San Diego protocol regarding BP

[brachialbabies]

So I've heard from a couple sources that it's actually illegal for a San Diego County EMT to transport anyone with a BP lower than 100 on scene. Is this true, and if so would it be appropriate to transport anyways if the patient has a signed DNR?

 

[dixie_flatline]

So I've heard from a couple sources that it's actually illegal for a San Diego County EMT to transport anyone with a BP lower than 100 on scene. Is this true, and if so would it be appropriate to transport anyways if the patient has a signed DNR?

Sorry, but your post doesn't make a whole lot of sense.

Unless a local provider can give more details, you're going to need to cite something more concrete than "I've heard". I know a few marathon regulars whose systolic is at or below 100 most of the time. Plus I just can't think of any case where it makes sense to refuse transport due to hypotension?

Regardless, if the pt has a signed DNR it only goes into effect for live-saving efforts. Even with a signed, verified, notarized DNR being presented by a power of attorney, you still have to provide some type of care (maximal or palliative only depending on the DNR) until arrest occurs. I'm not sure how that factors in to your question about transporting a hypotensive pt at all?

 

[adamjh3]

It depends on the circumstances.

I'll generally start to consider calling ALS if the patient has a systolic BP under 90 WITH other S/S, because they can perform interventions to raise BP that I as a BLS provider cannot.

But again, it all depends on the circumstances. If you're not sure, there's no shame in calling a BH to find out what you should do. As basics we don't have the education to trust ourselves.

 

[JPINFV]

Regardless, if the pt has a signed DNR it only goes into effect for live-saving efforts. Even with a signed, verified, notarized DNR being presented by a power of attorney, you still have to provide some type of care (maximal or palliative only depending on the DNR) until arrest occurs. I'm not sure how that factors in to your question about transporting a hypotensive pt at all?

Why does the power of attorney have to present the DNR?

What if the patient is A/Ox4 with capacity and hands you the DNR?

 

[dixie_flatline]

Why does the power of attorney have to present the DNR?

What if the patient is A/Ox4 with capacity and hands you the DNR?

....

It was a joke. Discussion of DNRs always engenders a spirited debate about making sure the DNR is legitimate. For the point of my question, the DNR is undeniably valid.

My main problem there was just that a DNR (in my experience) specifies what level of care should be provided for live-saving efforts (both kinds of DNR, at least in Maryland, result in hands-off at time of arrest). If the pt has a systolic below 100 (but still a pulse), unless there are other related issues, I failed to see how the DNR would factor into a transport decision.

 

[brachialbabies]

To clarify I guess my post was actually two separate questions..

Can BLS in SD County transport patients with a blood pressure less than a 100? Obviously if you arrived on scene you wouldn't leave the patient. But would it be more appropriate to stay on scene and turn over to ALS?

Scenario: non-trauma patient only responding to pain, has a BP less than 100, but is still breathing. Would ALS provide any sort of interventions apart from O2 in this case in the presence of a DNR? I would assume not. So would it matter at that point if BLS did the transport or not?

 

[adamjh3]

There are still too many open questions in that scenario. Is this their normal mental status? What are the pt's other VS? Why are you there? Where are they going?

A DNR is exactly what it says it is Do Not RESUSITATE. They have a BP so they obviously still have a pulse, they're not dead yet, so you're going to do what you can to keep them alive. However once they die (pulseless and apenic) that's where your interventions are limited or removed depending on the exact verbage of the DNR

ETA: Is it possible you're confusing a DNR with an advance directive?

 

[Sandog]

To OP
I think you may have some misconceptions about a DNR, you should reacquaint yourself with this order as it may become pertinent some day.

Below is sample text I found on a written DNR. It may help clarify.

I have discussed my health status with my physician, _________________.
I request that in the event my heart and breathing should stop, no person shall
attempt to resuscitate me.

 

[Monkey]

I've NEVER seen that in the protocol book. I would say that you are possibly hearing a specific agencies policy.

If you're on a medical aid, and the pt is below 100, then decide to upgrade or make base hospital contact and get their input as to upgrading or doing the transport yourself.

The only protocol regarding a BP below 100, that I can think of, that is written is assisting with NTG when a pt has a systolic sub 100.

 

[EMS49393]

My systolic blood pressure hovers between 90 and 96 regularly. There is really no such thing as a "normal" blood pressure. There is such a thing as a "normal" blood pressure for each individual person. It seems odd to base a transport decision on one assessment finding that may in fact be a completely normal finding for the patient.

You do need to be familiar with how to handle a patient with a DNR in your jurisdiction because most areas handle them differently. As Dixie stated, Maryland has a special DNR protocol, so special that it takes up several pages in our protocol book. My state has a specific EMS DNR form that allows for two options, (A) for advanced life support, everything up to and including medications, EKG, and airway control minus intubation, until arrest. After arrest, no heroic measures, and (B) for basic life support, palliative care only. Until a few years ago, the only form EMS was allowed to honor was the state EMS form. They have since changed and we can now honor every states DNR form as a form B. If you do not know your jurisdiction regulations, you need to make the effort and find out who to contact in regards to your specific protocols.

 

[certguy]

b/p policy

If you think about it the rumor you heard makes no sense.Playing murphy,if medics are unavailable,coming from a distance,or you have a short transport time you're supposed to wait???????

 

[Monkey]

If you think about it the rumor you heard makes no sense.Playing murphy,if medics are unavailable,coming from a distance,or you have a short transport time you're supposed to wait???????

Many local agencies have their own weird policies, although I cannot figure out why this would be one of them. It is NOT San Diego protocol, (I've looked several times to see if I could find it since reading this post).

As was stated, some BP's run low... putting that kind of restriction on transporting a pt, whether it be a GT or Medical Aid, sounds rediculous to me, but oh well.

 

[certguy]

San Diego protocal

When I get the computer up again,I'll do a post on how DNR's evolved im San Diego.It was interesting,yet frustrating.

 

[jjesusfreak01]

Until a few years ago, the only form EMS was allowed to honor was the state EMS form. They have since changed and we can now honor every states DNR form as a form B. If you do not know your jurisdiction regulations, you need to make the effort and find out who to contact in regards to your specific protocols.

I will happily honor another state's DNR form, providing I have handed off responsibility to MC, otherwise, thats a shade of grey I don't want to get involved with. Also, in NC we have a DNR and a MOST form (specifically details what is/is not wanted), so its always quite clear.

Back to the thread. I have transported patients with BPs below 100sys, pts with heplocks, and a patient who had just been given 15mg MS immediately prior to transport. This is as a basic. Of course, you make exceptions for hospice patients with DNRs. If 15mg of MS sends them into respiratory arrest, I am going to do nothing, which is exactly what a medic is going to do.

 

[Monkey]

...and a patient who had just been given 15mg MS immediately prior to transport. This is as a basic.

That IS against county protocol. However most private BLS agencies don't pay attention to it.

 

[TransportJockey]

That IS against county protocol. However most private BLS agencies don't pay attention to it.

In NM it was not against any protocols... but then again NM basics can give IN/IM/SQ Narcan, so it wasn't a major deal.

 

[Monkey]

Yeah, true, but he started with San Diego Protocols which are about as tight as they get.

 

[JPINFV]

In NM it was not against any protocols... but then again NM basics can give IN/IM/SQ Narcan, so it wasn't a major deal.

It's rather irrelevant anyways since most DNR orders call for pain management even if it quickens death.

 

[JPINFV]

That IS against county protocol. However most private BLS agencies don't pay attention to it.

Just curious, do you have a reference. In general, just because a medication was administered prior to transport by a health care facility does not mean that it's automatically a paramedic level call.

 

[TransportJockey]

It's rather irrelevant anyways since most DNR orders call for pain management even if it quickens death.

Whoops, missed the DNR reference. Sorry.