Altered LOC and Prudent questions for the EMT-B

[Asysin2leads]

Ahem. Let me amend my statement. If the brain is already mush and the person is acting cuckoo, then I guess yeah, they're not AMS from a lack of oxygen. Then again, something had to cause the encephalopathy in the first place... Oh never mind. Just in one of those moods, eh Ace? :roll:

[Dustdevil]

Sorry Ace. I gotta go with the fireman on this one. You appear to be looking at this from an ALS standpoint, which is inappropriate in this situation.

If you don't do a good assessment, why did you bother showing up on scene.

That is a question best posed to the community leaders who sent an EMT to do a paramedic's job. He's just doing what he's told.

Having some idea of your ability to treat is based almost entirely on your ability to perform an adequate/thorough assessment. You may not be able to treat anything that you find, but if you don't find anything you aren't going to do any treatment anyway.

Everything a basic can do for a patient is to be found in the primary survey. If you find nothing to treat in the primary survey, it's time to get on the road. If the patient is indeed having a cerebral or cardiac event, time is of the essence. I am not impressed by the thoroughness of an EMT's secondary and detailed assessment. It does nothing positive for the patient's condition. It delays his delivery to definitive care, and it keeps your ambo out of service an unreasonable amount of time. I don't even want to hear it when you come into my ER. Not only am I going to do the assessment all over again, regardless of your findings, but I am actually going to do something to treat them.

This is the problem with telling EMT's the big lie about all the valuable experience they will be getting as a basic before medic school. It's crap. It just causes a lot of screwing around in the field and playing with concepts they have inadequate education to even understand. How about learning a little anatomy and physiology before we get too carried away with eliciting all sorts of signs and symptoms we have no way to interpret or treat?

Take your AEIOUTIPS and OPQRST and DCAPBTLS and flush them. You're wasting the patient's time. ABCD and transport.

[Cookie]

I am actually going to agree with Dust on this one. :shock: Do your ABC's and giddy up and go. You can get the SAMPLE history in the unit as well as vitals and put them on oxygen.

[Ace844]

Sorry Ace. I gotta go with the fireman on this one. You appear to be looking at this from an ALS standpoint, which is inappropriate in this situation.

Perhaps, I wasn't clear I understand and agree with what you are saying to a point. My point was thus. You should attain an adequate education, to understand the WHO, WHAT, WHY, WHEN, ETC.. of this job. That is your responsibility as a provider. That has always been my stance and always will. It was also my impression that you had a similar opinion as well. Failing to do so is no defense on the individuals part. In the setting of actually doing this there are things which any level provider can recognize. In that recognition will alos be the ability to ensure that you as an advocate for your pt; they will then recieve with your help treatment and transport to a place and or other providers which COULD treat them more appropriately. I am not advocating delay in transport, treatment or care to do this. As a matter of fact on average a competent, adequately educated provider could do a complete MD comparable P/E-H&P in about 2-3 min tops... Thus one would garner a more complete and comprehensive picture and obtain an accurate, appropriate DX with which to continue the definitive care of your pt. Make no mistake, if you do this, you are begining the process of assisting the pt with that 'definative care'. If we didn't provide 'definative care;' then we wouldn't have professional practice standards or minimums which we are all compelled to follow.

If you don't do a good assessment, why did you bother showing up on scene.

:occasion5: AGREED!!

That is a question best posed to the community leaders who sent an EMT to do a paramedic's job. He's just doing what he's told.

See my response above

Everything a basic can do for a patient is to be found in the primary survey. If you find nothing to treat in the primary survey, it's time to get on the road. If the patient is indeed having a cerebral or cardiac event, time is of the essence.

I agree that most of the 'definative treatment' which would make the most difference for a pt is here. Or perhaps I should quantiufy that as this; the most noticable difference in a short period of time. In addition to what I wrote above here, i also submit for your consideration the following. If a BLS provider did only the most basic of assesments and only concentrated on symptomatology, and were to for example 'rapidly transport' a pt ( just to pick something out of a hat; a C/C of AMS) to say a level 3 facility which doesn't have 24 hr CT, or Neurology, etc... Then they have done the pt harm and a disservice by not ensureing their access to 'definative care'. Doing this would be DELAYING the pt's access to definative care, and potentially causing harm by increasing their potential Mortality!!

Conversely, if the BLS provider were to perform an assesment (***Note:::This is also operating under the assumption they can do so in a timely manner or while simutaneously ensuring the pt be transported to said facility. ***Multi-tasking is A LARGE PART OF WHAT WE DO!!!!**) as I have posted previously they may be able to ensure that the pt has an opportunity for ALS care, Transport to a fcaility which could handle a pt with their DDX ( I.E: 24 hr CT, Neurology, Intra-Arterial TPA, surgery, etc..), and as such still be performing and fulfilling their responsibilites and duties of the position of which they hold. Also in this vein they would be providing the pt with 'DEFINATIVE CARE' and ensuring that it gets continued through out their inital presentation.

I am not impressed by the thoroughness of an EMT's secondary and detailed assessment. It does nothing positive for the patient's condition. It delays his delivery to definitive care, and it keeps your ambo out of service an unreasonable amount of time. I don't even want to hear it when you come into my ER. Not only am I going to do the assessment all over again, regardless of your findings, but I am actually going to do something to treat them.

Again please read my previous statements, and I will further quantify them with this. Perhaps you are such an advocate for training and educatioin because you have been exposed a number of providers who lack the preceeding. This may make you prejudiced and or negatively opinionated in the future, don't you think? In addition, you should re-assess, and duplicate the pre-hospital assessment. This is because if they did as I have written it will allow you and the MD to begin to form an idea of the pt's baseline presentation and assess the effectiveness or lack there of, of initiated RX and therepeutic interventions. Medicine is all about trends, not knee jerk reactions to 1 low B/P, or one transient P/E finding. This issue, I guess may just be about subjective perspective as much as anything....

This is the problem with telling EMT's the big lie about all the valuable experience they will be getting as a basic before medic school. It's crap. It just causes a lot of screwing around in the field and playing with concepts they have inadequate education to even understand. How about learning a little anatomy and physiology before we get too carried away with eliciting all sorts of signs and symptoms we have no way to interpret or treat?

Take your AEIOUTIPS and OPQRST and DCAPBTLS and flush them. You're wasting the patient's time. ABCD and transport.

I agree and disagree with you on this and my statements and opinions are well documented here on that so I will refer you to them.... Your a smart guy, but I think the idea here for me at least is to try to drive and strive the profession towards positive change through the things and measure we have discussed on this board at length, and ad nauseaum. To allow institutional dogma and status quo to allow us to accept - outcomes, inadequate education and lacking care is unacceptable...For me at least. Thus we need to try to exert some peer pressure on the newbies to excel and take pride in their job-career as well as their function and to improve the profession and themselves. JMHLO & .02...

Out here,

ACE844

[Juilin]

See, this is good, post a new topic and we get some discussion on the boards! My questions were answered and not answered.

For the most part, I have to agree with dustdevil. I do not consider myself someone that is horrid uneducated and unfit for the job. But at the same time I am not qualified to make a diagnosis, I am not certified to administer any "definitive care" if I do make a diagnosis, and the hospital staff is going to perform their own assessment regardless of what I say or do and come to their own "diagnosis." At the same time, there is nothing bad and it's probably most beneficial to the patient if the wheel upstairs is turning and you are able to recognize and react to certain conditions. Even if its just "medic" or "drive fast"

I think I try to make my job too confusing sometimes and have to remember that all I can do are the ABC's. But hey, I can still be a wizard with the NC and quick to the NRB. :? :roll:

And I appreciate the info Ace, I will definitely check out all the website-info you posted.

Cheers,

Juilin

[Ace844]

”Juilin,”

I’m glad that you were able to learn from what was posted here. I hope that in the future you will continue to do so. This board has a wealth of knowledge and experience here which can be quite helpful to all of us.

For the most part, I have to agree with dustdevil. I do not consider myself someone that is horrid uneducated and unfit for the job. But at the same time I am not qualified to make a diagnosis, I am not certified to administer any "definitive care"

This whole “Definitive care” debate which been sparked here has made me wonder…Do we really provide it and what do we as a group think of this. My thoughts are mentioned clearly previously here. You mention above that

I am not certified to administer any "definitive care"

I disagree and I think that perhaps your pt’s may as well. I’ll try to illustrate that for you now.

Have you ever been on a call where your pt was severely hypoxic and due to the fact that

You

can still be a wizard with the NC and quick to the NRB.

The pt’s condition improved and so did there anxiety and level of distress. Or perhaps assisted a pts ventilations with a BVM?

Here’s a different example. Have you ever done an OB-Impending delivery call and when you arrive the delivery has already started, but there is shoulder dystocia, or a prolapsed cord?!?! You then perform the maneuvers and interventions necessary to correct these.

Other posters here have posted scenarios and about calls they’ve done where they felt their care was both definitive and made a difference. A prime and recent example would be “Asys’s” ‘Redemption thread’. Reading that it sure seemed to me like he made and had utilized working Diagnoses, provided definatve care to treat his pt, and made a definative difference in the pt's outcome, all the while ensuring his pts access to timely care, and further specialized definative care at an appropriate ER!!!!! :shock: 8)

Finally it seems to me that like my examples above, they all initiated that care after making a diagnosis….hmmm..that’s interesting..isn’t it… All of the above mentioned examples back up my opinions on and the statements I have made in this thread. They are all Basic interventions, they involve you as the pre-hospital clinician making a diagnosis and providing ‘definative care’ to said pt. Do you disagree?!??! Then I say go ahead, fail to undertake those interventions, post your verifiable story and outcome; and see if your med con. MD, OEMS, employing agency and pt agree that you are not able to provide your pt with a working DX, definitive care, or treatment based on the preceeding…!!!!!

if I do make a diagnosis, and the hospital staff is going to perform their own assessment regardless of what I say or do and come to their own "diagnosis." At the same time, there is nothing bad and it's probably most beneficial to the patient if the wheel upstairs is turning and you are able to recognize and react to certain conditions. Even if its just "medic" or "drive fast"

Please re-read my statement above in my response to “dust,” my response to you is there as well…

Hope this helps,

ACE844

[Dustdevil]

I am pleased with the constructive path of this topic. I am pleased that we all agree that for our friend to seriously pursue all relevant knowledge about both his patient and his profession are nothing but positive things to be considered. I am pleased that we also recognise that the true need for thorough assessment at the basic level (or even the advanced level) must be weighed carefully against the patient's need and desire to simply get to the hospital, and that it would be very rare for a delay in transportation to be justified. I am pleased that for once we have somebody asking a question who seems to be truly interested in honest answers. And I am very pleased that he has accepted those answers in the spirit in which they were intended without an attitude.

Definitely take each and every patient contact as a learning opportunity. You're not doing it just because you have to write something on your PCR, or even because the patient needs it. You are also doing it because it makes you a better medic in the long run. Practise makes perfect. Never turn down a chance to do a full assessment of anybody just because it may not be something exciting that is going to require exciting interventions. Every chest you listen to will make you better at lung and heart sounds. Every distal pulse you palpate will make you better at finding them. Every cranial nerve check you run will be one step closer to memorising the process by heart. Just be sure to not get so focused on these assessments that you lose sight of care and transportation priorities.

I think you're going to make a great medic, Juilin. :thumbright:

[hfdff422]

BLS level providers do have to remember that they are BLS level providers. I have personally met those "medic in training" who will frequently overstep their scope of practice. Unfortunately, some of them are on our department. They are dangerous to not only the patients but the EMS system as a whole. They will gladly tell the medic who catches up with them their diagnosis of the patient instead of their SAMPLE and vitals. Does this help the patient, or would it be more beneficial for the B to tell the medic all the pertinent information garnered from their SAMPLE and vitals. We are only trained in identifying signs and recording symptoms and taking BLS precautions and interventions. We need to be able to recognize what interventions to take when, and to that extent we are diagnosing, but to overstep our scope of practice by diagnosing what we are not trained to recognize is not good patient care.

Our job is to make sure the patient makes it safely to the next level of care, hopefully that is definitve care from a hospital or, in lieu of that, a medic. I still say it is irresponsible to suggest undertrained B level providers overstep their scope of practice and try to diagnose internal problems definitively, which is the feeling I get from some. The fact is that while there are many intelligent and capable B's out there, many are at the B level because of limited time, resources, or intellect. The ones in the latter category are the ones who are dangerous, and suggesting to them that they are capable of anything beyond their scope of practice will greatly endanger their patients. We need to stay within our scope of practice as much as possible to ensure patient safety. Our scope of practice includes assesment, transport, ABCD interventions, and some Rx interventions. Knowing what to do when we observe certain signs is important, but asking a B to diagnose PAT would be a waste of time- instead recognizing the tachycardia and taking them to the appropriate facility and hopefully making contact with a medic because it is tachycardia is the correct course of action.

[Juilin]

I think you're going to make a great medic, Juilin. :thumbright:

Thanks Dust, that means a lot. Sometimes certain calls make me wonder. :?

[medik8]

Thanks Dust, that means a lot. Sometimes certain calls make me wonder. :?

I have to second Dust here.....Great attitude Julian!!!

=D>

I like how you think, as well...

xoxo

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