Gross Neglegence?

[akflightmedic]

Chbare...Aussies use that silly "sister" thing too...

Imagine my surprise when I found out I was working with some sisters and these two Aussie blokes showed up.

[VentMedic]

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.

Actually, you pointed out what I missed.

If there was no immediate follow up CXR after intubation at the original hospital, there is little to say but the intubation could have caused the lung collapse.

Not knowing the full extent of the baby's medical history and anomalies, this intubation may only prolong the inevitable and/or the baby may have to be trached and pegged. That is not always a good thing especially in remote areas that lack in home care. Quite possibily without knowing the intent of the original hospital/doctor and if they were just waiting for the family to come to grips with realty, this may now have caused the baby and family to be put through several more weeks of torture.

Again, not enough information about the prognosis of this baby.

[SA_Medic]

Apologies for the delay in my reply, Monday's at the office is at best a day to have rather stayed in bed. Also apologies for not giving more information on this case, I was slightly more than a little pissed at the initial medical treatment and facility.

Starting at the beginning (and I wish I could show you this medical facility and it's staff). The only information we had at the time of dispatch was that the child (male) was born 2 months prem and is now 2 months old. The parents were unhappy with the current treatment being given at the Government facility and wished to have the child transported to the private facility 5min down the road. On arrival I found the following:

1) Baby weighing 1.2kg (slightly less than 3lbs)on CPAP,

2) Severe dehydration (evident by the loss of tugor on the abdo and calves)

3) Cyanosis (particularly evident in cranial area and the chest)

4) On palpation the child was cold (to the extent of my sats probe did not detecting anything, warming the baby with the warmer blanket helped)

5) The baby was not crying nor showing any normal / expected response from being examined

6) Auscultation revealed a rub of right and no audible air entry in left (PDA question: No murmur audible)

7) Resp: Rapid (-> 60/min) with deep suprasternal retractions

8) Pulse rate: 67 (as mentioned in initial post)

9) SATS: 56% on CPAP (as above)

10) IV insitu ® arm.

11) BP 50 systolic

12) Lymph nodes small and palpable

No labs nor any xrays were available (according to the treating doctor and nurse)

The treating doctor informed me that the child was admitted with pneumonia and has received no medication / antibiotics to treat the infection. The only treatment that was confirmed would be the CPAP and IV (as mentioned).

This is when I decided to intubate with a 2.5 tube and ready for CPR. I confirmed (as required) tube placement via auscultation (still no audible air entry left) and started bagging. With the stats going up and the HR increasing it was evident that no compressions would be needed. Thus we transported to the receiving facility while informing them that we are inbound and need an ICU bed. As mentioned earlier, chest x-rays were taken at the receiving facility revealing the pneumothorax of the left lung. I have not had the time yet to follow up with the paediatrician but will update you as soon as I have had the chance.

In reply to CH - True, we have three levels of qualification in SA.

1) BAA (EMT- which is a one month course or 3 months part time

2) AEA (EMT-I) Three months full time (only attainable if you have 1000 pt care hours documented, passed the entry exam and obviously the course)

3) CCA (EMT-A) 12 month full time (only attainable if you have documented 1000pt care ILS hours, passed the entry exam and the course itself)

The CAA / Paramedic course has changed in recent years allowing a school leaver to do a National Diploma via the Univ. No road experience required, yet after 4 years you walk out a Paramedic.

You can then go and do B-Tech, M-Tech and D-Tech in Emergency care.

The first two levels have a "under supervision" license whereas the rest have a "unsupervised" practitioners license. No doctor needed, nor any medical consult needed before administering meds / drugs as per protocol.

In reply to Kaisu - I am in Namibia, how does a situation like this develop? Probably the same way a doctor flies a pt to my city indicating she had a CVA that's visible on the ECG! I do a check and low and behold, she's had an anterior infarc (I will scan the 3lead print out when I remember).

In reply to Vent - I hope we use the same abbreviations here as you do over there.

PDA question, see above for answer

Probe was post ductal as you will no doubt have noted from my post above.

PMI - Apical Pulse? If so, there was a shift to the right

Sadly we do not have the "paediatric specialist" we can call to jump on our vehicles, nor am I allowed to ask for a x-ray to confirm tube placement. It's a resource that's bolted to the floor of the Govt hospital (some do not even have x-ray facilities). I so wish I had the facilities and resources you have across the waters. We still have to tube, confirm tube placement via auscultation, stabilize, load and go.

This makes for interesting conversation though and helps keep me on my toes and dreaming. Keep it coming

[VentMedic]

This baby will probably not survive. Was that the prognosis the doctor gave the parents that made them unhappy?

What type of long term pediatric care facilities do you have in SA to care for a baby on a ventilator with a trach and peg for the rest of his life if he does survive?

[SA_Medic]

I have no idea what the doctor told the parents. I arrived at the hospital finding the mother who does not speak, read or write any language myself or my crew understands. In South Africa we have excellent facilities to manage this type of case, sadly in Namibia there's none. I'm awaiting the phone call to tell me to fly this child the 4 hours required to South Africa, which I will most probably refuse to do.

[Kaisu]

WOW - sounds like you are a compassionate, professional practitioner in an area of the world that makes the zoo I run in look like the model of pre-hospital medical care. Forgive us for the assumption that you have access to the same resources as we do. I can imagine how pissed off you were. I get livid with less blatant examples of substandard care.

As a paramedic, there is only so much I can do to make improvements. I talk about deficiencies to anyone who will listen. The problems here are systematic and I cannot afford to alienate other members of the system. I work very hard to establish non-confrontational relationships so that we can work together to make things better. It's a fine line.

I do everything I can to ease my own conscience, pick my battles and accept my own limitations. Good luck to you and good work on that call.

[VentMedic]

I have no idea what the doctor told the parents. I arrived at the hospital finding the mother who does not speak, read or write any language myself or my crew understands. In South Africa we have excellent facilities to manage this type of case, sadly in Namibia there's none. I'm awaiting the phone call to tell me to fly this child the 4 hours required to South Africa, which I will most probably refuse to do.

I am not talking about a children's hospital but rather a pediatric nursing home that takes ventilator kids until they are 21 y/o. If they do manage to save this child in terms of the body, the baby will probably require special care for the rest of his life.

Unfortunately even in the US those facilities are few and often very crowded.

Edited October 19, 2009 by VentMedic

[SA_Medic]

@Vent - Oh, that type. Nope none of that that I am aware of in the whole of Africa.

@Kaisu - Nothing confrontational or derogatory meant towards you mate, it's just me being pissed that the technology and know how is out there but takes more than a few light years to reach us here on the dark continent. As you said, we do everything in out power and knowledge to ease our conscience and hopefully save a life or two along the way.

[chbare]

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.

[Kaisu]

What I find absolutely amazing about this conversation is the fact that although what we have here vs. what you have there is like day and night, we are still faced with making things better in the system.

I was trained in a very advanced part of the country for EMS in a state 2000 miles away from where I am now. We do things here that would absolutely floor my compatriots up north. If people have only worked in their own system, they don't know that there are better ways to do things. Some of the "better" ways up there are unworkable here because we don't have the equipment or the mindset to make use of the equipment.

I would love to start a dialogue with you specifically addressing how to bring progressive change when 1 - we are "just" paramedics and 2 - we need to get support of the hospitals and other health care providers.