Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Respiratory Therapy 101 – What? – More Responses

PJ Geraghty wrote:

I was described by a colleague as a “non-interventional paramedic.” It was the rare patient who received ALS treatment in my ambulance, and even then some of them got an IV because it was marginally indicated and I knew the wrath of the ED staff if I delivered the patient without what they would consider “appropriate” interventions.

I’ve taken that “wait-and-see” attitude into my organ donor management field as well…I’ll get calls from my staff or hospital staff asking what to do when a donor’s BP is “patent pending over 150 (Shem, House of God). Usually the answer is “let it go for now” and the problem resolves itself.

Medical personnel should intervene when necessary, of course, but should also consider how “necessary” that intervention is, and whether it’s likely to make a clinical difference in patient outcomes (including patient comfort).

That is precisely the point.

We have too much medical theater and not enough good medical care.

In the recent post by TOTWTYTR, From the Journal of Iatrogenic Medicine*, the discussion of the merits of giving dopamine and Lopressor is an example.

The main part of the debate was on adding the controversial Lopressor to the expected treatment with the not controversial dopamine. I wouldn’t even recommend giving the dopamine to this patient.

The protocol may state that the patient should receive dopamine, but my job is not to treat the protocol. My job is to treat the patient. I can twiddle my thumbs for the 4 minute ride and not even break a sweat. Although, with that patient, I would probably be sweating. And I would continuously be reassessing – all of the time.

As long as no further treatment appears to be indicated, I am reassessing – looking for a reason to change treatments.

Is the fluid accumulating in the lungs?

Stop fluids and reconsider dopamine.

Is the pressure no longer coming up?

Reconsider dopamine.

Looking at the ECG again, is there a reason to suspect that this is an SVT?

Consider vagal maneuvers and adenosine or sedation and cardioversion.

Unless I have some clear indication for a treatment, not just vital signs that will not look good on the paperwork, I prefer to watch and wait.

Benign neglect is much better than malignant attention.

A recent exchange between a nurse/medic and lovable old me.

Nurse/Medic – Why doesn’t your patient have an IV?

Rogue Medic – Are you going to use the bloods I draw?

N/M – No. Our lab will not accept EMS bloods.

RM – So, why should I stick this patient to provide an IV ten minutes earlier than you would and then have you stick the patient again to draw blood samples for your lab?

N/M – The patient has chest pain.

RM – No. The patient had chest pain several hours ago. The patient is currently asymptomatic.

N/M – Well he should have an IV.

RM – Go right ahead. At least he will not be getting stuck one extra time for this.

He is at a hospital that has Level One intravenous capability. They also have an excellent cath lab. He has received aspirin. He denies chest pain, difficulty breathing, weakness, dizziness, nausea, vomiting, . . . . He is pink, warm, and dry with a brisk capillary refill. His vital signs do not indicate any problems.

His only complaint is that he misses his recently deceased wife. A lot.

If he does join his wife during this hospital stay, it won’t be because he didn’t have a prehospital IV. If he suddenly becomes symptomatic and dramatically deteriorates during his hospital stay, likewise the lack of a prehospital IV will not be the cause. At most it will delay treatment for a couple of minutes. About the amount of time it would take to get a doctor in the room and give a report prior to the doctor giving treatment orders.

Treatment priorities for this patient will not generally be resolved by the intravenous route. RVI (Right Ventricular Infarction)[1] would, but he has no signs of RVI. Pain might. Arrhythmia won’t. Cardiac arrest won’t. STEMI (ST segment Elevation Myocardial Infarction)[2] might.

Cardiac arrest is treated by good CPR and rapid defibrillation. There is still no scientific support for all of the IV drugs we give. ACLS (Advanced Cardiac Life Support) does not even encourage rushing to start an IV.

The fanaticism of starting an IV life line is an old medic’s tale that is dying a slow painful death. As more and more realize the uselessness of the IV in many cases where it has been mandatory, more protocols are taking the emphasis off of the IV start and appropriately directing it toward accurate assessment/reassessment, appropriate care, and the right destination.

I suspect that N/M is upset that when working as a medic, she would be written up for not starting an IV on this patient. I will not.

One of the reasons is that I am quite comfortable discussing patient care with medical directors. I will make my case without wandering into irrelevant details. I will make a case for the patient. N/M would be making a case with something else in mind.

I have found that violating protocols, even in very dramatic ways, is acceptable to many medical directors – as long as I understand what I am doing and can explain how it is in the best interest of the patient. I have also learned that it is important to have a medical director who understands EMS.

Should we approach patient care with anything other than the best interest of the patient as our priority?

Footnotes:

^ 1 Recognition and Treatment of Right Ventricular Myocardial Infarction
By William E. Gandy

Updated: July 8th, 2008 05:26 PM GMT-05:00
From the March 2008 Issue of Emergency Medical Services

Free Full Text

^ 2 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
(Circulation. 2005;112:IV-89 – IV-110.)
© 2005 American Heart Association, Inc.
Part 8: Stabilization of the Patient With Acute Coronary Syndromes
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Comments

  1. Make a case to medical directors about why you did something differently? That must be nice.Every time I do something that deviates from protocols, or whatever people’s misguided concept of the standard of care is, I have to go about justifying it to every coworker I see for the next two weeks. Don’t worry, it’s trial by jury, far more American…

  2. I like that. Benign neglect vs Malignant intervention.

  3. Just for the record, I am the original “non interventional paramedic”. PJ just stole the idea from me. It IS a good one, though. 🙂

  4. Try being a basic truck and your partner is a first responder fresh out of school….Roll into the ER with a bad one then and see what happens …OMG! at least you guys are certified to do the skills….I have to explain what i am doing with a bad pt if i am a basic truck… And there is always that one RN you know what i am talking about that has to question everything you do and look downs on you. I just want to crawl under the bench seat every time i see her..any way sorry for rambling hope you don’t mind i found your site surfing around.

  5. Dan,It is important to get to know your medical director. The quality control people may just make it up as they go along. Understanding the medical director’s priorities is important for understanding how to present things to the medical director.I have left jobs because the medical director and I were not compatible. It is an important relationship. In a marriage, if things don’t work out, people usually don’t get killed. Usually.That is not always the case in EMS. I have been fortunate in having a large number of employers to select among, so picking the right medical director is pretty easy.

  6. ERP,I have always been a fan of benign neglect. I figured malignant attention is the opposite. The terminology is too kind for what it actually describes.

  7. TOTWTYTR,Somehow I suspect that arguing over this is like claiming to be more humble than everyone else. I’ll be Miss congeniality, this time. :-)Yes, it is good.

  8. Life of an EMT,That is one of the problems with doctors, nurses, medics, and basic EMTs – too often we do not realize that the closest ALS is in the ED. Waiting on scene 10 minutes, with an unstable patient, when you are 5 minutes from the ED, is a bad decision. Unfortunately, EMTs get written up for this all of the time.You can’t please everyone. Besides, every superhero needs a good villain. At least you’ve found a worthy villain. Maybe a house will fall on her. 🙂