Should I be worried about this call?

rich

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Relatively new EMT basic on a 911 truck under 1 year road experience so still learning a lot.... Dispatched out to ECF facility non emergent for ABD pain.
Arrive on scene find PT In ECF bed, presenting as lethargic. Alert to person and events. Normal baseline is AOX2 per staff - CVA and dementia hx.
Chief complaint per PT is ABD pain X 4 quadrants. Tender to palp, soft, no masses, non rigid.
No apparent onset of new cva per staff there's a deficit, unsure which side.
ABD pain X 4 hours - HX of constipation W/ no recent constipation, bowel movement prior to ems arrival... No blood noted, no emisis.
Per friend who lives in the ECF + nausea. Unsure on accuracy of ECF resident HX on PT due to resident possibly dementia etc.
PT noted to be on vicodin X 4 doses per day, and fentanal.
Noted to have RX of immodium as well.
Presenting W/ possible constipation.
Per physician report paperwork PT presents W/ hypotension.
Vitals obtained on scene W/ ECF BP cuff. BP found normotensive at 128/72.
SPO2 found low on room air at 89%
Pt placed on O2 - 4lpm NC. Corresponding O2 increase noted.
PT presents with secretions, but a patent unobstructed airway.
Lungs clear W/ no adventitous sounds noted for an 80 YO person.
Hr is wnl 86. Bgl slightly hyperglycemic near 300
Temp unable to be assessed. PT skin Presents as pink warm to touch and dry. Not hot cool or clammy. Skin intact no obvious abnormalities. No recent HX of trauma.
PT transferred to stretcher. Loaded to ambulance maintained on ems O2 monitored with no exacerbations or condition changes. Mentation maintained AOX2 lethargic, answering questions on prompting then returning to sleep.
PT presents as at normal baseline but lethargic due to generalized malaise/ABD pain.
No acute distress present.
PT transported to nearest Emergency facility without lights or sirens. Classified as a priority 3 non emergent transfer.

Give hand off to nurse n clear.

Show back up later n get basically called out by the nurse. Nurse Comes up n says you need to check your vitals machine or something. I'm like what?
Nurse says that the PT was a GI bleed, and went to resus because they got a BP in the 60s systolic.
Nurse then goes on to say ya the doc had me print out your run report and highlight some stuff. Nurse says it looks pretty weird when you pick someone up and the paperwork has hypotension right on it but you still get a good BP then get here and we get a low BP.

Basically the nurse insinuated that I made up the vital signs.
Now, in retrospect I should have reassessed vitals with a manual cuff on my own.
The other thing I kinda feel was I maybe should have treated the oxygenation issue more aggressively, possibly with a NRB but the NC at 4 lpm was appearing to raise O2 sats to an acceptable level at or above 90%.

So idk. At the end of it all transportation wasn't delayed. I guess technically definitive treatment was maybe delayed since the PT was initially brought into a regular er room and care handed to a er nurse not a resus staff?
I also kind of wonder if they thought my airway assessment was bs too since I wrote in my report that it presented W/ no abnormalities or adventitous sounds heard - they presented as normal 80 year old lungs in my opinion. I'd have considered the lung assessment a pretty severe alteration if this was a 20 year old patient, but sounded pretty unremarkable for 80.

There was no obvious signs of GI bleed. No Melina or hematamesis per staff, no hx of gi issues...

What do you think? If the doc was asking to have things highlighted on my run etc am I going to be facing some repercussions? Suggestions n comments appreciated.
 

Akulahawk

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There are a couple things to worry about and they're not about this call. One thing is that you didn't apparently reassess this patient at all (no vital signs) after your initial assessment. While you might consider using a BP machine on scene, always use the equipment provided for you because you have no idea if the equipment you find on scene has been properly calibrated. It's also very easy to do... one set on scene, one set upon loading the patient, and one set prior to unloading the patient at the destination. There's no excuse for failing to reassess the patient.

The other thing is that lungs, if they're clear, will sound the same whether they're 13 years old or 103 years old. You don't "adjust for age." If you think the lungs are pretty severely altered, then that's what your findings are. Unless the patient has very severe COPD, I'm not really all that worried about providing oxygen to this patient... so that's probably adequate or at least passable.

Also, you state the patient is presenting with possible constipation but you just noted prior to that the patient had a BM prior to your arrival. If the BM was normally formed, then there's no issue with constipation.

What concerns me is that you're a 911 EMT (on a 911 EMT/EMT truck I imagine) and you're not assessing patients very well.

It very well could be that this patient truly is extremely sick and you were unable to appreciate this, probably because you didn't do an accurate assessment.
 

ERDoc

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I can't say what to make of the doc highlighting things. I don't do things like that. If I have a problem with something that was done I will let the crew know. If it was something really stupid, like not checking a finger stick on an unconscious person with a sugar of 19, then I might shoot an email to the medical director. I don't look to get people in trouble, but sometimes a little remediation is needed.

You should always have 2 sets of vitals on your pts. GI bleeds can hide until there is a significant loss of volume. You will not know it is a GI bleed until the blood decides to exit the body and by that time there could be several liters. When you describe lung sounds, don't interpret them. Just state what you hear, rales, rhonchi, wheeze, clear, etc. Her pressure may very well have been what you got at the ECF, things change which is why reassessments should be done.
 

mgr22

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When you assess patients, how do you usually begin? As you're developing an initial impression based on what you see, you might want to palpate a distal pulse. You don't have to count the rate -- just get a sense of weak/strong, fast/slow, regular/irregular. You can do that even while you're speaking with patients or family or nurses. If you did that, great; if not, maybe it would have given you a clue about a perfusion issue before you even checked the BP.
 

akflightmedic

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For a new EMT, you sure use a lot of dem dar fancy words while lacking very basic assessment skills.

Do yourself a favor as you sound like you truly want to learn and improve. Ditch the recycling of other provider's words or notes and go back to recementing your foundation, maybe even build on it a little more, as you seem to be throwing a lot of flash up front at the moment with very little substance underneath.
 

highglyder

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If you can, attempt to review the chart with a training officer or someone from your medical director's office. Their knowledge will help you associate findings with presentations. You ought to bring this concern forward to your agency. There is nothing wrong with stating that you feel like you erred and that you want to learn from this call to avoid a repeat and to become a better provider. It shows an ability to identify deficiencies and a desire to resolve them.

You said you had under one year of experience. That's pretty vague. Your ability to make connections depends on the quality of your education, your exposure to calls, and your own personal experiences and knowledge base.

As others have said, asses and re-asses vitals at least several times. Just one set is nothing but a snapshot in time, especially if you can't link the values to causes. I would also have asked what led them to document hypotension. If the answer would be "multiple low readings", I'd be suspicious of the equipment.

Can you provide any additional information or clarification of what you already posted?
 

Gurby

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As everyone else has pointed out, the big thing is that unless it's a scoop-and-screw with 30-second transport, you should really have at least 2 sets of vitals signs on any patient going to an ED: "here's how he was on scene, and he maintained that during transport" or "here's how he was on scene, and here's how he's doing now". If you had checked a manual pressure at some point you would have discovered the problem. That said, a few things I wanted to mention that haven't been touched upon:

"SPO2 found low on room air at 89%"
"NC at 4 lpm was appearing to raise O2 sats to an acceptable level at or above 90%."

Exactly how much did the sat come up with O2? If he has no history of COPD, lungs are clear, and the cannula only brings him from 89 to ~90, I think that should be setting off alarm bells in your head. Not that you'll be able to do anything about it, but it would make me suspicious for something more serious going on than I had thought. 90% might be baseline for some patients, but for a lethargic patient with clear lungs and no history of lung problems, probably not.

Also, 300 is more than "slightly hyperglycemic", especially if he has no history of diabetes. I think this is another finding that should make you suspicious that something potentially serious is up.
 

Bullets

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I agree with everyone else, you need multiple sets of vitals, does EMT school still teach every 15 minutes for stable patients?

The nasal cannula is fine, if 4 wasnt bring the patient up then bump him to 6, 10, or whatever. NRBs suck for a number of reasons.

Also, stop abbreviating, not everyone knows what they mean, and using whiz bang medical language and abbreviations doesnt fool a well educated provider. Just the facts, say what happened.
 
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rich

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1 mile transport. That's why vitals were assessed on scene.... Pulses felt adequate, maybe slightly weak.

As I said, PT was reported to have a bowel movement by another resident at the facility. Per the nursing staff they had no idea. So yes. PT was reported to have had a bowel movement. Obviously if she did I'm pretty sure that could rule out constipation. But, as I said. I cannot determine the accuracy of the historian. I told the receiving facility that PT possibly had a bowel movement prior to ems arrival, but we are unsure. Any bowel movement that may have happened was gone by the time ems arrived.

Also, Why is everyone so against using correct terms. Use the correct medical terminology to describe what you are saying. It's not reserved for doctors or seasoned providers. It's the correct way to communicate between medical professionals. It's pretty simple. There's no reason someone shouldn't be allowed to use the proper medical term. It's absolutely ridiculous to even suggest that someone not use the proper terminology. It's not about fooling anyone. That's stupid, it's about using the correct terminology to say the facts.

Also. As far as the nasal canula, at or above 90% was my statement. I did not say that it raised a whole 1% and I called it good Checked it off as another PT saved.
At or above 90% means that spo2 values fluctuate. The PT had a room air of 89, the NC brought the values up to 90% and above meaning that the spo2 values did not go below 90% while maintained on 4LPM which is a satisfactory oxygen saturation...

My assessment skills are not poor, and I do know what I am looking for. I gave a good report to the receiving nurse including all of my findings, and that the reason behind having the PT sent out in the first place was documented as hypotension even though we found no hypotension.

There were no signs or symptoms indicating a GI bleed. No obvious signs at least, and to be honest for all I know my BP assessment was accurate at the time it was taken.
This isn't a case of I don't know how to assess a PT or that I don't know what to look for, because I can I assure you I do.
The only thing that could have possibly made a difference in this scenario would have been a manual blood pressure assessment prior to transport. Due to the close proximity of the hospital one pressure was taken on scene while history and everything thing else was gathered....
 

akflightmedic

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Read again. And note. I did not call you out for using proper terminology. I called you out for using words which did not match your assessment or knowledge based on what you presented, i.e copy/paste from other providers. Any new EMT who takes the time to assess and document all that you did yet is unable to get a second set of vitals due to a 1 mile transport and is then worried about the call...well, infer what you will as I already did.

Anyways...despite what I and the others said....YOU just identified the problem with your very last statement.

ALWAYS get a manual BP yourself. I love technology, I embrace it when I can, however I can be a bit of a dinosaur when it comes to my first set of vitals. I have always gone manual for first set. Aside from it placing my mind at ease, I do believe there is a different approach taking place when you do this. It slows the game down for all, the patient tries to quiet down and assist, you have 30 seconds of nothing but your thoughts as the stethoscope blocks everything out, it buys you time and believe me those few seconds can be very much needed sometimes and finally it is helping to establish a rapport between you and the patient...they are now trusting you.
 

Ewok Jerky

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This isn't a case of I don't know how to assess a PT or that I don't know what to look for, because I can I assure you I do.
Then why are you so worked up over this call?

We all miss things, especially when we are new. Don't come here asking for a review and then get butthurt when we give advice on how it could have gone better.

I agree with the others that your report doesn't sound exactly accurate, particularly the issue with lung sounds. Lung sounds are objective findings and should be reported as such. Also, every patient should have minimum 2 sets of vitals, at least one manually. Especially as a basic, you have plenty of time even on a 1 mile transport, get it while your partner is walking back tobopen the doors in the ambulance bay.
 

Akulahawk

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Also. As far as the nasal canula, at or above 90% was my statement. I did not say that it raised a whole 1% and I called it good Checked it off as another PT saved.
At or above 90% means that spo2 values fluctuate. The PT had a room air of 89, the NC brought the values up to 90% and above meaning that the spo2 values did not go below 90% while maintained on 4LPM which is a satisfactory oxygen saturation...
If a patient has an SpO2 of 89% on room air and you put the patient on 4LPM by nasal canula, I would very much expect the patient's SpO2 value to be >94%. If you look at the oxygen dissociation curve, there's a pretty steep dropoff that occurs around 92%. There's a reason why "we" like to see the SpO2 greater than that. My ED wants us to titrate to maintain 94% or greater unless the patient has severe COPD. The "extra 2%" is basically a buffer to allow momentary excursions below 92% and even to 90% while allowing for the patient to remain adequately oxygenated.
My assessment skills are not poor, and I do know what I am looking for. I gave a good report to the receiving nurse including all of my findings, and that the reason behind having the PT sent out in the first place was documented as hypotension even though we found no hypotension.
You found "no hypotension" using an unknown/untrusted machine that was supplied by the facility. You didn't use your own equipment. Your original statement/post has some serious implications for your ability to assess patients properly. If you had re-evaluated the patient upon loading into the ambulance and the VS were still reasonably good, it becomes much more difficult for the ED nurse and Physician to have an issue with your care. You cannot fudge the numbers to make yourself look good though. You must absolutely document exactly what was measured.
The only thing that could have possibly made a difference in this scenario would have been a manual blood pressure assessment prior to transport. Due to the close proximity of the hospital one pressure was taken on scene while history and everything thing else was gathered....
The hospital is just a mile away.... I have been known to get 3 full sets of vitals on transports where the hospital was literally 3 blocks away and I could physically see the front entrance. How did I do it? Very simply. One set on scene as part of the initial assessment (includes gathering HPI, past medical Hx, current meds and allergies). Only if the facility is not ready is my scene time delayed at all. One set upon loading (takes about 1 minute), do the ringdown, initiate transport, arrive at the hospital and get that 3rd set while parking at the ER entrance and before unloading.

I'm no super-medic, I've just learned how to be very efficient at time management while on scene. There's also a reason why I use the same equipment for each patient contact and that is one of consistency. My NIBP machine or manual cuff should perform the same for each successive reading so therefore I can reliably develop trends. Unless too low or too high, absolute numbers don't matter much to me but the trend does. That's why I try to get multiple sets of vitals because the trend is another data point. When you go from one piece of equipment to another piece of equipment, you cannot guarantee that the two are absolutely identically calibrated and will provide completely identical results. In the ER, my triage nurse uses his/her portable machine and as soon as I can, I put the patient on my monitor in the room because of this very issue. I want trend data that is known good because it's done on the same equipment.

That's just an inkling into why we're dog-piling on you about this stuff. We're showing you just where you have apparent shortcomings and letting you know why we have issues with it so that you can make the necessary corrections and become a better EMT.
 

SpecialK

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I remember ages ago a GI bleed we worked up as myocardial ischaemia and even gave aspirin and GTN to her. This was back when 12 lead ECGs were very new so many staff had not become used to using them routinely as a diagnostic tool and te old procedure was essentially written in a way that aspirin and GTN came first. Thankfully, we have moved on. So, the moral of the story is nothing is ever black and white, especially in prehospital care.

Always get more than one set of obs, minimum of two, to establish a trend. The exception is patients who have a minor problem that can be treated and discharged on scene. For example if I gave somebody paracetamol and ibuprofen for a headache, I would be happy with one set of observations to check for any significant abnormalities before leaving them on-scene. Like everything however, clinical judgement is required.

As for recording blood pressure, yes, always use your own equipment. If possible, always take a manual BP first. It is a good skill to keep sharp and it is a conduit for establishing a good rapport with your patient.

Most GI bleeds are not big, nasty things where the pt is chucking up (or pooing out) foul smelling red (or black) emissions, they are often quite well hidden and often have very non-specific symptoms.
 

Jim37F

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It's fine to get vitals with the sending facilities machine, I just annotate them as gotten PTA (prior to arrival) on my ePCR, but you should always bring in your own gear and grab your own set of vitals upon pt contact as part of your initial assessment before moving them to your gurney. And then once loaded the first thing I do when climbing in back, before my driver has even climbed in the cab, is grab a second set before there's road noise and bumps and all that. Even at freeway speeds, 1 mile is plenty of time to grab a BP, and a pulse/resp rate, if nothing else grab them when you park, heck I've had plenty of times where I'm driving, get to the hospital, open the back doors and find my partner grabbing a set of vitals. No problemo. And then grab one last set with the hospitals machine while waiting for a bed. That's 4 sets in a mile long transport. Even a scene call from a sidewalk a mile out and the nurse is demanding a report with trending vitals, the initial set you got prior to moving the patient to the gurney and the second set gotten enroute is two sets to trend right there.

Really the only exception to not getting two sets (even if you can see the ER entrance from where you picked up at) is a critical, load and go where you are busy actively managing the ABC's and aren't waiting for fire or a second crew or whoever because you're that much closer to the hospital than the second set of hands. And those situations are extremely rare, and nothing in your original post about the patient's condition leads me to believe that you can't spend the 2 minutes sitting to grab vitals. (Especially on a code 2 transfer)

Even though it's not a "critical error" that'll stop me from uploading my ePCR, having only 1 set of vitals will certainly get a supervisor asking me why if nothing else I didn't grab a second set using the hospitals machine after transfer of care, after all that's the first thing the hospital does when we put the patient in their bed, often times even before the nurse shows up to sign my form (and that signature IS a critical fail if left blank).

Otherwise quite being so defensive. You're the one who posted the scenario here asking for advice, and you got it. We've all had calls we've run less than perfectly, so just learn from it and take 2 sets of your own vitals from now so the hospital can't insinuate you made them up in the future if that's what you're worried about.
 
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rich

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Yeah basically lesson learned here is vitals vitals vitals. I can say it was a decent lesson learned, and I appreciate all of the input.
 
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rich

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On an unrelated note. Any tips for auscultating a BP while moving? Road noise seems to basically skew any sort of accuracy.... Palp is easy enough, but I would like to get proficient while moving. I am pretty decent with auscultating a BP stationary... Maybe it's just practice.
 

gotbeerz001

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On an unrelated note. Any tips for auscultating a BP while moving? Road noise seems to basically skew any sort of accuracy.... Palp is easy enough, but I would like to get proficient while moving. I am pretty decent with auscultating a BP stationary... Maybe it's just practice.
Do it a lot.
Focus on cuff and scope placement.
Raise the arm off edge of cot so road vibration doesn't transfer through.
Do it a lot.
 

Gurby

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On an unrelated note. Any tips for auscultating a BP while moving? Road noise seems to basically skew any sort of accuracy.... Palp is easy enough, but I would like to get proficient while moving. I am pretty decent with auscultating a BP stationary... Maybe it's just practice.

People say putting your feet on the stretcher will help, but it doesn't seem to make a big difference for me.

More often than not, when moving, I try/fail at auscultating and end up just palpating... I think as long as you get a reliable pressure prior to starting to move, palpating is okay. It's not ideal, but will at least let you know whether you're still in the same ballpark or not.
 

Jim37F

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Straighten out their arm, palm up, rest the arm on your leg (place a towel between the arm and your leg if so desired), and rest that foot on the bottom rail of the gurney to isolate a lot of the road noise. I like to try to palate the brachial pulse first so I know exactly where to place my stethoscope before I start pumping up the cuff, not hear anything and then fumble around with repositioning. Take advantage of red lights if possible. Make sure you have a good seal between the ear pieces of your steth and your ear (and that wearing it correctly so it's pointed forward into your ear canals). Make sure your using the correct bell or diaphragm side of the steth (give it a quick tap first so you know it's clicked over to the side you're using). And finally just practice a lot.
 

Qulevrius

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What Jim said. I can take BP (actually hear it) 9 out of 10 times en route to destination, and the only patients whose BP is hard to auscultate are geriatric. Even so, had a 94 y/o post-CVA yesterday with a beautiful, strong brachial pulse, made reassessments a breeze. Littmann helps too :D
 
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