Legal analysis of NTG vs. 12-lead

[Guest guest]

We've been juggling apples, oranges, grapefruit, and tomatoes here.

Let's try to sort this out from a legal point of view.

First, the first rule of practice is to do that which a reasonable and

prudent [choose one (FR)(EMT)(EMT-I)(Paramedic)(nurse)(physician)] with the same

level of education, training, and experience, would do in the same or similar

circumstances.

And keep in mind that the critical point may not be what you KNOW but what a

reasonable and prudent medic OUGHT TO KNOW.

So, what is reasonable and prudent for a FR to do with NTG? Depends on

several things.

First, let's take the situation where the patient has a prescription for NTG

and has some with her. Can the FR assist her in taking it? In that case the

FR becomes the patient's surrogate and is really operating under the

patient's prescription. However, the FR does not stand in parity with the

patient

most of the time, since the FR has greater medical knowledge than the patient,

and what is

reasonable and prudent for a medically trained person is different from that

of a layperson. So, the FR must first assess the patient to the extent of

his capability, education, training, experience, and protocols, and then

determine whether or not to give the NTG. If the patient croaks, the FR will

be

held only to the standard of care applicable to him.

So all the stuff about waiting on the ALS folks is beside the point. Each

level practices at his own standard of care. It might be reasonable and

prudent for an EMT to give the NTG based upon his assessment, but not for the

Paramedic. The EMT is not held to the standard of the Paramedic unless he has

advanced training and education, special permission from medical control, and so

forth. This will be highly dependent on state rules and regulations.

Now, let's take the Paramedic. The Paramedic operates at a higher standard

of care than the EMT. Therefore, what is reasonable and prudent for the

Paramedic may be far different from what is reasonable and prudent for the EMT.

Paramedics should know about coronary artery occlusions and how to spot them

on a 12-lead. Paramedics should know that NTG has a cautionary use in

patients with right ventricular infarcts. Therefore, it is reasonable and

prudent

that the Paramedic obtain a 12-lead if possible before administering a

vasodilator. Further, the Paramedic should know that oxygen administration and

NTG

administration can alter the EKG findings in certain cases; therefore, it is

reasonable and prudent to obtain a 12-lead prior to administering NTG if

possible.

There are always exceptions to every rule, and circumstances alter cases.

Every case turns upon its own facts. The practitioner is stuck with the facts,

no matter what they are. This is where assessment skills, critical

thinking, and judgment come into play. An EMT is not expected to exercise the

same

level of assessment skills as a Paramedic, although he may be quite capable of

thinking critically and using judgment up to his education and training level.

The Paramedic is not expected to exercise all the same skills as a

physician, although in some matters they may be equal.

So, it may be reasonable and prudent for an EMT to assist the patient in

taking her NTG so long as an adequate assessment, performed at the EMT's level

of

education, training, and experience, shows no contraindication. It might NOT

be reasonable for the Paramedic to administer NTG to the same patient

depending upon what the assessment findings are. Remember, if you have

assessment

toys, it's best to use them. Therefore, decline to use the EKG monitor at

your peril. The jury will not understand why you didn't use the expensive toy

you were provided if they are convinced you should have.

The lawyer will ask a paramedic whether or not he did a 12-lead and started

an IV prior to giving the NTG. Yes or no. That's all that need be asked.

Then, if the patient crashed, the plaintiff's expert will testify that the

paramedic should have done a 12-lead and started an IV prior to giving the NTG

and explaining all the reasons why. The expert will explain that the 12-lead

would have revealed the condition that contraindicated NTG, and that had an

IV been started, the hypotension could have been corrected, or prevented by a

bolus prior to NTG administration, et cetera.

The average medic will be unable, generally, to defend this, since most will

lack the sophistication of the expert witness, the ability to " teach the jury "

and deal with the nuances. [Of course this does not apply to any member of

this list, each of whom would certainly blow the plaintiff's expert out of the

water and leave them in tears. LOL]

So, when considering what to do, what not to do, and when to do it, ask

yourself, is it reasonable and prudent for me as a (your level of practitioner)

to

do this? That's the question you will have to answer if things go South.

Gene Gandy, JD, LP

**************

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[Guest guest]

Gene,

Although Wes didn't bring it up, we can't get away from it...it is the

proverbial Pineapple.

What does the protocols you are working under say?? To me the answer to Wes's

question is what does the EMS System the FRO is working under (or basic

transport provider) instruct them to do through protocol?? This is the answer

and if the protocol doesn't make sense, then we need to work to update the

protocol based upon the current practice and science so that it reflects the

most prudent way to perform based upon the expectations of the community.

In our system, we have 8 different first responder agencies.? All of them work

under our protocols and we have addressed this in a number of ways based upon

the agency that is on-scene.? We have a number of FRO's that are equipped in a

variety of ways...so our EMT-Basic protocol first of all asks our EMT-Basics to

perform a 12-lead prior to administering NTG if they have a device on scene that

can do it.? This allows us to have a pre-treatment 12-lead, even if we have no

advanced providers on scene.? Also,?if it says " ***ACUTE MI SUSPECTED*** "

they?can also?notify the receiving facility sooner to shorten our E2B.

Either way, our EMT-Basics give NTG based upon the guidelines in our

protocols...and those are built in an attempt to provide a system of care that

starts with the 911 call and carries through to the ED (hopefully).

Dudley

Legal analysis of NTG vs. 12-lead

We've been juggling apples, oranges, grapefruit, and tomatoes here.

Let's try to sort this out from a legal point of view.

First, the first rule of practice is to do that which a reasonable and

prudent [choose one (FR)(EMT)(EMT-I)(Paramedic)(nurse)(physician)] with the same

level of education, training, and experience, would do in the same or similar

circumstances.

And keep in mind that the critical point may not be what you KNOW but what a

reasonable and prudent medic OUGHT TO KNOW.

So, what is reasonable and prudent for a FR to do with NTG? Depends on

several things.

First, let's take the situation where the patient has a prescription for NTG

and has some with her. Can the FR assist her in taking it? In that case the

FR becomes the patient's surrogate and is really operating under the

patient's prescription. However, the FR does not stand in parity with the

patient

most of the time, since the FR has greater medical knowledge than the patient,

and what is

reasonable and prudent for a medically trained person is different from that

of a layperson. So, the FR must first assess the patient to the extent of

his capability, education, training, experience, and protocols, and then

determine whether or not to give the NTG. If the patient croaks, the FR will be

held only to the standard of care applicable to him.

So all the stuff about waiting on the ALS folks is beside the point. Each

level practices at his own standard of care. It might be reasonable and

prudent for an EMT to give the NTG based upon his assessment, but not for the

Paramedic. The EMT is not held to the standard of the Paramedic unless he has

advanced training and education, special permission from medical control, and so

forth. This will be highly dependent on state rules and regulations.

Now, let's take the Paramedic. The Paramedic operates at a higher standard

of care than the EMT. Therefore, what is reasonable and prudent for the

Paramedic may be far different from what is reasonable and prudent for the EMT.

Paramedics should know about coronary artery occlusions and how to spot them

on a 12-lead. Paramedics should know that NTG has a cautionary use in

patients with right ventricular infarcts. Therefore, it is reasonable and

prudent

that the Paramedic obtain a 12-lead if possible before administering a

vasodilator. Further, the Paramedic should know that oxygen administration and

NTG

administration can alter the EKG findings in certain cases; therefore, it is

reasonable and prudent to obtain a 12-lead prior to administering NTG if

possible.

There are always exceptions to every rule, and circumstances alter cases.

Every case turns upon its own facts. The practitioner is stuck with the facts,

no matter what they are. This is where assessment skills, critical

thinking, and judgment come into play. An EMT is not expected to exercise the

same

level of assessment skills as a Paramedic, although he may be quite capable of

thinking critically and using judgment up to his education and training level.

The Paramedic is not expected to exercise all the same skills as a

physician, although in some matters they may be equal.

So, it may be reasonable and prudent for an EMT to assist the patient in

taking her NTG so long as an adequate assessment, performed at the EMT's level

of

education, training, and experience, shows no contraindication. It might NOT

be reasonable for the Paramedic to administer NTG to the same patient

depending upon what the assessment findings are. Remember, if you have

assessment

toys, it's best to use them. Therefore, decline to use the EKG monitor at

your peril. The jury will not understand why you didn't use the expensive toy

you were provided if they are convinced you should have.

The lawyer will ask a paramedic whether or not he did a 12-lead and started

an IV prior to giving the NTG. Yes or no. That's all that need be asked.

Then, if the patient crashed, the plaintiff's expert will testify that the

paramedic should have done a 12-lead and started an IV prior to giving the NTG

and explaining all the reasons why. The expert will explain that the 12-lead

would have revealed the condition that contraindicated NTG, and that had an

IV been started, the hypotension could have been corrected, or prevented by a

bolus prior to NTG administration, et cetera.

The average medic will be unable, generally, to defend this, since most will

lack the sophistication of the expert witness, the ability to " teach the jury "

and deal with the nuances. [Of course this does not apply to any member of

this list, each of whom would certainly blow the plaintiff's expert out of the

water and leave them in tears. LOL]

So, when considering what to do, what not to do, and when to do it, ask

yourself, is it reasonable and prudent for me as a (your level of practitioner)

to

do this? That's the question you will have to answer if things go South.

Gene Gandy, JD, LP

**************

New MapQuest Local shows what's happening at

your destination. Dining, Movies, Events, News & amp; more. Try it out!

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