Implanted Debif Scenario

[medicdan]

This past summer, I was working at a performance venue as an EMT, and had a case I didnt really know how to handle. I was with an RN and another EMT, and they seemed to figure it out, but I'm wondering what you would do.

I was called over to an 78 y/o/m, sitting in a lawn chair in the sun. He reported that his internal pacemaker/defib shocked him while sitting. His wife (who was holding his hand), reported feeling a shock, and let go. Sitting, his pulse was approx. 95. Pt. reported getting the implant four years ago, and with one exception, it had never gone off. The one other time it had gone off, he was plunging a toilet. Pt. reported some pressure on his chest right after the shock, but said it went away quickly. Although resps were normal, he was a little sweaty (possibly related to being in the sun).

I called for some help, but the other EMT was on the other side of the grounds. As I was radioing for some help, the pt stood up, and said that he wanted to walk to the first aid station. I walked with him, and noticed that his pulse decreased as time went on, even though he was standing and walking. Once at the station, his BP was 135/90, pulse 90, resps normal. We have a BLS ambulance on the grounds, and the crew came over to see what was going on.
5 minutes later, his BP was 125/85, pulse 75, resps normal. After 10 minutes, pt stated he felt much better and wanted to leave. Although we encouraged him to go to the ER for assessment, he signed a refusal. We asked to stay around for a little while longer just so we could observe him, and he complied. Pt mentioned having an existing appointment with his cardiologist the next day. Fifteen minutes after arriving at the station, his BP was 122/88. pulse 70.

What would you do differently? Although his BP and pulse were high at the beginning, they stabilized. Pt felt much better, and was going to follow up with an MD. Should we have insisted on sending him to the ER?

 

[KEVD18]

press hard, your making three copies. have a nice day

 

[AJemt]

hard to tell....most of the standby's around here require ALS and BLS on standby, so he would have been the medic's pt to deal with. That being said, if pt is conscious, A&Ox4, and understands the risks of signing off, nothing else you can do. "sir, before i can let you sign this paper there's a few things i need. first i need to make sure that you understand the risks invovled, which include you walking out of this area and collapsing; you could get home and go to bed tonight and not wake up in the morning. do you understand this? and in your own words i need you to tell me what that means." (pt says i could die) "the other thing i have to do before i can let you sign is i have to call MY doctor that i work under and he has to say it's okay; if he wants you to go in to the hospital are you willing to go?" call OLMC, get the doc to talk to hte pt if you have to, if the pt says no absolutely not (had some like that) there is nothing you can do. sometimes you can get the wife involved and get her to try to talk him into it, or you might be able to call his cardio dr and say hey this is Paramedic Jones with XYZ ambulance, i have a pt of yours here who we need your input on - mr smith was doing AAAAA activity, his defib fired once, here's his current vitals, he says he has an appt with you tomorrow and does not want to go to hte hospital, are you compfortable with that and do you want to talk to him?

if the pt still says no sign off ama and document the bejeebers out of that. one company i used to work for had 2 copies of the ama form - white for provider yellow for pt - we wrote vitals, times, and asssessment findings (pertinant) on the side and what they signed off for and risks explained and told them if they changed their mind and wanted to go to the hospital to take that paper with them or to take it to their fam dr when they went to see them if they were goign for that particular problem.

i personally would want to see an EKG strip before signing him off (well, have a medic assess).

sticky situation.....one of the medics i used to work with spent over an hour on scene with a guy who was in svt that refused transport. the medic said you realize if i leave here without you you will be dead before anyone can get to you again? and he said yes.....pt never woke up the next morning. do what you can and let the rest go.

 

[KEVD18]

is calling your med control doc a requirment in your state/county/service? it isnt here and sounds like a superfluous step to me.

 

[medicdan]

Unfortunatly, we do not have it in our protocols to call OLMC in cases like this, and in fact, i'm wishing I had. I did document the case well, as did the RN who was in the station.
The patient called us a few weeks later. The day after the defib went off, the pt went to see his MD, and he downloaded the data from the pacemaker. It turns out the defib malfunctioned, and fired unnessecarily. Two weeks later, he was under the knife, getting new hardware.

 

[Grady_emt]

is calling your med control doc a requirment in your state/county/service? it isnt here and sounds like a superfluous step to me.

It is only required for us when the pt is <2 years old. Even though it is not required, if you feel that the pt needs to be evaluated, and is still refusing, having the OLMC MD speak with the pt cant do any harm, and is an additional provider above your level that may persuade pt to be evaluated.

But, like said, if still refusing, Sign & Print Here for our paperwork, Sign here for the State of GA (pressing hard, two copies).

 

[AJemt]

is calling your med control doc a requirment in your state/county/service? it isnt here and sounds like a superfluous step to me.

depending on what is wrong with the pt, or how the pt presents, yes it is state protocol - the sample AMA form in the bls protocol book is the form most services use (some do have their own forms), but either way you still have to call MC.
http://www.dsf.health.state.pa.us/health/lib/health/ems/bls_protocols_2004.pdf
http://www.dsf.health.state.pa.us/health/lib/health/ems/als_protocols-effective_07-01-07.pdf
http://www.dsf.health.state.pa.us/health/lib/health/ems/als_and_bls_protocol_tablet.pdf

i have called for bls release before, because protocol says i have to; most of hte docs are pretty cool about it, some are just like yeah he can sign goodbye but some of the docs helped write protocol so they really can't complain too much.

even if it's not required sometimes it's still a good idea, esp if you feel the pt needs seen - CYA type of thing at the very least.