On Every Patient, Get A [Insert Here] Measurement?

The new edition of the CPGs states vital signs must be measured in three instances

1. When ambulance personnel recommend non-transport (includes RR, HR, BP, CRT, GCS and temp),
2. When a vital sign is a pre-requisite for a medicine or treatment (e.g. GTN must have an SBP of > 100)
3. Following initiation of treatment for abnormal vital signs (e.g. re-checking an SpO2 if oxygen is given for hypoxia)

I don't see the point on measuring everything on everybody. It is pointless, not clinically significant and wasteful, and this is not my practice.

Most people are crap at counting a respiratory rate (myself included unless I really focus on it) either because they don't know how to do it properly or they can't be arsed but I am told it is quite a sensitive sign somebody is unwell.
 
SpecialK said:
Most people are crap at counting a respiratory rate (myself included unless I really focus on it) either because they don't know how to do it properly or they can't be arsed but I am told it is quite a sensitive sign somebody is unwell.
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Do you have ETCO2? You can use it to get a good RR, no?
 
If we're talking about taking a capillary sample in what would be considered the standard manner, then I'm only doing that when clinically indicated.

If we're talking about assessing blood glucose in the manner I previously described, then I guess the simple answer is because I can. I usually have the time and as long as this "unnecessary" assessment isn't taking me away from a more pertinent task, I'm of the opinion that you can never have too much information. While it's unavoidable at times, I hate not having the answer to a question the RN or MD asks; even when their question or expectation is unreasonable or unwarranted.
 
@hometownmedic5, definitely no reason to *not* get the BGL under those circumstances! It's basically costless and could provide useful info!
 
hometownmedic5 said:
I hate not having the answer to a question the RN or MD asks.
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There's nothing wrong with knowing what you don't know. Their education far exceeds that of the average EMS provider (general statement).

I'm not saying this is any kind of reasoning as to why I wouldn't be able to provide an answer, but I have no problems simply telling them I don't know, or "did not obtain". At this point the glucose issue seems trivial as I think most of us on here are smart enough to figure out who we would get one on, and who we wouldn't, within reason.

FWIW, I am with you on making the transition from in-field to hospital delivery as seamless as possible. I don't know that every nurse or EM physician expects a supermega (yes, I totally know that isn't a word) intelligent handoff from EMS everytime, nor do they have the time to listen, but I do make sure it is as efficient as one can anticipate.

All my IV's get locks, and before even worrying about a BGL for a completely benign complaint I usually will tell the hospitals that ask all the time. I think it's part of some sort of qualitative measure with their charting, nothing more, nothing less.

Also, because I forgot mention it in my original post, we're only required one set of V/S pertinent to the patient on an AMA, 2 sets of V/S pertinent to the patient for every transport, and V/S every 5 minutes if they're critical, on CPAP, both, given NTG, or a narcotic.
 
I only take 1 set of vital signs on 80% of my patients and haven't been yelled at for it yet. My state protocol says to check vitals every 5 minutes on a "critical" patient, which I find to be stupid and unrealistic. I'll take repeat measurements if the values are going to be relevant - if there has been a change in patient condition, if I gave a med, if I put them on CPAP, if I'm worried about them decompensating, etc. Any potentially sick patient I'll take 2 or 3 sets on but certainly not every 5 minutes.

I'm not sure how they expect us to get all these readings between taking H+P, talking to family/whoever, treatment, extrication, calling radio report, reading through paperwork, organizing thoughts for the hand-off report, re-assessing and continuing treatment, etc. If it's a truly sick patient I probably don't have time to sit there listening to BP's for half of the call. Our monitor's NIBP is worse than useless so that isn't really an option.

captaindepth said:
I am always surprised by how nurses ask if I checked a BGL even when I bring in a patient where checking a BGL would be completely irrelevant. I usually reply with something like " the pt is AAOx4 answering all questions appropriately with skin P/W/D, no signs of AMS, also the pt has no hx diabetes (and their chief complaint is a stubbed toe : )"
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This feels overly defensive / antagonistic. If I didn't check a sugar I just say, "sorry I didn't check that". If asked why I didn't check it, then I would explain.
 
Checking a blood sugar on every patient seems needless and wasteful. Checking a blood sugar on patients where it's clinically indicated however, is a different story. It's the same as performing a 12 lead. Do you do one on every patient? If no, why not? It's virtually costless and may provide vital information. Right. You don't do it because it's not clinically indicated.

And I've never, ever had a nurse ask me for a blood sugar on a patient when performing a handover, unless they were altered or it was clinically indicated. In any case, if it were clinicalynindicated, they would have already had that information from when I made the med patch.

A capillary blood sugar isn't a vital sign, per se. It's used as a diagnostic tool to rule out hypoglycemia in altered mental status patients.
 
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VentMonkey said:
Also, because I forgot mention it in my original post, we're only required one set of V/S pertinent to the patient on an AMA, 2 sets of V/S pertinent to the patient for every transport, and V/S every 5 minutes if they're critical, on CPAP, both, given NTG, or a narcotic.
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Pertinent to the patient - there's a good qualifier. I like that. I imagine it must be QA'ed, so that you don't get folks not performing BGL on an AMS patient, etc.?

I'm curious - why V/S every 5 minutes on a narcotic? I don't think administering a narcotic is *necessarily* indication of criticality (e.g. painful long bone fracture + narcotic does not = a critical patient), you know?

VentMonkey said:
I have no problems simply telling them I don't know, or "did not obtain". At this point the glucose issue seems trivial as I think most of us on here are smart enough to figure out who we would get one on, and who we wouldn't, within reason.
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Absolutely - I worry more about the least common denominator (and I think that's what systems are broadly concerned about), so maybe that's part of it, too? For mandatory vitals, I could see protocols saying "assess BGL for all patients exhibiting AMS," say, and being more nuanced than "all patients must have a BGL taken."

Gurby said:
I'm not sure how they expect us to get all these readings between taking H+P, talking to family/whoever, treatment, extrication, calling radio report, reading through paperwork, organizing thoughts for the hand-off report, re-assessing and continuing treatment, etc. If it's a truly sick patient I probably don't have time to sit there listening to BP's for half of the call. Our monitor's NIBP is worse than useless so that isn't really an option.
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+100%
Unless you're in a system that is heavily staffed (overstaffed?) I can't imagine a single crew having sufficient time to take good V/S every 5 minutes, with the caveat that throwing on the NIBP and pulse ox should be fine to CYA for charting purposes, no?

DEmedic said:
It's virtually costless and may provide vital information. Right. You don't do it because it's not clinically indicated.
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I think I might have been a bit overbroad, but if you've got the time and there is little to no cost involved, I don't see much harm. Of course, I guess I could say that for many things...like cervical "immobilization" prior to evidence that it really did cause harm.
 
EpiEMS said:
Pertinent to the patient - there's a good qualifier. I like that. I imagine it must be QA'ed, so that you don't get folks not performing BGL on an AMS patient, etc.?

I'm curious - why V/S every 5 minutes on a narcotic? I don't think administering a narcotic is *necessarily* indication of criticality (e.g. painful long bone fracture + narcotic does not = a critical patient), you know?



Absolutely - I worry more about the least common denominator (and I think that's what systems are broadly concerned about), so maybe that's part of it, too? For mandatory vitals, I could see protocols saying "assess BGL for all patients exhibiting AMS," say, and being more nuanced than "all patients must have a BGL taken."



+100%
Unless you're in a system that is heavily staffed (overstaffed?) I can't imagine a single crew having sufficient time to take good V/S every 5 minutes, with the caveat that throwing on the NIBP and pulse ox should be fine to CYA for charting purposes, no?



I think I might have been a bit overbroad, but if you've got the time and there is little to no cost involved, I don't see much harm. Of course, I guess I could say that for many things...like cervical "immobilization" prior to evidence that it really did cause harm.
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Because of the likelihood of de compensation from over administration would be my best guess in regards to the QA process. It's oneof several "core measures" tracked by our state and goes into a database, TMK. The same for CPAP and V/S q 5 minutes. There are something's we just can't dance around.
 
EpiEMS said:
throwing on the NIBP and pulse ox should be fine to CYA for charting purposes, no?
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I used to do this, but lately have decided that the monitor's NIBP just causes more problems than it's worth. I've seen it spit out 120/80 on a patient with a systolic of 70, and I've seen it spit out 70/x on a patient who was 120/80. If I really want to know what their pressure is, I take a manual. If I don't care I just chart 1 set of vitals. Nobody has given me a hard time about it yet, but I suppose if somebody does call me out on it I'll start doing what you suggest and have a bunch of PCR's that read: "120/80 ....... 50/42..... 208/130...etc".
 
VentMonkey said:
Because of the likelihood of de compensation from over administration would be my best guess in regards to the QA process. It's oneof several "core measures" tracked by our state and goes into a database, TMK. The same for CPAP and V/S q 5 minutes. There are something's we just can't dance around.
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Seems sensible, I guess, but that sounds like a least common denominator problem, you know what I mean? (Or am I off base?)

Gurby said:
Nobody has given me a hard time about it yet, but I suppose if somebody does call me out on it I'll start doing what you suggest and have a bunch of PCR's that read: "120/80 ....... 50/42..... 208/130...etc".
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Fair enough - I haven't had that kind of trouble with the LP15 (or LP12, for that matter). If they really want vitals all the time, they should be happy with whatever the monitor says - or get you a better monitor! (Speaking of which, what are you using?)
 
EpiEMS said:
Fair enough - I haven't had that kind of trouble with the LP15 (or LP12, for that matter). If they really want vitals all the time, they should be happy with whatever the monitor says - or get you a better monitor! (Speaking of which, what are you using?)
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Zoll E Series. We do have the different sizes of cuffs so that's not the issue. Sometimes it works and it's nice when it does, but it's frustrating that you can't trust it.
 
EpiEMS said:
Seems sensible, I guess, but that sounds like a least common denominator problem, you know what I mean? (Or am I off base?)
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Ep, not at all. I think I just chalk this up to a few things...

1. It's data retrieval needed to show our competencies, or lack there of. It isn't anything personal against me, nor a reflection of my treatment decisions, judgement, or knowledge as a provider.

2. Most paramedic curriculum only goes so far into critical thinking skills, and I think we have all known "Mongo the Medic" who struggles to think outside of his tiny box. The majority of forum posters on here, again, are that exception that took/ take it upon themselves to continue to learn ways, trends, and reasons behind performing care in a manner reflective of not only outstanding patient care, but also in a manner most likely to improve outcomes and shorten hospital stays.

3. Experience over time is also invaluable in the face of decision making. Couple this with strong critical thinking skills, and a desire to continue learning about, and reasons behind EBM.
 
Rectal tone test!
Kidding
 
VentMonkey said:
AKA: "The---insert trauma hospitals name here---Salute"
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Ours up here is called the "Harborview Handshake"

I feel like a thread could be started to collect all the names.
 
I think that sad reason why these vital signs are mandated is because people don't get it when they should.
 
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