Stressed guys messdd up on some calls.

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chickj0434

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Firefighter/emt and working on ambulance.

Ems director just talked to me and my partner about some complaints they had.

First call showed up guy had his bag packed and met us inside the ambulance. Said he had abdominal pain x3 days. Transport was 3 min. Didn't get a BP. Guess his BP was super high and the hospital said he later had stroke .

Second was a covid pneumonia call. Had to wear those suits. Speaking in complete sentences with cough. Said he feels a little bit out of breath. Sat monitor wasn't working so we put him on 4 lpm nasal said he feels better now. Again tried to get a BP best I could but with those suits can't put the scope in my ear.

Hospital called and said his BP was tanking and complained to our director.

So just feeling really discouraged right now. I like to think I do good work in the field but definitely messed up on these two.

Just needed to share
 
My suggestion, always get at least one full set of vitals ( my area requires two). Even if means waiting a second to unload patient at ER. And if you can’t hear ( which for me is an issue with the manual cuffs) you can always get a palpated BP.
if unable to at all, document document document and make sure to tell ER you were unable to for x,y,z.
 
One set of vital is interesting. Two send of vitals are a comparison. Three sets give you trends.

Not getting vitals is inexcusable. If you’re looking for someone to absolve your guilt, keep looking. Do better.
 
Always document at least two accurate sets of VS. It's okay to take a few seconds to get them... think of what taking a few extra minutes to get them could have meant for you or perhaps your patients.
 
Of all of the ways to mess up in EMS, it could have been far worse!

Make sure you get a couple sets of vitals, that was a non-negotiable when I actively worked in EMS. As @Jn1232th suggested, you can always palpate a blood pressure if you need to.

I found sometimes I messed up on the most mundane parts of working in EMS. Making sure I had all of my equipment before leaving calls, disconnecting patients from O2 before taking them out of the rig, etc. On of my ALS colleagues told me to slow down and be more methodical about my processes.

You're going to make mistakes, that's part of working in any career. Learn, grow, and move on.
 
MMiz said:
Of all of the ways to mess up in EMS, it could have been far worse!

Make sure you get a couple sets of vitals, that was a non-negotiable when I actively worked in EMS. As @Jn1232th suggested, you can always palpate a blood pressure if you need to.

I found sometimes I messed up on the most mundane parts of working in EMS. Making sure I had all of my equipment before leaving calls, disconnecting patients from O2 before taking them out of the rig, etc. On of my ALS colleagues told me to slow down and be more methodical about my processes.

You're going to make mistakes, that's part of working in any career. Learn, grow, and move on.
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Thank you. Definitely going to make sure it doesn't happen again. Going to slow down and bit and grab a set from now on.
 
Not getting a BP isn’t the end of the world. There are many ways to document perfusion status beyond a BP. Heads up, if you ever get an LVAD patient there is a really good chance you won’t be able to get a BP in the field.

I don’t reduce my ED triage based on the lack of an EMS vital sign. Almost all of my ambulance patients arrive without a temp. I don’t hold a fever against our medics. Likewise we get a lot of patients who have a one or two minute transport time and don’t get a full set of vitals, I’d rather have that crew available for calls than delay transport for a BP when they are otherwise well perfused.

It is important to document limitations in your report. I’ve given a lot of meds and interventions without a BP, pulse ox, or other vitals when the clinical benefit far outweighs the most risk. We do not have unlimited resources in the field or in the back of the bus. It often takes us 10 or 15 minutes (if not longer) to get an accurate temp or BP in the ED.

I did get a complaint once from the transporting agency (way up in the sticks) for not getting a BP before giving fluids or zofran to a patient who had a negative history, weak threads pulses, nausea, and delayed cap refill. The patient had clinical improvement during my care while we awaited transport, and our manual cuff had been left on a code patient (we didn’t realize this and were dispatched before we got back to the station, and our monitor malfunctioned and wouldn’t take a BP). I documented my clinical reasoning in my note, but sure enough the transporting agency complained. Our medical director couldn’t have cared less, and dismissed the complaint.
 
NomadicMedic said:
One set of vital is interesting. Two send of vitals are a comparison. Three sets give you trends.

Not getting vitals is inexcusable. If you’re looking for someone to absolve your guilt, keep looking. Do better.
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there are instances when you’re unable to get vitals, so to say it’s inexcusable to a bit far fetched.
 
One thing you said which caught my eye and you attempted to justify one of your failures is "the hospital is 3 minutes away".

Ok, so the guy met you outside with a positive Samosonite sign (I get it, this happens). However, them ambulating to your truck and the hospital being minutes away is no excuse to not assess. Yes, it is frustrating cause the call is BS, yes he could have walked there faster than it took for you to get there, yes this is a waste of your time and generated another report....we all understand that.

In the same breath, you are new and need a lot of experience and the only way to get that is to practice. So the guy climbs in your truck...depending on your department policy you can have anywhere from 10 minutes to as long as you need to sit right there and not spin a wheel. Take that time and do an assessment. What if you found a condition which the hospital 3 minutes away was not best destination for? Instead the patient now needs the hospital 10 minutes away, or greater. Set a 10 minute clock for yourself, do systems assessment, take vitals, listen to lung sounds. Do whatever you can in a reasonable time and then transport the patient.

Keep in mind, and I have said this before....just because YOUR clock stops in 3 minutes, that is NOT the end of the clock for the patient. Depending on how busy that facility is, once you unload the pt and give a quick verbal report, that patient could very easily have 15 minute, one hour, or even longer wait times before seeing a provider. Yeh that sounds crazy, but it can and does happen. So when you transport a patient and think to yourself the facility is only 3 minutes away, factor in your unloading/handover time, then also throw in an extra 15-30 minutes before the patient sees a provider, and then ask yourself...should I have done an on scene assessment or did I do the right thing by driving three minutes and dumping?
 
To the OP, in addition to the advice you've already gotten, maybe begin your assessment by noting the pulse "character" -- i.e., fast or slow, weak or strong, regular or irregular. It's not a replacement for documenting full sets of vitals, but it'll help you form an early impression without equipment. You can use a similar approach for respirations and mental status, and usually evaluate all three simultaneously during the first 30 seconds of patient contact.
 
If you are on an ambulance you typically have two trained providers. When you make patient contact (whether that's after traipsing through an apt building or SNF, or they met you on the curb with their luggage) is that while one person (usually the attendant) starts talking to the patient, you know A&O level, Chief Complaint, basic SAMPLE/OPQRST, the other guy/gal is getting the first set of vitals at that time.

So now you have your first set of vitals all before you ever turn a wheel (even if the patient met you outside). If by the time you finished you're initial assessment on scene, loaded the patient up on the gurney, wheeled them to the ambulance, go ahead and get that second set of vitals inside before driving off.

We've all heard "Critical patients reasses vitals ever 5 min, Stable every 15". Thats the max recommended intervals, if the hospital is 10 min drive, there's absolutely nothing wrong with taking another set of vitals on your nice stable patient at the 5 minute mark.

If your "Met you at the curb and climbed into the back of the ambulance as soon as you pull up patient" is only a couple minutes away from thr hospital (wouldn't be the first time I've picked someone up while we're within sight of the ER entrance....) you do that "Assessment and Vitals before leaving the scene", then 2 or 3 minutes later parking at the ER, take a second set before you actually pull the gurney out/walk the patient out.

And voila, 2 sets of vitals on a 2 min transport
 
First call showed up guy had his bag packed and met us inside the ambulance. Said he had abdominal pain x3 days. Transport was 3 min. Didn't get a BP. Guess his BP was super high and the hospital said he later had stroke .
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Generally speaking, distance to the hospital is not a good way to decide what treatments or assessments to do or not do. There are, of course, exceptions. However, take a few minutes on scene to actually assess your patient. You'll be surprised by what you might catch.

Second was a covid pneumonia call. Had to wear those suits. Speaking in complete sentences with cough. Said he feels a little bit out of breath. Sat monitor wasn't working so we put him on 4 lpm nasal said he feels better now. Again tried to get a BP best I could but with those suits can't put the scope in my ear.

Hospital called and said his BP was tanking and complained to our director.
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Sometimes patients get sicker after we drop them off. Sometimes they just crash out of the blue. I would learn to take a palpated BP for when you run into this again in the future.

So just feeling really discouraged right now. I like to think I do good work in the field but definitely messed up on these two.
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We all make mistakes, it's called the practice of medicine for a reason. Learn from these and move on.
 
Always wait a minute (or 5) at the scene: either in the ambulance or in the room and get a set of vital signs before you start transporting.

I was working with an experienced EMT-B, but he was in a hurry and "it is my patient so we will do what I say" so we left a hospital floor, and started transporting and he did the 1st set of VS. Then he asked me if he could put the patient on the monitor because the HR wasn't making sense to him. I told him yes, and pulled off of the freeway at the exit and stopped, and got into the back of the ambulance as my partner handed me the strip. 60 year male on the way to Rehab from a week in the hospital after a stroke was in SVT with a HR of 266. Nurse on the floor didn't believe the VS machine so told us made up vital signs. 16 years later that EMT-B still gets a good set of vitals before he starts transporting.
 
Here is my honest opinion on your two scenarios.

  1. It appears to be that the patient was ambulatory and in no obvious distress. You can easily see your primary assessment. Vital signs IS a secondary assessment. There is a lot to get done in three minutes, so I can understand the need to not. Additionally, had you found that he was hypertensive, it would not have changed your plan of treatment, as a BLS provider or an ALS Provider. There just isn't time. Your actions did not cause him to have a stroke and nothing you would have done would have prevented it.... With that being said. I would have still gotten one set, just as a reference point to the ED staff. For me, many times times we obtain them at the ED Entrance as part of triage.
  2. Unfortunately COVID has complicated everything. It is hard to do a manual blood pressure with full gowns/suits and a face shield. If you truly can not get a manual by auscultation, try by palpation. At least it gives you some idea of where thier BP is.
 
I must agree with @ZombieEMT; while skipping vitals was bad, you didn't cause the stroke.

I'll also be honest, and say that I have done the exact same thing. person called 911 from the train station, after take a 45 minute train from another city (might have been and pain, I don't remember). train station was 2 blocks from the ER (we can see the hospital from the train station), so we walked the patient to the truck, and left her in triage. the next shift, the ER attending pulls me aside, and tells me our BS patient was admitted to the ICU for something (hyperkalemia or some other weird labs). Were we wrong and lazy? yep. should we have taken vitals, and performed a better assessment? definitely. would it have changed anything with the patient's condition? nope. But it was still a failure on our part, because we didn't do what was expected of us.

I'm also not a fan of staying on scene to do prehospital stuff; the vast majority of what we do won't fix the patient's issues. So if we spend 10 minutes on scene, when the hospital is 2 minutes away, are what we are doing actually in the patient's best interest? If you are initiating ALS interventions that can fix the issue, that's a different story. But that's just my opinion.

Live and learn, don't make the same mistakes, and do what the best you can do in the patient's best interest
 
DrParasite said:
I'm also not a fan of staying on scene to do prehospital stuff; the vast majority of what we do won't fix the patient's issues. So if we spend 10 minutes on scene, when the hospital is 2 minutes away, are what we are doing actually in the patient's best interest? If you are initiating ALS interventions that can fix the issue, that's a different story. But that's just my opinion.
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This is where you and I disagree regarding this topic. By NOT assessing (which includes vitals), you absolutely have NOT done what very well may be in the patient's best interest. Regardless of performing any interventions, an assessment should be done. Why? Because you might find something with the vitals, you might find something with their presentation, or their responses to questions that would otherwise be missed when you act solely as a taxi all because you can see the ER a block away.

This is what I teach my students and new hires. Stop thinking YOUR job ended when you hit the ER door. Your job is to ensure the patient has continuity of care, and rapid identification of any concerns to the ER staff. If you walk the patient in and give the casual, wink wink, "all is good cause this person just rode a train 45 mins to get here and stopped a block away", you are conveying to the receiving team that everything is fine. Yes, they need to do their assessments too. But what about when that ER nurse is slammed and cannot get to that patient you brought in for 10-15 minutes or longer? It happens, a lot, especially in larger, busier systems.

So by doing a complete assessment, at least you have ruled out or did not identify any immediate major threats which means at THAT point in time, you have now done what is best for the patient. Anything less is an excuse or failure on your part as a clinician.
 
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Try not to feel too bad. As one of my mentors once said: "You are allowed to feel bad about something only until the end of the day, but before you go to bed, forgive yourself and make a commitment to do better on the next call." I've always lived by this maxim and it has helped me grow. Experience comes from making mistakes and anybody in EMS who has any meaningful time in service has made mistakes. Anyone who claims to have not made mistakes is either 1. Not paying attention 2. Hasn't been caught. 3. Doesn't have much time in service or 4. lying.

I've been in EMS for 20 years and one of the issues I've seen over and over again which results in poor clinical decision making is the lack of standards and process. 3 minutes away is very close but before you head to the closest hospital, best to assure that you are taking the patient to the right hospital. This requires a good history, assessment and at least 1 full set of vital signs - all patient's deserve that if you can, but sometimes you never get passed A(airway).

One other thing: EMS providers put a lot of energy into downplaying patient complaints instead of carefully evaluating the complaint. When I was a young medic I often thought people called 911 because they were lonely, wanted a ride, wanted attention, or I figured the universe was set out to inconvenience me. The longer I did the job the more I learned and realized, most patients call 911 for a reason, but only some of them are good at articulating that reason.
 
akflightmedic said:
This is where you and I disagree regarding this topic. By NOT assessing (which includes vitals), you absolutely have NOT done what very well may be in the patient's best interest. Regardless of performing any interventions, an assessment should be done. Why? Because you might find something with the vitals, you might find something with their presentation, or their responses to questions that would otherwise be missed when you act solely as a taxi all because you can see the ER a block away.

This is what I teach my students and new hires. Stop thinking YOUR job ended when you hit the ER door. Your job is to ensure the patient has continuity of care, and rapid identification of any concerns to the ER staff. If you walk the patient in and give the casual, wink wink, "all is good cause this person just rode a train 45 mins to get here and stopped a block away", you are conveying to the receiving team that everything is fine. Yes, they need to do their assessments too. But what about when that ER nurse is slammed and cannot get to that patient you brought in for 10-15 minutes or longer? It happens, a lot, especially in larger, busier systems.

So by doing a complete assessment, at least you have ruled out or did not identify any immediate major threats which means at THAT point in time, you have now done what is best for the patient. Anything less is an excuse or failure on your part as a clinician.
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I think there was confusion on what I posted, that goes hand in hand with what DrParasite said. My suggestion isn't to do nothing. While assessing vital signs is part of an assessment, it is not the only part of assessment. I grab radial on every single patient, regardless of length of transport or complaint. This alone tells me so many things. Heart rates/regularity/quality. Skin temperature and condition. That there is a blood pressure above 80. I am also in those two minutes asking questions that assessed mental status and forming a general impression. I can also assess in this time the respiratory effort. So of the basic vital signs, what have I not assessed, maybe a BP?

I agree that our job is more than A to B. We should consider what our actions have on the longer term for the patient. On a patient that appears stable on initial impression and has a two minute transport, there is not a benefit to waiting around to getting a detailed assessment prior to transporting. Maybe this is different as a BLS provider, than an ALS provider. However, if I assessed the patient's blood pressure and its 200/100, as a BLS provider what am I doing for that? I don't carry medication or treatment that can lower that. My best plan of action for that is rapid transport. And that patient's blood pressure would have still be 200/100 regardless of whether or not I wasted time to assess it.

Normally, if I had a transport time this short, I would assess vitals upon arrival at the triage station. Almost all my local hospitals have a vital signs machine available as soon as we walk in. A this point if our transport was only 2-4 minutes, assessment of the patient is still occurring within the first 10 and maybe even the first 5.
 
I guess I cannot argue with someone who does not know what they do not know. I already clearly explained reasons outside of possible treatments on why you should complete your own assessment. However, if you and others wish to continue to find justifications for doing otherwise, justifications for doing less than as providers in the field, then carry on. Just know that arguing for better pay, better scope, more respect...is simply a dream when these practices and mindsets continue.

Imagine a nurse saying "well the doctor is just a few feet away, and they will assess the patient quickly, and they are usually in the room within 2-3 minutes, so I will just hold off on my assessment cause I really cannot do anything anyways and nothing is going to change that patient's condition".

And go read this if you are going to rely on a radial pulse determining a BP to be "at least 80", which somehow does not seem all that concerning to you. And no mention of the patient's MAP in your assessment.

www.ncbi.nlm.nih.gov

Accuracy of the advanced trauma life support guidelines for predicting systolic blood pressure using carotid, femoral, and radial pulses: observational study

www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
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