Thursday, May 31, 2007
P.S.- Thanks for all the comments on my last couple of posts. I have talked to several other medics that I know and respect both as medics and as educators about the questionable calls of late. Through them and the comments that I have received I believe my course of thinking and treatment were right, which in turn has increased my confidence in my abilities. I thank my readers and commenter's for that....
Friday, May 25, 2007
Called out for decreased level of consciousness. Arrived to find an elderly lady sitting in a chair and you could hear the snoring from the hall. History from those on scene was non-existent, something like GERD and insomnia. We get her loaded up and start doing our thing. In the midst we find that her blood sugar is 48. OK, we can fix this, started a line and gave her some D-50 and she perked right up. Vitals were otherwise OK. She is slightly cool and very diaphoretic, both could be explained by the hypoglycemia. Her only complaint is slight, diffuse abdominal pain. I put her on the monitor and saw some depression, so I decided to do a 12-lead.
You tell me what you see, (I know that the clarity isn't that great, but it's the best I could do). Maybe I need to go back to 12-lead class, but I see depression in leads II, III, AVF, 5 and 6; elevation in V1, V2 and V3; with a left bundle branch block. She is completely alert now so I ask about her history. She has no cardiac history what-so-ever, only other things were diabetes and hypertension.
This is where me and the Medic I was working with differed in opinion. I saw an elderly lady with atypical pain and 12-lead changes who also happened to be hypoglycemic. We fixed one, and now we need to work on the other. I was proposing 325mg of aspirin and a spray of nitro, (she was already on O2), and a no-delay transport. In my mind she was a poster child for atypical presentation for MI. But, alas I was overruled. My partner saw an elderly diabetic that we fixed. He was not concerned with her 12-lead or her presentation. So we did nothing, just ran her in routine traffic and that was that. I didn't even ask him why afterwords.
So, am I right or wrong? Am I thinking correctly? Or am I the over-eager, sparky new kid? I think I am right, I think that the other medics that I have worked with are either burnt out, lazy, incompetent or scared. I don't know which, possibly a combination of all 4. Then again, sometimes I'm not so sure. This is just one call out of several here lately that me and the Medic have disagreed on the level of care that was needed. And I am usually wanting to treat the patient. Either because I think that something needs to be fixed right now, or for preventative reasons to try to head off something before it gets worse. The other thing is that I have been working with someone different just about every shift for the past month or so. So it's not just one person that this has happened with.
On the other hand, I have ran a few calls with 2 different medics that pretty much let me run the show and agreed with my decision making. One call was a trauma from a MVA that ended up coding on us. The other ended up being a head-bleed that had been down for almost 12 hours. That lady was in bad shape, she had fallen and puked. She was all bruised up and it looked like point lividity, except she had a pulse. She had also been laying in her own vomit for those 12 hours and had aspirated. I wanted to tube her but she was clenched and I couldn't get a nasal tube to pass. So I gave her a couple doses of Versed and then tubed her. The only thing either Medic did was bag the patient and hand me stuff when I asked for it.
So, do you see my delima? On one hand I am being told that I shouldn't do anything and the other we went all the way. I'd appreciate any and all comments on this matter.
Thursday, May 17, 2007
Get called out for an elderly lady that is sick, nausea/ vomiting for the past 3 days. When we get there she is just sitting on her chair, her husband fills in all the details for us, because she is stone deaf. The over-sized hearing aids are malfunctioning and a high pitched squeal is coming from one of them. We have her take it out and it makes us feel better, if not her, because she couldn't hear it in the first place.
We get her in the truck and go to work. Vitals, IV, a little O2 via nose-hose and monitor. Hhmmm... Her pressure is like 80 over nothing and she's got a rate of 32. Well, the BP could have been explained by her lack of intake and excessive output for the last 3 days, then again it could be compounded by her rate. She is pale and cool to touch, but dry. Radials are weak and her breathing is OK. History of CHF and a few other things.
We start down the road as I am thinking of exactly how I want to treat this woman. I don't know what her normal vitals are, so I don't know how far off what I am seeing now is. I've always been told error on the side of the patient, and to treat the patient, not the monitor. Another look at her and to me, she's slightly lethargic, or she could just be sleepy. Skin is not so great, and her breathing is a little faster now, but her lungs are clear. I decide on a small fluid bolus and recheck her BP. It is about 72 over nothing. 12-lead shows sinus brady, nothing else. Well, she is obviously deteriorating. I pull out the atropine and push 0.5 mg. while I am thinking I may have to pace this woman.
I take another look at the monitor screen and the little yellow blips are getting more numerous, but wait....those are the dreaded PVC's we've been taught about. OK, I can do this, check a pulse and see if they are perfusing.....nope...they are not. Damn. Change her over to a face mask and pour the O2 to her. I call for orders for Versed because she is not out of it enough to pace her without it. I get it, give it and start to try to pace her. It doesn't work. Shit, what now? The PVC's are continuing and getting worse. I am thinking she is getting ready to code on me any minute. The only other thing I can think of at the moment is R on T. OK, lidocaine first and then maybe dopamine. I pull it out and before I can push it, she goes into v-fib. Fuck me sideways. I shock her. Flatline. Damn. How in the hell can I do this own my own? I do the best I can. Luckily we are just a few minutes out from the ED. We pull in, pumping and pushing and grunting, trying feebly to bring her back. She never recovers.....
None of this ever happened. Well, some of it did, this was a call I ran, the woman did have a rate of 32 and a BP of 80. But I was driving. I am still an Intermediate, I haven't taken my state test yet, so my paramedic partner rode in with her. She is still alive. She never coded. But, if I was the medic I probably would have treated her at the time. And this could all be true instead of something that scares the living hell out of me. After the call, riding back to the station, I asked my partner if I would have been wrong to treat her. He outlined pretty much what I just wrote about. He wasn't an asshole about it, he was just talking and teaching. But in my mind, I could have killed her. I layed awake that night thinking. I realized that the classroom world and the real world are two totally different things. You can be the best in class, ace every test, know all the protocols back to front, be able to recite everything about every drug in your box, and you still don't know shit. I realized that I still have a lot to learn....