Putting Education into Practice

medichopeful

medichopeful

Flight RN/Paramedic
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Hi all,

Ok, so this is probably a stupid question, but I figure I'll ask anyways. After all, there are no stupid question! (Only stupid people :P)

Anyways, I'm reading up on oxygen and the use of it, physiology of it, etc.. My question is, is it appropriate to put that education to use as a basic? For example, if I have a patient and I think to myself "this patient only needs O2 via a NC at only 2 lpm, not 6 or a NRB at 15 because of this this and this," is it appropriate and legal for me to make that decision? Or as a basic should I just say "treat everything by the letter of the law/protocol to cover my own ***?"

In other words, what does this education lead to? Where is the line between "acting within scope of practice" and "practicing without a license?"

Now, I realize this question is incredibly stupid, so if you must go ahead and give me a hard time (just don't be too harsh! :wacko:). I just figured I'd ask before I did anything stupid and painted a target on my back!

Thanks all!
Eric

(I hope this makes sense. I'm running on very little sleep :ph34r:)
 
Technically, you're supposed to follow protocols. If it says EVERYONE gets 15lpm... well.. you have some work to overcome.


However, it's also your duty to not follow orders that can be harmful, or don't fit the true treatment modality as patients don't fit specific protocols. Protocol says if someone has chest pain, they get ASA/NTG/Hepain/Labetalol etc etc. What if you don't think it's cardiac in origin due to your assessment? You have an education, use it.

If you don't feel comfortable making a decision on your own, call med control and discuss it with them--- that's what they're there for.
 
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Hopefully your protocol does not say "give everyone 15lpm O2 via NRB".

My current protocols say something along the lines of "Consider O2 as needed to maintain SpO2 greater than 96%". That means I can use whatever method necessary to achieve that. If all they need is 1lpm via NC that is fine. In that case, it is the providers choice of what is most appropriate.

Now, it isn't mandatory that all patients have an SpO2 over 96%. If Grandma slips and bangs her knee and has an SpO2 of 93% and a history of CPOD and smokes a pack a day I'm not too worried about her SpO2. If that same grandma is having chest pain or SOB, I'm going to be paying more attention to it, and probably give her O2.
 
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The elderly female w/ COPD and on home O2 via NC @ 2 LPM who stubbed and broke her toe does not get back boarded or get high flow O2.

The hypoxic herion overdose does not get a NC.

Use your head and some common sense. It goes along way. Mass protocols state "Administer oxygen using APPROPRIATE oxygen delivery devise, AS CLINICALLY INDICATED". Guess what. You have to decide what's clinically indicated.

Furthermore Mass OEMS states in the introduction to the protocols:

13. “Exception Principle” of the Protocols
• The Statewide Treatment Protocols represent the best efforts of the EMS physicians
and pre-hospital providers of the Commonwealth to reflect the current state of out-of-
hospital emergency medical care, and as such should serve as the basis for such
treatment.
• We recognize, though, that on occasion good medical practice and the needs of
patient care may require deviations from these protocols, as no protocol can
anticipate every clinical situation. In those circumstances, EMS personnel deviating
from the protocols should only take such actions as allowed by their training and only
in conjunction with their on-line medical control physician.
• Any such deviations must be reviewed by the appropriate local medical director, but
for regulatory purposes are considered to be appropriate actions, and therefore
within the scope of the protocols, unless determined otherwise on OEMS review by
the State EMS Medical Director.

There is built in "wiggle room" as long as it's medically sound.
 
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Ditto to what Linus has posted.

Because we are trying to get our profession out of the "technician" realm and in to actual medics, we should be using our brains to determine what is best for our patient. That also indicates that if we have a difference of opinion between what we believe to be right and appropriate, we should take it up with our superiors/medical director.

One thing I learned in paramedic school is to understand why you are doing something rather than just doing it blind.

That's one reason I prefer "Clinical Operating Guidelines" or "Standards of Care" vs. protocols.
 
my protocall says 15LPM for every patient. but my opinion is, is that if you have a good reason and can prove it then make the change. on medical calls we are supposed to do 15LPM but if there sp02 is at 99% i would just put them on a NC at 2LPM. then in the report you should state why you chose to do that. thats my opinion and how i have seen it in my county.
 
firefite said:
my protocall says 15LPM for every patient. but my opinion is, is that if you have a good reason and can prove it then make the change. on medical calls we are supposed to do 15LPM but if there sp02 is at 99% i would just put them on a NC at 2LPM. then in the report you should state why you chose to do that. thats my opinion and how i have seen it in my county.
Click to expand...

Since you list Riverside County as your location, I'm going to assume that you work in Riverside.

Introduction to BLS Protocols

These policies are intended as thought processes or decision trees, not as absolute plans to fit every circumstance. Each patient encounter is unique, and a policy could not possibly be written to cover every circumstance. ... We expect [EMTs] and EMT-Ps to closely folow these policies in most circumstances, using their training and good judgment to determine those occasional instances when deviation from the standard of care as promulgated by them is required.
Click to expand...

Emphasis added

Page 1.

Throughout, essentially every protocol starts off calling for oxygen via NC at L/M or facemask at 10 L/M. However, most are immediately followed by "Regulate flow as clinically indicated." So, if you want to be a protocol purist, place NC on at 6 L/M. Document that based on assessment, oxygen isn't needed. Regulate oxygen down to O L/M and remove the nasal cannula.

http://www.rivcoems.org/downloads/downloads_documents/Protocol102904/6000.pdf
 
In my opinion i use NC way more than NRB because most of the time the patient doesn't need a NRB or they cant tolerate it, then you just do the blow by technique. i would talk to an officer about the time to use NC's or NRB's
 
hocomedic said:
if your local protocols say every patient gets 15lpm NRB then your ambulance shouldn't have NC's and there would be no decision to make. In my opinion i use NC way more than NRB because most of the time the patient doesn't need a NRB or they cant tolerate it, then you just do the blow by technique. i would talk to an officer about the time to use NC's or NRB's
Click to expand...

...and most of the time I just didn't use oxygen at all.
 
Why would you do ANYTHING that you believe would not benefit the patient?

You can always observe and adjust, observe and adjust. Isn't that within your scope? Maybe, in this fancied litigious world (because I've asked a number of times for someone to feed me the stats on the number of on-duty medics actually sued, with no takers!) all you'd need to do then would document your reason.

You wouldn't do anything without good reason would you?
 
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