I'd love to hear an experienced opinion on this....

OreoThief

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Hello, all....

I had an experience during one of my clinicals that seems to have stuck to me, and I wanted to know your take on the situation, just for my own knowledge. Of course, I realize that none of you were actually "there", but I'd love to hear your thoughts on this situation "in general".

Called to nursing home to transport 55 year old woman to hospital for "psychiatric evaluation". Upon arrival, we learn that this is a new resident, and they have little information on her, other than she is a diabetic, and for the last few days has been irritable and "not feeling well". I arrived to find a polite and responsive female, shaking and responsive. She had some trouble verbally communicating easily, but otherwise, seemed to be sharp as a tack. Husband was present, and stated that this shaking behavior is typical when her sugar is low. He left to retrieve some clothing and personal effects from home for her, and would meet us at the hospital. We transported her to the hospital, where her LOC and vitals dropped quickly, and during the ride, and inprocessing at the hospital, she drifted in and out of consciousness. When she was conscious, she still seemed reasonably alert, choosing to answer questions about her medical condition, and asking for clarification when needed. We had been there for approximately 2 minutes, and as I'm filling out the rest of my paperwork in the room, I hear screaming. I turn around to find three nurses holding this woman down, inserting a catheter, as the screams and protests, and fights with all of her might. She certainly seemed able to legally refuse care if she wanted to, in my opinion. She continued to scream, until they overpowered her, and she cried, giving up.

I may be a newbie, but I am reasonable. I understand that sometimes things have to happen, and that they are not always pleasant. I also know that there should be a level of medical necessity to put a patient through a procedure that can cause so much discomfort, both physically and emotionally. My question is, did the nurses perform a typical procedure for someone being brought in primarily for hypoglycemia? Even if the patient was determined to be "mentally incompetent", was this procedure necessary? I awared the nurses upon arrival that she was able to communicate and understand well, although they treated her as if she was incapable of making decisions. I felt that the catheter insertion was almost abusive treatment, or at a minimum, overly invasive, and very unnecessary.

Whether I'm right or wrong, I'd love to hear some feedback from the more seasoned EMTs.
 

bstone

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Never a quick answer to these sort of questions and experiences. In IL, if there was a petition to commit her then they can do just about anything. Not sure of your state laws. Let's wait to hear from additional opinions. I am eager to hear perspective.
 

reaper

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What was her BGL? Her symptoms can be from any number of things. Catheters are never nice to do and people to fight and scream with them, but they are necessary sometimes.

If this pt was in and out all the way in, then I would not feel confident in her ability to make medical decisions for herself. That would be left to the husband to make.
Did you ask the nurses why they were doing a cath on her? They may have told you the reason, they you would understand better.

If you see things that bother you ask questions. There are alot of things we do that are not nice, but need to be done. You will get used to it in time.
 

Ridryder911

EMS Guru
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+2 Points for asking instead of assuming. Like Reaper described it all depends upon the situation.

There are multiple medical conditions that can lead to altered mental status, as described her glucose levels maybe skewed; but I do doubt that since she had intermittently alertness. As well, I am sure they checked it immediately either in the field, or entry into the ER. As well, why was it not checked at the nursing home or even in the field? This is the common practice, with any altered mentation level both prehospital and entry into ER.

Now, don't take offense, but since you are new and do not have much clinical experience, when describing "shaking" and "vital signs dropping" from what to where is an open ended scenario. I have seen many students that have seen "shaking" labeled them as seizures, chills, etc.. when they were really purposeful movements from the patient or other causes. The same as "dropping of vital signs"; were the vitals a drop or just decreased? Yes, there is vast difference.

There is multiple reasons for altered level of mentations. From as described earlier hypoglycemia (which should be first thought of and addressed) to an increase ammonia level, electrolyte level imbalance, sepsis, cerebral perfusion problems from a CVA to the most common; senility and Alzheimer's. So one can see the problems of finding the cause... and yes, part of the procedures is to obtain urine sample and as well place a catheter in altered LOC patients. Since kidney perfusion is poor in diabetics, renal tests should be performed such as BUN, Creatinine clearance, and other key factors. Also remember, one of the last mentation rituals in people is the thought of having to actually go to the restroom to relieve themselves. This is why there is so many falls and resulted hip fxr's in nursing homes. So placing a catheter is a routine procedure in altered mentations to help prevent this as well as obtaining a sterile sample.

If we actually only performed tests that patients did want, we would never be able to diagnose anything. True, the patient has the right to refuse any procedure as long as they are competent to understand the risks of not having it performed. "Slipping in and out" of mentation would not present a picture that she was coherent enough to be responsible for her care. Again, one cannot find an accurate diagnosis without such tests.

Again, welcome to medicine. You will see fighting, screaming, patients all the time because of procedures... yes, it is really the norm. Unfortunately, some of these procedures do hurt (some more than others) most of the time they may be more uncomfortable (such as catheterising) or patients may feel loss of control. Yes, sometimes one will even see patients even restrained to permit such... again, without such a proper diagnosis will not be made.

Good luck in school
R/r 911
 
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OreoThief

OreoThief

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BGL and other info...

Hi guys,

Well, I tried to make my post as "unbiased" as possible, but being you asked, I'll tell you the rest of what I do know..... :unsure:

There was no BGL reported when we picked her up. That was one of the first things I asked the nurse at the assisted living home. She told me that she didn't know the PT's BGL. I asked her why she hadn't checked it, and she told me that this is a new patient, who had just arrived over the weekend...blah, blah, blah. I asked the nurse how long she had been caring for this patient, and she told me for two days. I told the nurse that a BGL takes less than a minute. I asked about the shaking, and it was mainly her arms moving, with movements large enough that I would not call them tremors. Purposeful? I don't know, but her husband said that they were a "normal" occurence when she is "low". Looking through her very limited medical file provided by the home, I did not see any medications that would indicate that she was under psychiatric treatment.

I stayed with this patient the entire time, and at no time, not even in the hospital, was her BGL checked. When I said her vitals were dropping, (and gees, I wish I still had the sheet that I was writing on, but had to turn it in when my clinicals were complete :sad:) I meant that I watched her BP and HR decrease. I recall seeing something like 90/50 during the ride. At one point, I couldn't find a pulse, and so as we took her out of the truck, I quietly told my medic that I could not find her pulse, and that it was probably just my inexperience. He smiled, and in less than 2 seconds, claimed to have found her pulse and that she was ok. I have had difficulty finding pulses before, so it was probably just me. :unsure:

The only other bit of information that I can tell you is that when the nurse who gave the PT the catheter was back behind the desk, the charge nurse looked at her, and said, "You know, you could have done a stomach scan instead.". I have NO idea what that means.....

Any more thoughts for me? I wish I had more information, but I'd rather not have it, than to make it up.

PS- R/r, I'm not in school anymore... you just sent me a welcome note, remember? :p
 

Ridryder911

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Chances are she might have Parkinson's type movements, as well as senility. I am sure that they obtained a glucose if they performed any lab tests. Even if they obtained a urine they will have a glucose reading.

Not endorsing the treatment by far, but I am wondering why the medics did not perform a FSBS?

For as the pulses, that will come with time. Remember, if they are awake, and even moving around.. they have a pulse.

Personally, I don't know what the nurse was referring to as a stomach scan? Sometimes a CT of the abd is ordered or some areas use a simple bladder scan to detect if the bladder is full or not, so needless catherizations can be reduced.

Medicine can be very confusing, especially as you start out... heck, even when you have been in it for a long time... :unsure:
 
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OreoThief

OreoThief

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Question about full bladder

So, could having a full bladder become an issue due to the inability to eliminate, caused by diabetes? I was not aware of this....
 

Ridryder911

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I don't believe having a "full bladder" was the issue on this specific case. It appears, that someone may have jumped the gun and wanted to place a foley to prevent an "accident". Not unusual as well, many much prefer to place a foley, than to have to continuously place them on a bed pan.. the problem is foley's have an higher incidence of infection.

Having a full bladder is not unusual in geriatric population, as well in those with diabetes. Remember, they have multiple problems associated with the disease process, including neuropathy that affects the entire body, excretion of proteins, and sugar through their urine. As well, as polyuria (increased urination). Even the geriatric population have an higher increase in UTI's and dehydration.

Again, since I cannot see the whole picture, it is hard to determine. There are too many variables in these type of scenarios and cases. All could be misinterpreted as wrong or right in treatment, again dependent upon the specific situationof the patient.

R/r 911
 

Airwaygoddess

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Bladder scanner

In some hospitals there is such a deivce call a bladder doppler machine or I have heard it also called a bladder scanner, it is used to check the volume of urine in the bladder.
 

Rattletrap

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I am still wondering why her BGL was not checked by you or your medic? Is it not allowed in your scope of practice/protocols?
 

bstone

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I am still wondering why her BGL was not checked by you or your medic? Is it not allowed in your scope of practice/protocols?


In my old BLS service they JUST started allowing BGL 2 years ago.
 
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OreoThief

OreoThief

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I cannot check BGL

As an EMT-B, we are not permitted to check BGLs, we can only "assist" under certain circumstances. I was not even an EMT at the time, I was only a student, and testing a BGL on one of my first calls was well beyond my scope. As for my Medic, I can't answer for him...

:unsure:
 

RESQ_5_1

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Luckily, we are allowed to obtain BGL's all the way down to the EMR level (EMT-B equivelant). Obtaining a BGL is almost habit here. Since abnormal glucose levels can cause many symptoms. Every altered pt we have gets an immediate BGL. And, I like that I can obtain one myself or with whomever i work with. We have staffing shortages and thus, many casual employees. Usually I work with EMRs or another EMT, but working with a paramedic happens from time to time.
 

KEVD18

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10/12/2007. thats when this thread was pronounced dead.
 

laina66

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catheter

I believe that this situation is similar to a situation I had during my clinicals (ER time)....we had a 2 y/o F come in with a fever and stomach cramps...mom didn't want a catheter placed...and obviously child is too young to talk for herself...but they needed a urine sample to run tests... the only way to get it was catheter---which wasvery uncomfortable for the child..and I had to help hold her down while both mom and baby cried and baby squiggled around endlessly...
While uncomfortable, this was necassary. Although it was not what the patient wanted...which a temperature as high as she had, and from her symptoms, specific tests needed to be ran and this was how they got the info they needed.


It sucks sometimes, but it is necassary.
 
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