Gross Neglegence?

[SA_Medic]

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.

True, I did entitle it that way and I did ask for your thoughts. I simply disagree with the postings on deciding when to give the child the benefit of the doubt because of quality of life. We all know babies (especially girls) have more fight in them than adults hence the decision to "terminate" would be easier on adults than infants. My question would be, who teaches you to decide on what acceptable quality of life and what not? There's no universal accepted standard for quality of life? Is it based on your specific area where you live and make a living?

The one thing this thread did emphasise is that there are huge gaps in the way we do things all over the world (a gap that does not seem to be closing at all). The gap in training and equipment availability is just as huge and ever increasing. I enjoy this type of conversation, it's borderline "getting personal and confrontational" and still teaches at the same time. Like probably 99% of the people on this site, I enjoy the expressions of views and interest in cases and scenarios like this.

Update on the patient:

According to the treating paediatrician rehydration is doing the trick and the process of re inflation of the lung has started with the vitals and saturation looking better.

[tniuqs]

'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?

Well I will take this one on do you think they even have virology in this government hospital in NAMBIA ? ... the child was 2 months premature, survived @ home for 2 months then admitted to Hosp ... no antibiotics no anti viral and sub therapeutic fluids replacement (hell why even bother if your withdrawing therapy) .. very curious.

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

Pneumonia I would highly suspect, very difficult to improve sats with BiPap with Pneumo and most likely cause a tension ... was this mask or NPT ?

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?

Better Query what were the prior films and were they offered for your review SA, knowing SA I highly doubt that every possible attempt at PMHX was attempted, this medic has worked from sinking rusty jackup oilrigs to some of the worse conditions in the world .... and just how was the Sudan SA Medic ? did you ever get that Kevlar coffee cup lid I sent you? Do readers in EMTcity even comprehend that one round of 10 days of Cipro can tuely save a life .... honestly sometimes I just get disgusted the judgments of some.

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?

See above statement, does the machine really matter USE what you have, and highly unlikely a volume vent was used (come on please) and with initial Sats on a cold foot and actually warming the kid to NTE the sat monitor is a waste of time (its perfusion related) .. BUT treated and markedly improved ... a no brainer query, I always took my sweet time with any newborn and RNS freaking out to get a heel cap gas, cause it tells you nodda when perfusion is compromised.

PDAs are reparable Arnie Schwarzenegger being just one example, in South Africa they are the Leaders in cardiac Surgery .... look to history.

Congenital heart defects?

Ok good question so this small patient survived at home for 2 months ...Quote: (a 2month old, premature (born 2months prem) does Coarctation of the aorta patients survive without treatment for 2 months at home AND or were the kids lower limbs blue and upper torso pink? kinda a DGA.

What was the prognosis of the baby?

Quite clear the outcome with this MD treating was DEATH, Hypothermia, inadequate fluid maintenance, with SAs interventions things are looking up well just uneducated humble opinion.

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.

And some times the patients actually SURVIVE, WE live in an entirely different world in N.A.

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.

Anecdotal, and SA Medic is no frigging student, and I can tell stories of R3 that are dumb as posts.

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, 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.

Vent this is an assumption and very atypical, of you have you ever been in Africa? SA simply did his job to the best of his abilities he is not an RRT ... if this kid does survive it is because of his actions ... and as you WELL know in NICU one just never knows until ... maybe just another female Stephen William Hawking in the making ?

I would not charge the MD with negligence I would send him a picture of the child playing on your lap in a year.

cheers

Edited October 21, 2009 by tniuqs

[tniuqs]

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.

A man of experience speaking here.

Wonder if the MD gave paracetamol, or isorbide .... ever hear of Nimbex ?

cheers

[VentMedic]

tniuqs, I did NOT bash any of SA medic's care. I merely pointed out there were too many unanswered questions about what transpired prior to his arrival and during the life of this child to charge this doctor with gross negligence. We also do not know what happened during birth. One can not say the doctor did not act in accordance of the family's wishes, which would not make it negligence if that was minimal care, until they panicked when death was close. If a baby is sent home under 2 kgs, it is usually for comfort care.

Ok good question so this small patient survived at home for 2 months ...Quote: (a 2month old, premature (born 2months prem) does Coarctation of the aorta patients survive without treatment for 2 months at home AND or were the kids lower limbs blue and upper torso pink? kinda a DGA.

That would depend on the CHD. Yes, we have had adults dx'd with a coarctation of the arota and have come to out Pedi surgeons for correction. The actress Kate Jackson did not have her ASD dx'd and repair until she was in her 30s. We also have to "grow" LBW and preemies to a suitable weight for before some cardiac surgery which we do that with a very low SpO2 to keep the ductus open. If the baby is able to maintain on just RA without the need for subambient and in some cases when communication for passage of blood between both sides of the heart is made by balloon spetoplasty(septostomy), the baby may be allowed to go home for awhile. However, we would not discharge a baby under 2 kg unless it was intended to be comfort care.

See above statement, does the machine really matter USE what you have, and highly unlikely a volume vent was used (come on please) and with initial Sats on a cold foot and actually warming the kid to NTE the sat monitor is a waste of time (its perfusion related) .. BUT treated and markedly improved ... a no brainer query, I always took my sweet time with any newborn and RNS freaking out to get a heel cap gas, cause it tells you nodda when perfusion is compromised.

This is in reference to the PMI from where you quoted me. A PMI should be marked on any infant you can see or feel it and most definitely if intubated. This can tell you if the baby is over inflated, develops a pneumothorax or possibly the tube slips down the right main stem. ETCO or TCM may not immediately reflect this. Thus, in the ambulance or helicopter where noise is a problem, we can watch the PMI.

Now for the SpO2. If a baby does have a PDA or even a CHD, the SpO2 might be low. For some CHDs we may run the SpO2 65% - 75% and will use nitrogen to low the FiO2 below 21% to obtain it. The placement of the probe pre or post ductal can also make a difference. Pre is usually on the right hand and post is the foot. You can even see a gradient on healthy newborns for about 15 minutes but we rarely bother with SpO2 right after birth in L&D unless there is a known problem and we are titrating gases and/or meds.

But again tniuqs, I did not pick apart any of the care SA provided. I just merely can not hang a doctor who may have been caught in the middle of the parents conflicted emotions. "Saving a life" can have different meanings. If there is no facility to care for a ventilator dependent trached child, this child is not going to have an easy go of it.

[VentMedic]

My question would be, who teaches you to decide on what acceptable quality of life and what not? There's no universal accepted standard for quality of life? Is it based on your specific area where you live and make a living?

There are some universally accepted standards for viability such as gestational age and weight. We will not resuscitate a 22 week baby but may one that is 22 5/6. A Grade 4 ICH and other preemie conditions are a bad situation and the parent will be told straight out the prognosis. The same for some congenital heart defects and syndromes. If the surgery is not an option, there will be a serious discussion toward comfort care. Some syndromes are not compatible with life for very long but may be discharged to live with their family until death with the knowledge nothing can be done. Anecephalic babies have been an issue in the courts especially when there is life support involved and some parents have opted to take their baby home. They are told of the prognosis and the baby could live for a long time. However, there will be no hope given that the baby will be normal. The same for a baby with a grade 3 ICH. We also now have organ procurement where the baby or adult does not have to meet brain death criteria but must have a poor prognosis or will die without the ventilator.

With any ventilator dependent baby whether it goes home or placed in a nursing home, the parents are told up front there are no guarantees and what to expect. While parents can have hope, they must be aware that medicine can not fix the problem and will only be able to resuscitate the baby just so many times before realty must realized. It the parents have trouble with this, in the U.S. we have ethics committees that can help make that decision once the parents' wishes for "everything done" becomes to unrealistic. Yes, the hospital and those working there will become villains in the eyes of some but sometimes the suffering of the baby and the prognosis must be realized. Someone finally has to say enough is enough.

Some of our U.S. hospitals, including the one I work for, have the reputation for being able to resuscitate a rock and prolong the life or death of an adult or infant indefinitely. Our egos allowed us to fill up nursing homes with both adults and kids from our heroic saves. Now, doctors are starting to take a more realistic approach with some patients.

[tniuqs]

'VentMedic' date='21 October 2009 - 09:09 PM' timestamp='1256180952' post='227201']

tniuqs, I did NOT bash any of SA medic's care. I merely pointed out there were too many unanswered questions about what transpired prior to his arrival and during the life of this child to charge this doctor with gross negligence. We also do not know what happened during birth. One can not say the doctor did not act in accordance of the family's wishes, which would not make it negligence if that was minimal care, until they panicked when death was close. If a baby is sent home under 2 kgs, it is usually for comfort care.

I believe that SA Medic was quite clear ... gross negligence or just give up because of lack of resources, I can not and will not fault the MD ... accept for his attitude as was the RN sister but be very wary my Mother a Korean VET was called a that an Nursing sister ! AND buried last year as you know donated her body to science that others may learn. this at the honerablbe rank of nursing sister Lieutenant and theres as an bloody "F' in that, she treated British, American, OZ and Kiwis ... AK don't you dare go there or the Wrath of Khan will come on your head like ton of fucking bricks.

That would depend on the CHD. Yes, we have had adults dx'd with a coarctation of the arota and have come to out Pedi surgeons for correction. The actress Kate Jackson did not have her ASD dx'd and repair until she was in her 30s. We also have to "grow" LBW and preemies to a suitable weight for before some cardiac surgery which we do that with a very low SpO2 to keep the ductus open. If the baby is able to maintain on just RA without the need for subambient and in some cases when communication for passage of blood between both sides of the heart is made by balloon spetoplasty(septostomy), the baby may be allowed to go home for awhile. However, we would not discharge a baby under 2 kg unless it was intended to be comfort care.

Ok so a failure to address an issue that can be surgically corrected should be discharged ps I was privileged enough to have worked with (Dr. Neil Finer an associate professor and now a Professor in the university of San Diego and stolen from the Royal Alex hospital in Edmonton, just like Wayne Gretzky ) so to hell with diaphragmatic herniation and ECMO btw we celibrate the 18th bithday of the first "experiment" next month and I will be there for Ashely,I was so privileged to be a very small part of her care.

This is in reference to the PMI from where you quoted me. A PMI should be marked on any infant you can see or feel it and most definitely if intubated. This can tell you if the baby is over inflated, develops a pneumothorax or possibly the tube slips down the right main stem. ETCO or TCM may not immediately reflect this. Thus, in the ambulance or helicopter where noise is a problem, we can watch the PMI.

Helicopter, your luck to get a Caravan, single engine on a gravel strip or if you damn luck a KA 100, thats if your G damn lucky, and PMI please educate me I am am a bloody idiot.

Now for the SpO2. If a baby does have a PDA or even a CHD, the SpO2 might be low. For some CHDs we may run the SpO2 65% - 75% and will use nitrogen to low the FiO2 below 21% to obtain it. The placement of the probe pre or post ductal can also make a difference. Pre is usually on the right hand and post is the foot. You can even see a gradient on healthy newborns for about 15 minutes but we rarely bother with SpO2 right after birth in L&D unless there is a known problem and we are titrating gases and/or meds.

Nitrogen gimme a break this in is Nambia fer fucks sake do you believe the world revolves around the US of A get a grip, SA_medic is asking for help, and did he do the right Thing I commend him and he should get the Noble prize for simply trying . I believe even dust would back me.

But again tniuqs, I did not pick apart any of the care SA provided. I just merely can not hang a doctor who may have been caught in the middle of the parents conflicted emotions. "Saving a life" can have different meanings. If there is no facility to care for a ventilator dependent trached child, this child is not going to have an easy go of it

.

You best not pick apart SA_medic care there is no conflict with patient care in a 3rd world country and because you have never walkied in his SA shoes .... nuff said nor have you treated a Teepee chest/ RSV from Frobisher bay /Iqaluit.

SA MEDIC gave this child the best possible chance at survival anything else would be negligence on your part Kudos my brother, cant wait till we meet.

And more assumptions, is trach required with recruitment for sats of NPT on 10 of PEEP ? is a Peg required for a child that an be on NG tube feed for 5 days WAY too many assumptions have been made here.

cheers

Edited October 22, 2009 by tniuqs

[chbare]

LOL, Caravan, you are quite spoiled. Try a Kodiak or the back of an Antonov 26 ( an 26) that was just cleared of boxes of fruit. I worked with South African doctors who agreed on the an 26's official name of "ghetto plane."

Take care,

chbare.

[tniuqs]

LOL, Caravan, you are quite spoiled. Try a Kodiak or the back of an Antonov 26 ( an 26) that was just cleared of boxes of fruit. I worked with South African doctors who agreed on the an 26's official name of "ghetto plane."

ever see a beaver or a herman nelson lol(and no sexual inference at all.)

A twin otter from Inuvik saved a MD with breast cancer in antarctic a walk in the park.

Take care,

chbare.

Chbare, and now YOU are to be capitalized ... brother you know, South African Medics are some of the best educated MO FO in the world and bitch less than the vast majority of offshore and hostile environments ... HATS OFF to them, I wish I could be even close, I still have a long way to go !

cheers

[VentMedic]

Ok so a failure to address an issue that can be surgically corrected should be discharged ps I was provilaged enough to have worked with (Dr. Neil Finer an associate professor and now a educator in university of San Diego and stolen from the Royal Alex hospital in Edmonton, just like Wayne Gretzky ) so to hell with diaphragmatic herniation and ECMO btw we celibrate the 18th bithday of or the first "experiment" next month and I will be there for Ashely,I was so privileged to be a very small of her care.

ECMO? I merely stated that some CHDs do not have to be surgically repaired immediately. Some are also missed until they present a problem.

This situation you describe is fixable. A diaphragmatic hernia is sitll considered viable and ECMO is NOT used for all diaphragmatic hernias. We can manage them to the OR on a conventional ventilator most of the time. ECMO is one of the last options but even at that many of our babies, pediatrics and adults still survive for a variety of disease processes including H1N1.

Helicopter, your luck to get a caravan, single engine on a gravel srtip if your G damn lucky, and PMI please educate me I am am a idiot.

Try the back of an open jeep to get to your helicopter several miles away.

I have no clue about what your knowledge base is about babies. Your post did not reflect that.

You best not pick apart SA_medic care because you have never walkied in his shoes .... nuff said nor treated a Teepee chest from Frobisher bay/ Iqaluit.

SA MEDIC gave this child the best chance at survival anything else would be me negligence on his part..

Are you threating me? Not once did I question his care. I questioned his reasons for assuming the doctor is guilty of gross negligence when he clearly stated the family could not provide any information due to a language barrier.

Actually I have worked under some less than ideal situations since I do transport babies to and from many countries. On a 24 hour transport to some islands, you have to be prepared for a lot of things including your own technology malfunctioning. As well I have gone with the pedi team to South America for surgical procedures and you probably have not seen surgery under those conditions on a baby. Or, maybe you have. I also don't believe they had much of an EMS system in that part of the Honduras. I have also worked in hospitals very crippled by hurricanes and in tents to provide care to sick babies and children. So spare the "you don't know" since you don't know my whole resume.

Again and again, SA's skills are not on trial here and never have been. The question was about the doctor. Why are you turning this into a pissing match over something that was never an issue?

Nitrogen gimme a break this in is Nambia fer fucks sake do you believe the world revolves around the US of A get a grip, SA_medic is asking for help, and did he do the right Thing I commend him and he should get the Noble prize for simply trying . I believe even dust would back me.

What is with the "fucks" word? Why are you swearing at me for offering some educational information?

Geez! Now you bash me for adding a little extra information about managing a CHD. This may or may not even have anything to do with this baby but since we were talking about CHD and SpO2, I tossed it in.

And more assumptions, is trach required with recruitment for sats of NPT on 10 of PEEP ? is a Peg required for a child that an be on NG tube feed for 5 days WAY too many assumptions have been made here.

cheers

The baby is intubated and on a ventilator with a pneumothorax existing in a preemie lung. Considering the age and weight of this child I am surprised this baby did't have some type of tube at home to supplement feedings. But then, again the intent of care at home has not been determined.

Edited October 22, 2009 by VentMedic

[tniuqs]

'VentMedic' date='21 October 2009 - 10:54 PM' timestamp='1256187283' post='227209']

ECMO? I merely stated that some CHDs do not have to be surgically repaired immediately. Some are also missed until they present a problem. This situation you describe is fixable. A diaphragmatic hernia is sitll considered viable and ECMO is NOT used for all diaphragmatic hernias. We can manage them to the OR on a conventional ventilator most of the time. ECMO is one of the last options but even at that many of our babies, pediatrics and adults still survive for a variety of disease processes including H1N1.

In the USA perhaps.

Try the back of an open jeep to get to your helicopter several miles away. I have no clue about what your knowledge base is about babies. Your post did not reflect that.

I left NICU years ago, the biggest reason was because of experimentation on 800 grams ... I will never look back BUT this kid was born @ 28 weeks, discharged and then returned @ 34 weeks with a pneumonia, perhaps aspiration only although R sided is more likely. My post was intended to support a friend, who is living and working in environments that most N.A. would and can not even comprehend, applying European or NA standards is not only folly but I feel disrespectful.

Are you threating me? Not once did I question his care. I questioned his reasons for assuming the doctor is guilty of gross negligence when he clearly stated the family could not provide any information due to a language barrier.

No why would I threaten you, but perhaps you missed another thread that evening, I was very upset that I was personally mistreated for pain 11/10, and my post was seriously and personally affected by a local MD who was grossly negligent in my care. Have you never wanted to choke out an MD for being an idiot ? I have.

Actually I have worked under some less than ideal situations since I do transport babies to and from many countries. On a 24 hour transport to some islands, you have to be prepared for a lot of things including your own technology malfunctioning. As well I have gone with the pedi team to South America for surgical procedures and you probably have not seen surgery under those conditions on a baby. Or, maybe you have. I also don't believe they had much of an EMS system in that part of the Honduras. I have also worked in hospitals very crippled by hurricanes and in tents to provide care to sick babies and children. So spare the "you don't know" since you don't know my whole resume.

Well there is one clinic in Honduras and part of my kit is in the back of their half ton because there only ambulance rolled and killed the only EMT-Bs (that needs a new carburetor btw) just in passing, we tryed to donate a used Ambulance but the Mexicans officials stopped it at the border, its sitting for a year now in Brownsville TX .

Again and again, SA's skills are not on trial here and never have been. The question was about the doctor. Why are you turning this into a pissing match over something that was never an issue? What is with the "****" word? Why are you swearing at me for offering some educational information?

Perhaps re look at the tenor, sometimes this can be misunderstood, I did and now this is my personal apology.

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

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 why would I threaten you but I do have a new spell check (today) and I apologize for the f bomb, the old website would have corrected that, it was intended to amplify the point, maybe the aspirin was sub therapeutic too.

Geez! Now you bash me for adding a little extra information about managing a CHD. This may or may not even have anything to do with this baby but since we were talking about CHD and SpO2, I tossed it in.

and good points, good education as always.

The baby is intubated and on a ventilator with a pneumothorax existing in a preemie lung. Considering the age and weight of this child I am surprised this baby did't have some type of tube at home to supplement feedings. But then, again the intent of care at home has not been determined.

No suprize at all to me, and or the Mother could have been in serious need of personal nutrition herself, (she resorted to the government hospital and that speaks volumes in itself) I would bet my bottom dollar she was breast feeding only, poor quality water and the assumption made was that the mother could even afford food let alone care for a sick infant, the mortality rate is extremely high in the continent of Africa.

http://www.stampoutpoverty.org/

Anyone care to support ?

In Closing the Grossly Negligent MD that "did not treat me" 3 days ago was an imported SA trained MD and "I don't give a crap type MD" .... maybe just my pain talking, again sorry Vent I do not want to lose you as my friend.

cheers