Need Help With A FF

[uglyEMT]

Hey all, need some outside perspective for a recent problem.

I have recently run into a Frequent Flyer (3 calls aday) and have done all that I think I could for the pateint but it doesn't seem to be working. I think the system is failing him.

First contact was for running out of meds and wanted a transport. During the call it was what he said that got my spidy senses up. "I am tired. I just want to lay down and go to sleep. If I wake up who would care."

OK I get him in the ED and begin telling the nurse everything then pull her aside a second (dont talk in front of my patient's) and explain what he said and that I feel I psych consult should happen.

4hrs later another crew brings him home. Dont you love taxi duty?

8hrs later I am bringing him back for "intoxication". Checked the pill bottle and 26 are missing. OK intoxication is now suspected overdose. AGain intake the ED (different nurse) explain everything including the prior visit and ask to speak to the head nurse. Speak to her and advocate for my patient that he needs a psych.

Heard from another crew he was brough home sometime later the same day. Nothing sense.

Well to my disheartening this AM on my way into my regular job I hear over my dispatch radio his address. OK I slow down a little to stay in range and here what the crew finds. Semi-concious empty pill bottles everywhere and empty liquor bottles. Just before I get out of range I hear ALS being called for.

Ok now all morning I have been sitting here trying to figure out what more I could have done. In the span of 72hrs this person was bounced in and out of the ED with each time getting worse and worse until now its an ALS call w/ OD. I think I made my case well to the ED nurses. Especially the short duration between visits and the increased worsening of his status. I think he just was pushed to the side and treated like a seeker when he was asking for help.

Has anyone been in this situation? What have you done or could be done. I just want to be my patient's advocate to the best I can.

Thanks

[crotchitymedic1986]

You need to go to the Director of Nursing at that facility and explain what has happened. At the end of the day you have to realize that there is only so much you can do. Another avenue would be to call the "mental health crisis line" in your area (or whoever is the gatekeeper to such services) and explain the situation. Lastly, a visit to the hospital Risk Management Department or even the CEO may assist, sometimes leaders have a better view of liablity situations than the folks on the front line, and as impossible as it may seem, he may have been seen by different doctors who were not aware of the previous issues (even though you told a nurse).

Also, I would make a note in your communications center about this patients recent activity so that he is transported every time. This is a lawsuit that is going to happen, would hate to see your company brought into it to, because someone got a refusal on him after 5 suicide attempts in 10 days).

[uglyEMT]

You need to go to the Director of Nursing at that facility and explain what has happened. At the end of the day you have to realize that there is only so much you can do. Another avenue would be to call the "mental health crisis line" in your area (or whoever is the gatekeeper to such services) and explain the situation. Lastly, a visit to the hospital Risk Management Department or even the CEO may assist, sometimes leaders have a better view of liablity situations than the folks on the front line, and as impossible as it may seem, he may have been seen by different doctors who were not aware of the previous issues (even though you told a nurse).

That is something to look into. I figured the head nurse would be fine but if I have to go a little higher I might have too. As far as the treating Dr. I figured he would at least take my PCR into consideration, I did note the prior visits and statements. See what I can do.

Also, I would make a note in your communications center about this patients recent activity so that he is transported every time. This is a lawsuit that is going to happen, would hate to see your company brought into it to, because someone got a refusal on him after 5 suicide attempts in 10 days).

That is noted in our crew quarters and on the call boxes, this guy will not be RMAed. I know Dispatch has a history file started as well so if necessary we have COAes. At our meeting tonight I will bring it up so all crews are notified, one good thing about being a Line Officer LOL

[firemedicmcse]

Hey all, need some outside perspective for a recent problem.

I have recently run into a Frequent Flyer (3 calls aday) and have done all that I think I could for the pateint but it doesn't seem to be working. I think the system is failing him.

First contact was for running out of meds and wanted a transport. During the call it was what he said that got my spidy senses up. "I am tired. I just want to lay down and go to sleep. If I wake up who would care."

OK I get him in the ED and begin telling the nurse everything then pull her aside a second (dont talk in front of my patient's) and explain what he said and that I feel I psych consult should happen.

4hrs later another crew brings him home. Dont you love taxi duty?

8hrs later I am bringing him back for "intoxication". Checked the pill bottle and 26 are missing. OK intoxication is now suspected overdose. AGain intake the ED (different nurse) explain everything including the prior visit and ask to speak to the head nurse. Speak to her and advocate for my patient that he needs a psych.

Heard from another crew he was brough home sometime later the same day. Nothing sense.

Well to my disheartening this AM on my way into my regular job I hear over my dispatch radio his address. OK I slow down a little to stay in range and here what the crew finds. Semi-concious empty pill bottles everywhere and empty liquor bottles. Just before I get out of range I hear ALS being called for.

Ok now all morning I have been sitting here trying to figure out what more I could have done. In the span of 72hrs this person was bounced in and out of the ED with each time getting worse and worse until now its an ALS call w/ OD. I think I made my case well to the ED nurses. Especially the short duration between visits and the increased worsening of his status. I think he just was pushed to the side and treated like a seeker when he was asking for help.

Has anyone been in this situation? What have you done or could be done. I just want to be my patient's advocate to the best I can.

Thanks

Don't assume the doctor will read your PCR. If you have a serious concern like this about a patient be sure to speak with the doctor directly as well as the nursing staff.

[HERBIE1]

I agree with firemedic. Unfortunately, many docs do not read our PCR's, so I would speak directly to him/her. Too often important, nonmedical details gets lost in the report from the nurse to the doctor. I also assume it was a different doctor on duty after the first visit. Explain the situation, explain the potential liability for your service, and it will be clear to the doctor it's also a liability for the hospital.

I don't know the laws around your area, but if someone expresses suicidal ideations around here- even without an attempt- they get an automatic consult with a mental health/social worker/psych professional of some type. The onus is then on the hospital staff to "prove" the person is not really suicidal.

Does the hospital have a crisis worker/psych department, or social worker on staff? Notify them directly. Other than that, you are right- do not allow ANYONE to let this guy refuse, advise them to document the heck out of everything the patient says, everything they see on scene, and as much prior history as possible. As was mentioned- there is only so much you can do, but clearly this guy is crying out for help. If he was truly serious about suicide, he would have done it by now, but the odds he will become successful on a future attempt are very high- especially if he feels his issues are not being addressed.

Good for you for taking notice and not letting this guy fall through the cracks. Sadly, there may be only so much you can do.

[uglyEMT]

I was speaking with my Captain over the issue and agrees that he is crying for help. One problem we have had on the later calls now... patient stability. These last call he was highly unstable and medical took over psych and he was transported to the nearest facility which unfortunatly doesn't have a psych staff. Hopefully once stablized he can get the help he needs.

I don't know why but I feel bad for this guy. I have had my share of FFs and the troubles they all experience. I dont look at them with distain or anything. I treat my patient be it the 1st time or the 50th time. For some reason the first time around I didnt peg him as a FF. Hearing his statment, and it was the only one, I felt he was looking for someone to listen and that day he happened to get me.

Hopefully if we are called back to this patient he willbe stable so I can have the psych over the medical and take him to a proper facility or at least notify all crews of the situation as well.

Thanks for the heads up on the staffs. I haven't seen Drs directly, most times it is my verbal and written to the nurse then we are off. I figured they actually took our words (written and verbal) seriously.

I will keep up on this as best as I can. Keep the help coming though, I might learn something else or at least someone else might learn something through this experience.

[HERBIE1]

I was speaking with my Captain over the issue and agrees that he is crying for help. One problem we have had on the later calls now... patient stability. These last call he was highly unstable and medical took over psych and he was transported to the nearest facility which unfortunatly doesn't have a psych staff. Hopefully once stablized he can get the help he needs.

I don't know why but I feel bad for this guy. I have had my share of FFs and the troubles they all experience. I dont look at them with distain or anything. I treat my patient be it the 1st time or the 50th time. For some reason the first time around I didnt peg him as a FF. Hearing his statment, and it was the only one, I felt he was looking for someone to listen and that day he happened to get me.

Hopefully if we are called back to this patient he willbe stable so I can have the psych over the medical and take him to a proper facility or at least notify all crews of the situation as well.

Thanks for the heads up on the staffs. I haven't seen Drs directly, most times it is my verbal and written to the nurse then we are off. I figured they actually took our words (written and verbal) seriously.

I will keep up on this as best as I can. Keep the help coming though, I might learn something else or at least someone else might learn something through this experience.

Whether or not our reports are taken seriously varies wildly- even in the same ER. Some docs really want a verbal report- especially on a critical patient. They want to know what we did and don't have time to read the written report. If I feel a nurse has not taken my verbal report seriously and there is an issue I want to stress, I try to wait until the doc goes in to see the patient(generally on the sicker ones, since the stable patients can wait a long time before the doc goes in.)

Example- Recently we had a guy who as mid 60's, PMH of ETOH abuse, and seizures. His roommate said he heard the guy making funny noises, found him awake, no shaking, but nonverbal. He called it a seizure. The guy was completely lucid when we arrive, but could barely lift his head off the couch. He denied ETOH- we saw no evidence of it, and he said he was compliant with his meds.

Mildly hypertensive, but I honestly cannot recall his vitals although everything else was essentially WNL. The patient was a poor historian, and getting information from him was like pulling teeth- he did not want to be bothered and denied having a seizure.

After an exam, we realized this guy had left sided weakness. Further information was he had a history of a car accident 40 years ago, which resulted in a loss of a kidney, spleen, and he had extensive damage to his left leg, which left him with decreased function in that leg. He could not explain the arm weakness- it was new onset- approximately 2 hrs ago. As I was interviewing him further, the man began to fix his gaze to the left, which eventually progressed to a grand mal seizure. I gave Valium and within a minute or so, he was verbal again, but post ictal. Thankfully the receiving hospital was also a stroke center. I had already given the radio report before his grand mal seizure, so when we arrived at the ER(not the telemetry hospital we called), I notified the nurse of the changes. There was simply no time to recontact medical control AND treat the patient. She seemed fixated on the alleged seizure we were initially called for, ignored the weakness, and all but ignored the rest of the report. I completed the patient report and went back to the room to drop it off when I noticed the doc in the room. I interrupted him- politely- and quickly explained the whole history- his PMH, and he said something to the effect of "Well, that certainly changes things- I was told this was a simple seizure." He was worked up for a CVA, we were still within the allowable window for a fresh CVA, but I honestly have no idea what the outcome was. It was clear that the doctor was incredulous that so much pertinent information was left out of the report the nurse gave him. He took my run sheet and .proceeded to read it very carefully. He was quite appreciative that I took the time to directly brief him, and since then, if he is working, he always asks a couple pertinent questions as we roll by- even before he officially sees the patient.

The thing about suicidal patients is that means they need a security stand by in an ER, a psych consult, and sadly I have seen nurses essentially ignore claims of suicidal thoughts. When questioned about it, the nurse says that the patient didn't really mean it, they are playing the system and the patient knows it generally means they get an overnight stay until they determine the patient is not a threat to themselves. Dangerous assumption to make, IMHO. Point is, you simply cannot assume the proper story is being relayed to the people who need to know. If in doubt, talk to the doctor directly since it's their ER, they are responsible for every patient, and it's their license on the line if something goes south.

[uglyEMT]

Thanks Herbie for that. I will make sure of that for the next time.

My one problem for not seeing the docs directly is usually I amnot "running" the call usually second chair and the CC handles everything else while I write the report. But in the past week or so it seems (and in this patients case is) like the normal CCs have been unavilable due to vacation schedules and I stepped in as the CC so it added the dynamic of giving verbals to the staff. I have given verbals before but usually with my CC over my shoulder.

I will keep you posted.

[HERBIE1]

Thanks Herbie for that. I will make sure of that for the next time.

My one problem for not seeing the docs directly is usually I amnot "running" the call usually second chair and the CC handles everything else while I write the report. But in the past week or so it seems (and in this patients case is) like the normal CCs have been unavilable due to vacation schedules and I stepped in as the CC so it added the dynamic of giving verbals to the staff. I have given verbals before but usually with my CC over my shoulder.

I will keep you posted.

Your welcome.

Quick question- "CC"? Is this crew chief?

Although I know there are many different configurations and roles for providers, I sometimes forget the role of internal politics. I have the luxury of having a partner who is the same provider level AND experience as myself. Even though I am in charge- at least in terms of the department, if my partner sees or hears something important that I may have missed, he can and will speak up without reservations. It's his license on the line too. Our roles are interchangeable, even though I am primarily responsible for airway and the report, it's not etched in stone. The situation dictates what needs to be done. Maybe I'm in a mood where the nurses are pissing me off and I don't want to talk to them- he will handle it for me. Maybe he's under the weather and does not feel like starting an IV- I'll take care of it. It is a nice position to be in.

Yes, technically it's supposed to be all about the patient, but in real life, we know squabbles and politics do come into play when providing patient care. You may step on a toe or bruise an ego, but as long as you are acting in the best interests of your patient, in the end you will be OK.

[uglyEMT]

Yes Herbie CC = Crew Chief

On my rigs we are the same way everyone is interchangeable but the CC is usually the most experienced person. Just lately that seems to be me

As an update the patient is still in the hospital and no further information given.