# Two Questions:



## Amelia (Apr 13, 2015)

Ok, these questions are completely unrelated, but I didn't want to double post (or make Chimpie grumpy- he he)

Question 1:

So I'm finishing up EMT school (yay!) and on Sat I did an ED 12 hour shift (which turned out very interesting, to say the very least). And one of the pts was a middle age women with stress syncope after her sister had passed (apparently sister was in hospice and they were very sleep deprived) and when sister passed, the pt passes out completely, altered mental status for many hours, decreased strength on left side (which I mentioned to the nurse I was following because they never caught it, thankfully it turned out to be nothing). Now, she was in the ED for 4-5 hours while she's complaining of incredible chest pain and saying she had trouble breathing, etc. They never put O2 on her which confused me. Her stats were all normal and good, but in EMT school they said that if they complain of dyspnea, has an altered mental status, and/or chest pain, throw a NRM on them. Is this just the different care between EMTs SOP and EDs?

Second question: We're learning about field reports and radio reports. I talked to my Instructor about if a certain diagnosis that I personally had would be taught in class which I thought was important (pre-eclampsia and post partum pre-eclampsia) but she said that there was no possible way they could teach every complication, fair enough. But I got to wondering, since I've "been there done that" If I were to get a woman in her later stages of pregnancy or recently had a baby (within 6 weeks) and she's complaining of a "weird" headache, and has pedal edema, and her BP is through the roof (mine was 218/110 my 2nd time around which was absolutely fantastic) can we give our field report as "Suspected Pre-E or Post Pre-E" even if it wasn't technically taught to us in class? I'm assuming we can since we say "suspected" and it would help prepare the ED for the patient? That was just an example. Saturday, I evaluated the most -adorable- 7 month old baby with croup and I knew it was croup, and I knew it was viral, and I knew if the baby was as smiley and giggly and as adorable as he was, he was fine- I didn't say anything because it wasn't my place to obviously. But in the back of the rig, would you treat and talk to the pts parents that you suspect its coup? Where do you draw the line?


----------



## luke_31 (Apr 13, 2015)

1: oxygen doesn't need to be given if sats are normal in the ED. As an EMT you should never withhold oxygen from a patient who has those complaints. 

2: for your report I would just list the signs and symptoms and not say a suspected diagnosis. I would hesitate to tell patients or parents what you think is the diagnosis, it's better to let the doctor say what they think it is. If you are wrong on the diagnosis it can cause problems at the hospital after you leave if the family believes you and not them. As a experienced paramedic I do treat based off signs and symptoms that would lead me to a suspected diagnosis, but I keep a very open mind to possibly being wrong and letting the family know that I'm treating the patient based off the signs and symptoms. If pressed to tell them what is wrong I will tell them that the hospital and doctor will have more tools and experience to find the diagnosis, and that I am treating based on it possibly being what I think it might be but I make it very clear that it's not a definitive diagnosis and if I wrong the patient is still being treated appropriately for the situation and they are being well taken care of.


----------



## COmedic17 (Apr 13, 2015)

1. ED's can pretty much do what they want (since it's a doctors orders). If the doctor doesn't think O2 is necessary, then they don't need to implement it. 


2. Your not a doctor. You can't diagnose people. You can tell them the signs and symptoms, and they will understand what you are getting at. That's why you call cardiac "alerts" and stroke "alerts". You can alert the hospital to a POSSIBLE life threatening condition, but you can't diagnose it. A way to portray a patient with probable pre-eclampsia -without diagnosing it- would be something like " Main hospital, Medic 1 *go ahead medic 1* we are enroute with a 26yo female whom is 32 weeks pregnant. Pt is complaining of a headache, has a blood pressure of 180/100, pulse of 115, pitting edema in lower extremities, but denies any seizure like activity at this time. Patient denied any past history of hypertension. Patient is on 4lpm of oxygen, on cardiac monitor, and has 2 bilateral IVs. Patient is also negative on stroke scale and a BG level of 106. ETA 5 minutes. Any questions"?


----------



## Amelia (Apr 13, 2015)

luke_31 said:


> 1: oxygen doesn't need to be given if sats are normal in the ED. As an EMT you should never withhold oxygen from a patient who has those complaints.
> 
> 2: for your report I would just list the signs and symptoms and not say a suspected diagnosis. I would hesitate to tell patients or parents what you think is the diagnosis, it's better to let the doctor say what they think it is. If you are wrong on the diagnosis it can cause problems at the hospital after you leave if the family believes you and not them. As a experienced paramedic I do treat based off signs and symptoms that would lead me to a suspected diagnosis, but I keep a very open mind to possibly being wrong and letting the family know that I'm treating the patient based off the signs and symptoms. If pressed to tell them what is wrong I will tell them that the hospital and doctor will have more tools and experience to find the diagnosis, and that I am treating based on it possibly being what I think it might be but I make it very clear that it's not a definitive diagnosis and if I wrong the patient is still being treated appropriately for the situation and they are being well taken care of.



You answer completely makes sense. We're just being taught to learn to do field impressions, is why I ask. I'm not sure if they're required by SD. Perhaps sometimes its more important to not do part of the assessment/reports then?


----------



## Amelia (Apr 13, 2015)

COmedic17 said:


> 1. ED's can pretty much do what they want (since it's a doctors orders). If the doctor doesn't think O2 is necessary, then they don't need to implement it.
> 
> 
> 2. Your not a doctor. You can't diagnose people. You can tell them the signs and symptoms, and they will understand what you are getting at. That's why you call cardiac "alerts" and stroke "alerts". You can alert the hospital to a POSSIBLE life threatening condition, but you can't diagnose it. A way to portray a patient with probable pre-eclampsia -without diagnosing it- would be something like " Main hospital, Medic 1 *go ahead medic 1* we are enroute with a 26yo female whom is 32 weeks pregnant. Pt is complaining of a headache, has a blood pressure of 180/100, pulse of 115, pitting edema in lower extremities, but denies any seizure like activity at this time. Patient denied any past history of hypertension. Patient is on 4lpm of oxygen, on cardiac monitor, and has 2 bilateral IVs. Patient is also negative on stroke scale and a BG level of 106. ETA 5 minutes. Any questions"?




Yeah, we're not to "diagnose" but our lessons include a field impression "suspected MI" or whatever. That's why I asked. Last thing you'd want to do is panic a preggo!!


----------



## luke_31 (Apr 13, 2015)

Easiest thing as a new EMT is to be reassuring to the patient and their family and relay that you are treating them appropriately and that the hospital will help even further.


----------



## COmedic17 (Apr 13, 2015)

Your field diagnosis is for reporting reasons only. But don't lie to your patient. I would just say " I'm a little concerned with your blood pressure since you have no history of hypertension. How about we get it checked out at the hospital just to make sure everything's ok?"
 I, however, would not say " I think you might have pre-eclampsia". Or " all your symptoms say you have pre-eclampsia".


----------



## chaz90 (Apr 13, 2015)

I think you can absolutely talk to some patients about what their problem seems to be. In your original post you mentioned a 7 month old with croup. In that case, I think it would be quite fair to explain to the parents what you believe the issue is, how you're going to treat their child, how you know the child is fairly stable and in no immediate danger, and that there are still other potential differential diagnoses that the hospital/ED staff will be investigating and treating. I do this kind of stuff all the time. 

To an obvious stroke patient and their family: "Sir/Ma'am, you're going to hear me call the hospital and use the term "stroke alert." I know this is scary and you've never had a stroke before, but it looks like you're likely having one right now. Fortunately, you called for help early after your onset of symptoms and we and the hospital are going to do everything we can to help you."

I do almost the same thing for STEMI alerts, but with even more emphasis on the "you appear to be having a heart attack; we are going to take good care of you; survival rates for this condition with modern medicine are absolutely remarkable." 

We do diagnose! Our diagnoses may not be as precise as the discharge diagnosis or as accurate in some cases, but every treatment plan we work on involves a diagnosis on some level. Some may be terribly vague, IE "AMS; unknown etiology with hypoglycemia ruled out and OD deemed unlikely," but these are still working diagnoses that allow us to treat and proceed. In some cases, our field impressions absolutely are the diagnosis and we know this with nearly 100% certainty before arriving at the ED. The challenge lies in remaining open to changing your mind as the patient's presentation changes and recognizing our potential for inaccuracy.


----------



## Amelia (Apr 13, 2015)

chaz90 said:


> I think you can absolutely talk to some patients about what their problem seems to be. In your original post you mentioned a 7 month old with croup. In that case, I think it would be quite fair to explain to the parents what you believe the issue is, how you're going to treat their child, how you know the child is fairly stable and in no immediate danger, and that there are still other potential differential diagnoses that the hospital/ED staff will be investigating and treating. I do this kind of stuff all the time.
> 
> To an obvious stroke patient and their family: "Sir/Ma'am, you're going to hear me call the hospital and use the term "stroke alert." I know this is scary and you've never had a stroke before, but it looks like you're likely having one right now. Fortunately, you called for help early after your onset of symptoms and we and the hospital are going to do everything we can to help you."
> 
> ...




I did take into account that they'd be grabbing me by the collar, shaking me and scraming "what's wrong with me?!?!" he he. But I'm sure we'll be asked that in a less-dramatic way. But if I see a pregnant woman (for example) and she has pitting edema and high bp and she has a headache and we're screaming down I-29 and she asks, I don't think I could lie and say that I didn't know. We're always taught to be honest. But if they'd ask, I would be pretty vague and let them know that the drs would know what is going on and how to treat it. However,  it would be hard for me not to say, "IF it is pre-e, I've had it twice, the docs took care of me so that I can come help you now." Or something of the like. Its all about the patient, right?  (no sarcasm, I promise.)

And that ^ is me hyped up on way too much caffeine after class- talking about... OB/GYN. he he


----------



## STXmedic (Apr 13, 2015)

chaz90 said:


> I think you can absolutely talk to some patients about what their problem seems to be. In your original post you mentioned a 7 month old with croup. In that case, I think it would be quite fair to explain to the parents what you believe the issue is, how you're going to treat their child, how you know the child is fairly stable and in no immediate danger, and that there are still other potential differential diagnoses that the hospital/ED staff will be investigating and treating. I do this kind of stuff all the time.
> 
> To an obvious stroke patient and their family: "Sir/Ma'am, you're going to hear me call the hospital and use the term "stroke alert." I know this is scary and you've never had a stroke before, but it looks like you're likely having one right now. Fortunately, you called for help early after your onset of symptoms and we and the hospital are going to do everything we can to help you."
> 
> ...


Quoted for emphasis.


----------



## Amelia (Apr 13, 2015)

With the croup all I said was "Oh there it is! I know that caugh." When he coughed. Other than that I said that he was adorable, and giggly and a pretty happy little guy. Geeze, this kid was adorable.

I was asked by one pt who was in for an asthma attack (older gentlemen, smoker) how he was supposed to exercise like his Dr wanted if he had this pinched nerve in his leg (sciatica, I'm assuming) without aggravating his asthma. Doc suggested walking but he said he didnt like that and that it made him too short of breath (hmmm, maybe quit smoking then??). I mean he was really asking me! I told him to ask his Doctor if yoga may be appropriate? I told him that if the Dr says its ok, gentle yoga may not aggravate his asthma and is good exercise." Heavy on the "IF YOUR DR SAYS ITS OK."  I said that probably 4-5 times in the 3 minute conversation he asked. 

I hope that wasn't out of line.


----------



## Amelia (Apr 13, 2015)

So honest but vague, and let the Drs take all of the heat.


----------



## Handsome Robb (Apr 13, 2015)

I tell patients what my working diagnosis or diagnoses is/are all the time. Like others have said it's always "because of this this and this I'm thinking this. But it could be this this this or this. Without further tests we can't be sure until the doctor sees you."

As far as withholding oxygen if you have a patient with chest pain and shortness of breath and is tachypneic but also has a history of anxiety, carpal pedal spasms and a normal SpO2 putting oxygen on them isn't going to help and potentially could draw out the episode creating a longer period of discomfort for the patient since they don't need oxygen, they need to slow their RR down and retain more CO2. 

Nothing says you have to put a NRB on patients with a complaint of chest pain and/or shortness of breath and frankly you can cause them hard of you do. Hyperoxygenation is bad for patients.


----------



## chaz90 (Apr 13, 2015)

Amelia said:


> I did take into account that they'd be grabbing me by the collar, shaking me and scraming "what's wrong with me?!?!" he he. But I'm sure we'll be asked that in a less-dramatic way. But if I see a pregnant woman (for example) and she has pitting edema and high bp and she has a headache and we're screaming down I-29 and she asks, I don't think I could lie and say that I didn't know. We're always taught to be honest. But if they'd ask, I would be pretty vague and let them know that the drs would know what is going on and how to treat it. However,  it would be hard for me not to say, "IF it is pre-e, I've had it twice, the docs took care of me so that I can come help you now." Or something of the like. Its all about the patient, right?  (no sarcasm, I promise.)
> 
> And that ^ is me hyped up on way too much caffeine after class- talking about... OB/GYN. he he



Deliberate obfuscation is rarely necessary. If a patient asks me what I think is wrong with them, I answer truthfully. As an important caveat, that means I sometimes admit to them that I have no idea but am proceeding as if it could be X, Y, or Z. I often attach modifiers like "this looks like" or "it seems", but I'm always honest.

I think what you've mentioned sounds perfectly appropriate. Explain what it seems to be, that you could be mistaken, and that either way you and the people at the next step of care are going to help out as much as possible. People react well to honesty and don't like having their questions dodged. I think any instructor trying to tell you differently is doing his students a disservice or not getting his point across effectively.


----------



## Amelia (Apr 13, 2015)

Handsome Robb said:


> I tell patients what my working diagnosis or diagnoses is/are all the time. Like others have said it's always "because of this this and this I'm thinking this. But it could be this this this or this. Without further tests we can't be sure until the doctor sees you."
> 
> As far as withholding oxygen if you have a patient with chest pain and shortness of breath and is tachypneic but also has a history of anxiety, carpal pedal spasms and a normal SpO2 putting oxygen on them isn't going to help and potentially could draw out the episode creating a longer period of discomfort for the patient since they don't need oxygen, they need to slow their RR down and retain more CO2.
> 
> Nothing says you have to put a NRB on patients with a complaint of chest pain and/or shortness of breath and frankly you can cause them hard of you do. Hyperoxygenation is bad for patients.



My feeling on this was (and is as an inexperienced student at this point of time), couldnt you put the NRM on with a low flow of O2? I know you can control the concentration, but it may help the pt feel better and calm her down a bit? Or even just a nasal cannula? I'm thinking more of a placebo "here's some oxygen so you know you're getting oxygen into your body" reassurance.


----------



## Flying (Apr 14, 2015)

Amelia said:


> My feeling on this was (and is as an inexperienced student at this point of time), couldnt you put the NRM on with a low flow of O2? I know you can control the concentration, but it may help the pt feel better and calm her down a bit? Or even just a nasal cannula? I'm thinking more of a placebo "here's some oxygen so you know you're getting oxygen into your body" reassurance.


In a person who is perfusing well but you deem it appropriate to try calming them with oxygen, try titrating from 0 L/min.
Start with a nasal cannula at no flow and increase the flow in small increments. You might be surprised at how many people get better around 0-2 L/min.


----------



## Amelia (Apr 14, 2015)

Plus, when I was in the back of a truck as a patient, they threw a nasal cannula on me first thing and I didn't have any dyspnea. I have no clue what my O2 stats were, but still... a lady is gasping and writhing in pain.... I'd want to do a little something. Infant concentration or something. But that's me. Make her feel better and her anxiety may come down and maybe then she'd regain some mental stability since it was all stress related.


----------



## Amelia (Apr 14, 2015)

Flying said:


> In a person who is perfusing well but you deem it appropriate to try calming them with oxygen, try titrating from 0 L/min.
> Start with a nasal cannula at no flow and increase the flow in small increments. You might be surprised at how many people get better around 0-2 L/min.




That's exactly what I was thinking. But this job is all about treating the patient as a hole, your gut, and adaptation to help the person. Hell, I'd maybe even just throw the NRM on her w/o oxygen and see if that calms her down a bit, since its all in her head anyway and her body reacting to how her head is not dealing with this news well.


----------



## Amelia (Apr 14, 2015)

But you guys are very right- and the last thing I'd want to do is cause her to hyperoxygenate- very very valid point. I'm starting to get all of this pieced out thanks to you guys.  Lots of stuff to consider that I haven't thought of.


----------



## Flying (Apr 14, 2015)

For this specific purpose, I would make a point on choosing a NC over a mask because the person is more likely to feel the flow of air at lower pressures, contributing to any placebo effect.

I find it fantastic that you are more in tune with the needs of the people who we transport than those who have been in EMS for x years. People will thank you for providing something tangible in terms of their treatment. (Some may appreciate our good buddy Fentanyl more, but that's another story.)


----------



## Amelia (Apr 14, 2015)

Oh, I don't get the Fentanyl friend for a while, which is very sad. Paramedic school is in my future, but not for a few years.  But thank you for the compliment. I just kept wishing I could do more other than hug her sister and daughter (I'm not paid staff, I can do that!)


----------



## NYBLS (Apr 14, 2015)

If you believe anxiety may be a root cause then oxygen is not the answer for two reasons. One, its never a good plan to give a drug to see if it may help. You only give a drug with a specific goal in mind and possible reactions and preparations to treat those reactions. Second, if it is anxiety related the patient will now believe they need oxygen to get through another anxiety related problem. Plus a NRB mask will make anyone anxious, try strapping one on your face after taking a short jog or doing some jumping jacks.


----------



## Amelia (Apr 14, 2015)

NYBLS said:


> If you believe anxiety may be a root cause then oxygen is not the answer for two reasons. One, its never a good plan to give a drug to see if it may help. You only give a drug with a specific goal in mind and possible reactions and preparations to treat those reactions. Second, if it is anxiety related the patient will now believe they need oxygen to get through another anxiety related problem. Plus a NRB mask will make anyone anxious, try strapping one on your face after taking a short jog or doing some jumping jacks.



She just kept asking for help to breathe. I think this situation is that little gray area between what we are taught in class and what is going on in the situation. Like I said- nasal cannula or NRM if she wants help to breathe with a tiny bit of O2 to make her feel better? I'd call the MD for sure before administering anything unless the Paramedic oks it. But that just seemed like it would be the step I would take if she were in my truck and I had say. I mean, if someone is yelling "help me, I can't breathe!" Do you just ignore her? Her mental status was so messed up that our coaching sure didn't work.


----------



## Amelia (Apr 14, 2015)

I"m really not being facetious. I'm still in that separation of head vs. heart. I just would have liked her to feel like she was getting some help is all. Even if all someone did was throw a NC around her ears and called it good. But shoulda-woulda-coulda, right?  I'm learning! I'm learning!


----------



## Gurby (Apr 14, 2015)

Amelia said:


> couldnt you put the NRM on with a low flow of O2?



I don't think this is actually possible because of the way a NRB works - oxygen fills up the reservoir, and then the patient inhales that.  If the O2 isn't flowing at a high enough rate, the bag won't be inflated, and the patient won't have any air to breathe (well not really, because 1 of the vent flap thingies is usually removed, which stops it from being a true non-rebreather).


----------



## epipusher (Apr 14, 2015)

Who are really wanting to help in this situation? Who are you really trying to help feel better? The patient or yourself?


----------



## Tigger (Apr 14, 2015)

Amelia said:


> She just kept asking for help to breathe. I think this situation is that little gray area between what we are taught in class and what is going on in the situation. Like I said- nasal cannula or NRM if she wants help to breathe with a tiny bit of O2 to make her feel better? I'd call the MD for sure before administering anything unless the Paramedic oks it. But that just seemed like it would be the step I would take if she were in my truck and I had say. I mean, if someone is yelling "help me, I can't breathe!" Do you just ignore her? Her mental status was so messed up that our coaching sure didn't work.


Oxygen does not magically give someone their ability to catch their breath. Odds are if someone is yelling at you that they can't breathe, they are breathing just fine. Now if they can barely speak more than a few words you might have a problem. That would probably be a good time to assess your patient then. It might behoove you to listen to their lung sounds, if they are moving good air and have clear fields throughout and are satting well and are yelling at you? They probably don't need oxygen.

Also, now would be a great time to kill the placebo idea. There is no reason to administer a medication unless you want its actions. Oxygen is not a pain reliever nor an anti-anxiety agent. Oxygen is a drug like any other, and has indications. We don't give our patients tubes of glucose to make them feel better cared for either, right?


----------



## Amelia (Apr 14, 2015)

Thats very true. Learning through experience and those much wiser, eh?


----------



## Amelia (Apr 14, 2015)

Epi- her. Im a very selfless person as would indicate my husbands and boys clothes are clean and mine are neglected until I find no clean clothes (oh yeah- i need to take care of myself too) i just need to be ok with "theres nothing else I can do." But im hoping that in the "zone" ill feel differently. The ED is not my territory, shall we say?


----------



## Aprz (Apr 14, 2015)

Tigger said:


> We don't give our patients tubes of glucose to make them feel better cared for either, right?


----------



## Tigger (Apr 14, 2015)

luke_31 said:


> 1: oxygen doesn't need to be given if sats are normal in the ED. As an EMT you should never withhold oxygen from a patient who has those complaints.



What exactly is the difference? If the ED is basing whether or not to provide oxygen only on spO2, why aren't we? For that matter do we really think the ED is basing their decision based purely on a number? Of course not. They assess the patient and determine what interventions are needed. EMS can do that too. I've said already, but if someone is yelling at you that they can't breathe, they can breathe just fine and need to be calmed down.



COmedic17 said:


> 2. Your not a doctor. You can't diagnose people. You can tell them the signs and symptoms, and they will understand what you are getting at. That's why you call cardiac "alerts" and stroke "alerts". You can alert the hospital to a POSSIBLE life threatening condition, but you can't diagnose it.


Doctors do not have a monopoly over the term "diagnose." Call it what you will, but it's silly to say that EMS does not diagnose. If we didn't diagnose (definition: identify the nature of (an illness or other problem) by an examination of the symptoms), how are we justifying our treatments?



Flying said:


> For this specific purpose, I would make a point on choosing a NC over a mask because the person is more likely to feel the flow of air at lower pressures, contributing to any placebo effect.
> 
> I find it fantastic that you are more in tune with the needs of the people who we transport than those who have been in EMS for x years. People will thank you for providing something tangible in terms of their treatment. (Some may appreciate our good buddy Fentanyl more, but that's another story.)


Alternatively, when you provide an improper medication you are just practicing bad medicine. Oxygen is medication just like fentanyl is. Not to mention that not every patient will respond well to such a treatment. Perhaps placing oxygen on someone will only worry them more...



Amelia said:


> Epi- her. Im a very selfless person as would indicate my husbands and boys clothes are clean and mine are neglected until I find no clean clothes (oh yeah- i need to take care of myself too) i just need to be ok with "theres nothing else I can do." But im hoping that in the "zone" ill feel differently. The ED is not my territory, shall we say?


Sometimes you won't have the treatments the patient needs, sometimes the patient does not need any treatment. There is a distinct difference there.


----------



## COmedic17 (Apr 14, 2015)

Tigger said:


> *What exactly is the difference?* If the ED is basing whether or not to provide oxygen only on spO2, why aren't we? For that matter do we really think the ED is basing their decision based purely on a number? Of course not. They assess the patient and determine what interventions are needed. EMS can do that too. *I've said already, but if someone is yelling at you that they can't breathe, they can breathe just fine and need to be calmed down.*
> 
> 
> Doctors do not have a monopoly over the term "diagnose." Call it what you will, but it's silly to say that EMS does not diagnose. If we didn't diagnose (definition: identify the nature of (an illness or other problem) by an examination of the symptoms), how are we justifying our treatments?
> ...




The difference is about 9+ years of medical schooling. 


Also, my protocol says ANYONE complaining of SOB or difficulty breathing gets atleast some 02. 

In addition, Your confusing a field impression with an actual clinical diagnosis. 

I can think someone has hyperkalemia due to other symptoms and field tests (vitals, EKG, etc),but until I have labs, all it is is a field impression of what I THINK is probably wrong. I do not have a ct scan. I can't diagnose a stroke. I can say someone failed the Cincinnati stroke scale, is hypertensive, and I am fairly certain they are having a stroke, but without a head scan I can not diagnose it. 

So no. We do not diagnose. Our treatments are based off of a field impression of what's probably wrong, based on signs and symptoms. It is not definitive.


----------



## Tigger (Apr 14, 2015)

COmedic17 said:


> The difference is about 9+ years of medical schooling.
> 
> 
> Also, my protocol says ANYONE complaining of SOB or difficulty breathing gets atleast some 02.
> ...


That is a purely semantic argument. A doctor's diagnosis is not carved in stone either. Field impression, working diagnosis, whatever else you call it, it's all the same. You take the information provided to you and make an educated assessment as to what is causing the patient's issues. But I digress, this is not a fight worth having. 

And spare us the "my protocol" argument, you can do better than that. Critical thinking, it's a thing. Assess your patients and treat appropriately. Most (if not all) protocols are prefaced with something along the lines of (borrowed from my book):



> These protocols are guidelines and cannot be expected to cover all clinical conditions and patient variables. On occasion, patient presentations may be handled with some deviation by providers.


.

Use clinical judgement. If you are justifying anything with "my protocols said so," you have not justified it at all.


----------



## PotatoMedic (Apr 14, 2015)

I'm having a hard time finding it but at one of the big EMS conferences there were a bunch of MD's (that is Medical Doctor if you didn't know (sorry couldn't resist)) that said paramedics do diagnose.  I'll keep looking because jems or emsworld did a thing on it.


----------



## Amelia (Apr 14, 2015)

You know what I should have sone is to ask the family to keep coaching her on her breathing. Im sure they were just as exhausted and stressed as she was. They probably needed some coaching too. I am very glad, however that she is ok and hopefully rested up.


----------



## Amelia (Apr 14, 2015)

And that's where I was confused- protocol vs common sense vs developing EMS critical thinking.


----------



## Flying (Apr 14, 2015)

The whole bit with the oxygen is a bit silly, my fault for encouraging off-label use.

I've always liked the idea of having a diagnosis to work with. Ideally, every call gets a basic assessment/history, from which we gain a theory or idea that we base our logistical decisions on.
Our theory will never be refined by laboratory data, but we still decide to order our priorities with the information we have.

How do we justify not going L&S on every call when we say we cannot tell what is truly going on? It seems to be more reasonable to say based on x findings we can say that this person won't die within the minute, and would appreciate a slow and smooth ride to the hospital.

Sorry in advance for beating the horse.


----------



## Ewok Jerky (Apr 14, 2015)

ED Doctors diagnose all the time, and then the hospitalist comes along and gives another diagnosis, and then the PA discharges with a third diagnosis.

Use your assessment skills to create a WORKING  diagnoais, use your clinical judgment to treat accordingly using protocols as a guideline. Act in the beat interest of your patient. You are a professional medical practitioner, have some respect!


----------



## Tigger (Apr 15, 2015)

Amelia said:


> And that's where I was confused- protocol vs common sense vs developing EMS critical thinking.


Use it all! There is no reason why any of that need by mutually exclusive. 

You probably see my big point now, your assessment is the most important part. Don't measure yourself based on what you can or cannot provide for your patient.


----------



## Amelia (Apr 15, 2015)

I got it.  Thanks guys. You're right, I need to trust my training and critical thinking more.


----------



## Amelia (Apr 15, 2015)

Better for an EMT to ask too many questions than not enough, eh?


----------



## chaz90 (Apr 15, 2015)

Amelia said:


> Better for anyone to ask too many questions than not enough, eh?


Fixed it for you


----------



## Gurby (Apr 15, 2015)

Let me tell you a story to confuse you more:

During my medic hospital time in the ED, a patient comes in having a psychotic break, completely out of control, ends up getting restrained and sedated.  I go in to check on the patient a little while later, notice pt is not hooked up to any monitoring (?!?!?!) and is snoring.  I figure I'll put pt on the pulse oximetry at least.  I have some trouble getting a good reading from it - pt has red nail polish, maybe bad circulation, I just can't get a number that's over 80... But hmmm, the pleth is good.... I went to find a nurse and said something like, "could you check on room x?  I'm sure it's nothing, but I can't get a good reading from the pulse ox".

Of course, as I should have known already, if you're getting a good pleth, the pulse ox is probably not lying to you, and the patient really did have an O2 sat in the 70's - maybe OD'd a little with sedatives and not protecting her airway or something.

In this situation I should have corrected the (in hindsight) extremely obvious problem, and THEN gone to talk to a nurse about it.  It would have taken no time at all to manually readjust patient, open the airway, and put a NRB on.  I was in "don't do anything unless you're told to" mode, which isn't a bad thing I guess when you're in the hospital, but in this situation I should have acted first and asked questions later.

Just some food for thought.


----------



## Amelia (Apr 15, 2015)

It is something to consider. I emailes my instructor to get her opinon too. She would know the local protocol is. But I think I would feel bad not giving her o2 as long as her SpO2 was under 99% (it was 95)  since 93% is mich closer to 94%


----------



## Amelia (Apr 15, 2015)

*much *emailed, and my fingers arent functioning properly apparently from copious amounts of note taking.


----------



## Amelia (Apr 15, 2015)

Let me ask this then: (keep in mind I'm a student) If you go to a pt. who has symptoms of an  MI, would you give them nitro to be safe? Like elevated BP because of an anxiety attack and chest pain, etc etc etc


----------



## Amelia (Apr 15, 2015)

*if he already has nitro prescribed to him and standing orders of course.


----------



## Tigger (Apr 15, 2015)

Amelia said:


> It is something to consider. I emailes my instructor to get her opinon too. She would know the local protocol is. But I think I would feel bad not giving her o2 as long as her SpO2 was under 99% (it was 95)  since 93% is mich closer to 94%


I'm not really sure what you are trying to say here. But regardless, it doesn't really matter how you feel about the whole thing. Take yourself out of the equation, we provide treatments based on evidence and not feelings. 



Amelia said:


> Let me ask this then: (keep in mind I'm a student) If you go to a pt. who has symptoms of an  MI, would you give them nitro to be safe? Like elevated BP because of an anxiety attack and chest pain, etc etc etc



What are the indications for the nitroglycerin? What do you mean "to be safe?"


----------



## Amelia (Apr 15, 2015)

I overthink things. You're right. I need to "Let it Go" (queue music)


----------

