Had a call the other night, ended up being way sicker than anticipated, and it was just frustrating because now getting monday morning quarterbacked, some of it from the OSH staff. Apparently one of the staff there has a reputation of resenting transport teams who come in because of not liking that they can't continue to care for the patient (which I understand on some level). But jebus, emailed our medical director to try and nitpick our call to death.
We were on scene for much longer than normal, over three hours. But there was setting up therapeutic hypothermia, iNO (and resulting technical issues with both, of course!), patient instability requiring multiple saline boluses, ventilator management, starting pressors, struggling to get the pt. sedated enough, getting the ETT secure enough for transport, getting peripheral access. We ran our asses off. My partner and I were actually very pleased because our teamwork was great, we got the patient stabilized, safely transported back to our home hospital, and pt. looked decent even for a little while. Ended up needing ECMO, but that was not on the table at all when we left. The biggest complaint it seemed was the length of time on scene.
It was so frustrating. I don't like to hang around on scene, I try and get in and out asap. It was the longest call I've ever been out on, second only to a pt. that had a pH of <6.8 CO2 of >120 when I arrived. Both times, ended up having a fairly long scene, but got home safe. The one with the crappy pH we may have coded a bit in the rig, but what's a code between friends, right? This most recent one was a rotor transport so we knew that once we were loaded in the air, there was very limited ability to do much. I would understand if every call I was on was 2-3 hours, but it's definitely not like that. The faster I can leave, the better!
It's just annoying people who a) weren't there and b) might not do transport think it's so easy to get all that stuff running quickly when there are only 2 people. If we were on the unit, we would have had 5-6 people, at least. Such a let down to feel really good about the work, teamwork and troubleshooting you did, and then have people come back and try and second guess (especially when you did return with a stable patient, and had made multiple calls back "home" to update/discuss/plan). It's not like we got in trouble or anything, but it really just was a letdown.
Specializes in Adult and pediatric emergency and critical care.
10 hours ago, PeakRN said:
In an adult study vec was show to have no effect or decreased pulmonary artery pressure. Naturally we need to view this with skepticism since adults and neonates have different physiology, but we still both have smooth muscle. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5914209/
Wrong study link, although still a great read on cardiac anesthesia.
I'm so glad we are using the package insert, I'll remember that the next time I'm giving sildenafil to one of our pulmonary hypertension kids who has been on it for more than two years.
An off label use of sildenafil for it's effect on PVR is hardly the equivalent of using a muscle relaxant to facilitate mechanical ventilation and then calling it therapeutic for PHTN. If PHTN is the problem we're treating, we sure don't kid ourselves that the NMB we're using is causing a fall in the PA pressure.
Quote
In an adult study vec was show to have no effect or decreased pulmonary artery pressure. Naturally we need to view this with skepticism since adults and neonates have different physiology, but we still both have smooth muscle.
I'm not understanding what smooth muscle and vecuronium have to do with each other.
Allow me to add some clarity to my posts. I don't think that you are a bad clinician. I've never met you and even if you didn't give the 100% best care (not that I'm saying that) we all make mistakes and all have room to improve.
I want to provide some outside view on the situation. Every time a get a parent complaint, complaint from an sending hospital, or from an EMS service there will always be some degree of validity to it. Maybe we need to do more education on why we discharged a patient that they referred in, maybe why their priority transport got a small room in the back, maybe why we were so hands off with cares. Maybe we did make a mistake. Often the problem is in communication and not in care, but that isn't to say that everyone have room for improvement in their practice.
I do think that EMS has a poor reputation among hospitals and the general public. It is a bit of a sore spot for me because I think a lot has nothing to do with the care that is provided but rather the public image we put on. This is a social media site, and I don't like when EMS talks poorly of other in public, it rarely makes you service look better and usually makes everyone look worse.
I commiserate with your experience. I've had plenty of calls that I thought went well and then later got pulled into the office. I'm sorry that you had so much frustration, but I don't support complaining in public about it. If you were one of my nurses we would have gone out to have mimosas to celebrate the complaints away after shift.
But I wasn't wondering why it happened. I wasn't curious or concerned about how could this have happened, nor was I asking for advice on how I could have managed my patient better, I would have given far more clinical details and less situational details in that case.
I am not EMS. I am an NNP who only does hospital to hospital transport. By and large, I do not see a "bad reputation" for transport teams for the care they provide, quite the opposite - I see us put on some sort of pedestal that we can fix anything.
If you didn't like my venting post, your last paragraph would have been sufficient. But, note I did not complain about the care provided by the OSH, or really any of the people from there, except the letter writer. And of course, I did not name any hospitals involved.
"Man, what a rough day, I got cut off on the freeway and missed my exit so I had to drive and extra 10 min home." "Well, did you do this, this, that or this? Were you driving dangerously or impaired? Did you consider trying to do x y and z?" "Uh? Just venting about a bad day, didn't actually do anything wrong." "Yeah, well, I just hate when people vent about other drivers"
If being supportive is too much to ask, silence is an option.
Specializes in Adult and pediatric emergency and critical care.
14 minutes ago, offlabel said:
An off label use of sildenafil for it's effect on PVR is hardly the equivalent of using a muscle relaxant to facilitate mechanical ventilation and then calling it therapeutic for PHTN. If PHTN is the problem we're treating, we sure don't kid ourselves that the NMB we're using is causing a fall in the PA pressure.
I'm not understanding what smooth muscle and vecuronium have to do with each other.
I'm just making an example that not every indication can be found in the package insert. Some indications are... off label.
Various paralytics have effects on smooth muscle through effects on nicotinic and muscarinic receptors. Effects vary from drug to drug and is generally understudied. Vec is known to precipitate muscarinic block.
Specializes in Adult and pediatric emergency and critical care.
Just now, LilPeanut said:
I am not EMS. I am an NNP who only does hospital to hospital transport. By and large, I do not see a "bad reputation" for transport teams for the care they provide, quite the opposite - I see us put on some sort of pedestal that we can fix anything.
If you didn't like my venting post, your last paragraph would have been sufficient. But, note I did not complain about the care provided by the OSH, or really any of the people from there, except the letter writer. And of course, I did not name any hospitals involved.
If being supportive is too much to ask, silence is an option.
You are in EMS. You provide emergency medical services and transport the patient. EMS is more than just the EMTs and Paramedics in an ambulance. Regardless of if a team is non-transport, ambulance based, HEMS, or fixed wing you respond to an incident outside of your hospital and then transport. What you do is DOT regulated as EMS care. Do you think that public would see you in the back of an ambulance or in a medical helicopter and say 'no, they're not EMS, clearly they are just NICU transport'?
I don't need to be blindly supportive and I'm allowed to have an opinion. You don't have to like my opinion. There is a good chance my opinion will not be the same as yours.
You are in EMS. You provide emergency medical services and transport the patient. EMS is more than just the EMTs and Paramedics in an ambulance. Regardless of if a team is non-transport, ambulance based, HEMS, or fixed wing you respond to an incident outside of your hospital and then transport. What you do is DOT regulated as EMS care. Do you think that public would see you in the back of an ambulance or in a medical helicopter and say 'no, they're not EMS, clearly they are just NICU transport'?
I don't need to be blindly supportive and I'm allowed to have an opinion. You don't have to like my opinion. There is a good chance my opinion will not be the same as yours.
By the way, what did you're medical director say?
Commended me on getting a very sick patient back safely. And let me know that this particular person has a habit of writing letters after every transport and complaining because she doesn't like people coming into "her" unit. Recommended I just brush it off, which is when I came here to just vent it out.
Various paralytics have effects on smooth muscle through effects on nicotinic and muscarinic receptors. Effects vary from drug to drug and is generally understudied. Vec is known to precipitate muscarinic block.
Really? There are no nicotinic receptors in smooth muscle. Vecuronium is known to precipitate a muscarinic block? A block?When? How often? At what dose? As evidenced by what? A dog study?
Specializes in Adult and pediatric emergency and critical care.
2 minutes ago, offlabel said:
Really? There are no nicotinic receptors in smooth muscle. Vecuronium is known to precipitate a muscarinic block? A block?When? How often? At what dose? As evidenced by what? A dog study?
The weird thing is that for some reason the ethics board keeps turning me down for my requests to harvest some neonatal pulmonary vasculature so I can test in the lab.
Specializes in Adult and pediatric emergency and critical care.
11 minutes ago, LilPeanut said:
Commended me on getting a very sick patient back safely. And let me know that this particular person has a habit of writing letters after every transport and complaining because she doesn't like people coming into "her" unit. Recommended I just brush it off, which is when I came here to just vent it out.
This most recent one was a rotor transport so we knew that once we were loaded in the air, there was very limited ability to do much. I would understand if every call I was on was 2-3 hours, but it's definitely not like that. The faster I can leave, the better! 
PeakRN
547 Posts
Wrong study link, although still a great read on cardiac anesthesia.
https://www.ncbi.nlm.nih.gov/pubmed/6137982