When the patient "falls between" protocols

[KellyBracket]

Looking for some help here.

I'm going to talk to a paramedic class about "assessment." Kind of a broad topic, but I want to have a discussion focusing on the patient who doesn't fall nicely into one protocol or another. Or who straddles two protocols at once.

Two examples - a patient with a tachycardia, somewhat unstable, but with risk factors for dehydration or infection. Cardiovert vs meds (and which meds), vs fluids.

Or a patient with difficulty breathing and wheezes, but a weak history for COPD - treat for CHF or COPD? Both?

Does anybody else have experience with a call where they couldn't figure out which protocol to use? Even better - if you had a conversation with the ED physician about your decision-making process!

 

[mgr22]

I'd stress the importance of "good medicine" as the foundation of care -- i.e. first decide what the patient needs, then determine how to do that within the protocols of wherever the medic happens to be working.

 

[NYMedic828]

Very frequently have a patient with COPD and CHF. All too often have BLS people diagnose and treat a wheezing pulmonary edema as asthma.

Symptomatic bradycardia and cardiogenic shock I've seen once.

SVT caused by sepsis.

The problem I most often run in to is most people are chefs not clinicians. They get scared to treat outside a protocol even if you fall into another one. We are absolutely permitted to treat multiple conditions at a time but people need to properly do their job and be educated enough to not mix certain meds and meds with certain conditions. I find this to be a large problem in EMS.

 

[NomadicMedic]

You absolutely cannot teach cookbook/protocol medics how to use "clinical judgment" to treat patients that are on the cusp of a protocol. Most just don't get it. How do you teach someone to think?

Sadly, there are a lot of "Flap A goes into Slot B" paramedics who blindly follow the recipe when it comes to treating anything that wheezes, looks like chest pain or came out of a rolled over motor vehicle.

Capnography can be an indicator if you're trying to differentiate between CHF and COPD. Serum lactate POC testing may indicate sepsis in a tachycardic patient... Really, as you well know, the "how do I treat this guy" is determined by experience, individual confidence in PT management and available diagnostics.

...and that's one of the reasons why I'm against giving Albuterol to Basics.

 

[KellyBracket]

...and that's one of the reasons why I'm against giving Albuterol to Basics.

Well, heck, I give albuterol to Basics. Usually if they're wheezing and have a history of asthma. I treat 'em just like real patients.

In all seriousness, I think most medical workers start off as "cookbook" clinicians, but then develop some clinical sense as they gain experience. I just want to lay some groundwork for this process. First and foremost, I want the medic to start thinking "How will I explain my assessment to the ED?"

NYMedic828, what happened with that septic bradycardia? That sounds intriguing.

As for treating when "straddling" several protocols. I agree that that discussion gets sophisticated pretty quickly. You have to be thinking a few steps ahead, and keep in mind "what if I'm wrong?" with each decision.

 

[NYMedic828]

Well, heck, I give albuterol to Basics. Usually if they're wheezing and have a history of asthma. I treat 'em just like real patients.

In all seriousness, I think most medical workers start off as "cookbook" clinicians, but then develop some clinical sense as they gain experience. I just want to lay some groundwork for this process. First and foremost, I want the medic to start thinking "How will I explain my assessment to the ED?"

NYMedic828, what happened with that septic bradycardia? That sounds intriguing.

As for treating when "straddling" several protocols. I agree that that discussion gets sophisticated pretty quickly. You have to be thinking a few steps ahead, and keep in mind "what if I'm wrong?" with each decision.

Septic bradycardic? All due respect I think you misread what I wrote. I was posting two separate examples. I wrote SVT w/ sepsis because I've met people who wanted to give adenosine to a severely AMS patient with a regular rate of 160 before seeking underlying causes. Basically they saw a potential to fit and protocol and were ready to take it without doing anything on their own.


Also, I think one big issue is that 9/10 original EMT/medic
programs essentially teach cookbook medicine as opposed to advocating any form of assessment based management.

 

[KellyBracket]

Wow, I just mashed all your words together and made up my own sentence! The heat in this state is denaturing my brain cells.

I appreciate the sepsis/SVT instance, that's a great sort of example, perhaps the best. Heck, some of us have even tried to cardiovert sinus tach. Ugh.

Let me try again, if my cerebrum is online this time. What was the confusion or complicating circumstances with the bradycardia and cardiogenic shock? Seems mostly straightforward - what made it odd?

Thanks for the help!

 

[NYMedic828]

Wow, I just mashed all your words together and made up my own sentence! The heat in this state is denaturing my brain cells.

I appreciate the sepsis/SVT instance, that's a great sort of example, perhaps the best. Heck, some of us have even tried to cardiovert sinus tach. Ugh.

Let me try again, if my cerebrum is online this time. What was the confusion or complicating circumstances with the bradycardia and cardiogenic shock? Seems mostly straightforward - what made it odd?

Thanks for the help!

Believe it or not, I know a lot of people who are just afraid to put two protocols together as simple as it may be. I suppose a better example may be symptomatic bradycardia in the presence of an MI.

Personally, I look at the protocols as a backup. I decide my treatment based on my knowledge and assessment first and then make sure it coincides with the protocols so I don't get in trouble. If it doesn't, il make it discretionary with the doc.

 

[Jon]

Dr. Bracket (I always wanted to say that),

I was set up to be a cook book medic once. I made it all the way though medic school without having a good understanding of the clinical "why". My final preceptor failed me, because I couldn't handle these questions. Looking back, I'm incredibly fortunate he did. I took my time doing it "right", and I'd like to think I know what I'm doing as a medic.

It seems that the patient that actually "fits" a single protocol is a statistical anomaly. Chest pain and shortness of breath go hand-in-hand. When they are wheezing and having chest pain - is it appropriate to treat down both the chest pain protocol AND asthma/COPD protocol? I say yes, sometimes.




In the end, I often find that the Laws of the House Of God are applicible to prehosptial medicine, too:

THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

Many times, we, as EMS providers, become so focused on what we "can" do that we don't ask "why does the patient need this?"

 

[abckidsmom]

I had a guy on Saturday with afib at 170, hypotension (70/50) and new (well day-old) aphasia. What's the priority? How ya gonna treat that without dislodging more clot and making more cva?

Add to that, our system doesn't believe we need a calcium channel blocker, so I had to make do with the choices of amio and metoprolol.

He was completely a asymptomatic except for the aphasia, totally alert and oriented, just couldn't speak or write.

He didn't even come close to fitting in a single protocol, and clinically, the goals in treating him are sort of contradictory.

These situations, while uncommon, aren't unheard of.

 

[Veneficus]

These situations, while uncommon, aren't unheard of.

Speak for yourself...

I have been a :censored::censored::censored::censored: magnet my entire career. More of my patients have fallen between guidlines than not.

What's more; the further I progress the more flawed and useless protocols become.

While I am sure they do improves outcomes compared to "not knowing" what to do, as medical science progresses, common If:then medicine becomes more and more obsolete.

Nobody ever calls me when the protocol is working, but judging from the amount of advice solicited when it is not working, I am starting to wonder if any of them work at all.

As for the OP, all I could possibly offer is already known.

Medicine is still an art, it is impossible to teach people to be artists, you can only coach and develop existing ones.

All the science in the world is useless to a person who cannot use it effectively.

That is by definition, the difference between a medical scientist and a practitioner.

I have taught EMS now for 10 years and discovered long ago, I cannot turn nothing into something. I can only make good people better.

EMS, like the military, in order to take somebody from 0 to hero uses drilling. I can think of no other healthcare field that does that. I don't think that is a coincidence.