kidney stones and a bgl?

[Rialaigh]

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...

 

[DesertMedic66]

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.

 

[NomadicMedic]

More is missed by not looking, than not knowing.

 

[Rialaigh]

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.

 

[DesertMedic66]

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.

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.

 

[exodus]

Aren't SPo2 and BGL both considered vital signs?

 

[Rialaigh]

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.

 

[Medic Tim]

Aren't SPo2 and BGL both considered vital signs?

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

 

[mycrofft]

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.

 

[Aprz]

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).

 

[Carlos Danger]

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:

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).

 

[NomadicMedic]

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.

 

[Carlos Danger]

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.

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.

 

[NomadicMedic]

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.

 

[Carlos Danger]

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.

 

[mycrofft]

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.

 

[chaz90]

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.

 

[Luno]

Thank you...

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:

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...

 

[Handsome Robb]

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.

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.

 

[ghost02]

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

Do you know the rational, perchance?