Any comments on this one......

[Aidey]

Protocols are written for the lowest common denominator. The protocols I work under probably cover ~500 paramedics, but when a couple of guys screwed up with the Lasix it was nearly taken away from everyone.

 

[MrBrown]

Ok, however, arent the protocols for EMT's written by MD's ????

Yes however it seems to Brown that many of them got their MD out the Weet Bix box and that many Paramedics got their Paramedic cert out out the same box.

There was no clinical indication for oxygen in this patient, let Brown repeat, there was no clinical indication for oxygen in this patient.

Try this on for size

1.4 OXYGEN ADMINISTRATION
Few sections contain specific instructions on oxygen and clinical
judgement is required. Oxygen does not necessarily provide benefit
and should usually only be given if the patient has:
• An abnormal airway or
• Moderate or worse respiratory distress or
• Shock or
• Inability to obey commands as a result of an acutely depressed
level of consciousness or
• Unrelieved cardiac chest pain or
• Smoke or toxic gas inhalation or
• An oxygen saturation <95% on air (unless they have COAD – see
COAD section).

Use the simplest device and lowest flow of oxygen that will achieve
the desired oxygen saturation, but do not spend time making
multiple adjustments.

Most patients will only require nasal prongs or an acute (ordinary) mask.
Non-rebreather masks should be reserved for when higher levels of inspired oxygen
are required and manual ventilation bags should be reserved for patients requiring
assistance with their airway and/or breathing.

If pulseoximetry is unreliable give oxygen as appropriate based on the above bullet points.

The oxygen flow rates to be used are:
• Nasal prongs 2-4 l/min.
• Acute (ordinary) mask 4-6 l/min.
• Nebulised drugs 8 l/min.
• Non-rebreather mask 6-8 l/min. Check that the valves are opening
and closing correctly. The flow rate should be the minimum
required to ensure that the reservoir bag does not fully deflate.
• Manual ventilation bag 8-10 l/min. Check that the valves are
opening and closing correctly. The flow rate should be the
minimum required to ensure that the reservoir bag does not fully
deflate. The most common cause of a deflating reservoir bag is an
excessive manual ventilation rate and/or an excessive tidal
volume.

Commentary
Oxygenation is not the same as ventilation. A patient can be well
oxygenated but barely breathing and a patient can be breathing
well but be poorly oxygenated. A pulseoximeter, providing it is
working correctly, tells you how much oxygen is bound to
haemoglobin as a percentage of maximum capacity, it does not tell
you how well the patient is breathing. Pulseoximeters can be
unreliable if the patient is cold, shocked, moving, shaking, has very
dirty fingers, or has been exposed to carbon monoxide. Do not
spend long periods of time trying to get a pulseoximeter reading
and always look at the patient rather than the pulseoximeter

 

[emt seeking first job]

Written by MDs, but they're often out of date, and assume EMTs aren't educated enough to know when oxygen is indicated.

Ask yourself, do you want to be "that guy" protocols like this are written for.

Well if god forbid, the patient has a bad outcome, I would want to be that guy who can defend his actions with the protocols.

I dont want to be that guy who has to explain why he did not follow the protocols.

Seven years in insurance claims left me with the impression that its best to follow what the standard procedure is.

 

[emt seeking first job]

Yes however it seems to Brown that many of them got their MD out the Weet Bix box and that many Paramedics got their Paramedic cert out out the same box.

There was no clinical indication for oxygen in this patient, let Brown repeat, there was no clinical indication for oxygen in this patient.

Try this on for size

The crew chief told me to adminster the 02.

The paramedics never told me to remove it.

There was no clinical indication that oxygen was detrimental to the patient.

We were < five minutes away from the ER.

It is hard to get obtain even an unpaid emt position in NYC.

 

[MrBrown]

Well if god forbid, the patient has a bad outcome, I would want to be that guy who can defend his actions with the protocols.

I dont want to be that guy who has to explain why he did not follow the protocols.

Seven years in insurance claims left me with the impression that its best to follow what the standard procedure is.

Brown is sure that those at Nuremberg thought whatever they did was a good idea at the time too or they were just 'following orders'

 

[emt seeking first job]

Brown is sure that those at Nuremberg thought whatever they did was a good idea at the time too or they were just 'following orders'

I was waiting for someone to write that.

:wacko::wacko:

If someone in charge ordered me to do something illegal or against the protocols I would refuse and report him or her.

By orders I meant lawful and valid orders.

 

[MrBrown]

The crew chief told me to adminster the 02.

And what makes your clown of a crew chief more clinically qualified than you?

The paramedics never told me to remove it.

Probably because they actually know about 5% more than you do

*Brown goes to look in the kitchen for an open box of Weet Bix

There was no clinical indication that oxygen was detrimental to the patient.

Do you have a blood gas machine in your ambulance?

There is evidence that oxygen can be harmful to select groups of patients, while this patient may not be one of them there is good evidence showing hyperoxia and hyperventilation can be very harmful.

We were < five minutes away from the ER.

And this makes a difference how?

It is hard to get obtain even an unpaid emt position in NYC.

[/quote]

And this makes a difference how?

 

[reaper]

The crew chief told me to adminster the 02.

The paramedics never told me to remove it.

There was no clinical indication that oxygen was detrimental to the patient.

We were < five minutes away from the ER.

It is hard to get obtain even an unpaid emt position in NYC.

Ok guys and Gals,

Lets just drop all this education here. It is shown here that cookbook medicine is in play, just so a position can be kept.

 

[Shishkabob]

Ok, however, arent the protocols for EMT's written by MD's ????

To be technical, no. Med director just signs them as if they were his.

Protocols are written for the lowest common denominator. The protocols I work under probably cover ~500 paramedics, but when a couple of guys screwed up with the Lasix it was nearly taken away from everyone.

We have I'm guessing slightly more than 100 Paramedics at our agency... we used to have liberal pain protocols (and technically still do compared to many places) where we could go 1-2mcg/kg Fent multiple times.

A couple of months ago, it was switched to 1mcg/kg Fent for patients between 10-70years of age with acute pain... a max of two times.

Apparently a couple of retards severely over sedated patients...

 

[emt seeking first job]

I appreciate all these insights and I will keept them in mind.

I am just curious, next time, does anyone here as the junior person suggest I refuse to throw the NRB on the patient and prevent anyone else at the scene from doing so ?

The other people would order me to leave.

If I did not they would request the police respond.

I would be arrested, removed from the scene, and guess what....on goes the NRB mask anyway.

 

[MrBrown]

We have over 3,000 Ambulance Officers be they Technicians, Paramedics or Intensive Care Paramedics working under one set of what are technically "standing orders" ....

*Brown checks the drug bag, frusemide, yep, unlimited morphine, yep, suxamethonium yep thats there too hmmm ........

*Brown puts down the drug bag and goes to the kitchen to look for an open box of Weet Bix

 

[Veneficus]

can I just ask a question about all of this?

In all of the protocols I have ever worked under, somewhere in them was usually written something along the lines of:

"Guidlines not meant to replace sound medical judgement," "Administer oxygen as appropriate," or "initiate or withold treatment as appropriate."

Are any of these items in the protocol book?

 

[MrBrown]

I appreciate all these insights and I will keept them in mind.

I am just curious, next time, does anyone here as the junior person suggest I refuse to throw the NRB on the patient and prevent anyone else at the scene from doing so ?

The other people would order me to leave.

If I did not they would request the police respond.

I would be arrested, removed from the scene, and guess what....on goes the NRB mask anyway.

You do not have to put everybody on an NRB, most people only need 2-3 litres on a cannula, if oxygen is even indicated at all.

Medicine is not a one size fits all process unless you are a barely homeostasasing looser cookbook medic with poor cerebral perfusion

*Brown goes to the kitchen once again in search of an open Weet bix box

 

[lightsandsirens5]

Brown is sure that those at Nuremberg thought whatever they did was a good idea at the time too or they were just 'following orders'

That is the closest I have ever seen anyone come to breaking Goodwin's Law and still get away with it.

 

[emt seeking first job]

You do not have to put everybody on an NRB, most people only need 2-3 litres on a cannula, if oxygen is even indicated at all.

Medicine is not a one size fits all process unless you are a barely homeostasasing looser cookbook medic with poor cerebral perfusion

*Brown goes to the kitchen once again in search of an open Weet bix box

Once again, I thank you for the input and will bear that in mind for the day in the future when I am the crew chief.

In four months I worked my way up from the guy they tell to check over the rig to the guy they tell to show the newer guy how to check over the rig.

Does Brown want to come to Brooklyn, the South non-hipster part of Brooklyn and shake things up ?

Does he want to be that guy ?

 

[MrBrown]

Once again, I thank you for the input and will bear that in mind for the day in the future when I am the crew chief.

So you are somehow devoid of any clinical rationalisation or your opinion as an Ambulance Officer is null and void when you are involved in treating a patient?

 

[emt seeking first job]

"Goodwin's Law".

???

 

[emt seeking first job]

So you are somehow devoid of any clinical rationalisation or your opinion as an Ambulance Officer is null and void when you are involved in treating a patient?

One of the cardinal rules of the public safety professions is if you are the new guy, keep your ears and eyes open and your mouth shut.

Imagine if I had never joined the service. What would have happened any way ?

Remember, the doctors wife called US, the vollies instead of 911 for the paid people. These were people of means that could clearly have paid out of pocket (if they had no coverage). They had lived in their home for 50+ years. They had a good impression of our service....

Once again, does Brown want to come to Brooklyn and change things ?

 

[Veneficus]

So you are somehow devoid of any clinical rationalisation or your opinion as an Ambulance Officer is null and void when you are involved in treating a patient?

I think it is a cultural issue. Most of the people I have met from that neck of the woods live in some pseudomilitary, longevity = knowledge, never question the system because it works mentality.

It would be very difficult for any one person to suddenly challange that, especially on a scene.

Probably better to bring it up at the station.

Brown,

The US EMS providers are digging in their heels to retain the laborer/tech mentality. They want nothing to do with being free thinking individuals. A free thinking individual is responsible and accountable for their decisions and actions. It is the only way to preserve the idea that people are absolved from their responsibility because they were "just following orders."

Right or wrong, it is what it is.

Personally, if some healthcare punter/hobbyist came into my place and started coercing my family into letting them give me treatments that weren't indicated, I don't care if that person had 6 kids and a disabled wife to feed, I would make sure the next order they followed was: "clean out your locker and don't come back."

 

[emt seeking first job]

I think it is a cultural issue. Most of the people I have met from that neck of the woods live in some pseudomilitary, longevity = knowledge, never question the system because it works mentality.

It would be very difficult for any one person to suddenly challange that, especially on a scene.

Probably better to bring it up at the station.

Brown,

The US EMS providers are digging in their heels to retain the laborer/tech mentality. They want nothing to do with being free thinking individuals. A free thinking individual is responsible and accountable for their decisions and actions. It is the only way to preserve the idea that people are absolved from their responsibility because they were "just following orders."

Right or wrong, it is what it is.

Personally, if some healthcare punter/hobbyist came into my place and started coercing my family into letting them give me treatments that weren't indicated, I don't care if that person had 6 kids and a disabled wife to feed, I would make sure the next order they followed was: "clean out your locker and don't come back."

Just to clarify, he questioned the o-2, he did not refuse. We have had people refuse o-2, we have had people refuse back-boards, we have had familes call us and the patient refused. We get them to RMA, the family to witness, and withold whatever treatment was refused, or left entirely.

We get a lot of out of state sons and daughters call for their parents, the prents refuse, we state our case but if they still refuse we leave.

Had the patient in the original post flat out refused the o-2, we would have witheld. He mrely questioned it and was satisfied with our answer.