Blood Pressure: ALS v. BLS

[Smash]

But from what the OP said they did not do a paramedic level assessment. They did a BP and said cya bye

It sounds like they did do a paramedic level assessment. It sounds like the OP had done a good assessment, which would lead them to trust her findings. They've confirmed the main problem that they were called for (hypertension), have recognised that there is nothing to be worried about, nor is there any reason to do a 12 lead, and have duly handed off. Maybe they could have spent a bit more time with the OP to explain this better. Other than that, I don't see a problem.

Edit: And we aren't attacking anyone, it's just that as an educator (I lecture at a large university that runs a full degree in paramedicine) I prefer to get people to think things through themselves, find the information they need and use it to develop their own practice. I find that this helps them conceptualise things better, rather than being spoon fed lists of numbers or "facts"

 

[Shishkabob]

Instead of attacking and thinking that I am absolutely ridiculous. Why don't you explain your decision in the hopes someone could learn something.

I don't want you to think we're attacking you, because we aren't. (Well, I know for a fact I'm not.) I'm one of the biggest fans of EMTs who want to learn more / do more / take their job seriously and be a help instead of just a gofer (Which you clearly do, as do most of the people who join a forum such as this). I hate gofers. Challenge yourself, challenge me, help the patient, do what you think is right (so long as you dont go over the no-no zone line)

But from what the OP said they did not do a paramedic level assessment. They did a BP and said cya bye

I can ask questions that an EMT wouldn't know to ask. Hell, I ask questions and do procedures that make other Paramedics confused. (Ask the next medic you see when the last time they did a 15-lead was)

Again, an ALS tool need not be used to do an ALS assessment.

 

[Lifeguards For Life]

Hell, I ask questions and do procedures that make other Paramedics confused.

He says this like it's a good thing:lol:

Just kidding L

 

[Shishkabob]

Good for my over-inflated, Para-God-ish ego.

 

[Lifeguards For Life]

Good for my over-inflated, Para-God-ish ego.

I was going the other way with that one, but again, I kid, I kid.

 

[Anjel]

So what would you of done if this was your pt. No BLS on scene.

As you were taking vitals and gathering info.

Would you of started a line?

Hooked them to a monitor? Maybe not an EKG But a monitor?

I am just curious.

Diarrhea 3 times in over 24hrs really isnt that big of a deal. I just am really curious as to why her BP was high. If it is supposed to be controlled by her meds.

Are the two related? Or just coincidence.

 

[usalsfyre]

Are the two related? Or just coincidence.

Maybe, maybe not. The big thing I want to know is when has she seen her PCP last.

 

[18G]

I wouldn't have been excited with this patient pre-hospital. Hypertension is RARELY ever treated by ALS in the field. I still wonder why BLS even calls ALS for hypertension unless it is an extreme case. The patient was pleasant, non-distressed, and completely asymptomatic of the finding. If your transport time is short (<20mins) just transport.

Maybe I missed it but what was the patient's history? She said she has been compliant with the HTN meds but was she really? Any dosage change? Has she been compliant with her diet? Any splurging on the sodium that increased fluid volume and contributed to increased BP? Does she also take a diuretic to help with control of B/P? Has she been compliant with that? Any renal issues? What's her output been like?

Primary hypertension can be from several different causes and its anyone's guess sometimes what causes BP to elevate in a person. It's certainly not for pre-hospital to diagnose the specific cause. Is she currently ill over all? Increased HR? Febrile? Stressed? Taken any stimulant meds?

Here in PA the decision for ALS to release must be a mutual decision. Rarely, does BLS ever dispute the ALS release decision but if BLS feels that ALS is being lazy or just doesn't feel comfortable than ALS has to ride.

 

[Lifeguards For Life]

So what would you of done if this was your pt. No BLS on scene.

It would still be a BLS call

As you were taking vitals and gathering info.

Would you of started a line?possibly, but not because of her bp. OP reports diahrea 3/24 but gives no indication as to fluid intakes, mild dehydration with turgor

Hooked them to a monitor? Maybe not an EKG But a monitor. There is really no reason too, just the same as there is no reason not too.

I am just curious.

Diarrhea 3 times in over 24hrs really isnt that big of a deal. I just am really curious as to why her BP was high. If it is supposed to be controlled by her meds.


Are the two related? Or just coincidence.



Can't be sure. However she does have a hx of hypertension. 18G's post above has excellent discussion on this

replies in bold above

 

[sirengirl]

Maybe, maybe not. The big thing I want to know is when has she seen her PCP last.

Here I will admit poor record keeping- I didn't think to ask when her last PCP visit was. And @ 18G, I got the impression that she is well enough mentally to be on top of her meds- of course there is no absolute way for me to know.

 

[Anjel]

I wouldn't have been excited with this patient pre-hospital. Hypertension is RARELY ever treated by ALS in the field. I still wonder why BLS even calls ALS for hypertension unless it is an extreme case. The patient was pleasant, non-distressed, and completely asymptomatic of the finding. If your transport time is short (<20mins) just transport.

Maybe I missed it but what was the patient's history? She said she has been compliant with the HTN meds but was she really? Any dosage change? Has she been compliant with her diet? Any splurging on the sodium that increased fluid volume and contributed to increased BP? Does she also take a diuretic to help with control of B/P? Has she been compliant with that? Any renal issues? What's her output been like?

Primary hypertension can be from several different causes and its anyone's guess sometimes what causes BP to elevate in a person. It's certainly not for pre-hospital to diagnose the specific cause. Is she currently ill over all? Increased HR? Febrile? Stressed? Taken any stimulant meds?

Here in PA the decision for ALS to release must be a mutual decision. Rarely, does BLS ever dispute the ALS release decision but if BLS feels that ALS is being lazy or just doesn't feel comfortable than ALS has to ride.

This is the assessment I was hoping for. Great reply.

 

[18G]

And @ 18G, I got the impression that she is well enough mentally to be on top of her meds- of course there is no absolute way for me to know.

I agree sometimes it's hard to tell for sure. You can always look at the bottles and see if they are empty or count to see how many are there to get an idea. Sometimes patient's say they are compliant just to pacify their providers and because they think they will "get in trouble" if they say they haven't been compliant.

 

[Aidey]

Alright sooo.... Today I got a call for diarrhea at an indipendent nursing home. I get up to the patient and she's 89, A&Ox3, currently feels okay, diarrhea x3 in the past 30 hours.

And yeah she was mildly dehydrated- enought to tent a little when I checked turgor.

Just an observation, she is 89, her skin is going to be significantly less elastic naturally. Turgor generally doesn't show up unless the person has 10%+ fluid loss. Even if a patient develops tenting when they aren't that dehydrated they are going to have other obvious symptoms.

 

[Lifeguards For Life]

Just an observation, she is 89, her skin is going to be significantly less elastic naturally. Turgor generally doesn't show up unless the person has 10%+ fluid loss. Even if a patient develops tenting when they aren't that dehydrated they are going to have other obvious symptoms.

Actually now that Aidey brings it up, the other vitals given do not support the claim that this pt is dehydrated in the least.

 

[Crunch]

I agree with Linus and the others as far as the reasoning behind the 12 lead not being necessary.

The other factor to "just in case" things like running a 12 in this situatio that most providers fail to take into account is cost to the pt. I know here the patient will be charged for the 12 lead, and the base charge and mileage fee will also be increased because it will become an ALS run. However, money should never be a factor in NECESSARY treatments and diagnostics.
It is unlikely even if the 12 lead showed something pathological that the course of the prehospital care would have been altered. The patient will likely get a 12 lead at the hospital, as I don't know anywhere that relys solely on ems ekgs.
Even if the ALS crew had run a 12 lead for you, it would not have told you everything is okay. The electrophysiology of the heart is only one component of blood pressure. And an EKG can be normal even when there is an underlying problem.

Would have it hurt the patient to run the 12? No.
Would there been any real gain in 99 out of 100 patients? Probably not

 

[the_negro_puppy]

I want to know why a lady with 3 x diarrhoea in 30 hours and is ambulatory needs and ambulance....

In other news, I had a sorta similar case last night. Independent living facility 80 y.o lady had fallen and hit her nose. Bleeding had stopped. But started again a few hours later and couldn't be controlled (dripping). Pt was on Warfarin + aspirin. 2 x NiBP found the pt to be around 220/100, hx of atrial fibrillation, CCF etc. I did a manual and got 210/90. I straight away did a 6 lead ECG (1-3 + aug leads)

Anyone with a cardiac hx with abnormalities such as high BP should really have an ECG done to rule out any problems or arrhythmias.

 

[CAOX3]

Hypertension is a priority 3 here, non emergent.

Even if the patient exibits signs of CVA upon your arrival and your medics dont have the ability to treat it, why waste window waiting for ALS to arrive, take them to the hospital.

If she has airway difficulties address them, control the airway and assist ventilations and take them to the hospital.

Your an EMT chances are at some point your going to encounter an emergency, and if the education and training wasnt provided the responsability lies with you to fill in the blanks. Its easy to defer to the medics all the time but there will be a time when you will have to make a decision on your own do you feel confident in those abilities?

Its pretty simple theory, your not going to be able to treat everything, you wont understand everything and many things will beyond the reach of even the most educated and experienced providers.

 

[boingo]

I'm wondering why the OP would call for ALS and then "chill" for 10 minutes waiting for them? If you think the patient is ill enough to warrant ALS, perhaps driving towards a hospital would be a better idea.

With that said, the patient is w/o complaint. I'm not in the habit of treating a number. The patient needs a work up, but not by an ALS crew, IMHO.

 

[sirengirl]

I want to know why a lady with 3 x diarrhoea in 30 hours and is ambulatory needs and ambulance....

Easiest answer: System abuse. My unit is BLS volunteer. Any call that comes in on our emergency line that the caller thinks is an emergency, we have to take. If we get there and they want to go, we have to take them. The nursing home that this particular patient was at, I was at 4 times yesterday. I actually transported a A&Ox3 58 y/o male, ambulatory, responsive, no pain, no discomfort, no n/v/d, no NOTHING, because he "felt a little off." Let it be known that this particular nursing home HAS SHUTTLE BUSSES.... and is an approximate 40 second drive from the hospital (given the light at the road being green). The simple answer, like I said, is system abuse- they don't want to deal with their own patients, they don't want to use their own resources, so they use ours instead for :censored::censored::censored::censored: that doesn't require an ambulance at all.

Even if the patient exibits signs of CVA upon your arrival and your medics dont have the ability to treat it, why waste window waiting for ALS to arrive, take them to the hospital.

Reminds me of a call I had recently. A&Ox2 female with severe confusion, aphasia, and right-sided grip loss that presented after ALS assessed and left. Rather than recall them I loaded her and made the two turns to the hospital for treatment. Ideal? No. But would they have been able to do anything different? Doubtable.

 

[IAems]

If there is a hospital as close to you as you are making it seem, "approximate 40 second drive from the hospital (given the light at the road being green)", the only reason I would call ALS is when I need extra hands (i.e. cardiac arrest). To our level of training and education as BLS providers, we can both agree that this patient may have needed an ALS assessment, probably not but err on the side of caution. That ALS assessment doesn't need to be in an ambulance. If you get the patient to an ER, that too is an ALS assessment. I'm a firm believer that if I can get the patient to the hospital in about the time that ALS can get to me, that's what I'm doing; the patient gets what the patient needs and my service area isn't deprived of ALS resources. This also boils down to understanding what ALS can and can't help you with, and what interventions you need them for.

Also, let's put this whole level of training thing in perspective. I would be a little ticked if a first responder "reminded" me to check a GCS for a patient A&Ox3 w/ no acute neurological deficits and a chief complaint of abdominal pain, when that first responder probably couldn't even tell me what a verbal response of 2 is or how that has anything to do in the least with a chief complaint of abdominal pain . . .

If it was as high as the OP says, and no EKG was done to clear the pt. I would not feel ok with taking that pt. Because if something happens I am screwed.

By the by, if a higher medical authority on scene clears a patient to your level of care, than whatever happens to that patient is on that higher medical authority, especially considering you specifically called them to assist you (as opposed to mutual response via 9-1-1), so I wouldn't worry too much about liability on this one. For gross negligence, I would call a Paramedic out, but for assessment preferences . . . sorry, they have more education, plain & simple.