the 100% directionless thread

[Chris07]

Why MICN must you order me to give 2mg of narcan IVP to an possible OD patient with a RR of 18, SpO2 of 96% on room air, and an EtCO2 of 38? I do not want to wake the patient up nor do I need to. I hate the thinking of "well they are only responsive to painful stimuli and breathing fine. Let's wake them up just because"

Can't you refuse to give it based on the fact that it's not clinically indicated?

 

[DesertMedic66]

Can't you refuse to give it based on the fact that it's not clinically indicated?

If the hospital orders it we don't have a choice really.

 

[CALEMT]

Can't you refuse to give it based on the fact that it's not clinically indicated?

If the hospital orders it we don't have a choice really.

Man that would be interesting if someone did that. Im pretty sure if someone refused a MICN's orders there would be a call to the sup pretty damn quick.

 

[NomadicMedic]

How about, "I'm gonna hold off on that unless his ventilatory status deteriorates en route. See you in a few."

What would happen if you did that? Would you get "a talking to" by the nurse? Who cares. Would you get a write up? Appeal it. Would you get hauled in front of the med director? Good! Could you defend your actions in front of your medical director? Sounds like you can.

Then do the right thing for your patients and stop being a sheep.

 

[DesertMedic66]

How about, "I'm gonna hold off on that unless his ventilatory status deteriorates en route. See you in a few."

What would happen if you did that? Would you get "a talking to" by the nurse? Who cares. Would you get a write up? Appeal it. Would you get hauled in front of the med director? Good! Could you defend your actions in front of your medical director? Sounds like you can.

Then do the right thing for your patients and stop being a sheep.

That's a double bladed sword I really don't want to fall on. I would more than likely get a phone call from the supervisor very quickly and probably have to go thru a whole investigation with my company and county. Yes I could defend my actions however if I burn my relationship with the MICNs and doctors if I call for orders (extra pain meds or pain meds for ABD pain for example) as soon as they hear my name there will be a 99% chance I will be denied orders.

I took my time giving it however. Got the patient in soft restraints and by the time I was giving it (not slamming it) we were already at the back doors to the ED

 

[exodus]

Why MICN must you order me to give 2mg of narcan IVP to an possible OD patient with a RR of 18, SpO2 of 96% on room air, and an EtCO2 of 38? I do not want to wake the patient up nor do I need to. I hate the thinking of "well they are only responsive to painful stimuli and breathing fine. Let's wake them up just because"

"Uhh, I copy 2mg Narcan IVP, protocol deviation for ALOC." I'd say restrain the patient and slam it right before you walk in. ./sarcasm

 

[exodus]

How about, "I'm gonna hold off on that unless his ventilatory status deteriorates en route. See you in a few."

What would happen if you did that? Would you get "a talking to" by the nurse? Who cares. Would you get a write up? Appeal it. Would you get hauled in front of the med director? Good! Could you defend your actions in front of your medical director? Sounds like you can.

Then do the right thing for your patients and stop being a sheep.

There's no harm in giving the narcan as long as it's not slammed and the patient is restrained. No need to make an *** out of yourself and burn bridges.

Although, not in our county, it is also indicated in suspected acute opiod OD. And I would consider being ALOC after a suspected OD being fairly acute.

Chances of having an airway compromise because of the ALOC are small, but they are there. What if the patient vomits enroute and have now aspirated because they weren't able to manage their away by being awake and alert?

There *are* reasons to give narcan to wake people up, but as far as desert's scenario, in our county it wasn't indicated and the MICN just wanted a pt who she could push by to the psych hall instead of the med beds.

 

[teedubbyaw]

Narcan is best served while moving the pt to the hospital bed.

 

[exodus]

Too late to edit my post. I just wanted to add that, I'm all for narcan for only respiratory depression in an ambulance, I was just trying to articulate there are reasons and some benefits to waking them up (slowly and not hypoxic)

 

[triemal04]

That's a double bladed sword I really don't want to fall on. I would more than likely get a phone call from the supervisor very quickly and probably have to go thru a whole investigation with my company and county. Yes I could defend my actions however if I burn my relationship with the MICNs and doctors if I call for orders (extra pain meds or pain meds for ABD pain for example) as soon as they hear my name there will be a 99% chance I will be denied orders.

I took my time giving it however. Got the patient in soft restraints and by the time I was giving it (not slamming it) we were already at the back doors to the ED

Just going to take a wild *** guess here, but if you give 2mg of narcan to someone, put them into bad to serious withdrawals and dump them off on the doctor and the non-moronic nurse's who don't answer the radio...yeah...you'll burn far more bridges that way than if you don't give to large a dose of narcan.

So. Let's recap. You were told to do something that was wrong and not medically indicated. You knew it was wrong and not medically indicated. Maybe you followed the order, maybe you didn't. But afterwards, you, as a good medical provider followed up on this by lodging a complaint with both your supervisor and medical director, right? Because, since you know that you are being told to do inappropriate things you are going to take steps to ensure that it doesn't happen again, to you or anyone else. Right?

 

[Carlos Danger]

I don't think I could work in a system where I had to take medical direction from nurses who don't know what they are talking about.

 

[Chewy20]

That's a double bladed sword I really don't want to fall on. I would more than likely get a phone call from the supervisor very quickly and probably have to go thru a whole investigation with my company and county. Yes I could defend my actions however if I burn my relationship with the MICNs and doctors if I call for orders (extra pain meds or pain meds for ABD pain for example) as soon as they hear my name there will be a 99% chance I will be denied orders.

I took my time giving it however. Got the patient in soft restraints and by the time I was giving it (not slamming it) we were already at the back doors to the ED

If they are going to deny the PATIENTS more comfort because of you, than thats pathetic.

 

[exodus]

Just going to take a wild *** guess here, but if you give 2mg of narcan to someone, put them into bad to serious withdrawals and dump them off on the doctor and the non-moronic nurse's who don't answer the radio...yeah...you'll burn far more bridges that way than if you don't give to large a dose of narcan.

So. Let's recap. You were told to do something that was wrong and not medically indicated. You knew it was wrong and not medically indicated. Maybe you followed the order, maybe you didn't. But afterwards, you, as a good medical provider followed up on this by lodging a complaint with both your supervisor and medical director, right? Because, since you know that you are being told to do inappropriate things you are going to take steps to ensure that it doesn't happen again, to you or anyone else. Right?

How is it not indicated on an ALOC patient without a secured airway?

 

[Handsome Robb]

How is it not indicated on an ALOC patient without a secured airway?

Because narcan is indicated for respiratory depression. Not ALOC.

And my GoPro stood up fantastically to my snowmobile accident, helmet not so much.

 

[DesertMedic66]

Just going to take a wild *** guess here, but if you give 2mg of narcan to someone, put them into bad to serious withdrawals and dump them off on the doctor and the non-moronic nurse's who don't answer the radio...yeah...you'll burn far more bridges that way than if you don't give to large a dose of narcan.

So. Let's recap. You were told to do something that was wrong and not medically indicated. You knew it was wrong and not medically indicated. Maybe you followed the order, maybe you didn't. But afterwards, you, as a good medical provider followed up on this by lodging a complaint with both your supervisor and medical director, right? Because, since you know that you are being told to do inappropriate things you are going to take steps to ensure that it doesn't happen again, to you or anyone else. Right?

Here's the issue, while it is only in my protocols to use narcan for respiratory depression (and really the only time I want to use it) we have a decent amount of people who will push narcan for any ALOC OD patient. In the hospital they wake up every single OD (from my experience).

There is no point in even trying to bring this issue up to management level. The doctors in each ED have "protocols" for their nurses and protocols on requesting medications from EMS providers.

My protocols differ from what the ED protocold are. So while using narcan to wake an OD patient may not be in my protocols it is in the hospitals. Using pain medications is not in my protocls for ABD pain but it is in the hospitals. When we make contact with the ED we are pretty much now using their protocols.

Edit: also let me add in that we are not able to titrate medications in my system without a base hospital order (MICN). So if we are going to give Narcan it has to be 2mg IV/IN/IM. If we call for orders to titrate we will more than likely be denied those orders and given the orders for the full 2mg.

 

[DesertMedic66]

If they are going to deny the PATIENTS more comfort because of you, than thats pathetic.

If the hospital MICN believes you are a ****ty medic based on prior experiences when you do a call in they will only take it with a grain of salt and will believe that the report is inaccurate.

 

[Carlos Danger]

Edit: also let me add in that we are not able to titrate medications in my system without a base hospital order (MICN). So if we are going to give Narcan it has to be 2mg IV/IN/IM. If we call for orders to titrate we will more than likely be denied those orders and given the orders for the full 2mg.

This is the biggest issue I have with this situation.

I don't necessarily have a huge problem with them wanting you to take up a suspected opioid OD, even despite them breathing well - I don't think there's any reason for it and I don't think it's a great practice, but whatev - however, the fact that they are forcing you to give such a large dose is simply stupid. It's not needed and it's potentially bad for the patient.

For an EMT who is dealing with a patient who is apneic or hypoxic from resp depression and they are in over their head and they need to do something and all they have is a metered-dose device of some type, then 2mg is fine. But for a paramedic who can easily divide the doses and is dealing with a patient who is already breathing adequately, it's asinine.

That, and having to take orders from an ED RN. I can't get past that one.

 

[Akulahawk]

Why MICN must you order me to give 2mg of narcan IVP to an possible OD patient with a RR of 18, SpO2 of 96% on room air, and an EtCO2 of 38? I do not want to wake the patient up nor do I need to. I hate the thinking of "well they are only responsive to painful stimuli and breathing fine. Let's wake them up just because"

I generally had two formats for calling hospitals. One was simply a radio report that was similar to a report I'd give at bedside to the receiving staff. The other was what I'd use when asking for orders, for whatever reason. It was generally clear that I wasn't asking for, nor expecting, orders for care of that patient, when simply giving a radio report.

If you disagree with the MICN's order, should one be given, just make sure you clarify the order in such a way that you're trying to point out why you don't think it's a great idea to do at that time. "Confirm 2 mg Narcan for a spontaneously breathing patient that is protecting their own airway, satting 96% on room air with an EtCO2 of 38?" The MICN might not exactly "like" having to repeat an order, but the restated stuff might make them rethink the order. Also, if there's and adverse event of some sort afterward, you then can bring that up later in a run review... and it's on tape. Or you can request to speak to the Base Hospital Physician about the order. Be polite and professional and if the order won't be detrimental to the patient, you should be able to choose when to "do it" and at what rate. After all, 2 mg Narcan SLLLOOOWWWWWWWWWWW IVP will still result in 2 mg being administered just as a 2mg Narcan bolus does.

Just be very certain what your county's policy is when you are refusing an MICN order. Remember, if the MICN doesn't give the proper order and you carry it out, YOU are the one they'll hang because you're the ultimate safety device. As an RN, if I think a medical provider's med orders (for instance) are unsafe or appropriate for that patient, I have the responsibility to NOT do it and question it.

 

[chaz90]

Evidently there was a cardiac arrest right near the start of a large Labor Day parade in Wilmington, and the news decided they should publish an article with a play by play of the events. It's interesting to read the description of this code from a layman perspective.

http://www.delawareonline.com/story...ency-delays-start--labor-day-parade/71836896/

 

[EMT2015]

Happy Labor Day!! To everyone working today, stay safe out there.