So is it me?

n7lxi said:
I don't really ever believe the, "I feel fine" statement. They called an ambulance for some reason and the symptoms were descriptive enough to warrant a paramedic response. Obviously something is going on. I find old people to be incredibly stoic when faced with huge amounts of pain or discomfort. Even if the patient says they're fine, do a full assessment. You won't find things unless you look. For example, the guy who's having a STEMI and states that he feels fine, just a little tired.

and as for your scenarios, I would answer no to both. I don't treat atrial fibrillation unless it's symptomatic. And not every syncopal episode needs to have a 500ml fluid bolus. However, I would look for other issues and not just sit on my hands and have a staring contest on the way to the hospital.

People say they're fine for a lot of reasons. Maybe they're scared. Maybe they don't know that they're really hurt. I agree that you need to listen to the patient, but you also need to do that assessment and not just take everything the patient says at face value.
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Oh absolutely on the assessment. Im talking after that or when someone else calls for them ( MVA or person down ).
Real life example :
female went syncopal for 5-10 seconds , friends called. Arrived on scene , person is cao x 4 . Pt says " I feel fine , this has happened before, I sometimes stand up fast and pass out". " Sure I'll go get checked out".
BP- 116/63 Pules - 70 - did assessment, nothing abnormal
Preceptor - " put a line in her and hang 1000cc normal saline"
Me to the patient - " how do you feel right now? "
Patient - " I feel perfectly fine"
Me - " are you thirsty? have you been drinking fluids? "
Patient - " yep , had breakfast and water and a gingerale before this happened"
Me -" do you feel sick to your stomach or anything?"
Patient - " nope "
Preceptor - " protocol says Iv fluids so do it "
Me- " umm, ok "

Ran the scenerio by my instructor that night
Instructor - " why ???? "
Me - " umm I dont know , because my preceptor controls my grade for the day "

This is the stuf im talking about. Treating those that really dont need treatment. Ive seen this over and over again running with different medics. Treating those that really dont need anything just because they can.
 
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Did you do orthostatics? I gotta tell you if she told me she stood up quickly and got dizzy then passed out I'd probably hang a line. :) (but that's just me...)

In short, you're still in student mode. Do what they want and then make your own decisions.
 
Protocols say line and hang a bang? what is this cookbook wizardry. How about treat the patient. I'd do orthostatics and tx. I'd only start a line if I was going to give something. We need to think about what we are doing an why. Why are we giving IV NS for ? postural hypotension? what is causing the postural hypotension? what will benefit of giving a bolus of NS in the pre-hospital environment to this patient.

I think its incredibly important when giving fluid challenges to consider why the patient is hypotension/poorly perfused, and what the net effect will be. Its not as simple as hypotension = fluid bolus
 
If a patient blatantly told me this happens all the time she knows she has orthostatic hypotension I'd follow the steps for a syncope, 3/12 BGL, vitals and ask her if she even wanted to go to the hospital.

More than likely she wouldn't get a line. Orthostatic hypotension is not a result of fluid deficiency it's a result of blood distribution to the lower extremities that some people especially the elderly cannot compensate for when they get up too quickly. They need to take it slow their body just needs more time to fight gravity.

9/10 times their body needs to fix it over a few minutes not me. If it takes longer than a few minutes it probably wasn't fully orthostatic in nature.
 
River I can empathize with you, I just finished my Internship tonight and during clinicals and internship I saw a few things I didn't agree with but at the same time, you said it yourself, they control your grade. It sucks but you have to make them happy. Once you're on your own you get to call the shots. It sucks to be bound by protocol for certain things but unfortunately that's the name of the game.

I was fortunate enough to have a preceptor who's young, genuinely interested in medicine and has an open mind. We had more than a few discussions and disagreements, never in front of a patient of course, that ended up being great learning experiences. He was usually correct but on a few occasions we'd look something up and my idea turned out to be correct rather than his. The nice part was he was totally game to hear my thoughts and was very humble when I was correct. Unfortunately not all preceptors are going to be that way. My program runs their interns with the same preceptor all the way through their internship unless there was an extenuating circumstance. I personally think that's the best way to go about it but I also had the opportunity to work with a ton of different medics while working as an intermediate and to see their styles and their thoughts on certain things.

Keep your head straight and keep on trucking' bud! I promise there's a light at the end of the tunnel!
 
You said something about a MVA. Did this lady pass out and cause the MVA?

Did you do a Ortho ?
How old was she?
Skin color?
did you do a ekg?

She said it happens often? Has she gone to the doctor about it?

Maybe your instructor was trying to lead you in a different direction and you failed to find another underlining cause.

My mega code in school was a 38 year old wheezing with history of asthma. I thought to my self this is going to be easy.. Luck would have it that I did a EKG,breath sounds and some digging and I found out he was having early stages of heart failure. (cardiac wheezing).. About 7 kids in my class failed that one...

Now if I had this lady I would start a bag too. I might just use it to keep the vein open. But if she crashed again i`d be ready.. I`ve had been on rides where PT's tell me ahh that feeling in my arm is normal.. I`ve had it for a few weeks... Sir your having what we call a TIA.. Just becareful
 
I guess as a young medic (experience wise) its very important to look at cause in effect. Why am I giving this drug, what will it do. Will it help the PT? I hope i never turn out to be a protocol drone. My teachers were very unhappy with students who did something because the book said too. They wanted you to say the PT NEEDS this and why.
 
The second a preceptor tells me the reason we do something is because the protocols say so, they lose all credibility.
 
legion1202 said:
You said something about a MVA. Did this lady pass out and cause the MVA?

Did you do a Ortho ?
How old was she?
Skin color?
did you do a ekg?

She said it happens often? Has she gone to the doctor about it?

Maybe your instructor was trying to lead you in a different direction and you failed to find another underlining cause.

My mega code in school was a 38 year old wheezing with history of asthma. I thought to my self this is going to be easy.. Luck would have it that I did a EKG,breath sounds and some digging and I found out he was having early stages of heart failure. (cardiac wheezing).. About 7 kids in my class failed that one...

Now if I had this lady I would start a bag too. I might just use it to keep the vein open. But if she crashed again i`d be ready.. I`ve had been on rides where PT's tell me ahh that feeling in my arm is normal.. I`ve had it for a few weeks... Sir your having what we call a TIA.. Just becareful
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No sorry Legion , didnt make it clear. These were different circumstances. Just siting 2 different types of calls. Only the syncope was a actual call I had.
 
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ahh gotcha.. sorry..


Well I guess what it comes down to.. is dont become these medics you don't like. If you do that will you still love ems.. Or are you just maybe getting burnt out with school and everything?
 
n7lxi said:
People say they're fine for a lot of reasons. Maybe they're scared. Maybe they don't know that they're really hurt. I agree that you need to listen to the patient, but you also need to do that assessment and not just take everything the patient says at face value.
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This is a very important point.

Some cultural groups need permission to express pain. Because they are not expressive does not mean they are in pain.

Many elderly patients, including some very sick and even dying ones, want to go home. They will say whatever they think it takes to get home, and denying pain is one of the most common things I have seen.

I have also seen a fair share of patients refuse pain meds "because they don't want to become addicts."

In a particularly disabled elderly patient, I asked her if she was afraid of missing work. She laughed, accepted the point, and asked for the meds.

Also, it is important to understand that just because you do not have the ability to mitigate something unpleasant, nobody does.

Laxatives and antiemetics with opioids and after opioids is one of those doctor things.

Sort of like giving antifungals after triple ab STI therapy. You know the lady will need it. Why make her come to another visit?
 
Yea , I pretty much decided to do whatever it takes to finish the class lol.

Ive already taking to kissing the lead instructors butt because she doesnt like how i look. I figure I can suck it up do what the preceptors want for another 8 weeks.
 
RiverpirateEMT said:
Yea , I pretty much decided to do whatever it takes to finish the class lol.

Ive already taking to kissing the lead instructors butt because she doesnt like how i look. I figure I can suck it up do what the preceptors want for another 8 weeks.
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Well if you look like a pirate, I don't blame her :rolleyes:
 
RiverpirateEMT said:
Meaning if the person feels fine , they probably are fine
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I'll agree to the reverse of that. It's worrisome when a patient tells me they think they're going to die and have that sense of impending doom. Often, they're very very right.

But even if the body is telling the patient something, the patient might be denial and tell us they're fine. I'm sure everyone has example stories.

As far as syncope being ALS, I imagine that originally became ALS criteria when people screwed up too often. I know I had one where we transported. No other symptoms, dysrhythmias, etc.. told the worried wife, "Don't worry. He's doing great. They'll probably release him in a few hours". While dropping off my next patient, nurses told me he coded/died.

I imagine this issue is a bigger one that's already been discussed a lot in medicine. Over treating / just in case...cost/benefit stuff. Don't know enough to say what the best balance is...
 
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What do YOU bring to the table?

All the stuff you're (OP) talking about is quite valid, but let's face it, you could be a dangerous medic!

Why? Because you're thinking for yourself. Naturally, and by now I hope you get it, school is about ingestion and regurgitation without the benefit of digestion. You're digesting a little too early and you're driving yourself nuts in the process!

The fact that you're 40 does make a significant difference because by now you understand the consequences of overdoing. Your preceptors haven't taken that road yet; please be gentle on them!

But ultimately, I'd like you to look at it this way; you are adding tools to your toolbox that, soon, you will have earned the right to discard or use for other things than were taught you at will.

Soon, it will be (mostly) just you and your patient and, yes, working around the system so you can offer the patient your very best, which will include under some circumstances a good dose of INACTION.

Remember, right now you're positioning yourself so you can provide the most good to the most people. That's the only thing that matters.
 
I just want to say thanks to everyone that has responded to this thread. I lost faith in this site about a year ago and decided I wasnt going to post here anymore. With everything going on I figured Id give it another chance and Im not disappointed.
 
Will you send me five dollars? (KIDDING!!).

I get it, you treat your assessment and don't want to follow protocols blindly.

BTW, my grade point average in nursing college went up when I started shaving my firefighter 1970's mustache.
 
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