Thanks go out to Mike (who I assume is an American Paramedic. If I’m wrong, let me know Mike) who has taken up the challenge of being the first to submit one of his own experiences to share with the readers of Medic999.
The post is in two parts – The first one is below and the second part will be published tomorrow.
I hope you enjoy reading his post! The conclusion coming tomorrow gives some very salient points as to what makes a good paramedic. Please leave some feedback for Mike, as I think we have another budding blogger in the wings here!
Im still on the look out to share more of your own experiences with the wonderful medical blogosphere. If you have any stories, email them to me anytime, for publication on a Saturday or a Sunday (Remember, you don’t have to be a paramedic, first aiders, St John, Red Cross, Firefighters etc etc are all welcome here) It would be really good to also hear from some of you who have been patients and have seen our profession on the other side, both good and bad. If you want more details about sending a post in, click here for the original information.
Any way, over to Mike
You are part of a 2 person paramedic (ALS – non-transport) unit co-responding with a township BLS ambulance to a suburban apartment complex in a certain east coast United State (okay…it’s NJ) about 6 years ago…sunset-ish.
Dispatched to “Unconscious” upgraded enroute to a “syncopal episode – pt’s now awake”
When you arrive, BLS meets you at the door with the comment; “he’s going to refuse and we just need you to get a blood sugar on him before he signs” …biting your tongue you go on in.
The Patient: – “Bill” – A 57 year old man with a lot on his plate.
Recently diagnosed with renal failure, he does home peritoneal dialysis, has type II (NIDDM) diabetes, recently medically retired from work as an engineer and just got divorced from his wife of 25 years. The apartment has that “just moved in because my freaking wife has left me look” but his demeanor is calm. He has that “I don’t want to be a bother to anyone” attitude typical of a guy who’s been through a lot but considers that to be his business and nobody else’s. He’s lying on the bed in the room he does his dialysis; lighting is somewhere between “mood” and “I can’t see you”
She’s in her mid-thirties, the only one of his kids to help him move after the divorce and she is barely holding it together – it’s obvious that something seriously freaked her out this evening.
Daughter: Dad “staggered and passed out” falling backwards onto his bed and was “out for about her minute” with “funny breathing”
Patient: “I tripped on the loose carpet, nearly lost my balance and landed on the bed”, claims to remember everything – categorically denies any complaint (chest pain, dyspnea, nausea/vomiting, etc)
Both seem credible.
Finished dialysis about 45 minutes earlier, ate a light supper prepared (and witnessed) by the daughter. He’s knowledgeable about his disease, compliant with his meds and has had no recent complications…he adds for emphasis that he’s never needed to call 911 and doesn’t need us now.
BLS give you vitals signs of: BP-104/70, P-74, R-16 and refused any further exam. He is polite but insistent – “honestly, I don’t want to waste your time, I’m fine”. Your glib-tongued partner gets him to agree to a blood sugar but he insists on using his own glucometer and gets 96 mg/DL (normal 60-120mg/DL)
You and your partner like this guy; he’s no-nonsense, decisive, a great historian and you’re empathetic but he doesn’t want anything to do with you or going to the hospital…period. You’re both okay with that. So you get out the refusal form and read the legalese about refusing treatment and transport, making sure he understands the liability issues…he does, consent is informed so you fill out the exam section of the form and get ready to hand it to him to sign when you tell your partner to put the monitor on to get a strip. He looks at you funny with a “why?…he’s refusing for pete’s sake” look on his face. For some reason though, you insist. The patient doesn’t want this but with an attitude of “well if it’ll get you out of here any faster” acquiesces.
Of course… it’s a junctional rhythm in the 40’s with huge honkin’ ST depression in Leads II and III isn’t it! (this was 6 months before we upgraded to the LP12 so all we could get was a 3 lead)
What Came Next:
BLS at this point don’t like the looks on your faces and admit sheepishly that his BP was “kinda’ hard to hear”! So now you and your partner are all over Bill like a bad suit, getting a pressure of 64/palp! The lights are turned up and Bill looks just beyond “a little pale”!
Now Bill realizes that “resistance is futile” and let’s you treat him, finally admitting that he did get “a little dizzy” earlier and now feels “sick to his stomach”! Before he knows it, Bill’s on O2 with a large bore IV and is being loaded. He does, however, insist on going to faraway hospital because “that’s where he always goes”. You’re okay with that, basically just happy he agreed to transport at all.
Enroute after 250cc fluid he is getting worse; repeat vitals are – BP 42/P, HR 40, R 28 and he’s pale as a ghost. Even though AMI is suspected you have to give 0.5mg Atropine and more fluid. You force a divert to much-closer hospital (this was before triage to PCI) and are mixing up Dopamine as you arrive – Bill’s condition is now much worse and he has that “I’m about to code on you” look on his face as you transfer care.
The Refusal Form:
Afterwards you walk out to the bay and your partner is standing by the medic unit with that refusal form in his hand and a strange, quizzical look on his face. The form had fallen out of the med bag while he was cleaning up and the realization that the potential end of your careers had been just a signature away slowly sinks in.
What made you insist on getting an EKG on this patient?
(And no, it’s not because of some super secret paramedic ”spidey-sense” that makes you almighty and all knowing – you are not one of those arrogant paramedics who think they know it all; you’ve been humbled too many times for that)
*Concluding part, to be posted tomorrow!*