Was I wrong?

[broken stretcher]

So I work with Dual trucks (1 ALS, 1 BLS provider)... we go on a call for a 31 male chest pain, clammy. Pt presents seated in a wheelchair outside the motel smoking a cigarette with his girlfriend. C/O chest pain, for a month, extremely worse today. Girlfriend states he had 2 grand mal seizures 3 and 7 hours prior to EMS arrival. Pt claims he was dx with CHF 3 days ago (not on any diuretics or anything for CHF)... also wants to by pass the nearest facility because the doc at the closer facility wouldn't fill his methadone script and he's having with drawls... basically we all know he's FOS... but that being said he's a good actor... holds his breath to decrease his sats, all sweaty and c/o this "severe chest pain" but anyway... I was still not comfortable BLS'ing this pt especially with the extended txp we would be having to the other facility... so when asked by my partner i said honestly I'm not really comfortable BLS'ing this. He got mad at me and said i didn't want to do calls. and jumped in the back and BLS'd it himself. Was I wrong for not wanting to/ feeling comfortable BLS'ing this pt?

 

[exodus]

ALS call all the way, withdrawal from methadone does include seizures, which is 100% and ALS call.

If he went through an als assessment + 12 lead, I'd feel fine riding in the back. But not after he does an ALS assessment.

 

[STXmedic]

Just from what you describe, I'd have had a paramedic in the back (especially since one was already on scene). Your partner not taking him is bs and lazy. But again, that's only going off of you saying his claimed history and him clammy with decreased O2 sats (whether he does it himself or not we can't tell).

Oh, and the seizures. Yeah, ALS.

 

[broken stretcher]

I just did not feel comfortable, even though the call was 400% BS, that did not make it BLS...

 

[broken stretcher]

yea we did not see any medications indicating seizures/CHF... we only saw methadone and lots of psych meds... methadone was prescribed for chronic pain from a car accident, but his doc finally put his foot down and said enough because it seemed he was sharing his meds with his girlfriend who was making just as much of a case for him getting more methadone as he was :wacko:

 

[EpiEMS]

That call is not BLS. I wouldn't feel comfortable tech'ing that call. I hear seizures and chest pain, I think "call for ALS."

 

[DesertMedic66]

ALS call all the way, withdrawal from methadone does include seizures, which is 100% and ALS call.

If he went through an als assessment + 12 lead, I'd feel fine riding in the back. But not after he does an ALS assessment.

This. At the BLS level I would not want to be with this patient if I had a medic on board. It doesn't matter if dispatch placed it in the CAD as a BLS call.

 

[mycrofft]

Withdrawing from opioids.

http://www.nlm.nih.gov/medlineplus/ency/article/000949.htm
Over six years on a detox section, I've withdrawn methadone (and heroin) patients with benadryl, tylenol and Lomotil just fine. Never saw a seizure, not a real one, and the reference from NIH does not list seizure as an opioid withdrawal symptom. Opioids do not suppress seizures, why should they cause them upon withdrawal?

Now, pregnant females are another matter. We were told that heroin (and thus methadone) withdrawal was lethal to a fetus, but a small NIH published study suggests otherwise.

http://www.ncbi.nlm.nih.gov/pubmed/9794682

Methadone has become such a politicized drug, and can be such a profit center, that science is rarely heard. And accounts by drug addicts of how they have to get their meds or die are usually incorrect.

However, follow your protocols. If you can't decline a transport, move them. If vital signs do not support transport or ALS, then don't unless for spider sense (meaning, the REST of your assessment) says otherwise.

 

[broken stretcher]

This. At the BLS level I would not want to be with this patient if I had a medic on board. It doesn't matter if dispatch placed it in the CAD as a BLS call.

Nope we make the call on scene A or Bls... We just get dispatch info over the air, no MDT or CAD system

 

[Wheel]

I would have ridden this ALS. BS or not, chest pain (especially with risk factors) is getting a 12 lead. Period.

 

[DrankTheKoolaid]

Even if you think it is BS, always remember Turkeys Die also. Just because someone has a drug habit does not mean they may not have anything else wrong.


ALS without question

 

[jrm818]

Even of you think so is BS, always remember Turkeys Die also. Just because someone has a drug habit does not mean they may not have anything else wrong.


ALS without question

Totally agree, just want to add a corollary: being a maybe crazy, manipulative, drug using frequent flier is a risk factor for many bad things. It sometimes doesn't seem like it if such patients call for BS repeatedly...but you can only tell in hindsight if this is one of those times. ALS all the way - as a medic I wouldn't be comfortable BLSing it in either.

Everyone hears the beginning of the boy who cried wolf, and learns that the boy was stoopid. No one hears the ending, where the shepherd supervisor, who heard his child employee crying for help walked the other way, is now facing a wrongful death lawsuit, and is up every night with insomnia from trying to figure out how he can tell the jury the kid is dead because he decided not helping a child yelling "wolf!" in a known wolf-prone area with a field full of wolf-food.

the other important lesson is you should feel good about standing your ground even though your partner may be making you feel like crap. It's natural to try to get your partners to like you, and that's a good thing, but don't let someone's else complacency put you at risk.

 

[Ewok Jerky]

BS calls sometimes require a more thorough workup and documentation so you don't get bit the a**. I would not have felt comfortable with this BLS and would not get upset about my partner getting upset, its my job on the line, and we all know rule #1 is look out for #1.

 

[mycrofft]

I'm surprised that the concept of basing interventions to pt exam and eval is not cited; rather, it is whether or not the pt is lying or one can get in trouble when if he dies.

Your eval should dictate your actions in accordance with your protocols. If they don't meet the protocol because something's screwy, recheck and/ or call for consult if time permits. Don't bend protocols. Don't hang around playing.

 

[MedicBrew]

If the junior medic feels uncomfortable for whatever reason, the senior medic should step up and take the call, Period!

During the call is, IMO, not the place to have the discussion on whether or not the BLS crew member should take the call. Take care of business; get your patient to the hospital. Then the senior crew member should speak with you about your concerns, discuss the circumstances about the patient, learn from it and move on to the next one.

Just my humble opinion

 

[jrm818]

I'm surprised that the concept of basing interventions to pt exam and eval is not cited; rather, it is whether or not the pt is lying or one can get in trouble when if he dies.

I don't disagree, but I would say that we all know there are times when patients are intentionally unreliable - speaking for myself, at least, I was trying to acknowledge this fact and encourage the OP to continue rejecting the tendency among some providers to blow off exam findings assuming the patient is lying.

I agree avoiding litigation shouldn't' be the reason for excellent care...but its at least an easily articulated reason for being conservative, if you're having a dispute with a sloppy partner.

 

[mycrofft]

Litigation is court's way of saying you're wrong…after the damage is done. Considering that before you do the thing is what it is supposed to promote. I hear you, jrm.

I guess the aspect I was accenting (base care on findings) just isn't sexy enough for internet discussion because it seems to be a no-brainer.

 

[phideux]

I would have went ALS, but going ALS, with a complaint of chest pain means he is going to where the medic feels is the most appropriate facility, which means if the hospital he wants to bypass is a cardiac place, we are going there. Him and his GF wanting methadone is a different problem

 

[Brandon O]

Almost nobody without underlying pathology can drop their oxygen saturation by voluntarily holding their breath.

 

[TheLocalMedic]

Everyone hears the beginning of the boy who cried wolf, and learns that the boy was stoopid. No one hears the ending, where the shepherd supervisor, who heard his child employee crying for help walked the other way, is now facing a wrongful death lawsuit, and is up every night with insomnia from trying to figure out how he can tell the jury the kid is dead because he decided not helping a child yelling "wolf!" in a known wolf-prone area with a field full of wolf-food.

Wow, that's great, I'm going to be stealing this for future use, if you don't mind.

As far as "turfing" calls to BLS, it's entirely up to the BLS provider to determine whether or not they are comfortable taking the call. An ALS provider may see enough to convince them that this patient doesn't require any ALS interventions, but if their BLS partner doesn't feel the same way they should err on the side of caution and maintain an ALS tech.