I'm sensing a new thread...How many gadgets and how dependent?

mycrofft

mycrofft

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The discussions about automatic VS monitors, glucometers, self-interp EKG's, pulse-oximeters, auto-CPR machines, etc. and the "making EMT jobs easier" thread have rasied this question: are we becoming machine techs or are we professionals practicing a special variety of medicine?


I can count the times I've seen machine interps contradicted by reality on the left hand...of everyone on this website. A glucometer reading of "120" when the pt was seizing and upon hosp was found to have one of "20"? A Schiller "AT-Plus" EKG machine which, instead of printing the latest, printed a saved EKG over and over, detected by staff when someone had the smarts to compare their vital signs to the EKG and saw radically different pulse rates. Auto0matic BP machines which are demmed "acceptable" with a variance of 10 mmHg on sequential diastolics? Anyone remember the original LifePak automatic "shock-on-T" machines? They had to be recalled, were shocking on U,V,W,X,Y and Z too.
What say??
 
I love automated stuff, as long as they are accurate, some of them you need, some of them are great when you have a critical patient and not enough hands.

Most of it you can verify, though. Where I ride, you ALWAYS take a manual BP first, then compare it with the auto. If its too off, you will only do manual BPs.

The autopulse you can confirm effectiveness by palpating for a pulse.

And you should always interpert your own rhythm strips and compare with the machine.

But some stuff you cant avoid. How are you going to get a BGL with out a glucometer?
 
I like and dislike automated machines. They can make our jobs easier, and they can make them a living hell. For instance, I never use the auto BP cuff. I hate them now, when I started, and I will always hate them. However like Sasha said.. how are you going to get a BGL with out a glucometer?
Machines are only as smart as the people that make them, and they are not right 110% of the time. Always confirm the BP with taking your own, always self interpret your own rhythm, and check the autopulse by palpating. However a few things like glucometer, ventilator, etc are needed.

Definitely see a pattern tho: old timers use less computers and more their own, the new kids like the computers and tend to do stuff their self. From what I've seen anyways.
 
I am TOTALLY in agreement with you about treatng the pt not the machine.
So, why switch back to auto when you are doing manual anyway?;)

On top of that, as with any other type of machine, there will be a declining period during which the degree or frequency of misleading readings increases leading to ultimate outright failure, during which period "robo-nurse" is making you more prone to operate with faulty info.

Will, or are, the admins fielding lower-qualified or less-experienced practitioners, depending upon automated help? (My bosses did and we occasionally get hoisted). Are they training everyone who needs to be expert on how and what to test at which frequencies to assure accuracy? How much time a day are you really alotted to test everything and make sure it works? How rapid is your replacement/repair function?
 
Oh, PS:

(And the answer to the gluose question is that a little glucose isn't harmful in the short time an urban ambulance has a pt on board, even if the obtunded pt is actually hyperglycemic; if I have the tools to do better I use 'em, but what are you going to do when the glucometer's out of strips or the calibration's off?).

We used blood-dipped test strips in the old days. Me and Barney cruising Bedrock...and sniffing for ketones (or maybe a urine test strip on incontinence) on breath, perspiration or urine. Sorta like canned pears for you whippersnappers. (heh heh heh).
(No, I don't taste for urine sugars either! :PVery strong motivator to keep good teststrips on hand, though!!!)
 
So, why switch back to auto when you are doing manual anyway?
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I guess people get lazy. "If a machine can do it for me, why should I have to?" I once heard someone recently say about an Auto BP cuff.
I personally do not "switch back to" auto machines. I do all my own BP cuffs, take my own pulse, etc. However I need a machine to get an SpO2, and BLG reading :P

Will, or are, the admins fielding lower-qualified or less-experienced practitioners, depending upon automated help? (My bosses did and we occasionally get hoisted)
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I honestly think so. Why? I have no idea... I don't trust computers to do my job. Well to a degree.

Are they training everyone who needs to be expert on how and what to test at which frequencies to assure accuracy?
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Nope. Plain and simple - nope.

How much time a day are you really alotted to test everything and make sure it works? How rapid is your replacement/repair function?
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Haha.. must you go there? Everything "should" be checked before a shift. I know I sure do! But I know a lot of people don't. We stock a few "spare" items that need to be tested (SpO2, AED & Battery, Glucometer, Suction, etc.)
 
mycrofft said:
(And the answer to the gluose question is that a little glucose isn't harmful in the short time an urban ambulance has a pt on board, even if the obtunded pt is actually hyperglycemic; if I have the tools to do better I use 'em, but what are you going to do when the glucometer's out of strips or the calibration's off?).

We used blood-dipped test strips in the old days.
Click to expand...

:( I would rather know my patients BGL before I give em anything for choogar problems. And blood dipped test strips in the back of a moving ambulance sounds like it has a looooot of potential for a spill and infection.

Why switch back to auto bps? Sometimes you just dont have enough hands in the back, that is one less thing you have to occupy your hands with, so you can work on getting those drugs going or whatever else has to be done. Plus I like having my most recent set of vitals up on the monitor to call in my radio report with!
 
Alike any device, they are only to assist and aid you in providing better care. They are never to replace good logic, assessment and hands on treatment!

R/r 911
 
One has to remember, 9 out of 10 times that an automated machine is wrong it is due to operator error.

I read all these post on NIBP. Everyone saying they are evil. These machines will normally be within 10 of a manual BP. If they are off more then that, you have problems. Cuff to big or to small, Pt tightening their arm during BP, Leak in the hose or cuff.

Most people in EMS are never taught how to properly use the equipment on their trucks. I have seen to many EMT's and medics complain about how their equipment sucks, only to find out they have hook it up wrong.

Cardiac monitors producing bad 12 leads or 3 leads filled with artifact. I can usually look at the pt and find the electrodes placed in the wrong spots.

Glucometers give false high readings. Normally caused by not letting the alcohol on the finger to dry completely.

Automated machines are made to enhance our care and are great tools, if used right. If you are someone that can never get a NIBP to read right, go ask for help. You may be using it wrong. Or, you may not be taking a manual BP correctly so you think the machine is wrong.

Sorry for the rant, just get tired of everyone complaining about the equipment, when it is usually operator error!
 
Oh DO NOT get me started on this subject. I am about to come unglued on some of the members on my squad about this topic. From what I have seen whenever we get called for ANYTHING the first thing these people grab is the AED. Why? because it has a built in BP cuff and POX. I have yet to see one person use a manual cuff and steth. to take a BP. Hello that is the first thing you learn in Vitals practicals!!! I am the only one that has ever done manual vitals. By the time these people get the crap hooked up I have done BP, pulse and Resp. (side note POX also does Pulse) And from my tests these automatic devices are not always right (duh).
 
reaper, right on!!

My coworkers not only misuse them, they break them, then don't do anything to fix them or rob pieces from other machines other people use. They cotionue to use them when they know they are malfunctioning. Sometimes I'm tempted to use the pun "cow-workers" from the vague look they get when I point out the pt had a BP of 70/40 but was obviously fine and subsequent manual, done by me, was about 120/70.

My doc was surprised at the 10 mm Hg fluctuation. I shot five in a row on myself, sitting still in a quiet room. diastolics alternated up and down, except for one which failed to work at all. He said that if he gave some meds and saw a ten mmHg change in diastolic he would think it was due to his actions and act accordingly.
 
Sasha, I'm sounding like a buggywhip salesman...

Yeah, I want good glucometer reading, and the usual source for the blood dipsticks was the IV start just before the tubing was crammed onto the catheter. But if not given working or reliable devices, or if I or another person is screwing up and making it fail, some glucose may act rapidly to stave off seizure and brain damage, whereas hyperglycemia takes much longer to cause more damage.
I have used a POx as "extra hands" when I was alone, but given that the manufacturer states a given devide is only for screening, is known to me from talking to the mfgr and from my practice that it is not reliable, my hiner was hanging if I made a wrong move and cited the device as the basis for my actions. I have used POx and auto EKG to reassure patients since many of mine start out distrusting or hating me. THEY trust the machine more and I do.
 
Case in point: This morning toned out to 83 yo male with possible GI bleed. Guy had tarry stool in his morning sit down and says the last time that happened.. back in '74... no maybe it was '75 the doctor told him he had an ulcer. Gentleman started coumadin 4 weeks earlier. Hx of bypass 10 years prior. Vitals all wnl.

He's talking in full sentences, color pink, cap refill good, no edema, Lung sounds equal bilaterally, breathing without effort, but my O2 sat is reading 86%. So, do I slap a NRB on the guy and start pushing high flow oxygen because the machine says so?

Technology is wonderful. The machines we have are great tools, but the best tool we have on all calls is the one we carry around between our ears.
 
I hated the one time the intermediate on our truck (bls for me) called MedControl and when they asked for the rhythm, she said "the monitor says unconfirmed sinus rhythm" (it really does say that on the strip...so she was just reading the strip instead of taking the time to interpret it).

So that's my story about how machines can be taking over.

Furthermore, with all the new technology, there is going to be less didactic teaching and more electronic teaching! The future providers will no longer have he actual patient care and treatment skills as opposed to machine and patient care.

However without some (EKG, Glucometer, pen light (hehe, technology!), it would be nearly impossible to interpret & treat thereof.
 
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Ironic...?

that we're using computers and the web to complain about too much dependence on machines?

The flip side, modern medicine is machine dependent and the survival rate for machine dependent treatments keeps increasing. Wonder why that is?

John E.
 
mikie333 said:
Furthermore, with all the new technology, there is going to be less didactic teaching and more electronic teaching! The future providers will no longer have he actual patient care and treatment skills as opposed to machine and patient care.
Click to expand...

Quite the opposite is true. With any piece of technology, more information is offered which requires a greater understanding. There is nothing worst than seeing a great piece of equipment like an ETCO2 monitor being used only to "see a good wave" without any understanding of what the shape represents or how the number can correlate to the patient's condition. It opens up a whole new discussion of the effects of various disease processes, ventilation and V/Q mismatching.

The simple little pulse oximetry can be introduced into discussions for neonates and shunting. Also, as with the example BossyCow mentioned, one could go with what you would expect with GI Bleed and O2 carrying capacity. What would it tell you about other possible signs and symptoms?

The more knowledge you have about your technology, the more uses you can find for it and a better understanding as to how it can guide you to look for other problems or causes that would not be as obvious otherwise or confirm what you may already suspect after a thorough assessment. You will also better understand its limitations and not stop your assessment because of a number.

As I mentioned in the Vents thread, ATVs are being encouraged prehospital. But with them that little discussion skimmed over in EMT and Paramedic school about tidal volume and minute ventilation may have to be expanded and adapted to the technology. Part of the failure with the older demand valves was the education did match the potential for the device. Thus, few understood its proper use and serious problems arose. That device was very "high tech" when it was first introduced. However, as years went by, the education still did not catch up and it went away until now with the ATVs are bringing back the technology but in a regulated form. That still may not be enough if the proper education about basic lung function and diseases is not done somewhere in the "how to application" of the ATV.

As more technology is developed, it brings in more elements that before were not readily observed. Thus, more research possibilities open up to explore the causes and effects. This is even true in EMS as now we can preserve more data from the therapies initiated.
 
Vent, do yo think that this means you need a higher level of training...

...and experience to use the higher level of technology to most patients' advantage? (I happen to think so, but the manufacturers [and admins] and I don't see eye to eye).
 
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John E, It's ironic if there is a strict man versus machine divide.

There isn't. At least not for me, I like my gadgets!

Of course, we notice it when a devices fails to meet our demands, and we ignore it when it meets our expectations. Just like people. Or air.

I can't cite figures about how many more people are doing better because they are being hooked up to cybernetic machines in the field (our subject, not in-house where nothing moves and bangs and gets wet, except New Orleans). I do know that Murphy's Law applies double to medical equipment and triple to anything with a tranducer, batteries, or a printer or transceiver involved. And then you add a tired or new or untrained user....
If all these whizbangs were so damn great, how come they turn over so fast? One week's wunderkind is next week's dreck:rolleyes:.
 
mikie333, I'm afraid you're right.

We need more clinical, not more video games, for hands on skills, even when it comes to using gadgets. But clinical experience can be very hard to get due to fears of malpractice. Let them see people hurt, sick, and dying, not Second Life.

My first Air Guard unit and I worked for two years to try to get clinical slots for our non-EMT med techs at local hospitals. We finally got one, the local VA, and to what did our folks get assigned? Pushing wheelchairs, emptying bedpans, and making beds. Not even dressing changes, which are instructive as to the healing process and how to put on a successfull dressing. These troops were supposed to be able to go to second echelon medical care nodes (a little smaller than a MASH but larger than a dressing station) when the Russkiyas crossed the Fulda Gap, but no practical experience even during our two week annal trainings. The reason: afraid of being sued due to mistakes by our techs.
 
mycrofft said:
...and experience to use the higher level of technology to most patients' advantage? (I happen to think so, but the manufacturers [and admins] and I don't see eye to eye).
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Knobologist does not equal clinician.

EMS get sold alot of stuff before they get any training on it. Thus, it is like the car salesman who saw them coming. Administrators get taken in and the EMS personnel don't have enough knowledge to carry on a good Q & A session with the salesperson. The implementation of the education should start before the purchase. It should continue well past the purchase.

CPAP should have taught some about the evaluation of technology but for most it didn't. I then have to laugh out loud when these same people inquire about getting ventilators. If you don't understand the basics, you shouldn't be messing with the big gadgets.

Too many become monitor watchers and write down numbers. There is not correlation with the clinical. As I mentioned before, using as ETCO2 for the sole purpose of a pretty wave demonstrates the short sightedness of both the management and the providers.

Recent happening which I love to use for teaching all medical groups:

Not too long ago in the hallway I passed two ambulance personnel pushing a stretcher toward our med-surg floor at the hospital with an elderly man wearing a NRBM having agonal respirations. He was hooked up to a CR monitor with SpO2 of 100% HR 70 (paced) and RR 10 but agonal. I stopped the stretcher, quickly inquired if he was going to the Comfort Care room. No, full code. I told them to divert into the ED which on just a few feet away. They argued that the vitals were "stable". I diverted them anyway. Got an ABG while a co-worker was preparing to bag and tube with doctor reading the chart for any hiden directives. Normally I wouldn't get an ABG on an obvious respiratory failure but this had something to be proved.

pH 6.9 PaCO2 130 PaO2 95 on a NRBM.

So yes, the PaO2 was high enough to reflect a high SpO2 but had a large A-a gradient. The PaCO was well above the norm and the pH was not compatible with life for much longer.

This was an ALS transport because the patient had a medicated IV hanging. The 2 Paramedics insisted on showing me and the doctor the EKG strips of a paced rhythm and the SpO2 from the monitor. My big question to them was "when did the patient's respiratory status change"? When they said they noticed it early on but the SpO2 stayed the same and no further assessment was done, I realized that there was little need to even discuss this further. They continued to defend their treatment or lack of because the monitor vitals were stable.

That scenario has little to do with even the advanced training for the use of technology but how some do become just plain stupid with it.

Of course my favorite trickery is for new doctors in the PICU on the night shift. I put an SpO2 monitor on the bed just enough to catch some light and the heart electrodes on myself. Then I tuck a teddy bear into the bed. I will call one of the new docs for low SpO2. Sure enough they come in and look directly at the monitor, mumble something about keeping an eye on the Sats for the night and go back to their call room. In the morning when we are about to round the doctor will ask which patient had the SpO2 problems. In front of his/her attending I will say Ted E. Bear. The attending will know immediately what happened and will go into a long lecture about monitor watching and clinical assessment...just as a reminder about how real medicine is still done.
 
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