97 year old, STEMI

[NomadicMedic]

97 year old Alz patient, in a nursing home. Active STEMI. Not able to contact DPOA. PT is a DNR/DNI. Last time we saw this patient the family "didn't really want anything done."

Frustrating. Frusssss. Trating.

Sometimes being a paramedic kind of sucks.

 

[Clipper1]

97 year old Alz patient, in a nursing home. Active STEMI. Not able to contact DPOA. PT is a DNR/DNI. Last time we saw this patient the family "didn't really want anything done."

Frustrating. Frusssss. Trating.

Sometimes being a paramedic kind of sucks.

This should not be a difficult decision with specific orders like a DNR/DNR this should not be a difficult call. Provide comfort through pain management, oxygen, any other therapy sort of intubation and trsnsport. The hospital physician is much more qualified to determine the best treatment to allow this patient to be comfortable. Calling the family should not be a priority for you. Allow those who understand the options do that and who may have been following the patients care.

Call your MY or the ER doctor.

 

[NomadicMedic]

This should not be a difficult decision with specific orders like a DNR/DNR this should not be a difficult call. Provide comfort through pain management, oxygen, any other therapy sort of intubation and trsnsport. The hospital physician is much more qualified to determine the best treatment to allow this patient to be comfortable. Calling the family should not be a priority for you. Allow those who understand the options do that and who may have been following the patients care.

Call your MY or the ER doctor.

I think you misunderstand. It is MY job to be a patient advocate, NOT a protocol monkey. It's MY job to reach out to the family about transport decisions, especially since they specified in the patient's paperwork their hospital choice is a non PCI capable facility. You should know that I've transported this patient before and while the family still wants this patient transported to the hospital, they wouldn't allow for any tests or invasive procedures to be performed. So, we transport ... why?

I would think that you might understand that ... but everything in your world is black and white, isn't it?

 

[Clipper1]

I think you misunderstand. It is MY job to be a patient advocate, NOT a protocol monkey. It's MY job to reach out to the family about transport decisions, especially since they specified in the patient's paperwork their hospital choice is a non PCI capable facility. You should know that I've transported this patient before and while the family still wants this patient transported to the hospital, they wouldn't allow for any tests or invasive procedures to be performed. So, we transport ... why?

I would think that you might understand that ... but everything in your world is black and white, isn't it?

No, it just sounded like you wanted to wait for a phone call before doing anything. Things can still be done at the hospital for this patient. PCI is not the only answer to an MI or for comfort either.

The attending/ER physician will still talk to the family. He or she will explain the alternatives for treatment options. The doctor will not be able to take just your word to withdraw all forms of care. Some tests are just routine to provide the best drugs for comfort for a patient of 97 and their disease processes. If you read a little more pharmacology you will find some things are in black and white.

 

[NomadicMedic]

No, it just sounded like you wanted to wait for a phone call before doing anything. Things can still be done at the hospital for this patient. PCI is not the only answer to an MI or for comfort either.

The attending/ER physician will still talk to the family. He or she will explain the alternatives for treatment options. The doctor will not be able to take just your word to withdraw all forms of care. Some tests are just routine to provide the best drugs for comfort for a patient of 97 and their disease processes. If you read a little more pharmacology you will find some things are in black and white.

At what point did I ever remark that I wanted to have a conversation with the doc to "to withdraw all forms of care"? You really need to stop putting words in people's mouths and reshaping a post to suit your own agenda.

I wanted to speak with the DPOA to:

1. possibly change the transport destination
2. advise them that this was an emergent issue
3. give the ER doc a heads up as to the POA's intent

And, FWIW, the first thing the Doc asked me was, "Did you speak to the family or POA?" The. First. Thing. See, I have a reputation of going above and beyond for the patients that I transport. The Docs know this. Our service is recognized as a PARTNER in the care of each patient, not just a horizontal taxi. Perhaps you should learn about other EMS systems before judging the competence of the paramedic based on your preconceived notions.

And Clipper, or Vent Medic, or whomever your pretending to be this week, I'm well aware that PCI isn't the only treatment path for an MI, and you have no idea how much I've pharmacology I've read.

 

[Clipper1]

At what point did I ever remark that I wanted to have a conversation with the doc to "to withdraw all forms of care"? You really need to stop putting words in people's mouths and reshaping a post to suit your own agenda.

I wanted to speak with the DPOA to:

1. possibly change the transport destination
   [*]advise them that this was an emergent issue
2. 
   give the ER doc a heads up as to the POA's intent

And, FWIW, the first thing the Doc asked me was, "Did you speak to the family or POA?" The. First. Thing. See, I have a reputation of going above and beyond for the patients that I transport. The Docs know this. Our service is recognized as a PARTNER in the care of each patient, not just a horizontal taxi. Perhaps you should learn about other EMS systems before judging the competence of the paramedic based on your preconceived notions.

And Clipper, or Vent Medic, or whomever your pretending to be this week, I'm well aware that PCI isn't the only treatment path for an MI, and you have no idea how much I've pharmacology I've read.

Glad you moved this post.
You may have a reputation of going above and beyond but how much time are you wasting? You have a DNR order if the heart stops. You have a DNI order for no intubation. You have med control to call a doctor if you are unsure of the destination. You might be asking a 97 y/o DPOA to make a medical determination using big words without any definitive data and contradicting what a doctor might tell them for the alternatives. A DPOA does not have to be a doctor or an attorney. Are you giving the doctors orders in writing based on your discussion on the phone and will this hold up in court? These questions might hurt your feelings and you will again give me warnings or even ban me for asking the same questions any good doctor, QA or attorney will want to know. To be a good patient advocate you need to know the limitations of your title. You also should not get so defensive about education. Reading and learning is a good thing. Believing you know it all and have no need to read more is not.

BTW....another example of a moderator making personal attacks.

 

[Handsome Robb]

Clipper.

Do you ever have anything else to say? All your posts are singing the same song.

The way you talk about EMS and paramedics makes me wonder if you've ever actually worked in the prehospital field or carry any EMS certifications.

What if the choice hospital refuses to accept due to the STEMI and no PCI capabilities? How is that providing good care for the patient if they don't end up where they want?

Paramedics bring a lot more to the table than just a ride. Maybe not all of us but some definitely can.

Further more a STEMI is a relatively easily correctable disease process...why not cath this lady? With the angles you've been advocatingim surprised you haven't recommended it yet.

 

[Clipper1]

Clipper.

Do you ever have anything else to say? All your posts are singing the same song.

The way you talk about EMS and paramedics makes me wonder if you've ever actually worked in the prehospital field or carry any EMS certifications.

What if the choice hospital refuses to accept due to the STEMI and no PCI capabilities? How is that providing good care for the patient if they don't end up where they want?

Paramedics bring a lot more to the table than just a ride. Maybe not all of us but some definitely can.

Further more a STEMI is a relatively easily correctable disease process...why not cath this lady? With the angles you've been advocatingim surprised you haven't recommended it yet.

I did mention the alternatives in the other posts. But, that is up to the ED doctor and the interventional Cardiologist...not the Paramedic. Either doctor can discuss with the DPOA in greater detail the interventions which can be done. A Paramedic will not know what a doctor can or will do nor will they be familiar with the options offered in a hospital.

Without your name and license number there is no way to know who you are either. I have invited members of this forum to professional forums where our names are known but there have been very, very few takers on that.

My responses sound the same because the discussions are all pretty much the same. You probably want to have your ego stroked regardless of doing patient care.

Many of the people posting here put stuff like "Ambulance Driver" or "Stretcher Fetcher" for their occupation. I prefer to leave it blank rather than trying to come up with some "title".

 

[Rialaigh]

Honestly, at least in this area, a 97 year old having a STEMI as described is not really an emergency. PT will get transported to a hospital, patient will (never say never)...never get cathed for this, because they are 97 with other medical problems. They will spend the night on a telemetry floor getting repeat labs, They will get their electrolytes balanced and a course of antibiotics for the inevitable UTI they have...and they will go to hospice or back to the nursing home. I don't know of any docs here that will cath a 97 year old.

Doesn't much matter if this patient goes to a PCI facility or not as long as they go to a facility with a "telemetry" floor. Ive got to think most families will want to keep grandma or grandpa as close to home as possible, but I'm not sure, and that is why If it were my call, I would try and get a hold of family prior to transport.

 

[FLdoc2011]

Honestly, at least in this area, a 97 year old having a STEMI as described is not really an emergency. PT will get transported to a hospital, patient will (never say never)...never get cathed for this, because they are 97 with other medical problems. They will spend the night on a telemetry floor getting repeat labs, They will get their electrolytes balanced and a course of antibiotics for the inevitable UTI they have...and they will go to hospice or back to the nursing home. I don't know of any docs here that will cath a 97 year old.

Doesn't much matter if this patient goes to a PCI facility or not as long as they go to a facility with a "telemetry" floor. Ive got to think most families will want to keep grandma or grandpa as close to home as possible, but I'm not sure, and that is why If it were my call, I would try and get a hold of family prior to transport.

I've seen plenty of 90 year olds cathed. Going to be a lot of variables to generalize and assume they're not going to intervene so you shouldn't make that assumption.

At least where I am we're routinely even doing CABG's on 80 year olds.

 

[NomadicMedic]

Just 'cuz you can, doesn't mean you should.

But I agree... Many variables to consider.

 

[TheLocalMedic]

I fail to see what all the commotion is about… This is a straightforward situation.

Make an effort to contact the DPOA, but if you can't, then no worries.

Give supportive care, as far as you can according to the POLST (and often this will allow for typical ACS treatment) and then roll to the nearest hospital with PCI ability. Let the receiving facility know all the details surrounding the situation and then let them decide.

I've seen people in their 90's go to the cath lab before, and just because they have a DNR doesn't necessarily mean that family/DPOA won't want this current acute condition to be treated. A UTI can be a life threatening situation too, and plenty of people with DNRs get treated for those, right? Just because they have a DNR doesn't mean you yell, "Run to the light!" and then shrug and walk away.

 

[Handsome Robb]

I did mention the alternatives in the other posts. But, that is up to the ED doctor and the interventional Cardiologist...not the Paramedic. Either doctor can discuss with the DPOA in greater detail the interventions which can be done. A Paramedic will not know what a doctor can or will do nor will they be familiar with the options offered in a hospital.

Without your name and license number there is no way to know who you are either. I have invited members of this forum to professional forums where our names are known but there have been very, very few takers on that.

My responses sound the same because the discussions are all pretty much the same. You probably want to have your ego stroked regardless of doing patient care.

Many of the people posting here put stuff like "Ambulance Driver" or "Stretcher Fetcher" for their occupation. I prefer to leave it blank rather than trying to come up with some "title".

Give me an example of me "needing my ego stroked". How do you know a Paramedic doesn't know the other options for treatments? You obviously assume that every single Paramedic is a brainless protocol monkey and that we can't possibly have knowledge of healthcare outside of our niche...

You're responses are all exactly the same. "You're a paramedic, you don't know anything, just transport and let the doctor figure it out". How is that constructive or productive?

The job of a paramedic is to be an advocate for their patient. In this situation especially, where the provider is familiar with the patient and has an idea of the family's plan for the patient how is it not our job to attempt to make contact with the family in this situation? Especially considering it may make a difference in the transport destination. How do we know the nearest PCI facility isn't a great deal further away than the hospital of choice? Is it really the best care for the patient and the family if they don't want the patient to undergo surgery to just assume that they might and transport the patient to a distant facility making it more difficult for the family to be with their loved one? Especially since this potentially could be the event that ends their life or greatly alters the way they are living.

It's pretty widely known who I am and where I work, I'll gladly tell you if you ask in a PM.

I fail to see what all the commotion is about… This is a straightforward situation.

Make an effort to contact the DPOA, but if you can't, then no worries.

Give supportive care, as far as you can according to the POLST (and often this will allow for typical ACS treatment) and then roll to the nearest hospital with PCI ability. Let the receiving facility know all the details surrounding the situation and then let them decide.

I've seen people in their 90's go to the cath lab before, and just because they have a DNR doesn't necessarily mean that family/DPOA won't want this current acute condition to be treated. A UTI can be a life threatening situation too, and plenty of people with DNRs get treated for those, right? Just because they have a DNR doesn't mean you yell, "Run to the light!" and then shrug and walk away.

The biggest issue in this scenario that I see is the fact that the choice facility is not PCI capable.

No one here is advocating that a DNR/DNI means do not treat. I will say that if a patient has a DNI order that kinda messes with surgical procedures that require general anesthesia...Sure you're intubating them for an elective procedure however they still now have to ween from the vent...maybe it's not an issue though.

 

[TheLocalMedic]

The biggest issue in this scenario that I see is the fact that the choice facility is not PCI capable.

No one here is advocating that a DNR/DNI means do not treat. I will say that if a patient has a DNI order that kinda messes with surgical procedures that require general anesthesia...Sure you're intubating them for an elective procedure however they still now have to ween from the vent...maybe it's not an issue though.

It doesn't much matter that the "choice" facility that family or the DPOA wants the patient transported to isn't PCI capable, because in this instance their choice doesn't much matter. Unless they are right there to tell you, against your advice, that they still want her transported to their original facility, the necessity (regardless of her DNR status) of going to a specialty receiving facility trumps that pre-determined choice.

 

[mycrofft]

There is sometimes a knife edge between being a "protocol monkey" and getting too emotionally involved. In the end you have to live with yourself.

 

[Handsome Robb]

It doesn't much matter that the "choice" facility that family or the DPOA wants the patient transported to isn't PCI capable, because in this instance their choice doesn't much matter. Unless they are right there to tell you, against your advice, that they still want her transported to their original facility, the necessity (regardless of her DNR status) of going to a specialty receiving facility trumps that pre-determined choice.

In the instance that you are unable to make contact I agree. However, why can't the fire department and your partner work on packaging the patient while you make a phone call. If you're short on hands have a staff member at the facility get them on the phone and bring the phone to you. These patients deserve the exact care that others without DNR/DNI/Hospice receive. They also deserve the opportunity to make decisions about their care, just like everyone else.

"You're mother/father/sister/brother/family member is having a heart attack. The hospital you usually have us transport to cannot do the surgery that is usually done to treat this emergency. Would you like us to take them there or to XYZ hospital which is the closest one which can do the surgery? They also have doctors which have other treatment options which the usual hospital may not have."

Pretty easy. We also don't know exactly what capabilities the usual hospital has. It can't do PCI but do they have cardiologists? That's something you can advise the family as well.

 

[triemal04]

In the instance that you are unable to make contact I agree. However, why can't the fire department and your partner work on packaging the patient while you make a phone call. If you're short on hands have a staff member at the facility get them on the phone and bring the phone to you. These patients deserve the exact care that others without DNR/DNI/Hospice receive. They also deserve the opportunity to make decisions about their care, just like everyone else.

"You're mother/father/sister/brother/family member is having a heart attack. The hospital you usually have us transport to cannot do the surgery that is usually done to treat this emergency. Would you like us to take them there or to XYZ hospital which is the closest one which can do the surgery? They also have doctors which have other treatment options which the usual hospital may not have."

Pretty easy. We also don't know exactly what capabilities the usual hospital has. It can't do PCI but do they have cardiologists? That's something you can advise the family as well.

It sounds like contact with the POA was tried and failed though. At that point you do have to make a decision either on your own, or in concert with a doctor.

Without more definative answers from the family I think in this case going to a PCI capable hospital is appropriate. The catch would you need to fill in the recieving doctor in on what was going on before you got there.

 

[Handsome Robb]

It sounds like contact with the POA was tried and failed though. At that point you do have to make a decision either on your own, or in concert with a doctor.

Without more definative answers from the family I think in this case going to a PCI capable hospital is appropriate. The catch would you need to fill in the recieving doctor in on what was going on before you got there.

I have no problem with that.

I do have a problem with paramedics that are too lazy and/or incompetent or scared to contact family or the POA to get a decision about the patient's medical care.

 

[cruiseforever]

Honestly, at least in this area, a 97 year old having a STEMI as described is not really an emergency. PT will get transported to a hospital, patient will (never say never)...never get cathed for this, because they are 97 with other medical problems. They will spend the night on a telemetry floor getting repeat labs, They will get their electrolytes balanced and a course of antibiotics for the inevitable UTI they have...and they will go to hospice or back to the nursing home. I don't know of any docs here that will cath a 97 year old.

At what age would it be an emergency? If the pt is DNR/DNI without special instrutions on POLST he would go to the PCI in our area.

Our take on DNR/DNI is agressive treatment up to the poiint of cardiac arrest. Special instrutions would be the supporative care route.

I am in my 50's I would like DNR. But I would also like to be taken to the PCI for my MI.

 

[Christopher]

97 year old Alz patient, in a nursing home. Active STEMI. Not able to contact DPOA. PT is a DNR/DNI. Last time we saw this patient the family "didn't really want anything done."

Frustrating. Frusssss. Trating.

Sometimes being a paramedic kind of sucks.

My oldest STEMI was 91yo, DNR/DNI, in a nursing home recovering from a hip fx. Received a stent in the LAD.