Would you have ALS'd this patient?

[MedicPrincess]

You get the call at 0702 hrs, your shift was over at 0700 (latelate call on your way back from a late call) so your already experiencing a moderate case of the tourettes.

Initially "Alpha" response for a sick call, pt c/o diarrhea.

You enter his apt to find a 74 yo M pt, seated in his LR chair watching the news. He appears a little pale but otherwise no obvious distress. As you approach and ask him whats going on he says the most aggravating thing a pt can say (IMHO), "I don't know."

Me: "Well Sir, why did you call for an ambulance today."
Him: "Something has to be done."
Me: "Okay, what is it you want something done about."
Him: "Two months ago I had a colonoscopy. I have had diarrhea ever since."
Me" "Okay, well have you talked to your regular physician about your onging diarrhea?"
Him: "I told'em in Biloxi last week. They said to go back to my Dr."
Me: "Have you noticed any blood when you go?"
Him: "Nope. Just a lot of poop all the time."
Me: "Are you hurting anywhere?"
Him: "Yesterday, my stomach hurt over here. But it seems a little swolled up. And I lost weight. I used to weigh 220 pounds in October, now I am down to 200."

He goes on to deny CP, SOB, N/V, Syncope. His ABD is SNT in all 4. BBS CTA.

Initial Vitals:
BP 136/91
HR 90, regular
RR 22
SaO2 96% RA

Meds:
Digoxin
ASA
Lortab
Toprol

No allergies

Pt stated Hx: HTN, "Heart Troubles" where his heart regularly "skips a beat or two"

As your partner is arranging things to get the stretcher in, the pt gets up and walks to where the stretcher is, about 6 feet. He appears a little out of breath from the short walk. He admits to feeling a "little" winded.

He doesn't want to go to the hospital that is literally 1 block from his house and 4 miles from your going home point. He wants to go to the hospital that is across town, and 10 miles from your going home point.

Now, would you go ahead and ALS him for a c/o diarrhea for 2 months, or just give him a ride in and have the chart done when you get there?

I will tell you my choice and why after some discussion

 

[BossyCow]

Possible hx of cardiac, his hr is a bit high, his rr is a bit fast, his o2 is a bit slow, and he's requesting to spend more rather than less time in your rig? I think I would call for an ALS eval on this guy.

The fact that he got winded so quickly means he's got some issues. I'd also want to know what preceded the colonoscopy. Was he experiencing some symptoms that caused the doc to order it?

 

[traumateam1]

No, I wouldn't of ALS'd him. Why? We don't have ALS here.

 

[KEVD18]

if i was a medic and got this call, yes i would have worked him up. usual routine. line, labs, XII, pe etc. im already on the scene and committed to the call. its not going to add much in the way of time to the call(maybe 10min). so what the hell, might as well turn a profit on the call.

if i go this call as a basic, i doubt i would call for medics unless he presented with the undeniable "oh poopy" look we all know and love. now, that probably not the right answer, but its how i would answer it based on the boston private ambulance scene. if i called for medics on that call, and the patient made it to the H without so much as a fart, i would get my rear end handed to me for wasting resources. thats just how it is up here(hence why i retired).

 

[JPINFV]

Coming from a So. Cal. perspective, I'd have to agree with Kev's plan. The patient has a lengthy history including cardiac issues. His vital signs are in that gray borderline area. Yes, a resting pulse of 91 is high. Yes, a BP of 136/91 (MAP 121) is a little on the high side. I'm not necessarily concerned with a RR of 22 with an SpO2 96 on room air. There's a few abnormal findings on the secondary and recent history. To me none of this amounts to something immediately life threatening to the patient. I think there's enough there, though, to preclude a paramedic handing the patient off to a basic for transport though. I'd of transported this patient non-emergent in position of comfort while maintaining a high degree of suspicion. I'd probably start the patient on O2 at 2-4 LPM NC (definitely not a NRB) and have the bed pain handy just in case.

 

[traumateam1]

if i was a medic and got this call, yes i would have worked him up. usual routine. line, labs, XII, pe etc. im already on the scene and committed to the call. its not going to add much in the way of time to the call(maybe 10min). so what the hell, might as well turn a profit on the call.

if i go this call as a basic, i doubt i would call for medics unless he presented with the undeniable "oh poopy" look we all know and love. now, that probably not the right answer, but its how i would answer it based on the boston private ambulance scene. if i called for medics on that call, and the patient made it to the H without so much as a fart, i would get my rear end handed to me for wasting resources. thats just how it is up here(hence why i retired).

Same here (if we had ALS), based on what I see from the OP's post.. he doesn't need ALS, what's another 60 minutes if he's had this for 2 months now? It would be a waste of resources, when they could be going to a code or some other call that truely needs ALS.

 

[BossyCow]

Same here (if we had ALS), based on what I see from the OP's post.. he doesn't need ALS, what's another 60 minutes if he's had this for 2 months now? It would be a waste of resources, when they could be going to a code or some other call that truely needs ALS.

What caused him to call today after 2 months?

 

[Tincanfireman]

In all honesty, I'd have probably transported him myself, but watched him like a hawk. Certainly O2 via N/C @ 4 LPM initially, but that could change based on skin color and PSO2. Some additional questions: What were his lung sounds? Did he know the outcome (findings) of the scope? You say he was a "little winded"; are we talking 1-2-3 word phases, or just heavier breathing? I'd have certainly gained INT access with an 18-20ga, but anything out of the ordinary in the above would have dictated a possible detour to a closer facility once we went enroute. In addition, I might have originally intended to take him to the more distant facility, but I also would have placed a quick call to my paramedic supervisor to get their input and advice and let an ALS unit meet us on the way if the supervisor directed an ALS response. (I'm not a big fan of fiddling around on scene if we can be getting to a hospital.) If they did direct an ALS response, the patient is going to have to live with the disappointment of going to the closer facility, unless there was a good reason to go a considerably longer distance. The "going home" part of this is a moot point by now; it's just going to be more time on the paysheet.

Good scenario; I'll be interested to follow this one.

 

[KEVD18]

now wait a minute here. nowhere did i say this patient doesnt need an als assesment and care.

what i said was, if i responded to this call as a medic i would work it up as such. but if i took this call as a basic on a private ambulance in ma, with that exact presentation, i more than likely would not have activated an als intercept based on those vitals etc. depending on who you work for in my service area, you either have an als truck flying your colors on every street corner(fallon comes to mind) or the one medic truck your company has might be three cities away doing a dialysis call(general...wait general/mercy...wait just mercy.....wait samaritan....they change their name so often i have trouble keeping up). if a truck from your service isnt available, you can either call the city for an intercept(and you better have a damn good reason, since theres only six medic truck for the whole damn city of boston) or you start calling around to all the other privates searching for a clear and available medic truck in your area(very time consuming and tough to accomplish).

so if i was on a basic truck, the odds are stacked against me getting medics unles i really need them(tell boston you have a code and they come running. tell them you have a diarreaha times two months with stable vitals and your answer wont be very polite). they also wont chase you. if you get them activated and on scene with you before you transport(read delay of transport waiting for als), muy bueno. but if you're on the way, they dont chase. given all that, i would proceed to the H bls only.

theres definatley something going on here. i dont know what it is, since i dont have an md and the support of diagnostic equipment. does it deserve an als assesment, without a doubt. no question in my mind. my response was simply weighing the availability of als as it has been in my experience v. the average transpor time to the H(<10min).

 

[JPINFV]

The simple fact is that until everyone on an ambulance is a paramedic (non emergent transport units can call their vehicle something other than an ambulance and don't get the shiny lights), basics will be transporting patients that should be attended to by a paramedic. I'm saying this because I want to keep this thread dealing with reality and not the perfect system.

Should paramedics be attending to this patient? Sure. (this answers the OP).
Should paramedics have been dispatched as a first response? Yes.
Should a lower level provider call for a paramedic? Given what has been posted so far, probably not.


This patient is sick, but the current information doesn't make it look like he is going to die in the next 10 or 15 minutes. The simple fact is that if basics were to call for a paramedic every time their patient wasn't perfectly within normal limits (yes, I know this is what we're taught to do, but I've never said that EMT-B training was good), then every single call from a nursing home would be a paramedic intercept and this would put the EMS system in a state of panic given its current set up. I don't see that anything would be gained by delaying transport or diverting to a closer destination. I know we're trained to see demons around ever corner and every little imperfection on physical exam as life threatening, but this simply isn't representative of reality. You simply can't call paramedics for every diarrhea patient with a cardiac history and borderline vital signs.

 

[Hastings]

Would check sugar / hydration and if clear, BLS it (have my partner take it).

 

[KEVD18]

Would check sugar / hydration and if clear, BLS it (have my partner take it).

i disagree. if you are there(i assume working a p/b truck), this should be your call.

something is amiss here and you need to be ready for it.

its cases like this where i sort of admire states that require the highest level provider to attend the call. its prevents lazy paramedicine.

 

[FFMedic1911]

From just reading,no i would not transport als.Granted every pt. has the chance to have something go wrong.I just hate the idea of having everything als just to be on the safe side.If the pt. needs als am all for it.If the clinical picture shows they don't than don't. KEVD18 I get what you are saying also and agree they are lazy medics.What I have also seen happen in ems is basics that have became so use to having medics that all they are now is ambulance drivers.This is espiacally true here in eastern Kentucky.When i started most of the departments where bls only and as a basic you had to be on top of your game.Now we have medics and the basics have last alot of their skills.

 

[KEVD18]

something about his call just strikes me as precipitous. maybe its because mp phrased it that way t make it seem like there was something where there was nothing but i dont have to stretch reality to see this call going south. if it does(did), i would much rather have a medic attending the call. if nothing more than it saves what time it does take to establish an iv, hook up the monitor etc. for that matter, id want to see the ekg before making the als bls call and in ma, medics cant do the classic "quick look" ekg(i.e. hoow it up, look at it and if theres nothing immediatley apparant, punt it off to bls). once the monitor is applied, its als till arrival and this patient needs a thorough exam.

one of the things that makes doing these online forum scenarios difficult are the variances in protocols. maybe in other states a medic can do a full workup on scene and of there's nothing showing, turf the call down to a basic crew. i have to look at things from the perspective of where i have spent my entire career practicing(region 4, ma). hell, here bls carry glucometers. they are to be used in the event of ams and suspected cva. once you pop a sugar, you have to call for medics, regardless of the reading. now, nobody does that, but its in the book.

 

[Hastings]

i disagree. if you are there(i assume working a p/b truck), this should be your call.

something is amiss here and you need to be ready for it.

its cases like this where i sort of admire states that require the highest level provider to attend the call. its prevents lazy paramedicine.

It is my call, if by call, you mean that I'm making the decision whether it requires my level of care or my partner's. And I would make the decision, with the assistance of pre-set guidelines set by my medical control, that this patient can be treated by my partner.

At worse, if things take a turn for the worst, it's not like I can't upgrade the call and jump in back.

 

[KEVD18]

yeah, ive met medics that would do anything to get out of teching a call, and thus havign to chart it, too.

as a self proclaimed brandy new medic, wouldnt it be better for your knowledge base and thus ultimatley be better for your patients(the whole reason we all got into this circus) to workup as many patients as possible and be as familiar with every atypical presentation you can be?

on the other hand, they dont pay you any better for being a great medic than they do for showing up and doing the bare minimum so why bother i guess.....

 

[Hastings]

yeah, ive met medics that would do anything to get out of teching a call, and thus havign to chart it, too.

as a self proclaimed brandy new medic, wouldnt it be better for your knowledge base and thus ultimatley be better for your patients(the whole reason we all got into this circus) to workup as many patients as possible and be as familiar with every atypical presentation you can be?

on the other hand, they dont pay you any better for being a great medic than they do for showing up and doing the bare minimum so why bother i guess.....

It's not about working to get out of a call. There's a practical purpose to splitting up the calls between you and your partner. I tend to believe that Basics are a little more than just drivers.

 

[KEVD18]

yes, there is a practical purpose to splitting them up.

als calls for the medic and bls calls for the basic. we seem to be on opposite sides of the fence as to what this call was. i should think when mp gets around to the update phase of this little mellow drama, we'll find out who was right.

basics are more than just drivers. conversely, i agree with R/r when he relentlessly says that every emergency patient deserves an als assesment and im also bound by my protocols that say once an als skill has been performed, its an als call ad infinitum. you might recall just over two hours ago when i said its exactly this disparity thats makes this sort of cross country discussion to be difficult. obviously your protocols dont have the same rule. what isnt obvious is why you wouldnt work this patient up?

further, yes you could very well jump in the back and take it; already behind the 8 ball becuase you dont have a line and a previous ekg to establish a trend/history.

 

[traumateam1]

http://www.metacafe.com/watch/745121/i_have_a_bad_case_of_diarrhea/

 

[ffemt8978]

http://www.metacafe.com/watch/745121/i_have_a_bad_case_of_diarrhea/

I don't know what's worse...the fact that video exists or the fact that you knew about it.

That 3:49 of my life just killed a few brain cells.