Just another regular dialysis patient....so it was supposed to be.

[shadowstewie]

So me and my partner go on this call today with this dialysis patient whom is a regular and we've transported him a couple times before. I'm usually the attendant and I talk to him most of the time. He's a 48 y/o Male, about 380 lbs, amputated leg, has MSRA, ESRD, Obesity, etc. Seems like a normal guy who has a lot of problems. I talk to him and he's always perfectly fine to talk to, can hear me clearly and everything just like a normal person. We go to the dialysis center to pick him up and he's hooked up to the vital signs monitor and right when we get there, it starts beeping really loud because his blood pressure was at like 134/78 and pulse was at 125. We re-check the blood pressure on the other arm and it beeps again when it's done and it is at 142/82 and pulse is now 132. We start wondering why it's so high. We ask him multiple times if he feels fine, if he's complaining of anything specifically chest pain and he says "no no im fine, i don't feel anything wrong with me at all, i don't know why its doing that". The nurse starts him on Saline and waits till its done and now his BP is at 154/78, pulse is at 133. He starts getting worried and he seems to be getting upset that it keeps beeping because it's basically saying that something is wrong with him. He starts to tear up because he thinks something could be really bad going on with him when he feel's perfectly fine. His BP and Pulse again is checked 5 min later and now its 164/84 and 136bpm. I'm looking at my partner at this time and am thinking about just loading him up and taking him to the ER, while we are just a BLS unit, that we would just go Code 3 and take him ourselves to a hospital a couple minutes away. The nurse starts to talk to his doctor to see if he's fine to go home since he feels fine and the doctor said he would call her back. I almost had to argue with her that if it went up one more time, I'm taking him Code 3 to the ER, and btw his normal BP is 115/72 and pulse 84. I don't care if the nurse or doctor is higher for me...i'm not going to let this patient wait in the dialysis center if his BP and Pulse is raising higher and higher by the minute. I'm going to do what's in best interest for the patient. But after about 3 more sets of vital signs, they seems to just flow around 140/76 and 134bpm. The whole point of this story of a call is a couple things, for one, I don't care what anyone says to me, whether a Paramedic, RN, Doctor, whoever...if I feel something is better for the patient that's going to help them, I'm going to do it, plus that's what our company is strongly advising us to do, is to argue and do what's best interest for the patient. And also....I know this patient since he's a regular and I've taken him a couple times...just to see him start to tear up and almost start crying every time the machine beeped stating he wasn't in good condition, it kinda killed me after I got off work and I started to feel really bad for him because he's a good guy, really nice, really cooperative, really grateful. Just to see him tear up got me to feel kinda bad while I was on the job, but it didn't really phase me until an hour after I got off. I've been an EMT for this company for almost 1 month and this is my first EMT job. I know this is normal to feel like this, but I was told that I will get used to it and that it's just my job and to do the best I can. Can anyone else help me out with this? I know I will get better to not let it bother me or anything but can anyone help me or tell me things they've done to help cope with emotional calls that you feel really bad for the patient or even family members? Thank you very very much.

 

[Dominion]

So me and my partner go on .....

Good lord sentence structure and paragraphs are your friend.

 

[Aidey]

Did you consider that his blood pressure may have been rising because he was getting upset an anxious that the machine was beeping and because everyone around him was acting like something was wrong?

If he's been attending dialysis there for a while the nurses and techs probably know him, and his baseline vitals pretty well. If you are planning on working for this company for a while, you need to be on good terms with these people, not questioning their judgment.

Dialysis patients are consistently some of the sickest we will see, however, at the same time, for many that is their normal operating level and there is nothing that can be done to fix it. Their bodies have so many problems they just don't work very efficiently anymore.

 

[Akulahawk]

Shadowstewie: Yeah, I know it's a forum and informal and all, but please, use good sentence and paragraph structure. It's just easier to read and follow what you're saying. As you go further in your education, it'll also help you with writing various papers.

Anyway, dialysis patients can be some of the sickest, problem ridden patients around. Sometimes when people start getting anxious, their bodies will start releasing epinephrine, which will cause the body to get into it's fight/flight response. You see elevated BP and heart rates, and it's totally normal. Also, remember, while you can be an advocate for your patient, once you turn the patient over to a higher level of care provider, that patient becomes their responsibility. Be extremely careful about overriding their decisions. It could be you who is making an improper patient care decision, which results in you losing your certificate if you do that. Also, once someone is placed on a dialysis machine, taking someone off of it improperly could result in them being VERY fluid overloaded or fluid deficient and both can be very bad for someone who has poor/non-functioning kidneys.

You've been an EMT for 1 month. There's a LOT to learn. If you STOP learning, you'd better get out of the profession... So keep on learning. Please!

As for "getting used to it"... it'll just happen naturally. I learned a long time ago that it's not your emergency or problem... it's the patient's emergency or problem. You are there to help them get to where they need to go. It may seem a little cold at first... but that attitude will help you cope with some of the more difficult calls. There's only so much you can do. The rest is out of your hands.

 

[shadowstewie]

Okay, I understand about that. The patient was already done with dialysis and unhooked from the machines. He only had a blood pressure cuff on which was monitoring his vitals. There was a call one time where 2 of our crew members were dealing with a patient and they had to call ALS because of some reason. Fire shows up along with a company who is regularly contracted with the Fire Department. The paramedics asked us to take the patient out of our ambulance and put him in the other ambulance because they are contracted with them. Then our EMT says, "No, he's our patient, he's already in our ambulance, come with us to the ER", the Paramedic says, "You need to listen to me or I will have your license pulled" and the EMT says, "Too bad", and shuts the back doors to the ambulance and tells the driver to go to the ER. The medics just stood there with their jaws dropped and couldn't believe it. Later on, Fire tried to say something about it and the EMS Agency dropped it in favor of the EMT because it was for the patient's best interest. And no, our dialysis patient was calm before and after he was tearing up and he was still Tachy.

 

[Aidey]

Not to mention if their treatment is ended early their blood won't be "cleaned" like it's supposed to, causing all sorts of electrolyte imbalances and causing their lab work to be off.

 

[Aidey]

The tachycardia may be normal for him. Immediately after a dialysis treatment the pt has a reduced blood volume because of the liters of fluid that have been removed. It can some times take the body a little while to reach homeostasis, especially in pts with artery/vein diseases (like someone with a hx of diabetes has a high likelihood of having).

There are also patients that have a reactive tachycardia to the reduced pre-load post treatment. Suddenly there is less fluid and their heart is like "wow, I can beat better!" and it speeds up.

If he's tearing up, he's probably not calm. The saline the RN gave him could have fixed tachycardia due to fluid loss, but by that time he was anxious which kept his pulse high.

I'm also very surprised that your EMT didn't get in trouble. If both ambulance companies are already on scene there is no delay in care for the ALS ambulance to take the pt. If a pt is an ALS pt, and the EMT refuses to turn pt care over they could end up with a major lawsuit on their hands if anything happened to the pt.

 

[Smash]

Great, now this has happened

Try again with some sentences and paragraphs thrown in for laughs and I may be able to manage some meaningful response.

 

[Dominion]

Also remember you treat the patient not the machine.

 

[Akulahawk]

Okay, I understand about that. The patient was already done with dialysis and unhooked from the machines. He only had a blood pressure cuff on which was monitoring his vitals. There was a call one time where 2 of our crew members were dealing with a patient and they had to call ALS because of some reason. Fire shows up along with a company who is regularly contracted with the Fire Department. The paramedics asked us to take the patient out of our ambulance and put him in the other ambulance because they are contracted with them. Then our EMT says, "No, he's our patient, he's already in our ambulance, come with us to the ER", the Paramedic says, "You need to listen to me or I will have your license pulled" and the EMT says, "Too bad", and shuts the back doors to the ambulance and tells the driver to go to the ER. The medics just stood there with their jaws dropped and couldn't believe it. Later on, Fire tried to say something about it and the EMS Agency dropped it in favor of the EMT because it was for the patient's best interest. And no, our dialysis patient was calm before and after he was tearing up and he was still Tachy.

Train of thought writing works for people who know how to do it well.

As for the other story, without knowing the specifics, I'd have to guess that the crew did put their certificates in jeopardy for what they did. If that patient had an adverse outcome, that would have required ALS intervention en-route, I would imagine that the end result might easily have been different for both the Paramedic and the EMT crew. There's a lot more that I could probably go into, but without knowing more, including OC EMS protocols, I'm going to hold off. Personally, I think they were probably very lucky that they retained their certs.

 

[Akulahawk]

Also remember you treat the patient not the machine.

They start drumming that into you in EMT school. It doesn't stop... evah...

 

[Smash]

Ok, I've waded through these posts, mopping the blood from my bleeding eyeballs, and so far all I can ascertain is this:

1) You didn't know what was wrong with the patient but you were going to take him away from the RN (who was at least attempting to consult with an MD) Code 3 (why?). 2) The patient got upset. 3) This upset you. 4) Some EMTs in your service need to be disciplined.

Have I missed anything?

 

[VentMedic]

Ok, I've waded through these posts, mopping the blood from my bleeding eyeballs, and so far all I can ascertain is this:

1) You didn't know what was wrong with the patient but you were going to take him away from the RN (who was at least attempting to consult with an MD) Code 3 (why?). 2) The patient got upset. 3) This upset you. 4) Some EMTs in your service need to be disciplined.

Have I missed anything?

Thank you for reading through that "paragraph" and I'm going to respond off your effort.

It is not that uncommon for the dialysis RNs to have to correct a few things before the patient is released. They know what they did during dialysis, including the recipe they were using that day. They know the doctor and the doctor knows the patient. By racing to an ED, you have placed the patient into unfamilar hands who will have to call the RN at the dialysis center and then get the information from the doctor before they can do very much.

The EDs are not always the "definitive" treatment for everything.

 

[Hoofguy]

That BP is not uncommon for someone coming off dialysis and he is a little tacky, so what? You need to drop the Charlie Sheen gun ho :censored::censored::censored::censored: before you lose that freshly printed license. You need to learn to step back and not try to be more than you are, you are a basic NOT a savior to the world..

So you were going to rip this patient out of the care of an RN and DR to run code 3 to the ER? Dude seriously if you did that here they would bust your *** when you showed up at the ER, you'd get that look like "code 3? serious?" and then the Dr would belittle you until you pissed yourself and cried..

I know you can't wait to turn on the pretty lights and sirens but this was not the run to even consider it. YOU made the patient cry, not the problem. I would be willing to bet the looks you were giving and what you were saying in front of the patient is what got him all freaked out..

Knock it down a few clicks

 

[Sasha]

I don't get why you paniced to begin with.. 134?? Did the patient finish the complete dialysis? They are often hypertensive prior to dialysis and will drop post dialysis, but not as signficantly if they did not finish their entire treatment.

Did you consider your cuff may be wrong? Of course he's going to start getting hypertensive you're scaring him to death!

He felt fine. A little critical thinking goes a long way.

The whole point of this story of a call is a couple things, for one, I don't care what anyone says to me, whether a Paramedic, RN, Doctor, whoever...if I feel something is better for the patient that's going to help them, I'm going to do it,

You don't think they have the patient's best interest at heart either? They have a lot more education than you, just because you think that something may be best, does not necessarily mean it's going to be best for them because you can't see the bigger picture. Especially in situations like these where you have little to no education at all in the situation at hand.

 

[Hoofguy]

That's another thing, did you manually take a pulse or BP? Or just look at the machine and want to go A-Team to the hospital? Treat the patient NOT the machine..

 

[Sasha]

That's another thing, did you manually take a pulse or BP? Or just look at the machine and want to go A-Team to the hospital? Treat the patient NOT the machine..

Even if the BP was correct, it's not hypertensive and does not warrant a code 3 response, especially if the patient feels fine.

 

[Aidey]

A special note on NIBP and dialysis pts. Most clinic dialysis machines (if not all now) have built in NIBP that goes off as often as its set. If the cuff is tight at the beginning of the treatment, and then you remove 4L of fluid from them, there is a chance the cuff will now be loose because of reduced edema. So when using NIBP ALWAYS readjust the cuff if you get an odd BP before calling in the cavalry.

 

[Hoofguy]

Even if the BP was correct, it's not hypertensive and does not warrant a code 3 response, especially if the patient feels fine.

Like I had said above that BP wasn't anything to be concerned with in the first place, however I was just curious if he bothered taking manual vitals instead of reading the machine.

 

[Ridryder911]

Okay, I will say it. Noobie, you and your partner have NO business in prehospital care, transporting live patients... heck; even dead one's. I would not even suggest being a driver of carcass removal transport system.

I will say thank-you though. Yeah, thanks for setting EMS back 40 years to the old "ambulance driver" stigma.

You both attempted to disguise yourself as a knowledgeable EMT's but in reality displayed the biggest case of dumbass! Seriously, you have just completed a first aid course and now you and your idiot partner attempts to interpret numbers that you have no clue what they represent!

As previously stated and discussed, there are multiple reasons for those numbers as well as numerous other potential risks and dangers. Again, material not taught in your first aid course.

If you do value your certification, then I would request to never work with that person again. I do hope the medics pursue and request formal action against your EMS and the other EMT. As well, as the patient and family take legal action and litigation against both of you.

I doubt that you will return and discuss this further, and I dare your partner to attempt to defend their action(s). I would welcome the opportunity!

I highly suggest to start hitting the books and gaining some real education and maturity. You will look back at this and hopefully chalk this up as experience on what not to do from now on.
R/r 911