08 March 2006

More fun with nurses

We picked up an elderly patient yesterday from a Cardiac unit in one of the local hospitals who was going to my "favorite" county nursing home. The nurse on the unit told us that the patient had been in for congestive heart failure, was feeling better, and nothing of note to report. When we get her on the stretcher, she begins complaining of nausea.

In the back of the ambulance, she goes from nausea to "I'm going to vomit" and complaining of abdominal pain. She and I are both frantically looking for something for her to throw up into. Yes, the ambulance carries basins for this, but they are in the cabinet that is partially blocked by the stretcher, so I couldn't see them and feeling blindly was not working. I got her a towel to buy myself some more time to find the basin, which I found shortly thereafter. When I look up at her, she's vomiting blood. Not good. I'm looking through the patient's discharge papers and find a history of a relatively recent upper GI bleed (i.e. bleeding in the esophagus or stomach). She says that she vomited blood with her breakfast and didn't keep down dinner last night either. She is noticeably dehydrated, which is consistent with her reported intake. Since we're almost at the nursing home, we decide to talk with the staff there and see what they would like done with the patient.

They seem to be as entirely surprised by her presentation and history as we were, and request that we take her immediately back to the ED. So back we go, lights and sirens this time. She doesn't vomit any more on the way back, but is still complaining of nausea and now dizziness/lightheaded on top of it. Her blood pressure was around 95/55, which isn't terrible, but isn't great for someone you think might be bleeding internally. When we get her into the ED, the nurse asks which unit just discharged her and calls up. Surprise! The patient is headed for hospice care and they aren't going to do anything for her. That might have been a good piece of information for the Cardiac nurse, or the nursing home people (if they knew) to have conveyed to us. She has an abnormal heart rhythm on the monitor which is probably due to her dehydration, but nobody gives her anything for that either. After spending the afternoon in the ED, she gets another ride with us back to the nursing home. This time still complaining of nausea, but not vomiting. Her afternoon nurse in the ED was very rude when we came for her, meeting us at the door, shoving paperwork at me with "she's in room 2 in the corner" and disappearing.

The discharge papers from the ED got under my skin a little though. They diagnosed her with "coughing up blood". I'm no doctor but I do know the difference between coughing and vomiting. If they wanted to claim it was something in her throat somewhere, fine, but she certainly did not cough it up. D was in the front of the ambulance and he knew the vomit sound before I even said anything. But we're just stupid EMT-Bs over-reacting to someone who is dying anyway, thinking we can get some excitement out of the deal.

Thankfully, D was doing the patient care for our next fun with nurses because I might've blown a gasket. We transferred a patient from the same hospital to a different nursing home. She was okay when we left the hospital, but by the time we got to the nursing home she had noticeably slurred and slowed speech and some right-sided weakness. D looks through her paperwork and finds that she is an insulin-dependent diabetic and nobody had given her any insulin today, she didn't get lunch (this is 4:00p), and the last time they took her blood sugar the night before it was 40. Bad times. Basically, the nurse at the hospital had noted on the patient's chart that she was being discharged that day, and everyone stopped taking care of her. At least the nurse at the nursing home was upset and started ordering people around to take care of her patient, good to see one nurse that day who knows how to do more than talk nicely to patients.

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