Unconscious Unknown Protocols

[fireflymedic]

Okay gang,

Here's a question for everyone out there. As I understand it, the general consensus for unconscious unknown protocol (at least in my area) is Narcan, D-50, and thiamine. Now I understand the reasoning behind it (narcan-opiate overdose, D-50-hypoglycemia, thiamine- help with absorbtion of D-50 especially in alcoholics), but I don't understand the reasoning for just giving each blindly hoping one will work as is often done around here. Frankly, I don't see the reason for it at all. A good patient assessment will tell you if the patient (can we say D stick anybody?) is hypoglycemic thus ruling out the D-50 and thiamine, and pinpoint pupils will give you the indication for narcan (plus any bystander info if they are so inclined or if you happen to get lucky - or FF). What I'd like to know is how many of you all maintain this protocol for unconscious unknown and what are your feelings on it? If that's not your protocol what is yours?

[cosgrojo]

I don't know that your protocols mean for them to be done blindly. In our protocols it always states that you should consider those treatments based on your assessment. So if the stick shows you a BGL of 20... then D50. Pin-point pupils and reasonable evidence to suggest narcotic OD... Narcan. If your protocols for possible OD don't include the introduction of air into the lungs BEFORE Narcan, then your protocols need to be reviewed.

I'm not sure that protocols are meant to be followed blindly without assessment, that appears to me to be dangerous. You still need to have some rationale behind your treatment. Otherwise you are doing the EMS no-no of treating the dispatch reason and not the patient.

[fireflymedic]

I agree with you they should not be done blindly, I am simply commenting that many medics do that (don't get me started down that path again, been there, done that, ain't going there again). As far as the introduction of air to lungs-any unconscious we have automatically gets O2 15 LPM NRB if breathing, if not, they buy a bag and a tube if they don't perk up). So I would say that's kind of an automatic. Perhaps I'm not understanding what you are saying by that. If so, please clarify. Around here, alot of medics go by cookbook medicine and don't understand the rationale for doing what they do. Was just curious if this was situation everywhere. Also, if your assessment reveals an underlying cause, then it is not truly an unconscious/unknown and you divert to the appropriate protocol. Not trying to start a protocol fight, just tryin' to learn and be curious here.

[albemt]

I think no matter where you go you will have EMS personal that are, as you say a cookbook medics. But you will also find them in all careers in the world. Protocols are put together to point us in the right direction and know that we are doing what the medical director would be doing. Then from there it should make us think what we are doing for the patient and why we are doing that.

So my belief is that they have to say what to do for a unconscious/unresponsive patient cause we do have medics that don't really know what to do and need to be able to follow the book page by page. They are unable to really think of why the body is doing what the body is doing.

When giving a drug follow the simple rule of "The 6 Rights"

1. Right patient

2. Right time

3. Right route

4. Right drug

5. Right dose

6. Right documentation

[fireflymedic]

Point well made

[akflightmedic]

The "coma cocktail" which you are referring to, is no longer taught and has not been taught in the general curiculum for years. It is a dangerous practice to just blindly administer drugs just because a pt is presenting unknown,unconcious. Our protocols and what I teach is assess your pt and treat accordingly.

I applaud you for trying to learn more and not just be a "cookbook" medic.

On another topic, we too taught the 6 rights, however our 6th right was not documentation but rather the right to refuse.

As to raise another point of discussion, I detest the term protocols, lucky for me my last few medical directors have agreed. The term protocol implies you follow a recipe with no deviation. The term "guidelines' is more representative of what we need to call our treatment modalities. Protocols can get you in trouble, especially if they are ever called into question in a court of law. If you do not follow step by step, you are liable. If you only have guidelines, this means you have the ability to assess and render treatment you deem appropriate for that particular situation.

[cosgrojo]

I agree with you they should not be done blindly, I am simply commenting that many medics do that (don't get me started down that path again, been there, done that, ain't going there again). As far as the introduction of air to lungs-any unconscious we have automatically gets O2 15 LPM NRB if breathing, if not, they buy a bag and a tube if they don't perk up). So I would say that's kind of an automatic. Perhaps I'm not understanding what you are saying by that. If so, please clarify. Around here, alot of medics go by cookbook medicine and don't understand the rationale for doing what they do. Was just curious if this was situation everywhere. Also, if your assessment reveals an underlying cause, then it is not truly an unconscious/unknown and you divert to the appropriate protocol. Not trying to start a protocol fight, just tryin' to learn and be curious here.

First off, there are no automatics in EMS, every situation is deserving of it's own treatment. That being said, I believe that I was mostly agreeing with your premise. I am not interested in a protocol fight (especially since I know nothing of your protocol). The O2 comment was simply to add subtext to your statement. There are a lot of medics, and intermediates with intubation abilities that will go for the tube on an unresponsive patient before doing anything else. We've had multiple violators in our area. I was stating that unconscious protocol is not simply D50, Thiamine, Narcan... that their are assessments and clinical evaluations that need to be done in order to do these things right.

Again, since I don't know your protocols I can only go by what you said they were. I appreciate that you were being simplistic in order to post a readable and easily understood scenario. I'm not fighting, just trying to define some of the sub-texts of the question at hand.

So we are in agreement.... good assessment and clinical judgement combined with a proper treatment plan based on the spirit of the protocols, performed by adequately intelligent and competent personnel = good patient care. :wink:

I think we just solved all of the problems of the world of EMS. I think we deserve a pat on the back.

As to your original question... I don't know what everyone elses protocols are.... so chime in everyone!

[cosgrojo]

All references in my last post to the word: protocol, shall henceforth be understood to mean guideline, as I agree with the good sir moderator.

*walking down to ambulance to scratch "protocol" off all our books* 8)

[Spock]

I like your differentiation between protocols and guidelines because it makes a great deal of sense. Unfortunately, we have protocols in my area because we also have far to many "cookbook" medics. The medical directors don't trust many medics to treat patients properly. We only give D50 if the BGM is <80. Thiamine is not provided in our drug boxes. Giving D50 to an unconscious patient having a stroke is harmful unless hypoglycemia is documented. As far as narcan I have never been impressed that pinpoint pupils absolutely and positively means opioid overdose. Bystander information and evidence found at the scene is very important. When in doubt, assess your patient. That is an alien thought for the cookbook medic.

Live long and prosper.

Spock

[fireflymedic]

Cosgro,

No offense was implied I was just curious as to how medical directors for other services handled this. We have quite liberal protocols at our service (only one in state outside of critical care ground trucks and flight crews) that are allowed to do surgical crics. We are fortunate to have an excellent medical director. I could not ask for better. he is actively involved and regularly meets with us to discuss changes to our GUIDELINES !!! HEHE. BTW, I do like that word better than protocols. Very approachable and doesn't make QA/QI be a negative thing which I have definitely learned to appreciate. Treats it more like a learning experience rather than punishment. Thanks for the input !