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Wednesday, December 10, 2008


NOTE: as usual when I write about my work environment all names and situations are changed in order to protect private patient information and to respect the privacy of co workers. Also, I am compelled to inform you that my opinions are my own and do not represent BHCHP as a whole.

Because I do not work at a hospital proper, there are certain policies and procedures in place for when a patient's condition deteriorates to the point of needing more acute care. These cases of course, can be broken down into emergent and non-emergent situations. For example, if Mr. A has a wound that just isn't healing, he may be considered for a hospital admission where he could receive more specialized care. That's non-emergent. Emergent could be a patient with a rapid change in condition such as a seizure, a heart attack or a loss of consciousness secondary to a fall.
Those types of rapid changes warrant a 911 call.

The other day I had a patient, we'll call him Mr. B, whose blood pressure began dropping over night. Mr. B can be said "run low" anyway, but this drop into a range of 85/58 was new. The night nurse reported Mr. B to be nauseous, had a poor appetite, and was hot and clammy to the touch, with a fever of 100.0. None of this is particularly strange during flu season, but Mr. B is a special case because he is a chemo and radiation patient. Fevers and changes in condition must be watched very carefully. The night nurse told me they had been encouraging fluids, but she was very concerned about the patient.

I went to go see him. It was just as the 11-7 nurse had said. He had been vomiting for the past few hours; we kept encouraging him to drink sips of juice and water as often as possible, but it was to no avail because after about an hour on my time his BP had dropped even more significantly. He was severely dehydrated, and needed to be checked out at a hospital. When his provider arrived, we called the hospital, notified Mr. B's oncologist, and sent Mr. B over via non emergent transportation.

This is where the trouble began. It wasn't a 911 call. Mr. B wasn't in crisis, he needed IV fluids, but wasn't in any imminent danger. He was breathing, had a steady pulse, and had not lost consciousness. So we called a private ambulance company. Now, I know it must be really crappy to be non emergent ambulance drivers in this situation. I'm sure these guys are not using their skill sets to the top of their game; they are very well educated, they know a lot about emergency care, but they are just being used as transporters. They are not responding to a crisis, they are there to wheel people like Mr. B onto the truck and stay with him in case his condition worsens on the way over to the hospital.
That being understood, someone has to do this job. It can't be paramedics, because we need them available for actual emergencies, and it can't be taxi drivers because they don't know anything about emergencies. So someone has got to do this non emergency handling of problems.

And more often than not, the people who are called in for the job take it out on the nurses. It began when I was called out to the hallway and they began drilling me about the patient's condition. I told them all I know, and then with a scathing look at his partner, one of them asked me, "so he's just.. vomiting? and has a fever?" Caught off guard, I stammered that his BP had dropped significantly. He stared at me. "So why this hospital? Why not a closer one?" I was stumped, of course the answer was that this patient was an oncology patient at the other hospital and needed to be seen by his primary, but I couldn't think. The EMT sighed dramatically, "Ok, so why is this guy here to begin with? " He was holding the patient's chart. In his hands. I had already told them he was there for respite during his chemo and radiation, and repeated myself and said we just needed him worked up because his vitals were tanking. Meanwhile, another patient began calling for me. Then Mr. B's NP appeared and took over. When she returned she told me how the EMTs had made fun of her for calling an ambulance for a patient just because he had the flu.

The patient did not "have the flu," as it turned out. He was dehydrated, and had some severe electrolyte imbalances as a result. He could have gone non responsive, or gotten a life threatening heart arrhythmia.

There is a lot of animosity between medical personnel of varying educational backgrounds and specialties. I had been following urban paramedic, until he was unable to write anymore due to being activated in the armed services again. Both my parents were EMTs. I get it. Sometimes the nurses who make a 911 call are not competent. They get scared, they dial three numbers. Ok, I can see it happening.
But more often than not people are just following policy. When I was a CNA working overnights in assisted living I had to call 911 for a patient with chest pain one night that wouldn't go away with aspirin. In this facility, there are no higher ranking medical people on at night than a CNA. I called my boss, an RN and he told me to call 911. I didn't have access to nitro or to oxygen, as we were an assisted living building, not a hospital. When the ambulance got there the paramedics checked her out and the pain went away with some 02. I asked that they leave her with me but they told me they had to take her. Protocol. Her family was FURIOUS with me. They called my boss and said that their mother often claimed she had chest pains when she just wanted attention. And now they had to pay for an ambulance an an ER visit. My boss stood by my actions. What if that one time she had not been doing it "for attention?" What if she died that night? If I hadn't called 911 and something had happened, then what?

Similarly, Mr. B had to go get checked out. He's a cancer patient. You don't mess around with a fever in a patient undergoing chemotherapy. He could be severely neutropenic. And it's not really an EMT's place to question why we're sending someone out. They can ask questions to get a feel for what care might be necessary on route to the hospital, but to question an order to send someone out seems ridiculous. Am I going to say, "Oh, you are right.. you better just be going then?" I believe their protocol demands they bring the patient with them unless the patient refuses outright. So are they going to talk me out of a concern and then just leave with no one in the truck? It seems unlikely. So their sarcasm and commentary only serves to belittle nursing staff, and to undermine authority. Which is not useful in high stress situations, even if they are not a matter of immediate life or death.

I do not want to perpetuate the bad blood between EMTs and nurses. Or nurses and doctors or nurses and aides or doctors and surgeons or nurses and nurses any of the like for that matter. And so I will refrain from saying some of the things that ran through my head during the rest of that morning. Instead I will make a plea to everyone, everywhere:

If you do not like your job; if you do not find joy in doing what you do; if you do not go home at the end of the day feeling good about what you've done... quit.

And if you claim that you'd like what you did if it weren't for the people, please re examine your motives. Most of us work in this field to help people. It's that simple. We've come here from different walks of life and for different reasons, but it all boils down to that one thing. We help people. So why be nasty to one another? It's only going to delay the service we provide. It's going to make us all feel badly about one another. How can we help others if we can't trust each other? How can I trust you when you are trying to make me look like an idiot? The system only works as well as one part can depend on the other. So EMTs, hold back your eye rolling. And for goodness sake stop asking me if this patient is homeless as if homeless is some new contagion. Nurses do not talk down to the EMTs, and if they do ask a reasonable question you just can't answer, admit it and grab the chart. Then maybe we can all go home at the end of the day and feel good about what we do.

If not, you're in the wrong place.

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