GI Bleed =12 lead?

[crotchitymedic1986]

I think you are asking the wrong question, the 12-Lead is the last thing you should be worried about. The real question is why you didnt transport a SYMPTOMATIC Hypovolemic patient. You had a low blood pressure, poor color, poor perfusion, and tachycardia. That should have been enough to let you know this patient should be transported. If your partner and yourself can not pick up on these basic assessment skills, you shouldnt bother with any higher technologic equipment. I am not questioning your intelligence, but my guess is if you had been on a basic truck you would have transported this patient. Dont let your lazy paramedic partners cost you your license -- yes i said your license -- this was a basic call. In the future, transport these patients that you do not feel easy about -- if your partner doesnt like it, volunteer to tech the call -- if he/she still doesnt like it, get a supervisor involved. I would have suspended you, not dinged you -- this is gross negligence.

[spenac]

I think you are asking the wrong question, the 12-Lead is the last thing you should be worried about. The real question is why you didnt transport a SYMPTOMATIC Hypovolemic patient. You had a low blood pressure, poor color, poor perfusion, and tachycardia. That should have been enough to let you know this patient should be transported. If your partner and yourself can not pick up on these basic assessment skills, you shouldnt bother with any higher technologic equipment. I am not questioning your intelligence, but my guess is if you had been on a basic truck you would have transported this patient. Dont let your lazy paramedic partners cost you your license -- yes i said your license -- this was a basic call. In the future, transport these patients that you do not feel easy about -- if your partner doesnt like it, volunteer to tech the call -- if he/she still doesnt like it, get a supervisor involved. I would have suspended you, not dinged you -- this is gross negligence.

I must have missed something as I do not see where the OP said they did not transport. And my comment said the extra minute which honestly it's less than that.

But I'm sure I missed the not transported statement some where. Sorry in advance.

[Mateo_1387]

I must have missed something as I do not see where the OP said they did not transport. And my comment said the extra minute which honestly it's less than that.

But I'm sure I missed the not transported statement some where. Sorry in advance.

Spen, I think he may be in reference to EMS49393's post.

Patient was strongly urged by paramedic to be evaluated at the ER. I guess it was a gut feeling based on experience and patient appearance. Patient is goes to the ER as a walkin.

Seeing as he did not quote his source, I will not be 100% sure.

[Mateo_1387]

...this was a basic call...

:shock:

Are you serious?

Some reasons why I would think otherwise...

She was also in heart failure secondary to lack of oxygen rich blood. The body can only compensate for so long. The ER performed a 12-lead and it showed ischemia and T-wave changes in every lead.

...along with a lot of blood in the stomach. I have no idea why there was no vomiting since the stomach isn't a real fan of blood.

Had she been vomiting blood, an NG tube may be in order, as well as possibly some fluid, and some nausea medication.

Staff report rectal bleeding for several days... Their last BP was in the 80's.

... partner took vitals ... comes up with something like 70/30, ...I notice something hinky in leads II/II/AVf. Decided to run the 12-lead, comes back with significant elevations in II/III/AVf/V5/V6 with reciprocal changes.

...there is no law against having two or more medical conditions at one time. Just because someone has a GI bleed does not mean they cannot have a cardiac event too.

If your partner and yourself can not pick up on these basic assessment skills, you shouldnt bother with any higher technologic equipment. I am not questioning your intelligence, but my guess is if you had been on a basic truck you would have transported this patient. ... this was a basic call

I do not mean to come off as rude, just trying to get to the bottom of this. You leave no choice, but I have to question your intelligence. What makes this a "basic" call? Should you transport the patient against their wishes if the patient is of sound mind and able to make their own decisions?

[crotchitymedic1986]

EMS49393 wrote:

Patient is a 25 year old female, with a chief complaint of "I just have the flu." Patient presents alert and oriented. Skin is pale, nearly white, including nail beds and lips. She appears to feel poorly and admits to being very tired for the past three days. Vital signs BP 90/50, which is normal for patient, HR 130's at rest, RR 24. Unable to obtain a pulse ox reading. Lung sounds clear and equal bilaterally. Patient is nauseated, however no vomiting, no diarrhea. Rest of physical assessment is unremarkable. Patient was strongly urged by paramedic to be evaluated at the ER. I guess it was a gut feeling based on experience and patient appearance. Patient is goes to the ER as a walkin. Apparently she stated to the triage nurse "I don't feel well" and looked bad enough that the triage nurse nearly set her pants on fire scrambling to find a gurney and a physician. The patient had a Hct of 12 and a Hgb of 3.2. She was also in heart failure secondary to lack of oxygen rich blood. The body can only compensate for so long. The ER performed a 12-lead and it showed ischemia and T-wave changes in every lead. The EGD showed several ulcers and mallory weiss tears in the esophagus, along with a lot of blood in the stomach. I have no idea why there was no vomiting since the stomach isn't a real fan of blood.

My point:

[b]The EMT talks about a "gut feeling" --- shouldnt have needed a gut feeling for this patient -- they should have transported. The medic had a gut feeling that told them this patiend was OK to go in the car, and MISSED THE EMTB-101 signs that this patient was in SHOCK.

At the time of the 911 call, this call was a simple BLS call, but it became an ALS call because they left her to go to the ER sometime later, on her own, which allowed her to deteriorate to the point that it became an ALS call.

[spenac]

EMS49393 wrote:

Patient is a 25 year old female, with a chief complaint of "I just have the flu." Patient presents alert and oriented. Skin is pale, nearly white, including nail beds and lips. She appears to feel poorly and admits to being very tired for the past three days. Vital signs BP 90/50, which is normal for patient, HR 130's at rest, RR 24. Unable to obtain a pulse ox reading. Lung sounds clear and equal bilaterally. Patient is nauseated, however no vomiting, no diarrhea. Rest of physical assessment is unremarkable. Patient was strongly urged by paramedic to be evaluated at the ER. I guess it was a gut feeling based on experience and patient appearance. Patient is goes to the ER as a walkin. Apparently she stated to the triage nurse "I don't feel well" and looked bad enough that the triage nurse nearly set her pants on fire scrambling to find a gurney and a physician. The patient had a Hct of 12 and a Hgb of 3.2. She was also in heart failure secondary to lack of oxygen rich blood. The body can only compensate for so long. The ER performed a 12-lead and it showed ischemia and T-wave changes in every lead. The EGD showed several ulcers and mallory weiss tears in the esophagus, along with a lot of blood in the stomach. I have no idea why there was no vomiting since the stomach isn't a real fan of blood.

My point:

[b]The EMT talks about a "gut feeling" --- shouldnt have needed a gut feeling for this patient -- they should have transported. The medic had a gut feeling that told them this patiend was OK to go in the car, and MISSED THE EMTB-101 signs that this patient was in SHOCK.

At the time of the 911 call, this call was a simple BLS call, but it became an ALS call because they left her to go to the ER sometime later, on her own, which allowed her to deteriorate to the point that it became an ALS call.

Thanks I missed that some how. Your right if you had no equipment but your 5 senses you should have been able to decide this patient needs ALS if on scene and more importantly a Doctor.

[Mateo_1387]

My point:

[b]The EMT talks about a "gut feeling" --- shouldnt have needed a gut feeling for this patient -- they should have transported. The medic had a gut feeling that told them this patiend was OK to go in the car, and MISSED THE EMTB-101 signs that this patient was in SHOCK.

It does not say what the gut feeling is, but maybe his gut feeling is that the patient is anemic due to hemorrhage. It also says that the EMT made the decision based on gut feeling and patient appearance Nobody ever said the EMT missed the signs and symptoms of shock (that is s/s according the just plain ol' medicine and not a 3 week first aid course).

At the time of the 911 call, this call was a simple BLS call, but it became an ALS call because they left her to go to the ER sometime later, on her own, which allowed her to deteriorate to the point that it became an ALS call.

Again, nothing has shown that this was a BLS call. You have not shown anything to prove otherwise.

To hash this out just a little more, there is medicine, and only medicine. Not ALS and BLS. Patients who call for an ambulance deserve a Paramedic who will give them a full evaluation. I liked spenac's quote which is "a complete exam is the best exam." This may include the use of the heart monitor, as well as using advanced exam techniques that should be taught in paramedic courses. EMT B's cannot provide these services. This patient should be transported by a Paramedic unit. Nothing less is acceptable.

Again, the patient may have decided to drive herself to the hospital after the ambulance crew came and evaluated her. I would assume anyone who thinks someone needs to be seen at the emergency room would not talk them out of transport, but rather try and talk them into being transported by ambulance. Sometimes though, you just cannot change someone's mind. We just don't know the whole story.

[crotchitymedic1986]

Mateo wrote:

Again, the patient may have decided to drive herself to the hospital after the ambulance crew came and evaluated her. I would assume anyone who thinks someone needs to be seen at the emergency room would not talk them out of transport, but rather try and talk them into being transported by ambulance. Sometimes though, you just cannot change someone's mind. We just don't know the whole story.

I respond:

Mateo, I realize you are new, but unfortunately lazy medics leave patients behind all the time. It is easy to see, although the OP will deny it, that this patient was talked out of going to the hospital via EMS.

My point was not that a 12Lead shouldnt be used, my point is that they should have realized that this patient was very sick with just the basic vital signs that they had. The patient was in compensatory shock. IF orthostatic vital signs had been taken, the medics may have discovered much worse vital signs (my guess is that this patients standing B/p was probably around 70palp). The OP wrote the question as if, "we did everything we could, do you think a 12 Lead would have showed us how critical the patient was ?" You didnt need a 12 Lead to see that.

You are right, in that some patients do refuse care, but I dont think it would have taken much talking on my part to talk this patient into going to the hospital via EMS. Note the OP did not say that the patient refused EMS transport after several minutes of us begging her to go, and getting a supervisor involved.

In conclusion: Technology is a wonderful thing; do 12Leads on everyone if you wish, use your glucometer, pulse ox, and KED whenever you get the chance --- but dont leave shocky patients at home.

[crotchitymedic1986]

Oh, i forgot --- the BLS versus ALS point. My point was that many EMTB's and EMTI's may be under the impression that they have no liability if there is a Paramedic on the scene. This is not true, if it can be proven that any EMTB or I should have seen the severity of the call with the skills they were taught.

For instance -- your patient has severe neck pain with left sided paralysis after trauma. Your paramedic chooses not to immobilize them -- the EMTI on the call is just as liable, as they were taught to immobilize this patient, and it is within their scope of practice to immobilize patients (bet you had to do a check off to prove you knew how to do it).

Any EMTI should be able to recognize compensatory shock. I dont care if she were transported by a BLS or ALS ambulance, the point is that this EMTI should have realized the severity of this patient if his/her medic did not for whatever reason. But typically, a GI bleed can be handled by any EMTI that can start an IV. If your system wishes to use an ALS unit (which would have also just started the fluid bolus), so be it. But the point was that the patient was not transported by EMS, and she should have been --- BLS or ALS

[spenac]

Sounds like we are presuming that they tried to talk patient out of going to ER by ambulance. In a forum why would a person state after multiple attempts to encourage to go patient still refused. At times patients say no. If they meet the criteria to decide for themselves nothing else can be done.

I still firmly believe in denying transport to those that do not need it but in the same breath I can not force those I know should go to go.

Now do any lazy medics actually try and talk patients out of going? My guess would be yes. Those need out of my profession so that we can advance to a point where we can actually do more treat and release. Where all can deny those that do not need an ambulance. We need people to treat the patients they get to the level needed.