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Disrespect from doctors


fiznat

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I had an active seizure today, a pretty good one: patient was seizing for a half hour before we got there in periods of tonic/clonic activity and then periods of unconsciousness. Actively seizing when we got there. Per our protocol I gave him 5.0mg Versed IM, 15lpm O2 NRB, and then (once he stopped seizing), started a line. I placed a NPA and monitored the patient's breathing quality on continuous end tidal CO2 monitoring. I noticed that the patient was extremely hot to the touch, and despite the 15lpm O2 I could only get a sat reading of 89 and 90%.

At the hospital the doctor takes one look at me and asks how much versed I gave. When I told him, the doctor's eyes widened and he told me that I "just turned a seizure into an intubation." As if it was my fault that the patient was not maintaining his saturations. They tried two rounds of flumazanil with no effect, and then intubated the patient.

Though he is the doctor and I am a mere paramedic, I thought that I was dealt with in a very disrespectful manner. The doctor took almost no time to actually assess the patient, instead turning almost immediately to me to place the blame. He more or less yelled at me in front of 3 or 4 nurses that I respect, chastising me for giving a dosage of medicine that our protocol specifically indicates.

To be clear, our protocol reads that if a patient is actively seizing and there is no IV access immediately available, we are to give 0.1mg/kg Versed IM to a max single dose of 5mg. This patient was well over 180lbs, so I gave 5.

It is extremely frustrating to be treated like this by the doctors who are supposed to be our mentors in these matters. This is not the first time where a doctor's misunderstanding (or complete lack of knowledge) of our protocol has lead to a paramedic getting blamed for something that is really not his/her fault: a route that it seems many doctors like to travel instead of taking the time to truly find out what is wrong.

I'm sick of being the scapegoat for these things, it isn't fair. True my knowledge is not as deep as the doctor's, and 5mg of versed may very well be a high dose for this kind of patient. ...But if that is the case, then the protocol needs to be changed.

Anyways, I guess I'm just frustrated. Anyone else experienced this?

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I had a doc chew me out for c-collar and back boarding a patient that was in a roll over complaining of neck pain with altered mental level. He stated it was not needed and did so in front of nurses, patients, etc before he even checked patient. I hope I get to testify against him when that patient sues the doctor.

I did screw up on another patient. Thankfully my mistake actually worked and helped patient, but actually could have killed him. The doctor there after he adjusted everything asked me to come to the break room and explained what I had done and how bad the outcome could have been. I had gotten tunnel vision and missed a major contraindication. But that doctor was cool. I learned a lot from him over several years.

My point is who the hell knows what some of theses docs are thinking. The one that tried to dress me down for doing what my protocols required I started telling him what I thought and my partner pulled me out of the ER. I don't mind a butt chewing for a mistake if it's handled right but I will not take public humiliation especially when no mistake made.

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My experience with IM midazolam has not been great. I find that basically all patients that I have administered it (or seen it administered) to don't acquire the properties you would like them to :wink: . I basically limit non-IV versed to IN (via MAD), which I find is a much more rapid onset and more predictable action. I would imagine that the versed admin was not the cause of the termination of the seizure activity (given it onset IM). Prophylactic actions are obviously of benefit though...

That being said, 5mg of midazolam (especially IM) isn't THAT much medication (especially if they are chronically on benzo's for their seizure disorder). Certainly not enough to warrant flumazenil administration, especially given the presentation and the fact that now you are eliminating benzodiazepines as a treatment. From the scenario that you presented, it sounds like there are bigger issues here and that the symptomatic status seizure is part of a much more serious problem that would account for the patients need for intubation. In my opinion there is no way the 5mg of versed somehow "bought" this guy a tube.

I would have asked the doctor what he would have done, if the patient simply remained post-ictal in the ER and began seizing say at triage. Ten bucks said he would have administered a benzo...

Any further info/hx on this call? PMHx, Meds, etc...

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I would have asked the doctor what he would have done, if the patient simply remained post-ictal in the ER and began seizing say at triage. Ten bucks said he would have administered a benzo...

Any further info/hx on this call? PMHx, Meds, etc...

I did ask the doc what he thought I should have done. He said I should have given only 2.5 of versed, or "better yet," IM Ativan. ...Even though, of course, that would be out of protocol for me but hey he doesn't seem to be aware of that. The doc also suggested that I could have just let the guy keep seizing (also out of protocol of course, and we had a 2 floor carry down as well).

The patient does have a history of Epilepsy. He takes dilantin, and his roommates said that they thought he was compliant with his meds. That was his only history/meds etc.

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Not sure what your protocols are, but our max dose of Versed is 5mg given in 1-2mg intervals, so I can see an MD raising his eyebrows at a 5mg Versed bolus, but if its what he needed, its what he needed.

Sometimes all you can do is nod your head and say "I'm sorry you think so, sign here."

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Not sure what your protocols are...

To be clear, our protocol reads that if a patient is actively seizing and there is no IV access immediately available, we are to give 0.1mg/kg Versed IM to a max single dose of 5mg. This patient was well over 180lbs, so I gave 5.

But yea, that is pretty much what I had to do. Nod and move on. ...Doesn't change the fact that it kinda sucks our docs don't know our protocols and instead choose to point fingers.

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"Let him keep seizing"? Give me a &%$# break. That would be negligent, and is certainly not an appropriate approach to the patient. He wouldn't let that fly in his ER, particularly with such an easy way of treating it.

5mg is an appropriate dose for any patient over 110 pounds. And if it didn't reverse with flumazenil, then other causes of the patient's coma need to be considered.

Some docs are just a$$wipes.

Surprisingly few ER docs consider themselves to be mentors or even remotely connected to EMS, even among residency trained ER docs. This is despite residency requirements for EMS activities, encouragement from faculty, and receptiveness by EMS squads. Either they get it, or they don't.

'zilla

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Oh crap, I just reread it and I see you gave 5mg IM, not IV. Okay, lets try this again, with feeling.

5mg is the max dose we can give IV. We give 10mg IM routinely, so the doc was just a prick. I've yet to have a patient who's seizure we've controlled with a benzodiazipine and need to be intubated. You could always go the dick route and next time bring them in actively seizing and say "All yours, sign here."

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