The improper incorrect thread: what do you do that's not in the protocols but WORKS?

[mycrofft]

Just to head off the nosies, and the newbies looking for a way around their bosses, I'm not looking for one-handed cricothyrotomies or substitute blood products. Is there one thing in your protocols which just doesn't work and everyone uses a workaround, or have you just noticed something you do which works but isn't in the protocols yet?

WARNING!!

This is going to turn into a dogfight real fast if people can't just sit back and go "Hmmmm...". How mature and colleageal can we pretend to be for a few hours??

 

[46Young]

Fluid bolus for a symptomatic hyperglycemic, NRB without O2 for an anxiety attack with carpal pedal spasm.

 

[firecoins]

NRB without O2 for an anxiety attack with carpal pedal spasm.

seconded


fdklsafjdksla

 

[emtbill]

Bicarb for hyperkalemic induced VT (must have 12 lead immediately prior to sustained VT)
Withholding NTG in right ventricle infarctions and suspected reduced ejection fraction (QRS>170ms)
Actually reading 12 leads to withhold antidysrhythmics when appropriate

Etc...none of these are in protocols. I call for orders when needed of course.

 

[EMS49393]

My protocols won't allow for administration of Zofran for any reason except active vomiting. I violate that all the time. STEMIs get Zofran unless contraindicated. They have enough problems without vomiting. I often give it with narcotics administered for extremity injuries, again, if you're foot is hanging off your leg, you deserve not to vomit.

I also administer fluid challenges to the hyperglycemic patient unless contraindicated, i.e., history of CHF, renal failure, etc.

I have battled the no NTG in the inferior STEMI and lost, several times. I won't do it, I refuse to do it. I can't spend the transport attempting to push the water back into the bowl after I flush away the patients preload. To my credit, I have had several physicians side with me and offer to go to bat for me when I get called on the carpet for not administering it in those patients.

My last system had very liberal protocols. So long as I could justify my treatment, I didn't have to worry. The protocols where I'm at now are very limited, probably because the medical director doesn't trust the medics, and after working here, I really can't blame him. But for me, I find it easier to err on the side of my patient and ask forgiveness after.

 

[reaper]

You really should read up on MI with RSI. NTG is very useful and not a danger, if used with care and fluids.

 

[Sasha]

Maybe I'm a prude, but I don't think people should be posting what they do against protocols... It's like asking someone to forward your posts to your boss.

 

[Shishkabob]

NRB without O2 for an anxiety attack with carpal pedal spasm.

I assume you still have some sort of air flowing to that NRB, or that you mean a simple mask / partial rebreather.




Not saying I've seen it, but I've heard medics say they've hinted to patients to say they are nauseous from morphine so they can give phenergan as to potentiate the morphine.

 

[EMS49393]

I try to talk down my patients with anxiety attacks. I have yet to have that not work. In the event that it fails me, once they pass out they'll reset their body anyway. I'm not a big fan of the CO2 rebreathing treatment, I worry about what harm it could cause a patient.

There are still services that carry phenergan? We dropped it the end of last year. All of the area hospitals have also ordered that it not be administered EXCEPT through a central line and that it must be diluted in a minimum of 50 mL of NaCl. I only ask because I'm in one of the least progressive services and service areas in the country (at least until August 16th) and I figured we'd be the last to drop phenergan and adopt Zofran.

As for "tattling" on myself publicly about deviating from protocols, I'm not really concerned about my boss knowing it because he already does. I never leave an ER without a physician signature when I deviate, just to cover my rear-end. I've also had an ER doc come to my rescue during a protocol review when I didn't give that NTG for a patient having an inferior STEMI. (I don't fluid challenge those with renal issues). I'm also the only medic in my service that has never been turned down for orders during a consult. I make it a point to work with my doctors and get to know them so they understand I'm not the run of the mill thrill-seeking (or worse yet, lazy) medic.

There comes a point and time where you have to trust in your education and yourself enough to do what you know is right for your patient. We don't always have a protocol or online medical control to bail us out. I'd go into my "we simply need to increase the education standards" speech, however I'm new here, and I'm not interested in flaming anyone that opted out of pursuing a degree as a paramedic.

 

[Shishkabob]

Many places around here are dropping Phenergan for Zofran, but places under MC from "BioTel", such as Dallas, actually carry both.

 

[emtbill]

You really should read up on MI with RSI. NTG is very useful and not a danger, if used with care and fluids.

Agreed, however it needs to be given IV drip in conjunction with fluids/pressors. The sublingual bolus given in the field is what's dangerous for right sided MI.

Maybe I'm a prude, but I don't think people should be posting what they do against protocols... It's like asking someone to forward your posts to your boss.

I disagree; do what's right for the patient. You don't have to deviate from your protocols to do what's right. If you want to withhold a drug when your protocols say to give it, you withhold it because it's contraindicated, not because you think the protocols are wrong. On the other hand, if you believe a treatment is necessary that is completely opposite from protocol (like bicarb for hyperkalemic VT), that should be an online order

There are still services that carry phenergan? We dropped it the end of last year. All of the area hospitals have also ordered that it not be administered EXCEPT through a central line and that it must be diluted in a minimum of 50 mL of NaCl. I only ask because I'm in one of the least progressive services and service areas in the country (at least until August 16th) and I figured we'd be the last to drop phenergan and adopt Zofran.

Unfortunately yes. I am fighting to stock zofran but for now we are stuck with phenergan. I have only given it once in the past year and gave it deep IM.

 

[reaper]

Agreed, however it needs to be given IV drip in conjunction with fluids/pressors. The sublingual bolus given in the field is what's dangerous for right sided MI.



I disagree; do what's right for the patient. You don't have to deviate from your protocols to do what's right. If you want to withhold a drug when your protocols say to give it, you withhold it because it's contraindicated, not because you think the protocols are wrong. On the other hand, if you believe a treatment is necessary that is completely opposite from protocol (like bicarb for hyperkalemic VT), that should be an online order



Unfortunately yes. I am fighting to stock zofran but for now we are stuck with phenergan. I have only given it once in the past year and gave it deep IM.

And I am sure you can provide the study to prove this? I am sure a lot of cardiologists would love to read up on it!

 

[Smash]

And I am sure you can provide the study to prove this? I am sure a lot of cardiologists would love to read up on it!

It sounds a bit odd to me too. Increasing preload so you can safely reduce preload? Why not just leave it alone?

 

[medic417]

Unfortunately yes. I am fighting to stock zofran but for now we are stuck with phenergan. I have only given it once in the past year and gave it deep IM.

Actually it is smart to have multiple types of anti-emetics as some patients do better with different ones.

 

[Sasha]

It sounds a bit odd to me too. Increasing preload so you can safely reduce preload? Why not just leave it alone?

Nitro increases blood flow to the myocardium by way of coronary arterty dilation. A good thing, especially in an MI!

 

[akflightmedic]

Actually it is smart to have multiple types of anti-emetics as some patients do better with different ones.

And as I have posted before on here, phenergan's PRIMARY use (recommended by the manufacturers) is that of antihistamine, not anti emetic.

So yes, it is nice to keep a drug that has dual purpose if needed, which is why I still stock it.

http://www.drugs.com/phenergan.html

 

[vquintessence]

Abstaining from IV access in a good amount of febrile seizures (all contingent on mental status/motor activity, grade & duration of fever, ability to knock it down, blah blah).

 

[Melclin]

Nitro increases blood flow to the myocardium by way of coronary arterty dilation. A good thing, especially in an MI!

The main point of GTN is to reduce demand on the heart, by reducing preload and afterload. In lower doses, venodialation occurs followed by arterial dilation with higher doses. The dilation of coronary arteries is ancillary to the affect on pre and afterload.

I heard at uni, that there was some suggestion that the dilation of the coronary arteries didn't have any affect on cardiac chest pain, but I'll have to check on that, it doesn't make intuitive sense.

Preload is important in the proper working of circulation in the right side of the heart. I'm a little sketchy on the details and 1:30am so I'll not waffle too much, but needless to say because preload is in some way important to right coronary perfusion, and GTN drops preload, GTN can be reasonably said to be contraindicated in inferior STEMIs and RVIs etc.

EDIT: GTN is what we call nitro here.

 

[johnrsemt]

my old service had a medical control committee; and they had the worst time getting past giving something for vomiting only: so our medical director told us to document that we "gave ..... (whatever drug we carried at the time) for vomiting"; just not to put down when the patient vomited.
"Zofran given for vomiting" ( patient hasn't vomited for 12 years, he just feels like he is about to, he gets it.)

 

[EMS49393]

The sub-lingual dose of NTG is 400 mcg whereas I can titrate a NTG drip to begin at as low as 10 mcg/min and control the increase in relation to my patient's pain and blood pressure.

Show me some studies that state the huge dose of NTG isn't dangerous in the right-sided MI.

When I was an intermediate, long before 12-leads, I had a patient's very good blood pressure tank on me after administering NTG for his chest pain. We never got him back, despite aggressive fluid resuscitation. I later found out that he had a right-sided MI, however since I didn't have 12-lead capabilities and was but an intermediate anyway, all I could do was follow the protocol (I didn't have the education not to) and kill my patient.

I want proof. I want to see studies. Until I see them, I remain firm that a dose of 400 mcg is a bit extreme when dealing with that type of MI. I'm not in the business of jacking with homeostasis. It's bad enough you're battling an MI, but lets add battling hypovolemia to the mix.