The ambulance is already on scene, bringing the little girl and mother out to the ambulance.
Everyone is looking to see what is going on.
Who could be making so much noise?
The noise is not from the ambulance, not from my truck, not from the police cars, nor from any of the emergency noise makers you would expect.
The noise is from the little girl screaming.
Piercing all sound barriers.
All except one.
We place her in the ambulance ask a couple of questions and then start to the specialty hospital that is both a burn center and a pediatric center. We have too many people on the ambulance – Dad up front, 2 EMTs in back with me, Mom, and our little patient. We’re not really at clown car capacity, but the amount of room is not as comfortable as I would like. Rather than be able to spread out my gear and have easy access to it, I need to pass my bags to the EMTs, so they can pass individual items back to me. On some calls this might be a problem, but this will not be one of them.
Mom is sitting across from me, on the other side of her daughter, holding her daughter’s hand. Looking for someone to ease her daughter’s pain. All of the right people showed up with all of the right equipment to do just that. Everything is working as it should when a well trained group of people, who do this on a regular basis, work together.
Mom is feeling so much guilt for her inability to protect her child. Feeling she has betrayed her child – allowing a curious child, and what healthy child isn’t curious, allowing a curious child to see the handle of a pot calling to her.
The handle is tempting her from over the edge of the stove.
It is making funny noises.
What is going on there?
What child doesn’t want to know?
Well, Mom feels guilt for not being there to stop the inquisitive climbing, the reaching for the pot.
Guilt for not being able to have the scalding, boiling water land instead on Mom and spare her daughter.
Guilt for not keeping up with the developmental progress of her daughter, ever exploring the unknown.
Guilt because today the monster was not just an imaginary one in the closet.
And she was not able to protect her daughter.
The little girl did pull the pot down onto her chest, onto her arms, onto her legs, and onto her diaper.
Mom deserves praise for being smart enough to immediately remove the diaper and prevent far more serious burns from developing. We forget that diapers are designed to trap water. Trapped boiling water on the groin is sometimes overlooked in the panic following a scalding of a child.
The screaming is not likely to be any worse if the child’s groin is being scalded, but the pain she feels could be worse.
Her expression of pain is 10/10, right now. Can her pain get any worse?
Yes, her pain can get worse, but how can she express it any differently, any more clearly?
She probably cannot.
But Mom has prevented the worst part of the scalding through her quick action of removing the diaper. Telling Mom this does nothing to ease her pain or her daughter’s pain.
I call OLMC (On Line Medical Command) for orders for some morphine to help ease the baby’s pain. Morphine is not the best drug for this, but it is traditional and medicine is enamored of tradition. Fentanyl is much safer.
Dr. No Narcs answers the OLMC phone. Inside I cry, but even he would not force this patient to continue to suffer extreme pain, would he?
He tells me not only does he not want me to give any morphine, he does not want me to start an IV, but he does want me to keep sterile dressings on the burns. He is board certified in both emergency medicine and internal medicine. All of that education is wasted when it is not used. He doesn’t seem to know a thing about EMS or a patient’s experience of pain.
Calling another hospital for medical command, after you have been refused orders, is discouraged. Since it would be irresponsible of me not to call the destination hospital, where they do not know me, I call. They are no better than Dr. No Narcs.
Unknown Useless Doctor – We’ll manage the pain when you get here.
RM – But she’s in severe pain. Can’t you hear her.
UUD – I do not appreciate medics questioning my orders.
RM – I’m not asking for the orders for me – I’m not the one in pain.
UUD – Bring the child in and leave the medicine to the doctors.
I am having a Richard III moment, but I have no kingdom to offer in exchange for a competent doctor. My patient suffers tragically.
We arrive at the hospital (a burn center and a pediatric hospital). By now the little girl is having periods of unresponsiveness, not that I attempt to awaken her – she is already receiving far too much painful stimulus.
Her periods of unresponsiveness are lasting about 5 seconds at a time. She is exhausted. Whatever energy she had that might have been needed to help her heal, has been dramatically diminished.
The doctor, one of the pediatricians, is going to start an IV personally. The doctor is not exactly trusting the ED staff to do this. I am reminding the doctor about the obvious pain. Should anyone need any reminding with a screaming child?
The doctor states that oral acetaminophen with codeine will be enough.
The area is overflowing with university medical centers, yet physicians who understand pain management are as scarce as hen’s teeth.
The doctor gets the IV on the first try, but the little girl pulls away before it is secured. Two more unsuccessful attempts, then success. Before securing the line, the doctor gives one milligram of morphine. By now, the little girls unresponsive periods have increased to 15 seconds long and about a minute apart.
Now, over an hour after pulling the pot off of the stove, she has some relief. With the morphine she sleeps. How appropriate. How inappropriately delayed.
Oh, don’t pretend you know what is best for this child – what if she stops breathing?
She would have to stop thrashing about violently for respirations to even begin to be a concern. We are having trouble just keeping her on the stretcher, never mind keeping sterile dressings on for even the 8 second bronco riding time.
As in the respiratory rate drops down from 60 breaths per minute to 50 breaths per minute?
Or to 40 breaths per minute?
That really would be a problem؟
This child is nowhere near respiratory arrest.
If there should be any question about the respiratory drive, and the medic misses the signs, what would make anyone think that Mom will be anything other than alarmist about any problem with her baby’s breathing?
She is feeling under-protective and feels a need to atone for that. Will she remain silent?
What about the medic, only an arm’s length away from the patient?
How could a competent medic miss dangerous respiratory depression in this child?
The only way this can be justified is if you allow dangerous medics in the system.
Do we knowingly endanger the population of patients by scattering hand grenades with faulty pins among the people they turn to for protection?
That would be completely wrong, but does not seem to be uncommon.
Mom felt guilt for not protecting her daughter from a foreseeable dangerous situation.
I feel guilty for being a good little Nazi and just following orders.
Orders designed to allow medical directors to feel comfortable endangering patients and allowing them to delude themselves that they are protecting those patients.
I have betrayed my patient by following the orders of not one, but two different indifferent medical command doctors who refused to allow for the treatment of a tiny patient – a patient they could clearly hear over the phone.
Hippocrates would never have approved of this.
To have the means of easing a patient’s pain, but to refuse the treatment to the patient.
Why is OLMC sometimes the sound barrier impervious to all entreaties?
I continue this and expand on some of the comments in: