# Would you have ALS'd this patient?



## MedicPrincess (Dec 4, 2008)

You get the call at 0702 hrs, your shift was over at 0700 (latelate call on your way back from a late call) so your already experiencing a moderate case of the tourettes.

Initially "Alpha" response for a sick call, pt c/o diarrhea. 

You enter his apt to find a 74 yo M pt, seated in his LR chair watching the news.  He appears a little pale but otherwise no obvious distress.  As you approach and ask him whats going on he says the most aggravating thing a pt can say (IMHO), "I don't know."

Me:  "Well Sir, why did you call for an ambulance today."
Him: "Something has to be done."
Me:  "Okay, what is it you want something done about."
Him:  "Two months ago I had a colonoscopy.  I have had diarrhea ever since."
Me"   "Okay, well have you talked to your regular physician about your onging diarrhea?"
Him:  "I told'em in Biloxi last week.  They said to go back to my Dr."
Me:   "Have you noticed any blood when you go?"
Him:  "Nope.  Just a lot of poop all the time."
Me:   "Are you hurting anywhere?"
Him:  "Yesterday, my stomach hurt over here.  But it seems a little swolled up.  And I lost weight.  I used to weigh 220 pounds in October, now I am down to 200."

He goes on to deny CP, SOB, N/V, Syncope.  His ABD is SNT in all 4.  BBS CTA.

Initial Vitals:
BP 136/91
HR   90, regular
RR   22
SaO2   96% RA

Meds:
Digoxin
ASA
Lortab
Toprol

No allergies

Pt stated Hx:  HTN, "Heart Troubles" where his heart regularly "skips a beat or two"

As your partner is arranging things to get the stretcher in, the pt gets up and walks to where the stretcher is, about 6 feet.  He appears a little out of breath from the short walk.  He admits to feeling a "little" winded.

He doesn't want to go to the hospital that is literally 1 block from his house and 4 miles from your going home point.  He wants to go to the hospital that is across town, and 10 miles from your going home point.

Now, would you go ahead and ALS him for a c/o diarrhea for 2 months, or just give him a ride in and have the chart done when you get there?

I will tell you my choice and why after some discussion


----------



## BossyCow (Dec 4, 2008)

Possible hx of cardiac, his hr is a bit high, his rr is a bit fast, his o2 is a bit slow, and he's requesting to spend more rather than less time in your rig? I think I would call for an ALS eval on this guy. 

The fact that he got winded so quickly means he's got some issues. I'd also want to know what preceded the colonoscopy. Was he experiencing some symptoms that caused the doc to order it?


----------



## traumateam1 (Dec 4, 2008)

No, I wouldn't of ALS'd him. Why? We don't have ALS here.


----------



## KEVD18 (Dec 4, 2008)

if i was a medic and got this call, yes i would have worked him up. usual routine. line, labs, XII, pe etc. im already on the scene and committed to the call. its not going to add much in the way of time to the call(maybe 10min). so what the hell, might as well turn a profit on the call.

if i go this call as a basic, i doubt i would call for medics unless he presented with the undeniable "oh poopy" look we all know and love. now, that probably not the right answer, but its how i would answer it based on the boston private ambulance scene. if i called for medics on that call, and the patient made it to the H without so much as a fart, i would get my rear end handed to me for wasting resources. thats just how it is up here(hence why i retired).


----------



## JPINFV (Dec 4, 2008)

Coming from a So. Cal. perspective, I'd have to agree with Kev's plan. The patient has a lengthy history including cardiac issues. His vital signs are in that gray borderline area. Yes, a resting pulse of 91 is high. Yes, a BP of 136/91 (MAP 121) is a little on the high side. I'm not necessarily concerned with a RR of 22 with an SpO2 96 on room air. There's a few abnormal findings on the secondary and recent history. To me none of this amounts to something immediately life threatening to the patient. I think there's enough there, though, to preclude a paramedic handing the patient off to a basic for transport though. I'd of transported this patient non-emergent in position of comfort while maintaining a high degree of suspicion. I'd probably start the patient on O2 at 2-4 LPM NC (definitely not a NRB) and have the bed pain handy just in case.


----------



## traumateam1 (Dec 4, 2008)

KEVD18 said:


> if i was a medic and got this call, yes i would have worked him up. usual routine. line, labs, XII, pe etc. im already on the scene and committed to the call. its not going to add much in the way of time to the call(maybe 10min). so what the hell, might as well turn a profit on the call.
> 
> *if i go this call as a basic, i doubt i would call for medics unless he presented with the undeniable "oh poopy" look we all know and love. now, that probably not the right answer, but its how i would answer it based on the boston private ambulance scene. if i called for medics on that call, and the patient made it to the H without so much as a fart, i would get my rear end handed to me for wasting resources. thats just how it is up here*(hence why i retired).




Same here (if we had ALS), based on what I see from the OP's post.. he doesn't need ALS, what's another 60 minutes if he's had this for 2 months now? It would be a waste of resources, when they could be going to a code or some  other call that truely needs ALS.


----------



## BossyCow (Dec 4, 2008)

traumateam1 said:


> Same here (if we had ALS), based on what I see from the OP's post.. he doesn't need ALS, what's another 60 minutes if he's had this for 2 months now? It would be a waste of resources, when they could be going to a code or some  other call that truely needs ALS.



What caused him to call today after 2 months?


----------



## Tincanfireman (Dec 4, 2008)

In all honesty, I'd have probably transported him myself,  but watched him like a hawk. Certainly O2 via N/C @ 4 LPM initially, but that could change based on skin color and PSO2.  Some additional questions:  What were his lung sounds?  Did he know the outcome (findings) of the scope? You say he was a "little winded"; are we talking 1-2-3 word phases, or just heavier breathing?  I'd have certainly gained INT access with an 18-20ga, but anything out of the ordinary in the above would have dictated a possible detour to a closer facility once we went enroute. In addition, I might have originally intended to take him to the more distant facility, but I also would have placed a quick call to my paramedic supervisor to get their input and advice and let an ALS unit meet us on the way if the supervisor directed an ALS response.  (I'm not a big fan of fiddling around on scene if we can be getting to a hospital.) If they did direct an ALS response, the patient is going to have to live with the disappointment of going to the closer facility, unless there was a good reason to go a considerably longer distance.  The "going home" part of this is a moot point by now; it's just going to be more time on the paysheet. 

Good scenario; I'll be interested to follow this one.


----------



## KEVD18 (Dec 4, 2008)

now wait a minute here. nowhere did i say this patient doesnt need an als assesment and care.

what i said was, if i responded to this call as a medic i would work it up as such. but if i took this call as a basic on a private ambulance in ma, with that exact presentation, i more than likely would not have activated an als intercept based on those vitals etc. depending on who you work for in my service area, you either have an als truck flying your colors on every street corner(fallon comes to mind) or the one medic truck your company has might be three cities away doing a dialysis call(general...wait general/mercy...wait just mercy.....wait samaritan....they change their name so often i have trouble keeping up). if a truck from your service isnt available, you can either call the city for an intercept(and you better have a damn good reason, since theres only six medic truck for the whole damn city of boston) or you start calling around to all the other privates searching for a clear and available medic truck in your area(very time consuming and tough to accomplish). 

so if i was on a basic truck, the odds are stacked against me getting medics unles i really need them(tell boston you have a code and they come running. tell them you have a diarreaha times two months with stable vitals and your answer wont be very polite). they also wont chase you. if you get them activated and on scene with you before you transport(read delay of transport waiting for als), muy bueno. but if you're on the way, they dont chase. given all that, i would proceed to the H bls only.

theres definatley something going on here. i dont know what it is, since i dont have an md and the support of diagnostic equipment. does it deserve an als assesment, without a doubt. no question in my mind. my response was simply weighing the availability of als as it has been in my experience v. the average transpor time to the H(<10min).


----------



## JPINFV (Dec 4, 2008)

The simple fact is that until everyone on an ambulance is a paramedic (non emergent transport units can call their vehicle something other than an ambulance and don't get the shiny lights), basics will be transporting patients that should be attended to by a paramedic. I'm saying this because I want to keep this thread dealing with reality and not the perfect system. 

Should paramedics be attending to this patient? Sure. (this answers the OP).
Should paramedics have been dispatched as a first response? Yes. 
Should a lower level provider call for a paramedic? Given what has been posted so far, probably not. 


This patient is sick, but the current information doesn't make it look like he is going to die in the next 10 or 15 minutes. The simple fact is that if basics were to call for a paramedic every time their patient wasn't perfectly within normal limits (yes, I know this is what we're taught to do, but I've never said that EMT-B training was good), then every single call from a nursing home would be a paramedic intercept and this would put the EMS system in a state of panic given its current set up. I don't see that anything would be gained by delaying transport or diverting to a closer destination. I know we're trained to see demons around ever corner and every little imperfection on physical exam as life threatening, but this simply isn't representative of reality. You simply can't call paramedics for every diarrhea patient with a cardiac history and borderline vital signs.


----------



## Hastings (Dec 4, 2008)

Would check sugar / hydration and if clear, BLS it (have my partner take it).


----------



## KEVD18 (Dec 4, 2008)

Hastings said:


> Would check sugar / hydration and if clear, BLS it (have my partner take it).



i disagree. if you are there(i assume working a p/b truck), this should be your call.

something is amiss here and you need to be ready for it.

its cases like this where i sort of admire states that require the highest level provider to attend the call. its prevents lazy paramedicine.


----------



## FFMedic1911 (Dec 4, 2008)

From just reading,no i would not transport als.Granted every pt. has the chance to have something go wrong.I just hate the idea of having everything als just to be on the safe side.If the pt. needs als am all for it.If the clinical picture shows they don't than don't. KEVD18 I get what you are saying also and agree they are lazy medics.What I have also seen happen in ems is basics that have became so use to having medics that all they are now is ambulance drivers.This is espiacally true here in eastern Kentucky.When i started most of the departments where bls only and as a basic you had to be on top of your game.Now we have medics and the basics have last alot of their skills.


----------



## KEVD18 (Dec 4, 2008)

something about his call just strikes me as precipitous. maybe its because mp phrased it that way t make it seem like there was something where there was nothing but i dont have to stretch reality to see this call going south. if it does(did), i would much rather have a medic attending the call. if nothing more than it saves what time it does take to establish an iv, hook up the monitor etc. for that matter, id want to see the ekg before making the als bls call and in ma, medics cant do the classic "quick look" ekg(i.e. hoow it up, look at it and if theres nothing immediatley apparant, punt it off to bls). once the monitor is applied, its als till arrival and this patient needs a thorough exam.

one of the things that makes doing these online forum scenarios difficult are the variances in protocols. maybe in other states a medic can do a full workup on scene and of there's nothing showing, turf the call down to a basic crew. i have to look at things from the perspective of where i have spent my entire career practicing(region 4, ma). hell, here bls carry glucometers. they are to be used in the event of ams and suspected cva. once you pop a sugar, you have to call for medics, regardless of the reading. now, nobody does that, but its in the book.


----------



## Hastings (Dec 4, 2008)

KEVD18 said:


> i disagree. if you are there(i assume working a p/b truck), this should be your call.
> 
> something is amiss here and you need to be ready for it.
> 
> its cases like this where i sort of admire states that require the highest level provider to attend the call. its prevents lazy paramedicine.



It is my call, if by call, you mean that I'm making the decision whether it requires my level of care or my partner's. And I would make the decision, with the assistance of pre-set guidelines set by my medical control, that this patient can be treated by my partner.

At worse, if things take a turn for the worst, it's not like I can't upgrade the call and jump in back.


----------



## KEVD18 (Dec 4, 2008)

yeah, ive met medics that would do anything to get out of teching a call, and thus havign to chart it, too.

as a self proclaimed brandy new medic, wouldnt it be better for your knowledge base and thus ultimatley be better for your patients(the whole reason we all got into this circus) to workup as many patients as possible and be as familiar with every atypical presentation you can be?

on the other hand, they dont pay you any better for being a great medic than they do for showing up and doing the bare minimum so why bother i guess.....


----------



## Hastings (Dec 4, 2008)

KEVD18 said:


> yeah, ive met medics that would do anything to get out of teching a call, and thus havign to chart it, too.
> 
> as a self proclaimed brandy new medic, wouldnt it be better for your knowledge base and thus ultimatley be better for your patients(the whole reason we all got into this circus) to workup as many patients as possible and be as familiar with every atypical presentation you can be?
> 
> on the other hand, they dont pay you any better for being a great medic than they do for showing up and doing the bare minimum so why bother i guess.....



It's not about working to get out of a call. There's a practical purpose to splitting up the calls between you and your partner. I tend to believe that Basics are a little more than just drivers.


----------



## KEVD18 (Dec 4, 2008)

yes, there is a practical purpose to splitting them up.

als calls for the medic and bls calls for the basic. we seem to be on opposite sides of the fence as to what this call was. i should think when mp gets around to the update phase of this little mellow drama, we'll find out who was right.

basics are more than just drivers. conversely, i agree with R/r when he relentlessly says that every emergency patient deserves an als assesment and im also bound by my protocols that say once an als skill has been performed, its an als call ad infinitum. you might recall just over two hours ago when i said its exactly this disparity thats makes this sort of cross country discussion to be difficult. obviously your protocols dont have the same rule. what isnt obvious is why you wouldnt work this patient up?

further, yes you could very well jump in the back and take it; already behind the 8 ball becuase you dont have a line and a previous ekg to establish a trend/history.


----------



## traumateam1 (Dec 4, 2008)

http://www.metacafe.com/watch/745121/i_have_a_bad_case_of_diarrhea/


----------



## ffemt8978 (Dec 4, 2008)

traumateam1 said:


> http://www.metacafe.com/watch/745121/i_have_a_bad_case_of_diarrhea/



I don't know what's worse...the fact that video exists or the fact that you knew about it.

That 3:49 of my life just killed a few brain cells.


----------



## Ridryder911 (Dec 4, 2008)

MedicPrincess said:


> You get the call at 0702 hrs, your shift was over at 0700 (latelate call on your way back from a late call) so your already experiencing a moderate case of the tourettes.
> 
> Initially "Alpha" response for a sick call, pt c/o diarrhea.
> 
> ...




As the old saying goes_:....."If you asked the question, should I ? Then you should had!..."_


There is a *true legitimate ALS response here!* Hmmm.... lost >20 pounds in < 2 months (Mayday!),  SHoB upon exertion, Postitive Cardiac History with an irregular pulse, currently taking Digoxin! ... 


Can you say severe electrolyte imbalance, possible Dig tox!  Potential cardiac arrest?... Hello..!?

Your Honor, I rest my case!... 

....I don't care if they are 15' from the ER! How far is from an ER that a patient cannot arrest on you?... 

Chalk it up on experience, and count yourself lucky...

R/r 911


----------



## MedicPrincess (Dec 5, 2008)

I was wonder what to R/R so long to jump on this.  But I am actually impressed at the number of you that would call for ALS, or do it, if your able.  

I did ALS him.  Took 3 text messages enroute with some teasing about talking patients into transport..... new medic....  the usual.

Now, what caused him to call today?  Well he told them about when he was in Biloxi at the VA clinic.  They told him to get seen and he was just tired of it.

With the diarrhea x2 months alone and weight loss I was wondering about Potassium, Mag, Sodium.... all those deficienies.   But you know, its common for medics to BLS pts that are being transported for "abnormal labs" when the labs that are abnormal are the critical low Potassium and Mag.  The Digoxin raised some flags.  The weight loss had me a little worried.  THe SOB on exertion sealed the ALS deal for me. 

It was one of those cases where something in my head told me this wasn't going to turn out well.  Call it Murphy's Law....  Its that late/late call, seems fairly simple, an ongoing problem, that no apparent distress patient....  Murphy would tell you this pt will go south on you.

So I told my partner to just get going, Monitor/IV enroute, O2 was in place as soon as he hit the stretcher.... save a little time.  Initially, SR with PVC's every 4-5 beats.  Pts reiterates that is his norm.  He got an 18g RAC with LR KVO.  Accucheck was 74.

He began with trigemny about the time I was calling in my report... about 5 out.  During the radio report, bijemny ensued.

After the radio report, with hosptial about 3 blocks away, his PVC's went from unifocal to multifocal, and then R on T....  Unconscious and V-Tach followed.  (Along with a very long string of tourrets silently and something along the lines of "Oh no you don't!")

Dropped to supine, with the unintentional thump to the chest as I was saying, "SIR!"....  and he went back into bijemny and very lethargic.  Quick call back to the ER to let them know of the change as we pulled in.....

and quite a bit of the teasing to follow about making my late call "Worth it" and sending my pt into V-Tach.....


----------



## Ridryder911 (Dec 5, 2008)

Glad to see you did the right thing, as well as some aerobic pucker power ...

R/r 911


----------



## Jon (Dec 5, 2008)

KEVD18 said:


> something about his call just strikes me as precipitous...


 
I'm right with you. Question: What's skin turgor look like? Is the dude dehydrated? I know I'd be with that going on.

I'd likely lean towards having an onscene medic initiate care.... however, if we were BLS, I'd probably just go to the hosptial... because our hospitals are close enough, and by the time I get a medic onscene and give a report, I might as well just have ridden it in to the local ER.

Jon


----------



## MedicPrincess (Dec 5, 2008)

Ridryder911 said:


> Glad to see you did the right thing, as well as some aerobic pucker power ...
> 
> R/r 911


 
I get a lot of teasing from the "old medics" about talking to many people into transport and "showing off" and ALS'ing to many patients.... you know work smarter not harder.  The funny thing is, on my shift anyway, some of the ones doing the teasing also will throw in the IV and work up the iffy pts as quick as I do.  

My poor partner laughs at me at least once per shift.  He says he can't tell when I am "freaking out a little" unless he looks real close and sees me chewing on my bottom lip.  Apparently his last 2 partners outwardly stressed when things were bad.....  I bite the inside of my mouth....  So when this happened all he heard was the "Oh no you don't!" without alot of commotion so he changed to emergency response.


----------



## KEVD18 (Dec 5, 2008)

MedicPrincess said:


> He began with trigemny about the time I was calling in my report... about 5 out.  During the radio report, bijemny ensued.
> 
> After the radio report, with hosptial about 3 blocks away, his PVC's went from unifocal to multifocal, and then R on T....  Unconscious and V-Tach followed.  (Along with a very long string of tourrets silently and something along the lines of "Oh no you don't!")



so hastings, what would your plan have been here. your bls partent is teching, your up front tooling along sipping on your coffee and he pokes his head up and says he's in v tach.

you dont have a line, no previous ekg and thus no monitor attached. basically your screwed becuase you were being hard headed and lazy.

mp may very well have saved this guys life becuase she had the forsight to see this call going south. on your truck, im willing to bet his family would have planted him.


btw, strong work mp, id work with you any day.


----------



## triemal04 (Dec 5, 2008)

KEVD18 said:


> so hastings, what would your plan have been here. your bls partent is teching, your up front tooling along sipping on your coffee and he pokes his head up and says *the guy's uncoscious now*.
> 
> you dont have a line, *no ekg at all*. basically your screwed becuase you were being hard headed and lazy.
> 
> ...


Fixed that one for you.    Now it's time to pull over, get out, get in the back, and start working up the unconscious pt from scratch.  Good luck.


----------



## KEVD18 (Dec 5, 2008)

triemal04 said:


> Fixed that one for you.    Now it's time to pull over, get out, get in the back, and start working up the unconscious pt from scratch.  Good luck.



strong work on the modifications sir. i was using hind sight where we had that info, but you're totally right. all the hapless basic in the back would know is that the excrement had hit the ventilation device. 

now, in this case, the truck was mere blocks from the H. how much of that was luck? they could very well have been miles.

who said something about the distance from an er a patient is allowed to code? was that more or less than 6 blocks?

oh yeah, and you get the distinct pleasure of rolling into an er with a code that you made your bls partner take becuase you didnt want to do the work.....ooops, i mean you wanted the basic to have the experience.

the defendant is charged with negligence and involuntary manslaughter.

"so mr paramedic, you decided to overlook a 20lb weight loss in <2 months, dyspnea on excetion, irregular pulse with a cardiac hx and taking cardiac meds and let a basic tech the call."

"yes, your honor. i wanted his to get some experience"

"experience in what, allwoing patients to die?"

"uuuummmmmm......"

"i find the defendant quilty. your sentenced to 18months in the house of corrections and 1.5 million in damages."


----------



## daedalus (Dec 6, 2008)

An anecdotal example of a thump to the chest. Very cool.


----------



## daemonicusxx (Dec 6, 2008)

ALS, shortness of breath gets all the als stuff. so does N/V, zofran.


----------



## Foxbat (Dec 6, 2008)

Reminds me of one of my first ride-alongs.
We were dispatched for a pt. requesting lift assist only; so we lift this old guy, help him get into bed, he refuses to go to the hospital. In the same time, he looks kind of weak and lethargic; after asking him and his wife about it, our medic finds out the pt. has been like that for the last few days. Medic persuades him to call his doctor who advises him to go to the hospital with us, and he finally agrees.
While en route, he goes into VT (still CAO*4). A typical BLS call, yeah.


----------



## KEVD18 (Dec 7, 2008)

daemonicusxx said:


> ALS, shortness of breath gets all the als stuff. so does N/V, zofran.



dyspnea on excertion isnt quite the same thing as difficulty in breathing/shortness of breath. im fourty pounds overweight and smoke a pack a day. i have a little doe from time to time and i have only ever needed als once.

but i get what you're saying.


----------

