To ECG or not to ECG (opinion thread)
- Thread starter TheGodfather
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Generally I support the idea that the most complex patients need to be given the most capable provider. In the prehospital arena, that provider is the paramedic.
I am not suggesting that patients cannot be turfed, only it is best to pick and choose which ones get turfed and I do not agree that the patient initially presented meets that criteria.
It is not so much of a "you never know" mentality, as knowing that the patient has a high likehood of being a trainwreck.
Putting aside psychomotor skills, I think that an ongoing assessment with a higher level provider, not saying the paramedic is the perfect provider, is in order in the chronically ill with nonspecific complaints.
Generally if the patient is admitted, a lot of tests are run. Perhaps not in the ED, but geriatric specialists are quick to point out that this is a prudent practice. A patient with a non specific compliant that cannot be diagnosed in the ED is ccertain to be admitted for this shotgun approach to testing. Particularly if the pt is an unreliable historian or has decreased mental capacity.
What to do in the ED? The easy answer is as little as possible before punting to medicine and letting them figure out things over hours or days.
I think you are getting a bit carried away here.
There is a difference between dedicating a pt to basically ICU level resources and deciding that one of the lowest educated healthcare workers is not sufficent.
While it is not a very popular idea in the US yet, the paramedic is useful for more than acute care and in an aging populous, are more and more going to be called to evaluate not so much who needs emergent healthcare, but who needs healthcare in general.
Advanced assessment also gives appropriate destination decisions.
When you run all of your tests on an ALS ambulance and cannot find anything wrong with a geriatric patient, it doesn't mean nothing is wrong. It means the most common emergencies are not present.
It doesn't mean that this person doesn't need medical care, it means they do not need emergent medical care.
Having said that, the emergency system is the entry portal for the healthcare system in US society. The ability to use knowledge and a more advanced assessment both initially and ongoing allows earlier identification of the need for care and which care passed an ABC assessment.
The reason most elderly patients are admitted is because even the ED does not always possess the diagnostic capability or resources to handle the problems of this patient group. It does not mean they do not need medical care and it does not mean they need an ICU.
I listed dehydration, because it does not often require emergent treatment. But still needs to be treated. I guess I should have been more clear as to why.
The early identification and timely intervention of nonacute healthcare problems is warrented in the geriatric population. Care does not end at the ED but it often begins in the field. As we see more and more people unable to have access to primary care, this population will grow.
A paramedic will not have all the diagnostics or treatments for nonacute healthcare issues. But they will have more knowledge and better critical thinking skills than an ABC assessment.
In the future I also expect to see both treat and release as well as alternate destinations as a standard of US EMS practice just like it is in other nations out of financial necessity.
Unfortunately, my opinion is that the modern geriatric patient population, especially with chronic vs. acute illness, is just too complex of a patient for a basic to do an appropriate assessment on.
I also think that the assessment needs to be more inclusive than just "you are not having a heart attack or stroke, and therefore just need a taxi ride to somebody who can figure this out." But a more indepth and ongoing assessment can be done on the way to the hospital.
When you have the flu, the intervention a doctor performs is rather minimal, if any at all. But it is the assessment that nothing more serious is going on than that.
The same applies for prehospital care. There is a reason certain procedures and assessment decisions have age ranges on them. If you notice, they are usually based around extremes of age.
That does not go away in the hospital. As 1 example, a suspeced if not diagnosed pneumonia patient (regardless of acuity) who is over the age of 65 is going to a floor, or if bad ICU. They are not getting amoxicillin with instructions to come back if things worsen.
Would you put a patient you were certain would get admitted in the back of a taxi that had an AED?
I recently got in trouble for performing [what I feel is] good standard patient care on a patient I had recently. I'll give the scenario(1), my interventions(2), and what my agency's argument against me was (3)
***note: don't get too hung up on the nitty gritty of the patient care/status/etc, that's not the point; I'm going to be really brief***
I work a medic/basic truck.
1) Called to a local assisted living center for a 91yo F - "sick person".
ATF pt lying supine in bed, AOx3. staff states she has been not feeling well since the start of the morning (it was now 1300ish) and they would like her to be checked out. Staff also stated patient has been depressed due to a recent loss of mobility.
Consider complications of loss of mobility including PE and DVT. Also consider unreliable mental and complaint status do to psych issues
CC: "not feeling well" -no chest pain, dib, etc.
skin: NWD
Aatent
B: 16 clear bilaterally, non-labored; spo2 96 RA
C: pulse 94, strong radial.
Is this a normal finding in a 91 year old?
D: PERRL, intact neuro.
E: afebrile
(these are a rough estimate):
BP: 146/84
PR:90-100 Regular
This seems troublesome to me.
RR:16NL
SPO2: 96 RA
BGL: ~110
S: "feels sick"
A: IV contrast
M: too long to list
P: DM, Pacemaker, 2 stents (unknown date), "cardiac", stroke, hyperlipidemia.
L: breakfast x4(ish)hrs PTA (didn't eat much then/recently due to depression)
E: woke up feeling ill
From malnutrition to events precipitated by a serotonin release, this all looks significant to me.
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2) In a nutshell: IV TKO, blood draw for hospital, BGL, 4-lead, 12-lead (to rule out silent cardiac event--- because she is OLD, FEMALE, and DIABETIC) - 12-lead was normal, nothing worth mentioning.
a 12 lead is not the ideal tool to rule out ischemic events outside of the heart
I deemed this patient BLS, handed off to my EMT-B partner, and drove in without incident/change in status.
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3) My boss told me I was incompetent as a paramedic, and also stated that if I had any intuition of patient being in an acute coronary state, why would I ever let the patient be taken BLS. He stated also that "we just don't do that" (referring to doing quick rule-out 12-leads), and if I were to do that, I should take the patient in everytime....
a bit of an over reaction
Last time I checked, BLS caregivers are more than capable of handling calls like that. The practice of performing 12-lead ECGs on the elderly with broad "non-emergent" complaints (IMO) should be done ALWAYS.
BLS are not capable of anyhting more than CPR and an AED. They also lack more advanced and ongoing assessment skills.
After I described the patient state and what I found on my assessment he said, "you should not have performed the 12-lead, and you should have just let the patient be taken in BLS" ----- ok, now, let's say hypothetically this patient has a silent MI... we just delayed ACLS care 20-30 minutes because we didn't perform a 30 second 12-lead...... In his words, it would be ok to lessen my goal of optimum patient care, to meet standards of "what their standards are" --- this is not okay with me....
Ruling out an MI and turfing is not optimal patient care. I highlighted a few things above to demonstrate even with just the basic information here, something is wrong with this patient. Further assessment is warrented.
Opinions? Am I taking this too critical? Let's hear it!
Some things to consider in red
Remeber343
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Vene, Im sorry the emts you work with are only really first responders in your eyes. Our area must be fortunate to have such decent emts that can actually do assessments and such. Maybe if you were to educate them instead of talk down it would change things?
And what exactly do you find disturbing about the patients vitals?
And what exactly do you find disturbing about the patients vitals?
I think you misunderstand me.
It is not the fault of the individual EMTs for the curriculum they are taught and held to. Even the latest update is grossly over simplified, skill based, and taught as unconnected facts to be memorized.
It is not fair to hold people accountable for what they were never exposed to.
The discussion also has to assume the mean level of EMT, not exceptional ones, or ones with other backgrounds.
To "educate" these providers, while many do there best here, you are talking about discussing mutliple topics and how to integrate them over hundreds of hours.
It would just be easier to send them to medic class. Even with its insufficencies, it produces capable providers.
What do I find disturbing about these vitals?
A decreased mobility patient with too many meds to list and with elevated BP, wa pulse that is elevated and nearly tachy, is not right.
Further increases in compensatory mechanisms may be chemically limited, (b-blockers, ace inhibtors, thyroid suppression, etc) which hides an underlying acute pathology or exacerbation of a chronic one.
While there exists the possibility that there is some level of anxiety in the patient causing it, that is a diagniosis of exclusion warrenting a more detailed assessment.
"Assessment is not solving a mystery, it is an interrogation for which there must be a confession."
-Me
Can't speak for Vene, but I've yet to meet an EMT who could present an assessment as anything other than "really sick, needs to go right now", "maybe some really vague (neuro, "heart") issue going on and might need to go" or "stupid and waste of my time". They frequently get the last two mixed up. Very, very rarely can they narrow it down further than a general body system (cholecystitis and not "GI problems"). Come to think of it though, thats a lot of paramedics too...
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As a clinician there are 2 things that can potentially land you in court.I recently got in trouble for performing [what I feel is] good standard patient care on a patient I had recently. I'll give the scenario(1), my interventions(2), and what my agency's argument against me was (3)
***note: don't get too hung up on the nitty gritty of the patient care/status/etc, that's not the point; I'm going to be really brief***
I work a medic/basic truck.
1) Called to a local assisted living center for a 91yo F - "sick person".
ATF pt lying supine in bed, AOx3. staff states she has been not feeling well since the start of the morning (it was now 1300ish) and they would like her to be checked out. Staff also stated patient has been depressed due to a recent loss of mobility.
CC: "not feeling well" -no chest pain, dib, etc.
skin: NWD
A
B: 16 clear bilaterally, non-labored; spo2 96 RA
C: pulse 94, strong radial.
D: PERRL, intact neuro.
E: afebrile
(these are a rough estimate):
BP: 146/84
PR:90-100 Regular
RR:16NL
SPO2: 96 RA
BGL: ~110
S: "feels sick"
A: IV contrast
M: too long to list
P: DM, Pacemaker, 2 stents (unknown date), "cardiac", stroke, hyperlipidemia.
L: breakfast x4(ish)hrs PTA (didn't eat much then/recently due to depression)
E: woke up feeling ill
-----------------------------------------
2) In a nutshell: IV TKO, blood draw for hospital, BGL, 4-lead, 12-lead (to rule out silent cardiac event--- because she is OLD, FEMALE, and DIABETIC) - 12-lead was normal, nothing worth mentioning.
I deemed this patient BLS, handed off to my EMT-B partner, and drove in without incident/change in status.
----------------------------------------
3) My boss told me I was incompetent as a paramedic, and also stated that if I had any intuition of patient being in an acute coronary state, why would I ever let the patient be taken BLS. He stated also that "we just don't do that" (referring to doing quick rule-out 12-leads), and if I were to do that, I should take the patient in everytime....
Last time I checked, BLS caregivers are more than capable of handling calls like that. The practice of performing 12-lead ECGs on the elderly with broad "non-emergent" complaints (IMO) should be done ALWAYS.
After I described the patient state and what I found on my assessment he said, "you should not have performed the 12-lead, and you should have just let the patient be taken in BLS" ----- ok, now, let's say hypothetically this patient has a silent MI... we just delayed ACLS care 20-30 minutes because we didn't perform a 30 second 12-lead...... In his words, it would be ok to lessen my goal of optimum patient care, to meet standards of "what their standards are" --- this is not okay with me....
Opinions? Am I taking this too critical? Let's hear it!
1) Doing something you should not have done...
2) NOT doing something you SHOULD have done.
The former would never relate to doing a 12 lead ECG.
The latter is impossible to defend in court.
You have the equipment and skill to carry out and interpret the ECG. The fact that you CAN do it means that if anyone involved in the care of this patient SHOULD have done it then that person should have been you!
Your agency is treading into murky waters by suggesting otherwise. it may be that they want to justify the end decision and not doing an ecg supports their view of what decision should have been taken. ask them to put their comments in writing... and file away that piece of paper...somewhere safe.
you made a good call.
Sure, I was being more facetious to prove a point that, either you can use some independant thought along with tests, or ONLY base your decisions of what a test tells you.
Which is really my point. I understand your opinion that the more difficult patients should be in the care of the provider who is better equipped to deal with them, in this case a paramedic, but, as you said, there isn't much that will be done right away for this patient; their problem will take time to resolve, and are, at present, relatively stable.
No, I'm not. It's the best analogy I can come up with, and it's really not to bad. I'm not saying that the RN would need to do anything more for that patient other than sit and talk and perhaps come up with a better history, which is what the paramedic would be doing on the way in, just that, by your reasoning it would appear that you should want an RN with them. After the patient has been appropriately assessed (just pretend that this would be done prehospital as well) you have two choices: letting a low level provider sit with the patient while having a higher level provider available in a timely manner, or have the higher level provider be with them constantly ; that's before you arrive at the ER. After you arrive, after the patient has been assessed, you have the choice of either having nobody sit with the patient (I suppose you could stick a CNA with them) and a higher provider available in a timely manner, or having a higher level provider, in this case a RN, constantly with the patient. While not the perfect comparison, it is valid.
The paramedic COULD be useful for more than acute care (many allready are, but I mean nationally), but at present aren't. Yes, things should head in that direction but currently haven't. It doesn't change the situation at hand though; while this lady needed to be evaluated and treated by a MD (or PA/NP even though you dislike them, or a paramedic with the ability and education to prescribe and refer etc etc) this was not someone who medically needed constant supervision by the highest available medical personell.
Absolutely, just because I can't figure out what, if anything is wrong with someone doesn't mean that there isn't something wrong. But, that failure to reach a diagnosis does not mean that every patient that happens to needs me, or another paramedic riding with them. Some will do just fine with an EMT. Some won't. It depends on a lot of things.
As you said though; they don't need emergent care. And possible, depending on the patient, they don't need any care I can provide them beyond a ride to someone who can. Though there are many more factors that come into play that I'm not listing, but when that is the situation...
They will. As I said, I'm all for taking someone in who I won't be doing anything for if what I've found in my history/exam will potentially speed up there care once it get's reported. As presented, I don't see this as being the case. There are things that are concerning, but even an EMT can be told to be sure to pass these on, and in this case the paramedic would still be right there if it didn't happen. Remember, this isn't like immedietly turfing the patient, but only doing so after a thourogh assessment, and relaying that to the EMT.
Again, I don't really disagree. I'd like to see the US move in that direction, both by upping the education required and then increasing the responsibility and accountability of the providers. And, while an EMT isn't completely capable of assessing all patients, they aren't needed to in this situation; a paramedic has allready assessed the patient. The EMT should still do there own, but a (hopefully) better eval has been done with the results reported and/or written down for the EMT to pass on to the recieving facility. And yes, this should be a better assessment than "no stroke no heart attack." If it takes a couple minutes longer...so what?
I suppose I could come up with a situation where I would do that that, but really, no they'd go in by ambulance. I don't think that admission to the hospital can be the decider for who will take a patient though. You said it above, people will get admitted for many reasons, valid and appropriate, and sometimes not. And again, because someone is admitted does not mean that they need immediate or even quick treatement, just continual care that is not available outside a hospital.
I think this is just going around in circles at this point. What I know/have seen/done colors my side, and the same will apply to you. I understand your feeling about why a patient like this should be handled by a paramedic, and in many situations it probably is the correct one, for many lousy reasons. I just don't agree, for many lousy reasons.