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

[mobey]

I was going to make a comment about asymptomatic hypertension and medical stability, but ERDoc will just tell me how wrong I am. I defer to him. I just brings 'em.

(I don't think asymptomatic hypertension makes you too unstable to discharge from the ER). *hides*.

I tend to agree.

It is quite likely that this pt's BP will normalize over the next few days as thier medication schedule gets back on track.

Asymptomatic HTN is not an emergency which requires an ambulance trip to the ER, therefore, I would not force that on the patient.

[ERDoc]

I was going to make a comment about asymptomatic hypertension and medical stability, but ERDoc will just tell me how wrong I am. I defer to him. I just brings 'em.

(I don't think asymptomatic hypertension makes you too unstable to discharge from the ER). *hides*.

Come on asys, you've been in this job long enough. Don't doubt yourself. Overall, asymptomatic htn is not treated in the ER. Here is the link to the most recent ACEP guidelines (you didn't think I'd do all of the work for you, did you?)

http://www.acep.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8806

Basically, without evidence of end-organ damage asymptomatic htn is left for the PCP, as long as it is under 200/120 (must be sustained, not a one time reading in the ER).

As for my question of pain in ischemic strokes, most do not present with pain. The brain is not good at sensing ischemia, unlike the heart. Hemorrhagic strokes will almost always have some degree of pain associated with them.

[mobey]

As for my question of pain in ischemic strokes, most do not present with pain. The brain is not good at sensing ischemia, unlike the heart. Hemorrhagic strokes will almost always have some degree of pain associated with them.

Funny how my experience reflects this exactly, yet I have never put 2 and 2 together.

[Kiwiology]

Basically, without evidence of end-organ damage asymptomatic htn is left for the PCP general practitioner as long as it is under 200/120 (must be sustained, not a one time reading in the ER emergency department / A+E).

Bro, missed opportunity to order lots of expensive tests and ca-ching cash in on those greedy money hungry HMOs!

Haven't you passed the Part 1 Exam from the College of Kiwiologists yet?; I expect better from my Kiwiology Registrar bloody hell I need to pay for my private jet somehow!

As for my question of pain in ischemic ischaemic strokes, most do not present with pain. The brain is not good at sensing ischemia ischaemia unlike the heart. Hemorrhagic haemmorhagic strokes will almost always have some degree of pain associated with them.

See, I told you the body was super smart; it's like hey man you don't want to feel what's happening up in your noggin right now because it's getting pretty buggered which means you're more than likely going to suffer and/or end up massively debilitated so hopefully if we keep it pain free and this ischaemia continues you'll just drop dead and never know what hit you!

Oh, you gotta learn how to spell man seriously!

Edited January 25, 2012 by kiwimedic

[ERDoc]

The brain is insensitive to pain. That's why they can poke the brain and not cause pain. It is the other structures in and around the brain that cause the pain of headaches and strokes.

Oh, you gotta learn how to spell man seriously!

Sorry brah, I know my spelling is puckeroo (pakaru?), but I'm a little thick on the Kiwiology.

[romneyfor2012]

It is all about HOW you handle it, you can serve me a steak or a shit-sandwich, I prefer the steak. Here is how I would have handled it, and how I always handle it. First I try to take a pressure in the room before I load them up, it takes 30 seconds (especially if it is a short trip, and I do not want to drag all my equipment out). Many times I have found something irregular, then you simply tell the nurse, hey grandmas B/P is 200/140, do you still want us to take her. If cant take vitals in room, I usually take them in the ambulance before we leave the ramp (again, most discharges are short trips especially if going to nursing home). If I find something weird, first I double check it to make sure I am not the idiot, and then I just step back in the ER find the nurse and tell her, hey I found this, you still cool with sending them back ? Sometimes whatever I find is "normal" for that patient, sometimes it had been a while since v/s were taken, or something changed and the patient did not inform the staff because they had been there too long already and wanted out. I have never had a nurse or doctor get mad at me for asking, but I serve them steak, not a shit sandwich. As a matter of fact, I almost always get a gracious thank you.

[runswithneedles]

You have to stop and remember, other than essential medical information, the ED doesnt have to give you any paperwork. While you may think it was a half-assed H&P, at least you got something to help write your chart. The age of the past CVA is irrelevant, she has a deficit from it and that is enough. We also dont know if the ER Doc, talked to her primary before discharge.

The packet I had received from them was not normal in camparison to others I had received. Every other I had taken did have a narrative of how they got here and why. This one was boxs to check and things to circle. Very simplistic and very lacking in anything useful for my narrative to medicare. And also the hospitals in my area have a record system that if they have had surgeries or other visits their it ould combine their medical histories and drug lists from their last visit

I also didnt question the nurse. I was in my truck when I discovered her BP was the way it was. And the answers Im giving you are coming right off this patients paperwork or whatever I can manage to translate from chicken scratch to English.

And for this Im very much sorry that I cant give you guys the best info.

Good thing I just packaged and left. I wouldve served the passive agressive shit sandwich.

Sorry it has taken me so long to respond. I have been on a 48 hour hiatus of running my ass off doing homework, studying, and working. (And bouncing off the walls from my monster binges on the side)

[1EMT-P]

It sounds like maybe the ED didn't do a complete assessment. If they had then she would not have been discharged based upon her brief history & chief complaint . Instead she should have been admitted for observation on telemetry pending a CT scan of the head & follow up testing. In the future I would encourage you to review your patients vitals starting from admission to discharge, look for trends that suggest problems, also always document how you find a patient in the ED & if you do find something abnormal report it to the ED & document who you reported it to.

[nypamedic43]

The packet I had received from them was not normal in camparison to others I had received. Every other I had taken did have a narrative of how they got here and why. This one was boxs to check and things to circle. Very simplistic and very lacking in anything useful for my narrative to medicare. And also the hospitals in my area have a record system that if they have had surgeries or other visits their it ould combine their medical histories and drug lists from their last visit

This patient was going home. Why would you need a narrative and nurses notes? And what would you do with them after you get the patient home? Give it to the family? Put it with your chart so that billing can shred it when they get to that particular chart for the day or week? You knew she has had a stoke in the past and has a deficit from it. You knew why she had been taken to the ED on this particular occassion. You only really need the most basic of information to do your chart and she is only going to be billed for a ride home. And the issue for medicaid can be rectified by writing something like this...

" Patient is being transported by ambulance to her residence from the ED. Patient is going by ambulance because of history of past stroke which has left her with deficits that left her bedbound and unable to travel by wheelchair. Paitent was moved to the stretcher with bed linen and secured with 4 straps."

You need to state how they were moved and why they are going by ambulance. Those 3 sentences, or something kind of like them are all you need to get your company paid for the transfer.

It sounds like maybe the ED didn't do a complete assessment. If they had then she would not have been discharged based upon her brief history & chief complaint . Instead she should have been admitted for observation on telemetry pending a CT scan of the head & follow up testing. In the future I would encourage you to review your patients vitals starting from admission to discharge, look for trends that suggest problems, also always document how you find a patient in the ED & if you do find something abnormal report it to the ED & document who you reported it to.

Did you read the whole thread? The OP stated that the patient had had a CT done and was found to be normal. She had some asymptomatic hypertension, which as ERDoc stated above, is usually not treated in the ED and that it would probably normalize after a couple of days, when she gets back into her regular medication regimen.

Personally, if my dispatcher tells me to go to the ED, pick up a patient and take them home, that's what I am going to do. As long as that patient doesn't look like they are in distress at the time I make contact and the report that I get from the nurse doesn't red flag anything...I am going to do what I am paid to do....take them home. I dont need a complete history, nurses notes, med list or thier past surgeries. By talking with nurse prior to transport, I can get all that info, and if I cant get it, then I would talk to the family when I got the patient home.

I dont second guess DOCTOR's and NURSE's that have years more education and experience than I have when it comes to discharging a patient. I don't need them pissed off at me because I think that I know better than them...because I dont.

[DwayneEMTP]

Ter, I'm thinking that we've worked in different places if you are comfortable taking what is given without seriously considering the possiblility of having to reject a transport.

Hauling everyone I'm given isn't my job, patient advocacy is my primary job.

I had an extremely drunk patient, blew in the .6's I think that the ER hit with Haldol to control his behavior. Called my truck to take him back to detox yet I was unable to rouse him, regardless of stimulus tried. Detox will only take patients that can walk 10 steps without assistance and answer questions. I refused him.

An 80ish year old female that was being discharged home. U/a pt is clutching her chest saying that she's having a hard time breathing, like someone is sitting on her...Right? No current ECG, positive significnat history of cardiac issues, ect. I refused her until her PCP could evaluate her. Nurse says, while standing in her room, "Jesus Fucking Christ! If we call you have to take her! Now fucking take her!" I think that it turned out to be angina, but still...I'm not taking that patient to an unmonitored home. More paper, more bullshit.

Called for an unresponsive patient at a nursing home. Pt is breathing about 40 times/min, hypotensive at...something, lungs show crackles to clavicals (after sitting her up, she was laying with her bead tilted so that her head was the lowest part of her body. I think that they were trying to help her die)...DNR is for no heroic measurs only. I get to the ER at about 0300, and the nurses are pissed that I brought her, as she has a DNR. Dr. wakes up, is pissed because we brought her because she has a DNR, despite my explanation that it is very clearly heroic measures only. Pt is now sitting up, breathing much better, lucid, listening to the ER staff complain because we didn't let her die. Doc says to take her back, I refuse and put her in a bed...(at this time I wasn't really sure where the lines are drawn for them to be legally liable, so wanted to make sure that they were invested.) I wrote paper....it turned into a mess, but they never had such a conversation with me again.

I could go on, and tell more stories more or less like these..but the point is this, depending on where you live, and the quality of the local hospitals, taking each patient that you're given is not always a no brainer....

Dwayne