Thinking versus Doing

[Lithium]

Reading another thread got me to thinking; why is it that EMS providers (specifically ALS) are usually so gung-ho to do procedures and administer medications to patients, instead of for patients?

When I took my ALS program, it was told to us over and over and over and over again that simply because we have these added skills, we didn't necessarily need to use them. There was a few scenarios during our lab time where they were designed to be run purely as BLS (monitoring/supportive with no ALS intervention) as the instructors wanted to see if we could defend what we did. Needless to say, this upset a few people as they jumped the gun a few times.

The opposite side of the spectrum however, physicians (whether interns, resident or attending) are very hesitant to go ahead with treatment modalities without first consulting with other physicians and nursing staff. Why would that be? Could it be that they're more concerned about whether this treatment is going to help the patient, rather then just give them something to do?

So why is it that we like to play with our toys? Where does this mentality develop from? What are your stances?

-Jacob

[hammerpcp]

What is this reputation thing? I think Jacob is worth way more then 5.6. Unless that is 5.6 out of 6.0? To answewr your question I think that a of of ER dr's like to use their toys just as much as the medics. I know one in particular that will snow any pt with haldol etc.. who puts up the slightest resistence.

[Ridryder 911]

That is why I stress treat appropriately, not so much accordingly. I disagree, that here in the U.S. I have seen more labs, med.'s ordered, and changed to new med.'s without ever seeing or getting a history of the patient. Internal medicine orders, to be changed by consult, cardiologist to be changed by pulmonolgists, to be changed by endocrinologist.. and on. Now, remind you there are test that accompany each as well.

Far as inappropriate care, I believe it is important to justify anything you do... even from placing a splint to LSB, each could cause damage and maybe not needed. Med.'s as well, but at the same time not to ever withhold or second guess if they are needed.

R/r 911

[flight-lp]

Very well spoken.........

[Scaramedic]

Far as inappropriate care, I believe it is important to justify anything you do... even from placing a splint to LSB, each could cause damage and maybe not needed. Med.'s as well, but at the same time not to ever withhold or second guess if they are needed.

R/r 911

I couldn't agree more Rid. The problem is that too many EMS personnel justify their interventions by "it's protocol." There are many threads on this very website where members justify treatment by that infamous phrase.

Maybe it's because I went to Paramedic school a few years back and the program director was a very old school Paramedic, but we were taught to justify everything by how it affects the pt. It was pounded into our heads that any treatment, or lack of treatment was to go through a process like this in our head.

1. What is the problem? What is the physiological process or what is the injury that is affecting the pt?

2. What interventions are available?

3. How will it relieve/treat or support the patient? Not just "it will make the pt feel better," but what it does physiologically.

4. Is it necessary? Will it cause more harm than good?

5. What are the options with this care?

6.. What are the follow ups or other care I need to give and does this treatment affect those?

Only then do I decide to use the intervention or not. It takes no more then 5-10 seconds to run this process thru my head. If I answer all these questions I am ready with answer if an MD asks why I did something. Also by following these guidelines I am not using my "toys" without reason.

Peace,

Marty

:joker:

[BushyFromOz]

while i can understand some (particularly newbies) people using the old addage of the "protocol told me to do it", there is no excuse for not knowing, or finding out the rationale of why you are doing it

[AZCEP]

My scenarios tend to include knowing why something is being done. Knowing when is good, knowing how is important, but knowing why separates us from the organ grinder's monkey.

I would recommend to all of the instructor/preceptor/concerned obervers to bring this up when you are watching a student struggle with a concept. Start the new thinking down this line, and they will fall back to it each time they are under pressure when they are done with you.

[buckeyedoc]

We had a run the other night for a CHF pt. If I were a "by the book" man, I would have given NTG before I gave Lasix. Our protocol specifically states that NTG is the 1st round med for CHF. Well, I bypassed NTG and went straight to Lasix. Why, her b/p was 102/something. I gave report to the nurse as to why I didn't give NTG and she gave me the nastiest look. I am fortunate that I run with a good Basic. I trust him and he trusts me. Before I could open my mouth, he "informed" (in a not so loving way) about the pt.'s b/p being close to being under our protocol limits. She proceeded to instruct me that she knew my protocol better than I did and that I should've given NTG anyway. It was at that point that she said that I should have tried a 500cc bolus to increase her b/p. The doc had made it in before I got out of the room (which is unusual at this hosp). I gave him a brief rundown of what happened and that I withheld NTG. Moral of the story....protocols are guidelines. EMS is not a by-the-book field.

Oh, the nurse was a new grad. She came up to me and apologized for her mistake. She said that she was nervous because this was her first "critical" pt., although it is the norm for us anymore. In regards to her knowing my protocols better than me, she has never seen my protocols.

[Ace844]

We had a run the other night for a CHF pt. If I were a "by the book" man, I would have given NTG before I gave Lasix. Our protocol specifically states that NTG is the 1st round med for CHF. Well, I bypassed NTG and went straight to Lasix. Why, her b/p was 102/something. I gave report to the nurse as to why I didn't give NTG and she gave me the nastiest look. I am fortunate that I run with a good Basic. I trust him and he trusts me. Before I could open my mouth, he "informed" (in a not so loving way) about the pt.'s b/p being close to being under our protocol limits. She proceeded to instruct me that she knew my protocol better than I did and that I should've given NTG anyway. It was at that point that she said that I should have tried a 500cc bolus to increase her b/p. The doc had made it in before I got out of the room (which is unusual at this hosp). I gave him a brief rundown of what happened and that I withheld NTG. Moral of the story....protocols are guidelines. EMS is not a by-the-book field.

Oh, the nurse was a new grad. She came up to me and apologized for her mistake. She said that she was nervous because this was her first "critical" pt., although it is the norm for us anymore. In regards to her knowing my protocols better than me, she has never seen my protocols.

Sadly this is typical 'new nurse' behavior... You did the right thing.

ACE844

[buckeyedoc]

Sadly this is typical 'new nurse' behavior... You did the right thing.

ACE844

I'm usually not hard on new nurses. I understand that you have to start somewhere and beginning your clinical career is a hard thing. However, I expect a nurse, new or otherwise, to treat me and my partner with respect.

Doc