Partners who think they are the hospital.

[NYMedic828]

Does anyone work with people like this frequently?

One of my partners thinks he is the greatest medic of all time.

Today for example we get called by BLS for an AMS possibly hypoglycemic.

Turns out she was sick for 3 days with vomitting, severely hypotensive at like 60/40 heartrate 100+. Hot to touch. Ruling out possible sepsis.

He does a quick 3/12 lead while I stick an IV in her arm. He gets the bag hooked up and I say "lets get going." (We are still upstairs in the apartment)

He decides, no, we are gonna stay here and let 500ccs of the bag go through to "stabilize" her. He also said he didn't want to move her just yet because with such hypotension if we move her too quickly she could get an arrhythmia. I have never heard that one before.

I told him I felt we should go to the hospital, we can just as easily give fluid while we move and get her to a place that can correct the sepsis. He disagreed with me and I left it at that as to not start a scene in front of the family.

The same thing happened a couple weeks back with an obvious GI bleed. Severe hypotension, he wants to stay on scene because he thinks he can stabilize the patient with his magical bag of normal saline. I just don't get it.

 

[bstone]

NS is a powerful tool, but not nearly as much as BS.

 

[abckidsmom]

NS is a powerful tool, but not nearly as much as BS.

This is an excellent quote.

 

[bstone]

This is an excellent quote.

Why thank you, Dana! Want to put it as your signature and quote me? Then two people would have done that!

 

[firecoins]

He decides, no, we are gonna stay here and let 500ccs of the bag go through to "stabilize" her. He also said he didn't want to move her just yet because with such hypotension if we move her too quickly she could get an arrhythmia. I have never heard that one before.

I told him I felt we should go to the hospital, we can just as easily give fluid while we move and get her to a place that can correct the sepsis. He disagreed with me and I left it at that as to not start a scene in front of the family..

I don't like being a protocol pus but NYC remac makes it clear to not delay transport in these kinds of situations.

 

[RocketMedic]

More than that, delaying transport for something like that puts you out of service for even longer and it does the patient no good. 500mL of NS won't stabilize someone any more than a chicken dance will.

 

[Handsome Robb]

500mL of NS won't stabilize someone any more than a chicken dance will.

I don't know...I do a pretty mean chicken dance. h34r:

I must be spoiled but all my partners and I have gotten along just fine and I'm like a medic jumper, being per diem but working full time hours in the past and near full time hours now I end up working with a lot of different medics although I tend to have a set partner that I work most of my hours with. Never really had issues like this.

 

[STXmedic]

I could understand if it was to start a more aggressive treatment, such as a levophed drip. But to hang around just to watch 500mLs infuse is fairly retarded. Especially since a half a liter bolus is likely to not do a damn thing.

 

[Handsome Robb]

I could understand if it was to start a more aggressive treatment, such as a levophed drip. But to hang around just to watch 500mLs infuse is fairly retarded. Especially since a half a liter bolus is likely to not do a damn thing.

Especially since you only retain 1/3 of that volume in your vascular space over an hour if I'm not mistaken. 165 mLs roughly... Not going to do a whole lot of anything.

 

[bstone]

Especially since you only retain 1/3 of that volume in your vascular space over an hour if I'm not mistaken. 165 mLs roughly... Not going to do a whole lot of anything.

All depends on how dehydrated you are, the tonicity of the solution, and how your lymphatic system is feeling at the moment.

 

[NYMedic828]

I could understand if it was to start a more aggressive treatment, such as a levophed drip. But to hang around just to watch 500mLs infuse is fairly retarded. Especially since a half a liter bolus is likely to not do a damn thing.

Which it didn't.

Her pressure was unchanged by time of arrival at the ER. He does this all the time.


Is there any validity whatsoever behind his statement of We cant move her too quickly with her pressure, she could develop an arrhythmia.

I have never heard that one before but im sure I could be wrong.

 

[Veneficus]

One of my partners thinks he is the greatest medic of all time..

I think everyone thinks this way sooner or later, it just manifests in different ways, the medic who thinks they are the greatest because of something they thinnk or do or the medic who thinks they are the best because of everything they don't do or think about in the name of humility.

The balance of confidence and arrogance is tough to master and most people including me, slip back and forth from time to time.

It is a constant struggle.

Today for example we get called by BLS for an AMS possibly hypoglycemic.

Turns out she was sick for 3 days with vomitting, severely hypotensive at like 60/40 heartrate 100+. Hot to touch. Ruling out possible sepsis...

You mean "suggesting possible sepsis"?

He does a quick 3/12 lead while I stick an IV in her arm. He gets the bag hooked up and I say "lets get going." (We are still upstairs in the apartment)

He decides, no, we are gonna stay here and let 500ccs of the bag go through to "stabilize" her. He also said he didn't want to move her just yet because with such hypotension if we move her too quickly she could get an arrhythmia. I have never heard that one before..

500cc isn't much, probably won't even increase intravascular volume any.

This is the first I have heard of causing an arrrhythmia in this way also.

I would suggest if moving was going to cause it though, 500cc of saline wasn't going to prevent it unless you were planning to have her walk to the truck.

I told him I felt we should go to the hospital, we can just as easily give fluid while we move and get her to a place that can correct the sepsis. He disagreed with me and I left it at that as to not start a scene in front of the family...

Well since sepsis has a 30-50% mortality rate, maybe he was giving her a few more minutes to say "goodbye" to her home incase she didn't make it back?:wacko:

The treat on scene vs. transport to the hospital, is a fundamental argument of medical philosophy. Not just with medics. But since the US system is largely set up based on transport, he probably won't win many arguments about it there. If he thinks 500cc of saline is the solution to a possible sepsis, he probably doesn't know enough to successfully or even intelligently argue the matter either.

The same thing happened a couple weeks back with an obvious GI bleed. Severe hypotension, he wants to stay on scene because he thinks he can stabilize the patient with his magical bag of normal saline. I just don't get it.

Seen ED docs do the same thing actually.

This crazy idea you can "stablize" somebody requiring surgery before surgical correction of the underlying surgical pathology.

One of the most respected emergency physicians in the US (an EM specialist) I have ever met once told me: "The only purpose of an emergency physician in severe trauma or any other surgical emergency is to wave "goodbye" to the patient on their way to surgery."

He even went on to tell me in his opinion ED docs shouldn't even waste time evaluating such patients.

I think the theory of restoring homeostasis (resuscitation) prior to surgical intervention is flawed logic based on outdated information.

If you look at the guidlines for control of ruptured aneurysm and the obviously indusputable scientific evidence that has come from military conflicts dating back to WWI, in patients requiring surgery, presurgical resuscitation attempts represent a severe breakdown in critical thinking.

But you see it in emergency departments all over the world.

 

[CCNRMedic1982]

I can see starting tx in the house especially for someone that hypotensive but not waiting for 500cc of fluid to finish. The is a little validity to his arrhythmia statement like maybe a sinus arrest or she could go into a v-tach or have a few PVCs. I would wanna know her hx and I believe you said she was altered. If this wasn't normal for her. Acute alteration in mental status is a life threat to me. Also, not sure how long your transports are but if she didn't improve her pressure with fluid resuscitation then I would've thought about giving a vasopressor. What was her me ration, sugar, hx. Just curious sounds like there might have been more to it.

 

[NYMedic828]

Sorry Ven, I was trying to word it the best I could without saying "I'm diagnosing sepsis without labs or anything."

We have to write a presumptive diagnosis on our
Pcr.


Our transport time is 10 minutes to 3 different facilities around us.

The full story is

60 year old female
Sick supposedly 3 days to a week.
Vomiting x 2 days. No blood or anything in vomitus.
No GI conplaints. No pain complaints.
History HTN/diabetes.

Initial vitals
BP 60/39 via monitor.
HR 110 sinus tach on the 3 lead. No ectopy.
RR 20
SPo2 100%
BGL 335 (she didnt take her insulin that morning)
Hot to touch. Normal skin otherwise.
12 lead unremarkable.

By arrival at ER BP unchanged we gave 1250cc while she was with us.
ED told us her core temp was 101.5*
Last I knew when we left 20 min later ED had her on another 2 liters via 2 IVs and were giving levophed.

I don't see any validity behind causing an arrhythmia with movement due to hypotension. I can understand as a result of such poor perfusion the heart becomes irritable, but I don't understand how movement would add to that. And I don't think the heart which recieves the most immediate supply of oxygenated blood is going to be your first concern in that regard.

In NYC out main goal with such close transport times is supposed to be keeping the patient alive to make it to the ER not staying onscene trying to play doctor with limited resources.

 

[Veneficus]

Sorry Ven, I was trying to word it the best I could without saying "I'm diagnosing sepsis without labs or anything."

We have to write a presumptive diagnosis on our
Pcr..

I thought you were trying to say sepsis was your presumptive dx, but typed you ruled it out.

Thinking one thing and typing another is something I am guilty of regularly, especially when multitasking beyond my capability to do so.

 

[NYMedic828]

I thought you were trying to say sepsis was your presumptive dx, but typed you ruled it out.

Thinking one thing and typing another is something I am guilty of regularly, especially when multitasking beyond my capability to do so.

Well I did say "possible sepsis" as a means of saying "suggesting" it.

 

[CCNRMedic1982]

You don't understand how movement would effect cardiac irritability? Yes the heart will always get its blood first but if the amount of oxygenated blood being delivered to the heart is decreased then having the pt. move will increase myocardial oxygen demand increasing workload on the heart to some extent. Heart becomes irritable arrhythmias are possible. But I do agree that the pt. should have been moved and transported. The need for transport did not outweigh the risk of a possible arrhythmia. ( which I feel like we are pretty good at correcting).

 

[Veneficus]

You don't understand how movement would effect cardiac irritability? Yes the heart will always get its blood first but if the amount of oxygenated blood being delivered to the heart is decreased then having the pt. move will increase myocardial oxygen demand increasing workload on the heart to some extent. Heart becomes irritable arrhythmias are possible. But I do agree that the pt. should have been moved and transported. The need for transport did not outweigh the risk of a possible arrhythmia. ( which I feel like we are pretty good at correcting).

I am thinking if the stress of being lifted onto a cot and moved was enough to throw this patient into a lethal rhtym, that patient needs to get to the hospital more than she needs treatment of 500cc of NS.

 

[NYMedic828]

You don't understand how movement would effect cardiac irritability? Yes the heart will always get its blood first but if the amount of oxygenated blood being delivered to the heart is decreased then having the pt. move will increase myocardial oxygen demand increasing workload on the heart to some extent. Heart becomes irritable arrhythmias are possible. But I do agree that the pt. should have been moved and transported. The need for transport did not outweigh the risk of a possible arrhythmia. ( which I feel like we are pretty good at correcting).

I was not referring to the patient moving themself.

I was referring to us moving the patient onto a scoop stretcher and onto the cot.

No one is going to argue that the patient exerting their own effort will cause stress.


Thanks for the PM Ven. Always a good read.

 

[CCNRMedic1982]

Right, I understood and agree just using "movement" as a general term. No argument just responding to the original question in your post as to why movement could possibly cause an arrhythmia. With pt moving themselves or otherwise.