What do you mean, you don't have racemic epi? November 19, 2004

The run: Rescue 257 calls King base notifying and requesting online direction from us for a 4 year old little boy, with a history of asthma and recent URI, in moderate to severe respiratory distress for 15 minutes. Thru the phone I can hear the boy with loud stridor. RA257 stated that they were 4 minutes from King (an EDAP - emergency department approved for pediatrics), and 10 minutes from Harbor (a PCCC - pediatric critical care center). With this child is such distress, and being that the paramedics cannot (within the scope of their practice) intubate children...I direct them to bring the child to King. Children decompensate quickly, and the extra 6 minutes to get to Harbor may become very significant.

They arrive at King, about 3 minutes later. This child looked like shit. He was sitting upright on the paramedic gurney, drooling, grunting, retracting, pale, and with loud respirations. We immediately set up for intubation...but hope we don't have to. Once we intubate him, it'll be a long hard process of getting him extubated. We get further history from the paramedics and the mother. Turns out the kid's story sounds like croup - cold, seal-like cough. Treatment, racemic epinepherine and dexamethasone...and that's it. Most kids turn right around immediately, and (get this) go home. So, we call respiratory therapist stat to the ER, and request the nurse to give an albuterol mist in the meantime, plus dexamethasone. I stay in the critical area to supervise/assist the junior residents.

So, RT (respiratory therapy) comes down right away. I ask him to give the kid the racemic epi. His response "they decided they want everything to go thru the pharmacy and nursing." What, you've got to be kidding?? Didn't the Times say that those departments were the two most incompetent departments, with most of the high profile mishaps directly related to them??

So, now we have to write an order...find someone (who, I don't know...*I* can't go) to go to the pharmacy and pick up the epi. They can't read the time, or the numeral "2" is too squiggly, or whatever...the doctor needs to rewrite it. It takes (count them) 30 minutes to get this first line drug. This poor child is here, gasping for breath, vomiting, grunting, waiting for this drug...and all we could do as doctors is wait for him to decompensate enough to intubate. So, while we wait I ask the nurse for the albuterol. Wouldn't you know, it's lock in the "suremed" vending machine. And in order to get the drug out of the machine, you need the patients ID number. But, he doesn't have one, now does he? And he won't have one until the ident people come down and get his insurance information. In the meantime, we all look at each other...with our hands completely tied. We ask RA257 to go out to their rig and get more albuterol...so at least we're doing something.

Do you realize, that for 30 minutes we did no more for this child than they did in the field.

That extra 6 minutes it would have taken to get to Harbor suddenly didn't seem so significant.


Miranda5 said...

That just sucks. SUCKS. I can't even take it in...but you know, the other day we had an admit to ICU of someone in respiratory failure, and I couldn't seem to get it through admissions head that our admit was more important than the "excessive sweating" they had at their desk. I couldn't put in orders, we couldn't get meds, etc. because they weren't admitted. Of course, the admissions person ended up with a suspension (she's done this more than once) but that didn't help the person, did it?

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