Pediatric code

[mstovall]

I heard about a disturbing code and was at the hospital that this neo-nate was brought into. The Crew was sent to a city approximately 2.5 hrs away to transport back a baby that had just had surgery. They had an EMt-B, Paramedic, and Neo-natal doctor on board. The baby coded approximately 35 minutes on the way back. The hospital that they left was a pediatric hospital and next to (three blocks) a level I trauma center. The baby was in respiratory failure. The doctor made the decision to travel the remaining distance code III (lights and sirens) back to the small town hospital, which if I called a level III trauma center may be pushing it.

My question is in this situation, shouldn't the decision on whether to turn back be up to the medic? The doctor was not part of medical direction for the service, but was in charge of the baby's care. He also passed a level II trauma center and a place that is in the process of certifying as level II. He also passed three level III hospitals.

What is you legal responsibility as a medic on this truck in your eyes? What is the responsibility for the safety of the crew on the EMT that is driving?

The good news in the baby is still alive, but the baby was bagged the remaining hour and a half in a truck, code III on an interstate. I would have thought it would have been best to have either stopped or returned to the children's hospital until the child was more stable for transport.

Michael

[Freaknuggetz_chick]

i would have gone over the docs head, irregardless of what my protocols say. its my unit. he can have care responsibility, but by passing all those hospitals makes me question the docs judgement. call my medical director, find out what hospital he/she wants me to go to. prolly the ped hosp. that would be my first choice. but you dont want codes in the back. we are not a hospital, plain and simple.

[VentMedic]

There are too many questions that should have been answered before the transport began and even before arriving at the originating hospital.

This transport was doomed because those initiating the transport from all ends did not recognize the level of care needed for transporting a neonate long distance. That also includes the doctor that accompanied the baby. The peds hospital should have had some protocols and guidelines in place for every type of transport.

Did the ambulance service ask the stability of the baby and what was expected of the ambulance crew? Our NICU transport team essentially only wants a truck and warm bodies to carry some equipment regardless of your title. We are straight forward about that before contracting the ambulance service for a transport.

How much Neonatal experience did the paramedic have? Did he/she assume he/she could handle a baby long distance or be of adequate assistance to the doctor?

I am reading into this that the Paramedic was not at all experienced in neonatal transports. If he/she were experienced in neonatal transport, at least a few of my questions listed here would have be asked prior to departure from the originating hospital.

The doctor may have had a false sense of security by thinking a "Paramedic" can do it all. The Paramedic may have been thinking the same with having a doctor accompanying the baby.

Once realizing they did not have an adequate team or environment to work the baby, the doctor should have diverted to a hospital that had some level of NICU or decent ED.

The level of trauma center is not as important as the level of NICU within a hospital for neonates. However, there should still be nurses and doctors experienced in neonates that can assist during an emergency at an ED that provides higher level of care.

What was the surgery?

Was this a stable back transport? Why then a doctor?

Did the peds hospital have a transport team?

Was the neonatal doctor an attending or resident?

Who authorized the transfer at the originating hospital, receiving hospital and ambulance service?

Was the baby already intubated prior to transport or did that occur enroute? I would take it the baby may have be intubated enroute since nobody should bag a baby long distances in this day of technology unless in the case of equipment failure.

Who supplied the isolette?

Who supplied the meds?

Who ran the code?

A good neonatal team will NOT run Code 3. Some of our transports are 100s to 1000s of miles in distance and several different modes of transportation may be utilized. NICU teams are trained to be a self sufficient unit. However, we will park preferably at a hospital of whatever level if we have to and work a baby if we still have a long distance to travel. This takes the pressure off the driver who may make an error while driving if knowing the baby is coding and we are a long way from home. We will not relinquish care of that baby unless authorized by our medical director to do so if there is a qualified NICU team at that hospital. Usually we just want to plug into some electricity, O2 and an overhead warmer if available to open the cover of the isolette for easier access. Once the baby is stable, we will continue our transport.

Glad the baby lived and hopefully will not be in the trach and peg group.

Moral of the story; ask questions before departing. If you are transporting with only one hospital staff member (MD, RN, RRT), make sure you are clear on responsibilites. We see incidents happen way too often with interfacility transports where a hospital staff member is placed to accompany the patient and no one knows what anybody is capable of. Never assume you can do something you have only read about, done maybe once or that it looks easy enough. Be honest with those who will be your team members for the next few minutes or few hours.

[CBEMT]

The only time this situation was possible for me (post-cardiac arrest pedi and all), the doctor in charge of the transport told me to make a list of all the hospitals between our origin and destination, with their phone numbers.

I always considered the doctors on our PICU and NICU transports to come under my state's "Medical Control at the Emergency Scene" protocol, basically covering what to do with a doctor at your scene.

As with most, it says that if the physician is willing to accompany the EMS crew and document his/her interventions and orders, than the EMS crew is to defer to the physician's care. (If the crew feels there is a major conflict between the doctor's orders and standard care, on-line medical control is to be contacted and put in touch with the on-scene MD.)

So, I always felt that I had my medical control in the back of the truck- with the caveat that everyone on board knew that the PICU nurse was really in charge anyway, since the MDs were residents.

[jsadin]

Freaknuggetz, you start thinking it's ok to go over a doc's head and you'll be looking for work in short order. That is HIS patient and he decides where you go and how you get there, not you. Not matter how justified you may feel, you do not have MD after your name. If his actions result in a poor outcome for the patient, it's his arse on the line, not yours.

[VentMedic]

Freaknuggetz, you start thinking it's ok to go over a doc's head and you'll be looking for work in short order. That is HIS patient and he decides where you go and how you get there, not you. Not matter how justified you may feel, you do not have MD after your name. If his actions result in a poor outcome for the patient, it's his arse on the line, not yours.

That can be very true depending on how they contracted your company. If the physician is a resident who just "wanted to ride along" without any transport experience assuming you were actually going to do the primary care, then you may have a problem. Unless you and your medical director have lots of neonatal experience in a NICU, I would suggest calling his/her superior or attending to get the doctor pointed in the correct direction of care or divert for care at a closer facility while waiting for a qualified team. This is the reason roles and responsibilities should be established at the originating hospital when ANY PERSON accompanies the patient, regardless of title, that is not a member of your staff. The American Academy of Pediatrics (AAP) also has guidelines established for the requirements of the personnel transporting children.

Sometimes the egos of Paramedics cause them to find themselves in situations that are not adequately educated or trained for. This can happen easily when they start a "BS chat" session with the resident who also may not be ready for such responsibility either. Together, they can make for a very bad situation. Specialized physicians, especially neonatal, of any level should have some transport orientation before assuming any long distance transport unless they are with an experienced Specialty transport team.

Specialty teams rarely take physicians along except for the purpose of training them. Transplant and ECMO are usually the exceptions to the rules. The team performs under the orders and protocols of their medical director. If the physician in training does not abide by the rules established, they may get a time out and could find themselves taking a taxi back to the NICU to "chat" the attending physician.