84 YOF Cardiac Patient - Walk to Ambulance?

[Simusid]

My medic friend was in a restaurant recently and heard someone yell "Call 911!" He found an 84 year old woman slumped deeply in her chair. She was unresponsive. Skin color was gray/ashen, respirations were described as "death rattle". She was not choking on food and her companion told my friend that she had an "arrhythmia". I believe my friend said she had no radial pulse (not sure) and he was just about to start CPR. At this point she spontaneously had some amount of recovery. She was probably not quite alert and oriented.

By this time ALS arrived and took over the scene and my friend went back to his dinner. Shortly after, he saw the medics walk this patient out the door. No stretcher, no stair chair, no O2.

My friend, a 20+ year veteran, instructor, and intensly passionate about his job ....well.... lets just say he had some SERIOUS objections to what he viewed as inadequate patient care.

I suppose if she was alert enough to walk, she'd be alert enough to refuse a stretcher. So I guess I have two questions. One, if she didn't adamantly refuse, were the medics (and they were medics not BLS) wrong to walk her out with no O2? Two, if you were faced with someone in a restaurant who maybe was embarrassed about getting on a stretcher, how hard would you work to convince them otherwise and what would you try to do?

 

[rhan101277]

An unresponsive patient should have a carotid artery checked as well as radial. They could be having a rhythm that has low BP and distal pulses may not be palpated.

You should never walk a suspected cardiac patient to the ambulance, oxygen or not. As far as convincing them if there was stretcher access, I would explain that if I suspected an MI was happening that it could do more damage and aggravate the situation by walking.

 

[MrBrown]

Hmmm, no

 

[Shishkabob]

What makes you / your friend so sure it WAS cardiac in nature?

 

[EMSLaw]

With that presentation, they'd take about a step to my stretcher, with lifting assistance.

 

[Simusid]

What makes you / your friend so sure it WAS cardiac in nature?

My question is less about this specific assessment and whether or not my friend was correct or not. As a minimum she had AMS, poor skin CTC, inadequate breathing and a stated history of arrhythmia. Take that as a given and with that my questions remain... would you walk her to the truck and if she didn't want to go how hard would you try to convince her.

I'll add a third question, again given that the above signs/symptoms are correct and she is walked out, AND collapses with an MI on the way, could that be misfeasance?

 

[rescue99]

My medic friend was in a restaurant recently and heard someone yell "Call 911!" He found an 84 year old woman slumped deeply in her chair. She was unresponsive. Skin color was gray/ashen, respirations were described as "death rattle". She was not choking on food and her companion told my friend that she had an "arrhythmia". I believe my friend said she had no radial pulse (not sure) and he was just about to start CPR. At this point she spontaneously had some amount of recovery. She was probably not quite alert and oriented.

By this time ALS arrived and took over the scene and my friend went back to his dinner. Shortly after, he saw the medics walk this patient out the door. No stretcher, no stair chair, no O2.

My friend, a 20+ year veteran, instructor, and intensly passionate about his job ....well.... lets just say he had some SERIOUS objections to what he viewed as inadequate patient care.

I suppose if she was alert enough to walk, she'd be alert enough to refuse a stretcher. So I guess I have two questions. One, if she didn't adamantly refuse, were the medics (and they were medics not BLS) wrong to walk her out with no O2? Two, if you were faced with someone in a restaurant who maybe was embarrassed about getting on a stretcher, how hard would you work to convince them otherwise and what would you try to do?

Wow...was this in Detroit? Seen it many times. One just never gets over the constant stream of stupid flowing out there :wacko: Your friend could have made a citizens complaint but, I doubt he thought about it at the time.

 

[wyoskibum]

Monday morning quarterback

Having not been privy to the assessment and not having the full patient history, I would hesitate to second guess the crew providing care.

It is possible that the patient had a syncopal episode due to vagal stimulation after a large meal? Perhaps the patient has had simular episodes and once conscious, was able to communicate that to the responding crew? There are so many variables. Only the person doing the assessment and making decisions based on that can answer the question.

Just like I would hesitate to question why a 20+ year medic would start CPR on a patient who had respirations and didn't check for carotid pulse. I'm sure he had his reasons to do what he was going to do.

 

[FLEMTP]

Not only do I WALK my cardiac patient's to the stretcher... i make them JOG!!!!B)

 

[Simusid]

What makes you / your friend so sure it WAS cardiac in nature?

My question is less about this specific assessment and whether or not my friend was correct or not. As a minimum she had AMS, poor skin CTC, inadequate breathing and a stated history of arrhythmia. Take that as a given and with that my questions remain... would you walk her to the truck and if she didn't want to go how hard would you try to convince her.

I'll add a third question, again given that the above signs/symptoms are correct and she is walked out, AND collapses with an MI on the way, could that be misfeasance?

 

[46Young]

The first time you walk a pt (elderly, nonetheless) with a syncopal episode and they drop on you, you'll wish you never did, and probably be in fear of your job and maybe your card. Now, if the pt is embarassed to be carried out and will not go by cot or chair no matter how hard you try to convince them of the contrary, then have them sign a refusal on your PCR regarding that before they walk.

The skin will tell you a lot about a pt, and shouldn't be dismissed. Even in the event of a suspected vasovagal syncope, where the pt now feels better, a 12, L/S, BGL, orthostatic vitals, stroke test and such ought to be performed before walking the pt. And by walking the pt I mean that the pt is proud and doesn't want to cause any more of a scene, as I would never walk a pt with any medical complaints. Unless it's a minor injury or something, I'll always advise that we're carrying the pt. Once in a while they'll want to walk, despite my every attempt to convince them otherwise. Someone who's been on this earth for 70, 80, or 90 years will be pretty set in their ways, and some 30 something "kid" isn't going to force them to do anything they don't want. Get family to convince tham, or have them sign a refusal of that specific treatment.

 

[lightsandsirens5]

The first time you walk a pt (elderly, nonetheless) with a syncopal episode and they drop on you, you'll wish you never did, and probably be in fear of your job and maybe your card. Now, if the pt is embarassed to be carried out and will not go by cot or chair no matter how hard you try to convince them of the contrary, then have them sign a refusal on your PCR regarding that before they walk.

The skin will tell you a lot about a pt, and shouldn't be dismissed. Even in the event of a suspected vasovagal syncope, where the pt now feels better, a 12, L/S, BGL, orthostatic vitals, stroke test and such ought to be performed before walking the pt. And by walking the pt I mean that the pt is proud and doesn't want to cause any more of a scene, as I would never walk a pt with any medical complaints. Unless it's a minor injury or something, I'll always advise that we're carrying the pt. Once in a while they'll want to walk, despite my every attempt to convince them otherwise. Someone who's been on this earth for 70, 80, or 90 years will be pretty set in their ways, and some 30 something "kid" isn't going to force them to do anything they don't want. Get family to convince tham, or have them sign a refusal of that specific treatment.

Excellent post. I agree 100%.

And try doing this stuff as a 20 year old kid (which you probably have). I had a 90 somthing female pt the other night. Well, anyhow, we are on the road on the way to the hospital and I am getting all my stuff ready to start a line. I ask her if she has ever had an IV before and she says; Yea I have. Are you going to give me one? Cause you know you don't even look old enough to shave.~~~~~end of thread hijack

At my service we try to get the gurney as close too all patients as we can to minimise waking distance. And if we cannot get the gurney close enough, we use stair chairs or folding streatchers. I would also try everything I could to get a possible cardiac pt onto the gurney and keep them off of their feet. It just seems like a no brainer to me. I understand if the pt is embaressed, but it has been my experience that all it take is a little persuasion and they usually climb right onto the gurney.

 

[Veneficus]

Not only do I WALK my cardiac patient's to the stretcher... i make them JOG!!!!B)

If you were in Pttsburg you could add.

"through the snow, uphill both ways"

 

[Jersey]

What makes you / your friend so sure it WAS cardiac in nature?

What makes you so sure it wasn't?

With a presentation like this, even if there's a clear 12 lead etc it is cardiac! Unless you have an I-STAT in the back of your rig, there's no way you're going to be able to even begin to be able to make that decision. Also usually patients (especially this age) that present like this fall into three general categories:

Arrhythmia (Patient has a history of this!) Runs of fib/tach, SVT, acc A-Fib etc
TIA/Stroke
Sx

Standing a patient up and having him/her walk is poor patient care, and will not stand up in front of a jury. I worked too hard to get my card and the experience I had, lets try to be professionals instead of ambulance jockeys.

 

[wyoskibum]

He who lives in glass houses.....

What makes you so sure it wasn't?

With a presentation like this, even if there's a clear 12 lead etc it is cardiac! Unless you have an I-STAT in the back of your rig, there's no way you're going to be able to even begin to be able to make that decision.

There is so much speculation going on. If you apply cookbook medicine to any situation, someone is going to find fault no matter what. Not to mention that we are already getting what little information 3rd hand.

I'm going to give the Medic the benefit of the doubt and say that he/she did what they though appropriate with the information that they had. After all, it was their patient and their decision.

 

[EMSLaw]

I don't think the jury will be too impressed when you say, "We were at the end of a double, so City EMS rules were in effect."

That being said... hopefully, there was no adverse outcome to the patient.

 

[Jersey]

I am probably one of the biggest proponents of paramedics understanding why they're doing something rather than just doing it because the book says so.

We were given little information, true. However based on that information, I can absolutely judge the crews behavior. There is no acceptable reason to "walk" this patient to the ambulance or even down stairs to a stretcher when there has been confirmed syncope of unknown etiology. Making irresponsible patient decisions such as these sets our profession back both in the eyes of upper level medical providers as well as the public.

 

[colafdp]

Standing a patient up and having him/her walk is poor patient care, and will not stand up in front of a jury.

Do you mean the "serious" patients, or do you lift every pt you encounter? Just wondering

 

[rescue99]

Not only do I WALK my cardiac patient's to the stretcher... i make them JOG!!!!B)

Stress test?

 

[Jersey]

Do you mean the "serious" patients, or do you lift every pt you encounter? Just wondering

Good clarification point that I overlooked on second read. Of course, I walk a lot out to my ambulance (and have even done so once or twice to my SHUT DOWN aircraft) but that's another story. However, I would never ever ever walk a suspected cardiac, syncope or other moderat-severe, or severe patient out. It's poor care, and will put your card on the line when something happens.