Things you've missed

[akroeze]

So I've been thinking about starting this thread for a while now and I'm just getting around to it. What have you missed that was so painfully obvious after the fact? I mean you look back and say "How could I have missed that??"

Here is mine (I've talked about it on here before):

We go for a SOB, first response car (medic) is on scene before we are. Pt has stable V/S, NRB@15lpm looks to be NSR in Lead II. C/O SOB (half sentences) and unable to ambulate without increased SOB. FR Medic states she thinks the lungs are clear but there may be some oh-so-faint fine crackles in the bases. My preceptor and I both listen and we both agree that we can't tell if they're there or not.... we both think we MIGHT hear something but don't know for sure.

Pt has a Hx of MIs but states he has no C/P at all however the last time he had an MI he didn't have pain either, just this SOB. This throws up red flags so we decide to load and go (~35min leisure drive to the hospital, less with L/S). He doesn't seem to be in much distress. We stand/pivot/sit to the stretcher. Start to the hospital L/S as a precaution though he doesn't seem to be in much distress. Talking to him for a couple of minutes and then he says he's starting to feel a heaviness in his chest. OK, assess for Nitro/ASA, get V/S, go to give the Nitro.... he won't lift his tongue....

He won't lift his tongue because he is semi-conscious.

He has a Rt deviated gaze.

Recheck V/S.... normal (little to no change from previous).

Ok, glucometer.... normal....

Ok.... this guy is having a stroke. That is what I thought. That is what I went with.... can't auscultate the lungs properly (at all) due to road noise. Look at the monitor... oh, he's throwing trigeminal PVCs.... odd for a stroke, I'll have to look that up later.

Well in the end he was having a massive MI, heart failure and flash PE. He was FULL.... and I missed it. All the Hx leading up to it... the way he presented.... I should have known what it was... it was so OBVIOUS and I missed it!

I felt really bad about that for a very long time.... I'm still somewhat shaken up by how I missed something so obvious.

Does anyone else have something like that?

[Lithium]

I'm honestly glad you felt bad about this. Not because I'm a sadistic person (well ... perhaps? haha) but mainly because it shows that you are genuinely concerned about your patient assessments, and to feel like you missed something so crucial shows that you still have room to grow and perfect your technique.

If it's any consolation, I can't recall off the top of my head any incidents where I 'missed' something that was crucial (but rest assured, there has been a few of those moments). However, many incidents come to mind where I was completely off base and wrong with my field impression. (ie. 36 y/o F whom I believed to be having a hemorrhagic stroke, was actually treated at the hospital for a catatonic shizophrenic episode with accompanying lower GI bleed :shock: _, well i guess not really treated for the catatonia, as that was previously diagnosed ... anyways)

If you think you're unsure sometimes as a PCP, just wait til you make the jump to ACP. My average scene time as a PCP was 16 minutes, as an ACP its closer to 25 or 30. Your assessment skills will become more enhanced over time and you'll be sure to leave no stone unturned.

peace

[678 Responding]

If you think you're unsure sometimes as a PCP, just wait til you make the jump to ACP. My average scene time as a PCP was 16 minutes, as an ACP its closer to 25 or 30. Your assessment skills will become more enhanced over time and you'll be sure to leave no stone unturned.

peace

25 - 30 minutes ON SCENE!? HOLY *$%& Batman!! How long does it take to do an assessment. Not trying to bash your style, but I feel that's kind of long. I mean, if someone is having an obvious MI or even unobvious like this case, collect med info, allergies, basic questions, V/S, load and go, continue your assessment and treatment on the way. Even if I spent that much time on a scene as a BLS provider, the medics would CHEW ME UP, as I would anyone else in their position. The only way I can justify spending that much time on a location would be if i had mechanical trouble (stretcher, vehicle) or arguing with the PT to go to the hospital. Like I said, not trying to bash, but just trying to make a point.

[Dustdevil]

25 - 30 minutes ON SCENE!? HOLY *$%& Batman!! How long does it take to do an assessment. Not trying to bash your style, but I feel that's kind of long. I mean, if someone is having an obvious MI or even unobvious like this case, collect med info, allergies, basic questions, V/S, load and go, continue your assessment and treatment on the way. Even if I spent that much time on a scene as a BLS provider, the medics would CHEW ME UP, as I would anyone else in their position. The only way I can justify spending that much time on a location would be if i had mechanical trouble (stretcher, vehicle) or arguing with the PT to go to the hospital. Like I said, not trying to bash, but just trying to make a point.

Your point is lost. Perhaps you aren't familiar with the terminology though. An ACP is an ALS paramedic. And, as was well explained, it takes an advanced provider longer because he's doing more than taking a pulse, respirations, and blood pressure before transporting. When you have nothing to offer the patient, then yes, you need to get off the scene. But an ACP will in many cases be providing on-scene treatment to the patient instead of making him wait through a ride to the hospital before receiving any care. After all, that is what we are there for. If that takes half an hour, so be it. It still beats waiting until they're seen by a busy ER doctor.

[Neesie]

ok. I will add my little missed "obvious" story. It makes me kinda laugh now when I think back to it.

Call was to a pedestrian vs vehicle. First crew got on scene then police called stating there may be a second pt. My partner and I responded to that for back up. Getting on scene we were met by police who stated that no there was no second pt so we decided to help out the first crew. They had pt immobilzed and doing CPR. I got tunnel vision and went straight to the pt and first crew. I helped them get the pt into the ambulance. My partner drove for them and left me on scene to gather info and pt belongings etc. Police were telling me (while I was picking up shoes, etc) that the pt was standing in the middle of the street when he accidentally stepped into on coming traffic which happened to be a semi. (pt was drunk) as I am picking things off the ground, I found a pool of blood from pt's head. Beside it I found some white/grey mushy stuff. I thought to myself "is this grey matter? I have never seen grey matter....holy crap!!!" As I look around a little more, I notice a potatoe...then another one...I look up and there is a wagon full of spuds and some of them had fallen off the wagon. SOOOO, it wasn't grey matter after all....just mushed spud! I have never had tunnel vision like that before that and never since! How embarassing!! 8-[ :)/

[Lithium]

Thanks Dust for clarifying a bit, but 678, you can think that's a long time if you like, but in reality it's not. Now, don't get me wrong, if the patient is critical (ie. severe trauma, arrest etc), you can bet your butt we will be off scene in under 10 minutes and I'll have most of my assessments and interventions performed enroute. But in those calls where there is nothing seriously wrong, I will take my time to figure out what's going on.

peace

[Ridryder 911]

Show me a medic with a total scene time of less < 30 minutes on a medical call.... and I show you something they missed or did not perform.

R/r911

[AZCEP]

Scene times need to be considered relative to the transport times.

Our average transport time is 40+ minutes. If we are on scene for 15-20, then transport for 40, have we really assisted anyone? Most of the time, probably not. Medical or trauma, chief complaint-meds if available-allergies-do they want to go to the hospital-then we are moving. Initial treatment aside, everything is done in the ambulance enroute.

[akroeze]

Just out of curiosity, what more assessing does an ACP do that a PCP doesn't?

SAMPLE

OPQRST

VS

BS

12 Lead/3 Lead

and the like

What does an ACP do more that takes that much longer for assessment?

[Lithium]

What does an ACP do more that takes that much longer for assessment?

Didn't you ride with an ALS crew? We're not saying that EVERY call should be half an hour on scene. But also please don't think we rely solely on those mnemonics to perform our assessments. The ACR will list those same mnemonics, as that is what the MoH wants to ensure was assessed.

For instance, even though that most calls are medical related, I still perform very throrough and detailed PHYSICAL assessments. No, not the typical "okay, can you squeeze my hands?" thank you!" and then have the gall to document and report that there is no deficits. I'm probably one of the few ACPs in Ontario, who on every respiratory call, will perform a complete physical chest assessment. Have you ever seen an ACP, or PCP for that matter percuss a chest? No. Why not? Beats the heck out of me ... chest percussion to me is as essential as a stethoscope. However, I won't do it in the back of the ambulance, purely because I can't hear as well. Secondly, since I'm disrobing the patient of most of their clothes anyways (and yes, women can leave their bra on) I do it in the privacy of their home, which I guess 'prolongs' my scene time. Also, what about spirometry? I've 'acquired' ( ) a spirometer, and routinely use it on these patients as well. All it takes is a few extra seconds and all I do is ask my local ER nurse for a few of those disposable mouth covers and bingo, another assessment tool. So, this patien is complain of dyspnea, you ausculate and find the lungs are pretty clear, maybe a little shallow, SPO2 is 98% on RA, what would you think? Now, after percussion, I tell you their chest sounds a little dull and their expiratory flow is diminished ... now what do you think?

As well, I really like to sit through my calls and think, absorb what's going on and try and put it all together. How many cranial nerves are you evaluating when you speak to your patient and shine a light in their eye(s)? How many of them aren't you evaluating, what does that tell you, what doesn't that tell you, and more importantly, how does it relate to the patient in front of you?

peace