Please tell me what I missed with this patient

[daedalus]

I'm not too up to date on the cost of procedures, but how much does acquiring a 12 lead actually cost? Also do you acquire a BGL on patients who are altered with a history of neuropsych disorders (i.e. dementia)?

Its not a question of how much it costs, but how much it is billed for.

 

[daedalus]

You consider this guy healthy?

70 y/o
IDDM
3 cardiac stents that were placed 5-6 years ago.


Other things to consider:
Why was the patient getting a colonoscopy? Routine or diagnostic?
When was his last EKG? Did he already have one done as part of the pre-procedure prep?

Depending on why the test was being done and the person's ability to handle stress can trigger complications also. Some people might prefer open heart surgery to having a colonoscopy.



Almost all of our neuropsych patients get ECGs especially if they have been treated or will be treated medications for their psych disorders. They will also be closely monitors if they are also on any respiratory medications during that treatment.

If the patient calls an ambulance and has probably been through the healthcare system a few times, I seriously doubt if they are going to be concerned about what an EKG costs. Nor, should you make it their concern by telling them you are not doing a test because it costs too much. They may take that as discrimination.

You and I seem to differ in our subscriptions to common sense. I would not have preformed a field EKG.

 

[Epi-do]

With his hx, a monitor should have gone on. N&V is an indicator of cardiac problems.

I guess, what I am just not getting is why his hx of stents 5 years ago would indicate a need for a monitor today. I realize diabetics may not present with typical cardiac issues, but I really am not getting why NV alone would justify a monitor.

I do agree that N&V can indicate cardiac problems, but alot of times there are other things going along with it to make one think it may be cardiac.

Polyethylene glycol (PEG) solutions such as Golytely, Colyte, Nulytely, Trilyte and Halflytely work by pushing a large volume of fluid through the bowel to force out waste. They cause no significant electrolyte shifts, so they are considered safer than OSP solutions but still have some risks for patients with certain disease processes or conditions.

It was Trilyte he was taking. I just couldn't remember the name of it when I wrote the original post.

What was found to be the problem with this pt? Also, if there was anything found, what would you have done to fix it?

We didn't make it back to that particular hospital as of yet today, so I do not know if anything was found.

A cardiac monitor was not warranted for this patient, who was being taken to the hospital for an outpatient test.

Actually, the patient called 911 for the NV. It was not a scheduled transport for an outpatient test. He just made sure we knew he had the test scheduled at 1130 and was concerned that he wouldn't be out of the ER in time to make the test.

I really am not trying to be "difficult," I really am just not seeing how this particular patient's history + complaint = cardiac monitor. As a new medic, I typically tend to be overly cautious with my patients, but I just didn't see a need here to do any advance interventions.

I really do want to understand the reasoning behind this and a simple "because of his history" answer just isn't making enough sense to me. If that were the only reason, then wouldn't it stand to reason that every single diabetic I run on that has a cardiac history should get put on the monitor? "Excuse me sir, I know that you fell and twisted your ankle, but I need to check your heart because of your medical history" seems like overkill to me.

As for the nurses, it was more the snippy attitude they had about the whole thing that I have an issue with, than them questioning why he wasn't put on a monitor. If you feel I could have done something better for my patient, teach me, don't chastize me.

 

[VentMedic]

You and I seem to differ in our subscriptions to common sense. I would not have preformed a field EKG.

The OP asked whether the RN was justified in asking why this patient was not being assessed by an ALS provider. The RN's education gives him/her a deeper understanding about many complications about each type of disease processes as well as the prep for different tests. Sometimes this knowledge can make one more cautious or have more questions that should be answered. The RNs are with a patient a lot longer than EMS providers and like to anticipate things before they go wrong.
So, caution is used with patients that do present with a significant history in the hospital setting.

Unfortunately the RN made the mistake that prehospital providers have the same level of knowledge and take the same precautions as hospitals. The RN was probably wrong for making that assumption. The EKG will probably be done anyway in the ED and maybe again prior to the colonoscopy. Cardiac monitoring will also be available during the procedure.

As I already stated, just get the patient to the hospital. Given his hx, something made him call at 0600. If he just wanted a ride to the hospital for the test, he would have called at 1000 to make sure he got to the test on time. He too might understand how brittle his medical history makes him and recognizes the need for some caution.

Epi-do

As for the nurses, it was more the snippy attitude they had about the whole thing that I have an issue with, than them questioning why he wasn't put on a monitor. If you feel I could have done something better for my patient, teach me, don't chastize me.

Given the hx along with the N/V and the PEG (even though it is less likely to shift the electrolytes drastically), I would have put him on a cardiac monitor and may not have done the 12-lead...depends. 3 stents that are 6 years old can become a problem depending on how closely they have been monitored especially with the IDDM hx. As I said before, stents may be a temporary fix and many patients end up with a CABG within 10 years of placement or at least returning to the cath lab a couple of times.

The N/V does not have to be a sign of a cardiac event that is occurring but rather the cause of one that can occur for the reasons I mentioned in earlier posts.

Some of us "healthy" types have arrhythmias when actively vomiting or feeling the urge and if dehydrated or haven't eaten for a couple of days may have PVCs. But, if healthy, we can quickly get back to homeostasis.

 

[JPINFV]

Almost all of our neuropsych patients get ECGs especially if they have been treated or will be treated medications for their psych disorders. They will also be closely monitors if they are also on any respiratory medications during that treatment.

If the patient calls an ambulance and has probably been through the healthcare system a few times, I seriously doubt if they are going to be concerned about what an EKG costs. Nor, should you make it their concern by telling them you are not doing a test because it costs too much. They may take that as discrimination.

I was using the neuropsych patient as an example of when you would still run a routine POC test (glucose measurement) even though any ALOC could easily be explained by the underlying disorder.

 

[daedalus]

VentMedic, You like to make passive aggressive hits on prehospital providers, and it is becoming a pattern. Perhaps these nurses had no idea what they were talking about. After all, they are not trained in the medical model. If you hear hooves, think a horse, not a zebra. The patient had ingested bowel prep, than vomited.

Your philosophy of patients always having hidden zebras because of the lack of education of prehospital providers is a little silly.

 

[VentMedic]

I was using the neuropsych patient as an example of when you would still run a routine POC test (glucose measurement) even though any ALOC could easily be explained by the underlying disorder.

I knew what you meant but I was pointing out there are many indications for an ECG or at least cardiac monitoring.

Another example: If I do just a 10 - 15 mg Albuterol tx in the back of an ambulance or in Flight on any patient, regardless of age and hx, they get a cardiac monitor.

 

[daedalus]

I knew what you meant but I was pointing out there are many indications for an ECG or at least cardiac monitoring.

Another example: If I do just a 10 - 15 mg Albuterol tx in the back of an ambulance or in Flight on any patient, regardless of age and hx, they get a cardiac monitor.

But there is indeed an indication, because you administered a beta agonist.

 

[JPINFV]

I'm not sure if I would consider an atypical presentation of an MI in a patient with risk factors for atypical presentations to be looking for Zebras. The entire point of DDxs is to rule in/out diagnosises. You don't just compile a list and pick the most likely, espeically when it's fairly easy to rule out some of the items on that list with POC testing.

 

[VentMedic]

Your philosophy of patients always having hidden zebras because of the lack of education of prehospital providers is a little silly.

Hidden zebra? The patient had 3 stents that are 6 years old, IDDM, N/V and the age of 70.

But, you are right. No need to learn anything else or look for different things. Every disease or condition is simple with no complexities and the EMT book provides everything you need to know.

Wonder why some want the education levels increased in EMS?

I've already read enough anti-education remarks on this forum the past two days. It seems like the next generation in EMS won't be setting the education stanard at a higher level either.

As an EMT-B, you need to advance your own education before criticizing Paramedics and RNs. Who are you to judge the knowledge and protocols another healthcare provider who is a higher level than EMT-B and may work in a different environment? I also think your listed occupation of GOMER transporter in your profile pretty much sums up what you think of your job and this profession along with the concept of patient care. The term GOMER transporter can be as offensive to patients as was the use of the words Ambulance Driver in the serious article about atypical symptoms in women having MIs. You took great offense to that by the way you posted that thread.

 

[chute43]

I think the nurse mainly heard the pts hx and not the complaint. I believe that higher level providers(generally RNs) sometimes forget we practice signs/symptom based medicine(we treat what we see), where as they practice medicine based upon diagnostic test (lab values, ultrasounds, EKGs etc). This is ofcourse my opionion based upon my own observations, and not an across the board the shot at RNs.

Just my thought. We used to have a fair amount of RNs questioning why we didn't treat CP secondary to MVAs with Nitro/ASA. Because all they heard was CP, and nothing else. So I now say "sternal pain secondary to MVA"

kary

 

[MSDeltaFlt]

I can see where Vent is coming from here. Her education, training, and experience alone blows everything I got out of the water hands down. So, yeah, technically this pt probably should have been put on a cardiac monitor.

Would I have actually done it? Uh... er... um... naw. Don't think I would have. That being said, I still think Epi was justified in her decision.

My humble 0.02.

 

[daedalus]

Hidden zebra? The patient had 3 stents that are 6 years old, IDDM, N/V and the age of 70.

But, you are right. No need to learn anything else or look for different things. Every disease or condition is simple with no complexities and the EMT book provides everything you need to know.

Wonder why some want the education levels increased in EMS?

I've already read enough anti-education remarks on this forum the past two days. It seems like the next generation in EMS won't be setting the education stanard at a higher level either.

As an EMT-B, you need to advance your own education before criticizing Paramedics and RNs. Who are you to judge the knowledge and protocols another healthcare provider who is a higher level than EMT-B and may work in a different environment? I also think your listed occupation of GOMER transporter in your profile pretty much sums up what you think of your job and this profession along with the concept of patient care. The term GOMER transporter can be as offensive to patients as was the use of the words Ambulance Driver in the serious article about atypical symptoms in women having MIs. You took great offense to that by the way you posted that thread.

Sounds like someone needs to laugh and smile every so often. The cool thing is, once I get my california paramedic license, I will get to decide not to preform EKGs everyday of my career, no matter what somebody tells me on the internet.

You also do not get to decide what is offensive and what is not. Get off that high horse and go have a good time at a comedy show, it will be and educational experience for you. Comedy tradionaly pokesfun at offensive topics. You could say...comedy makes us a little more human

 

[VentMedic]

Sounds like someone needs to laugh and smile every so often. The cool thing is, once I get my california paramedic license, I will get to decide not to preform EKGs everyday of my career, no matter what somebody tells me on the internet.

It is about the patient and not your ego with the "because I can attitude". You do what is best for the patient and don't base it on their ability to pay or belief that patients are GOMERs.

You also do not get to decide what is offensive and what is not. Get off that high horse and go have a good time at a comedy show, it will be and educational experience for you. Comedy tradionaly pokesfun at offensive topics. You could say...comedy makes us a little more human

Medicine is not intended to be a comedy show. Although some of our patients are humorous at times, they can have very serious disease processes that must be addressed. When it comes to patient care, I am serious about my profession(s). If I am on a forum talking about comedy shows or some other fluff stuff, I'll make jokes.

You still have a long way in your education, although not that long in CA, to be a Paramedic. You can easily research many of the things that I make statements about to sort out the data for yourself. Often I post the links to the information so you don't have to trouble yourself searching.

 

[fma08]

70 y/o
IDDM
3 cardiac stents that were placed 5-6 years ago.

That would have been enough for me with a complaint of nausea and vomiting to warrant a monitor or XII lead. Again, one newbie's opinion.

The question is, what do you feel you should have done. We weren't there, we didn't see/examine the patient at all. Do you think you should have done something different? If so what and why? Did you learn anything from the call? Those are the more important questions.

 

[daedalus]

My program is 12-14 months long, about average across the united states. It may not be the longest, but its certainly better than a mill.

 

[daedalus]

That would have been enough for me with a complaint of nausea and vomiting to warrant a monitor or XII lead. Again, one newbie's opinion.

The question is, what do you feel you should have done. We weren't there, we didn't see/examine the patient at all. Do you think you should have done something different? If so what and why? Did you learn anything from the call? Those are the more important questions.

Thats the way I feel. N&V after ingesting bowel prep is not an indication for 12 lead EKG. I agree with VentMedic in the fact that the patient will recieve procedural EKG monitoring, but that is not my job on scene.

 

[Epi-do]

The question is, what do you feel you should have done. We weren't there, we didn't see/examine the patient at all. Do you think you should have done something different? If so what and why? Did you learn anything from the call? Those are the more important questions.

I am guessing these questions are for me. Honestly, I don't feel as if there was anything different I should have done. After hearing what others had to say, I understand why concern regarding a cardiac event could be warrented, but honestly don't think that was his issue. He was so concerned about how long he was going to be in the ER and whether or not he would get released in time to make it to his scheduled test that I can't help but wonder if he didn't just want a ride downtown so he would be there for it, but I digress. Even though I didn't put him on the monitor, I did do a complete assessment otherwise before turning him over to my partner.

Probably the biggest thing I have taken away from this run is that while I already take PMHx into consideration when evaluating/treating my patients, some histories may warrent taking a second look at the patient and just double checking to make sure there isn't more to the story. That, and I need to trust myself more and try to not second guess myself so much. Then again, the reason it is called experience is because you get it right after you needed it, right?

 

[mycrofft]

Oh crikey. I'm a nurse and a former EMT-Ambulance (nowadays EMT-B)

You have caught me on a day I am sick unto death of knowitall armchair nurse "administrators" and especially nurses with no field experience who decide to add to the mix. Please don't anyone take this as a universal truth, but you have to know that many, many nurses think EMT's are basically moving men, know-it-all noobs and need to be kept in their place. Sorry, that's how it is in many places, if it is different for you, you have done an excellent job and the nurses are being allowed to work realistically and not prodded into senseless "fannyflage" (backside coverage) by their managers and administrators.

Vitals reveal cardiac signs? Pt anxious, in pain, SOB, or a little too keen to explain some chest pain away as "gas"? If your protocols call for an EKG, do it, but if we do EKG's (start IV's, do ABG's, etc.) on every person who is the equivalent of this patient who vomits and is a diabetic with a half-decade old hx of cardiac stent but has normal vital signs, what kind of professional autonomy/judgement is that? If the nurse bothers you, tell her to take it up with your manager and give that nurse your manager's card.

 

[Ridryder911]

Wow! I swear even in first aid classes we teach one of the most ominous signs of an AMI (especially silent) is nausea? Especially those with a hx. of stent placement (oh by the way, stent re-occlusion is about 5 years) and diabetics as mentioned do present with even more silent conditions.

Want to make that a valid case and explain yourself upon why you did not? Since, you have a patient with a + cardiac history, s/s of an AMI. This is how many AMI's are missed.

p.s. XII leads are not charged at any higher rate than traditional ECG.

Again ... think outside the box, sometimes it is Zebras.

R/r 911