# A Potential Problem?



## ffemt8978 (Jun 15, 2004)

I've noticed a disturbing trend among several of the EMT's that I work with.  I've already taken into consideration the different amounts of experience with those involved, and the fact that we are a volunteer department.  I was wondering if any of you have also noted these conditions:

1. RELYING TOO MUCH ON EQUIPMENT - Recent call where the EMT took a blood pressure while the patient was wearing a coat and a sweatshirt.  EMT did not question the BP of 100/70 and logged it on the paperwork as such.  (PT was CAOx4 and moving around).  When I asked the EMT about the BP, I was informed that that was the reading they had obtained.  No explanation for why they did not remove the coats or question the numbers so obviously out of norm for the patient's condition.

1A.  RELYING TOO MUCH ON EQUIPMENT (PART 2) - Recent call where the automatic BP machine in the back of the ambulance was not working.  I asked the other EMT to take a manual BP and was informed they couldn't hear it in the back of a moving ambulance.  I performed a manual BP by palpation, and later explained what I did to the other EMT.  The other EMT stated they had learned this in the class, but were told never to do it.

2. GIVING UP PATIENT CARE: Several newer EMT's immediately give up patient care as soon as a senior EMT (Higher qualification or more experience at same qualification) arrives on scene.  Newer EMT's are losing valuable experience doing this.  Personally, I try not to take patient care unless something is being done wrong.

3. MEMORIZATION WITHOUT UNDERSTANDING: Several EMT's can quote those various mnemonics, but don't truly understand what they are for.  I was asked why Last Oral Intake was important on a trauma patient, so I explained to the EMT about the requirements for surgery.

3A. MEMORIZATION WITHOUT UNDERSTANDING (PART 2): EMT's are able to recite the various parts of the human body, but don't understand how everything works together.  I know that the anatomy requirements of the EMT class have been trimmed down significantly, I just think it's a bad idea.  Patient with severe RUQ and RLQ pain...other EMT asked me why I asked pointed questions about pregnancy, gall bladder, kidney stones, ulcers, and hepatitis.


Any way, I was wondering if this is just a local problem, or if it's nationwide.  I'm done venting for now, and thanks for listening.


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## Chimpie (Jun 15, 2004)

When taking BP, I was taught to do it against bare skin, or over a thin tshirt at most.  Anything else can give you false readings.  Four years as a MFR I've stuck to my training and have had zero problems.

As a MFR for an industrial plant we (usually a group of 4 or more of us, some MFRs, some EMTs) would respond to all medical emergencies.  If two MFRs arrived on scene first and a EMT arrived third, the EMT would only take over care if it was necessary.  And just because the EMT began care of the PT (lets say applying a bandage) didn't mean that the patient was theirs.  If the EMT decided that he needed to step in he would just pat on us on the shoulder or just give us a look and the patient was his.  This worked out well for us.

Chimp


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## sunshine1026 (Jun 15, 2004)

I can't imagine being told NOT to take a BP by palpation...it is such a useful skill to have when you're in a noisy situation.  

We also have people who seem to have forgotten the skills they learned in class, such as taking a manual BP, obtaining a good history, etc. etc. etc.  I don't know if this is because they don't run a lot of calls (we have a mostly volunteer service here) and the skills just get rusty/forgotten, or if they never became proficient at them in the first place and somehow slid on through class. 

Most of the calls that we run we have ALS with us. Some of the providers are good about letting us (EMT-Bs) provide primary patient care, and others won't let go of it for love or money, even if the call can be handled on a BLS level.  I've been very lucky to have mostly the first type, and I have learned a lot because of it.


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## SafetyPro2 (Jun 15, 2004)

Our rule is that the first person at the patient is the primary provider and is in charge of patient care. Doesn't matter if its a brand new probie, so long as they're an EMT, they're in charge. In fact, when I first came on, my Captain told our crew that for the first month or so, I was to be the patient care person on all EMS calls so that I'd get familiar and comfortable with it quickly. That's not to say that everyone else is shy about making suggestions if the patient person's missing something, but they're still in charge and have the final say. 

Only difference is in a full arrest. Then, the first person will start CPR until the AED arrives (unless the first person happens to have it), and the AED person is in charge.

I agree on the over-reliance on technology. We discontinued using our automatic BP machine because it was so inaccurate and touchy. We do use a pulse oximeter on most every call, but we're not supposed to base treatment on the SPO2 reading, something a few people do occasionally do.


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## ffemt8978 (Jun 27, 2004)

Well, I've got another complaint about relying too much on technology.  :angry: 

Sick Kid Call

I mentioned in that link that we transported a 6yoF who was suffering from N/V and dehydration.  Her initial BP on scene was 100/60, which is about normal for her age.  We get her in the back or our ambulance, and one of the other EMT's hooks up the Auto BP cuff.  The initial reading was 137/91  :blink: , and the EMT tried to tell me that that was her BP.  I asked the third EMT present to get me a BP by palpation, and I was told it was 112/70 (in the back of a speeding ambulance). <_< 

I'm attending an EMT class with our EMS Captain, and I think that I'll bring this up to him and let him handle it.


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## MMiz (Jun 27, 2004)

I have two beliefs.  First, in the field, when responding to an emergency, there is no excuse for not taking a manual BP as an initial reading.  Our critical care units have the BP units on their LifePaks, but they still take it manually.

That said, I use the hospital's equipment when getting BP, PulseOx, and pulse when I'm transporting a BLS patient from the facility.  We get a baseline, then take another manual measurement when we first get into the unit w/o the engine running.  From there we get vitals every 15 minutes.

That's how I was taught, and that's how I do it.  That's how I've always seen others do it.  I've had transports longer than an hour, and I've always taken vitals every 15 minutes, per company protocols.  Do the patients sometimes get flustered, sometimes, but it's rare.  Usually they feel good knowing you are doing your job.  

If I can hear a BP in the back of an ambulance, I get one by palpation.  There have been times where I've gotten one that doesn't match up with my baseline or previous measurements, and then I'll do it over again, usually with success.

That's just me though, but I think in general that's how most of the people I've seen also operate.


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## ffemt8978 (Jun 27, 2004)

I just get the feeling that our new EMT's take every vital sign as the gospel, and don't question their mechanical equipment.

I absolutely agree 100% that a manual BP should always be done first.  I've also had patients where I wasn't able to get any vital signs at all simply because I was busy with other things.  Of course, some EMT's believe that there is absolutely no excuse for not getting a set of vitals.

Case in point.  We responded to a two-vehicle MVA with multiple ejections, so we called for a helicopter while in route.  I take over C-spine on one of the patients and we proceed to get her boarded and collared and get a rapid assessment done (admitted LOC, some chest/abdomen pain).  We get her on the cot and go to put her in the ambulance so that we can get vitals and a more complete history.  Well guess what, the helicopter arrived at this time.  I was later approached about why I had not obtained any vital signs on scene (approximately 10 minute on scene time before helicopter arrived).


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## rescuecpt (Jun 28, 2004)

My biggest gripe is EMTs who look at the pulse rate and BP on the ALS monitor and use that for the paperwork.  A. they are technically not trained to use that and B. the pulse on the monitor and the peripheral pulses may be different due to poor perfusion - chances are if someone is hooked up to the monitor they are having problems which might cause that.

At my FD I am an officer, so usually I don't touch the patient, I just direct patient care - I am the overseer who makes sure that the team can see the whole forest - because sometimes when you're directly treating someone you might only see the tree.  At my ambulance corps, I do a lot more hands on patient care, and I work with a great ALS provider - we work very well together and usually don't even have to tell the other what to do.


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