# Emt approach



## sisoybolso (Jul 17, 2013)

DISPATCHER TELLS YOU

_8 YEARS OLD MALE
_UNCONSCIOUS
_ WAS PLAYING FOOTBALL AT RECESS ( 90 DEGREES OUTSIDE)
_RESPIRATIONS 8
_PULSE 110
_BP UNKNOWN
_ Hx UNKNOWN

HOW WOULD YOU TAKE CARE OF THIS PATIENT FROM A TO Z
STARTING FROM SCENE SAFETY TO TRANSPORT INCLUDING ACTIONS THAT YOU TAKE.
IF ANY QUESTIONS ABOUT THE SCENE PLEASE ASK ME AND I WILL GIVE YOU DETAILS.
tHANK YOU FOR YOUR TIME


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## Medic Tim (Jul 17, 2013)

sisoybolso said:


> DISPATCHER TELLS YOU
> 
> _8 YEARS OLD MALE
> _UNCONSCIOUS
> ...



welcome to EMT life

Are you asking because you are not sure (ie, homework) or is this a call you had and want to present it as a scenario?

and there is no need to YELL


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## Achilles (Jul 17, 2013)

Why are you yelling?
I won't do you're Homework. 

What would you do?


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## chaz90 (Jul 17, 2013)

LOUD NOISES!

Well, first things first, let's manage this patient's breathing. This is obviously slow and inadequate for an 8 year old, so BVM assisted ventilations as we start to package and get more info. Let's get a better history. He was playing outside in hot weather and then collapsed. Did anyone see it? What happened directly before? What other assessment findings do we have? EtCO2? SpO2? Depth of breathing? Blood Glucose? How about we actually get a BP. Neuro exam findings? Either way, my next step in the rig would be to get an IV and have fluids hung and ready. The remainder of my treatments need more assessment findings and history than we have so far. Are there no adults on scene that may have been supervising him? Perhaps older sibling or child with contact info for parents?

BTW, number one on my differentials right now is seizure and now post-ictal. We shall see though.

Also, I hope this isn't a homework question I was suckered into. I'm a trusting guy.


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## sisoybolso (Jul 18, 2013)

I am so sorry about upper case letters.
This is not a homework I am a new EMT and that was my first call and I wanted to see how others EMTs would manage this situation.
I am from a small city in Lancaster Pa.( nothing ever happens here)
Anyways, thank you for your time.
  As I get to the scene I was approached by one of the teachers and the principal, they stated the kid was playing in the hot and just collapsed.
My first concern was his airway, breathing and circulation.
Also I was concern about any trauma.


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## J B (Jul 18, 2013)

If pt is unresponsive, doesn't that make it an automatic upgrade to ALS unless you're very close to hospital?

Follow ABCs, and I guess  we can mostly rule out trauma since other people saw him "just collapse"?

I'm also a new EMT.  I can imagine this being scary but it is pretty much right out of a textbook.




chaz90 said:


> Well, first things first, let's manage this patient's breathing. This is obviously slow and inadequate for an 8 year old, so BVM assisted ventilations as we start to package and get more info.



I notice you make no mention of airway adjuncts.  The textbook says unresponsive pt should be getting an OPA.  Did you just forget, or would you not use OPA/NPA in this patient?

I've always kind of questioned this because what if you put an OPA in a pt like this, he wakes up and gags/vomits/aspirates?  What if he wakes up enough to have a gag reflex, but not enough to pull out the OPA?  It seems like an OPA has a good chance of making the situation much worse.


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## chaz90 (Jul 18, 2013)

J B said:


> I notice you make no mention of airway adjuncts.  The textbook says unresponsive pt should be getting an OPA.  Did you just forget, or would you not use OPA/NPA in this patient?
> 
> I've always kind of questioned this because what if you put an OPA in a pt like this, he wakes up and gags/vomits/aspirates?  What if he wakes up enough to have a gag reflex, but not enough to pull out the OPA?  It seems like an OPA has a good chance of making the situation much worse.



Most unresponsive patients still have enough of a gag reflex to prevent OPA usage. I would probably put in an NPA (more likely two), but would hold off on even trying for an OPA or not until I find out if it was a seizure. If the patient doesn't begin to regain consciousness, I'd then move towards at least trying an OPA to see if a gag is intact. If they gag, remove before they vomit. If they vomit, have suction at the ready.


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## Mariemt (Jul 18, 2013)

Assist vents first
 load him into air conditioned ambulance. Get a bp and to hospital if a ways out do an als intercept
Body temp
 Bgl
Need to know allergies. School know? How does his face, neck look? Lung sounds? Need an epi pen?
 How did he look this morning at school? Hopefully teacher close by , have teacher ride along to give you last several hours of history
Als please


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## J B (Jul 18, 2013)

chaz90 said:


> Most unresponsive patients still have enough of a gag reflex to prevent OPA usage. I would probably put in an NPA (more likely two), but would hold off on even trying for an OPA or not until I find out if it was a seizure. If the patient doesn't begin to regain consciousness, I'd then move towards at least trying an OPA to see if a gag is intact. If they gag, remove before they vomit. If they vomit, have suction at the ready.



Sounds good, thanks for clarifying.


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## Anonymous (Jul 18, 2013)

First things first! This patient needs C-Spine!!!












I Kid. I Kid.


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## Wheel (Jul 18, 2013)

Anonymous said:


> First things first! This patient needs C-Spine!!!
> 
> 
> 
> ...



You kid, but a fall with altered loc would be boarded in many places. It makes me cringe a bit.


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## Wes (Jul 18, 2013)

In all honesty, I might have someone take c-spine and stabilize the neck until we have an idea of what's going on.


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## phideux (Jul 18, 2013)

Anonymous said:


> First things first! This patient needs C-Spine!!!
> 
> 
> 
> ...



And a NRB @ 15LPM :rofl:


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## Wes (Jul 18, 2013)

Sadly, the EMT curriculum has been watered down to C-spine, NRB at 15 LPM, and request ALS.


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## Wheel (Jul 18, 2013)

sisoybolso said:


> DISPATCHER TELLS YOU
> 
> _8 YEARS OLD MALE
> _UNCONSCIOUS
> ...



I read this in the voice of the drill instructor from full metal jacket, obscenities added of course.


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## Mariemt (Jul 18, 2013)

Wes said:


> Sadly, the EMT curriculum has been watered down to C-spine, NRB at 15 LPM, and request ALS.



Actually, if you want to pass the nremt you need to titrate O2. Over oxygenating a patient with a head injury or on  a cardiac call will get you a big ol wrong answer.

Our protocols have us keeping a code patient in the 94% range.


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## Wes (Jul 18, 2013)

You just made my day!


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## EMTnurse (Jul 18, 2013)

J B said:


> If pt is unresponsive, doesn't that make it an automatic upgrade to ALS unless you're very close to hospital?
> 
> Follow ABCs, and I guess  we can mostly rule out trauma since other people saw him "just collapse"?
> 
> ...



I wouldn't necessarily use one unless I was having difficulty establishing and maintaining a patent airway. I tend towards the least amount if intervention to achieve my goal.


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## Mariemt (Jul 18, 2013)

J B said:


> If pt is unresponsive, doesn't that make it an automatic upgrade to ALS unless you're very close to hospital?
> 
> Follow ABCs, and I guess  we can mostly rule out trauma since other people saw him "just collapse"?
> 
> ...


It depends, is he having trouble breathing due to snoring? Can you open his airway by the head tilt chin lift? 
The opa will benefit him then, but if his airway is open already the opa may just cause him to vomit


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## Chronic510 (Jul 19, 2013)

This is a rather simple scenario lol

I would have my partner hold c-spine.
Check ABC's

Breathing is slow, but if perfusion is adequate? I'd use a non-rebreather at 15lpm. You can never use too much oxygen.

After i would try and get a sample/history and determine wether c-spining this patient is necessary. After that I would pack'em and go. I would get vitals in the rig on the way. and re-asses for any changes.

As an EMT we are limited to what we can do. Just because someone is unconcious doesnt make it an ALS call. From the scenario you've given? This patients vitals seem rather stable. 


(Btw, for registry purpose's? You'd typically slide in an npa, and assisted ventilations)

But keep in mind. That can change at any given moment


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## Mariemt (Jul 19, 2013)

Chronic510 said:


> This is a rather simple scenario lol
> 
> I would have my partner hold c-spine.
> Check ABC's
> ...


yes,  you can use too much oxygen. Titrate that stuff please! 

And you really only need an NPA if his airway is being obstructed by soft tissue falling back. You can tell if the head tilt chin lift works.  If that works, use an NPA if you can get chest rise and fall, you don't always need an NPA, this would be more assisted by giving an extra Brest I between rather than breathing for him.

Also he collapsed, didn't fall off anything, I wouldn't do c spine 

And there is nothing stable about him. Call als!


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## chaz90 (Jul 19, 2013)

Chronic510 said:


> This is a rather simple scenario lol
> 
> I would have my partner hold c-spine.
> Check ABC's
> ...



Unconscious patients are absolutely ALS. Level of responsiveness is one of your vital signs, and unresponsive is definitely out of the norm. Also, airway adjuncts aren't something to just use for the NR. I use some kind of airway adjunct every time I'm using a BVM. More airway protection is a good thing when you're using a temporary airway/ventilation fix like a BVM.


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## Wheel (Jul 19, 2013)

Chronic510 said:


> This is a rather simple scenario lol
> 
> I would have my partner hold c-spine.
> Check ABC's
> ...



What do you think is wrong with this child that it is just simple BLS? An unconscious child breathing eight times a minute when it was seemingly fine moments before is far from normal. What kind of pathology could cause this? What could ALS do that you can't? What else should you be checking on an unconscious person other than ABCs?


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## Handsome Robb (Jul 19, 2013)

Wheel said:


> What else should you be checking on an unconscious person other than ABCs?



I'm guessing I'm not allowed to answer this question... 

If you truly think this is a call BLS is capable of handling you're sadly mistaken my friend...

What can help guide our differential as to why this kid is unresponsive? I'm thinking of an acronym.

Schools have a file on every student that includes history, allergies and medications. Well at least here they do.

I agree with whoever said seizure. Definitely up there on my list.


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## Carlos Danger (Jul 19, 2013)

J B said:


> I notice you make no mention of airway adjuncts.  The textbook says unresponsive pt should be getting an OPA.  Did you just forget, or would you not use OPA/NPA in this patient?
> 
> I've always kind of questioned this because what if you put an OPA in a pt like this, he wakes up and gags/vomits/aspirates?  What if he wakes up enough to have a gag reflex, but not enough to pull out the OPA?  *It seems like an OPA has a good chance of making the situation much worse.*



By definition, a patient who will accept an OPA needs one. Especially kids, because their tongue and soft tissue obstruct their airway easily, especially with PPV. 

You probably lessen the likelihood of aspiration with an OPA in place, since it will allow you to use lower pressures and make gastric insufflation a little less likely. If the patient wakes up, they will gag for a few seconds and you will take the OPA out. No problem.



Chronic510 said:


> As an EMT we are limited to what we can do. Just because someone is unconcious doesnt make it an ALS call. From the scenario you've given? *This patients vitals seem rather stable. *



An 8 year old who is unresponsive and hypoventilating is anything but stable. 

A RR of 8 in a pediatric patient is actually an ominous sign, and such a patient can decompensate very quickly if his airway and ventilation are not properly managed in a hurry.


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## J B (Jul 19, 2013)

Halothane said:


> By definition, a patient who will accept an OPA needs one. Especially kids, because their tongue and soft tissue obstruct their airway easily, especially with PPV.
> 
> You probably lessen the likelihood of aspiration with an OPA in place, since it will allow you to use lower pressures and make gastric insufflation a little less likely. If the patient wakes up, they will gag for a few seconds and you will take the OPA out. No problem.
> 
> ...



I see, makes sense.  Thanks.


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## sisoybolso (Jul 22, 2013)

More information about this patient:
The school yard teacher noticed that he was running to catch the football and all of the sudden collapsed. She thought the tripped, but then realized something was terribly wrong when he did not get back up. 

He and his fellow classmates were eating lunch in the cafeteria. However, he was not really hungry so he decided to sell his lunch to someone else. 

SpO2 reading is 94%

Depth of breathing Shallow and irregular/some snoring resps

Blood Glucose? Not available until ALS Arrives


how does his skin look? cold  and sweaty

Glasgow coma scale? 12
if you have anymore questions please ask.


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## Mariemt (Jul 23, 2013)

OK, he is snoring so needs an adjunct. Could have mentioned this earlier. That alone might make his breathing better. 
I'd try to add an extra breath in to bring his resp up a few.
.I'm not waiting for als. I am capable of a bgl. However I'm going to load and go and intercept als.


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## mycrofft (Jul 23, 2013)

1. Assessment and vitals.
2. Does the pt fit any protocols?
   YES: Use it
   NO: ABC, support vitals, MAYBE cervical precautions.
3. Transport.

Ideas to entertain:
1. Postictal (needs off the hot ground and check for accidental injury).
2. Congenital cardiac or cerebrovascular abnormality (needs tincture of hospital ASAP).
3. Cryptic trauma (earlier blunt trauma to abdomen or head =>delayed downtime).Needs hospital (ultrasound, labs etc).
4. Illness (meningitis, etc etc etc). To hospital.
5. Heat illness: to hospital
6. Unknown: to hospital.

Do we see a pattern here?

BTW: what's with all the oxygen in the absence of clinical need? I know, your company has it in its protocols.


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## Mariemt (Jul 23, 2013)

mycrofft said:


> 1. Assessment and vitals.
> 2. Does the pt fit any protocols?
> YES: Use it
> NO: ABC, support vitals, MAYBE cervical precautions.
> ...


He is snoring and not breathing as much as he should.  I haven't given the patient o2 yet just a few extra breaths. I would like to see his o2 around 96, but with his snoring, his o2 SATs will likely go down soon and the EMT should be ready for o2


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## sisoybolso (Jul 23, 2013)

Patient fits in Pennsylvania the diabetic emergency protocol.
The idea of my posting here was to see how emts from other states would handle this call from the gate.
BSI, scene safety, number of patient, NOI, advise ALS, general impression, history taking all of that ( that's what I did at least)
he collapsed to the ground so he is not a trauma patient, plus we found out he did not eat lunch, was running like crazy.
Thank you so much in advance.
That was my first call and like I said I would like to know how you guys would take care of this situation and compare to what I did.


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## Mariemt (Jul 23, 2013)

Mariemt said:


> Assist vents first
> load him into air conditioned ambulance. Get a bp and to hospital if a ways out do an als intercept
> Body temp
> Bgl
> ...



And here I sat with bgl in my first post. Yay me


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## chaz90 (Jul 23, 2013)

sisoybolso said:


> Patient fits in Pennsylvania the diabetic emergency protocol.
> The idea of my posting here was to see how emts from other states would handle this call from the gate.
> BSI, scene safety, number of patient, NOI, advise ALS, general impression, history taking all of that ( that's what I did at least)
> he collapsed to the ground so he is not a trauma patient, plus we found out he did not eat lunch, was running like crazy.
> ...



Where to begin? 

What was the patient's BGL? Also, altered blood sugar (if indeed it is abnormal) doesn't always mean diabetes. Patients do not necessarily "fit into protocols" because some parts of their presentation falls into one category. If I'm following your line of thinking, you're using the fact that he's altered with a decreased appetite for one meal as justification for assuming he is experiencing a "diabetic emergency" (too broad of a category BTW).

Do some reading on the pathophysiology of Diabetes Mellitus Type I and II, and you will find neither disease leads to this kind of presentation as a matter of course. Type I Diabetes (suspected over type II due to age and history of this patient) is a problem with lack of insulin production leading to hyperglycemia. These patients aren't diagnosed just by suddenly passing out while running. A healthy 8 year old will not experience a drastic drop in blood sugar due to missing one meal and running around. Unless he accidentally shot up Grandpa's insulin at lunch, this really isn't a likely diagnosis.


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## Mariemt (Jul 23, 2013)

chaz90 said:


> Where to begin?
> 
> What was the patient's BGL? Also, altered blood sugar (if indeed it is abnormal) doesn't always mean diabetes. Patients do not necessarily "fit into protocols" because some parts of their presentation falls into one category. If I'm following your line of thinking, you're using the fact that he's altered with a decreased appetite for one meal as justification for assuming he is experiencing a "diabetic emergency" (too broad of a category BTW).
> 
> Do some reading on the pathophysiology of Diabetes Mellitus Type I and II, and you will find neither disease leads to this kind of presentation as a matter of course. Type I Diabetes (suspected over type II due to age and history of this patient) is a problem with lack of insulin production leading to hyperglycemia. These patients aren't diagnosed just by suddenly passing out while running. A healthy 8 year old will not experience a drastic drop in blood sugar due to missing one meal and running around. Unless he accidentally shot up Grandpa's insulin at lunch, this really isn't a likely diagnosis.



Dang I thought I read it was a diabetic emergency, not that he just followed protocol for one. Lol.

Yes, I would still have gotten a bgl just because I do with all unresponsive patients.  I just do. 
Yes, all type 1 I have seen are usually diagnosed after severe thirst, fast weight loss, excessive urination etc. Which goes hand in hand with hyperglycemia,  not hypoglycemia.

What was this patients outcome?


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## mycrofft (Jul 24, 2013)

sisoybolso said:


> Patient fits in Pennsylvania the diabetic emergency protocol.
> The idea of my posting here was to see how emts from other states would handle this call from the gate.
> BSI, scene safety, number of patient, NOI, advise ALS, general impression, history taking all of that ( that's what I did at least)
> he collapsed to the ground so he is not a trauma patient, plus we found out he did not eat lunch, was running like crazy.
> ...



Natasha Richardson will be happy to hear that falling down doesn't result in delayed fatality. 

My experience with diabetics (worked jail's subacute section where we stabilized diabetics for six years) did not have them taking shallow resps.

h34r:

EDIT: I put that poorly. A fall can result in a delayed fatality, but what I meant to say was it can herald or be succeeded by a fatality (say, aneurysm rupture, closed abdominal injury, cerebrovascular event, all due to an earlier trauma but not complained about). Teachers seeing kid out and playing/running around does minimize that. Not a criticism, just an observation. Steady on!


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## rmabrey (Jul 24, 2013)

I'll be in the minority here and say this patient needs c-spine. 

Collapsed, unresponsive, while playing football. Yeah, Im not rolling into an ER with that story and no spinal precautions.


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## Mariemt (Jul 24, 2013)

rmabrey said:


> I'll be in the minority here and say this patient needs c-spine.
> 
> Collapsed, unresponsive, while playing football. Yeah, Im not rolling into an ER with that story and no spinal precautions.



I would had he been hit. But he wasn't just went down. Being 8, he didn't fall far.


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## sisoybolso (Jul 24, 2013)

Mariemt said:


> And here I sat with bgl in my first post. Yay me



Yes you did.


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## sisoybolso (Jul 24, 2013)

Mariemt said:


> Dang I thought I read it was a diabetic emergency, not that he just followed protocol for one. Lol.
> 
> Yes, I would still have gotten a bgl just because I do with all unresponsive patients.  I just do.
> Yes, all type 1 I have seen are usually diagnosed after severe thirst, fast weight loss, excessive urination etc. Which goes hand in hand with hyperglycemia,  not hypoglycemia.
> ...



In Pennsylvania only ALS can measure bgl.
I am an EMT so that limits my actions


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## sisoybolso (Jul 24, 2013)

rmabrey said:


> I'll be in the minority here and say this patient needs c-spine.
> 
> Collapsed, unresponsive, while playing football. Yeah, Im not rolling into an ER with that story and no spinal precautions.



The school yard teacher saw him falling.


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## sisoybolso (Jul 24, 2013)

Mariemt said:


> Dang I thought I read it was a diabetic emergency, not that he just followed protocol for one. Lol.
> 
> Yes, I would still have gotten a bgl just because I do with all unresponsive patients.  I just do.
> Yes, all type 1 I have seen are usually diagnosed after severe thirst, fast weight loss, excessive urination etc. Which goes hand in hand with hyperglycemia,  not hypoglycemia.
> ...


 As I arrived to the scene I did not know it was a diabetic emergency (later I found out)


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## Mariemt (Jul 24, 2013)

sisoybolso said:


> In Pennsylvania only ALS can measure bgl.
> I am an EMT so that limits my actions


Seriously?  
I measure BGL on all my unresponsive patients, possible stroke patients , intoxication calls....etc
You wouldn't believe how many possible strokes are actually low blood sugar.  How many intoxicated people are hyper or hypo. And a majority of altered statuses are low bgl.

Take that away from basics and why have bls?


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## sisoybolso (Jul 24, 2013)

Mariemt said:


> Seriously?
> I measure BGL on all my unresponsive patients, possible stroke patients , intoxication calls....etc
> You wouldn't believe how many possible strokes are actually low blood sugar.  How many intoxicated people are hyper or hypo. And a majority of altered statuses are low bgl.
> 
> Take that away from basics and why have bls?



I agree with you, welcome to the commonwealth of Pa.


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## PaddyWagon (Jul 25, 2013)

Mariemt said:


> Seriously?
> I measure BGL
> Take that away from basics and why have bls?



The reasoning around these parts is that basics stop short of invasive procedures and a stick is invasive.


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## Jim37F (Jul 25, 2013)

PaddyWagon said:


> The reasoning around these parts is that basics stop short of invasive procedures and a stick is invasive.



Which to me, is slightly ridiculous since BGLs are designed to be used at home by non medically trained people going about their daily lives. But I guess it's a slightly moot point when county dispatches ALS to every little call


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## Mariemt (Jul 25, 2013)

Jim37F said:


> Which to me, is slightly ridiculous since BGLs are designed to be used at home by non medically trained people going about their daily lives. But I guess it's a slightly moot point when county dispatches ALS to every little call


Not to mention someone slightly altered,  a basic can give oral glucose and keep it basic level. This case no, the child needed Iv dextrose but many cases a bit of glucose does the trick. Saves the medics for more critical pts


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