Moron CNA's

[ilemtbwantn2bTXEMT-P]

A few months back before moving to Texas my partner and I that shift got a call for the 78y/o male pt c/o bleeding from the urethra. On arrival the only the thing the CNA said to me when I asked whats goin on was "Don't worry he's fine now, we gave him a shower and put a diaper on him". My partner and I looked at the floor to see a growing puddle of blood, by the time we got him to the ER a 5min drive with or without Lights/Siren he was getn shocky B/P was 100/70. We worked for a Private then that even for a bleeder wouldn't ok us to go Lights/Sirens for really anything so it took us about 30 mins to even to get on the scene from the time of dispatch.

 

[Sasha]

So what else besides a low BP (Which suprisingly isn't that low and would be considered normal for a good number of patients) had the patient going "shocky"?

 

[CAOX3]

Ok, care to give us a little more information, because the presence alone doesn't mean someones dying, it could be a simple UTI, kidney infection or many other things. Was it traumatic, any abdominal or back pain? I'm not overtly concerned with the pressure alone, what was his mental status like, how was his color, heart rate? Estimate the blood loss , was it gross red blood.

And why was the CNA a moron? Was this a nursing home, assisted living, residence? If this patient was indeed sick, which has yet to be determined why the hell can't you make a transport priority determination.


You can't throw out a vital sign which in many cases can be completely normal, call everybody a moron, claim the guys dying with out giving us a little more info.

 

[Veneficus]

Don't get so excited

A few months back before moving to Texas my partner and I that shift got a call for the 78y/o male pt c/o bleeding from the urethra. On arrival the only the thing the CNA said to me when I asked whats goin on was "Don't worry he's fine now, we gave him a shower and put a diaper on him". My partner and I looked at the floor to see a growing puddle of blood, by the time we got him to the ER a 5min drive with or without Lights/Siren he was getn shocky B/P was 100/70. We worked for a Private then that even for a bleeder wouldn't ok us to go Lights/Sirens for really anything so it took us about 30 mins to even to get on the scene from the time of dispatch.

You sound a bit overenthusiastic. Contrary to what is taught in class, not everything is an emergency.

I am not a CNA nor a moron, and I don't find anything terribly wrong.

The most common cause of painless urethral bleeding is cancer. Not exactly an emergency.

If it was a traumatic injury, it would be more urgent, but still probably not worthy of lights and sirens.

There was a medical issue and the facility cleaned him up and made arrangements for him to go to another facility 5 minutes away. Why is that a problem? If he was dying, I am sure it would have warrented a 911 call.

"a lot" of blood is a relative term. What you consider a lot and what I do are likely very different.

It's not interesting to me unless 45% of the patients blood volume is lost before therapy, and not exciting until the total blood volume has been replaced at least once during.

I like sick people.

But if there wasn't a urologist on staff, he likely would have sat in the ED on fluids and maybe even a unit of blood or two for another hour or so until they could get one or transfer him to one.

 

[ilemtbwantn2bTXEMT-P]

Ok fair enough more information on the run. Mental Status changed rapidly en route to the ER he was alert however we couldn't detrmine orientation due to a language barrier patient was pale and his pulse I remember was high. What we later found out that the facility initialoly didnt want to admit to us was that the pt had yanked out his catheter and then a CNA tried to solve the problem by attempting to put in a new one the blood was bright red. I'm not sure exactly what the CNA hit, but something wasn't right at all, because it was a steady stream of blood. By the time we arrived at the ER the pt only would slightly respond when moved and it was getn hard to have him stay awake. His B/P on the Monitor at the ER when they hooked him up was 90 systolic I can't remeber the dystolic though.

 

[clibb]

Ok fair enough more information on the run. Mental Status changed rapidly en route to the ER he was alert however we couldn't detrmine orientation due to a language barrier patient was pale and his pulse I remember was high. What we later found out that the facility initialoly didnt want to admit to us was that the pt had yanked out his catheter and then a CNA tried to solve the problem by attempting to put in a new one the blood was bright red. I'm not sure exactly what the CNA hit, but something wasn't right at all, because it was a steady stream of blood. By the time we arrived at the ER the pt only would slightly respond when moved and it was getn hard to have him stay awake. His B/P on the Monitor at the ER when they hooked him up was 90 systolic I can't remeber the dystolic though.

He yanked out his catheter? It was probably THEN the damage was made, not when the CNA (which I highly doubt) tried to put it back in. How did you transport him? This is a patient we would had called a full trauma on, which all GI bleeds are due to our protocols. We would had gone code 3 and we're a 911 company.
Did you ask the CNA how much blood he had lost? How long ago he yanked the tube? Is this his norm? They should be able to tell you how alert he is since they take care of him every day.
These are questions that you learn to ask in EMT class, not CNA class. EMT is pre hospital, CNA is the first stage of hospital care.

 

[Veneficus]

He yanked out his catheter? It was probably THEN the damage was made, not when the CNA (which I highly doubt) tried to put it back in. How did you transport him? This is a patient we would had called a full trauma on, which all GI bleeds are due to our protocols. We would had gone code 3 and we're a 911 company.
Did you ask the CNA how much blood he had lost? How long ago he yanked the tube? Is this his norm? They should be able to tell you how alert he is since they take care of him every day.
These are questions that you learn to ask in EMT class, not CNA class. EMT is pre hospital, CNA is the first stage of hospital care.

I agree the damage was probably caused when the guy yanked his catheter.

Having said that, there is the possibility that some damage was caused or aggrivated on the recatheterization.

Either way of no consequence.

People in their right mind also don't pull foley catheters out. Tugging on them is sort of discomforting.

While transecting a urethra is medical emergency, what are all the fancy lights, sirens, and ALS planning on doing for that? Without an invasive intervention they are not authorized to do, they can't even stop the bleeding.

The use of lights and sirens is more of a danger than it is worth.



life and death...

 

[clibb]

I agree the damage was probably caused when the guy yanked his catheter.

Having said that, there is the possibility that some damage was caused or aggrivated on the recatheterization.

Either way of no consequence.

People in their right mind also don't pull foley catheters out. Tugging on them is sort of discomforting.

While transecting a urethra is medical emergency, what are all the fancy lights, sirens, and ALS planning on doing for that? Without an invasive intervention they are not authorized to do, they can't even stop the bleeding.

The use of lights and sirens is more of a danger than it is worth.



life and death...

Veneficus,

All GI bleeds WITH excessive bleeding (Paramedic's decision) we have to transport Code 3 with ALS intervention and treated as a trauma patient. So heated blankets, soft cot, warm fluids, etc. That's just our protocols. But, I do agree with you when it comes to your opinion on lights and sirens.

 

[Veneficus]

Veneficus,

All GI bleeds WITH excessive bleeding (Paramedic's decision) we have to transport Code 3 with ALS intervention and treated as a trauma patient. So heated blankets, soft cot, warm fluids, etc. That's just our protocols. But, I do agree with you when it comes to your opinion on lights and sirens.

You are of the mind that adding fluid to this injury is a good idea?

 

[clibb]

You are of the mind that adding fluid to this injury is a good idea?

Oh yeah, of course it is.

 

[Veneficus]

Oh yeah, of course it is.

What is the goal of that fluid?

 

[Sasha]

What is the goal of that fluid?

Make koolaid.

 

[HotelCo]

Make koolaid.

The question is: what flavor?

 

[Veneficus]

In addition to adding fluid and pressure to an uncontrolled bleed, crystaloid may increase GFR, which initially can help with renal medulary perfusion, but at some point, you could have so much loss that while pressure may be maintained, you will not be perfusing the renal medula,(one of the more sensitive tissues to the initial injury of hypoperfusion) or any other organ for that matter.

Be mindful of correlating SBP with perfusion. It is a complicated relationship that doesn't always correlate.

 

[Sasha]

The question is: what flavor?

Red.

 

[Tommerag]

Like Vene said, pumping the patient full of fluid can keep the blood pressure higher and in the normal range, but remember NS, LR etc doesn't carry O2 there for poor perfusion. In class we were taught that keeping the pressure lower like 80 systolic is better then keeping it at 100 for internal bleeding. Don't bleed out as fast then.

 

[mycrofft]

Urethral bleed is not a GI bleed.

Also, bloody urine can seem to be a much larger volume of undiluted blood. During the thirty minutes to get to the scene, the pt was in a medical setting and directly or indirectly under a MD's care. The distance from scene to hospital was negligible.
This is not to say that there may be other incidents where lights and siren were denied despite indications, but in this one as described, nope.
Been there, done that.:blush:

 

[EMS49393]

Red.

Depends on the medic, it could be pink by the time they reach the ER.

 

[abckidsmom]

Also, bloody urine can seem to be a much larger volume of undiluted blood. During the thirty minutes to get to the scene, the pt was in a medical setting and directly or indirectly under a MD's care. The distance from scene to hospital was negligible.
This is not to say that there may be other incidents where lights and siren were denied despite indications, but in this one as described, nope.
Been there, done that.:blush:

That's what I was going to say...this is not a GI bleed, and it's important to note that, if for no other reason than not looking like a moron when you're justifying the traffic accident to the officer.

5 minute transport? Sounds like you'll be there in 5 minutes. Ever notice how much time you save with lights and sirens? Not much, usually.

 

[Sasha]

Depends on the medic, it could be pink by the time they reach the ER.

I didn't know there was pink flavored koolaid.