True but thinking like a Paramedic or someone with more education you will have a better understanding of the signs, symptoms, medications and events where some trauma incidents are precipitated by a medical emergency or may cause one. That does not mean you have to do everything you might do with a medical emergency but it will make you more acutely aware to anticipate something or that the memorized values in an EMT text are sometimes useless if you have a better understanding of all types of shock and also of some medical emergencies. Sometimes the trauma scene itself is a distractor and a more pertinent issue is missed. The advanced education can also make you more acutely aware of the effects of pain, head trauma and positioning.
What if EMT/Paramedic was one program instead of 2?
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True but thinking like a Paramedic or someone with more education you will have a better understanding of the signs, symptoms, medications and events where some trauma incidents are precipitated by a medical emergency or may cause one. That does not mean you have to do everything you might do with a medical emergency but it will make you more acutely aware to anticipate something or that the memorized values in an EMT text are sometimes useless if you have a better understanding of all types of shock and also of some medical emergencies. Sometimes the trauma scene itself is a distractor and a more pertinent issue is missed. The advanced education can also make you more acutely aware of the effects of pain, head trauma and positioning.
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I think you misunderstand what I wrote. I said I tend to think like a basic, meaning: It's far better to be leaving the scene sooner rather than later, do the basic stuff to keep the patient alive, do the more advanced stuff in route to the hospital. Trauma isn't just a surgical disease, it's got a critical time component to it as well. Delaying delivery of the patient to a Trauma Surgeon unnecessarily doesn't improve things for the patient. I did NOT say that I tend to ignore the advanced level thinking in terms of looking for signs, symptoms, medications, potential MOI, events leading up to a crash, and so on. I consider all those things and more when I'm working a trauma. There's very little that I'd consider doing on scene with a trauma patient, unless other circumstances require that I stay on scene for a bit. Then I'll consider doing other interventions as necessary, but in a timely, efficient manner, still with the end goal of delivery of the patient to definitive care without unnecessary delay. That doesn't mean drive at ludicrous speed, it just means get there safely and with minimal delays.
From the moment I arrive at the scene, my end goal is delivery of the patient to the appropriate facility. In between those points, I'm going to have assessed the patient, determined the likely extent/severity of injury, determined the treatment plan and destination, and initiated what I can of that plan. And yes, I can be, at times, incredibly detailed as to what I find during my assessment... I'm not as good at doing medical exams as I am at doing trauma focused exams because most of my pre-EMS education focused mostly on traumatic injury evaluation.
The point is don't be of the impression that I'm just an EMT wearing a Paramedic patch. I very much consider what needs to be done, when, relative to my end goal. I'm also very inquisitive and look for precipitating medical causes for traumatic injury, because I know that sometimes a medical problem can begin a chain of events that lead to the patient getting injured. If I can do something on scene that will diminish the time to definitive care, then I'm going to do that, however, there's often little I can do on scene that I can't do in route. This is more specific to trauma than medical.
medic417
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Really? How are they going to treat the patient? They can't give D-50 or Insulin so all they are doing is getting a number which will be rechecked at the hospital.
VFlutter
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medic417
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Oral glucose
Guess rectally if they are out cold.
EpiEMS
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My run-of-the-mill diabetic patients tend to be mildly hypoglycemic, but alert. Don't necessarily need to get them to the ED.
DrParasite
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I wasn't aware paramedics could give insulin... in fact, I mentioned that to an ER nurse coordinator, and she shuddered and said there is no way she would want any paramedic giving insulin in the field. too many variables, esp considering most hyperglycemic patients aren't imminently dying, it's better to leave them hyper until they get to an ER, where an endocrinologist can do a full assessment to figure out why their sugar is so high.
Not only that, but I would love to be able to check BGLs. yes, if the patient is AMS (but awake), I can check their BGL and then have them enjoy some oral glucose or a PB&J sandwich. if they just think their sugar is high but otherwise AOx3, I can check it for them. If they are unconcious, than I'm going to need ALS for D-50.
and if they are showing signs of a stroke, I can check their BGL, if it's normal, package and start heading to the stroke center. if it's low, wait for ALS to arrive, raise the sugar back to normal, and have patient return to normal, and have the patient sign the RMA.
EpiEMS
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Certainly is better for the system if we can treat and release hypoglycemic patients who present as conscious.
medic417
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LOL. That nurse is not as educated as she thinks. All the supposed checks they say we will mess up is hog wash. As soon as you roll in with a hyperglycemic they immediatly push insulin so they have prevented the same tests that they are claiming we will intefer with. And very few ER's have endocrinolgists on hand, so again ER doc will immediatly push insulin.
As to basics using glucometer I am all for it. I just disagree that a basic can do all that is needed for the diabetic, when in reality beyond a non altered patient that is slightly low there is nothing a basic can do with those numbers besides give the hospital a heads up. A heads up is a good thing. Paramedics can use glucagon, D-50, Insulin, fluid bolus, etc based on patient needs to begin correcting the patients issues.
Insulin will not be pushed immediately. Handheld glucometers have their limitations. Fluids will be started first while more testing is done to determine if it is DKA or HHS. If it is DKA, insulin will follow the initial fluid bolus. Electrolyte stabilization will also have to be done quickly. This is a multifactorial process and not just one med to cure all.
Those with HHS may not require insulin at all.
VFlutter
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Or maybe you are not as educated as you think.......we do not immediately push insulin when they come in. We usually start with fluids and then titrate an insulin drip. Sometimes we will bolus sometimes we will not, the preferred method is starting with an infusion. The goal is to slowly bring down the blood sugar over hours. They also usually draw various labs before starting treatment.
In the hospital insulin is considered a high risk drug and must be verified by a second RN every time we draw it up.
In areas with less than a 30min transport time there is really no reason to be giving insulin in most situations.
medic417
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I agree you bring it down slow. Insulin can be given in small steps when a response is not seen to fluids. We draw all labs in the field. So the hospital has labs.
I have worked in multiple systems and have had insulin available in many. I disagree with any use of to close to the hospital to treat a patient. If the patient needs care it should be given.
I have worked in multiple systems and have had insulin available in many. I disagree with any use of to close to the hospital to treat a patient. If the patient needs care it should be given.
What insulin and what are your protocols for initiation? How much fluid are you giving first? Is this the same for HHS?
Every hospital should repeat the labs since you have given fluids and insulin and use yours only as a baseline.
VFlutter
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I would argue that in most situations waiting for the ER is better for the patient. Giving insulin through a pump is safer and more controlled than drawing up multiple doses from a vial. What is that 5-10 min wait going to change? just stick with the fluids
What are your protocols / dosing for SubQ and IV insulin? What kinds of insulin do you carry?
medic417
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I work under guidelines not your typical protocols. We treat based on common accepted medical practice. If we carry a tool or a drug we can use it in any fashion that is acceptable medical practice based on what we see with current patient. We are not stuck with protocols that say do this if you have this. We do what the patient needs. We carry fast and long acting insulin.
Yes our blood draws serve as the baseline. Now the hospital is ahead of the curve and can see how they need to adjust the treatment.
The current services I work in are more than 30 minutes out are only 911.
Yes our blood draws serve as the baseline. Now the hospital is ahead of the curve and can see how they need to adjust the treatment.
The current services I work in are more than 30 minutes out are only 911.
VFlutter
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Ok.....do you have some type of guidelines* (insert whatever word you want) for insulin administration? You pick up a patient who is 800 mg/dl, how much of what do you give? You give X units of insulin and The BGL is now 600. Do you give more? What is your goal over that 30mins? To reduce it to what level and at what rate? Now their BGL is 42..... Ruh roh
I am just trying to get an understanding of how you would approach this and how you justify immediate treatment over delaying treatment for the ER. And not just because "my patient has a problem, they need this, I have this, why wouldn't I" Yes this 600lb no neck COPD patient needs to be intubated, yes I can intubate, but that doesn't mean I should RSI him in his living room when I can be in the ER in 5 mins where anesthesia can do it in a more controlled environment...
Over treatment is not good treatment. Take the ego out of it. There is nothing wrong with waiting for definitive care.
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Not all EMTs are working on ambulances. In extremely remote areas like the one I live in, EMTs serve as first responders, since it may take a good 45 minutes before the transporting ambulance(which is ALS) to arrive.
Communitys out here cant afford to run an ambulance service that transports, so they just have volunteer agencys with EMTs that respond to calls. Even though were basically just first responders, its nice to have the little bit of extra education an EMT course provides, and adds a few interventions MFRs cant do. If you did away with EMT and just had a longer paramedic course, poor rural areas like mine would be affected.
In the big city it probably makes no difference, since people there expect an ambulance in 5 to 10 minutes, so EMT first responders are kind of pointless, but out here it can save lives to have an EMT first responder on scene in minutes until ALS arrives a good half hour to 45 minutes later, especially in the winter when its 20 below.
If you just made EMT school part of Paramedic school, we'd have zero volunteer EMTs, since most of us have day jobs and couldnt afford to spend 2years becoming a paramedic.
Communitys out here cant afford to run an ambulance service that transports, so they just have volunteer agencys with EMTs that respond to calls. Even though were basically just first responders, its nice to have the little bit of extra education an EMT course provides, and adds a few interventions MFRs cant do. If you did away with EMT and just had a longer paramedic course, poor rural areas like mine would be affected.
In the big city it probably makes no difference, since people there expect an ambulance in 5 to 10 minutes, so EMT first responders are kind of pointless, but out here it can save lives to have an EMT first responder on scene in minutes until ALS arrives a good half hour to 45 minutes later, especially in the winter when its 20 below.
If you just made EMT school part of Paramedic school, we'd have zero volunteer EMTs, since most of us have day jobs and couldnt afford to spend 2years becoming a paramedic.
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With todays technology not many hospitals are going to wait on lab results obtained in the field when they can have current data within a couple of minutes at the bedside by their own calibrated equipment.
Can you give us a hint at least as to what state you are in so we can look up the protocols? I am curious about this since even the CCEMTP had limitations when it came to insulin being initated by Paramedics.
I believe he's in Texas, meaning the medical director makes that call.
That said, I'm hesitant to start playing with insulin without knowing a K+.
medic417
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Texas.
No point trying to discuss further as it's obvious you big city fellars done know it all. You don showed this ignorant country bunkin he arnt smart.:wacko:
Ok. Now as stated we bring it down slow. We don't go pump them full of insulin just cause we got it. We way the risks vs benefit with every patient.
No point trying to discuss further as it's obvious you big city fellars done know it all. You don showed this ignorant country bunkin he arnt smart.:wacko:
Ok. Now as stated we bring it down slow. We don't go pump them full of insulin just cause we got it. We way the risks vs benefit with every patient.