# What would you do in this situation?



## jdox0776 (Nov 12, 2014)

911 call dispatched breathing problems.  Pt had BP 200/110, RR 30 labored, diminished breath sounds bilaterally, tachypnic, diaphoretic peril, spO2 94%, glucose 208, seizure hx due to metabolic disorder (malabsorption of Calcium, potassium, magnesium)

Would you perform ECG (cardiac monitoring)?  capnography waveform?, apply o2?  IV access?  Load and go VS stay and play?


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## Ewok Jerky (Nov 12, 2014)

How old is this patient? Male or female? Any other med Hx? HTN, DM, CHF? Any other symptoms, chest pain? Been sick lately? Has this been going on for days or hours?

If I was BLS I would probly O2 @2L, request ALS intercept and transport Code 2, no reason to hang around. 

ALS interventions would depend on a more thorough Hx and physical exam.


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## DesertMedic66 (Nov 12, 2014)

What's the pulse rate? O2, maybe capo if I'm feeling fancy, 12-lead, and establish a saline lock just incase I need it later on, and then a nice drive to the ED.

Edit: I may also consider a breathing treatment.


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## OnceAnEMT (Nov 12, 2014)

Is this acute or slow onset? If slow-er onset, I'm thinking pneumonia. If lung sounds are diminished, could be so much buildup that you just don't notice the fluid. I'm NRB at 10-15 and coaching at this point. If they continue to degrade, BVM. If they don't degrade further, considering CPAP. Not much reason to stay and play. Code 1 to ED, upgrade if they continue to deteriorate. Curious of the answers to the other Hx questions?

I'd 12 lead if they have more history than the metabolic disorder and aren't a minor.


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## ERDoc (Nov 12, 2014)

I would recommend seeking a lawyer's opinion, as was recommended on the other website where you asked this question.


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## OnceAnEMT (Nov 12, 2014)

ERDoc said:


> I would recommend seeking a lawyer's opinion, as was recommended on the other website where you asked this question.



That would be for legal advice. This is looking for practical advice. I would bet most scenarios on this forum are from real world calls, and the poster is looking for another opinion. There is nothing wrong with trying to better your practice.


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## ERDoc (Nov 12, 2014)

I'll stay out of it, but on the other site, it ended up she was looking for legal advice to start a lawsuit and even had an RN relative chime in.


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## OnceAnEMT (Nov 12, 2014)

ERDoc said:


> I'll stay out of it, but on the other site, it ended up she was looking for legal advice to start a lawsuit and even had an RN relative chime in.



No worries, I don't mean to harp on you. Hopefully the OP has read the rules here and understands that they won't get any legal advice in the event that this escalated to a point beyond being a scenario.


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## ERDoc (Nov 12, 2014)

No problem.  I know I'm the new guy so it's all good.  Unfortunately the other site underwent an upgrade (reverse perhaps) and the thread is gone.


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## jdox0776 (Nov 12, 2014)

beano said:


> How old is this patient? Male or female? Any other med Hx? HTN, DM, CHF? Any other symptoms, chest pain? Been sick lately? Has this been going on for days or hours?
> 
> If I was BLS I would probly O2 @2L, request ALS intercept and transport Code 2, no reason to hang around.
> 
> ALS interventions would depend on a more thorough Hx and physical exam.


39 yoa male, pulse 98, acute tachypnic onset, no hx of heart disease, hx metabolic disorder (malabsorption of calcium, potassium, magnesium) chest pain, slightly altered LOC, possibility metabolic levels were low as he had been out of his meds


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## Ewok Jerky (Nov 12, 2014)

jdox0776 said:


> 39 yoa male, pulse 98, acute tachypnic onset, no hx of heart disease, hx metabolic disorder (malabsorption of calcium, potassium, magnesium) chest pain, slightly altered LOC, possibility metabolic levels were low as he had been out of his meds



What meds is he out of?

As I already stated, at the BLS level nothing much would change...maybe a little effort to actually make the intercept rather than just request it, depending on what the 12-lead says. Oh wait I dont have that I'm still BLS.

What was this guy up to when this all started happening?

Slightly altered make me a little less inclined to go Code2 although I don't know what slightly altered means. Is he altered or slow to respond? GCS? LOC?

How about a Neuro exam?

If I had all the toys I would certainly want a 12-lead, pulse ox and even capnography. 

Not convinced this is an electrolyte problem...


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## jdox0776 (Nov 12, 2014)

Out of his Calcitriol for hypoparathyroidism, GCS 15 initially, fully conscious, alert/oriented initially then confusion (slow to respond), neuro intact.  He had just awakened when it occurred.


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## jdox0776 (Nov 12, 2014)

Here is the rhythm, for leads II to III.  No 12 lead was done.


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## Gurby (Nov 12, 2014)

Is this a BLS or an ALS call?  If it's a BLS call, we have to assume we have no EKG info, no IV access/drugs, no capnography.  There isn't really much BLS is going to do for this patient besides calling for ALS intercept... And once the ALS gets there, there isn't much they can do either.  

Rhythm strip looks like bad news bears.  12 lead, aspirin nitro transport to PCI facility most likely?


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## teedubbyaw (Nov 12, 2014)

jdox0776 said:


> Here is the rhythm, for leads II to III.  No 12 lead was done.



12 lead just may have revealed a STEMI. 

Who are you trying to sue and why?


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## DesertMedic66 (Nov 12, 2014)

jdox0776 said:


> Here is the rhythm, for leads II to III.  No 12 lead was done.


What did you do or would you have done for this patient?


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## OnceAnEMT (Nov 12, 2014)

This scenario is going downhill faster than the patient did. Kind of interested in the scoop now.


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## jdox0776 (Nov 12, 2014)

I just wanted an opinion, not asking for legal advice, don't need it.


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## OnceAnEMT (Nov 12, 2014)

jdox0776 said:


> I just wanted an opinion, not asking for legal advice, don't need it.



Its a STEMI. I need 2 leads of greater than > 1 mm ST Elevation, and that looks like it would fit the bill. To ask again, is it an ALS or BLS response? If its BLS getting the 2 lead, then we know we need to get to a PCI center now. This will soon be a time dependent emergency (if you don't consider it one already), and ALS won't save this guy. If you can get an intercept now or en route with little to no delay, then hell yes, get a solid 12 lead and make sure. If it was originally an ALS response, I would've hoped for a 12 lead to start. But now its certainly needed.

Diminished lung sounds are interesting. But my guess here is that the breathing is so labored and shallow that it isn't worth much of a listen. If I can't get even a 5 lead now or very soon, be it mine or ALS, I'm code 3 to a PCI center (if it would make a difference in the area, naturally). Consider down grade if improvement is shown en route.


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## teedubbyaw (Nov 12, 2014)

Grimes said:


> Its a STEMI. I need 2 leads of greater than > 1 mm ST Elevation, and that looks like it would fit the bill. To ask again, is it an ALS or BLS response? If its BLS getting the 2 lead, then we know we need to get to a PCI center now. This will soon be a time dependent emergency (if you don't consider it one already), and ALS won't save this guy. If you can get an intercept now or en route with little to no delay, then hell yes, get a solid 12 lead and make sure. If it was originally an ALS response, I would've hoped for a 12 lead to start. But now its certainly needed.
> 
> Diminished lung sounds are interesting. But my guess here is that the breathing is so labored and shallow that it isn't worth much of a listen. If I can't get even a 5 lead now or very soon, be it mine or ALS, I'm code 3 to a PCI center (if it would make a difference in the area, naturally). Consider down grade if improvement is shown en route.



I wouldn't call a STEMI by way of a 2 lead reading. Almost guarantee it is one, but you really should have a 12 lead.


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## Gurby (Nov 12, 2014)

teedubbyaw said:


> I wouldn't call a STEMI by way of a 2 lead reading. Almost guarantee it is one, but you really should have a 12 lead.



Actually II and III are continuous leads right?  I guess technically you shouldn't need the other leads - with a good chest pain story you can probably still call it.  We still want the 12 lead, but I don't know that it's strictly necessary for the purposes of calling this a STEMI.

...Well, I guess we need to see reciprocal changes as well.  So yeah, more leads.


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## teedubbyaw (Nov 12, 2014)

Gurby said:


> Actually II and III are continuous leads right?  I guess technically you shouldn't need the other leads - with a good chest pain story you can probably still call it.  We still want the 12 lead, but I don't know that it's strictly necessary for the purposes of calling this a STEMI.
> 
> ...Well, I guess we need to see reciprocal changes as well.  So yeah, more leads.



They are contiguous. Lead II is non-diagnostic by itself for ST elevation. Adding lead III doesn't mean much. 

That is a very specific injury pattern, and I don't doubt the 12 lead would confirm a STEMI.


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## OnceAnEMT (Nov 12, 2014)

teedubbyaw said:


> I wouldn't call a STEMI by way of a 2 lead reading. Almost guarantee it is one, but you really should have a 12 lead.



I completely agree, which is why I would love to have that ALS intercept. But patient life > my reputation. Its a what if. Didn't even know getting just a 2 lead was still a thing...


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## STXmedic (Nov 13, 2014)

An exceptionally regular rhythm with a rate of roughly 90, no P waves, possibly wide QRS, and only a filtered 3-lead view? Am I the only one that thinks that looks an awful lot like a paced rhythm?...


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## jdox0776 (Nov 13, 2014)

Grimes said:


> Its a STEMI. I need 2 leads of greater than > 1 mm ST Elevation, and that looks like it would fit the bill. To ask again, is it an ALS or BLS response? If its BLS getting the 2 lead, then we know we need to get to a PCI center now. This will soon be a time dependent emergency (if you don't consider it one already), and ALS won't save this guy. If you can get an intercept now or en route with little to no delay, then hell yes, get a solid 12 lead and make sure. If it was originally an ALS response, I would've hoped for a 12 lead to start. But now its certainly needed.
> 
> Diminished lung sounds are interesting. But my guess here is that the breathing is so labored and shallow that it isn't worth much of a listen. If I can't get even a 5 lead now or very soon, be it mine or ALS, I'm code 3 to a PCI center (if it would make a difference in the area, naturally). Consider down grade if improvement is shown en route.


ALS, that rhythm was 4 minutes before respiratory arrest followed by cardiac arrest.


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## jrm818 (Nov 13, 2014)

Gurby said:


> Actually II and III are continuous leads right?  I guess technically you shouldn't need the other leads - with a good chest pain story you can probably still call it.  We still want the 12 lead, but I don't know that it's strictly necessary for the purposes of calling this a STEMI.
> 
> ...Well, I guess we need to see reciprocal changes as well.  So yeah, more leads.



The presention of this scenario is very strange and I doubt anyone is getting a realistic picture of how events unfolded.

That said, a reminder
You need not just more leads, but also different mode.  There is much unsupported dogma in ems, but "you can't diagnose a stemi in monitor mode" is actually true


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## STXmedic (Nov 13, 2014)

jrm818 said:


> The presention of this scenario is very strange and I doubt anyone is getting a realistic picture of how events unfolded.
> 
> That said, a reminder
> You need not just more leads, but also different mode.  There is much unsupported dogma in ems, but "you can't diagnose a stemi in monitor mode" is actually true


I wish I could like this more than once.


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## jdox0776 (Nov 13, 2014)

ERDoc was right I was on another site before I had all the evidence and facts.  I have proof now.  As I stated on the other site just because you are a "layperson" doesn't mean that you are "acting out of grief to point the finger to blame someone else".  When this happened I was wanting to go back to school but wasnt sure what I wanted to do.  I decided to go to EMS school.  I am not asking for legal advice because I already know I have a case and I do have a lawyer.  I know no one wants to admit that EMS does in fact make mistakes, it does happen.  What bothers me is those mistakes may have contributed to his demise.  I know what they did and didnt do (some of which is hearsay).

My brother had a reputation with the local hospital, he was known to have very poor hygiene and to be VERY needy.  EMS had been called out on several different occasions.  These particular EMS were approaching the end of their 24 shift.  He presented with these symptoms.  They were at my house for WAY too long as he should have been load and go.  I knew they didnt an ECG initially as the PCR stated and recently I got the ECG report from ambulance service thats.  The first one never existed.  The second one I posted was labeled as NSR.  It was not, I already had it interpreted.  They did not do an ECG, attempt IV access until 30 min later, no cap wave.  Minutes before he arrested he had what I initially thought was a seizure but realized it looked different.  He postured.  There are errors all over PCR.  A lot of things were not documented, ALL the symptoms, no description, onset, duration of said seizure, the three failed IV attempts, chief was listed as cardiac arrest and it should have been that he couldnt breathe.  He was having trouble speaking full sentences and I told them he couldnt breathe.  Chief complaint should be the presenting symptom said by the patient or family member not the end result.

They panicked when this all went down, whoever reported the information to the ER was rattled.  According to PCR they arrived at ER at one time and ER records say a later time.  I knew they were there longer than the PCR stated.  They couldnt even intubate because his trachea had deviated left.  They certanly couldnt gain IV access with his extremities clamped down.  So no initial ECG, no Oxygen, no IV, no cap wave, no cardiac monitor.  They did the 2 lead because they didnt have time for a 12 lead.  His symptoms were not taken seriously, I get they didnt realize how serious it was but thats why you have protocols for what should be done for resp distress, none of which was done at first.  Funny thing is the previous call that wasnt life threatening the first two things they did was gain IV access and cardiac monitor, they were out of my house within 10 minutes.  They plain and simple didnt want to touch, I admit he smelled but EMS comes in contact with many different fluids, he smelled particularly bad with his diaphoresis.  They wanted him to physically get up and walk to the stair chair but he wasnt physically able to .  It took 30 minutes before they finally did when I yelled at them to help him, my brother had been helplessly flopping around trying to do what they asked him to do.  His limbs simply would not allow it, his body was out of his control, he couldnt walk.

It bothers me that the PCR clearly shows an attempt to cover it up, I guess they hoped my aunt and I wouldnt dig further.  I have mad respect for EMS, its not an easy job but it requires empathy, respect, urgency, complete dedication to the patient even if they are difficult and you would really rather to pass this one up.  I have been there when I was MA, some patients make you *dread* but you still have to put your smile and do your job.  I have nothing against any of you I am just trying to understand why all this happened, wrong time, wrong place.  They should have observed the danger instead of assuming it wasnt.  No one followed protocol for prehospital assessment.  Its funny for so long I didnt know what I wanted to with my life.  Out of this tradgedy it became clear.  I had wanted to be a EMT ever since I was a kid and I would really like to stay here and be part of your community.  It is important for all EMS to stay on their toes planning to expect the unexpected in every single call.


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## jdox0776 (Nov 13, 2014)

STXmedic said:


> An exceptionally regular rhythm with a rate of roughly 90, no P waves, possibly wide QRS, and only a filtered 3-lead view? Am I the only one that thinks that looks an awful lot like a paced rhythm?...


This was the rhythm he had 4 min before arrest.  They did somehow manage to get a brady rate with ectopy after four round with Lucas, epi and a bi carb, they tried pacing but was unsuccessful.  He had not been shocked at this point but as you can see from the top of the strip they had just powered it on.  He should have been on the cardiac monitor from the get go.  I do have the other strips where he alarmed and the pacing attempts that followed.  Im not sure at this point if I will get flamed off the board for this.  I apologize.  I am not seeking legal advice I just really needed to vent to you guys.


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## teedubbyaw (Nov 13, 2014)

So what makes you a medical expert specializing in the field of EMS? Are you an equally trained paramedic? If not, how do you know what should have been done vs not? How do you know they didn't follow protocols? Sorry for your loss, but just make sure your accusations are factual. I know it's easy to want to put the blame on someone, and if it's warranted, then so be it, but don't do it out of grief.


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## Handsome Robb (Nov 13, 2014)

teedubbyaw said:


> So what makes you a medical expert specializing in the field of EMS? Are you an equally trained paramedic? If not, how do you know what should have been done vs not? How do you know they didn't follow protocols? Sorry for your loss, but just make sure your accusations are factual. I know it's easy to want to put the blame on someone, and if it's warranted, then so be it, but don't do it out of grief.



Agreed.

The way you describe symptoms may have presented very differently than what was observed by EMS. There's plenty of times the family is freaking out about something when there's truly nothing to freak out about. From your description I would've done a 12-lead at bedside, waveform capnography maybe but not necessarily. Still probably would've spent about as much time on scene as them. 

Why was your brother out of his medications? Non-compliance with medications can't be blamed on EMS. 

With that said I'm very sorry for your loss.


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## Gurby (Nov 13, 2014)

jrm818 said:


> You need not just more leads, but also different mode.  There is much unsupported dogma in ems, but "you can't diagnose a stemi in monitor mode" is actually true



You're right - I forgot!  I know I learned that at some point...  I would want a 12-lead anyways if I saw that on a monitor and was going to call a STEMI alert over the radio.


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## Ewok Jerky (Nov 13, 2014)

Sorry you lost your brother at such a young age.

We are monday morning quarter backing with second hand information over the internet.

It is absolutely not fair to apply our "what would you dos" to the EMS on scene.


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## jdox0776 (Nov 13, 2014)

teedubbyaw said:


> So what makes you a medical expert specializing in the field of EMS? Are you an equally trained paramedic? If not, how do you know what should have been done vs not? How do you know they didn't follow protocols? Sorry for your loss, but just make sure your accusations are factual. I know it's easy to want to put the blame on someone, and if it's warranted, then so be it, but don't do it out of grief.


apparently you didnt read the entire message.  I looked up the prehospital protocols for my state which applies to the entire state.  No,  am not a fully trained EMT yet (not until  finish school)  My aunt was a cardiac care nurse (CCU) for over 25 years and before that she was a paramedic.  Point is they were there for 30 minutes before he went completely south.  Why wasnt an ecg done?  PCR says they did one but it doesnt exist (per the records lady at the ambulance service) and the one they did finally do was reported as NSR normal sinus rhythm on PCR when it actually was not normal.  I got the official interpretation for it a couple days ago.  It was one of those "you just had to be there" to see how bad he looked.


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## jdox0776 (Nov 13, 2014)

Handsome Robb said:


> Agreed.
> 
> The way you describe symptoms may have presented very differently than what was observed by EMS. There's plenty of times the family is freaking out about something when there's truly nothing to freak out about. From your description I would've done a 12-lead at bedside, waveform capnography maybe but not necessarily. Still probably would've spent about as much time on scene as them.
> 
> ...


ECG would have been the most important thing they could have done, I had been taking care of him since our father died.  We were trying to get him on SSI.  He didnt always remember to take his meds and sometimes we didnt have the money for them (he didnt have insurance or medicaid and they were costly) He did have his meds on the night in question, he had been out of them prior though, he didnt always eat right either.


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## Ewok Jerky (Nov 13, 2014)

I am sure this was a terrable situation for you do deal with, but if you looking for validation, or for us to blame this all on the responding medics, you might be out of luck.

No offense but it sounds like a train wreck waiting to happen.


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## Tigger (Nov 13, 2014)

jdox0776 said:


> It was one of those "you just had to be there" to see how bad he looked.



And we weren't. So what do you want from us?


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## jdox0776 (Nov 14, 2014)

I am wondering why two fully trained paramedics would skip over protocol and then try to cover it up.  Does anyone not take responsibility for their actions.  If a mistake is made own it.  Regardless if they were approaching 24 hours on the clock.  Certain symptoms warrant certain tests like an ecg, forget about he capo, the ecg would have told them all they needed to know and how to proceed.


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## Ewok Jerky (Nov 14, 2014)

jdox0776 said:


> I am wondering why two fully trained paramedics would skip over protocol and then try to cover it up.



I don't know why two fully trained paramedics would skip over protocol and then try to cover it up. That doesn't make sense.

You should address your concerns to the parties involved not an anonymous internet forum that doesn't have all the facts.

Sorry but that's just how it is. You aren't going to get the answer your looking for here. And it sounds like you are lashing out which will put most EMS (or me at least) on the defensive.


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## luke_31 (Nov 14, 2014)

jdox0776 said:


> I am wondering why two fully trained paramedics would skip over protocol and then try to cover it up.  Does anyone not take responsibility for their actions.  If a mistake is made own it.  Regardless if they were approaching 24 hours on the clock.  Certain symptoms warrant certain tests like an ecg, forget about he capo, the ecg would have told them all they needed to know and how to proceed.


Statewide protocols aren't what most services use. They are just that a statewide guidance for what is allowed by the state to be done. Each county and company can have different protocols based on what their medical director allows. Also whatever we say here is ultimately not relavent as in the court system the paramedics would be held to the standard of other paramedics within the system they are in. Different systems have different ways of doing things and it would be biased to take a paramedic in one system and hold them accountable if they don't perform like someone in another system who has different resources and possibly additional training required in their system that is not provided by the other system.


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## Tigger (Nov 14, 2014)

jdox0776 said:


> I am wondering why two fully trained paramedics would skip over protocol and then try to cover it up.  Does anyone not take responsibility for their actions.  If a mistake is made own it.  Regardless if they were approaching 24 hours on the clock.  Certain symptoms warrant certain tests like an ecg, forget about he capo, the ecg would have told them all they needed to know and how to proceed.


Have your brought your concerns directly to the EMS agency and/or your state's EMS regulatory body? Your state EMS office should have a way to deal with provider complaints. That is the right way to do it, not to go digging around looking for someone's peers to fry them for you. If you want something changed and people held accountable, go out and do it the right way.


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## jdox0776 (Nov 14, 2014)

Tigger said:


> Have your brought your concerns directly to the EMS agency and/or your state's EMS regulatory body? Your state EMS office should have a way to deal with provider complaints. That is the right way to do it, not to go digging around looking for someone's peers to fry them for you. If you want something changed and people held accountable, go out and do it the right way.


I already have.


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## jdox0776 (Nov 14, 2014)

I had to wait until I got the ecg report because only then did I have the evidence to back up what I was saying.  From what I was told it should have been attached to the PCR when I originally picked it up.  It took forever to get the hospital records but their ecg wasn't in there.  They are investigating my complaint.  It's hard to have to wait


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## Angel (Nov 14, 2014)

No one here has the answer for you. If you want to vent that's fine, but maybe it would be better suited for a blog or diary of some sort.


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## Tigger (Nov 15, 2014)

jdox0776 said:


> I had to wait until I got the ecg report because only then did I have the evidence to back up what I was saying.  From what I was told it should have been attached to the PCR when I originally picked it up.  It took forever to get the hospital records but their ecg wasn't in there.  They are investigating my complaint.  It's hard to have to wait



I'm sorry, but that's how these things work. We aren't going to tell you that something was done wrong when you haven't presented anything close to an easy to follow story, and even then I still would not pass judgement.


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## triemal04 (Nov 19, 2014)

While a very unfortunate situation, I saw the thread that ERDoc referenced earlier, and for what it's worth the OP made it much clearer that she was getting involved in a lawsuit and looking for anything to bolster that.


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## PFDEMT (Nov 22, 2014)

since good ol louisville metro lets me as a emt get 12-lead i will check that..
also I would perform a stroke assesment buddy..* bp elevated and alterted= possible cva.*

But no cardiac history I am thinking *CVA!!!!!!!!!!!!!!!!!! 2lpm via n/c, with some nice diesel flapping in the wind.*


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## Akulahawk (Nov 22, 2014)

PFDEMT - while doing a stroke assessment isn't a bad thing, it's probably way down the list of things to do. My sense is that this guy had multiple issues going concurrently. This guy has respiratory complaints, a non-diagnostic ECG that is somewhat suspicious for _something_, a BP that's elevated, pale/diaphoretic skin signs, a note above that seems to indicate that the guy's trachea is deviated left (why?), posturing, along with a seizure disorder due to some metabolic issues, I'm just thinking that 2L of O2 by N/C and some diesel is going to be the magic treatment that's going to prevent this guy's demise. 

There's just too much missing from this for me to even _begin_ to figure this one out. Toss into the mix that there's a lawsuit brewing about this situation... I have my own suspicions about what may have happened in the hours before the call happened, but I'm not going to say what I think in this case.


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## Gurby (Nov 22, 2014)

Akulahawk said:


> I'm just thinking that 2L of O2 by N/C and some diesel is going to be the magic treatment that's going to prevent this guy's demise.



Seems to me that probably nothing we do is going to have much impact on this patient's long-term outcome, aside maybe from making a good transport decision and not spending too much time ****ing around on scene?


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## Akulahawk (Nov 22, 2014)

Gurby said:


> Seems to me that probably nothing we do is going to have much impact on this patient's long-term outcome, aside maybe from making a good transport decision and not spending too much time ****ing around on scene?


Actually, mostly my comment was "aimed" at the 2L of O2 by N/C... Seriously small drop in the bucket for what this guy needs... and needed probably a few hours ago. Making a good transport decision, while it would have been good to have done it early on, probably wouldn't have affected the outcome one whit.


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## JamesW (Nov 23, 2014)

beano said:


> How old is this patient? Male or female? Any other med Hx? HTN, DM, CHF? Any other symptoms, chest pain? Been sick lately? Has this been going on for days or hours?
> 
> If I was BLS I would probly O2 @2L, request ALS intercept and transport Code 2, no reason to hang around.
> 
> ALS interventions would depend on a more thorough Hx and physical exam.



Code 2? Here in Texas, we are not allowed to go code 2 since there was an issue of crashes related to drivers not hearing us. We only drive code 1 or 3.


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## TransportJockey (Nov 23, 2014)

JamesW said:


> Code 2? Here in Texas, we are not allowed to go code 2 since there was an issue of crashes related to drivers not hearing us. We only drive code 1 or 3.


Not all places use the same.terms for.emergent and nonemergent transport


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## JamesW (Nov 23, 2014)

jdox0776 said:


> 911 call dispatched breathing problems.  Pt had BP 200/110, RR 30 labored, diminished breath sounds bilaterally, tachypnic, diaphoretic peril, spO2 94%, glucose 208, seizure hx due to metabolic disorder (malabsorption of Calcium, potassium, magnesium)
> 
> Would you perform ECG (cardiac monitoring)?  capnography waveform?, apply o2?  IV access?  Load and go VS stay and play?



As a basic, I would definitely start with PPV w/ oxygen. I would consider CPAP if I felt he could maintain his breathing on his own, if not then BVM. He would definitely get a 12 lead also. those vitals are not stable enough for stay and play, he would need advanced care pretty fast. He would probably get insulin from ALS along with some kind of blood pressure meds.


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## STXmedic (Nov 23, 2014)

JamesW said:


> Code 2? Here in Texas, we are not allowed to go code 2 since there was an issue of crashes related to drivers not hearing us. We only drive code 1 or 3.


I go code 2 all the time... Especially at night. We may not designate as "code 2", but we do it all the time.


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## JamesW (Nov 23, 2014)

TransportJockey said:


> Not all places use the same.terms for.emergent and nonemergent transport


Ah. Code 1 here is non-emergent (no lights or sirens)
Code 3 is both lights and sirens.


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## STXmedic (Nov 23, 2014)

JamesW said:


> As a basic, I would definitely start with PPV w/ oxygen. I would consider CPAP if I felt he could maintain his breathing on his own, if not then BVM. He would definitely get a 12 lead also. those vitals are not stable enough for stay and play, he would need advanced care pretty fast. He would probably get insulin from ALS along with some kind of blood pressure meds.


Do you work for an area that ALS gives insulin? That's exceptionally rare if so.


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## JamesW (Nov 23, 2014)

STXmedic said:


> I go code 2 all the time... Especially at night. We may not designate as "code 2", but we do it all the time.


I would definitely understand the issue of driving code 2 at night in neighborhood areas.


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## STXmedic (Nov 23, 2014)

JamesW said:


> I would definitely understand the issue of driving code 2 at night in neighborhood areas.


Or highways at any time.


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## JamesW (Nov 23, 2014)

STXmedic said:


> Do you work for an area that ALS gives insulin? That's exceptionally rare if so.


I just finished EMT-B school. Im not sure about insulin but i know for a fact that they can do glucagon.


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## TransportJockey (Nov 23, 2014)

JamesW said:


> I just finished EMT-B school. Im not sure about insulin but i know for a fact that they can do glucagon.


Glucagon raises blood sugar via a release and conversion of glycogen


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## STXmedic (Nov 23, 2014)

JamesW said:


> I just finished EMT-B school. Im not sure about insulin but i know for a fact that they can do glucagon.


Glucagon is given for the opposite indication. Most states are absolute No's for prehospital insulin, but Texas is a little different than most states when it comes to protocols. I still know of only two systems that use insulin, though.


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## JamesW (Nov 23, 2014)

TransportJockey said:


> Glucagon raises blood sugar via a release and conversion of glycogen



I know, I was stating the meds i know that Austin Travis county gives for blood sugar related emergencies.


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## TransportJockey (Nov 23, 2014)

STXmedic said:


> Glucagon is given for the opposite indication. Most states are absolute No's for prehospital insulin, but Texas is a little different than most states when it comes to protocols. I still know of only two systems that use insulin, though.


We might be adding it soon... but even presidio doesn't carry it that I know of


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## JamesW (Nov 23, 2014)

STXmedic said:


> Glucagon is given for the opposite indication. Most states are absolute No's for prehospital insulin, but Texas is a little different than most states when it comes to protocols. I still know of only two systems that use insulin, though.



What is the reason for not letting them carry insulin?


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## TransportJockey (Nov 23, 2014)

JamesW said:


> What is the reason for not letting them carry insulin?


Requires refrigeration is one.of the main


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## STXmedic (Nov 23, 2014)

TransportJockey said:


> We might be adding it soon... but even presidio doesn't carry it that I know of


No? Well cut that down to one; I thought they did.


JamesW said:


> I know, I was stating the meds i know that Austin Travis county gives for blood sugar related emergencies.


Yeah, glucagon is very common. I would hope they did.


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## JamesW (Nov 23, 2014)

What would you do for someone who has DKA or HHNS?


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## TransportJockey (Nov 23, 2014)

JamesW said:


> What would you do for someone who has DKA or HHNS?


Fluid


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## STXmedic (Nov 23, 2014)

JamesW said:


> What would you do for someone who has DKA or HHNS?


Fluids for dehydration, zofran for nausea.


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## Gurby (Nov 23, 2014)

JamesW said:


> What is the reason for not letting them carry insulin?



Even in the hospital, insulin doses must be witnessed by another person when drawn up.  It is dosed in very tiny amounts, can be hard to dose when you don't know the pt's history very well, and can very easily kill someone.  

Even in places that do carry insulin, I don't think anyone should be administering it pre-hospitally for a BGL of 200.  Also, a BP of 200 probably isn't getting treated if that's their only complaint and they aren't symptomatic.  Obviously this patient IS symptomatic... But if for instance somebody's chief complaint is ABD pain that's been going on for 3 days, and they have history of HTN, and they're moving around and in a lot of pain... Meh.  A BP of 200 in and of itself isn't concerning - it's important to look at the whole picture.


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## Akulahawk (Nov 23, 2014)

Gurby said:


> *Even in the hospital, insulin doses must be witnessed by another person when drawn up.*  It is dosed in very tiny amounts, can be hard to dose when you don't know the pt's history very well, and can very easily kill someone.
> 
> Even in places that do carry insulin, I don't think anyone should be administering it pre-hospitally for a BGL of 200.  Also, a BP of 200 probably isn't getting treated if that's their only complaint and they aren't symptomatic.  Obviously this patient IS symptomatic... But if for instance somebody's chief complaint is ABD pain that's been going on for 3 days, and they have history of HTN, and they're moving around and in a lot of pain... Meh.  A BP of 200 in and of itself isn't concerning - it's important to look at the whole picture.


This is not always the case. It's certainly a good idea to have another person witness the amount of insulin drawn though, and many hospitals mandate this, but the last hospital I was in did not require another person to witness the insulin. Some people are quite sensitive to insulin, so any amount given to them can really affect their blood glucose level in short order. Prehospitally, a BGL of 200 isn't all that concerning anyway. Perhaps with a very long transport and following fluid admin might insulin be something to consider in small amounts if the BGL remains extremely high.


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## Angel (Nov 24, 2014)

Insulin is one drug I do not want in my protocols


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## TransportJockey (Nov 24, 2014)

The other problem with insulin in a DKA or HHNK patient is that you do NOT want to lower the CBG too much too fast. IT can cause some nasty effects


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## jonathan carreto (Dec 1, 2014)

Um I dont like that glucose level.


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## Gurby (Dec 1, 2014)

jonathan carreto said:


> Um I dont like that glucose level.



Why not?


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## jonathan carreto (Dec 1, 2014)

Too high.


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## jonathan carreto (Dec 1, 2014)

No ur right the about the BGL gurby. Just something to note


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## Gurby (Dec 2, 2014)

I mean I guess it's a bit high... But we know he has some weird metabolic disorder, and maybe he hasn't been compliant with his meds, and I'm much more worried about whatever else is going on with him.  Normal people can have elevated BGL during an MI, so I'm a bit concerned by what it might indicate... But I'm not too worried about the BGL itself - they can deal with it in the ER once everything else is stabilized.

So really you were right before - you were right to not like the elevated BGL.  Given patient's history it might not actually mean much/anything, but it could also be more evidence to indicate that he's having an MI.  

It's especially good to note this as basic, since you can't take a 12-lead, this could help guide your treatment/transport decisions.

Just my thoughts.


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## Gurby (Dec 2, 2014)

Just did a bit of internet research, and people don't really agree on this, but the BGL itself may indeed be a problem after all...  According to one source, "There is an inverse linear relationship between admission glucose concentration and chance of surviving to hospital discharge following myocardial infarction".  That is to say, the higher someone's BGL is upon admission following an MI, the lower their survival rate is...  It seems like we don't know for certain whether actively controlling the BGL makes a difference but it's a topic that is being researched.


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## Akulahawk (Dec 2, 2014)

Is the point they're researching the patient's BGL when admitted to the hospital from the ED or the patient's BGL when the patient arrives at the ED? Even though I've done precisely zero internet research into this matter at all, I highly suspect that the point that's being looked at is _hospital _admission. One of the reasons I suspect this is the case is that it's a whole lot easier to track serial BGL's on patients that are in a clinical setting than in the prehospital setting and unless the prehospital providers were all on-board with collecting that data, I doubt that checking an MI patient's BGL is going to be high on their "to-do" list. 

Insulin is quite the interesting stuff... and not stuff that I would feel all that comfy with giving in the field to patients that don't already have a Type I DM diagnosis _and_ therefore don't have insulin in their daily regimen, such as dealing with nutritional, correctional, and sliding scale doses. 

The garden variety hyperglycemic patient probably doesn't need insulin right away. In any event, when the body is put under stress, cortisol is released and one of the outcomes of that is gluconeogenesis which leads to hyperglycemia anyway... at least "hyper" relative to their normal BGL. 

At this point, if a BGL is checked, the info is "good to know" but leave the control of BGL to the ED. If the BGL isn't "HIGH" on the meter, it's better to be a bit elevated than too low. If you draw some blood and it looks like red Karo syrup, the BGL is probably way too high.


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## Gurby (Dec 2, 2014)

Akulahawk said:


> Is the point they're researching the patient's BGL when admitted to the hospital from the ED or the patient's BGL when the patient arrives at the ED? Even though I've done precisely zero internet research into this matter at all, I highly suspect that the point that's being looked at is _hospital _admission. One of the reasons I suspect this is the case is that it's a whole lot easier to track serial BGL's on patients that are in a clinical setting than in the prehospital setting and unless the prehospital providers were all on-board with collecting that data, I doubt that checking an MI patient's BGL is going to be high on their "to-do" list.
> 
> Insulin is quite the interesting stuff... and not stuff that I would feel all that comfy with giving in the field to patients that don't already have a Type I DM diagnosis _and_ therefore don't have insulin in their daily regimen, such as dealing with nutritional, correctional, and sliding scale doses.
> 
> ...




For our purposes my last post was basically academic speculation.  There are a handful of theories about what causes the correlation and not enough evidence to really say.

Agree on not doing anything to address this BGL in the field.


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