Bad Care


As I mentioned in my last post, from time to time I’ll post about some of the bad care that I see as a Quality Assurance Auditor. Our goal where I work is not to punish providers, but to use cases that are not up to the standards set for quality care as educational purposes.

During the meetings with the paramedic, we go over the deficiencies we find and point out better ways to provide care. In most cases, the paramedic takes our suggestions and we see steady improvement in both their care and their documentation.

So here is the carefully redacted report, or at least the parts that are pertinent. I’ll add notes below the image.

The patient was a 74 year old male.

Here are the things that I noted as deficient in this report.

  1. The crew performed a 12 lead EKG, which was good. Unfortunately, the medic who wrote the report (the tech) didn’t attach a copy. That’s actually a minor lapse, but it’s important for down stream readers including doctors and nurses at the hospital to have an EKG to refer to when they do their own EKG. That way they will be able not only to see what the medics saw, but to compare it for changes in the EKG which would indicate if the patient was getting worse or better.
  2. The medic did not document the patient’s Past Medical History, Medications, or Allergies. Since¬† ¬†the patient may not remember any of that, it’s important to note as the hospital doesn’t want to give the patient a medication that might harm him.
  3. There is no physical exam of the patient. That includes skin condition, respiratory condition, lung sounds, evaluation of peripheral edema, respiratory rate, or even if the patient currently has chest pain.
  4. The doctors office may have started an IV, given Aspirin, or treatment for the chest pain. We’ll never know since none of that was documented in the report. There are also no vital signs as obtained by the doctor’s office, so there is no means of comparing them with what the providers obtained.
  5. The heart rate is pretty fast, which should be of concern as there are a number of reasons, none particularly good, for tachycardia. The medic notes the EKG rhythm as being “NSR” which is “Normal Sinus Rhythm.” Clearly this is not as it’s above the upper limit for NSR which is 100 beats per minutes.
  6. The patients respiratory rate is also a bit above the normal range. The CO2 level is a bit below the normal range. Both of those, along with the tachycardia, should be of concern.
  7. The patient reports chest pain and increased Work of Breathing (WOB) on exertion. Since we don’t know his medical history or medications, there is no way to know if this is typical for him or a change in his condition.
  8. The term “non diagnostic” means that there are no changes to the EKG that would indicate a cardiac event. One of the things auditors do is “overread” the EKG to confirm the medics impression. Mostly paramedics are pretty good at interpreting EKGs, but still it’s important to confirm that.

I will note that the crew did transport to the appropriate facility, which is sometimes an issue, but not here,

Since the medical record is at best incomplete, we can only work on the premise that the care was also incomplete. There is more than a bit of likelihood that the patient may have suffered some harm as necessary treatment was not administered by the paramedics on the call and responsible for providing care.

There is always the possibility that proper care was delivered, but there is no way of determining that from the report.

The EMS Coordinator for the agency will likely have a sit down with the medic who was the tech and discuss the report and the lapses in care.

It sounds harsh, but as I said, the goal is not to punish or embarrass the provider, but to provide education to improve both his delivery of care and the documentation of that care.



Previous article Journal of Iatrogenic Medicine
Next article Of Masks and Men
After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.