# What would you have done?



## Jondruby (Jul 16, 2015)

A few week ago we were called to a residence for a 14-16 year old pt who is having trouble breathing. Like a 03:30 call, we are a BLS service, but dispatch kept saying a nurse was on scene and was requesting Neb treatments. We respond we are a BLS and dont carry NEBs. We get to the scene and this nurse has started and IV and had a neb mask on with saline. We are like "Whoa, where did she get this stuff?" cuz we are at the nurses house. (the pt was friends with the nurse and was babysitting kids while nurse was gone). We run thru some questions and it turns out the pt was stung by a bee before lunch the day before, shes has stridor resps and doesnt look good. Nurse says "we need epi!" Then nurse grabs the epi out of my partners hand and administers it. (which didnt help at all). CRAP! Nurse then starts telling us we need go and we are all wondering if we transport because of the IV. ALS is gonna meet us on the interstate so they lock the IV and we roll, nurse coming along. My partner askes where she works, nurse says "I used to work in (fillintheblank) ER" So shes like where do you work now? Nurse, "I am the head of a clinic in (a different town)." We meet ALS and they take care of it from there, both us and that paramedics documented the crap outta that call. Apparently our nurse friend had some "supplies" in her closet. I dont know what ever happend to her. Upon reflection and taking with the Paramedics afterwards, we have concluded how we could have handeled it better, have never been thrown into a situation like that ever. Oh and a detail that I left out, smelled like the Nurse had been hitting the bottle pretty hard before all this took place.


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## chaz90 (Jul 17, 2015)

Hmm...Don't really know what to make of this scenario. It doesn't necessarily sound like an allergic reaction from what little you wrote, but we'd need a lot more info to even begin looking at this from a medical perspective. 

Like most other scenarios at a BLS level, the treatment side of this is pretty straightforward. Recognize some sort of adventitious lung sounds with a clinical correlation of SOB, call for ALS if closer than the hospital, and hopefully begin packaging/transport and meet ALS. 

I don't quite understand the hesitancy behind transporting with the IV in place, though I know local regulations vary. If you didn't place it or know it was there, you can't exactly refuse to deal with the patient or pull it out just because it's there. If local protocols demand an ALS transport of a saline lock, just as well that you already called for ALS due to the patient condition. Even though you're BLS, I'm fairly confident you're still allowed to treat and transport ALS patients if you find them and the ED is closer. 

I would not have allowed the nurse to grab my epinephrine. Not quite sure how anyone allowed this to happen the way you wrote it, as it implies you A. Had your Epi-Pen out B. Didn't stop the bystander as she grabbed it from you and C. Didn't prevent her from administering a potentially harmful medication that came from your bag after you arrived on scene. These are all pretty huge issues, and none of them happen instantaneously. I've heard of and seen uncooperative bystanders before, but I've never seen anyone try to grab my gear or medications. 

Lastly, why would you let the nurse ride in the back with you?! She's already proven herself uncooperative and interfered with care. Honestly, I would have called ALS, begun transport without the nurse, and documented the IV as being placed by someone else before I ever arrived on scene. Case closed, transport complete, care transferred without issue.


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## ERDoc (Jul 17, 2015)

I hope you got the nurse's name and notified the state board of nursing.  She's practicing medicine without a license.  You should have put her in her place right from the start and taken control of the scene.  She sure as hell should not have been allowed in the ambulance if she is going to interfere with your care.


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## Handsome Robb (Jul 18, 2015)

Stridorous respirations without other signs of anaphylaxis and the rapid onset makes me think epiglotitis even if the age isn't textbook but like Chaz said there's not enough information here to approach this medically. 

I'd have put the nurse in their place real quickly, definitely wouldn't have allowed them to take Meds from me let alone administer them and they absolutely wouldn't have been anywhere near the ambulance let alone riding with. If they were that unruly Id have PD enroute. Either to the scene or to the intercept with ALS.


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## Akulahawk (Jul 18, 2015)

As soon as that nurse started going down the road of wanting to run the call, I would have then told her that I've got it from here, thanks for the report... have a nice day. Her job is done as soon as she's given me report and I assume care. I would have documented what care was provided prior to my arrival, documented my findings, etc. Stridor without other signs of anaphylaxis makes me think epiglottitis or other airway problem, not anaphylaxis. The patient isn't likely reacting to the bee sting at this point as an allergic reaction. I wouldn't have allowed the nurse to function beyond BLS once I arrived on scene. Most protocols as a Paramedic (and even an EMT for that matter) don't allow a nurse that's not on duty in an EMS role to go beyond BLS anyway.


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## Clare (Jul 18, 2015)

Whatever treatment was initiated prior to your arrival is outside of your control so I wouldn't worry about that. 

It sounds like you needed to clarify the intent of the ambulance response and the nurse coming with you.  For example where you responded using the provisions of MPDS Card 35 on the basis of a registered nurse, doctor or midwife having made a diagnosis and referral decision where ambulance response is for transport with clinical monitoring, or were you called for assistance with active treatment? Was the nurse accompanying you in the role of whatever your equivalent of A-Zero or the flying squad is, i.e. as a clinical escort to provide treatment, or just as a family member/support person? 

If you were simply requested for transport and provided a clinical escort then you need to clarify what the jurisdictional arrangements are regarding treatment, for example, locally the clinical escort is in charge of delivering treatment.  This does not however prevent the ambulance crew from intervening if, for example, the clinical escort is not able to provide the required treatment or they wish to provide grossly inappropriate treatment the crew think is not appropriate.  At the end of the day however, the clinical escort is ultimately responsible for the treatment they provide. You should clarify what your local arrangements are regarding this.  

On the other hand, if you "just showed up to somebodies house and there happened to be a nurse there who thought X and Y treatment was necessary" well, certainly ambulance personnel have an obligation to listen to their rationale and take into account what they have said, however, whoever is at the scene cannot request treatment that the ambulance personnel do not think is clinically indicated.  Again, you need to clarify what your local arrangements are regarding this, as, for example, locally a Doctor-on-scene may ask ambulance personnel to act outside their delegated scope of practice and this can be done if ambulance personnel feel it is appropriate.


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## GirevikMedic (Jul 22, 2015)

It looks like everyone else has covered the main points here so I won't beat that horse any more. I will ask this though.... OP what is your experience level? Fairly new to EMS and/or fairly new to 911? Just a guess (and I could be wrong and it's meant with no offense) but it sounds like this may be the case. Or at the least a lack of experience with odd scenes. If that's the case I can see where certain aspects of this run may have gotten away from you guys. Use this, and the feedback here, as learning tool for the future. Don't be afraid to put any bystander (or provider) in their place if/when need be.


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## Akulahawk (Jul 23, 2015)

As an example from Sacramento County's policies for EMS, when there's an RN at the scene, I provide the following:

Procedure for rn at the scene: 
A. Identification: 
1. Recognition by the Paramedic; -OR- 
2. Valid California RN license; -OR- 
3. Valid SCEMSA Mobile Intensive Care Nurse (MICN) certification.​B. An RN may perform basic life support (BLS) procedures at the discretion of the Paramedic. 
C. An MICN may assist and make suggestions but may not provide Base Hospital orders on site.​In the above quote, "Paramedic" also means "EMT." The reason for the "Paramedic" reference is that most emergency calls are run by Paramedics and only very rarely by EMT personnel. It's very rare for a EMT/EMT crew to transport someone to the ER. This is NOT to be confused by the "Medical Scene Authority" policy that applies to on-duty _prehospital_ personnel. This would include MICNs and Flight Nurses that are assigned to prehospital duties. That particular policy would _not_ apply to the situation in this thread. The above quote is what would apply and would be the reason I'd do what I said I'd do in an earlier post. If, in my opinion, the RN is interfering with my care, then I will call Law Enforcement and have the RN removed from my scene and possibly charged with obstructing my care. In California, that's Penal Code 148.


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## Jondruby (Jul 23, 2015)

Well personally, I know the scenario was  not good to begin with, I was just a ride along at the time so It didn't seem like my place to say something (although maybe I should have since no one else did) and I really couldn't provide care since I was not certified. To cut my team some slack we have never realy ecountered a situation like that before, working a small rural area, we usually don't get alot belligerent patients, not that we have never had any but this situation kinda took us by surprise. Thanks for your anwsers, my crew discussed it after the fact and we have decided what we should have done and what we should do next time. Our conclusion: sometimes you just gotta be a tough guy and lay down the law.


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## Jondruby (Jul 23, 2015)

P.S. I have had more odd calls and my crew had totally worked thru them no problems. We are a volunteer service so we are not constantly bombarded with calls, if the pager goes off we run to the shed and take it from there. Thanks for the advice guys.


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