Please tell me what I missed with this patient

[VentMedic]

"The most common side effects with OsmoPrep [and others I looked up] are abdominal bloating, abdominal pain, nausea, and vomiting"
-Manufactures website

Pt with anxiety(causes nausea) before colonoscopy ingests bowel prep(common side effects include nausea, vomiting, and pain), and experiences an episode of isolated vomiting.

occums razor

Plus, while this patient may receive EKG in the hospital, we are talking about the field.

It seems you missed a few things about the OsmoPreP.

Oral sodium phosphate (OSP) solutions, including FLEET, Visicol and OsmoPrep, draw water into the gut to promote cleansing. They may be easier to tolerate, but can cause dehydration and electrolyte imbalances. A high phosphate load may also not be safe for patients with kidney, heart, liver, or certain intestinal diseases.

 

[Juxel]

Occam's razor may apply to some scenarios, but if you use it to dictate your practice of medicine you are going to have a very short career. Please don't fall into that trap. I've seen all too many EMS careers end prematurely due to people falling into traps like this.

 

[Veneficus]

This is a good point. Why do we do this in the field? Should the EMT be restricted to driving and assisting the paramedic on scene? Why is it okay to punt patients who we do not believe deserve paramedic care to EMTs? RNs do not get to punt "BLS" patients to CNAs, they take care of each patient at the same level with the advanced education they have.

Daedalus,

While I see your point and respect your opinion I do not think having an EMT ride a call is “punting” in the traditional sense. Where I am from the idea of punting is to transfer not only care but the responsibility of care.

If the medic is in the front of the truck, all the basic has to do is ask for help. If in a tiered response a medic defers to a basic a patient complaining of CP radiating to arm and jaw, SOB, N/V and impending doom, it is not the basic who will be answering for that. So it seems to me more like delegation of a task more than transfer of responsibility.

In addition, both nurses and physicians (don’t know about others) have to delegate care on a regular basis, not only for logistical reasons, but to develop other providers.

Anecdotally I worked in a system as a medic where the highest level provider was required to ride calls, I am not sure who made the requirement, and while there were exceptional individuals, most of the basics took exceedingly long to develop into a competent provider or partner. When they advanced to medic school their knowledge was often no better than somebody who never saw a patient before.

I do NOT (bold for the critics who accuse my advocacy of greater education as an attack on basics) support the idea of basics being a “go for” and a “driver.”

 

[BLSBoy]

Before an EMT gets a pt when there is an ALS provider on scene, an ALS rule out assessment should be made.
Vitals, ECG, XII lead if indicated, BGL.

Period.

 

[daedalus]

Daedalus,

While I see your point and respect your opinion I do not think having an EMT ride a call is “punting” in the traditional sense. Where I am from the idea of punting is to transfer not only care but the responsibility of care.

If the medic is in the front of the truck, all the basic has to do is ask for help. If in a tiered response a medic defers to a basic a patient complaining of CP radiating to arm and jaw, SOB, N/V and impending doom, it is not the basic who will be answering for that. So it seems to me more like delegation of a task more than transfer of responsibility.

In addition, both nurses and physicians (don’t know about others) have to delegate care on a regular basis, not only for logistical reasons, but to develop other providers.

Anecdotally I worked in a system as a medic where the highest level provider was required to ride calls, I am not sure who made the requirement, and while there were exceptional individuals, most of the basics took exceedingly long to develop into a competent provider or partner. When they advanced to medic school their knowledge was often no better than somebody who never saw a patient before.

I do NOT (bold for the critics who accuse my advocacy of greater education as an attack on basics) support the idea of basics being a “go for” and a “driver.”

Actually, I am not convinced that punting to the EMT is a bad idea, I was just posing questions because VentMedic made a valid comparison to RNs and CNAs. We do have the ability to preform an ALS assessment and than BLS the call in Ventura County.

VentMedic, I am starting to see what you mean, as in looking at a 12 lead as an opportunity to catch something. I am by far not the most experienced provider here, but I have rarely been failed by simplicity.

 

[vquintessence]

Its not so much the "Chest tightness" that caused them to do a XII lead on you, it was the fact that you recieved several doses of Epi, which puts strain and increased workload on the heart.

Right, and exactly. The interventional medications in that instance were a significant part of needing the 12 lead, however my point (however poor it ended up being) was that it was done as another diagnostic to completely rule out complications and/or catch other etiologys at work for my present condition.

I was young, healthy/fit, and no pmhx (esp no cardiac hx). Was probably slightly tachy from the epi and albuterol, but being that age as well as a healthy demographic within it, can certainly handle and metabolize rather effectively those doses and stressors on the vascular system. The 12 lead was just another diagnostic to offer further assurance, for my benefit (and my poor mum), that I was alright.

Someone already recently said it, but a 12 lead should just be considered part of vitals in situations where a grey area exists (ex: the N/V). Sure, that can be trivialized by us in EMS as a "waste of effort", but that's what we've also done with temperature. We all know the importance of having a temp for a pt with PNA or febrile sz or neurogenic insults or etc, but because we have trivialized requiring thermometers, a lot of EMS doesn't even allow their employees to use them.

What if we were to go so far as trivializing the need to get a BP for much of our "BLS" pts? (lets leave aside the violent, the refusals and the impractical [e.g. airway issues]) I can look at a lot of pts and have a general idea of their BP based on HPI, PMHx, skin c/t/c, weight, race and sex. Because I can guess based on experience and prejudices, doesn't mean I'm right and ergo should never do it. Give the pt all ya got when there is a grey area. Sure, setting up EKG's are repetitive and sometimes tedious, but it's our job. We lose respect among healthcare when we give ourselves the ability to write off performing diagnostic tests for the grey area pts.

 

[medic_chick87]

Before an EMT gets a pt when there is an ALS provider on scene, an ALS rule out assessment should be made.
Vitals, ECG, XII lead if indicated, BGL.

Period.

Exactly what I was going to say. As per my county protocol all pts get a full assessment, including a quickie ECG just to make sure you've covered all your bases before you can turn it over to your EMT partner. As many have all ready said, I would have done one just to rule out cardiac because of the age and hx. But since none of us were there, you are the only one who can say whether he was "Big Sick vs Little Sick" I'm sure you made the best judgment call. Just next time do a "quickie" ECG, even if you dont think it will help with your deferential.

 

[Epi-do]

I appreciate all of the replies and insight. I have definately taken a few different things away from what has been posted.

Now, for the update I got from the nurse that had patient care at the hospital. It was deteremined all of this patient's symptoms were as a direct result of drinking the Trilyte and the side effects from doing so. He was released from the ER in time to make it to his colonoscopy and was rather upset with the nurse when he asked if they would call the ambulance back to take him home after the test and she told him no, but that a taxi could be called instead.

 

[VentMedic]

He was released from the ER in time to make it to his colonoscopy and was rather upset with the nurse when he asked if they would call the ambulance back to take him home after the test and she told him no, but that a taxi could be called instead.

This could also have been an error of the pre-admit and discharge instructions. We tell our patients they are not to drive themselves for any procedure where sedation, hypnotics and/or pain meds are given. Our hospital system has a courtesty van and also arranges for transport if the need a higher level of transportation. The patient may have been just following orders but didn't understand them and called for the wrong transport. I do try to give elderly people the benefit of the doubt even if it appears they are playing the system. Most just don't understand it. Anyone here try understanding the Medicare changes a couple of years ago?

If you have ever tried you arrange for an ambulance transport from either a hospital or for one of your own loved ones, you will find it is a very complicated and confusing process even if you work in the system. Who to call for what is a huge area to cover. Before our hospital system started doing our own CCT or "ALS" IFT, we literally had menus for what each ambulance service could or could not do Often there was one thing missing from the list and someone from the hospital staff would end up going anyway.

Sorry for the rambling since this is not the case for this patient. Just keep in mind how confusing and overwhelming the whole U.S. healthcare system is.

 

[daughertyemta]

nurses being nurses. They always wanna jump the EMTs for something they didn't do. But they couldn't perform out in a squad. Cardiac hx yea prob. shouldve had a monitor but that was your medics call and if he down graded it then so be it. As long as you felt comfortable with it. Thats all that matters. Obsivously following your protocols and what not also. It could have went either way.

 

[JPINFV]

^
Can we leave the conspiracy theories to Coast to Coast AM?