What should have been done?

[Veneficus]

So are you saying that you would not preform any ALS skills on said pt?

I am saying if I thought the pt had an ectopic pregnancy I would not delay transport to wait for an ALS unit to arrive if a BLS unit was already on scene and capable of immediate transport.

If I was an ALS unit that responded as the initial unit I would start a line in addition to other treatments based on my findings. In the event of a suspected ectopic I would make a determination if I was going to run fluid based on clinical signs of hemostasis. But either way I doubt the fluid would be a determining factor in outcome.(unless it was a massive hemorrhage in which case a fluid bolus would likely make it worse.) I would be more concerned about slowing or stopping the bleed. (which could also be done by an astute basic while in route to surgery)

I maintain slowing or stopping a bleed and rapid transport would be more effective in a ruptured ectopic pregnancy than any ALS procedure available on most squads in the US.

I also am not too bad at Hx and PE and could probably narrow down the diagnosis a little closer than abd pain as presented by the OP, which would determine exactly what treatment I thought appropriate in the event it was not likely an ectopic.

 

[medic417]

This could all be avoided if only ALS responded in the beginning.

 

[triemal04]

This could all be avoided if only ALS responded in the beginning.

Ding ding ding! We have a winner!

 

[daedalus]

I am saying if I thought the pt had an ectopic pregnancy I would not delay transport to wait for an ALS unit to arrive if a BLS unit was already on scene and capable of immediate transport.

If I was an ALS unit that responded as the initial unit I would start a line in addition to other treatments based on my findings. In the event of a suspected ectopic I would make a determination if I was going to run fluid based on clinical signs of hemostasis. But either way I doubt the fluid would be a determining factor in outcome.(unless it was a massive hemorrhage in which case a fluid bolus would likely make it worse.) I would be more concerned about slowing or stopping the bleed. (which could also be done by an astute basic while in route to surgery)

I maintain slowing or stopping a bleed and rapid transport would be more effective in a ruptured ectopic pregnancy than any ALS procedure available on most squads in the US.

I also am not too bad at Hx and PE and could probably narrow down the diagnosis a little closer than abd pain as presented by the OP, which would determine exactly what treatment I thought appropriate in the event it was not likely an ectopic.

Right.

ALS "skills" would not make a measurable benefit in outcome for a rupturing ectopic pregnancy. If I was an ALS unit, a line would be started en route, but really only so the nurse would not have to do it. Oxygen and a monitor are going to do jack as well. This is just one of those emergencies that require diesel bolus even if it is just BLS transport. If BLS could get her to the hospital faster than ALS, so be it.

Paramedics should be far from offended or have their egos hurt because they cannot do anything for these patients. Even an Emergency Med physician is going to consult the surgical service.

 

[VentMedic]

Right.

ALS "skills" would not make a measurable benefit in outcome for a rupturing ectopic pregnancy. If I was an ALS unit, a line would be started en route, but really only so the nurse would not have to do it. Oxygen and a monitor are going to do jack as well. This is just one of those emergencies that require diesel bolus even if it is just BLS transport. If BLS could get her to the hospital faster than ALS, so be it.

Paramedics should be far from offended or have their egos hurt because they cannot do anything for these patients. Even an Emergency Med physician is going to consult the surgical service.

The measurable part would be in the recognition of this being an emergency and time should not be wasted. Someone with a lower level of training may not recognize this.

The same argument could be used for a trauma. ALS skills may not be utilized but the knowledge to know it is not a time for "stay and play" is useful as are the skills/education if something needs to be done.

The ALS or BLS attitude needs to vanish and medicine should prevail. A doctor may examine a patient like this with all seriousness but will probably be relieved to tell the patient it is something relatively simple rather than an etopic pregnancy.

 

[medic417]

Right.

ALS "skills" would not make a measurable benefit in outcome for a rupturing ectopic pregnancy. If I was an ALS unit, a line would be started en route, but really only so the nurse would not have to do it. Oxygen and a monitor are going to do jack as well. This is just one of those emergencies that require diesel bolus even if it is just BLS transport. If BLS could get her to the hospital faster than ALS, so be it.

Paramedics should be far from offended or have their egos hurt because they cannot do anything for these patients. Even an Emergency Med physician is going to consult the surgical service.

"diesel bolus" Needs to be stricken from EMS terminology. The few seconds saved by driving at high rates of speed, blowing intersections etc do no good and actually endanger all.

 

[Ridryder911]

Again, it is an ALS call. Ruptured ectopic pregnancy is life threatening. Patients can develop shock syndromes and is one of the few situations fluid therapy can be helpful. Agreed, early recognition is the key and I have yet seen very many of those at the BLS level recognize such.

I agree diesel medicine is a horrible analogy and should never be spoke of. Expeditious treatment and transfer should definitely be seek out but one should never imply over zealous transporting. Consulting with local medical control and advising the physician so they can possibly alert appropriate consults and surgical crews.

R/r911

 

[daedalus]

Again, it is an ALS call. Ruptured ectopic pregnancy is life threatening. Patients can develop shock syndromes and is one of the few situations fluid therapy can be helpful. Agreed, early recognition is the key and I have yet seen very many of those at the BLS level recognize such.

I agree diesel medicine is a horrible analogy and should never be spoke of. Expeditious treatment and transfer should definitely be seek out but one should never imply over zealous transporting. Consulting with local medical control and advising the physician so they can possibly alert appropriate consults and surgical crews.

R/r911

Diesel bolus hardly means reckless driving or even code 3 transport. At least in my book. It just means driving the rig to the hospital and not telling someone its just gas and sign out AMA.

Is it an ALS call? You bet! Should most everything be ALS in the first place? Even better!

But in this case, its best just to get the patient to the hospital. EMTs may fail to recognize this. I said may, I know there are quite a few capable providers on this forum, but many are not like you.

 

[Veneficus]

Again, it is an ALS call. Ruptured ectopic pregnancy is life threatening. Patients can develop shock syndromes and is one of the few situations fluid therapy can be helpful. Agreed, early recognition is the key and I have yet seen very many of those at the BLS level recognize such.

Rid,

The key here I think is "may be helpful" which would depend on the extent of the bleed. for some time now the surgical community has been promoting more judicious use of fluid for hemorrhage. In the last presentation I have heard, fluid and permissive hypotension have no difference in outcome for bleeding from blunt trauma. (which I would argue is what a ruptured tube is.) Crystallod will have no appreciable effect.

I also agree with Daedalus, neither will a heart monitor or any other "ALS device" carried prehospital. Some basic maneuver, like direct pressure, will reduce the size of the cavity as well as increase pressure outside of the vessles which could help to control the bleed. In the preshospital setting I think it would be more useful an itervention that salt water in a vein for this pathology.

I agree diesel medicine is a horrible analogy and should never be spoke of. Expeditious treatment and transfer should definitely be seek out but one should never imply over zealous transporting. Consulting with local medical control and advising the physician so they can possibly alert appropriate consults and surgical crews.

R/r911

Agree in full. Drive safely!

 

[redcrossemt]

"diesel bolus" Needs to be stricken from EMS terminology. The few seconds saved by driving at high rates of speed, blowing intersections etc do no good and actually endanger all.

^ THANK YOU!

First, ClarkEMS, some people have been hard on you. Most of them are trying to help, though. Even if a few here don't appreciate your work, you will many times see patients who will appreciate the fast response and initial (life-saving) care you provide. I understand that you guys are volunteers trying to help, and applaud you for doing that, and for wanting to educate yourself and learn more.

Regarding this patient, any chance she was intoxicated or under the influence of other mind-altering substances?

Did you ask any questions regarding the possibility of pregnancy?

Did you explain that the ambulance is free? Why would someone in excruciating pain choose a taxi over an ambulance if both were free?

It's not clear to me who provides the taxi vouchers...? Whatever service/department is providing the vouchers may have a huge liability.

Did this caller call 911? Public safety's non-emergency number? A campus clinic or health service non-emergency number? Who dispatches you? Do they not dispatch an ambulance as well?

Did you provide any care after she "crashed"? Oxygen maybe? Was teatment for shock indicated?

I manage a non-transporting QRS/FR service at special events. If a call goes to a dispatch center (via 911 or direct phone), then an ALS ambulance is dispatched simultaneously with us. We only cancel them for bandaid calls. If they took a "cancel" from us on a medical call, and the patient got sick or died later, they could be in big trouble. We like to let them take the refusal - they have the toys, and can take on the responsibility. If we are called direct or flagged down for anything that seems like more than simple first aid in the immediate area, we find out an age, chief complaint, breathing status, and mental status then call. If we have more than a minute or two response time we request ALS rolls (non-emergently) for an unknown medical and readvise once we arrive on-scene.

 

[Ridryder911]

Here is a link with a good article on ectopic pregnancies. Ironically I was surprised when it was discussed traditional surgery was not recommended on such but rather laproscopy was performed even in such cases of rupture.

http://www.obgyn.net/displayarticle...res/mcgill-student-projects/ectopic-pregnancy

R/r 911

 

[Veneficus]

good article rid

 

[VentMedic]

Ironically I was surprised when it was discussed traditional surgery was not recommended on such but rather laproscopy was performed even in such cases of rupture.


R/r 911

If it rare to see traditional surgery in young people these.

Besides some of the usual gallbladder and appendix, congenital heart defects, hysterectomies and AAAs are removed/repaired with minimally invasive or nontraditional procedures. Many patients are 23 hour admits after surgery and discharged the next day.

 

[ClarkEMS]

^ THANK YOU!

First, ClarkEMS, some people have been hard on you. Most of them are trying to help, though. Even if a few here don't appreciate your work, you will many times see patients who will appreciate the fast response and initial (life-saving) care you provide. I understand that you guys are volunteers trying to help, and applaud you for doing that, and for wanting to educate yourself and learn more.

Regarding this patient, any chance she was intoxicated or under the influence of other mind-altering substances?

Did you ask any questions regarding the possibility of pregnancy?

Did you explain that the ambulance is free? Why would someone in excruciating pain choose a taxi over an ambulance if both were free?

It's not clear to me who provides the taxi vouchers...? Whatever service/department is providing the vouchers may have a huge liability.

Did this caller call 911? Public safety's non-emergency number? A campus clinic or health service non-emergency number? Who dispatches you? Do they not dispatch an ambulance as well?

Did you provide any care after she "crashed"? Oxygen maybe? Was teatment for shock indicated?

I manage a non-transporting QRS/FR service at special events. If a call goes to a dispatch center (via 911 or direct phone), then an ALS ambulance is dispatched simultaneously with us. We only cancel them for bandaid calls. If they took a "cancel" from us on a medical call, and the patient got sick or died later, they could be in big trouble. We like to let them take the refusal - they have the toys, and can take on the responsibility. If we are called direct or flagged down for anything that seems like more than simple first aid in the immediate area, we find out an age, chief complaint, breathing status, and mental status then call. If we have more than a minute or two response time we request ALS rolls (non-emergently) for an unknown medical and readvise once we arrive on-scene.

Yeah, I understand completely with the posts, and I appreciate the help which is why I posted this in the first place


She wasn't intoxicated or under the influence of anything. She knew where she was, what she was doing, did not slur speech, etc. The reason she did not want to take the ambulance was because she didn't want to make a scene of it, I told her it would be best to go on an ambulance, but she refused. The Clark Police Department provide the free taxi upon notification of a refusal. The students are encouraged not to use 911 for whatever reason the University has, I am not educated on the exact reasons why students are told to call Clark Police dispatch. Once Clark dispatch gets the call they page us and we respond. Meanwhile, the MedStar is tied into our radio system so they hear what is going on and can be in direct contact with us or dispatch, generally though they just sign on to a frequency when they are notified by Clark dispatch. As far as I know, the ambulance is only dispatched along with us for certain calls on campus, all other times we get there and we get permission from the patient to get an ambulance and we call it in. Usually police are on scene to help as well. No treatment for shock was indicated. When she "crashed" I mean more that she went from being pretty normal other than the pain to sweaty with some slight paleness and clearly showing signs of extreme pain. The ambulance got to the scene so quickly that we didn't even have time to do anything more for her.

 

[sarahharter]

i agree with many things stated on the posts above. i however do have some concerns. where i run, FR are not allowed to do pt assessments and have to be with an EMT or MEDIC. They were pretty much there to assist the EMT and drive. I also believe in ALS being dispatched initially for pretty much any call, i have been dispatched BLS and it really should have been ALS. i have also been on calls where BLS could transport to the hospital faster than ALS could be on scene. I think that the college has a good idea but maybe they meed to expand on the concept and have emts and medics on staff. i undertsand that most of the FR are going through EMT school however i think that they should have someone with more experience and training there also. and the fact that the students dont call 911 if kinda fishy to me and if i were a parent of the student i would be questioning that. However to the FR i appriciate that you want to learn more and do help with what you can.

 

[emtfarva]

Diesel bolus hardly means reckless driving or even code 3 transport. At least in my book. It just means driving the rig to the hospital and not telling someone its just gas and sign out AMA.

Is it an ALS call? You bet! Should most everything be ALS in the first place? Even better!

But in this case, its best just to get the patient to the hospital. EMTs may fail to recognize this. I said may, I know there are quite a few capable providers on this forum, but many are not like you.

everything is an als call, ok. My company does a 911 contract for taunton, ma 55% of the calls are of psych in nature. You as a medic want to go 7 calls a day and deal with psychs. not including grandma has a cold, the ocasional code or two or three, rectual bleeds, n&v, mvc, falls, h/a. That is a day in the life of tauton rescue. I firmly belive in tiered systems. It keeps medics free for more crital pts. and I am not saying that this case didn't need als. Part of our star of life states transport to diffentive care...

 

[Ridryder911]

everything is an als call, ok. My company does a 911 contract for taunton, ma 55% of the calls are of psych in nature. You as a medic want to go 7 calls a day and deal with psychs. not including grandma has a cold, the ocasional code or two or three, rectual bleeds, n&v, mvc, falls, h/a. That is a day in the life of tauton rescue. I firmly belive in tiered systems. It keeps medics free for more crital pts. and I am not saying that this case didn't need als. Part of our star of life states transport to diffentive care...

Well, most of the calls you described needs ALS assessment and intervention. The psych, grandma with a cold maybe really pneumonia, and rectal bleeds are considered potentially life threatening.

No one ever disclaiming definitive (check spelling) care, but what is determined as definitive care? Does all abrasions and minor lacerations need to be seen in a ER? Instead staffing two trucks or even possibly three, keep a Paramedic on one each. In the long run it is much more economical and then the patient always has access if needed.

R/r 911

 

[emtfarva]

Well, most of the calls you described needs ALS assessment and intervention. The psych, grandma with a cold maybe really pneumonia, and rectal bleeds are considered potentially life threatening.

No one ever disclaiming definitive (check spelling) care, but what is determined as definitive care? Does all abrasions and minor lacerations need to be seen in a ER? Instead staffing two trucks or even possibly three, keep a Paramedic on one each. In the long run it is much more economical and then the patient always has access if needed.

R/r 911

I know what you are talking about. Currently Tauton staffs 2 dedicated rescuse from 08:00 to 21:00. After 21:00 they go down to 1. also we do some refusals. most of the time Fire will cancel the ambulance prior to arival for very minor cases. Unfortntly, Taunton has a lot of it's population has mental problems (as most of MA has). Most of the time a whole back hall of our local hosp is loaded with crisis Pts. also, for a truly psych pt, Als has no power other than to bls the call anyway. Mass does not let our medics chemically restraind our Pt's. and a good basic can write down r/o pneumonia also. the only thing medics can do in mass is also what basic do execpt for a line. we also have about 4-5 als transfer trucks around the area if taunton needs help, which they do quite often. (Let me get this out of the way, I CAN'T SPELL. SPELL CHECK DOES NOT WORK. Thank you) What I am saying is that a teired system might be better. Bls and als gets dispatched at the same time. Bls gets there and see's it's a als call they provide first response, package the pt for the medics and clear up for the next call. Same thing with a bls call, they can cxl the als crew and let them be clear. this also works if the als crew is at the hosp, the bls crew can start the first response or transport the pt. The whole point to ems is to get a PT THAT WANTS TO GO TO THE HOSP TO THE HOSP. WITH OR WITHOUT ALS. TRANSPORT THAT IS WHAT WE DO. WE ARE JUST A BIG TAXI CAB WITH MEDICAL TRAINING AND LIGHTS. Don't get me wrong I hate calling myself that but we are transportation. it is that simple. Now of course this system would work ok because our transport times are less than 10 min. I wouldn't know about long transtports. except the transports that go to higher level of care from another hosp. btw, or taunton ambulances are staffed at the P, I level. and most of our Als transfers are staffed at the P, b level, including my truck.

 

[RESQ_5_1]

A BLS ambulance transported her....thats the part I keep tripping on. An acute abdomen requires a paramedic, an IV, oxygen, monitor, and frequent vitals. An etopic can turn deadly quickly. Not to mention its just nice to have the option to give Zofran( or antimetic of your companys choice) vs having someone vomit all over your truck.

That's interesting. I work a BLS unit and have transported quite a few acute abds. And, I provided all the things you list in this post.

Actually transported a 2 1/2 y/o male with what the hospital diagnosed as a Fecalyth (google it). The sending hospital ruled out appendicitis and sent us on a 2 hour ground transfer for a surgical consult. Everything was fine until about 25 minutes from the receiving hospital. My pt suddenly (and I mean SUDDENLY) had no abd pain. I had my partner turn on the lights and we continued hot to the hospital. We sat in the ER for 45 minutes waiting for a nurse to even look at him (after we explained what happened en route). The surgeon came down and was extremely unhappy. Turns out our little guy had appendicitis (initially ruled out by the sending facilities DOCTORS). And, it burst on our little road trip. Luckily, he turned out ok. Not that I want to toot my own horn, but I would have to say that by paying attention to my pt and a good assessment, I probably prevented something worse from happening. Unlike the "educated" personnel that assumed it was something different because that was what they were told and opted not to look for themselves.

 

[emtfarva]

I got off topic

First of all I want say, Clark don't take this the wrong way. I want this comment to be a learing exp.

What you did was wrong. I know you are a first responder for a college campus. I am not dogging first responders. What you should have done and what you should do from now on is have this Pt evaled by emts or medics. Anyperson with a cc of abd pn, chest pn, head injury, AMS, major trauma should be checked out by emts or medics. (I might be missing a few things on that list. but i am sure some of my fellow emts will come up with some more and post them.) If you know about any of the above cc's when you are dispatched you should automaticlly call for an ambulance. Don't take a risk of getting sued because you let a critcal pt take a cab to a hosp and then that person dies. and please don't let a pt with abd pn walk down stairs or anywhere for that matter. don't let a chest pn pt walk either. just a few tips. like i said don't take it the wrong way. Learn from it and become better at your job.

Farva