Here is the scenario:
You are a Security Officer/EMT in a senior apartment complex. Your intended purpose is that of first aid, and first response in the event of emergencies requiring transport/patient requests transport. Your scope of practice is at the EMT-B Level. You are typically notified of emergencies via phone call, pull cords located in various locations in apartments and common areas, and/or lifeline pendants some residents choose to utilize. You have no transport capabilities, but a private ambulance(almost always dual medic) and a municipal engine (usual staffing is 3 FFs, usually at least one has their -B card) have an average response time of approx. 10 minutes L&S, but rarely more than 20 running non-emergent as long as traffic isn't too bad. Most of the line members of your department have a good working relationship with the local emergency services. Management of the facility has a rocky relationship at times, mostly due to set in stone, yet unwritten policies of calling for an ambulance for "emergencies" that are more than within the capabilities of the staff. One example is any fall in a common area that also involves any amount of bleeding, even in cases of rug burn and opening up of old scabs. The QA/QI is almost non-existant, and consists of having the instructor of the monthly con-ed have a call-review using redacted narratives from run reports. The instructor is a former chief of one of the well known 3rd service in a major city in my area, and in effect tells the staff to "Call 'transporting private ambulance company redacted for privacy sake' for everything. That way any liability is on them and not you or 'Community where I work.'
That being said, here is one call where management was (in my opinion) needlessly questioning my treatment. Please tell me what you would've done, and if there is anything I have missed.
A lifeline pendant is activated in an apartment at around midnight. While responding with your EFR partner, your dispatcher makes contact with the apartment. You are told that the issue is a patient CC of "indigestion". You arrive on scene to find a male patient sitting in an arm chair in the bedroom, with his wife nervously waiting at the door to guide you to her husband. the patient reports that he was lying in bed trying to go to sleep approx. 90 minutes prior when he started experiencing "really bad indigestion" When you ask him to explain what it feels like, he rates it 10+ on a 0-10 scale and states "It's like an elephant standing on my chest". When you ask him to point out where he is feeling discomfort, he points to his sternum, and notes that it is radiating to his left arm. I radioed dispatch to call the ambulance, with a CC of sub-sternal chest pain radiating to the left arm. While waiting for the ambulance, I proceed to get vitals, history, and a med list together. Patient reported that he took 4 aspirin, a bunch of Rolaids, and Nitro x2 over the 90 minute span. Patient does not remember the last time he took any nitro, but states he took the aspirin just before he activated his life line. Initial vitals were 150's/80's, RR 18, equal and unlabored, HR was 70 and irregular. SpO2 was 93% room air. Lung sounds are clear bilaterally. Skin was pale, cool, and clammy. Pupils were equal, round, and reactive. Patient is allergic to statins and penicillin. History of triple CABG approx 1 year ago, hypertension, a-fib, CAD, and type 2 diabetes. I assisted him in taking a 3rd nitro tablet, placed him on O2 via canula at 4 liters, and checked his blood sugar, which was 270. The patient reported "That's high for me. I usually don't go any higher than 200, unless it is just after eating." I re-assessed vitals. BP changed to mid 130s/low 70s, otherwise remain as above. Pt expressed relief after nitro, which is now rated at 6-7 out of 10. Transport crew arrives on scene at this time. I reported patient's history, meds, my findings, and helped the transport crew in packaging the patient for transport.
A few days go by, and I am asked the following:
1. Asked me if I was treating this as a cardiac issue (figured it was pretty obvious that I was)
2. He asked me why I went with a nasal canula over a non-rebreather since the SpO2 was 93%. (Keeping in mind that the patient was not experiencing SOB)
I am wondering if anyone has any studies showing the benefit of O2 in cardiac cases, and/or instances where a canula is preferable over a non-rebreather.(The manager in question is of the "NRB@ 10-15 liters is always the preferred O2 delivery method, with the ONLY exception being if the patient refuses the mask, in which case a NC can be used). I am looking for some studies online, and perusing a few of the current EMT textbooks, but have yet to find anything definitive for either argument.
You are a Security Officer/EMT in a senior apartment complex. Your intended purpose is that of first aid, and first response in the event of emergencies requiring transport/patient requests transport. Your scope of practice is at the EMT-B Level. You are typically notified of emergencies via phone call, pull cords located in various locations in apartments and common areas, and/or lifeline pendants some residents choose to utilize. You have no transport capabilities, but a private ambulance(almost always dual medic) and a municipal engine (usual staffing is 3 FFs, usually at least one has their -B card) have an average response time of approx. 10 minutes L&S, but rarely more than 20 running non-emergent as long as traffic isn't too bad. Most of the line members of your department have a good working relationship with the local emergency services. Management of the facility has a rocky relationship at times, mostly due to set in stone, yet unwritten policies of calling for an ambulance for "emergencies" that are more than within the capabilities of the staff. One example is any fall in a common area that also involves any amount of bleeding, even in cases of rug burn and opening up of old scabs. The QA/QI is almost non-existant, and consists of having the instructor of the monthly con-ed have a call-review using redacted narratives from run reports. The instructor is a former chief of one of the well known 3rd service in a major city in my area, and in effect tells the staff to "Call 'transporting private ambulance company redacted for privacy sake' for everything. That way any liability is on them and not you or 'Community where I work.'
That being said, here is one call where management was (in my opinion) needlessly questioning my treatment. Please tell me what you would've done, and if there is anything I have missed.
A lifeline pendant is activated in an apartment at around midnight. While responding with your EFR partner, your dispatcher makes contact with the apartment. You are told that the issue is a patient CC of "indigestion". You arrive on scene to find a male patient sitting in an arm chair in the bedroom, with his wife nervously waiting at the door to guide you to her husband. the patient reports that he was lying in bed trying to go to sleep approx. 90 minutes prior when he started experiencing "really bad indigestion" When you ask him to explain what it feels like, he rates it 10+ on a 0-10 scale and states "It's like an elephant standing on my chest". When you ask him to point out where he is feeling discomfort, he points to his sternum, and notes that it is radiating to his left arm. I radioed dispatch to call the ambulance, with a CC of sub-sternal chest pain radiating to the left arm. While waiting for the ambulance, I proceed to get vitals, history, and a med list together. Patient reported that he took 4 aspirin, a bunch of Rolaids, and Nitro x2 over the 90 minute span. Patient does not remember the last time he took any nitro, but states he took the aspirin just before he activated his life line. Initial vitals were 150's/80's, RR 18, equal and unlabored, HR was 70 and irregular. SpO2 was 93% room air. Lung sounds are clear bilaterally. Skin was pale, cool, and clammy. Pupils were equal, round, and reactive. Patient is allergic to statins and penicillin. History of triple CABG approx 1 year ago, hypertension, a-fib, CAD, and type 2 diabetes. I assisted him in taking a 3rd nitro tablet, placed him on O2 via canula at 4 liters, and checked his blood sugar, which was 270. The patient reported "That's high for me. I usually don't go any higher than 200, unless it is just after eating." I re-assessed vitals. BP changed to mid 130s/low 70s, otherwise remain as above. Pt expressed relief after nitro, which is now rated at 6-7 out of 10. Transport crew arrives on scene at this time. I reported patient's history, meds, my findings, and helped the transport crew in packaging the patient for transport.
A few days go by, and I am asked the following:
1. Asked me if I was treating this as a cardiac issue (figured it was pretty obvious that I was)
2. He asked me why I went with a nasal canula over a non-rebreather since the SpO2 was 93%. (Keeping in mind that the patient was not experiencing SOB)
I am wondering if anyone has any studies showing the benefit of O2 in cardiac cases, and/or instances where a canula is preferable over a non-rebreather.(The manager in question is of the "NRB@ 10-15 liters is always the preferred O2 delivery method, with the ONLY exception being if the patient refuses the mask, in which case a NC can be used). I am looking for some studies online, and perusing a few of the current EMT textbooks, but have yet to find anything definitive for either argument.
the average oxygen concentration in the world is 21%. 