no reason to say the doctor is grossly negligent. The doctor may have been been giving you bizzare explainations for the HR and condition of the baby because he may have learned something as I have about some EMTs and Paramedics. That is, I avoid all ethical conversations with them about terminating life support on babies or even adults. I don't like to be called a murderer and it is often useless to continue any discussion with some. We also see their reaction when the ED doctor terminates a code that they have worked in the field for an hour thinking "he just doesn't care" about either the patient or them and their hard work. Sometimes we have even avoided terminating a code until a couple of the more "emotional" Paramedics have left the ED.

Now if the conditions are as bad as you say, I do not see a good future for a child that is ventilator dependent with a trach and peg.

The U.S. health care system is far from perfect and you will have less than perfect employees in every system.

The U.S. also has its share of horror stories and I see many of them in the ED or by doing Neo/Pedi Specialty transport. I also pick up babies and children in regions that I sometimes find it hard to believe those primitive conditions exist in the U.S. The U.S. stats are also extremely poor for infant mortality. Even with all our resources we can not prevent some of the issues that lead to a high death rate because they often happen before the baby is conceived and while still in the uterus.

Edited October 21, 2009 by VentMedic