Another Systolic BP Drop

[MediMike]

From the sounds of it the majority of you have never had a "10/10" px pt. who didn't actually present as such. Must be nice. I'm a huge fan of px management, don't get me wrong, but none of us were there, we didn't see how the patient was truly presenting, and outside of the OP no one knows what type of system they were working in.

Prior to everyone jumping on the bandwagon have any of you wondered if perhaps this was a rural area with limited resources? Judging how the only ED access was by ferry I'm gonna guess it was. So you have a pt. presenting with HTN (has not taken meds) and px similar to prior event of cholitis, are you going to potentially take the ONLY ALS unit out of service for this patient? We don't all have unlimited resources and mutual aid agreements. Before you start flipping out about the worst care ever etc., how about you consider other possibilities.

 

[Anonymous]

From the sounds of it the majority of you have never had a "10/10" px pt. who didn't actually present as such. Must be nice. I'm a huge fan of px management, don't get me wrong, but none of us were there, we didn't see how the patient was truly presenting, and outside of the OP no one knows what type of system they were working in.

Prior to everyone jumping on the bandwagon have any of you wondered if perhaps this was a rural area with limited resources? Judging how the only ED access was by ferry I'm gonna guess it was. So you have a pt. presenting with HTN (has not taken meds) and px similar to prior event of cholitis, are you going to potentially take the ONLY ALS unit out of service for this patient? We don't all have unlimited resources and mutual aid agreements. Before you start flipping out about the worst care ever etc., how about you consider other possibilities.

:unsure:

 

[Melclin]

From the sounds of it the majority of you have never had a "10/10" px pt. who didn't actually present as such. Must be nice. I'm a huge fan of px management, don't get me wrong, but none of us were there, we didn't see how the patient was truly presenting, and outside of the OP no one knows what type of system they were working in.

Prior to everyone jumping on the bandwagon have any of you wondered if perhaps this was a rural area with limited resources? Judging how the only ED access was by ferry I'm gonna guess it was. So you have a pt. presenting with HTN (has not taken meds) and px similar to prior event of cholitis, are you going to potentially take the ONLY ALS unit out of service for this patient? We don't all have unlimited resources and mutual aid agreements. Before you start flipping out about the worst care ever etc., how about you consider other possibilities.

Well one assumes (perhaps wrongly) that the OP would be clever enough to mention the fact that while the pt states 10/10, they sit there calmly, state they could easily sleep with the pain and don't even feel the need for analgesia, if it were the case.

We comment on the information given.

While I don't necessarily disagree with you about removing the ALS from the region, I'd also argue that the long transport time in agony and lack of ALS intercept, should the pt peg out, could be more of a reason for this pt to be ALS.

More than that though I think this is an obvious case of why its a problem to have a system where one tier can't do anything and the other tier is the only one that can do everything. This person probably doesn't need a specialist intensive care paramedic but they do need IV pain relief, maybe a little fluid, perhaps an anti-emetic at some stage and certainly someone with more than an advanced first aid certificate to assess and monitor their condition (especially given the transport time, not despite it).

 

[Handsome Robb]

Prior to everyone jumping on the bandwagon have any of you wondered if perhaps this was a rural area with limited resources? Judging how the only ED access was by ferry I'm gonna guess it was. So you have a pt. presenting with HTN (has not taken meds) and px similar to prior event of cholitis, are you going to potentially take the ONLY ALS unit out of service for this patient? We don't all have unlimited resources and mutual aid agreements. Before you start flipping out about the worst care ever etc., how about you consider other possibilities.

Fair enough but if that's the case then it sounds like staffing needs to be evaluated and adjusted at or the possibility of a dedicated HEMS/fixed wing service for the simple fact of the inaccessibility of the region but that probably isn't plausible from a cost standpoint. If there is only one ALS provider available I would guess that the call volume of the region is pretty low but that's an assumption.

How do you decide which ALS patient gets that ALS provider? It doesn't make sense to staff an ALS provider if all they are going to do is sit around and turf calls while they wait for that rare "life threatening emergency". I've said it before, if you choose to live in extreme rural areas you have to accept the risk that help may be very far away in the case of an emergency. You can't live out in the sticks and expect response times that an urban or even a less rural area receives.

In my opinion this lady is obviously an ALS patient from the info provided even if it is only for pain management, which has been stated repeatedly throughout this thread. Patient care is what we are here for correct? To me this case seems like substandard care by the medic, not the OP.

I always auscultate on scene, but this pt was large enough that auscultation during transport was too muffled and impossible to hear, in which case I trust palpation more than I do NIBP.

Just an observation but throughout my clinicals for school I have yet to see a floor that doesn't use NIBP on every patient.

Myself and most if not all of my coworkers use it on a daily basis at work with perfectly fine readings. I routinely get close, if not identical numbers that the NIBP gave me. (I know, I know, n=1). You just need to use some common sense to decide if the number it spits out makes sense. If I see a number I don't like/agree with in relation to patient presentation, HPI or pt Hx I'll auscultate one. Per protocol our first BP is supposed to be manual but I'll be honest, it doesn't always happen that way.

Like everything we use NIBP is a tool and you need to be able to troubleshoot the tools you work with. There are a few main reasons for abnormal readings from an automated BP cuff. Off the top of my head incorrectly fitted or placed cuff or the patient voluntarily or involuntarily moving or flexing the extremity while it is taking a reading come to mind.

 

[mrswicknick]

Prior to everyone jumping on the bandwagon have any of you wondered if perhaps this was a rural area with limited resources? Judging how the only ED access was by ferry I'm gonna guess it was. So you have a pt. presenting with HTN (has not taken meds) and px similar to prior event of cholitis, are you going to potentially take the ONLY ALS unit out of service for this patient? We don't all have unlimited resources and mutual aid agreements. Before you start flipping out about the worst care ever etc., how about you consider other possibilities.

^^^ We have two medics for the entire county, a lot of things that should be ALS in other areas usually become BLS. Its one area where I really wish WA would offer ILS as an option, but instead the best we get is IV technician which most of our crews are, and if fluids may be needed one will be found for transport.

In my honest opinion, and I should have clarified earlier, the pt was experiencing "10/10" pain, however it looked to me that it was really only moderate, there was grimace but she wasn't screaming or having any labor in respiration... With all things considered I believe both the BLS crew on scene and the two medics determined from that taking a medic unit OOS for pain meds alone would have been unnecessary. Sorry for not clarifying.

 

[Medic Tim]

^^^ We have two medics for the entire county, a lot of things that should be ALS in other areas usually become BLS. Its one area where I really wish WA would offer ILS as an option, but instead the best we get is IV technician which most of our crews are, and if fluids may be needed one will be found for transport.

In my honest opinion, and I should have clarified earlier, the pt was experiencing "10/10" pain, however it looked to me that it was really only moderate, there was grimace but she wasn't screaming or having any labor in respiration... With all things considered I believe both the BLS crew on scene and the two medics determined from that taking a medic unit OOS for pain meds alone would have been unnecessary. Sorry for not clarifying.

What is the call volume like for the als unit?

It seems like a waste to not use them when a pt needs them. If the system needs more resources you will never get them unless you show the need for it. By turfing these pts to bls you are not helping your pt or the county, as I said earlier you will not get more als units if you can not show they are needed, and it is a huge liability issue for the Medic and service.

 

[DrankTheKoolaid]

Im also from an extremely rural AKA frontier area. 2 Paramedic / EMT trucks to cover our entire county 24 hours a day covering about 1000sq/mi. And that is in the mountains kind of area. Snow and winding roads are the norm. Lets put it this way in the 1400sq/mi (another system covers 400sq/mi of the furthest part of our county) our county covers we dont have a single 4 way stop sign intersection or a single traffic light.

So please do not try to use that as an excuse for substandard care. Never should you neglect 1 patient because you MAY get another. If another call happens and they have to wait so be it. That just helps identify a unit shortage in your system that can either be fixed or not. Worried about taking ALS out of area fine you treat her for pain and prepare for the worst and launch air if available. Not put it on a lower provider who is unable to do ANYTHING for her.

And not quite sure why people keep bringing up the HTN as it was a complaint, it wasnt it was just a secondary finding. This patient was pale, diaphoretic with 10-10 abd pain that is the issue.

 

[Aidey]

I always auscultate on scene, but this pt was large enough that auscultation during transport was too muffled and impossible to hear, in which case I trust palpation more than I do NIBP.

What was her actual BP then since you auscultate one on scene. And your post implied that it was always too loud to auscultate during transport.

You may not trust NIBP but it is the standard in the majority of medical facilities I've ever been in. I'm pretty sure that the technology isn't that awful if it is being used so widely. As NVRob said, you have to learn to use your equipment and evaluate the results you get. Is there a basis for your dislike of NIBP beyond "I just don't like it"?

 

[MediMike]

^^^ We have two medics for the entire county, a lot of things that should be ALS in other areas usually become BLS. Its one area where I really wish WA would offer ILS as an option, but instead the best we get is IV technician which most of our crews are, and if fluids may be needed one will be found for transport.

I'm gonna guess...Vashon? Maybe Orcas? The state used to offer an IV monitor cert which at least let BLS providers run NS after an ALS provider/IV Tech started the line.

Corky I understand you cover a huge area, what's your call volume? Adequate utilization of resources is a game many of us have to play.

Yeah, it would be great if you could get as many units as you wanted, hell you make every patient ALS, give any patient with a stubbed toe some analgesia. And I disagree with anyone who states that they won't turf a non-serious call on the chance that another call will come in. It's called triage.

 

[DrankTheKoolaid]

re

Call volume is only around ~3k a year if memory serves.

This isnt a patient with a stubbed toe.

And no that is not triage. Triage assumes you have other patients pending.

And irregardless of the final outcome which has nothing to do with the discussion and the pain subsiding lets take a look at the facts.

Patient is Morbidly obese (difficult to evaluate to put it mildly)

Intial exam notes pale and diaphoretic, along with grimacing (obvious pain along with a sympathetic response to it) with stated 10-10 pain from a patient that knows what pain is (childbirth)

VS note HTN consistent with pain (we'll get back to this one later)

Now lets look at age, this patient grew up during the depression era and typically it is hard for them to ask for help to begin with since it was so pushed on them during their early years to suck it up and move on.

While en route the patients BP dropped back to her normal range when the pain was self limited for unknown reasons. This negates the argument that the HTN was due to her missing her medication and leads back to a patient that was truely in pain and was dumped on a BLS provider unable to provide any relief. Also is this paramedic who evaluated her some sort of fortune teller who was able to see that this patient who already had nausea and vomiting on scene was going to be able to tolerate a trip on a boat and not vomit again?

I can go on and on from a CQI/QA standpoint as that is my job.

But the better thing to do is look at this like a human and consider if this was your wife/mother/daughter. Would you want them just dumped onto a gurney with nothing gained other then a high ambulance bill for the ALS evaluation, or would you want her to actually get some treatment and relief since she is already going to be billed at the higher ALS rate because of the crappy dump and run the medic pulled on her?

 

[mrswicknick]

I'm gonna guess...Vashon? Maybe Orcas? The state used to offer an IV monitor cert which at least let BLS providers run NS after an ALS provider/IV Tech started the line.

Corky I understand you cover a huge area, what's your call volume? Adequate utilization of resources is a game many of us have to play.

Yeah, it would be great if you could get as many units as you wanted, hell you make every patient ALS, give any patient with a stubbed toe some analgesia. And I disagree with anyone who states that they won't turf a non-serious call on the chance that another call will come in. It's called triage.

Call volume is usually 8-10 ALS and 2-3 BLS a day, though sometimes we can't find a damn thing to do and sometimes we can't clear airlift quick enough to get the next one out.

As for the NIBP issue, our machines are pretty much a joke, the cuff's have never been replaced, and they are about as accurate as my 2 year old sister unless the conditions are perfect. I find more than not I have to auscultate after I get a NIBP because there is a 120 point gap or, more often than not, the machine cant even get a BP. I cant remember the initial auscultated BP, but let me be clear, I auscultate everything. This is one of the few pt's where It was just close to impossible to auscultate during Tx.

 

[MediMike]

Patient is Morbidly obese (difficult to evaluate to put it mildly)

Why does that make them harder to evaluate? What is it you are expecting to find?

Intial exam notes pale and diaphoretic, along with grimacing (obvious pain along with a sympathetic response to it) with stated 10-10 pain from a patient that knows what pain is (childbirth)

Fair enough, you've got a point of reference there. Now that being said, a grimace does not indicate 10/10 px to me. Screaming, howling, crying indicates 10/10 pain. You must have seen some pretty low key births.

Now lets look at age, this patient grew up during the depression era and typically it is hard for them to ask for help to begin with since it was so pushed on them during their early years to suck it up and move on.

This is a nice thought process, but asinine. You can't apply a blanket statement like this to everyone born in a certain era. How do you know she wasn't one of the top 1% back in those days? Still living happily with no problem asking for assistance. Or maybe she was hooked on opium back in the day, and ran in the same circles as JFK with whom she suffered an ectopic pregnancy...(I could go on but I won't)

While en route the patients BP dropped back to her normal range when the pain was self limited for unknown reasons. This negates the argument that the HTN was due to her missing her medication and leads back to a patient that was truely in pain and was dumped on a BLS provider unable to provide any relief. Also is this paramedic who evaluated her some sort of fortune teller who was able to see that this patient who already had nausea and vomiting on scene was going to be able to tolerate a trip on a boat and not vomit again?

C'mon now...if the medic wasn't a fortune teller who could see that the patient wouldn't vomit again, then he also wasn't a fortune teller who could see that the HTN would resolve therefore not being caused by the lack of HTN medications! Haha...

I can go on and on from a CQI/QA standpoint as that is my job.

I'm glad, the world needs people like you.

But the better thing to do is look at this like a human and consider if this was your wife/mother/daughter. Would you want them just dumped onto a gurney with nothing gained other then a high ambulance bill for the ALS evaluation, or would you want her to actually get some treatment and relief since she is already going to be billed at the higher ALS rate because of the crappy dump and run the medic pulled on her?

Does your agency bill for an ALS eval? Thats surprising if they do, I don't know of any agencies in my state that operates along those lines. It's obvious that you are looking at the absolute worst case scenario possible here with this patient, while I am taking a more conservative look. I will NEVER advocate against px medication, when you look at prehospital EMS there's not much we really do that makes a damn bit of difference other than px meds and a few other small things, but if you are operating in a busy system with limited resources you have to look at the good of the community rather than a morbidly obese pt. who is presenting with abdominal px described as similar to past episodes of cholitis post participating in an activity known to make that cholitis flare up. Could she use 2-4 of MSO4? Yeah probably. Maybe a touch of Zofran? Doubtful. The vomiting was not intractable, it happened once with EMS there. There's a time and place for medication, prophylactically dosing any patient who has vomited with an antiemetic is unneeded.

I also don't take kindly to people attacking providers who work in different systems than they, who do not have the entire story, and who weren't on scene.

Now, all that being said, energetic discussions are fun! Don't sound so crappy lol

 

[DrankTheKoolaid]

Why does that make them harder to evaluate? What is it you are expecting to find?

Can you honestly tell me you can do a through abdominal assessment on a morbidly obese gut and feel anything but fat rolls because I certainly cant. That is why Morbid Obesity is a reason for inclusion to most trauma alerts because they are difficult to evaluate, obviously someone with much more expertise then both you and I seems to think they are difficult to evaluate..........

Maybe consider a class on societal and cultural differences as not everyone howls and screams at pain, and at some point you have to listen to a pale and diaphoretic patient when they tell you they have 10 - 10 pain

Yeah that was a gross generalization, but something we as providers have to consider when dealing with any patient and their perceived and expressed perceptions to events and scales we give them.

As to the vomiting I stand by it. This "medic" is about to put this woman on a boat (read motion sickness) after she had nausea and vomiting in front of him without even bothering to give some ODT zofran at the very least?

And unfortunately yes in California that is the norm to get billed at a higher rate even for a ALS eval you didn't request. Jems just had an piece a few months back after complaints in San Fran regarding MVA patients who never requested an ambulance that still were billed high ALS rates when a medic came up to eval a patient who refused care or evaluation after someone else called them. IE law enforcement or some do gooder.

And your right, I was looking at worst case scenario. As any field provider should be doing. You plan for the worst so you don't get caught with your pants down when the :censored::censored::censored::censored: hits the fan. I am a HUGE proponent of field administered analgesia, and this woman obviously could have benefited from it.

And yup as long as lower providers read these scenarios and unconsciously formulate how they are going to treat patients when they become paramedics, I want to make sure it is aggressive and compassionate care, not substandard typical Fire-based medicine (SoCal directed) that dumps anything with a pulse on a BLS providers. Our patients deserve better then that.

And yes we obviously don't have the whole story, but from what we do have its pretty obvious to me.

Thanks for playing. These chats make us all think and see differing view points!

 

[MediMike]

I've worked in several systems over the last 10 years and never seen morbid obesity listed as an indication to call a trauma alert. This pt. wasn't a victim of trauma, or did I miss the line where she was nailed by a falling log? I suppose if you were concerned regarding an aortic dissection we could've done a precautionary airlift.

10/10 px is PAIN. Not abdominal discomfort. I grimace when I get gas, I curl up in the fetal position and am immovable with a kidney stone. Maybe a class on critical thinking would do you some good.

Many systems don't carry Zofran ODT, or consider an anti-emetic to make it a mandatory ALS call due to the fact that a medication was administered. Seeing as how this patient lives on a island with access only by ferry maybe motion sickness is not a problem. I agree that with a call to their doc perhaps an IM dose could have been administered.

What is the worst case scenario you're looking at here? I have yet to find one where the ALS provider is going to provide any good. If it's as bad as you seem to think it is, with a 50minute ferry ride staring you in the face you should be advocating for an air lift here.

Seeing as how the px resolved, I don't see how the patient would have benefited from analgesia, while I can definitely see how an ALS bill would have contributed to your company's pocket. The OP even states that the px seemed moderate. Adequate. Utilization. Of. Resources.

And again(and again and again and again), yes, patients do deserve better than what they receive in many areas. In a perfect world I could also ride a liger to work whilst getting a backrub from Keira Knightley. I can see you've got some significant issues with SoCal's turfing policy which has influenced your growth as a medic, and it's good to look at past experiences and learn from them. I worked in King County with the famed Medic One fellas for a number of years back in the day and saw exactly what you did. As I grew older I realized that they provide the best care that they can with the limited resources and funding that they have. I'm not familiar with SoCal outside of the horrible rep they've received via these forums and word-of-mouth so I don't know what their excuse is!

Medic Tim-Just saw your response, there are better ways of lobbying for more units than by taking them OOS and putting the rest of the community at risk, especially in what seems to be a moderately busy system.

 

[DrankTheKoolaid]

Haha, no she was not a trauma and that was not my point. The powers that be realize that morbidly obese patients should be included into the trauma system sooner, because they are difficult to evaluate. So why should we believe this morbidly obese patient is any easier to evaluate simply because she is not a victim of trauma?

And the end result of her pain subsiding has nothing to do with this.

The issue is a medic turfing to a BLS provider a elderly, pale and diaphoretic patient with stated 10 - 10 abd pain with active nausea and vomiting. That is my issue. That to me indicates a failure in a proper exam or being able to interpret the findings

But for the sake of argument, would you still agree with this medics dumping of the patient if she coded on the ferry. Or went into shock and perished secondary to some abdominal issue that was trivialized by the medic?

 

[MediMike]

But for the sake of argument, would you still agree with this medics dumping of the patient if she coded on the ferry. Or went into shock and perished secondary to some abdominal issue that was trivialized by the medic?

Hahaha glad to see some laughter out of ya finally. In either of those situations there's absolutely nothing that either of us could do man. If the patient coded she's done for. An 81?y/o patient isn't going to survive a 30m resus attempt and if you're keeping up on current trends (which I know are just trends) BLS is just about as good at resuscitating cardiac patients as ALS if not better, or if it was a ruptured AAA/TAA all we're gonna do is turn her blood pink or kill her kidneys with Dopamine. It would be a flight situation at that point. Unfortunately this patient chose to live in an area with limited access/egress and limited prehospital resources. From the patient's presentation, in an adequately staffed region, I could see taking her as ALS. In a region where the judgement call needs be made, I can also see the provider choosing BLS.

Two different viewpoints my friend!