Wednesday, April 1, 2009

Realms of Control

Pediatric Advanced Life Support (PALS) is a two-day long course designed to teach front-line providers how to manage the very young when they become very sick. Like so much else in my training, the gritty specifics of the class are by now pretty hazy, but I do remember one thing: how to take one look at a kid and know if she is really sick.

This kid was really sick.

Even in the arms of her mother, her entire body heaved with the effort of breathing. She was profusely diaphoretic, pale, and cool in the extremities. Her lungs sounded rhonchorous, or maybe stridorous, or maybe wheezy. They definitely sounded bad. The shirt she was wearing was covered down the front with vomit from an interrupted meal, and it looked like more was on the way. Blood pressure was low. Oxygen saturation was low. Heart rate was high.

The specifics don't matter. This child was seriously ill with a condition that remained beyond my control. Despite all of my training, the giant red bag that I carry on my back, the uniform, the lights and the sirens, the definitive answer for right here, right now, was to scoop the kid up and run to the hospital.

It is a difficult thing to explain to a terrified family. I told them that I didn't know what was wrong with their child, but I was sure she was quite unwell. I explained that things are likely to get worse if we can't get her to the hospital quickly, and we need to get moving right away. Don't worry about finding her a jacket, don't worry about her shoes. Let's go.

The family looked at me, shocked. Can't I do something? I'm not sure exactly what it was they envisioned me doing in their living room, but certainly it was more than to tell them their child was sick. And even though we had fancy looking tools: the cardiac monitor, end tidal CO2 waveform capinography, intravenous fluids and oxygen bottles, the truth was out. All of our training and experience, tools and protocols were nothing but fluff. They were along for the ride, as we were, against an uncontrollable pathology and a random outcome that only the hospital on the hill could really make sense of.

So off we went, down the road above the speed limit with the lights and sirens doing their noisy work. I went though my routine as I was trained, knowing that the efforts would land without much effect. And though it upset me to remain unable to offer any definitive treatment, it helped all of us to know that something, anything, was being done. The hospital was only ten minutes away.

The doctors converged on the supine patient, a ring of white coats bending forward to look over the similarly colored child. They attached monitors and took assays of varying types through the cluster of work. They called resources in from across the hospital, pulled out the stops, and brought experience and reason to bear. It was more than forty minutes before one of them stepped out of the room to talk with the frightened parents.

"Ms. Reynolds," they said, "we're not quite sure exactly what the problem is yet, but we know your child is very ill."


medicblog999 said...

I feel the same on this. I never ever, go into a house without my full response bag, however, when I am going in for a potentially poorly baby/toddler, I always consider if I actually need to take anything in with me. Only one of two things are going to happen:
1) The child is poorly, really poorly. I would then do exactly what you did, grab the kid and get him/her on my ambulance and away, top speed.
2) The child is not poorly and will most likely be absolutely fine. Things can now really slow down a bit, and I can tell most of what I need to just by looking at the child i.e. maintaining eye contact, moving all four limbs, no increased effort in respiration, good colour etc etc.
If my child was poorly, I would know one thing, I wouldnt want a paramedic to be hanging around in the house trying to get some obs!
You did the best and most effective treatment for the child by getting the little one to the hospital as fast as was humanly possible.

Bernice said...

That is absolutely the most terrifying thing I can every encounter. A sick child whom I feel will feel no real benefit from my skill-set other than my foot in the floorboards.

Shaggy said...

Just a couple of rhetorical questions: Why do children then get an ambulance driver when adults get paramedics? Why would an adult with the same presentation get a thorough assessment and no delay in necessary treatment, but all a child gets is a fast ride to the hospital?

RC Huder said...

I had a similar situation. Young child with stridor and additional effort used just to breath. History of a cold with no symptoms that would cause concern. One look at her and I knew I was out of my depth. So I did what you did. I loaded her and ran for the hospital. Supportive care en-route. Turns out she had epiglottises. If I had done anything else I might have made things significantly worse. Knowing when you when you are in over your head is very important on the street. Nice job.

MedicMatto said...

Horrifying story. I dont know anyone who would ever doubt you for your load and go technique. Do the best you can, when you can, which it sounds like you did.

Adam Thompson, EMT-P said...

Well hey there Fiznat, it's FL_Medic from emtcity. I'm really impressed with your blog, you might have to change the title to "Adolescent medic" soon. Check out my blog if you get a chance, and make sure to drop a line.


Anonymous said...

My FD had a similar call (not sure of your specifics) but the child that was sick had stridor and the medics quickly grounded themselves away from their emotion and scooped and ran. But not before the nebulized saline and epi. Nothing
WORSE than really sick/injured children.

They were commended by the ER staff. They did a great job.

Anonymous said...

I am beginning to agree with Adam after taking a long hiatus from your blog. You need to annotate and tell us what you did. Unfortunately death is a necessary evil to make someone a seasoned and experienced medic. Many are now in other fields of work; burn-out. Brains, Drowning and choking brings experience. Classes are different. So many sloppy medics taking 4-5 month classes. We had to yell out "children are not small adults" every single time the instructor said child on the first day of peds. I guess that tactic is out of the curriculum according to 'new guys'. Your instructor did something right that you picked up on this. I agree with your boss in turning down your preceptorship but you could be heading down the path-- at least you tried. If I had not fumbled on a call (child with brains on the ground- brain dead) under a preceptor with 20-years on the job I would never have learned enough to be "set loose". When you live in a place where there are more medics than field jobs people are weeded out fast. My preceptor won "state paramedic of the year" a few years later. I will be interested to see your suplemental information on the TX en-route and see if us stupid guys from a "bygone era" when the job really was still fun can 'precept you to be a preceptor'. Maybe some pranks and 'good natured' "hazing" in a way that builds comradery on the job would be helpful in some areas; moreover, it helps when things are mundane. These calls will be helpful when you get the "real deal" when you need to work them up. I will tell you from experience that you almost pass-out with relief when the color comes back and the parents stop screaming! INDIANAPOLIS