"Experience teaches slowly, at the cost of mistakes."-James Frode

Have you ever made an error while working on a patient? Most (or all) of us have-your humble narrator included. A majority of those errors were probably minor: perhaps forgetting to document a finding or not following specific equipment-use directives. Although such errors don't happen regularly, many EMS providers have come to accept them as normal. I fervently disagree with accepting mistakes as the cost of doing business, but you can read this month's case and form your own opinion.

Scenario

It's finally fall. Summer's heat and humidity have abated, and all seems well with the world-then dispatch interrupts your calm. "Unit 13, respond for an adult male, sick at Jay Gardens Psychiatric Hospital, Arline Road and Stern Street. Time out is 1203." The in-vehicle computer indicates your patient is a 50-year-old male employee complaining of abdominal pain.

On arrival, your partner takes vitals while you size up the patient. He says he's had abdominal pain for the past day or so and identifies the lower left abdomen as the location of his most severe pains. He tells you he vomited for the first time about an hour ago, but appears well nourished. He's alert and oriented x 3, and seems to be in no immediate distress. He denies experiencing any chest pain or shortness of breath. He takes no medications, doesn't smoke and reports no significant medical history.

His vitals: pulse 90, respirations 12 and BP 140/84. He has equal and reactive pupils and doesn't have pale conjunctivas. He has no jugular vein distention. His 12-lead ECG shows sinus rhythm at 90, with no ectopy or ischemic changes. Capillary refill takes one second, and the patient doesn't have orthostatic (positional) changes when you sit him up. The abdomen is soft and minimally tender in the left lower quadrant with no rebound tenderness.

In keeping with good medical practice, you administer high-flow oxygen via non-rebreather mask. Your protocols allow you to place an IV or heparin lock in the patient. You elect to go with the heparin lock.

You insert it and inject 2 mL of saline drawn from an ampule in the drug kit. (The heparin lock model you use requires you to inject 2 mL of normal saline into the device after placement.)

As you tape down the device and prepare the patient for transport, he suddenly complains of chest pain and shortness of breath. His pulse is now 200, and he's cyanotic.

Suddenly, the patient seizes and becomes pulseless and apneic. You start CPR, intubate the patient and begin rapid transport. Your efforts prove unsuccessful.

At the hospital, the emergency department physician says, "Sometimes this happens. Folks die, and we just happen to be witnesses."

You go back to your vehicle to straighten things up. You place a new heparin lock in the drug case and look for the open sterile saline ampule so you can replace it. You pick up the open ampule and read the label. Suddenly, your stomach churns, and you feel faint. The label doesn't say "Sterile Saline for Injection-5 mL." It says "Dopamine 800 mg/5 mL."

You quickly do the math-a maximum therapeutic dose of dopamine is 20 mcg/kg/minute. Assuming a large man, a maximum therapeutic dose for him might be 2,000 mcg per minute (20 mcg x 100 kg). You administered 160,000 mcg-80 times the therapeutic amount-in the second it took to inject it! Your patient died from a catastrophic medication error. This story doesn't have a happy ending for anyone.

Discussion

We're all familiar with the small errors we learn from and get past. But we're also familiar with the big mistakes that make us shudder. That's exactly what I did today when I heard about a child who was accidentally killed during an MRI.

As you know, an MRI uses a powerful magnet to obtain high-resolution images of internal structures. Patients and workers alike are instructed to leave all metal objects at the door. In this case, an oxygen tank was left in the room and became a projectile when the magnet was powered up.

The tank flew to the center of the MRI unit, striking a fatal blow to the child's head.

These stories exemplify how a small error can lead to a catastrophe if ignored or missed. Someone once said the price of freedom is eternal vigilance. It's also the price of high-quality patient care.

Paul Werfel, NREMT-P, paramedic program director for the University Medical Center at State University of New York, Stony Brook, may be reached via e-mail at pwerfel@epo.hsc.sunysb.edu.

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