Thinking versus Doing

[UMSTUDENT]

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.

With a systolic blood pressure of 102 what else made you think this was a problem related to CHF? Was this patient presenting with any sign of infection? What was the onset of congestion? Does your system have CPAP available for first line treatment?

[mediccjh]

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.

Yes, you beat me to it.

PULSE OXIMETRY HAS NO USE ON A BLS AMBULANCE!!! If they need oxygen, just give it!!!!!

[ERDoc]

You know, after reading this and several other posts with the whole ALS/BLS debate, I'm glad I work in the hospital where we can provide pt care. This system is so fractured, is there any chance of repairing it?

[PRPGfirerescuetech]

You know, after reading this and several other posts with the whole ALS/BLS debate, I'm glad I work in the hospital where we can provide pt care. This system is so fractured, is there any chance of repairing it?

YES

email me to find out how....

[MeekoBB]

Slightly off topic...This reminds me of debate I had with a former coworker who said that we CANNOT put O2 more than 2-3 LPM on a COPD pt after we we dispatched to a difficulty breathing call w/ hx of copd.

We got into so much that we brought it up to our supervisors...Everyone told us that you treat what is presenting, you do not treat the hx....pt c/o diff breathing, you provide O2, and if the copd was that extreme to just be ready to bag the pt. Treating the hx is what the doctor's job is.

[Awolfa]

I am a new paramedic (6 months) and I my first sets of shifts I was ready willing and gunning to push my first drugs ect. (Funny thing is my very 1st pt as a paramedic coded on me 1min from the er defib and cpr didnt even get to intubate :x :x) I finally got the good chest pain call. Hx of MI elevated bp, pain rated at a 10 non reproducable, diaphoretic, and had "the look" O2 ASA and nitro x2 given with no change. 12 lead showed elevation (cant remeber which leads) had orders for 2-4 MS and nitro prn. Had another paramedic in the back get the IV while I drew up my very first narc as a paramedic. Right when I was ready pt began having seziures and an ALOC. Sat back thought about it and decided to hold off. Called the er and informed them of change Dr said its your choice on the ms otherwise just x-port. I held off and contiunued x-port. Pt ended up being admited and because pt was out of town never was able to follow up. But I know how bad that temptation was to push it because I was/am still new and want to play..

[Lithium]

I'm glad this was revived.

Not to criticize you awolfa, but I do think that this is something every practicioner goes through. I can only speak for myself, but I often wonder if new surgeons are as eager to start 'cutting' their patients? Eventually, the novelty wears off.

I remember, I was an ALS provider for about 4 or 5 years before I had the opportunity to decompress a chest. After that call, I hope I never have to do it again.

Even when I was a new PCP, about 3 months in, the only drug I hadn't given at that time was Epinephrine 1:1000. We got called out for a male child experiencing extrem shortness of breath after eating at a seafood restaurant. The whole time on the way in, I remember this was going to be in. On arrival, as we walked into the restaurant, I spotted the child across a few tables and you could hear him coughing and wheezing, and he was COVERED in hives head to toe. I was getting excited, but then after patient contact and thorough assessment, we ended up just giving salbutamol for his SOB and transported. His vitals and even a thororugh physical were not indicative of a patient experience anaphylaxis, and that was one of the calls that has still stuck with me. Just because I can do something, doesn't mean I have to. And yes, I agree with northernmedic about how once you give a med, you can't take it back.

peace