Caring for the Patient

MonkeyArrow

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Disclosure: This narration is not a reflection of my opinion on the matter. It is merely a recollection of facts as I was it happen. I was not on the medic crew, and do not have all the facts of the situation.

I was working in the ED today. Our ED is set up where ambulances park in the bay, unload their patients, and wheel them inside "sitting the wall" while one partner (the one with the MDT) goes to check in with registration, get a destination/room number, etc. Anyways, so today, an ALS crew came in with a lady who was screaming and writhing in pain and general discomfort. She was complaining about pain, stating she was cold (with 2 blankets on her), generally groaning and mumbling in angst. The EMT with the patient didn't seem to try to comfort or alleviate any of the patient's concerns. After about 5 minutes of this constant complaining by the patient while things were still being situated, the partner with the patient kind of threw one of the blankets over the patient in a way that covered her face, considering that she was in a semi- fetal position on the gurney. Anywho, point being after she got into a room and was evaluated by a doctor, she was administered pain meds IV. Approx. 10 mins. post med administration, patient was doing much better and was no longer complaining of pain, and became drowsy. BTW I don't know what the CC was or what the diagnosis was but vital signs remained stable throughout- no contraindications to field analgesia that I know of. Also, seems like this patient may have been through the system a few times before.

We have sheets and blankets and blanket warmers in the ED readily available. The crew was an ALS unit capable of administering pain meds in the field. No IV access by EMS. (No O2, no cardiac monitoring, no etc.)
 

DesertMedic66

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No contraindications for pain meds but you don't know what the C/C was? A lot of systems (mine included) will not allow us to give pain meds for abd pain (we can call for base order but are often denied).

Not every patient needs O2 or EKG monitoring. I know several medics who use O2 as a placebo for pain but in my experience it has never worked for patients in true pain
 
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MonkeyArrow

MonkeyArrow

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No contraindications for pain meds but you don't know what the C/C was? A lot of systems (mine included) will not allow us to give pain meds for abd pain (we can call for base order but are often denied).

Not every patient needs O2 or EKG monitoring. I know several medics who use O2 as a placebo for pain but in my experience it has never worked for patients in true pain
In favor of keeping my personal opinions and biases from affecting anyone else's reaction, I'll respond to you via PM.
 

Rin

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Is it possible they were BLS? All of our squads say "Paramedic Unit" on the side but often run with BLS crews.
 

teedubbyaw

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What if it wasn't in their protocols? What if they knew her as a seeker? What if they have more information than you, have tried their best to comfort her, and you are just making assumptions?
 
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OnceAnEMT

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As mentioned, sounds more like a protocol thing on their part, or an assumption on your part. The system we see has ibuprofen and APAP, but usually sticks to fentanyl on transports. I wouldn't expect them to roll in with a drip running. For all you know, they sent 70mcg of fent 10 minutes ago IV or IM that wasn't enough, and beat the 2nd dose to the hospital.
 

Tigger

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Could this be substandard care? Sure. But as someone only tangentially involved with this patient you may want to be careful about making assumptions about the crew and sharing that with others.

Many EMS agencies need to improve their quality assurance programs, but this is not how that is done.
 

Akulahawk

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While this patient wasn't given pain meds in the field and got some at the hospital, it very well could be that the patient has a complaint that doesn't fit the pain control protocols that they have to follow. For example, if someone obviously has isolated limb pain, I'd be able to give pain meds for that but if the person is having flank pain that's consistent with the previous 10 times they've passed kidney stones and I have an appropriate med on board, I wouldn't be able to give that med on protocol because I'm limited to limb pain only. It's also possible that I might call in for orders and get denied for it too...

Simply put, I just don't see enough information presented to base any sort of coherent thought as to whether that patient got adequate field care as far as that locality is concerned. Could the patient have gotten pain control prior to arrival at the ED? Sure. It could have resulted in some people losing their licenses if they provided it. I'm all for providing adequate pain control and it's something we really suck at doing for a variety of reasons, not the least of which is a fear of continuing someone's drug-seeking behavior.

My own thoughts about prehospital pain control is pretty much this: Get the patient to a tolerable level of pain. The patient should still feel pain so they can feel if something is getting worse and so they also know they're not dead yet. ;) Tolerable doesn't mean comfortable and it doesn't mean no pain. It's pain you can "live with" for a little while so that you can be evaluated properly and so that you're not writhing around. Properly done, it also means that there's little chance of me overmedicating you because I'm not giving you enough to stop you from breathing. I'm going to select a pain control modality that matches the need. That can range from an ice pack to drugs... and no, I'm not going to try to hook the pacer up to you and try to use it like a TENS unit. Sure it'd be fun watching your muscles twitch for a while, but that's not the effect I'm looking for. :D
 

OnceAnEMT

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and no, I'm not going to try to hook the pacer up to you and try to use it like a TENS unit. Sure it'd be fun watching your muscles twitch for a while, but that's not the effect I'm looking for. :D

I may or may not try that. That's hilarious :p Poor man's e-stim... pacer pads.
 
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MonkeyArrow

MonkeyArrow

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Is it possible they were BLS? All of our squads say "Paramedic Unit" on the side but often run with BLS crews.

No. All of this EMS system's rigs are ALS.

What if it wasn't in their protocols? What if they knew her as a seeker? What if they have more information than you, have tried their best to comfort her, and you are just making assumptions?

What if they knew her as a seeker? I don't know how you can judge this person's pain legitimacy with any sense of accuracy. First off, the system is big enough to where this specific crew has more than likely not come into contact with this patient more than 3 times. Second of all, if it's in your protocols to provide pain relief, what is the risk vs reward to giving pain meds. You give a minimal dose- the risk is practically none (medically) You're not saving the patient from "a life of addiction/dependence when the ER doc just gave the same pain meds that you could've given literally 10 minutes after you rolled the patient into our doors. The reward- potentially relieving legitimate pain.

I guess the trying their best to comfort her is really at the heart of my question. EVEN IF she is a seeker and EVEN IF she is using the ambulance as a taxi and EVEN IF its not in your protocols to administer pain meds, how does it reflect on your crew to bring a patient in on a gurney who is screaming that she is cold? Honestly, one extra blanket could've alleviated that concern. I would spend an extra 2 minutes in the ambulance bay before unloading my patient to give her that extra blanket- try to calm her down to where she's not screaming and hollering into the ED. I think that reflects poorly on me and my partner if I bring a patient (non-psych) into the department in that condition.

As mentioned, sounds more like a protocol thing on their part, or an assumption on your part. The system we see has ibuprofen and APAP, but usually sticks to fentanyl on transports. I wouldn't expect them to roll in with a drip running. For all you know, they sent 70mcg of fent 10 minutes ago IV or IM that wasn't enough, and beat the 2nd dose to the hospital.

Like anything, it's possible that they gave her IM fentanyl and it wore off 10 minutes later but HIGHLY unlikely. This is an urban system with no extended transport times- less than 10 minutes from scene to hospital (any one of many).
While this patient wasn't given pain meds in the field and got some at the hospital, it very well could be that the patient has a complaint that doesn't fit the pain control protocols that they have to follow. For example, if someone obviously has isolated limb pain, I'd be able to give pain meds for that but if the person is having flank pain that's consistent with the previous 10 times they've passed kidney stones and I have an appropriate med on board, I wouldn't be able to give that med on protocol because I'm limited to limb pain only. It's also possible that I might call in for orders and get denied for it too...

Simply put, I just don't see enough information presented to base any sort of coherent thought as to whether that patient got adequate field care as far as that locality is concerned. Could the patient have gotten pain control prior to arrival at the ED? Sure. It could have resulted in some people losing their licenses if they provided it. I'm all for providing adequate pain control and it's something we really suck at doing for a variety of reasons, not the least of which is a fear of continuing someone's drug-seeking behavior.

While I surely do not have enough information to come to an educated conclusion, I also have enough prior knowledge and common sense to be able to piece together the clues here. An EMT who blankly daydreams while throwing a sheet over their patient's face to try to comfort them certainly doesn't lead to a good first impression. It makes you pause for a moment and wonder...what else did(n't) they do?

Anyways, why should the patient being a seeker have any impact on the care she receives? The hospice patient who bakes cookies you cookies every Friday when you pick her up for dialysis should not be treated differently than the "seeker". Even so, just as you guys chastised me for making assumptions about this crew, you guys made an assumption about justifying the IMO substandard care that this patient received because she is a seeker. If you tell me not to judge the crew, you surely shouldn't be judging the patient in the same sentence.
 

Akulahawk

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No. All of this EMS system's rigs are ALS.



What if they knew her as a seeker? I don't know how you can judge this person's pain legitimacy with any sense of accuracy. While pain itself is subjective, often there are other signs that the patient is in pain/discomfort. Most people that are in pain exhibit an increased HR and BP. Most people exhibit behaviors that are associated with pain. There are non-verbal pain scales that use those signs and behaviors. They don't necessarily quantify pain, but often the higher the score, the more likely the patient is in pain and the lower the score, the more likely the patient isn't in pain. First off, the system is big enough to where this specific crew has more than likely not come into contact with this patient more than 3 times. Second of all, if it's in your protocols to provide pain relief, what is the risk vs reward to giving pain meds. You give a minimal dose- the risk is practically none (medically) You're not saving the patient from "a life of addiction/dependence when the ER doc just gave the same pain meds that you could've given literally 10 minutes after you rolled the patient into our doors. The reward- potentially relieving legitimate pain. I believe I stated above that EMS crews often have to deal with only being authorized to provide pain control under very specific circumstances by protocol and while it's good to call in for orders to provide pain control via OLMC, that can be denied. That results in a patient, who may be experiencing severe pain, being unable to receive medication for their pain. It could very well be that the EMS and/or the OLMC physicians do not believe that the paramedics in that system are capable of properly titrating pain meds. Every EMS system I've been in has been less than aggressive about treating pain in the field. The hospitals I've been in have been pretty aggressive about pain control... usually.

I guess the trying their best to comfort her is really at the heart of my question. EVEN IF she is a seeker and EVEN IF she is using the ambulance as a taxi and EVEN IF its not in your protocols to administer pain meds, how does it reflect on your crew to bring a patient in on a gurney who is screaming that she is cold? Honestly, one extra blanket could've alleviated that concern. I would spend an extra 2 minutes in the ambulance bay before unloading my patient to give her that extra blanket- try to calm her down to where she's not screaming and hollering into the ED. I think that reflects poorly on me and my partner if I bring a patient (non-psych) into the department in that condition.
If I'm hollering that I'm cold and it's very warm out, I'd be very, very surprised if one more non-warmed blanket would help with my sensation of being cold. It could be that perhaps this patient is having chills and actually has a temp of 104... yes, it can (and does) happen.


Like anything, it's possible that they gave her IM fentanyl and it wore off 10 minutes later but HIGHLY unlikely. This is an urban system with no extended transport times- less than 10 minutes from scene to hospital (any one of many).


While I surely do not have enough information to come to an educated conclusion, I also have enough prior knowledge and common sense to be able to piece together the clues here. An EMT who blankly daydreams while throwing a sheet over their patient's face to try to comfort them certainly doesn't lead to a good first impression. It makes you pause for a moment and wonder...what else did(n't) they do?

I didn't say that I agreed with the EMT's actions. You just indicated above that your system is all ALS, therefore the EMT isn't doing much in the way of patient care and may well be burned out. I'm not excusing or justifying the act, rather I'm suggesting a reason for it.

Anyways, why should the patient being a seeker have any impact on the care she receives? The hospice patient who bakes cookies you cookies every Friday when you pick her up for dialysis should not be treated differently than the "seeker". Even so, just as you guys chastised me for making assumptions about this crew, you guys made an assumption about justifying the IMO substandard care that this patient received because she is a seeker. If you tell me not to judge the crew, you surely shouldn't be judging the patient in the same sentence.
Because there was a lot, I put many of my comments in red, above, inline with yours. Yes, this patient could very well be a seeker and EMS isn't equipped or trained to really effectively deal with these patients and it also puts the ED staff in a bind because they now can't properly evaluate the patient beyond what the ambulance crew says was happening. The ED also has a LOT more pain control meds available to them than EMS does. That patient could very well be a pain clinic patient and may not be allowed to receive opiates for pain control. While this may not be the case for that patient, a friend of mine was being managed by a pain clinic and if she went to the ED, she couldn't get any opiates as that would cause problems for her with the pain clinic. You could pretty much just about cut her in half and she would have to refuse morphine or Fentanyl.

The reason I'm providing this stuff isn't necessarily to judge the provider or the patient... but rather to remind us about a subject that we do sometimes forget about.
 

Tigger

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Even so, just as you guys chastised me for making assumptions about this crew, you guys made an assumption about justifying the IMO substandard care that this patient received because she is a seeker. If you tell me not to judge the crew, you surely shouldn't be judging the patient in the same sentence.

No, I did not attempt to justify that crews behavior, because I don't know what said behavior is. Your brief anecdote in no way provides the necessary information to determine whether or not substandard care was provided. If you don't have the requisite information to make these assumptions, you should not be making them.
 

Kevinf

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I've had senile dementia patients that to all outsiders would have looked and acted like we were mistreating or ignoring them because nothing you could do short of completely snowing them out (very unethical just to get some peace and quiet) would calm them down. So it looks like we are standing around and "not doing anything" for patients which are yelling and calling for help and other such when they aren't in any actual distress. If you are that concerned, make a call into their company and talked to a supervisor. That crew should have documented what was going on during that call so it should get sorted out one way or another.
 

avdrummerboy

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Based on your replies, you seem more concerned about the lack of another blanket than pain management. If you're just checking in you don't necessarily need to go grab a blanked because you might be moving to a bed in 30 seconds. If you have to 'hold the wall' and wait it our for a bit, then sure, go grab another blanked.

As to pain management/ meds, not knowing the full story (C/C, PMHx, other meds already taken, etc) and not knowing the system/ protocols, it's incredibly hard to judge and monday morning QB the crew on this particular call.
 

Kevinf

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I forgot to add that I generally won't put more than two blankets on a patient either. After the second blanket if they aren't warming up, another blanket isn't really going to help and they just end up a tangled mess within a few minutes that you have to work through to access the patient. If they're really that cold with two blankets I'll crack a hot pack or two.
 

UnkiEMT

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For example, if someone obviously has isolated limb pain, I'd be able to give pain meds for that but if the person is having flank pain that's consistent with the previous 10 times they've passed kidney stones and I have an appropriate med on board, I wouldn't be able to give that med on protocol because I'm limited to limb pain only. It's also possible that I might call in for orders and get denied for it too...

Reading that reminds me how much I love my protocols, almost every last one of them ends in "The above may be superseded by the discretion of the provider, pending review of the Medical Director."

The only time I HAVE to call for OLMC is once I surpass a certain limit on the quantity of a drug, and my medical director is a sweetheart, I've never had him turn me down.
 

Akulahawk

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Reading that reminds me how much I love my protocols, almost every last one of them ends in "The above may be superseded by the discretion of the provider, pending review of the Medical Director."

The only time I HAVE to call for OLMC is once I surpass a certain limit on the quantity of a drug, and my medical director is a sweetheart, I've never had him turn me down.
When you have that kind of latitude and as long as you have the knowledge, that's a great set of protocols. One thing I also like about that one sentence is that while it removes the rigid restrictions, it also adds serious accountability when/if you do decide to step beyond that.
 
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