Guest guest Posted October 6, 2008 Report Share Posted October 6, 2008 Toni, In Texas NTG is a basic EMT drug that may be given if the service's medical director approves it. Other drugs that Texas allows EMTs to give under medical director and under standing orders are epi 1:1000 and albuterol by small volume inhaler. Also activated charcoal. GG > > Wes, as a non-paramedic provider.we are only allowed to " assist with the > patient's own nitro " which is nothing more than they would have done > themselves without that same 12-lead EKG. > > Or are you saying that services are allowing a true administration of nitro? > > Toni > > From: texasems-l@yahoogrotexasem [mailto:texasems-l@yahoogrotexasem] On > Behalf Of ExLngHrn@... > Sent: Monday, October 06, 2008 15:06 > To: Paramedicine@ParamedicinePar; e2b@...; > ekg_club@yahoogroupekg_c; texasems-l@yahoogrotexasem; ems-l@... > Subject: NTG vs. 12-lead > > Which should come first -- nitroglycerin or obtaining (and/or interpreting) > a 12-lead EKG??? I'm asking because I've seen some EMS services that allow > non-paramedic providers to administer nitroglycerin prior to a baseline > 12-lead EKG. > > Personally speaking, as a paramedic, I'd like to see a baseline 12-lead so I > can look for ischemia prior to administering a vasodilator, not to mention > ruling out the possibility of a right-sided MI. > > Thoughts anyone? > > -Wes Ogilvie > -Attorney/Licensed Paramedic > -Austin, Texas > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2008 Report Share Posted October 6, 2008 These are two different things entirely. It is irrelevant what the doctor has told the patient to do. You operate under your standard of care and your protocols. When we, as medical professionals, give a drug, we are bound to know everything about it. Remember the 5 R's? Right patient, Right drug, Right Dose, Right Time, Right Route? I would add two more to that. Right REASON and Right Documentation. So what's happening to the patient NOW is what drives your actions, not what was happening when the doctor wrote the prescription. Gene G. > > Just a question about the NTG. What about the doctor than sends the patient > home with a bottle of NTG tells him to take 3 to see if relieves his chest > pain if not call 911? The doctor does not tell him to check his blood > pressure before he takes the pills or between each pill. I know times are > changing, but MONA (Oxygen, Aspirin, Nitro if bp over 100 and Morphine if bp > over 100) and I will state again what about that bottle that was just sent > home with that pt? > > Debbie > > NTG vs. 12-lead > > Which should come first -- nitroglycerin or obtaining (and/or > interpreting) a 12-lead EKG??? I'm asking because I've seen some EMS > services that allow non-paramedic providers to administer nitroglycerin > prior to a baseline 12-lead EKG. > > Personally speaking, as a paramedic, I'd like to see a baseline 12-lead > so I can look for ischemia prior to administering a vasodilator, not to > mention ruling out the possibility of a right-sided MI. > > Thoughts anyone? > > -Wes Ogilvie > -Attorney/Licensed Paramedic > -Austin, Texas > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2008 Report Share Posted October 6, 2008 Which should come first -- nitroglycerin or obtaining (and/or interpreting) a 12-lead EKG??? I'm asking because I've seen some EMS services that allow non-paramedic providers to administer nitroglycerin prior to a baseline 12-lead EKG. Personally speaking, as a paramedic, I'd like to see a baseline 12-lead so I can look for ischemia prior to administering a vasodilator, not to mention ruling out the possibility of a right-sided MI. Thoughts anyone? -Wes Ogilvie -Attorney/Licensed Paramedic -Austin, Texas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2008 Report Share Posted October 6, 2008 Agree. Depending on the delay between arrival of FRO and ALS I would say wait. Sent via BlackBerry by AT & T NTG vs. 12-lead Which should come first -- nitroglycerin or obtaining (and/or interpreting) a 12-lead EKG??? I'm asking because I've seen some EMS services that allow non-paramedic providers to administer nitroglycerin prior to a baseline 12-lead EKG. Personally speaking, as a paramedic, I'd like to see a baseline 12-lead so I can look for ischemia prior to administering a vasodilator, not to mention ruling out the possibility of a right-sided MI. Thoughts anyone? -Wes Ogilvie -Attorney/Licensed Paramedic -Austin, Texas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2008 Report Share Posted October 6, 2008 Wes, as a non-paramedic provider.we are only allowed to " assist with the patient's own nitro " which is nothing more than they would have done themselves without that same 12-lead EKG. Or are you saying that services are allowing a true administration of nitro? Toni From: texasems-l [mailto:texasems-l ] On Behalf Of ExLngHrn@... Sent: Monday, October 06, 2008 15:06 To: Paramedicine ; e2b ; ekg_club ; texasems-l ; ems-l@... Subject: NTG vs. 12-lead Which should come first -- nitroglycerin or obtaining (and/or interpreting) a 12-lead EKG??? I'm asking because I've seen some EMS services that allow non-paramedic providers to administer nitroglycerin prior to a baseline 12-lead EKG. Personally speaking, as a paramedic, I'd like to see a baseline 12-lead so I can look for ischemia prior to administering a vasodilator, not to mention ruling out the possibility of a right-sided MI. Thoughts anyone? -Wes Ogilvie -Attorney/Licensed Paramedic -Austin, Texas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2008 Report Share Posted October 6, 2008 But Wes, as a lawyer, how much trouble would a FR be in if they didn't start treatments (according to their protocol) prior to the arrival of the paramedic? Wouldn't that be akin to waiting to bandage an injury so that the transporting medic can see it prior to treatment? Barry Sharp, MSHP, CHES Program Coordinator Tobacco Prevention & Control Texas Dept. of State Health Services Barry.Sharp@... PLEASE NOTE NEW MAILING ADDRESS: P.O. Box 149347 Mail Code 2018 Austin, Texas 78714-9347 NTG vs. 12-lead Which should come first -- nitroglycerin or obtaining (and/or interpreting) a 12-lead EKG??? I'm asking because I've seen some EMS services that allow non-paramedic providers to administer nitroglycerin prior to a baseline 12-lead EKG. Personally speaking, as a paramedic, I'd like to see a baseline 12-lead so I can look for ischemia prior to administering a vasodilator, not to mention ruling out the possibility of a right-sided MI. Thoughts anyone? -Wes Ogilvie -Attorney/Licensed Paramedic -Austin, Texas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2008 Report Share Posted October 6, 2008 > In my opinion one should never delay treatment in order to obtain > diagnostics. Pain is muscle when discussing the heart and to wait to > administer NTG for chest pain pending ALS arriving and performing an EKG > I think is reckless. Many, myself included, would disagree. I am a huge proponent of pain management. Probably more than most. But for a medical provider to blindly give NTG without a thorough evaluation -- especially if this first responder is only an EMT -- is reckless. And the first time that first responder watches his patient rapidly go from complaining of pain, to hypotensive unconsciousness and aspiration, he'll forever remember why that wasn't such a good idea. > If the patient is truly having an MI NTG won't > resolve the pain and that in itself is diagnostic and indicates the need > for immediate transport. I believe you are putting too much faith in the diagnostic value of NTG. He needs immediate ALS transport, regardless of the outcome of an NTG challenge. There is neither diagnostic nor therapeutic benefit attained through blind nitro administration by non ALS equipped personnel that outweighs the risk. I certainly would not allow it on my licence, were I the medical director. Rob RN/EMT-P (Retired) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2008 Report Share Posted October 6, 2008 Barry: First of all, I'm arguing the protocol a bit.? Of course, I would hesitate to recommend that any level of EMS provider not follow their protocols. The difference in this case would be that the first responder can describe the injury to the transporting paramedic.? Can a FR (without a 12-lead) describe the ischemia/infarct? -Wes Ogilvie NTG vs. 12-lead Which should come first -- nitroglycerin or obtaining (and/or interpreting) a 12-lead EKG??? I'm asking because I've seen some EMS services that allow non-paramedic providers to administer nitroglycerin prior to a baseline 12-lead EKG. Personally speaking, as a paramedic, I'd like to see a baseline 12-lead so I can look for ischemia prior to administering a vasodilator, not to mention ruling out the possibility of a right-sided MI. Thoughts anyone? -Wes Ogilvie -Attorney/Licensed Paramedic -Austin, Texas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2008 Report Share Posted October 6, 2008 True. But I as an FR I would rather explain the situation I found to you as a paramedic in a patient report than to you as a lawyer sitting in front a jury. Unfortunately we sometimes have to practice defensive medicine rather than ideal medicine. That is unless we change the state to an all EMT-P system where everyone is fully trained, fully equipped and fully funded. (Sorry, I was starting an out-of-mind experience...like an EMS Wa-Mu commercial.) Barry Barry Sharp, MSHP, CHES Program Coordinator Tobacco Prevention & Control Texas Dept. of State Health Services Barry.Sharp@... PLEASE NOTE NEW MAILING ADDRESS: P.O. Box 149347 Mail Code 2018 Austin, Texas 78714-9347 ________________________________ From: texasems-l [mailto:texasems-l ] On Behalf Of ExLngHrn@... Sent: Monday, October 06, 2008 4:25 PM To: texasems-l Subject: Re: NTG vs. 12-lead Barry: First of all, I'm arguing the protocol a bit.? Of course, I would hesitate to recommend that any level of EMS provider not follow their protocols. The difference in this case would be that the first responder can describe the injury to the transporting paramedic.? Can a FR (without a 12-lead) describe the ischemia/infarct? -Wes Ogilvie NTG vs. 12-lead Which should come first -- nitroglycerin or obtaining (and/or interpreting) a 12-lead EKG??? I'm asking because I've seen some EMS services that allow non-paramedic providers to administer nitroglycerin prior to a baseline 12-lead EKG. Personally speaking, as a paramedic, I'd like to see a baseline 12-lead so I can look for ischemia prior to administering a vasodilator, not to mention ruling out the possibility of a right-sided MI. Thoughts anyone? -Wes Ogilvie -Attorney/Licensed Paramedic -Austin, Texas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2008 Report Share Posted October 6, 2008 Most services in my area allow Basics(some even allow ECA's) to administer nitro from ambulance stock. Patient states they have chest pain. Check BP if above local protocal minimum, usually 100 systolic, basic places patient on O2, basic reaches into bag gets out aspirin and administers it, then basic pulls out nitro and administers it. Remember in Texas medical director decides what can and can't be done at each level for the most part. > > Wes, as a non-paramedic provider.we are only allowed to " assist with the > patient's own nitro " which is nothing more than they would have done > themselves without that same 12-lead EKG. > > > > Or are you saying that services are allowing a true administration of nitro? > > > > Toni > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2008 Report Share Posted October 6, 2008 Just a question about the NTG. What about the doctor than sends the patient home with a bottle of NTG tells him to take 3 to see if relieves his chest pain if not call 911? The doctor does not tell him to check his blood pressure before he takes the pills or between each pill. I know times are changing, but MONA (Oxygen, Aspirin, Nitro if bp over 100 and Morphine if bp over 100) and I will state again what about that bottle that was just sent home with that pt? Debbie NTG vs. 12-lead Which should come first -- nitroglycerin or obtaining (and/or interpreting) a 12-lead EKG??? I'm asking because I've seen some EMS services that allow non-paramedic providers to administer nitroglycerin prior to a baseline 12-lead EKG. Personally speaking, as a paramedic, I'd like to see a baseline 12-lead so I can look for ischemia prior to administering a vasodilator, not to mention ruling out the possibility of a right-sided MI. Thoughts anyone? -Wes Ogilvie -Attorney/Licensed Paramedic -Austin, Texas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2008 Report Share Posted October 6, 2008 On Monday, October 6, 2008 17:12, " Debbie Fishbeck " said: > Just a question about the NTG. What about the doctor than sends the patient > home with a bottle of NTG tells him to take 3 to see if relieves his chest > pain if not call 911? Well, first of all, I have responded to those people many times and found them critically hypotensive because of it. So the plan is obviously not foolproof. However, before that prescription is made, a thorough medical evaluation has been performed to ensure that it is appropriate for the patient and his condition, as well of an evidence-based determination of risk vs. benefit. When a first responder -- again, especially an EMT-Basic -- encounters the patient, he does not have the benefit of that information. Not to mention that, if the patient hadn't maxed out on NTG, he probably wouldn't have called EMS in the first place. So really, the two scenarios do not make a valid analogy. Rob RN/EMT-P (Retired) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2008 Report Share Posted October 6, 2008 On Monday, October 6, 2008 17:15, " , Rick " said: > So Rob, you are a basic provider, the closest ALS unit is 25 minutes > away and the patient has nitro prescribed by his physician and he asks > you to help him take it, your telling me you would sit on-scene until > ALS arrived and would deny the pain relief that the patient may obtain > from nitro? Completely different scenario from the one being discussed. But I would agree with you. Unless there is evidence that it would be contraindicated, it would be appropriate to " assist " (whatever that means) the patient with his own medication. What is not appropriate is to recommend or prescribe such medication on your own (or according to " protocol " ), which is what I understood Wes to be inquiring about. I've always wondered why this " assist the patient " scenario was so hotly discussed. In my experience, I have just very rarely even seen it occur. Most patients who call 911 have maxed out on NTG before you get there. Those that have not are quite capable of taking it without " assistance " . And those who are not capable of taking it without assistance are usually in an exclusionary category anyhow. Rob RN/EMT-P (Retired) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2008 Report Share Posted October 6, 2008 All my patients called after they had taken maybe 6 or 9 nitros without effect. That was because they carried their nitro pills in a matchbox in the pocket of their overalls or in an aspirin tin in the toolbox of their tractor. I'm surprised at you, , that you didn't mention that. I expect your patients carry theirs in their tackle box down there, don't they? GG > > rob.davis@... wrote: > > " When a first responder -- again, especially an EMT-Basic -- encounters > the patient, he does not have the benefit of that information. Not to > mention that, if the patient hadn't maxed out on NTG, he probably > wouldn't have called EMS in the first place. So really, the two > scenarios do not make a valid analogy. " > > First of all, the original post was about an EMT-B *assisting* with NTG > already prescribed to the patient, which satisfies all those careful > screening criteria by the physician you described. Secondly, I've found > probably as many patients in the field who called 911 after that first > or second Nitro as you have found the profoundly hypotensive ones who > took far too many, so the analogy is valid enough. > > Let me pose this question: Just what is the significance of that 3 Nitro > limit, other than simply a threshold for the *patient* to call 911? Does > it really have any bearing on the actions of EMS providers? After all, > we're dealing with a medication with a 3-5 minute half life here. > > I'm not advocating allowing EMT-Basics to administer Nitro on their own > hook. I'm simply asking, in my reply to Wes' original post, what is so > dangerous about an EMT *assisting* with prescribed Nitro - MI locale be > damned -, provided the patient has an acceptable blood pressure and no > clinical signs of preload dependency, and is it beyond the realm of > possibility that an EMT-B can be taught to assess for those signs? > > So far, no one seems to have answered. > > . > > > > > > -- > Grayson, CCEMT-P > www.kellygrayson. ww > > > ************** New MapQuest Local shows what's happening at your destination. Dining, Movies, Events, News & amp; more. Try it out! (http://local.mapquest.com/?ncid=emlcntnew00000001) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2008 Report Share Posted October 6, 2008 Actually, , it was about EMT-Bs and EMT-Is being allowed to give NTG on their own. Not the patient's prescribed NTG. -Wes In a message dated 10/7/2008 12:03:16 A.M. Central Daylight Time, Grayson902@... writes: _rob.davis@..._ (mailto:rob.davis@...) wrote: " When a first responder -- again, especially an EMT-Basic -- encounters the patient, he does not have the benefit of that information. Not to mention that, if the patient hadn't maxed out on NTG, he probably wouldn't have called EMS in the first place. So really, the two scenarios do not make a valid analogy. " First of all, the original post was about an EMT-B *assisting* with NTG already prescribed to the patient, which satisfies all those careful screening criteria by the physician you described. Secondly, I've found probably as many patients in the field who called 911 after that first or second Nitro as you have found the profoundly hypotensive ones who took far too many, so the analogy is valid enough. Let me pose this question: Just what is the significance of that 3 Nitro limit, other than simply a threshold for the *patient* to call 911? Does it really have any bearing on the actions of EMS providers? After all, we're dealing with a medication with a 3-5 minute half life here. I'm not advocating allowing EMT-Basics to administer Nitro on their own hook. I'm simply asking, in my reply to Wes' original post, what is so dangerous about an EMT *assisting* with prescribed Nitro - MI locale be damned -, provided the patient has an acceptable blood pressure and no clinical signs of preload dependency, and is it beyond the realm of possibility that an EMT-B can be taught to assess for those signs? So far, no one seems to have answered. > . > > -- Grayson, CCEMT-P www.kellygrayson.www Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 6, 2008 Report Share Posted October 6, 2008 rob.davis@... wrote: " When a first responder -- again, especially an EMT-Basic -- encounters the patient, he does not have the benefit of that information. Not to mention that, if the patient hadn't maxed out on NTG, he probably wouldn't have called EMS in the first place. So really, the two scenarios do not make a valid analogy. " First of all, the original post was about an EMT-B *assisting* with NTG already prescribed to the patient, which satisfies all those careful screening criteria by the physician you described. Secondly, I've found probably as many patients in the field who called 911 after that first or second Nitro as you have found the profoundly hypotensive ones who took far too many, so the analogy is valid enough. Let me pose this question: Just what is the significance of that 3 Nitro limit, other than simply a threshold for the *patient* to call 911? Does it really have any bearing on the actions of EMS providers? After all, we're dealing with a medication with a 3-5 minute half life here. I'm not advocating allowing EMT-Basics to administer Nitro on their own hook. I'm simply asking, in my reply to Wes' original post, what is so dangerous about an EMT *assisting* with prescribed Nitro - MI locale be damned -, provided the patient has an acceptable blood pressure and no clinical signs of preload dependency, and is it beyond the realm of possibility that an EMT-B can be taught to assess for those signs? So far, no one seems to have answered. > . > > -- Grayson, CCEMT-P www.kellygrayson.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 7, 2008 Report Share Posted October 7, 2008 On Tuesday, October 7, 2008 00:02, " Grayson " said: > I'm simply asking, in my reply to Wes' original post, what is so > dangerous about an EMT *assisting* with prescribed Nitro - MI locale be > damned -, provided the patient has an acceptable blood pressure and no > clinical signs of preload dependency, and is it beyond the realm of > possibility that an EMT-B can be taught to assess for those signs? Nothing wrong with that. We do that all the time. It takes about two years, and we call it " paramedic school " . Rob RN/EMT-P (Retired) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 7, 2008 Report Share Posted October 7, 2008 Gosh, you went to paramedic school just to learn to take orthostatic vital signs, auscultate lung sounds and look at jugular veins? Guess you got your money's worth and then some, huh? rob.davis@... wrote: > > On Tuesday, October 7, 2008 00:02, " Grayson " <Grayson902@... > <mailto:Grayson902%40aol.com>> said: > > > I'm simply asking, in my reply to Wes' original post, what is so > > dangerous about an EMT *assisting* with prescribed Nitro - MI locale be > > damned -, provided the patient has an acceptable blood pressure and no > > clinical signs of preload dependency, and is it beyond the realm of > > possibility that an EMT-B can be taught to assess for those signs? > > Nothing wrong with that. We do that all the time. It takes about two > years, and we call it " paramedic school " . > > Rob > RN/EMT-P (Retired) > > -- Grayson, CCEMT-P www.kellygrayson.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 7, 2008 Report Share Posted October 7, 2008 On Tuesday, October 7, 2008 17:12, " Grayson " said: > Gosh, you went to paramedic school just to learn to take orthostatic > vital signs, auscultate lung sounds and look at jugular veins? Gosh, you went to a CCEMTP course and didn't learn that there is more to competent cardiac assessment than that? So they do your incomplete assessment, administer nitro, and the patient bottoms out. Now what? Just wait for ALS while the patient crashes? And how easy is it going to be for ALS to get a line on this patient now? It's hard enough to justify the inability to help someone because of limited resources. It is impossible to justify the inability to help someone when we are the cause of their crisis. Rob RN/EMT-P (Retired) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 7, 2008 Report Share Posted October 7, 2008 Okay, Rob. Favor us with what a *complete* assessment is. Let's pretend you've got your RVI patient there, and are prepared to bring the full weight of your prodigious ALS mojo to bear upon the problem. There's your guy; a little bradycardic at 52, BP is oh, say 118/64 or so, he's complaining of epigastric pain, he's pale, he's diaphoretic. He's infarcting his proximal RCA in a big way. He's a sick dude. And the Basic EMTs have been anxiously awaiting your arrival, the ALS pro from Dover, to work more magic than oxygen and and reassurance can provide. They have a full bottle of the patient's NTG at the ready - as yet unused of course, because they fear the RVI Boogeyman, and they could have given ASA, but doggone it, he's an asthmatic and they're just not sure if he's got nasal polyps or not, and they're too dumb to know the significance of that anyway - so they've just spent the last twenty minutes twiddling their thumbs waiting for your okay to assist the patient with a dose or three of NTG. So you arrive, peer into the depths of your Marquette interpretation algorithm, and say, " He doth exhibit ST segment elevation in Leads II, II and AVR. Verily, he suffers from an inferior wall infarction! Perchance doth he suffer from right ventricular infarction as well? Mayhap Lead V4R shall tell the tale! " And verily it does. He does indeed have some platelets aggregating in a most unfortunate spot, and his right ventricle is probably in the shitter. And you ponder the question, " Lo, shall I render unto him the Nitro? Will his blood pressure crumpeth, or will he remain stalwart against the insidious drop in right ventricular filling pressure? However shall I feel comfortable taking the chance? " So tell us what your *complete* assessment will be, and why it is inconceivable that these two EMT-Basics cannot perform the same - without the two year requirement to become one of the anointed ALS Ones. rob.davis@... wrote: > > On Tuesday, October 7, 2008 17:12, " Grayson " <Grayson902@... > <mailto:Grayson902%40aol.com>> said: > > > Gosh, you went to paramedic school just to learn to take orthostatic > > vital signs, auscultate lung sounds and look at jugular veins? > > Gosh, you went to a CCEMTP course and didn't learn that there is more > to competent cardiac assessment than that? > > So they do your incomplete assessment, administer nitro, and the > patient bottoms out. Now what? Just wait for ALS while the patient > crashes? And how easy is it going to be for ALS to get a line on this > patient now? It's hard enough to justify the inability to help someone > because of limited resources. It is impossible to justify the > inability to help someone when we are the cause of their crisis. > > Rob > RN/EMT-P (Retired) > > -- Grayson, CCEMT-P www.kellygrayson.com Quote Link to comment Share on other sites More sharing options...
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