Fumble!

My agency’s protocols have requirements for base contact in certain situations. Some high-risk medications, a few rare and aggressive procedures, and certain types of refusals require base contact. When I was the QA Coordinator for my agency, one of my responsibilities was to ensure that those base contact demands were met. Medics would rebel against the base contact requirements. They felt like they made no sense. Especially infuriating to medics was a requirement to contact our base when transporting an emergency patient to another hospital. I would try to explain that base contact was a safety net for high-risk situations, and provided a second (or third) mind to work on the problem.

If you aren't screwing up, base contact should be no problem. 

That said, a couple of years ago, I responded to a grocery store for a fall. A woman got out of her car in the parking lot, took her infant out of the back seat, and dropped him onto the asphalt from approximately waist height. The baby cried for several minutes, but was soothed with snuggles and a pacifier before I arrived. When I got there, the baby was sleeping in Dad’s arms. The parents planned some fairly extensive travel with the kid, so they wanted me to “check him out.”

By MesserWoland [CC BY-SA 3.0], via Wikimedia Commons    

The patient was a three-month-old male without apparent injury. He was warm, pink, and dry with a heart rate of 150 and a respiratory rate of 40.  I didn’t take a blood pressure, but he had capillary refill under two seconds. The secondary exam was completely atraumatic. I explained to the worried parents that the infant was at low-risk of injury. There was no visible trauma and infants aren’t very good about “toughing it out.” If they hurt, they cry, and this baby wasn’t crying. I explained that occult injuries could exist, but that I would feel comfortable with their travel plans. If they wanted ambulance transport to an emergency department, I would facilitate that, but the baby seemed fine to me. I even told a story about my wife stumbling and tossing my two-month-old end over end about ten feet in the air. Babies are tough.

The parents seemed relieved and agreed that ambulance transport seemed excessive in this case. I filled out a refusal form for them to sign. My protocol requires base contact for all transport refusals in patients less than five years of age. So I called base and explained what I saw and what I did. My description was pretty much the first half of the previous paragraph, word for word.

The resident on the other end of the biophone asked to talk to the patient’s mother, so I handed the phone off. After a minute or two of chatting, mom handed the phone back to me. I put it to my ear. “They are agreeing to transport now,” the doctor said.

Well, that wasn’t what I was looking for. As a matter of fact, that was the exact opposite of the outcome I was looking for. But I understand several salient facts. First, I am an hourly employee. It is not a big deal to transport his kid to a pediatric emergency department. Second, transport would cost me nothing. Arguing, on the other hand, would have costs. Thus, I asked for the infant’s car seat and we got to work installing it in the ambulance.

As I took the child from his father’s arms, I noticed that the child’s head didn’t look quite right. I paused and examined the kid more closely, running my hand over his scalp.

He had a huge temporal hematoma. Huge. This kid was trying to grow a second head out of the side of his skull. How did I miss that? I palpated his head! There was no hematoma when I touched it! Did I miss it, or did the hematoma grow after my exam?

The child was hurt. I missed it on my first pass. It actually worked out that the infant had skull fractures and a small subdural hematoma. He was admitted for overnight observation and sent home the next day. And I was going to let them go without further evaluation to travel.

I felt like a total butthole. To this day, I still don’t know how I missed an injury like that. My index of suspicion was too low, I was moving too fast, and I dropped the ball. Complete fumble on my part.

Me, on that call...  Fumble! Ball! BALL!
Photo by AJ Guel (originally posted to Flickr) [CC BY 2.0], via Wikimedia Commons

The biophone physician saved me. More importantly, he probably saved the patient. I called him and thanked him for acting as a safety net. He was humble and told me it was just his job. He preferred all pre-verbal children who worry the parents enough to call 911 deserve to be seen in an ED. My threshold (then) was much lower than that. I am grateful to him for stopping me from making an error.That, ladies and gentlemen, is why biophone contact requirements exist. Medics who are screwing up don’t know that they are screwing up. Screwing the pooch feels exactly the same as rocking a call, when you are in the moment. An extra, uninvolved brain applied to the situation can save everyone a whole lot of trouble. I no longer complain about making base contact.