ALS upgrade for no reason

[STXmedic]

What interventions did you perform?

 

[JPINFV]

What interventions did you perform?

I was really tempted to ask the same question. I guess the "treat the slightly low glucose with oral glucose" would be the answer. However at that 'low,' the better answer would be just stopping for lunch.

 

[VFlutter]

stating there was nothing more they would have done besides start an iv, which they did try 1 time in there rig but blew out the vein.

That just sounds lazy. If there is a medical need for an IV then they should have gotten an IV. If there was no immediate medical need they should not have tried to get one. You don't try once then send them BLS if you don't get it. I am assuming if they were successful with the IV that would require them to ride with you to the ER? Or did they try the IV after they already took the patient themselves?

pulse ox 94 on 4 lpm n/c....

We put pt on cot and give 12lpm.

Care to explain why 12lpm was appropriate? I guess its better than 15

 

[kurtemt]

The ALS crew tried en route. 5 min eta so only time for 1 attempt. Granted out medics have a bad ratio for successful iv's but that's another story. But that was the only difference in the level of care ALS vs bls. Hence my original question.

I could see if the pt was unstable or still exhibiting signs of seizure. Our best educated guess is that it was most likely related to hypoglycemia which we treated with oral glucose. Although it could be more serious problem so I can see the need for ALS. It can be debated both ways. I don't think either are necessarily wrong. It would have been nice for me and my partner to finish the call.

It was a good bls call for us though. I think we handled it well. Hope you all agree.

 

[Action942Jackson]

The difference is between a technician and clinician. A technician responds with X, Y, Z in presence of B. A Clinician asks why is B presenting itself, who caused it, and what can be done Pre-hospital to fix things.

This might be a simple open and shut case in your eyes being a technician. But there is A LOT more involved here. What are his meds? Any recent changes in his meds? Are there any meds that can cause seizures? Any history of bleeding CVA? Old people + Seizures + Low BGL can often equal = A non-traumatic head bleed. Also, even in your 6 min transport, should this patient begin to vomit or seize again, the likelihood of advanced airway management without patient decomp is warranted in this case. Also, what if they're seizing because they're CO2 values are high? Without doing a full clinician based assessment, you are causing the system to fail, because you think you can handle the run.

I hope you can understand I am not belittling you. I am merely trying to point out that a simple run to you based on your short limited (your limited based on your scope of practice) assessment skills can result in a negative patient outcome if not assessed properly. As far as you being an EMT, you did what your scope has determined you can provide. What I'm replying to is the lack of proper ALS clinician assessment of the patient.

In all honesty that guy should of had how every many attempts to obtain IV access during transport. 1 try in 5 minutes is down right pathetic. Imagine if they spent 5 mins getting an IV on a pedi code? Not good.

 

[KellyBracket]

... Our sop for any transport to an emergency room is to call medical control first, give report of findings and interventions, and give our closest and then desired er.
...

That sounds like a really unwieldy protocol. I wonder what problem it was designed to solve, and if it is actually solving anything. Perhaps they have a lot of diversion problems?

 

[JPINFV]

The difference is between a technician and clinician. A technician responds with X, Y, Z in presence of B. A Clinician asks why is B presenting itself, who caused it, and what can be done Pre-hospital to fix things.

The flip side of this is that the prehospital treatment and workup is very limited. For a primary seizure, EMS won't come close to a cause just because of the technical limitations involved with no access to labs outside of POC glucose and no ability to image. As you pointed out, however, the value of EMS, and paramedics in particular, is the vigilance of being prepared in case badness happens.

In this sense, EMS is a combination of EM as minutemen and anesthesiology motto of vigilance.

On a side note, the symbolism that goes into specialty board seals is very interesting.

 

[Action942Jackson]

The flip side of this is that the prehospital treatment and workup is very limited. For a primary seizure, EMS won't come close to a cause just because of the technical limitations involved with no access to labs outside of POC glucose and no ability to image. As you pointed out, however, the value of EMS, and paramedics in particular, is the vigilance of being prepared in case badness happens.

In this sense, EMS is a combination of EM as minutemen and anesthesiology motto of vigilance.

On a side note, the symbolism that goes into specialty board seals is very interesting.

Completely agree! However, I do love that pre-hospital ultrasounds are gaining headway and popularity. Although far-fetched as you would only find POC labs on CCU buggies, it's not beyond the realm of EMS to incorporate both of the items you described. But in this case the POC labs would of taken 15 mins, not very practical in this scenario or any metro based system with short transport times.

 

[JPINFV]

Completely agree! However, I do love that pre-hospital ultrasounds are gaining headway and popularity. Although far-fetched as you would only find POC labs on CCU buggies, it's not beyond the realm of EMS to incorporate both of the items you described. But in this case the POC labs would of taken 15 mins, not very practical in this scenario or any metro based system with short transport times.

You're going to ultrasound, what, exactly for a seizure?

Ok, you've run a chem7 on your iStat and the patient is severely hyponatremic. You're going to do... what... exactly? The patient is already going to be fluid restricted during the transport (you aren't exactly going to be giving him water to drink) and I don't think anyone is going to be giving EMS hypertonic saline anytime soon for electrolyte abnormalities... especially since hyponatremia can be very dangerous to correct quickly and ones where normally the treatment is water restriction (because you know someone is going to get the 133 mEq/mL and decide to treat it with hypertonic saline).

 

[chaz90]

Completely agree! However, I do love that pre-hospital ultrasounds are gaining headway and popularity. Although far-fetched as you would only find POC labs on CCU buggies, it's not beyond the realm of EMS to incorporate both of the items you described. But in this case the POC labs would of taken 15 mins, not very practical in this scenario or any metro based system with short transport times.

A FAST ultrasound would have absolutely no bearing on this patients complaint. Also, why would even having access to lab values help pre-hospitally for this patient? Most times I've heard iSTAT thrown around for EMS it's been in regards to basic electrolytes, cardiac markers, or maybe blood gasses. We may see these results, but there's no way we're going to even think about addressing them in the field, and nor should we! Correcting electrolytes and starting Keppra can certainly be left for the ED.

 

[Action942Jackson]

But in this case the POC labs would of taken 15 mins, not very practical in this scenario or any metro based system with short transport times.

Apparently, you guys might need to step away from the computer for a minute so you can re-read my post. I said that neither of these are practical in THIS scenario.

We are not beyond the possibility of EMS having these diagnostic tools, which are just that DIAGNOSTIC. Anything that can shorten the diagnostic time of a patient in the ED, can lead to better patient care. Which is what it's all about right?!?

Good gravy. Good thing I have firefighter friends, they were able to put down the flames you guys threw at me. Only singed a couple of nose hairs.

 

[JPINFV]

Apparently, you guys might need to step away from the computer for a minute so you can re-read my post. I said that neither of these are practical in THIS scenario.

We are not beyond the possibility of EMS having these diagnostic tools, which are just that DIAGNOSTIC. Anything that can shorten the diagnostic time of a patient in the ED, can lead to better patient care. Which is what it's all about right?!?

Good gravy. Good thing I have firefighter friends, they were able to put down the flames you guys threw at me. Only singed a couple of nose hairs.

The problem is that both the chem 7 is going to be repeated anyways just as a part of a standard work up (never mind internal medicine's fetish for daily labs) and the rest of the differientals are going to be worked up anyways. No one is going to look at an electrolyte abnormality and decide that a CT wasn't needed.

 

[Aidey]

Apparently, you guys might need to step away from the computer for a minute so you can re-read my post. I said that neither of these are practical in THIS scenario.

How about we keep our posts relevant to THIS scenario? If you want to discuss advanced diagnostic tools make a new thread.

 

[KellyBracket]

First off kurtemt, it sounds like you did a good job. Don't get too sucked in to the glucometer reading, though. When the only tool you have is a hammer, every problem looks like a nail! Read up some more on hypoglycemia and on seizures (biiiiig topic!), and keep on at it. You've got the right attitude.

I think I'm going to play devil's advocate about EMS POC tests. Even if we do "just repeat all the labs," it takes time to get those results. Although we occasionally take action based on our history and exam, a lot often depends on the numbers from the lab. With preliminary results, we can get the ball rolling on both treatment and appropriate admission.

If, for example, EMS brought me an altered nursing home patient, with a slight tachycardia, it would be great to have a POC lactate handy. Over 4? Awesome, continue fluids, check another lactate, while at the same time calling ICU - done! Under 2? Fine, dig deeper, check other labs, start working on admission to the floor.

Now, if only we could get you guys to check a urine on the rig...

 

[kurtemt]

First off kurtemt, it sounds like you did a good job. Don't get too sucked in to the glucometer reading, though. When the only tool you have is a hammer, every problem looks like a nail! Read up some more on hypoglycemia and on seizures (biiiiig topic!), and keep on at it. You've got the right attitude.

Thank you I appreciate that, and I will look into and study up on low bgl and its relation to seizures.

 

[Handsome Robb]

I will echo Dr. Bracket, Kurt, and say good job on this call.

One thing I'd like to add is I've seen a few of these "why ALS?"threads lately and had it happen to me at work with newer EMTs when my partner is out sick.

Example: pink, warm and dry 13 year old female, walking, talking, A&O, vitals "WNL" who took ~20 mg/kg of amitriptyline about 20 minutes prior to my arrival. My partner argued and argued with me that he could handle the call for a solid 5 minutes until I finally put my foot down and pulled the paramedic card on him. When he opened the back doors at the ER she was hypotension, obtunded and requiring very close attention to her airway. Not his fault, he just didn't have the education to understand what was happening inside this girl's body.

The issue was is he didn't know and/or realize the gravity of the situation we were about to be in. Not his fault, they don't teach that stuff beyond mentioning it in EMT school.

Don't take this as me nitpicking, just showing how even when the "numbers" don't indicate ALS intervention there still could be a reason the patient should be assessed and attended by a paramedic that you don't realize because you were never taught about it.

 

[Christopher]

Thank you I appreciate that, and I will look into and study up on low bgl and its relation to seizures.

I think the only takeaway from this is it is bizarre to have to call to find out who takes the patient. From my own experience, if the BLS crew has not cancelled me prior to ALS arrival, this probably means the patient should receive an ALS transport.

Another point would be a nasal cannula is a powerful tool in the right hands

Otherwise, I would concur you went down the right path.

 

[DrParasite]

As everyone knows how much I love ALS upgrades for no good reason, in this case, I would probably say the ALS upgrade was justified.

first time seizure, with no history? What caused the seizure? was it his low BGL, does he have a tumor in his brain, does he have a chemical imbalance in his brain, or any other reason that I don't konw about? can whatever caused the first seizure cause another one? sure. what can BLS do with an actively seizing patient? stare at the patient, and drive to the ER. what can ALS do? Benzos, although I would argue, while you might stop the seizure activity, the underlying cause is still there.

Personally, with a BGL greater than 50, you shouldn't be having hypogylemic seizures, so I would be thinking it's something else. not that the BGL shouldn't be fixed if you could.....

Put the patient on a nasal canula, and take a nice easy ride to the ER. if ALS is there, and wants to come along for the ride, sure. if they aren't, and he isn't seizing, no worries, nice easy ride to the ER. If the ALS wants to start an IV and do the stare of life, sure, you can both do it. This way if he starts seizing again, they can stop it, and if not, you both got to practice your stair of life together. It's only 5 minutes, nothing to stress over.

And if they want to release, or you want to cancel them because he isn't seizing, I can support that too, just take a nice easy ride to the ER.

 

[chaz90]

what can ALS do? Benzos, although I would argue, while you might stop the seizure activity, the underlying cause is still there.

I think you may be confusing the effects of benzos with those of paralytics. Benzos actually are able to stop the seizure activity in the brain through an increase in GABA binding affinity and hyperpolarization of neuronal membrane potentials. Of course they aren't effective 100% of the time, but they do have an effect on the seizure itself. I understand they don't fix the underlying condition that may have originally caused the seizure.

 

[DesertMedic66]

If paramedics were on-scene with a primary seizure patient, then they need to go along. I agree with not waiting if they weren't on scene, but disagree with any sort of emergent transport for a patient who is presenting as stable at this time.

Agreed