# So, this kind of made me wonder...



## Buzz (Aug 13, 2008)

We had to go pick up a patient from a psych hospital yesterday dispatched as priority 3: pneumonia. We showed up, and they had him on a nasal cannula at 5Lpm *laying flat on his back*. He was extremely hypoxic, diaphoretic, his respiration were at 38 per minute, his limbs were freezing, but his core was quite warm. My partner leaned over him to listen to lung sounds, which means she leaned over him. The nurse decides to tell us he has MRSA in his sputum AFTER she had just put her face in front of his (which I don't think was smart anyways, but they could have given us a heads up since they were standing there watching us the whole time). They also waited to say he had a history of unexpectedly swinging at people that were near him, granted given his condition, I wasn't expecting him to do that: We got a blood pressure of 80/40 initially. 

We put him on a NRB@15Lpm, sat him all the way up, elevated his legs, and his B/P rose, his breathing slowed, and his pulse got a bit stronger. His extremities were still ice cold and he was still looking quite pale, but he improved quite a bit. His B/P was up to 100/70 and his respiratory rate was down to 24 by the time we got him to the ED.

It just sort of upset me that they didn't even have him sitting up. I know it's a psych hospital, but I would have thought that is sort of a common knowledge sort of thing. We probably should have been dispatched at a higher priority as well. Any longer and he'd probably have been much worse off. 

Just wanted to vent a little.


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## VentMedic (Aug 13, 2008)

Remember they did call for your help.  Don't let the word hospital fool you. This sounds like a free standing speciality facility.

You want to sit somebody up with low BP?  

And, if they had put him in trendelenburg, that would have further compromised his airway besides being controversial as treatment. 

If they had sat him up and bottomed his BP to a much lower level, what, at a BLS level, would you have been able to do to remedy that? 

This patient's body is trying to compensate. Raising the legs is only a temporary fix.  If this is sepsis, it can progress very rapidly.  Since this is a psych hospital, they probably don't do vital signs that often and would not attempt a rectal temp on this patient to have caught the potential severity of it earlier.  

Even in the hospital, that patient will be flat, but with a high concentration of O2 and IVs also going, until the BP stabilizes .   If you visit a progressive ICU, you will even see ARDS patients in the prone position (with the aide of special beds).  

O2 can be a wonderful drug and alleviate some symptoms but it isn't always the cure by itself.  

Also, if this is a free standing psych hospital, their capabilty to provide a higher flow of O2 might be limited to 5 liters by concentrator if they do not have medical gas pipes throughout their hospital.   If they were using O2 tanks, unless they had Hs available, a D or E cylinder would be depleted quickly with a 15 l/m NRBM.  

Taking a swing at others? You are in a psych hospital.  Be mindful of your body position in relation to the patient and that applies to any situation. 

The clue of this being dispatched as PNA should tell you the patient may have something in their sputum and may even cough or breathe on you.   

You use as many commonsense precautions as possible with patients because most of the time they have bugs that haven't been cultured yet.   A large percentage of the patients you transport will be infected or colonized with something and sometimes too many things to even begin to list.   If you do a large number of nursing home or any type of transports, you should be familiar with things like clostridium difficile (C-Diff), MRSA, VRE and Hep C, but your precautions should be universal and equipment cleaning habits flawless. 

I even avoid close contact with some co-workers when they are sneezing and wheezing no matter how many times they tell me it is just allergies by their own diagnosis.


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## Buzz (Aug 13, 2008)

VentMedic said:


> Remember they did call for your help.  Don't let the word hospital fool you. This sounds like a free standing speciality facility.
> 
> You want to sit somebody up with low BP?
> 
> ...



I sat him up because we were hearing rales in all fields on his lungs and he was cyanotic. He wasn't able to speak anyways, but he was clearly having difficulty breathing. Sitting him up was really my best attempt at improving breathing, despite his B/P. I got lucky that he improved, but my thought was that airway and breathing do come before circulation, right? Raising the legs as well was our feeble attempt at raising his blood pressure.

As for the O2 limitations, they may not have been able to put him on a NRB, but he definitely wasn't hooked up to a concentrator. He was hooked up to the system in the walls. I've also seen other patients in that facility with a simple mask on as well.


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## Ridryder911 (Aug 13, 2008)

Sounds like he has multiple problems.. Of course pneumonia, septic shock; just to name a few. 

Personally, I have found positioning has very little to do with pressure as long as it is not extreme. As well, I have as of yet seen any trendelenburg work any more affective than the supine position. 

I agree with Vent ... no matter what the sign on the outside says I doubt they have clinical experience in physical illnesses. I did a brief stint right out of nursing school at a Psych Rehab Center and they knew nothing of emergency or seriously ill patients (physically ill that is). Although, they should have had training in MRSA ( I don't blame you on being upset), I do doubt they truly understand all the details. Remember, they usually are treating the mind not the body. 

I usually, just thank them (at least they did call) and proceed. I have grown to realize majority of us cannot be an expert in all fields. I doubt that many Paramedics or even critical care nurses are vastly trained and specialized enough to treat bi-polar or understand multiple psychiatric conditions as a long term and interventions associated with long term treatment of mental illness. They same they say about us attempting to treat psych patients. (yes, we punt to them). So, I have grown to hope they recognize problems and call the experts (us) to treat and stabilize. Let them deal with their speciality and we will deal with ours....


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## BossyCow (Aug 13, 2008)

A Psych hospital is going to be heavy emphasis on the Psych and less on the medical aspects. To expect topnotch, state of the art medical care in a psych facility is futile. Sort of like expecting an orthopedic practice to pick up on pneumonia.

It's so easy to see what we do a dozen times everyday to be obvious to everyone. For example, the staff at the psych hospital probably didn't understand why you wouldn't assume the pt would take a swing at you and why you didn't know the pt would be infected with all kinds of bad nasties. 

We all have our areas of knowledge and familiarity. The problems arise when we assume our familiarities should be common to all.


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## VentMedic (Aug 13, 2008)

We also still have some of the myths of O2 treatment floating around like "don't put more than 2 L on a COPD patient".   Then you have others trying to put blanket statements on each potential diagnosis without confirmation of the actual problem or other existing problems.  Others believe their protocols are the right and the only way.  Examples: 4 L/m for CP,  2 L for Stroke,  no O2 for presumed "hyperventilation".  

Oxygen therapy is probably one of the simplest treatments you can offer and yet few understand it.  Nor, do enough people take the time to understand the physiological differences between long and short term treatment.   There's alot of mixed messages out there for those who don't do acute medicine very often and even for those that do.  

Psychiatric RNs are also very cautious (which can be a good thing) about giving albuterol treatments to everyone as others may have a tendency to believe it is needed for everything without checking for other medications and preparing for the reaction.   

Neither Nursing and their many specialites nor EMT/Paramedic programs can teach all aspects of everything.    

The nurses "may" have been thinking that if they lost the BP, they may  have nothing in the way of fluids or meds.  If breathing became very labored or ceased, they could still use a BVM.   I have bagged many patients to assist their ventilations or for total support during a resuscitation of various types until I can get a tube into my hands and see a safe opportunity to intubate.    This may not always be done in the order in the field.  However, if I have someone that is proficient with a BVM, I can get my IV access before attempting intubation.  

Thus, there are different approaches to every situation depending on the level of training, speciality, location and the continued education of the providers.  

The fact that this pt had crackles in all fields may indicate, as Rid mentioned, many more problems than PNA.   Also, what pre-existing diseases did the patient have?  If one had listened to Bernie Mac's lungs on a good day even  before his PNA, you may have heard crackles at least in the bases and possibly in other areas as well.   That goes for many lungs problems.   Of course, your situation has other signs and symptoms.  

As far as infection control, there are still some that do little about being cautious even if made aware.  I still see CCT teams that don't do anything to protect themselves or the ventilator from infections. This then gives way for both the providers and the ventilator to contaminate others.    Many EMS providers who bring a patient to the ED while ventilatating by tube or mask are rarely mindful of where that bag's exhaust is spraying.  And, they may even know the patient had MRSA in their sputum from a report in the nursing home. 

We do tell ambulance crews about C-Diff (plus the isolation stuff outside the door should be a clue) but some still keep their same gloves on and touch other surfaces on their way to the ambulance.   When you say MRSA, very few will ask where?  It could be isolated to a wound although good cleaning should be a routine of all equipment as well decreasing the contact with your uniform.  

You shouldn't have to be told about everything to still use the same precautions.   I rarely know the Hep C status of most of the patients I stick a needle into but I am still going to use the same careful technique and precautions each time I do the procedure.   The same for any respiratory patients.   I don't know if that could is from MRSA or TB.   Am I going to wear a HEPA Respirator every time?  No, but I am going to stand outside of their direct cough and avoid using oxygen equipment which ventilates its exhaust into the room without filtering if there are others nearby.   I might go with a dual limb CPAP/BiPAP machine versus a single limb.  But then that will be my consideration for extended time on this therapy.   I also do not consider an oxygen mask to be an effective barrier if TB or some other highly infectious virus or bacteria is suspected.   If I listed all the bugs I am exposed to, with and without immediate knowledge,  in just one 12 hour shift at the hospital, it would be a very scary list.  

There are also some very potent strains of bacteria out there that can wreak havoc on the lungs and who body.   Just because you don't hear the term MRSA, you should still use commonsense and avoid getting into the line of their droplet spray.   Having knowledge of MRSA shouldn't otherwise affect your treatment.  

Sorry about the soapbox and straying off track.  I just have some higher expectations for EMS providers since they are exposed to many types of situations with little information about the blood and sputum cultures of the patients not to mention the potential for violence at scene.  Ambulances also transport many patients from many different facilities so there should be an awareness of  exposing patients some infection.   

I also grew up in EMS during the early 1980s when a major disease came about to which we had absolutely no information about where, why and and how.   That also brought rise to a very potent strain of TB.   There were a lot of lessons to be learned from that time.  Unfortunately, education to the general public and some health care providers have lapsed on some issues over the past decade.


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