A young paramedic, who works for a different agency within the system, but we share a common medical director, came to me this week and wanted to confirm that he was correct in arguing with his supervisor on a certain medical issue. It seems that he ran a call on a woman who was complaining of vertigo and shortness of breath. He found a weak radial pulse, and the monitor (ECG) showed a sinus rhythm at a rate of 86, and her BP was 84/50. Our young medic started a line, and was preparing to give some fluids, and that is where the trouble began.
The supervisor that was on scene felt for a radial pulse, and got a pulse of 36. He insisted that this meant that the patient was bradycardic, and that the young medic administer atropine. The medic refused, and an argument ensued. Our young medic was instructed to "treat the patient and not the monitor" and ordered again to give the atropine. Young medic refused. After the call, our young medic friend was written up for insubordination and failure to follow orders, and sent to see the QA department. The QA department SIDED WITH THE SUPERVISOR, and now the medic faces a discipline hearing, where he is likely to get suspended. The woman from QA told him not to depend on the monitor, as she has seen a Lifepack get a BP and an O2 sat from a mannequin.
So he came to me, and asking for my take, and I gave my opinion. For those who may not know, here it is: The reason for the discrepancy between the patient's pulse and the rhythm on the ECG was caused by blood pressure. It takes a systolic blood pressure of about 80-90 for a person to have a palpable radial pulse. Since the patient's BP was so close to 80, it is likely that some pulses were reaching that threshold, while others were not. Since the monitor showed a heart rate of 86, giving Atropine would not have corrected the issue, as this was likely a fluid issue, or perhaps even a problem with vascular tone. In either case, the appropriate treatment would have been fluids, and if that failed, Dopamine should be considered. I told the medic that he should get the Medical Director involved, and get him to come to the discipline hearing if possible.
I am really starting to become convinced that there are very few competent people working anywhere in our health care system. That includes everyone from medics and nurses to the doctors. I am not sure where these idiots come from, or how they manage to pass the state test, but they are out there, and they actually get promoted to positions of power. Unbelievable.
The radial pulse/BP thing is like day two of EMT school isn't it? The rule of thumb I've used for, oh, 30 years or so is a radial pulse = a systolic BP of 90, brachial = 80, and so on. If the supervisor had been on the ball, he would have looked at the monitor, checked the radial pulse, checked the brachial pulse, and understood what was going on.
ReplyDeleteGiving Atropine to a patient with a rate in the 80s is malpractice. It's not a matter of treating the monitor, it's a matter of knowing what's on the monitor and how it relates to the patient in front of you. Which obviously the young medic understood, but the stupervisor (what else to call him?) and QA lady don't.
From what I see of our QA people, they only look at which boxes are checked, don't read the narrative portion, and don't have a good sense of what is really going on with patients in the field. Seems like ours isn't the only system with that problem.