Thinking versus Doing

[Dustdevil]

There are very few calls that I will not do anything more then just transport to the ER with nothing other then a phsyical assessment. My monitor is a tool, and most seem to think it is a treatment (which it isn't). It doesn't take buy a minute to put someone on the monitor and check things out. I have found problems there that I wouldn't have if I hadn't have done that. Granted they might not have needed to be treated right then or there, at least I knew about the problem (or was able to eliminate a cause).

And even if you don't need to treat it, you don't look like a tool when the ER puts them on the monitor and finds something that easy that you did not find.

Reminds me of some of the medics here. Somebody comes in with diarrhoea, and they just hand them Imodium and a lecture about liquid diets instead of doing a proper exam and finding out that an ear infection was the reason for the diarrhoea in the first place. Treat your patient, not his symptoms.

Without assessment, we are nothing.

[Lithium]

So, you'll have to excuse my ignorance about this, but aren't monitors standard practice in the USA, even at the BLS level?

I realise there is a difference in education and standards, but here, I would say every patient contact gets atleast a 10 second strip printed off of them and usually continuous cardiac monitoring, regardless if the crew is BLS or ALS. Every PCP in Ontario is taught basic cardiology and rhythm interpretation, I guess I was assuming that was typical everywhere ...

Jacob

[AZCEP]

For most of the U.S. the only monitor BLS providers can use is pulse oximetry or glucometers.

Neither carry the ability to significantly do anything about what is found, but they are allowed to be used. ECG's are not in the BLS scope, and aside from an AED, aren't needed anyway.

[theotherphil]

During my brief reading of this site, I see a lot of referrals to protocols. Here in the UK, we don't use protocols in the strict sense of the word. We work to guidelines and are free to interpret and use them as we see fit. As long as we can justify our actions and that we work in the best interests of the patient then that is fine. I suppose the fact that we work autonomously gives us a greater freedom to act by using guidlines.

As has been said above, we rarely use any advanced interventions unless it is truely needed. We don't even cannulate unless we are going to medicate or feel we may have to medicate. You won't go far wrong by doing the basics well and intervening where absolutely necessary.

[stretcher monkey]

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?

Maybe thats because they have that option. Even if you're 100% certain what you're doing is correct it's sometimes just human nature to get someone else's opinion. Us pre-hospitallers don't often get that luxury.

[Asysin2leads]

Protocols are nothing more than what they use to hang you when the you know what hits the fan.

[northernmedic]

I have always prided myself on being a less is more type of guy. You can always give another drug if you really need to but you can't take it back once you give it. I think in many places we have cultivated a culture where we judge a provider by the by their scope of practice. This is bad. My partner and I recently had a paramedic from Alberta ride with us. My system is a targeted ALS system where we only do ALS calls so all our ALS providers get a lot of hands on exposure to maintain skills. We have quite progressive medical directives but nothing too crazy. This individual proceeded to lecture us on how they had learned things like percardiocentesis, ABG sampling and intrapartal exams in their course ( but only on manikins) and how we were behind the times. My point is this: an individual is juding us based only the tools in our kit not core paramedic abilities like history taking, physical exam skills or the ability to develop an effective treatment plan and interact with the patient. A person like this in mind is the most dangerous type of paramedic since they are only thinking of what they can do TO the patient not what they can do FOR them.

Rant off.

[VillageEMT]

Lithium,

BLS ECGs are, unfortunately, rare in the US. In our little village the BLS EMTs are taught to set up both 3 and 12 lead ECGs and to at least know when something doesn't look right so they can alert the ALS. If we are picking up an "ALS assist" enroute from another squad they are sometimes surprized to find a 12 lead strip waiting for they when they get on board. ( They shouldn't be surprized but they should be training their BLS better.) With half-hour plus transports BLS/ALS teamwork is a must.

I think that the best approach to many problems is Occam's Razor "the lex parsimoniae" (law of succinctness):

entia non sunt multiplicanda praeter necessitatem,

which translates to: entities should not be multiplied beyond necessity.

(That is, the fewer assumptions an explanation of a phenomenon depends on, the better it is.) (Ref: Wikipedia)

Or as we say in Engineering "never assume, in only makes an ASS out of U and ME"

[HellsBells]

For most of the U.S. the only monitor BLS providers can use is pulse oximetry or glucometers.

Neither carry the ability to significantly do anything about what is found, but they are allowed to be used. ECG's are not in the BLS scope, and aside from an AED, aren't needed anyway.

- AZCEP

This is coming from a canadian point of view, so I don't know exactly what the American level of training is like for BLS providers, but I disagree with almost everything written in this post.

I find that pulse oximetery is a very useful tool, and can significantly alter the course of treatment. I assume your BLS providers are allowed to give oxygen? If so, the pulse oximeter (along with proper pt assessment) can give an indication of what type of oxygen therapy the pt. needs and also how well present oxygen therapy is working.

As far as BGL's and Monitors go, the BLS provider may not be able to do anything about it, but I believe that there is no harm in having good dianostic tools at their disposal, as it will help to speed the treatment process along when the patient does come into contact with ALS care.

[kevkei]

HellsBells,

I'll beat everyone to the chase and keep it short. Treat the pt, not the pulse oximeter. The values obtained by SpO2 are very limited in their significance and are often over stated.