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

[runswithneedles]

Thank you very much for all of your constructive criticism. I was figuring it would be worse. Since some of you ladies and gentleman have been users on this board for years and medics for decades. I seek to acquire as much of the collective knowledge I can whether it be medical knowledge or professionalism. In regards to my statement towards the ED I was very frustrated and irritated that I had my dispatcher barking up my ass asking where the f*** was I they are getting pissed and when I get there they don't have the paperwork I need ready. Im working on my temper but it's crap like that always gets my goat. >:-/

[paramedicmike]

You haven't answered the questions posed to you about this situation, though. Were you legitimately looking for answers? Or were you just venting?

[runswithneedles]

Ooops. Here's additional info. Pt brought in via 911. Pain present at time of arrival to emergency department. Rated 10/10 originating from posterior region of the head. CT scan completed WNL. She has a daughter who checks up on the pt and her husband regularly. Stroke test revealed only her pre-existing left sided weakness. Nothing else remarkable. Patient did not appear to be in any type of distress on our arrival. Am I forgetting any other questions?

[paramedicmike]

Well, there are these three:

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.

And then there's the one I asked about why you didn't take her back inside if you were worried about it.

[runswithneedles]

I would like to point out. I did not call them idiotic assholes. I called them idiots. And as Dwayne pointed out it was my ignorance and lack of knowledge regarding hemo-dynamics and crystalloids that made me say they were idiots in the first place. And for that I take back what I said. Now to answer the questions I forgot.

Workup: Besides the CT scan which was negative for a new CVA.

Blood work up was done only finding glucose was 205 mg per deciliter and WBC of 3.9

She was prescribed vicodin PO upon discharge.

I dont know the precise numbers in regards to ischemic strokes. I will take a stab in the dark and say a fair amount since it is by definition oxygen deprivation of the brain due to poor perfusion or lack of in a given part of the brain.

And what do you mean by providing evidence?

And to be truthful of the matter I didnt know I had much of a choice that I could return her to the ED after assuming care. I didnt know how to handle it when my boss rings my neck out for turning a run down. I didnt know how to explain to ED nurse Im not taking her back home after just wheeling her out the door. My gut wasnt screaming at me saying that this patient is unstable nor unfit to return home. But at the same time my mind told me their was the possibility of something happening.

most of what im reading to you now Im reading for the first time of her ED record. (Boss gets pissed if I delay transfer so most of the time we load and go. Read paperwork while doing the report)

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.

Im trying my hardest to give you guys what you need. It sucks because the two page (or one page front and back) assessment I had beg to get has chicken scratch that easily steals my crown. And it has no narrative.

Is that normal for ED's paperwork to not include a narrative

Edited January 24, 2012 by Mike Ellis

[nypamedic43]

If she is going home, why do you need anything other than an H&P, med list and a face sheet. Nurses notes dont go home with the patient, they stay with the hospital chart and/or are faxed to thier regular doctor. Discharge papers and follow up appts, if any, should have gone home with the patients family.

My only question is this one...why is she going home by ambulance? Is she confused? Unable to ambulate? This patient should have been going home by wheel chair van or family POV if she wasn't confused and could walk. We have to show WHY the patient needs to go by stretcher in order to get paid for the trip, unless the family pays up front.

Should she have been discharged? I dont know that answer. But if I was concerned about the elevated BP and she still had a headache, I would have taken her back in and spoken with the Doc in charge.

edited for spelling

Edited January 24, 2012 by nypamedic43

[Kiwiology]

Not sure what you mean by "narrative" but a medical note will look something like past history, current presentation, assessment, impression/diagnosis, treatment, plan and discharge information; for example here is one I prepared earlier ...

PHx - hangs around internet forum frequented by Doctorates of Emergentology

Hx - last 2/7 increasing anxiety ++ while on frequented forum, +++ when hassled about accent and funny speeling by Doctorate of Emergentology; SOB/hyperventilation/tight feeling in chest ... no LOC

O/E - no sympts, resting comfortably, skin dry/warm, no CP, ECG SR, P70 S1/S2 OK nil added, lungs clear. CBC lipids lytes OK.

Imp - ? psychogenic

Plan - Counselled to stay away from bad, evil Doctorates of Emergentology on internet forums, PO diazepam PRN, d/w Consultant Forumologist, ref for O/P F/U 4/52

Rx - stat diazepam 2mg PO 1 x tab prn not to exceed three in 24 hours, 10 tabs no repeats

/S/ Kiwi MBChB

ED SHO

NZMC 18789 Whacker

We don't know if she had a history of hypertension and was on a bag of blood pressure lollies she left at home so 180 might have been normal for her; we picked up a bloke from medical centre who had BP of 220 and for him that was just normal. I do appreciate what you are saying tho in that a headache is one symptom of an acute neurological event or severe uncontrolled hypertension however if the hospital have had her glazed in that big donut machine and not found anything then hmm

Medicine is both an art and a science; and is often times not that artsy or scientific .... if we can rule out serious pathology (stroke, cerebral haemmorhage, space occupying lesion, tumour etc) then we sort of default to the "we're not sure" diagnosis and provide appropriate symptom relief which in this case may have been appropriate or it may not have, she might be dead on the kitchen floor we don't know.

Edited January 24, 2012 by kiwimedic

[HERBIE1]

I'm going to assume that the ER doc spoke with the patient's attending before discharging the patient, found out about a baseline, PMH, ,mentation, etc- maybe she's normally hypertensive, as noted by others here, and maybe she is a DNR. Sounds like the patient was worked up appropriately to me- in my humble, non medical school backed opinion.

[Kiwiology]

I'm going to assume that the ER doc spoke with the patient's attending before discharging the patient

Gosh I wish we had your medical system, here you only get a Consultant Physician if you are really crook; rest of the time it's the Reg or if they have died from fatigue then a dangerously underfed, overworked and chronically burnt out House Surgeon.

Dear Jeebus, let me get into medical school so I can work in said system and earn enough money to buy a boat ...

[runswithneedles]

If she is going home, why do you need anything other than an H&P, med list and a face sheet. Nurses notes dont go home with the patient, they stay with the hospital chart and/or are faxed to thier regular doctor. Discharge papers and follow up appts, if any, should have gone home with the patients family.

My only question is this one...why is she going home by ambulance? Is she confused? Unable to ambulate? This patient should have been going home by wheel chair van or family POV if she wasn't confused and could walk. We have to show WHY the patient needs to go by stretcher in order to get paid for the trip, unless the family pays up front.

Should she have been discharged? I dont know that answer. But if I was concerned about the elevated BP and she still had a headache, I would have taken her back in and spoken with the Doc in charge.

edited for spelling

According to her physicians necessity (gotta love medicare and their ring circus) She is bed bound, has dementia (which was not stated in her half assed version of a H&P.) Requires medical supervision (though it does not state why). She cannot sit or support herself in a wheelchair due to L sided weakness caused by a CVA (age of CVA not stated in H&P)