Need ALS feedback

[Janmarie3]

I'm a BLS provider right now, I have been for 2 years...I should be ALS by now but we don't have that luxury out here. We have our medics come from 30 miles away. Majority of the time I can discern if the patient needs more then what I could do and would cancel the medic before he arrived. I was on an ALS call this morning and I felt concerned enough to keep the medic coming. But when the medic got there I was not pleased with the way he cared for the patient..maybe I'm wrong and if I'am I have learned something and if I'm not wrong then he deserved the butt chewing I gave him later on today.

We were called out ALS for a 75 y/o male having possible heart trouble. We arrived onscene and the man looked very pale and just plain sick. His chief complaint was he couldn't catch his breath and he was a little disoriented. BP was 180/100, resp were fast and shallow, he was shaky and dizzy. When I felt his pulse it was very irregular...his brother said that it was not normal for him. Any irregular heart beat is not normal to me. I put him on high 02 and after awhile he became more oriented and remembered more about the incident. He said that he had taken his meds which consisted of BP pills, blood thinners and insulin, then he sat down to eat...the room started spinning, he felt dizzy and faint. He was diagnosed with diabetes a week ago and he had a hx of heart. He also had a heart flutter. So I kept the medic coming because I wanted him on the heart monitor. We met the medic en route...he came in the Ambulance and I gave him an update on the patient. The medic looked put out in the first place and when he asked the patient if he had any pain, and patient denied any...he was just about to turn around and walk out when I asked him to check his heart, he had an irregular heart beat. He finally put him on the monitor. He noticed what I was saying, but still he turned to the patient and said that this is normal for you...we ended up transporting w/o the medic aboard. We had no incident en route except that the patient still felt he couldn't catch his breath. His brother who was riding up front was not pleased with the medic either.

Later on today we had another ALS call...in and out of consciousness, pt was alert but not oriented...same medic came out...we actually transported with him aboard but he did not do anything...no IV....no 02.

After that call was over I had a little talk with him...I don't think he was pleased with me...but it was my patients and he didn't do anything for them.

So was the Medic right in what he did and didn't do? Or was I wrong?

[Scaramedic]

No JanMarie I do not believe you were out of line in talking to the medic. Just make sure when you do address an issue do not come off accusatory, it then puts someone in a defensive mode and nothing is accomplished.

As far as the pt it could have been several things.

1. Most obvious, he took too much insulin and his BS was low. Easily ruled out by a Glucometer or even a chemstrip.

2. When you said his pulse was irregular was it fast or slow. Many diabetic pts are put on Beta blockers, and you mentioned a BP medication in your scenario. Beta blockers can lead to decreased heart rates which then can lead to arrhythmia's since the heart itself is getting ischemic from lack of blood.

3. You can also get a mixture of points 1 & 2. Normally when a diabetics blood sugar decreases the heart increases to make up for poor energy use. Beta blockers will stop this increase making the pt even worse off then in a normal hypoglycemic episode. Beta blockers are your "olols" propanolol (Inderal), atenolol (Tenormin), and metoprolol (Lopressor, Toprol) in case you did not know.

So in my humble opinion he should have ran an EKG and gotten a blood sugar double quick on arrival. If he failed to do this he was out of line.

Peace,

Marty

:joker:

[Janmarie3]

He never even checked his BGL and Its not in my scope to do it. And when I did talk to him, I didn't start out chewing him out...I did it in a nice way...like asking him why he didn't do certain things...but when he said that it was because he was on a 14 hours standby the night before and his shift was almost over...I guess I told him that was a poor excuse for not giving my patient his attention or even some patient courtesy.

[JPINFV]

When you say that the HR was irregular, was it an irregular rate (^--^-^----^-^--^---^ etc) which could be A-flutter, given the hx of a "heart flutter", or more of a constantly skipping beats (^---^------^---^------^---^------)(PVCs, might not be trigeminy, which a BLS treatable cause would be hypoxia)?

[Janmarie3]

ooops sorry...his pulse was so irregular that it would skip beats...it was strong enough...but it would stop...and then start again.

[JPINFV]

Nothing to be sorry about. We aren't taught about heart problems in basic class. Did the pulse quality improve with oxygen (less skipped beats)?

[Janmarie3]

Nothing to be sorry about. We aren't taught about heart problems in basic class. Did the pulse quality improve with oxygen (less skipped beats)?

No his hr remained the same it was in the 90 to 100 range, but I was concerned because it would stop when there should have been at least 3 to 4 beats and then it would start again. The only thing that improved with 02 was his color, his alertness and able to recall more of what happened to him and what he felt like. His breathing became less labored. He said he would get these fibrillation's now and then and he knew exactly when they were going to happen because the room would start spinning and he'd feel like throwing up, the shakiness...everything he described that happened to him. I don't know...I'd rather be safe then sorry....I know the medics mannerism was way out of line...but what I wanted to know is should the medic have stayed with him and monitored his heart?

When someones heart stops beating a few beats and then starts again and it remains that way throughout transport, which was a 30 minute transport...it does concern me. And the medic didn't even follow us in case there was complications. I can totally understand being tired and burned out..I run that way often but I would never compromise pt care.

[TechMedic05]

He never even checked his BGL and Its not in my scope to do it. And when I did talk to him, I didn't start out chewing him out...I did it in a nice way...like asking him why he didn't do certain things...but when he said that it was because he was on a 14 hours standby the night before and his shift was almost over.

Wow, that's just awesome. I think everyone in EMS, except a rare few, understand that sometimes you may be called near the end of shift - or, more aggravatingly, sent really really really far away on a transfer half an hour before end of shift. It happens. For those that know about it, you already know! Just do the call!. For those who do not know about it - Now you know. Just do the call! It's frustrating, yes. Guess what, being an EMS provider in the majority of systems automatically puts you at the bottom of the 'totem pole' of the world. We bow to the needs of towns, cities ["Operational Need"] as well as hospitals and nursing facilities, and even our own companies [again, "Operational Need"] who, in my experience, rarely back you up. It happens.

This case is truly a shame, in my opinion. Granted - I am in no position to Monday morning quarterback these calls - If your statement above is accurate, the responding Paramedic admits [somewhat] that s/he should've done something there.

Sorry, pet peeves.

[Ridryder 911]

Sounds like to me that the Paramedic probably seen that the patient was on some Beta Blockers and probably had a history of atrial fib, not atrial flutter. As well, since he was not hurting he is asymptomatic, and really there is nothing to physically to do. However; he was definitely wrong on his examination, assessment and even treatment skills.

For the patient was a diabetic, and had history of of some symptoms, then your obligated to assess the patient. Yes, he is definitely wrong if he did not cardiac monitor, and at least perform a FSBS and yes he should had transported!. For as oxygen therapy, that is good, but really unless it is ectopic beats, caused by hypoxemia, it is not going to change anything.

Sure at shift change, I could be grumpy too if the patient denies any changes, or has a preceding history of this, just by looking at the med.'s.. then have a basic to tell me how to perform my job, when they were not aware of the med.'s is for this condition and that >10% of the population has an irregular pulse! Some helpful hints.... don't call me out to take care of your patient, (when you are not able to) then tell me how to do it! For as a butt, chewing, I would hate to see the remainder of you after you attempted to chew my butt out.. and you were the one who called, and lacked the knowledge, experience, and skill to do anything but slap oxygen on him.... be forwarned, your name will be remembered!

EMS is a quirky thing, and there are appropriate ways to handle things, and as one that wants to advance one career, you might learn what we call "diplomacy".. offer assistance, smile, thanks guys, etc.. will get more further results. It might the same medic next time, trying to save your butt on a full arrest, trauma, etc.. as well be your preceptor, testing examiner, etc.. be careful of throwing stones ...

R/r 911

[cfaulknor]

Well Rid, the original poster stated that he *couldn't* do a blood sugar because of a scope issue, and BLS rigs don't get heart monitors... I don't think it was so much a lack of experience... Basics are not taught the difference between A-Fib and A-flutter and most of us don't know a PVC rhythm from a PVC plastic pipe... This isn't a lack of ability, it's a fault in our system. It's unfortunate that the only ALS available is over a half hour out, but the the patient would benefit from ALS care, then it needs to be there.

As for the medic, if he *stated* that his behavior and [lack of] patient care was because of an approaching shift change, it is WRONG regardless of the patients condition... That is no reason to leave... If the patient didn't need ALS after a thorough assessment (not giving a diabetic a BGL is NOT thorough) then I could understand.

My .02