# Run on 84 yo female



## Epi-do (Sep 3, 2007)

Dispatched for chest pain, arrive to find 84yoWF laying in bed, complaining of L&RUQ abdominal pain that comes and goes.  Patient states symptoms originally began 2 days ago, with today's episode starting 45-60 minutes prior to calling 911.  Pt. has a history of one similar episode happening one year prior, but did not seek treatment at that time.  

She presents as A&Ox3, PERL, skin is pale, cool, and dry.  She denies chest pain, difficulty breathing, vomitting.  States she does feel nauseous and weak.  Initial VS's are 182/98, HR 62, RR 16. 

Pt is moved to a stair chair to get her to the lower level of the house.  At that time she states she feels dizzy and nausea has gotten worse.  Pt is transfered to cot and then to truck.  Second set of VS:  ~160/80 (I don't remember exactly), HR 58, RR 18, SpO2 97%.  Pt. also states dizziness has gotten better now that she is laying down again.  Pt. placed on O2 @ 4 lpm via NC.

Pt states only hx is htn and hypothyroidism.  Meds include atenolol, simvastatin, lasix, atropine, and synthroid.  When asked about shy she takes lasix and atropine, she insisted they were for her htn.  Only allergy is sulfa.

The particular ER the patient wanted to go to wants a radio report for every single patient coming in by ambulance, so they were contacted and a report was given.

Pt reassessed.  States pain and nausea are worse.  Rates pain 9/10.  Pain in LUQ increases with palpation.  VS are now ~150/60, HR 50, RR18, SpO2 96%  Skin is still pale, cool, dry although pt states she feels as if she is beginning to have a cold sweat.  At this point we are only 1-2 minutes out from the hospital.  Switch pt. over to NRB @ 15 lpm.  Pt still denies CP, difficulty breathing, but begins to have dry heaves.

Literally, as we are pulling into the hospital, pt's HR drops to 42 for a few seconds and then comes right back up to 56.  At this time, pt states she feels much more nauseous and begins to vomit again.  (The vomitting came _after_ the drop in heart rate, not before.)

Total transport time was 9 minutes and pt was transported BLS.  A medic had been onscene with us and evaluated the pt, including putting her on the monitor.  Nothing remarkable was noted on the monitor, and the medic, like myself, thought the pt would be ok going in BLS and that it didn't look like what was going on was cardiac in nature.

As we transported the patient and were almost to the hospital, I began to wonder if this was a cardiac event, just an atypical presentation of something.  She never once complained of chest pain or pressure, just abdominal pain.  I never requested another medic because I could get to the ER first.

Outside of the medic taking her in, is there anything else BLS-wise I could have done for her?  What could have been done for her ALS outside of maybe putting in a line and having her on the monitor?  I did talk to the two medics onstation about this run when we got back, but am just curious about what others think.


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## Flight-LP (Sep 3, 2007)

IV and monitor would be about the limits that ALS could physically provide, perhaps consideration for an anti-emetic. However, this should have been an ALS pt. on the sole presenting facts. An elderly woman with dizziness and upper quandrant abdominal pain warrants more than just a monitor "hook up". Personally, any elderly pt. that I have with a potential atypical cardiac presentation gets a 12 lead with continuous monitoring. I would question the following possibilities....................Abdominal aneurysm, non-Q wave MI, acute cholecystitis, pancreatitis, and hiatal hernia. OR could just be stomach bug, better to error on the side of caution.............................


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## KEVD18 (Sep 3, 2007)

iv o2 monitor and, more importantly, als level intervention if(read when) the pt tanked. now take the same situation but extend your tp time by 15 min and your up the creek

at the bls level, o2 pink basin and drive like hell


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## Epi-do (Sep 3, 2007)

KEVD18 said:


> now take the same situation but extend your tp time by 15 min and your up the creek



Had we been going to any other hospital, when I asked my partner where we were at, the answer would have been 10-15 from the ER.  I would have definately requested a medic at that point.

I guess for me, the biggest issue is what did I not pick up on initially to make me think "ALS patient" as opposed to "stomach bug".  Yes, I did recognize that she needed more than I could do for her, but at that point it was going to take longer to get ALS than to get to the hospital.  

Of course, I can sit here and second guess myself all night long.  In the middle of the situation I did the best I could do for the patient.  The majority of the time I still feel that way once the patient is delivered to the ER, but every once in a while I can't help but feel I missed something and should have done something differently.  This is one of those times where I feel as if I missed something.  That is a big part of why I am now in medic class - so I can provide better patient care.  I know there is alot to learn over the next year (and beyond class), but in the meantime I have to work within the restrictions of being a basic.  I just want to be the best basic I can be with the resources I have available to me.


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## Epi-do (Sep 4, 2007)

Ended up back at the ER and checked on what happened with this patient.  Apparently she was discharged from the ER.  I don't know what the final diagnosis was or if she was transfered to another hospital, but I do know that she wasn't admitted to that hospital.  Unfortunately, that is all the nurse could find out for me.  I would have liked to have known a little bit more about it.


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## Gbro (Sep 4, 2007)

> I would have liked to have known a little bit more about it.



We used to hear back on most trauma calls, However Hippa has taken it away from us.
I didn't like hippa from the start, and i hate it today.
you should see the expressions i got when i had surgery last winter when i refused to sign the hippa forms. Poor admit. Lady didn't know what to do!


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## akflightmedic (Sep 4, 2007)

The medic is an idiot or lazy.

Sorry, but the intial vitals and impression warrant an ALS transport. Therefore, one of the two above listed options apply to this medic in particular.

Second, as an EMT it is always your responsibility, especially if a medic is on scene, to know your limits. I am not putting blame on you but I have seen it too many times. A medic shows up and is being lazy, makes the EMT take the call and feel like an idiot for calling ALS to start with. This should never occur!

In addition, if you feel the slightest bit uncomfortable, you should insist they ride in with you no matter what they say or how they try to convince you otherwise.

Last, I have also seen the reverse where the EMT does not realize what he does not know and feels overly capable or confident of handling an ALS pt in a BLS capacity. Do not ever let pride get in the way of patient care. I do not think this occurred in this situation, but just a general statement for any that may read this. 

On another note, for the above poster, why would you refuse to sign a HIPAA form? What does that prove other than making the clerks job harder than what it already is? Even if you do not sign it, they will still abide by all the rules that apply under HIPAA. It is merely a federal requirement that you be informed of your rights and the signature is the hospitals way of proving they did their part.


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## BossyCow (Sep 4, 2007)

Gbro said:


> We used to hear back on most trauma calls, However Hippa has taken it away from us.
> I didn't like hippa from the start, and i hate it today.
> you should see the expressions i got when i had surgery last winter when i refused to sign the hippa forms. Poor admit. Lady didn't know what to do!




HIPPA does not in any way stop you from getting a detailed and accurate run review on every patient you transport from your MPD or the staff at the ER.  There is a specific exception to HIPPA regarding the sharing of information on a pt. you transported for the purpose of your improved skills and training.  

I am able to get pt. outcome and further treatment on all pts trauma or medical.  If someone is refusing to give you that information based on HIPPA, you are either asking the wrong question or trying to get the information from the wrong person.  

HIPPA was created to keep our medical information private.  As a former hospital employee whose Ultrasound results were shared with her boss prior to being shared with her physician, I'm in support of the law.  Most of the problems associated with HIPPA are based on a huge misunderstanding of the law, its purpose and implementation. 

Your refusal to sign "HIPPA paperwork" was silly.  The paperwork you sign is merely an acknowledgement that the HIPPA policy was explained to you and you received a copy of the policy to read over and who to contact regarding questions you had on it.  Not signing for the receipt of that paperwork is pointless.


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## akflightmedic (Sep 5, 2007)

Sorry, pet peeve of mine.


Is is NOT HIPPA!!

It is HIPAA!!

Hip uh  not hip puh.

Health Information Portability and Accountability Act

H       I                P                  A                  A



Yes, I am weird but its one of my quirks!


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## BossyCow (Sep 5, 2007)

Mea Culpa, I know better!


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## Ridryder911 (Sep 7, 2007)

Knock, knock 

_ Who's there?_

HIPAA

_ HIPAA Who ?_

Can't tell ya ! .....:wacko:

Couple of things, appearantly EMT's are poorly trained in HIPAA. By refusing to sign the HIPAA form, means nothing! All that form is stating that you have been advised that the medical institution has advised you that they follow HIPAA guidelines, and by signing it means that you agree you were informed, that's all... basically, no skin of their nose, rather they proabaly documented patient was obnoxious, and refused to sign forms. One can obtain as much information as before HIPAA, if you know the proper channels to obtain medical information correctly. For EMS follow-up's, have your company discuss with the medical information officer in the  (medical records) department. Describe, that it is to be used for Quality Assurance, and Follow Up's; and sign the proper documentation, this is usually all that is required. As long as you had direct contact with that patient, they cannot refuse information. 

I agree HIPAA can be a pain, but; it is here forever, and there was a need to for it. Unfortunately, it did not change the reason it was designed for and has caused problems afterwards. 
R/r 911


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## Gbro (Sep 8, 2007)

> Bossy said
> Your refusal to sign "HIPPA paperwork" was silly. The paperwork you sign is merely an acknowledgement that the HIPPA policy was explained to you and you received a copy of the policy to read over and who to contact regarding questions you had on it. Not signing for the receipt of that paperwork is pointless.



When one protests something because it doesn't sit well with one, Who are you to say it is pointless?

We were searching the woods one night for an accident victim as there was a great amount of blood and hair in drivers compartment, FD, LEO's, EMS. I asked the deputy sheriff to radio dispatch and call the ER's (two in 40 mile radius) to find out if anyone consistent with MVA trauma/head injury was brought in by POV, Dispatch returned that* "HIPPPPPPPA"* rules prevented the Er from giving out that kind of information.

Please feel free to endorse what you like!


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## akflightmedic (Sep 8, 2007)

Gbro said:


> When one protests something because it doesn't sit well with one, Who are you to say it is pointless?
> 
> We were searching the woods one night for an accident victim as there was a great amount of blood and hair in drivers compartment, FD, LEO's, EMS. I asked the deputy sheriff to radio dispatch and call the ER's (two in 40 mile radius) to find out if anyone consistent with MVA trauma/head injury was brought in by POV, Dispatch returned that* "HIPPPPPPPA"* rules prevented the Er from giving out that kind of information.
> 
> Please feel free to endorse what you like!



Did dispatch just say that or did they actually call the ER and get that response; only curious because I want to know where the idiot works. HIPAA dose NOT forbid that kind of information release and someone, somewhere does not know the limits of their job.

I am always amazed at these HIPAA disucssion, everyone has input but very few are correct.

As a great side tangent, how many of you have actually read the law? I do not mean had it explained to you in an inservice, I mean actually googled it, sat down and read it. Very few I surmise. The history itself is long and sordid. They were trying to implement this law or a variation of it in the late 1980s!!! Look how long it took to become law and how many times it had to get revised.

This law is another example of poor information existing within the EMS education system. It is here to stay and it effects us every day within our job, yet no one knows anything about it. They just hear Bubba Joes interpretation of the law in EMT class or Susie Rescue's take on it during squad meetings and assume they are indeed correct and it must all be fact!

Never assume what someone says as fact. Respect their opinion and do your own homework; become more educated about your chosen career and read up on stuff regardless of how boring it may seem. Passing down bad information from one generation to the next is horrible practice yet so easy to do in this instance cause knowing this stuff is not the cool, exciting or fun part of the job.


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## BossyCow (Sep 9, 2007)

Gbro said:


> When one protests something because it doesn't sit well with one, Who are you to say it is pointless?
> 
> Please feel free to endorse what you like!



I absolutely agree with the right and even obligation to protest something you disagree with.  However, the comments you have made regarding HIPAA are not based in accurate knowledge of the rule.  The disagreements you have with it are based on an inaccurate practice of it by your local ER staff.  None of the problems that you state you have with HIPAA are consistant with the law as written.  So, pretty much, you are upset about something because you assume that it means something it doesn't. 

Your refusal to sign the document is not a protest.  It goes no further than the admitting clerk who simply wrote on the document, pt. refused to sign.  

Personally, I see some value in HIPAA.  As I said in my earlier post, I had a supervisor in the department where I worked at a hospital access my medical records.  I was brought into the ER with belly pain. She used to work in Radiology so she went to a former co-worker and had quite a cozy chat about my ultra-sound.  I would have preferred to discuss my ultra-sound with my physician prior to hearing about it from my boss, but in the pre-HIPAA days, this sort of thing happened frequently. 

The instance you gave about the head injury also was totally inaccurate.  I have repeatedly gotten information of a similar nature from our local ER.  Perhaps they couldn't give that info over the radio, but a cell phone call from law enforcement should have been sufficient to deal with that.  

Your MPD can get you any and all information about any pt. you transport including what treatment occurred at the facility they were transferred to.  

So, how does your anger relate to HIPAA again?


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## Ridryder911 (Sep 9, 2007)

Gbro said:


> When one protests something because it doesn't sit well with one, Who are you to say it is pointless?
> 
> We were searching the woods one night for an accident victim as there was a great amount of blood and hair in drivers compartment, FD, LEO's, EMS. I asked the deputy sheriff to radio dispatch and call the ER's (two in 40 mile radius) to find out if anyone consistent with MVA trauma/head injury was brought in by POV, Dispatch returned that* "HIPPPPPPPA"* rules prevented the Er from giving out that kind of information.
> 
> Please feel free to endorse what you like!



I agree HIPAA is a pain, the main part is not being able to release information to immediate family members without direct permission of the patient (part of that paperwork you refused to sign) and the other is increased poor communication among health care agencies, and finally poor understanding and interpertation of the ruling. 

Even before HIPAA, one should had never released any information to anyone in regards to their medical condition, treatment, etc. It has been called the privacy act for quite some time and unfortunately it was not enforced well enough, so HIPAA had to be installed to prevent leakage to insurance companies. (HIV patients was being discreminated against, as well as insurance companies attempting to find out pre-existing conditions in able to NOT provide coverage) 

In the ER when a patient has a reportable condition (involving violent act such shooting, spousable-child-geriatric abuse, public health such as small pox, T.B., etc) the ER will contact appropriate authorities. We can contact the law enforcement agency that they may want to respond, but cannot give detail information in regards to their health without permission. 

AK is right, information that is usually given over the radio (no names) but medical information and adresses is not covered by HIPAA. As well, if your agency does not use electronic billing, it as well is not affected by the regulation, but still has to use privacy act. 

R/r 911


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