Lock or Line?

[DwayneEMTP]

Beings this thread is already off in the ditch and I don’t see medictx as likely to come back to it….

This just occurred to me…I couldn’t imagine that s/he was serious about calling for an IV, and then I thought, how does anyone learn in that environment?

When I started my post didactic clinicals I studied the protocols for this system and thought, “Holly shit! Everything is should/may/might/consider/5-20mg…etc.! They don’t tell me to do anything! (Which isn’t completely accurate of course, but it seemed so in the beginning)

‘Cause see…I had this fool proof plan. I would simply follow the protocols to the letter, and then when someone said, “Hey dumbass! What were you thinking when you did X?!?” I would simply point to the protocols and say, “See! Right there…says I should! Black....And....White! Uhhuh…that’s right…Who’s the dumbass now!?”

But it turns out, through a completely irresponsible oversight on the Medical Directors part I believe, that s/he failed to write the necessary ‘cover your ass’ parts into the protocols.

I soon discovered though, that when not allowed to simply connect the dots…(are you sitting down?)…That I’m actually capable of finding my own way (Knock on wood). Now, to those of you smarter than me this was probably not such a huge epiphany for you, but it took me completely by surprise.

But I wonder…If I had been allowed, or even forced, to be a cookbook medic, how long would it have taken me to learn to think? To step out of the pocket and actually run with the ball? Know what I mean?

I think there’s probably many of us that leave school thinking, “There is way too much stuff in my head. I have a smorgasbord in my head, yet I’m unable to make even a simple a sandwich when I want one!” Lead me. Just friggin TELL me what to do!

I guess I’m wondering how many medics would find the confidence to do medicine if allowed/pushed to do so, but are mentally neutered by restriction…?

Dwayne

[CBEMT]

Everybody gets a lock.

Right at the end of their IV line.

Locks are a grey area here. It's not in line with current protocol, but nobody's ever been called out for starting JUST a lock. That I know of.

To me, doesn't matter either way. We restock out of the hospital, so no matter where we've transported to, we have their stuff on board. And cost is not a significant factor as a result. Yeah, we have stuff in stock, but in terms of IV supplies we hardly ever have to dip into them. Same with collars, first-aid supplies, etc. The only things we really have to order on a regular basis are monitor paper, glucometer strips, and headblocks (we use disposables).

[Ridryder 911]

Not to retaliate back to medictx, but in all seriousness it was obviously difficult to understand their posts. Many times trust has to be ensured before "standing orders", and not having the ability to logically communicate, they may have to "ask permission"?

I as well as many apparently have not seen that type of medical control since the late 70's. Personally, I am lucky and would not even consider working such a place. My same opinion in regards to protocols; if the services protocols are > 100 pages, something is wrong. Only pertinent medical conditions should be covered, the rest should be assumed and discussed per medical director as "standard of care". Everyone should know to place oxygen on a hypoxic patient, I really do not need a paper telling me such.

The real subject again goes back to educational values. Although, it appears we are sometimes "beating a dead horse"; posts similar to those in question brings out that we are sometimes our worst enemy. Just when we thought we have progressed in areas, we find out that many still have direct medical control. Apparently, many feel at unease on making diagnostic type decisions and need a set guideline. Unfortunately, as many have alluded to medicine is never black and white, rather gray. Medicine is made up of science, but practiced as an art, therefore really never repetitious. Each case is really unique and cannot be handled step by step, nor the person delivering the care only have a "shake & bake" training to only understand and allow those type of protocols.

Really, to even be discussing "locks or fluids" is sad. Not having the common sense or knowledge to know when and treat accordingly, if and when the patient needs fluids or not? Really, think about it.

The one thing about EMS forums is that it does awaken me unfortunately on how little EMS has advanced. Both in the little progression of the systems and of the educational requirements needed to provide care to the sick & injured. Apparently we are not as progressive as we had assumed we were nationally. Really, this is shameful and discouraging, basically it is kinda sad.

R/r 911

[tniuqs]

I have to admit that this thread did help me out, I got to looking and I only had 2 hep locks left in my bag of tricks, this due to a patient that I was treating Q8 H with bug juice, (bit of a remote spot lately).

I had a buddy pick a couple up from the local ... how do you say .... borrowed with no intent of replacing, I believe it is called "pacifically" tee he, pulling a "Radar" and taken directly from the MASH appropriations and accusation protocols.

cheers

[speedygodzilla]

I wasn't going to post this at first, seeing that I am a EMT and I neither start lines or locks. However working in the ER I have seen many patients with lines that in my opinion would of been much better off with a lock. For instance a older gentlemen had fallen possibly due to a low blood glucose with a BP of the 200s over the 120s. When he got to the ER he had at least 300 cc through the line that did not appear to be dripping anymore. However the line stay in him on his way to CT and everything and got tangle up in all the cords and the line was one more cord that got in the way numerous times. I have also had several large pts that have a line on and their clothes and getting them into a gown is much harder with the line attach. I see no benefit in the line. Please inform me of the benefits so that I may better understand why I see so many of them brought into us. We don't even have the equipment to start just a line in the ER, always a lock.

I had an idea to fix this problem in the ER. Turn a line into a lock in an instant with something like a sealing head. Just take a look

http://www.medical.saint-gobain.com/products_materials/cFlexUltra.asp

You could seal it past the port and it could still be used for an IV as needed and would make just as great as a lock as any other lock.

[medictx]

Scaramedic I did not attack or try to bully anyone. R/r911 took it upon themself to be rude and not investigate ffurther before responding. I apologize to you and anyone else that I may have offended.

I was just stating and opinion that starting a IV should not be considered a conveinence because its something extra to have to hold or it gets tangled-up in the monitor cables. And that you should follow your protocols and standing orders. And if they were un-clear, consult with your MC for clarification. I did not once say anything about calling for orders to start an IV, thats reticules. I'm not even sure who posted that comment. And I agree with you about that there are "Mother may I " and cookbook medics out there that can not think out side the box. However, protocols and standing orders or recipe's as you refer, are in-place for reasons, and are given to us by a doctor(s) whom are more prepared based on our pt. assessment to dictate to us the best course of treatment for said pt. If you or one of your family members needed emergency medical assistance (heaven forbid), you would want the best medical treatment, and you would want the medic to follow the doctors orders for the best possible treatment. Not just some medic who has the ability to think outside the box, and thinks he knows whats best and just does whatever is a convenience.

I hope your anwser would be NO. I would want someone who followed orders (recipe) to the letter. I'm sure that you have had a doctor come up to you and say great job, your treatment was perfect, he couldn't have done it better, you followed the recipe like clockwork. To me, following orders is a strong system and medic, and one that demonstrates the up-most professionalism and dedicated to education and progress to give the best possible emergency medical care.

Again I apoloigze for offending this forum.

MedicTX.

[Dustdevil]

If you or one of your family members needed emergency medical assistance (heaven forbid), you would want the best medical treatment, and you would want the medic to follow the doctors orders for the best possible treatment. Not just some medic who has the ability to think outside the box, and thinks he knows whats best and just does whatever is a convenience.

I hope your anwser would be NO. I would want someone who followed orders (recipe) to the letter. I'm sure that you have had a doctor come up to you and say great job, your treatment was perfect, he couldn't have done it better, you followed the recipe like clockwork. To me, following orders is a strong system and medic, and one that demonstrates the up-most professionalism and dedicated to education and progress to give the best possible emergency medical care.

Well, plus 10 for both humbling yourself, as well as taking the time to attempt to explain yourself here. That's admirable. But I'm afraid you will find very little support here for your opinion on this topic. You see, there just aren't that many people I know who work in a system like you describe. Everywhere I have worked for over twenty years expected me to know what was best for my patients, and to use my clinical judgement to determine a proper course of therapy for them. That does not involve doctors orders or a cookbook of written protocols. And, like Rid, I would not even consider working in such a Neanderthal system.

Although it is not necessarily a poor reflection on you personally -- after all, your system is probably the only one you've ever experienced -- it sounds like your system sucks. You're doing what Johnny and Roy did in 1972, not what professional paramedics do in the 21st century. I know that you are not responsible for that, and if you want to keep your job, you have to play the game. But I hope that your experience here at this forum will help to open your eyes to what is going on in the rest of the EMS world, because honestly, the world has changed, and you would be unwise to not recognise that and attempt to place your local limitations upon the rest of us.

Would I be correct to assume that you work in a large urban centre, probably in South Texas, where the majority of the medics attend accelerated technical schools instead of degree programmes?

[Scaramedic]

I agree, kudos for having the guts to come back and explain yourself. I do not agree with you but I respect your honesty and integrity.

[JPINFV]

Maybe it's because I'm not a medic, but to me I see that the primary objective in most cases for a lock or a line is to administer medications. If both achieve that goal, and there is no need to run fluids, how would it be neglecting the patient to choose a lock due to easier management?

[Asysin2leads]

medictx, you do have some valid points, but I still think you're missing the big picture.

You are right to say protocols are doctor's orders and should be followed pretty much as written, and if your medical director, by way of protocol or not states "Only use 0.9% NS @ KVO for IV access, don't use saline locks" then yes, we should be only hanging bags, and using a saline lock, even if there is no difference, would be improper and unprofessional. If our medical director gives us something to do, we should do it, its his (or her) license, that means he (or she) gets to make the rules.

The thing I think you're missing is that do to the nature of the human body in all its glory with all its different variables, no protocol is going to cover every single patient 100% of the time. Its just plain impossible. I can give you three different asthma patients, presenting with the same vitals, the same EKG, and even pretty much the same history, and one of them will need a nebulizer, one will need some mag sulfate and some epi, and one will need to be intubated. That is why the educational component of paramedic class is so much greater than the skills component. I wish we could just follow protocol. It would be so much easier. I wouldn't even have to put down the PSP to treat a patient. Unfortunately, that just isn't the way it is.

I gave a good example of how strictly following protocol is not always what is best for the patient. I had an elderly male, with a BP of 80/P, and an EKG showing rapid atrial fibrillation. I felt the hypotension was due to dehydration, which could be corrected with a fluid bolus, and the rhythm treated with amiodarone. Whoever the newly minted protocol monkey on the other end of the telemetry line, however, stated that since his BP was below 90mm hg, he was an unstable patient and needed to be cardioverted.

This was a patient who fell into certain criteria, but still managed to slip through the cracks of the protocols, and when that happens, we have to do what is right for the patient, which is our guiding principal.