# How do you maintain med drip rates on your truck



## crotchitymedic1986 (Jan 12, 2009)

I still cant believe that most of the ambulances in the US do not use an IV pump or dial-a-flow type devices for maintaining accurate medication drip rates.  Can you imagine being a patient in the ICU and hearing a nurse say, "yes, that looks about like 5mcgs per minute, sure wished we had a pump".  In my opinion, "eyeballing" dopamine, is a huge risk to our patients.
So how do you do it at your service ?  We find money for all the other pieces of equipment on the truck, why not pumps ?


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## KEVD18 (Jan 12, 2009)

heres how i go about it:

before doing any call requiring an infusion, i proceede to have at least thirteen shots of tequila.

then, i blindfold myself and mix the bag by touch.

after starting the iv one handed and hammered, i hook the bag up. i put the drip chamber right next to my head and time it by ear. 

i find this method works rather well. of course, im usually pretty banged up from the tequila, so it really doesnt matter much to me.


so, is that enough conflict inspiration for you? if not, paid v. volley is usually good for the type of fight you're lookign for.


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## remote_medic (Jan 12, 2009)

we have pumps for interfacility transports only (not acutally kept on the truck but rather at base). We simply eye ball Dopamine for emerg calls. I haven't had to do this yet and quite frankly don't want to have to.


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## crotchitymedic1986 (Jan 12, 2009)

Not trying to start a fight, just trying to improve EMS.  There was a time in EMS when we didnt have 12lead, capnography, pulse oximeters, safety needlees, one man stretchers, and about 1/2 the meds in your drug box today.  We tend to improfe with time.  And just like you look at my generation and say you guys used to stick needles in people's hearts ?  The next generation will look at you and say, "You use to hang dopamine on patient without a pump ?"

It is time to improve, if for no other reason :  Patient safety.


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## KEVD18 (Jan 12, 2009)

crotchitymedic1986 said:


> Not trying to start a fight


 

yeah, right.

how is starting a fight on an internet message board going to change things?

in my state, it takes an average of seven years to change a protocol going through a half dozen different committees and review boards. i cant just one day walk in to my bosses office and demand four channel alaris pumps.

every topic you've started to date has been inflammatory. i know a little bit about inflammatory posts, having written one or two myself. get off the soapbox dude. its getting annoying.


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## crotchitymedic1986 (Jan 12, 2009)

I beg to differ.  My posts may be about controversial subjects, but I have not called anyone a name, or even got into a verbal confrontation with anyone, so I must not be too inflammatory.  If you do not like my posts, simply ignore them, you are not mandated to read them, like them, or respond to them.

As far as your 7 year comment, every journey starts with a single step, so why not make that step now, so that you will have the equipment you need in 7 years ?  And you do not have to have the most expensive pump out there to get the job done.  I assume your service found a way to pay for 12-lead monitors a few years ago, this is no different.


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## ffemt8978 (Jan 12, 2009)

crotchitymedic1986 said:


> I beg to differ.  My posts may be about controversial subjects, but I have not called anyone a name, or even got into a verbal confrontation with anyone, so I must not be too inflammatory.  If you do not like my posts, simply ignore them, you are not mandated to read them, like them, or respond to them.
> 
> As far as your 7 year comment, every journey starts with a single step, so why not make that step now, so that you will have the equipment you need in 7 years ?  And you do not have to have the most expensive pump out there to get the job done.  I assume your service found a way to pay for 12-lead monitors a few years ago, this is no different.



So how do you propose to pay for all of these "advances" you think we should have?  You know, like taking EVERY patient to the hospital to run a full range of tests just to reduce (but not eliminate) a 0.01% fatality rate?  Considering Medicare/Medicaid will be insolvent by 2019 at the current rate, I'm genuinely curious about this.  

Feel free to start another thread on this, if you want.


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## KEVD18 (Jan 12, 2009)

crotchitymedic1986 said:


> I beg to differ. My posts may be about controversial subjects, but I have not called anyone a name, or even got into a verbal confrontation with anyone, so I must not be too inflammatory. If you do not like my posts, simply ignore them, you are not mandated to read them, like them, or respond to them.
> 
> As far as your 7 year comment, every journey starts with a single step, so why not make that step now, so that you will have the equipment you need in 7 years ? And you do not have to have the most expensive pump out there to get the job done. I assume your service found a way to pay for 12-lead monitors a few years ago, this is no different.


 
every truck ive worked on had pumps. i have just found that tequila bottles are easier to work with a lower failure rate


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## crotchitymedic1986 (Jan 12, 2009)

Well first of all, I am not so full of myself to assume that I am right about everything, or that everyone should do it my way.  I am merely asking questions.  But to answer your question, I dont think that "cost" should be the primary gauge for deciding to do what is right.  If it is the right thing to do, then we need to find a way to do it, regardless of price.  

But I have not mandated that you spend a fortune either.  For instance, on the patient refusal front, I think I have a solution that is low cost or no cost:

Instead of transporting everyone (as you suggested), why not just make it mandatory for a supervisor or a 911 operator to talk to the patient on a recorded phone line, and ask the patient, "are you refusing EMS transport at this time ?"  If the patient is truly refusing AMA, and says "yes" on the recorded line, then you have even more proof to back up your claim that you tried everything.  But it the patient hadnt refused, then he would say, no I am not refusing, they told me I didnt need to go, then you have corrected the lazy medic's mistake.  

I mean how many refusals do you get in a shift ?  I think a supervisor could make those calls (if you are a bigger/busier service, then you probably have layers of supervisors who could do it).   Doesnt cost you a thing, unless you dont have unlimited calls on your cell package.  And think of what it could save you.


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## ffemt8978 (Jan 12, 2009)

crotchitymedic1986 said:


> Well first of all, I am not so full of myself to assume that I am right about everything, or that everyone should do it my way.  I am merely asking questions.  But to answer your question, I dont think that "cost" should be the primary gauge for deciding to do what is right.  If it is the right thing to do, then we need to find a way to do it, regardless of price.
> 
> But I have not mandated that you spend a fortune either.  For instance, on the patient refusal front, I think I have a solution that is low cost or no cost:
> 
> ...



Hmm...that's not what you said here...


crotchitymedic1986 said:


> This is why i am against leaving patients at home, until the day we have the ability to do labs and xray. Which isnt to say you did anything wrong, but there is just no way to rule out every possible diagnosis with the limited tools we have.
> 
> Think about it this way: A 14 year old girl comes to the ER for dyspnea, after breaking up with her boyfriend. She is obvioulsy hypeventilating, and everyone knows it, and treats her accordingly. But they will not discharge her until they do a blood gas to confirm hyperventilation. If the ER doc will not discharge her without supporting lab work, I do not understand why we feel so comfortable to not transport this same patient to the ER.



So which is it?  And not every service has a supervisor you can call...unless you call medical control for EVERY refusal.  If you're referring to your agencies supervisors and not med control, keep in mind that not everyone gets promoted to a supervisory level because they are good at EMS or medicine.

Around here, we use our clinical judgement, training, and experience and if we have any thoughts that the patient should go to the hospital but they still refuse, we call medical control.


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## crotchitymedic1986 (Jan 12, 2009)

Now, how do we pay for the pumps ?  

1.  You could use dial-a-flows. We can argue over their accuracy, but it is more accurate than an eyeball.

2.  Maybe you start with one reconditioned pump on the supervisor's vehicle if you have one.  Or on one truck.

3.  Maybe the hospital will sell or donate their old ones to you.

4.  Maybe you do some fund raising.

5.  Maybe you can apply for a grant.

We dont know what possibilities are there, until we make the first steps.  Many times in my career, the conversation started with "we cant afford that", but somehow, someway, we always found a way to get what we needed.  

Then again, maybe an IV pump is not the most important piece of equipment that your service needs.  You may still be waiting on 12Lead or certain medications.  My point is that whatever you shouldnt give up just because you think you cant afford it.


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## Sasha (Jan 12, 2009)

> 2. Maybe you start with one reconditioned pump on the supervisor's vehicle if you have one. Or on one truck.



So everytime a truck needs a drip they have to call a super or THAT truck and delay treatment until that truck or super can get to them? What if more than one truck needs it at a time?



> 3. Maybe the hospital will sell or donate their old ones to you.


That's a liability. Technically if something went wrong with the pump, the hospital could be sued. 



> 4. Maybe you do some fund raising.


Some company's have enough trouble getting their employees to show up, much less show up to something extracurricular such as a bake sale or begging for money.



> 5. Maybe you can apply for a grant.


Good luck with that.


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## crotchitymedic1986 (Jan 12, 2009)

Both statements are accurate:  In the absence of lab and xray, I am against the individual medic being able to talk people out of going to the hospital.  The solution I proposed solves that problem.  I am not worried about the patient who actually refuses AMA, I am concerned about the patient who should be transported, but is talked out of transport, and then dies hours later.

And as far as the .01%, we hope that is the real number, but we have no idea.  It could be 20% for all we know (actually there was a study performed by AMR that showed for every 100 patients who refused, you would have 7 hospital admissions, 2 ICU admissions, and 1 death).


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## crotchitymedic1986 (Jan 12, 2009)

Sasha said:


> So everytime a truck needs a drip they have to call a super or THAT truck and delay treatment until that truck or super can get to them? What if more than one truck needs it at a time.
> 
> That's a liability. Technically if something went wrong with the pump, the hospital could be sued.
> 
> ...



*1.  Supervisors typically respond to arrests and critical calls.  It may not be the best solution, but it may be the best solution for right now.  Maybe you can only afford to buy one pump per budget year. *

*2.    That is incorrect, once they have donated or sold them to you, they have no ownership or liability.*

*3.  Employee performance will rise or fall to the expectation level that leadership and the other employees have set.  This is not a slam against your service, but if your greatest accomplishment is that all the warm bodies showed up for work today, then you have bigger problems than IV pumps, your service needs to dust off its mission statement and change the culture.*


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## remote_medic (Jan 12, 2009)

crotchitymedic1986 said:


> And as far as the .01%, we hope that is the real number, but we have no idea.  It could be 20% for all we know (actually there was a study performed by AMR that showed for every 100 patients who refused, you would have 7 hospital admissions, 2 ICU admissions, and 1 death).




Source?

ABC (extra characters to meet the 10 character minimum to make a post)


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## crotchitymedic1986 (Jan 12, 2009)

source for what ????????????


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## ffemt8978 (Jan 12, 2009)

crotchitymedic1986 said:


> source for what ????????????



The AMR study you cited.


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## crotchitymedic1986 (Jan 12, 2009)

That is the source:  American Medical Response.  I worked there when they did it back in the 90s.  I doubt you can link it on the web, as that is not the kind of information a private, for profit service, would want floating on the web.  It was an internal CQI project, but I am sure that anyone that still works there can get you a copy of it, as they frequently preached about it in every new employee orientation.


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## Sasha (Jan 12, 2009)

crotchitymedic1986 said:


> That is the source:  American Medical Response.  I worked there when they did it back in the 90s.  I doubt you can link it on the web, as that is not the kind of information a private, for profit service, would want floating on the web.  It was an internal CQI project, but I am sure that anyone that still works there can get you a copy of it, as they frequently preached about it in every new employee orientation.



So it's a study that only YOU saw? That's a real good proof, love. Real good proof.


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## crotchitymedic1986 (Jan 12, 2009)

No, everyone that worked there saw it -- and it is a pretty big company.  And if you did the math, you realize that makes it more like a 1% failure rate instead of .01% failure rate.  A 1-2% failure rate is pretty much universal across all industries, so I see no reason to believe that we wouldnt have a 1% failure rate.  I bet everyone in this room knows about a case that a medic totally screwed up in 2008, even if it didnt result in a death.  Do you really think that we are 100% perfect in every EMS agency in the USA ?  

But like I said, even 1 preventable death is 1 too many.


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## crotchitymedic1986 (Jan 12, 2009)

moving this back to the refusal thread, as this is an IVpump thread.  Please go to that thread for info regarding published studies.


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## ffemt8978 (Jan 12, 2009)

crotchitymedic1986 said:


> moving this back to the refusal thread, as this is an IVpump thread.  Please go to that thread for info regarding published studies.



Really?  This should be interesting.


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## KEVD18 (Jan 12, 2009)

crotchitymedic1986 said:


> moving this back to the refusal thread, as this is an IVpump thread. Please go to that thread for info regarding published studies.


 

yeah, telling the boss how to run his board is always a good idea/.//.


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## crotchitymedic1986 (Jan 12, 2009)

Not telling anyone how to do anything.  Just trying not to confuse the topics.


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## exodus (Jan 12, 2009)

crotchitymedic1986 said:


> Both statements are accurate:  In the absence of lab and xray, I am against the individual medic being able to talk people out of going to the hospital.  The solution I proposed solves that problem.  I am not worried about the patient who actually refuses AMA, I am concerned about the patient who should be transported, but is talked out of transport, and then dies hours later.
> 
> And as far as the .01%, we hope that is the real number, but we have no idea.  It could be 20% for all we know (actually there was a study performed by AMR that showed for every 100 patients who refused, you would have 7 hospital admissions, 2 ICU admissions, and 1 death).





Okay, that means:
7% would have been inserted later into the ER. (Who cares, they're alive)
2% would have gone to ICU (If you have to go to the ICU, chances are you're getting transported because you can not sign an ama refuse)
and 1 % die.... So?

SO
I'm going to throw away money and time into a program where 90% of the transports aren't even needed?


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## crotchitymedic1986 (Jan 12, 2009)

Refusal topic moved back to the refusal thread :  "ethical question", please post your questions there


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## ffemt8978 (Jan 12, 2009)

crotchitymedic1986 said:


> Refusal topic moved back to the refusal thread :  "ethical question", please post your questions there



Let me make this real clear for you...It is not up to you to decide what topics should go where, and if a thread is getting off topic.  Nor do you get to determine what responses get posted here or in any other thread.  If a Community Leader feels a thread has strayed too far off topic, we will deal with it.

Any questions?


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## Veneficus (Jan 12, 2009)

Drip rates, x-rays, and labs, oh my...

While I see your points, I think the thing the US is going to get used to in a hard fast way is that while we talk about providing the best care to everyone, talk is cheap. What really speaks is money. The current EMS and larger healthcare system in the US is improperly funded and stressed to the breaking point. Simply changing a few EMS practices is probably not going to be cost effective or make much difference in outcome.

“Amateurs talk tactics, experts talk logistics.” I once heard. Overcrowding ERs by transporting every patient does not equate to better patient care. You want to save more lives, start lobbying for prevention, not rescue. Many people don’t like it, but EMS is best suited for this change at the moment. (not perfect, but best)

There was a time when medics were taught how to set up a drip. I can show you how to set up dopamine drip accurate to 0.1 ug/min/kilo with just the flow dial on a 60gtts drip set. Many tests including labs and x-rays do not change care decisions in the ED, they provide some legal shielding. (examples too numerous to type out) 

I think modern reliance on technology may be being carried too far. I posted somewhere else that physical exam is a dying art. How many medics do you know percuss? Listen to heart sounds? Actually palpate structures effectively? Thorough history? (look at NREMT and the stupid idea that medical and trauma assessment are separate.)

I am particularly fond of the acronym VOMIT. Victim Of Medical Imaging Technology. (Basing treatments off of erroneous or nonspecific findings because of the limits of these tests and the overreliance on them which causes excessive cost and/or potential/actual physical harm to patients.)

Most of the changes you seek for improvement could be enacted by better education and training, not defaulting to toys and somebody else’s remote judgments.

Just my $0.02


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## ffemt8978 (Jan 12, 2009)

Excellent points, veneficus!!!!


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## crotchitymedic1986 (Jan 12, 2009)

Totally agree vene, it is due to poor education that we need the pump to protect the patient.  You claim you can titrate with a 60 drop set, and many have memorized several clever tricks for calculating dopamine.

But if i changed the concentration of dopamine in everyones truck tomorrow from 800 to 400 or 1600mcgs, or vice-versa, most medics would be lost as to how to calculate an accurate drip rate.  Patients lives are too important for guessing and guesstimating.


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## Veneficus (Jan 12, 2009)

crotchitymedic1986 said:


> Totally agree vene, it is due to poor education that we need the pump to protect the patient.  You claim you can titrate with a 60 drop set, and many have memorized several clever tricks for calculating dopamine..



How many have actually used these clever tricks? Not to boast but because I was required in school back in the day to be able to calculate and set up drips. Change whatever variable you want, 10 gtts, concentration, desired dose, etc. All I need is a pen and a few seconds and it will not be a guess, but a fairly accurate and precise measured dose. It even functions in the absence of a DC or AC current.



crotchitymedic1986 said:


> But if i changed the concentration of dopamine in everyones truck tomorrow from 800 to 400 or 1600mcgs, or vice-versa, most medics would be lost as to how to calculate an accurate drip rate.  Patients lives are too important for guessing and guesstimating.



There are several safety mechanisms built in, like the amount of medication in the vial, lower suggested dose limits prior to toxic doses, protocols, etc. There are probably few more than I that demand accuracy and precision in poisoning patients, but I would rather have a capable provider than 1000 machines.


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## DrankTheKoolaid (Jan 12, 2009)

*re*

If it's field initiated we use Dial-a-Flow, for IFT's there usually either on a syringe pump or IV pump.

Corky


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## Sapphyre (Jan 12, 2009)

crotchitymedic1986 said:


> *1.  Supervisors typically respond to arrests and critical calls.  *



They do?  One shift last week I had 2 arrests, back to back.  No Sup ever showed....  Now, the fire captain was there, but, he's always on the engine.  Oh, and the BC never showed either....  

Maybe I should go start yelling at my sups for not showing on my arrests and STEMIs.  Because, you know, some dude on an internet forum told me that sups are supposed to show on critical calls.   Dude, if you want your service to get pumps, take your own advice and get your service pumps.  My service is not gonna do it for emergency trucks.


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## Jon (Jan 12, 2009)

back in "the day"... ALL drips were calculated by DRIP RATE... we still use the "old" technology - so what?

And please DO NOT post random numbers unless you can find a source to back them.


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## JPINFV (Jan 12, 2009)

crotchitymedic1986 said:


> That is the source:  American Medical Response.  I worked there when they did it back in the 90s.  I doubt you can link it on the web, as that is not the kind of information a private, for profit service, would want floating on the web.  It was an internal CQI project, but I am sure that anyone that still works there can get you a copy of it, as they frequently preached about it in every new employee orientation.


If it's not in a peer reviewed journal, then it isn't a scientific study and probably shouldn't be used outside of that company. Too many variables involved to simply say "Oh, because AMR said so!"


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## marineman (Jan 12, 2009)

JPINFV said:


> If it's not in a peer reviewed journal, then it isn't a scientific study and probably shouldn't be used outside of that company. Too many variables involved to simply say "Oh, because AMR said so!"



Given the news headlines in the past several months I wouldn't trust a single thing put out by AMR regardless of peer review. If you can't ensure that a medic is actually a certified medic prior to hiring you have no business conducting research. 

About half our trucks (ones that do more IFT's) have pumps on them but they usually don't get used on emergency calls. For the roughly 5-max of 10 minute transport a few mikes/minute won't be a major factor in whether or not our patient lives or dies.


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## reaper (Jan 13, 2009)

I tried to heed the warning!!!


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## Scout (Jan 13, 2009)

crotchitymedic1986 said:


> And as far as the .01%, we hope that is the real number, but we have no idea.  It could be 20% for all we know (actually there was a study performed by AMR that showed for every 100 patients who refused, you would have 7 hospital admissions, 2 ICU admissions, and 1 death).




where would one find details this "study" done in the 90's. I'm sure it is of little relivance being possibly almost 20 years old. But it would be nice to see. Would you also have studies done in this century to allow a tend to be extrapulated?


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## crotchitymedic1986 (Jan 13, 2009)

On the refusal topic, please go to the "ethical question" thread, where those questions have been answered (this is an IV pump thread).  And I disagree that a study that was not published in a scientific journal is not worthy of review.  If that were the case, there would be no reason to do any internal CQI within your service.  Many services choose to keep their dirty laundry in-house.  I would suggest that you do an internal study within your own service and see what your results are.  Just do a follow up call on your refusals and see how many were admitted to the hospital  ?

As far as IVpumps, I didnt demand that you buy just 1 or put it on the supervisors truck, I just made the suggestion that was a good way to start. It may not work for your service to do it that way, then again, it may be the perfect way to start.  To those who know how to calculate a Dopamine drip with pen and paper, congratulations.  But we all know that most medics rely on the field guide.  

There is a reason hospitals dont "eyeball" their drip rates.  If eyeballing was a safe alternative, hospitals wouldnt waste money on pumps.  Just because we have always done it a certain way, doesnt make it right.  There was a time when we threw dirty needles in the trash because there was no such thing as sharp containers.


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## Sasha (Jan 13, 2009)

My service is gonna run right out and buy some pumps RIGHT NOW! Because some guy claiming to be a medic online told us too.

(We have one, on the CC truck for IFT transfers. Amazing that we haven't needed more.) 

A very good point was brought up in the chat. Unless you know your patient's actual weight, down  to the pound, even with a pump you're still guessing drip rates. (That came from KevD. Shocking, right?)


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## crotchitymedic1986 (Jan 13, 2009)

You shouldnt buy them because I told you to, you should buy them because you are a patient advocate, and are concerned for your patient's safety.  

I would say that it is a smarter use of money than buying 12-Lead, which no one hesitated to buy.  If you can afford that, you can afford a new or reconditioned IV pump.


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## JPINFV (Jan 13, 2009)

crotchitymedic1986 said:


> And I disagree that a study that was not published in a scientific journal is not worthy of review.



So if someone had an unpublished 'study' from an ambulance company and asked you to change your treatments based only on this study and some rhetoric, then you would do so without even a chance to see the study?


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## crotchitymedic1986 (Jan 13, 2009)

No, but if your own company's internal study showed a problem, would you ignore it because it wasnt published in JEMS (P.S. I also referenced published studies in that thread, all you have to do is google keywords to find them).

Do you have any study's that prove that it is not a problem ?  Why dont you go back and just look at your 12/08 calls at your service?  All you have to do is pull the refusals, then call the patients, and tell them as part of your service's follow-up, you wanted to check on them and make sure they are OK.

Wouldnt take you long, and then you can come back with real statistics and refute everything I have said (but I think we know what the statistics would show).


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## Sasha (Jan 13, 2009)

crotchitymedic1986 said:


> You shouldnt buy them because I told you to, you should buy them because you are a patient advocate, and are concerned for your patient's safety.
> 
> I would say that it is a smarter use of money than buying 12-Lead, which no one hesitated to buy.  If you can afford that, you can afford a new or reconditioned IV pump.



I'd say 12 leads are a lot more important than IV Pumps, a lot more frequently used. You have a pen and paper way of figuring out drip rates, and you have a manual way of setting them. You don't have a pen and paper way to figure out what's going on with the heart. 

You didn't address the weight issue, by the way. What's your answer for that?


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## Veneficus (Jan 13, 2009)

Sasha said:


> I'd say 12 leads are a lot more important than IV Pumps, a lot more frequently used. You have a pen and paper way of figuring out drip rates, and you have a manual way of setting them. You don't have a pen and paper way to figure out what's going on with the heart.
> 
> You didn't address the weight issue, by the way. What's your answer for that?



not all infusions are weight based.

I disagree that more pumps are needed, more educaton and training on how to properly set up a drip is needed.


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## JPINFV (Jan 13, 2009)

crotchitymedic1986 said:


> No, but if your own company's internal study showed a problem, would you ignore it because it wasnt published in JEMS (P.S. I also referenced published studies in that thread, all you have to do is google keywords to find them).


JEMS is NOT a peer reviewed journal. May I suggest something like The Journal of Emergency Medicine to see what a real medical journal looks like?


> Do you have any study's that prove that it is not a problem ?  Why dont you go back and just look at your 12/08 calls at your service?  All you have to do is pull the refusals, then call the patients, and tell them as part of your service's follow-up, you wanted to check on them and make sure they are OK.


I'm willing to bet that my current company had zero refusals on 12/08/08. Besides, QAing a call after the fact isn't the same as calling someone not on scene for 'permission' to not kidnap a patient. Yes, QA "studies" don't normally get published, but they also aren't used to change policy at companies outside of the company that the "study" arose from. 


> Wouldnt take you long, and then you can come back with real statistics and refute everything I have said (but I think we know what the statistics would show).



Real statistics like that AMR "study" that no one has seen?


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## Sasha (Jan 13, 2009)

Veneficus said:


> not all infusions are weight based.
> 
> I disagree that more pumps are needed, more educaton and training on how to properly set up a drip is needed.



But a good deal of them are! One of his primary examples, dopamine, is! So, you would still be estimating, which is why he's so pro pump.


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## crotchitymedic1986 (Jan 13, 2009)

Weight:  Ask the patient, or estimate.  It is not optimal, but it is all you can do with an unconscious patient who cant get on a scale.  

So I guess your contention is that there are absolutely no safety issues with running meds off of a pump, therefore hospitals should stop using pumps and go to our method.  Are you saying if your grandma's ICU nurse was administering a Heparin drip without a pump, you wouldnt say anything ?


And to prove my point, I will give you a dopamine drip problem that you cant look up on a chart.  We will see how long it takes to get an answer, please show your math:

You need to administer dopamine to a premie baby that weighs 2.3kg.  Please calculate the rate needed to administer 21mcg/kg/min of dopamine drip that has the concentration of 3200 mg (you doubled the dose to minimize fluid intake, as the infant has other meds running). You are using a 60gtt set.


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## crotchitymedic1986 (Jan 13, 2009)

If you will kindly go to the thread, as stated previously, i posted two of many studies i found on the internet that were in medical journals.  

12/08 was referencing the month and year, not month and day.


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## Chimpie (Jan 13, 2009)

Do you have a link to your thread?


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## Sasha (Jan 13, 2009)

crotchitymedic1986 said:


> Weight:  Ask the patient, or estimate.  It is not optimal, but it is all you can do with an unconscious patient who cant get on a scale.
> 
> So I guess your contention is that there are absolutely no safety issues with running meds off of a pump, therefore hospitals should stop using pumps and go to our method.  Are you saying if your grandma's ICU nurse was administering a Heparin drip without a pump, you wouldnt say anything ?
> 
> ...




Yet your argument for pumps is that eyeballing it is an estimation! What is guessing a weight based drip rate to set a pump with, but an estimation? We are NOT the hospital, they can weigh all their patients. Have you not worked in the field? Got the "Uhhhh I don't know" answer, or an answer that is totally off from what they really do weigh? Had a patient tell you they're 200lbs as you load them onto the bariatric stretcher and struggle to get the siderails up? Or the "Uhhhhhm the last time I was weighed was at the doctor.... six years ago. "

So that would make IV pumps in the field just as useless and dangerous as eyeballing the drip rate, no? Because your dopamine drip is based off an estimation of the patient's weight.


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## crotchitymedic1986 (Jan 13, 2009)

It is the "ethical question" / refusal thread.


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## crotchitymedic1986 (Jan 13, 2009)

I am sorry I disagree.  In your example, there is no better solution, as we can not weigh an unconscious patient.  I realize that, and accept it, until stryker or ferno start putting scales on our stretchers.  And you are correct, that if you put in bad info, you will get a bad output, but the same is true for eyeballing the rate, as you are using the same weight either way.  But with a pump, your patient will not be accidentally overdosed because someone left the clamp wide open (ever hear of an EMS induced Lidocaine seizure), or will not get a 1000ccs of fluid when you meant to only bolus 250ccs, but again forgot the clamp.   Most of today's pumps can calculate the drip rates for you, insuring you do not make a math error, and over or underdose your patient.  

Very few medics have needle sticks or have caught hepatitis or HIV from their patients, but we use PPE, safety needles, and sharps containers to prevent those few occurences.  You probably have a fairly low chance of crashing your ambulance today, but you always strap the patient down just in case.   You probably have an intersection in town that is dangerous enough to make you slow down at the green light when driving L&S.  I am willing to bet you probably dont have any employee that has been hit by a car, but i bet you wear something reflective when on the highway at night.  This is no different.


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## crotchitymedic1986 (Jan 13, 2009)

No one has solved my Dopamine drip problem yet ?


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## crotchitymedic1986 (Jan 13, 2009)

My posts are not coming through for some reason.  Most of the things we do in the name of employee or patient safety are to prevent events that rarely happen, but are catastrophic when they do occur.  

No one has answered the dopamine drip calculation question I posted.


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## Veneficus (Jan 13, 2009)

crotchitymedic1986 said:


> You need to administer dopamine to a premie baby that weighs 2.3kg.  Please calculate the rate needed to administer 21mcg/kg/min of dopamine drip that has the concentration of 3200 mg (you doubled the dose to minimize fluid intake, as the infant has other meds running). You are using a 60gtt set.



21ug/kg/min on a medication with a maximum recommended dose of 20ug/kg/min makes me nervous. Time to step up to something a bit stronger possibly even ECMO in the NICU while you sort out whatever issue is causing you to have a neonate on multiple meds, including high dose pressors, and restricting fluid. I cannot imagine what EMS system would be running multiple meds on this patent out of an emergency truck and not IFT. (Which would mean all you are really doing is playing with the interventions already started in most cases)

Since 400mg of dopamine in a 250 bag of D5W is 1600ug/ml I would think that you mean 3200ug not 3200mg. Otherwise depending if you are using the adult or pediatric concentration of 75mg in 250 of a 40mg/ml solution, you are between 8-10x the normal concentration in the bag, not 2x. 

But using the formula drops/min= volume x gtts/ml x desired dose/ volume on hand.

Adult: 250ml x 60gtts/ml x 48ug (2.3 kilo x 21ug/min) / 3200ug/ml = 225 drops/min

Why not step up to a 10 gtts?

250ml x 10gtts/ml x 48ug /3200ug/ml = 37.5gtts, 1 about every 2 minutes.

At the pediatric concentration: 75mg of 40mg/ml in 250ml you have: (1) 60gtts/ml/kg solution/minute = 5 ug/kg/min. 1 drop =5ug then 4 drops = 20. So 4 drops/min with double the concentration (4/2) and you get 2 drops/min.

Who needs a pump for 1 drop every 30 seconds?


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## Veneficus (Jan 13, 2009)

crotchitymedic1986 said:


> I am sorry I disagree.  In your example, there is no better solution, as we can not weigh an unconscious patient.  I realize that, and accept it, until stryker or ferno start putting scales on our stretchers.  And you are correct, that if you put in bad info, you will get a bad output, but the same is true for eyeballing the rate, as you are using the same weight either way.  But with a pump, your patient will not be accidentally overdosed because someone left the clamp wide open (ever hear of an EMS induced Lidocaine seizure), or will not get a 1000ccs of fluid when you meant to only bolus 250ccs, but again forgot the clamp.   Most of today's pumps can calculate the drip rates for you, insuring you do not make a math error, and over or underdose your patient.



Not trying to be a jerk, but it doesn't stop you from typing in 3200mg instead of 3200ug. At one hospital I work at we did an experiment with the preprogrammed dopamine drip on a pump and found it to be only accurate to the nearest whole number.


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## crotchitymedic1986 (Jan 13, 2009)

no i meant a concentration of 3200 mg of dopamine. And the point is to show the ability to calculate the drip correctly, which an IV pump can do every time.


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## Veneficus (Jan 13, 2009)

crotchitymedic1986 said:


> no i meant a concentration of 3200 mg of dopamine. And the point is to show the ability to calculate the drip correctly, which an IV pump can do every time.



why would you put 8 or 10 times the concentration of a med in an IV bag and not switch to a more effective med?


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## Veneficus (Jan 13, 2009)

crotchitymedic1986 said:


> no i meant a concentration of 3200 mg of dopamine. And the point is to show the ability to calculate the drip correctly, which an IV pump can do every time.



250ml x 60gtts/ml x .048 (ug converted to mg) / 3200mg = .225 drops min.

I would like to see the manufacturer specs for a pump that could do that. I seriously doubt it is that accurate.

I also want a cookie and a gold star for my work on this.


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## crotchitymedic1986 (Jan 13, 2009)

You do get a cookie and a gold star. Good job


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## crotchitymedic1986 (Jan 13, 2009)

Since I brought it up, if you have forgotten how to do a dopamine drip calculation, the easiest way to get a dead-accurate calculation is to multiply everything togther and then divide by the concentration:

So if you want to administer 10mcgs to a 100kg pt, and you have an 800mcg concentration:

  10 x 100 x 60 / 800 = 75gtts


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## Jon (Jan 13, 2009)

That is great... except for the math-challenged providers.

I can do that - but many of my partners look at me as if I'm crazy when I ask them to double check my numbers. That's why I write everything out when I do drip rates.


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## traumateam1 (Jan 13, 2009)

Jon said:


> That is great... *except for the math-challenged providers.*
> 
> I can do that - but many of my partners look at me as if I'm crazy when I ask them to double check my numbers. That's why I write everything out when I do drip rates.



Yup... that'd be me.


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## crotchitymedic1986 (Jan 13, 2009)

I am one of those math challenged people:   you can buy a pocket calculator for $1.00 -- if you have a computer/internet on your truck, you have a free calculator.


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## Jon (Jan 13, 2009)

crotchitymedic1986 said:


> I am one of those math challenged people: you can buy a pocket calculator for $1.00 -- if you have a computer/internet on your truck, you have a free calculator.


Right. But that still doesn't let your partner check your numbers.

You started this thread talking about using a pump or dial-a-flow to prevent errors... then you propose a method that makes what you are doing more difficult for you to double-check yourself or to have your partner double-check you - do you want to take a shortcut, or do what is best for your patient?


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## JPINFV (Jan 13, 2009)

crotchitymedic1986 said:


> So if you want to administer 10mcgs to a 100kg pt, and you have an 800mcg concentration:
> 
> 10 x 100 x 60 / 800 = 75gtts


-5 for not including units... dimensional analysis for the win.


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## ffemt8978 (Jan 13, 2009)

crotchitymedic1986 said:


> My posts are not coming through for some reason.  Most of the things we do in the name of employee or patient safety are to prevent events that rarely happen, but are catastrophic when they do occur.
> 
> No one has answered the dopamine drip calculation question I posted.



You may want to check out this thread that explains why...
http://www.emtlife.com/showthread.php?t=10598


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## crotchitymedic1986 (Jan 13, 2009)

two separate issues Jon. 

1.  Whether you have a pump or not, you need to be able to calculate the drip rate.  And as you mentioned, you then need to double check it.  My method does not stop you from looking at your field guide or preprinted dosage chart.  If you prefer your partner to doublecheck, they can calculate with their method and you can compare.  But my method gives you the exact dosage, not a guestimation.

2.  Once you have calculated that drip, it then needs to go on a pump to insure the patient gets that dosage.  

Again, there is a reason why hospitals use pumps, and that is a much more controlled environment.  If not using a pump was a safe alternative, hospitals wouldnt waste money on the pumps.


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## remote_medic (Jan 13, 2009)

wow, go to work for a 24 hour shift and look what happens...


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## marineman (Jan 13, 2009)

Back to the talk a few pages ago here's a cot we're trialing. Power cot that has a display of pt's weight in kg

http://www.monstermedic.com/Products/Powermed-X.aspx


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## tydek07 (Jan 16, 2009)

We carry pumps for long-distance transfers... we do not use them for lidocaine or dopamine drips and such for short distance transport to the ER. I see nothing wrong with using you noggin' and getting the correct rate going by drips


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