Treatment Question

[usalsfyre]

This doesn't scream haemorrhage to me, at least initially. It sounds more like one of the many poorly cared for oldies who are miscellaneous crook and a bit dry. I'm having a hard time picturing this pt from the narrative and the second pressure is certainly cause for concern.

Yeah, when I went back and looked I realized there was more of a time differential than I thought when I initially read the scenario.

Sux and an apology is considered to be inhumane by a lot of people round these parts. Even very sick pts with generally still get some level of sedation/analgesia for intubation.

They get SOMETHING for sedation analgesia, but at almost homeopathic doses (0.5-1mcg/kg of fent for intubation I read somewhere...yikes)

 

[Melclin]

I am sorry but I gotta back up RocketMedic here as well. If my transport time was 7 minutes long then I am sorry but pain management is certainly not the top thing on my list in this case. .

As I stated before I've got some reservations about opiates in this case...but transport time is not (nor should it ever be) one of the factors.

....

I'll bet I can acomplish this in around a minute, and I've pushed narcs as we were backing in the ED bay before.

I don't understand this "7 mins transport time isn't much argument". I get that a you'd wanna boogie for a serious abdo bleed, but this pt doesn't scream severe bleed to me. Aside from the hx, the pulse pressure is pretty decent. wonder what her temp was. I'm not having a go at you, but why is this a do everything on the way kind of case? Initially the pt doesn't present as being massively time critical. You've had your time to do all the initial assessment before the pressure drops. Surely 7 mins is then plenty to draw up a drug.

Besides, the transport time is 7 mins but the time to analgesia is much much more than that. I regularly give morphine in the ambulance bay to set the pt up for the move to a hospital bed or the long wait for a doc to pull their thumb out of their arse and write up a Tylenol or something equally inappropriate. I sometimes give drugs on stretcher while waiting for a bed. Does it absolutely have to have been done before you role in the door? How do things work in the states? Do triage nurses administer pain relief at all? Do pt's have to be seen by a doctor before analgesia is written up?

 

[usalsfyre]

I just find this forum amusing in the fact that certain people like to dissect peoples entire post.

If you put it out there, then it's fair game. Don't whine when you don't like the replies. A very god way to learn is being picked apart, and it's what your medical director and clinical department are going to do.

In the OP 83% sats and a borderline pressure without knowing a baseline doesn't scream "get the narcs to me",

I'll just say an SpO2 sans waveform is about as useful as ETCO2 sans waveform.

I am sorry. If you wanna spend 10 minutes on scene to get history, vitals, O2 on board, 3 lead, line, 12 lead, consult,

Unless your taking every patient to a trauma/cardiac/stroke center that never goes on divert a lot of the stuff you mention is pretty vital to direct traffic.

etc and then take you 7 minutes to give meds then great.

On most calls a vial of fentanyl and a vial of versed live in my shirt pocket so there's not any delay in having the meds available.

Me personally I like to work on the way, if anyone on here can do all the above in 7 minutes and give pain meds then great. Time does play a role in certain interventions and if I don't have some basic stuff done then I am not jumping to give pain meds. I am not cold hearted or unsympathetic.

Not cold hearted or lacking empathy, but it's more important to work quickly and keep your routine than relieve pain? Patient focus folks, patient focus...

If you can draw up, and administer pain meds in under a minute congrats I am excited for you and you deserve a merit badge.

IN it's really not that hard...

You can ask 20 medics, RN's, or MD's about the same situation, call, patient, whatever and you will most likely get a good amount of different answers. Every provider does some stuff different. On this forum we all come from different backgrounds, skill levels, knowledge base, experience, states, protocols, stengths, weaknesses, you get my drift.

Very true.

Does this mean our patient's are getting a lesser quality of care because we are different.

Quite honestly? Yes. Some patients get crappier care because of the provider or system. This happens at all levels.

In my short time on the forum there is alot of good info and experienced people on here, but there are also ALOT of egos. Anyone can keyboard quaterback a situation

Very true, however a lot if those egos are earned, mine included. I'm willing to take my lumps though when deserved.

 

[Melclin]

On most calls a vial of fentanyl and a vial of versed live in my shirt pocket so there's not any delay in having the meds available.

Whats wrong with your drug bag?

 

[usalsfyre]

Whats wrong with your drug bag?

Unfortunately the DEA requires me to walk around to the side door, unlock the #?*+@^! safe and put the vials in my pocket on every call, and then return them to the #?*+@^! safe when we get to the ED. It's really a pain in the arse.

 

[Melclin]

Unfortunately the DEA requires me to walk around to the side door, unlock the #?*+@^! safe and put the vials in my pocket on every call, and then return them to the #?*+@^! safe when we get to the ED. It's really a pain in the arse.

Oh right... I was just taking the piss. So you don't actually have a bag that you take into all your jobs that has all your drugs in it?

 

[usalsfyre]

Oh right... I was just taking the piss. So you don't actually have a bag that you take into all your jobs that has all your drugs in it?

Drugs are in the airway bag along with around 35-40 pounds of other stuff depending on the model of portable suction. Maybe one day we will convince them to buy the Thomas packs instead of an Iron Duck bag.

 

[CANMAN]

For some reason I cannot quote when replying....Anyway your missing my point or misinterpreting what I am saying. Getting vitals, and all the stuff I listed in previous post that you quoted is the meat and potatoes, I wasn't trying to say its not. I was saying that if a provider does all that stuff sitting on scene, then transports its easy to do anything in seven minutes, but myself I like to do things in transit and don't sit on scene all day like some (call dependent). Also like I said before, different systems can change how you do things. In Baltimore we don't just run around with narcs in our pocket for "faster administration times." By the time I access a safe, and another lock, all to prevent the addicts from breaking into the unit and stealing the narcs I am sure you can have your pocket vial drawn up. Your not comparing apples to apples and thus the point I was trying to make about you having no idea how other systems function and how that can impact things.

You can toot your own horn all you want. I haven't gotten to where I am by bring a slack ***, un-educated, closed minded provider. I have had the opportunity to work with some really bright people and great clinicians, in some really prestigious institutions but have never come across anyone who says "I have earned my ego." Well I am glad you think that highly of yourself and its good you do because to the majority your most likely viewed as a pompous ***. Like I said different places, different systems. That attitude would get you no where fast in my department.

 

[usalsfyre]

For some reason I cannot quote when replying....Anyway your missing my point or misinterpreting what I am saying. Getting vitals, and all the stuff I listed in previous post that you quoted is the meat and potatoes, I wasn't trying to say its not. I was saying that if a provider does all that stuff sitting on scene, then transports its easy to do anything in seven minutes, but myself I like to do things in transit and don't sit on scene all day like some (call dependent).

I see what your saying, different strokes for different folks. I usually do things like assessments, IVs and meds while my partners hooking up the monitor, getting the 12 lead and figuring out how to remove the patient.

You can toot your own horn all you want. I haven't gotten to where I am by bring a slack ***, un-educated, closed minded provider.

Never said you were. In fact you've put forth some extremely good info on other threads. I just think you've lost patient focus from what you posted here. But I've never seen you actually work, so u have no idea.

I have had the opportunity to work with some really bright people and great clinicians, in some really prestigious institutions but have never come across anyone who says "I have earned my ego."

Everyone who is good at what they do has some ego investment. Every. Single. Person. If you don't believe your a good clinician, it's highly unlikely you are one. That said, there's people in this forum and that I know in real life that run circles around me. A few of them are not as loud and obnoxious as I can be. But they all have egos.

Well I am glad you think that highly of yourself and its good you do because to the majority your most likely viewed as a pompous ***.

Maybe...but guess who their glad to see when they call for a backup truck on a critical patient. I have learned not everyone will like me. I can live with that. I've got friends and a family who do.

Like I said different places, different systems. That attitude would get you no where fast in my department.

One of the problems with the Internet is it's sometimes easier to be an @ss. I'm probably guilty of this. However, any department or service that thinks "years of service" or "seniority" at that particular place make you better is not the place for me. A person should stand on his own merits.

 

[MrBrown]

I am sorry but I gotta back up RocketMedic here as well. If my transport time was 7 minutes long then I am sorry but pain management is certainly not the top thing on my list in this case ... honestly NO ONE dies from pain either.... Think about how many people with abdominal pain present to the ED themselves and sit in the waiting room at large hospital for hours, I know in my area, inner city, it isn't unheard of to wait 8 hours.

Come on bro that's pretty crap. Pain management is one of the most important things an Ambulance Officer does, if not arguably the most important because we know the most important sure aint going to cardiac arrests and dangling out of helicopters ...

It is not unheard of to wait 6 or 8 hours here at the emergency department but not if you are in 10/10 pain you'd probably get seen in under 30 minutes

Hell, we put 45mg of morphine into a bloke the other night and it didn't touch his blood pressure.

We put 20mg into Nana and it didn't touch hers either

Sux and an apology is considered to be inhumane by a lot of people round these parts. Even very sick pts with generally still get some level of sedation/analgesia for intubation.

Brown thinks what usalsfyre is referring to is the "cascade anaesthesia technique" which Brown has read about in an anaesthesia textbook as being a legitimate medical thingamadongle

If you wanna spend 10 minutes on scene to get history, vitals, O2 on board, 3 lead, line, 12 lead, consult, etc and then take you 7 minutes to give meds then great. Me personally I like to work on the way, if anyone on here can do all the above in 7 minutes and give pain meds then great.

Gosh what is it with you Americans and this over zealous attitude that you have to rush in, throw the patient on some form of extracation device and race them to the hospital?

Here it is very common to spend 20 minutes at a job inside the house dealing with the patient, Brown has spent almost an hour at a job where Nana broke her leg before making sure she had enough morph and ketamine to where she was not in significant pain before we moved her. We do most of our assessment and treatment at the scene unless the patient is very unwell

Also like I said before, different systems can change how you do things. In Baltimore we don't just run around with narcs in our pocket for "faster administration times." By the time I access a safe, and another lock, all to prevent the addicts from breaking into the unit and stealing the narcs I am sure you can have your pocket vial drawn up. Your not comparing apples to apples and thus the point I was trying to make about you having no idea how other systems function and how that can impact things.

And yet this has absolutely no bearing on anything whatsoever, doesn't matter to Brown where the morphine is, doesn't change Brown's decision to give it or not.

 

[usalsfyre]

In Baltimore we don't just run around with narcs in our pocket for "faster administration times." By the time I access a safe, and another lock, all to prevent the addicts from breaking into the unit and stealing the narcs I am sure you can have your pocket vial drawn up.

Somehow I missed this....

Why is it inner city providers think they have the market sewn up on crazy addicts?

My drugs are stored in a safe. As I stated earlier, I pull drugs on every call, just like I take equipment in. Otherwise I can't treat pain, do a neuroprotective RSI, treat status seizures or sedate an agitated patient. The narcs are as much a part of my equipment as the cardiac monitor. There's systems where the medics carry the narcs on their person, yet these locales don't seem to have medics getting shot over their drugs.

I've worked in and with many different systems in two different states, I'm aware there's operational differences.

 

[RocketMedic]

I don't think that we want to find how this patient reacts to morphine unless we have to.
And yes, I'd splint a fracture before I give narcs. A decrease in pain is an indicator to good positioning, and I'd rather stabilize a fracture before medication. I know Brown thinks I'm wrong, but I know I'm right.

 

[STXmedic]

And yes, I'd splint a fracture before I give narcs. A decrease in pain is an indicator to good positioning, and I'd rather stabilize a fracture before medication. I know Brown thinks I'm wrong, but I know I'm right.

Many more people than Brown will think you are wrong. That's cruel, heartless, and bad medicine. Have you ever seen traction at a hospital? That patient is HEAVILY sedated before they do anything!

 

[usafmedic45]

I don't think that we want to find how this patient reacts to morphine unless we have to.

Wait until you experience severe orthopedic or visceral pain and then see how you feel about that.

And yes, I'd splint a fracture before I give narcs. A decrease in pain is an indicator to good positioning,

So is the decrease in pain you get after a slight dose of narcotics and THEN again after splinting. However, you honestly shouldn't be reducing most fractures in the field to begin with but let's stay on topic.

I know Brown thinks I'm wrong,

Well, USAFMedic45 thinks you're a borderline sadist or at least, not very :censored::censored::censored::censored:ing considerate of your patients.

but I know I'm right.

"...but I think I'm right."

Fixed that for you.

 

[RocketMedic]

No, I said stabilize. Stabilization and traction are different things. Pain management is important, but skipping basic steps to push narcs is bad medicine. If you're medicating critical patients for pain before transport or assessment, you might be doing something wrong

 

[Aidey]

Or you might actually be doing something right.

I'm liberal with pain meds. Unless you snow someone giving them some pain meds right off is not going to eliminate your ability to assess them.

 

[usafmedic45]

Pain management is important, but skipping basic steps to push narcs is bad medicine.

But assuring the patient is free of pain and not made to hurt more is too. It's not skipping anything. It simply is shuffling the order to place comfort over checklist medicine.

If you're medicating critical patients for pain before transport or assessment, you might be doing something wrong

Who said anything about not assessing? Who said anything about critical? If the patient is critical, honest to G-d critical, I have bigger concerns than the extremity fractures and therefore formal splinting before transport or assessment isn't going to be a concern either. When it's an isolated broken leg or arm, your priority is the alleviation of pain and further damage. The best way to do that is to make the patient as free of pain as possible then to apply the splint. Welcome to the way that every MD I have ever worked under has told us how to do it. You might think you know you're right, but if you aren't willing to listen to constructive criticism your opinion of your own skills does not matter a whole lot to anyone else. The inability to strongly critique your approach things in way that isn't simply patting yourself on your back is very dangerous in a medical provider.

 

[ffemt8978]

Keep it polite

 

[Melclin]

And yes, I'd splint a fracture before I give narcs. A decrease in pain is an indicator to good positioning, and I'd rather stabilize a fracture before medication.

The same thing can be achieved with pain relief first. Its just that instead of agony turning into slightly less agony, its uncomfortable turning to less uncomfortable.

Pain management is important, but skipping basic steps to push narcs is bad medicine

It seems like a pretty common idea over your way, and I'll admit, it lingers here too, that morphine is some massive step in pt care and something to be avoided at all costs. Morphine isn't skipping a basic step, it IS a basic step.

To me, splinting a serious fracture happens like this. Inhaled/intranasal analgesia, support in a position of comfort, morphine until still in pain but reasonably comfortable, in with more anaesthetic gas, splint, pt wakes with pain, morphine until pt is comfortable enough to snooze. I just can't fathom splinting a femur or humerus or something without any analgesia, that's just awful.

 

[MrBrown]

I just can't fathom splinting a femur or humerus or something without any analgesia, that's just awful.

You are correct mate but what is more awful is these blokes with such notions like 2mg of morphine is an acceptable dose, nobody died from being in pain, get everybody to the hospital really quick, if you are close to the hospital don't bother with pain meds, morphine puts everybody into respiratory arrest ....

Brown is not trying to pick on specific people but the idea that such notions exist and are actively defended by our international colleagues is a bit frightening