Just because you can...

EMSComeLately

EMSComeLately

Forum Crew Member
Messages
85
Reaction score
21
Points
8
Respectfully and humbly, I have an ALS curiosity while I'm still in EMT school (though a future medic hopeful).

Today in class we covered Pharmacology including administering Glucose. The paramedic instructor indicated that they'd simply start an IV and administer dextrose.

My question is this...even though paramedics have the skills and scope of practice for more advanced interventions, shouldn't the more basic approaches be attempted first if it is indicated before escalating to more advanced options? (This specific scenario assumes that an IV wouldn't have otherwise been indicated for any other intervention).

Sure...I assume Dextrose is likely faster acting and a greater guarantee of success, but for my own education, is it the first step per the standards of care before exhausting other BLS options?

This is just an example...there may be other cases where an ALS intervention is selected over attempting a less evasive BLS option as well.
 
They are teaching advanced techniques, presuming that the basic techniques are already known.

I believe many medics seem to want to jump to advanced technique when a simple intervention will do.

Example: Military exercise in hot conditions, exercisees wearing MOPP 4 (full) chemical gear. Two aid stations, one manned by doctors, the other by techs.
MD's gave IV fluids for heat exhaustion and/or dehydration. Techs gave oral 1/2 strength Gatorade and refilled canteens with water. Techs returned troops to action faster and had a 0% return rate. MD's sat on their guys and gals for hours. Oral hydration and sugar fix (probably not eating right also) as good or better than IV.

However, many advanced techniques ARE superior for initial treatment, and when appropriate situations are detected with superior advanced assessment techniques, they are called for.
 
We often do strive for the least invasive method of fixing the problem. In the hypoglycemic example you mention, I'd always try oral glucose/juice prior to starting a line and giving IV dextrose. It's better for the patient, less harsh as far as rapid BGL swings, and prevents even the low risk of IV complications. We sat on scene for 30 minutes the other day coaxing a patient to drink juice to bring his sugar up. It may have been easier to dart him with Glucagon or grab a line, but we chose the least invasive method and it worked well. This doesn't necessarily apply for all examples, but the one you used is certainly appropriate.
 
EMSComeLately said:
Respectfully and humbly, I have an ALS curiosity while I'm still in EMT school (though a future medic hopeful).

Today in class we covered Pharmacology including administering Glucose. The paramedic instructor indicated that they'd simply start an IV and administer dextrose.

My question is this...even though paramedics have the skills and scope of practice for more advanced interventions, shouldn't the more basic approaches be attempted first if it is indicated before escalating to more advanced options? (This specific scenario assumes that an IV wouldn't have otherwise been indicated for any other intervention).

Sure...I assume Dextrose is likely faster acting and a greater guarantee of success, but for my own education, is it the first step per the standards of care before exhausting other BLS options?

This is just an example...there may be other cases where an ALS intervention is selected over attempting a less evasive BLS option as well.
Click to expand...

Sure basics before ALS ... yet again..What was is the patient's condition? Slightly hypoglycemic, able to converse and hold a drink? Sure I am all in favor of orange juice and a slice of pizza...Yet if the patient has a low glucose with a potential decreased level of consciousness am I going to place anything into their mouth? Again back to basics airway.

Next for every second glucose is not sufficient the brain is suffering.. hence again the reason for fast and efficient treatment. Digestion and absorption rate is much slower per mouth.. intestional etc.. again brain cells are dependent upon glucose.

Third.. you know exactly how much glucose is admin. albeit per D50w (25 grams) or D25w or D5W...

Yes, treat appropriately and not just technically, and one should be able to justify all treatments; but one has to be sure at the same time what is the most appropriate and prejudice to your patient.

R/r 911
 
Basic interventions are typically attempted first. In the situation you presented, the instructor may have been speaking broadly, in that most hypoglycemics we get called for aren't conscious and will thus get an IV and D50. If I have a patient thats still alert enough, I'd rather just have them eat some food. There are medics, though, that are so focused on performing the "cool" skills that they deliver inappropriate/unnecessary patient care just to perform the more invasive techniques.

With that said, once you become a paramedic, do this for me: eliminate "basic" and "advanced" skills from your vocabulary. We are the only branch of medicine that distinguishes between the two. Instead, perform the most appropriate care or interventions that the patient needs, always trying to accomplish the most with the least. That's it. If a patient needs airway maintenance and jaw-thrust is all they need, great. If they're crashing and they need a tube, do it. Provide patient care and don't get caught up with the technicalities of "this is a basic skill and this is an advanced."
 
If they can protect their airway and follow instructions, I don't know anyone who wouldn't try oral glucose first. Except for one guy who had a patient drink a 250 bag of D10 because he "didn't want to wait around for oral glucose to work." Yea, that happened.

Learning to balance efficacy with invasiveness is an important skill.
 
chaz90 said:
We often do strive for the least invasive method of fixing the problem. In the hypoglycemic example you mention, I'd always try oral glucose/juice prior to starting a line and giving IV dextrose. It's better for the patient, less harsh as far as rapid BGL swings, and prevents even the low risk of IV complications. We sat on scene for 30 minutes the other day coaxing a patient to drink juice to bring his sugar up. It may have been easier to dart him with Glucagon or grab a line, but we chose the least invasive method and it worked well. This doesn't necessarily apply for all examples, but the one you used is certainly appropriate.
Click to expand...


I agree with everything here. That being said, I was called to a SOB call the other day (pt didn't feel well, tired, can't catch her breath). It turns out her sugar was 30. She was alert and oriented, so I gave her some oral glucose to suck down. The nurse looked at me like I was crazy for not giving her D50, since I had IV access.

I proceeded to explain my reasoning for not giving it, because it was unnecessary and hard on veins. The nurse looked at me like I had two heads.
 
Where I did my ride-time, the practice was to have patients drink D50 from the vial. I don't remember it being specified in the protocols, but it was done all the time. aksfjkjfb;df.
 
Thanks for the perspectives...the classroom scenario wasn't specific so I can't say whether the paramedic instructor would have defaulted to IV/Dextrose regardless of the situation or would have taken a tiered approach for interventions.

I appreciate the insights as I continue this journey...clinical rides starting soon and I'm sure I'll get an even greater appreciation for textbook vs. field approaches.
 
I know too many medics who have the mentality of, "Screw it, I don't want to wait around and feed this guy. Let's just give him D50." Or they think it's easier to just pop in a line and give them dextrose rather than coaxing them to eat and drink, then wait around for them to get their sugar up.
 
STXmedic said:
Basic interventions are typically attempted first. In the situation you presented, the instructor may have been speaking broadly, in that most hypoglycemics we get called for aren't conscious and will thus get an IV and D50. If I have a patient thats still alert enough, I'd rather just have them eat some food. There are medics, though, that are so focused on performing the "cool" skills that they deliver inappropriate/unnecessary patient care just to perform the more invasive techniques.

With that said, once you become a paramedic, do this for me: eliminate "basic" and "advanced" skills from your vocabulary. We are the only branch of medicine that distinguishes between the two. Instead, perform the most appropriate care or interventions that the patient needs, always trying to accomplish the most with the least. That's it. If a patient needs airway maintenance and jaw-thrust is all they need, great. If they're crashing and they need a tube, do it. Provide patient care and don't get caught up with the technicalities of "this is a basic skill and this is an advanced."
Click to expand...

What, give up the right to whack someone because they're a "Basic"? :cool:(We used to be "EMT-Ambulance" and "EMT-Paramedic"...not "medic", but "paramedic").

STX, I like that.
 
Tigger said:
If they can protect their airway and follow instructions, I don't know anyone who wouldn't try oral glucose first. Except for one guy who had a patient drink a 250 bag of D10 because he "didn't want to wait around for oral glucose to work." Yea, that happened.

Learning to balance efficacy with invasiveness is an important skill.
Click to expand...

I knew people who'd shoot in two glucagon injectors first. Just 'cause.:unsure:
 
medicsb said:
Where I did my ride-time, the practice was to have patients drink D50 from the vial. I don't remember it being specified in the protocols, but it was done all the time. aksfjkjfb;df.
Click to expand...

I've seen that a few times, sometimes the medic would squirt in a soda or something. A 250 bag sounds far grosser to me though.
 
All things being equal, BLS before ALS. you will hear that a lot. But often the ALS intervention offers something that the BLS does not. However, I always prefer a BLS intervention over ALS when ALS is not needed. In your example, for a person who is awake, has a gag reflex and has mild hypoglycemia, oral glucose is indicated and that would be sufficient assuming there were no other problems.
 
NPO said:
All things being equal, BLS before ALS. you will hear that a lot. But often the ALS intervention offers something that the BLS does not. However, I always prefer a BLS intervention over ALS when ALS is not needed. In your example, for a person who is awake, has a gag reflex and has mild hypoglycemia, oral glucose is indicated and that would be sufficient assuming there were no other problems.
Click to expand...

How do you test for an intact gag reflex, exactly? :glare:
 
I beg to differ :rofl:
 
DEmedic said:
Yep, I've held conversations with a few women who turned out to have no gag at all.
Click to expand...

The street walkers along international blvd don't count.
 
Ahh, Tukwila.

Anyway, back to the topic at hand. I've had patients drink an amp of D50 or dumped it in a glass of diet soda, I've also used jellybeans, cake frosting and an ice cream that I purchased from street vendor.

If I can, I'll always feed someone before sticking them and giving them an amp of D50.

Interestingly enough, when I was working BLS in King County, we rolled to an unresponsive diabetic at a nursing home. The guy was really obtunded and couldn't swallow. We didn't have glucometers on our truck, but the nursing home staff did. Guy's sugar was like 22, so I called for medics. The medics got there and berated me for calling. Then they sat him up with a bunch of pillows and proceeded to pour orange juice into him, Even though he couldn't swallow and was responsive only to really loud verbal stimuli or sternal rub. Classy, Huh?

That's a case I would have started a line and pushed the sugar...
 
You must log in or register to reply here.
Back
Top