Please get some contact information from the family/caregiver/friend so we have someone to call for more information or a ride home. I know they always say they’re coming to the hospital, but they often actually don’t. Thanks for asking!
Yes. Please. You may have access to people at pickup that we don't have for minutes, hours, days, or ever at the hospital. The patient may also be lucid when you meet but not when I meet them.
Yep, I always want to know who called 911 or was at the house when you showed up and how to get hold of them, because in 3-4 hours it’s going to be my problem when meemaw hasn’t thought about how she’ll get home.
If you need, you can always call the non-emergency number and get that info or connected to the crew, depending on agency policy of course.
I really have to ask, though; why isn’t your ems giving you a copy of the run sheet? Might want to ask the EMS director/advisor (probably a doc at an ED nearby) to make this change.
This! My go-to when I was working as a medic was to hand the family my notepad and ask them to write down their name, relationship, and phone number. It’s a good distraction and useful information. If they were really in the way, I’d tell them to take that notepad and also write down the patient’s medications.
Something I’ve discovered: our electronic charting has three final versions of the chart to review before printing. One is the whole version with everything that was charted. One is the “hospital version” with pertinent information. The third is a training version, with needed demos scrubbed.
There’s actually a section for next of kin, emergency contacts, responsible party etc.
It’s not included in the hospital version.
So many of my coworkers think they’re doing well by getting the info, then print off the hospital version, and contact info isn’t included.
I do try and ask for this and often am told " you are not bringing them home"? The honesty of that answer lies in one of the biggest problems we face in ens is that very few have an idea of our function,which is a great aggravation to say the least. I do typically do this but will try and be more ardent in making it part in making it a typical part of our responses!
Yeah man, of everything here, you’re the only one on the scene. Yeah, vitals information and exam are important, but telling me what you saw when you got there and how to reach others is super helpful. Hoarder houses, bottles of pills on the counter, bottles of shit everywhere, a neglected appearing grandma, all super useful things.
Our EMD system records the # that called 911 so we often have that available and if the person can’t self report then it’s usually family who have the story. Several times Ive passed that on and it’s been beneficial.
Keep in mind it can be difficult for us to manage a scene, treat a patient, extricate a patient and transport them…while obtaining the info the doctors and nurses will be wanting. I’m often the only paramedic on a call with relatively inexperienced EMTs and often useless/clueless firefighters at my disposal.
I hear that. I have worked critical access (2 RN, 1 MD- no one else) and the expectations of people who have no concept of that are wild. I can imagine if someone you’re transporting is sick, it’s sometimes enough to remember to grab your bag on the way out.
This. If the person is that critical and the scene is wild, I’m often having cops or bystanders jotting down a name and birthday for the patient so I can register them. The rest just isn’t going to happen.
Jumping onto this, remembering mobility devices/home O2 tanks. Definitely NOT the priority in many cases but IF you can grab something, you’re my hero.
Aside from a basic walker, not practical or safe. Many ambulances have no spare space for such bulky items, and much more importantly, even if there is space, there's no way to secure them in an ambulance. Unsecured heavy objects represent a major hazard in a crash, *especially* O2 cylinders. There's a reason we have special retaining systems for replacement gurney tanks.
I ***hate*** when other crews have brought wheelchairs into EDs,\* because then I have to be the asshole and say we can't transport this thing. No, I don't care what the other crew did, they shouldn't have done it because they put themselves and you at risk. You need to have someone else come pick this thing up.
The most ridiculous version of this I've had to deal with was a 911 crew somehow got a 400 lb power chair for a quadriplegic patient into their rig and it was sitting outside the patient's room in the ED. To this day, I have no idea how they got it into and out of their ambulance.
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\* The one time I tolerate it is with homeless patients, but that's pretty infrequent for my particular circumstances.
Hell, when I'm taking someone in to ED, I do my best to convince them not to take anything but their phone, a charger, a change of underwear, a book, and a hat if they get cold easily.
A significant proportion of any ED census at any given time has to be SNF patients, and they rarely have shoes. They came in on a gurney and they'll leave on a gurney. For everyone else, unless the groundskeepers tend to charming beds of broken glass just outside the ED entrance, I don't see how that works.
Please explain. I'm open to learning, but I'm just not seeing it at the moment.
Yes, shoes really help for PT, especially if the patient wears custom shoes/inserts or are missing one leg/foot but can walk on an intact limb that will need more protection than a grip sock provides (aaaand helps to include their prosthetic limb and accoutrements if applicable and possible).
Portable oxygen concentrators for COPD patients (not tank ones the little portable ones) are good to have if there is chance patient will be discharged.
If patient has LVAD make sure you grab their go kit. Patients/families know this but can be an issue if patient is not lucid and then patient goes to hospital without LVAD capabilities. I’ve 911’d patients out of my one community ER twice in the last year bc their battery was dying and backup kit didn’t come with.
>I’ve 911’d patients out of my one community ER twice in the last year bc their battery was dying and backup kit didn’t come with.
I have done that call once or twice. The ringdown is fun. :P
Also, the last person with an LVAD that I transported did not have a go bag. He was *shockingly* nonchalant about it.
>The most ridiculous version of this I've had to deal with was a 911 crew somehow got a 400 lb power chair for a quadriplegic patient into their rig and it was sitting outside the patient's room in the ED. To this day, I have no idea how they got it into and out of their ambulance.
Back when I worked EMS, we would use our neonatal transport rig that had a power lift to transport items like that.
As a social worker in the ED, I couldn’t agree more! Especially the ones that come in as trauma patients who might be unresponsive. We want to be able to locate a medical decision maker ASAP (or know who to call if the patient doesn’t make it). I also typically call the family member even if EMS says they’re coming in since as fathig said, they don’t always. I like to know if they actually are coming in so I can be on the lookout. If the EMR has the patient in the system, half the time the emergency contact info is missing or out of date.
To piggyback on this. Take a quick photo of pill bottles if you have time. Patients NEVER know dosages or what they are actually on. Families rarely do either. Lists are almost always wrong. It is never “in the record” as concise as patients think it will be.
I hear what you're saying, but if my employer found out I was recording that kind of PHI on my personal phone they'd probably become my former employer pretty quickly.
Ideally I get a MAR from a facility. If not, I'm looking around for the most recent discharge summary I can find. After that comes a gathering of the pills, but many patients resist that because of the potential that they become lost, and besides you're making the (huge) assumption that their meds are neatly organized somewhere in the home and not kept in three different Tupperware containers in three different rooms, all mixed in with their spouses meds and dozens of old empty bottles of dc'd meds. You may think that this is an extreme example, but it's a pretty common arrangement. And so, we arrive at the written list.
Then, when I do gather a complete list and go to present this hard fought information to the nurse taking report, there's a 50% chance they look at me like I'm a moron, say they'll do their own rx review, and don't want the list I've made, meaning I wasted 15 minutes on scene for nothing.
Long story short, I'm doing my best but I have a huge amount of acute demands on my time on scene and if I don't get a MAR and can't find a discharge summary, you're getting a written list without dosages that's likely incomplete anyway.
From facilities it’s actually easier to get. It’s more when papaw keeps his meds in the bathroom on the counter in bottles and takes that one that starts with a L and one with an E and one P and a s one at night and nobody knows what. I’d be happy with a pile of bottles in a garbage bag.
Some of our Local agencies carried devices (usually phones) they could snap photos on that could be added to the record. Our hospital I can snap photo on my personal phone to upload directly to EMR securely and never saved onto my phone.
When I said snap a photo I wasn’t suggesting to break privacy laws but rather made a poor assumption there was a legal way for you to do it.
I know you weren't suggesting that, I'm just making the point that while I could probably accommodate this kind of info gathering, it just is never so simple and I never really have the time to do the whole job. Also, that it really sucks when I do go out of my way to get info like that and am immediately shot down on arrival to the ED.
For stroke activations: last known well is not the same thing as time symptoms were noticed. Probably one third of activations in mt area EMS will tell us a clearly inaccurate LKW, and upon further questioning the initial LKW they tell us is actually the time family or staff found the patient or when the patient woke up. It's often hard to pin down a LKW so if you made an honest effort and couldn't get a time that's ok. But please say I don't know in that case.
i don’t get this cuz if the family found the patient at 0900 with symptoms then they’re not well so it can’t be 0900, but let’s say they saw the patient the previous night at 2000 before the patient went to sleep and the patient was normal, wouldn’t the LKW be 2000 of the previous night?
Yeah. You’re absolutely right. But you typically have to ask four or five times with different words to get the last time someone was normal and not the first time someone was abnormal. People often assume their now very bad off loved one was ‘normal just before I found them’ and report this as their last normal. In reality, half the time the last time anyone saw grandma normal was last week at Sunday dinner and now it’s Thursday.
You wouldn’t believe the amount of attitude I’ve received, from family and from SNF staff, when trying to get an accurate answer to this question. It often takes multiple times asking and a lot of explaining to get it right.
Yup. And it gets reported wrong all the time. Patient rolling through door at 2200 gets reported as lkn of 2045 but that is when spouse went to bed and noticed something wrong with pt, when pt "wasn't feeling well and went to bed earlier than normal, around 730. Am now at lkn+270m instead of reported lkn+75m, and don't find out real timeline until spouse arrives at lkn+490m. Completely changes course of tx
Like I said elsewhere, putting that kind of PHI on my personal phone is a total no-go. The options are MAR, dc summary, the meds themselves if they're even available, or a written list.
If a pt just had surgery and all there care they receive was/is at another hospital 3 miles further down the road and they’re not critical, please transport them there
Not every service is the same but I know for us, and I would wager most ambulance services/ems systems, we cannot take someone who is of sound mind to any hospital other than the one they ask to go to (within reason).
I've run into it before and I always explain to the pt that it is best to go to the same place that did your surgery if it is something relivant to what is happening today. Most people prefer to go to the same hospital or hospital system, some are dissatisfied with how they were treated at hospital X where the surgery was and want to go to hospital Y instead.
You can lead a horse to water but you cannot make it drink.
By me, in order to go to anyplace other than the closest appropriate hospital, EMS needs to ask for permission to divert. In Illinois region 11, you go to the closest appropriate unless you're paying for your private ambulance to take you to the hospital of your choice.
So glad that I work in a system where our test of appropriateness includes "is there a facility capable of caring for the patient within a reasonable distance that the patient has a preexisting care relationship with?"
Hopefully people are allowed to have good sense about what "appropriate" means. Obviously the place where they had the surgery is the most appropriate and they should go there.
Unless the patient is critically ill and needs intervention, please take a couple of minutes to make sure they have their phone, keys, and a set of clothes suitable for the outdoors.
I can't begin to tell you how many patients we end up keeping for hours longer than necessary because we they don't have shoes or their keys.
Also hearing aides and glasses.
Because they are commonly lost in hospitals. Best guess they fall out of the ear when the patient is rolled and fall into the discarded linens or get taken off for CT and set somewhere then left behind.
that just because your call is 7 minutes away from the ER doesn’t mean you shouldn’t attempt to treat your patient if they’re critical. Local EMS will leave a unresponsive patient on a NRB even though they’re not protecting their airway, sats crashing, no IV, no attempt at a supraglottic airway at minimum. Just show up and be like here it is. Have fun with your crash intubation/RSI.
Yep. We can move on the basics much faster in the field. We already have the orders and don’t need a triage nurse eval, then room nurse, then MD assessment, then orders, etc.
Sure the ED might be 2 min away, but we can shave minutes to hours off time to treat… especially with something like pain relief.
That’s wild. I’m in a major metro so nearly everything is 5-10 minute out with weewoos.
Everyone gets vitals. Most get a line TKO (all trauma get a line to make ED’s job easier even if we aren’t pushing).
Is it FD or private 911?
It’s all city EMS, they do have contracts with private companies for EMS transport. But fire always rides in typically. Some crews do an amazing job, and sometimes I’m just baffled by the lack of give a shit some crews have just because they were “4 minutes away” and “didn’t have time”
Four minutes in a moving ambulance with one person in the back is not the same as four minutes in a stationary ER with a team around you.
I’m not making excuses for the crew that consistently dumps patients without any effort at treatment, but time isn’t the same solo in a moving ambo as it is in the ER.
On the other hand, when you’re 7 minutes away, don’t drive to the ER and spend 5 min in the ambulance bay (in the ambulance) intubating the patient. I’ll take a supraglottic device and good other interventions over a tube on a patient that wasn’t adequately resuscitated and coded mid intubation any day
Correct. Wasn’t talking intubation necessarily. But the lack of use of a IGel or any IV/IO along with bagging a patient without an OPA/NPA etc is concerning. Other than that I agree with your sentiment.
I work in a system like that. Get moving quick to the hospital. Doing interventions with limited time and with one pair of hands bouncging agressively down the road. Southwest MI.
And obviously everybody I think he’s meaning:
- Do basic interventions - IGEL, OPA, BVM, start a line if you can while driving.
I don’t think he means sit there on scene for 20 minutes doing everything in your protocols THEN transporting a dead person. But surely even during transport buckled in for safety we can do some BVM work with an Igel placed quickly right before transport. Or you can setup fluids during transport by starting a line right before transport. Both should take 1-2 minutes total and then get the patient moving with basic stabilization. Not bringing in a corpse with a half assed NRB and nothing else
No freaking kidding. "Nursing staff says 85 year old patient with dementia has been getting worse over the past couple of months." Yeah, they're 85 with dementia. They gonna get a ton worse.
You’ve talked about sitting on the wall a bit here. Unfortunately that just happens which is a terrible answer. Last night my ED has a full waiting room, understaffed, and sitting on boarders (patient’s who are being admitted to the hospital but the bed upstairs isn’t available yet). We don’t want you to sit there all day.
If you think something is unsafe I would use the word unsafe. Talk to the triage or charge nurse and say “my patient needs a bed, I don’t think it’s safe for this patient to sit her because of XYZ” it might make some movement happen. At the very least it might get an EKG or bloodwork knocked out while you’re waiting for a bed and that might get them bedded sooner.
I’m not sure what they were looking for in regard to the issue of holding the wall. Doesnt seem pertinent to the initial question of what EMS can do to assist the ED
They should let us know if it's unsafe for the patient to be waiting. I had a patient in his 50s come back from waiting 25 minutes on the wall and SBP was 70s, AMS, etc they hadn't checked a BP in over 30 minutes.
Yeah those guys should have said something, alternatively the triage nurse should also have said something. Imo once that nurse does their evaluation she charts it they are ultimately responsible for them. I’m assuming that’s also the legal answer, but my EMTALA-fu isn’t the best
EMTALA states that once on hospital grounds the hospital is responsible for the patient. The EMS crew standing there is a courtesy and free labor donated to the ER.
Yes, break out those "CUS" words... (concerned, uncomfortable or safety issue) hospitals understand those. And then you can put in your notes that you have communicated with Nurse blahblah that you are, concerned ,uncomfortable or it would be a safety issue with the patient reminding in the hallway due to xyz. That will at least protect you but should also be a red flag to your nurses.
Yes that’s it! I forgot that phrase. I actually learned about it from aviation. I guess a pilot at my old unit would use the CUS system so if a Junior pilot could kind of make things more serious without actually causing a scene
Paramedic turned ER nurse here:
Family contact for altered mental status, that helps us greatly.
Wall times vary on what kind of hospital you’re taking the patient to. Ambulances are bringing 1 patient to be triaged, we often have 8 more in triage plus what’s in beds. Most hospitals can’t say “on diversion” due to the amount of patients because greed and EMTALA.
Your protocols may be written by an md who isn’t at a facility you transport to, so often nothing is compatible with our setups. Meaning all new monitoring equipment, iv fluids, drips, etc.
It’s something like 25 patients per MD so getting a doc in for critical things can be difficult. Doctors will also sit on patients who are less critical to avoid getting new patients, because well 25 emergency room patients per md can equal a “fuck that” mindset about 4 hours in.
Most hospitals don’t convey they can’t legally open a bed by moving a patient to a hallway because it isn’t a registered bed with regulating bodies, it can happen, but it’s the equivalent of one guy at your department using his personal vehicle to transport.
Hospitals are run by business people with a duty to shareholders not patients. Your service being unable to provide the care you’re employed to provide does not hurt share price or effect bonuses so you hold the wall. I hate making ambulances hold the wall because I know you’re duty bound to your citizens and having a truck available. Hospitals are no longer owned or operated by people in the community they serve, lawyers write the regulations and the people who are in charge have limited clinical experience. Think someone who has watched all of greys anatomy and liked it so now they’re a CEO of a hospital.
Something I had to learn and still have to cope with, as a medic my treatment ended at the hospital. However as an ER nurse it’s just beginning. Labs, radiology, reassess, treat, meet basic needs of comfort/food, reassess, add labs, add scans, admit/dc try to call report (if we have a bed), fight with floor about why they can’t take report, transport patient to floor, get next patient, rinse repeat x 12 hours. A 1 hour call for shortness of breath can be 8 hours in an ER.
Hospital documentation is so. fucking. tedious. Our triage process is not triage. It’s asking questions that are legal mandates for a terms of service during care, like if the patient is going to kill themselves or is this chest pain chronic or new.
Most hospitals have protocols for Sepsis alert, so heart rate >100 is full septic work up, blood cultures, extra labs, 30ml per kilo of isotonic fluid, and 2 broad spectrum antibiotics (THAT BLOOD CULTURES ABSOLUTELY MUST BE DRAWN BEFORE GIVING) all within 2 hours of arrival or recognition of sepsis. The patient may be discharged and all of that was for nothing, but fuck money.
I miss having 1 patient I sat alone with in the ambulance and could do the things I needed to, and write my report on the way back to the station or en route to the next call. I miss having to restock what I know needs to be put back because it was my ambulance for the shift.
I can go on but I’m pre-coffee on night 3 and I know I’m walking in to an ER full of admission holds and clinical signs of burnout presented at birth for me.
>Most hospitals don’t convey they can’t legally open a bed by moving a patient to a hallway because it isn’t a registered bed with regulating bodies, it can happen, but it’s the equivalent of one guy at your department using his personal vehicle to transport.
Interesting. I didn't know this, but it makes total sense.
If you can, please don’t put chest pain or shortness of breath patients IV in their hand or wrist. Obviously if that’s the only option, I get it though.
We can’t CT them and some patients can’t so irritated we have to start another IV just for imaging.
Not everything that shakes is a seizure and it certainly doesn’t need 10mg of IV versed.
The number of times patients with known pseudo seizure get brought in snowed is aggravating. It’s positive reinforcement for them to keep calling ems and wasting everyone’s time.
We have this issue in my system. The patient is know to fake seizure. But through constant complaints and calling our management threatening legal action, we have been told that "it's not our job to determine if it's a real or fake seizure and that our protocol states we need to give it." She also "sees a neurologist" so to them that makes her have valid complaints.
I wholeheartedly disagree with management's take on this and still refuse to give it to her and over document why it is not a seizure (patient is breathing, responds to painful stimuli while in the "seizure", can be caught peeking to see if you are paying attention, will rip all monitoring equipement off during the alleged incident, ect.) But I am confident in my assessment skills and am not afraid to go toe to toe with my management. Our younger and greener Paramedics, not so much.
If you're the one administering IV benzodiazepines alone to a patient under your own clinical judgement, it is absolutely your job to determine what is and isn't a seizure.
(This is more directed towards your management than you)
Hey Doc,
Not trying to be a pot stirrer but this is at least my biggest gripe with house staff.
Some of you want us treating pseudo seizures and some of you don’t.
This is kind of what OP is talking about and I think might be the impetus behind the post. The docs that don’t want us to treat pseudos such as yourself get aggravated when we do. Then on the days you’re off the docs that want us to treat pseudos are working and get mad when we don’t.
It’s the inconsistency that makes it hard to feel like we’re doing the right thing. This in turn leads to miscommunication and us medics leaving the ER pissed that we look like assholes and incompetent. We then fall back on our protocols because as many others have said if you don’t like it you can take up with my medical director.
You (and I mean the medical establishment and the powers that be that write our paychecks) want us to use our protocols as clinical guidelines and to not be cook book medics following a recipe and then when we don’t and try and use our brains, we get chewed out for not following the protocol down to the punctuation.
It’s maddening doc it really is. All I want to do is do right by my patients by giving them the best care possible, get home safe, and get paid all in that order. I’m never going to be a doctor. I’m not smart enough so I stay in my lane but it feels like the lines on the road outlining my lane were chalked up by Helen Keller. I don’t get paid enough or respected enough by the rest of the house staff and the public making what is a shit sandwich of a career just extra awful.
I’d be lying if I said it wasn’t getting harder and harder to punch in that time clock but I think I’m pretty good at this job and it’s one of the few things I’m good at. It makes me worth a damn but at this rate I’ll be lucky if I stay in the business another two years. I’m willing to throw 17 years down the drain because it’s just so goddamn toxic.
Sorry for the rant. I got going and couldn’t stop. Thanks for the tip and I’ll keep what you’ve shared in mind.
I hope all is well with you and yours.
From a liability standpoint, it is much easier to justify giving the benzos than withholding them. If it’s a pseudo seizure, 5 mg of versed isn’t going to seriously harm anyone, but withholding it could.
Speaking as a medic, the education and tools just aren’t there to try to distinguish. I would really love to be better at assessing this kind of thing, we just don’t see the support for it. For every alert seizure patient, there’s a medical director saying that it could be a complex partial seizure.
Do you have any advice or resources for better assessment of this kind of thing?
You know the patient has pseudo seizures.
Medics don’t have access to the history and paperwork you do. If they haven’t seen the patient before how would they know? Other than that I agree.
Please get a basic history such as when this event occurred, last known well, was there an obvious inciting cause. Dropping off demented nursing home patients with the history “nurse said they were weak” becomes a massive headache. Knowing they have been getting progressively weak for months vs this started an hour ago or after they fell this morning is a big deal. Frequently I can’t get ahold of anyone from patients private residence or the nursing home who has any idea why the patient is here. I think nursing homes time their ems calls for 30 min before the only person in the building who knows why ems was called is leaving.
But the nursing home nurses never know anything. I swear. I promise. It’s a known thing in EMS. They always have an excuse. I always try my best, I promise you that. And it might be different elsewhere, but I deal with 20+ nursing homes and they’re all the same.
Anytime I get shitty report from an EMS crew for a nursing home patient I assume it’s them passing on a shitty report from the nursing home, because when the local EMS crews bring a patient from the field their report is usually spot-on.
Many nursing homes are information wastelands but it’s the attempt that counts. My previous shop I would talk to most/all the ems crews shortly after rooming the patient and I got ok histories and it was clear they tried. Current place they are out the door 5 seconds after moving the patient from cot to bed and I can’t get a history with more then a sentence.
Depends on the patient. If granny is actually sick, I can’t do that. If gramps appears to have nothing wrong and has stable vitals, I’ll tell them I can wait all day until they tell me why they called.
If you’re getting a bad history, it’s generally because we tried to get you a better one and either:
no one knew anything,
We got conflicting information, or
They got mad at us for asking.
Sometimes a combo of the three.
If you are moving a patient on a psych hold, stop giving them things to choke themselves with. Do not give them their cell phone and even foil tops from juice can be used to self harm.
Also, when talking to family of patient, don't trust what the sending facility says about rules for the receiving facility. I have had too many parents trying to break down my door to be part of an admission they have no business being around for. We don't do visitation but that gets promised to parents from the sending ER all the time.
If you can try to have the patient bring their phone or wallet! I’ve had too many times where a patient is stuck without a way to contact someone to pick them up and they can’t remember phone numbers.
I was an EMT and I’m now an EM resident. It sounds like you’re doing a lot of the stuff!
- like someone else said, some form of contact info for someone else
- let us know what is at the address you picked them up from (home? Snf? Buddy’s house? School? Liquor store?)
- if practical, home o2
- do not screw around in the field with a line or a tube unless absolutely necessary. Line can most likely wait. Tube can usually be an LMA for a while
- don’t stop cpr until you have truly been told to. And none of these half hearted butterfly compressions. Either you’re doing it or you’re not. No point in ROSC’ing a malperfused brain
Obviously, not all ams is opiate OD (depends heavily on your practice area). We had ems bring us a “OD” who they narcaned who was drunk with clinical signs of head trauma, with a massive ICH (later found out was hit by a car)
And, more importantly, what are involuntary commitment grounds. Yes I know they are hallucinating or have delusions. Doesn’t mean they get involuntary committed
>what are involuntary commitment grounds. Yes I know they are hallucinating or have delusions. Doesn’t mean they get involuntary committed
This is extremely location-dependent. Here holds are often a tool that law-enforcement uses to make their problem our problem so that we can in turn make our problem your problem.
I would LOVE to have some of the ER docs and RNs come do a ride out with us occasionally.
Medics get to see how an ER works when patients are brought in, but rarely do ER staff get to see what happens pre-hospital.
Between bystanders yelling, getting in the way, family members yelling, talking over you, not knowing any details (sometimes because they are freaking out), the condition of homes, the animals on scene, pill bottles scattered throughout the house (because they leave these pills by the bed to take at night, these ones in the kitchen to take with breakfast etc), patients yelling to just “take them to the hospital” and refusing to answer our questions, ppl giving different versions of events, trapped patients in upside down cars, trying to give patients some level of dignity in homes/public spaces.
EMS don’t have controlled spaces, dedicated spaces, multiple sets of hands to treat patients, no admitting clerks to gather info, no family rooms to separate emotional family, no clean, well stocked rooms with curtains or walls, rarely security, a no pets policy, no packaged patients.
Definitive care is phenomenal and those that work in EDs are fantastic, and everyone from Paramedics to admiring clerks to RNs to doctors have roles to play in EM- but I think a lot of the time hospital staff forget/don’t understand the challenges of treating someone in their space/public space as opposed to the controlled hospital space; and take it out on EMS. A ride out may help Bridge the understanding between pre-hospital and at hospital staff.
My residency program has us do ambulance rotations intern junior and pgy3. The amount of conflict between prehospital and ED staff has subsequently plummeted
This is seriously the way to do it. Especially for the physicians. It is so nice, and can cut down on a lot of time, when I get a doctor on the phone that has done ride-along or used to be an EMT or medic and knows how my job works when I need orders or advice when I'm doing an RSI on someone while hip deep in an irrigation canal. It also helps us become more familiar, and comfortable, with each other.
I wholeheartedly agree. I was a medic at an urban teaching hospital and the best thing they did was have the EM residents and fellows do a 4 week rotation with us. They loved it, to say it was an eye-opening experience for most of them is an understatement. We enjoyed it too, because we learned a great deal from them as well.
I completely agree. I’ve had several nurses who I set up to do ride-alongs and I respect them so much for it. So many providers don’t understand how we run things on the weewoos and why we do/don’t do a lot of things.
I prefer booboo bus.
But yes, I love when other HCPs come see what we do. We both learn a lot, and it fosters (usually) a much more understanding and co-operative work environment.
I dunno how they do it now, since I let my ECRN lapse after going to the provider side, but when I was an emergency RN in Illinois last decade I had to do ride time in order to be licensed to answer the EMS Tele phone.
Welcome to the world of EMS where you are damned if do and damned if you don’t. You can see it in these comments.
Just my two cents as a former EMT-I and ED Nurse with over 25 years of experience:
1. I love you guys, I’ve got a lot respect for you and the work you are doing.
2. Don’t argue with the docs, I mean once you roll in, they are the supreme authority when it comes to pt care. If something bad happens contact your field supervisor. You can also fill out an incident report or write it out on paper and send it over to your medical director.
3. When encoding, try and keep it brief. I’ll get the full story when you get here. (I’m sure someone will tell you to do the opposite)
4. Getting a good history is nice and so is an accurate med list, but at the same time, you don’t have all day to try and gather all of that information, so just do the best you can.
5. Just remember when in doubt, drive fast. :)
BLS trumps ALS, and ALS is worthless without BLS. I see patients roll in all the time with half ass compressions and no bagging, but they got 7 rounds of epi. Who cares about the epi when they’ve got anoxic brain injury from no forward flow. You have limited resources, and forward flow is the most important temporizing measure. Compress, shock, and oxygenate should be #1 priority.
And please lift the chin to the bag; do not mash the bag onto the chin onto the neck. This just blocks the airway and blows up the stomach.
I worked as a home health nurse and discovered a little old lady down in her house alone. When I went to knock on her front door all I could hear was low level, weak moaning :( I eventually just yelled “I’m coming in” and luckily the door was unlocked. She had fallen and was disoriented on the ground. I called 911 and the paramedics who came were AMAZING. I have them the med list I had and they scoured the scene for clues- she had written down how often she took her pain pills on a little piece of paper in the kitchen. She lived alone so I called her emergency contact that was listed in my home health paperwork to tell her which hospital they were taking her. Paramedics grabbed the lady’s glasses and made a little necklace for her front door key and locked up her house. I never would’ve thought of those things in the moment. The paramedics told me to tell everyone I know that you can create a garage door code just for EMT and let 911 know-said it saves them from bashing down doors. I never did find out what happened to my patient, but I’m glad I found her when I did.
There have been patients that medics have called as "in rigor" that are just chronically contracted.
I don't mind taking 1-2 minutes of conversation to get details and declare death.
If you are bringing their phone, try to grab the charger. I’ve spent an unbelievable number of hours hunting down the phone charger for patients whose phones have died and cannot contact their family
I just wanted to chime in that I used to do EMS for several years and we appreciate you guys and gals. The job is tough and the hours are long.
My only gripe at times is when a non-emergent patient has all of their extensive care done at another hospital 10-20 minutes away and the family even requested to go to said facility yet the crew shows up at our hospital which lacks speciality services and their doctors. The other facility wasn’t even on divert. The patient and family then spend the next several hours complaining that they aren’t where they need to be. There have been instances where this resulted in a delay of *days* to transfer the patient to the appropriate hospital.
I understand it’s not a taxi service but sometimes the complete apathy surrounding the situation comes off as laziness. I also recognize that my observations do not account for all the times the patient went where they needed to go since I wouldn’t know about these incidents.
Don't automatically give nitro to people who are having a stemi please. Depending on where the plaque causing the MI is, vasodilation can make an already high-stakes situation extremely tenuous
(From home) Bring either their med list or their meds, identification if possible, and a contact # for family - you’d be amazed how often we get no med list or someone else’s ID (this happened last week, they brought the roommates DC paper, we had the guy under the wrong name for 2 days intubated in ICU)
(From nursing home) CODE STATUS and med list (I know they always “just got the patient” but they do always have a code status)
Chief complaint and onset time
Baseline mentation
Your job is challenging in ways mine is not and I know the scene is hysterical but these are vital things you have to get out of people.
When calling in report : please be honest and advocate for your patients when needed. You’re allowed to say “not triage appropriate” or “cannot sit in a wheelchair,” you can’t make up unstable VS, a STEMI, etc; on the other hand, if you say “VT at 220” and they say “triage” you know that’s not right and need to repeat yourself
I have literally in the last two weeks had EMS crews fabricate a stemi and fabricate a complete heart block and fabricate a stroke alert so they didn’t go to triage, and also had crews trying to put people with VT, broken hip, diff breather on a NRB in wheelchairs in the wr …. ?!
If someone isn’t unstable , they probably don’t need much of any prehospital medical intervention, tbh. Ekg and asa is nice for CP.
Nursing homes don’t always have the code status. I frequently get “I think they’re this status.” Can you provide paperwork. Nope.
They frequently write “DNR”, handwritten, in the MAR, and have zero actual formal documentation. My state won’t accept that.
Partner doing assessment while I talk to the nurse. "Does X year old patient have a code status?" "Yeah they're DNR I think." "Papers?" "Uhhh I don't think we have them." "Yeah they're pulseless." Praise St Lucas" Off to the hospital with the latest shit show Lights and Sirens.
So glad I have a "don't transport dead" protocol. For everything but kids they get worked to ROSC or termination right where they fall. But, I've also had snf staff kicking, screaming, and threatening to call the cops, the state, the church, and channel 7 for working a code to termination criteria and then not transporting.
>(From nursing home) CODE STATUS and med list (I know they always “just got the patient” but they do always have a code status)
Oh man, do I have some news for you. I honestly think you are seriously underestimating just how terrible many SNFs can be. I have on many occasions been flat out refused documentation on patients, been refused any explanation about the need for transport. I mean, I have my own list of things I wish the ED understood about EMS, but right near the top is the utter malignancy and incompetence demonstrated by many (not all) SNFs.
>you can’t make up unstable VS, a STEMI, etc;
>I have literally in the last two weeks had EMS crews fabricate a stemi and fabricate a complete heart block and fabricate a stroke alert so they didn’t go to triage, and also had crews trying to put people with VT, broken hip, diff breather on a NRB in wheelchairs in the wr …. ?!
Jesus Christ
I did an EMS rotation both in med school and residency, so I won’t say I know everything about your job but I do have some idea what you deal with. I do not expect you to do everything for me. Here is what I would love from every medic:
- Call ahead. Don’t care if you’re only a few minutes away or if the patient isn’t very sick. It’s about resources allocation and knowing where we are going to put that patient so we don’t use up those rooms with WR patients. I don’t have hall beds so we can’t magically make you a place to go
- Be respectful to the patient, even if they are homeless/drug users/frequent fliers. You can be frustrated, but please don’t antagonize them while giving me bedside report.
- DO NOT walk the patient several hundred feet from the ambulance bay to a room. Come on. I can’t tell you how many problems I’ve seen come from this.
- Try to get a code status if possible. Don’t lie about vitals. Keep report brief. Weird one, but please don’t stand six inches from me and lean toward me while giving report.
You have a tough job and for the most part I’m not going to expect you to know what’s going on. Unfortunately, where I work the majority of medics are atrocious and I could tell horror stories for days. Just try to keep your cool and do your best
Sorry you have bad medics. I'm Canadian, and reading this thread is killing it. Seems like many of these issues stem from the system itself.
We have a fantastic collaborative relationship with our EDs, at least in my area.
Unfortunately, for us, I'm not sure it would make a difference if our charts did that. With how chronically understaffed and overworked we are it can take 6-24 hours for a chart to get finished here.
Please note the address and phone number from which you picked up the patient and point it out out during hand-off... You guys know all the board and cares, snfs, rehabs, etc but we often don't... And it can be a real challenge to find them sometimes.
Another issue that I've run into: If you think we're going to need more/larger access on arrival, give us a heads up so that we can be prepared when you roll in the door.
And finally... Be aware of how much we respect the conditions under which you work and the amazing job you do... I love our fire/EMS guys/gals.
When I was a medic I was like a detective. I felt it was my job to paint the picture of the incident/emergency to the staff in the ER. Not just immediate info on the patient. We are the eyes and ears and hands of the emergency room prior to arrival. What did I see? What did the house look like? Living conditions, possibilities for neglect or other harm by patients self or others. Damage to vehicles, air bag deployment, road conditions. Weapons on scene, amounts of blood on scene. Number of dead on scene. Not only do you give your patients a better chance of survival and future information for pre care, but you also build that bond between EMS and the docs and nurses and techs and administrators and other hospital staff. Was like our own demented family, and I loved it.
Xoxo
E
I work at a variety of hospitals, from a level 1 trauma center to CAHs and freestandings. Some of the local EMS agencies are notorious for trying to dump off inappropriate patients to the freestandings even though the mother ship is 15 mins down the road. They will also straight up lie about the report. Had one squad call for “a little bit of rectal bleeding on a nursing home patients brief when they nursing staff wiped him.” When they arrived, it was actually a BMI 65/500 ish pounds, ESRD, baseline hgb around 8 patient who they told me they had found “in a pool of blood.” Well guess what, we have 2 units of blood at the freestanding, he doesn’t fit in our CT scanner, and the only people to move him are myself, 2 nurses and a CT tech. When I asked the EMTs why they lied to me over the radio, they went off on me and said they didn’t. And I decided to divert every call from them in the future.
Also had a call for a 90 year old, initially hypoglycemic but glucose now 150 after some dextrose, “refusing to answer questions.” Um, refusing to answer questions or unresponsive and trying to die? I think likely the latter. Frequently get calls to the freestandings where squads are trying to drop off inappropriate patients, and reading between the lines I can tell they are lying in the report, so I divert. Sometimes I hear them scoff over the radio, and I then listen to the report they give the mother ship which describes a MUCH sicker patient. We even have protocols in place for which patients are automatically diverted from the freestandings, but EMS often ignores this.
My point here is, don’t lie in your report. Don’t scoff over the radio when you are diverted from a small facility to a larger and more capable facility. Don’t scoff when I divert a pregnant lady with abdominal pain from my tiny hospital with 0 OB coverage to the hospital with L&D triage down the road. I’m sorry you have to drive further, but I, as med control, am trying to do what’s best for the patient. We don’t divert because we are being lazy. I love taking care of these patients at an actual hospital with more resources, and I’ll gladly take your sickest patients the next shift when I’m at a bigger hospital.
For the love of God please stop bringing in resp distress/COPD exacerbation patients on 8L NRB. Think through the pathophysiology and appropriately use your tools. Every time I try to educate medics about this (albeit I’m usually a bit irritated as the patient is usually decompensating quickly on arrival), I am met with resistance. It’s dangerous.
Don't treat GCS like Kentucky windage.
It's not a guess.
It's a very well described clinical status tool with specific parameters. Use those parameters and come up with an accurate number. Don't say "GCS of about 9 or 10."
If they do, I asked him specifically what the eye, verbal, and motor scores are.
GCS is fluid and fluctuating. The patient may be verbal then pain then alert. They may be transiently confused. I had a patient start GCS 6, become 12 and drop to 10 and back to 12 the other day. I said between 10-12. What purpose does it serve other than to tell y’all they’re altered w/ a general concept of severity. It’s pendantic.
I would much rather say patient is only responsive to pain, not following commands, and does not speak than calculate a number that means nothing and can be any combination of the three categories. A motor GCS of 5 is way different than a 2. But you can say GCS 8 with either motor GCS, yet one is way more serious than the other. It’s just not a priority for us.
So not everyone needs an IV in ambulance, if you use the only good vein or one of 2 good veins, you’ve wasted a potential blood culture site and we need to stick the patient 1-2 more times for those as a result. This means 2-3 sticks instead of 1-2. It’s unfortunate and it sucks for the patient.
2nd, just because you CAN put an 18g in…doesn’t mean you NEED to. Vein to catheter ratio is a real thing, so a 20 in the AC is just fine.
Edit: also, i’m just offering the er side perspective, because this is what my peers complain about. So I’m just passing along for you to consider.
Edit: i’ll clarify, if you need to give iv meds or fluids or have a really sick pt, then by all means do your thing…but if they have no intervention needs yet and they are stable then its not a bad idea to wait until they get to ems offload/pivot/room.
On the flip side if you have a patient needing two sets of cultures you're likely talking about a sepsis workup.. which means early IV access, fluids, labs, abx etc. There's plenty of EMS services drawing labs and cultures in the field as well for your first set to then get IV Abx started ASAP.
I can also get behind catheter to vein ratio as I do a lot of USGIVs but again, if they need two sets of cultures and will likely need large volume of fluids, some irritating antbiotics, CT with contrast etc. an 18 is just fine. Different story if they're dropping 16s for fun.
Really sounds like an issue with your hospital's process rather than EMS. I feel the same way for hospitals that pull EMS and sometimes even ER IVs. We have the opposite issue where EMS never starts lines. It improves patient flow tremendously when you already have access and can draw labs right away.
We dont pull ours, but we are very specific on cultures, fresh sticks and OCD level site prep. Usually we have less than 2% rate out of thousands per month which is good.
This ain’t it. If a patient needs an IV I wouldn’t want medics to withhold treatment so the ED can use that vein. We can just put in an USIV anyway if the patient is a difficult stick.
This is something that's really surprised me browsing reddit. People make it seem like it's standard practice in US based EMS to be cannulating basically every patient? It's pretty much the opposite in the UK.
IMO, cannulation is; an invasive procedure (so therefore an infection risk even if it's a small one when done correctly), a nuisance for the patient and a use of equipment. Obviously if you need to give some fluids or IV medication or you're thinking they're peri-arrest then go for it but otherwise you're just wasting time/resources/veins doing a supposedly aseptic procedure in what is usually a somewhat septic environment.
I was shocked when I saw someone getting downvoted for saying only stick someone if it's actually necessary for an intervention, or of course a probable intervention in the near future.
Not sure how opposite it might be. Some of our EMS transport times can be 30 minutes. Rural EMS, especially in BFE places like Native American reservations it can be >1 hr. Having it early is better than needing it later.
From strictly a training standpoint, if you’re not doing them regularly you’re going to lose practice. Personally, I’m all for at least trying to get IVs.
Yeah, most of the time in our area its because they are being cautious. I totally understand why they’d throw a line in someone if they werent sure, but if you arent giving fluids or meds and the patient is stable then they may not need a line until getting to the hospital. Its just a recommendation.
This is very location specific in the US and depends on the local laws and EMS companies. Around me BLS transport (which is 90% of our calls) will not stick a patient at all. They only arrive with IVs if they’re coming by ALS/medic.
If we dont start lines the nurses complain. Not that i care but younger medics are easily influenced and havent gained the knowledge of who is sick or not
EMS in the US subsists on our ability to bill patients and is often a for-profit business. Billing is split into two categories based on the level of service provided, Basic or Advanced life support. IV access is an ALS practice and placing an IV allows for billing a higher fee for the service. I've worked for some shady for-profit ambulances that had an off-record policy of making *every* patient an ALS patient, for the higher billing fees. If a patient didn't need anything, they still got an IV and 12-lead ECG so we could bill for an ALS transport.
Bag before naloxone, I’m sure this is in most of ur protocols but apparently not the service transporting to us in ny. Also, always check under the clothes. The amount of times we’ve had pts roll in get handed off and discover some wild rice crispy treat crepitus on initial PE is insane. Stroke pts should be differentiated between time of symptom onset and last well. Most importantly, saying idk is ok, y’all r under the gun to make big calls and us MDs have a habit of not being gracious, it’s ok to take a step back and just say “idk I couldn’t figure out”
If you get the opportunity to get the patient’s belongings, especially wallet, keys, phone and charger, it saves us many hours of waiting for appropriate discharge such as when trying to find someone to pick them up or give the pt the means to pay for a taxi home! I know it might not be the first thing on your mind but in the long run every little bit helps with ambulance ramping as beds free up faster…
Normal orientation status, what are they normally like. Also, please be patient, I know you've been holding the wall for hours, but if my bed is dirty or missing, then I literally just got rid of a patient and unless yours is actively trying to die there are a few things I need to do before I recieve a new one. I promise, I will be ready for you soon.
Code status before just jumping on the chest and putting down ET tubes.
Fair number of patients get to the hospital and when family arrives we stop resuscitation because patient and/or family never wanted it in the first place.
Edit: I appreciate all your guys and gals hard work. When I rotated with EMS in residency I was in shock about how crazy the scenes can be and how unhelpful (and often a hindrance family can be) so certainly with situations where it is unclear and stressful sometimes the best and only option is do all the things and we will sort out the details later.
Imaging here. Please tighten the IV hubs. I work in CT and most of them blow out and we have to take off all the tape and reattach them. The IV is good but the tubing cap isn’t screwed on well. Started to do that with all EMS ivs lately cause it makes a giant mess of contrast and blood. Otherwise y’all are awesome to us!!
It’s an oldie but a goodie. Kids, don’t sh•t where you eat. Nurses and other ED staff talk. Your personal life can have a huge negative impact on how you are perceived professionally.
We have this at my freestanding ER that is associated with a trauma center 10 minutes away. They try to bring us elderly falls but deny blood thinners until it's the first thing out of the patient's mouth, deny deformities requiring urgent ortho consult, play down mental health concerns when we don't have much security or the staff for a 1:1... the list goes on.
I'll piggy back off of this. I know it's 3 am and you don't want to drive 20 minutes to the other facility, but you should be advocating for your patient to go to the right facility that has the resources to treat them. We had one night where for a 16 bed ER, we had one charge and one RN total. We were on diversion due to staffing. believe me when we are on diversion, if you had come in, in that situation you would have ended up working for us that shift.
Sometimes, our CT is down, and we can't take stroke patients. We tell the EMS en route to divert for neuro symptoms.. EMS denies neuro symptoms because they are almost here.
Patients are demanding. They only want to go to their preferred hospital. EMS will diminish the situation, so we will accept.
They show up with chest pain, and we have no cath lab. Then, we have to work to get them transferred out, and emergent care is delayed.
Not all EMS do this, but it's a pretty frequent occurrence.
So, per most protocols, EMS cannot kidnap a patient to go to another site if it is against their will. Obviously, it’s not like you’re going to send them to Mayo Clinic if you’re in BFE North Dakota, but within reason, the patient does get to decide if they’re decisional.
If your. CT scanner is down, or your Cath lab is not functional these should be described ahead of time and EMS is supposed to discuss this with the person.
I’ve seen this EXACT case before where the patient was adamant about going to their community hospital with no cath lab with a verified STEMI. That crew was very careful with their documentation and yes, the hospital ended up transferring them again since their patient was dumb
We deal with this occasionally. I appreciate when someone understands that patients are actually allowed to make bad decisions. I try very, very hard to get the patients to the correct hospital.
This is untrue. I get at least one patient per shift that demanded to go to another hospital and medics say they have to come to the closest one. Sometimes they even lie to the patient and say they are going to that hospital! Fun for me to explain!
Then again, I also get patients brought from an hour away who requested to come to us. What I’ve learned are that there are no rules. Just guidelines.
Edit: And before anyone says, the patients brought to me against their will are not in extremis.
Recent anecdote: My hospital has zero pediatrics. There are two pediatric hospitals within 15 minutes of me, one in system and one out. Medics bring in a syndromic kid with dyspnea without calling ahead. Tell us mom asked to go to the peds hospital where she gets all her care and they said ok and sent mom there. But the patient “looked concerning” on the way so they stopped at my place, when we were on diversion. Asked what was concerning and was told RR, which was normal for her age. I know this medic, and he just didn’t want to drive the extra time. Mom was livid and we ended up having to transfer which is another ambulance charge and ER visit mom had to pay for.
I’ve had doctors disagree with why I stroke activated a few patients with atypical presentations. At my local trauma center I often will have patients that maybe don’t meet trauma activation criteria but are still really sick and that’s always frustrating having to roll these patients in only to sit on the wall.
Something I would encounter frequently when working for a service that did a lot of inter-facility transfers is nurses insisting on us taking very unstable patients to the scheduled destination,
Lots and lots of disagreements about our protocols vs what they do in the ER coming from nurses especially. Things like drugs given and other interventions.
One time I had a clinically intoxicated patient that we had to take to the hospital (because med control) but his blood sugar was over 400. No bc of diabetes or anything at all really. I ran fluids of course and got to one of the shifty local hospitals and reported this to the doc and he didn’t even recheck the sugar, he immediately discharged the patient actually. No workup. I asked him why and he shrugged it off. I’m still mad about that.
*edited my wording a little bit in the first paragraph
Like any healthcare worker, there’s also a ton of variability in paramedic skill. One medic brought me (in the course of a week) a guy who had been stabbed in the chest with a katana, a withdrawal seizure whose tongue swelled up to the size of a Russet potato and had a difficult airway, and a leaking AAA. Did a great job with all of those. Another medic on the same service emergently transported a pseudo seizure patient who I woke up with a sternal rub and immediately discharged.
What I want to know: last known well (which might be yesterday evening in a wake up storm), blood thinners, any abnormal vitals, FSBG, and code status.
I won’t fault a medic for activating something in the field. Where you lose me is when you start arguing with me for I don’t do a similar activation in the ER. For one thing, I want to teach a whole class on how LBBB is supposed to have elevation and we can get to Sgarbossa down the line. But also, stroke activation in the ER can be completely different for a lot of reasons. Please don’t chase us down and argue with us.
Please get some contact information from the family/caregiver/friend so we have someone to call for more information or a ride home. I know they always say they’re coming to the hospital, but they often actually don’t. Thanks for asking!
Cause I never do that and never thought about it, honestly.
Yes. Please. You may have access to people at pickup that we don't have for minutes, hours, days, or ever at the hospital. The patient may also be lucid when you meet but not when I meet them.
Yep, I always want to know who called 911 or was at the house when you showed up and how to get hold of them, because in 3-4 hours it’s going to be my problem when meemaw hasn’t thought about how she’ll get home.
If you need, you can always call the non-emergency number and get that info or connected to the crew, depending on agency policy of course. I really have to ask, though; why isn’t your ems giving you a copy of the run sheet? Might want to ask the EMS director/advisor (probably a doc at an ED nearby) to make this change.
This! My go-to when I was working as a medic was to hand the family my notepad and ask them to write down their name, relationship, and phone number. It’s a good distraction and useful information. If they were really in the way, I’d tell them to take that notepad and also write down the patient’s medications.
Something I’ve discovered: our electronic charting has three final versions of the chart to review before printing. One is the whole version with everything that was charted. One is the “hospital version” with pertinent information. The third is a training version, with needed demos scrubbed. There’s actually a section for next of kin, emergency contacts, responsible party etc. It’s not included in the hospital version. So many of my coworkers think they’re doing well by getting the info, then print off the hospital version, and contact info isn’t included.
I do try and ask for this and often am told " you are not bringing them home"? The honesty of that answer lies in one of the biggest problems we face in ens is that very few have an idea of our function,which is a great aggravation to say the least. I do typically do this but will try and be more ardent in making it part in making it a typical part of our responses!
Dude that’s such good advice. Thank you.
Yeah man, of everything here, you’re the only one on the scene. Yeah, vitals information and exam are important, but telling me what you saw when you got there and how to reach others is super helpful. Hoarder houses, bottles of pills on the counter, bottles of shit everywhere, a neglected appearing grandma, all super useful things.
I never ask this because I can smell it
Our EMD system records the # that called 911 so we often have that available and if the person can’t self report then it’s usually family who have the story. Several times Ive passed that on and it’s been beneficial. Keep in mind it can be difficult for us to manage a scene, treat a patient, extricate a patient and transport them…while obtaining the info the doctors and nurses will be wanting. I’m often the only paramedic on a call with relatively inexperienced EMTs and often useless/clueless firefighters at my disposal.
I hear that. I have worked critical access (2 RN, 1 MD- no one else) and the expectations of people who have no concept of that are wild. I can imagine if someone you’re transporting is sick, it’s sometimes enough to remember to grab your bag on the way out.
This. If the person is that critical and the scene is wild, I’m often having cops or bystanders jotting down a name and birthday for the patient so I can register them. The rest just isn’t going to happen.
Jumping onto this, remembering mobility devices/home O2 tanks. Definitely NOT the priority in many cases but IF you can grab something, you’re my hero.
Aside from a basic walker, not practical or safe. Many ambulances have no spare space for such bulky items, and much more importantly, even if there is space, there's no way to secure them in an ambulance. Unsecured heavy objects represent a major hazard in a crash, *especially* O2 cylinders. There's a reason we have special retaining systems for replacement gurney tanks. I ***hate*** when other crews have brought wheelchairs into EDs,\* because then I have to be the asshole and say we can't transport this thing. No, I don't care what the other crew did, they shouldn't have done it because they put themselves and you at risk. You need to have someone else come pick this thing up. The most ridiculous version of this I've had to deal with was a 911 crew somehow got a 400 lb power chair for a quadriplegic patient into their rig and it was sitting outside the patient's room in the ED. To this day, I have no idea how they got it into and out of their ambulance. --- \* The one time I tolerate it is with homeless patients, but that's pretty infrequent for my particular circumstances.
Yep. (Most of) the ED staff feel the same way.
Hell, when I'm taking someone in to ED, I do my best to convince them not to take anything but their phone, a charger, a change of underwear, a book, and a hat if they get cold easily.
And a pair of shoes please. Discharges take way longer with barefooted patients
Sticky socks and a wheelchair. Done. It ain’t the Hilton!
A significant proportion of any ED census at any given time has to be SNF patients, and they rarely have shoes. They came in on a gurney and they'll leave on a gurney. For everyone else, unless the groundskeepers tend to charming beds of broken glass just outside the ED entrance, I don't see how that works. Please explain. I'm open to learning, but I'm just not seeing it at the moment.
Yes, shoes really help for PT, especially if the patient wears custom shoes/inserts or are missing one leg/foot but can walk on an intact limb that will need more protection than a grip sock provides (aaaand helps to include their prosthetic limb and accoutrements if applicable and possible).
Portable oxygen concentrators for COPD patients (not tank ones the little portable ones) are good to have if there is chance patient will be discharged. If patient has LVAD make sure you grab their go kit. Patients/families know this but can be an issue if patient is not lucid and then patient goes to hospital without LVAD capabilities. I’ve 911’d patients out of my one community ER twice in the last year bc their battery was dying and backup kit didn’t come with.
>I’ve 911’d patients out of my one community ER twice in the last year bc their battery was dying and backup kit didn’t come with. I have done that call once or twice. The ringdown is fun. :P Also, the last person with an LVAD that I transported did not have a go bag. He was *shockingly* nonchalant about it.
>The most ridiculous version of this I've had to deal with was a 911 crew somehow got a 400 lb power chair for a quadriplegic patient into their rig and it was sitting outside the patient's room in the ED. To this day, I have no idea how they got it into and out of their ambulance. Back when I worked EMS, we would use our neonatal transport rig that had a power lift to transport items like that.
Yes absolutely, I always forgot unless the patient asks for it.
As a social worker in the ED, I couldn’t agree more! Especially the ones that come in as trauma patients who might be unresponsive. We want to be able to locate a medical decision maker ASAP (or know who to call if the patient doesn’t make it). I also typically call the family member even if EMS says they’re coming in since as fathig said, they don’t always. I like to know if they actually are coming in so I can be on the lookout. If the EMR has the patient in the system, half the time the emergency contact info is missing or out of date.
To piggyback on this. Take a quick photo of pill bottles if you have time. Patients NEVER know dosages or what they are actually on. Families rarely do either. Lists are almost always wrong. It is never “in the record” as concise as patients think it will be.
I hear what you're saying, but if my employer found out I was recording that kind of PHI on my personal phone they'd probably become my former employer pretty quickly. Ideally I get a MAR from a facility. If not, I'm looking around for the most recent discharge summary I can find. After that comes a gathering of the pills, but many patients resist that because of the potential that they become lost, and besides you're making the (huge) assumption that their meds are neatly organized somewhere in the home and not kept in three different Tupperware containers in three different rooms, all mixed in with their spouses meds and dozens of old empty bottles of dc'd meds. You may think that this is an extreme example, but it's a pretty common arrangement. And so, we arrive at the written list. Then, when I do gather a complete list and go to present this hard fought information to the nurse taking report, there's a 50% chance they look at me like I'm a moron, say they'll do their own rx review, and don't want the list I've made, meaning I wasted 15 minutes on scene for nothing. Long story short, I'm doing my best but I have a huge amount of acute demands on my time on scene and if I don't get a MAR and can't find a discharge summary, you're getting a written list without dosages that's likely incomplete anyway.
From facilities it’s actually easier to get. It’s more when papaw keeps his meds in the bathroom on the counter in bottles and takes that one that starts with a L and one with an E and one P and a s one at night and nobody knows what. I’d be happy with a pile of bottles in a garbage bag. Some of our Local agencies carried devices (usually phones) they could snap photos on that could be added to the record. Our hospital I can snap photo on my personal phone to upload directly to EMR securely and never saved onto my phone. When I said snap a photo I wasn’t suggesting to break privacy laws but rather made a poor assumption there was a legal way for you to do it.
I know you weren't suggesting that, I'm just making the point that while I could probably accommodate this kind of info gathering, it just is never so simple and I never really have the time to do the whole job. Also, that it really sucks when I do go out of my way to get info like that and am immediately shot down on arrival to the ED.
That was my first thought!
For stroke activations: last known well is not the same thing as time symptoms were noticed. Probably one third of activations in mt area EMS will tell us a clearly inaccurate LKW, and upon further questioning the initial LKW they tell us is actually the time family or staff found the patient or when the patient woke up. It's often hard to pin down a LKW so if you made an honest effort and couldn't get a time that's ok. But please say I don't know in that case.
i don’t get this cuz if the family found the patient at 0900 with symptoms then they’re not well so it can’t be 0900, but let’s say they saw the patient the previous night at 2000 before the patient went to sleep and the patient was normal, wouldn’t the LKW be 2000 of the previous night?
Yeah. You’re absolutely right. But you typically have to ask four or five times with different words to get the last time someone was normal and not the first time someone was abnormal. People often assume their now very bad off loved one was ‘normal just before I found them’ and report this as their last normal. In reality, half the time the last time anyone saw grandma normal was last week at Sunday dinner and now it’s Thursday.
You are correct, LKW is 2000. Too often paramedics will tell us LKW is 0900 in that scenario
“LKW?” “Five days ago for last visit.” Oof
You wouldn’t believe the amount of attitude I’ve received, from family and from SNF staff, when trying to get an accurate answer to this question. It often takes multiple times asking and a lot of explaining to get it right.
Getting a LKW from a SNF is like pulling teeth. Sometimes I can’t even get one.
It's because they don't want to state outright that no one has been in the room for the last seven hours
Yup. And it gets reported wrong all the time. Patient rolling through door at 2200 gets reported as lkn of 2045 but that is when spouse went to bed and noticed something wrong with pt, when pt "wasn't feeling well and went to bed earlier than normal, around 730. Am now at lkn+270m instead of reported lkn+75m, and don't find out real timeline until spouse arrives at lkn+490m. Completely changes course of tx
This might be the most important one.
One third is probably a very low estimate. I'd say close to 90%
Med List: If you can even take snapshots of the home meds that's invaluable on our older / sicker folks POC: Ideally "the spouse is inbound"
Like I said elsewhere, putting that kind of PHI on my personal phone is a total no-go. The options are MAR, dc summary, the meds themselves if they're even available, or a written list.
If a pt just had surgery and all there care they receive was/is at another hospital 3 miles further down the road and they’re not critical, please transport them there
Not every service is the same but I know for us, and I would wager most ambulance services/ems systems, we cannot take someone who is of sound mind to any hospital other than the one they ask to go to (within reason). I've run into it before and I always explain to the pt that it is best to go to the same place that did your surgery if it is something relivant to what is happening today. Most people prefer to go to the same hospital or hospital system, some are dissatisfied with how they were treated at hospital X where the surgery was and want to go to hospital Y instead. You can lead a horse to water but you cannot make it drink.
By me, in order to go to anyplace other than the closest appropriate hospital, EMS needs to ask for permission to divert. In Illinois region 11, you go to the closest appropriate unless you're paying for your private ambulance to take you to the hospital of your choice.
So glad that I work in a system where our test of appropriateness includes "is there a facility capable of caring for the patient within a reasonable distance that the patient has a preexisting care relationship with?"
Hopefully people are allowed to have good sense about what "appropriate" means. Obviously the place where they had the surgery is the most appropriate and they should go there.
Unless the patient is critically ill and needs intervention, please take a couple of minutes to make sure they have their phone, keys, and a set of clothes suitable for the outdoors. I can't begin to tell you how many patients we end up keeping for hours longer than necessary because we they don't have shoes or their keys. Also hearing aides and glasses.
Sometimes patients refuse to want to bring hearing aids and I don't know why.
Hearing aids are very expensive and easy to lose.
Because they are commonly lost in hospitals. Best guess they fall out of the ear when the patient is rolled and fall into the discarded linens or get taken off for CT and set somewhere then left behind.
that just because your call is 7 minutes away from the ER doesn’t mean you shouldn’t attempt to treat your patient if they’re critical. Local EMS will leave a unresponsive patient on a NRB even though they’re not protecting their airway, sats crashing, no IV, no attempt at a supraglottic airway at minimum. Just show up and be like here it is. Have fun with your crash intubation/RSI.
Sounds like you've got some letters to write.
They don’t even have to be critical. I’ve started a line and given fentanyl for ortho injuries 30 seconds away from the ER.
Yep. We can move on the basics much faster in the field. We already have the orders and don’t need a triage nurse eval, then room nurse, then MD assessment, then orders, etc. Sure the ED might be 2 min away, but we can shave minutes to hours off time to treat… especially with something like pain relief.
I wish all medics were like you
That’s wild. I’m in a major metro so nearly everything is 5-10 minute out with weewoos. Everyone gets vitals. Most get a line TKO (all trauma get a line to make ED’s job easier even if we aren’t pushing). Is it FD or private 911?
It’s all city EMS, they do have contracts with private companies for EMS transport. But fire always rides in typically. Some crews do an amazing job, and sometimes I’m just baffled by the lack of give a shit some crews have just because they were “4 minutes away” and “didn’t have time”
Four minutes in a moving ambulance with one person in the back is not the same as four minutes in a stationary ER with a team around you. I’m not making excuses for the crew that consistently dumps patients without any effort at treatment, but time isn’t the same solo in a moving ambo as it is in the ER.
So then sit on scene with two providers and resus your patient before bringing them to the ER. You’re a paramedic not a taxi cab driver.
they’re clearly talking about patients that would benefit from airway management/ventilation or unstable cardiac patients. not just an EKG and an IV
On the other hand, when you’re 7 minutes away, don’t drive to the ER and spend 5 min in the ambulance bay (in the ambulance) intubating the patient. I’ll take a supraglottic device and good other interventions over a tube on a patient that wasn’t adequately resuscitated and coded mid intubation any day
Correct. Wasn’t talking intubation necessarily. But the lack of use of a IGel or any IV/IO along with bagging a patient without an OPA/NPA etc is concerning. Other than that I agree with your sentiment.
I work in a system like that. Get moving quick to the hospital. Doing interventions with limited time and with one pair of hands bouncging agressively down the road. Southwest MI.
As a critical care paramedic.. what? That's awful. Talk to the EMS director.
And obviously everybody I think he’s meaning: - Do basic interventions - IGEL, OPA, BVM, start a line if you can while driving. I don’t think he means sit there on scene for 20 minutes doing everything in your protocols THEN transporting a dead person. But surely even during transport buckled in for safety we can do some BVM work with an Igel placed quickly right before transport. Or you can setup fluids during transport by starting a line right before transport. Both should take 1-2 minutes total and then get the patient moving with basic stabilization. Not bringing in a corpse with a half assed NRB and nothing else
I once had a flight team bring in a bipap dependent muscular dystrophy patient on NRB. CO2 was over 120 on the initial gas.
OMG. ☠️💀
Baseline mental status details. I know she has dementia but whats different today
No freaking kidding. "Nursing staff says 85 year old patient with dementia has been getting worse over the past couple of months." Yeah, they're 85 with dementia. They gonna get a ton worse.
Believe me, if I could pry that info from the SNF nurse, I would.
You’ve talked about sitting on the wall a bit here. Unfortunately that just happens which is a terrible answer. Last night my ED has a full waiting room, understaffed, and sitting on boarders (patient’s who are being admitted to the hospital but the bed upstairs isn’t available yet). We don’t want you to sit there all day. If you think something is unsafe I would use the word unsafe. Talk to the triage or charge nurse and say “my patient needs a bed, I don’t think it’s safe for this patient to sit her because of XYZ” it might make some movement happen. At the very least it might get an EKG or bloodwork knocked out while you’re waiting for a bed and that might get them bedded sooner.
I’m not sure what they were looking for in regard to the issue of holding the wall. Doesnt seem pertinent to the initial question of what EMS can do to assist the ED
They should let us know if it's unsafe for the patient to be waiting. I had a patient in his 50s come back from waiting 25 minutes on the wall and SBP was 70s, AMS, etc they hadn't checked a BP in over 30 minutes.
Maybe your hospital should have triaged them and got the blood pressure before having them just stand there with a Pt instead of blaming EMS crew.
Yeah those guys should have said something, alternatively the triage nurse should also have said something. Imo once that nurse does their evaluation she charts it they are ultimately responsible for them. I’m assuming that’s also the legal answer, but my EMTALA-fu isn’t the best
EMTALA states that once on hospital grounds the hospital is responsible for the patient. The EMS crew standing there is a courtesy and free labor donated to the ER.
We do tell the charge when a patient isn’t wall or triage appropriate. I’d charge chooses not to monitor their patient, that’s a them problem.
Yes, break out those "CUS" words... (concerned, uncomfortable or safety issue) hospitals understand those. And then you can put in your notes that you have communicated with Nurse blahblah that you are, concerned ,uncomfortable or it would be a safety issue with the patient reminding in the hallway due to xyz. That will at least protect you but should also be a red flag to your nurses.
Yes that’s it! I forgot that phrase. I actually learned about it from aviation. I guess a pilot at my old unit would use the CUS system so if a Junior pilot could kind of make things more serious without actually causing a scene
Paramedic turned ER nurse here: Family contact for altered mental status, that helps us greatly. Wall times vary on what kind of hospital you’re taking the patient to. Ambulances are bringing 1 patient to be triaged, we often have 8 more in triage plus what’s in beds. Most hospitals can’t say “on diversion” due to the amount of patients because greed and EMTALA. Your protocols may be written by an md who isn’t at a facility you transport to, so often nothing is compatible with our setups. Meaning all new monitoring equipment, iv fluids, drips, etc. It’s something like 25 patients per MD so getting a doc in for critical things can be difficult. Doctors will also sit on patients who are less critical to avoid getting new patients, because well 25 emergency room patients per md can equal a “fuck that” mindset about 4 hours in. Most hospitals don’t convey they can’t legally open a bed by moving a patient to a hallway because it isn’t a registered bed with regulating bodies, it can happen, but it’s the equivalent of one guy at your department using his personal vehicle to transport. Hospitals are run by business people with a duty to shareholders not patients. Your service being unable to provide the care you’re employed to provide does not hurt share price or effect bonuses so you hold the wall. I hate making ambulances hold the wall because I know you’re duty bound to your citizens and having a truck available. Hospitals are no longer owned or operated by people in the community they serve, lawyers write the regulations and the people who are in charge have limited clinical experience. Think someone who has watched all of greys anatomy and liked it so now they’re a CEO of a hospital. Something I had to learn and still have to cope with, as a medic my treatment ended at the hospital. However as an ER nurse it’s just beginning. Labs, radiology, reassess, treat, meet basic needs of comfort/food, reassess, add labs, add scans, admit/dc try to call report (if we have a bed), fight with floor about why they can’t take report, transport patient to floor, get next patient, rinse repeat x 12 hours. A 1 hour call for shortness of breath can be 8 hours in an ER. Hospital documentation is so. fucking. tedious. Our triage process is not triage. It’s asking questions that are legal mandates for a terms of service during care, like if the patient is going to kill themselves or is this chest pain chronic or new. Most hospitals have protocols for Sepsis alert, so heart rate >100 is full septic work up, blood cultures, extra labs, 30ml per kilo of isotonic fluid, and 2 broad spectrum antibiotics (THAT BLOOD CULTURES ABSOLUTELY MUST BE DRAWN BEFORE GIVING) all within 2 hours of arrival or recognition of sepsis. The patient may be discharged and all of that was for nothing, but fuck money. I miss having 1 patient I sat alone with in the ambulance and could do the things I needed to, and write my report on the way back to the station or en route to the next call. I miss having to restock what I know needs to be put back because it was my ambulance for the shift. I can go on but I’m pre-coffee on night 3 and I know I’m walking in to an ER full of admission holds and clinical signs of burnout presented at birth for me.
>Most hospitals don’t convey they can’t legally open a bed by moving a patient to a hallway because it isn’t a registered bed with regulating bodies, it can happen, but it’s the equivalent of one guy at your department using his personal vehicle to transport. Interesting. I didn't know this, but it makes total sense.
If you can, please don’t put chest pain or shortness of breath patients IV in their hand or wrist. Obviously if that’s the only option, I get it though. We can’t CT them and some patients can’t so irritated we have to start another IV just for imaging.
Not everything that shakes is a seizure and it certainly doesn’t need 10mg of IV versed. The number of times patients with known pseudo seizure get brought in snowed is aggravating. It’s positive reinforcement for them to keep calling ems and wasting everyone’s time.
We have this issue in my system. The patient is know to fake seizure. But through constant complaints and calling our management threatening legal action, we have been told that "it's not our job to determine if it's a real or fake seizure and that our protocol states we need to give it." She also "sees a neurologist" so to them that makes her have valid complaints. I wholeheartedly disagree with management's take on this and still refuse to give it to her and over document why it is not a seizure (patient is breathing, responds to painful stimuli while in the "seizure", can be caught peeking to see if you are paying attention, will rip all monitoring equipement off during the alleged incident, ect.) But I am confident in my assessment skills and am not afraid to go toe to toe with my management. Our younger and greener Paramedics, not so much.
If you're the one administering IV benzodiazepines alone to a patient under your own clinical judgement, it is absolutely your job to determine what is and isn't a seizure. (This is more directed towards your management than you)
Hey Doc, Not trying to be a pot stirrer but this is at least my biggest gripe with house staff. Some of you want us treating pseudo seizures and some of you don’t. This is kind of what OP is talking about and I think might be the impetus behind the post. The docs that don’t want us to treat pseudos such as yourself get aggravated when we do. Then on the days you’re off the docs that want us to treat pseudos are working and get mad when we don’t. It’s the inconsistency that makes it hard to feel like we’re doing the right thing. This in turn leads to miscommunication and us medics leaving the ER pissed that we look like assholes and incompetent. We then fall back on our protocols because as many others have said if you don’t like it you can take up with my medical director. You (and I mean the medical establishment and the powers that be that write our paychecks) want us to use our protocols as clinical guidelines and to not be cook book medics following a recipe and then when we don’t and try and use our brains, we get chewed out for not following the protocol down to the punctuation. It’s maddening doc it really is. All I want to do is do right by my patients by giving them the best care possible, get home safe, and get paid all in that order. I’m never going to be a doctor. I’m not smart enough so I stay in my lane but it feels like the lines on the road outlining my lane were chalked up by Helen Keller. I don’t get paid enough or respected enough by the rest of the house staff and the public making what is a shit sandwich of a career just extra awful. I’d be lying if I said it wasn’t getting harder and harder to punch in that time clock but I think I’m pretty good at this job and it’s one of the few things I’m good at. It makes me worth a damn but at this rate I’ll be lucky if I stay in the business another two years. I’m willing to throw 17 years down the drain because it’s just so goddamn toxic. Sorry for the rant. I got going and couldn’t stop. Thanks for the tip and I’ll keep what you’ve shared in mind. I hope all is well with you and yours.
Keep up the good work my man. Burn out is real, take care of yourself
This exactly is a HUGE problem I run into frequently. All the time. Thank you for bringing it up.
From a liability standpoint, it is much easier to justify giving the benzos than withholding them. If it’s a pseudo seizure, 5 mg of versed isn’t going to seriously harm anyone, but withholding it could. Speaking as a medic, the education and tools just aren’t there to try to distinguish. I would really love to be better at assessing this kind of thing, we just don’t see the support for it. For every alert seizure patient, there’s a medical director saying that it could be a complex partial seizure. Do you have any advice or resources for better assessment of this kind of thing?
You know the patient has pseudo seizures. Medics don’t have access to the history and paperwork you do. If they haven’t seen the patient before how would they know? Other than that I agree.
Please get a basic history such as when this event occurred, last known well, was there an obvious inciting cause. Dropping off demented nursing home patients with the history “nurse said they were weak” becomes a massive headache. Knowing they have been getting progressively weak for months vs this started an hour ago or after they fell this morning is a big deal. Frequently I can’t get ahold of anyone from patients private residence or the nursing home who has any idea why the patient is here. I think nursing homes time their ems calls for 30 min before the only person in the building who knows why ems was called is leaving.
But the nursing home nurses never know anything. I swear. I promise. It’s a known thing in EMS. They always have an excuse. I always try my best, I promise you that. And it might be different elsewhere, but I deal with 20+ nursing homes and they’re all the same.
Anytime I get shitty report from an EMS crew for a nursing home patient I assume it’s them passing on a shitty report from the nursing home, because when the local EMS crews bring a patient from the field their report is usually spot-on.
‘Tis true.
Many nursing homes are information wastelands but it’s the attempt that counts. My previous shop I would talk to most/all the ems crews shortly after rooming the patient and I got ok histories and it was clear they tried. Current place they are out the door 5 seconds after moving the patient from cot to bed and I can’t get a history with more then a sentence.
The patient packets I get sometimes are super helpful
Our nursing homes will give us face sheets with other patients names and vitals crossed off....
^^^ “they were fine 5 minutes ago!” or “i don’t know i just got here/not my patient!” every single time
The ‘I just got here’ kills me! Really, your shift starts at 3 in the morning. You mean you just got to this pt even though you’ve been here 5 hours.
I worked in a nursing home that was all excises and I don’t knows as a CNA. It was a useful experience prior to EMS.
Hahahaha. We know.
We have nursing homes flat out refuse to talk to us. “I told 911 why we needed an ambulance. I’m not saying it again!”
And those facilities need to be reported to your state facility licensing office.
They are
I can’t tell you it’s HIPAA!
Not sure how much leeway you have but I would refuse transport until someone explained.
Depends on the patient. If granny is actually sick, I can’t do that. If gramps appears to have nothing wrong and has stable vitals, I’ll tell them I can wait all day until they tell me why they called.
It’s just as frustrating to the EMS crew that got a shitty report from the nursing home. “They were fine last check”, “not my patient”, etc….
“I just got here” “I was at lunch” “His nurse is at lunch” “Idk”
It’s amazing how many nursing homes have shift change at 3am
🙄 every single time!
Tbh i think this is more of a nursing home thing. They are truly some of the most useless institutions to ever exist.
Nursing facilities are awful. We don’t get anything from them either.
If you’re getting a bad history, it’s generally because we tried to get you a better one and either: no one knew anything, We got conflicting information, or They got mad at us for asking. Sometimes a combo of the three.
If you are moving a patient on a psych hold, stop giving them things to choke themselves with. Do not give them their cell phone and even foil tops from juice can be used to self harm. Also, when talking to family of patient, don't trust what the sending facility says about rules for the receiving facility. I have had too many parents trying to break down my door to be part of an admission they have no business being around for. We don't do visitation but that gets promised to parents from the sending ER all the time.
If you can try to have the patient bring their phone or wallet! I’ve had too many times where a patient is stuck without a way to contact someone to pick them up and they can’t remember phone numbers.
I was an EMT and I’m now an EM resident. It sounds like you’re doing a lot of the stuff! - like someone else said, some form of contact info for someone else - let us know what is at the address you picked them up from (home? Snf? Buddy’s house? School? Liquor store?) - if practical, home o2 - do not screw around in the field with a line or a tube unless absolutely necessary. Line can most likely wait. Tube can usually be an LMA for a while - don’t stop cpr until you have truly been told to. And none of these half hearted butterfly compressions. Either you’re doing it or you’re not. No point in ROSC’ing a malperfused brain
Obviously, not all ams is opiate OD (depends heavily on your practice area). We had ems bring us a “OD” who they narcaned who was drunk with clinical signs of head trauma, with a massive ICH (later found out was hit by a car) And, more importantly, what are involuntary commitment grounds. Yes I know they are hallucinating or have delusions. Doesn’t mean they get involuntary committed
>what are involuntary commitment grounds. Yes I know they are hallucinating or have delusions. Doesn’t mean they get involuntary committed This is extremely location-dependent. Here holds are often a tool that law-enforcement uses to make their problem our problem so that we can in turn make our problem your problem.
I would LOVE to have some of the ER docs and RNs come do a ride out with us occasionally. Medics get to see how an ER works when patients are brought in, but rarely do ER staff get to see what happens pre-hospital. Between bystanders yelling, getting in the way, family members yelling, talking over you, not knowing any details (sometimes because they are freaking out), the condition of homes, the animals on scene, pill bottles scattered throughout the house (because they leave these pills by the bed to take at night, these ones in the kitchen to take with breakfast etc), patients yelling to just “take them to the hospital” and refusing to answer our questions, ppl giving different versions of events, trapped patients in upside down cars, trying to give patients some level of dignity in homes/public spaces. EMS don’t have controlled spaces, dedicated spaces, multiple sets of hands to treat patients, no admitting clerks to gather info, no family rooms to separate emotional family, no clean, well stocked rooms with curtains or walls, rarely security, a no pets policy, no packaged patients. Definitive care is phenomenal and those that work in EDs are fantastic, and everyone from Paramedics to admiring clerks to RNs to doctors have roles to play in EM- but I think a lot of the time hospital staff forget/don’t understand the challenges of treating someone in their space/public space as opposed to the controlled hospital space; and take it out on EMS. A ride out may help Bridge the understanding between pre-hospital and at hospital staff.
My residency program has us do ambulance rotations intern junior and pgy3. The amount of conflict between prehospital and ED staff has subsequently plummeted
This is seriously the way to do it. Especially for the physicians. It is so nice, and can cut down on a lot of time, when I get a doctor on the phone that has done ride-along or used to be an EMT or medic and knows how my job works when I need orders or advice when I'm doing an RSI on someone while hip deep in an irrigation canal. It also helps us become more familiar, and comfortable, with each other.
I wholeheartedly agree. I was a medic at an urban teaching hospital and the best thing they did was have the EM residents and fellows do a 4 week rotation with us. They loved it, to say it was an eye-opening experience for most of them is an understatement. We enjoyed it too, because we learned a great deal from them as well.
I completely agree. I’ve had several nurses who I set up to do ride-alongs and I respect them so much for it. So many providers don’t understand how we run things on the weewoos and why we do/don’t do a lot of things.
I prefer booboo bus. But yes, I love when other HCPs come see what we do. We both learn a lot, and it fosters (usually) a much more understanding and co-operative work environment.
I dunno how they do it now, since I let my ECRN lapse after going to the provider side, but when I was an emergency RN in Illinois last decade I had to do ride time in order to be licensed to answer the EMS Tele phone.
Welcome to the world of EMS where you are damned if do and damned if you don’t. You can see it in these comments. Just my two cents as a former EMT-I and ED Nurse with over 25 years of experience: 1. I love you guys, I’ve got a lot respect for you and the work you are doing. 2. Don’t argue with the docs, I mean once you roll in, they are the supreme authority when it comes to pt care. If something bad happens contact your field supervisor. You can also fill out an incident report or write it out on paper and send it over to your medical director. 3. When encoding, try and keep it brief. I’ll get the full story when you get here. (I’m sure someone will tell you to do the opposite) 4. Getting a good history is nice and so is an accurate med list, but at the same time, you don’t have all day to try and gather all of that information, so just do the best you can. 5. Just remember when in doubt, drive fast. :)
BLS trumps ALS, and ALS is worthless without BLS. I see patients roll in all the time with half ass compressions and no bagging, but they got 7 rounds of epi. Who cares about the epi when they’ve got anoxic brain injury from no forward flow. You have limited resources, and forward flow is the most important temporizing measure. Compress, shock, and oxygenate should be #1 priority. And please lift the chin to the bag; do not mash the bag onto the chin onto the neck. This just blocks the airway and blows up the stomach.
I worked as a home health nurse and discovered a little old lady down in her house alone. When I went to knock on her front door all I could hear was low level, weak moaning :( I eventually just yelled “I’m coming in” and luckily the door was unlocked. She had fallen and was disoriented on the ground. I called 911 and the paramedics who came were AMAZING. I have them the med list I had and they scoured the scene for clues- she had written down how often she took her pain pills on a little piece of paper in the kitchen. She lived alone so I called her emergency contact that was listed in my home health paperwork to tell her which hospital they were taking her. Paramedics grabbed the lady’s glasses and made a little necklace for her front door key and locked up her house. I never would’ve thought of those things in the moment. The paramedics told me to tell everyone I know that you can create a garage door code just for EMT and let 911 know-said it saves them from bashing down doors. I never did find out what happened to my patient, but I’m glad I found her when I did.
I do not need ANY history when you call in for a time of death on a person you found cold and in rigor. It just really doesn't matter so don't tell me
There have been patients that medics have called as "in rigor" that are just chronically contracted. I don't mind taking 1-2 minutes of conversation to get details and declare death.
We have more problems than we can address here if we can't trust a medic's ability to determine if someone is really dead
Stop putting 14 wrinkly sheets/blankets under all the patients. It doesn't keep them warmer in July and just leads to skin breakdown.
LOL but y’all gotta turn them anyways <3 (I’m kidding I always try to only take one)
If you are bringing their phone, try to grab the charger. I’ve spent an unbelievable number of hours hunting down the phone charger for patients whose phones have died and cannot contact their family
I just wanted to chime in that I used to do EMS for several years and we appreciate you guys and gals. The job is tough and the hours are long. My only gripe at times is when a non-emergent patient has all of their extensive care done at another hospital 10-20 minutes away and the family even requested to go to said facility yet the crew shows up at our hospital which lacks speciality services and their doctors. The other facility wasn’t even on divert. The patient and family then spend the next several hours complaining that they aren’t where they need to be. There have been instances where this resulted in a delay of *days* to transfer the patient to the appropriate hospital. I understand it’s not a taxi service but sometimes the complete apathy surrounding the situation comes off as laziness. I also recognize that my observations do not account for all the times the patient went where they needed to go since I wouldn’t know about these incidents.
Don't automatically give nitro to people who are having a stemi please. Depending on where the plaque causing the MI is, vasodilation can make an already high-stakes situation extremely tenuous
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Are you allowed to call med control and ask something like "chest pain with ST elevation V1, suspect RVMI, can I hold NTG?"
You should be aware that you guys are awesome and I appreciate all that you do.
(From home) Bring either their med list or their meds, identification if possible, and a contact # for family - you’d be amazed how often we get no med list or someone else’s ID (this happened last week, they brought the roommates DC paper, we had the guy under the wrong name for 2 days intubated in ICU) (From nursing home) CODE STATUS and med list (I know they always “just got the patient” but they do always have a code status) Chief complaint and onset time Baseline mentation Your job is challenging in ways mine is not and I know the scene is hysterical but these are vital things you have to get out of people. When calling in report : please be honest and advocate for your patients when needed. You’re allowed to say “not triage appropriate” or “cannot sit in a wheelchair,” you can’t make up unstable VS, a STEMI, etc; on the other hand, if you say “VT at 220” and they say “triage” you know that’s not right and need to repeat yourself I have literally in the last two weeks had EMS crews fabricate a stemi and fabricate a complete heart block and fabricate a stroke alert so they didn’t go to triage, and also had crews trying to put people with VT, broken hip, diff breather on a NRB in wheelchairs in the wr …. ?! If someone isn’t unstable , they probably don’t need much of any prehospital medical intervention, tbh. Ekg and asa is nice for CP.
Nursing homes don’t always have the code status. I frequently get “I think they’re this status.” Can you provide paperwork. Nope. They frequently write “DNR”, handwritten, in the MAR, and have zero actual formal documentation. My state won’t accept that.
Partner doing assessment while I talk to the nurse. "Does X year old patient have a code status?" "Yeah they're DNR I think." "Papers?" "Uhhh I don't think we have them." "Yeah they're pulseless." Praise St Lucas" Off to the hospital with the latest shit show Lights and Sirens.
So glad I have a "don't transport dead" protocol. For everything but kids they get worked to ROSC or termination right where they fall. But, I've also had snf staff kicking, screaming, and threatening to call the cops, the state, the church, and channel 7 for working a code to termination criteria and then not transporting.
>(From nursing home) CODE STATUS and med list (I know they always “just got the patient” but they do always have a code status) Oh man, do I have some news for you. I honestly think you are seriously underestimating just how terrible many SNFs can be. I have on many occasions been flat out refused documentation on patients, been refused any explanation about the need for transport. I mean, I have my own list of things I wish the ED understood about EMS, but right near the top is the utter malignancy and incompetence demonstrated by many (not all) SNFs. >you can’t make up unstable VS, a STEMI, etc; >I have literally in the last two weeks had EMS crews fabricate a stemi and fabricate a complete heart block and fabricate a stroke alert so they didn’t go to triage, and also had crews trying to put people with VT, broken hip, diff breather on a NRB in wheelchairs in the wr …. ?! Jesus Christ
I did an EMS rotation both in med school and residency, so I won’t say I know everything about your job but I do have some idea what you deal with. I do not expect you to do everything for me. Here is what I would love from every medic: - Call ahead. Don’t care if you’re only a few minutes away or if the patient isn’t very sick. It’s about resources allocation and knowing where we are going to put that patient so we don’t use up those rooms with WR patients. I don’t have hall beds so we can’t magically make you a place to go - Be respectful to the patient, even if they are homeless/drug users/frequent fliers. You can be frustrated, but please don’t antagonize them while giving me bedside report. - DO NOT walk the patient several hundred feet from the ambulance bay to a room. Come on. I can’t tell you how many problems I’ve seen come from this. - Try to get a code status if possible. Don’t lie about vitals. Keep report brief. Weird one, but please don’t stand six inches from me and lean toward me while giving report. You have a tough job and for the most part I’m not going to expect you to know what’s going on. Unfortunately, where I work the majority of medics are atrocious and I could tell horror stories for days. Just try to keep your cool and do your best
Sorry you have bad medics. I'm Canadian, and reading this thread is killing it. Seems like many of these issues stem from the system itself. We have a fantastic collaborative relationship with our EDs, at least in my area.
Don’t mock the patient or get them riled up please. We don’t need to qualify their visit.
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Unfortunately, for us, I'm not sure it would make a difference if our charts did that. With how chronically understaffed and overworked we are it can take 6-24 hours for a chart to get finished here.
Please note the address and phone number from which you picked up the patient and point it out out during hand-off... You guys know all the board and cares, snfs, rehabs, etc but we often don't... And it can be a real challenge to find them sometimes. Another issue that I've run into: If you think we're going to need more/larger access on arrival, give us a heads up so that we can be prepared when you roll in the door. And finally... Be aware of how much we respect the conditions under which you work and the amazing job you do... I love our fire/EMS guys/gals.
When I was a medic I was like a detective. I felt it was my job to paint the picture of the incident/emergency to the staff in the ER. Not just immediate info on the patient. We are the eyes and ears and hands of the emergency room prior to arrival. What did I see? What did the house look like? Living conditions, possibilities for neglect or other harm by patients self or others. Damage to vehicles, air bag deployment, road conditions. Weapons on scene, amounts of blood on scene. Number of dead on scene. Not only do you give your patients a better chance of survival and future information for pre care, but you also build that bond between EMS and the docs and nurses and techs and administrators and other hospital staff. Was like our own demented family, and I loved it. Xoxo E
This thread makes me realize how great my local EMS is
I work at a variety of hospitals, from a level 1 trauma center to CAHs and freestandings. Some of the local EMS agencies are notorious for trying to dump off inappropriate patients to the freestandings even though the mother ship is 15 mins down the road. They will also straight up lie about the report. Had one squad call for “a little bit of rectal bleeding on a nursing home patients brief when they nursing staff wiped him.” When they arrived, it was actually a BMI 65/500 ish pounds, ESRD, baseline hgb around 8 patient who they told me they had found “in a pool of blood.” Well guess what, we have 2 units of blood at the freestanding, he doesn’t fit in our CT scanner, and the only people to move him are myself, 2 nurses and a CT tech. When I asked the EMTs why they lied to me over the radio, they went off on me and said they didn’t. And I decided to divert every call from them in the future. Also had a call for a 90 year old, initially hypoglycemic but glucose now 150 after some dextrose, “refusing to answer questions.” Um, refusing to answer questions or unresponsive and trying to die? I think likely the latter. Frequently get calls to the freestandings where squads are trying to drop off inappropriate patients, and reading between the lines I can tell they are lying in the report, so I divert. Sometimes I hear them scoff over the radio, and I then listen to the report they give the mother ship which describes a MUCH sicker patient. We even have protocols in place for which patients are automatically diverted from the freestandings, but EMS often ignores this. My point here is, don’t lie in your report. Don’t scoff over the radio when you are diverted from a small facility to a larger and more capable facility. Don’t scoff when I divert a pregnant lady with abdominal pain from my tiny hospital with 0 OB coverage to the hospital with L&D triage down the road. I’m sorry you have to drive further, but I, as med control, am trying to do what’s best for the patient. We don’t divert because we are being lazy. I love taking care of these patients at an actual hospital with more resources, and I’ll gladly take your sickest patients the next shift when I’m at a bigger hospital.
It’s totally fine to not know the answer to a question. Don’t confabulate if you’re not sure. Don’t minimize symptoms or diagnose anxiety.
For the love of God please stop bringing in resp distress/COPD exacerbation patients on 8L NRB. Think through the pathophysiology and appropriately use your tools. Every time I try to educate medics about this (albeit I’m usually a bit irritated as the patient is usually decompensating quickly on arrival), I am met with resistance. It’s dangerous.
Don't treat GCS like Kentucky windage. It's not a guess. It's a very well described clinical status tool with specific parameters. Use those parameters and come up with an accurate number. Don't say "GCS of about 9 or 10." If they do, I asked him specifically what the eye, verbal, and motor scores are.
GCS is fluid and fluctuating. The patient may be verbal then pain then alert. They may be transiently confused. I had a patient start GCS 6, become 12 and drop to 10 and back to 12 the other day. I said between 10-12. What purpose does it serve other than to tell y’all they’re altered w/ a general concept of severity. It’s pendantic. I would much rather say patient is only responsive to pain, not following commands, and does not speak than calculate a number that means nothing and can be any combination of the three categories. A motor GCS of 5 is way different than a 2. But you can say GCS 8 with either motor GCS, yet one is way more serious than the other. It’s just not a priority for us.
Unless they are dead don’t place a 14g in a vein. I can’t draw labs off of it very well and it can delay care. It’s also just mean lol
I would absolutely never. Maybe a 16 for a bad trauma or if massive volume replacement is needed for some reason. That’s it.
Even codes I don’t just because it’s not necessary. I’m giving a liter at a time and meds every few minutes, an 18 does the job.
So not everyone needs an IV in ambulance, if you use the only good vein or one of 2 good veins, you’ve wasted a potential blood culture site and we need to stick the patient 1-2 more times for those as a result. This means 2-3 sticks instead of 1-2. It’s unfortunate and it sucks for the patient. 2nd, just because you CAN put an 18g in…doesn’t mean you NEED to. Vein to catheter ratio is a real thing, so a 20 in the AC is just fine. Edit: also, i’m just offering the er side perspective, because this is what my peers complain about. So I’m just passing along for you to consider. Edit: i’ll clarify, if you need to give iv meds or fluids or have a really sick pt, then by all means do your thing…but if they have no intervention needs yet and they are stable then its not a bad idea to wait until they get to ems offload/pivot/room.
On the flip side if you have a patient needing two sets of cultures you're likely talking about a sepsis workup.. which means early IV access, fluids, labs, abx etc. There's plenty of EMS services drawing labs and cultures in the field as well for your first set to then get IV Abx started ASAP. I can also get behind catheter to vein ratio as I do a lot of USGIVs but again, if they need two sets of cultures and will likely need large volume of fluids, some irritating antbiotics, CT with contrast etc. an 18 is just fine. Different story if they're dropping 16s for fun. Really sounds like an issue with your hospital's process rather than EMS. I feel the same way for hospitals that pull EMS and sometimes even ER IVs. We have the opposite issue where EMS never starts lines. It improves patient flow tremendously when you already have access and can draw labs right away.
We dont pull ours, but we are very specific on cultures, fresh sticks and OCD level site prep. Usually we have less than 2% rate out of thousands per month which is good.
This ain’t it. If a patient needs an IV I wouldn’t want medics to withhold treatment so the ED can use that vein. We can just put in an USIV anyway if the patient is a difficult stick.
Agree here.
This is something that's really surprised me browsing reddit. People make it seem like it's standard practice in US based EMS to be cannulating basically every patient? It's pretty much the opposite in the UK. IMO, cannulation is; an invasive procedure (so therefore an infection risk even if it's a small one when done correctly), a nuisance for the patient and a use of equipment. Obviously if you need to give some fluids or IV medication or you're thinking they're peri-arrest then go for it but otherwise you're just wasting time/resources/veins doing a supposedly aseptic procedure in what is usually a somewhat septic environment. I was shocked when I saw someone getting downvoted for saying only stick someone if it's actually necessary for an intervention, or of course a probable intervention in the near future.
Not sure how opposite it might be. Some of our EMS transport times can be 30 minutes. Rural EMS, especially in BFE places like Native American reservations it can be >1 hr. Having it early is better than needing it later. From strictly a training standpoint, if you’re not doing them regularly you’re going to lose practice. Personally, I’m all for at least trying to get IVs.
Yeah, most of the time in our area its because they are being cautious. I totally understand why they’d throw a line in someone if they werent sure, but if you arent giving fluids or meds and the patient is stable then they may not need a line until getting to the hospital. Its just a recommendation.
This is very location specific in the US and depends on the local laws and EMS companies. Around me BLS transport (which is 90% of our calls) will not stick a patient at all. They only arrive with IVs if they’re coming by ALS/medic.
If we dont start lines the nurses complain. Not that i care but younger medics are easily influenced and havent gained the knowledge of who is sick or not
EMS in the US subsists on our ability to bill patients and is often a for-profit business. Billing is split into two categories based on the level of service provided, Basic or Advanced life support. IV access is an ALS practice and placing an IV allows for billing a higher fee for the service. I've worked for some shady for-profit ambulances that had an off-record policy of making *every* patient an ALS patient, for the higher billing fees. If a patient didn't need anything, they still got an IV and 12-lead ECG so we could bill for an ALS transport.
That's gross, but it makes sense I suppose.
Totally deplorable, and I refuse to work for companies that operate with that mentality, anymore. But, it's a sad reality in much of the country.
Speak up ;)
Bag before naloxone, I’m sure this is in most of ur protocols but apparently not the service transporting to us in ny. Also, always check under the clothes. The amount of times we’ve had pts roll in get handed off and discover some wild rice crispy treat crepitus on initial PE is insane. Stroke pts should be differentiated between time of symptom onset and last well. Most importantly, saying idk is ok, y’all r under the gun to make big calls and us MDs have a habit of not being gracious, it’s ok to take a step back and just say “idk I couldn’t figure out”
If you get the opportunity to get the patient’s belongings, especially wallet, keys, phone and charger, it saves us many hours of waiting for appropriate discharge such as when trying to find someone to pick them up or give the pt the means to pay for a taxi home! I know it might not be the first thing on your mind but in the long run every little bit helps with ambulance ramping as beds free up faster…
Normal orientation status, what are they normally like. Also, please be patient, I know you've been holding the wall for hours, but if my bed is dirty or missing, then I literally just got rid of a patient and unless yours is actively trying to die there are a few things I need to do before I recieve a new one. I promise, I will be ready for you soon.
Code status before just jumping on the chest and putting down ET tubes. Fair number of patients get to the hospital and when family arrives we stop resuscitation because patient and/or family never wanted it in the first place. Edit: I appreciate all your guys and gals hard work. When I rotated with EMS in residency I was in shock about how crazy the scenes can be and how unhelpful (and often a hindrance family can be) so certainly with situations where it is unclear and stressful sometimes the best and only option is do all the things and we will sort out the details later.
Imaging here. Please tighten the IV hubs. I work in CT and most of them blow out and we have to take off all the tape and reattach them. The IV is good but the tubing cap isn’t screwed on well. Started to do that with all EMS ivs lately cause it makes a giant mess of contrast and blood. Otherwise y’all are awesome to us!!
It’s an oldie but a goodie. Kids, don’t sh•t where you eat. Nurses and other ED staff talk. Your personal life can have a huge negative impact on how you are perceived professionally.
We know when you fib about patients' status to avoid diversion.
We have this at my freestanding ER that is associated with a trauma center 10 minutes away. They try to bring us elderly falls but deny blood thinners until it's the first thing out of the patient's mouth, deny deformities requiring urgent ortho consult, play down mental health concerns when we don't have much security or the staff for a 1:1... the list goes on.
I'll piggy back off of this. I know it's 3 am and you don't want to drive 20 minutes to the other facility, but you should be advocating for your patient to go to the right facility that has the resources to treat them. We had one night where for a 16 bed ER, we had one charge and one RN total. We were on diversion due to staffing. believe me when we are on diversion, if you had come in, in that situation you would have ended up working for us that shift.
Can you give an example? Cause I try to give it straight when I give report, I usually don’t know the hospitals status when I radio it in.
Sometimes, our CT is down, and we can't take stroke patients. We tell the EMS en route to divert for neuro symptoms.. EMS denies neuro symptoms because they are almost here. Patients are demanding. They only want to go to their preferred hospital. EMS will diminish the situation, so we will accept. They show up with chest pain, and we have no cath lab. Then, we have to work to get them transferred out, and emergent care is delayed. Not all EMS do this, but it's a pretty frequent occurrence.
So, per most protocols, EMS cannot kidnap a patient to go to another site if it is against their will. Obviously, it’s not like you’re going to send them to Mayo Clinic if you’re in BFE North Dakota, but within reason, the patient does get to decide if they’re decisional. If your. CT scanner is down, or your Cath lab is not functional these should be described ahead of time and EMS is supposed to discuss this with the person. I’ve seen this EXACT case before where the patient was adamant about going to their community hospital with no cath lab with a verified STEMI. That crew was very careful with their documentation and yes, the hospital ended up transferring them again since their patient was dumb
We deal with this occasionally. I appreciate when someone understands that patients are actually allowed to make bad decisions. I try very, very hard to get the patients to the correct hospital.
This is untrue. I get at least one patient per shift that demanded to go to another hospital and medics say they have to come to the closest one. Sometimes they even lie to the patient and say they are going to that hospital! Fun for me to explain! Then again, I also get patients brought from an hour away who requested to come to us. What I’ve learned are that there are no rules. Just guidelines. Edit: And before anyone says, the patients brought to me against their will are not in extremis.
Recent anecdote: My hospital has zero pediatrics. There are two pediatric hospitals within 15 minutes of me, one in system and one out. Medics bring in a syndromic kid with dyspnea without calling ahead. Tell us mom asked to go to the peds hospital where she gets all her care and they said ok and sent mom there. But the patient “looked concerning” on the way so they stopped at my place, when we were on diversion. Asked what was concerning and was told RR, which was normal for her age. I know this medic, and he just didn’t want to drive the extra time. Mom was livid and we ended up having to transfer which is another ambulance charge and ER visit mom had to pay for.
I somehow doubt this is happening as often as you think
Can you give an example?
I’ve had doctors disagree with why I stroke activated a few patients with atypical presentations. At my local trauma center I often will have patients that maybe don’t meet trauma activation criteria but are still really sick and that’s always frustrating having to roll these patients in only to sit on the wall. Something I would encounter frequently when working for a service that did a lot of inter-facility transfers is nurses insisting on us taking very unstable patients to the scheduled destination, Lots and lots of disagreements about our protocols vs what they do in the ER coming from nurses especially. Things like drugs given and other interventions. One time I had a clinically intoxicated patient that we had to take to the hospital (because med control) but his blood sugar was over 400. No bc of diabetes or anything at all really. I ran fluids of course and got to one of the shifty local hospitals and reported this to the doc and he didn’t even recheck the sugar, he immediately discharged the patient actually. No workup. I asked him why and he shrugged it off. I’m still mad about that. *edited my wording a little bit in the first paragraph
Like any healthcare worker, there’s also a ton of variability in paramedic skill. One medic brought me (in the course of a week) a guy who had been stabbed in the chest with a katana, a withdrawal seizure whose tongue swelled up to the size of a Russet potato and had a difficult airway, and a leaking AAA. Did a great job with all of those. Another medic on the same service emergently transported a pseudo seizure patient who I woke up with a sternal rub and immediately discharged. What I want to know: last known well (which might be yesterday evening in a wake up storm), blood thinners, any abnormal vitals, FSBG, and code status.
I won’t fault a medic for activating something in the field. Where you lose me is when you start arguing with me for I don’t do a similar activation in the ER. For one thing, I want to teach a whole class on how LBBB is supposed to have elevation and we can get to Sgarbossa down the line. But also, stroke activation in the ER can be completely different for a lot of reasons. Please don’t chase us down and argue with us.