Sunday, January 10, 2010


In a quiet, unassuming way, the call is terrifying. In two ways, actually.

She's laying at the bottom of a half-staircase, surrounded by a fire crew. Nothing appears unremarkable. She's awake and talking. She's pink, warm, and dry. She isn't covered in blood. No bones project from her skin.

She isn't moving anything below her waist.

The fire paramedic looks up at me, and gives me a short report. It's all fine until he closes with, "We called medical control to ask about solumedrol -- they said no."

It's all I can do not to gape and shake my head. We move on with the call. Backboard, trauma entry, code 3 to the big hospital. She has true neuro and motor deficits below the level of her bellybutton.

I try to comfort her, reassure her, but she knows exactly what's going on and how ominous it is. I try so hard not to lie to my patients. It's a struggle not to tell her everything will be alright. I don't know that it will be. She's an avid cyclist. She talks about riding hundred-mile races.

After we leave her in the capable care of the trauma team, I ponder the fire medic's seemingly-innocuous words. Did he know anything about the solumedrol he'd asked for, or had he just heard somewhere that it could be used for spinal injury? Did he know about the plethora of studies that question it's effectiveness, or even the dose? I'm sure he didn't realize it would have taken 11 or 12 of the 125mg vials we carry to reach the 30mg/kg dose in this comparatively small patient.

I am forced by these circumstances to come back to my previous point, which is that we should all stick to our areas of expertise. I don't know step one about fighting a house fire. I know just enough about vehicle extrication to be dangerous. I know enough about HazMat to run the hell away. I leave those things to the fire department -- it's their expertise.

But I do know about prehospital medicine. I know the protocols, and the science and medicine behind the protocols, and when medication X or procedure Y is really necessary. I have an idea of when you can step outside the protocols, call medical control for permission to do something unusual.

I know enough to know that asking a doctor if you can give a patient steroids for a spinal injury, in the city, without knowing the dose, only makes you look a fool. That's my area of expertise.

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