Special Edition: Fierce Resistance, Betrayal
Digest
This podcast episode details a simulated EMS scenario involving a 72-year-old male at a skilled nursing facility presenting with near syncope and altered mental status. The paramedic, playing a non-transporting role initially, must assess the patient, Philip, who is pale, sweaty, and denies any event. Despite the patient's denials and a conflicting assessment from another medic who wants to treat it as BLS, the primary paramedic identifies critical signs suggestive of sepsis, including tachycardia, tachypnea, diaphoresis, and a concerning shock index. The episode highlights the challenges of differential diagnosis, the importance of gathering a thorough patient history, and the critical decision-making process for ALS interventions like IV access and fluid resuscitation. A significant portion of the discussion revolves around interpersonal conflict between the medics, with one paramedic advocating strongly for aggressive ALS treatment due to suspected sepsis, while the other appears resistant. The episode emphasizes the importance of time as the patient's enemy, the correct hospital choice, and the need for continuous reassessment and treatment during transport. The hosts break down the scenario, praising the primary paramedic's clinical judgment and de-escalation techniques, while also discussing the potential for systemic issues and the importance of feedback in EMS. The episode concludes with a performance rating and reflections on the complex dynamics of patient care.
Outlines
Introduction to EMS 2020 Special Edition and Rating System
The hosts introduce a special edition of EMS 2020 using patient scenarios from "Master Your Medics" books, transitioning to a video format. They explain the 0-2 rating system for performance: 0 for missing critical treatment, 1 for correct actions, and 2 for exceeding expectations. Game mechanics involving dice rolls for interventions and mitigating factors are also introduced.
Scenario Setup: Fire Response and Initial Dispatch
The scenario begins with the paramedic assigned to a fire response, acting as a non-transporting provider. They are dispatched to a skilled nursing facility for a 72-year-old male with near syncope or altered mental status. The ambulance company is busy, with a seven-minute ETA.
Scene Arrival and Pre-Arrival Assessment
En route to the scene, the paramedic briefs the crew to consider broad differential diagnoses for syncope due to the patient's presentation and the busy ambulance company. Information about local hospitals, including a stroke center, ICU/cath lab, and trauma center, is gathered, along with available transport options.
Navigating the Facility and Initial Patient Contact
Upon arrival at the skilled nursing facility, the team faces a confusing layout but receives directions to room 134B. They are given a patient packet and proceed to the room, where a caretaker explains the patient, Philip, became unresponsive after attempting to stand.
Patient Presentation and Caretaker Interview
Philip appears pale and sweaty but denies any incident, claiming he didn't want to stand. While vital signs are being taken, including a 12-lead ECG, the paramedic interviews the caretaker, Carol, who details Philip's agitation and unresponsiveness when helped to stand, noting new sweating.
Vital Signs, Initial Treatment, and History Gathering
Philip's vitals reveal AFib with a heart rate of 112, BP 116/74, SpO2 99%, RR 20, and BGL 171. Nasal cannula oxygen is applied. The paramedic discusses the concerning condition with Carol and performs a recognition check, noting Philip recognizes one medic but has negative thoughts.
ALS vs. BLS Assessment and Sepsis Concerns
The paramedic determines the call warrants ALS assessment due to altered LOC, pallor, and diaphoresis, despite the patient's denial. Concerns about potential sepsis are raised due to symptoms and history, leading to a disagreement with another medic who downplays the severity.
Detailed Patient History and Sepsis Justification
The EMT gathers detailed patient information, including medications (hypertension, cholesterol, Xarelto) and past medical history (hip replacement, falls, subdural hematoma, AFib). The paramedic reiterates sepsis concerns, citing tachycardia, tachypnea, pallor, diaphoresis, and poor orientation, along with a UTI smell.
IV Access, Transport Decision, and Patient Refusal
IVs are started, and fluids are administered. Despite Philip's reluctance, transport is decided due to his condition and potential sepsis. The paramedic justifies the transport based on vital signs, denial of the event, and caretaker report, emphasizing the risks of not transporting.
Pre-Transport Handoff, Hospital Choice, and Conflict
IVs are secured, and monitoring continues with fluid administration. The paramedic confirms sepsis suspicion with another medic before transporting Philip to a hospital with ICU services, not the closer ER. A conflict arises regarding the paramedic retaining Patient in Charge (PIC) status during transport due to disagreements over the patient's care.
PIC Retention Justification and Interpersonal Dynamics
The paramedic explains the decision to retain PIC status and potentially write up the situation, citing concerns about the other medic's approach and the patient's condition. A dice roll outcome leads to offense from the other medic, who requests supervisor contact information.
Transport Monitoring and Critical Care Factors
The patient is transported to the appropriate hospital with continuous monitoring of vitals, lung sounds, and ongoing fluid administration. The paramedic stresses that time and correct hospital choice are critical, and the only ways to fail are by choosing the wrong hospital or stopping treatment.
Scenario Review: Clinical Simplicity vs. Interpersonal Conflict
The hosts review the call, noting its clinical simplicity was overshadowed by interpersonal dynamics and one medic's reluctance to escalate care. They praise the initial assessment, task delegation, and information gathering.
Effective Assessment and Communication Techniques
The paramedic's strategy of de-escalating with the caretaker, recognizing altered mental status despite denials, and addressing hostility directly is highlighted. The challenges of role-playing a resistant medic and the importance of clinical justification for ALS interventions are discussed.
Sepsis Debate, Shock Index, and Systemic Issues
The discussion focuses on the shock index (0.96) and the debate over sepsis, emphasizing the difficulty of pushing back against a resistant medic. The potential for errors due to medic resistance and systemic issues in providing feedback is explored.
Importance of Feedback and Learning from Cases
The hosts stress the value of seeking feedback, even without formal systems, and learning from cases where initial assessments might be challenged. Phrasing concerns directly and avoiding accusatory language is discussed as an effective communication strategy.
PIC Retention, IV Justification, and System Loopholes
The decision to retain PIC status and the justification for starting an IV are debated, considering system loopholes like EMTs transporting patients with locked IVs. The evolution of transport protocols and the risk of misinterpreting the need for ALS intervention are explored.
Time as the Enemy and Lack of Feedback
The critical role of time and correct hospital choice is reiterated. The lack of active QA/QI in some systems allows medics to rely on "vibes" without consequence, highlighting the importance of actively seeking feedback, especially on initially dismissed cases.
Ignoring Evidence and Evaluating Performance
The scenario demonstrates the flawed approach of ignoring evidence and believing patient denials to deem a patient "not sick." The hosts consider gross incompetence versus malice and question the medic's acceptance of patient denials as an unacceptable response.
Call Review, Performance Rating, and Conclusion
The hosts reflect on the call, acknowledging personal anger and the effectiveness of the paramedic's interventions. The performance is rated, expressing overall satisfaction despite the challenging interpersonal dynamics and the medic's reluctance to escalate care. The episode concludes with outro and sponsor information.
Keywords
Syncope
A temporary loss of consciousness due to insufficient blood flow to the brain, with various potential causes. Near syncope refers to the feeling of impending faintness.
Altered Mental Status (AMS)
Any deviation from a person's normal state of consciousness or cognition, with a wide range of possible underlying causes.
Skilled Nursing Facility (SNF)
A healthcare facility providing 24-hour medical care and rehabilitation services, often post-hospitalization.
Sepsis
A life-threatening condition where the body's response to infection causes organ damage, characterized by a dysregulated host response.
Shock Index
The ratio of heart rate to systolic blood pressure (HR/SBP), with a value >0.9 often indicating shock or hypoperfusion.
Patient in Charge (PIC)
The individual responsible for overall patient care during an emergency, typically the most senior or experienced provider.
ALS vs. BLS
Advanced Life Support (ALS) involves complex medical interventions, while Basic Life Support (BLS) includes fundamental emergency care.
Medical Director
A physician overseeing the medical aspects of EMS, establishing protocols and ensuring quality patient care.
Tachycardia
An abnormally fast heart rate, often a sign of the body's response to stress, infection, or other medical conditions.
Diaphoresis
Excessive sweating, which can be a symptom of various medical conditions, including shock, fever, or anxiety.
Q&A
What is the rating system used in this podcast episode?
The podcast uses a 0-2 rating system for evaluating paramedic performance: 0 for missing critical treatment, 1 for correct actions, and 2 for exceeding expectations.
What are the key vital signs and initial findings for the patient, Philip?
Philip's vitals include a heart rate of 112 (AFib), BP 116/74, SpO2 99%, RR 20, and BGL 171. He is pale, diaphoretic, smells of urine, and has a shock index of 0.96.
What was the primary medical concern that arose during the scenario?
The primary concern was potential sepsis, indicated by Philip's vital signs, altered mental status, diaphoresis, and urine smell, despite his denial of illness.
Why did the paramedic decide to retain Patient in Charge (PIC) status during transport?
The paramedic retained PIC status due to concerns about the other medic's assessment, believing they were downplaying the patient's condition to treat it as BLS, contrary to clinical evidence.
What is the significance of the "shock index" in this scenario?
The shock index of 0.96 is significant as a value above 0.9 suggests potential shock or hypoperfusion, contributing to the suspicion of sepsis.
How did the paramedic address the conflict with the other medic regarding the patient's care?
The paramedic directly questioned the other medic's assessment, highlighted clinical indicators of sepsis, and expressed concerns about potential mismanagement as a BLS case.
Show Notes
Table of contents
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