Might I suggest that if you perceive me as arrogant, it is merely because I am mirroring the arrogance you project:
ER Doc: “So did I hear the nurse say you gave her Nitro? Why Nitro?”
AD: “Well, I’m not absolutely sure it isn’t her emphysema acting up, and I’ve already given her a neb treatment. But she’s hypertensive, she’s got wheezes and rales, jugular venous distension, exaggerated air hunger, +3 pedal edema, and she complains that she’s hot. Smelled a bit like a CHFer to me.”
ER Doc (with an air of exaggerated patience): “Still doesn’t explain why you gave Nitro to a CHFer.”
AD: “That’s one of the primary treatments for hypertensive CHF exacerbation or acute pulmonary edema; vasodilatation with Nitro and CPAP.”
ER Doc (openly arrogant now, in full view of half a dozen witnesses and my patient): “That’s just wrong. Nitro will make her worse.”
AD (stunned that he’d say such a thing): “…!…”
ER Doc (again, in public): “You shouldn’t have given her Nitro.”
AD (tired of playing the “politely deferential” game): “I’m not going to debate you, Doc. And this is not the place for this discussion.”
ER Doc: “It’s a good thing you’re not going to debate me. Because I’m the one that went to medical school.”
AD (smiling thinly): “Gee, that’s a coincidence. So did all the people that taught me to use Nitro and CPAP as the first line treatment for acute pulmonary edema. Do you suppose they pulled the idea out of their asses?”
ER Doc (condescendingly): “Perhaps you’re thinking of morphine and Lasix. Those are the preferred treatments for acute CHF exacerbation.”
AD (agreeably): “That would indeed be correct. If this were 1999.“
Did you expect me to just roll over like a lapdog? I appreciate the fact that you went to medical school and all, and that your knowledge base far exceeds mine, but I was already doing this job for five years while you were still popping zits and studying for the MCAT.
And if you’re going to stand there and tell me that reducing preload is not a desirable thing in a hypertensive patient with acute pulmonary edema, you’re simply proving that all your superior medical training still failed to teach you how to think.
And if you dress me down in public again, particularly when you’re wrong, you’re gonna see how well I do condescension.
our ambulances dont carry morphine OR lasix.
-lu
Arrogance and ignorance are a bad mix. Good responses on your part.
Woe to that ER doc! do they realize who they are messing with here? I think not!
Well said!
You can be sure that if you gave morphine or Lasix, my first question to you would be "Why didn't you give her nitro?" I'd be the first to admit that I've made my share of mistakes, but it continually amazes me to see the level of incompetence in many smaller ED's. We deal with it every day in transferred patients, and we're no ivory tower. Keep up the good work.
And for those of you who see arrogance in my comment, you've never been on the phone with me trying to figure out just what the hell is going on, because the guy on the other end has not even the most basic idea or plan. This is just reality. I am in no way perfect, just your basic pit doc with my finger in the dike like everyone else.
Hopefully He/She learned NEVER to dress anyone down in front of anyone again.
Pissing contests surely do not serve the patient nor the spectators, and while you seemed to handle that with the aplomb and tact that we have all come to know and love……
Do you think your point was made?
Or did it sail right over Alter Ego M.D.'s head?
Good case AD.
J
Reminds me of the time I woke up early in a.m. and passed out–then when I came to, I could hardly breathe, broke out in hives and began puffing up like a puffer-fish all in seconds! When I began looking at my body, I saw two bite marks on my wrist, and it was immediately clear to me that I must have been bitten by a spider or something while sleeping, and was having an anaphaletic reaction. Now, I'm no doc, but I'm a Mom who likes to read and educate herself, so Dh was sent to grab the Benadryl bottle and I took a dose, and then off to the ER we went. By the time I got in there, I was swollen and covered with hives over my whole body. By the time the ER doc got in to see me, the initial dose of Benadryl I'd taken at the house was rapidly wearing off and I could feel the reaction gathering strength. The ER doc pooh-pooed my taking Benadryl and told me that I was having HEART OR KIDNEY Problems and that he had to start me on an IV and start doing HEART AND KIDNEY TESTS. I had to keep insisting (as my breath grew shorter and the horrible shaky feeling grew) that I was in shock from a spider or something bite, and needed MORE BENADRYL FAST. He kept arguing with me, and told me that my hives were from "something" being wrong with my kidneys! And so was the swelling, and I'd "probably passed out because something is wrong with your heart–we need to get you on an EKG machine." I Said, "I NEED MORE BENADRYL." He said, "I don't even know WHY you took any to begin with–it has NOTHING to do with what's going on with you!" I started thinking, "This guy is going to let me die right in front of him!" I finally managed to say, "I"ve got BITE MARKS on my wrist!" He about jumped out of his skin when that sunk in, and never mind that every single person who'd looked at me up to that point had ALL written on the chart that I had bite marks . . . When I finally got his attention enough that he LOOKED at my bite marks, he said, "That changes every thing!" and almost ran out of the room and within a minute or so, a nurse was in handing me Prednisone and more Benadryl! Long story short, I ended up on Prednisone for 10 days, and Benadryl every 3.5 hours around the clock religiously. I think I should have been kept in the hospital, as I passed out again, had my hands swell up so much my skin split on my hands and was sick for days and days. But I think he was so embarassed he just wanted me gone! The nurses said he was fresh out of med school and thought he knew every thing. It was very scary . . .had I not still had a bit of air left to argue with him, I think he'd have come close to letting me die while he ran all his little heart and kidney tests. (Absalutely NO history of any heart or kidney problems, and no hives or swelling before I woke up that morning. . . he should have known better–I had explained how rapidly I began swelling–doubt heart and kidney problems would develop within 30 seconds to that degree!)
I'll never forget the day an ER doc said to me: "Nurse Bo, you're so good that I'm surprised you didn't go to medical school!"
I replied: "Why thank you. And Doc, you're so good that I've always been surprised that you didn't go to nursing school!"
So? What'd he say then AD?? Don't leave us in suspense!!
I can't speak to the technical content, but I admire your restraint. I've had vaguely similar encounters and have found that tact isn't a strength for me.
Jim
Is there an "AD in your pocket" you can buy that I can get out next time a doctor pulls that kind of stunt?
Heck even I know that nitro would have worked, great job AD!
Many, many years ago I was explaining to an ER doc treatment for an auto accident patient with facial injuries. When I got to 'and we put her on X liters of oxygen' the doc said 'oxygen -why did you give her oxygen!?!' I just looked at her and said 'Why not?' Got no answer.
I have had the same comment many times. Although, we are so backwoods here that nitro isn't even in our protocol for treating CHF, good old lasix and morphine per protocol. (we just got 12 leads last month!) I always try to call the ER, and give them nitro instead. I have had quite an argument with a few docs over this. Amazing how they let that degree blind them to common sense!
go get 'em, AD!!!!
Keep up the good work!!!!
In nursing school, the protocol was nitro first, even in the level 1 ER we trained in….watched the nurses do this many times during clinicals…NO morphine or lasix til they could determine what was going on….
The largest difference between a doctor and God is that God is aware that he is not a doctor…..
LOL!
Freaking love it.
Reminds me of some the jerks I worked with at a large east coast hospital. The ones that make you think their medical school consisted of 1 year of advanced first aid and 3 years of ego stroking and arrogance enhancement.
Fortunately, I've met enough MDs that remember they're human, that they have their job, I have mine, and as long as we don't tell each other how to do our jobs we'll get along fine.
Sounds like this boy is setting himself up for a very unpleasant future experience either in the ER or in Court (or both) with no back up from those of the staff with a clue.
Blue Devil Doc,
The sad thing is, this was a board certified EM Doc in a major medical center!
At the end of that conversation I would have asked (and I would because I ahve already done it once) "So, just where did you go to medical school?"
You know they are going to answer.
My response would have been "Well then, you need to go and get your money back!"
AD Stated:
<<<
And if you dress me down in public again, particularly when you're wrong, you're gonna see how well I do condescension.
>>>>
Sell tickets.
Not even 1999. How about the 1980's.
It is just that some of the slower, less literate people in the EMS world have resisted switching from medications for fluid overload (only some CHF patients have fluid overload) to actually providing effective treatments.
Withholding Nitro will make the patient worse. As would transferring care to this barber.
Rogue Medic,
I think you just insulted the barbers.
I'm with RM on this one. Try 1989. Which is when we switched to NTG spray and went to 0.8mg spray if the systolic BP was >150.
I don't remember the last time I've given MS for CHF. We still use Lasix on occasion, but it's mostly NTG and CPAP.
You have to wonder if some of these doctors went to the "Close Cover Before Striking" medical school.
"Draw this stethoscope and you could have a career in medicine."
Comrade E.B. Misfit,
I think you just insulted the barbers.
For that, I do apologize.
TOTWTYTR,
I think he is just trying to pretend that he is very young. Shall we deluge him with AARP applications?
Oh my….Does that sound familiar.
Medic(Starts report at ER to receiving RN) MVA, one victim, ejected found unresponsive under the..
Interrupted by the..
ER MD(Family Practice MD Moonlighting): Any allergies? Medications?
Medic: He was unreponsive when we found him under the car so I controlled the airway tossed him on a board and brought him in.
ER MD: So you do not know if he has any allergies or medications??
Medic: See above.
ER MD: Any history?
Medic: He was the only one we could find in the vehicle or ditch after Rescue and Deputies searched. No one to tell us anything and you may notice he is unresponsive and has been! Tube down his throat also!!
ER MD: So you do not have any history for me?
Medic(snarling a bit): See above.
ER MD: So who called? Someone had to call?
Medic: Deputy saw the headlights and pulled over to investigate.
ER MD: So the deputy doesn't know anything??
Medic(getting upset): Deputy could not lift the car off him.
ER MD: Oh he was UNDER the car?
Medic(Dear Lord please keep me from killing this idiot!)Correct !! Under the car!!
ER MD: How did he get there?
Medic (as partner and firefighters are positioning themselves for intercept) I don't know!! Maybe he parked it on top of himself!!
ER MD: Well you best not get smart with me mister I know your Medical Director!!
Medic(as partner and Fire drag him out) Smufgh Aggpphh Dumpphh arggghh!!!