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.