Clinical Judgment and Protocols

[mobey]

I, in no way, shape, or form will work outside the scope of my practice, if it means I lose my job- unless, it is for my family, and that is the only exception.

So there you have it.

The rest of the arguing is just noise.

JB is willing to work "outside" the box for family only because his ethical/moral stance is that only they deserve the very best. The rest of his patients get the basic cookbook medicine from a cookie-cutter medic.

This argument will never go anywhere since this is 2 different styles of treatment trying to prove themselves right. One with law on thier side, one with morals on thier side.

Here is some reading for ya JB, from the man who wrote the "cookbook".

Cowboys in EMS

[tcripp]

Who in their right mind would drill a diabetic that was hypoglycemic, prior to trying glucagon?? Oh wait- you , that's right!!

Um. I would. Becuase it isn't forbidden to drill a diabetic who is hypoglycemic. Where is that written? Even the makers of the EZ IO market that "intraosseous (IO) access is the preferred method for establishing vascular access in diabetes". They also promote that "any drug you can give IV can be given IO".

As a matter of fact, there are multiple locations you can drill, so if you are cautious about the damage you can cause by drillng in the lower extremities...well, go for the humeral head.

Now, let's look at the effect of the glucagon that has an onset of 5-20 minutes vs the instant access provided by the IO delivery. With a stroke, time is of the essence.

And, lastly, Dwayne mentioned that his concerns were that she had used up all of her glycogen stores which would have made the glucagon useless.

So, if Dwayne is called to the stand...I'd be part of the peer review that would agree (with what information has been presented here) that he's not alone in he treatment decision.

[Johnboy]

I don't even know what to say- I am baffled at the ignorance

[mobey]

I don't even know what to say- I am baffled at the ignorance

Please... by all means.... say nothing!!

EDIT: Perhaps you were refering to the article? sheesh, I hope not!

Edited April 5, 2011 by mobey

[uglyEMT]

WOW missed a good thread LOL

Dwayne your an ass clown

Hell your the ass clown I WANT on my rig when TSHTF.

OK let the Basic have a stab at the ridiculousness (is it a word?). If I understand correctly, Dwayne you had a diabetic PT that was unconscious and possibly CVA due to facial droop which was a new symptom as per witnesses. You ran through your brain and found your diabetic algorithm and realized D50 would be best BUT also realizing the time window for a CVA and doing ninja brain math realized a very short window thus moving to your CVA algo. Realizing the hypoglycemia could be masking the CVA OR cause CVA like symptoms you decided to go D50 which normally would be given IV. Upon trying IV you couldn't get a stick due to dehydration collapsing the veins (or prior venous issues). Upon trying to move the patient's extremities you felt resistance and possible crepitus thus not wanting to further injure the patient you decided on a IO which upon me researching means you drilled the bone to inject directly to the marrow (hopefully I understood that right)My link . Knowing this would cause extreme pain if and when the patient regained consciousness decided some lidocane, a pain killer, would be appropriate. Now I had to look this up so bear with me....

Contraindications

Lidocaine hydrochloride is contraindicated in patients with a known history of hypersensitivity to local anesthetics of the amide type. Lidocaine hydrochloride should not be used in patients with Stokes-Adams syndrome, Wolff-Parkinson-White syndrome or with severe degrees of sinoatrial, atrioventricular or intraventricular block in the absence of an artificial pacemaker.

My link

Upon realizing this is the only contraindication and not knowing if she was, guessing here witnesses said no, you felt OK to use this mode of pain relief under the assumption she would regain consciousness due to the overlying symptom being low blood sugar and D50 would correct this issue. Also noting what possible side effects could be caused and anticipating them you felt you were within specified area protocols, likely standing orders, so no consult was needed.

Now thinking ahead the benefit to the patient at this point would be coming out of a depressed state of consciousness and also possible resolve of the CVA S&S which would not necessitate the call to have the team readied. If the CVA S&S did not resolve all you have done is give the clinical team access to add whatever meds they need once in the ED without any wasted time. Thus again keeping your ninja skills sharp and wielding the time window for proper treatment of the CVA.

After all this at some point your employer for whatever reason decided to terminate you and used this call along with two others. Even though at this point I am assuming (see now I am making an ass out of you AND me) the previous call was all within protocols and standing orders. So basically you stood your ground with an inept manager and walked instead of betraying your belief in patient care.

Ok so did I miss anything? If no then why all the hostility? You followed protocol, stood within the bounds of excellent patient care, used sound clinical judgment and moved forward in your algorithms to the benefit of the patient. Nowhere do I see a "cowboy" mentality, nowhere do I see anything outside good clinical judgments, nowhere do I see anything wrong except a bad management decision.

Now if a Basic can follow this, ok had to look up a few things but linked my sources (see not that hard), then how does a seasoned medic with advanced (well according to them, no link to source no dice) protocols not follow the mention used, the pathways used, or drugs used?

12 year old? Naaaa they would follow too.

Troll? Ding Ding Ding we have a winner!!!! Here is your prize

To everyone else, too bad this thread got derailed, it seemed like a great one, even for the Basics and Intermediates out there. We all need to be thinking this way. We have guidelines not handcuffs.

BTW johnboy with just these few posts in this thread to go by I would rather have my probie and a firemonkey in the back with me helping then you Mr. Paragod. Please stay off my rig. Also if your wondering who gave you the minus in the Beiber jab it was me. That kid has a great future as a medic and has the balls to admit his flaws here and moves forward as a better provider for it and I as one of the members here am glad he is part of our profession.

edit to add link for lidocane no other changes made

Edited April 5, 2011 by UGLyEMT

[Johnboy]

You idiots on this site have blown me away, this isn't a site for learning. You people are idiots ! Plain and simple. I was on here for a week and am already done. You assholes simply amaze me. You all feed off of each others stupidity. Dwayne , as I said before - you deserved to be fired, why - because you are a strum job... Period...

[Happiness]

So there you have it.

The rest of the arguing is just noise.

JB is willing to work "outside" the box for family only because his ethical/moral stance is that only they deserve the very best. The rest of his patients get the basic cookbook medicine from a cookie-cutter medic.

This argument will never go anywhere since this is 2 different styles of treatment trying to prove themselves right. One with law on thier side, one with morals on thier side.

Here is some reading for ya JB, from the man who wrote the "cookbook".

Cowboys in EMS

Mobey that link was the best response yet. Thank you for brining that to the ring

You idiots on this site have blown me away, this isn't a site for learning. You people are idiots ! Plain and simple. I was on here for a week and am already done. You assholes simply amaze me. You all feed off of each others stupidity. Dwayne , as I said before - you deserved to be fired, why - because you are a strum job... Period...

HUMMMMMMMMMMMM your still leering around, remember we can see you it is 3:34 pm pacific stanard time, and your looking at this thread.

[mobey]

You idiots on this site have blown me away, this isn't a site for learning. You people are idiots ! Plain and simple. I was on here for a week and am already done. You assholes simply amaze me. You all feed off of each others stupidity. Dwayne , as I said before - you deserved to be fired, why - because you are a strum job... Period...

First off let me say as a senior member here: Don't let the door hit ya!

Secondly, because I do not believe you are truly leaving - You have yet to PROVE you are right, and we are wrong!

You are just repeating the same uneducated garble over and over, and inserting insults in an attempt to make yourself look superior.

Think about this for a minute: You are the ONLY person here with your point of view..... out of all the Medics reading and or responding, you are the ONLY individual that disagrees. Hmmm...... Could it be that your protocol and standard of care is below the norm?

Your continuous swearing and namecalling will not be tolerated here. You may not be banned, but something tells me the members here will see to it you leave.

When you are calmed down and ready to act like a professional, and have an intellegent debate, c'mon back!

[Paramagic]

Hypoglycemic symptoms are related to the brain and the sympathetic nervous system. Decreased levels of glucose lead to deficient cerebral glucose availability (ie, neuroglycopenia) that can manifest as confusion, difficulty with concentration, irritability, hallucinations, focal impairments (eg, hemiplegia), and eventually, coma and death. Stimulation of the sympatho-adrenal nervous system leads to sweating, palpitations, tremulousness, anxiety, and hunger.

The adrenergic symptoms often precede the neuroglycopenic symptoms and, thus, provide an early warning system for the patient. Studies have shown that the primary stimulus for the release of catecholamines is the absolute level of plasma glucose. The rate of decrease of glucose is less important. Previous blood sugar levels can influence an individual's response to a particular level of blood sugar. However, one must appreciate that a patient with chronic hypoglycemia can have almost no symptoms.

Hope this helps..

JB

Well, it helps me understand hypoglycemia, but what I am still having trouble with is how this pathology eliminates the transmission of impulses via the nervous system, to the point where even spinal reflexes are eliminated, thereby rendering hte patient unable to mount a response to noxious stimuli.

Please explain, I am struggling with this and would like to understand it better.

[Just Plain Ruff]

You idiots on this site have blown me away, this isn't a site for learning. You people are idiots ! Plain and simple. I was on here for a week and am already done. You assholes simply amaze me. You all feed off of each others stupidity. Dwayne , as I said before - you deserved to be fired, why - because you are a strum job... Period...

First off see that little red x at the top of your computer screen, that's the door, let it hit you in the ASS as you click it. No one here will miss you

But I suspect you will never leave and will continue to post your wealth of knowledge to edumacate us dumb buffoons as to the real wisdom of the Johnboy version of medicine.

Nothing we say will change your mind so I suggest that this topic be locked so Johnboy can go on and let another EMTCity member know his absolute knowledge of EMS. I'm sure we're all waiting with baited breath your next set of posts.