Your aggressiveness

[Flasurfbum]

How aggressive do you get when treating patients?

This was brought on because of PALS today. I got a question wrong, which basically said the NRB was no longer sufficient for the pt. in question. As usual, 2 answers were wrong off the bat, but 2 were real possibilities, and, in my opinion, it really depends on the aggressiveness of the medic.

One stated a BVM is sufficent.

The other stated that intubating the pt was the right course of action.

Being aggressive, and staying one step ahead of the problems is what I have been taught, and I went with. So, I choose intubation.

I was wrong.

So, not just pertaining to this question, but in general, how aggressive do you get with intubations, IOs, and med admins?

I am a fan of pushing meds as a last resort, but when do you go straight to the drug box?

[VentMedic]

American Heart Association Pediatric (PALS) Resuscitation recommendations:

Strong emphasis on BVM ventilation based on the Gausche airway study showing BVM outcome was better than intubation outcome when performed by Prehospital providers.

[jsadin]

That's not an easy question to answer.

Every patient is going to be different and require different levels of response. A rapidly deteriorating patient is going to get a more aggressive effort than a one that is holding their own. Aggressive treatment can bite you in the arse if it's done without compelling reason.

[MSDeltaFlt]

Here's the deal. My pt had better prove to me that they DON'T need something done. They called me for a reason.

[VentMedic]

If you want to pass PALS, you follow the recommendations and materials presented in class.

If you want to work on a child in the field, you follow the guidelines/protocols given to you by your medical director. Hopefully you have established and maintained competency for those procedures. Any questions about specific circumstances for invasive procedures should be clarified by your medical director.

Being aggressive is not always a good thing if you are functioning outside of your comfort zone. Also, not being aggressive because of your limited comfort zone is not good either. Not knowing or over stating one's comfort zone or limitations can also lead to problems. More education, practice and experience will usually make the answers to your questions become clearer.

There are some EMS agencies that no longer allow Paramedics to intubate pediatrics due to the dire outcomes of inexperience when it involves intubating children.

[AZCEP]

There are some agencies that should lock the laryngoscopes and ETTs up so their providers can't get ahold of any of them, adult or pediatric. :shock:

You do make a good point Vent. A provider has to have a nth level of comfort prior to engaging in some procedures. If they don't then they really shouldn't try to "wing it" to impress someone. I think Flasurfbum was looking for insight as to how aggressive some providers are in general, and not specifically with pediatric patients though.

Do the absolute minimum until the patient decides that they really need more. Once that happens you have to be able to escalate rapidly and accordingly.

[Flasurfbum]

Vent, I did pass PALS, but being the anal-retentive person I am, I want to know WHY I got it wrong. I had instructors with decades of experience telling me that I was correct in my answer as far as the field answer is concerned, but to play, I gotta pass first.

I will look up the protocall next clinical I am on, but going from R36 to R6 very quickly, to me at least, suggests a rapid downhill outcome for my pt, should I not act quickly, and aggressively.

Do you have a link to that study?

Not questioning you, or the study, but I would be interested to see the results.

[Flasurfbum]

You do make a good point Vent. A provider has to have a nth level of comfort prior to engaging in some procedures. If they don't then they really shouldn't try to "wing it" to impress someone. I think Flasurfbum was looking for insight as to how aggressive some providers are in general, and not specifically with pediatric patients though.

Do the absolute minimum until the patient decides that they really need more. Once that happens you have to be able to escalate rapidly and accordingly.

You are correct there. The PALS test kind of spurred this discussion, and I was referencing it. I do not mind the opinions from the learned members here, though.

Here is a link to the protocalls for the Fire/Rescue agency I do my clinicals with.

Perhaps it is a bit of Firefighter training subconsciously kicking in, but rather then waiting for my patient to go downhill, I would like to stay ahead of the game, and be proactive in my treatments.

Of course, I would not intubate a patient who is slightly SOB, vitals WNL, and no abnormal lung sounds, but if their vitals are heading downhill, with severe difficulty breathing, and abnormal lung sounds, at a minimum, I would be setting up to tube the pt, if not already dropping him. (this is if C-PAP was not an option)

[ccmedoc]

I agree with AZCEP, you should do only what the patients needs. For this reason only, not 'because you can'.

Aggressive treatment is a noble thought, but you tread a fine line between helpful and harmful. Aggressive is not always what the patient needs, especially kids.

I think as a rule, least invasive interventions first are best. You should be bagging while preparing your intubation equipment anyway, how can that be the wrong answer? Priorities brother..

--Just sayin'

[unknown]

Here's the deal. My pt had better prove to me that they DON'T need something done. They called me for a reason.

MIKEY YOU KNOW THEY CALL YOU JUST CAUSE YOU ARE A NICE GUY, THEY WANT TO SEE YOU WETHER THEY ARE SICK OR NOT!

OH BY THE WAY I GOT A HANG NAIL ON MY BIG TOE......

SO LETS CALL IT A TRAUMA

171 MILES HEADING OF 325 33 YOLD FEMALE 155 LBS