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Monday, August 29, 2011

Tunnel Vision

We got yet another call for a fall victim. As I walked into the apartment I announced our presence.A man from the back bedroom said that that we should come on back. The old man had tried to get up to go the the bathroom and had fallen down at the foot of his bed. His right ankle was going in angles that should not be possible.

My patient didn't appear to be in much pain so I asked. He said that it was hurting real bad. I told him that we'd try and do something about that and then started asking other questions while my engineer got some vitals. I found out that the guy didn't trip and fall like we first suspected. He had felt dizzy and then passed out. That changed the entire call. Now we were investigating why he passed out instead of focusing on a broken bone.

My thoughts immediately went to his blood pressure. My guess was that it would be low. His heart rate was good. A little high but that would probably be from the pain. His EKG was normal too. And the winner was his BP. It was a touch low, 88/60. I asked the patient if he had taken his medications that day, among which were his meds for his hypertension. He said that he had. I then inquired if it was possible that he took more than one dose. He thought about it for a while and eventually realized that he had taken all his pills twice that morning.

About that time AMR showed up. This time they had with them a shiny new intern that was just realizing that paramedic school taught you the bare basics and that dealing with real patients was more challenging. I gave the intern a quick synopsis, "Male,75, fall victim, broken ankle." This forces the intern to do his own assessment instead of relying on mine. It also allows the preceptor to see how his intern is doing. While the intern went to work on his assessment I told the preceptor everything that I had found out. We then sat back and let the intern run the show.

After an 'exhaustive' 30 second assessment the student asked his EMT to go get a splint (which was in the ambulance down 3 stories and on the other side of the apartment complex). He said that his plan was simply to splint the ankle and take the patient the hospital. I kept my mouth shut hoping that his preceptor would correct his so called plan. Once the EMT arrived with the splint I had to step in. I asked the intern if he wanted to start the IV or if I should. He hadn't considered an IV. At this point his preceptor stepped in as he should have trying to get in between his student and a rapidly angering fire medic. The preceptor said that they would do the IV en route to the hospital.

At this point I went from trying to let them run the show so the intern could get some experience to patient advocate. This was my patient. I told them that we were starting an IV up here so that we could do a fluid challenge on the way to the bus. Once at the ambulance they could recheck his BP and see if they might be able to give a little bit of MS for pain relief. While the intern started the IV I told the EMT to get an ice pack on the ankle before splinting it. Once all this was done I let them take my patient.

I'm sure the preceptor thought I was totally out of line. I know a lot of medics don't feel pain management is something that they need to look at seriously. Because of my preceptor and my life experiences I am a staunch advocate for pain relief. And studies show that it's better for patient healing as well. Hopefully the intern learned something.
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