# Moron CNA's



## ilemtbwantn2bTXEMT-P

A few months back before moving to Texas my partner and I that shift got a call for the 78y/o male pt c/o bleeding from the urethra. On arrival the only the thing the CNA said to me when I asked whats goin on was "Don't worry he's fine now, we gave him a shower and put a diaper on him". My partner and I looked at the floor to see a growing puddle of  blood, by the time we got him to the ER a 5min drive with or without Lights/Siren he was getn shocky B/P was 100/70. We worked for a Private then that even for a bleeder wouldn't ok us to go Lights/Sirens for really anything so it took us about 30 mins to even to get on the scene from the time of dispatch.


----------



## Sasha

So what else besides a low BP (Which suprisingly isn't that low and would be considered normal for a good number of patients) had the patient going "shocky"?


----------



## CAOX3

Ok, care to give us a little more information, because the presence alone doesn't mean someones dying,  it could be a simple UTI, kidney infection or many other things. Was it traumatic, any abdominal or back pain?  I'm not overtly concerned with the pressure alone, what was his mental status like, how was his color, heart rate?  Estimate the blood loss , was it gross red blood.

And why was the CNA a moron?  Was this a nursing home, assisted living, residence?  If this patient was indeed sick, which has yet to be determined why the hell can't you make a transport priority determination.


You can't throw out a vital sign which in many cases can be completely normal, call everybody a moron, claim the guys dying with out giving us a little more info.


----------



## Veneficus

*Don't get so excited*



ilemtbwantn2bTXEMT-P said:


> A few months back before moving to Texas my partner and I that shift got a call for the 78y/o male pt c/o bleeding from the urethra. On arrival the only the thing the CNA said to me when I asked whats goin on was "Don't worry he's fine now, we gave him a shower and put a diaper on him". My partner and I looked at the floor to see a growing puddle of  blood, by the time we got him to the ER a 5min drive with or without Lights/Siren he was getn shocky B/P was 100/70. We worked for a Private then that even for a bleeder wouldn't ok us to go Lights/Sirens for really anything so it took us about 30 mins to even to get on the scene from the time of dispatch.



You sound a bit overenthusiastic. Contrary to what is taught in class, not everything is an emergency.

I am not a CNA nor a moron, and I don't find anything terribly wrong.

The most common cause of painless urethral bleeding is cancer. Not exactly an emergency. 

If it was a traumatic injury, it would be more urgent, but still probably not worthy of lights and sirens. 

There was a medical issue and the facility cleaned him up and made arrangements for him to go to another facility 5 minutes away. Why is that a problem? If he was dying, I am sure it would have warrented a 911 call.

"a lot" of blood is a relative term. What you consider a lot and what I do are likely very different.

It's not interesting to me unless 45% of the patients blood volume is lost before therapy, and not exciting until the total blood volume has been replaced at least once during.

I like _sick_ people. 

But if there wasn't a urologist on staff, he likely would have sat in the ED on fluids and maybe even a unit of blood or two for another hour or so until they could get one or transfer him to one.


----------



## ilemtbwantn2bTXEMT-P

Ok fair enough more information on the run. Mental Status changed rapidly en route to the ER he was alert however we couldn't detrmine orientation due to a language barrier patient was pale and his pulse I remember was high. What we later found out that the facility initialoly didnt want to admit to us was that the pt had yanked out his catheter and then a CNA tried to solve the problem by attempting to put in a new one the blood was bright red. I'm not sure exactly what the CNA hit, but something wasn't right at all, because it was a steady stream of blood. By the time we arrived at the ER the pt only would slightly respond when moved and it was getn hard to have him stay awake. His B/P on the Monitor at the ER when they hooked him up was 90 systolic I can't remeber the dystolic though.


----------



## clibb

ilemtbwantn2bTXEMT-P said:


> Ok fair enough more information on the run. Mental Status changed rapidly en route to the ER he was alert however we couldn't detrmine orientation due to a language barrier patient was pale and his pulse I remember was high. What we later found out that the facility initialoly didnt want to admit to us was that the pt had yanked out his catheter and then a CNA tried to solve the problem by attempting to put in a new one the blood was bright red. I'm not sure exactly what the CNA hit, but something wasn't right at all, because it was a steady stream of blood. By the time we arrived at the ER the pt only would slightly respond when moved and it was getn hard to have him stay awake. His B/P on the Monitor at the ER when they hooked him up was 90 systolic I can't remeber the dystolic though.



He yanked out his catheter? It was probably THEN the damage was made, not when the CNA (which I highly doubt) tried to put it back in. How did you transport him? This is a patient we would had called a full trauma on, which all GI bleeds are due to our protocols. We would had gone code 3 and we're a 911 company.
Did you ask the CNA how much blood he had lost? How long ago he yanked the tube? Is this his norm? They should be able to tell you how alert he is since they take care of him every day.
These are questions that you learn to ask in EMT class, not CNA class. EMT is pre hospital, CNA is the first stage of hospital care.


----------



## Veneficus

clibb said:


> He yanked out his catheter? It was probably THEN the damage was made, not when the CNA (which I highly doubt) tried to put it back in. How did you transport him? This is a patient we would had called a full trauma on, which all GI bleeds are due to our protocols. We would had gone code 3 and we're a 911 company.
> Did you ask the CNA how much blood he had lost? How long ago he yanked the tube? Is this his norm? They should be able to tell you how alert he is since they take care of him every day.
> These are questions that you learn to ask in EMT class, not CNA class. EMT is pre hospital, CNA is the first stage of hospital care.



I agree the damage was probably caused when the guy yanked his catheter. 

Having said that, there is the possibility that some damage was caused or aggrivated on the recatheterization. 

Either way of no consequence.

People in their right mind also don't pull foley catheters out. Tugging on them is sort of discomforting.

While transecting a urethra is medical emergency, what are all the fancy lights, sirens, and ALS planning on doing for that? Without an invasive intervention they are not authorized to do, they can't even stop the bleeding.

The use of lights and sirens is more of a danger than it is worth.



life and death...


----------



## clibb

Veneficus said:


> I agree the damage was probably caused when the guy yanked his catheter.
> 
> Having said that, there is the possibility that some damage was caused or aggrivated on the recatheterization.
> 
> Either way of no consequence.
> 
> People in their right mind also don't pull foley catheters out. Tugging on them is sort of discomforting.
> 
> While transecting a urethra is medical emergency, what are all the fancy lights, sirens, and ALS planning on doing for that? Without an invasive intervention they are not authorized to do, they can't even stop the bleeding.
> 
> The use of lights and sirens is more of a danger than it is worth.
> 
> 
> 
> life and death...



Veneficus,

All GI bleeds WITH excessive bleeding (Paramedic's decision) we have to transport Code 3 with ALS intervention and treated as a trauma patient. So heated blankets, soft cot, warm fluids, etc. That's just our protocols. But, I do agree with you when it comes to your opinion on lights and sirens.


----------



## Veneficus

clibb said:


> Veneficus,
> 
> All GI bleeds WITH excessive bleeding (Paramedic's decision) we have to transport Code 3 with ALS intervention and treated as a trauma patient. So heated blankets, soft cot, warm fluids, etc. That's just our protocols. But, I do agree with you when it comes to your opinion on lights and sirens.



You are of the mind that adding fluid to this injury is a good idea?


----------



## clibb

Veneficus said:


> You are of the mind that adding fluid to this injury is a good idea?



Oh yeah, of course it is.


----------



## Veneficus

clibb said:


> Oh yeah, of course it is.



What is the goal of that fluid?


----------



## Sasha

Veneficus said:


> What is the goal of that fluid?



Make koolaid.


----------



## HotelCo

Sasha said:


> Make koolaid.



The question is: what flavor?


----------



## Veneficus

In addition to adding fluid and pressure to an uncontrolled bleed, crystaloid may increase GFR, which initially can help with renal medulary perfusion, but at some point, you could have so much loss that while pressure may be maintained, you will not be perfusing the renal medula,(one of the more sensitive tissues to the initial injury of hypoperfusion) or any other organ for that matter.

Be mindful of correlating SBP with perfusion. It is a complicated relationship that doesn't always correlate.


----------



## Sasha

HotelCo said:


> The question is: what flavor?



Red.


----------



## Tommerag

Like Vene said, pumping the patient full of fluid can keep the blood pressure higher and in the normal range, but remember NS, LR etc doesn't carry O2 there for poor perfusion. In class we were taught that keeping the pressure lower like 80 systolic is better then keeping it at 100 for internal bleeding. Don't bleed out as fast then.


----------



## mycrofft

*Urethral bleed is not a GI bleed.*

Also, bloody urine can seem to be a much larger volume of undiluted blood. During the thirty minutes to get to the scene, the pt was in a medical setting and directly or indirectly under a MD's care. The distance from scene to hospital was negligible.
This is not to say that there may be other incidents where lights and siren were denied despite indications, but in this one as described, nope.
Been there, done that.:blush:


----------



## EMS49393

Sasha said:


> Red.



Depends on the medic, it could be pink by the time they reach the ER.


----------



## abckidsmom

mycrofft said:


> Also, bloody urine can seem to be a much larger volume of undiluted blood. During the thirty minutes to get to the scene, the pt was in a medical setting and directly or indirectly under a MD's care. The distance from scene to hospital was negligible.
> This is not to say that there may be other incidents where lights and siren were denied despite indications, but in this one as described, nope.
> Been there, done that.:blush:



That's what I was going to say...this is not a GI bleed, and it's important to note that, if for no other reason than not looking like a moron when you're justifying the traffic accident to the officer.

5 minute transport?  Sounds like you'll be there in 5 minutes.  Ever notice how much time you save with lights and sirens?  Not much, usually.


----------



## Sasha

EMS49393 said:


> Depends on the medic, it could be pink by the time they reach the ER.



I didn't know there was pink flavored koolaid.


----------



## abckidsmom

Sasha said:


> I didn't know there was pink flavored koolaid.



Yeah, sure...it smells like lemonade.


----------



## ilemtbwantn2bTXEMT-P

clibb said:


> He yanked out his catheter? It was probably THEN the damage was made, not when the CNA (which I highly doubt) tried to put it back in. How did you transport him? This is a patient we would had called a full trauma on, which all GI bleeds are due to our protocols. We would had gone code 3 and we're a 911 company.
> Did you ask the CNA how much blood he had lost? How long ago he yanked the tube? Is this his norm? They should be able to tell you how alert he is since they take care of him every day.
> These are questions that you learn to ask in EMT class, not CNA class. EMT is pre hospital, CNA is the first stage of hospital care.



According to the staff he had been bleeding for about an hour when they called but they had no idea how long before that. There was no way to truly assess his Mental Status other than AVPU or LOC, he only spoke Russian, so ALS wouldn't have really been able to do much more for the guy then we did. The CNA's and Nursing staff had no clue abotu his Mental Status or anything when we asked them, and its safe to note too on arrival at the ER when they asked where he came from and we told them the Doctor just shook his head, and told us later his thoughts on the place, which were far from positive.


----------



## Veneficus

ilemtbwantn2bTXEMT-P said:


> According to the staff he had been bleeding for about an hour when they called but they had no idea how long before that. There was no way to truly assess his Mental Status other than AVPU or LOC, he only spoke Russian, so ALS wouldn't have really been able to do much more for the guy then we did. The CNA's and Nursing staff had no clue abotu his Mental Status or anything when we asked them, and its safe to note too on arrival at the ER when they asked where he came from and we told them the Doctor just shook his head, and told us later his thoughts on the place, which were far from positive.



Welcome to EMS.


----------



## WTEngel

Quite possibly the most unprofessional and poorly written rant I have seen in a while. 

Please don't bring your poor attitude to my state.


----------



## Frozennoodle

Veneficus said:


> You are of the mind that adding fluid to this injury is a good idea?



If I truly suspected shock I'd pop an 18 in him and hang NS TKO and monitor pressure en route titrating to 80-90 systolic if it dropped below 80.  I'd start a second 18 in the other arm and apply a saline lock.  Blankets for warmth and loose dressings to sop up the blood w/o direct pressure.  That's if I even had time to do half of that in the 5 minutes it takes to go around the block to the hospital.


----------



## defib

*wow!*

Interesting post. Im thinking an IV would be good preferably 16g with a small bolus 250-500. But the big thing would be oxygen which is a bls skill. The iv size is more for the facility if he needs blood or surgery. A second one would not be a bad idea. Maybe check his blood sugar as well since nobody in a " normal " state would pull out a foley.


----------



## Veneficus

defib said:


> Interesting post. Im thinking an IV would be good preferably 16g with a small bolus 250-500. But the big thing would be oxygen which is a bls skill. The iv size is more for the facility if he needs blood or surgery. A second one would not be a bad idea. Maybe check his blood sugar as well since nobody in a " normal " state would pull out a foley.



a 16G in a 78 y/o? 

That seems excessive to me.


----------



## defib

If you can get it why not? What is the goal of this. The person was stating the patient was in shock. By the limited information we have to assume this is the cause of his problems. And the ability to give rapid boluses of fluid is determined by catheter size and length, and tubing size and length. At least I wasnt activating a trauma alert. ( kind of redundant where im at! lol) 
The difference in pain is negligible. If you can't get a line would you put an IO in him? Depending on my pt's presentation maybe. But given the info ( poss hypotensive pt with possible altered mental status and tachycardia. What are your options? Aggressive Tx or passive.

Not trying to start a war, I'm new here. But I believe in good dialogue and exchange of ideas.


----------



## Veneficus

defib said:


> If you can get it why not? What is the goal of this. The person was stating the patient was in shock. By the limited information we have to assume this is the cause of his problems. And the ability to give rapid boluses of fluid is determined by catheter size and length, and tubing size and length. At least I wasnt activating a trauma alert. ( kind of redundant where im at! lol)
> The difference in pain is negligible. If you can't get a line would you put an IO in him? Depending on my pt's presentation maybe. But given the info ( poss hypotensive pt with possible altered mental status and tachycardia. What are your options? Aggressive Tx or passive.
> 
> Not trying to start a war, I'm new here. But I believe in good dialogue and exchange of ideas.



It is not about the pain.

Most 78 year olds are not 16g material. Which means you may not get the first stick and you may wind up with nothing.

Then you are escalating, when more conservatgive treatment would possibly have succeeded. 

You perform medical treatments that are indicated, not because you can. If a 20g works, why use a 16g? A central line works, why not that?

It is overkill.

It is not a question of passive or aggresive. It should be indicated, accurate, and as precise as possible.

"Don't use a cannon to kill a mosquito."


----------



## iftmedic

This is a pointless thread


----------



## Sasha

I'm still not convinced it was shock. he pulled out his cath, so usually that means one of two things, he's just a grumpy old man who likes to pull at things, or he is normally AMS. 

What time was this call? I have had a ton of patients who are normally wakeful and alert but are very somnolent for me. But then we are there at midnight, so it's to be expected.

What is his blood pressure normally? A ten point difference isn't really that big of deal considering or rather assuming your first BP was manual, and this one was a machine. 

I wouldn't go with the large gauges. That's unnecessary. Even if he ended up getting a transfusion, they can push it through smaller than that. Instead of "If you can get it, why not?" let's stop thinking in terms of frivilous treatments and think more in terms of "Why do I need it?" A 16ga is going to be more traumatic than an 18 or 20 and you're probably going to end up blowing the only one or two good veins you've got for a line.

If you want to go along with "This is shock!!!!" then why spill blood you don't need to spill by poking a hole with an IV that's too big and blowing it? You're just making the situation worse. Go with the smallest effective appropriate gauge.

He doesn't need fluids. Why? So you can dilute the fluid he has, increase BP when the pressure will make him bleed faster?


----------



## Sasha

iftmedic said:


> This is a pointless thread



Then don't comment on it?


----------



## MrBrown

Brown thinks this "moron" of a nurse has more intelligence than you mate seriously.  She is right, some old bloke who pulled out his catheter is not going to be status 1 in need of an RSI qualified Intensive Care Paramedic.

They called you for a ride to the hospital, not your medical opinion.

Now you have not defined what a "large" amount of blood is, remember that every layperson knows head wounds bleed "a lot" but anybody with some anatomical knowledge knows that is not because they have torn a major artery but because of the large capillary innervation of the scalp.

A "large" puddle of blood may only be a few mL but widely distributed in area rather than volume.  This old bloke is going to have less physiologic reserve than somebody like Brown who is young and healthy so you are kinda partially correct in that if this guy was pissing blood everywhere its going to be more of a concern than in somebody who is younger.

You obviously failed to keep up with the concept that blood pressure is a poor indicator of the degree of perfusion inadequacy.  Did you not learn that in the compensated to early decompensatory stages of hypovolaemic shock the patient may be normotensive.  Did you ask about his urine output? How long had he been having this big bad serious bleed? 

Brown is shocked you did not call for a helicopter and tell the HEMS Doctor what a big serious emergency was so he or she could pull some gelofusine out of the Thomas Pack, pop on a CAT and airlift him back to the major trauma centre for immediate definitive surgery.

Yes, Brown is taking the piss because don't look now bro but you 100 hour wonder ambo course is showing, 



defib said:


> But the big thing would be oxygen which is a bls skill. The iv size is more for the facility if he needs blood or surgery.



Why is oxygen the most important thing?

Do you think any anaesthetist is going to use your crappy prehospital line to give blood products?  

You and the bloke who posted this would be good working together


----------



## Veneficus

MrBrown said:


> Do you think any anaesthetist is going to use your crappy prehospital line to give blood products?


 

In fairness, actually they do. :unsure:


----------



## Frozennoodle

Veneficus said:


> In fairness, actually they do. :unsure:



I love you two.  XD


----------



## MrBrown

Veneficus said:


> In fairness, actually they do. :unsure:



Some here might .... but if this bloke was that crook they'd put in a central line



Frozennoodle said:


> I love you two.  XD



Brown loves you too mate but remember you have to compete with Mrs Brown, however many daughters the Brown's end up having, Brown's home made burritos and guac and sleep.

Um, .... how much did you love Brown again?


----------



## usalsfyre

MrBrown said:


> Some here might .... but if this bloke was that crook they'd put in a central line


Most here would too, but I've seen my crappy prehospital linesh34r: used to infuse blood while the IJ is set up(or femoral if the ED doc is doing it, which raises the question, why does EM seemingly ONLY do femorals?) many times.


----------



## mycrofft

*We done putting the boots to the OP?*

Metacommunicatonally speaking, (i.e., off thread) folks using handheld devices tend to exhibit parapgraph and punctuational deficits. Versus us longwinded sitdown keyboarders..:blush:

I consider this to be a ventilation session, and note that the OP hasn't gotten into post/reply fights with the repliers.


----------



## Frozennoodle

MrBrown said:


> Some here might .... but if this bloke was that crook they'd put in a central line
> 
> 
> 
> Brown loves you too mate but remember you have to compete with Mrs Brown, however many daughters the Brown's end up having, Brown's home made burritos and guac and sleep.
> 
> Um, .... how much did you love Brown again?



Depends on how many burritos you're making ;p


----------



## Veneficus

usalsfyre said:


> (or femoral if the ED doc is doing it, which raises the question, why does EM seemingly ONLY do femorals?) many times.



safety


----------



## usalsfyre

Veneficus said:


> safety


Even with US guidance being the standard now?


----------



## Veneficus

usalsfyre said:


> Even with US guidance being the standard now?



It is not standard. 

And in a moment of pride I would like to say that my manual skills are consistantly better than those using ultrasound.

But when you look at the complications of an IJ or subclavian should something go amiss, compared to the femoral, it really is no comparison at all.


----------



## VFlutter

MrBrown said:


> Yes, Brown is taking the piss because don't look now bro but you 100 hour wonder ambo course is showing



A CNA program is only 5 weeks (100ish hrs) as well


----------



## usalsfyre

ChaseZ33 said:


> A CNA program is only 5 weeks (100ish hrs) as well



5x40 hours is 200 hours. Meaning their education is nearly double that of the EMTs that often disdain them. Not to mention they have far less autonomy.

(Holy crap that sounded Ventmedicish :blink: :wacko


----------



## Frozennoodle

usalsfyre said:


> 5x40 hours is 200 hours. Meaning their education is nearly double that of the EMTs that often disdain them. Not to mention they have far less autonomy.
> 
> (Holy crap that sounded Ventmedicish :blink: :wacko



They don't get trained in emergency medical care. They have BLS CPR but their focus is on longterm rehabilitation and care.  It's apples and oranges.


----------



## Sasha

It doesn't matter. OP still jumped the gun and sounded pretty immature in his rant.


----------



## defib

*ahem!*

Mr.Brown before you start giving me attitude. Maybe you should think about something. You don't know me. I don't know you. You don't know where I work or who I work for. I really don't care who you work for. 

You want interactive exchange of ideas then you do not insult people new to a site. If I have to explaine to you the necessity of oxygen in a possible altered patient then maybe you need a refresher course. 

I came here looking for intellectual and interesting conversation. If all I get is grief and insulted then I shall bid good day to everyone here. Have a nice life!


----------



## Aidey

He wasn't insulting someone new to the site, he was questioning someone who appeared to be regurgitating debunked, out-of-date information. 

You said "oxygen would be the big thing" without any explanation of why you believed that to be true. Exchanging ideas means that you're going to have to defend those ideas.


----------



## Sasha

defib said:


> Mr.Brown before you start giving me attitude. Maybe you should think about something. You don't know me. I don't know you. You don't know where I work or who I work for. I really don't care who you work for.
> 
> You want interactive exchange of ideas then you do not insult people new to a site. If I have to explaine to you the necessity of oxygen in a possible altered patient then maybe you need a refresher course.
> 
> I came here looking for intellectual and interesting conversation. If all I get is grief and insulted then I shall bid good day to everyone here. Have a nice life!



He wasn't giving you attitude. Sorry, if you're looking to be spoon fed and coddled, this isn't the place. We have no problem telling you if you're wrong, and even so this is still the nicest EMS forum out there. The other ones can get quite brutal.


----------



## Veneficus

defib said:


> If I have to explaine to you the necessity of oxygen in a possible altered patient


 

Could I impose upon you to explain it to me?


----------



## Sasha

Veneficus said:


> Could I impose upon you to explain it to me?



I can explain it! "The book says so, so it is written, so it must be done!!!!"


----------



## Tommerag

Everyone gets 15 lpm via NRB. Duh


----------



## Veneficus

Tommerag said:


> Everyone gets 15 lpm via NRB. Duh



That's great, but without seeing the thought process and rational it is very difficult to convince adult learners initial education was flawed.


----------



## MassEMT-B

In my basic class, our instructor told us for the state test everyone gets o2. He said in real life, your company may want you to (more money for them) but it is not indicated for everyone and should not be given to everyone. Maybe I had a good basic class.


----------



## 18G

I personally would not have been real excited over this patient and screaming "shock" based on the info presented so far. 

As far as the blood pressure I always try to ascertain a baseline and look at the medications the patient is taking to determine if there is an acute change in BP and if so to what degree. 

A B/P of 100/70 is on the low end for most people and would be cause to increase your awareness of the patients perfusion status but in and of itself it isn't gonna make me get excited. 

One important point about assessing blood pressure is don't just look at the systolic value. In a patient experiencing a compensatory response with arterial vasoconstriction your gonna see an increase in the diastolic value and have a narrowing of the pulse pressure (difference between systolic and diastolic) which occurs pretty early on. 100/70 is low but the pulse pressure is ok and doesn't indicate the arterial side is constricting to maintain perfusion. This isn't always absolute but is something to assess always. 

A pressure of 114/96 (pulse pressure of 18) would be concerning to me in a bleeding patient. It appears to be a decent pressure but in the grand scheme of things its saying something else. 

To the OP... it sounds like you jumped the gun by a long shot. Calm down, ASSESS your patient, and understand that L&S rarely ever saves an amount of time that makes any difference in patient outcome. 

Nursing homes are a unique little playground. Learn the dynamics of the nursing homes you go to frequently and be assertive in getting the staff to get you the information you need to establish your patient's baseline. If your not assertive, 9 out of 10 times your not gonna get it just by asking the CNA or nurse in the room when you get there.


----------



## Sasha

Assertiveness doesn't change the "I don't know, this is my first night with this patient"


----------



## 18G

Sasha said:


> Assertiveness doesn't change the "I don't know, this is my first night with this patient"



Sure it does. 

Being assertive means that the CNA or nurse in the room goes and finds the charge nurse or goes to the nurses station and copies the information from the chart and brings it to me.


----------



## Sasha

18G said:


> Sure it does.
> 
> Being assertive means that the CNA or nurse in the room goes and finds the charge nurse or goes to the nurses station and copies the information from the chart and brings it to me.




Or you can get off your butt and go get the chart yourself. Which may or may not be accurate. According to charts half my white patients are black. 

You think the charge knows the patients? Hahahahaha.


----------



## Aidey

If I attempted to get a chart myself they would be on the phone with my supervisor faster than I could spell the patient's name. I have never seen a place that had the charts in an open area where anyone could walk up and grab one. If it is sitting on the tabel in the room, sure I might snag it, but I'm not going to go to the nurse's station and start pawing through stuff.


----------



## 18G

Sasha said:


> Or you can get off your butt and go get the chart yourself. Which may or may not be accurate. According to charts half my white patients are black.
> 
> You think the charge knows the patients? Hahahahaha.



When I'm assessing and treating my patient it's not my job to "get off my butt" to go get the chart. For one, I am not "on my butt" since I am actively doing my job and trying to put the pieces of the puzzle together to figure out what is wrong with the patient. And I don't make it a habit of leaving my patient once they are under my care. 

After almost 20yrs of experience in dealing with nursing homes on a regular basis, the charge nurse does know how to get the information I need from the chart. You just have to clue them in on the importance and they get it.


----------



## rhan101277

Sasha said:


> Assertiveness doesn't change the "I don't know, this is my first night with this patient"



I get this alot as well.


----------



## Sasha

We just walk up and grab our chart. Never had a problem.

I also trust my partner enough to get my vitals while im going through paperwork and chart.





Aidey said:


> If I attempted to get a chart myself they would be on the phone with my supervisor faster than I could spell the patient's name. I have never seen a place that had the charts in an open area where anyone could walk up and grab one. If it is sitting on the tabel in the room, sure I might snag it, but I'm not going to go to the nurse's station and start pawing through stuff.


----------



## johnrsemt

I usually didn't just walk up and 'grab' the chart;  but if they didn't have paperwork ready for us I would offer to take the chart to the office and copy what we needed out of it while my partner would talk to the patient and the nurse/CNA.   Surprising how much more help you get , and how much better you are treated when you offer to help:  copy the chart, etc.

   Other things we would do when we had down time would be go to the ECF's and offer to help them:  take water pitchers with ice to patients at night; days, stop and say hi to all the patients.  I had a partner who liked to play the piano:  get lots of surprised looks from the staff;  but when we came back for transports they would do everything they could to help us.        
    Another thing that we did was make a list of paperwork that we needed for each transport:  either doc appts, dialysis or ED runs; and gave it to all the ECF's.  That way they had exactly what we needed ready when we got there.


----------



## clibb

Veneficus said:


> That's great, but without seeing the thought process and rational it is very difficult to convince adult learners initial education was flawed.



I give them 15 lpm via nasal cannula.


----------



## Sasha

clibb said:


> I give them 15 lpm via nasal cannula.





Uhm..... wow!


----------



## usalsfyre

clibb said:


> I give them 15 lpm via nasal cannula.


You know, because of the number of hospice calls my service does I've actually learned there are NCs that are designed to do this...


----------



## Sasha

usalsfyre said:


> You know, because of the number of hospice calls my service does I've actually learned there are NCs that are designed to do this...




Yeah but not your run of the mill cannula and its humidified which i have never seen.pregospitally.


----------



## usalsfyre

Sasha said:


> Yeah but not your run of the mill cannula and its humidified which i have never seen.pregospitally.



Yep, it would be, _poor form_ to do this with a normal NC to say the least.


----------



## Sasha

usalsfyre said:


> Yep, it would be, _poor form_ to do this with a normal NC to say the least.




I dont think a normal cannula would tolerate it. When we tried to push 10lpm through a 6lpm percent lock it popped off the o2 tree im sure the same would happen exceedingthe flow rate for a cannula


----------



## Meursault

Sasha said:


> I dont think a normal cannula would tolerate it. When we tried to push 10lpm through a 6lpm percent lock it popped off the o2 tree im sure the same would happen exceedingthe flow rate for a cannula



I may have... witnessed someone accidentally turn the regulator on a D tank to 20 LPM with a nasal cannula attached and on the patient. It didn't pop off in the short time between bumping the regulator dial and noticing the unexpectedly loud hissing sound. The patient found it uncomfortable, but she had other things on her mind.

I'm not entirely sure why our portable regulators even go to 25 LPM, as most of them on the BLS trucks don't have the attachments for CPAP.

There's also an interesting article I first saw here about using 15 LPM via NC during intubation to passively oxygenate the patient.


----------



## Sandog

I think the moral of this story is to show professional courtesy. It is just impolite to call a fellow health care worker a moron. Karma has a strange way of reflecting your actions.


----------



## jrm818

MrConspiracy said:


> I may have... witnessed someone accidentally turn the regulator on a D tank to 20 LPM with a nasal cannula attached and on the patient. It didn't pop off in the short time between bumping the regulator dial and noticing the unexpectedly loud hissing sound. The patient found it uncomfortable, but she had other things on her mind.
> 
> I'm not entirely sure why our portable regulators even go to 25 LPM, as most of them on the BLS trucks don't have the attachments for CPAP.
> 
> There's also an interesting article I first saw here about using 15 LPM via NC during intubation to passively oxygenate the patient.



I assume you're referring to the "Levitan NO DESAT" method found here?

http://www.epmonthly.com/features/current-features/no-desat-/

The article advises using combined 15LPM NRB and 15+LPM NC oxygen administration for preoxygenation and continuing the NC administration throughout intubation.  It even suggests that the combined NRB NC administration may sometimes be enough to serve as a bridging therapy and avoid a tube altogether.

I had assumed that a normal nasal cannula will take a 15LPM flow, but I've never tried it.


----------



## ChorusD

So, permissive hypotension is a good thing.  However, I personally believe there should be a difference in permissive hypotension and permissive exsanguination. h34r:

Is there possibly a need for products like hetastarch in the prehospital setting?


----------



## MrBrown

Brown does not think so to be honest, there may be a role for some of these new whiz bang synthetic clotting factors or haemoglobin in the future.

Permissive hypotension really only applies in uncontrolled bleeding and most of that is probably internal, we can control external bleeding fairly well with pressure and the combat application tourniquet


----------



## Veneficus

ChorusD said:


> So, permissive hypotension is a good thing.  However, I personally believe there should be a difference in permissive hypotension and permissive exsanguination. h34r:
> 
> Is there possibly a need for products like hetastarch in the prehospital setting?



Not really. 

Several years ago I was at a trauma conference where they presented evidence that synthetic volume expanders cost more and had the same outcome.

They are demonstrated better suited to the military where it is better to carry a bunch of 250ml colloid solutions than litres of saline.

As demonstrated in the recent wars, massive transfusion is the solution to major hemorrhage. 

In terms of "permissive exsanguination" the solution is simply to stop the bleeding. 

Stands to reason pushing more water at higher pressure through a leaky hose would do what except make it leak more?

One of the major problems in hemorrhage is the lack of metabolite carrying capacity. Water doesn't do it.

Here is a brief clip on hetastarch:

Home › Drugs A to Z › H › He › Hetastarch Prescribing Information
   Print | Save or Share Hetastarch
Dosage Form: injection
Ads by Google
Helminth Therapy
www.Ovamed.org/a new IBD approach (TSO) developed by Weinstock, Summers and Elliott!

Smoking cessation drugs
www.healthline.comTips on how to stop smoking. Free tips to help you quit!

98% Thyroid Disease Cured
www.greenlife-herbal.com100% Natural Herbs, with TGA, GMP, SGS. Thousands of recovery cases!

6% Hetastarch
In 0.9% Sodium Chloride Injection Hetastarch Description
6% Hetastarch in 0.9% Sodium Chloride Injection (Hetastarch Injection) is a sterile, nonpyrogenic solution for intravenous administration.

The composition of each 100 mL is as follows:

Hetastarch 6 g 
Sodium Chloride, USP 0.9 g 
Water for Injection, USP qs 
pH adjusted with Sodium Hydroxide, NF if necessary 
Concentration of Electrolytes (mEq/L): Sodium 154, Chloride 154 
pH: approximately 5.5 with negligible buffering capacity 
Calculated Osmolarity: approximately 309 m0sM 

Hetastarch is an artificial colloid derived from a waxy starch composed almost entirely of amylopectin. Hydroxyethyl ether groups are introduced into the glucose units of the starch, and the resultant material is hydrolyzed to yield a product with a molecular weight suitable for use as a plasma volume expander and erythrocyte sedimenting agent. Hetastarch is characterized by its molar substitution and also by its molecular weight. The molar substitution is approximately 0.75 which means Hetastarch has an average of approximately 75 hydroxyethyl groups for every 100 glucose units. The weight average molecular weight is approximately 600,000 with a range of 450,000 to 800,000 and with at least 80% of the polymers falling within the range of 20,000 to 2,500,000. Hydroxyethyl groups are attached by either linkage primarily at C-2 of the glucose unit and to a lesser extent at C-3 and C-6. The polymer resembles glycogen, and the polymerized D-glucose units are joined primarily by α-1,4 linkages with occasional α-1,6 branching linkages. The degree of branching is approximately 1:20 which means that there is an average of approximately one α-1,6 branch for every 20 glucose monomer units.

The chemical name for Hetastarch is hydroxyethyl starch.

The structural formula is as follows:

Amylopectin derivative in which R2 and R3 are H or CH2CH2OH and R6 is H, CH2CH2OH, or a branching point in the starch polymer connected through an α-1,6 link to additional D-glucopyranosyl units.


Hetastarch injection is a clear, pale yellow to amber solution. Exposure to prolonged adverse storage conditions may result in a change to a turbid deep brown or the formation of a crystalline precipitate. Do not use the solution if these conditions are evident.

The flexible plastic container is fabricated from a specially formulated polyvinylchloride. Solutions in contact with the plastic container may leach out certain chemical components from the plastic in very small amounts; however, biological testing was supportive of the safety of the plastic container materials. The container solution unit is a closed system and is not dependent upon entry of external air during administration. The container is overwrapped to provide protection from the physical environment and to provide an additional moisture barrier when necessary.

The closure system has two ports; the one for the administration set has a tamper evident plastic protector.

Hetastarch - Clinical Pharmacology
The plasma volume expansion produced by Hetastarch injection approximates that of 5% Albumin (Human). Intravenous infusion of Hetastarch injection results in expansion of plasma volume that decreases over the succeeding 24 to 36 hours. The degree of plasma volume expansion and improvement in hemodynamic state depend upon the patient's intravascular status.

Hetastarch molecules below 50,000 molecular weight are rapidly eliminated by renal excretion. A single dose of approximately 500 mL of Hetastarch injection (approximately 30 g) results in elimination in the urine of approximately 33% of the dose within 24 hours. This is a variable process but generally results in an intravascular Hetastarch concentration of less than 10% of the total dose injected by two weeks. A study of the biliary excretion of Hetastarch in 10 healthy males accounted for less than 1% of the dose over a 14 day period. The hydroxyethyl group is not cleaved by the body but remains intact and attached to glucose units when excreted. Significant quantities of glucose are not produced as hydroxyethylation prevents complete metabolism of the smaller polymers.

The addition of Hetastarch to whole blood increases the erythrocyte sedimentation rate. Therefore Hetastarch injection is used to improve the efficiency of granulocyte collection by centrifugal means.

In randomized, controlled, comparative studies of Hetastarch injection (n=92) and Albumin (n=85) in surgical patients, no patient in either treatment group had a bleeding complication and no significant difference was found in the amount of blood loss between the treatment groups.1-4

Ads by Google
Helminth Therapy
a new IBD approach (TSO) developed by Weinstock, Summers and Elliott!
www.Ovamed.org/

Maintain Healthy Kidneys
Probiotic Kidney supplement to promote healthy kidney function
www.kibowbiotech.com

Smoking cessation drugs
Tips on how to stop smoking. Free tips to help you quit!
www.healthline.com
Indications and Usage for Hetastarch
Hetastarch injection is indicated in the treatment of hypovolemia when plasma volume expansion is desired. It is not a substitute for blood or plasma.

The adjunctive use of Hetastarch injection in leukapheresis has also been shown to be safe and efficacious in improving the harvesting and increasing the yield of granulocytes by centrifugal means.

Contraindications
Hetastarch injection is contraindicated in patients with known hypersensitivity to hydroxyethyl starch or with bleeding disorders or with congestive heart failure where volume overload is a potential problem. Hetastarch injection should not be used in renal disease with oliguria or anuria not related to hypovolemia.

Patients with pre-existing coagulation or bleeding disorders should not be given Hetastarch injection.

Warnings
Life-threatening anaphylactic/anaphylactoid reactions have been rarely reported with Hetastarch injection; death has occurred, but a causal relationship has not been established. Patients who develop severe anaphylactic/anaphylactoid reactions may need continued supportive care until symptoms have resolved.

Hypersensitivity reactions can occur even after Hetastarch injection has been discontinued.

"_Usage in Plasma Volume Expansion
Hetastarch injection has not been adequately evaluated to establish its safety in situations other than treatment of hypovolemia in elective surgery.

Large volumes of Hetastarch injection may transiently alter the coagulation mechanism due to hemodilution and a mild direct inhibitory action on Factor VIII. Administration of volumes of Hetastarch injection that are greater than 25% of the blood volume in less than 24 hours may cause significant hemodilution reflected by lower hematocrit and plasma protein values. Administration of packed red cells, platelets, or fresh frozen plasma should be considered if clinically indicated_"

Futhermore

"_Hematocrit may be decreased and plasma proteins diluted excessively by administration of large volumes of Hetastarch injection. Administration of packed red cells, platelets, and fresh frozen plasma should be considered if excessive dilution occurs._"

http://www.drugs.com/pro/hetastarch.html


----------



## Sasha

MrConspiracy said:


> I may have... witnessed someone accidentally turn the regulator on a D tank to 20 LPM with a nasal cannula attached and on the patient. It didn't pop off in the short time between bumping the regulator dial and noticing the unexpectedly loud hissing sound. The patient found it uncomfortable, but she had other things on her mind.
> 
> I'm not entirely sure why our portable regulators even go to 25 LPM, as most of them on the BLS trucks don't have the attachments for CPAP.
> 
> There's also an interesting article I first saw here about using 15 LPM via NC during intubation to passively oxygenate the patient.



Oh it wasn't an instant pop off. It took a few minutes, but would continually pop off until we turned the flowrate down.


----------



## ChorusD

Veneficus said:


> In terms of "permissive exsanguination" the solution is simply to stop the bleeding.
> 
> Stands to reason pushing more water at higher pressure through a leaky hose would do what except make it leak more?
> 
> One of the major problems in hemorrhage is the lack of metabolite carrying capacity. Water doesn't do it.




I think everybody can agree with that statement.  And you obviously know substantially more about products like hetastarch than I do.  But, along the lines of what Brown said, I can't help but think there can be a place for HBOC products in the future, or something like that.  Not as a definitive solution but as a better means of support until the pt's reach definitive care.


----------



## Veneficus

ChorusD said:


> I think everybody can agree with that statement.  And you obviously know substantially more about products like hetastarch than I do.  But, along the lines of what Brown said, I can't help but think there can be a place for HBOC products in the future, or something like that.  Not as a definitive solution but as a better means of support until the pt's reach definitive care.



sorry about the length of post,

copy and paste kicked my butt


----------



## ChorusD

Oh i figured you thought I need to quit smoking


----------



## Veneficus

ChorusD said:


> Oh i figured you thought I need to quit smoking



No, sorry.  Thought i copied only the part that I wanted and when I was trying to type in my comments i didn't notice the rest of the post ad I sent it off before previewing it because I was distracted.


----------

