Vanshing Act

Well, that was an interesting way to use a bag-valve mask; I'll certainly have to try to remember it for future reference. We laugh, but it's a real problem facing paramedics and emergency medical technicians -- on-scene hazards. A couple weeks ago, we saw Doris getting nailed in the side of the head by a combative patient, and now, we see Mark getting bitten by a dog. Dealing with these kinds of hazards is usually left to improvisation, though I was a bit surprised that one of the medics announced he had a gun in the ambulance. In the past, I've seen clipboards, oxygen tanks, portable radios, and my personal choice, a virtually indestructible flashlight from Streamlight. Personally, I've run into houses full of cats, all of them combative and wanting to scratch my eyes out, tripped over multiple piles of pizza boxes, and never mind the ever-present cars that somehow don't understand that flashing lights mean "Warning! Emergency crews working!" And then there was that fire fighter that nailed me in the head with an axe.. but we won't go there. His biceps were the size of my thighs, and I'm pretty sure he knows where I live.

Some patients will lie about some things; some patients will lie about everything. The lie is not directed to the physician, and is an important factor to consider in treating the patient. Confronting this is rarely, if ever, helpful -- but knowing this can be very useful. I bring this up because of Mr. Lipson, Jeanie's liver transplant patient who had been drinking. Although I'm not trying to assign blame or second-guess how things would have gone, I don't think Jeanie's direct confrontation of his lies helped much. For obvious reasons, alcohol is a no-no for liver transplant patients (who have a not-so-great five year survival rate, but that's not the point), and confronting Mr. Lipson with his drinking backed both patient and provider into a corner. This doesn't let anyone give in gracefully, and so calling UNOS was all that was left for Jeanie to do. I probably would have simply referred the matter to Mr. Lipson's personal physician and let him deal with it; it isn't the emergency department staff's place to be making these decisions, for a couple reasons. First, we don't have all the information we need, and second, we don't have a relationship with the patient. Something like this needs to be dealt with carefully, and judged in context, not in isolation. Mr. Lipson would have a series of specialists who know him well, and they can deal with this problem better than anyone in an emergency department could have. That the result might have been the same is not really the point.

Rose, in her Cliff Notes, asked if Doug had learned anything about going behind people's backs to perform procedures from the Josh McNeil case, and I agree. This said, Dana is old enough to give or withdraw consent to a medical procedure regardless of what her parents want, and the physician is morally, ethically, and legally required to take that under consideration, the protests of certain posters in alt.tv.er notwithstanding. (See the long thread about this, under the subject header of "a few things to bear in mind" for more information. I won't re-state what I said there due to space constraints, but basically, around here, it is the opinion of the provincial government that a 15 year-old can authorize a procedure like epidural anesthesia without her parent's permission, though getting their approval is probably a good idea anyway.)

And now, Lucy. To be completely, 100% fair, Carter should have been supervising her more carefully and been checking her skills with procedures, and a trauma is probably not the best place to learn how to do "routine" things like arterial sticks. He should have been teaching her how to start IV lines directly, hands-on, and watching her do it instead of simply saying, "Start the line," and then walking away. This said, one of the most important skills in medicine is to know when you're in over your head, and boy, does Lucy ever need to learn that one. She should have asked for help, and Carter let her off lightly, in my opinion. Let's hope that, come the next couple episodes, she smartens up and starts really learning.