Ever Just Had A Patient You Wanted To ......

[uglyEMT]

Ok this is a vent, a question, and asking for some advise.

I had a run of calls the other night that I swear every patient did everything to make me look bad and I wanted to scream, "Really!?!"

First one was a patient complaining of shoulder pain, I am working the patient up with my Captain observing so I am making sure I cross my Ts and dot my Is. When I ask the patient could he move his shoulder (after a quick assesment not finding deformation of clavical or scapula or possible dislocation of the shoulder joint) I get the no can't move it it hurts to much. I turn to my Captain (working as my partner) and ask for my sling and a crevat as I am going to immobilze in place (pt said it felt better in the position he was holdign it, tight to his chest slightly elevated and had good pulse and sensory but no motor so I agreed to the POC). As I am prepping my sling my Captain asks if the patient really couldn't move his arm. Like a miracle the simple laying of my Captain's hand on the arm and the patient has full range of motion WTF 2 minutes ago you said NO now you act like everything is fine. Needless to say an ice pack and an RMA later we are back on the rig. All the while I feel the daggers shooting from the Captain's eyes while traveling back to the satation.

Call two, possible broken wrist / fore arm. Again I am teching the call with the Captain watching. Again, ask what happened and while taking in the history I am doing a quick visual exam. I go to check my PMS as I do see deformity in both the radius and the ulna proximal to the wrist. I feel a strong radial pulse and the patient says he feels my touch on his finger tips. OK on to the M, again patient states no movement. I am thinking possible tendon damage due to the broken forearm. Again as I prep my SAM and crevate Captain walks over and does another PMS check and BAM patient wiggles all his fingers and makes a fist but says it hurts. I get "the look" and we prep his arm for the break and transport.

On our way back from this call my Captain asks did I even bother to check PMS on either of my patients. To which I replied of course, pt stated no movement, but had P and S and due to my assesment of the injuries felt loss of Motor was justified (pt one I felt was a sprained shoulder and movment hurt, pt 2 I thought was tendon and ligament damage due to the break). To which I was advised if I really did a thorough PMS I would have tried harder to get the patients to move their injuries. Look at what happened when I did. GRRRRRRRR UGGGGGGHHHHH

I know darn well I did a good PMS and with my assesments and felt why put the patient in discomfort to try and get them to move their injuries when with pulse and sensory being strong the risk of comprimise wasn't high and immobilzation would be sufficent. Just to have them a few minutes later start moving said areas when asked by the Captain and make me feel like they were doing it on purpose just to make me look bad.

What would you do in those situations? I felt like bitch slapping both of them to be honest then the Captain. But thankfully my adult brain worked and not my school yard brain and I just quietly mumbled under my breath probably every curse under the sun and then invented a few.

I know this sounds like rambeling or whatever and I am sorry about that I just had to get it out. Any suggestions for next time I encounter this problem?

[CPhT]

Here's a different line of work, but similar idea. I'm a pharmacy technician currently, while I'm in school for EMT-B (long run, EMTP). The pharmacy I work for is a "compounding" pharmacy, which means that we make every medicine from pure drug (usually powder form, sometimes liquid) and add it to the base to get whatever strength and amount is needed. Typically, our new patients need this process explained, as they can't grasp why CVS takes 15 minutes to "make" a prescription and it takes us hours, if not days.

Flash forward to my time spent in our non-sterile lab. I get a call from the boss saying that a patient is unhappy with her Neuro Formula #10, which is Amitriptyline, Baclofen, Clonidine, Ketamine, Ketoprofen, Loperamide, Pentoxifylline, Lidocaine, and Tetracaine in a cream/ETOH base. It's a pain cream, and a seriously potent one at that. PT claims that the cream isn't working as good as last time and that it's lumpy. The boss says she needs to pick it up before we close, which is in 2 hours. I tell him that it's not doable. I said "I'll make the Rx, finish it after hours, box it up, and physically take it to the UPS store, and she'll get it tomorrow. She can use what she has now, and this way I can make sure it comes out perfect". My idea apparently was the most offensive and horrific plan devised, because the boss shoots back a "I can't believe you don't want to do your job. What is so difficult about this prescription that you can't get it done in 2 hours?". I just said "fine, I'll set aside everything else, I'll get it done, and she can be happy. Oh, by the way, can you have one of the other techs either come in to do all of the OTHER prescriptions I have to make, or start calling people telling them their Rx won't be done?".

So into the lab. Measuring out all of the powders takes roughly 30-45 minutes, because we have a 1% margin of error (manufacturers have a 15% margin by law, this is our bosses "standard"). Get all the powders measured and mixed into the cream base. Get it topped off to the amount the PT requested. Set it on the EMP machine (think combination paint mixer/ blender) for 5 minutes. Next, it goes through the cream mill, which literally smooshes the product between three rollers to further blend and mix the product. Each run takes roughly 20 minutes, and this product needs 4 runs. So... roughly 1.5hrs later, it goes back on the EMP machine for a finishing run of 5 minutes. Just as I'm pulling it down off the EMP and slapping the label on the jar, my intercom beeps in.

Boss: "Hey, are you done with the Neuro 10 yet?"

Me: "Yeah, putting the label on it now. It'll be in the window in 2 minutes."

Boss: "Oh, didn't anyone tell you?"

Me: ".......I don't like where this is going."

Boss: "The patient called. She can't make it up tonight. She'll be in tomorrow around 5pm."

Sorry for the long story, I just wanted to give an accurate impression of what it takes to make some of this junk.

[ERDoc]

Ugly, don't sweat it. The story always changes. You can have a med student, resident and attending see the same pt and each one will have a different story. Part of it might be the way you are approaching the pt. Don't ask them if they can do something, tell them to do it. Don't say, "Can you move your fingers?" Instead, tell them, "Move your finger," or, "Squeeze my hand." They are more likely to comply when you directly tell them to do something. In the end, it is really irrelevant what the real deal is. The pt is going to be splinted and shipped to the ER. It sounds to me like your captain needs to get off his high horse.

[uglyEMT]

CPht I know your profession well. My father has several compounds made monthly. It is amazing what you guys come up with.

ERDoc thanks for the heads up on "telling" my patient what to do. I guess I take the nice guy approach often and it is like second nature to ask them not tell them. I will give it a try next time. I will say sometimes I do demand things from my unstable patients just to keep them "with" me yet my stable ones are sometimes treated with kid gloves. BTW Captain's high horse is being put in the barn at years end due to retirement so I just have to hold out for 3 more months.

[DwayneEMTP]

I wonder too if you may have been rushing due to your captain being there and didn't connect with these patients as well as you should have? From your posts I'm comfortable with your intelligence and commitment and this doesn't sound like the kind of issue I would expect you to have unless you were in a hurry maybe...

But as the doc says, different people sometimes get different responses and some patients, for whatever reason, are committed to making you look like an ass. I used to hate going into the ER having missed relevant meds during my assessment and history so I developed this, sometimes ridiculously, thorough montra of asking...

Do you take any meds every day?

Are there any meds that you're doctor has told you to take that you've chosen not to?

What meds have you taken in the past?

Why did you stop taking them?

What do you take when you get a headache? How about a stomach ache?

Do you take any herbal remedies for anything?

Have you taken any medicine, for any reason in the last 3 months?

After having gone through all of this, and getting either 'no' or 'nothing' over and over again as I'm dropping one patient off in the ER I hear him start to rattle off his cardiac meds to the doc...I look over at him with a look on my face like..."Really??" and he says, "What?! I didn't know you meant those!"

I've come to believe that when these things happen off and on that it's just the EMS Gods kicking you in the balls and reminding you to pay attention to business, but when it happens regularly, (say...twice in one night?) maybe they're telling you that your assessment is getting weak in some way.

Dwayne

[uglyEMT]

I've come to believe that when these things happen off and on that it's just the EMS Gods kicking you in the balls and reminding you to pay attention to business, but when it happens regularly, (say...twice in one night?) maybe they're telling you that your assessment is getting weak in some way.

Dwayne

Thank you Dwayne for the honest response, especially that last line. I guess tonight I will be cracking open the books and refreshing my PMS skills, or at least seeing if I was missing anything. I don't think I did but figured I would through it out here just to see if it was me, the EMS Gods, or just a bad night.

I will say I don't think I missed anything other then getting them to move said hurt appendage and my clincial thinking saying they probably couldn't. My clinical thinking might have been off, like you said, with my Captain looking over my shoulder.

As for the meds, ALL THE FREAKIN TIME, especially up my way where prescription drug abuse is very prevelent. I had one where I asked all the right questions, ran through a list of possible meds that could be causing said s/s got No's across the board. Asked about illicet drugs and ETOH and got No's. ER Tech asks and gets Weed laced with Meth. I look at my partner and the medic riding with us like WTF and the ER Tech asks the medic why its not on the report said everything we did and the PT goes its just weed I grow it in my yard so its not illicet. Guess the Meth was home grown too

But I do see what you are getting at that just because my patient said no he couldn't I stopped there and didn't try farther, which I stated, due to P and S being strong and I was splinting no matter what. I guess it was a disconnect between me and my patients. Could have seen the anxity in my eyes or face with my Cap behind me. Maybe the pt just liked the Captain better and looked at me like a noob. I don't know but I will reread my PMS chapter just to refresh a bit.

[HERBIE1]

As doc said, folks can give multiple answers to the same questions, depending on who's doing the asking, where, when, and how. I demonstrated this concept to one of my students, He asked a patient if they had any medical problems, and began to list possibilities- cardiac, high blood pressure, asthma, etc. The patient dutifully replied, no to all. I smiled, then asked the patient what medications he takes every day and he replied with a laundry list. My student was flustered, but wrote them all down. Then I smiled and asked the patient- already knowing the answer I would get from him: "So- you are taking all these pills for your heart, your sugar, and your asthma, why did you say you didn't have any of these problems?" The patient: -looking at me like I was a complete moron: "Because I DON'T have those problems as long as I'm taking those medications."

I looked at the student, his jaw dropped and he just shook his head. It was the easiest lesson I ever taught. LOL

[Bernhard]

Like a miracle the simple laying of my Captain's hand on the arm and the patient has full range of motion WTF 2 minutes ago you said NO now you act like everything is fine.

That's why he's the Captain...

Don't hesitate, happens all the time. I encounter this when I'm the first responder: until the other team steps in, the patients history has changed somehow. On the other side it happens that when I was the supervisor, the patient tells me more than anyone else. There is no special sign identifying me as such, but somehow there is some magic.

May be the patient needs some unexpected time to think, so the next provider gets answers to questions the first provider asked.

It helps if questions are very clear (basic language, no single technical term). The suggestions of asking the patient to do something instead of if he can do something works often, too. For the medication I have near 100% success rate if I simply ask "Where is your medication?" instead of trying to find out if there is any medication at all.

Still, such things happen. Beating the patient doesn't help much, though (I guess, rarely tried).

[DwayneEMTP]

Good response Ugly...

And yeah, trusting patients is almost always a bad idea in my opinion. Not from an adversarial point of view, but from a psychological one.

They are afraid of everything most often. They are afraid that if they tell you the truth that you won't think that they are sick enough to be taken seriously. They need help, and want desperately for someone to take them seriously, so they exaggerate. I don't blame them one bit..but I still have to figure out a way to wrangle the truth from them. And that must begin with distrust.

Or they feel really sick but are afraid that if they admit to all of their symptoms that you'll start IVs or do other unpleasant things that they are terrified of. So they lie about the acuity of their issues. Again, I have to distrust them if I'm going to care for them.

Or they are aware that they have done this to themselves with drugs, alcohol, foolish actions and believe you will ridicule them, or not care for them properly if you know...so they lie...

See the theme here? Normally believing someone a liar is a disrespectful thing...but when we understand that most of these patients feel that they MUST lie to get cared for properly, then hopefully we can see them in a different light. We must care for them enough to distrust nearly everything they say until we can verify it empirically

In this instance, House is right. Where he is wrong in my opinion is that not every set of symptoms should initially be diagnosed as Lupus. :-)

And an afterthought. You had verified circulation and sensory patency, yet your capt was able to get these patients to move their limbs.

What did he gain from that?

What might have been lost?

I'm curious as to your opinion of the cost/benefit to his intervention. After all, verifying pulse/sensory doesn't necessarily mean you get to keep it, right?

Dwayne

[BushyFromOz]

I swear, half the times we ask patients questions and all we do is prime them for their second and real resonse later on.

Seriously, crews joke about this stuff all the time, patients giving answers full of half truths and sometimes outright lies, im surprised your Captain didn't have a laugh about it like most normal operators would.