# So I had this run the other night....



## Epi-do (Apr 7, 2008)

We were dispatched on a run for difficulty breathing in an area that pulls another department along with us.  When we get there, the engine crew is slowly waltzing into the house (typical for this particular crew), but has actually grabbed their EMS equipment (highly unusual for this crew under the circumstances).  We grabbed our cot, left it just inside the front door, and I walk into the living room to see a woman in her 50's sitting on the couch in obvious distress.  

She has a history of CHF, COPD, stroke x 1, MI x 1, and anything else you can think of.  Some of her medications include the usual stuff - albuterol, lasix, dig, and countless others I can't remember.  She is unable to take ASA because it causes her to bleed.  She states she has taken two home albuterol nebs without any relief.

The medic off the engine immediately tells the patient she is going to give the patient another albuterol treatment to help her breathing.  Because of the engine crew in the way, I can't get close to the patient, but ask about breath sounds.  The medic says she hasn't listened to them, and then is unable to find a stethascope to actually do it.  The rest of her crew moves out of the way and I am able to get in and take a listen - crackles in all lobes.  She didn't quite have the "percolator" sound going on without the stethascope, but she was getting close to it.

The medic is not even talking to the patient at this point.  I suggest we get her onto the cot and out to the truck, so we help her to stand and pivot onto the cot.  Even with a NRB @ 15 lpm she became very winded simply standing up.  Out to the truck, and the medic actually decides to join me.  She promptly give the patient 5 of albuterol via nebulizer.

I continue to talk to the patient and get even more information - the pitting edema in her legs is not normal for her, she feels just like she has in the past when she was hospitalized for heart failure, she feels "really congested, like my lungs are full."  The medic is worried about getting an IV, so I double check the vital signs the engine crew attempted to get.  SBP 160, HR 115-120, RR 28-30 & shallow.

I ask the medic if she wants to give the patient any nitro, and she tells me that she thinks she will just hold off for right now and see what the albuterol does.  Ok....she's the medic, right?  I then ask if she wants the patient put on the monitor.  I was shocked when she actually agreed to it.

Throughout our transport to the hospital, the patient never improved, and the medic never treated her for CHF.  It seems to me that there was every single sign, except a big flashing neon one over the patient's head, that indicated this was a CHF problem and not a COPD/asthma problem.  Am I way off base here?  

I just have to keep reminding myself that in about 4 months I will be a medic and won't have to depend upon her to treat my patients that require ALS care.  It's just really frustrating to know what this patient needs and not be able to just do it because I am still "just" a medic student and I was on duty and not on a clinical.


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## BruceD (Apr 8, 2008)

Forgive me, I will not be approaching this from the point of view of what treatment would have been appropriate, without having been there I would be hesitant to comment on this one. (also, I'm not sure how "...MI x 1, and anything else you can think of..." would affect patient treatment.)  I guess in this instance, i would be called devil's advocate.

I seemed to notice a subtle pattern of general contempt, loathing, or disdain for the efforts put forth and the abilities of those you work with, at least those mentioned in your post.

Perhaps you could consider the following...
1) Speak with the medic you worked the patient with, ask her to go through their thought processes with you.  Perhaps there was something she picked up on that didn't shout out at you.  Every situation in life can be a learning experience (sometimes for you, sometimes for them!)
2) If a patient's life was endangered or inappropriate care was given, perhaps suggest a review/CEUs/extra training/QA/whatever, although probably not to the medic's face 
3) Occasionally, when there is a personality incompatibility, it may be worthwhile to request a different shift, different partner, or even a different area.  It doesn't even have to be apparent why you are requesting movement.

tc & gl
-B


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## Epi-do (Apr 8, 2008)

BruceD said:


> Perhaps you could consider the following...
> 1) Speak with the medic you worked the patient with, ask her to go through their thought processes with you.  Perhaps there was something she picked up on that didn't shout out at you.  Every situation in life can be a learning experience (sometimes for you, sometimes for them!)
> 2) If a patient's life was endangered or inappropriate care was given, perhaps suggest a review/CEUs/extra training/QA/whatever, although probably not to the medic's face
> 3) Occasionally, when there is a personality incompatibility, it may be worthwhile to request a different shift, different partner, or even a different area.  It doesn't even have to be apparent why you are requesting movement.



1)  Bruce, you are correct in stating I do not particularly care for this medic's abilities.  However, this run is just one of many where "questionable" decisions have been made.  I have been on runs with her where she hasn't been able to figure out how to use her own equipment (and it wasn't a matter of the equipment was new and she was unfamiliar with it, she simply did not know how it worked), then there was the DOA we had that was laying in his bed, ice cold, rigored, and had lividity.  She hooked the patient up to the monitor, so I did ask her why she did so once we were outside the house.  She told me that she needed to "confirm asystole in three leads before declaring the patient dead."  Our protocols state that if the patient is cold, rigored, or has lividity that an EMT-B can call the patient, and that there is no need to put the patient on the monitor.   

This particular patient had a history of both CHF and COPD, so it would be possible for one to argue that she simply made a mistake when choosing to follow our COPD protocol as opposed to our CHF protocol.  However, she initially made the decision to go one direction over the other without ever listening to breathsounds.  The patient hadn't yet gotten bad enough for breath sounds to be audible without a stethoscope, therefore, how can anyone reasonably decide if they should treat for wheezes or crackles?  At least here, our protocols allow for two entirely different treatments depending upon which of those two breath sounds you hear.  When asked why she treated the patient the way she did, she stammered around and couldn't say what made her choose to treat the way she did.  (Which was asked after patient care was transferred to the ER staff.)

2)  I would love to be able to recommend this run be reviewed, or some remedial training take place.  Heck, do a department-wide EMS training on CHF vs. COPD - it would be a good review for everyone.  However, we do not work for the same department.  She works for one fire department, and I work for a different one.  I am not even sure where I would start if I wanted to have the issue addressed.  

3) While it may not seem like it from my original post, my issue with this medic is not personal - in fact, on the way back from the hospital to drop her off we had a great conversation.  I first met her almost 10 years ago, before either one of us had went to medic school and were both basics.  My issue is with how she does/doesn't treat her patients.  I refuse to change shifts/houses because of someone I only occassionally take runs with, and who works for a different department.  I absolutely love my crew, and don't want to work with anyone else.  The occassional mutual aid run is not going to make me leave "my guys."  Soon enough I will be finished with medic class, and at that point she will no longer have to transport on my truck as the primary medic when we do run together.  I just have to be patient and wait out the next 4 months or so.


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## BruceD (Apr 8, 2008)

I understand not wanting to leave 'your guys'.  

From your description alone, ya, sounds like wrong decisions were made, but I'd have to leave that to the paramedics to answer.

If she is as consistently bad at treating patients as you say, perhaps you need to approach your superiors to approach hers?  You would definitely want to have your ducks in a row, with the rank difference or you will get eaten.

4 months will pass by before you know it.
tc
-B


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## johnrsemt (Apr 8, 2008)

is she th one you and I were talking about?    if so she is the same at her part time job from what I have heard.


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## Epi-do (Apr 8, 2008)

Yep - the same one I was talking about with you the other day.  Just frustrated and needed to vent about the situation.


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## skyemt (Apr 9, 2008)

firstly,

are you asking a real question, or trashing a medic?

the latter will not get you many constructive answers...

i think the first thing to do in that situation would be to actually ask the medic what the thought process was, and why certain decisions were made the way they were...

there might be a line of thought that you were not aware of... again, there might not be... but you don't allow for the possibility if you don't ask...

then, if you are posting a question about treatment modalities, you will be providing a better context for constructive answers...

it is always easier to pass judgement when you are a step removed...

why not just ask the medic about it?


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## Epi-do (Apr 9, 2008)

skyemt said:


> firstly,
> 
> are you asking a real question, or trashing a medic?



Although I was frustrated and venting about this run, I want opinions from others about treatment modalities.  The intent was not to trash this medic, and I probably should have waited until I had a chance to cool off before posting about it.



skyemt said:


> i think the first thing to do in that situation would be to actually ask the medic what the thought process was, and why certain decisions were made the way they were...



I did ask the medic about it - below is part of my response to BruceD.  I highlighted the part where I say so.



Epi-do said:


> This particular patient had a history of both CHF and COPD, so it would be possible for one to argue that she simply made a mistake when choosing to follow our COPD protocol as opposed to our CHF protocol.  However, she initially made the decision to go one direction over the other without ever listening to breathsounds.  The patient hadn't yet gotten bad enough for breath sounds to be audible without a stethoscope, therefore, how can anyone reasonably decide if they should treat for wheezes or crackles?  At least here, our protocols allow for two entirely different treatments depending upon which of those two breath sounds you hear.  *When asked why she treated the patient the way she did, she stammered around and couldn't say what made her choose to treat the way she did.  (Which was asked after patient care was transferred to the ER staff.)*



This medic was able to give me no explanation at all when asked about it.  (And, no, I was not confrontational about it when I asked her.)  In fact, she never answered my questions about it and changed the subject quickly to an OD run we had on a previous shift.  We then talked the rest of the way back to her firehouse about people we both knew from a different department, where we both got our start in EMS/fire.  Like I said before, my issue with this person is not personal at all.  

I am just wondering if I am way off base for thinking this patient should have been treated for CHF instead of COPD.  She isn't what I would call a frequent flier, but she does have a significant medical history, and we do run on her every couple months or so.  If this run came out 4-5 months from now, I would have been the medic providing patient care.  Based on what I have been taught in class and on clinicals, I would treat for CHF.  I am just trying to understand why the medic opted to go a different way, and am unable to get any sort of answer from her.


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