Taking unnecessary risks?

[the cableguy]

10yr boy presents to the ED with the antenna from a remote control racecar lodged in his oropharynx. Reports he tripped and fell jamming the antenna into his mouth. Parents attempted but were unable to remove it at home. I cut the antenna so that only 6 inches or so is protruding from his mouth and tug on it a few times but it doesn't budge, at all. The kid barely tolerates this. Xray shows there is a coil at the end of the antenna that is preventing it from being backed out. Not that it matters, but the kid must have been gnawing on the end of the antenna (a la oral fixation)when he tripped and rammed it into the left soft palate. I discuss with the mom what our options are : a) sedate the kid (he is very anxious) and attempt removal, b) send him over the pass at night on snowy roads to see a surgeon at least and hour away maybe 2 hours depending on who is available. She decides she wants me to give it a shot. Informed consent is signed and I discuss my planned approach, possible risks and immediate response to any complications that might arise (worse trauma, bleeding, infection, respiratory depression and compromise from sedation, etc...). I sedate the kid with ketamine (My first time using this med. Great drug!), inject him with lido/epi and start working on him. I am unable to rotate it out so end up going in with a scalpel. After seeing the coil on the xray and taking a closer look inside his mouth I could tell the coil was very superficial and I was able to successfully make two incisions and cut the coil loose. He had some increased secretions from the ketamine (next time I'll combine with atropine) and, of course, bleeding from the incision. We suctioned his oropharynx occasionally as needed and the bleeding stopped within a few minutes. The kid recovered from sedation with out incident. The mother was VERY grateful and I was quite pleased I did not have to send them over the pass to see a surgeon.

 

Now, I never called my MD backup. Mainly, because the MD working as my backup that night is not competent in the ED and I knew he would be unhelpful. My typical MD backup is awesome in the ED and great in a pinch. I may or may not have called him. I felt a little on edge about doing the procedure but also confident I could handle it. I did take the time to consider what the possible complications were and how I would respond to them and discussed all of this with the ED nurse.

 

Well, the other PA that works here (with 12 yrs experience) gets wind of this and, in one breath, tells me "good job" but in the very next sentence says he NEVER would have done that and I took an big unnecessary risk. He says that if something went wrong I would have been in serious trouble since I did not consult with my MD, who was unaware of what I was doing.

 

Thoughts and advice are welcome. Thanks in advance.

[marilynpac]

The other PA was right. Very high vascular area. I would have called the MD, even though he isn't good just b/c of cya medicine. Yes, you did an excellent awesome job...with no incident, but it would have been a healthy lawsuit b/c no MD call.........I would have called him, but that's just me. IMHO.

[Hemegroup]

Whew! Good job. Wouldn't it depend on the agreement you have with your SP/group? Meaning, aren't you specifically given written authorization to manage trauma when there's no MD present?

[kittryn]

unbelievable. highly unacceptable risk. you could have killed him.

[EMEDPA]

GOOD JOB....but....if he started bleeding uncontrollably and you couldn't intubate you would have needed to crich him....there are situations in which I would do that procedure(mostly outside of the u.s.) but with an available transfer to peds ent I probably would not have tried it in your situation...might have kept him over night in your facility in obs and transferred to ent in am. but still, good job.

[DrPA]

interesting, glad it worked out

[kittryn]

GOOD JOB....but....if he started bleeding uncontrollably and you couldn't intubate you would have needed to crich him....there are situations in which I would do that procedure(mostly outside of the u.s.) but with an available transfer to peds ent I probably would not have tried it in your situation...might have kept him over night in your facility in obs and transferred to ent in am. but still, good job.

 

you are more diplomatic than I... :O

[marilynpac]

Don't mean to hijack this post but congrats to hemegroup PA-C!!!!! Good luck in your PA life....

[EMEDPA]

as an aside we had someone in a slightly similar situation(can't go into specifics) in our obs unit waiting for ent to come and evaluate who started bleeding massively and SPONTANEOUSLY(would have certainly died outside the hospital) who was almost criched...guy had betadine on his neck and cover was off the scalpel when the third person to try to intubate got a blind tube with a tiny( 6.0 in large adult) tube. er doc #1 couldn't see anything even with suction and a glidescope....er doc #2 saw nothing....anesthesiology called stat to obs, saw nothing and got his 2nd attempt in blindly....wasn't directly involved in that case but spoke with one of the docs...big pucker factor...guy almost got d/c'd from the er to go f/u in the ent office as an outpt but the er doc wasn't comfortable with that and stuck the guy in obs until ent was available to come in....bottom line...don't **** around in the airway....

[Hemegroup]

Don't mean to hijack this post but congrats to hemegroup PA-C!!!!! Good luck in your PA life....

 

aww shucks, thank you ma'am ...

[the cableguy]

Thanks for the input.

[Fairmeadow]

Good job, but, as has been pointed out, if it had gone the other way, you would have been having a different conversation about it. No matter how good you are, you will have a bad outcome sooner or later. I would have consulted ENT before trying it. I, as an ER PA, have done similarly risky procedures, but only when no one more qualified was available, and the pt. would have had an adverse outcome without it. I do admire you for your willingness to be challenged. That is how you learn. Just CYA.

[brookspa]

I do solo ER. I get it. Good job. Now avoid things like this whenever you can. I have done similarly dubious things myself and the rule in my head is , if i think i should get back up, then i should have already done so. but you get my drift. good job, glad there was a good outcome...keep those big boys swinging.

[eze8923]

if i think i should get back up, then i should have already done so.

wise words to live by.

 

nonetheless, glad that the eventual outcome was a good one.

[Just Steve]

To The Cableguy: Thank you for posting this case for the discussion to ensue. I think these type of critical thinking discussions are a valuable resource for all to learn by. I appreciate your willingness to share your case.

[jmj11]

To The Cableguy: Thank you for posting this case for the discussion to ensue. I think these type of critical thinking discussions are a valuable resource for all to learn by. I appreciate your willingness to share your case.

 

I find this to be a most interesting discussion and reveals how complex the psycho-social-legal aspects of medicine can be. I only worked solo ER for three years and I know exactly what you are talking about. I had a team of about 5 ER docs, any one could be on call for back up. One, out of the five, was very incompetent. I don't know why. He seemed very intelligent. He was very nice. But his judgement was terrible. First of all, he couldn't make a decision. He would mull over the choices to infinity, unable to make a choice. I watch him lead a code and it was terrible. The man died while the team was waiting on Dr. X to decide what he should do. I found out early that if I went to him, that he would be scared to death to do anything and the patient would suffer.

 

However, different from your situation, I did have other avenues. It was a rural hospital but there was a bigger city 35 miles away. I quit going to Dr. X when he was my supervisor because of my concern for the patient. But I would either call the surgeon in the other town or even have our EMTs transfer the patient to the bigger city ER (in 30 minutes).

 

So, if I really wanted to CYA, I would have gone to this Dr. X with each complicated case. However, I knew that I could decide and take action, helping the patient in the end. Often my concern for the patient out-weighted my fear of being sued.

 

I wonder how many other PAs have faced such situations in even non-ER settings? I really think shows like "House" raise patients expectations to an unrealistic level. They imagine that a team of competent doctors are just sitting around all day discussing their case. Then this one genius and miracle-worker doctor always does the right thing . . . to find that one in a million obscure dx and effective tx.

[browndog]

I appreciate your willingness to share your case as well. This is how we all grow.

[MikeyBoy]

Thanks for the case... a great lesson for us students.

[cobramarty]

Is ketamine considered 'conscious sedation'? Can you do that alone? Ususally sedation/airway management and procedure are done by 2 different people. When we only have single doc coverage- 12midnight to 10am, we are not to do conscious sedation and also the procedure as just one person.

It is one thing to be able to handle the procedure but you also have to be able to handle the complication. With the antenna in, the airway was fairly stable. Once you mess with it, a whole boatload of problems could happen.

Did you CT the neck and chest? Was there any medialstinal air present? Is there potential for mediastinitis over the next 12 hours? Did you cover him with antibiotics? Do you have peds at your hospital? We don't have ENT coverage at our hospital and all potential ENT type cases get transfered out.

Your guardian angel was watching over you and the patient that day. I would rather be safe than lucky.

Now if the patient was having respiratory compromise, all bets are off and do what is needed to stabilize and then transfer to peds facility.

[the cableguy]

There is a degree of risk with most things in medicine, including inaction. Yes, the appropriate CYA strategy would have been to send the child to the ENT doc. However, I felt that sending the mother and child over the mountains at night while its snowing heavily on a 2hr drive presented greater risk. This is a salient point that seems to have been missed by a few or maybe even disregarded. It factored heavily into my decision making. That would have been just grand had they stranded/wrecked their car because I wanted to cover my rear. In my neck of the woods there is very little cell-phone coverage (none going over the mountains) and people carry survival gear in their vehicles.

 

Regarding specialists, my experience has been that they are (mostly) unhelpful with telephone guidance as it seems their standard response is "I'll need to see the pt in order to evaluate them." Understandably so too I guess. CYA right?

[cobramarty]

I guess my response to my PA would be 'Good Job-shake his hand, ...then you were lucky, you must involve your doc (competent or not) and don't do that again'.