Sunday, November 9, 2008

Blind Faith

Working alongside so many medical professionals of varying qualification and experience has given me a profound respect for that which I do not know. It is not a rare occurrence that I am confronted with a patient who suffers from a condition that I have never heard of, or with which I am only lightly familiar. These circumstances are particularly frustrating for me, because instead of drawing from my own experience and knowledge, I am forced to rely entirely on what I am told by the nurse or doctor on scene. Many times I feel I am not getting enough information, and other times I feel like the information may be incorrect. Still, my personal lack of education on the subject limits my ability to question, and hampers my greater understanding of this patient who will soon be under my care.

We were called last week to a small clinic for a patient who we were told had shortness of breath. The patient had undergone a procedure during which he was sedated with Propofol and placed on his left side while maintaining his own airway. When the procedure was over and the sedative discontinued, the patient complained of “a little sore throat” and some nasal congestion. At that point in time the measured oxygen saturation (SPO2) dropped from a baseline of 97% to 92% for a few minutes (then returning back to baseline). Concerned, the clinic performed a chest x-ray and thought they saw some infiltrates in the lower lobe of the left lung. They wanted this patient brought to the emergency room for evaluation and, as they put it, twenty-four hour monitoring of the oxygen saturation. They were apparently worried that the patient had aspirated during the procedure and was on the verge of some sort of pulmonary emergency. The patient, now completely without complaint having never noticed any shortness of breath with an oxygen saturation of 99% on room air, looked confused and frightened.

I admit I don’t know much about the risks involved with laterally positioned patients under Propofol sedation. I don’t know how to read a chest x-ray and I only understand a little about what a lung infiltrate is. I have a good familiarity with pulse oximetry and clinical assessment though, and this case raised a few flags with me. I was skeptical, but the doctor told me this story with such earnest interest and concern that I couldn’t help but be impressed. He had the paperwork all ready and asked us if we were capable of monitoring the pulse oximetry while transporting this patient with the lights and sirens on. He said that he had spoken with the physician in the receiving ER and they would be anxiously awaiting our arrival. Barring what I was told and what I saw with the patient, everything about this call seemed to suggest something serious was going on. Still, there the patient sat with a weak story, no complaint, and no sign of any trouble.

I wanted to raise my eyebrows and ask a few tough questions. Are you sure the pulse ox was reading correctly? Didn’t you listen to lung sounds? Didn’t you listen to your patient? How likely is it that the shadow you saw on the chest x-ray is a physiologic change and no emergency at all? Are you sure this patient really needs to go to the EMERGENCY room? Is there something I’m missing here?

…But I couldn’t. The truth is, I don’t really know enough about any of this to be questioning a physician’s impression so directly. I am anecdotally familiar with pulse oximetry and the tendency for the sensor to slip and read low. I know that even healthy patients sometimes read low on the pulse-ox for benign reasons, but I am not sure of the exact mechanisms and science behind pathologic reductions in those same readings. Surely this physician was much more familiar, and I feel I must have some (if even blind) respect for the decisions that come from such experience and training. He must know something that I don’t. The same goes for the x-ray. Surely the radiologist understands the difference between pathologic and physiologic changes on a plain film. Who am I to question him, even if the story just doesn’t seem right?

And so we transported the patient as we were told. I sat in the back and plugged in the pulse-ox, talked with the patient and did my regular assessment. I didn’t find anything wrong with him, and the pulse ox sat at 99% for the duration of the trip. When we got to the emergency room the triage nurse rolled her eyes. She sent the lady to the waiting room.

I know a lot of medics who would have argued with the doctor. Some of them have no problem asking those pointed questions and wearing their distain for a questionable call on their sleeves. Relaying this story to an experienced medic I know, I was chastised and told to rely on my own assessment. “Did the patient look sick to you,” I was asked. When I replied that he didn’t, the answer was “Then he probably wasn’t.”

He’s right, the patient probably wasn’t sick. It was probably a bunch of trumped up nonsense arising from a cautious physician worried about iatrogenic disease and the resulting repercussions. I saw that within my first minute with these people on scene. …But I had no way of being sure. I trust my assessment and I trust my experience. I am proud of my abilities and I think I am a capable provider. Still, I know that there are sharp lines that divide what I know for sure and what I do not, and there is much more of the latter than there is of the former. If a doctor tells me his patient is sick and I don’t think he really is, would it really be prudent to follow my instincts over his? I’m not so sure.


Research after the Fact:

A pulmonary infiltrate is the filling of airspaces within the lungs with fluid, inflammatory exudates, or cells that increase the visual impression of soft tissue density on a chest x-ray. Sometimes this can be a pathologic finding, but there a is also a potential that the condition may be physiologic, where normal airspace folding and collapse creates the same visual impressions (“Atelectasis”). The left lower lobe is the most frequent location of benign atelectaisis in ICU patients. (source)

In a recent study on critical care monitoring, pulse oximetry accounted for almost half of 2525 false alarms (1). In another study looking at patients recovering from anesthesia (2), 77% of low pulse-ox alarms were false in nature. A recent survey (3) found that highly trained medical professionals may have little understanding of pulse oximetry and it's clinical application. In that survey, 30% of physicians and 93% of nurses thought that the pulse-ox measured PaO2. (It actually uses a measure of hemoglobin oxygen saturation to esimate arterial saturation, SpO2).


Ambulance Driver said...

Friends don't let friends use pulse oximetry alone to guide clinical decisions.

Sounds like your doctor friend didn't know that.

brendan said...

What do you call the guy who graduated last in his medical school class?

Remember the answer the next time you're given a handoff report like this one.

Dan said...

"You know what they call the guy who graduates at the bottom of his med school class?


There are good and bad medics, nurses, EMTs, and doctors. It's definitely tough to balance your own instincts against the superior training (and experience?) of a doctor. It's worse, however, when the doctor is telling you that somebody you know to be sick is not. It's even worse when you are that person.

It sounds like you did a good job of not stepping on toes and providing good care.

Anonymous said...

Just to reiterate what Dan said. Its best to just listen to the information passed by the doctor and/or nurse and then base your treatment on your own assessment and findings. People can get pretty rusty away from regular emergency work and this can show in some of the calls we get to clinics. It can get pretty ugly when professional egos are bruised and doesn't look good in front of the patient either way. Best just to use this experience as a learning aid. As one of my instructors used to say believe no one, reassess everyone and recheck everything. Take care, Paramedic Pete.

Herbie said...

Further proof that the pulse-ox is useless. Refer to my rant.

Anonymous said...

I am now doing some consulting work for a new ambulance service in our city. Even though there is only one, relatively small 911 contract area, the applications we have on file exceed the shifts we need filled. Right now the ambulance business is in TIGHT competition. Large services like AMR, and Rural/Metro can weather a 5-year profit loss just to 'run out' any pesky competition. It is in the new handbook, and was discussed at the last company meeting where employees signed for the new manual: if an employee argues with a doctor or any other medical personnel trying to transfer out a patient it is grounds for immediate termination. ZERO TOLERANCE. For there is at least 25 new medics anxious to work 911 calls and extricate not people from a car wreck, but themselves from a "transfer only service". I wish, for 30 minutes out of every shift, medics would consider "WHERE DOES MY PAYCHECK COME FROM"? "HOW CAN OUR COMPANY AFFORD TO PROVIDE NON-SUBSIDIZED TO HALF THE COUNTY". The answer is, all the non-emergency work we do. To give anyone interested into the profit scope of an ambulance service, wheelchair and medi-cab service barely breaks even; rather, it brings in the stretcher/paramedic work which at the current reimbursement rates, makes rogue medics no longer needed at "mom and pop" ambulance services (you know, the ones that bend over backward when your loved one dies or you have a school/ divorce visitation schedule). See if the "giants" care as much. P.S., I just met with one of the administrators of a local hospital. Since most admissions come from the ER, nurses don't toss patients into the waiting room in these parts (there are 5 more hospitals offering late and TV in the rooms for patients who have a bad experience at another hospital). Shit roles down hill. There is a reason why you find crusty old RN's working in a prison at 2/3 salary, maybe they lost all the good jobs they had AND their reputation.