Two Questions:

[Amelia]

Ok, these questions are completely unrelated, but I didn't want to double post (or make Chimpie grumpy- he he)

Question 1:

So I'm finishing up EMT school (yay!) and on Sat I did an ED 12 hour shift (which turned out very interesting, to say the very least). And one of the pts was a middle age women with stress syncope after her sister had passed (apparently sister was in hospice and they were very sleep deprived) and when sister passed, the pt passes out completely, altered mental status for many hours, decreased strength on left side (which I mentioned to the nurse I was following because they never caught it, thankfully it turned out to be nothing). Now, she was in the ED for 4-5 hours while she's complaining of incredible chest pain and saying she had trouble breathing, etc. They never put O2 on her which confused me. Her stats were all normal and good, but in EMT school they said that if they complain of dyspnea, has an altered mental status, and/or chest pain, throw a NRM on them. Is this just the different care between EMTs SOP and EDs?

Second question: We're learning about field reports and radio reports. I talked to my Instructor about if a certain diagnosis that I personally had would be taught in class which I thought was important (pre-eclampsia and post partum pre-eclampsia) but she said that there was no possible way they could teach every complication, fair enough. But I got to wondering, since I've "been there done that" If I were to get a woman in her later stages of pregnancy or recently had a baby (within 6 weeks) and she's complaining of a "weird" headache, and has pedal edema, and her BP is through the roof (mine was 218/110 my 2nd time around which was absolutely fantastic) can we give our field report as "Suspected Pre-E or Post Pre-E" even if it wasn't technically taught to us in class? I'm assuming we can since we say "suspected" and it would help prepare the ED for the patient? That was just an example. Saturday, I evaluated the most -adorable- 7 month old baby with croup and I knew it was croup, and I knew it was viral, and I knew if the baby was as smiley and giggly and as adorable as he was, he was fine- I didn't say anything because it wasn't my place to obviously. But in the back of the rig, would you treat and talk to the pts parents that you suspect its coup? Where do you draw the line?

 

[luke_31]

1: oxygen doesn't need to be given if sats are normal in the ED. As an EMT you should never withhold oxygen from a patient who has those complaints.

2: for your report I would just list the signs and symptoms and not say a suspected diagnosis. I would hesitate to tell patients or parents what you think is the diagnosis, it's better to let the doctor say what they think it is. If you are wrong on the diagnosis it can cause problems at the hospital after you leave if the family believes you and not them. As a experienced paramedic I do treat based off signs and symptoms that would lead me to a suspected diagnosis, but I keep a very open mind to possibly being wrong and letting the family know that I'm treating the patient based off the signs and symptoms. If pressed to tell them what is wrong I will tell them that the hospital and doctor will have more tools and experience to find the diagnosis, and that I am treating based on it possibly being what I think it might be but I make it very clear that it's not a definitive diagnosis and if I wrong the patient is still being treated appropriately for the situation and they are being well taken care of.

 

[COmedic17]

1. ED's can pretty much do what they want (since it's a doctors orders). If the doctor doesn't think O2 is necessary, then they don't need to implement it.


2. Your not a doctor. You can't diagnose people. You can tell them the signs and symptoms, and they will understand what you are getting at. That's why you call cardiac "alerts" and stroke "alerts". You can alert the hospital to a POSSIBLE life threatening condition, but you can't diagnose it. A way to portray a patient with probable pre-eclampsia -without diagnosing it- would be something like " Main hospital, Medic 1 *go ahead medic 1* we are enroute with a 26yo female whom is 32 weeks pregnant. Pt is complaining of a headache, has a blood pressure of 180/100, pulse of 115, pitting edema in lower extremities, but denies any seizure like activity at this time. Patient denied any past history of hypertension. Patient is on 4lpm of oxygen, on cardiac monitor, and has 2 bilateral IVs. Patient is also negative on stroke scale and a BG level of 106. ETA 5 minutes. Any questions"?

 

[Amelia]

1: oxygen doesn't need to be given if sats are normal in the ED. As an EMT you should never withhold oxygen from a patient who has those complaints.

2: for your report I would just list the signs and symptoms and not say a suspected diagnosis. I would hesitate to tell patients or parents what you think is the diagnosis, it's better to let the doctor say what they think it is. If you are wrong on the diagnosis it can cause problems at the hospital after you leave if the family believes you and not them. As a experienced paramedic I do treat based off signs and symptoms that would lead me to a suspected diagnosis, but I keep a very open mind to possibly being wrong and letting the family know that I'm treating the patient based off the signs and symptoms. If pressed to tell them what is wrong I will tell them that the hospital and doctor will have more tools and experience to find the diagnosis, and that I am treating based on it possibly being what I think it might be but I make it very clear that it's not a definitive diagnosis and if I wrong the patient is still being treated appropriately for the situation and they are being well taken care of.

You answer completely makes sense. We're just being taught to learn to do field impressions, is why I ask. I'm not sure if they're required by SD. Perhaps sometimes its more important to not do part of the assessment/reports then?

 

[Amelia]

1. ED's can pretty much do what they want (since it's a doctors orders). If the doctor doesn't think O2 is necessary, then they don't need to implement it.


2. Your not a doctor. You can't diagnose people. You can tell them the signs and symptoms, and they will understand what you are getting at. That's why you call cardiac "alerts" and stroke "alerts". You can alert the hospital to a POSSIBLE life threatening condition, but you can't diagnose it. A way to portray a patient with probable pre-eclampsia -without diagnosing it- would be something like " Main hospital, Medic 1 *go ahead medic 1* we are enroute with a 26yo female whom is 32 weeks pregnant. Pt is complaining of a headache, has a blood pressure of 180/100, pulse of 115, pitting edema in lower extremities, but denies any seizure like activity at this time. Patient denied any past history of hypertension. Patient is on 4lpm of oxygen, on cardiac monitor, and has 2 bilateral IVs. Patient is also negative on stroke scale and a BG level of 106. ETA 5 minutes. Any questions"?

Yeah, we're not to "diagnose" but our lessons include a field impression "suspected MI" or whatever. That's why I asked. Last thing you'd want to do is panic a preggo!!

 

[luke_31]

Easiest thing as a new EMT is to be reassuring to the patient and their family and relay that you are treating them appropriately and that the hospital will help even further.

 

[COmedic17]

Your field diagnosis is for reporting reasons only. But don't lie to your patient. I would just say " I'm a little concerned with your blood pressure since you have no history of hypertension. How about we get it checked out at the hospital just to make sure everything's ok?"
I, however, would not say " I think you might have pre-eclampsia". Or " all your symptoms say you have pre-eclampsia".

 

[chaz90]

I think you can absolutely talk to some patients about what their problem seems to be. In your original post you mentioned a 7 month old with croup. In that case, I think it would be quite fair to explain to the parents what you believe the issue is, how you're going to treat their child, how you know the child is fairly stable and in no immediate danger, and that there are still other potential differential diagnoses that the hospital/ED staff will be investigating and treating. I do this kind of stuff all the time.

To an obvious stroke patient and their family: "Sir/Ma'am, you're going to hear me call the hospital and use the term "stroke alert." I know this is scary and you've never had a stroke before, but it looks like you're likely having one right now. Fortunately, you called for help early after your onset of symptoms and we and the hospital are going to do everything we can to help you."

I do almost the same thing for STEMI alerts, but with even more emphasis on the "you appear to be having a heart attack; we are going to take good care of you; survival rates for this condition with modern medicine are absolutely remarkable."

We do diagnose! Our diagnoses may not be as precise as the discharge diagnosis or as accurate in some cases, but every treatment plan we work on involves a diagnosis on some level. Some may be terribly vague, IE "AMS; unknown etiology with hypoglycemia ruled out and OD deemed unlikely," but these are still working diagnoses that allow us to treat and proceed. In some cases, our field impressions absolutely are the diagnosis and we know this with nearly 100% certainty before arriving at the ED. The challenge lies in remaining open to changing your mind as the patient's presentation changes and recognizing our potential for inaccuracy.

 

[Amelia]

I think you can absolutely talk to some patients about what their problem seems to be. In your original post you mentioned a 7 month old with croup. In that case, I think it would be quite fair to explain to the parents what you believe the issue is, how you're going to treat their child, how you know the child is fairly stable and in no immediate danger, and that there are still other potential differential diagnoses that the hospital/ED staff will be investigating and treating. I do this kind of stuff all the time.

To an obvious stroke patient and their family: "Sir/Ma'am, you're going to hear me call the hospital and use the term "stroke alert." I know this is scary and you've never had a stroke before, but it looks like you're likely having one right now. Fortunately, you called for help early after your onset of symptoms and we and the hospital are going to do everything we can to help you."

I do almost the same thing for STEMI alerts, but with even more emphasis on the "you appear to be having a heart attack; we are going to take good care of you; survival rates for this condition with modern medicine are absolutely remarkable."

We do diagnose! Our diagnoses may not be as precise as the discharge diagnosis or as accurate in some cases, but every treatment plan we work on involves a diagnosis on some level. Some may be terribly vague, IE "AMS; unknown etiology with hypoglycemia ruled out and OD deemed unlikely," but these are still working diagnoses that allow us to treat and proceed. In some cases, our field impressions absolutely are the diagnosis and we know this with nearly 100% certainty before arriving at the ED. The challenge lies in remaining open to changing your mind as the patient's presentation changes and recognizing our potential for inaccuracy.

I did take into account that they'd be grabbing me by the collar, shaking me and scraming "what's wrong with me?!?!" he he. But I'm sure we'll be asked that in a less-dramatic way. But if I see a pregnant woman (for example) and she has pitting edema and high bp and she has a headache and we're screaming down I-29 and she asks, I don't think I could lie and say that I didn't know. We're always taught to be honest. But if they'd ask, I would be pretty vague and let them know that the drs would know what is going on and how to treat it. However, it would be hard for me not to say, "IF it is pre-e, I've had it twice, the docs took care of me so that I can come help you now." Or something of the like. Its all about the patient, right? (no sarcasm, I promise.)

And that ^ is me hyped up on way too much caffeine after class- talking about... OB/GYN. he he

 

[STXmedic]

I think you can absolutely talk to some patients about what their problem seems to be. In your original post you mentioned a 7 month old with croup. In that case, I think it would be quite fair to explain to the parents what you believe the issue is, how you're going to treat their child, how you know the child is fairly stable and in no immediate danger, and that there are still other potential differential diagnoses that the hospital/ED staff will be investigating and treating. I do this kind of stuff all the time.

To an obvious stroke patient and their family: "Sir/Ma'am, you're going to hear me call the hospital and use the term "stroke alert." I know this is scary and you've never had a stroke before, but it looks like you're likely having one right now. Fortunately, you called for help early after your onset of symptoms and we and the hospital are going to do everything we can to help you."

I do almost the same thing for STEMI alerts, but with even more emphasis on the "you appear to be having a heart attack; we are going to take good care of you; survival rates for this condition with modern medicine are absolutely remarkable."

We do diagnose! Our diagnoses may not be as precise as the discharge diagnosis or as accurate in some cases, but every treatment plan we work on involves a diagnosis on some level. Some may be terribly vague, IE "AMS; unknown etiology with hypoglycemia ruled out and OD deemed unlikely," but these are still working diagnoses that allow us to treat and proceed. In some cases, our field impressions absolutely are the diagnosis and we know this with nearly 100% certainty before arriving at the ED. The challenge lies in remaining open to changing your mind as the patient's presentation changes and recognizing our potential for inaccuracy.

Quoted for emphasis.

 

[Amelia]

With the croup all I said was "Oh there it is! I know that caugh." When he coughed. Other than that I said that he was adorable, and giggly and a pretty happy little guy. Geeze, this kid was adorable.

I was asked by one pt who was in for an asthma attack (older gentlemen, smoker) how he was supposed to exercise like his Dr wanted if he had this pinched nerve in his leg (sciatica, I'm assuming) without aggravating his asthma. Doc suggested walking but he said he didnt like that and that it made him too short of breath (hmmm, maybe quit smoking then??). I mean he was really asking me! I told him to ask his Doctor if yoga may be appropriate? I told him that if the Dr says its ok, gentle yoga may not aggravate his asthma and is good exercise." Heavy on the "IF YOUR DR SAYS ITS OK." I said that probably 4-5 times in the 3 minute conversation he asked.

I hope that wasn't out of line.

 

[Amelia]

So honest but vague, and let the Drs take all of the heat.

 

[Handsome Robb]

I tell patients what my working diagnosis or diagnoses is/are all the time. Like others have said it's always "because of this this and this I'm thinking this. But it could be this this this or this. Without further tests we can't be sure until the doctor sees you."

As far as withholding oxygen if you have a patient with chest pain and shortness of breath and is tachypneic but also has a history of anxiety, carpal pedal spasms and a normal SpO2 putting oxygen on them isn't going to help and potentially could draw out the episode creating a longer period of discomfort for the patient since they don't need oxygen, they need to slow their RR down and retain more CO2.

Nothing says you have to put a NRB on patients with a complaint of chest pain and/or shortness of breath and frankly you can cause them hard of you do. Hyperoxygenation is bad for patients.

 

[chaz90]

I did take into account that they'd be grabbing me by the collar, shaking me and scraming "what's wrong with me?!?!" he he. But I'm sure we'll be asked that in a less-dramatic way. But if I see a pregnant woman (for example) and she has pitting edema and high bp and she has a headache and we're screaming down I-29 and she asks, I don't think I could lie and say that I didn't know. We're always taught to be honest. But if they'd ask, I would be pretty vague and let them know that the drs would know what is going on and how to treat it. However, it would be hard for me not to say, "IF it is pre-e, I've had it twice, the docs took care of me so that I can come help you now." Or something of the like. Its all about the patient, right? (no sarcasm, I promise.)

And that ^ is me hyped up on way too much caffeine after class- talking about... OB/GYN. he he

Deliberate obfuscation is rarely necessary. If a patient asks me what I think is wrong with them, I answer truthfully. As an important caveat, that means I sometimes admit to them that I have no idea but am proceeding as if it could be X, Y, or Z. I often attach modifiers like "this looks like" or "it seems", but I'm always honest.

I think what you've mentioned sounds perfectly appropriate. Explain what it seems to be, that you could be mistaken, and that either way you and the people at the next step of care are going to help out as much as possible. People react well to honesty and don't like having their questions dodged. I think any instructor trying to tell you differently is doing his students a disservice or not getting his point across effectively.

 

[Amelia]

I tell patients what my working diagnosis or diagnoses is/are all the time. Like others have said it's always "because of this this and this I'm thinking this. But it could be this this this or this. Without further tests we can't be sure until the doctor sees you."

As far as withholding oxygen if you have a patient with chest pain and shortness of breath and is tachypneic but also has a history of anxiety, carpal pedal spasms and a normal SpO2 putting oxygen on them isn't going to help and potentially could draw out the episode creating a longer period of discomfort for the patient since they don't need oxygen, they need to slow their RR down and retain more CO2.

Nothing says you have to put a NRB on patients with a complaint of chest pain and/or shortness of breath and frankly you can cause them hard of you do. Hyperoxygenation is bad for patients.

My feeling on this was (and is as an inexperienced student at this point of time), couldnt you put the NRM on with a low flow of O2? I know you can control the concentration, but it may help the pt feel better and calm her down a bit? Or even just a nasal cannula? I'm thinking more of a placebo "here's some oxygen so you know you're getting oxygen into your body" reassurance.

 

[Flying]

My feeling on this was (and is as an inexperienced student at this point of time), couldnt you put the NRM on with a low flow of O2? I know you can control the concentration, but it may help the pt feel better and calm her down a bit? Or even just a nasal cannula? I'm thinking more of a placebo "here's some oxygen so you know you're getting oxygen into your body" reassurance.

In a person who is perfusing well but you deem it appropriate to try calming them with oxygen, try titrating from 0 L/min.
Start with a nasal cannula at no flow and increase the flow in small increments. You might be surprised at how many people get better around 0-2 L/min.

 

[Amelia]

Plus, when I was in the back of a truck as a patient, they threw a nasal cannula on me first thing and I didn't have any dyspnea. I have no clue what my O2 stats were, but still... a lady is gasping and writhing in pain.... I'd want to do a little something. Infant concentration or something. But that's me. Make her feel better and her anxiety may come down and maybe then she'd regain some mental stability since it was all stress related.

 

[Amelia]

In a person who is perfusing well but you deem it appropriate to try calming them with oxygen, try titrating from 0 L/min.
Start with a nasal cannula at no flow and increase the flow in small increments. You might be surprised at how many people get better around 0-2 L/min.

That's exactly what I was thinking. But this job is all about treating the patient as a hole, your gut, and adaptation to help the person. Hell, I'd maybe even just throw the NRM on her w/o oxygen and see if that calms her down a bit, since its all in her head anyway and her body reacting to how her head is not dealing with this news well.

 

[Amelia]

But you guys are very right- and the last thing I'd want to do is cause her to hyperoxygenate- very very valid point. I'm starting to get all of this pieced out thanks to you guys. Lots of stuff to consider that I haven't thought of.

 

[Flying]

For this specific purpose, I would make a point on choosing a NC over a mask because the person is more likely to feel the flow of air at lower pressures, contributing to any placebo effect.

I find it fantastic that you are more in tune with the needs of the people who we transport than those who have been in EMS for x years. People will thank you for providing something tangible in terms of their treatment. (Some may appreciate our good buddy Fentanyl more, but that's another story.)