I am a nursing student working as a new EMT, and I ran into a difficult situation on the job recently that had me thinking, and I would love your input.
My partner and I were on a call for a typical interfacilty transport (dialysis back to SNF). When we arrived on scene, I was surprised to find that my patient was in mild to moderate respiratory distress. The dialysis nursing staff stated that she had been wheezing all morning, and that they did not feel there was an acute issue. I honestly wasn't sure if I trusted the staff's opinion, as her respiratory rate was fluctuating between 18 and 26, she was speaking 3-4 word sentences, she appeared somewhat labored, and the wheezing was audible without auscultation. As a result, I began to consider whether or not this call warranted an ER visit, and I automatically offered my patient oxygen. However, she refused the oxygen, stating that she felt the nasal cannula was uncomfortable. I continued to interview my patient regarding her symptoms, and she kept saying, "I feel fine. I want to go home," even when I asked if she wanted to see a doctor.
For me, this patient was alert and oriented x2 and showed some signs of confusion, which I was told by the dialysis nursing staff to be normal for her.
I struggled to decide if my patient was of sound mind to refuse treatment. On one hand, the dialysis nursing staff did not seem concerned and the patient was refusing treatment, but on the other hand, I felt that my patient needed treatment. Because the SNF was less than 15 minutes away, we decided to transport the patient back, and allow the staff that knew her to make the call. In the back of the ambulance, I noticed no change in mental status, but I did note that her respiratory rate would increase to about 30 for one minute after coughing.
Turns out my patient was on Zithromax for PNA, but the receiving RN knew little else about her, as she had just returned from vacation.
So, my questions are:
Did my patient have the right to refuse treatment given her history of confusion (and possibility for confusion related to SOB)?
Do you think I was jumping the gun to consider switching this to an ER call?
If she was sound of mind, what are ways you would recommend to document this?
didn't you say she was being treated for pneumonia? hey, she has...pneumonia. she still needs to go out for her dialysis but she is under treatment for her pneumonia. in that case the snf is already aware of her baseline and treatment duration (one day? one week?) so they are in a better position to evaluate her. even if the nurse to whom you gave report is just back from vacation, not everyone on the floor is. absent a clear and sudden emergent decline, i think you listen to the dialysis nurses and take her home to the snf, and let them deal with it.
GrnTea -This was my partner's rationale, as well. As a new EMT, I cannot help but highly scrutizine my actions just because I want to make sure I am delivering the best care I can, so I appreciate your input.
Cayenne06 -I was pretty surprised to learn that the pulse ox was not in our scope of practice back when I was getting my certification. I definitely encounter nurses on a regular basis that are surprised to learn that we cannot obtain it, too. I even once had a nurse scold me for not obtaining a pulse ox at a private residence.
I was actually surprised that you couldn't obtain a SaPO2, myself, as our EMT's can, and if they don't and the patient is on O2, then they will be docked in their documentation and treatment during QI.
NBB, my point was, whenever in doubt, use your support system; field sups, your ALS units, medical control, look towards your protocol and SOP book. You should never be reprimanded when you do, and if you are, then they are just wrong.
When I was working as a Paramedic, I always told my new ones, that I would rather be called and nothing be wrong, then not called and something be horribly wrong.
I think that is some reassuring advice, ambgirl2nurse, and it is an excellent point. In retrospect, I do wish I had done that - just to be absolutely safe, since I did get that "iffy" feeling, and you certainly are right in that it does no harm to the patient. I certainly hope that as I become more experienced, these decisions become easier to make! Thanks for your input.
EMT-Bs cannot use a pulse oximeter? Wow! You need to get over to west Texas, lol! In our area, our EMT-Bs can handle the oxygen in all sorts of manners (even pulse oximetry, lol!), nebulize meds, IM glucagon, IM Epi 1:1000, intranasal fentanyl/Narcan/Versed, drop emergency airways (King) along with all the other expected stuff. But, we may be a lot more rural of an area in comparison to yours... lots of volunteer services here serving our small farm towns.
Back to the original post though, my reply is just a confirmation with others that medical control contact should always be an option in your mind, or request for an ALS/MICU intercept. I am a paramedic, and like the others here, I would much rather meet up with you so we don't take chances with the patient. Even as a paramedic, I have bypassed contacting field supervisors before because my gut said to contact medical control, and I'm glad I went with my gut. Remember who has the "M.D." after their name --- usually not the supervisor or service director, right? :) (And yeah, I got some butt-chewing for bypassing my "superiors" and going directly to medical control. Oh well. Even that trauma heals eventually)
Tough call on that one for you. IMHO, your heart and head were in the right place.
It is because EMT's aren't educated in how the pulse-ox works and the pulse-ox isn't in their scope of practice that they can't use the device. Their medical director at the State or local level generally keeps the EMT from using that device. EMT-Intermediates can, as can Paramedics. Paramedics can interpret and titrate oxygen flow to maintain a desired SpO2 level... just as Nurses can. Nurses should spend some time getting to know what EMT personnel at all levels can do as they're not all the same.
Okay. It took me all of 5 minutes to learn how to turn on and apply a pulse ox. If all an EMT-B has to do is write down or report the number (just like they would do with a BP, which is definitely more difficult to take correctly), it is stupid and dangerous for them to not be "allowed" to learn how to use one. My sister is an EMT-B, and it never occurred to me that she wouldn't be trained something so utterly basic as pulse ox.
Is it your call to take the pt to the ER when the nurses have been with her for hours and their assessment is that she is ok? A SNF is a skilled NURSING facility. They will take care of her. And call back if she does need to go to the ER later.
What did her lungs sound like. Just after dialysis there is a risk of overload, pneumonia or not. There are so many things to be taken into consideration. Wheezes, rales, pulse ox. Try to think of the patient as a whole and all the things that could possibly be causing respiratory problems.
Is it your call to take the pt to the ER when the nurses have been with her for hours and their assessment is that she is ok? A SNF is a skilled NURSING facility. They will take care of her. And call back if she does need to go to the ER later.
An EMT-Basic isn't necessarily allowed to make that call, however a Paramedic can if warranted. It depends on the pt, situation and the Paramedic.
I had a call where our local PACE provider wanted the patient transferred to a SNF and not the ER (despite what the POA wanted). The patient had been ill for a few days c/o abd pain, N/V. When I got on scene to do the transfer and assessed her, she was past coffee ground emesis and starting to have what I call "chocolate milk" emesis, diaphoretic, with not so great but not awful VS. I overrode the transfer to SNF and took her to the ER for a GIB.
Okay. It took me all of 5 minutes to learn how to turn on and apply a pulse ox. If all an EMT-B has to do is write down or report the number (just like they would do with a BP, which is definitely more difficult to take correctly), it is stupid and dangerous for them to not be "allowed" to learn how to use one. My sister is an EMT-B, and it never occurred to me that she wouldn't be trained something so utterly basic as pulse ox.
Please don't get me wrong. I think that using the pulse ox is a very easy skill to learn... and even I can teach someone how to use it in a matter of a couple minutes. The problem with EMT's using them is that they don't get enough background (think A&P) to know how to interpret the results. Remember, you can have someone who has a 99-100% SpO2, who is severely hypoxic. The EMT doesn't learn how the pulse ox can be misleading. Because of this, the EMT doesn't deal with the pulse ox and has to follow protocol for delivery of oxygen in a given situation. Given the appropriate educational background, I see no reason to keep an EMT from using the device. I don't care how the EMT gets the appropriate education, as long as it's done.
I don't think it's at all dangerous to withhold the use of this device, especially when you realize that the EMT will be 1:1 with that patient for the entire duration of the ride. They also at least learn that decreased LOC is one of the first signs of hypoxia...
I understand the reasoning, but I don't necessarily like it. Those West Texas EMT's probably have quite a bit more education than the "standard" EMT in the use of advanced airways, certain medication use, and the pulse ox, to name a few things, but that stuff isn't in the usual EMT training program that you'd find in most of the US. New EMT's have a LOT to learn about the practicalities of things and that's why they're put with more experienced EMT's.
I wasn't there, so I can't really say what I'd have done in the situation the OP was put in... but I will say that I'd just have to assess the patient myself and get the background myself as well, before I decided to transport to the ED vs. back to SNF.
Really, it's the history that is going to "drive" that decision point as that's what I'll use to determine if the problem is acute or chronic.
I understand what you are saying, but EMT-Bs are allowed to take a BP, and that is subject to much more interpretation, and is harder to do correctly, than a pulse ox. I thought a major role of EMT-Bs was to gather data for the other practitioners to interpret. I just fail to see the difference between a BP and a pulse ox. Hell, you need way more A&P to truly interpret a BP than you do to interpret a pulse ox, and anyway the EMT-Bs aren't trying to interpret it; they are just getting the info.
Much like a tech isn't supposed to interpret a 12lead- they just apply the electrodes.
nurseprnRN, BSN, RN
1 Article; 5,116 Posts
didn't you say she was being treated for pneumonia? hey, she has...pneumonia. she still needs to go out for her dialysis but she is under treatment for her pneumonia. in that case the snf is already aware of her baseline and treatment duration (one day? one week?) so they are in a better position to evaluate her. even if the nurse to whom you gave report is just back from vacation, not everyone on the floor is. absent a clear and sudden emergent decline, i think you listen to the dialysis nurses and take her home to the snf, and let them deal with it.