I think I made a booboo. Took a pt home that prolly wasn't ready

[runswithneedles]

This is probably one of the worst places to admit a possible mistake. But I would like to hear your opinions on this one. Yesterday I was dispatched to take home a approx 75 yo female who had been admitted to the ED for a severe headache which lasted about 1.5 hrs. She has a hx of CVA resulting in L sided weakness and a-fib. She was on a blood thinner ( not coumadin or warfarin) I can't recall the name. Anyways ED assessed her and gave her a 1000 CC NS bolus and called us to take her back home. According to ED records her bp was around 160/108. Pulse 83 RR 18 no spo2. This lady was Spanish speaking only so assessment was very limited. Prior to departing the ER bay I took a set of vitals. BP 180/102 pulse 84 irregular RR 20 Spo2 89% RA. Her ED records (a joke to say the least) had no indications for HTN or medications. Her skin color was pink and warm. After the run I was starting to believe the headache she had was caused by Uncontrolled HTN. And the idiots in that ED mightve made it worse with that bolus. I feel now I should've pulled her out of my truck and taken her back in and said I will not take her. What are your thoughts to this?

[DwayneEMTP]

Not sure why this is the worst place really....

How did she get to the hospital? By ambulance also? Did she care for herself or have a support system at home.

A few things that you need to be careful of if you don't want to get flamed is calling a whole group of people with educations and certifications well above yours 'idiots', as it's likely not accurate, as you've no real ability to determine such a thing at your certification level, and simply uncool in general. Particularly when you believe that she was on a blood thinner, but didn't look it up to see what it was. How do I know? 'Cause you remember those drugs.

Many older people have elevated blood pressures. It's possible that this is baseline for her as she gets older, though you'd certainly expect to see some evidence of a pharmaceutical attempt to control it in her records, or there could be a current pathology that has it temporarily elevated, or, or she could have been having a stroke, or your b/p could have been wrong. As much as you likely hate to hear it, we all make mistakes sometimes.

One thing that is certain is that the bolus, at least to the best of my ability to understand, didn't cause an increase in hypertension. Hypertension is either a physiolocial compensation, or the activation of the compensation mechanisms due to some type of pathology. Add'l fluid, within limits, will almost always drop the b/p in a non hemodynamically challenged patient, not raise it. (You think that it sucks to admit that you're wrong here? See how much we learn when everyone explains all that I've not considered with the above statements)

Though at your level of education those numbers seem horribly elevated, it's really not so uncommon, nor terribly dangerous to have a b/p in that range acutely, (without significant comorbidities), though certainly not desireable chronically.

Though you are kinda freaked out about the b/p, despite her other numbers being relative normal...(I can't really comment on the SPO2 without some more info), you have kind of missed the main reason that you should have considered transporting or not....

How was her headache? What did you stroke assesment show? Was she better than when admitted? Worse? What is her historical baseline? And on, and on....

I'm guessing that those things weren't really considered because you were to focused on what the assholes at the ER missed. And don't tell me that she spoke spanish so there was no way to tell. Truly, don't do that...

When you get focused on pointing out the deficits of others, it's really important that you don't allow that to cause deficits of your own...

See? No sunshine and rainbows here, but that wasn't so bad, right? You had the balls to post, and that's excellent, now have the committment to hang with this thread, to continue the conversation and learn every single friggin' thing that you can from this call, as there is a ton that you can, and should learn...and you'll never be afraid to be wrong here again. Trust me...

Dwayne

[Timmy]

I agree with Dwayne but certainly without a comprehensive history or list of medications it’s hard to paint a full picture and formulate a constructive answer.

Saying that and coming from an Australian background I find it quiet bizarre an ambulance would be taking a patient back home, but anyway…

Like Dwayne indicated, non symptomatic hypertension is generally not a great cause of concern in the elderly, especially if the lady is already medicated and her BP was generally normotentsive in the ED. I’m sure if you didn’t speak a word of English and presented to a hospital your BP would be up as well. Your reassessment is also important because when things get busy in ED sometimes the nurse in charge is foaming at the mouth to clear the beds and things get missed, if you ascertained that she was still symptomatic with a headache and hypertension then reassessment by the treating doctor may be necessary because there really discharging the patient with no change since there admission, kinda defeats the purpose of attending an ED I guess. Never be afraid to pipe up and say you’re not happy with a patient, get someone to reassess them, that way if things go south on the way home at least your covered and attempted to advocate for the patient.

Certainly in the limited Emergency Departments I’ve worked in its common practise to call the family or a responsible individual to take the patient home after we’ve explained what treatments have been attended to in the hospital and what care might be needed at home. This lady has a history of a left sided weakness and can’t speak English, to me the next questions here after medical consultation certainly reflect towards discharge planning. Is it safe for the patient to return home to there current environment? are there support measures taking place? If she can’t speak English does the patient even understand why funny looking people were poking and prodding here for a few hours? Is she a frequent flyer for similar presentations, if so why? Does she not understand how to take her medications and that’s why this “uncontrolled” hypertension occurs?

I think observational skills for a paramedic are quiet important, I mean its all well and good for the hospital to ask a few questions to our non English speaking patient in regards to discharge planning but you guys are actually in there homes and have a front row seat to the home environment and can report back to the hospitals. I’m assuming the ambulance was needed because the patient has ambulation issues? I’d be more worried about discharging this lady home if there isn’t some support structures in place more so than her blood pressure.

Edited January 23, 2012 by Timmy

[ERDoc]

A few questions for the OP:

1. What workup did these idiotic assholes do in the ER?

2. What percent of people with ischemic strokes have a headache?

3. What is the acute treatment of asymptomatic hypertension? Provide evidence.

[chbare]

This actually ties in to the recent critical care fascination on this site and really illustrates the fact that focusing on the core components of being a good entry level provider is critically important. Much more so than a two week critical care class IMHO.

Mike, you are at a good place to present ideas. People will not hold your hand and we are sometimes brutally honest. This applies to every member. I've been here several years and have a couple thousand posts under my belt; however, people wouldn't think twice about calling me out. I wouldn't have it any other way. Make this a good learning experience and you'll find this can potentially make you a better provider who appreciates constructive criticism.

[Kiwiology]

This is probably one of the worst places to admit a possible mistake.

You are correct, I am a scary mother fucker and now I'm going to eat your children for your mistake ...

Saying that and coming from an Australian background I find it quiet bizarre an ambulance would be taking a patient back home, but anyway…

I know for a fact you blokes have NEPT just like we have the Patient Transport Service ... some bloke in a van with three days training is a good money maker for giving Nana a lift home ...

1. What workup did these idiotic assholes do in the ER?

Hey come on now, you know I don't speak Spanish and the overworked, underfed and dangerously fatigued House Surgeon had to go on his Resident Medical Officer Association mandated break ... what, I can put on a pair of scrubs and wear this listening thingo around my neck and pass for a doctor? Bloody hell it's not my fault the Registrar died from fatigue last week and we haven't been able to get anybody else to cover. Shit man we are trying to provide healthcare for free-to-the-patient here!

One thing that is certain is that the bolus, at least to the best of my ability to understand, didn't cause an increase in hypertension

Correct. Isotonic fluid will not raise blood pressure in the normal person who is not volume depleted because the body has this awesome capability of maintaining pOsm 300mOsm/kg (well in reality it's (2[Na⁺] + (glucose/18) + (BUN/3)) but this isn't USMLE Step 1 here ... and if it were the answer would be "ask the Registrar who died last week from fatigue" and if you crazy American's did your bloods in mmol/l like we do it's just (2Na⁺) + Glucose + BUN)) so um yeah getting back from our chemistry lesson the extra fluid will just get sent to the kidneys and pissed out.

Honestly if it were me I'd have had words with the Doctor, if need be speak to the Consultant Physician because in that state the lady is not in a fit state to leave the emergency department; she is an undifferentiated patient who needs further investigations.

I would expect more, even out of an at-the-worst a dangerously overworked, underfed and chronically fatigued House Surgeon.

Don't expect any more out of a Kiwiologist tho, those guys are really bad at killing people!

[paramedicmike]

In addition to ERDOC's questions, why *didn't* you take this patient back into the ER upon obtaining the vitals about which you seem pretty concerned?

[ERDoc]

Honestly if it were me I'd have had words with the Doctor, if need be speak to the Consultant Physician because in that state the lady is not in a fit state to leave the emergency department; she is an undifferentiated patient who needs further investigations.

I would expect more, even out of an at-the-worst a dangerously overworked, underfed and chronically fatigued House Surgeon.

Thanks for the basic science flashbacks. I thought I had slayed those demons but you had to go and revive them. I'm on the floor in the fetal position as I type. You damn Kiwiologists and your accents.

As for the above, how do we know more wasn't done? The OP has not told us what was done other than a fluid bolus. In addition to my previous questions, I have a few more:

1. What is the pt's code status?

2. Was there a discussion with the pt/family that led to the discharge?

[tcripp]

1. What is the pt's code status?

2. Was there a discussion with the pt/family that led to the discharge?

In my little world, the only way we can get paid is if the transfer is medically necessary, the patient can't otherwise sit/stand without assistance OR the family has agreed to pay for the trip (which usually is done up front).

So, what was the reason for your transporting her to her home? Certainly not for a higher level of care.

[Kiwiology]

So, what was the reason for your transporting her to her home? Certainly not for a higher level of care.

It's very common for the Ambulance Service around the part of the planet that is ripe in Consultant Kiwiologists and some of those Aussieologists (although I don't trust them bastard Aussieologists ....always wanting to go to the beach) to transport people from home to hospital, hospital to home or to outpatient appoints where medically necessary. We have a separate branch called the Patient Transport Service (PTS) and in AU it's called Non Emergent Patient Transport (NEPT).

It may have been part of their contract with the hospital if they're a private service or a private hire where the patient paid for it.

Thanks for the basic science flashbacks. I thought I had slayed those demons but you had to go and revive them. I'm on the floor in the fetal position as I type. You damn Kiwiologists and your accents.

UK House Surgeon: Hey did you hear the bloke in two screaming bloody murder?

Me: Yeah, something about jelly; sounded a bit nunngered, I let the Reg handle it, jelly expert that bloke is

Consultant: Why did you give him gelofusine for?

Me: Where you from again mate?

Consultant: Ketchum, Idaho

Me: Nah bro you can't catch 'em, over your head they go, not gelofusine, jelly, like the wobbly desert y'know?

I do hear it's pretty backwards in Idaho ....almost like upstate NY where volunteers don't have a blood pressure cuff

Dramitisation - may not have happened

As for the above, how do we know more wasn't done? The OP has not told us what was done other than a fluid bolus.

True, seems pretty unusual

Edited January 23, 2012 by kiwimedic