Whats your "criteria" for starting iv access on a pt?

[Bishop2047]

Sounds like a lot of lawsuits waiting to happen.

Prosecutor: So when you attempted the pericardiocentesis you believed that you could perform any task that was "necessary" and that you felt "comfortable" with?

CB: Yes sir and I didnt even have to pull over, cause I am just that hardcore. Also I had just watched a Youtube video a week ago on the subject so the procedure was fresh in my mind.

Prosecutor: Well it seems clear that you are inline with the laws that govern medical professionals in this made up utopia. No further questions your honour.

 

[Peak]

That’s your job. Mine is adamant about having our district operationally autonomous. No doctors or nurses on our trucks, because we don’t need them. Our staff is trained to handle any case thrown at them. Critical Care here does not have protocols, they have guidelines. Their care is based on their research and experience, much like that of a physician.

You just told me to stop generalizing nurses as ****ty, but then you just generalized new medics as stuck up and self righteous.

Tell me how to manage a field delivery or critical care transport of a ductal dependent 800 gram DTGA. What is the emergency procedure if they lose communication?

How about a 1200 gram CAVC? What are goal saturation. What happens if you give high flow oxygen?

 

[Akulahawk]

Propofol is short acting, and isn’t hard to manage as long as you have vasoactive drugs and airway control available. I’ve never felt uncomfortable managing a propofol drip, and I’m not critical care.

Why are you managing propofol drips if you are not critical care?

Your attitude is, quite honestly, scary. You present yourself as someone who knows way more than they actually do, and that is going to end up hurting a patient.

We’re allowed to manage propofol here without critical care. You do you, I’ll do me. Cheers

Propofol is not that bad of an agent when you're not moving or unnecessarily stimulating your patient. Most of the time it is generally predictable. Most of the time. I'm comfortable with Propofol but I also know it can do some scary stuff at times. Propofol isn't a benign drug.

 

[cruiseforever]

Propofol is not that bad of an agent when you're not moving or unnecessarily stimulating your patient. Most of the time it is generally predictable. Most of the time. I'm comfortable with Propofol but I also know it can do some scary stuff at times. Propofol isn't a benign drug.

So very true. I am not a fan of it if we are transferring a pt. that has been on it for some time in an ICU. It takes a while to make the proper adjustment to keep them comfortable.

 

[Akulahawk]

At my agency, as long as you do the right thing, the district backs you. A guy at my work did a finger thoracotomy on a pt before they had a protocol for it, and since it worked they backed him and wrote a protocol for it. I work for a hardcore progressive agency.

Sounds like they did a "since it worked we're going to write a protocol so we don't get sued for it." Do I know how to do a finger thoracostomy? Yes. In the absence of a protocol, would I do one without being authorized to perform surgery and a verbal order from a Base Physician to perform said procedure? Not a chance. I have learned many things over the past 25-ish years of taking care of patients in several different areas of medicine. What keeps me from getting into too much trouble? I know what my limits are and I will only step outside those limits in very specific and defensible situations.

 

[Peak]

So very true. I am not a fan of it if we are transferring a pt. that has been on it for some time in an ICU. It takes a while to make the proper adjustment to keep them comfortable.

I think it depends on what your sedation goals are. I think that propofol is a great drug to maintain a RASS -1 to -2 for adults in a dark, quiet ICU. That being said it requires far larger doses to maintain that level of sedation in the ED or during transport, and I typically find versed or Ativan to be a more effective sedation agent without going into what is clearly anesthetic dosing. Precedex is a great sedation option in many cases, and giving a dose of haldol or ketamine can also help bridge that transport gap.

 

[mrhunt]

Sounds like they did a "since it worked we're going to write a protocol so we don't get sued for it." Do I know how to do a finger thoracostomy? Yes. In the absence of a protocol, would I do one without being authorized to perform surgery and a verbal order from a Base Physician to perform said procedure? Not a chance. I have learned many things over the past 25-ish years of taking care of patients in several different areas of medicine. What keeps me from getting into too much trouble? I know what my limits are and I will only step outside those limits in very specific and defensible situations.

Exactly. I'll call for consults and base orders even when it doesn't REQUIRE a base order. I took a transfer a while ago where guy was doped up as **** on pain meds and 20 mins or less into transfer is just in excruciating pain.... Called base for 50mcg of fentanyl.

It's a standing order that I cAn make automatically, but was concerned cause he JUST had 8mg morphine and a bunch before that.

So if things went south and he od'd and I had to narcan him I could at least have put in my narrative that meds were approved by Dr so and so, and by Micn Betty boop.

Takes the pressure off of me to a good extent.

 

[Akulahawk]

I think it depends on what your sedation goals are. I think that propofol is a great drug to maintain a RASS -1 to -2 for adults in a dark, quiet ICU. That being said it requires far larger doses to maintain that level of sedation in the ED or during transport, and I typically find versed or Ativan to be a more effective sedation agent without going into what is clearly anesthetic dosing. Precedex is a great sedation option in many cases, and giving a dose of haldol or ketamine can also help bridge that transport gap.

That's where I was going with my propofol post. Great drug for what it's indicated for. It's the "far larger" doses part that I'm not sure are understood... partly because of what those "far larger" doses can do considering both the "expected" and "less common" side effects. I do like propofol, just not as much for transport, even if it's just down the hall.

 

[silver]

Will the OR use an IV placed in the field? I have no idea, but I think I'd want to know before using veins to get a line that I personally have no need for. Whether the hospital's policy is "right" in your eyes, putting a line in that they can't or won't use is a wasteful procedure and just subjecting your patient to more discomfort. If you need a larger line for transport that might be one thing, but placing something because "the patient is getting surgery" might not be as helpful as you think. They're pretty good at IVs in preop...

Also your attitude isn't going to win you any friends and being "that guy" doesn't improve patient care.

We use IVs from the field. Generally we determine if its safe to induce with whatever is in place or not and then if needed place additional IVs. That being said, the most frustrating thing is seeing a 22 in the AC with distal targets that weren't attempted. The AC just isn't reliable enough for long term use.

 

[Tigger]

idk where you work, but there’s only one hospital I know of in my area who won’t use EMS lines. Most of my transfers have EMS lines that are from anywhere from 4-24 hours old. Nurses here use whatever is established.

We use IVs from the field. Generally we determine if its safe to induce with whatever is in place or not and then if needed place additional IVs. That being said, the most frustrating thing is seeing a 22 in the AC with distal targets that weren't attempted. The AC just isn't reliable enough for long term use.

What the ED does and what other units in the hospitals do are often different, at least here. Here the floors and ICUs aren't going to use your lines (or even that of the sending) unless the patient needs immediate management and most of the time these patients get diverted to the ED anyway.

 

[Peak]

I think I mentioned this in a previous thread, but our IV policy is essentially that field EMS IVs will come out within 24 hours.

IVs that are started in the hospital (whether that be the ED, clinic, or inpatient areas), by outside hospitals, or HEMS/CCT are all treated the same and stay in until there is a medical indication for removal. I’ve had several IVs that have lasted over a month and a small handful that have lasted 6 weeks.

Unfortunately for a long period of time one of the local EMS agencies wouldn’t even use a tegaderm over their IVs and often the skin was just as dirty at insertion as the remainder of the extremity meaning that there was most likely a cursory at best wipe with an alcohol pad. While there are many IVs inserted in the field with good technique, the few bad apples soured it for everyone.

 

[PotatoMedic]

I think I mentioned this in a previous thread, but our IV policy is essentially that field EMS IVs will come out within 24 hours.

IVs that are started in the hospital (whether that be the ED, clinic, or inpatient areas), by outside hospitals, or HEMS/CCT are all treated the same and stay in until there is a medical indication for removal. I’ve had several IVs that have lasted over a month and a small handful that have lasted 6 weeks.

Unfortunately for a long period of time one of the local EMS agencies wouldn’t even use a tegaderm over their IVs and often the skin was just as dirty at insertion as the remainder of the extremity meaning that there was most likely a cursory at best wipe with an alcohol pad. While there are many IVs inserted in the field with good technique, the few bad apples soured it for everyone.

The hospital system that I worked at had the police that any central line not placed in the ICU would be replaced asap once the patient was in the ICU and stable enough for the procedure. Pissed a lot of ER docs off.

 

[DrParasite]

I’m an American. Never lived anywhere else. Critical Care Paramedics aren’t trained to the level of physicians, but they are trained to be autonomous like physicians. I don’t believe our critical care medics ever contact medical control for anything.

that's cool. I imagine their medical director gives them a lot of autonomy, that's awesome. Are they on a CCT ambulance, or just hanging out at the station? maybe they are in a flycar, so they are always available?

I’ve never contacted medical control, I literally just call critical care.

you call critical care for what? orders? advice? a discussion on what to do since you're not sure what to do?

It’s easier than way because those guys are always at our base and always available to meet us. They are single resource, and they are the highest level of medical authority in our county.

I am pretty sure your medical director is a little higher than a critical care medic. It sounds like your critical care paramedics are supervisors. Please educate me on the educational differences between your critical care paramedics and your regular paramedic? I mean, a doctor goes to med school, residency, and maybe a fellowship.... a paramedic has an associates degree in EMS... do your CC paramedics have a masters degree? how much more educated are your CC paramedics than the regular paramedics?

They can override any fire or EMS Officer in terms of medical treatment.

haha, maybe if your county, but in most places I have worked, it's the treating paramedic who is in charge... and if I'm the treating medic, and this is my patient, well, the CC paramedic better have a damn good reason for overriding my treatment path. After all, if I'm not competent enough to do my job, then why was I credentialed as a paramedic by the medical director, and allowed to work on the ambulance in the first place?

I respect the HELL out of my medical directors, but they expect us to talk to critical care before calling them.

I have never called critical care for anything. If I have a weird call, I might call a supervisor for guidance. if I'm not sure what to do, I might discuss it with my partner. if I need advice, I might ask the senior fire medic on what they think I should do. But again, I'm asking for help, I don't expect someone to tell me what I should do with my patient unless I ask them to.

If I need medical orders, or have an unusual clinical situation, that doesn't fit any of my protocols, and I need to consult someone to give me advice, I am going to pick up the phone or radio and want to speak to someone who has MD/DO after their name. But that's just me...

 

[DrParasite]

Tell me how to manage a field delivery

well, I'm just a dumb hose dragger, but I imagine mom does most of the work... as moms have been doing for the past 10,000+ years... once the baby comes out, warm, suction, dry and stimulate the little poop machine until they start crying... and don't drop the newborn... mom's tend to panic when those slippery suckers hit the ground...

How did I do?

 

[DrParasite]

At my agency, as long as you do the right thing, the district backs you. A guy at my work did a finger thoracotomy on a pt before they had a protocol for it, and since it worked they backed him and wrote a protocol for it. I work for a hardcore progressive agency.

Translation: you can do whatever you want, as long as it is successful. if it's not successful, they are going to throw you to the wolves, and you are on your own.

hardcore and progressive are not the terms I would have used to describe an agency that you describe...... scary is much more like it.

 

[ffemt8978]

Translation: you can do whatever you want, as long as it is successful. if it's not successful, they are going to throw you to the wolves, and you are on your own.

hardcore and progressive are not the terms I would have used to describe an agency that you describe...... scary is much more like it.

I was thinking more along the lines of "reckless", "a malpractice attorney's dream" and maybe even "dangerous".

 

[Peak]

well, I'm just a dumb hose dragger, but I imagine mom does most of the work... as moms have been doing for the past 10,000+ years... once the baby comes out, warm, suction, dry and stimulate the little poop machine until they start crying... and don't drop the newborn... mom's tend to panic when those slippery suckers hit the ground...

How did I do?

Poorly, especially since you chose to selectively quote such a small portion of the question that you missed it entirely. If you think just warming, drying, and stimulating is is all you need to manage a shunt dependent 28 weeker then it all the more proves how little most clinicians understand about OB and neos.

Even if you want to address it as a simple full term birth then I would point out the historic mortality of moms and babies over those 10,000 years. It’s about as valid as saying that we don’t need modern medicine because humanity survived without it for 10,000 years.

 

[Carlos Danger]

I place one because I have a suspicion that this patient is not as “stable” as the RN says she is. When the nurse whispers to me that she thinks the patient is faking it, and I look in the file and see the doctors narrative on what he found going on with their aorta, I do another IV because I’m thinking about what I would do if the patient crashed in route.

I call BS on that entire story.

 

[DrParasite]

Poorly, especially since you chose to selectively quote such a small portion of the question that you missed it entirely. If you think just warming, drying, and stimulating is is all you need to manage a shunt dependent 28 weeker then it all the more proves how little most clinicians understand about OB and neos.

my bad, I thought you were asking about two separate patients, esp since you said " Tell me how to manage a field delivery or critical care transport of a ductal dependent 800 gram DTGA. " Now if you had said "Tell me how to manage a field delivery of a premie who requires critical care transport of a ductal dependent 800 gram DTGA" than I would have had no clue how to handle it. I know my limits, and that's faaaar beyond my abilities.

Even if you want to address it as a simple full term birth then I would point out the historic mortality of moms and babies over those 10,000 years. It’s about as valid as saying that we don’t need modern medicine because humanity survived without it for 10,000 years.

The exact same argument (with the studies supporting it) have been made about prehospital ALS... but that's a different topic altogether. not going there

 

[wtferick]

There isn't any evidence that rotating IV sites every 72 hours, as long as the site looks good, shows any benefit.

Where are you that a hospital has a director of nursing? DONs are a nursing home thing.

A lot of Hospitals tend to have multiple DONs...