1-800-Rent-a-doc
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Let me start by saying that no offence is intended for those in the noblest of professions: physicians. However small, rural ER's tend to allow anyone with an MD to moonlight in their unit. This leads to that "first-year podiatrist resident" syndrome we frequently see.

I am a flight paramedic in a rural area who frequently responds to such situations. When enroute to a small ER to transfer a patient, we are frequently asked to call the ER as they have a question regarding the dosage of a medication, treatment procedure, etc. Doesn't exactly inspire confidence...

On this one particular night, we were requested to a small (5 bed) ER to transfer an unresponsive pt from an MVC. We arrived a short while later, and entered the room geared up for a trauma.

Here the story remains hazy.

There was an MD, RN, LPN, and EMT working in the ER, and each had a different (totally different) story about the patient. Our best guess was that the guy was brought in seizing. There had never been an MVA--the patient's family transported him in by car. The patient stopped seizing shortly after arrival. The staff at this ER was evidently unfamiliar with the postictal period following most seizures. Thinking that the patient was in an MVA, was seizing from a head injury, and now had an "altered mental
status" the resident/physician decided he should intubate (which he had never done on a live patient). Assuming that 2mg of valium was enough to sedate the patient, he attempted visualization with a laryngoscope. The patient strenuously objected to this. (Which adds to the head injury theory--he's now combative!!) A few more milligrams of valium were given, the doc tried to tube, the nurses tried to tube, etc.

Somewhere in all of this the patient vomited and seriously aspirated. He goes hypoxic, unresponsive, and bradys down. Well, now he's an easy tube, so one of the nurses finally gets a tube in while the other gives a full milligram of atropine IVP. So we finally get there to find the patient quite combative again, as any of us would be with an ET tube down our throat. We operate out of a fairly small helicopter, where a combative patient is definitely a bad thing. It's going to be about a 45 minute flight to the tertiary care center, so the flight nurse and I opted to paralyze the patient with Norcuron, which lasts 35 - 45 minutes, and should wear off about the time we get to the other hospital.

The resident/physician overheard our discussion, rushes into the room, snatches the syringe of paralytic from my hand stating "You can't give him that!" and left the room as quickly as he entered. I doped the patient up with a decent quantity of valium while the flight nurse pursued the physician to straighten out the matter. Apparently the physician thought that the medication would paralyze the patient for three to four DAYS. The situation was remedied and the patient sedated and paralyzed.

Apparently during the patient's hypoxic episode and resulting bradycardia, the patient (understandably) dropped his BP. The ER staff hung "dopamine" on him to help correct this. So on our arrival the patient had a HR (after the atropine) of 160/min Sinus tach, with a B/P of 180/130 with DOBUTAMINE running at 20 mcg/kg/min rather than the dopamine they thought they had hung. We quietly turned the IV drip off, and disconnected the line once we got out to the helicopter. Needless to say we were very eager to leave before anything else happened!

The patient was flown to the receiving hospital with no difficulty, and remained hospitalized for a lengthy period due to the aspiration and airway trauma he had sustained. No evidence of trauma or head injury was found. All of this illustrates the need for good history taking. A few moments getting the straight story would have saved this gentleman a lengthy hospital stay, a lot of money, and probably a few brain cells.


David in the MidWest