Lazy EMT'S

[CobraIV]

I work in an ER and about 98% of the nurses hate basics. When a radio patch comes in for a medical patient the nurses always question why BLS? In any event I bring up a scenario that happen while I was working in the ER.

911 call for 34 year old female with chest pain. Patient states pain on left side, in her chest, pain shoots down left arm. Patient has no allergies, no meds besides over the counter sleepaids and no cardiac history. Patient had some discomfort before going to bed. Patient woke up to more pain and called 911. Patient is warm pink and dry. Blood pressure is 132/90. Pulse is 112 and her respirations are 20......

Patient arrives to ER, the patient was able to give her full name and social security number. Patient was loaded off strecher to bed.

Now, the nurses had a problem with this picture. Besides it being late in the shift 4:40am, the crew had not placed oxygen on the patient nor was any asprin given. Now as an EMT myself I felt this was a good question since the chief complaint was chest pain. I was taught o2 was like chicken noodle soup when you had a cold(obviously not all patients are the same I know this) I don't know if it was lazyness by the crew since it was early in the morning or bad judgement. This patient wasn't a "frequent flyer". The crew left as fast as they came. The patients ekg came back normal sinus rhythm. Iv fluids were started. Her blood pressure went up and another ekg was preformed revealing a stemi. The patient was ALS to a cath lab. I don't know what the end result was.

My experiences are diffrent from one and others just curious to some other ones insight.

 

[NomadicMedic]

Did the PT have an IV? Did the patient get any nitro from the medics? Did the medics do a 12 lead? What was the PTs Spo2 on ambient air?

Sorry. Strike all of that. I misunderstood. I thought the PT was turfed by medic to BLS.

 

[rmabrey]

There really isn't much excuse for not giving ASA or O2. There are good reasons why that came in BLS. The main one being, hospital is closer than ALS care.

 

[NomadicMedic]

There are good reasons for not giving O2. Like a room air sat of 98%.

 

[Carlos Danger]

I work in an ER and about 98% of the nurses hate basics. When a radio patch comes in for a medical patient the nurses always question why BLS? In any event I bring up a scenario that happen while I was working in the ER.

Probably, like many people, these nurses (quite mistakenly, IMO) believe that ALS is always better and should always be initiated anytime a patient is the least bit sick. I don't see how that indicates that they "hate" basics.

911 call for 34 year old female with chest pain. Patient states pain on left side, in her chest, pain shoots down left arm. Patient has no allergies, no meds besides over the counter sleepaids and no cardiac history. Patient had some discomfort before going to bed. Patient woke up to more pain and called 911. Patient is warm pink and dry. Blood pressure is 132/90. Pulse is 112 and her respirations are 20......

Patient arrives to ER, the patient was able to give her full name and social security number. Patient was loaded off strecher to bed.

Now, the nurses had a problem with this picture. Besides it being late in the shift 4:40am, the crew had not placed oxygen on the patient nor was any asprin given. Now as an EMT myself I felt this was a good question since the chief complaint was chest pain.

Of course I can't explain the actions or inactions of these EMT's, but if this is representative of how basics typically perform here, it is no wonder the nurses would rather patients not be brought in BLS.

 

[rmabrey]

There are good reasons for not giving O2. Like a room air sat of 98%.

Yeah, but most EMT's still do it.

 

[J B]

There are good reasons for not giving O2. Like a room air sat of 98%.

This pt was transported by emt-b's, who are taught to automatically give O2 to everyone. So in this case, she should have been on O2. It's possible that protocols are different in OP's state, I don't know.

Yeah, but most EMT's still do it.

As they should, because their protocols indicate it...

 

[NomadicMedic]

This pt was transported by emt-b's, who are taught to automatically give O2 to everyone. So in this case, she should have been on O2. It's possible that protocols are different in OP's state, I don't know.

Originally Posted by rmabrey
Yeah, but most EMT's still do it.

As they should, because their protocols indicate it...

And that you STILL believe this is okay is a shining example of what's wrong with EMS.

 

[jrm818]

This pt was transported by emt-b's, who are taught to automatically give O2 to everyone. So in this case, she should have been on O2. It's possible that protocols are different in OP's state, I don't know.



As they should, because their protocols indicate it...

OP is in boston....from MA ACS protocols

"ASSESSMENT / TREATMENT PRIORITIES
1. Ensure scene safety and maintain appropriate body substance isolation precautions.
2. Maintain open airway and assist ventilations as needed.
3. Avoid hyperoxygenation; administer oxygen using an appropriate oxygen delivery device, as
clinically indicated. If pulse oximetry is available, give supplemental oxygen only if the oxygen
saturation level is less than 94%.
4. Obtain appropriate assessment, (O-P-Q-R-S-T), related to event.
5. Obtain appropriate (S-A-M-P-L-E) history, related to event.
6. Monitor and record ECG and vital signs.
7. Initiate transport as soon as possible, with or without ALS. Do not allow patients to exert themselves and properly secure to cot in position of comfort, or appropriate to treatment(s) required."

ASA is another issue....but perhaps in general ED nurses or an ED based EMT aren't the best ones to be determining the appropriateness of field treatment....

 

[Carlos Danger]

Is it possible that the EMT's in question simply didn't suspect a cardiac origin for the chest pain? Right or wrong, that would probably explain their actions.

perhaps in general ED nurses or an ED based EMT aren't the best ones to be determining the appropriateness of field treatment....

Laypersons in many cases even know that nitroglycerin, aspirin, and expeditious transport to the ED are appropriate prehospital treatments for a suspected heart attack.

So I think it'd be a pretty tough sell that ED nurses - who have far more training than EMT-B's, receive patients from EMS all day long, and work alongside ED physicians and cardiologists every day - actually know less about appropriate BLS treatment than do many laypersons.

 

[jrm818]

Is it possible that the EMT's in question simply didn't suspect a cardiac origin for the chest pain? Right or wrong, that would probably explain their actions.



Laypersons in many cases even know that nitroglycerin, aspirin, and expeditious transport to the ED are appropriate prehospital treatments for a suspected heart attack.

So I think it'd be a pretty tough sell that ED nurses - who have far more training than EMT-B's, receive patients from EMS all day long, and work alongside ED physicians and cardiologists every day - actually know less about appropriate BLS treatment than do many laypersons.

I agree the crew may have failed to consider the diagnosis...wouldn't surprise me in the least.


That said, in my experience many ED RN's, although wonderful in many ways, have limited knowledge of EMS protocols, and certainly tend to not keep up with protocol changes (e.g. Massachusetts change to the O2 administration portion of the protocol.) I don't know if the OP works outside the ED, but if he's indeed in MA, he seems to have missed a protocol revision or two... I would think a medical control physician would probably be a better evaluator of EMS performance relative to their protocol-ized expectations.

I agree that ASA should have been administered given the history in the post by the OP, although I wonder if the EMS crew heard the same version of the history (either due to poor history taking or patient's irritating habit of changing stories just when it is most likely to make the original history-taker look like an idiot). That said, the nurses seemed to have four criticisms of the EMS crew (no O2, No ALS, its 5AM and I want to go home, and no ASA) and only one seems possibly legitimate.

 

[J B]

OP is in boston....from MA ACS protocols

3. Avoid hyperoxygenation; administer oxygen using an appropriate oxygen delivery device, as
clinically indicated. If pulse oximetry is available, give supplemental oxygen only if the oxygen
saturation level is less than 94%.

...

6. Monitor and record ECG and vital signs.

Do basics have pulse ox on their trucks in MA/Boston? Given that it's talking about ECG's in the same bullet list, might that be written for paramedics?

I suppose the phrase, "administer oxygen ... as clinically indicated" gives you room to use your discretion, so kudos to MA. I know many places just give everybody O2, though...

And that you STILL believe this is okay is a shining example of what's wrong with EMS.

Not saying it's good that many people get O2 when they shouldn't, I'm saying it's not the place of the guy who took a 1-semester EMT-B course to ignore protocols put in place by a committee of people with vastly superior knowledge and experience.

Obviously we are patient advocates and sometimes you need to use your judgement and go outside the box. However, I think it's a bit of a stretch to call people following their protocols a "shining example of what's wrong with EMS."

Overuse of O2 and spinal precautions frustrates me, too, but if you want to effect a change you need to go higher up the food chain.

 

[rmabrey]

As they should, because their protocols indicate it...

My protocols as an EMT at my employer are curriculum.

Does that mean im going to put every patient on high flow O2 via NRB?

No

 

[Jim37F]

Around here EMTs don't carry ASA, NTG, epi, or Pulse Oxs on BLS ambulances. (Not even blood sugar meters).

The standing field treatment protocol for chest pain here, as far as oxygen goes, simply says give oxygen. Not give oxygen prn, or if SpO2 is XX, just give oxygen. So for an EMT-B here, this patient is supposed to be on O2 15LPM NRB since that's how we're trained. Although I suppose if you honestly don't think your patient needs high flow you could give 2L via nasal cannula and still be technically within protocol.


However, that's a moot point as fire department ALS is dispatched to every call, whether cardiac arrest or stubbed toe, so unless you're doing an event standby and can see the ED entrance from where you are, the chances of a chest pain patient being transported BLS is slim to nill here.

 

[Mariemt]

I have yet to give o2 for a cardiac call since their o2 has always been satisfactory for me. I always give ASA for suspected cardiac but that is protocol.
Of course I can also run a strip and give nitro too.

Only chest pain I have needed o2 for as of yet is after auscutating crackles. Pts had pneumonia.

 

[Akulahawk]

If the BLS crew isn't allowed to give ASA (not in protocol/scope for them), then the patient won't get ASA by the EMTs. If the O2 protocol states give if <94% and the patient's SpO2 is 97%, the patient won't get O2. I've met many nurses that don't know there actually IS a difference between an EMT and a Paramedic... or they think that ASA is so basic that everyone can give it, when that may not actually be the case.

I'm not faulting the nurses, it's just that they get about ZERO education about other providers, including EMS, as to what their scope of practice actually is.

 

[DrParasite]

please allow a step by step resonse to your post

I work in an ER and about 98% of the nurses hate basics. When a radio patch comes in for a medical patient the nurses always question why BLS? In any event I bring up a scenario that happen while I was working in the ER.

ehhh, don't really care if the nurses hate basics. I work in the field, and 98% of the basics and medics hate nurses. For some reason, I don't see the nurses losing sleep over it, and I would hope your EMS aren't losing sleep over it either. BTW, in my experience, most nurses barely know the difference between ALS and BLS, and if BLS gives a good report, they don't care.

911 call for 34 year old female with chest pain. Patient states pain on left side, in her chest, pain shoots down left arm. Patient has no allergies, no meds besides over the counter sleepaids and no cardiac history. Patient had some discomfort before going to bed. Patient woke up to more pain and called 911. Patient is warm pink and dry. Blood pressure is 132/90. Pulse is 112 and her respirations are 20......

Based on the MPDS, this would be dispatched as an Alpha response, BLS only.

Patient arrives to ER, the patient was able to give her full name and social security number. Patient was loaded off strecher to bed.

doesn't sound like the patient is in any distress...

Now, the nurses had a problem with this picture. Besides it being late in the shift 4:40am, the crew had not placed oxygen on the patient nor was any asprin given. Now as an EMT myself I felt this was a good question since the chief complaint was chest pain. I was taught o2 was like chicken noodle soup when you had a cold(obviously not all patients are the same I know this) you were taught wrong; modern medicine says not everyone needs oxygen, despite what the EMT curriculum says I don't know if it was lazyness by the crew since it was early in the morning or bad judgement. This patient wasn't a "frequent flyer". The crew left as fast as they came. The patients ekg came back normal sinus rhythm. Iv fluids were started.

normal ekg? so I'm guessing the patient appeared not sick? or at least not acutely sick and in need of emergent interventions? yes, something changed, but at least initially the patient seemed to be in no distress

Her blood pressure went up and another ekg was preformed revealing a stemi. The patient was ALS to a cath lab. I don't know what the end result was.
My experiences are diffrent from one and others just curious to some other ones insight.

sounds like new oneset of an undiagnosed cardiac condition that even the receiving nurse didn't find until the BP spiked.

Not for nothing, but I have heard plenty of really good things about Boston EMS, as well as Boston EMTs. I would imagine (and this is only a guess, no first hand knowledge) that being a busy urban system, they see a lot of patients, and know the difference between sick and not sick.

Patient's conditions change all the time. If the patient was in N/S, a medic would have probably turfed it to BLS, esp with normal vitals. Maybe this was just a freak thing? a completely unanticipated event, and one no one could have predicted?

I'm sure your nurses have never given a report about a stable patient during shift change and the next shift they come in found the patient died or ended up needed surgery to fix something.

 

[randomfire]

Does anyone know how long it takes for baby aspirin to start working? We carry it but I have literally never seen anyone give it because every station around is within a 10 minute drive of a cardiac center so people say there is no point.

 

[Akulahawk]

Does anyone know how long it takes for baby aspirin to start working? We carry it but I have literally never seen anyone give it because every station around is within a 10 minute drive of a cardiac center so people say there is no point.

According to my drug book, it's onset time is between 5 and 30 minutes. I would imagine that it might be a bit faster if it's chewed and swallowed vs just swallowed. Also, the sooner you get it onboard, the sooner it takes effect. Waiting for it to be given at the ED just lengthens the time before administration. Remember, you're giving it for it's antiplatelet effects. You don't want the clot to become bigger.

 

[chaz90]

Does anyone know how long it takes for baby aspirin to start working? We carry it but I have literally never seen anyone give it because every station around is within a 10 minute drive of a cardiac center so people say there is no point.

People are wrong. How long have you been in EMS that you've not once seen ASA administered for chest pain?