To ECG or not to ECG (opinion thread)

[triemal04]

Why wouldn't you activate the cath lab?

new onset LBBB needs diagnostic and possibly interventional catheterization. Where did the LBBB come from? Is it ischemic in origin and the LBBB is hiding the STEMI?

If you aren't going to cath them they at minimum need to go to the angio suite.

Really? Really? Is that what you think you've learned in school? That because somebody does not know that they have a LBBB, something that they may have had for years, been told about and forgot, or possibly never been told about in more than a passing way you should immedietly call for the cath lab to be opened when they say "no, I don't think I have that problem"?

Do you really think that the patient with a LBBB of unknown duration and no other cardiac symptoms will be placed in an "angio suite?"

Do you really know what actually goes on in a hospital after you drop off a "critical" cardiac/CVA/trauma/whatever patient?

:censored::censored::censored::censored: me. http://www.medscape.com/medline/abstract/19857407 That's an abstract but all I can post that you'll have access to. http://www.medscape.com/viewarticle/717550 There's a nice interpretation of the same study for you. The final sentence would be the most pertinent.

Part of learning and being competent is keeping up with developing trends. Granted, this is only one study but it is much better to follow than simply saying a "new" LBBB=trip to the cath lab without knowing what you are talking about.

Mods feel free to delete if this is considered "not nice."

 

[Handsome Robb]

I have a bundle branch block, I'm in my mid 20s. I wouldnt call in a cath activation for a patiet with a headache and an incidental LBBB on a 12 lead that I my self wouldn't have preformed. A lot of people walk around with them, and unless I'm working up a patient and ACS is in the differential, an LBBB is probably going to be treated as an incidental finding.

I'll agree to disagree. At the least the receiving ER is going to hear about this new onset BBB so the doc can decide what to do with it.

I agree, people do walk around with them all the time, but what's the etiology behind this one. I'm not sure I would call it incidental with symptoms presenting, even if they aren't textbook cardiac.

My thought process just for :censored::censored::censored::censored:s and giggles. Severe headache + new onset LBBB could very well be a CVA and AMI from something throwing multiple clots...but that's a pretty big zebra depending on the age, health and history of the patient as well as completely defies Occam's razor.

triemal the thread started with a 90 year old patient, I'm willing to bet they would have noticed a BBB by now but hey I'm just a young dumb medic student so feel free to disregard anything I have to say about it.

I'll bow to your superiority now.

 

[triemal04]

triemal the thread started with a 90 year old patient, I'm willing to bet they would have noticed a BBB by now but hey I'm just a young dumb medic student so feel free to disregard anything I have to say about it.

I'll bow to your superiority now.

And the original post had nothing to do with the post that referenced a LBBB. For kicks, let's say that it did. So, by your criteria you would activate the cath lab for this patient? Why? For what reason?

Do you really think that it is that out of the ordinary for people...MANY people to walk around with a bundle branch block and have no clue that it's there, even if they were told about it? It's like afib that way. There is a reason that a previous EKG is needed to make that determination, and even then, unless it was a very, very recent one, or there are extenuating circumstances (like elevated cardiac enzymes, symptoms of ACS, a LBBB with concordance, etc etc) it still isn't a sure thing. New is a relative term.

I'm not superior to anyone. Inferior to most usually. But you are close to finishing school. Now is when you get to decide what type of paramedic you will be. It can either be the type that only listens to other pseudo-paramedics, or the kind that follows along, as best they can, with medicine. You can think about what is happening, and make your decisions based on what is appropriate, or what "that really smart paramedic told me to do."

 

[Handsome Robb]

And the original post had nothing to do with the post that referenced a LBBB. For kicks, let's say that it did. So, by your criteria you would activate the cath lab for this patient? Why? For what reason?

Do you really think that it is that out of the ordinary for people...MANY people to walk around with a bundle branch block and have no clue that it's there, even if they were told about it? It's like afib that way. There is a reason that a previous EKG is needed to make that determination, and even then, unless it was a very, very recent one, or there are extenuating circumstances (like elevated cardiac enzymes, symptoms of ACS, a LBBB with concordance, etc etc) it still isn't a sure thing. New is a relative term.

I'm not superior to anyone. Inferior to most usually. But you are close to finishing school. Now is when you get to decide what type of paramedic you will be. It can either be the type that only listens to other pseudo-paramedics, or the kind that follows along, as best they can, with medicine. You can think about what is happening, and make your decisions based on what is appropriate, or what "that really smart paramedic told me to do."

Fair enough. My biggest problem is looking at the big picture and I will admit that.

 

[triemal04]

Fair enough. My biggest problem is looking at the big picture and I will admit that.

More often than not that can be the problem that get's a lot of people in trouble. And why there is such a problem in the US.

If I came across as harsh I do apologize, this is just one of those days when the posts here have lowered my threshold for aggravation. And the beer doesn't help either...:blush:

I am serious though when I say that this is the time when you get to decide what type of paramedic you will be. Don't stop learning and only listen to those around you, and don't decide to not use resources and information that is available because other people at your level don't. But, at the same time, while you should be aware of zebra's, don't get caught up in them and ignore what is actually happening right in front of you.

You've hopefully learned quite a bit going through school, and hopefully will continue to seek out better educational opportunities, but, moreso initially than later on, there will be a problem in sorting out all that info and applying it to the situation at hand. It is easy to get bogged down and start chasing imaginary problems. Try not to do that. If looking at the big picture really is a problem for you (and kudos for being able to recognize that) then don't go to work somewhere that doesn't have a strong FTO program. As with deciding how much or little you want to continue to learn, don't set yourself up for failure by going somewhere where you won't have any direction.





And don't listen to drunk people on the internet when it's 11pm. :beerchug:

 

[tacitblue]

IIRC, it was 20% of CVA patients are also having a cardiac related problem or MI. and an EMT can't be a strong patient advocate? please explain why not? exactly, the highest level of care that is warranted based on the situation. Sometimes that is an EMT. and maybe not in your state, but there are quite a few EMTs who can formulate a coherent verbal report to the ED staff to make sure they are not brushed off into a corner and left to dwindle. I know I've done it, and seen others give great reports to ER staff as well. and what if the BLS provider does know what he is doing and can paint the picture? does that mean there is no need for the medic?

I've been blown off by the nurse on a serious patient. She wanted to have me put the patient in the fast track section of the ER. A quick chat with one of the ER attendings was all I needed to do to move the patient back to the emergency section of the ER. So you don't need to be a medic in order to be a patient advocate.do you test every patient's blood sugar? as part of their vital signs? if so, why not do 12 lead as part of your vital signs to look for any abnormality?
if the patient was bleeding into his abdomen and subsequently died, and that injury could have been fixed if he had done the CT? yes, I think I might find a little fault in that.will the CATH lab be able to fix the left bundle branch block? What if it shows a STEMI? gonna activate the CATH lab? what about new onset of AFib? would that warrant treatment? how about a pulse ox of 70? think that might warrant you doing some type of corrective action, even if it's asymptomatic or abnormal symptoms?

Even when one does everything right, things can be missed. Reason I mention the CT is that there is evidence that serial abdominal exams are more sensitive for surgical bellies than a CT scan. Medical providers have to weigh risk vs benefit and critically analyze each test they want to preform to find utility. A CT scan is the equivalent of hundreds of x rays, that's a lot of radiation that could be avoided when there is a better an cheaper option. However, every once in a while one may slip through the cracks.

I'm not trying to be a douche, but do you understand the concept of sensitivity and specificity? It's good to know. And, If I am performing a 12 lead as part of my "vital signs assessment" on every patient, I am doing something very wrong.
These take time and will add Very little of value in the workup of many o my patients. By your logic, why not throw every patien on side stream capnograpghy just to check out how they are ventilating... Many many folks are seen at the ED for various complaints and certain tests that you think might be preformed are not, because a competent emergency physician was able to apply her knowledge of the utility of these various tests to the patient's presentation and decide they were not useful and would not add value to the workup. In the process she saves the patient a significant amount of money and the dangers that over testing can produce.

You can look in almost any area of medicine and see controversy over various tests. Look at Prostate Specific Antigen or breast cancer screening. Sometimes getting information from a test can really only add confusion and uncertainty to the clinical picture.

 

[Handsome Robb]

More often than not that can be the problem that get's a lot of people in trouble. And why there is such a problem in the US.

If I came across as harsh I do apologize, this is just one of those days when the posts here have lowered my threshold for aggravation. And the beer doesn't help either...:blush:

I am serious though when I say that this is the time when you get to decide what type of paramedic you will be. Don't stop learning and only listen to those around you, and don't decide to not use resources and information that is available because other people at your level don't. But, at the same time, while you should be aware of zebra's, don't get caught up in them and ignore what is actually happening right in front of you.

You've hopefully learned quite a bit going through school, and hopefully will continue to seek out better educational opportunities, but, moreso initially than later on, there will be a problem in sorting out all that info and applying it to the situation at hand. It is easy to get bogged down and start chasing imaginary problems. Try not to do that. If looking at the big picture really is a problem for you (and kudos for being able to recognize that) then don't go to work somewhere that doesn't have a strong FTO program. As with deciding how much or little you want to continue to learn, don't set yourself up for failure by going somewhere where you won't have any direction.





And don't listen to drunk people on the internet when it's 11pm. :beerchug:

No worries dude, no offense taken. I understand the grumpiness I had an episode of it yesterday as well.

The agency I work at as an Intermediate now and hope to move up to a medic spot at the end of school seems to have a pretty solid FTO period. 6 weeks with an FTO then 6 months as a second seat medic before you are cleared to work with an Intermediate partner. Not the most progressive protocols but not mother-may-I by any means.

When I can look at something it is much easier for me to see the big picture rather than reading something but I still definitely need to do a lot of work on it either way. The cool thing about now is all the partners I have worked with so far have always asked me what I'm thinking "from a medic point of view" either on scene or after the fact. It has helped quite a bit.

I don't want to be that guy that finishes school then just does the minimal CEUs to keep my cert up. It is just very overwhelming with school right now and all the conflicting information when it comes to textbook vs. real life.

Drink a brew for me! :beerchug:

Sorry to derail the thread, back to the scheduled programming

 

[tacitblue]

Even when one does everything right, things can be missed. Reason I mention the CT is that there is evidence that serial abdominal exams are more sensitive for surgical bellies than a CT scan. Medical providers have to weigh risk vs benefit and critically analyze each test they want to preform to find utility. A CT scan is the equivalent of hundreds of x rays, that's a lot of radiation that could be avoided when there is a better an cheaper option. However, every once in a while one may slip through the cracks.

I'm not trying to be a douche, but do you understand the concept of sensitivity and specificity? It's good to know. And, If I am performing a 12 lead as part of my "vital signs assessment" on every patient, I am doing something very wrong.
These take time and will add Very little of value in the workup of many o my patients. By your logic, why not throw every patien on side stream capnograpghy just to check out how they are ventilating... Many many folks are seen at the ED for various complaints and certain tests that you think might be preformed are not, because a competent emergency physician was able to apply her knowledge of the utility of these various tests to the patient's presentation and decide they were not useful and would not add value to the workup. In the process she saves the patient a significant amount of money and the dangers that over testing can produce.

You can look in almost any area of medicine and see controversy over various tests. Look at Prostate Specific Antigen or breast cancer screening. Sometimes getting information from a test can really only add confusion and uncertainty to the clinical picture.

and just a quick follow up for DrParasite; the cath lab isn't going to "fix" a left bundle block, but in patients where ACS is likely based on their history and physical- finding a new or presumably new LBBB on the electrocardiogram is considered a STEMI and treated as such. The reason I brought it up in my original post was to demonstrate why a pretest suspicion is needed to guide interpretation; some people have LBBBs and teasing out folks who need to go to the cath lab now is based on why you even did the 12 lead in the first place. And see, that is it right there. Hang out here for a minute with me and really think about that.

Throwing everything at a patient to see what sticks may leave you going down a path that has nothing to do with what is really going on.

 

[DrParasite]

Even when one does everything right, things can be missed. Reason I mention the CT is that there is evidence that serial abdominal exams are more sensitive for surgical bellies than a CT scan. Medical providers have to weigh risk vs benefit and critically analyze each test they want to preform to find utility. A CT scan is the equivalent of hundreds of x rays, that's a lot of radiation that could be avoided when there is a better an cheaper option. However, every once in a while one may slip through the cracks.

you know, you might be right. A lot of radiation vs the slim chance of finding anything. I agree. unless your dead family member is the one who slipped through the cracks. and mom/dad/son/daughter would still be alive if they had done the CT scan, had been that one who slippled through the cracks, and fixed the problem, would you still be against CT scan of the abdomen following the serious MVA?

I'm not trying to be a douche, but do you understand the concept of sensitivity and specificity? It's good to know. And, If I am performing a 12 lead as part of my "vital signs assessment" on every patient, I am doing something very wrong.
These take time and will add Very little of value in the workup of many o my patients.

time? what, maybe 5 minutes to do a 12 lead? apply 12 stickies, tell the patient to hold still, analyze, save, print, look at results? 99% of the time it looks normal, 1% of the time it shows something significant, and you are aware of it before it becomes critical? Ok, so the CT scan is a lot of radiation, that's bad, I agree, what's the downside to a 12 lead? you need to buy another package of stickies? a little electricity through the patient?

By your logic, why not throw every patien on side stream capnograpghy just to check out how they are ventilating... Many many folks are seen at the ED for various complaints and certain tests that you think might be preformed are not, because a competent emergency physician was able to apply her knowledge of the utility of these various tests to the patient's presentation and decide they were not useful and would not add value to the workup. In the process she saves the patient a significant amount of money and the dangers that over testing can produce.

You can look in almost any area of medicine and see controversy over various tests. Look at Prostate Specific Antigen or breast cancer screening. Sometimes getting information from a test can really only add confusion and uncertainty to the clinical picture.

You know, we can go back and forth on this, but the reality is, in the ER, if you are sick, and old, you get a 12 lead. if you come in by ambulance with toe pain, you get a 12 lead. if you come in with abd pain, you get a 12 lead. if you come in with an ear ache, you get a 12 lead. doesn't cost much, isn't invasive, doesn't take much time, and it's part of your medical chart. most of the time, it shows nothing abnormal. and if something abnormal is found, well, now you know, it can be properly investigated to ensure it's not life threatening.

most of the time, yes, it's a waste of time and stickies, I won't disagree. but it's still done, and if people who make more money and have more education in medicine do it as a standard practice, maybe you can admit they might know a little bit more than you?

If not, lets agree to disagree. Time to move on to bigger and better disagreements.

 

[EMSLaw]

Emslaw whats your take as a practicing lawyer on this. Especially if something went wrong and the BLS hadnt noticed it or patient wasnt still on the monitor.

It gets complicated. Really, lawsuits against EMS providers are fairly rare, as far as I can tell, at least for medical related things (as opposed to wrecking out your rig on the way to the call). That is, in reported opinions. It's always hard to tell what goes on that doesn't result in an opinion or is settled. There are ways to find out, but I will admit I haven't done the research. It would make an interesting presentation someday.

Getting back on point, the question is going to be whether a reasonable paramedic under the circumstances would have done the same thing, one. And two, whether the outcome would have been any different had things been done in the way a reasonable paramedic would have done them.

Say your released patient codes. Presumably, the EMT realizes this and starts CPR, while the medic pulls over and goes to work. The patient dies. The question would then be whether if there had been a medic in the back, anything would have happened differently than it did. It's entirely possible the answer is no. Patients die even in world-class research hospitals every day, and there's nothing that can be done to prevent it. If the answer is yes, though, then there would be trouble.

So, my take is that it would be a very situation-dependent issue. Starting a line on the patient is an ALS treatment, though, as opposed to a mere evaluation, so that might enter into it. If your medical control signs off on you releasing to BLS, then it will be more on him, as the ultimate medical authority.

The best I can do is equivocate. If there's no indication from any diagnostic tools in the field that the patient requires a paramedic, then based on the information available, would a reasonably prudent paramedic still have ridden the call in? If yes, then would the outcome have been any different? A lot of it is going to depend on your local protocols, both the written ones and the way things operate on a day-to-day basis.

For example, NJ is an interesting place when it comes to EMS. Not only because we have a tiered system, but also because we have a dearth of paramedics (something like 1500 active medics in the entire state). In suburbia or the more rural parts of the state, ALS might not always be available. As a BLS provider, I'm expected to have a good understanding of what paramedics can do. The idea that every patient needs a paramedic is foreign to me - and would get me frequent posterior-chewings from the local medics (who expect to be cancelled when my 'chest pain with difficulty breathing' job turns out to be a hyperventilating 16 year old, or something like that). Some EMTs are more 'paramedic dependent' than others, and Paramedics can release to BLS after evaluation. However, the last step in that process is asking the BLS crew if they are comfortable treating the patient. If the answer is 'no', then the paramedic should ride the call in anyway. Is the whole process reasonable? I don't know if it's ever been tested.

Sorry I can't be more helpful.

 

[epipusher]

Previous cardiac arrest patient now has ROSC. Pt is intubated with bvm assistance(bls skill). IV slowed to tko rate(bls skill). No more drugs needed to be given(no amio or lido drip). Perfect sinus at 80, 12-lead unremarkable. Pt is now bls, correct?? Direct paramedic contact is no longer needed per a previous post or two.

 

[Veneficus]

late to the party,didn't read the whole thread

But I agree with the whole first page mostly.

This patient needed a 12 lead.

This patient should not have been turfed to BLS.

if I could?

Elderly patients only usually present with symptoms of general illness, even when they are extremely sick. Including with conditions that are not consistent with the symptoms.

12 lead for acute MI.

Did you interpret the 12 lead for all of the conditions it can pick up or just ST elevation?

If just the later, then you made an error in turfing to BLS.

IV therapy...

If you started an IV because "just in case, to help out the hospital, or any other reason than for treatment, you made a medical error of performing an unindicated procedure. (This is especially true if the facility has a policy of removing field IVs and placing their own)

Getting paid for what you do.

I can also see why your service is upset they equipped and trained and ALS provider at considerable expense to be paid for less. Much less.

If you go to a doctor with a complain and it turns out to be minor, do you think you will be billed less than the basic rate the doctor charges for being a doctor because you did not need an advanced treatment?


I do not agree with your supervisor as to why but it looks to me like you made a mistake. Something all of us do from time to time.

Not the end of the world, use it as a learning experience and move on.

 

[triemal04]

Previous cardiac arrest patient now has ROSC. Pt is intubated with bvm assistance(bls skill). IV slowed to tko rate(bls skill). No more drugs needed to be given(no amio or lido drip). Perfect sinus at 80, 12-lead unremarkable. Pt is now bls, correct?? Direct paramedic contact is no longer needed per a previous post or two.

Now come on, that's going just a tiny bit to far. There is a difference between someone who experienced a severe, acute event like that and someone in the original post.

There is a difference between someone who has a high likelihood of experiencing an acute event and some in the original post.

There is a difference between someone in extremis, where a paramedic intervention won't help and someone in the original post.

The list could go on, but that should be pretty clear, yes?

 

[triemal04]

But I agree with the whole first page mostly.

This patient needed a 12 lead.

This patient should not have been turfed to BLS.

if I could?

Elderly patients only usually present with symptoms of general illness, even when they are extremely sick. Including with conditions that are not consistent with the symptoms.

12 lead for acute MI.

But why? You should be one of the more qualified people to answer this, and likely have more in-hospital experience than most, so I'd like to hear.

For the sake of arguement, say that TheGodfather did a full exam, interpreted the 12-lead as well as any EM doc, etc etc, and found nothing that wasn't posted. What was the need for a paramedic? I'm all for taking a patient in at a higher level, even if nothing is done if talking to the doc/RN will ensure that the patient get's the care they need, but this doesn't appear to be someone like that.

I've spent a fair amount if time inside several hospitals, and the situation I laid out for what would happen on her arrival is accurate, at least from what I've seen and know.

Patients can be much sicker than they appear, and it isn't always possible to determine that initially, but a decision does need to be made about who treats them and when it happens. At all levels and locations. What makes this situation so different?

 

[Veneficus]

But why? You should be one of the more qualified people to answer this, and likely have more in-hospital experience than most, so I'd like to hear.

For the sake of arguement, say that TheGodfather did a full exam, interpreted the 12-lead as well as any EM doc, etc etc, and found nothing that wasn't posted. What was the need for a paramedic? I'm all for taking a patient in at a higher level, even if nothing is done if talking to the doc/RN will ensure that the patient get's the care they need, but this doesn't appear to be someone like that.

I've spent a fair amount if time inside several hospitals, and the situation I laid out for what would happen on her arrival is accurate, at least from what I've seen and know.

Patients can be much sicker than they appear, and it isn't always possible to determine that initially, but a decision does need to be made about who treats them and when it happens. At all levels and locations. What makes this situation so different?

Assuming all of the above.

As I said, geriatrics are a complex patient.

They present with nonspecific symptoms. They also have complex medical and pharmaceutical interactions. The med list being too long to type sounds like a polypharmacy issue.

In order to unravel complex patients, it takes a higher level of knowledge and understanding. While not perfect, ALS is more suited to it.

Will it require intervention most of the time during transport? Probably not. But the ability to more accurately diagnose as well as offer supportive care, makes it more beneficial to use an ALS provider than a BLS one.

Forget about the "what if scenarios" a dehydrated patient does feel better with some iv fluid.

 

[triemal04]

Assuming all of the above.

As I said, geriatrics are a complex patient.

They present with nonspecific symptoms. They also have complex medical and pharmaceutical interactions. The med list being too long to type sounds like a polypharmacy issue.

In order to unravel complex patients, it takes a higher level of knowledge and understanding. While not perfect, ALS is more suited to it.

Will it require intervention most of the time during transport? Probably not. But the ability to more accurately diagnose as well as offer supportive care, makes it more beneficial to use an ALS provider than a BLS one.

Forget about the "what if scenarios" a dehydrated patient does feel better with some iv fluid.

I don't completely disagree with any of that, but again, from a medical standpoint, I still have to ask, "why?" Not because this patient may or may not need anything done, but, will the paramedic be able to alter the final outcome for this patient, or even offer them a higher level of comfort? (and yes, a patient who is dehydrated, and this could be a case depending on how long the low food intake was going on for, should get a paramedic.)

This patient should be evaluated by a paramedic, and in a better way than "your BP and pulse are fine, no ST-elevation, no acute complaint and I need to be off scene in 10 minutes so the EMT get's to take you." And, if they are going to be turfed to a lower level than that had better be happening. But, once it is, and nothing is found...why the need?

You said it yourself, this patient needs a higher level of care than a paramedic can offer (at the current time and for the long forseeable future), but still doesn't need any acute care, or neccasarily any comfort care.

Would this be any different than being triaged in the ER to either a fastrack unit staffed by midlevel providers, or to the main section?

 

[Veneficus]

I don't completely disagree with any of that, but again, from a medical standpoint, I still have to ask, "why?" Not because this patient may or may not need anything done, but, will the paramedic be able to alter the final outcome for this patient, or even offer them a higher level of comfort? (and yes, a patient who is dehydrated, and this could be a case depending on how long the low food intake was going on for, should get a paramedic.)

This patient should be evaluated by a paramedic, and in a better way than "your BP and pulse are fine, no ST-elevation, no acute complaint and I need to be off scene in 10 minutes so the EMT get's to take you." And, if they are going to be turfed to a lower level than that had better be happening. But, once it is, and nothing is found...why the need?

If you can unravel a geriatric patient and be off scene in 10 minutes, you are better than I am.

There are many things that can cause dehydration, like insensible sweating when they have the thermostat turned up to 85F for ages on end.

But we are also entertaining the idea that the ALS provider is at the peak of ability.

I have taken a number of absolute trainwrecks out of nursing homes. Some who just needed "transport" for evaluation in the ED. (one of which was for altered labs and was in torsades when I found her)

BUt zebras aside, it takes time to really evaluate those patients. The more eyes and minds you have on a patient longer, the better it is for the patient.

but still doesn't need any acute care, or neccasarily any comfort care.

I am not sure that this conclusion is supported by the presentation given.

Would this be any different than being triaged in the ER to either a fastrack unit staffed by midlevel providers, or to the main section?

I have no use for "midlevel" providers and do not agree with this practice at all. It exists in no other nation except the USA and the healthcosts reflect its uselessness.

The only real benefit I can see with it is that it will help speed the doom of the current system and bandaides such as this can be taken off when it is inevitably, seriously, and effectively revamped.

 

[Medic Tim]

Canada has PAs and NPs

 

[triemal04]

If you can unravel a geriatric patient and be off scene in 10 minutes, you are better than I am.
Just to be utterly clear, I meant that doing an "assessment" like that would be WRONG; more would be needed before, in good conscious and following best practice, the patient could be turfed.
There are many things that can cause dehydration, like insensible sweating when they have the thermostat turned up to 85F for ages on end.
Certainly; I wasn't trying to say that decreased intake was the only way, just didn't want to list everything I could think of.But we are also entertaining the idea that the ALS provider is at the peak of ability.
We are, for this scenario at least. I know it isn't a reality nationally, but I still would like to hear a good, sensible, well though out medical reason to send a paramedic with this patient instead of an EMT.
I have taken a number of absolute trainwrecks out of nursing homes. Some who just needed "transport" for evaluation in the ED. (one of which was for altered labs and was in torsades when I found her)
As have many of us, from nursing homes AND hospitals; but you can't use that to guide all your care. More on that below.BUt zebras aside, it takes time to really evaluate those patients. The more eyes and minds you have on a patient longer, the better it is for the patient.

I am not sure that this conclusion is supported by the presentation given.

I have no use for "midlevel" providers and do not agree with this practice at all. It exists in no other nation except the USA and the healthcosts reflect its uselessness.
Fair enough. And I can understand, and to some extent emphasize.
The only real benefit I can see with it is that it will help speed the doom of the current system and bandaides such as this can be taken off when it is inevitably, seriously, and effectively revamped.

As I said above, most people who do this for awhile and have a decent brain will realize that some, maybe even alot, of the "stable, non-critical" patients that we take from nursing homes (or hospitals in my own experience) are anything but. And while that is more evidence that a very sick person does not always appear as such, and that a "higher level of care" is not always what it seems, you can't base all of your future decisions off that.

At some point, good clinical judgement must come into play. Patients can definetly fool you, and our resources in the field are somewhat limited, both in knowledge (as an entire group) and in diagnostic ability by the lack of labs, xrays, ct, etc. For the record, I DO NOT want this to turn into an arguement about whether or not paramedics as a whole are cabable of making that type of clinical decision. Otherwise, the only decision you can be left with is that every patient, no matter what, needs a paramedic, not only to assess them, but to be in constant attendance with them. Because you never know, right?

To take that further, if that is an opinion that is held, then on arrival, the patient should be given every test available, for every possible problem; you never know right? And even doctors can be fooled.

Maybe there's a better way to put this. If you were working in the ER, and this patient came in, and, again, saying that there was nothing else untoward found in either the physical exam or history (including evaluating their med list), what would you do for them initially? Blood work? A urine screening? Maybe some fluids?

Or would you do all of the above and then order a RN to stay with them on a 1:1 basis instead of treating them like most other relatively low (at this point) acuity patients? If you wouldn't do that, why the need for a paramedic to bring them in. If you would, why?

 

[Ramis46]

Yeah I know that when I was a Basic that i had a paramedic start an IV ( which can be observed by a B) and put monitor on pt, but then pushed some Fentanyl. I got in trouble for atteneding the pt because after the fentanyl the pt felt good. There for i feel if you obtained 12-lead, and started an IV its a ALS call (according to our protocal). However I feel from where you are coming from. If you have ruled out everything, why cant a basic/Intermedite attend the call? really... Just like ever "sick person" that turns out to be an anxiety call... come on america...