Poetic, do u use Suppository or PO dissolving in this particular indication? was reviewing the updated circulation Aha, and it lists rectal aspirin as a class 1 intervention, No other specifications on regular vs. Suppository.
rectal administration of ASA
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Poetic, do u use Suppository or PO dissolving in this particular indication? was reviewing the updated circulation Aha, and it lists rectal aspirin as a class 1 intervention, No other specifications on regular vs. Suppository.
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Ours comes as a prepared ASA suppository. I think the tablets in a 5cc with saline would be a good, plausible method in a pinch, though.
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Yes, 325mg
Edit: If you were trying to make your own, then I'd imagine 4x81 would still be appropriate. Would be worth talking to your MD about it.
Edit: If you were trying to make your own, then I'd imagine 4x81 would still be appropriate. Would be worth talking to your MD about it.
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324!!!!!
I love when nurses correct me about my dose and I'm like, "uh....4x81"
They just can't seem to wrap their head around how we have them chew 4 baby asa rather than one icky adult one.
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324!!!!!
I love when nurses correct me about my dose and I'm like, "uh....4x81"
They just can't seem to wrap their head around how we have them chew 4 baby asa rather than one icky adult one.
Our PR dose comes as 325mg! Suck it!! Lol that's actually one of my pet peeves, too
Right up there with O2 "stats" :glare:
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Not to derail the thread... But I can't stand it when I hear anyone, let alone medical staff say "o2 stats"
It is like nails on a chalk board to me.
It is like nails on a chalk board to me.
JPINFV
Gadfly
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Psych is going to have a huge issue. Also a bunch of the "tricks" used in EMS are "off label" uses. BP cuffs as makeshift tourniquets, irrigating eyes using a nasal cannula. Heck, the "use oxygen for everything" is off label to an extreme.
Also...
http://www.naemsp.org/Documents/POSITION OffLabelUseofMedicalProducts.pdf
mycrofft
Still crazy but elsewhere
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"Five is four" time again. I'm going to piss some folks off.
Again, off label means you are on your own.
Leaving protocols mean you are on your own.
Argument doesn't change that, it's the facts.
=================================
OK, any actual rectal cardiac aspirin protocols aside:
It is sometimes necessary to depart from protocols; because either you don't know what the whole picture is and therefore the protocol you THINK is appropriate isn't working and SOMETHING has to be done, or you are in a situation there is no protocol (which you can remember right then) will address. But it ought to be rare and it ought to make sense in retrospect and require NO concealment.
An aspirin tab up the rectum to someone who is likely going to die might make for an offbeat side note on the post-mortem report but not likely to be an incident report by itself. However, the underlying frame of mind is.
An attitude that it is alright to frequently and even systematically improvise medical treatment in lieu of the protocols (and especially against them and the manufacturer's instructions) is willful negligence or outright malpractice. It is dangerous and brimming with hubris. When someone kills a patient through such a misadventure usually they have been treating patients "by exception" repeatedly in the past, outguessing medical control often because they failed to understand what was truly wrong or were trying to undo a mistake they had already made.
So if it works, fine, you made a save despite protocols. If you find improvisation is a frequent fact of practice, you need a better set of protocols (i.e., get another employer), or you need to sit down over some waffles after shift sometime and figure out why it is that you are so special.
PS: if your cardiac pt was on anticoagulants and has hemorrhoids and your aspirin tab ulcerates one of them....
Again, off label means you are on your own.
Leaving protocols mean you are on your own.
Argument doesn't change that, it's the facts.
=================================
OK, any actual rectal cardiac aspirin protocols aside:
It is sometimes necessary to depart from protocols; because either you don't know what the whole picture is and therefore the protocol you THINK is appropriate isn't working and SOMETHING has to be done, or you are in a situation there is no protocol (which you can remember right then) will address. But it ought to be rare and it ought to make sense in retrospect and require NO concealment.
An aspirin tab up the rectum to someone who is likely going to die might make for an offbeat side note on the post-mortem report but not likely to be an incident report by itself. However, the underlying frame of mind is.
An attitude that it is alright to frequently and even systematically improvise medical treatment in lieu of the protocols (and especially against them and the manufacturer's instructions) is willful negligence or outright malpractice. It is dangerous and brimming with hubris. When someone kills a patient through such a misadventure usually they have been treating patients "by exception" repeatedly in the past, outguessing medical control often because they failed to understand what was truly wrong or were trying to undo a mistake they had already made.
So if it works, fine, you made a save despite protocols. If you find improvisation is a frequent fact of practice, you need a better set of protocols (i.e., get another employer), or you need to sit down over some waffles after shift sometime and figure out why it is that you are so special.
PS: if your cardiac pt was on anticoagulants and has hemorrhoids and your aspirin tab ulcerates one of them....
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No one is recommending that paramedics go rogue and start inventing uses for things. The OP stated his medical director advised them to give ASA PR. Physician gives order, order isn't illegal or potentially lethal, paramedic follows order...
Also, your description of giving ASA PR as being "off label" is not accurate. Off label is using a med for any purpose not approved by the FDA. It has nothing to do with route of administration. In this case, ASA is being considered for treatment of ACS, which is very much FDA approved.
In many cases, trials don't exist for certain uses, or the target trial is too high risk to be considered practical for trial by a pharm company. Obstetrics is an example. Magnesium sulfate is not FDA approved for use in pre-term labor, but it is a mainstay of treatment in L&D units worldwide. Peds is another example. In some cases, it is simply too difficult to get a study approved in order to prove safety and efficacy. This is a very common occurrence in peds.
Additionally, a physician deciding to give a med off label does not necesserily mean that they are on their own. Much of the evidence that the FDA uses to approve additional uses for meds comes from data collected by physicians using meds off label. In fact, for many off label uses there exists lots of published literature that supports the use of that med for the off label purpose, and that precedent has been shown to be legally defensible, just as much as using a med for an FDA approved use has been shown to be legally indefensible in many cases (no shortage of shysters ready to take your case and add it to some class action law suit.)
I agree, paramedics should not be practicing medicine. That is the doctors job. A hard line stance against off label use is not really practical though. If we eliminated off label use, a great deal of the pharmacological interventions used in medicine today would go away.
Also, your description of giving ASA PR as being "off label" is not accurate. Off label is using a med for any purpose not approved by the FDA. It has nothing to do with route of administration. In this case, ASA is being considered for treatment of ACS, which is very much FDA approved.
In many cases, trials don't exist for certain uses, or the target trial is too high risk to be considered practical for trial by a pharm company. Obstetrics is an example. Magnesium sulfate is not FDA approved for use in pre-term labor, but it is a mainstay of treatment in L&D units worldwide. Peds is another example. In some cases, it is simply too difficult to get a study approved in order to prove safety and efficacy. This is a very common occurrence in peds.
Additionally, a physician deciding to give a med off label does not necesserily mean that they are on their own. Much of the evidence that the FDA uses to approve additional uses for meds comes from data collected by physicians using meds off label. In fact, for many off label uses there exists lots of published literature that supports the use of that med for the off label purpose, and that precedent has been shown to be legally defensible, just as much as using a med for an FDA approved use has been shown to be legally indefensible in many cases (no shortage of shysters ready to take your case and add it to some class action law suit.)
I agree, paramedics should not be practicing medicine. That is the doctors job. A hard line stance against off label use is not really practical though. If we eliminated off label use, a great deal of the pharmacological interventions used in medicine today would go away.
forgive my lapse of modesty
That is debatable. Some would describe that as innovation.
Somebody turned the defibrilator to maximum on their first shock instead of escalating doses. Despite guidelines and manufacturer recommendation.
Somebody figured out that sildenafil citrate worked better for something other than pulmonary hypertension.
Somebody figured out that permissive hypotension was better for patients than making them bleed kool-aid.
Certainly this is not negligence nor malpractice?
This actually sounds like the story of my life...
I have done many breakfasts, dinners, and even drinks to figure why I am the exception to all rules since kindergarten. Finally, after much grief, I just accepted it and found my niche. Which is not only accepted, but valued.
To this day I have never said "I want to be a doctor" but I find myself here all the same, mostly because of "peer pressure" from docs I have worked with.
I am of the opinion, perhaps arrogantly so, that most people I encounter simply don't understand medicine. At least they don't seem to understand it the way I, and a small minority of people I call mentors, do.
Whether they are doctors, nurses, or medics, they understand what to do when they see X, which usually has to be defined for them in some quantitative or list format, so they can perform Y treatment according to the guidlines, protocols, whatever. Perhaps with some finite and rudimentary understanding of what it is doing to a particular organ or system.
Then when a "new" study comes out, everyone is quick to want to add it to their back of tricks, because the conclusion says it should or does work.
There are even "standardized" ways to describe patient conditions. Great examples are NYHA and RIFLE scores. Then everyone and their brother finds the need to "tweak" them coming up with more variations of the score to be more accurate.
But how many see the obviousness of the truth?
If you must constantly tweak and modify, it means the score doesn't work!
Medicine is total body, philosophy, biological, and social. It is goal oriented and "why" is the most important part. Followed closely by "then what?"
Any provider who only sees a specific pathology or a specific organ, etc is going to fall way short many times. Despite our ideals to carve out hyperspecialization to make up for the vastness of knowledge and skill required so anybody can do it.
The problem with selecting applicants for medicine based on grades and standardized tests is that it predicts the ability to pass medical education based on mastery of academia. It does not even begin to measure capability to be a doctor. This directly leads to cookbook providers.
As has been brought up on this board a few times, PAs and other midlevels can produce research that shows they have the same effect as doctors who treat soley off of algorythms and standardized guidlines.
They spin this into showing how great they are. The opposite side of that coin is how bad doctors that do that are. What is worse, if you support such guidline treatment as the rule rather than the opinion it is, then a provider could easily be replaced by a computer algorythm which would print you out a bar coded prescription at the end of a form you fill out online.
It will be no less accurate then providers who do the same thing and perhaps even more so.
Makes you wonder what you pay for doesn't it?
2 questions I always ask myself about every patient,
1. Why will this treatment help them?
2. Am I trying to make this patient fit the treatment or the treatment fit the patient?
I know an ICU doc who likes to say "The trick to being a good intensivist is following the guidlines, knowing they will not work, until just before the point of no return, and at that moment, you can document your justification for not following them any longer and doing what you need to."
This doesn't bring discredit, it points out the flaw in the guidline system. Satisfy the master before you do what is needed.
This same doctor also likes to say "The reason you never hear of a guidline made up by a great clinician instead of a body is because great clinicians are busy taking care of patients and do not have the time needed to tell everyone else what to do in order to make themselves seem knowledgable."
Rules are tools devised for the safety of fools.
Having said all of that, not all rogue ideas are good simply because they are roguish.
Medicine is an art, not a math equation.
That is debatable. Some would describe that as innovation.
Somebody turned the defibrilator to maximum on their first shock instead of escalating doses. Despite guidelines and manufacturer recommendation.
Somebody figured out that sildenafil citrate worked better for something other than pulmonary hypertension.
Somebody figured out that permissive hypotension was better for patients than making them bleed kool-aid.
Certainly this is not negligence nor malpractice?
This actually sounds like the story of my life...
I have done many breakfasts, dinners, and even drinks to figure why I am the exception to all rules since kindergarten. Finally, after much grief, I just accepted it and found my niche. Which is not only accepted, but valued.
To this day I have never said "I want to be a doctor" but I find myself here all the same, mostly because of "peer pressure" from docs I have worked with.
I am of the opinion, perhaps arrogantly so, that most people I encounter simply don't understand medicine. At least they don't seem to understand it the way I, and a small minority of people I call mentors, do.
Whether they are doctors, nurses, or medics, they understand what to do when they see X, which usually has to be defined for them in some quantitative or list format, so they can perform Y treatment according to the guidlines, protocols, whatever. Perhaps with some finite and rudimentary understanding of what it is doing to a particular organ or system.
Then when a "new" study comes out, everyone is quick to want to add it to their back of tricks, because the conclusion says it should or does work.
There are even "standardized" ways to describe patient conditions. Great examples are NYHA and RIFLE scores. Then everyone and their brother finds the need to "tweak" them coming up with more variations of the score to be more accurate.
But how many see the obviousness of the truth?
If you must constantly tweak and modify, it means the score doesn't work!
Medicine is total body, philosophy, biological, and social. It is goal oriented and "why" is the most important part. Followed closely by "then what?"
Any provider who only sees a specific pathology or a specific organ, etc is going to fall way short many times. Despite our ideals to carve out hyperspecialization to make up for the vastness of knowledge and skill required so anybody can do it.
The problem with selecting applicants for medicine based on grades and standardized tests is that it predicts the ability to pass medical education based on mastery of academia. It does not even begin to measure capability to be a doctor. This directly leads to cookbook providers.
As has been brought up on this board a few times, PAs and other midlevels can produce research that shows they have the same effect as doctors who treat soley off of algorythms and standardized guidlines.
They spin this into showing how great they are. The opposite side of that coin is how bad doctors that do that are. What is worse, if you support such guidline treatment as the rule rather than the opinion it is, then a provider could easily be replaced by a computer algorythm which would print you out a bar coded prescription at the end of a form you fill out online.
It will be no less accurate then providers who do the same thing and perhaps even more so.
Makes you wonder what you pay for doesn't it?
2 questions I always ask myself about every patient,
1. Why will this treatment help them?
2. Am I trying to make this patient fit the treatment or the treatment fit the patient?
I know an ICU doc who likes to say "The trick to being a good intensivist is following the guidlines, knowing they will not work, until just before the point of no return, and at that moment, you can document your justification for not following them any longer and doing what you need to."
This doesn't bring discredit, it points out the flaw in the guidline system. Satisfy the master before you do what is needed.
This same doctor also likes to say "The reason you never hear of a guidline made up by a great clinician instead of a body is because great clinicians are busy taking care of patients and do not have the time needed to tell everyone else what to do in order to make themselves seem knowledgable."
Rules are tools devised for the safety of fools.
Having said all of that, not all rogue ideas are good simply because they are roguish.
Medicine is an art, not a math equation.
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Rules and protocols, are designed to allow individuals the ability to treat patients, when they possess neither the educational background, experience, or legal scope of practice to make independent medical judgements. Whether you like it or not, agree or not, paramedics (and all healthcare providers) are bound by a scope of practice that they exceed only at their own peril. The idea that you can do whatever you want to a patient because your intentions are noble and are what you perceive to be in the patient's best interests is total crap.
And with the current topic - can anyone show me a study where an aspirin tablet, and whether it's even absorbed through the rectal mucosa? There are aspirin suppositories, but several of you are talking about sticking an aspirin tablet up someone's butt. That tablet is designed to dissolve in the stomach, where saliva and stomach acids break it down. I'm not sure the same happens in a relatively dry area like the rectum. Absent a study that says an aspirin tablet is readily dissolved and absorbed when given rectally (and if there is, by all means share) then it's somewhat pointless, even if you "think" it might be reasonable.
mycrofft
Still crazy but elsewhere
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Why couldn't I have typed that instead of my long rant?
And from a reply above that:
1. "I agree, paramedics should not be practicing medicine. That is the doctors job.
2. A hard line stance against off label use is not really practical though. If we eliminated off label use, a great deal of the pharmacological interventions used in medicine today would go away."
1. Right on.
2. It is a practical concern if it is field technicians doing it, though. Giving medicines under a standardized protocol is one thing, but inventing uses or doing something because someone said something sometime or you read an article is not a technician's role.
The #1 nightmare of every field tech (besides the one where you respond and get out of the rig with no pants on or you forgot the equipment) is to have a pt for whom your best isn't good enough. It happens. It happens in the Mayo Clinic. Flailing around pharmacodynamicaly or otherwise is reserved for "the guy with the BIG stethoscope" back at the hospital. If you can ring him or her up and get an order, then fine. But people die and a tech who is constantly improvising either needs to help re-write the protocols, or find a way to regain a medical controller's confidence.
mycrofft
Still crazy but elsewhere
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From Veneficus:
"I know an ICU doc who likes to say 'The trick to being a good intensivist is following the guidlines, knowing they will not work, until just before the point of no return, and at that moment, you can document your justification for not following them any longer and doing what you need to'.....
This same doctor also likes to say 'The reason you never hear of a guidline made up by a great clinician instead of a body is because great clinicians are busy taking care of patients and do not have the time needed to tell everyone else what to do in order to make themselves seem knowledgable' ".
Also, the body would catch the individual in the parking lot and beat the ho!y cr@p out of them.:wacko:
Instead of "they will not work", I'd say "they will , at some point, fail". Some fail a lot sooner than others. If things go wrong in a hospital through interventions to remedy earlier interventions (positive feedback cycle) there are more resources to call on to calm things down. That's why people don't try to finely regulate blood sugar in the field by insulin injections ; seen that in house, and it gets hairy.
"I know an ICU doc who likes to say 'The trick to being a good intensivist is following the guidlines, knowing they will not work, until just before the point of no return, and at that moment, you can document your justification for not following them any longer and doing what you need to'.....
This same doctor also likes to say 'The reason you never hear of a guidline made up by a great clinician instead of a body is because great clinicians are busy taking care of patients and do not have the time needed to tell everyone else what to do in order to make themselves seem knowledgable' ".
Also, the body would catch the individual in the parking lot and beat the ho!y cr@p out of them.:wacko:
Instead of "they will not work", I'd say "they will , at some point, fail". Some fail a lot sooner than others. If things go wrong in a hospital through interventions to remedy earlier interventions (positive feedback cycle) there are more resources to call on to calm things down. That's why people don't try to finely regulate blood sugar in the field by insulin injections ; seen that in house, and it gets hairy.
I never disputed this.
However, my interpretation is there needs to be less providers, not more rules.
Like I said, I am not keen on paying for "providers" whos diagnostics and treatments could easily be replaced by a computer.
In the same instance, I am also not keen on doctors who feel they need to turf less complicated patients to other providers.
I would explain it such:
A musician cannot skip practicing basics only to play the most complicated pieces. They cannot delegate the less interesting pieces to somebody else because they don't want to be bothered.
Not because I say so.
Because only with mastery and practice of basc exercises does this muscician maintain their mastery.
The reason that all of these people without the education, experience, etc. exist is because not enough training for those who would. Not out of some shortage of qualified applicants. But out of greed. A purposeful shortage to maintain outrageous levels of income. (usually by acting as a healthcare manager)
It is not the fault of the patients these levels exist, it is out of their desperation for care. When other nations have a physician shortage, they don't create midlevels and techs and other stop-gaps, they get more physicians. (by multiple short and long term mechanisms)
But people follow rules because of what they don't have doesn't mean they are providing the best care. This is because patients don't neatly fit into 70% or 30%, etc. There is no way to identify them as such yet.
The only reasons I have heard as to why they are treated as such are: "It is better than nothing" and "so we have someplace to start when we don't know."
Call me elitist, but I find that overvalued.
It really has nothing to do with whether I agree or not. I has to do on what patients accept as what they find valuable. I am also not opposed to making every provider soley responsible for their own decisions.
I see it as self regulating actually. The first or second time you make a mistake and are heldto account, you won't repeat that. But under the current system, you could routinely provide bad care and be seen in the right as "following scope, or protocols, or guidlines, etc, etc.
I think providing treatments shown not to work or be beneficial because the rules say so is totally crap. Especially when those rules are written to protect poor providers or providers that a physician accepts responsibility for. It cuts both ways.
In fact somebody with an unlimited license to practice medicine can and do make treatment decisions based on noble intentions and the perception of the patient's best interest. The desire not to try to practice all parts of medicine is self imposed based on recognizing limits of knowledge and ability. Not surprisingly, it works.
It is easy to believe that following rules releases you from responsibility for poor outcomes. As I pointed out in my last post with a quote, following the rules to satisfy rules knowing from both knowldge and experience the treatment won't work plays a very dangerous game. Maybe you can sleep at night believing that because you followed the rules you are not responsible for the outcome.
Fortunately, there are still providers at senior levels who still believe they are responsible no matter what. Perhaps not legally, but morally, and since laws can be changed for convenience, it is probably better that morals are not so easy to change.
If you really believe those rules are always for the better, i respectfully invite you to come and see otherwise. But you might not find it too pleasurable knowing that you are not helping or harming others who are greatful for your care and efforts in order to protect yourself from "peril."
I am intrigued by this use of the word "peril" actually. Perspective:
You follow a protocol which costs somebody their only chance at life or a good life. You go home, "protected" from responsibility of your (collective your) inadequecy.
As opposed to:
You (collective you) do not have the capacity to effect largely positive outcomes so after a few mishaps have to find a job you are more qualified for outside of patient care whether you like it or not, even if it means a lesser standard of living.
Back on topic,
I have no doubt that some of it will be absorbed. Probably more the longer you leave it there.
I sincerely doubt it will be absorbed at a rate or quantity that would make any difference.
I think it is a rediculous idea to shove a pill up somebody's *** and absent some extremely convincing evidence, I will accept personal responsibility in not doing it to my patients because I don't believe it will work. (soley off of my ability to choose to do that or not, and what I believe is best.)
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mycrofft
Still crazy but elsewhere
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Maybe if you pushed it up further.....:rofl:
mycrofft
Still crazy but elsewhere
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Yup
the_negro_puppy
Forum Asst. Chief
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The anus of my patient is my least concern in an unconscious ACS scenario
boerbull
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We use Aspegic iv, if patients are not able to take medication P.O.