Bgl invasive

[Akulahawk]

Just the opposite, a Basic would rule out stroke, e.g. with a quick Cincinnati stroke scale; since you can rule out many of the other issues and can get a good to fair educated guess that hypoglycemia is the issue than a little sugar probably wont hurt them even if it was something else. I know that there are rare issues that upping the glucose can interfere but the majority of the time, perhaps over 99% of the time this is not an issue and would be out of the scope of an EMT-B anyhow.



I agree with you and that was what I was trying to explain to Tigger is that in Pennsylvania ALL priority Pt's get high flow O2. You and I both know that the AHA says that is not the case but this is on the books for the EMT-B protocol.

Now I have noticed that in Philly the medics and up (ED staff) will listen to you if your a Basic and you have proven yourself. I don't know if this goes for other places as well?

The one big thing here is that your in CA and PA is mostly rural so their BLS protocols play the rule of averages and assume that medics are over 30 minutes away in most cases and the EMT-B has to act with a sense of urgancy. This doesn't really apply to me since I am in Philly. Pittsburgh and for a lesser degree Scranton are the same way but the remainder of this huge state is mainly utilizing a Basic EMS system using QRS and the like for its First Responders... Is Cali similar in that respect, I know that there is a lot of more city area so I would think that they have EMT-P's factored higher into their protocols in general? Tell me if this is so I am real curious to know.

So you can determine that a patient is having a CVA vs BGL problem from doing the Cincinnati Stroke Scale? Mind if I as you a quick question then? Since brain cells don't work when they don't have sufficient glucose entering them and they don't work when they don't have sufficient oxygen entering them, how is it possible to determine which is which without a glucometer to tell you what the blood glucose level is?

You see, the Cincinnati Stroke Scale is only going to be of diagnostic value when the patient normoglycemic... so in a patient with CVA symptoms, I'm going to try to rule out the most obvious problem: blood sugar levels that are too low.

 

[emergancyjunkie]

Are you certified yet as either an EMR or an EMT?

Also, you may want to get some good con-ed such as ACLS-B and maybe train to become an instructor because it will really help you know the topics in a whole new way. There is a lot of training out there and yes, hands on is highly recommended

Believe it or not I hold no ems cert as of now the most medical training I had before starting this was first aid merit badge in bsa and cpr

Sent from my Desire HD

 

[JPINFV]

Just the opposite, a Basic would rule out stroke, e.g. with a quick Cincinnati stroke scale; since you can rule out many of the other issues and can get a good to fair educated guess that hypoglycemia is the issue than a little sugar probably wont hurt them even if it was something else. I know that there are rare issues that upping the glucose can interfere but the majority of the time, perhaps over 99% of the time this is not an issue and would be out of the scope of an EMT-B anyhow.

Personally, I find it hard to believe that oral glucose is going to cause an abundance of harm if the patient was having a stroke. My problem is that a patient who is hypoglycemic can be a false positive under Cincinnati, and if I had to take a bet with a diabetic patient who was positive under Cincinnati and an unknown BGL, I'd bet that the patient was hypoglycemic, not suffering from a CVA.

I agree with you and that was what I was trying to explain to Tigger is that in Pennsylvania ALL priority Pt's get high flow O2. You and I both know that the AHA says that is not the case but this is on the books for the EMT-B protocol.

Looking through PA's BLS protocol, first there's the standard 'deviate if need be, contact med control if possible, document' line. It looks like BLS services can be approved for pulse oxymetry, so that's a place where I would make use of the 'get out of jail' card, and document my justification based off of AHA 2010 guidelines (actually based on 201, chest pain with a BP >100 isn't a "priority condition" requiring administration of high concentrations of oxygen.

I'll also note that the PA protocols exemplify everything wrong with the current EMS thought process. If a provider needs strict guidelines requiring the use of oxygen, then they shouldn't be in a position to operate without direct oversight.

The one big thing here is that your in CA and PA is mostly rural so their BLS protocols play the rule of averages and assume that medics are over 30 minutes away in most cases and the EMT-B has to act with a sense of urgancy. This doesn't really apply to me since I am in Philly. Pittsburgh and for a lesser degree Scranton are the same way but the remainder of this huge state is mainly utilizing a Basic EMS system using QRS and the like for its First Responders... Is Cali similar in that respect, I know that there is a lot of more city area so I would think that they have EMT-P's factored higher into their protocols in general? Tell me if this is so I am real curious to know.

California has a highly regionalized system based off of the counties. So the protocols and policies of one area can vary greatly from another area in the state. The urban areas are pretty much all paramedic first response, while the rural areas can vary, including a few that use an intermediate level (EMT-II).


Personally, when an emergency is occurring based off of assessment I agree that a sense of urgency needs to occur, but I don't think a sense of urgency can be required through protocols or policy. It has to happen because the provider is operating off of his or her education, training, and assessment of the situation. Additionally, very rarely is an emergency so serious that action needs to be taken without being able to conduct a decent assessment. The respiratory arrests, respiratory failures, and cardiac arrests are the exception, and then in those the initial stabilizing interventions should be self-evident.

 

[emergancyjunkie]

So you can determine that a patient is having a CVA vs BGL problem from doing the Cincinnati Stroke Scale? Mind if I as you a quick question then? Since brain cells don't work when they don't have sufficient glucose entering them and they don't work when they don't have sufficient oxygen entering them, how is it possible to determine which is which without a glucometer to tell you what the blood glucose level is?

Wouldn't the smell of the persons breath help tell you if its a diabetic emergancy or a cva

Sent from my Desire HD

 

[JPINFV]

Wouldn't the smell of the persons breath help tell you if its a diabetic emergancy or a cva

Sent from my Desire HD

Only a specific hyperglycemic emergency, but not all hyper or hypoglycemic emergencies.

 

[Jay]

So you can determine that a patient is having a CVA vs BGL problem from doing the Cincinnati Stroke Scale? Mind if I as you a quick question then? Since brain cells don't work when they don't have sufficient glucose entering them and they don't work when they don't have sufficient oxygen entering them, how is it possible to determine which is which without a glucometer to tell you what the blood glucose level is?

You see, the Cincinnati Stroke Scale is only going to be of diagnostic value when the patient normoglycemic... so in a patient with CVA symptoms, I'm going to try to rule out the most obvious problem: blood sugar levels that are too low.

The Cincinnati Stroke Scale by design is a strong indicator and will be 70% accurate per supporting studies. The main difference aside from this is that with a CVA you will more than likely see one-sided difficulty vs. two-sided due to the nature of the CVA. Besides you should have some kind of an indicator of hypoglycemia, the Pt themselves, family, a medic-alert tag or something and if that is the case of course you would be leaning towards hypoglycemia but then again what if someone is hypoglycemic (mild to moderate) and experiencing a CVA, wouldn't they more than likely be experiencing either right or left sided difficulty (along with a possible indicator of their BGL having an issue, e.g. their breath)?

 

[emergancyjunkie]

Only a specific hyperglycemic emergency, but not all hyper or hypoglycemic emergencies.

Ok. Would a patient present with one sided difficulty in a diabetic emergency.

Sent from my Desire HD

 

[Jay]

Personally, I find it hard to believe that oral glucose is going to cause an abundance of harm if the patient was having a stroke. My problem is that a patient who is hypoglycemic can be a false positive under Cincinnati, and if I had to take a bet with a diabetic patient who was positive under Cincinnati and an unknown BGL, I'd bet that the patient was hypoglycemic, not suffering from a CVA.



Looking through PA's BLS protocol, first there's the standard 'deviate if need be, contact med control if possible, document' line. It looks like BLS services can be approved for pulse oxymetry, so that's a place where I would make use of the 'get out of jail' card, and document my justification based off of AHA 2010 guidelines (actually based on 201, chest pain with a BP >100 isn't a "priority condition" requiring administration of high concentrations of oxygen.

I'll also note that the PA protocols exemplify everything wrong with the current EMS thought process. If a provider needs strict guidelines requiring the use of oxygen, then they shouldn't be in a position to operate without direct oversight.





California has a highly regionalized system based off of the counties. So the protocols and policies of one area can vary greatly from another area in the state. The urban areas are pretty much all paramedic first response, while the rural areas can vary, including a few that use an intermediate level (EMT-II).


Personally, when an emergency is occurring based off of assessment I agree that a sense of urgency needs to occur, but I don't think a sense of urgency can be required through protocols or policy. It has to happen because the provider is operating off of his or her education, training, and assessment of the situation. Additionally, very rarely is an emergency so serious that action needs to be taken without being able to conduct a decent assessment. The respiratory arrests, respiratory failures, and cardiac arrests are the exception, and then in those the initial stabilizing interventions should be self-evident.

Huh? That's exactly what I said! That a little sugar won't hurt anybody and that according to the latest AHA protocols the Pt usually won't require O2, I was saying that in PA they do for some odd reason. But that's PA for you! Read again what I wrote, for some reason your stating the complete opposite. Also, I know what you are talking about with the SpO2 requirements in PA but that is by unit approval only. For individuals look up the state matrix, it will show everyone from FR through Medic and what they can and cannot do, SpO2 is listed for BLS providers with training only and is a number or asterisk on the form. I will try that for my "Get out of jail card"

Thanks for cleaning up about CA but remember that there are no Intermediate providers here yet, just BLS or ALS and most crews in rural areas run BLS only! AEMT will be the first ever intro to EMT-I level providers in the state.

 

[Jay]

Believe it or not I hold no ems cert as of now the most medical training I had before starting this was first aid merit badge in bsa and cpr

Sent from my Desire HD

Are you in school now for EMT?

 

[emergancyjunkie]

Are you in school now for EMT?

Yeah. Had the option back in high school but passed on it for welding

Sent from my Desire HD

 

[JPINFV]

Ok. Would a patient present with one sided difficulty in a diabetic emergency.

Sent from my Desire HD

The main difference aside from this is that with a CVA you will more than likely see one-sided difficulty vs. two-sided due to the nature of the CVA.

It can present 1 sided, and is one of the reasons why the Los Angeles Prehospital Stroke Scale includes hypoglycemia as a rule out (it's specificity and sensitivity are both in the mid to upper 90%s).

 

[JPINFV]

Huh? That's exactly what I said! That a little sugar won't hurt anybody and that according to the latest AHA protocols the Pt usually won't require O2, I was saying that in PA they do for some odd reason. But that's PA for you!

I'm actually saying, based off the oxygen administration and BLS assessment section (201 and 202) that administration of high concentration of supplemental oxygen is not required unless the patient is hypotensive.

Thanks for cleaning up about CA but remember that there are no Intermediate providers here yet, just BLS or ALS and most crews in rural areas run BLS only! AEMT will be the first ever intro to EMT-I level providers in the state.

To be fair, the EMT-II level was only recognized in maybe 2 or 3 counties n the entire state (we've since moved to AEMT, but the EMT-IIs are grandfathered in at their old scope), and there were so few that they might as well not have existed for the vast majority of the state.

 

[Akulahawk]

It can present 1 sided, and is one of the reasons why the Los Angeles Prehospital Stroke Scale includes hypoglycemia as a rule out (it's specificity and sensitivity are both in the mid to upper 90%s).

And thus the reason why I check blood glucose levels. Ruling out blood sugar problems as a cause of the symptoms allows the test greater accuracy. CPSS just isn't as sensitive or specific as the LAPSS is, as JP indicates above.

 

[Tigger]

I think it should be an option and the EMT-B should be able to take a BGL on the stable Pt but it should be out for a "Priority" Pt.

I fail to follow your reasoning on why only the less sick patients should get a full set of vitals. Sorry, but if you have a sick patient and you suspect a hypo/hyperglycemic cause, a BGL should be obtained. The patient could do it themselves, there is no reason that a competent basic trained (shown) the use of glucometer should not be able to do this. Seconds rarely, if ever count in an emergency and thinking they do will only lead to rushed, less than excellent care.

Also, what is this with categorizing patients as "priority" and "stable." Treat the patients symptoms. If the patient is sick and you're on a BLS truck and out of treatments, get medics or initiate transport.

In PA even SpO2 is not generally allowed for a BLS provider and what does that take... 10 seconds... If that? The state does recognize the ACLS-B course and does allow BLS providers to take an SpO2 after having their ACLS-B certificate (8 hours) but they can very well yank your numbers for doing this without the ACLS-B training. I know it is sort of stupid but you probably know that there are some EMT-B's out there that can barely do their current scope of practice and anything else will confuse them, well guess what, the state of PA [and a ton of other ones out there] will hold off these *simple* procedures for what, maybe 5% of the certified population of Basics. It does suck, I agree with you but everything here is coming from information that I either heard or read on the state level!

Wait, you need a class to use a pulse oximeter? That's terrible. SpO2 is non-invasive and I look at as just another vital sign. Could I do without the reading? Of course I can, but it is really useful for telling off protocol monkeys that insist on giving 02 to every remotely sick patient regardless of respiratory status. I know the patient doesn't need supplemental 02 from my assessment, but if I my partner still questions me I can show him the reading and suddenly he believes me...

I agree with you and that was what I was trying to explain to Tigger is that in Pennsylvania ALL priority Pt's get high flow O2. You and I both know that the AHA says that is not the case but this is on the books for the EMT-B protocol.

Now I have noticed that in Philly the medics and up (ED staff) will listen to you if your a Basic and you have proven yourself. I don't know if this goes for other places as well?

I have not placed someone on an NRB in the last four months, and I absolutely, positively refuse to put someone on 02 just because that's what my textbook said to. A NC is usually sufficient to remedy any respiratory distress, should it be present. Oxygen is not a wonder drug, if it's not indicated my patient isn't getting it.

One of the best ways to show the ER staff that you are better than average bottom-feeding basic is to utilize your critical thinking skills and determine what interventions will actually benefit the patient. The ER staff is not going to think you (plural) are a good provider/are cool because you put someone on oxygen "just in case," they are going to think you (plural) are a moron that is incapable of doing anything besides religiously following the protocol book.

As JP noted, nearly every protocol book makes it very clear that the protocols are "treatment guideline" that one can deviate from provided it is justifiable and in the patient's best interest. Incidentally, the Massachusetts protocols no longer call for blanket 02 treatments, it leaves that up to the discretion of the provider.

 

[18G]

In PA even SpO2 is not generally allowed for a BLS provider and what does that take... 10 seconds... If that? The state does recognize the ACLS-B course and does allow BLS providers to take an SpO2 after having their ACLS-B certificate (8 hours) but they can very well yank your numbers for doing this without the ACLS-B training. I know it is sort of stupid but you probably know that there are some EMT-B's out there that can barely do their current scope of practice and anything else will confuse them, well guess what, the state of PA [and a ton of other ones out there] will hold off these *simple* procedures for what, maybe 5% of the certified population of Basics. It does suck, I agree with you but everything here is coming from information that I either heard or read on the state level!

I was an EMT for about 15yrs in South-Central, PA and EVERY BLS ambulance and most QRS units had a pulse oximeter. And what is the ACLS-B course? Being a PA EMS provider since I was a teen-ager I have never even heard of this course in PA let alone it being a requirement to use a pulse oximeter. Is this new in the past year?

The only requirement that I am aware of in PA for EMT's to use pulse oximetry is learning it through some form of continuing education. Honestly, the majority of EMT's never had formal education on using a pulse oximeter. I never did when I was an EMT... Granted I think EMT's should have formal education on using it (should be included in Basic).

And also, the new PA protocol are very specific in addressing the oxygen needs of the patient. No longer is the blanket treatment of 100% O2 in the protocols. It specifically states titrate SpO2 >94% in many of the protocols.

 

[CAOX3]

We never had spo2 up until about five years ago, I use it now because it's a required vital sign for asnt suspected respiratory distress patient. The problem I see is new providers rely on it, some couldn't even distinguish between rales and a wheeze.

They get all wound up in numbers, blasting someone with high flow oxygen even if they live in the high 80's. Your not going to fix thirty years of lung damage on a ten minute trip to the hospital, make them comfortable if thats spo2 of 88 or 98.

 

[Tigger]

Yes, the loss of assessing someone's respiratory status is a risk with using the pulse ox. If someone is relying on a 40 dollar finger clip to make clinical decisions, a larger problem is afoot. That said, I'm still happy to be provided with one.

Sent from my out of area communications device.

 

[JPINFV]

Yes, the loss of assessing someone's respiratory status is a risk with using the pulse ox. If someone is relying on a 40 dollar finger clip to make clinical decisions, a larger problem is afoot.

Using a pulse ox to assist in making a clinical decision is not the same as failing to asses a patient's respiratory status. The people (I hesitate to use the term "provider") who fail to assess the patient's respiratory status are either ignorant, new, lazy, incompetent, or a combination. A pulse oximeter adds to the respiratory assessment, not replaces it.

 

[johnmedic]

I've seen basics completely botch checking blood glucose levels, using lancets like scalpels etc.. some people find it easy to make a simple skill dangerous or at least very complicated. Our basics could read sp02, check bg & place combi tubes a few years ago in one county immediately after emt certification and I think it did infinitely more good than bad, idk if that's still the case as I'm no longer in that county.

Sent from my G2X on tapatalk. Forgive my typos. ; )

 

[imadriver]

I've seen basics completely botch checking blood glucose levels, using lancets like scalpels etc.. some people find it easy to make a simple skill dangerous or at least very complicated. Our basics could read sp02, check bg & place combi tubes a few years ago in one county immediately after emt certification and I think it did infinitely more good than bad, idk if that's still the case as I'm no longer in that county.

Here in Florida, I went to school and work. I was taught that sp02 was a basic skill? Didn't realize it wasn't everywhere else??


Anyway, the BGL I think would be important to a Emergency BLS crew... I work an ALS system so never really encountered it. but our EMT's in Florida are allowed to use Kings, start IV's (if trained), use sp02, use Capnography on our kings, and even IO once trained and cleared directly by our MD. But we can't check BGL's... There is always the "trick" with the IV needle, although, I've herd of a few arguments about that. Since the Glucose Meter is gauged for Capillary blood, it does indeed give a different reading SOMETIMES from what I've personally tested. But then again it could be chalked up to other causes too.