One of my EMS truths is that while there may be boring calls and calls that are less than exciting, there are no “routine” calls. There is no EMS patient that doesn’t deserve the absolute best that we have to give them. Every single patient we take into our care, be it a scheduled dialysis transport or a simple discharge from a hospital to a nursing home deserves to have professional, competent, and caring EMS providers taking care of them. They all deserve our best care, our best assessments, our best comfort, our best compassion, and most of all, our simple act of caring about them as a person and a patient. Never forget that, you may just save a life during one of your “routine” calls.

This gues post in the form of a case study comes to us from a paramedic who works in Tennesee. He was kind enough to write it up for our benefit and I think that it hammers the EMS truth above home quite nicely, what do you think?

Case Presentation: The Importance of Diligence

Setting: You are assigned to an ALS unit which is staffed for 8 hours during the daytime hours and is tasked with interfacility, clinic/MD office, and back-up 911 response. It is the last hour of your shift and you are dispatched to a local dialysis center for a patient return post Dialysis treatment because all of the BLS units are busy. The weather outside is cool and rainy. The only dispatch information you recieve is the previous run number from the pick-up and the patient’s name and age. You are responding to a 69 year old male patient who is “unable to maintain balance in a wheelchair” based upon the PCS form on file and who suffers from End Stage Renal Disease requiring Mon-Wed-Fri dialysis.

Initial Presentation/Nursing Report: Upon arrival on scene you enter the clinic to find the nursing staff beginning their tear down and decontamination for the day. This patient was the last one to be sent home and they are anxious to get him out of the facility. The LPN who took care of the patient tells you that the patient has successfully completed a full dialysis treatment with 1800ml of fluid pulled off. The patient did not receive any antibiotic therapy while at the facility and the patient has a right chest dual-port indwelling catheter. The catheter has been flushed with heparin prior to capping. Per facility, patient did not bring a lunch to eat, and it is “normal” for him not to eat. He is a diabetic and he did receive his scheduled insulin. His baseline mental status is normally awake, alert, and oriented, but the patient has generalized muscular weakness as a result of a previous stroke that affected his right side. His last blood glucose was reported as “normal”, although an actual reading was not readily available. Vital signs post treatment were reported as 138/72, Pulse of 90, Respirations 16/min, and Pulse Oximetry of 98% on room air. After report, the nurse directs you and your partner to the patient who is seated in a chair waiting for you. It is cool in the clinic.

Initial Assessment: You find a 69 year old African American male patient who is initially slow to respond to questions (requiring obvious mentation to answer simple questions), but is otherwise oriented to person, place, and time. The patient is in no obvious distress but on approach you notice the patient appears jittery and is having fine tremors in both upper extremities. You feel his wrist for a pulse and note the patient feels cool and dry with somewhat poor skin turgor. His radial pulse feels highly irregular and weak. You ask the patient for permission to assess his blood sugar due to his history and then move the patient to the cot via a stand-and-pivot to assess his gait. The patient denies any chest pain, shortness of breath, dizziness, nausea, vomiting, diarrhea, visual disturbances, or trouble swallowing.  You secure the patient to the stretcher per policy in a semi-fowlers position for comfort and then move the patient to the unit for further assessment.

In the ambulance you assess the patient’s vital signs. His blood pressure is actually 178/92 and his heart rate is highly variable. You place him on a four lead EKG which reveals a sinus arrhythmia interspersed with episodes of severe sinus bradycardia. His heart rate varies from the 90s down into the 40s. This correlates with the palpation of his radial pulse as well as the reading from the pulse oximeter. His respirations are 18, his lungs are clear/equal x 4 anteriorly, and his heart tones do not reveal a murmur or gallop. His room air oxygen saturation is 95%. There is some trouble with the glucometer but the initial BGL reading verified by two checks with separate monitors reveals a blood sugar of 38mg/dl by finger stick. Curiously enough, the patient is still protecting his airway and able to swallow. His distal pulses are intact at the dorsalis pedis and equal bilaterally, as well as at his wrists. His pupils are equal, round, and reactive to light. The neuromotor check reveals no deficits beyond what you assume to be his normal right sided motor weakness. His cranial nerves appear grossly intact. The patient does not feel warm and he adamantly denies any chills or feeling feverish. He has not had a fever per his discharge paperwork. Of further note, patient has a history of cardiac disease including CHF and past MI with CABG, renal failure, stroke, hypertension, insulin dependant diabetes mellitus, and high cholesterol. The patient’s last oral intake of food was at breakfast approximately 7 hours ago but he states he has been drinking small amounts of water all day. He states he does not bring food to the clinic and that he “feels this way all the time,” and the crews “just take me home” where he eats.

Treatment/Transport: The patient initially refuses to be transported to the hospital. Upon obtaining the blood glucose level (BGL) of 38mg/dl, the EMT is instructed to administer 15 grams of oral glucose gel over five minutes, which the patient takes without difficulty. Oxygen is NOT administered due to there being no evidence of hypoxia or respiratory distress/increased respiratory drive. After five minutes, a blood glucose check is performed on the opposite extremity. The BGL after the first tube is 43mg/dl. The patient is still refusing transport to the ER, so a second tube is administered by the unit EMT. At this time, the decision is made to involve medical control at the patient’s hospital of choice where the ER physician is NOT comfortable with the patient going home. The physician agrees with the unit Paramedic that transport should be “highly encouraged”. After conversation and the second tube of oral glucose, the patient agrees to be transported and asks his daughter be notified. Scene time at this point is 20 minutes. The third glucose check is 51mg/dl. A phone call is made to the daughter, who becomes angry and demands he be brought home. She continually protests his decision to be taken to the ER. When she is informed that he will be taken to the hospital, she says “fine” and that she will “meet us there.” Due to the patient’s presentation and history, an attempt is made to establish IV access on scene without success. Transport is initiated with the plan of performing an emergency access of the indwelling line should IV administration of medication be necessary.

During transport, the patient’s blood pressure reaches around 200 systolic and 90 – 100 diastolic over consecutive readings. His head is repositioned and he is placed in the high fowler’s position due to the hypertension. His sinus arrhythmia continues. A 12-lead is obtained which is non-diagnostic for any ST changes, T-wave peaking or inversion, or underlying arrhythmia. The patient remains awake and responsive, and while some improvement in mentation is noted after administration of glucose his blood sugar remains in the 40s during transport despite a third tube of glucose being administered. Transport time is 20 minutes to a definitive neurological and cardiac facility with PCI and IR capabilities.

Post Transport/Hospital Course: Upon arrival at the hospital the patient continues to be severely hypertensive and continues to have profound episodes of bradycardia from the sinus arrhythmia. During triage, his blood pressure spikes to 238/114 and his blood glucose is found on consecutive readings to be “LO” from multiple extremities. The patient is placed in the resuscitation room. The ER Fellow immediately places a central line due to an inability to establish an EJ or PIV by ED Techs and RNs. The patient is placed on a Dextrose solution once this is done and the Cardiology service is called in for further assessment.

The family continues to be belligerent and derisive and actually calls to complain about the crew, threatening to change services because of what they feel was an unnecessary trip.

During follow-up the next day, the patient was reported as continuing to have persistent hypertension requiring inpatient medication therapy as well as requiring antibiotic therapy for a possible blood stream infection. The cardiology consult discovered that the patient’s right carotid artery was nearly fully occluded which necessitated the patient to undergo a carotid endartectomy to remove the plaque and clot. The nursing staff told both the crew and the family that the care the patient received more than likely prevented him from having a massive and fatal stroke.

It was later reported that the patient continued to utilize the ambulance service despite the complaint they called in on the crew members involved in this call.

Discussion: This case illustrates the importance of diligence on the part of EMS crews. In this case, the patient’s presentation could easily have been dismissed by the crew for a number of reasons: the unfamiliarity with the patient combined with the history could lead the crew to ascertain this was “normal” for this patient, the findings could have been explained by the environment the patient was in, the end of shift factor could have made the crew anxious to finish a “simple dialysis” transport, and so-on. Despite these factors, suspicion lead to the identification of a major initial issue – hypoglycemia – which led to an even greater issue being identified and fixed before a major adverse event occurred. Had this patient gone home, these issues would not have been rectified, and the patient would have most probably suffered because of them.

This call underscores the importance of performing an initial assessment on every patient, no matter how “routine” the call is. The discharge information and post-treatment vital signs provided by the dialysis clinic were completely incorrect. The patient had not received a competent acute care assessment. Had transport been based upon the information provided by the dialysis facility alone, significant harm could have come to him.

As EMS we need to always remember that we are Patient Advocates. Our patients deserve us to always stand up for what is best for them. Apathy should never stand in the way of proper patient care.  

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Nicely said, Chance and nicely done. Nobody said that doing the right thing was always easy, but you did it here. EMS providers have to be focused on patient advocacy for every patient and every call. Thanks for sharing, and thanks for caring.

Chance Gearheart, AAS, EMT-P is a Paramedic who works part-time as a 911 and Critical Care Transport Team Paramedic, he also volunteers with a County Sherriff’s Rescue Team, and is full time for a Children’s Hospital as a Pedi/Neo Critical Care Transport Team Paramedic. He has been in EMS for 9 years, with three and a half of them spent as a Paramedic. He can be reached for any questions or discussion at chancegearheart (at) gmail.com.