# How would you treat?



## pumper12fireman (Feb 18, 2008)

Time: 0230
Called for a fall at a residence, you are a FF/EMT riding on a BLS rig, dispatched with an EMT/Medic ambulance. The two rigs arrive at the same time, and enter the home. You arrive to find an 88y/o woman, alert and telling us how she fell. She's been down for 4 hours.

Vitals:
AVPU-a/ox3
A-open
B-clear, bilateral breath sounds- 14/min
C-pulse at 80, strong and regular

BP- 98/64
Pupils- PEARL
Pulse- still at 80
Skin- warm and dry
Respiration- still at 14
SpO2- 99%

We stood her up, and BP dropped to 84/56, pulse upped to 100

A-none
M- hydrocodone, "heart medicine"
P-hypertension
L-unremarkable
E-got up to go to bathroom
BP is normally 120/80

No O2 was started, and shock treatment wasn't started. The medic got out his release form, and we went home. Am I missing something? Why wasn't more treatment rendered? The medic we work with has tons of time on the job, but seems, at times he likes to release, rather than treat. As a probie on the fire rig, I didn't want to second guess, especially on scene...Maybe the "heart medicine" was an antihypertensive, and dramatically drops her BP?


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## Flight-LP (Feb 19, 2008)

The change in vitals really isn't that drastic. An old rule of thumb for positive tilts, i.e. orthostatic hypotension is a 20% drop. If the lady is alert with good presentation and no dizziness / lightheadedness, she can absolutely refuse treatment with an understanding of the potential risks associated with an AMA refusal. I offer treatment and transport, if refused I tell 'em the potentials. If they still refuse, they are on their own. Sign the dotted line, have a nice day, call us again if you feel the need.................

BTW - "Normal BP" is sometimes too subjective of a term to take seriously, be cautious when accepting it as an absolute......................


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## pumper12fireman (Feb 19, 2008)

Flight-LP said:


> The change in vitals really isn't that drastic. An old rule of thumb for positive tilts, i.e. orthostatic hypotension is a 20% drop. If the lady is alert with good presentation and no dizziness / lightheadedness, she can absolutely refuse treatment with an understanding of the potential risks associated with an AMA refusal. I offer treatment and transport, if refused I tell 'em the potentials. If they still refuse, they are on their own. Sign the dotted line, have a nice day, call us again if you feel the need.................
> 
> BTW - "Normal BP" is sometimes too subjective of a term to take seriously, be cautious when accepting it as an absolute......................




Ah, okay..that makes a little more sense now. The low BP was just a red flag from EMT class...and I will remember then "normal BP" as subjective..


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## Outbac1 (Feb 19, 2008)

Hydrocodone is a pain medicine. The following is from Wikapedia. I added the underline in the quote.

   "Hydrocodone or dihydrocodeinone is a semi-synthetic opioid derived from two of the naturally occurring opiates, codeine and thebaine. Hydrocodone is an orally active narcotic analgesic and antitussive. Marketed as Vicodin, Anexsia, Dicodid, Hycodan (or generically Hydromet), Hycomine, Lorcet, Lortab, Norco, Novahistex, Hydroco, Tussionex, Gentex, Vicoprofen, Xodol, Bekadid, Calmodid, Codinovo, Duodin, Kolikodol, Orthoxycol, Mercodinone, Synkonin, Norgan, and Hydrokon, hydrocodone is commonly available in tablet, capsule, and syrup form. .... As a narcotic, hydrocodone relieves pain by binding to opioid receptors in the brain and spinal cord. It can be taken with or without food as desired. When taken with alcohol, it can intensify drowsiness. It may interact with monoamine oxidase inhibitors, as well as other drugs that cause drowsiness. It is in FDA pregnancy category C: its effect on an embryo or fetus is not clearly known and pregnant women should consult their physicians before taking it. Common side effects include dizziness, lightheadedness, nausea, drowsiness, euphoria, vomiting, and constipation. Some less common side effects are allergic reaction, blood disorders, changes in mood, mental fogginess, anxiety, lethargy, difficulty urinating, spasm of the ureter, irregular or depressed respiration, and rash.

  Hydrocodone is habit-forming, and can lead to physical and psychological addiction however, the potential for addiction varies from individual to individual depending on unique biological differences."

 My concern would be why did it take 4 hours for her to call for help? If I was on scene I would be asking  how mobile is she normally? Does she use a walker? Has this happened before? Why does she takes the pain med? What does she take for her high B/P?  Most people with high B/P here take some combination of diuretics and beta blockers. (There are lots of drugs to choose from.) Has she been eating well? Is she dehydrated? Poor skin turger? Has she been sick lately with some N&V? Could she be septic from a flu or UTI? Some of these questions can be answered just by looking around the house or apartment. How neat and tidy is the place? If you can see the place is usually neat and clean but now there are several days of dirty dishes on the counter. This may indicate she is not up to her usual standard. There are always lots of questions. 

   If she is A&O x3 she certainly can refuse Tx & transport. I would want to know more than her B/P is a bit low sign here and have a nice day. Since I wasn't there I'm not going to second guess your medic. Perhaps he had the answers and maybe he's been there before. Just keep in mind that there is lots of history to get when on scene.  Many Doctors will tell you that most of their Dx is based on history.


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## VentMedic (Feb 19, 2008)

I would have been concerned about why she didn't call earlier and would have checked for signs of pressure on her skin where she had been laying as part of the assessment. 

Elderly patients also have difficulty remembering exactly when they took their medicine even though they are A&O. One does not have to be 88 y/o to start forgetting things.  This leads to accidental ODs.  I would have asked her where she kept her meds and got her permission to check them.  You may have found a whole pharmacy or several pharmacies in her cabinet.  Even if she is not taking all of them it is easy to grap the wrong bottle.  

Elderly patients have decreased sensation and usually injuries are noticed by the people caring for them and not the patients themselves.  This can include hip fractures. 

I would also have checked if she had any home health services or family nearby.  I would politely and respectfully ask her if there is anybody that you could call for her just to check on her later.  The answer will probably be "No" because elderly people do not want to bother or burden anyone.  This can also include EMS which might also be a reason she didn't call earlier. 

These patients sometimes fall through the cracks of social services because their needs are not readily identified or blown off.   This could definitely apply if the medic had seen her before for simiar situations.  The patients themselves are afraid to ask for help in fear of being placed in a "Nursing Home" and losing everything including their freedom and dignity.

Although the geriatric population makes up a large percentage of EMS calls, geriatric assessment is not adequately taught in EMT or Paramedic programs.


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## BossyCow (Feb 19, 2008)

I would need more information, like what caused the fall. Was she dizzy, is she still dizzy? Blood sugar could have been low early in the AM. Without the answers to those questions I'm not able to question the medics choice. 

I know a lot of the elderly fall calls we go on have a very embarrassed pt. who doesn't want to 'be a bother'. There is a tendency to minimize the effects of the fall and the events leading up to it. I generally take the time for a pretty intensive Q&A about the event, have they ever had something like this happen before....are they still dizzy....when and what did they last eat.... when did they take their meds last and which ones.

Most of the elderly will answer the questions because it would be rude not to. And besides, it's so nice to have that young man/woman taking such an interest and being so polite.


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## pumper12fireman (Feb 19, 2008)

Outbac1 said:


> My concern would be why did it take 4 hours for her to call for help? If I was on scene I would be asking  how mobile is she normally? Does she use a walker? Has this happened before? Why does she takes the pain med? What does she take for her high B/P?  Most people with high B/P here take some combination of diuretics and beta blockers. (There are lots of drugs to choose
> from.) Has she been eating well? Is she dehydrated? Poor skin turger? Has she been sick lately with some N&V? Could she be septic from a flu or UTI? Some of these questions can be answered just by looking around the house or apartment. How neat and tidy is the place? If you can see the place is usually neat and clean but now there are several days of dirty dishes on the counter. This may indicate she is not up to her usual standard. There are always lots of questions.
> 
> If she is A&O x3 she certainly can refuse Tx & transport. I would want to know more than her B/P is a bit low sign here and have a nice day. Since I wasn't there I'm not going to second guess your medic. Perhaps he had the answers and maybe he's been there before. Just keep in mind that there is lots of history to get when on scene.  Many Doctors will tell you that most of their Dx is based on history.



Patient had Life Alert, and it took them that long to call our dispatch, apparently. She was a little confused, but not dizzy. BGL was at 110...

She complained of constipation from the hydrocodone, and was taking it from arthritis pain management. Now that you mention it, she had been sick with a "cold" the past week. She did use a walker, and physical examination of where she fell revealed nothing important. 

With the low BP, possible dehydration (poor turger was present) from the constipation, in addition to the diuretic (lasix) she was on (no beta blocker), could that have drawn enough water out of the vascular system to cause hypotension??


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## VentMedic (Feb 19, 2008)

Did anybody contact the Life Alert company to "alert" them there might be a problem with the system?  Who gave you the 4 hour time frame?  Did Life Alert admit to waiting 4 hours to your dispatch?  

Do you feel comfortable knowing her "Life Alert" system might be malfunctioning without someone else (family or the alarm company) knowing about this when you left?  Or did you check with your dispatch to make sure someone in the alarm company was looking to the problem? 



> She was a little confused, but not dizzy.



Two different things.  

A&O x 3 does not hold as much value with geriatrics as facts you learn from  Q&A as BossyCow mentioned. 

Did she still have signs of a "cold"?

What was her appetite like?  Was she able to drink fluids?  Were her mucosal membranes moist or dry? 



> in addition to the diuretic (lasix) she was on (no beta blocker),


From where did you learn that she was was on lasix and not taking a beta blocker since in your first post:



> M- hydrocodone, "heart medicine"





> Maybe the "heart medicine" was an antihypertensive


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## Outbac1 (Feb 19, 2008)

Questions begat more questions.

 She has a "heart cond." which may be HTN. I wonder if she has more heart problems? It would be nice to know all her meds and how compliant she is with them. We know she is not steady on her feet at the best of times as she has a walker. She appears to have gotten away with the fall not hurting her.  I wonder what her diet is like? How much fluid she gets. Is she a big or small woman? ( 5'2", 110lbs or 5''4" 200lbs). I would probably try to talk her into going to the hospital. Here it is a $120.00 ambulance bill but the work up and tests are free. Maybe money is a concern for her. I think she needs more investagation and as Vent said the Lifeline needs checking out.


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## pumper12fireman (Feb 19, 2008)

VentMedic said:


> Did anybody contact the Life Alert company to "alert" them there might be a problem with the system?  Who gave you the 4 hour time frame?  Did Life Alert admit to waiting 4 hours to your dispatch?
> 
> Do you feel comfortable knowing her "Life Alert" system might be malfunctioning without someone else (family or the alarm company) knowing about this when you left?  Or did you check with your dispatch to make sure someone in the alarm company was looking to the problem?
> 
> ...



On the lasix issue, I talked to my captain today while on shift, and he echoed the same concerns I had. He talked to the medic and told captain her heart
medicine was lasix, we (the firefighters) must have missed the pt. state that. 

She did still have the "cold", and appetite was normal, fluid intake normal (as in, no change, since "cold started" as far as amounts, that question wasn't asked), and her muscous membranes were dry. 

On the life alert issue, that issue was taken care of the next day by my captain, dispatch, and the pt.'s daughter (all contacted Life Alert)...once again, all unknowns on my part, since I hadn't been on shift since then...I just didn't wanna bring it up on scene, and wanted to find a good time to ask my captain what he thought as he's also a paramedic...

So, in short, I probably should have just talked to him, and the medic before posting here..my apologies..


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## VentMedic (Feb 19, 2008)

No problem there because I think everyone mentioned things that can be useful for your next assessments. 

Elderly people need to have an advocate without feeling like their rights are being intruded on. We do have a couple of EMS services in Florida that work closely with social service agencies that will check on the patients who might otherwise slip through the cracks of the system(s).  Usually the fear of a nursing home and their pride keep many elderly people from asking for more help.


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## pumper12fireman (Feb 19, 2008)

VentMedic said:


> No problem there because I think everyone mentioned things that can be useful for your next assessments.
> 
> Elderly people need to have an advocate without feeling like their rights are being intruded on. We do have a couple of EMS services in Florida that work closely with social service agencies that will check on the patients who might otherwise slip through the cracks of the system(s).  Usually the fear of a nursing home and their pride keep many elderly people from asking for more help.




I couldn't agree more, we need to be pt. advocates for all, but especially the elderly.


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## Niftymedic911 (Feb 22, 2008)

Hello to all........

I was recently invited by VentMedic to come join you guys on the forum.  It seems like a nice place.  Now, to the subject at hand......

It is all too easy for anyone to monday morning quarterback the scenario or actual call at hand.  I wasn't there so I don't know.  But what I will comment on was the fact that as a profession EMS provider, he decided to "whip" his refusal form out.  Yes, she did not want to go..... but as a "professional Paramedic" he should of taken the time to REALLY explain to the patient.  Not just the usual if you don't go your gonna die BS.  The real reson why we're as a whole still not technically considered a professional profession, is simply this as an example.  Public education is one of THE most important items with elderly patients.   People nowadays refer to them as "Gomers", "WTF she can get up", "COME ON!" kinda calls.  Where is the professionalism in that???  If we want to be taken professionally, then we need to act professionally.  "whipping a refusal form", is definately not professional.  How about taking the time to say: "Mam, I understand your situation, I understand that you don't want to bother us, to be honest, you don't bother us.  We want what's best for you.  Your blood pressure is slightly off, you fell, why not take a decent ride with us and we can chat up a storm on the way"??  Not, do you want to go with us.  No, ok sign here and we'll be out of your hair.  

Another thing is also apparent.  The LifeAlert system.  Why would you leave the elderly person home with a malfunctioning system???  Do you realize, even though she signed a refusal, that you guys could also be considered negligent for her death, should she die???  Even, if you were a newbie, you still have a right to say things.  Maybe it will help you younger folks to realize this......  That if that old person or "Gomer", didn't walk the face of the Earth, maybe you couldn't speak with freedom, or better yet, have the very things that you take for granted.  These people deserve more then what people treat them.  It all comes down to R E S P E C T.  I suggest anyone who treats patients like this, find out what it truly means to you.   

Do I think this person needs a ride to the hospital.  No, but does that change my treatment..... the bottom line is it shouldn't.  A word of advice.  Develop a social service referal program for your agency.  You not only respond and help, but now you put an agency that is out there for whatever means, that person may need available to them.  

My agency.... Lee County Emergency Medical Services, is a Professional, Progressive and Aggressive 3rd service ALS 9-1-1 primary response agency.  Through partnerships with United Way and various other agencies, we provide that whatever means needed approach for the elderly patient.  Should we run on Mrs. Walker again for the 4th time in a month, the social services referal we fill out and send electronically, allows the agency to contact and provide elder care, employment opportunities, and various forms of education for the elderly.  The cost of the program is shared is all done with donations to your local united way.  Thus cutting the responses to those "not again calls" that occur.  I suggest if this intrgiues you to bring a very progressive program for the elderly to your agency.  Look up:
www.lee-ems.com/ems/default.htm and click the 2-1-1 program.

We handle over 75,000 calls for service a year and have completed in 2 years since the program start date, refered over 8700 patients to the 2-1-1 social service referal program.  It does work, I've seen it numerous times.

Yours in EMS,
Nifty


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## VentMedic (Feb 22, 2008)

Welcome Nifty,

The assessment on this patient appears to have been very thorough but an AMA form doesn't automatically release one from liability as you mentioned.  We could fill many forum pages on just that issue alone.  Many agencies now leave specific instructions and are designed more like an OR release form which requires a little more than just a signature. 

I think the services that Lee County EMS, FL have been implementing throughout the years show that EMS can evolve into a well functioning Community and Patient oriented entity achieving high marks in the medical profession.   

Many times much focus is given to a text book assessment.  I, myself, would be traumatized by just lying on the floor for 4 hours and being unable to get up or to call help.   The elderly are a strong group and have many coping mechanisms for survival despite a healthcare system that seems to go out of its way to make things difficult when it comes to medication and transportation for medical needs.  There just aren't enough funds for them also.  With the additional problems of EMS being overburdened and under funded in some areas, the elderly may sometimes feel the brunt of others' frustrations.

These are observations in general and not meant to offend the original poster.  I was made more aware of the situations of the elderly by having a 91 y/o mother.  Her experiences with healthcare in the last weeks of her life were worrisome for even those with the best of plans or knowledge of the system.


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## TsmithFF10 (Mar 20, 2008)

Nice article on Orthostatic Hypotension:

http://www.aafp.org/afp/20031215/2393.html

Be sure to look at "Etiologies and Drugs That Can Cause Orthostatic Hypotension".


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