Medic spins out

[TheLocalMedic]

Even the best of us have bad days, but some seem to have worse days than others... Last week, a medic I know had one of these worse days, and now she's under some serious scrutiny.

She had two patients at the same scene, a woman who was unconscious in diabetic ketoacidosis and her husband who was having crushing chest pain. Granted, this is a crappy situation to be put in, but this is where a medic really has to get it in gear and start making some command decisions so that both patients will get the care they need. The logical choice, if I may be a Monday morning quarterback, would have been to treat both at scene while calling for an additional ambulance to take one of the patients (there was another unit posted not far away at the time).

Instead, she made the decision to try and treat and transport both. In the process she got completely overwhelmed and started to spin out. After a 30 minute scene time where neither patient was given any treatment besides having their vitals taken, they loaded up and transported code 3 to the nearest hospital. The medic tried repeatedly to start an IV in the DKA patient on the gurney, and it wasn't until nearly 5 minutes into the transport that she even got nitro and aspirin into the cardiac patient who was sitting in the captain's seat.

Later the cardiac patient was shown to be having a STEMI with elevated troponin and was flown to a cardiac cath lab. I do not know the outcome of the DKA patient, but I do know that the medic was never successful in getting that IV she was trying so hard for. The EMT that she was working with wide-eyed after the call, saying that he was shocked at how frazzled his partner had become, saying that "she totally lost it".



As I said before, this whole situation can be somewhat challenging, but after hearing about how this medic lost her cool and spun out it really makes me question her abilities...

Have you had challenging scenes with multiple patients? How did you deal with them? Is there anything you would do differently looking back?

 

[mycrofft]

Not a common occurrence and not everyone is mass casualty stuff. NO one is trained enough because it is not possible.
However...
Cardiac takes precedence over DKA (re treatment sequence) as it is more acute and potentially lethal. This comes with experience, education, and reading EMTLIFE.

 

[WolfmanHarris]

This speaks to the issues of having such a gap in education between your higher and lower level providers. Providing this Paramedic with an EMT whose training and usual role makes them a driver/assistant leaves the Paramedic swinging in the wind without a partner who can act independently.

For the purposes of comparison I'll use the system here in Ontario. A PCP (BLS) has two years of college education prior to entering practice, an ACP has a further one year. A BLS provider is able to acquire and interpret ECG's (3, 12 or 15), provide ASA, NTG, etc. but more importantly are used running calls, even with an ACP partner. Unless a call specifically calls for their extended scope of practice, the ACP does not run every call. Both partners would be used to working collaboratively and should have an understanding of each others scope of practice.

This is certainly a complicated scene, but by no means is unreasonable for two providers to effectively manage both patients while awaiting a second transport unit. Especially if there are any first responders (unconscious would get us FF's tiered up here) on scene to delegate some basic tasks to.

Certainly the choice to attempt to manage two high acuity patients alone in the back seems like a poor one, but had the system design and education allowed for a better crew arrangement the Paramedic may not have been left so alone.

 

[EMSANTHEM]

i understand your point but lets be real here she should have called for an additional ambu period, plus as stated above it wasn't that far off this medic really must have been razzled.

 

[exodus]

EMT starts BLS treatment on the CP: 12 lead, o2, nitro; as medic gets line and pushes drugs on DKA. They switch, EMT monitors DKA's airway and vitals + checking glucose. All while another ALS unit is on their way.

 

[shfd739]

EMT starts BLS treatment on the CP: 12 lead, o2, nitro; as medic gets line and pushes drugs on DKA. They switch, EMT monitors DKA's airway and vitals + checking glucose. All while another ALS unit is on their way.

Beat me to it. Give the EMT partner some tasks at their level- dont leave them standing with nothing to do.

 

[exodus]

Beat me to it. Give the EMT partner some tasks at their level- dont leave them standing with nothing to do.

I was surprised this isn't what happened. This call wouldn't have gone this way in our area since we have ALS engines with us, I could see our medics employing this to the EMT's on scene until fire showed up.

 

[DesertMedic66]

I was surprised this isn't what happened. This call wouldn't have gone this way in our area since we have ALS engines with us, I could see our medics employing this to the EMT's on scene until fire showed up.

I see our medics using this in a more broad way..

 

[Hockey]

EMT starts BLS treatment on the CP: 12 lead, o2, nitro; as medic gets line and pushes drugs on DKA. They switch, EMT monitors DKA's airway and vitals + checking glucose. All while another ALS unit is on their way.

Beat me to it. Give the EMT partner some tasks at their level- dont leave them standing with nothing to do.

Yup.

Failure to delegate.

Failure to step back, take a deep breath, and take charge.

 

[Maine iac]

In a pinch no reason a competent medic couldn't take both pt's.

Or call for a second truck.

Just depends on how far out the second truck was.

No different from a STEMI pt being driven by a friend to the hospital.

Load them both up and go. If you did nothing at all on scene tell the STEMI to sit or lay on the bench (I can take 3 fully immobilized pt's in my ambulance), and deal with the unresponsive pt. If you quickly figure out it is probably DKA, run in your fluids and turn your attention to the STEMI if you still have transport time left.

Give him ASA, try to get a hx and if possible run a 12 lead.

Give your hospital notice that you have an unresponsive coming in, and if you managed to have a 12 lead stating STEMI say you have a STEMI coming in also as a second pt.


It all depends on how good the attending feels on scene if you are going to stay and figure out why the pt is unresponsive, or just go.

 

[Handsome Robb]

EMT starts BLS treatment on the CP: 12 lead, o2, nitro; as medic gets line and pushes drugs on DKA. They switch, EMT monitors DKA's airway and vitals + checking glucose. All while another ALS unit is on their way.

This call would go the opposite way with my partner and I. EMT takes DKA, starts a line and fluids going and protects the airway while the medic attends the chest painer. Besides the DKA being unresponsive the whole treatment path is within my scope as an I whereas interpreting 12-leads is not. Now my partner and I have a rock solid trust between us so that's different than a system that doesn't have set partners. The fact that I'm 6 weeks away from finishing medic school helps as well.

If you are absolutely forced to transport both together chest pain gets 4/12-lead and on the cot in POC while unresponsive DKA gets pads and scoop stretcher on the bench seat.

You can monitor both, just change between leads and pads periodically to take a peak. The monitor might not like it but it should work in a pinch, just keep it in monitor mode and don't go anywhere near pacing/defib/SAED mode.

We can monday morning quarterback this call all we want but in the end none of us were there, we don't know what was going through the medic's head, those are both high acuity patients and if her partner and the fire crew is so bad that they can't provide BLS care to help her something needs to be done.

 

[Tigger]

Have you had challenging scenes with multiple patients? How did you deal with them? Is there anything you would do differently looking back?

What sort of system is this in? Is it even possible for the medic to get another unit on-scene i.e. supervisor, fire crew, hell even a cop to drive the ambulance freeing up the partner to help out in back. Just because it's conceivably possible to monitor both patients in back during transport does not mean it's necessarily the best practice.

Where I work when I have multiple patients I call for another ambulance because that's what our QA prefers and I would prefer to transport only one patient if possible, especially considering the lack of room in the back of Type IIs. We have the resources to do this, I am aware that many places do not.

 

[johnrsemt]

Why would you even have to have the Uncon DKA on a monitor for a short transport? She is unconscious, watch that she keeps breathing; if you can't get a quick IV then ignore it. Fluid won't help her in short term while ASA, NTG and possibly O2 will help the STEMI patient.

I had one similar; and put the chest pain patient on the monitor and used the finger pulse ox off the monitor to keep an eye and ear on the unconscious pt. (I keep the SPO2 monitor so that it alarms at less than 80%, or 60HR. So it would tell me if that patient did anything she didn't have my permission to do.

 

[FourLoko]

Thanks for sharing, helps stretch my EMT brain.

Nitro and/or asprin for chest pain guy you say? I'd be on the EMT to handle that ASAP if I was going to work on DKA lady.

 

[medichopeful]

Disregard

 

[TheLocalMedic]

Agreed all the way around. Definitely a scene that could have been managed better in many respects.

So here's my next question...

Given that this medic had a rough day, she also has a history of spinning out like this on several other critical calls. The EMTs all dread working with her, and I have heard that a few have had to interdict when she gets spun. One reportedly had to force her out of the way after trying nine (count 'em, NINE) IV attempts on a patient who was stroking out while the patient was still sitting in her own car. The thought of transporting this patient apparently hadn't even crossed her mind, she was just focused on getting her IV...

How should this person be dealt with? We have a CQI process in place, but this medic is personal friends with the person who does our CQI as well as the ops manager. It seems as though there won't be any repercussion for her history of poor mistakes...

 

[DrParasite]

an unconc person in DKA? biggest thing to worry about is an airway issue. as long as the airway is maintained, the other stuff is not as important.

an elderly man with CP? who is having a stemi? this person is going to deteriorate if left untreated. ASA, NTG, oxygen, 12 lead, transport to a stemi hospital?

both calls don't sound too bad. in fact, most need stabilization and transport to an appropriate hospital. Then again, I'm just an uneducated EMT, so more educated paramedics might know more.

best solution to this call would be to call for a second ALS truck once 2 ALS patients was identified. why this wasn't done wasn't explained.

Even if you take both (and I know many paramedics who can handle more than one ALS patient at once), get help. a supervisor, a firefighter or cop to drive the ambulance, and have your EMT help with the transport.

If your EMTs don't know what they are doing in a situation like this, than your system has failed the in their education. if your paramedics don't know what to do, the training department needs to reeducate her. and if management continues to allow this time of situation to happen (9 times is 8 times too many), than it is a gross failure of your management system.

and if you can't do the job, than maybe this isn't the career field for you. Suck to say it, but some people aren't meant to deal with emergencies, and need to be let go before someone dies as a result of their incompetence.

 

[Melclin]

While this is undoubtedly an "I wish I had a few more hands" type of situation, I think the outcome you described is unacceptable. To have been on scene for half an hour and not have done anything of consequence with two profoundly ill patients...what was she doing, taking a 700 blood pressures consecutively? That amount of time is plenty to manage them completely separately in series, let alone cleverly spreading yourself between them to save time.

If she has a history of this sort of thing, and its still going on despite guidance and good management, then she isn't learning from her mistakes. Its time to makes some changes. But it doesn't sound like she's getting any guidance or even an acknowledgement from someone senior that she could have done better. I've worked with one or two people of whom this scenario reminds me and I can safely say I'd prefer they gave up their ticket.


I can think of plenty of worse days to have in this job than to have two awesome patients at once. When it comes down to it, there are really only a couple of things that need to be done. Calling for back up the second you realise that you have more pts than you can handle, before you even know whats wrong with them. Partner managing the airway of the DKA pt on their side. While you, between the two pts, give an aspirin, pop two lines in, hang a bag of fluid and give some morphine +/- nitro. Its no more than you would have ideally been doing with one pt really. I mean, a second line and a bag of fluid would be nice on a STEMI pt just in case, so simply doing the same extra bits but in a different pt is not really that much of a stretch.

If the wait is too long for backup, put the DKA on the bed, the STEMI on the chair and get thee to some back up/hospital. You've gotta get moving, but you even said that a lack of back up was not the problem. And that seems like the biggest mistake here. This "situation" suddenly becomes two separate, relatively normal, everyday jobs once the 2nd crew from around the corner turns up five minutes later. Not getting them moving early is almost inexcusable.

All that said, there are communication and logistical issues with some scenes that can turn a stubbed toe into a 45 minute job, so one has to take into account the possibility that there is more to this job than meets the eye.

 

[q209]

The medics who taught my courses repeatedly reminded us that medics can develop tunnel vision, and it was up to the EMT to provide the posterior impulse correction at whatever level necessary. Their quote: the medic saves the patient, the EMT saves the medic...

 

[STXmedic]

Their quote: the medic saves the patient, the EMT saves the medic...

/facepalm