# kidney stones and a bgl?



## PotatoMedic (Jul 16, 2013)

Someone was telling me you should do a bgl for a pt with possible kidney stones?  Is there any useful information pertaining to kidney stones that you can get out of a bgl?


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## TransportJockey (Jul 16, 2013)

I dunno about there being any correlation, but I start an IV on those patients and I usually get a glucose check off of my IV sticks anyways, so all my kidney stone patients get sugar checked.


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## Medic Tim (Jul 16, 2013)

TransportJockey said:


> I dunno about there being any correlation, but I start an IV on those patients and I usually get a glucose check off of my IV sticks anyways, so all my kidney stone patients get sugar checked.



This^^^.  Plus some toradol or other pain medication usually.


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## Carlos Danger (Jul 16, 2013)

TransportJockey said:


> I dunno about there being any correlation, but I start an IV on those patients and I usually get a glucose check off of my IV sticks anyways, so *all my kidney stone patients get sugar checked.*



Why? Do you check a BG every time you start an IV?


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## DesertMedic66 (Jul 16, 2013)

Halothane said:


> Why? Do you check a BG every time you start an IV?



Why not? You already have a blood sample from the flash on the IV. It's the same around here, every time an IV is started a BGL test is done on the blood from the flash.


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## blindsideflank (Jul 16, 2013)

it will probably be elevated from a stress response.

also, is this questioning assuming that you KNOW its kidney stones or is this flank pain that you assume is kidney stones?

edit: read OP again, pancreatitis is a bigger worry than kidney stones. gall bladder blockages and infections leading to the pancreas, peritonitis to sepsis (a stretch)
lots of reasons to get a sufgar i suppose, hard to say why you are thinking "possible kidney stones"


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## Carlos Danger (Jul 16, 2013)

DesertEMT66 said:


> *Why not?* You already have a blood sample from the flash on the IV. It's the same around here, every time an IV is started a BGL test is done on the blood from the flash.



I realize that if you are starting an IV anyway, there is very little additional effort or cost involved in checking a BG, but  "why not" just doesn't strike me as a great reason for doing things that are otherwise not indicated. 

So I just wondered if there was a better (physiologic) reason for the practice.


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## Carlos Danger (Jul 16, 2013)

FireWA1 said:


> Someone was telling me you should do a bgl for a pt with possible kidney stones?  Is there any useful information pertaining to kidney stones that you can get out of a bgl?



You sure it was kidney stones and not gallstones?


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## DesertMedic66 (Jul 16, 2013)

Halothane said:


> I knew someone would say that. And I thought that might be the reason for the practice, but I just wondered if there was a better (physiologic) one.
> 
> I realize that if you are starting an IV anyway, there is very little additional effort or cost involved in checking a BG, but  "why not" just doesn't strike me as a great reason for doing things that are otherwise not indicated.
> 
> Maybe I'm just lazy.



It might not be indicated but it takes less than 30 seconds to do and costs next to nothing. Ive been surprised by numbers before. 

We had a 40 Y/O male who had a tib/fib fracture. Medic got the IV to push pain meds and I got a sugar on it. 357 for the sugar with no history or family history of diabetes and no other C/C.


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## PotatoMedic (Jul 16, 2013)

This was not a clinical situation rathan more of a question of 'is there any clinical info between the two?'. On a semi related note would right or left flank pain present with pancreatitis or gualstones?


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## VFlutter (Jul 16, 2013)

DesertEMT66 said:


> We had a 40 Y/O male who had a tib/fib fracture. Medic got the IV to push pain meds and I got a sugar on it. 357 for the sugar with no history or family history of diabetes and no other C/C.



Stress induced hyperglycemia can occur fairly quickly especially with catecholamine excess as you would see in a patient with extreme pain.


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## milehimedic (Jul 16, 2013)

Chase said:


> Stress induced hyperglycemia can occur fairly quickly especially with catecholamine excess as you would see in a patient with extreme pain.



This^^. The way I understand it, the fight or flight response we experience during extreme pain events like a kidney stone causes the liver to release more glucose, that in turn isn't metabolized, because pt is writhing in pain rather than running from a threat. Hence, hyperglycemia. Is this basically what's happening?


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## TransportJockey (Jul 16, 2013)

Medic Tim said:


> This^^^.  Plus some toradol or other pain medication usually.


Yep. The prime reason I do IVs for all my abd pain patients. 



Halothane said:


> Why? Do you check a BG every time you start an IV?



Actually yea I do. It's a minimal cost and minimal time assessment if I've already got the blood at hand. Gives me a more complete picture... Plus our local hospitals ask for a sugar on everyone anyways.


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## Carlos Danger (Jul 16, 2013)

milehimedic said:


> This^^. The way I understand it, the fight or flight response we experience during extreme pain events like a kidney stone causes the liver to release more glucose, that in turn isn't metabolized, because pt is writhing in pain rather than running from a threat. Hence, hyperglycemia. Is this basically what's happening?



That's exactly what's happening. 

And it's one of the reasons why a single BG on an asymptomatic patient is not valuable information.


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## Carlos Danger (Jul 16, 2013)

DesertEMT66 said:


> It might not be indicated but it takes less than 30 seconds to do and costs next to nothing. Ive been surprised by numbers before.
> 
> We had a 40 Y/O male who had a tib/fib fracture. Medic got the IV to push pain meds and I got a sugar on it. 357 for the sugar with no history or family history of diabetes and no other C/C.



Do you put a NC on everyone, too?


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## DesertMedic66 (Jul 16, 2013)

Halothane said:


> Do you put a NC on everyone, too?



If O2 is clinically indicated then yes, but not may patients need O2. 

I don't get what that has to do with getting a BGL on a flash from the IV. You already have a blood sample so it's not going to hurt anything, delay patient care, or cost any money.


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## Rialaigh (Jul 16, 2013)

DesertEMT66 said:


> If O2 is clinically indicated then yes, but not may patients need O2.
> 
> I don't get what that has to do with getting a BGL on a flash from the IV. You already have a blood sample so it's not going to hurt anything, delay patient care, or cost any money.



I think the basic premise is it is a low cost start to "poor medicine".  We constantly complain that we (EMS) want more ability to practice in the field and make independent decisions but we consistently do things like bgl's on tons of people with no indication that shows we just follow the tree of treatment....


Do all abd. pains need bgl's, no they do not. Do many of our diabetic patients need their sugar checked, no they do not. 


As far as the OP's question goes, I think chase hit it on the head


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## DesertMedic66 (Jul 16, 2013)

Rialaigh said:


> I think the basic premise is it is a low cost start to "poor medicine".  We constantly complain that we (EMS) want more ability to practice in the field and make independent decisions but we consistently do things like bgl's on tons of people with no indication that shows we just follow the tree of treatment....
> 
> 
> Do all abd. pains need bgl's, no they do not. Do many of our diabetic patients need their sugar checked, no they do not.
> ...



But once again what is the harm in testing the blood that you already have? I have found many patients BGLs to be out of the normal range by doing the test on all IV starts. 

Our hospitals take blood and test it for a whole range of stuff on almost every patient and one of the tests they do is a BGL test. It helps the doctors get a better picture of what's going on and that is what it allows us to do also.


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## TransportJockey (Jul 16, 2013)

Rialaigh said:


> I think the basic premise is it is a low cost start to "poor medicine".  We constantly complain that we (EMS) want more ability to practice in the field and make independent decisions but we consistently do things like bgl's on tons of people with no indication that shows we just follow the tree of treatment....
> 
> 
> Do all abd. pains need bgl's, no they do not. Do many of our diabetic patients need their sugar checked, no they do not.
> ...



Do all patients in a facility need a CBC or BMP drawn? No, but doctors in the ER tend to order them as a shotgun test. And those also include a glucose level. It's a noninvasive diagnostic procedure. You're not administering a drug just for the hell of it. Comparing it to oxygen administration is kind of apples to oranges.


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## Trashtruck (Jul 16, 2013)

Just because I start an IV doesn't mean I'm going to check a sugar(and yes, the strips are costly so there is a cost component to using these all the time)
Just because I start an IV doesn't mean I'm going to draw labs.
Just because I have a pulse oximeter doesn't mean I'm going to use it on every patient.
Just because the pulse oximeter will measure carboxyhemoglobin doesn't mean I'm going to use that function just because I place it on a patient. I mean, yeah, it takes less than a few seconds for a reading, but I don't care about somebody's SpCO for the most part.
12-leads on everybody? Why?

I do see the flip-side of all this. Some call it 'comprehensive' and some call it 'overkill'.

The classic VOMIT acronym comes to mind.

Why does everybody receive this treatment(in some systems)?


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## Rialaigh (Jul 16, 2013)

TransportJockey said:


> Do all patients in a facility need a CBC or BMP drawn? No, but doctors in the ER tend to order them as a shotgun test. And those also include a glucose level. It's a noninvasive diagnostic procedure. You're not administering a drug just for the hell of it. Comparing it to oxygen administration is kind of apples to oranges.



Just because it does not harm the patient or carry any significant risks does not mean it's good medicine. It's still poor medicine to use ANY resources that you don't need to on patients that have basically no indication for the test or intervention. I hate that hospitals draw CBC's and BMP's  on everyone, including the patient that was here 14 hours ago for the same complaint...


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## DesertMedic66 (Jul 16, 2013)

Rialaigh said:


> Just because it does not harm the patient or carry any significant risks does not mean it's good medicine. It's still poor medicine to use ANY resources that you don't need to on patients that have basically no indication for the test or intervention. I hate that hospitals draw CBC's and BMP's  on everyone, including the patient that was here 14 hours ago for the same complaint...



A couple of posts ago I mentioned the call I had with the patient who fractured his Tib/Fib and had a high BGL test, while there was no indication to lead anyone to think of diabetes, the patient did in fact turn out to have uncontrolled diabetes type 1. 

No indication was found for the BGL test but the test was preformed and the findings were abnormal.


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## NomadicMedic (Jul 16, 2013)

More is missed by not looking, than not knowing.


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## Rialaigh (Jul 16, 2013)

DesertEMT66 said:


> A couple of posts ago I mentioned the call I had with the patient who fractured his Tib/Fib and had a high BGL test, while there was no indication to lead anyone to think of diabetes, the patient did in fact turn out to have uncontrolled diabetes type 1.
> 
> No indication was found for the BGL test but the test was preformed and the findings were abnormal.



Yes, and once out of every 1000 patients under the age of 30 that get radiated with a head CT the ER docs happen to stumble on a brain bleed....


Doesn't make it good medicine. Yes the cost and exposure risk of a BgL is significantly less than that of a head CT but the principle is the same. In broad terms your enabling these people to use 9-1-1 as a primary care service. 



There will always be exceptions that people can point to. Using outlying data points to base your care off of is poor medicine.


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## DesertMedic66 (Jul 16, 2013)

Rialaigh said:


> Yes, and once out of every 1000 patients under the age of 30 that get radiated with a head CT the ER docs happen to stumble on a brain bleed....
> 
> 
> Doesn't make it good medicine. Yes the cost and exposure risk of a BgL is significantly less than that of a head CT but the principle is the same. In broad terms your enabling these people to use 9-1-1 as a primary care service.
> ...



It's less than a dollar for a test strip of a name brand BG test strip. When you buy in bulk that cost goes down even more. Where is the exposure risk of the test when you already have the blood in the flash of a needle?

Not doing a simple test that causes no harm to the patient, costs next to nothing, can help shape a better picture of what's going on, and may even lead to a very abnormal finding is poor medicine.


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## exodus (Jul 16, 2013)

Aren't SPo2 and BGL both considered vital signs?


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## Rialaigh (Jul 16, 2013)

DesertEMT66 said:


> It's less than a dollar for a test strip of a name brand BG test strip. When you buy in bulk that cost goes down even more. Where is the exposure risk of the test when you already have the blood in the flash of a needle?
> 
> Not doing a simple test that causes no harm to the patient, costs next to nothing, can help shape a better picture of what's going on, and may even lead to a very abnormal finding is poor medicine.




Do you push narcan on every cardiac arrest too? Pretty cheap cost, huge upside for a cardiac arrest save, basically no risk of allergies or poor reaction...etc...etc.....

even more simply put do you check rebound tenderness in the abdomen and palpate the spine and do a vision check on every patient you pick up with ankle pain....? why not...cost is 0...could help shape a better picture of a larger underlying problem...could lead to a very abnormal finding....



This is a fairly cyclical discussion that will go no-where and really derail this thread, I would love to discuss it more at length on when is the appropriate and not appropriate time to give or withhold intervention and treatments of various sorts in the field and in the hospital.


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## Medic Tim (Jul 16, 2013)

exodus said:


> Aren't SPo2 and BGL both considered vital signs?



they are both required vitals at one of the services I work for.


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## mycrofft (Jul 16, 2013)

I skipped reading the other answers after#5. 

How do you determine in the field it is kidney trouble? That is a prime avenue, right up there with pancreatitis, to seeking scheduled meds. Not that complaints of pain should no be addressed, but starting treatment down a path not related to what is really wrong is a waste of time and an avenue to maltreatment.

Are we talking pain, or/and tenderness  on percussion, a couple inches below the scapulae? Or flank pain, groin pain, or simple c/o red urine? Fever? Recent trauma?

Only link I see is high serum glucose is not good in the long run for kidneys, especially along with hypertension; long term hyperglycemia can lead to renal failure, which is essentially painless and without many clinical s/s until advanced.

BTW, if they are c/o red urine, and it dipsticks positive for blood, r/o rhabdomyolysis and the pt introducing blood into the sample themselves intentionally.


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## Aprz (Jul 17, 2013)

I agree with Rialaigh, Halothane, and Trashtruck. It's the same argument as doing a 3-lead or 12-lead on every patient because the electrodes are cheap and it's a non invasive diagnostic, or giving oxygen 2 liters per minute by nasal cannula because it's cheap and benign for most patients.

It may actually not be cheap for your patient too. Some companies charge per diagnostics and treatment they do. I know of one company that charged about $200 for oxygen by nasal cannula, and another company that charges by packets of electrodes (even if they didn't use the whole packet).

Gathering more information than you should may be misleading or confusing for you, or whoever reviews your prehospital/patient care report (PCR).


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## Carlos Danger (Jul 17, 2013)

DesertEMT66 said:


> Not doing a simple test that causes no harm to the patient, costs next to nothing, can help shape a better picture of what's going on, and may even lead to a very abnormal finding is poor medicine.



I am sorry, but you have it exactly backwards. 

First, getting a glucose in a patient who has no clinical signs of hyper- or hypo- glycemia does not give you a better picture of what’s going on. 9/10 times, it will simply tell you what you already know: that their BG is normal. Maybe 0.5 or 1 out of 10 times, the BG will be out of the range you expected. But if they are asymptomatic, so what? Are you going to give glucose to someone whose BG is 55, if they look and feel just fine? Are you going to give insulin to someone whose BG is 300, if they look and feel normal? Of course not. So why are you even looking?

Second, there is a strong movement in healthcare right now away from doing tests "just because" and towards only doing testing that is clinically indicated and that will directly affect your care of the patient. This is happening for several reasons:


Unnecessary testing is just that....unnecessary. If you don't need a piece of data to make the decision you are trying to make, then you just don't need that piece of data. 


Cost. Even very cheap tests add up very fast when you do them on lots of patients.  


Risk to the patient. Patients are actually killed every year by unnecessary treatments that they received as a result of inaccurate or anomalous results that came from tests that weren’t even indicated for their condition. Most of those tests were done "just because" they were "cheap and harmless".


Legal risk to you or your company. Charting abnormalities (say, a BG of 400) and then not treating it is inviting questions about your care from a non-clinician who may be reviewing the chart for some reason. It's just another reason not to bother looking for something that you aren't going to treat. 

The problem isn’t so much with the practice of routinely checking a BG with IV starts. The problem is with the general mindset that “more info is always better” and “cost doesn’t matter as long as it’s low”, and ignoring the fact that patients are, in fact, exposed to some level of additional risk with testing.


This hits the nail right on the head:


Aprz said:


> *It's the same argument as doing a 3-lead or 12-lead on every patient because the electrodes are cheap and it's a non invasive* diagnostic, or giving oxygen 2 liters per minute by nasal cannula because it's cheap and benign for most patients.
> 
> *It may actually not be cheap for your patient* too. Some companies charge per diagnostics and treatment they do. I know of one company that charged about $200 for oxygen by nasal cannula, and another company that charges by packets of electrodes (even if they didn't use the whole packet).
> 
> *Gathering more information than you should may be misleading or confusing for you*, or whoever reviews your prehospital/patient care report (PCR).


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## NomadicMedic (Jul 17, 2013)

I certainly don't take a blood sugar on everybody, but most I do. Any history of diabetes or anyone who's even remotely altered. Please don't tell me you've never caught hypoglycemia that was masquerading as something else.

Same with a 12 lead... chest pain, abdominal pain, difficulty breathing. They all get a 12 lead. 

How about nasal capnography? Difficulty breathing, overdose, a patient that I'm providing pain management, altered mental status … I'm looking at a waveform on all of these people.

Serum lactate. Altered mental status, difficulty breathing, warm to the touch, anybody I may think might be septic…

Is that far too much? Am I getting too much information? I don't think so. It helps me correlate the clinical picture and provides more information to the emergency department when I get there. Now, doing them blindly on everyone is overkill, but I expect to see that more from untrained providers (See the argument against Narcan for BLS providers) who are just shooting in the dark as opposed to a care provider who's looking for something specific.


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## Carlos Danger (Jul 17, 2013)

DEmedic said:


> I certainly don't take a blood sugar on everybody, but most I do. Any history of diabetes or anyone who's even remotely altered. Please don't tell me you've never caught hypoglycemia that was masquerading as something else.
> 
> Same with a 12 lead... chest pain, abdominal pain, difficulty breathing. They all get a 12 lead.
> 
> ...



Look, if you are seriously asking me whether I think it is "too much" to get a BG on a patient with AMS, or a 12-lead on a patient with CP / potential anginal equivalents, or capnography on a patient who is obtunded or having respiratory difficulty.....then you completely missed the point of my post.


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## NomadicMedic (Jul 17, 2013)

I understood the point of your post, but I think you grossly misrepresented the idea of "too much information" is confusing. That's a idea that keeps paramedics as "place fold A into slot B" practitioners. My point is that Paramedics should all of the options available to them to help provide a full clinical picture to the ED. 

And you know as we'll as I do that some services require a blood sugar on every patient that walks through the door. 

I agree that THAT is overkill, but statements like "too much information is confusing" is just ignorant and SHOW ME proof of the "low level risk" associated with a blood sugar that's taken off an IV start.


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## Carlos Danger (Jul 17, 2013)

Come on, man. Don't try to spin it as though I'm saying that paramedics shouldn't do BG's on everyone because they aren't smart enough to use the info properly. 

I said nothing even remotely like that. Either you really didn't understand the point of my 7 previous posts, or you are just being disingenuous.


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## mycrofft (Jul 18, 2013)

DEmedic said:


> I understood the point of your post, but I think you grossly misrepresented the idea of "too much information" is confusing. That's a idea that keeps paramedics as "place fold A into slot B" practitioners. My point is that Paramedics should all of the options available to them to help provide a full clinical picture to the ED.
> 
> And you know as we'll as I do that some services require a blood sugar on every patient that walks through the door.
> 
> I agree that THAT is overkill, but statements like "too much information is confusing" is just ignorant and SHOW ME proof of the "low level risk" associated with a blood sugar that's taken off an IV start.



Paramedics were designed to be protocol driven technicians in the field.


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## chaz90 (Jul 18, 2013)

mycrofft said:


> Paramedics were designed to be protocol driven technicians in the field.



What we were designed to do in the 1970s is a far cry from how we need to function today. As you're well aware, we've taken hard fought steps to move beyond calling Rampart for orders to start an IV of D5W (Well, most of us. *Cough*LA County *Cough*)The modern paramedic will get left behind and rightly trampled if they remain nothing more than a protocol driven monkey.


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## Luno (Jul 30, 2013)

*Thank you...*



Halothane said:


> I am sorry, but you have it exactly backwards.
> 
> First, getting a glucose in a patient who has no clinical signs of hyper- or hypo- glycemia does not give you a better picture of what’s going on. 9/10 times, it will simply tell you what you already know: that their BG is normal. Maybe 0.5 or 1 out of 10 times, the BG will be out of the range you expected. But if they are asymptomatic, so what? Are you going to give glucose to someone whose BG is 55, if they look and feel just fine? Are you going to give insulin to someone whose BG is 300, if they look and feel normal? Of course not. So why are you even looking?
> 
> ...



Pointless tests, grabbing at possibilities of outcomes, "just because."  This is the mindset that has driven this industry for too long.  "Well, what does it hurt..." Is one of the worst indications in medicine.  Tests, medications, procedures, all need to be indicated, not because we're grasping at straws...


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## Handsome Robb (Jul 30, 2013)

Rialaigh said:


> Do you push narcan on every cardiac arrest too? Pretty cheap cost, huge upside for a cardiac arrest save, basically no risk of allergies or poor reaction...etc...etc.....
> 
> even more simply put do you check rebound tenderness in the abdomen and palpate the spine and do a vision check on every patient you pick up with ankle pain....? why not...cost is 0...could help shape a better picture of a larger underlying problem...could lead to a very abnormal finding....
> 
> ...



We get dinged on our chart review if we don't give an arrest Narcan.

BGL is also considered a mandatory vital sign by my protocols.

So do I practice bad medicine by following my protocols? I'd love to be able to use my discretion but unfortunately I need my income to pay my bills. So until that changes ill be giving Narcan to every arrest and checking CBGs on everyone even if I don't think it's indicated.


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## ghost02 (Jul 30, 2013)

Robb said:


> We get dinged on our chart review if we don't give an arrest Narcan.



Do you know the rational, perchance?


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## VFlutter (Jul 30, 2013)

Robb said:


> So do I practice bad medicine by following my protocols? I'd love to be able to use my discretion but unfortunately I need my income to pay my bills. So until that changes ill be giving Narcan to every arrest and checking CBGs on everyone even if I don't think it's indicated.



I do not think anyone would argue to ignore your protocols. And as such I do not think following a protocol is considered "practicing bad medicine" when you have no choice in the matter. But making a conscious autonomous decision to do something is a different situation.




ghost02 said:


> Do you know the rational, perchance?



I am assuming because many arrests are related to drug overdoses and Narcan is considered to be harmless.


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## Handsome Robb (Jul 30, 2013)

ghost02 said:


> Do you know the rational, perchance?



Three words: Lowest common denominator.


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## ghost02 (Jul 31, 2013)

Is the LCD what protocols are written for?

Aside from that, Narcan does not seem to be have been out long enough to be considered harmless, but then again I am ignorant in these matters.


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## Handsome Robb (Jul 31, 2013)

ghost02 said:


> Is the LCD what protocols are written for?
> 
> Aside from that, Narcan does not seem to be have been out long enough to be considered harmless, but then again I am ignorant in these matters.



Generally, yes. We all have to follow them but the amount of leeway we're given really depends on the LCD. It's pretty difficult to have some medics allowed to do something while others are not unless you have an established promotional ladder such as MedStar does with their 1-6 levels. We don't have that.

In cardiac arrest Narcan is pretty harmless. In patients with a pulse it definitely can cause problems, aspiration/vomiting, seizures, severe detox symptoms, so on and so forth.


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## ghost02 (Jul 31, 2013)

Good to know, thanks!


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## Rialaigh (Jul 31, 2013)

Robb said:


> We get dinged on our chart review if we don't give an arrest Narcan.
> 
> BGL is also considered a mandatory vital sign by my protocols.
> 
> So do I practice bad medicine by following my protocols? I'd love to be able to use my discretion but unfortunately I need my income to pay my bills. So until that changes ill be giving Narcan to every arrest and checking CBGs on everyone even if I don't think it's indicated.



Not saying you practice bad medicine. Your making a cost/benefit choice, the benefit of keeping your job is greater than the risk of a useless test/intervention to a patient. 

Now people who do things within their own power just for the hell of it....because they can...because its always done that way....because the hospital will do it anyways...etc..etc...


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## KellyBracket (Aug 1, 2013)

TransportJockey said:


> Do all patients in a facility need a CBC or BMP drawn? No, but doctors in the ER tend to order them as a shotgun test. And those also include a glucose level. It's a noninvasive diagnostic procedure. You're not administering a drug just for the hell of it. Comparing it to oxygen administration is kind of apples to oranges.



It's true that these are drawn fairly frequently in the ED, but I would hesitate to use this as a rationale for rote BGL tests. While they may occasionally reveal an occult, previously unsuspected condition, this can also really complicate the evaluation. Perhaps the clinician hoped that the "usual labs" would be normal, and support their clinical impression that the patient is well and healthy. _Buuut_, then the WBC comes back just a little elevated - then what? Ignore this result? Explain it away in the chart? Order  a second round of tests?

This has been explained as the *nose-picking in public* problem: What do you do with unexpected findings? If the BGL is 25 in a patient who looks hale & hearty, what's your next move? If your femur fracture has a BGL of 200, how does this affect your management? How about if it's 300, or 400, or 1000?

If you have an idea what you are going to do with your unexpected "nugget," then fire away with your lancet. But if you aren't sure, perhaps you shouldn't go mining for gold.

BTW, routine Narcan for cardiac arrests is about the silliest thing I've heard of today. There is indeed a downside, but that's a matter for another thread.


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## Carlos Danger (Aug 2, 2013)

TransportJockey said:


> Do all patients in a facility need a CBC or BMP drawn? No, but doctors in the ER tend to order them as a shotgun test. And those also include a glucose level. It's a noninvasive diagnostic procedure. You're not administering a drug just for the hell of it. Comparing it to oxygen administration is kind of apples to oranges.



Actually, these are often ordered not as a "shotgun test", but because depending on how the lab works, it is cheaper to get a BMP than just K or C02, and cheaper to get a CBC than just a WC.


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## TransportJockey (Aug 2, 2013)

Halothane said:


> Actually, these are often ordered not as a "shotgun test", but because depending on how the lab works, it is cheaper to get a BMP than just K or C02, and cheaper to get a CBC than just a WC.



That I didn't know. Thanks for clearing that one up  I actually figured it would be more expensive to run the battery than a single test


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## KellyBracket (Aug 2, 2013)

Halothane said:


> Actually, these are often ordered not as a "shotgun test", but because depending on how the lab works, it is cheaper to get a BMP than just K or C02, and cheaper to get a CBC than just a WC.



Despite this disincentive, some physicians will specifically order, say, just a K+, or just a hemoglobin/hematocrit, since they don't want to deal with a clinically-trivial bump in the WBC or chloride. Everyone gets confused when this happens, and half the time the whole lab gets sent regardless.


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## Carlos Danger (Aug 2, 2013)

KellyBracket said:


> Despite this disincentive, some physicians will specifically order, say, just a K+, or just a hemoglobin/hematocrit, since they don't want to deal with a clinically-trivial bump in the WBC or chloride. Everyone gets confused when this happens, and half the time the whole lab gets sent regardless.



That's what happened at my last hospital. We would order an H&H, and get back a CBC, or just a K and get back a BMP, because it was cheaper. Even after some members of the medical staff got pretty irate, the lab would keep doing it.

Where I am now, we've largely solved that problem with POC tests for Hgb and lytes. 

I don't know how much cheaper it is, but if even just a little less money per test, I'm sure it added up over time, and it's hard to argue with numbers. Though I'm sure the lab never took into account the other costs associated with the unnecessary lab results.

You probably don't have to have residents order very many blood cx because a WBC was a little high in a clinically healthy patient before you've negated any savings from running the unnecessary tests.


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## Clipper1 (Aug 2, 2013)

Halothane said:


> That's what happened at my last hospital. We would order an H&H, and get back a CBC, or just a K and get back a BMP, because it was cheaper. Even after some members of the medical staff got pretty irate, the lab would keep doing it.
> 
> Where I am now, we've largely solved that problem with POC tests for Hgb and lytes.
> 
> ...



Our POC allows us to see all the values and then select only those ordered. It is sometimes difficult for lab or who ever is running the POC technology to ignore other abnormal values and just select those ordered. It is also time consuming to constantly call the doctors when tests not selected are grossly abnormal or critical to see if they want that result entered as well.  To report the value not ordered to the doctor can be a big issue if the doctor says "I didn't order that. Let the Cardiologist or whatever specialist deal with that."


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## Dwindlin (Aug 4, 2013)

"The delivery of good medical care is to do as much nothing as possible."  This nugget gets forgotten all too often.


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## Aprz (Aug 4, 2013)

Dwindlin said:


> "The delivery of good medical care is to do as much nothing as possible."  This nugget gets forgotten all too often.


<3 House of God


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## Dwindlin (Aug 4, 2013)

Aprz said:


> <3 House of God



I actually dislike most of the book.  But there should be an entire damn class on the laws of the house taught in medical school.  Especially the one I quoted above and "placement comes first."


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## Sandog (Aug 5, 2013)

> *Glucose metabolism in renal stone patients.*
> Iguchi M, Umekawa T, Takamura C, Sugihara I, Nakamura K, Kohri K, Kurita T.
> Source
> 
> ...



http://www.ncbi.nlm.nih.gov/pubmed/8266608


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