kidney stones and a bgl?

[VFlutter]

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.

I do not think anyone would argue to ignore your protocols. And as such I do not think following a protocol is considered "practicing bad medicine" when you have no choice in the matter. But making a conscious autonomous decision to do something is a different situation.

Do you know the rational, perchance?

I am assuming because many arrests are related to drug overdoses and Narcan is considered to be harmless.

 

[Handsome Robb]

Do you know the rational, perchance?

Three words: Lowest common denominator.

 

[ghost02]

Is the LCD what protocols are written for?

Aside from that, Narcan does not seem to be have been out long enough to be considered harmless, but then again I am ignorant in these matters.

 

[Handsome Robb]

Is the LCD what protocols are written for?

Aside from that, Narcan does not seem to be have been out long enough to be considered harmless, but then again I am ignorant in these matters.

Generally, yes. We all have to follow them but the amount of leeway we're given really depends on the LCD. It's pretty difficult to have some medics allowed to do something while others are not unless you have an established promotional ladder such as MedStar does with their 1-6 levels. We don't have that.

In cardiac arrest Narcan is pretty harmless. In patients with a pulse it definitely can cause problems, aspiration/vomiting, seizures, severe detox symptoms, so on and so forth.

 

[ghost02]

Good to know, thanks!

 

[Rialaigh]

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.

Not saying you practice bad medicine. Your making a cost/benefit choice, the benefit of keeping your job is greater than the risk of a useless test/intervention to a patient.

Now people who do things within their own power just for the hell of it....because they can...because its always done that way....because the hospital will do it anyways...etc..etc...

 

[KellyBracket]

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.

It's true that these are drawn fairly frequently in the ED, but I would hesitate to use this as a rationale for rote BGL tests. While they may occasionally reveal an occult, previously unsuspected condition, this can also really complicate the evaluation. Perhaps the clinician hoped that the "usual labs" would be normal, and support their clinical impression that the patient is well and healthy. Buuut, then the WBC comes back just a little elevated - then what? Ignore this result? Explain it away in the chart? Order a second round of tests?

This has been explained as the nose-picking in public problem: What do you do with unexpected findings? If the BGL is 25 in a patient who looks hale & hearty, what's your next move? If your femur fracture has a BGL of 200, how does this affect your management? How about if it's 300, or 400, or 1000?

If you have an idea what you are going to do with your unexpected "nugget," then fire away with your lancet. But if you aren't sure, perhaps you shouldn't go mining for gold.

BTW, routine Narcan for cardiac arrests is about the silliest thing I've heard of today. There is indeed a downside, but that's a matter for another thread.

 

[Carlos Danger]

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.

Actually, these are often ordered not as a "shotgun test", but because depending on how the lab works, it is cheaper to get a BMP than just K or C02, and cheaper to get a CBC than just a WC.

 

[TransportJockey]

Actually, these are often ordered not as a "shotgun test", but because depending on how the lab works, it is cheaper to get a BMP than just K or C02, and cheaper to get a CBC than just a WC.

That I didn't know. Thanks for clearing that one up I actually figured it would be more expensive to run the battery than a single test

 

[KellyBracket]

Actually, these are often ordered not as a "shotgun test", but because depending on how the lab works, it is cheaper to get a BMP than just K or C02, and cheaper to get a CBC than just a WC.

Despite this disincentive, some physicians will specifically order, say, just a K+, or just a hemoglobin/hematocrit, since they don't want to deal with a clinically-trivial bump in the WBC or chloride. Everyone gets confused when this happens, and half the time the whole lab gets sent regardless.

 

[Carlos Danger]

Despite this disincentive, some physicians will specifically order, say, just a K+, or just a hemoglobin/hematocrit, since they don't want to deal with a clinically-trivial bump in the WBC or chloride. Everyone gets confused when this happens, and half the time the whole lab gets sent regardless.

That's what happened at my last hospital. We would order an H&H, and get back a CBC, or just a K and get back a BMP, because it was cheaper. Even after some members of the medical staff got pretty irate, the lab would keep doing it.

Where I am now, we've largely solved that problem with POC tests for Hgb and lytes.

I don't know how much cheaper it is, but if even just a little less money per test, I'm sure it added up over time, and it's hard to argue with numbers. Though I'm sure the lab never took into account the other costs associated with the unnecessary lab results.

You probably don't have to have residents order very many blood cx because a WBC was a little high in a clinically healthy patient before you've negated any savings from running the unnecessary tests.

 

[Clipper1]

That's what happened at my last hospital. We would order an H&H, and get back a CBC, or just a K and get back a BMP, because it was cheaper. Even after some members of the medical staff got pretty irate, the lab would keep doing it.

Where I am now, we've largely solved that problem with POC tests for Hgb and lytes.

I don't know how much cheaper it is, but if even just a little less money per test, I'm sure it added up over time, and it's hard to argue with numbers. Though I'm sure the lab never took into account the other costs associated with the unnecessary lab results.

You probably don't have to have residents order very many blood cx because a WBC was a little high in a clinically healthy patient before you've negated any savings from running the unnecessary tests.

Our POC allows us to see all the values and then select only those ordered. It is sometimes difficult for lab or who ever is running the POC technology to ignore other abnormal values and just select those ordered. It is also time consuming to constantly call the doctors when tests not selected are grossly abnormal or critical to see if they want that result entered as well. To report the value not ordered to the doctor can be a big issue if the doctor says "I didn't order that. Let the Cardiologist or whatever specialist deal with that."

 

[Dwindlin]

"The delivery of good medical care is to do as much nothing as possible." This nugget gets forgotten all too often.

 

[Aprz]

"The delivery of good medical care is to do as much nothing as possible." This nugget gets forgotten all too often.

<3 House of God

 

[Dwindlin]

<3 House of God

I actually dislike most of the book. But there should be an entire damn class on the laws of the house taught in medical school. Especially the one I quoted above and "placement comes first."

 

[Sandog]

Glucose metabolism in renal stone patients.
Iguchi M, Umekawa T, Takamura C, Sugihara I, Nakamura K, Kohri K, Kurita T.
Source

Department of Urology, Kaizuka Municipal Hospital, Osaka, Japan.
Abstract

The calciuric response and the changes of plasma glucose and insulin produced by a 75-gram oral glucose tolerance test were determined in 27 male patients with idiopathic calcium renal stones (6 with dietary hypercalciuria, 5 with nondietary hypercalciuria and 16 with normocalciuria) and 22 healthy male subjects. The subjects were classified as obese (> or = 120% ideal weight) and nonobese. The incidence of an abnormal response to glucose loading was similar in the stone patients and the healthy subjects. In addition, the plasma glucose and insulin levels after oral glucose load did not differ between the stone patients and control subjects and were affected by the individual degree of obesity. Urinary calcium excretion increased significantly after glucose ingestion in both the stone patients and the control subjects. Urinary calcium excretion was greater in the stone patients than in the control subjects due to the presence of patients with nondietary hypercalciuria, and the increment in urinary calcium excretion in the dietary hypercalciuric and normocalciuric stone patients was indistinguishable from that in the control subjects. The degree of obesity did not affect the increment in urinary calcium excretion. These results suggest that overconsumption of refined carbohydrates such as sugar-sweetened soft drinks, soda and cakes may be a risk factor for stone formation, especially in the patients with nondietary hypercalciuria.

http://www.ncbi.nlm.nih.gov/pubmed/8266608