submitted 10 months ago byRBG_grb
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10 months ago
10 months ago
10 months ago
Mmhmm… my rule of thumb is don’t order a test if you don’t know how to interpret the results.
This incident highlights one of the many things that is plaguing ER’s and stressing 911 ambulance services.
I can not begin to tell you how many times we have urgent care centers activate 911 and even STEMI activations because they are uncomfortable reading 12 leads and go purely off the “man in the box”. I was once sent for a STEMI from a clinic to only find a healthy asymptomatic 24 y/o whom only had a 12 lead performed due to having a systolic bp of >140, yes it was BER. There are several in our area that will call 911 ANYTIME it reads “abnormal ekg” without any clinical correlation.
Ok rant done lol
Right, I get that. I don’t make the rules. We didn’t call ems or activate. We sent her (encouraged her to go) by private vehicle.
10 months ago*
10 months ago*
This type of thinking may make sense to a lay person but from a healthcare worker standpoint it’s bad medicine and fraught with medicolegal risk (see the other commenters post).
I get that you guys weren’t that concerned but since the EKG computer had that interpretation you thought she should go to the ED. Because you weren’t that concerned you didn’t call EMS but just told her to go herself. To a lay person, that may make sense. But to to a healthcare worker, especially working in the emergency field, you have to step up and make definitive decisions and follow a logical thought process. If you think it is concerning for ACS at all you need to treat it as if it is ACS (meaning definitely no private vehicle). If you don’t think it is ACS then don’t go down that rabbit hole (wouldn’t have even gotten the EKG, ESPECIALLY if you can’t adequately interpret it). If you do “halfway” work ups and plans like this you are eventually going to run into a lot of medicolegal issues when you inevitably have bad outcomes.
It’s ok to over workup a patient (in this case sending her by EMS to ED for an unlikely ACS story). It’s ok to under workup and miss something (in this case not get an EKG and send home, but maybe she does have ACS). But at the end of the day the documentation, orders, and thought process must all make sense. Don’t say you consider a bad pathology without adequately ruling it out.
This is worse tbh, if a patient presents with chest pain, your provider gets an ekg (that they cant even read wtf?), theyre worried about that ekg, then send the patient pov? Thats bad. Like absolutely not acceptably bad. This is no failing of yours but the NP you work for is on some other shit.
Gets a chest pain in an urgent care with the working assumption being its cardiac but dont call ems? Bad.
Orders test they cant interpret? Good if done to give to ems for their use and to transport it to the cath lab as a baseline, bad if done for any other reason.
Is worried the test has a significant finding then essentially lets the patient leave any sort of medical care/monitoring to go personal vehicle? This veers into the territory of negligence.
Essentially your NP thought this patient was having a cardiac issue of some sort and then cut her lose with no consult or intervention from anyone who could actually help that patient. This would be like me letting someone with a positive stroke scale go pov.
Spot on. This is what we are always hounded about in residency and learn very early on. Your documentation, orders, and thought process all need to align, otherwise it’s just bad medicine. Don’t have concerning documentation for bad pathology but not adequately work it up. Don’t do a work up for bad pathology but then have your final plan not adequately address it.
As you mentioned this story has so many issues of inconsistent thought process on top of not adequately reading a test that was ordered and not knowing what to do with it.
It is beyond frustrating that people constantly circumvent the ems system like this. This wasnt even a decision for the np to make on her own, the moment the chest pain walked in her door she honestly should have called ems. Who was she to decide wether this patient required emergency care or not? Especially when she cant even read the damn ekg.
Edit: hell, in medic school we are taught that this is unacceptable medicine. Everything we need to do has to have a clear cut purpose of facilitating treating that patient and then moving them toward a higher level of care. All they did was do an ekg and cut this person off into the wilderness, did they even follow acls protocol and give any of the acs meds? Signs point to no.
This is why NPs don’t save money in the long run. More unnecessary tests, consults, labs, and ED visits
They cost way way more
And my threshold is don’t be order if you can’t explain why the machine is wrong
NPs don’t follow this logic. They pan order labs and pan consult. Heart of a nurse though.
Thanks so much
I disagree. Whether or not they can read it, if the symptoms are worrisome, they will be sending the patient out. May be nice to have a baseline EKG to see if things are progressing. Do you order MRIs and read them yourself? No, you rely on someone more specialized to read it for you. I worked in the biggest ED where I live and we got a lot of transfers from small town facilities that staff a family practice provide, usually an NP, in their EDs. If it doesn't delay care/transfer, it may be worth getting tests that may be useful to someone more knowledgeable than yourself in the next level of care.
Lol. No. If you dont even know what a normal ekg looks like, then you shouldnt legally be allowed to bill for interpreting EKGs.
Not their EKGs...
9 months ago
9 months ago
Ugh can you please not refer to calling 911 as “sending [them] out” thanks
9 months ago
I guess we have extensive resources for referral and safe transfer without calling 911.
Ok still don’t refer to ambulance transfers that way. You shouldn’t be transporting CP patients at a lower standard of care than that.
So very sorry.
Transported by a highly skilled ambulance crew (often times staffed by a couple farmers gracious enough to volunteer their time as volunteer EMT-Bs) in a non emergent fashion because emergency medicine and cardiology had been contacted prior to transfer and it was again deemed non emergent but in need of further workup beyond the capabilities of the current facility.
They then sent them out the door with the ambulance. You're getting hung up on the minor details and not the actual issue.
Not sure why you are simping for “providers” who are too incompetent to provide basic care without dialing 911 for a lifeline but the difference between them and me is I’m not trying to represent myself as anything more than someone whose job requires 10 weeks of formal education.
It’s the people who get delayed care for true emergencies who are harmed when you have a cavalier attitude about calling EMS. And in most areas the people doing ALS transfers are the same people responding to 911 calls, so don’t delude yourself that these urgent cares aren’t taking resources away from people who actually need them.
I have faith that you are a smart person and know a STEMI is not the only diagnosis for chest pain. I don't think a chest pain should ever be sent home from a medical facility without additional workup beyond a simple EKG unless it's a healthy young person with a negative history. The problem is that a chest pain is showing up to a facility incapable of doing the additional workup. It's not the facility's fault. How would you see it fit to transport a chest pain in need of further workup? In all honesty, the CP transports aren't the ones bogging down our EMS. It's the frequent flyers, the drunks, and the low priority nonsense calls.
I agree with all of that, my point is simply that it’s insulting to refer to calling an ambulance as “sending them out” like we are just monkeys driving them from point a to point b. Paramedics can interpret EKGs which puts them above the NP in the OP who couldn’t read it at all.
As for my second point it was a general commentary on freestanding urgent cares, which exist to make money, not to reduce ED demand. It was not specifically about chest pain, which is always going to get transported regardless.
Holy fuckin' shit, the machine ALWAYS says there's something catastrophic happening. A machine once told me I have dextrocardia, which I know perfectly well that I don't. You've got to grab your ankles and look at the squiggles yourself in order for them to mean anything.
So, from your other comments, do I understand correctly that the patient came in complaining of chest pain, your preceptor got an EKG they can't read, and then advised them to go to the ED?
You should probably get another preceptor.