My partner froze up

[EMTT760]

To make a story short. My partner is a fairly new EMT with around 3 months experience, less actually because he is part time. He works with the mentality of "doing it to put it on a resume for fire". Yesterday, we had a known diabetic PT who was discharged from a E.R. room. He was admitted for a fall, the PT is also a amputee. The transport was supposed to be from the E.R. to a Rehab/SNF facility. Typical mundane transport, complacency would suggest.

En-route, we transported him through traffic. Total time was around 27 mins, we offload the patient from the ambulance into the facility. I notice my partner in the back with the PT. The PT was shivering. I ask " why is he shivering so much?"" My partner said he's cold. I think to myself " Ok, just cover him up with blankets no big deal". We get the PT to his room and at this point he's shaking/shivering pretty bad. I asked the PT when's the last time the hospital checked the insulin, when his last meal and any recent medication changes. He responded " They checked it this morning". It was now 4:00 P.M. in the afternoon. I asked him how cold are you on a scale from 1/10. He responds 8/10. I tell my partner to get the nursing staff ASAP and come back with a glucometer and a thermometer. The nursing staff comes back his temp is 100*, glucose level 173, O2 sat 90%. He's still shivering violently at this point.

I tell my partner we need to transport him to the nearest E.R. 5-10 mins away ASAP. Prepare himself for a radio report, etc. He protests and opt's for ALS..... I told him that would be a waste of time and we should just transport him ourselfs.

Since it was his PT, I let him make the decision to call ALS/Fire. So we standby for another 5-7 mins till they arrive on scene. The Medics started talking crap saying we gave them a " downgraded ALS call, they could have handled it". Then they get the PT in the back of the ambulance and realize how serious his condition is. He started to lock up his extremities. My partner seemed very relieved that ALS took him.



However, I hate living up to that whole expectation of " BLS" or just a " EMT-B". I also started working an a E.R. tech recently. So i'm not afraid to throw myself into a serious situation.

I'm just upset at my partner for taking the easy way out. Is my frustration justified?

 

[chaz90]

So...Slight fever, chills, and a likely unreliable/low normal SpO2 reading? What's the issue here? Give the poor man a blanket and some Tylenol and move on. I certainly don't see the reasoning behind A. Transport back to the ED B. Calling for ALS or C. Worrying about your partner "freezing up."

What do you think was going on with this patient that made him so obviously "serious?" Genuine question here.

 

[EMTT760]

I asked a M.D. the that same question. She said the low SP02 level, and the crackle sound when he was breathing. His respiratory rate was at 20/min. Pulse of 119. She thinks that it could be undiagnosed pneumonia, perhaps possibly Sepsis. Just's just merely speculation.

I mean we covered him with 2-3 blankets and he was still shivering pretty bad..
.

 

[chaz90]

Huh? Then how do you know he decompensated quickly if you didn't transport him or follow up? Pneumonia is always a strong possibility in the hospitalized and elderly population, but this patient had no complaints at all besides "shivering" and you made no mention of adventitious lung sounds or tachycardia initially. I'm not discounting the possibility of pneumonia, but the doc's speculation without laying eyes on the patient isn't exactly a diagnosis.

Honestly, this patient sounds quite stable and in no immediate need of transport back to any hospital from what you initially posted. As the patient was just evaluated at the ED, they would have monitored his SpO2 and core temperature there as well. Many nursing facilities attempt to keep these patients out of the ED as much as possible and treat them in house as well. Many times CXRs can be completed at an imaging center or in the facility, and antibiotics (if needed) can be administered through the SNF as well after seeing the facility doc.

 

[EMTT760]

I meant to say he decompensated on the initial transport to the SNF. All the small details like the PT's history I wasn't 100% filled in. I was driving on this call. The nursing staff refused acceptance of the PT at the SNF. So we have to either 1) Take him to the E.R. ourselves or 2) Call ALS.

 

[GirevikMedic]

I'm going to have to side with chaz90 on this one so far. His change in presentation being only that of shivering from point A to point B isn't a huge concern. In fact, if it were a case of a febrile illness the chills/shaking is simply a physiological byproduct of the skin feeling cold despite increased body temperature due to blood shunting to the core during an immune response. Pulse rate of 119 isn't dangerously high and, though could be related to illness, could also be - at least to some extent - increased heart rate due to increased muscular activity and motion associated with the shivering. Respiratory rate of 20 wouldn't be anything to get worked up over either. A few things can influence the pulse ox reading to be less than accurate. Cold temperatures and poor fit - both good possibilities here - are a couple of those things. Blood glucose was a bit high, but not anywhere close to being problematic.

So i'm not afraid to throw myself into a serious situation.

This here caught my eye for a couple reasons. First, I'll say kudos for being willing to get your feet wet and/or your hands dirty if/when needed. But... 1) Recognize what truly is and isn't "a serious situation". Hint: The vast majority of what we see, statistically, is not uber serious. 2) Be careful when going to that mind set. This isn't a TV show with a happy ending in 30-60 minutes every time. Over step your bounds one too many times - or just one bad time - and it's a lesson learned with no easy version. Explaining yourself to CQI and/or a medical director when they already know the correct and incorrect answers is not favorable place to be.

I'm just upset at my partner for taking the easy way out. Is my frustration justified?

He's got 3 months of part-time experience so I'd say cut him some slack. Getting comfortable with routine IFT experience as a fresh newbie can be daunting enough as it is - let alone having to make patient care decisions that deviate from the expected plan.

 

[Brandon O]

True rigors (shaking chills) are a quite specific finding for high fever. I would never discount it. For all the times we talk about being "chilly," how many times have you ever seen (or ever personally) actually shivered? Especially violent shivering, e.g. that shakes the bed?

It certainly sounds like a very consistent picture of pneumonia, and I'm a little puzzled that some folks seem to be trying to explain this one away. Obviously we weren't there, and the gentleman doesn't seem in danger of crashing right that second, but to park him in a SNF and head for lunch seems to me like one of those things you'd regret.

 

[chaz90]

True rigors (shaking chills) are a quite specific finding for high fever. I would never discount it. For all the times we talk about being "chilly," how many times have you ever seen (or ever personally) actually shivered? Especially violent shivering, e.g. that shakes the bed?

It certainly sounds like a very consistent picture of pneumonia, and I'm a little puzzled that some folks seem to be trying to explain this one away. Obviously we weren't there, and the gentleman doesn't seem in danger of crashing right that second, but to park him in a SNF and head for lunch seems to me like one of those things you'd regret.

My thoughts were more focused on what the OPs problems were with his partner and why he thought the patient seemed immediately "serious" or "critical." I'm not discounting the possibility of pneumonia, and even mentioned earlier that it seems quite within the realms of possibility.

The initial post had nothing about lung sounds, tachycardia, or complaints other than shivering. I'm trying to figure out how this fever and shivering began during the return to the SNF, and was a bit confused as to why the debate was even suggested of making this BLS or ALS. It's not that I'm ruling out pneumonia or even saying it's unlikely, but it seems like this likely would have been assessed a short time earlier.

If the nursing staff refused the transfer of care, I understand that a return to the ED is likely the only option, but I don't understand what the actual changes were in the patient's condition between leaving the ED and arriving at the SNF. What was the discharge condition at the ED?

 

[Brandon O]

Right, obviously we're short on info and this is the sort of situation that's best avoided. Presumably this condition either developed after transport (or realistically after the last person in the ED paid the patient any attention) -- which would be rather fulminant -- or it developed earlier, in which case you get to have one of those "is he supposed to look like that?" conversations with the sending facility. But only if you assess in the ED when you can still engage with them.

Or call them from the road, which I've done...

 

[EMTT760]

My thoughts were more focused on what the OPs problems were with his partner and why he thought the patient seemed immediately "serious" or "critical." I'm not discounting the possibility of pneumonia, and even mentioned earlier that it seems quite within the realms of possibility.

The initial post had nothing about lung sounds, tachycardia, or complaints other than shivering. I'm trying to figure out how this fever and shivering began during the return to the SNF, and was a bit confused as to why the debate was even suggested of making this BLS or ALS. It's not that I'm ruling out pneumonia or even saying it's unlikely, but it seems like this likely would have been assessed a short time earlier.

If the nursing staff refused the transfer of care, I understand that a return to the ED is likely the only option, but I don't understand what the actual changes were in the patient's condition between leaving the ED and arriving at the SNF. What was the discharge condition at the ED?

I'll fill you in on a bit more information. I apologize if was I wasn't clear initially. When he wen't to pick up he was originally admitted for a fall to the E.R., my partner was the one taking the report from the R.N. at the E.R... Initially, his appearance in the E.R. seemed like he was ready to leave and in overall good condition. He was ANOX3, fully oriented and talking. He did ask the nurse about a pain narcotic and how much relief it would give him. I don't have the details as to what that was. The E.R. staff were very eager to discharge him, infact we had 4 R.N.'s and a tech assist us in the transfer to our gurney which I consider rare and unusual. Usually, that's left to us to " deal with it". Maybe we'll get one other person.

I don't have any other details other than that. He does have a history a UTI's, Diabetes My partner did the PCR on him not me.

As, I've stated before. Sometime during the transport right around the 30 min, mark. He begun developing hypothermia/shivering. Which progressed worse and worse.

 

[RedAirplane]

If your partner ever freezes up, just stop by the nearest coin laundry and toss him in the dryer for five minutes.

 

[exodus]

As, I've stated before. Sometime during the transport right around the 30 min, mark. He begun developing hypothermia/shivering. Which progressed worse and worse.

But he wasn't hypothermic? Also, putting additional blankets on him would cause more harm if that was the problem. SPO2 of 90% is okay. HR of 120 is also okay. This patient was 100% stable and probably didn't even need transport to the ER. He needed some tylenol. What was his pressure?

 

[Tigger]

If you are going to attempt to question your partners judgement you need to have the full story and probably have read the PCR.

Though I am unsure as to why the SNF would refuse this patient (give him Tylenol and some fluids and see if he improves), that's not the point. If you have an issue with the way your partner handled the call you should bring it up in a professional manner. And if you are a mentor or someone that is trying to help make him competent you need to make it educational. Saying "I would have done it this way" is meaningless unless you properly justify your position.

 

[akflightmedic]

My partner did the PCR on him not me.

Herein lies my issue and is something I do not accept. While the others have addressed the potential diagnosis and your partner's "freezing"...I am going to call you out on your excuses.

You have repeatedly said, "I was driving". "it is partner's patient", "partner did PCR" etc...yet in spite of this, you feel you have the ability to critique and condemn.

All of your words in my mind translate to "It's not my job", which I simply never accept, especially if you have input on how things should have been done better,

My advice to you...when you go retrieve patients, you take a few extra minutes to familiarize yourself with the patient, regardless of if it is your turn to tech or not. You have a right to know what is in your truck, you will learn something new every time (since you want to be better), and when things go south (as they inevitably will if you do this long enough) you are already somewhat prepared with base line information.

There is absolutely no reason both you and your partner cannot perform an assessment when receiving a patient. I do not mean a full detailed head to toe (but is good practice for you), but a basic exam would be prudent. Touch your patient, talk to them, hear them...those three things along will reveal so much.

 

[Chewy20]

Quit trying to put it on your partner dude. To be honest, it sounds like you freaked the kid out by saying "we need to get to the ER now" and he did not feel comfortable so he pawned it off on ALS. Why didn't you step up being the senior and say "I will take it, don't worry about it." I am sure he gladly would of said go for it.

Where are the pertinent negatives? Has this happened to him before? What was his blood pressure? Why are you thinking possible sepsis? From the picture you painted this guy could have went right back to his bed in the SNF and tell the nurse whats going on. Doesn't sound like your partner froze, it sounds like he made a decision and it happens to be one you didnt like because you wanted a reason to go L&S to the hospital. Even though this pt does not need to be rushed even if going to the ER...

My advice, stop blaming others for not knowing whats going on with the pt in the back of your ambulance.

He begun developing hypothermia

his temp is 100*

What?

 

[ERDoc]

I don't hear anything too concerning in this story that would make me say L&S or even ALS was needed. I can see the SNF refusing the pt. This pt at minimum meets SIRS criteria and probably sepsis criteria, not that the SNF would know that though. Other than IVF, ALS is not going to have much else to offer than BLS does, especially in a 5-10 min ride but I would rather see the pt go back to the hospital he was just discharged from since all records will be there. This call sounds like a CF all around and it's probably due to lack of experience by all involved. The pt had a fever, people with fevers shiver. The heart rate was high, people with fevers have higher heart rates. That pulse ox could be normal for the pt.

 

[CALEMT]

I'm just upset at my partner for taking the easy way out. Is my frustration justified?

No, your partner has 3 months experience and from what I'm guessing is a brand new EMT. Now really ask yourself: What is wrong with this pt that warrants ALS and a transport back to the ED. Every vital sign that I see isn't anything that a EMT couldn't take care of. HR of 120, little high but considering he is shivering I would worry about that. SP02 maybe that his normal range, sometimes SP02 will be thrown off with cold hands (and to be honest you shouldn't let SP02 dictate what you do). BGL well he is a diabetic and his last meal was quite some time ago so give him something to eat. Fever of 100 and he's becoming hypothermic? Don't you mean hyperthermic? Even so a temp of 100 isn't considered hyperthermic, give him a Tylenol.

From the picture you painted theres no real reason for ALS and transport to the ED, unless I'm missing something here. Like akflightmedic says don't use "I was driving or it wasn't my PCR" as an excuse. Both of you have the responsibility of knowing whats going on with the pt. When I worked BLS and was doing the exact same type of transports that you are doing my partner and I would "divide and concur" that means one would go get and look through the paperwork and the other would start the assessment and vitals. Thats what I found that worked best.

 

[johnrsemt]

From experience and a little research a patients HR will go up 15-20 beats per minute for every Degree in temperature: so a temp of 100 would be between 22-30 HR increase (if normal is 90, then 120 is perfectly ok): This is coming from a person who used to be nicknamed Tachy due to getting worried about patients with Increased HR who had fevers.
Shivering may or may not be a problem; He may not have wanted to be at the ECF and was doing it intentionally (I can usually make myself shiver at will).
Blood Glucose of 173 is not a problem: he needs a little insulin.
ECF nurse refused to take him; that is a problem he would have to go back to ED, but not ALS.