Pissed off about CP

[Arizonaffcep]

Ok...I was working in the ED the other night. One of the patients (was the medic for a 3 bed zone) who had come in earlier in the day for shoulder pain was actively infarcting. It wasn't a STEMI, however, his first trop was 8.something. No...that's not a typo. Second was over 13.00. So...why did it make me angry? Actually sick to my stomach is a better description. First, this patient is 5'7" ish (I'll give no HIPAA info away...so easy folks ), 540 lbs (probably the reason??). CCU had been down to eval, and the CCU attending had said that the only thing to be done was a heparin drip and admission to the floor (NOT the ICU). I can kind of understand based on the thought that with his trop that high, he'd been infarcting for a LONG time, and nothing would reverse that damage. The problem...HE'S 31!!!!!! From my understanding, another issue was he was "too big for the cath table." Which I might understand, the table is THIN...would hardly hold me (and thanks to Dr. Burbee, I have a 36 inch waist!).

This whole thing has me irritated and angry. It seems like they should have done SOMETHING! So...to make it worse...as the night progressed, the RN and I noticed his ST seg. in a couple of leads (mostly II) was starting to raise. By shift change, he was still in the ED, awaiting a second visit from CCU (due to us nagging them to come see him). Am I alone in this? I hope not. This really is the first thing that I've seen. I feel that the system has really let him down.

One thing I hadn't mentioned, is at about 4am, he did get orders for Lasix...gee I wonder for what?!?! His lungs were starting to fill...I work again on Sunday, and plan to follow up on him, and will post what I find afterwards. Thanks for letting me vent.

[Just Plain Ruff]

Bad mojo batman.

Someone there should have pushed for a transfer to a facility who would take him.

unfortunately with his weight he would be a terrible candidate for open heart and I can honestly believe that he would be too big for the table.

I am in no way second guessing your treatment nor your advocacy for this patient but if this is the way they would treat one of their own, how do they treat those who are not their own? Most facilities would go the extra mile for one of their ER employees yet it seems like they dropped the ball on this one.

I hope and pray he did ok.

I know you are frustrated with this situation but sometimes you just have to accept it and go on. Hopefully this guy did ok.

[VentMedic]

By the floor bed, the doctor probably meant tele which may have been appropriate for this patient. This is not that uncommon since progressive tele floors can monitor, do the necessary drips, can usually do CPAP and have a relatively low nurse to patient ratio. If there will not be more aggressive treatment or the need for a ventilator, the CCU bed may not be necessary. Also, not everyone with an MI goes to the cath lab.

[paramedicmike]

You're pissed off that they didn't do more. What more did you want them to do?

-be safe

[Arizonaffcep]

You're pissed off that they didn't do more. What more did you want them to do?

-be safe

That's the thing, I don't know what els they could have done...until his EKG started to change while still in the ED, which I would assume means that the MI is extending. It was a gut reaction. Sitting back and not doing anything for a 31yo AMI...feels WAY weird.

[EMS49393]

That's a sh***y situation. Being a big fan of hearts, I felt bad just reading your story. Was an actual cardiologist consulted? I saw you say CCU, but I didn't understand what staff was actual involved in determining disposition for the patient. I've only seen a few cath lab tables, but I'm fairly certain they would be able to hold a person of that size. I would think the biggest issue would be actual fear of doing anything versus doing nothing. If they attempt to balloon the guy, giving his size, they might be thinking that he will surely arrest mid-procedure. If they let him go, he may damage a great deal of heart muscle but be less likely to arrest at their hands. It's complete BS, and if I ever reached my dream of being a cardiologist, I would give the guy a chance in the cath lab. Although he's morbidly obese, he's 31. If for nothing else, his age may be the only thing that would get him through this. I would also cover my hind end by explaining to this poor fellow that he has a snowballs chance in hell of surviving this event with the help of the cath lab and probable stent placement, and even less of a chance without.

I guess I'm like a lot of paramedics, nurses, and hopefully doctors. I want to do everything to save a patient that might be saved. I can sympathize with you though as I've had to stand by and watch people fiddle their bums while patients are in the active process of dying rapidly.

There is a good thing to come out of this experience... You know you still care about your job and your patients. You have still have something a lot of people no longer have (if they ever had it to begin with).

[VentMedic]

That's the thing, I don't know what els they could have done

Why don't you start following the care ED patients get once they leave the ED? Learn the reasons why some therapies are done and not others. Learn the risks and benefits for different patients. The same cook book is not always followed for each paitient. Since there are known histories and values, there are more (or less) options. You should have been able to have asked your ED physician or the CCU physician that saw this patient some questions for a learning experience. Also, learn what the various units and floors can handle in terms technology and drips. Get to know more about medicine, the reasons behind the medicine and what really happens to a patient within the walls of a hospital. Don't be afraid to ask questions.

This patient may get a cardiac cath but later. As I have already stated, not everyone with an MI happening at that moment gets a cardiac cath for a variety of reasons. You told us very little about this patient except he was obese and his troponin level was elevated. Other labs? Medical history? Overall health issues? Patient's acknowledgement of his health and disease processes as well as the risks?

It is great that you are a patient advocate but learn more about what to advocate for and why with a sound point of view from medicine and not emotions because he was your age or an employee. You will eventually see young children come through your ED that already have their Living Wills and DNR/DNIs set up or where end of life may have to be discussed instead of intubation.

[Arizonaffcep]

Why don't you start following the care ED patients get once they leave the ED?

That's a hell of an assumption that I don't. I do, what I meant by that statement was a cath/angioplasty, etc had been ruled out...according to the off going shift because of weight and size of table. Which, I take Pt's the cath lab all the time (I do work in the ED...), and have seen it. It's quite narrow. My thought...if that's a driving reason not to do it, find another facility with cath/angio abilities and transfer if their table is bigger, etc. etc. etc. Or, see if we (as a hospital) can come up with a way to "widen" the table so it would work. Adapt and overcome, especially for the patient, is the name of the game.

Learn the reasons why some therapies are done and not others. Learn the risks and benefits for different patients.

I am still learning (as is everyone is medicine...or you need to get out). But...I have worked in the ED for 2 1/2 years, and as a street medic for 4 years before that, and have done literally every type of job a paramedic can do clinically and prehospital in Pima County (except work as SWAT medic...no real interest). It seems as though you think I am dumb, and am quite, um new(?) at this medicine thing.

The same cook book is not always followed for each paitient.

All I have to say on this is-KISS OFF! How DARE you assume I'm a cook book medic! My wife and own our own EMS school, where cook book medicine is left at the door! You don't know me. Don't assume you do.

Since there are known histories and values, there are more (or less) options. You should have been able to have asked your ED physician or the CCU physician that saw this patient some questions for a learning experience. Also, learn what the various units and floors can handle in terms technology and drips. Get to know more about medicine, the reasons behind the medicine and what really happens to a patient within the walls of a hospital. Don't be afraid to ask questions.

I know about risk vs. benefit and how it expands or contracts on your options list. In my OP, I didn't post much detail, because I was mostly venting. But...I knew they considered medical therapy for breaking up the clot, but the dosage required based on weight would have caused a CVA. So...that's about it. As I have worked at UMC for 2 1/2 years, I do know what floors can do what. He would have gone to 4W, the CCU floor-with remote tele. My thought on ICU was...if they aren't going to do anything to stop the infarct, then they can expect...oh, maybe CHF, sudden onset pulmonary edema, and any number of arrhythmias. 4NW (cardiac ICU) is much better equipped to deal with that than a floor with just tele. Trust me, I've seen how 4W runs a code...Also, as UMC is a teaching hospital...it was the reason I went there, to expand upon my knowledge in every way I can.

This patient may get a cardiac cath but later. As I have already stated, not everyone with an MI happening at that moment gets a cardiac cath for a variety of reasons. You told us very little about this patient except he was obese and his troponin level was elevated. Other labs? Medical history? Overall health issues? Patient's acknowledgement of his health and disease processes as well as the risks?

Not at UMC, unless they say "oh the table can handle him now." While I don't remember specifically what his other labs were...I do remember that they were what was to be expected from a person infarcting. Hx...I believe he was a diabetic, with absolutely NO cardiac HX prior. He know's he's fat. But doesn't appear to do anything about it.

It is great that you are a patient advocate but learn more about what to advocate for and why with a sound point of view from medicine and not emotions because he was your age or an employee. You will eventually see young children come through your ED that already have their Living Wills and DNR/DNIs set up or where end of life may have to be discussed instead of intubation.

I've already been around long enough to deal with kids at end of life--both expected and unexpected. Here's the thing...it's not really emotional, but that deep down "gut feeling" that SOMETHING needed to be done. Surely, you've been in medicine for a while...you know what a gut feeling is, and hopefully, you don't typically ignore it.

Do me a favor...unless you are going to post to me as an "adult to adult" and not "adult to child/newbie/etc." don't post. Go elsewhere, as you have really succeeded in offending me, especially with the cook book part.

[Eydawn]

Easy tiger! Vent wasn't trying to be condescending... she's just expounding from her own experience and education. She's right... there's only so much that can be done and you may not have all the clues necessary to the situation. I don't think she's trying to imply that you're stupid, a cookbook medic, or otherwise...

Remember that both sides here aren't playing with the full deck of info...

Peace....

Wendy

CO EMT-B

[akroeze]

Do me a favor...unless you are going to post to me as an "adult to adult" ... don't post.

Physician heal thyself!

Vent was in no way trying to insult you or put you down. You are the one who is doing the assuming here in that you are assuming that Vent automatically is against you.