other people's emergencies: random thoughts of an urban paramedic

For more than twenty years I've worked as a paramedic for the city of Boston, Massachusetts. The opinions expressed in this diary are mine alone, and do not represent the views of Boston EMS. Names, dates, locations, and physical characteristics have been changed to ensure patient confidentiality.

Saturday, May 16, 2009

To Some People, When You're Right, You're Still Wrong

Tonight we responded to the Aquarium MBTA station, where a woman was supposed to be having an allergic reaction to gluten. We could see her on a bench, surrounded by concerned-looking commuters and MBTA workers. From a distance, she didn't appear to be in any great distress. People in anaphylactic shock tend to pass out, after all, or to gasp for air, or at least to lay down.

As we got closer, though, I could see that her face was covered with hives. In fact, her entire body was covered with hives. Her breathing didn't seem too bad, but when I took hold of her wrist to check her heart rate, I couldn't find a pulse.

"Do you feel lightheaded?" I asked.

The woman looked at me, opened her mouth to reply, and promptly passed out.

Grabbing her arms and legs, we lowered her to the platform. My partner filled a syringe with epinephrine and injected it into the skin over her forearm. A few seconds later, she groaned and began to stir.

One of the EMTs tried to take her blood pressure, but he couldn't hear anything. The woman was awake now, as long as she didn't try to sit up.

My partner gave her an injection of Benadryl. We started an IV. Every few minutes, the EMT took her blood pressure again. After a liter of saline solution had run into her body, she still didn't have much of a pulse.

My partner suggested an injection of 1:10,000 epinephrine. Normally this course of treatment is reserved for patients in cardiac arrest. By this time, though, I didn't see any other choice. After two doses of medication and a huge bag of IV fluid, the woman still didn't have any blood pressure. being down in the subway, we were a long way from the ambulance, and an even longer way from the hospital.

He injected the medication into the IV. We lifted her onto the stretcher and wheeled her to the elevator at the far end of the station. As we rode up to street level, the EMT took yet another blood pressure, and reported it to be 70. That wasn't much, but at least it was something.

The woman's eighteen-year-old son wanted us to bring her to the Beth Israel Hospital, all the way across town. I looked at the rush-hour traffic, and told him, sorry, that it just wasn't possible. At least three other hospitals were closer, and with such a low blood pressure, a cross-town trek wouldn't really be safe.

"Her sister is in that hospital," the son said. "She's dying. That's why we're here. We came all the way from San Diego to be with her."

I felt terrible, but this really didn't change anything. It would take us at least twenty-five minutes to get over there. With little or no blood pressure, that would be a risky proposition.

The son understood. He didn't debate the point. We took her to a closer hospital, though I felt lousy about it.

The woman looked better as we wheeled her into the emergency department. Her blood pressure still hadn't gone above 70, but she remained awake, and the hives had cleared somewhat. She didn't seem to mind that we'd gone to the closer hospital. I was grateful for that.

In the treatment room, a nurse started a second IV. A doctor went in to examine her. A moment later, he came out to the front desk, where I was writing the report on the call.

Whatever he was going to say to me, I knew it would be confrontational. We've always enjoyed a fantastic relationship with the nurses and clerks at this particular hospital, and with nearly all of the other physicians, too. But for some reason, this doctor never has a pleasant word for us. When he's not ignoring EMTs and paramedics, he's criticizing them for something.

The last time I dealt with him, he accused us of letting a heroin addict leave without treatment. If he'd checked his facts first, he would have learned that we were the ones who'd brought the addict back from respiratory arrest, and that we were the ones who'd convinced him to go to the hospital. In fact, we were the ones who'd caught the patient escaping, long after we'd transferred responsibility for care over to the emergency department staff. But the doctor assumed that we were incompetent, and so he laid into us, right there in front of the patients and hospital staff, barking at us about our responsibility to safeguard our patients, and threatening to report us to the state EMS authority. And when he learned that it had been his staff that had slipped up, and not us, he refused to back down, never once offering an apology. Since then, several other EMS personnel have told me that they, too, have had run-ins with him. My partner tonight summarized the whole thing by saying, "He's a real asshole."

Tonight's interaction didn't improve our relationship. He walked over to me and said, "Did you give that patient epinephrine?" It sounded more like an accusation than a question.

I told him about the epinephrine, the Benadryl, and the IV fluid. I felt confident in what we'd done, because we'd followed state EMS protocols to the letter. And, more importantly, the patient's condition had improved. We'd delivered the woman to the emergency department awake, with a blood pressure, and in no respiratory distress.

"How much epinephrine did you say you gave her?" He'd heard me the first time. As usual, he felt the need to challenge our care.

I repeated the dosages. "Oh, that explains it," he said. "No wonder she's shivering." Then he turned around and marched away.

Of course the patient was shivering. The temperature downstairs had been about forty degrees, and she'd been laying on the concrete floor of a subway station. Plus, we'd given her substantial doses of epinephrine, a substance that stimulates the nervous system. That would make anyone shiver.

But the shivering, apparently, was the biggest thing the doctor could blame us for. Ignoring the fact that we'd reacted to a life-threatening situation quickly and reasonably, and ignoring the fact that shivering was a normal side effect of a necessary treatment, he chose this as the basis upon which to criticize us.

I didn't expect him to thank us. I didn't expect him to congratulate us. But I didn't appreciate being criticized for something that wasn't even wrong.

For a moment I thought about responding in kind, by telling him what I really thought about him and his opinions. But then I decided against it. No matter what he says, I know that we treated that patient well.

If he wants to be a jerk, that's his business. I'm not going to follow suit.

31 Comments:

Blogger Last Angry Man said...

Yes, I remember Doctors such as that. Not with fondness, either.

I once had one, in the old EW at the Brigham, demand that I let him know when a particular piece of equipment would be repaired. I'd been there all of five minutes, and was just getting into it, and told him so.

That was unsatisfactory, until I pointed out that he couldn't necessarily determine a diagnosis without running tests, and neither could I.

He was much nicer after that.

5:40 PM  
OpenID actualparamedic said...

certainly a job well done, even if dr. poofy pants was in usual form.

strong work!

5:44 PM  
Blogger TS said...

Last Angry Man:

That's pretty funny. Thanks for the laugh.

Actualparamedic: Thanks for the support. I feel better now, having vented.

6:41 PM  
Blogger Norma said...

Another job well done (in very less-than-ideal surroundings) by you and your team. Some people aren't happy unless they're making someone else miserable. Kudos for you for answering him with restraint...I'm not sure I would have been able to hold off! :)

7:29 PM  
Blogger VA PhireMedic said...

I used to want to be a doctor, but I don't want to be "that" doctor...and I love being a medic too much. Also, I had never really thought about giving the second round of high-dose epi as you did...good call, I never would have thought of that one, but then, thats what you get when you've been doing it as long as you have!

10:21 PM  
Anonymous Anonymous said...

Why don't you go to his superior (Chief of Emergency Medicine or whatever that hospital calls the doc who runs the ER)? Play it up as a patient safety issue- tell the hospital boss that if Dr. Jerkoff is going to treat the Paramedics with such contempt, he might miss an important point related to the patient. Hopefully a couple of these incidents will result in someone talking to Dr. Jerkoff about his behavior. It's always tragic to lose or patient or have a patient suffer health effects that they don't have to, but it's inexcusable if patient care suffers because of someone's arrogance.

10:23 PM  
Blogger TS said...

Norma:

That's the impression that I get, too--that this guy needs to belittle others to make himself feel important.

VA Phiremedic:

Don't give me too much credit. It was my partner's idea. And he's been doing it half as long as I have.

Anonymous:

That's an excellent suggestion. And maybe I should do that. To be honest, though, I don't see myself following through with it. In theory, this guy's attitude might harm patients. But so far I haven't seen any actual evidence of that. He had nothing to do with the addict running away, and he didn't harm the patient with the allergy by questioning us. The only thing he's done wrong is to insult us, and while this might theoretically make him likely to patients with his arrogance, I've seen no actual evidence that this has occurred. Governing boards of hospitals tend not to act on unsubstantiated allegations, and if the board were to dismiss the matter, I think it would only embolden him to treat us even worse. Until I see him do something more harmful, I think I'll just continue to vent here. Meanwhile, I'll decide on a case-by-case basis whether the benefits of telling him off outweigh the drawbacks.

Thanks for the input.

7:31 AM  
Blogger Last Angry Man said...

TS, I almost (broadly) posted exactly what you just said. My recollection of hospital politics (BWH, NEMC) is that they would "close ranks" in most similar situations (even if the lot of them didn't like the doctor in question), and it would rebound negatively on you.

8:36 AM  
Blogger Linda said...

Sounds like Dr. Jerkoff is the perfect name for that guy as he sounds like the type that would find something wrong no matter what you did right. Some people are just like that and there's not really much you can do to change them. I think that by being the bigger man and not lowering yourself to his level, you've proven beyond a doubt your level of professional as a paramedic.

You don't need this clown telling you that you did a good job, you just need to look at the patient that you just treated who now has a pulse and a blood pressure when before there wasn't one to know that you did good. After all, I'm sure she didn't mind the shivering knowing that it was secondary to her life being saved.

Good job no matter what Dr. Jerkoff had to say!

8:43 AM  
Blogger Last Angry Man said...

Linda, very true. TS does not require this Doctor to laud him; TS knows he does a fine job. So do we.

I'm curious if the Doctor might change his tune, if he had to try to stabilize someone lying on a concrete floor in a train station, rather than in an ER with all of the bells and whistles readily available.

9:45 AM  
Blogger Jonathan said...

Hey TS,
Sounds like this guy fits into the "what do you call a Doctor that graduates at the bottom of his Their Class? You call them Doctor" Category.

This is precisely what bothers me (and my family and freinds) about EMS. Is that most Doctors and a few Nurses really Don't understand what we do, or are capable of in the field. I think it should be a requirement for both Nursing and MD school to ride for at least a month with us so they See what we can do. Though in that guys case I don't think he'd understand.

11:56 AM  
Anonymous mistab said...

I feel sorry for the nurses that have to work with the doctor that you mention...you have the "luxury" of leaving after your handoff and paperwork...they're stuck with him for 8-12 hours

12:39 PM  
Blogger TS said...

Jonathan:

I couldn't agree more. In fact, I posted on this very subject previously. (See "It's All About the Doctor," September 4, 2007)

And, yes, I agree completely that doctors generally have no idea what it's like to treat a patient in an austere environment. Occasionally, we'll run into a doctor who really does get it. But most don't. And that can be frustrating.

12:40 PM  
Blogger TS said...

Mistab:

That's a great point! I know that other EMS personnel have had difficulty with this guy, but I don't know how he interacts with the nurses. Next time I go to that hospital, I'll try to remember to ask.

12:42 PM  
Blogger Last Angry Man said...

I'll bet they don't have many kind words about him.

12:57 PM  
Anonymous Beverly said...

What?!? Someone called this guy an asshole?? I'll bet, given what you've written, he's worse than that. I've worked with an ER doc who is notorious for being slow. Recently, when he came through the crowded waiting room on his way back from lunch (yes, he takes a lunch, of course) started bellowing about the hold-up and how slow WE were. I almost lit into him but I was too busy and the room was too packed.

1:11 PM  
Anonymous JAM said...

In reference to Docs riding with pre-hospital personal, I know firsthand that Brown University requires their med students to perform ride time. When I was working with the municipal service I retired from, we would have a med student with us for like 3-4 weeks. Unfortunately the service I used to work for wasn't that busy, and they just sat around studying. However, I would always take the time and opportunity to show them the equipment on the truck, and explain to them our protocols and standing orders.

We would also have either new residents and ED attending Docs ride with us also. That was done as part of their orientation.

1:27 PM  
Blogger TS said...

Beverly:

You know how I feel, obviously!

1:53 PM  
Blogger TS said...

JAM:

Medical students and residents are required to ride here, too, as are nurses in the Certified Emergency Nurse (CEN) program. But for the most part, the ride consists of a single shift.

The attitude of these observers varies. A few seem genuinely interested in how we do things. But an equal number make it perfectly clear that they are spending time with us only because they have to. It's sad, but the very people who are supposed to be enlightened by their experience with us get nothing from it because of a preconceived notion that, not being doctors, we have nothing to show them.

The most egregious example of this came from a first year surgical resident. He arrived two hours after the shift started. He asked no questions, and showed no interest in knowing what we did or what kind of equipment we carried. Two hours later, after going on exactly one call, he asked us to drop him off at the hospital. He'd seen enough, he said, and since he lived near the emergency department, being left off there would save him the cost of a subway ride.

With this kind of thing happening, is it any wonder that some doctors think of us as nothing more than "ambulance drivers"?

2:04 PM  
Anonymous mark baard said...

amazing story, man. sounds like you saved a life. the doctor sounds like he came right out of central casting for one of those antagonists on ER, or something.

5:17 PM  
Blogger KT said...

Yeah, have one ED Doc out here who started laughing at me in the middle of a handover... Suffice the say my partner and the nurses around all didn't see what was wrong with the handover, but the Doc apparantly thought 'I wasted too much time with irrelevant details'.

Such as past medical history...

Had a few 'encounters' with her, has a reputation amongst ambo's and nurses as a pain to work with. It's a shame to get that attitude when you're only trying to do your job to deliver the best Pt care you can...

11:06 PM  
Anonymous Brendan said...

Hey TS, I'm curious about this doc...is he very old, young, etc? I don't know if this is a general trend or not, but most of the Dr. Jerkoff's I've dealt with have been newer to the ED and have the majority of their EMS knowledge based off watching Scrubs (where we po' bambalance folk don't do shit and the docs can sho' do our jobs without breaking a sweat). Just a thought....

1:36 AM  
Anonymous MichiganEMT said...

I have had similar incidents happen, but not in the same way. I have had a doctor approach me, on my scene, and announce that he was taking over my patient. One doctor actually grabbed me and tried to push me out of the way. On this instance, I motioned toward a Michigan State Trooper on scene and told the dr. that he either leaves or goes to jail for assault and interfereing with an EMT. I have had to explain to dr.s that if they assume patient care they have to ride to the er with us. To not do so would be patient abandoment. Of course, they don't understand this. So much for advanced education!

1:50 AM  
Blogger TS said...

Mark Baard:

He does, doesn't he?

KT:

Sorry to hear that. But I suppose we all get these kinds of attitudes at one time or another.

Brendan:

He's older, and is not new to medicine by any means.

Michigan EMT:

That's another thing that happens all too frequently. Everybody wants to get involved until they actually have to take some responsibility, then they want nothing to do with the situation.

9:25 AM  
Anonymous Anonymous said...

I don't think it's worth doing anything (confronting him or going to his superiors). The guy is a jerk (probably genetically) and he just so happens to be a doctor.

One day his arrogance will probably cause him to make a serious mistake that he'll have to live with. I'd just let nature take its course.

As far as the residents, well I think that's just a shame. As with many younger folks, respect is no longer a big issue. Even if you have little interest, would it be so hard to show some respect and enthusiasm? It's very possible that one day the resident or a member of his family will need EMS, and he should be damn thankful people like you are out there responding to calls.

Moral of the story, some people just don't get it and they're not worth your time or your effort.

9:35 AM  
Blogger TS said...

My feelings exactly.

10:14 AM  
Blogger brendan said...

The most egregious example of this came from a first year surgical resident. He arrived two hours after the shift started. He asked no questions, and showed no interest in knowing what we did or what kind of equipment we carried. Two hours later, after going on exactly one call, he asked us to drop him off at the hospital. He'd seen enough, he said, and since he lived near the emergency department, being left off there would save him the cost of a subway ride.As far as I'm concerned, he did not complete his observation requirement, and would forward that information to his residency program.

But I can be an @$$hole like that.

1:40 PM  
Blogger TS said...

Brendan:

That thought crossed my mind. But really, what would it accomplish? Would it force him to learn what EMS personnel really do? Cause him to respect us more? I really don't think it would.

Some battles simply aren't worth fighting, and to me, this was one of them.

1:51 PM  
Anonymous nitpicker said...

I know its nitpicky, but 1:10,000 epinephrine is not more potent than 1:1,000 epinephrine. In fact, it is more dilute. 1mg of epinephrine is still 1mg of epinephrine, regardless of whether it is in 10cc (1:10000) or 1cc (1:1000). There is certainly a difference between the IV and IM/SQ routes, which is what I think you were getting at, but there is no difference in the potency of the drug itself...

2:19 PM  
Blogger TS said...

Nitpicker:

You're right, of course. I was trying to make the point that we were resorting to somewhat extraordinary treatment, and didn't pay enough attention to the way I was presenting the information.

I'll correct it in the post. Thanks.

7:53 PM  
Anonymous Anonymous said...

Sounds like a typical a-hole "entitled" jerk that lives in the town I am a cop in.....

9:25 PM  

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