Documenting Pre-Hospital Medical Command Decisions

[docB]

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Most of us get called frequently to advise EMS on matters such as termination of resuscitation efforts. This is obviously an area that has significant risk for lawsuits. However documentation for these types of cases is usually poor or nonexistent. If you agree to termination of efforts the patient will not come to your ER and no chart will be generated and so there’s no way to document.

Many docs, knowing this, go through a long list of questions and even rattle off some discussion and justification on the radio when they know it’s a recorded line hoping they can access that recording years down the line should a suit occur.

Others just hope that EMS will document appropriately. This is not always the case as EMS sometimes works more to put the onus of the decision on the EP than to paint a picture of appropriate action by everyone involved.

This is a tricky issue and one that my hospitals deal with poorly. What does everyone else do with these?

 

[Jeff698]

I do essentially what you mentioned with the recorded line. I give a brief summary of what I was told back to the paramedic to be sure I understand the scenario and do it in a way that documents my rationale on the recorded line.

Of course, I have no idea what happens with those tapes so maybe I'm just making myself feel better.

Take care,
Jeff

 

[Dwindlin]

Were I worked prior to school, even if we didn't transport we had to take our PCR to the doc that approved what ever we did for them to review and sign.

 

[docB]

Were I worked prior to school, even if we didn't transport we had to take our PCR to the doc that approved what ever we did for them to review and sign.

Good solution. We definitely don't do that here.

 

[emtcsmith]

I know for sure at one "university" level medical command hospital in my area they have actual paperwork they use each time they answer the phone. From what I've read over on those forms the amount of actual information on it varies, but its at least something. Also, in there "command desk" area there is a phone number for different EMS officers, cqi, dispatch, etc if they want to call someone else in regards to a specific incident.

Considering medical command contacts are for critical issues and often not notification only, I would hope the hospital had strong documentation on its end. I'm pretty sure ems reports are avail within a specific time frame to hospitals also.

 

[traumasurg]

Were I worked prior to school, even if we didn't transport we had to take our PCR to the doc that approved what ever we did for them to review and sign.

Where I work we have a different for
for deaths in the field. In addition to the normal pcr we have to paint the picture and take the paper to the med control physician and let him read it and he must sign it and the EKG strip.

 

[docB]

I know for sure at one "university" level medical command hospital in my area they have actual paperwork they use each time they answer the phone. From what I've read over on those forms the amount of actual information on it varies, but its at least something. Also, in there "command desk" area there is a phone number for different EMS officers, cqi, dispatch, etc if they want to call someone else in regards to a specific incident.

Considering medical command contacts are for critical issues and often not notification only, I would hope the hospital had strong documentation on its end. I'm pretty sure ems reports are avail within a specific time frame to hospitals also.

Here's the problem we have, if the patient doesn't come in and get registered there's no chart or medical record number so even if you write a huge note there's nowhere to put it. We don't even have a name as EMS has a policy against giving that kind of info over an open radio channel. We can't dictate a note as there's no MRN.

 

[WilcoWorld]

Next to the radio we have a binder full of one page worksheets for all frequent call types (refusing transport, divert straight to psych (yes, please!), terminate efforts, etc. We record date, time, ambulance company, EMS provider, a one liner on the case and check off boxes as we see fit. These get saved...somewhere.

I don't always fill these out for calls, but I try to. It seems that most attendings are inconsitsent about filling these out on busy days.

 

[jbar]

Here's the problem we have, if the patient doesn't come in and get registered there's no chart or medical record number so even if you write a huge note there's nowhere to put it. We don't even have a name as EMS has a policy against giving that kind of info over an open radio channel. We can't dictate a note as there's no MRN.

Where I worked we would call the hospital on the Nextel (cell phone mode) That way you can get around worrying about sending patient info over the air. So you could have the medics call in on a cell phone/land line.

Also where I worked when we got paged out each run had a unique call number. If they have a similar system you can ask the medics for the run number, put that on your form. It's not the same as a chart but at least it would have a unique identifier. Then have a box or 3 ring binder for all the call ins.

 

[leviathan]

We would contact the EP by cell phone for advice on what to do, but I don't think we ever documented the name of the physician. In retrospect that may have been a mistake...

 

[Siggy]

Here's the problem we have, if the patient doesn't come in and get registered there's no chart or medical record number so even if you write a huge note there's nowhere to put it. We don't even have a name as EMS has a policy against giving that kind of info over an open radio channel. We can't dictate a note as there's no MRN.

I'm going to preface this by saying that this might be one of the extremely rare things that So. California EMS gets right. Online medical control (which is required for just about any serious call) is handled over the radio by a RN with only a handful of orders that requires an MD/DO to sign off on (I imagine that field termination would be one of them, but don't quote me on it). Long story short, the RN fills out a report [pdf file]that is essentially the same as the PCR filled out by the paramedics with the paramedics transmitting just about everything over the radio. While no name is transmitted, birth date, run number, and base contact number are all recorded to match up the base report with the field PCR. This allows the base hospital to generate a document that is submitted to the county EMS authority to document their interaction with the field crew. Additionally, the radio traffic is recorded through the radio at the base station.

 

[deleted109597]

Cell phones are not a secure form of communication. As a matter of fact, essentially they are the same as the radios that EMS uses anyway. It's like a walkie talkie, and anyone trying can record those lines (remember Newt Gingrich?).

 

[southerndoc]

Cell phones are not a secure form of communication. As a matter of fact, essentially they are the same as the radios that EMS uses anyway. It's like a walkie talkie, and anyone trying can record those lines (remember Newt Gingrich?).

It depends on which area you are in. In most major metropolitan areas, EMS utilize trunk-based or 800 MHz systems that are digital and sometimes encrypted. In rural areas, EMS often utilize the 150 MHz spectrum which anyone with a scanner can listen to.

Cell phones are a little harder to listen to. Not impossible, but difficult. Some networks also do a rudimentary encryption with them as well.

Regarding a nurse documenting lengthy patient reports, one of the things I cannot stand is a detailed radio report for a non-emergent patient. Actually a lengthy report at all if they aren't requesting orders. Tell me you're bringing in a chest pain with ST elevation in inferior leads. Mention the vitals if they are abnormal. Otherwise, give me your ETA and we'll have the cath lab waiting. If you're bringing in grandpa with abdominal pain and it's not emergent, then don't even bother calling in. Just show up. Nurses spend a LOT of time documenting non-important stuff broadcasted over the radio that must be repeated in person anyhow.

 

[Siggy]

Regarding a nurse documenting lengthy patient reports, one of the things I cannot stand is a detailed radio report for a non-emergent patient. Actually a lengthy report at all if they aren't requesting orders. Tell me you're bringing in a chest pain with ST elevation in inferior leads. Mention the vitals if they are abnormal. Otherwise, give me your ETA and we'll have the cath lab waiting. If you're bringing in grandpa with abdominal pain and it's not emergent, then don't even bother calling in. Just show up. Nurses spend a LOT of time documenting non-important stuff broadcasted over the radio that must be repeated in person anyhow.

When I alluded to EMS in So Cal being screwed up, I really really meant it. The lengthy radio reports in LA and OC counties in California aren't for the giggles of the paramedics. Both of the counties EMS authorities don't trust their medics further than they can throw them and essentially requires lengthy reports. Morphine for chest pain? That's a base hospital order. ST elevation in inferior leads? Hopefully you'll have a paramedic that can identify that since the only thing both of those counties care about is if the paramedics can read ***Acute MI Suspected*** on the top of the 12 lead print out. We haven't changed all that much since Emergency was filmed.

 

[traumasurg]

When I alluded to EMS in So Cal being screwed up, I really really meant it. The lengthy radio reports in LA and OC counties in California aren't for the giggles of the paramedics. Both of the counties EMS authoritys don't trust their medics further than they can throw them and essentially requires lengthy reports. Morphine for chest pain? That's a base hospital order. ST elevation in inferior leads? Hopefully you'll have a paramedic that can identify that since the only thing both of those counties care about is if the paramedics can read ***Acute MI Suspected*** on the top of the 12 lead print out. We haven't changed all that much since Emergency was filmed.

Wow

 

[jbar]

Maybe if places stopped trying to put a medic on every fire truck you could:

1: Stop pushing firefighters who aren't good at medicine towards medic for career reasons and

2: Get rid of the bad medics because you don't need as many. That might help.

 

[Siggy]

Maybe if places stopped trying to put a medic on every fire truck you could:

1: Stop pushing firefighters who aren't good at medicine towards medic for career reasons and

2: Get rid of the bad medics because you don't need as many. That might help.

Shh. That sort of crazy talk isn't allowed in the areas where the heroic fire fighters take their precious time away from watching Rescue Me, Ladder 49, and Backdraft to respond to your pathetic little medical call. After all, we can't expect them to interpret 12 lead ECGs or start a saline lock without step by step directions.

 

[Dwindlin]

Shh. That sort of crazy talk isn't allowed in the areas where the heroic fire fighters take their precious time away from watching Rescue Me, Ladder 49, and Backdraft to respond to your pathetic little medical call. After all, we can't expect them to interpret 12 lead ECGs or start a saline lock without step by step directions.

I lol'd at "...saline lock not indicated for use with an external jugular IV."

 

[jbar]

As my partner used to say: "if my patient isn't on fire why are they here?"

I joke, I know there are some good FF/medics out there. But I don't think you get keep your skills up unless you make the medicine your priority. Which means running more than one medical call a day, transporting the patient to the hospital, etc.

 

[rhan101277]

I wanted to ask the med control folks this question. I am sure there are poor paramedics out there, but aren't there a few whom you trust their clinical judgement? They paint you a very good picture of the patient condition and you do not worry about making those serious calls with those medic.

A little off topic but:

Our instructor actually teaches us more than is in the book, so we can be thinking paramedics. We go really deep into capnography, ABG's. More so than other schools around here. Some say well you can't do ABG's in the ambulance, that is true, but what if you are transporting a patient to some rural hospital. Some of those rural physicians need some assistance on interpreting ABG's.

 

[Apollyon]

I wanted to ask the med control folks this. Yes there are sorry paramedics out there, but aren't there a few whom you trust their clinical judgement.

A little off topic but:

Our instructor actually teaches us more than is in the book, so we can be thinking paramedics. We go really deep into capnography, ABG's. More so than other schools around here. Some say well you can't do ABG's in the ambulance, that is true, but what if you are transporting a patient to some rural hospital. Some of those rural physicians need some assistance on interpreting ABG's.

Your grammar is so stilted that I cannot understand what is the question that you are asking.

 

[rhan101277]

Your grammar is so stilted that I cannot understand what is the question that you are asking.

The first half of my post is a question. The second part was just a generalized comment about the paramedic school I attend and the quality of education that we get there. Sorry for my sub-standard grammar I was sleepy. I fixed my grammar in the above post.

 

[jbar]

Wow. If you want to learn ABGs, great. But its pretty ridiculous to think that you are going to be running around helping docs with their ABGs. Truth is if they've forgotten winter's formula it takes about 3min online or in a clinical manual to look it up. And you're going to piss off/embarrass a lot of docs if you even suggest that you can help them with it.

I'm all for learning above and beyond the minimum. BUt it ends up being a lot of confusing noise unless people are solid on their basics. So I'd expect a medic student to know every drug they carry (indications, contraindications, side effects etc), have their assessment down cold, be able to explain the pathophys of any major disease, etc before they spend time on ABGs.

Truth is if you don't use it in the field you are just going to forget it. Better to spend that extra time on something useful, like ECGs and be a rock start at that than spend hours studying random stuff in case a trauma surgeon decides to ask you how many packs of platelets you'd give their patient.

 

[Siggy]

I'm all for learning above and beyond the minimum. BUt it ends up being a lot of confusing noise unless people are solid on their basics. So I'd expect a medic student to know every drug they carry (indications, contraindications, side effects etc), have their assessment down cold, be able to explain the pathophys of any major disease, etc before they spend time on ABGs.

Truth is if you don't use it in the field you are just going to forget it. Better to spend that extra time on something useful, like ECGs and be a rock start at that than spend hours studying random stuff in case a trauma surgeon decides to ask you how many packs of platelets you'd give their patient.

Question for you jbar. Do you think that point of care testing will become standard in the next 5-10 years for regular ground ambulances as the technology improves and becomes cheaper? You can already do POC ABGs on the iSTAT, but my understanding is that the cartridges are too expensive to be useful in the field (cost v benefit). Of course, in my little world paramedic education would be, at a minimum, an associates degree and not 9-12 months with no real academic prereqs.

 

[canjosh]

Question for you jbar. Do you think that point of care testing will become standard in the next 5-10 years for regular ground ambulances as the technology improves and becomes cheaper? You can already do POC ABGs on the iSTAT, but my understanding is that the cartridges are too expensive to be useful in the field (cost v benefit). Of course, in my little world paramedic education would be, at a minimum, an associates degree and not 9-12 months with no real academic prereqs.

I know you asked jbar, but I thought give my 2 cents...long time paramedic matriculating to med school in 2010 (hopefully!).

I can't think of many circumstances where POC testing will improve outcomes or change initial ED treatment. Blood glucose is the obvious exception. ED personnel place little value on field findings anyways, and I can't see there being a shift in this thought process. I mean, would you call cardiology for NSTEMI admission based on a positive Trop-I in the field? Or hang O-neg for occult bleeding with a field hemoglobin of 5? I would imagine that the answer is (appropriately) 'no'. More importantly, does knowing some lab values a little earlier really change outcomes...probably not. So, until studies are done proving otherwise...I don't see utility for much POC testing in the vast majority of EMS systems.

When I was involved in pedi/neonatal transport, we carried the i-stat with ABG cartridge. It was obviously useful in this environment, as most of our patients were intubated. All we cared about was pH, pCO2, pO2, and base deficit. Any other capability, even in that highly acute and specialized environment, would have been excessive.

As to not take the thread off into another galaxy...field termination of efforts was standing orders where I worked 911. Also, there is a difference (to me) between resuscitation avoidance and resuscitation termination...so just to clarify, the problem area is with patients who have had EMS resuscitation initiated, and now they want to terminate?

If your folks don't have standing orders for resuscitation avoidance, that's a big issue: i.e. blunt trauma full arrest=death. In my mind, termination of efforts criteria should be pretty darn clear and should not usually require input from online medical control.

 

[docB]

In my area more and more weight is being given to prehospital data. In an effort to attract more volume (wheather that is a good, bad or indifferent aim is a debate for another time) we now call a code stroke and have EMS take the patient directly to the CT based on their prehospital assement. We call code MI prior to arrival based on the EMS report of ST elevation (we don't quite have telemetry yet).

 

[jbar]

I don't think it'll be standard, but I'm willing to be swayed if there was good evidence that it improved outcomes somehow. The problem I see is

1: training medics to interpret the results (this is something that medical students struggle with, people who spend a lot more time every day looking at lab values than medics)

2: Improving outcomes. Yeah ECGs let you bypass the ED and go to the cathlab, but what are you changing in triage by an istat? I don't think you'll be bringing the patient straight to the MICU, the still need things like foley, central lines etc that should probably be done in the ED. Are you really going to be picking up patient's that look fine by exam, mental status, and vital signs but have screwed up ABGs?

3: Scene time. We love our toys in the field and want to use them. But as seen with medics and trauma, there is a concern about staying and playing rather than scooting to the ED. I could see a lot of medics getting excited about sitting on scene and sorting out the patient's anion gap while this is just taking a rig out of the system and delaying transport.

The only real uses I could see is

1: for critical care transport, where you are transporting the patient for over an hour and have to change vent settings.

2: If the medical system significantly changes and you have to take people to different hospitals based on the results (ie if the patient has an anion gap you can't take them to hospital x because they don't have a MICU)

But I'll say this, the istat people are going to be pushing it into the field and then trying to get people to justify it just like the prehospital ultrasound companies. Data first, then buy the expense toys.

 

[southerndoc]

At most hospitals the delay in stroke treatment is actually lab data and not the CT scan. Most places can have CT's done and read in 30 minutes, but it often takes 40 minutes to get platelets and INR back (unless you have bedside testing).

 

[Siggy]

But I'll say this, the istat people are going to be pushing it into the field and then trying to get people to justify it just like the prehospital ultrasound companies. Data first, then buy the expense toys.

...which was why I specified a 5-10 year frame and not immediately. Right now, I agree that given the cost, time to acquire, and education level of the average medic that it's not worth it. I also agree that you shouldn't take a tool and try to shoehorn it into an environment because it's new or shiny. Similarly, I don't think that you can adequately run a study on a tool until it's improved to the point that it is field capable. My understanding on the iStat is that some of the tests could take upwards of 5-10 minutes to run. Well, in that time frame for a lot of patients (especially since it won't be the first thing to be done), you'll probably already have a destination and initiated transport.

I'm not sure for certain, but I'm willing to bet that similar arguments were made against 12 leads prior to them being essentially the standard of care. How many places were bypassing the ER or activating the cath lab based on a prehospital 12 lead?

 

[jbar]

If we want to cut down on medical costs things like putting ultrasound and istat on every ambulance isn't going to help. I don't think putting the istat in the ambulance is going to save time over having it in the ED. The patient is still going to get a neuro exam from a physician before the CT, and there are a lot more hands to do things simultaneously in the ED than in the back of the rig.

The problem I have with some of these things is that a lot of ambulances are still run with two people, so unless they take a FF there is only one person in the back. And the time that you spend doing the istat or US you aren't doing vital signs, a 12 lead, a second IV, talking to the patient, getting medical history and.... (to tie it back to the OP) your documentation. Spending the five minutes to write down the patients name, DOB, meds, allergies, history and a set of vitals is enough that you could make a copy for the ED and they'd have something useful even if you have to run out the door.

 

[docB]

At most hospitals the delay in stroke treatment is actually lab data and not the CT scan. Most places can have CT's done and read in 30 minutes, but it often takes 40 minutes to get platelets and INR back (unless you have bedside testing).

Agreed. But the crews just love it when they get to roll the patient to CT. They love it when the code MI gets called based on their EKG too. People swarm, adrenaline pumps. It's just like on TV. I agree it doesn't do much for outcomes. But it's good for business.

 

[emtcsmith]

My EMS documentation when medical command is contacted obviously includes that for what its worth in the big picture.

For a refusal I usually document if the doctor talked to the patient, family, as well as the doctors name and facility. For orders I will typically write "orders granted for....by ...." Or for medical or trauma notification only/I need you to call another hospital for notification. I'll document "contacted x hospital speaking with dr.x for notification only."

The city ems system I work in doesn't make any routine notification to nurses. The system is way to busy both EMS and hospital side for anything like this to be practical espically since most patient's are not actually sick.

 

[canjosh]

If we want to cut down on medical costs things like putting ultrasound and istat on every ambulance isn't going to help. I don't think putting the istat in the ambulance is going to save time over having it in the ED. The patient is still going to get a neuro exam from a physician before the CT, and there are a lot more hands to do things simultaneously in the ED than in the back of the rig.

This is where increased POC testing is most likely to streamline clinical decision making, IMO.

For docB and others, if EMS bypasses the ED to go to the cath lab...when/how is BUN/Cr determined, aortic aneurysm excluded, etc? I assume the cath lab draws peripheral blood while the patient is catheterized and does POC testing? What about CXR? The community ED I work in requires a stop in the ED for STEMIs. We still activate the lab based on EMS interpretation of the ECG. However, the cath lab people aren't in house 24/7, and the ED time allows us to do the CXR, iStat, heparin (after radiographic assessment of the mediastinum), prep the groin, etc. Just wondering how the more comprehensive institutions handle the logistics...thanks!

 

[rhan101277]

I was not talking about using the ABG everyday, just that it can be a useful tool when it comes to critical care transport. Really any transport where the physician thought it was necessary for one to be performed. It tells you a good deal about the patient and it can be of some assistance if the patient starts going downhill and you have some history to work with.

I still have a long way to go in class, I just want to be a good provider and not the everyday medic who just hangs a IV bag, puts a patient on 02 and EKG, because that is all the know to do.

Now most medics are very good, but I have seen very bad one's and I am sure it affects patient outcomes to an extent.

 

[docB]

This is where increased POC testing is most likely to streamline clinical decision making, IMO.

For docB and others, if EMS bypasses the ED to go to the cath lab...when/how is BUN/Cr determined, aortic aneurysm excluded, etc? I assume the cath lab draws peripheral blood while the patient is catheterized and does POC testing? What about CXR? The community ED I work in requires a stop in the ED for STEMIs. We still activate the lab based on EMS interpretation of the ECG. However, the cath lab people aren't in house 24/7, and the ED time allows us to do the CXR, iStat, heparin (after radiographic assessment of the mediastinum), prep the groin, etc. Just wondering how the more comprehensive institutions handle the logistics...thanks!

I didn't say they bypass the ED for the cath lab, just for the CT. There is a place in town that claims that they have EMS bypass the ED for the cath lab but I've never actually found a medic who has seen it happen. The last meeting I was at where we could ask them how they were doing that they claimed that the cardiologists ordered the tests and got the labs back "stat."

 

[Dwindlin]

I was not talking about using the ABG everyday, just that it can be a useful tool when it comes to critical care transport. Really any transport where the physician thought it was necessary for one to be performed. It tells you a good deal about the patient and it can be of some assistance if the patient starts going downhill and you have some history to work with.

I still have a long way to go in class, I just want to be a good provider and not the everyday medic who just hangs a IV bag, puts a patient on 02 and EKG, because that is all the know to do.

Now most medics are very good, but I have seen very bad one's and I am sure it affects patient outcomes to an extent.

While this is a great attitude to have and I am in no way suggesting that you shouldn't want to learn all you can the reality is you will always be limited by your protocol. This is why as another person pointed out, it is important to have down solid those skills and treatments and assessment tools you are able to do. Again not suggesting you shouldn't learn all you can, simply reminding you that often times even with a vast knowledge base you will be very limited.

 

[canjosh]

I didn't say they bypass the ED for the cath lab, just for the CT. There is a place in town that claims that they have EMS bypass the ED for the cath lab but I've never actually found a medic who has seen it happen. The last meeting I was at where we could ask them how they were doing that they claimed that the cardiologists ordered the tests and got the labs back "stat."

Ahh, sorry it was jbar that made mention of that.

Skipping the ED doesn't seem like the smart thing to do, although it would make life easier for the ED.

 

[canjosh]

I was not talking about using the ABG everyday, just that it can be a useful tool when it comes to critical care transport. Really any transport where the physician thought it was necessary for one to be performed. It tells you a good deal about the patient and it can be of some assistance if the patient starts going downhill and you have some history to work with.

I still have a long way to go in class, I just want to be a good provider and not the everyday medic who just hangs a IV bag, puts a patient on 02 and EKG, because that is all the know to do.

Now most medics are very good, but I have seen very bad one's and I am sure it affects patient outcomes to an extent.

I think you're placing too high a value on POC lab tests. Yes, ABGs are useful in critical care environments. They really don't tell you all that much though (at least not stuff that's acutely fixable). I have used i-stat ABGs in the pedi/neonate transport environment (2-4 hours with the patient was common) and a lot of our patients were intubated--often at the referring facility. If the referring facility had a relatively fresh gas, we'd make vent adjustments and head back home. Depending on the transport time, we'd probably check one more gas en route and adjust the vent as necessary.

The only times I can see an ABG being useful is in the ventilated scenario described above, initial evaluation of the DKA pt (in the ED), and post-CPR damage assessment (in the ED). So, you're really talking about a limited setting (ventilated patients with long transport times).

It's great that you're driven to learn about the science behind prehospital care. However, as somebody else already mentioned, you'll have trouble applying the 'excess' knowledge as a field provider. This is one of the reasons I a) work in 'other-than-911' environments b) am applying to medical school.

 

[rhan101277]

I understand I am limited by protocols. If there is something I can learn that will help someone make it to the ED alive then that is what I am trying to do. Our medic instructor teaches some from the book and then uses slides occasionally to give us extra education. These slides come from PGY1 and PGY2 books.

Protocols however do not help you make you field diagnosis. You need to figure that out yourself and then go to the proper protocol. Also if you feel a better treatment is necessary but not in protocol, like a different medicine, just call up med control.

 

[canjosh]

Over time, you will learn that usually the best thing you can do to help someone make it to the ED alive is to treat with diesel. Believe me, you don't need to come here and tell us why you want to learn more about paramedicine. Many of the people here have 'been there, done that'. Not sure what you're referring to in the PGY1/2 books. Field 'diagnosis' should be quick, dirty, and clinical. Don't waste time trying to make a protocol fit, or trying to treat something that just needs diesel and an ED. I think medics often need to be reminded to 'first, do no harm'. We often forget that the quality of prehospital care isn't directly correlated to the procedures done or drugs given. Really, one of the most important things you should learn about is the transport decision...which facility is most appropriate for this patient?

 

[Dwindlin]

I understand I am limited by protocols. If there is something I can learn that will help someone make it to the ED alive then that is what I am trying to do. Our medic instructor teaches some from the book and then uses slides occasionally to give us extra education. These slides come from PGY1 and PGY2 books.

Protocols however do not help you make you field diagnosis. You need to figure that out yourself and then go to the proper protocol. Also if you feel a better treatment is necessary but not in protocol, like a different medicine, just call up med control.

Again, unless its in your scope you can't do it (even with medical direction telling you too). Most times if there is an alternate treatment for something that falls with your scope it will already be in your protocol.

...Really, one of the most important things you should learn about is the transport decision...which facility is most appropriate for this patient?

Couldn't agree more with this. My medical director used to tell us that one of the most useful things we can do for the ED is let them know if the patient is "sick" or "not sick".

 

[Jeff698]

To any paramedics or paramedic students out there, I say this as a 21 year paramedic and attending EM physician...

Learn all you can. Don't be limited by the actual use of this knowledge. Understand that just because you know something, however, doesn't mean there is a good use for it. Knowledge is never a bad thing. Unwise attempts at the application of it, however, can be bad.

In my paramedic instructor days (and now in my medical director days) I taught/teach ABG interpretation at a basic level to emphasis the pathophysiologic concepts I'm attempting to teach. I don't expect my graduates to actually be interpreting ABGs or correlating them with electrolytes and clinical condition to make treatment decisions.

As for the use of POC testing, I think (other than the aforementioned d-stick) it doesn't currently have the potential to alter treatment. I do, however, think that POC troponins, in my department, have the potential to alter the logistics of flow through my ED.

As an example, if I have EMS bring me a pt with chest pain, a non-diagnostic 12 lead and a negative troponin, all I need is a H&P and chest xray to admit. If I want to discharge, I may or may not need more. A positive trop will also speed up my disposition. This isn't because I'm not going to run additional tests but because my disposition decision points rest on story, 12 lead and troponin. If I want to admit, I just need to determine the best place for them and I need a negative trop to put them on the floor.

Clearly the use of any lab test is going to be both physician and department dependent. Your mileage can and will vary.

Take care,
Jeff

BTW, just because POC trops CAN decrease my ED LOS doesn't mean their expense is worth it. I can think of several other things for EMS to spend their money of but if they're dying to do the test and willing to put up with the CLIA crap, I'll find something useful to do with it.

 

[Dwindlin]

To any paramedics or paramedic students out there, I say this as a 21 year paramedic and attending EM physician...

Learn all you can. Don't be limited by the actual use of this knowledge. Understand that just because you know something, however, doesn't mean there is a good use for it. Knowledge is never a bad thing. Unwise attempts at the application of it, however, can be bad.

In my paramedic instructor days (and now in my medical director days) I taught/teach ABG interpretation at a basic level to emphasis the pathophysiologic concepts I'm attempting to teach. I don't expect my graduates to actually be interpreting ABGs or correlating them with electrolytes and clinical condition to make treatment decisions.

As for the use of POC testing, I think (other than the aforementioned d-stick) it doesn't currently have the potential to alter treatment. I do, however, think that POC troponins, in my department, have the potential to alter the logistics of flow through my ED.

As an example, if I have EMS bring me a pt with chest pain, a non-diagnostic 12 lead and a negative troponin, all I need is a H&P and chest xray to admit. If I want to discharge, I may or may not need more. A positive trop will also speed up my disposition. This isn't because I'm not going to run additional tests but because my disposition decision points rest on story, 12 lead and troponin. If I want to admit, I just need to determine the best place for them and I need a negative trop to put them on the floor.

Clearly the use of any lab test is going to be both physician and department dependent. Your mileage can and will vary.

Take care,
Jeff

BTW, just because POC trops CAN decrease my ED LOS doesn't mean their expense is worth it. I can think of several other things for EMS to spend their money of but if they're dying to do the test and willing to put up with the CLIA crap, I'll find something useful to do with it.

The bolded portion is what I was trying to convey in my earlier post...you just said it much more eloquently than I ever could...