Did EMT give patient rights properly? What would you do?

[curiousprepa]

Hi everyone, I recently had to deal with a family emergency.

 

The paramedic team did not give us a lot of information when assisting with the emergency. One paramedic took the blood sugar of my family member and found the BG below 60 mg/dL. I saw one paramedic initiate an IV. The same paramedic reported giving D50W. I did not see the D50W administered. I saw a bag of NS attached to one of the IV lines. Even seenig the fluids administered to my loved one's body, the paramedic team said, that they were administereing "medicine." They did not specify that it was D50W. They also said that "HIPPA was going to release patient information" if refusing care from the ED. When asked again what it was, they did not give examples of how HIPPA would affect us during care. The only thing I was educated on was taking my loved one to a hospital for slurred speech after finding a blood sugar below 60 mg/dL. The paramedic said that the reason why they would need to take my loved one to the hospital is to rule out CVA over hypoglcyemica.

 

After 15 minutes of D50W administration, my loved one was alert, but still had slurred speech. They did not give him the option to refuse treatment by being trasnported to a hospital. They kept saying that people should be alert and oriented within 5 minutes. They did not specificy the meaning of this when asked.

 

After 30 minutes of D50W administration, my loved one was able to smile. His grip was equal to gravity. He was able to state his name, and date of birth.

 

What would you guys have done after finding hypoglycemia? Was protocol properly followed?

[winterallsummer]

Even though it sounds like it definitely could have been handled better, it sounds like they did the right thing.  And if this were a loved one and you were not medically savvy, it would be in your best interest for them to transport to the hospital if their AMS didn't resolve with D5.  So even though they probably lacked tact, it sounds like the bottom line is they did do their jobs correctly.  I hate poor customer service too, especially in medicine when the "customer" is so vulnerable, but I would rather have a rude EMS staff that did the right thing then a polite one that wasn't thinking about CVA, etc.  Just my 2 cents.

[curiousprepa]

That's what I was thinking too. I just wanted to make sure.

[SocialMedicine]

Always keep in mind the differential   do not always assume the obvious esp when other possibilities can be fatal (CVA)

 

If a patient is altered mental status, in this manner, most states have implied consent laws. 

 

Not sure why you are complaining ... and not sure why the medics spent over 30 minutes at scene if they thought the patient could be having a CVA .. Local protocols differ widely for EMS ..... 

[curiousprepa]

Not sure why you are complaining ... and not sure why the medics spent over 30 minutes at scene if they thought the patient could be having a CVA .. Local protocols differ widely for EMS ..... 

 

My goal wasn't to complain about the situation. I wanted to make it more of a learning experience of what should be done and what should not have been done. The feedback will help me in the future.

 

From what I understand, the goal of EMS is to make the patient stable. They measure BG wtih a glucomonitor to determine if the BG is within 60 mg/dL to 110 mg/dL. They initiate the IV with 180mL D50W in 1L NS to bring up the BG above 60 mg/dL. I was confused about the next step.

 

Once they have achieved BG stability, it would be better for them to get a CT scan to r/o CVA? Once again, I'm just wondering. I thought there would be further physicial examination to determine findings r/o CVA before initiating a CT scan.

 

My goal was to learn from the situation.I have a tendency to write things out in detail to describe what happened. I also have a tendency to use quotations to avoid subjective words in hopes of getting better feedback. I'll try my best to practice my writing next time.

[UGoLong]

Our protocol is to start normal saline and then slowly administer D50  through the same line, using a somewhat large, pre-filled syringe (which takes work; it's like pushing cold maple syrup.)  D5 comes in IV bags;  I don't believe that D50 ever does. That's probably why you saw normal saline hung.

 

The patient is usually transported. Patients can refuse only if they are alert and oriented. If the patient is a diabetic with low blood sugar, they will snap out of that very quickly with D50 and be themselves again. If not, a needless trip to the ER beats the heck out of leaving a stroke at the scene. As you will learn in PA school, you first rule out things that could kill the patient before you settle on an innocuous diagnosis like low blood sugar.

 

This crew could have been more forthcoming but I can't tell what kind of scene it was for them either -- lots of upset relatives in their faces, milling around, asking lots of questions while they were trying to take care of the patient. If they had the spare manpower to work with you or had people out getting their cot, equipment, etc. Even what run they might had just come from before heading to your house.

 

Scenes can be difficult for both the crew and the family. Crews should try harder, but families need to cut them some slack too.

[curiousprepa]

Thanks again UGoLong.

[fakingpatience]

Coming from a currently practicing paramedic (not pa or student yet!) perspective:

 

If your loved one wasn't a diabetic, being hypoglycemic would be concerning and I would always push/ encourage transport. If the patient is a diabetic I will usually treat on scene, and talk with them, if they can give me a good reason why their sugar dropped (ie I took my insulin and forgot to eat, I'm a brittle diabetic...) fine, do an AMA. If not I again strongly encourage transport.

 

As you mentioned they said, I would also have been concerned that the slurred speech didn't resolve quickly with dextrose administration. Although it's unclear what the post treatment BLG was.

 

Also, many areas are now moving away from D50 to D10, which would look very similar to a saline bag, but in a 250ml bag. Personally I piggy back both D10 and D50, unless I want to limit the fluids the patient is receiving.

 

As someone mentioned earlier, if the patient is altered then they are unable to transport to the hospital. Slurred speech alone would not = altered, but if the speech was so slurred communication was difficult then it could be a consideration. Further, technically once 911 is called we always have to recommend transport to the ER via ambulance and advice of risk of deterioration of condition up to and including death. Some companies will ding a provider for having too many refusals, because they do not bill for most of them. Regardless, I would be concerned about the slurred speech taking 30 mins to resolve as typically is very quick with dextrose administration.

 

One thing that many paramedics do not necessarily do well as a whole is explaining to patients their options. We are so used to people calling because they want to go to a hospital, we can forget that that is not always the case. I have a speech I give often that goes like this (in addition to explanations of risks...) "we are here now, we are more than happy to take you via ambulance to the hospital. You also could go in a car with a family member to a hospital, urgent care center, or contact your family provider to get seen. By all means if anything changes or you just change your mind you are always more than welcome to call us back and we'll take you to the hospital". Not saying that is the only, or by any means best way, but I think it's important that patients know their right to refuse, and their options.

 

Haha sorry for how long this writing is! Oh and I have absolutely no idea whatsoever that they meant with your HIPAA quote earlier.

[curiousprepa]

Thanks fakingpatience.

 

The explanation from an EMS background is extremely helpful. From what I understand so far, the primary focus is emergency intervention. It seems that once EMS has ensured that the person is stable, they give them the option to go to the hospital for further evaluation.

 

The explanation of patient options seem to be different with every scope of practice, and situation. For instance, during my work as a current CNA, I learned that I can not provide emergency treatment because it is not within my scope of practice. I can only give patients the option to speak to nurses and staff about their well-being, care, and treatment plan.

 

It was good to learn about the different takes on the situation from people with different backgrounds. I hope to apply this to the application process in some shape or form in the future. 

[SocialMedicine]

I disagree, EMS provider of many years here. EMS provides life saving interventions and transports to the hospital right alongside those interventions. Medics are not really trained to provide ongoing care, diagnosis, treatment planning. The interventions they provide are within the framework of transporting to an emergency room. 

[curiousprepa]

So do medics provide emergency intervention, and transport to hospitals for clinicans, such as nurses, doctors, PAs, or NPs, to evaluate the patient further?

[Arthropathy]

EMS is trained and required to stabilize and transport.  If your family member was altered, then they are legally and medically unable to make decision to refuse transport.  In these cases EMS has an obligation to transport to a hospital.  The only way to get around this is with an invoked healthcare proxy stating that you have the legal right to make medical decisions for the patient.

 

While it sounds like the crew might have been rude, they certainly made the right decision to treat hypoglycemia (<60) and to transport the patient, especially since there was inadequate response to treatment (slurred speech).

[fakingpatience]

So do medics provide emergency intervention, and transport to hospitals for clinicans, such as nurses, doctors, PAs, or NPs, to evaluate the patient further?

Exactly! But although we are not trained to do a full exam, nor able to perform many tests needed to obtain a definitive diagnosis, alert and oriented patients are still within their rights to refuse transport (with the understanding of our limitations on evaluation). At any point in time, with care by any level of provider a competent patient has the right to refuse care / leave

[curiousprepa]

Thanks for clarifying everyone. I'll read up more on each person's role in the healthcare system.

[EMEDPA]

you said"

 during my work as a current CNA, I learned that I can not provide emergency treatment because it is not within my scope of practice. I can only give patients the option to speak to nurses and staff about their well-being, care, and treatment plan."

 

I would hope you would provide emergency care if you found someone with resp. distress, significant bleeding, or in need of cpr while screaming for help...

[curiousprepa]

 

you said"

 during my work as a current CNA, I learned that I can not provide emergency treatment because it is not within my scope of practice. I can only give patients the option to speak to nurses and staff about their well-being, care, and treatment plan."

 

I would hope you would provide emergency care if you found someone with resp. distress, significant bleeding, or in need of cpr while screaming for help...

 

So far from what I have known as a CNA, I can perform CPR, ACLS, Heimlich maneurver, and emergency assessment of the situation by taking vitals, using a gluomonitor, and checking for both ABC and bleeding. I am told to report things to nurses and clinicans who are licensed to physicially assess and give further emergency intervention as needed. In assisted living facilities, nurses will usually check for BG level to determine if emergency intervention is needed. However in hospitals, CNAs can use a gluomonitor to check BG during emergencies. 

 

In all places, RNs are the ones who usually provide emergency treatment, especially for hypoglycemia, if ordered by MD, DO, NP, or PA. In assisted living facilities, they can delegate this to a LPN. In hospitals, they can delegate this to a CNA who are trained to place in IVs.

 

However, I feel that it is good to learn protocols for emergency situations. Especially if people want to pursue a degree as a clinican. More so because I feel there is not enough time and training to learn this while in school.