Friday, May 25, 2007

A lot to learn #2.....

Here we go again..... I have had the opportunity to run some decent calls here lately. But all of them have made me re-think my critical thinking skills as a prospective new Medic. I don't see myself as a sparky kid that wants to push every drug in the box and use all the nifty tools I have available. But I think that if the patients need it, well...they need it. That's what we're there for. I'll let you decide...

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.


Scott said...

Hi. I just found you through Ambulance Driver, and I am going to link to your site because this is very interesting.

I am not a doctor or medic, so I am not qualified to answer your question. (I'll be heading off to nursing school, soon.) But I did do a ton of 3rd riding in high school.

I know you had to go with what your trainer said and also not have a big argument in front of the patient. Was there any danger in giving the shot of nitro? If you saw an MI, I wonder why the other guy didn't.

Anonymous said...

The person who signs the run report is the one who has to answer that question. If the medic is the one taking responsibility, ultimately, for this patient, then you did what you could do.

You'll learn something from all the people you work with. Some people will teach you good things. Other people will do things so foolish and backwards that you'll learn how NOT to do things.

Doing your field rides as a student or with an FTO when you get hired isn't so much about doing the right thing. It's about doing what other people expect you to do, and then having them sign off verifying your competency. When you're on your own, you can do things how you want.

It's hard to arm-chair QB a call that I wasn't on. But I'll tell you this: If you rolled into a hospital in the system I work in, handed the doctor that 12-lead, and said, "We gave her an amp of D50 because her sugar was low, but nothing else."

You'll get the, "Son, do you have a learning disability" look.

Don't get fooled. A gold patch doesn't mean that someone knows how to be a good medic. All it means is that they passed the NREMT.

Tunnel vision will always plague you. It will screw you every time. But you'll make mistakes like this too. It's a not a question of whether or not you will make mistakes. It's a question of do you learn from your mistakes?

Ken said...

Hey - good article. Here's my take on it....

Looking at the 12 lead, it looks like you have significant ST elevation in V1, V2, V3 and what could be some reciprocal change in II, III, and AvF. So, if nothing else, there's at least anterior ischemia there, and potentially more. Now, who knows if it's really an MI, or an indication of hypoxia/ischemia of another cause.

In either case, I'd have treated it.

I had a similar situation this weekend, actually. Got dispatched for the unknown - looked like a panic attack, but she had some nondescript shoulder pain (which she refused to describe, too) - so I figured I'd run a 12 lead. Both myself and my medic partner (I'm a preceptee too) agreed that we didn't think it was an MI (There was no visible ST depression or anything else that raised an eyebrow) - But given that there was some odd pain, we treated it as an MI anyway. I transmitted the 12 lead and figured we were done with it.

Lo and behold....we come wheeling into the ER and I've got an entire team of nurses and a doc there waiting. Turns out that there was some T-wave inversion as well as biphasic T-waves in the precordial leads. We both missed them. Within an hour, the EKG showed 5+ mm of ST elevation in ALL precordial leads. Went to the cath lab within 45 minutes.

These things happen....

RevMedic said...

I presume that you transported that patient. What was found at the hospital? I think that I would have treated her for the cardiac. Elderly female, diabetic and all that - atypical presentation. What were her Vitals? Excellent presentation. Thanks.

Anonymous said...

A negative 12 lead doesn't always mean that the patient is not having an MI. It simply means they're not having an STEMI. 12 leads will miss a good percentage of MIs.

Blue Ridge Medic said...

To answer a few questions: I saw an MI with atypical pain. I wanted to treat it as such: ASA, Nitro, etc. Her vitals were on the low side of normal, 100/60 or something like that, can't remember now, rate and respirations were ok. Yes, the patient was transported, albeit routine traffic, to the hospital. Other than D-50, nothing invasive was done.

Anonymous said...

with a Left BBB, you CAN"T diagnose ischemia with the 12 lead, she has to go get her enzymes checked at the ED. Unless she had a really strong story for an ischemic event, I wouldn't get excited about it.

Kaylene said...

Don't forget, women present differently than men do when they have an MI. In women, any pain from the waist up and just "not feeling well", can be signs that they're having an MI. There are many in the medical field that don't know this, or who are being slow to pick up on it(or don't care).

I was an OB nurse, so I am not proficient at reading an EKG, but if you have it, you might run it by someone who does have experience in that field, and see what they have to say. I don't know if the lady needed to go lights and sirens to the ER. It seems that she was alert, oriented and talking with you all after you treated the low blood sugar. I am assuming the ER was able to look at the EKG reading, and I'm sure they were more than capable in handling it from there.

Commend yourself for picking up on what you saw and felt. You did a good job. Unfortunately, it is difficult being the new person on the block. I have personal experience with that, as well as being the youngest RN in the unit, too. You don't get much respect. I think it's wonderful for you, though, that there are medics out there that are comfortable letting you handle the situation. You can learn both ways, and learning is probably what is most important right now, if not always. Hang in there! You will do fine.

As for the problem with different medics doing things differently, welcome to medicine! As long as it's not out of the guidelines of a certain technique(i.e. sterile technique), pretty much anything goes, because we are all individuals, who develop our own way of doing things. It doesn't mean it's right or wrong, it is just personal taste. You will find that you develop your own way of doing things as time goes own.