Emergency to the local nursing home. “Altered mental status” says the MDT.
“He has not eaten all day, and he hasn’t had his medicine all day either. He has to go to the hospital.” says the lady, in a loud voice, with an accent I could only describe as from another continent.
He sure enough looks altered.
His skin is pale. It’s cool. It’s diaphoretic. His radials are strong at 70, and his respirations are normal.
This looks familiar…
“D-stick is twelve” reports partner-of-the-day.
“Let’s give him some sugar, and see what happens.”
Six or so minutes pass, and 300ml of 5% Dextrose have been infused when the patient miraculously awakens.
Take THAT, Lazarus!
“What the hell are you doing here? What’s going on?” asks the now unaltered male patient.
“Your blood sugar dropped really low, and we need to run you up to the hospital” replies POD.
“The hell you are!”
After establishing the baseline info, like name, date, social security number, names of children, date Kennedy was assassinated, address, phone number, name of the Secretary of State, wedding date, favorite color, and the names of the two US Senators from our state, we are convinced the patient is of conscious mind to make an informed decision.
“Read this warning first, then sign your name on this paper when you are comfortable with releasing us from liability.”
Signatures obtained, we begin to walk out of the nursing home with our empty stretcher.
“Hey, the guy in 9 is going to need to eat something. His blood sugar got really low, but he’s okay now.”
“NO! He has to go to the hospital!” is the loud, accented reply.
“He doesn’t want to go, and I am not inclined to force him, ma’am.”
“YOU HAVE TO TAKE HIM! THE DOCTOR SAID SO BY TELEPHONE!”
“Actually, no, we can’t take him, since that would be illegal.”
“You wait right here. I’m going to call the doctor right now.”
“Make sure you tell the doctor that you didn’t feed the patient all day, and that he is now awake after we raised his blood sugar to 126.”
“Oh, and don’t forget to give him a sandwich or something, or else his blood sugar will drop again” adds POD. “Have a nice day.”
I always hate “altered mental status” to nursing homes. Or “failure to thrive.” Often this is some kind of turfing game.
Back in the day, there were 911 providers – usually county services – that simply would not go to nursing homes and there were other providers, public and private, who would take patients to other locations than where the nursing home physician had directed. So we would get these “emergency” calls to nursing homes outside of our normal emergency service area. On the weekend, we could count on these calls coming in, sometimes two or three, starting around 745-830am and 4-5pm and sometimes 1115-Midnight. Shift change hours you understand. Nurses would arrive and find one of two things. Some would be patients who had been ignored for a shift or two and who were messy. Some would be patients who were problem patients and the weekend staff didn’t want to deal with them so they’d turf them out to the hospital, figuring their shifts would be over before the patient would return. In the days before “diversion” hospital ER staff hated to see these people coming because they really had no idea of what the baselines for these patients really were.
I learned that, if the roommate was coherent, I could (and still can) get a better report on the baseline, any changes, and when they actually occurred, from the roommate.
But then there are the patients who have changed – and you can only treat what you have because you really don’t know what these people are normally like.
It must be nice to be the dominant provider in your area so that these people have to keep calling you for service and your bosses support you in your decision-making in such cases.
Where I come from, the greatest offense, other than not providing adequate billing information and signatures, is not poor patient care but doing anything to offend the “customer,” in this case, the staff of the nursing home.
One of the privates in our area loves to turf these calls to 9-1-1, especially at night. I guess the reimbursement is too low to make it worth their while to put up a truck for these calls. The nursing home staffs are surprised, not pleasantly, when we show up instead and don’t care what they or their doctor say.
It’s even more unpleasant for them when we terminate resuscitation on one of their patients and tell them that we aren’t transporting. They go into vapor lock and it just does not compute.
We’ve been fortunate…most of the wailing and gnashing of teeth over hypoglycemia and terminated resuscitations have stopped around here.
Once in a while there’s an issue…but not often. Those get turfed to me (duty supervisor) and I let them know the same thing.
I’m lucky to be an EMT at two smaller companies where we’re both 911 and private line coverage for many of our local homes. It’s pretty rare for a nurse or administrator who doesn’t have a POA give that sort of problem. However, one of my coworkers responded to a cardiologist’s office, where a man accompanying a patient was showing signs consistent with cardiac distress. The nurse (wife of the doctor, as I heard) was demanding that he be transported, that we had to take him. The man had been trying to explain that he was already under care for the issue, as it had been happening for a couple weeks, and that he did NOT want to be transported to the hospital for several very good reasons. My coworker took the refusal, as the nurse tried to browbeat him into forcing the man to go to the hospital. He told her it was illegal and he wasn’t doing it and left. The nurse called the paramedic office manager to complain, and my coworker got a call from the office manager, who said, “What did you do wrong?” Coworker took a second, and said, “Nothing?”
“Exactly.”