She was about 45 years old and had been sick for over a week with it coming out both ends. I found her sitting up on the bed in her trailer, so pale she was nearly translucent and her skin was on fire. We don’t carry thermometers (a rant for a different day), but I’m certain she was very febrile. Her only complaint was weakness.

The plan was to get orthostatic vital signs and give her some fluid. I figured she wasn’t too dehydrated yet since she was sitting upright and still conscious. I was wrong. She didn’t have radial pulses or a measurable blood pressure. We had to make her stand to get to the gurney (she was big and the space was little). Surprisingly, she was able to tolerate that very well.

Her initial presentation made me underestimate the severity of her condition at first. We started the transport code 2 (no lights or sirens), but I changed my mind rather quickly. She was agitated during the transport. Even though she could answer all the orientation questions correctly, she wasn’t following commands very well. I put a line in her while we rushed her in code 3. We have relatively short transport times in town and had her to the ER in less than 10 minutes.

In the ER, she presented with the same color and skin temp as before. She still didn’t have radial pulses lying supine with fluid infusing wide open. The monitor showed a sinus tach at nearly 150/min. Here’s where it gets scary.

The doc strolled into the room and took one look at the monitor. She announced that she was seeing SVT and asked what the pressure was. When she was told that two prehospital folks, an RN, an RT and the NIBP machine were all unable to obtain a pressure, she responded with: “That’s impossible – she’s conscious.” At that point, I knew this patient was in serious trouble.

The doc ordered the ER crew to try again for a blood pressure and asked for diltiazem for the supposed SVT. I picked my jaw up off the ground and told the RN drawing the diltiazem up that I thought they might be making a mistake. He agreed and pointed out to the doc that they didn’t have a pressure yet. The doc waited until the NIBP machine spit out a couple of numbers. Once she had a pressure, she promptly ordered 25mg of diltiazem IVP. I told her I thought she was making a mistake and she ignored me.

The diltiazem worked, the patient’s heart rate fell and the patient got less agitated. No one could feel radial pulses still, but the NIBP machine spit out some more numbers. She ordered a second 25mg bolus. I walked out. I was outside in the ambulance bay, venting my frustration on the phone to another medic, when my partner came out and announced that our patient had coded.

Worst of all: none of the four caregivers assisting the doc voiced opposition to this treatment plan. I would hope that at least one of the RNs working on the patient would’ve realized her heart rate was compensation for her severe hypotension, unless, of course, they all believed the NIBP machine. One of the staff told me they thought the patient had an AAA because they found lividity on her back. The blood pooling was because her pressure was so bad. Besides, if she did have an aneurysm, wouldn’t that be a contraindication for diltiazem?

Days later, I was told by another physician in the ER not to make a big deal about the incident. Turns out, the offending doc is the clinical quality improvement person for the ER. I was told she will make my life miserable if I tattled. I’m not one to buy conspiracy theories, but this advice came from someone I trust implicitly. So, for therapeutic reasons, I share my story with you.