The call is for a possible stroke -- a fifty-year old cancer patient can't move her right side.
I'm thinking it's not a stroke. Maybe weakness, maybe a tumor. But it could be a stroke. We'll see when we get there.
The woman is lying in bed. Her eyes look up at me as I come through the doorway. She is alert, her skin is warm and dry. She looks scared.
She was fine a half hour ago, she says when she took a nap. She woke up and now can't move her right arm or right leg.
Her right arm lies lifeless at her side. She can't squeeze my hand. I lift the arm up and it falls back to the bed. She can't lift her right leg, but when I have her try to push against my hand, I feel some force against it, like the strength is coming from her hip. Odd.
Her speech is clear. No facial droop. Never had anything like this happen before.
Her only history is breast cancer that was cured, and then a year ago, cervical cancer. She's undergoing chemo. And now she can't move her right side. Fifty years old
We lift her up onto our stretcher. She can't weigh more than a hundred pounds.
Out in the ambulance, I check her out. Her heart rate is in the 130's. Her BP is 110/70. Lungs are clear.
No headache. Pupils are equal and reactive. Her right arm is still flaccid. Odd.
I check her other arm for a vein and don't see much. She tells me she has a port.
Okay, I say. I'll let them use that at the hospital. Spare you a needle.
Thanks. I've had my share of needles lately.
I do have to check your sugar, I say. It's just protocol. You ever had any sugar problems? Diabetes?
No.
It's a little prick in the finger. We have to do one on all possible stroke patients. I don't do it, they'll ask what your sugar is, and I'll say, I don't know, but your not diabetic, but they'll still need to do it anyway. Its best to just do it.
Okay.
I prick her finger and squeeze out a little drop of blood. I press the glucometer strip against it, and watch as the blood is sucked into the strip, and the machine starts its countdown.
5, 4, 3, 2, 1. Reading -- 66.
Okay, that's interesting. Your sugar is a little low. Not greatly so -- the normal range is 70-110 -- but a little low. Have you been eating?
Not much. I haven't had an appetite.
Well, protocol again. I really should put in an IV and give you a little sugar water. Just to cover all the bases. So we can rule out your sugar being the cause, which I doubt it is. I've had patients I thought were having massive strokes only to find their sugar down in the 20's, but 66 isn't very low.
If you have to, she says.
All I can find is a thin vein in her hand, which I thread a 24 into.
I squirt out half an amp of D50 into the sharps box, and then stick the needle into a 250 bag of saline and draw out 25 cc. I shake the new mix of 12.5 grams of D25 up and then push it through the saline lock. It flows easily. When I am done, I toss the bristojet into the sharps box, and pick up my clipboard to notate it.
As I am writing, I feel a tap on my leg.
I look over at the patient.
"Hey, look at this," she says. She kicks her right leg up and down and waves her right arm, squeezing her hand in and out, in time like a vaudeville performer.
She has a smile on her face like a little girl at a magic show.
Friday, September 28, 2007
Tuesday, September 25, 2007
Nephews
For years I have been on the regional medical advisory council. One of our responsibilities is to come out with the regional paramedic guidelines. It is always very exciting for me to get to use a new guideline for the first time. I think we worked on this for so long, went though many drafts and discussions and now here I am actually putting our work into play.
I remember the thrills of giving ativan on standing orders for a seizure for the first time, utilizing the spinal immobilization guidelines where I no longer had to put a collar around their neck and strap to a board every patient from a fall or MVA, and ceasing a futile resuscitation after 20 minutes of ACLS. Recently I gave Zofran for nausea for the first time and was able to give up to 15 mg of Morphine for pain on standing order.
I think wow all that effort around the meeting table actually made a difference here on the street.
***
Last week we got called to a person collapsed with no pulse. Okay, I told myself, I'm going to get a tube. I haven't had one for a while. This will be my first tube under our new regional intubation guidelines. After much discussion our committee decided to limit the number of intubation attempts to 2. An attempt is defined as putting the blade in the patient's mouth. You do it twice and don't get the tube, you use a rescue airway or allow a second medic one attempt. (There is an exception clause, which permits another attempt, but requires significant justification). I usually always get the tube on the 1st or 2nd attempt, but still there have been a couple times I have had to go in again. I ask myself, what will I do if I don't get the tube on the first two attempts. Will I go to the LMA or will I try again. I didn't particularly agree with the committee's decision on this one but I did agree with their point about if you are going to intubate, give yourself your best chance to get the tube -- set up right, get the head in proper position, have suction available, have the bougie out if needed. Don't just go in blindly.(I guess the literature shows the more intubation attempts the worse outcomes and greater the trauma to the patient.)
As we approach, we get updated. CPR in progress. Oh, yeah, and by the way, the patient weighs 500 pounds.
When we pull into the driveway I see a woman rolling on the ground screaming. A man approaches us, waving to us to hurry. He is in tears.
I get out of the passenger side, open up the side door and jump in the back. I detach the portable suction and grab a bougie, which lays on the counter and put them both on the stretcher where I already have my monitor, 02 and house bag secured. I jump back out, go around to the back and help my partner pull out the stretcher. The man tells us the patient -- his aunt dropped in the garage when a car backfired as it was pulling out. As we wheel around the corner we survey the scene -- a huge woman lies on her back. One police officer is doing CPR -- standing up straddling the patient, while another works the ambu-bag. Around them are several young men, who we learn are nephews, all anxiously asking how is she doing? How is she doing?
I apply the monitor -- asystole. The officers says they got in one shock, but the last check showed no shock advised.
I go to the airway now. The patient's head is purple and as large as I have ever seen a head. I learn she is only 40, but has a significant heart history. I strap the tube holder around her neck in preparation, then larengyscope in hand, a number 8 tube laid on a wrapped to the side, I try to open her mouth. She has protruding teeth and her jaw is heavy. I can barely open the mouth, and slide the blade in. Thankfully, there is no vomitus. I lift up and gaze in at the now lit airway. I can't see anything. I move the blade to the left and lift higher, moving the tongue out of the way. Again, I am in luck it is not the biggest tongue. At least there is room to pass a tube -- only there is no view of the chords. I can just make out the epiglottis. But time is running out and there goes my first attempt.
It's back to the ambu-bag.
"How's she doing? Is she breathing?"
I ask for a pillow to put under her head. I attach the capnography filter to the end of the ET tube and reach for the boogie. Here goes. I go in again. Again all I see is the epiglottis. I pass the bougie running it along the epiglottis till the tip disappears from view and then I feel the bumps of the tracheal rings. I realize only now that I have forgotten to place the tube over the bougie. No matter. I place it over the bougie and thread it down until it stops. I crank it to the right with a twist and have my partner pull the bougie which is now sticking out of the top out. I look at the monitor and am thrilled with what I see.
insert strip
The tiny oscillations of CPR. I'm in. I attach the ambu back. Good wave form. Check lung sounds. Equal.
I struggle to attach the tube holder, but it won't fit around her head. My partner hands me some tape and I finally get it secured.
"How come your not going to the hospital? How's she doing? Sir, can you tell us?"
What follows is chaos.
The crowd of nephews more seeming to arrive with each minute presses in on us. I send my partner for the board, and while on one hand I want the officers to hold the crowd back, on the other we are going to need them to help lift the patient. I also need to get an IV, but she has no neck and in the dimness of the garage I can't see any veins. I'm thinking let's get her in the ambulance and then maybe I can get something.
We still don't have the EZ-IO yet, so my only choice is down the tube with epi, which I do. Still asystole.
We need to tie straps to straps to get them to fit around the patient. I am still amazed that the officers switching on and off CPR are able to do CPR on their feet. The woman's sternum must be two and a half feet off the ground.
We finally get her rolled onto the board and strapped. The board starts to break apart as we lift, my partner and I, the two officers and at least five crying nephews, but we manage to get it on the stretcher and then with the same muscle power get the stretcher up. I am holding the tube. My eyes on the monitor.
insert strip.
Still good wave form. Thank god for capnography.
In the ambulance, one officer does CPR, while my partner bags and I look for an IV. The other officer sits in the driver's seat, ready for the word to go. I tell the other officer I'll cut him loose as soon as I get an IV and get some drugs in. The back door opens and a nephew jumps in. How's she doing? You need to get out. Why aren't you going to the hospital? The other officer says we better get moving, they are going nuts out there. I get the flash and start slamming in epi and atropine. I take over CPR while the officer gets out. We're on our way.
I look out the back window and see the other officer following us in his cruiser and behind him a caravan of speeding nephews.
The capnography is up to 70. I see an organized rhythm.
insert strip
But I can't feel a pulse -- there is no place to even attempt. No neck. I would have to cut her pants to get to a femoral if I could even find that, plus it is hard enough just keeping her on the stretcher with her belly shifting its center of gravity with each turn. The officer is doing a great job of driving slow. I look out the side window and see one of the nephews has overtaken the police officer behind us and is driving parallel to the ambulance, trying to see what is going on. I feel like I am in a movie chase scene -- a wagon train being overtaken by Indians or an undercover hero being chased by foreign agents.
The capnography drops down to 18, and now there is no question but to do CPR again. More epi and atropine. I try to patch to the hospital, and as I give the report, we go around a corner and the patient shifts on the stretcher and my legs are pinned between the body and the bench seat. I'll tell you the rest at the hospital, I say. Is the patient intubated? they ask. Yes! I throw the radio down. And with great effort manage to center the woman back on the board.
At the hospital the back door opens and the nephews pile in. How's she doing? Easy, I say.
Again, we need them to help ease the patient out of the back. I have to shout at them to pull out slowly. The capnography wave form is still looking good. I know the tube is still solid.
Into the ER we go, nephews and all. They have us go to one room, but it is too small, so we parade back through the ER to another room, we finally slide the patient onto their bed, and the nephews are lead from the room by the officers and security.
The patient is asystole. The total down time is deduced at almost forty minutes now. The physicians argue about whether to declare the patient dead, which they do.
A tech comes up to me and says he gives me credit for bringing the patient in and not calling her at the scene.
I don't even bother to explain.
Sorry, nephews, your aunts dead. We're not going to the hospital. Ashes to ashes. We're out of here.
I don't think so.
Later one of the nephews tearfully thanks me for our efforts. Another walks by seething and says nothing.
***
I am glad for many things. For getting the tube. For bougies and wave form capnography. Ten years ago, I wouldn't have gotten the tube and that would have made the situation that much more stressful.
I'm grateful that we will be getting the EZ-IO on our trucks, although I wish it was now and not "soon." Maybe if I could have gotten earlier IV assess the drugs might have brought her back and not just produced a temporary rhythm and possible marginal cardiac output.
I'm glad no one was hurt on the call.
I'm glad I'm not 500 pounds.
I'm glad that she was as loved as she was.
I remember the thrills of giving ativan on standing orders for a seizure for the first time, utilizing the spinal immobilization guidelines where I no longer had to put a collar around their neck and strap to a board every patient from a fall or MVA, and ceasing a futile resuscitation after 20 minutes of ACLS. Recently I gave Zofran for nausea for the first time and was able to give up to 15 mg of Morphine for pain on standing order.
I think wow all that effort around the meeting table actually made a difference here on the street.
***
Last week we got called to a person collapsed with no pulse. Okay, I told myself, I'm going to get a tube. I haven't had one for a while. This will be my first tube under our new regional intubation guidelines. After much discussion our committee decided to limit the number of intubation attempts to 2. An attempt is defined as putting the blade in the patient's mouth. You do it twice and don't get the tube, you use a rescue airway or allow a second medic one attempt. (There is an exception clause, which permits another attempt, but requires significant justification). I usually always get the tube on the 1st or 2nd attempt, but still there have been a couple times I have had to go in again. I ask myself, what will I do if I don't get the tube on the first two attempts. Will I go to the LMA or will I try again. I didn't particularly agree with the committee's decision on this one but I did agree with their point about if you are going to intubate, give yourself your best chance to get the tube -- set up right, get the head in proper position, have suction available, have the bougie out if needed. Don't just go in blindly.(I guess the literature shows the more intubation attempts the worse outcomes and greater the trauma to the patient.)
As we approach, we get updated. CPR in progress. Oh, yeah, and by the way, the patient weighs 500 pounds.
When we pull into the driveway I see a woman rolling on the ground screaming. A man approaches us, waving to us to hurry. He is in tears.
I get out of the passenger side, open up the side door and jump in the back. I detach the portable suction and grab a bougie, which lays on the counter and put them both on the stretcher where I already have my monitor, 02 and house bag secured. I jump back out, go around to the back and help my partner pull out the stretcher. The man tells us the patient -- his aunt dropped in the garage when a car backfired as it was pulling out. As we wheel around the corner we survey the scene -- a huge woman lies on her back. One police officer is doing CPR -- standing up straddling the patient, while another works the ambu-bag. Around them are several young men, who we learn are nephews, all anxiously asking how is she doing? How is she doing?
I apply the monitor -- asystole. The officers says they got in one shock, but the last check showed no shock advised.
I go to the airway now. The patient's head is purple and as large as I have ever seen a head. I learn she is only 40, but has a significant heart history. I strap the tube holder around her neck in preparation, then larengyscope in hand, a number 8 tube laid on a wrapped to the side, I try to open her mouth. She has protruding teeth and her jaw is heavy. I can barely open the mouth, and slide the blade in. Thankfully, there is no vomitus. I lift up and gaze in at the now lit airway. I can't see anything. I move the blade to the left and lift higher, moving the tongue out of the way. Again, I am in luck it is not the biggest tongue. At least there is room to pass a tube -- only there is no view of the chords. I can just make out the epiglottis. But time is running out and there goes my first attempt.
It's back to the ambu-bag.
"How's she doing? Is she breathing?"
I ask for a pillow to put under her head. I attach the capnography filter to the end of the ET tube and reach for the boogie. Here goes. I go in again. Again all I see is the epiglottis. I pass the bougie running it along the epiglottis till the tip disappears from view and then I feel the bumps of the tracheal rings. I realize only now that I have forgotten to place the tube over the bougie. No matter. I place it over the bougie and thread it down until it stops. I crank it to the right with a twist and have my partner pull the bougie which is now sticking out of the top out. I look at the monitor and am thrilled with what I see.
insert strip
The tiny oscillations of CPR. I'm in. I attach the ambu back. Good wave form. Check lung sounds. Equal.
I struggle to attach the tube holder, but it won't fit around her head. My partner hands me some tape and I finally get it secured.
"How come your not going to the hospital? How's she doing? Sir, can you tell us?"
What follows is chaos.
The crowd of nephews more seeming to arrive with each minute presses in on us. I send my partner for the board, and while on one hand I want the officers to hold the crowd back, on the other we are going to need them to help lift the patient. I also need to get an IV, but she has no neck and in the dimness of the garage I can't see any veins. I'm thinking let's get her in the ambulance and then maybe I can get something.
We still don't have the EZ-IO yet, so my only choice is down the tube with epi, which I do. Still asystole.
We need to tie straps to straps to get them to fit around the patient. I am still amazed that the officers switching on and off CPR are able to do CPR on their feet. The woman's sternum must be two and a half feet off the ground.
We finally get her rolled onto the board and strapped. The board starts to break apart as we lift, my partner and I, the two officers and at least five crying nephews, but we manage to get it on the stretcher and then with the same muscle power get the stretcher up. I am holding the tube. My eyes on the monitor.
insert strip.
Still good wave form. Thank god for capnography.
In the ambulance, one officer does CPR, while my partner bags and I look for an IV. The other officer sits in the driver's seat, ready for the word to go. I tell the other officer I'll cut him loose as soon as I get an IV and get some drugs in. The back door opens and a nephew jumps in. How's she doing? You need to get out. Why aren't you going to the hospital? The other officer says we better get moving, they are going nuts out there. I get the flash and start slamming in epi and atropine. I take over CPR while the officer gets out. We're on our way.
I look out the back window and see the other officer following us in his cruiser and behind him a caravan of speeding nephews.
The capnography is up to 70. I see an organized rhythm.
insert strip
But I can't feel a pulse -- there is no place to even attempt. No neck. I would have to cut her pants to get to a femoral if I could even find that, plus it is hard enough just keeping her on the stretcher with her belly shifting its center of gravity with each turn. The officer is doing a great job of driving slow. I look out the side window and see one of the nephews has overtaken the police officer behind us and is driving parallel to the ambulance, trying to see what is going on. I feel like I am in a movie chase scene -- a wagon train being overtaken by Indians or an undercover hero being chased by foreign agents.
The capnography drops down to 18, and now there is no question but to do CPR again. More epi and atropine. I try to patch to the hospital, and as I give the report, we go around a corner and the patient shifts on the stretcher and my legs are pinned between the body and the bench seat. I'll tell you the rest at the hospital, I say. Is the patient intubated? they ask. Yes! I throw the radio down. And with great effort manage to center the woman back on the board.
At the hospital the back door opens and the nephews pile in. How's she doing? Easy, I say.
Again, we need them to help ease the patient out of the back. I have to shout at them to pull out slowly. The capnography wave form is still looking good. I know the tube is still solid.
Into the ER we go, nephews and all. They have us go to one room, but it is too small, so we parade back through the ER to another room, we finally slide the patient onto their bed, and the nephews are lead from the room by the officers and security.
The patient is asystole. The total down time is deduced at almost forty minutes now. The physicians argue about whether to declare the patient dead, which they do.
A tech comes up to me and says he gives me credit for bringing the patient in and not calling her at the scene.
I don't even bother to explain.
Sorry, nephews, your aunts dead. We're not going to the hospital. Ashes to ashes. We're out of here.
I don't think so.
Later one of the nephews tearfully thanks me for our efforts. Another walks by seething and says nothing.
***
I am glad for many things. For getting the tube. For bougies and wave form capnography. Ten years ago, I wouldn't have gotten the tube and that would have made the situation that much more stressful.
I'm grateful that we will be getting the EZ-IO on our trucks, although I wish it was now and not "soon." Maybe if I could have gotten earlier IV assess the drugs might have brought her back and not just produced a temporary rhythm and possible marginal cardiac output.
I'm glad no one was hurt on the call.
I'm glad I'm not 500 pounds.
I'm glad that she was as loved as she was.
Sunday, September 16, 2007
Hyperexcitability and Abnormal Movements
The 84 year old woman, who lives at home, says she is light-headed, feels shaky and is seeing white spots, but she really doesn’t want to go to the hospital.
“Well, if you are light-headed, feeling shaky and seeing white spots, you need to go to the hospital,” I say.
“Okay,” she says.
That was easy.
We get her in a Johnny top and on the stretcher. Out in the ambulance, I do a 12 lead and a full assessment. She has a sinus rhythm with occasional PACs and a right bundle branch block. No ST elevations. Her lungs are slightly decreased, but it could just be that my hearing is slightly decreased. Her skin is warm now, although she says she felt sweaty earlier. Her abdomen is soft, her grip strengths are equal.
Her blood pressure is 180/100. Her heart rate is in the 90’s. She is Satting at 95% so I put her on a cannula at 2 lpm.
I try to get a history, but she is 84, partially deaf and a poor historian.
On the way to the hospital, I notice that she seems uncomfortable.
I ask her is she is in pain and she says her back hurts. Is this new pain or old pain?
I have arthritis, she says.
So you have had this pain before?
What?
The pain.
She is holding her belly and looks like she is trying to sit up more, so I undo the belt and slide her up, but it doesn’t seem to help. She seems very anxious.
I am starting to get concerned, but no matter what I ask, I can’t get a good answer.
I’m going to throw up, she says.
I quickly grab an emesis basin, and while she belches, I take out the med kit and pull out an ampule of Phenergan. I draw up 12.5 mg and dilute it in 10 cc of NS. I tell her I am giving her something for her nausea as I push it slowly through the saline lock I put in her arm.
We are just a few minutes from the hospital now so I tell her I am going to call the hospital and tell them we are coming.
My patch starts out routine. “I’m four minutes out with an 84 year old female complaining of light-headedness, shakiness and seeing white spots...” But as I am talking she is changing in front of my eyes. She gets a crazy unfocused look. She seems like she is trying to come off the stretcher, but doesn’t seem to have control of her left side. She arches her back and is grasping at her chest with her right arm.
I don’t remember what I say on the rest of the patch, something about the patient is going nuts and I’m not certain what is going on.
When we get to triage the patient cannot follow commands, her left side is weak, she is moving strangely, almost spastically, and she is still nauseous. If I ask her a question, I get a nonsensical answer. She is completely altered. Her skin is also diaphoretic and she looks quite pale.
We get her into a room and the nurse gets a doctor and as I relate the history, he assesses her. He runs through the same diagnostic possibilities I had thought of – everything from throwing a clot to MI to AAA.
I did give her some Phenergan – 12.5 for her nausea, I say.
Phenergan? He says.
Yeah. Phenergan 12.5
Was she like this before you gave her the Phenergan?
No, she was a little crazy, something was going on, but she wasn't like this. She could talk to me at least.
It could be the Phenergan, he says – it’ll make them do this.
Really? I've seen it makes them very lethargic, and I know it can produce a produce a dystonic reaction, but nothing like this.
***
I see the nurse the next day. I ask her about the patient. The CAT scan was clean. As soon as the Phenergan wore off, she was alert and oriented with equal neuros. Still, they admitted her for observation. She did after all have that problem about being light-headed, feeling shaky and seeing white spots.
***
I check the drug appendix for Phenergan at the back of my protocol book.
Under side effects, it says: “May impair mental and physical ability.”
Under contraindications, it reads “Hx of prior idiosyncratic/hypersensitivity reactions to Phenergan.”
I hope they tell her to remind any future paramedics who offer her Phenergan that she now apparently is one of those people who have had an idiosyncratic/hypersensitivity reaction to Phenergan.
I talk to some other medical people who have witnessed the same phenomenon in patients, particularly elderly. Phenergan can make them go crazy, they say.
The link below on Phenergan side effects mentions "Hyperexcitability and abnormal movements."
***
Next time, I give Zofran.
(Or if I am out of Zofran, for the elderly at least start with 6.25 mg of Phenergan instead of the full 12.5 mg.)
“Well, if you are light-headed, feeling shaky and seeing white spots, you need to go to the hospital,” I say.
“Okay,” she says.
That was easy.
We get her in a Johnny top and on the stretcher. Out in the ambulance, I do a 12 lead and a full assessment. She has a sinus rhythm with occasional PACs and a right bundle branch block. No ST elevations. Her lungs are slightly decreased, but it could just be that my hearing is slightly decreased. Her skin is warm now, although she says she felt sweaty earlier. Her abdomen is soft, her grip strengths are equal.
Her blood pressure is 180/100. Her heart rate is in the 90’s. She is Satting at 95% so I put her on a cannula at 2 lpm.
I try to get a history, but she is 84, partially deaf and a poor historian.
On the way to the hospital, I notice that she seems uncomfortable.
I ask her is she is in pain and she says her back hurts. Is this new pain or old pain?
I have arthritis, she says.
So you have had this pain before?
What?
The pain.
She is holding her belly and looks like she is trying to sit up more, so I undo the belt and slide her up, but it doesn’t seem to help. She seems very anxious.
I am starting to get concerned, but no matter what I ask, I can’t get a good answer.
I’m going to throw up, she says.
I quickly grab an emesis basin, and while she belches, I take out the med kit and pull out an ampule of Phenergan. I draw up 12.5 mg and dilute it in 10 cc of NS. I tell her I am giving her something for her nausea as I push it slowly through the saline lock I put in her arm.
We are just a few minutes from the hospital now so I tell her I am going to call the hospital and tell them we are coming.
My patch starts out routine. “I’m four minutes out with an 84 year old female complaining of light-headedness, shakiness and seeing white spots...” But as I am talking she is changing in front of my eyes. She gets a crazy unfocused look. She seems like she is trying to come off the stretcher, but doesn’t seem to have control of her left side. She arches her back and is grasping at her chest with her right arm.
I don’t remember what I say on the rest of the patch, something about the patient is going nuts and I’m not certain what is going on.
When we get to triage the patient cannot follow commands, her left side is weak, she is moving strangely, almost spastically, and she is still nauseous. If I ask her a question, I get a nonsensical answer. She is completely altered. Her skin is also diaphoretic and she looks quite pale.
We get her into a room and the nurse gets a doctor and as I relate the history, he assesses her. He runs through the same diagnostic possibilities I had thought of – everything from throwing a clot to MI to AAA.
I did give her some Phenergan – 12.5 for her nausea, I say.
Phenergan? He says.
Yeah. Phenergan 12.5
Was she like this before you gave her the Phenergan?
No, she was a little crazy, something was going on, but she wasn't like this. She could talk to me at least.
It could be the Phenergan, he says – it’ll make them do this.
Really? I've seen it makes them very lethargic, and I know it can produce a produce a dystonic reaction, but nothing like this.
***
I see the nurse the next day. I ask her about the patient. The CAT scan was clean. As soon as the Phenergan wore off, she was alert and oriented with equal neuros. Still, they admitted her for observation. She did after all have that problem about being light-headed, feeling shaky and seeing white spots.
***
I check the drug appendix for Phenergan at the back of my protocol book.
Under side effects, it says: “May impair mental and physical ability.”
Under contraindications, it reads “Hx of prior idiosyncratic/hypersensitivity reactions to Phenergan.”
I hope they tell her to remind any future paramedics who offer her Phenergan that she now apparently is one of those people who have had an idiosyncratic/hypersensitivity reaction to Phenergan.
I talk to some other medical people who have witnessed the same phenomenon in patients, particularly elderly. Phenergan can make them go crazy, they say.
The link below on Phenergan side effects mentions "Hyperexcitability and abnormal movements."
***
Next time, I give Zofran.
(Or if I am out of Zofran, for the elderly at least start with 6.25 mg of Phenergan instead of the full 12.5 mg.)
Monday, September 10, 2007
Evaluations
Some towns' police departments call us to check out prisoners' medical complaints, typically those suffering from jailitis. The cops get annoyed when we bring the stretcher in. He's not going to the hospital, we just want you to check him out, they say.
If you want to make the cops happy, you finesse a refusal out of the prisoner. You say: "You look okay, sign here."
But that is sort of against official EMS policy. In this state, we are required to offer treatment and transport three times before getting a refusal.
The issue of evaluations is murky. We cannot tell anyone they can't go to the hospital if they think they are sick. You have a complaint, we transport. That's the nature of the job. That's how the system is set up.
So I ask the prisoner if he wants us to take him to the hospital and he says yes. When I tell this to the sergeant, he says, "Bull-!" He isn't going to the hospital!"
I want to say, "Then why did you call us?"
It seems they want us to evaluate the prisoners so they can write in their report the patient was medically cleared, but we can't clear people. It's not in our scope of practice.
This has now been communicated again to the towns and for a little while now, we have stopped getting prisoner evaluation calls. But we do get other requests for evaluations.
We get called to evaluate the 2 year old who was locked in the car for ten minutes. We get called to evaluate the man punched in the nose. We get called to look at the scratches a woman got on her arm during a fight with another woman.
Your kid looks fine.
You got punched in the nose.
Yes, you have scratches on your arm.
The refusal form says "I am refusing treatment and/or transport against the recommendation of..."
But the thing of it is as a man of I hope some common sense I really don't want to recommend to someone that they sit in a waiting room for five hours only to be told:
"Your kid looks fine -- I mean he was only in the car for ten minutes."
"Yes, you got punched in the nose. Medical science hasn't yet figured out how to unpunch someone. Suck it up."
"Yeah, those are scratches. Don't lick them."
Legally we have to recommend treatment and transport to everyone.
"While it appears you are fine and not hurt, legally I must recommend treatment and transport to you. It's just something I have to do. It is standard policy."
The other day we get called for a fall at a business. We find two women sitting on couches in the lobby. One tripped on the escalator, the other says she hurt her knee helping the other up. Two patients, one ambulance. I'm wondering if I need another ambulance. My first question is "What hospital do you want to go to?"
"I don't want to go to the hospital," says one.
"Me, neither," says the other.
Okay...
"I just want to be evaluated," says the one.
"Me too. I just want an evaluation," says the other.
What do I say:
1. "I have nothing available today, but I can try to fit you in at 10:30 tomorrow."
2. "I can take you to the hospital and they can evaluate you there. In fact, I recommend (times 3) that you be treated and/or transported. If you refuse my recommendation (times 3), sign right here at the 'X' times one."
3. "Evaluation! Get out of here! Just go on! Get! What are you doing? Calling an ambulance for an evaluation? Go on! Git!"
What did I do? I told them I could take them to the hospital where a doctor could evaluate them or they could go see their own doctor. They shrugged and got up and walked back to their offices.
Later the first responder told me the women had been joking while waiting for us (He had slowed us down to a non-priority response.) "Good thing we're not bleeding to death."
***
I guess I have no real problem with someone wanting to know my opinion. My problem is that I am not supposed to tell them what I really think. Or can I? I don't think you need to go to the hospital, but you might want to go see a doctor or someone with more specialized training. I'm just a paramedic, and while I think I am good at my job, legally I can't give you the medical opinion you seek. If you don't want to go to the hospital with us, we just ask that you call us if you change your mind or your condition changes.
That's what I say and it usually does the job.
I don't know why I get so worked up about it.
Nature of the business, I guess.
As far as the cops go, if they don't want the patient to go, I say, well, he may not be hurt or sick, and I'm not convinced he is, but if he wants to go and you don't want him to, then I'm going to need you to sign my run form, clearing me from liability.
If you want to make the cops happy, you finesse a refusal out of the prisoner. You say: "You look okay, sign here."
But that is sort of against official EMS policy. In this state, we are required to offer treatment and transport three times before getting a refusal.
The issue of evaluations is murky. We cannot tell anyone they can't go to the hospital if they think they are sick. You have a complaint, we transport. That's the nature of the job. That's how the system is set up.
So I ask the prisoner if he wants us to take him to the hospital and he says yes. When I tell this to the sergeant, he says, "Bull-!" He isn't going to the hospital!"
I want to say, "Then why did you call us?"
It seems they want us to evaluate the prisoners so they can write in their report the patient was medically cleared, but we can't clear people. It's not in our scope of practice.
This has now been communicated again to the towns and for a little while now, we have stopped getting prisoner evaluation calls. But we do get other requests for evaluations.
We get called to evaluate the 2 year old who was locked in the car for ten minutes. We get called to evaluate the man punched in the nose. We get called to look at the scratches a woman got on her arm during a fight with another woman.
Your kid looks fine.
You got punched in the nose.
Yes, you have scratches on your arm.
The refusal form says "I am refusing treatment and/or transport against the recommendation of..."
But the thing of it is as a man of I hope some common sense I really don't want to recommend to someone that they sit in a waiting room for five hours only to be told:
"Your kid looks fine -- I mean he was only in the car for ten minutes."
"Yes, you got punched in the nose. Medical science hasn't yet figured out how to unpunch someone. Suck it up."
"Yeah, those are scratches. Don't lick them."
Legally we have to recommend treatment and transport to everyone.
"While it appears you are fine and not hurt, legally I must recommend treatment and transport to you. It's just something I have to do. It is standard policy."
The other day we get called for a fall at a business. We find two women sitting on couches in the lobby. One tripped on the escalator, the other says she hurt her knee helping the other up. Two patients, one ambulance. I'm wondering if I need another ambulance. My first question is "What hospital do you want to go to?"
"I don't want to go to the hospital," says one.
"Me, neither," says the other.
Okay...
"I just want to be evaluated," says the one.
"Me too. I just want an evaluation," says the other.
What do I say:
1. "I have nothing available today, but I can try to fit you in at 10:30 tomorrow."
2. "I can take you to the hospital and they can evaluate you there. In fact, I recommend (times 3) that you be treated and/or transported. If you refuse my recommendation (times 3), sign right here at the 'X' times one."
3. "Evaluation! Get out of here! Just go on! Get! What are you doing? Calling an ambulance for an evaluation? Go on! Git!"
What did I do? I told them I could take them to the hospital where a doctor could evaluate them or they could go see their own doctor. They shrugged and got up and walked back to their offices.
Later the first responder told me the women had been joking while waiting for us (He had slowed us down to a non-priority response.) "Good thing we're not bleeding to death."
***
I guess I have no real problem with someone wanting to know my opinion. My problem is that I am not supposed to tell them what I really think. Or can I? I don't think you need to go to the hospital, but you might want to go see a doctor or someone with more specialized training. I'm just a paramedic, and while I think I am good at my job, legally I can't give you the medical opinion you seek. If you don't want to go to the hospital with us, we just ask that you call us if you change your mind or your condition changes.
That's what I say and it usually does the job.
I don't know why I get so worked up about it.
Nature of the business, I guess.
As far as the cops go, if they don't want the patient to go, I say, well, he may not be hurt or sick, and I'm not convinced he is, but if he wants to go and you don't want him to, then I'm going to need you to sign my run form, clearing me from liability.
Monday, September 03, 2007
Better Safe than Sorry
It was twenty minutes before my crew change when the tones went off. A fall at a local restaurant. I shook my head. I had dinner out plans for the evening that were going to get shot to hell now.
Outside the restaurant we found a polite well dressed man in his sixties sitting on a bench. He was alert, but his brow was slightly clammy. His wife said as they were leaving, he told her he suddenly felt weak, and then his eyes rolled back and he keeled over. Fortunately she was able to ease him down. He was unconcious for maybe thirty seconds, but he was looking much better now, she said.
I asked a few questions. He told me he had no chest pain, no trouble breathing. He said he felt fine and apologized for troubling us. He'd been overworked lately, and probably not eating or drinking enough.
His vitals sitting were normal. We had him stand and I did orthostatics. His heart rate went up ten beats, but his blood pressure stayed the same. He asked what I thought.
It might be nothing, I said. You could go home and take it easy and make certain you get plenty of fluids (And I could make it to Outback in time for a grilled sirlon and a cold Foster's before they close for the night), and then follow up with your doctor in the morning, but then I added, that's no guarantee that it won't happen again. As much of an inconvenience as it might be for you (And no steak for me), my recommendation is that we take you down to the ED. You always have to take it seriously when someone passes out. It might be nothing, but it could be something serious. Best to get it checked out now. You know, better safe than sorry.
Okay, whatever you think is best, he said. I'm agreeable.
We chatted on the way to the hospital. I explained his 12 lead ECG looked normal, his lungs were clear, his blood sugar and vital signs were good. I talked about what he could expect at the hospital -- blood tests, another ECG. He asked a few questions, occasionally using a medical term like syncope.
You obviously have some type of medical background, I said.
No, I'm in law, he said, I've just picked it up over the years.
He was a nice man, and I had an odd feeling that I knew him from somewhere, but couldn't place him.
At the hospital, he thanked me for our care and shook my hand.
Later that night sitting in front of the TV finally having my dinner (a sandwich and a can of beer) I did a double take. There on the 35" TV screen was my patient.
"Been a victim of medical malpractice?" he snarled. "Missed work or suffering needless pain? I'm attorney XXX. I'll fight for YOUR rights!"
Better Safe than Eating Out.
Outside the restaurant we found a polite well dressed man in his sixties sitting on a bench. He was alert, but his brow was slightly clammy. His wife said as they were leaving, he told her he suddenly felt weak, and then his eyes rolled back and he keeled over. Fortunately she was able to ease him down. He was unconcious for maybe thirty seconds, but he was looking much better now, she said.
I asked a few questions. He told me he had no chest pain, no trouble breathing. He said he felt fine and apologized for troubling us. He'd been overworked lately, and probably not eating or drinking enough.
His vitals sitting were normal. We had him stand and I did orthostatics. His heart rate went up ten beats, but his blood pressure stayed the same. He asked what I thought.
It might be nothing, I said. You could go home and take it easy and make certain you get plenty of fluids (And I could make it to Outback in time for a grilled sirlon and a cold Foster's before they close for the night), and then follow up with your doctor in the morning, but then I added, that's no guarantee that it won't happen again. As much of an inconvenience as it might be for you (And no steak for me), my recommendation is that we take you down to the ED. You always have to take it seriously when someone passes out. It might be nothing, but it could be something serious. Best to get it checked out now. You know, better safe than sorry.
Okay, whatever you think is best, he said. I'm agreeable.
We chatted on the way to the hospital. I explained his 12 lead ECG looked normal, his lungs were clear, his blood sugar and vital signs were good. I talked about what he could expect at the hospital -- blood tests, another ECG. He asked a few questions, occasionally using a medical term like syncope.
You obviously have some type of medical background, I said.
No, I'm in law, he said, I've just picked it up over the years.
He was a nice man, and I had an odd feeling that I knew him from somewhere, but couldn't place him.
At the hospital, he thanked me for our care and shook my hand.
Later that night sitting in front of the TV finally having my dinner (a sandwich and a can of beer) I did a double take. There on the 35" TV screen was my patient.
"Been a victim of medical malpractice?" he snarled. "Missed work or suffering needless pain? I'm attorney XXX. I'll fight for YOUR rights!"
Better Safe than Eating Out.
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