November 5, 2013

The Opposite of Good Pediatric Care

Usually Peter C. at the ‘Street Watch: Notes of a Paramedic’ blog offers good tips and points of view to improve paramedic care.  I like his blog and read it at least weekly.  A recent post, however, seems to be almost exactly the opposite of good care.  

He tells the story of transporting an out-of-control 6-year old male to the hospital after the boy was violent and destructive in school.  They chase him through the school after he escapes the principal, bodily carry him by the belt to the bed, and decide not to restrain him: “Someone suggests restraints, but they don’t appear necessary.  I can hold him on the stretcher simply by extending my arm.”  Enroute to the hospital, Peter is punched by the child.  Rather than reevaluate the (apparently incorrect) restraint decision, he goads the child into striking him twice more.  The child begins to shriek and Peter then spurs him into screaming louder.  After opening and trying to access the ambulance cabinet twice, the patient strikes the paramedic again.  Peter minimizes the child’s position by pointing out that the medic is big (“a giant”) and the patient is only a child, followed by what seems to be a chase throughout the interior of the ambulance.  The whole call seems to be a pear-shaped, screaming, cursing mess.  The child eventually gives up until he is handed off at the hospital, where he escapes hospital staff and runs away.  Overall, it seems as though the author is mostly complaining that the call is a waste of EMS resources. 

I understand the courage it takes to blog about EMS.  You are putting yourself, your actions, and your opinions out for public scrutiny.  So I hope that I have completely misinterpreted this post, because like I said, I usually like the blog and the author.  But I don’t see that as likely here.

What bothers me the most about this call is the apparent lack of empathy for the boy, who is reportedly diagnosed with mood disorder and ADHD.  Mood disorder is an unhelpful diagnosis that doesn’t tell you a whole lot, because it encompasses a bunch of specific issues.  It’s like saying pulmonary disorder or cardiac problem – it could be a minor or a major issue with a range of presentations.  Mood disorders are divided by whether they present as manic or hypomanic episodes.  The most common mood disorders that you’ve heard of are probably Major Depression and Bipolar Disorder, but there are a bunch of others.  It is pretty rare to see a six-year old with this kind of diagnosis – most people don’t show these kinds of consistent psychiatric behaviors until adolescence, plus pediatric psychiatric diagnoses are obscured by the propensity for magical thinking and poor impulse control anyway. It makes me think that this kid has a ghastly life.  I think there is probably a high likelihood of molestation or rape, violence in the home, neglect (40 pounds is at the small end of the range for six), physical abuse, or similar underlying causes.  These are terrifying potential causes for this behavior that would mess anyone up psychologically.

In my opinion, this child should have been handled differently.  Physical restraints are an obvious minimum choice that should have been taken after a single attempt at deal making (e.g. you won’t need to wear these if you behave).  I understand that the adult male paramedic could manage the kid physically and I also understand that it seems distasteful or wrong to physically restrain a small child.  But this is an issue of the safety of the patient and the caregiver.  The child showed a propensity to escape his seat belts, making it clearly unsafe to be in a moving vehicle.  If a patient cannot control themself, it is up to us to control them – safely, respectfully, and humanely.  Along those lines, it sounds as though chemical restraint may have been very appropriate to help the child be controlled and be safe.  Again, distasteful and feels wrong, but the patient needs our help to be safe.  Even bringing along more personnel, like a police officer, is an appropriate choice. 

What it comes down to is that I don’t ever need to be struck.  I also don’t need to assign 100% of my attention to physically holding a patient down.  Physical or chemical restraint would have deescalated the situation and allowed the medic to contemplate the call: what’s going on here, is there anything else I can be doing, what’s the cause of all this, etc.  I think more contemplation would have helped the call go better.  Physical and chemical restraint also helps the receiving facility, helps them understand the severity of the patient’s presentation, and would have lessened the chance of seeing the patient bolting out the ambulance bay doors with security guards in pursuit.

Part of the problem with blogging is that you can’t always relate the whole story in the interest of privacy and readability.  I would be very interested if this is “normal” behavior for this child, or is it something happening for the first time.  If it was the first time he has been this out of control, it raises the suspicion of an acute process like hypoglycemia, toxic ingestion, or other medical causes.  I don’t know if that was considered, or if the diagnoses of ADHD and mood disorder resulted in the medic assuming this behavior was due background crazy.

What really bothered me most deeply is taunting the patient into striking the medic repeatedly.  Think about how that makes a child feel.  Powerless.  Weak.  Vulnerable.  Nothing he can do can hurt or otherwise affect this grown man that holds him in his power.  This is the message that the medic chose to give to the patient who already thinks the only way to affect his environment is through violence and escalation.  Now think about how that relates to his likely history that probably includes molestation or violence.  Challenging the patient that a five-year old girl hits harder is really close to continuing the abuse.  It is bullying, unnecessary, mean spirited, and utterly devoid of professionalism.  It probably escalated the behavior and made the situation worse.  It has no place in an ambulance whatsoever.  Peter had an opportunity to make something in this boy’s life better and instead showed him that nothing he does can affect what is going to happen.

I expect better from prehospital providers, and I hope you do too.  We all have off days, but you cannot let a patient get this out of hand.  It does no good for you, your partner, or the patient. 

Check out the rest of his blog, as there are usually good posts published.  Not this one, unfortunately.

Have a good one and stay safe.

1 comment:

Dwayne said...

Easily one of the most amazing posts that I've read this year, and perhaps in many years.

It illuminates what should be the spirit, in my opinion, of EMS. We need to care for the emotional well being of our patients, not only their physical.

As the father of a 17 year old severely autistic son, I can only hope that such a medic with a more complete patient assessment goal runs on him when/if his time comes.

Excellent post, thanks so much for sharing.