Posted by: medicblog999 | May 1, 2009

Over to you – Post 1

peopleThanks 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

yes-no

 

THE REFUSAL

Part 1:

 

The Setting:

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.

 The Call:

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”

The Daughter:

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.

The Complaint:

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.

The History:

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. 

The Exam:

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)

The Dilemma:

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.

The EKG:

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.

The Question:

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!*

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Responses

  1. My answer is simple – it is the fact that you are obviously a good Paramedic. Although any Paramedic worth their salt should/would do an ECG (sorry EKG) on a collapse ? cause patient. It’s all about being thorough. Thank god you did though, you obviously played a huge part in saving this guy’s bacon.

  2. For starers, very well written. I will definitely pop back in for tomorrow’s conclusion.

    I would say the ECG (still pronounced Eee-Kay-Gee, LOL) was done because it’s the final step in a complete work-up for a possible syncopal episode that you have not found a possible cause for.

  3. Road Doc took my answer. The strip has to be run, period. There’s no getting around it and I only trust vitals from folks I trust. And if there’s a refusal in the works, I get my own for just this reason.

    Iffy on the Dopamine though. Thinking it through, sure his pressure will go up but his already struggling hepatic and renal system is doomed.

    We go by the mantra “fill the pipes before you shrink them.” But I was not in the heat of the moment following what I thought was best for the patient, simply wondering aloud.

    Great stuff, make sure to pass along your blog address when you you’re ready to share more.

    HM

  4. I read only a 250 cc fluid challenge, my apologies. Again, my comments on the dopamine were simply thinking out loud and you have to do what is right and within protocols.

    As far as what to do when your older and more experienced partner doesn’t see what you see, I take the “you can say I told you so when he walks out of the hospital” mentality.
    New in EMS we feel like every horse is a zebra (tired cliche, I know) but there are no horses in the zoo and I work in the zoo.

    I often use definitive terminology like, “Wow, look at this inverted T wave, we better treat this” or “I don’t like this hypotensive presentation, I’m treating it.”
    This not only adds the CYA factor, but might jog the “wiser” one on scene to just follow along if not help.

    There is no sure fire way to get them to listen, the same way there is no sure fire way to slow down a new paramedic who runs down a protocol without gathering the proper information.

    Each team is different, each care giver driven by a different spirit. Find that spirit and exploit it when you have to.

    In this case, maybe bribe him with a new cup of coffee after the code 3, tools flying, near death transport.

    HM


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