If, in moving through your life, you find yourself lost...go back to the last place where you knew who you were, and what you were doing, and start from there. Bernice Johnson Reagon.

26 December 2011

Frequent flyers...

You know, when the ED nurses call you by your first name as you are escorted, ambulatory, into the ED, and can recite your birthday without hesitation, I think it is safe to assume you have spent way too much time in the ED...just sayin'...

22 December 2011

Implications...

Around these parts a case that happened in an adjoining county has once again made the news. You can go to the WRAL TV5 website and see this report, with links to several more.

Basically, EMS was called to the residence, something occurred between the responding paramedic and the patient, he was not transported, and he died a short time later. That is basically what I know of the call. Other than the legal maneuvering that has gone on in the aftermath. That report can be found here.

So...yesterday I put up a status update on Facebook hoping to generate a little discussion. And it worked. Of course, it was sort of one sided. Kind of a "yeah, he screwed up, but they are throwing him under the bus" sort of thing.

Again, I am not privy to the facts, except as reported, and of course what I have heard from folks who worked in that county at the time. Yes, some mistakes were made, and we will never really know exactly what happened that afternoon. There are two stories, and I think what actually happened is somewhere in the middle.

But, I am sort of reminded of my experience years ago with a patient who refused treatment and transport and was dead within 90 minutes of his signing of the refusal form.

The dispatch was for an 'unconscious person'. After traveling the 14 or so miles out into the rural countryside, as we arrived, I saw an older man walking across the road to a small house, waving us down. When my partner and I entered the living room, I immediately headed to the older female who was lying on the sofa, since she looked like she was pretty sick. She then pointed me to the older man, who was seated in a chair.

He looked worse.

Pale, ashen, diaphoretic. A little cyanosis around the mouth and the hands. And what seemed like labored breathing.

Yep, seen that before. It wasn't good those other times, either.

Long story short, over the next 45 minutes I begged and pleaded with this gentleman to allow me to treat him and take him to the ED. I did get a pulse check (cool and clammy skin with a weak and irregular pulse) and a capillary refill check (a little over two seconds). He adamantly refused a blood pressure check and an ECG (although I could not have run a 12-lead with my now-classic Marquette 1200 'boat achor').

Finally, his wife said "Why don't you just do to the damn hospital?" To which he replied "Naw, God dammit, I ain't. And ya'll can get the hell out of my house!"

He did agree to sign my refusal (and I bet his signature is still embedded in that aluminum clipboard). We went back to the station and I sat down to write (yes, write...we used to have to do things that way) my call report.

And a short time later, we were dispatched to the residence again.

There was no one outside to wave us down this time. I heard the crying from the front yard. His wife was still on the sofa. "He's in the kitchen." There he was, prone on the floor. He had gotten up to get a glass of water and collapsed as he was drinking it.

We started the code, according to the latest guidelines at the time. We had to wait for a neighboring agency ambulance to arrive to help us out (30 minutes later). We emptied the drug boxes (because that is what we did in those days) and transported to the nearest ED about 20 miles away.

Twenty-four milligrams of epinephrine 1:10,000. 300 milligrams of lidocaine. Three milligrams of atropine. 100 mEq of sodium bicarbonate. The maximum dose of bretylium (I don't remember how much that was). 3,000 ml noraml saline. Two IVs. A well placed 7.5 ET tube. And he's still dead.

Word got around fast. At that time, there were only about 15 practicing paramedics in the county. We were a small, tight knit group. And there were a couple of folks at the local hospital who did not count me as one of their favorite people (it may have been my outspokenness, or maybe my winning personality). They were looking to blame this man's death on my cold heartedness.

Remeber that call report? Well, I had documented that I had offered to provide an assessment that he repeatedly refused. I had documented my dozen or so offers to take him to the hospital that he refused. I documented that I had told him that I thought he was having serious medical issues (I actually told him 'heart attack') and that if he did not go to the hospital he could die. And I documented that he repeated it back to me.

And I documented, word for word, what he told me when we finally left.

The medical director reviewed the call, and contrary to what some other folks wanted, he found that I did nothing wrong, that I had handled the call well, and that was that.

All because of a thorough call report narrative.

Now, I don't know the details of what happened in Orange County, but I have to ask this- was there a good call report written? Did he document attempting to contact paraents, neighbors, or school officials? Did he document that the patient, although a minor, had demonstrated capacity to udnerstand the consequences of not going to the hospital? Did he document a thorough assessment, to include more than one set of vital signs, lung sounds, and an ECG?

I don't know. But I do know that a good call report can save your ass, while a bad one will leave it hanging.

10 December 2011

There is more than one way to skin a cat, so they say...

Recently I had the opportunity to meet a very nice older lady who was complaining of chest pain. In my EMS system, that gets you 324mg of aspirin pretty darn quick. Usually, the firefighters have given before I get there, but on this occasion they had not.

Allergy.

I asked the nice lady about her allergies and she told me that she was allergic to Benadryl and aspirin. She said Benadryl made her sleepy and that aspirin upset her stomach sometimes.

Just about that time my partner handed me the 12-lead ECG that displayed ST elevation in V1, V2, and V3, with reciprocal changes in II, III, and aVF. Add to that her being pale, diaphoretic, and more than a little restless….

So, I told her that it was really important that she take the aspirin for her heart, and she quickly told me she could not take it because she was allergic to aspirin.

OK… plan ‘B’.

Me: “OK, tell you what. Let’s try this newer drug that works just like aspirin.”

She: “OK. Because I am allergic to aspirin. What’s this new drug called?”

Me: “It’s called acetylsalicylic acid. It’s abbreviated ASA.”

She: “OK.” (chews them up)

She: “These sure do taste like aspirin.”

Me: “They do taste like aspirin. But they are acetylsalicylic acid.”

She: “That’s fine. You know what’s best, young man.”