# Behavioral Emergency



## IAems (Jun 20, 2011)

So, was there an underlying medical cause?

Called to respond to a board & care for an involuntary psychiatric hold written prior to arrival for "danger to others" by a registered nurse (who is part of a local psychiatric evaluation team).  I arrive on scene to find the patient ambulatory and wandering the hallways, with the RN assessing the patient behind a bulletproof glass screen (having made no actual patient contact).  The patient is scared off by my uniform and wanders down to her room.  RN dismissively gives a report which pretty much is summarized by, "Your patient's in room 24" (it was like trying to pull teeth to even get a med list which included only Prozac and Topamax).

Upon patient contact, patient exhibiting anxiety with severe dissociative speech (either conduction or jargon aphasia, e.g., "I have two stomachs but the moon can hardly be held responsible for a syllable.  YOU HAVE NO FEET!! You have no feet.")  The RN denies any immediate trauma.  With a verbal GCS response of 3, I can't really obtain any sort of verbal assessment; this patient wouldn't even respond, "yes" or "no" or shake their head.  Pupils are bilaterally dilated to about 6mm but equal and responsive to light.  V/S as follows; HR: 136 W/R, RR: 20 (No accessory muscle use or increased effort of breathing, but seemingly increased tidal volume), BP 150/90, BGL 146.  No facial droop.  No slurred speech.

Now I'm aware that this sort of speech disorder is common of Schizophrenia, but the RN denies any such history, stating, "Patient only has Bipolar Disorder." To which, I ask about the Topamax which I believe is for Seizures and am told, "No, no, no."  When I bring up the tachycardia and hypertension, I'm told, "She's just anxious."  So, I transport the patient to the requested facility (12 minutes out) as I'm hoping that the patient's primary physician will be able to answer some of these questions, but instead of taking directly to the psychiatric ward as requested, I decide to clear the patient through the ER for a medical evaluation first.

Well, apparently, according to the doctor, I should have followed the nurse's orders and taken the patient directly up to the psychiatric floor, which I disagree with.  The reason for this, I was told, was that ER departments are unable to deal with involuntary psychiatric patients without prior notice (on that note for US practitioners: Is there some sort of EMTLA exception for psychiatric patients that I'm unaware of).  Anyway, my patient was apparently medically cleared in a very short period of time, suggesting my assessment was lacking.  

Did I overreact?  Was this simply undiagnosed schizophrenia masking the symptoms of an anxiety attack?  Was I wrong in seeing the apparent S/S of a possible OD?  What about postictal from a recent, unwitnessed seizure as the Topamax suggests?  Let me know what you think or where to look to learn more.  Thanks


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## Aidey (Jun 21, 2011)

Topamax, along with a number of other seizure medications are commonly used for bipolar disorder. This includes Lamictal, Depakote, Tegretol, and Trileptal. 

Both severe manic and depressive episodes can cause psychosis. Given the limited information available I doubt I would have taken the pt to the ED rather than the psych ward.


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## Anjel (Jun 21, 2011)

sounds like a mental break to me and possibly onset of a new condition. Or one no one knew they had anyway. 

I used to work in a psych office and what you described is pretty common. 

I probably would of taken them straight to the psych ward.


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## bigbaldguy (Jun 21, 2011)

We're told over and over again to always err on the side of caution. If the patient bumps his head use full C spine precautions. If the patient says their stomach hurts do a 12 lead ect. Then when we do, we get hammered for over reacting. It's just a tough call all around where you draw the line. I think it just comes down to experience (which I don't have) in making these desicions. Did you over react, maybe but if this patient was having a stroke or something and you didn't check your hunch you'd get hammered for that too, maybe more than hammered maybe sued fired ect. I guess all guys like you and me can do is keep looking like the occasional idiot who over reacts rather than run the risk of letting our inexperience kill someone because we're too proud to admit we just aren't sure about something.


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## Farmer2DO (Jun 21, 2011)

I absolutely would have taken the patient to the ED.  Only documented psych hx is bipolar, with an altered mental status not completely explained by the history.  Also, a HR of 136 is pretty excessive.  None of our psych departments here would even consider taking this patient.

As far as I know, there is no EMTALA exception for psych.  I think the hospital was handing you a line of crap because they didn't want to deal with a psych.  Also, I take orders from physicians, not nurses.

You were completely correct and appropriate in doing what you did.


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## BandageBrigade (Jun 21, 2011)

How does emtala apply? Patient was a direct admit to the hospital, the hospital had accepted care.  They were not refusing the patient in anyway. There had to be a doctors orders for the patient to be admitted; as far as I know a nurse cannot get a patient admitted without a physicians orders.


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## Farmer2DO (Jun 21, 2011)

BandageBrigade said:


> How does emtala apply? Patient was a direct admit to the hospital, the hospital had accepted care.  They were not refusing the patient in anyway. There had to be a doctors orders for the patient to be admitted; as far as I know a nurse cannot get a patient admitted without a physicians orders.



EMTALA applies because it mandates an appropriate medical screening examination.  Where I am, that doesn't happen in psych.  A patient with a HR of 136 and unexplained AMS needs to be examined medically.  

The doctors order most likely came over the phone, from the nurse sitting behind to bullet proof glass that hadn't assessed the patient.  That doesn't count as a medical screening evaluation.  If this patient went to psych with a HR of 136 and later had a bad outcome (let's say PE) and was unable to verbalize their complaints, for whatever reason, everyone involved would have their a$$ in the frying pan.  IAems assured that he wouldn't be part of the campfire, and tried to ensure appropriate care for his patient at the same time.  I still say, good choice to go to the ED.


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## 8jimi8 (Jun 21, 2011)

Direct admits are usually MD to MD phone consults. Having an MD order lretty much clears you to bypass the ED, no?  I have directly interfered with a discharge (for direct admit) to a psych facility by using the words uncontrolled chest pain second to pulmonary hTN.  The receiving MD refused the pt upon hearing my assessment. So possibly the answer was calling med control?  What do you think?


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## IAems (Jun 21, 2011)

*If only . . .*



8jimi8 said:


> So possibly the answer was calling med control?  What do you think?



In LA, BLS does not make contact with med-control (which for us is base hospital contact), only ALS does.  No kidding.  I have brought this problem up to the County on multiple occacions only to be dismissed.  I wish I and my fellow basics could contact med-control for orders in these unusual circumstances, but you're kind of on your own.  Also, since I'm not directly hearing the order from the physician, I can't assume that a physician made any such order, especially at a board and care which may or may not have physician oversight.  If this was hospital to hospital that would be one thing, but we're talking about a board and care where patients wander hallways left to their own devices and come and go as they please.  For all I know this could have been controlled substances. . .  It wouldn't be the first time I've seen it at a board and care.


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## Seaglass (Jun 21, 2011)

I don't think your choice was unreasonable, but I would've taken the pt straight to the psych floor. My reasons: 

-There's nothing there that strongly indicates a non-psych emergency to me. Misdiagnosis, maybe--this could be the first presentation of schizoaffective disorder--but not a head injury or something similar. Those vitals are worth another look, but may not be all that scary, depending on the patient. For someone young, out of shape, and agitated, I wouldn't be too worried. 

-The psych floor may actually be more likely to recognize a non-psych emergency. In my experience, a lot of providers outside that specialty will chalk up everything they see to the psych issue, no matter how poorly it fits.

All that being said, I'm used to good psych facilities. If I didn't have those, or I knew the ED staff was good with psych pts, I'd have gone there. Regardless, I would've called med control. CYA.


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## jccilm (Jun 21, 2011)

Seaglass said:


> I don't think your choice was unreasonable, but I would've taken the pt straight to the psych floor. My reasons:
> 
> -The psych floor may actually be more likely to recognize a non-psych emergency. In my experience, a lot of providers outside that specialty will chalk up everything they see to the psych issue, no matter how poorly it fits.



So you're saying that because the psych department was definitive care that they would do a better job at treating the patient than the ED?


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## firetender (Jun 21, 2011)

This involves a common problem with calls like this; TRUST.

I really don't trust the RN's at the facility either. They had negligible patient contact, therefore no real physical evaluation went on. Compound that with not really trusting the patient to provide accurate data to work with and you have a reason to have a more thorough evaluation of the patient done at an ER prior to admission in the Psych ward. You were between a rock and a hard place and acted appropriately.


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## socalmedic (Jun 22, 2011)

@IA, yes you can contact medcontrol just call the hospital ED and ask to speak with an MICN she will tell you their recorded number. then go from there, you will have to tell them a few times that you are BLS and need a destination decision, they will be confused, the RN, this is usual just roll with it.


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## Aidey (Jun 22, 2011)

Out of curiosity how do we know for sure that the RN never directly assessed the patient? Is there any indication that the RN hadn't done a more extensive assessment prior to EMS arriving on scene?


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## IAems (Jun 22, 2011)

*Good question, depressing answer*



Aidey said:


> Out of curiosity how do we know for sure that the RN never directly assessed the patient? Is there any indication that the RN hadn't done a more extensive assessment prior to EMS arriving on scene?



I've worked with this particular RN for two years now and I can guarantee she didn't conduct a physical assessment.  Sometimes a psych hold is written before patient contact, but that's a whole other issue.


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## Aidey (Jun 22, 2011)

There are times when psych holds here are written before the practitioner has seen the patient and I understand why. Most of these cases are patients who are court ordered to do certain things like take their meds, not drink/do drugs, or attend weekly counseling sessions. When they violate the court order the psych hold is automatically issued. 

There are also times where a friend/family member gives them enough information to warrant a psych hold. The practitioner has the ability to decide NOT to have the patient transported if the clinical picture doesn't meet what was described. 

Considering the potential for things to go wrong when confronting someone in their home, I understand getting the hold paperwork ahead of time.


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## CAOX3 (Jun 22, 2011)

IAems said:


> Did I overreact?  Was this simply undiagnosed schizophrenia masking the symptoms of an anxiety attack?



Could be, but I dont think it changes anything. 



IAems said:


> Was I wrong in seeing the apparent S/S of a possible OD?


No you werent wrong? Its a likely avenue to explore.



IAems said:


> What about postictal from a recent, unwitnessed seizure as the Topamax suggests?



Could be but again Im not sure it makes this an emergency, people with a seizure hx, well they have seizures. 



IAems said:


> Let me know what you think or where to look to learn more.  Thanks



I think you did fine, you relayed your suspicions, thats all you can do.  Im not going to come unglued because I believe the patient needs to go to the ER rather then a floor, You fullfilled your obligations, choose your battles wisely and if you plan on spending any amount of time in EMS your going to need thick skin this field is full of second guessing Monday morning quarterbacks.


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## Seaglass (Jun 22, 2011)

jccilm said:


> So you're saying that because the psych department was definitive care that they would do a better job at treating the patient than the ED?



Not really. Just that I'm more likely to trust them not to be distracted by the patient's most obvious signs. (Again, this only really applies to the ones I know.)


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## IAems (Jun 22, 2011)

*Absolutely right, but . . .*



Aidey said:


> There are times when psych holds here are written before the practitioner has seen the patient and I understand why. Most of these cases are patients who are court ordered to do certain things like take their meds, not drink/do drugs, or attend weekly counseling sessions. When they violate the court order the psych hold is automatically issued.
> 
> There are also times where a friend/family member gives them enough information to warrant a psych hold. The practitioner has the ability to decide NOT to have the patient transported if the clinical picture doesn't meet what was described.
> 
> Considering the potential for things to go wrong when confronting someone in their home, I understand getting the hold paperwork ahead of time.



I will completely agree that there should be _occasional cases_ where a practitioner doesn't physically assess a patient prior to writing a psych hold, but when that's _the rule_ more often than the exception, I do have a little bit of a problem.  For example, I shouldn't be telling the RN about abnormal vital signs or dilated pupils, or have them completely dismiss me when I'm simply asking for clarity regarding medications.  Honestly, with this particular nurse I'm lucky to (A) know where the patient is, (B) receive any sort of report, and (C) find myself in any semblance of a controlled environment.  I'm not complaining, really, that's what I love about EMS, but it is nice when our fellow health care providers make _*some*_ attempt . . .


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## Journey (Jun 22, 2011)

IAems said:


> I will completely agree that there should be _occasional cases_ where a practitioner doesn't physically assess a patient prior to writing a psych hold, but when that's _the rule_ more often than the exception, I do have a little bit of a problem.  For example, I shouldn't be telling the RN about abnormal vital signs or dilated pupils, or have them completely dismiss me when I'm simply asking for clarity regarding medications.  Honestly, with this particular nurse I'm lucky to (A) know where the patient is, (B) receive any sort of report, and (C) find myself in any semblance of a controlled environment.  I'm not complaining, really, that's what I love about EMS, but it is nice when our fellow health care providers make _*some*_ attempt . . .



Was the psych ward located in or attached to a hospital? 

By stating earlier that you worked with this RN, in what capacity? Are you trained as a Mental Health professional? What psych training did your EMT training give you to make a list of differentials as they pertain to mental health issues?

Do you know how long this patient was with the RN or if there was a court or other medical professionals involved?  The patient has prescription medications so some history was at least known and probably played a role in the assessment. 

Psych patients benefit from getting to an environment where they can be unrestrained even if in a locked room. Being tied down in an ED in full public view with Security Guards is not an effective initiation of good treatment. Not only is it traumatic for this patient but also for the toddler who might be in the bed next to them. 

If this was a hospital based or even a free standing psych unit, their admission workup normally requires an ECG and labwork. 

This sounds more like you just don't like this nurse for whatever reason and as an EMT, you want to prove her wrong every chance you get. Your agrument is sounding more personal than professional with each post you make.  What you are doing is proving is you may have limited knowledge of the system you work in for mental health admissions.  Learn about what others actually do first before going off on an RN whom you only see for a few minutes.   

And, the RN may be giving a report what she believe is appropriate for your level of training.  It is not uncommon for facilities to only give limited information knowing the level of EMT. Why go indepth with medications and advanced procedures done when that report has already been given to the other facility and whatever else is in the paperwork or easily accessible on some computer systems. No physician or RN should even rely just on the information relayed to them about medications from an entry level provider who has not had any pharmacology in their training. Of course there will be exceptions but most EMTs are still just held to the knowledge in a 110 hour course.


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## exodus (Jun 22, 2011)

Easy answer: Call the recieving hospital, let them know what you found and ask if THEY want you to continue to their facility or go through the ER first. Many times they won't mind the pt being cleared by an ER, especially if it's an off-site location.


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## Journey (Jun 22, 2011)

exodus said:


> Easy answer: Call the recieving hospital, let them know what you found and ask if THEY want you to continue to their facility or go through the ER first. Many times they won't mind the pt being cleared by an ER, especially if it's an off-site location.



Several factors may be involved here especially if it is a hospital based unit.

The hold in the ED may cancel out the direct admit which may then mean another evaluation which will require the patient to be tied up in the ED longer and not getting the necessary treatment. The patient may also lose his bed at that facility and will have to wait longer until another doctor or someone can arrange for transfer to another facility. In the meantime a bed is being occupied for a physical exam which could have been done in the psych unit especially if hospital based. Another ambulance will then have to be called to transfer the patient to another facility and possibly one where his doctor does not have privileges.  Thus, the initial ambulance crew may have created a problem which so many in EMS complain about. In this example the Wake County APP makes sense but that is designed for those who do not already have a direct admit established. Although in this case the APP could have been called to talk at a more informed level with the RN and have a better understanding for the basis of the admission...hopefuilly.


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## CAOX3 (Jun 22, 2011)

IAems said:


> I will completely agree that there should be _occasional cases_ where a practitioner doesn't physically assess a patient prior to writing a psych hold, but when that's _the rule_ more often than the exception, I do have a little bit of a problem.  For example, I shouldn't be telling the RN about abnormal vital signs or dilated pupils, or have them completely dismiss me when I'm simply asking for clarity regarding medications.  Honestly, with this particular nurse I'm lucky to (A) know where the patient is, (B) receive any sort of report, and (C) find myself in any semblance of a controlled environment.  I'm not complaining, really, that's what I love about EMS, but it is nice when our fellow health care providers make _*some*_ attempt . . .



See your worrying about things you have no control over, you made an attempt to obtain a report she didn't comply or didn't care.  Your not going to change the work ethic of an incompetent nurse so don't even bother attempting it.

Your  job now is to address the needs of the patient with or without the nurses help.

I think you did that. You fought for what you believed to be in the best interest of the patient, sometimes we don't get the results we're looking for, the point is you made the attempt and at times your just going to have to be satisfied with that.


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## Journey (Jun 22, 2011)

IAems said:


> Well, apparently, according to the doctor, I should have followed the nurse's orders and taken the patient directly up to the psychiatric floor, which I disagree with.  The reason for this, I was told, was that ER departments are unable to deal with involuntary psychiatric patients without prior notice (on that note for US practitioners: Is there some sort of EMTLA exception for psychiatric patients that I'm unaware of).  Anyway, my patient was apparently medically cleared in a very short period of time, suggesting my assessment was lacking.



This is one problem with anonymous forums. It is very easy to seek out sympathetic advice and opinions from people who don't know you and are more than willing to support one of their own instead of seeking out more information and getting alittle education in the process from those in your immediate area like the doctor.  You want everyone, and many will, to agree the RN is an idiot according to your version of the story and you also want to prove the doctor wrong.  Yet, you have not shown where your assessment indicates a specific knowledge of psych patients. You also may not be aware of which EDs are better equipped to handle involuntary psych holds. There are many precautions that facility must take when these patients are in their ED. So instead of trying to justify your actions, get more informed about the protocols, facilities and laws governing your area.  You can only expect others to justify your actions solely based on your story. I would like to know the RN's and doctor's side.  

We can all pat you on the back in the internet way but it really does not help you with the next psych patient. Your attitude towards the RN and now this doctor may also influence your judgement for the next patient. You may keep making the same mistakes over and over because you have not looked for reliable information based on your area and your resources.   I think that is a good argument for an EMT to advance their education rather than getting years of experience at a Basic level without knowing more about the many disease processes including the psych situations.


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## IAems (Jun 22, 2011)

Journey said:


> Was the psych ward located in or attached to a hospital?
> 
> By stating earlier that you worked with this RN, in what capacity? Are you trained as a Mental Health professional? What psych training did your EMT training give you to make a list of differentials as they pertain to mental health issues?



This nurse works with a Local PET and refers calls to us.  We work with several hospital PET groups and I have nothing but the best to say for most of them.  I will admit EMT specific training was brief, and I only have an A.S. in Psychology (might as well be nothing), but any EMS provider is trained in behavioral emergencies.     



Journey said:


> Psych patients benefit from getting to an environment where they can be unrestrained even if in a locked room. Being tied down in an ED in full public view with Security Guards is not an effective initiation of good treatment. Not only is it traumatic for this patient but also for the toddler who might be in the bed next to them.



Couldn't agree with you more.  I have actually been involved in changing local policies regarding mandatory restraint placement on non-combative, non-violent psychiatric patients and, at my own company, through the oversight of multiple mental health professionals and medical direction, instituted a psychiatric / behavioral emergency in-service involving orientation to various warning signs and symptoms of behavioral emergencies, as well as orientation to the DSM-IV-TR, and even very basic self-defense with a strong emphasis on minimizing potential harm to both the health care provider and the patient. 



Journey said:


> If this was a hospital based or even a free standing psych unit, their admission workup normally requires an ECG and labwork.



This facility's work-up does not require either or, at the very least, does not require it at intake.



Journey said:


> This sounds more like you just don't like this nurse . . .[and] want to prove her wrong every chance you get. Your argument is sounding more personal than professional with each post you make.  Learn about what others actually do first before going off on an RN whom you only see for a few minutes.



I will admit that her attitude toward patients is a little disconcerting to me.  I've seen passionate nurses and they are worth their weight in gold, and I've seen burned-out providers while always trying to remember to give people the benefit of the doubt because this industry (and psychology in particular) is tough.  I agree, the previous posts have been more personal than professional, but, psychology is what brought me into the industry and I sometimes get a little too worked up about it.  You have given me some more things to consider, but as an EMS provider, should I be considering an admission process?  And is it _always_ best to trust someone's word just because they have letters after their name?


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## Journey (Jun 22, 2011)

IAems said:


> I will admit that her attitude toward patients is a little disconcerting to me.  I've seen *passionate nurses *and they are worth their weight in gold, and I've seen *burned-out providers *while always trying to remember to give people the benefit of the doubt because this industry (and psychology in particular) is tough.  I agree, the previous posts have been more personal than professional, but, psychology is what brought me into the industry and I sometimes get a little too worked up about it.  You have given me some more things to consider, but as an EMS provider, should I be considering an admission process?  And is it _always_ best to trust someone's word just because they have letters after their name?



Just because another professional is not openly passionate does not mean they do not care. Some have learned to no wear their emotions on their sleeve for all to see including the patient.  RNs and other health care workers may have grave info about patients that they must not show for it not being the appropriate time. They may also have worked a couple of suicide attempts or successful along with doing a few involuntary psych holds. This RN may have had to place an 8 y/o into involuntary custody who displayed anything but human behavior. In the ED one RN may work a couple of pedi codes and maybe two or 3 adult codes in a slow day. They may have had to be present to console a patient who miscarried after multiple pregnancy attempts.  All of the emergencies that each ambulance brings in may land on the RN's plate. When they are caring for 10 patients at any given time, they have to adjust and not get weepy or constantly getting upset when the system is not perfect and neither are the care givers or patients.   When you keep that in perspective, you can see why on the nursing forums there are not endless threads about the stupid things EMS providers do everyday when bringing or picking up patients. Yeah the nursing forums are full of ramblings but rarely do they point out the faults of other professions such as the way those in EMS do. Maybe that comes with education and more experience from working as a multidisciplinary team with many patients in your care at one time.  Those in the hospital are also quick to realize their errors as the statistics show for medication.  Somebody is always looking and believe me when I say if that RN sent an unstable patient to a psych unit, the incident would be noted formally and she would be expected to answer for her actions which may include the nursing board's involvement.


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## Journey (Jun 22, 2011)

IAems said:


> And is it _always_ best to trust someone's word just because they have letters after their name?



Just like the midwife thread, if someone has higher education than you and more experience in a particular speciality, do not kick them to the curb. Use them and learn from them. EMT school specialize in very little and the even includes emergency medicine.  I do respect education and experience. What might appear wrong to me might actually be correct.  

Let me give you a recent practical example.  In the ED, due to all the uproar about an oxygen article (and a poorly written one at that), I had an EMS crew screaming at me that I was going to kill the patient because I put them on a NRB while setting up for a BiPAP trial knowing we would probably be intubating anyway. What they didn't understand, even after myself and the physcian tried to explain, was while the SpO2 was 98%, the A-a gradient was 400 mmHg with a lactate of 7 0mmol/L in a patient who already has renal insufficiency.  Until the oxygenation/ventilation and BP MAP could be stabilized to obtain a decent ScvO2, a higher level of oxygen was going to have to stay in place until other rescue measures are achieved.   Thus, the EMS crew went away  in anger and frustration that they couldn't "save" the patient from the idiots in the ED.  I'm sure on some EMS forum, maybe even this one, they vented their frustrations about how the ED staff was harming the patient and got all to agree with them.


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