RE: D-Sticks As A Baseline Vital Sign

[Guest guest]

Actually, meant solely as a commentary on the urban legends of EMS.

My preference is to do a glucose check on any patient whose condition requires a

rule-out of a diabetic abnormality as part of reaching my field differential

diagnosis.

Wes

Sent from my iPad

> Touché, well played. Match point Alyssa.

>

> Sent from my iPhone,

> McGee, EMT-P, EMT-T

>

>

>

> Ah, the personal attack and mockery which indicates complete lack of an

> argument, or otherwise lack of the ability to hold a civilized discussion

> with intelligent points on the topic.

>

> But no, really - *I'm* the immature and inexperienced person here.

>

> Alyssa Woods, NREMT-B

> CPR Instructor

>

>

>

>

> But Rick, my partner's ex-cousin's brother-in-law's preceptor had a patient

> once broke both of his legs and they did a blood glucose and it was

> high..... so they backboarded him then flew him to a big hospital in the

> helicopter and everyone was so upset that they had to have a debriefing.

>

> Wes

>

> Sent from my iPad

>

> On Sep 1, 2010, at 7:59,

rick.moore@...wrote:

>

> You are comparing apples to oranges. I agree that a BG is needed on the

> patients with those complaints and in the ED most will get at least a basic

> metabolic panel which would include the glucose. My point is that an EMS

> crew using a home BGL monitor under less than ideal conditions is not a

> diagnostic test. Even in an ED where the staff listens very well to the EMS

> report they will still run baseline chemistries to confirm or deny any of

> these readings. To me a protocol to perform a finger stick BG on every

> patient falls under the " because we can " category. In reality taking

> baseline vital signs on every patient falls under the " because we have

> always done it that way " doctrine, however JC and the legal community have

> established this as a standard of care and they are not invasive. A triage

> set and then a discharge set at a minimum has been established as the way to

> indicate the patient " improved " or at least didn't deteriorate under your

> care. The home safety type questions are mandated by JC and CMS. I don't

> know of any regulatory or accreditation agency that mandates random blood

> glucose testing.

> I am not opposed to finger stick BGL's when the presentation indicates,

> but to perform it on a stumped toe or sore throat because it is protocol is

> inappropriate in my opinion.

>

> From: texasems-l [mailto:

> texasems-l ] On Behalf Of

> krin135@...

> Sent: Tuesday, August 31, 2010 8:25 PM

> To: texasems-l

> Subject: Re: D-Sticks As A Baseline Vital Sign

>

> In a message dated 08/31/10 20:10:46 Central Daylight Time,

> rick.moore@...

rick.moore%40stdavids.com > writes:

>

> Using your logic every time someone seeks medical care the care provider

> should run every diagnostic test available just in case they have some

> process that may or may not be related to the chief complaint. That

> should

> reduce the cost of health care nicely.

> You should treat the patient based on recognized standard of care as

> dictated by the chief complaint. And say you do find a normally

> responding

> patient with a BGL of 500. What are you going to do about it Alyssa? It's

> not

> your job to diagnose the worlds ills. Even Internal Medicine docs don't

> run

> every test every time.

>

> Rick

>

> that being said, I could justify at least a finger stick BG on any

> patient

> I saw in the ED based on any complaints of weakness (global or specific),

> mental status change from slurred speech to loss of consciousness, loss

> of

> energy, depression, anxiety, fall, blurred vision, headache, nausea.....

>

> So how many patients do you think that I saw didn't need a BG?

>

> you check blood pressure, pulse and respirations on every patient, even

> if

> they don't have a history of hypertension, irregular heart beat or lung

> problems...

>

> the triage nurses ask about safety at home (including questions designed

> to

> identify abuse)...won't that also increase the cost of health care by

> identifying people who need social service intervention?

>

> There are good arguments about using a blood glucose as a screening tool

> to

> identify folks who need further evaluation for diabetes....in order to

> catch them earlier, before significant end organ damage is done, which

> *will*

> ultimately reduce the cost of health care in most of those folks.

>

> I'd have to see a better argument than the one you have advanced, Mr.

>

> before I condemned Ms. Woods' idea.

>

> I will admit that I was a bit unusual, being a physician who 'came up

> through the ranks' and actually tended to listen to the reports of the

> Basics

> and Medics (many of whom I helped train in my early career) that I worked

> with.

>

> That being said, even someone who 'felt normal' but had a field BG of 500

> would deserve at least a referral for follow up after evaluation in the

> ED....and even someone who 'feels normal,' but has a BG that high should

> be

> considered for transport.

>

> ck

>

>

[Guest guest]

Alyssa responded to the list not to Wes personally so I believe that makes her

comments fair game for anyone to comment on. Perhaps my response was more over

the top than yours but I was saying the same thing that you said. I do know Wes

well and consider him a friend and tend to stick up for him (as he does for me).

I for one would love to see the results of Alyssa's research project and would

certainly entertain a change in my personal practice if so indicated by the

studies.

Rick

From: texasems-l [mailto:texasems-l ] On Behalf

Of krin135@...

Sent: Wednesday, September 01, 2010 9:01 AM

To: texasems-l

Subject: Re: D-Sticks As A Baseline Vital Sign

Time out!

Alyssa: I think that Wes' finger was firmly in his cheek when he wrote

that.

Rick: Since Alyssa seems to have been responding to Wes, and not you, your

response is a bit beyond measured, ESPECIALLY since Alyssa has proposed a

research project evaluating the use of the FSBG as a reasonable additional

'vital sign' in a population suspected of a significant underdiagnosis of

diabetes. She's trying to replace 'best opinions' and 'dogma' with

research/science.

and anyone who knows Wes (and his apprenticeship with Mr. Grady) would

expect something like his response.

ck

In a message dated 09/01/10 08:40:58 Central Daylight Time,

rick.moore@... writes:

" But no, really - *I'm* the immature and inexperienced person here. "

If you are considering this a personal attack on you and not an attack on

the fact that we in EMS depend more on dogma than science then I would

agree with the sentence above.

Rick

Re: D-Sticks As A Baseline Vital Sign

> >

> > In a message dated 08/31/10 20:10:46 Central Daylight Time,

> > rick.moore@...

rick.moore%40stdavids.com > writes:

> >

> > Using your logic every time someone seeks medical care the care

provider

> > should run every diagnostic test available just in case they have some

> > process that may or may not be related to the chief complaint. That

> should

> > reduce the cost of health care nicely.

> > You should treat the patient based on recognized standard of care as

> > dictated by the chief complaint. And say you do find a normally

> responding

> > patient with a BGL of 500. What are you going to do about it Alyssa?

It's

> not

> > your job to diagnose the worlds ills. Even Internal Medicine docs don't

> run

> > every test every time.

> >

> > Rick

> >

> > that being said, I could justify at least a finger stick BG on any

> patient

> > I saw in the ED based on any complaints of weakness (global or

specific),

> > mental status change from slurred speech to loss of consciousness, loss

> of

> > energy, depression, anxiety, fall, blurred vision, headache,

nausea.....

> >

> > So how many patients do you think that I saw didn't need a BG?

> >

> > you check blood pressure, pulse and respirations on every patient, even

> if

> > they don't have a history of hypertension, irregular heart beat or lung

> > problems...

> >

> > the triage nurses ask about safety at home (including questions

designed

> to

> > identify abuse)...won't that also increase the cost of health care by

> > identifying people who need social service intervention?

> >

> > There are good arguments about using a blood glucose as a screening

tool

> to

> > identify folks who need further evaluation for diabetes....in order to

> > catch them earlier, before significant end organ damage is done, which

> *will*

> > ultimately reduce the cost of health care in most of those folks.

> >

> > I'd have to see a better argument than the one you have advanced, Mr.

>

> > before I condemned Ms. Woods' idea.

> >

> > I will admit that I was a bit unusual, being a physician who 'came up

> > through the ranks' and actually tended to listen to the reports of the

> Basics

> > and Medics (many of whom I helped train in my early career) that I

worked

> > with.

> >

> > That being said, even someone who 'felt normal' but had a field BG of

500

> > would deserve at least a referral for follow up after evaluation in the

> > ED....and even someone who 'feels normal,' but has a BG that high

should

> be

> > considered for transport.

> >

> > ck

> >

> >

[Guest guest]

Alyssa responded to the list not to Wes personally so I believe that makes her

comments fair game for anyone to comment on. Perhaps my response was more over

the top than yours but I was saying the same thing that you said. I do know Wes

well and consider him a friend and tend to stick up for him (as he does for me).

I for one would love to see the results of Alyssa's research project and would

certainly entertain a change in my personal practice if so indicated by the

studies.

Rick

From: texasems-l [mailto:texasems-l ] On Behalf

Of krin135@...

Sent: Wednesday, September 01, 2010 9:01 AM

To: texasems-l

Subject: Re: D-Sticks As A Baseline Vital Sign

Time out!

Alyssa: I think that Wes' finger was firmly in his cheek when he wrote

that.

Rick: Since Alyssa seems to have been responding to Wes, and not you, your

response is a bit beyond measured, ESPECIALLY since Alyssa has proposed a

research project evaluating the use of the FSBG as a reasonable additional

'vital sign' in a population suspected of a significant underdiagnosis of

diabetes. She's trying to replace 'best opinions' and 'dogma' with

research/science.

and anyone who knows Wes (and his apprenticeship with Mr. Grady) would

expect something like his response.

ck

In a message dated 09/01/10 08:40:58 Central Daylight Time,

rick.moore@... writes:

" But no, really - *I'm* the immature and inexperienced person here. "

If you are considering this a personal attack on you and not an attack on

the fact that we in EMS depend more on dogma than science then I would

agree with the sentence above.

Rick

Re: D-Sticks As A Baseline Vital Sign

> >

> > In a message dated 08/31/10 20:10:46 Central Daylight Time,

> > rick.moore@...

rick.moore%40stdavids.com > writes:

> >

> > Using your logic every time someone seeks medical care the care

provider

> > should run every diagnostic test available just in case they have some

> > process that may or may not be related to the chief complaint. That

> should

> > reduce the cost of health care nicely.

> > You should treat the patient based on recognized standard of care as

> > dictated by the chief complaint. And say you do find a normally

> responding

> > patient with a BGL of 500. What are you going to do about it Alyssa?

It's

> not

> > your job to diagnose the worlds ills. Even Internal Medicine docs don't

> run

> > every test every time.

> >

> > Rick

> >

> > that being said, I could justify at least a finger stick BG on any

> patient

> > I saw in the ED based on any complaints of weakness (global or

specific),

> > mental status change from slurred speech to loss of consciousness, loss

> of

> > energy, depression, anxiety, fall, blurred vision, headache,

nausea.....

> >

> > So how many patients do you think that I saw didn't need a BG?

> >

> > you check blood pressure, pulse and respirations on every patient, even

> if

> > they don't have a history of hypertension, irregular heart beat or lung

> > problems...

> >

> > the triage nurses ask about safety at home (including questions

designed

> to

> > identify abuse)...won't that also increase the cost of health care by

> > identifying people who need social service intervention?

> >

> > There are good arguments about using a blood glucose as a screening

tool

> to

> > identify folks who need further evaluation for diabetes....in order to

> > catch them earlier, before significant end organ damage is done, which

> *will*

> > ultimately reduce the cost of health care in most of those folks.

> >

> > I'd have to see a better argument than the one you have advanced, Mr.

>

> > before I condemned Ms. Woods' idea.

> >

> > I will admit that I was a bit unusual, being a physician who 'came up

> > through the ranks' and actually tended to listen to the reports of the

> Basics

> > and Medics (many of whom I helped train in my early career) that I

worked

> > with.

> >

> > That being said, even someone who 'felt normal' but had a field BG of

500

> > would deserve at least a referral for follow up after evaluation in the

> > ED....and even someone who 'feels normal,' but has a BG that high

should

> be

> > considered for transport.

> >

> > ck

> >

> >

[Guest guest]

I wasn't going to comment on this topic, because I think it's more a matter of

opinions rather then actually affecting patient care, but since it's already a

discussion ...

I think a much more useful thing to do prehospitally is draw a full rainbow of

blood when you start the IV. That gives a lot more data then just a single blood

stick, potentially saves the patient some pain later on, and may speed up their

hospital process significantly. Of course, this is dependent on the ED accepting

your tubes, which many don't (stupidly.)

For the " average " paramedic system in the U.S. (outside of those with truly

extended transport times) I don't see the benefit in doing routine fingersticks.

If you have an indication, by all means. I regularly do them by venous blood but

fortunately I'm using a glucometer that is calibrating correctly for venous

blood (as I hadn't even considered the reading may be wrong otherwise.) Of

course, if the causation of the incorrect reading is due to the tourniquet, I

would imagine it would still give an incorrect reading regardless of the unit

used.

Austin

> While I don't recall it ever being mandated by protocol, it has always been my

practice to do a D-stick on every patient unless emergency interventions and

time prevented it. I recognize that sometimes your hands are so full just

keeping the patient alive with airway and other mandatory interventions that you

don't have enough hands to do it. But even in codes, I have always tried to do

it if there is enough personpower. We don't hear much about hypoglycemia's role

in cardiac arrest, but I have had some patients who arrested and were seriously

hypoglycemic. Also hyperglycemic.

[Guest guest]

I wasn't going to comment on this topic, because I think it's more a matter of

opinions rather then actually affecting patient care, but since it's already a

discussion ...

I think a much more useful thing to do prehospitally is draw a full rainbow of

blood when you start the IV. That gives a lot more data then just a single blood

stick, potentially saves the patient some pain later on, and may speed up their

hospital process significantly. Of course, this is dependent on the ED accepting

your tubes, which many don't (stupidly.)

For the " average " paramedic system in the U.S. (outside of those with truly

extended transport times) I don't see the benefit in doing routine fingersticks.

If you have an indication, by all means. I regularly do them by venous blood but

fortunately I'm using a glucometer that is calibrating correctly for venous

blood (as I hadn't even considered the reading may be wrong otherwise.) Of

course, if the causation of the incorrect reading is due to the tourniquet, I

would imagine it would still give an incorrect reading regardless of the unit

used.

Austin

> While I don't recall it ever being mandated by protocol, it has always been my

practice to do a D-stick on every patient unless emergency interventions and

time prevented it. I recognize that sometimes your hands are so full just

keeping the patient alive with airway and other mandatory interventions that you

don't have enough hands to do it. But even in codes, I have always tried to do

it if there is enough personpower. We don't hear much about hypoglycemia's role

in cardiac arrest, but I have had some patients who arrested and were seriously

hypoglycemic. Also hyperglycemic.

[Guest guest]

Quick question -- do any of the hospitals you transport to routinely accept

blood draws done in the prehospital setting?

Wes Ogilvie

Sent from my iPad

On Sep 1, 2010, at 9:49, " B. Austin " abaustin+yahoogroups@...>

wrote:

>

> I wasn't going to comment on this topic, because I think it's more a matter of

opinions rather then actually affecting patient care, but since it's already a

discussion ...

>

> I think a much more useful thing to do prehospitally is draw a full rainbow of

blood when you start the IV. That gives a lot more data then just a single blood

stick, potentially saves the patient some pain later on, and may speed up their

hospital process significantly. Of course, this is dependent on the ED accepting

your tubes, which many don't (stupidly.)

>

> For the " average " paramedic system in the U.S. (outside of those with truly

extended transport times) I don't see the benefit in doing routine fingersticks.

If you have an indication, by all means. I regularly do them by venous blood but

fortunately I'm using a glucometer that is calibrating correctly for venous

blood (as I hadn't even considered the reading may be wrong otherwise.) Of

course, if the causation of the incorrect reading is due to the tourniquet, I

would imagine it would still give an incorrect reading regardless of the unit

used.

>

> Austin

>

>

>

> > While I don't recall it ever being mandated by protocol, it has always been

my practice to do a D-stick on every patient unless emergency interventions and

time prevented it. I recognize that sometimes your hands are so full just

keeping the patient alive with airway and other mandatory interventions that you

don't have enough hands to do it. But even in codes, I have always tried to do

it if there is enough personpower. We don't hear much about hypoglycemia's role

in cardiac arrest, but I have had some patients who arrested and were seriously

hypoglycemic. Also hyperglycemic.

>

>

[Guest guest]

most will not take our blood draws. Because they want to draw the blood them

self for bill and to make sure it do right.

Sent from my Verizon Wireless BlackBerry

Re: D-Sticks As A Baseline Vital Sign

Quick question -- do any of the hospitals you transport to routinely accept

blood draws done in the prehospital setting?

Wes Ogilvie

Sent from my iPad

On Sep 1, 2010, at 9:49, " B. Austin " abaustin+yahoogroups@...>

wrote:

>

> I wasn't going to comment on this topic, because I think it's more a matter of

opinions rather then actually affecting patient care, but since it's already a

discussion ...

>

> I think a much more useful thing to do prehospitally is draw a full rainbow of

blood when you start the IV. That gives a lot more data then just a single blood

stick, potentially saves the patient some pain later on, and may speed up their

hospital process significantly. Of course, this is dependent on the ED accepting

your tubes, which many don't (stupidly.)

>

> For the " average " paramedic system in the U.S. (outside of those with truly

extended transport times) I don't see the benefit in doing routine fingersticks.

If you have an indication, by all means. I regularly do them by venous blood but

fortunately I'm using a glucometer that is calibrating correctly for venous

blood (as I hadn't even considered the reading may be wrong otherwise.) Of

course, if the causation of the incorrect reading is due to the tourniquet, I

would imagine it would still give an incorrect reading regardless of the unit

used.

>

> Austin

>

>

>

> > While I don't recall it ever being mandated by protocol, it has always been

my practice to do a D-stick on every patient unless emergency interventions and

time prevented it. I recognize that sometimes your hands are so full just

keeping the patient alive with airway and other mandatory interventions that you

don't have enough hands to do it. But even in codes, I have always tried to do

it if there is enough personpower. We don't hear much about hypoglycemia's role

in cardiac arrest, but I have had some patients who arrested and were seriously

hypoglycemic. Also hyperglycemic.

>

>

[Guest guest]

most will not take our blood draws. Because they want to draw the blood them

self for bill and to make sure it do right.

Sent from my Verizon Wireless BlackBerry

Re: D-Sticks As A Baseline Vital Sign

Quick question -- do any of the hospitals you transport to routinely accept

blood draws done in the prehospital setting?

Wes Ogilvie

Sent from my iPad

On Sep 1, 2010, at 9:49, " B. Austin " abaustin+yahoogroups@...>

wrote:

>

> I wasn't going to comment on this topic, because I think it's more a matter of

opinions rather then actually affecting patient care, but since it's already a

discussion ...

>

> I think a much more useful thing to do prehospitally is draw a full rainbow of

blood when you start the IV. That gives a lot more data then just a single blood

stick, potentially saves the patient some pain later on, and may speed up their

hospital process significantly. Of course, this is dependent on the ED accepting

your tubes, which many don't (stupidly.)

>

> For the " average " paramedic system in the U.S. (outside of those with truly

extended transport times) I don't see the benefit in doing routine fingersticks.

If you have an indication, by all means. I regularly do them by venous blood but

fortunately I'm using a glucometer that is calibrating correctly for venous

blood (as I hadn't even considered the reading may be wrong otherwise.) Of

course, if the causation of the incorrect reading is due to the tourniquet, I

would imagine it would still give an incorrect reading regardless of the unit

used.

>

> Austin

>

>

>

> > While I don't recall it ever being mandated by protocol, it has always been

my practice to do a D-stick on every patient unless emergency interventions and

time prevented it. I recognize that sometimes your hands are so full just

keeping the patient alive with airway and other mandatory interventions that you

don't have enough hands to do it. But even in codes, I have always tried to do

it if there is enough personpower. We don't hear much about hypoglycemia's role

in cardiac arrest, but I have had some patients who arrested and were seriously

hypoglycemic. Also hyperglycemic.

>

>

[Guest guest]

The typical reason given for not accepting EMS blood tubes is that they are

hemolyzed and require a redraw. JEMS published a study a few months back that

indicates that hospital drawn samples are found hemolyzed more often than EMS

samples. The most common issue I find with EMS drawn samples is related to

identification of the samples. Most facilities require the sample (each tube) be

labeled with patient name, dob and the date time and initials of the person

drawing. EMS seems to like to draw the tubes and place them in a ziplock bag and

label the bag with the patient's name or pull the tubes from a shirt pocket and

indicate they belong to the patient they are delivering.

Rick

From: texasems-l [mailto:texasems-l ] On Behalf

Of mark_opian@...

Sent: Wednesday, September 01, 2010 9:57 AM

To: texasems-l

Subject: Re: D-Sticks As A Baseline Vital Sign

most will not take our blood draws. Because they want to draw the blood them

self for bill and to make sure it do right.

Sent from my Verizon Wireless BlackBerry

Re: D-Sticks As A Baseline Vital Sign

Quick question -- do any of the hospitals you transport to routinely accept

blood draws done in the prehospital setting?

Wes Ogilvie

Sent from my iPad

On Sep 1, 2010, at 9:49, " B. Austin "

abaustin+yahoogroups@...>

wrote:

>

> I wasn't going to comment on this topic, because I think it's more a matter of

opinions rather then actually affecting patient care, but since it's already a

discussion ...

>

> I think a much more useful thing to do prehospitally is draw a full rainbow of

blood when you start the IV. That gives a lot more data then just a single blood

stick, potentially saves the patient some pain later on, and may speed up their

hospital process significantly. Of course, this is dependent on the ED accepting

your tubes, which many don't (stupidly.)

>

> For the " average " paramedic system in the U.S. (outside of those with truly

extended transport times) I don't see the benefit in doing routine fingersticks.

If you have an indication, by all means. I regularly do them by venous blood but

fortunately I'm using a glucometer that is calibrating correctly for venous

blood (as I hadn't even considered the reading may be wrong otherwise.) Of

course, if the causation of the incorrect reading is due to the tourniquet, I

would imagine it would still give an incorrect reading regardless of the unit

used.

>

> Austin

>

> On Aug 31, 2010, at 12:55 AM,

wegandy1938@... wrote:

>

> > While I don't recall it ever being mandated by protocol, it has always been

my practice to do a D-stick on every patient unless emergency interventions and

time prevented it. I recognize that sometimes your hands are so full just

keeping the patient alive with airway and other mandatory interventions that you

don't have enough hands to do it. But even in codes, I have always tried to do

it if there is enough personpower. We don't hear much about hypoglycemia's role

in cardiac arrest, but I have had some patients who arrested and were seriously

hypoglycemic. Also hyperglycemic.

>

>

[Guest guest]

When I was working prehospital in Pennsylvania, I only had one incident where a

hospital refused my blood draw, and that was more related to personality (they

wanted me to individually label each tube and I--being a stupid young brash

paramedic--refused and tossed them in the trash.) Every other hospital (from

podunk to two Level I trauma centers) happily accepted my draws. Some of them

might have later round filed them, but the two hospitals I transported to most

frequently did send them to the lab.

Now, I'm an ER nurse. Noone brings in blood tubes at either hospital I've worked

at. I have suggested to the local paramedics that they take our tubes and draw

blood, and would have gladly sent them to the lab. Whether that is " in policy "

for the hospital or not, I don't know.

I've never heard a reasonably valid reason for not accepting blood from

prehospital providers. They may exist, but most have been related to technique

of draws, but anyone who has worked both prehospitally and in the emergency room

knows the 10% isn't confined to one practice area.

Austin

> Quick question -- do any of the hospitals you transport to routinely accept

blood draws done in the prehospital setting?

>

> Wes Ogilvie

>

> Sent from my iPad

>

> On Sep 1, 2010, at 9:49, " B. Austin " abaustin+yahoogroups@...>

wrote:

>

>>

>> I wasn't going to comment on this topic, because I think it's more a matter

of opinions rather then actually affecting patient care, but since it's already

a discussion ...

>>

>> I think a much more useful thing to do prehospitally is draw a full rainbow

of blood when you start the IV. That gives a lot more data then just a single

blood stick, potentially saves the patient some pain later on, and may speed up

their hospital process significantly. Of course, this is dependent on the ED

accepting your tubes, which many don't (stupidly.)

>>

>> For the " average " paramedic system in the U.S. (outside of those with truly

extended transport times) I don't see the benefit in doing routine fingersticks.

If you have an indication, by all means. I regularly do them by venous blood but

fortunately I'm using a glucometer that is calibrating correctly for venous

blood (as I hadn't even considered the reading may be wrong otherwise.) Of

course, if the causation of the incorrect reading is due to the tourniquet, I

would imagine it would still give an incorrect reading regardless of the unit

used.

>>

>> Austin

>>

>>

>>

>>> While I don't recall it ever being mandated by protocol, it has always been

my practice to do a D-stick on every patient unless emergency interventions and

time prevented it. I recognize that sometimes your hands are so full just

keeping the patient alive with airway and other mandatory interventions that you

don't have enough hands to do it. But even in codes, I have always tried to do

it if there is enough personpower. We don't hear much about hypoglycemia's role

in cardiac arrest, but I have had some patients who arrested and were seriously

hypoglycemic. Also hyperglycemic.

>>

>>

[Guest guest]

Which is completely valid, in my opinion. Most hospitals have either automated

systems (such as those annoying scanners/printers) or use hospital labels. Many

ERs are held (hostage) to laboratory standards such as the direction of labels,

information contained, or the need for barcode labels, etc. The reason for

bedside labeling in the hospital is to attempt to eliminate the many mistakes

made by phleb techs (or nurses) who are doing a dozen draws in an hour for

morning labs. While it has some relevancy to all other hospital settings, it is

much less necessary for EMS. Not to mention, who would actually be able to read

the handwritten labels anyway? My handwriting is illegible anyway, then add in

the curved surface of the tube, trying to use a grease pen (or stay on the tiny

label), the bouncing of the truck, etc. It's pointless.

Austin

> The typical reason given for not accepting EMS blood tubes is that they are

hemolyzed and require a redraw. JEMS published a study a few months back that

indicates that hospital drawn samples are found hemolyzed more often than EMS

samples. The most common issue I find with EMS drawn samples is related to

identification of the samples. Most facilities require the sample (each tube) be

labeled with patient name, dob and the date time and initials of the person

drawing. EMS seems to like to draw the tubes and place them in a ziplock bag and

label the bag with the patient's name or pull the tubes from a shirt pocket and

indicate they belong to the patient they are delivering.

> Rick

>

> From: texasems-l [mailto:texasems-l ] On Behalf

Of mark_opian@...

> Sent: Wednesday, September 01, 2010 9:57 AM

> To: texasems-l

> Subject: Re: D-Sticks As A Baseline Vital Sign

>

>

>

> most will not take our blood draws. Because they want to draw the blood them

self for bill and to make sure it do right.

> Sent from my Verizon Wireless BlackBerry

>

> Re: D-Sticks As A Baseline Vital Sign

>

> Quick question -- do any of the hospitals you transport to routinely accept

blood draws done in the prehospital setting?

>

> Wes Ogilvie

>

> Sent from my iPad

>

> On Sep 1, 2010, at 9:49, " B. Austin "

abaustin+yahoogroups@...>

wrote:

>

>>

>> I wasn't going to comment on this topic, because I think it's more a matter

of opinions rather then actually affecting patient care, but since it's already

a discussion ...

>>

>> I think a much more useful thing to do prehospitally is draw a full rainbow

of blood when you start the IV. That gives a lot more data then just a single

blood stick, potentially saves the patient some pain later on, and may speed up

their hospital process significantly. Of course, this is dependent on the ED

accepting your tubes, which many don't (stupidly.)

>>

>> For the " average " paramedic system in the U.S. (outside of those with truly

extended transport times) I don't see the benefit in doing routine fingersticks.

If you have an indication, by all means. I regularly do them by venous blood but

fortunately I'm using a glucometer that is calibrating correctly for venous

blood (as I hadn't even considered the reading may be wrong otherwise.) Of

course, if the causation of the incorrect reading is due to the tourniquet, I

would imagine it would still give an incorrect reading regardless of the unit

used.

>>

>> Austin

>>

>> On Aug 31, 2010, at 12:55 AM,

wegandy1938@... wrote:

>>

>>> While I don't recall it ever being mandated by protocol, it has always been

my practice to do a D-stick on every patient unless emergency interventions and

time prevented it. I recognize that sometimes your hands are so full just

keeping the patient alive with airway and other mandatory interventions that you

don't have enough hands to do it. But even in codes, I have always tried to do

it if there is enough personpower. We don't hear much about hypoglycemia's role

in cardiac arrest, but I have had some patients who arrested and were seriously

hypoglycemic. Also hyperglycemic.

>>

>>

[Guest guest]

It may be pointless but we have to label the samples at the bedside in the ED as

well and in most emergency conditions we do not have pre-printed labels yet when

blood is drawn. I have been involved in mix-ups that resulted in failure to

label the tubes at the bedside in the ED. Tubes can be labeled in the room by

the medic prior to handing them over. This eliminates the bouncing of the truck

issue.

As you stated we are held hostage to the lab standards and they are in place

largely because there have been issues. As someone once told me, for every

policy written there is someone's name in invisible ink on the bottom of it.

Rick

From: texasems-l [mailto:texasems-l ] On Behalf

Of B. Austin

Sent: Wednesday, September 01, 2010 10:29 AM

To: texasems-l

Subject: Re: D-Sticks As A Baseline Vital Sign

Which is completely valid, in my opinion. Most hospitals have either automated

systems (such as those annoying scanners/printers) or use hospital labels. Many

ERs are held (hostage) to laboratory standards such as the direction of labels,

information contained, or the need for barcode labels, etc. The reason for

bedside labeling in the hospital is to attempt to eliminate the many mistakes

made by phleb techs (or nurses) who are doing a dozen draws in an hour for

morning labs. While it has some relevancy to all other hospital settings, it is

much less necessary for EMS. Not to mention, who would actually be able to read

the handwritten labels anyway? My handwriting is illegible anyway, then add in

the curved surface of the tube, trying to use a grease pen (or stay on the tiny

label), the bouncing of the truck, etc. It's pointless.

Austin

On Sep 1, 2010, at 10:12 AM,

rick.moore@...> wrote:

> The typical reason given for not accepting EMS blood tubes is that they are

hemolyzed and require a redraw. JEMS published a study a few months back that

indicates that hospital drawn samples are found hemolyzed more often than EMS

samples. The most common issue I find with EMS drawn samples is related to

identification of the samples. Most facilities require the sample (each tube) be

labeled with patient name, dob and the date time and initials of the person

drawing. EMS seems to like to draw the tubes and place them in a ziplock bag and

label the bag with the patient's name or pull the tubes from a shirt pocket and

indicate they belong to the patient they are delivering.

> Rick

>

> From: texasems-l

[mailto:texasems-l ] On

Behalf Of mark_opian@...

> Sent: Wednesday, September 01, 2010 9:57 AM

> To: texasems-l

> Subject: Re: D-Sticks As A Baseline Vital Sign

>

>

>

> most will not take our blood draws. Because they want to draw the blood them

self for bill and to make sure it do right.

> Sent from my Verizon Wireless BlackBerry

>

> Re: D-Sticks As A Baseline Vital Sign

>

> Quick question -- do any of the hospitals you transport to routinely accept

blood draws done in the prehospital setting?

>

> Wes Ogilvie

>

> Sent from my iPad

>

> On Sep 1, 2010, at 9:49, " B. Austin "

abaustin+yahoogroups@...

> wrote:

>

>>

>> I wasn't going to comment on this topic, because I think it's more a matter

of opinions rather then actually affecting patient care, but since it's already

a discussion ...

>>

>> I think a much more useful thing to do prehospitally is draw a full rainbow

of blood when you start the IV. That gives a lot more data then just a single

blood stick, potentially saves the patient some pain later on, and may speed up

their hospital process significantly. Of course, this is dependent on the ED

accepting your tubes, which many don't (stupidly.)

>>

>> For the " average " paramedic system in the U.S. (outside of those with truly

extended transport times) I don't see the benefit in doing routine fingersticks.

If you have an indication, by all means. I regularly do them by venous blood but

fortunately I'm using a glucometer that is calibrating correctly for venous

blood (as I hadn't even considered the reading may be wrong otherwise.) Of

course, if the causation of the incorrect reading is due to the tourniquet, I

would imagine it would still give an incorrect reading regardless of the unit

used.

>>

>> Austin

>>

>> On Aug 31, 2010, at 12:55 AM,

wegandy1938@...

wrote:

>>

>>> While I don't recall it ever being mandated by protocol, it has always been

my practice to do a D-stick on every patient unless emergency interventions and

time prevented it. I recognize that sometimes your hands are so full just

keeping the patient alive with airway and other mandatory interventions that you

don't have enough hands to do it. But even in codes, I have always tried to do

it if there is enough personpower. We don't hear much about hypoglycemia's role

in cardiac arrest, but I have had some patients who arrested and were seriously

hypoglycemic. Also hyperglycemic.

>>

>>

[Guest guest]

I apologize ; I also count Wes as a friend, however, I would trust that

anything that we said was not intended as an acerbic argument towards the

other, and that neither of us would get offended. I misunderstood his

message, and for that I apologize. I should have sent him a message

off-list, and will correct my actions in the future.

I will make sure to let you all know the results of any studies or surveys I

embark upon, as I'm hoping they will be useful to everyone present.

I had not really put this out as a discussion on the group yet as I know of

stories in which people who are new to a profession or area wind up losing

the credit for the hard work they put into something; that credit instead

going to whomever was overseeing them. Ergo, I've been a little hesitant to

announce the specificities of my intentions or plans, and carefully selected

who I chose to seek council from.

Please don't feel insulted if I haven't talked with you about it; I'm simply

attempting to be careful, and have as of yet only talked with a few trusted

colleagues.

This particular listserve discussion was actually aimed at addressing a

related matter, and not intended to strictly advocate d-sticks, though at

some point, I expressed my personal opinion, and here we are.

I was actually attempting to see if I could get some ambulance companies who

have it in their protocols in on a quick survey/interview so that I

could gather some data, however, since I don't see evidence as to any such

company's existence, I am currently altering my methodology to attempt to

get a good group from which I can draw *anonymous, self reported*information.

Alyssa Woods, NREMT-B

CPR Instructor

>

>

> Alyssa responded to the list not to Wes personally so I believe that makes

> her comments fair game for anyone to comment on. Perhaps my response was

> more over the top than yours but I was saying the same thing that you said.

> I do know Wes well and consider him a friend and tend to stick up for him

> (as he does for me). I for one would love to see the results of Alyssa's

> research project and would certainly entertain a change in my personal

> practice if so indicated by the studies.

> Rick

>

> From: texasems-l [mailto:

> texasems-l ] On Behalf Of

> krin135@...

> Sent: Wednesday, September 01, 2010 9:01 AM

>

> To: texasems-l

> Subject: Re: D-Sticks As A Baseline Vital Sign

>

> Time out!

>

> Alyssa: I think that Wes' finger was firmly in his cheek when he wrote

> that.

>

> Rick: Since Alyssa seems to have been responding to Wes, and not you, your

> response is a bit beyond measured, ESPECIALLY since Alyssa has proposed a

> research project evaluating the use of the FSBG as a reasonable additional

> 'vital sign' in a population suspected of a significant underdiagnosis of

> diabetes. She's trying to replace 'best opinions' and 'dogma' with

> research/science.

>

> and anyone who knows Wes (and his apprenticeship with Mr. Grady) would

> expect something like his response.

>

> ck

>

> In a message dated 09/01/10 08:40:58 Central Daylight Time,

> rick.moore@...

rick.moore%40stdavids.com > writes:

>

> " But no, really - *I'm* the immature and inexperienced person here. "

>

> If you are considering this a personal attack on you and not an attack on

> the fact that we in EMS depend more on dogma than science then I would

> agree with the sentence above.

> Rick

>

> Re: D-Sticks As A Baseline Vital Sign

> > >

> > > In a message dated 08/31/10 20:10:46 Central Daylight Time,

> > > rick.moore@...

rick.moore%40stdavids.com >

40stdavids.com>

> > rick.moore%40stdavids.com > writes:

> > >

> > > Using your logic every time someone seeks medical care the care

> provider

> > > should run every diagnostic test available just in case they have some

> > > process that may or may not be related to the chief complaint. That

> > should

> > > reduce the cost of health care nicely.

> > > You should treat the patient based on recognized standard of care as

> > > dictated by the chief complaint. And say you do find a normally

> > responding

> > > patient with a BGL of 500. What are you going to do about it Alyssa?

> It's

> > not

> > > your job to diagnose the worlds ills. Even Internal Medicine docs don't

> > run

> > > every test every time.

> > >

> > > Rick

> > >

> > > that being said, I could justify at least a finger stick BG on any

> > patient

> > > I saw in the ED based on any complaints of weakness (global or

> specific),

> > > mental status change from slurred speech to loss of consciousness, loss

> > of

> > > energy, depression, anxiety, fall, blurred vision, headache,

> nausea.....

> > >

> > > So how many patients do you think that I saw didn't need a BG?

> > >

> > > you check blood pressure, pulse and respirations on every patient, even

> > if

> > > they don't have a history of hypertension, irregular heart beat or lung

> > > problems...

> > >

> > > the triage nurses ask about safety at home (including questions

> designed

> > to

> > > identify abuse)...won't that also increase the cost of health care by

> > > identifying people who need social service intervention?

> > >

> > > There are good arguments about using a blood glucose as a screening

> tool

> > to

> > > identify folks who need further evaluation for diabetes....in order to

> > > catch them earlier, before significant end organ damage is done, which

> > *will*

> > > ultimately reduce the cost of health care in most of those folks.

> > >

> > > I'd have to see a better argument than the one you have advanced, Mr.

> >

> > > before I condemned Ms. Woods' idea.

> > >

> > > I will admit that I was a bit unusual, being a physician who 'came up

> > > through the ranks' and actually tended to listen to the reports of the

> > Basics

> > > and Medics (many of whom I helped train in my early career) that I

> worked

> > > with.

> > >

> > > That being said, even someone who 'felt normal' but had a field BG of

> 500

> > > would deserve at least a referral for follow up after evaluation in the

> > > ED....and even someone who 'feels normal,' but has a BG that high

> should

> > be

> > > considered for transport.

> > >

> > > ck

> > >

> > >

[Guest guest]

No offense taken. Sorry if there was a misinterpretation from my comments.

Wes

Sent from my iPad

> I apologize ; I also count Wes as a friend, however, I would trust that

> anything that we said was not intended as an acerbic argument towards the

> other, and that neither of us would get offended. I misunderstood his

> message, and for that I apologize. I should have sent him a message

> off-list, and will correct my actions in the future.

>

> I will make sure to let you all know the results of any studies or surveys I

> embark upon, as I'm hoping they will be useful to everyone present.

>

> I had not really put this out as a discussion on the group yet as I know of

> stories in which people who are new to a profession or area wind up losing

> the credit for the hard work they put into something; that credit instead

> going to whomever was overseeing them. Ergo, I've been a little hesitant to

> announce the specificities of my intentions or plans, and carefully selected

> who I chose to seek council from.

>

> Please don't feel insulted if I haven't talked with you about it; I'm simply

> attempting to be careful, and have as of yet only talked with a few trusted

> colleagues.

>

> This particular listserve discussion was actually aimed at addressing a

> related matter, and not intended to strictly advocate d-sticks, though at

> some point, I expressed my personal opinion, and here we are.

>

> I was actually attempting to see if I could get some ambulance companies who

> have it in their protocols in on a quick survey/interview so that I

> could gather some data, however, since I don't see evidence as to any such

> company's existence, I am currently altering my methodology to attempt to

> get a good group from which I can draw *anonymous, self reported*information.

>

> Alyssa Woods, NREMT-B

> CPR Instructor

>

>

>

>

>>

>>

>> Alyssa responded to the list not to Wes personally so I believe that makes

>> her comments fair game for anyone to comment on. Perhaps my response was

>> more over the top than yours but I was saying the same thing that you said.

>> I do know Wes well and consider him a friend and tend to stick up for him

>> (as he does for me). I for one would love to see the results of Alyssa's

>> research project and would certainly entertain a change in my personal

>> practice if so indicated by the studies.

>> Rick

>>

>> From: texasems-l [mailto:

>> texasems-l ] On Behalf Of

>> krin135@...

>> Sent: Wednesday, September 01, 2010 9:01 AM

>>

>> To: texasems-l

>> Subject: Re: D-Sticks As A Baseline Vital Sign

>>

>> Time out!

>>

>> Alyssa: I think that Wes' finger was firmly in his cheek when he wrote

>> that.

>>

>> Rick: Since Alyssa seems to have been responding to Wes, and not you, your

>> response is a bit beyond measured, ESPECIALLY since Alyssa has proposed a

>> research project evaluating the use of the FSBG as a reasonable additional

>> 'vital sign' in a population suspected of a significant underdiagnosis of

>> diabetes. She's trying to replace 'best opinions' and 'dogma' with

>> research/science.

>>

>> and anyone who knows Wes (and his apprenticeship with Mr. Grady) would

>> expect something like his response.

>>

>> ck

>>

>> In a message dated 09/01/10 08:40:58 Central Daylight Time,

>> rick.moore@...

> rick.moore%40stdavids.com > writes:

>>

>> " But no, really - *I'm* the immature and inexperienced person here. "

>>

>> If you are considering this a personal attack on you and not an attack on

>> the fact that we in EMS depend more on dogma than science then I would

>> agree with the sentence above.

>> Rick

>>

>> Re: D-Sticks As A Baseline Vital Sign

>>>>

>>>> In a message dated 08/31/10 20:10:46 Central Daylight Time,

>>>> rick.moore@...

> rick.moore%40stdavids.com >

> 40stdavids.com>

>

>>> rick.moore%40stdavids.com > writes:

>>>>

>>>> Using your logic every time someone seeks medical care the care

>> provider

>>>> should run every diagnostic test available just in case they have some

>>>> process that may or may not be related to the chief complaint. That

>>> should

>>>> reduce the cost of health care nicely.

>>>> You should treat the patient based on recognized standard of care as

>>>> dictated by the chief complaint. And say you do find a normally

>>> responding

>>>> patient with a BGL of 500. What are you going to do about it Alyssa?

>> It's

>>> not

>>>> your job to diagnose the worlds ills. Even Internal Medicine docs don't

>>> run

>>>> every test every time.

>>>>

>>>> Rick

>>>>

>>>> that being said, I could justify at least a finger stick BG on any

>>> patient

>>>> I saw in the ED based on any complaints of weakness (global or

>> specific),

>>>> mental status change from slurred speech to loss of consciousness, loss

>>> of

>>>> energy, depression, anxiety, fall, blurred vision, headache,

>> nausea.....

>>>>

>>>> So how many patients do you think that I saw didn't need a BG?

>>>>

>>>> you check blood pressure, pulse and respirations on every patient, even

>>> if

>>>> they don't have a history of hypertension, irregular heart beat or lung

>>>> problems...

>>>>

>>>> the triage nurses ask about safety at home (including questions

>> designed

>>> to

>>>> identify abuse)...won't that also increase the cost of health care by

>>>> identifying people who need social service intervention?

>>>>

>>>> There are good arguments about using a blood glucose as a screening

>> tool

>>> to

>>>> identify folks who need further evaluation for diabetes....in order to

>>>> catch them earlier, before significant end organ damage is done, which

>>> *will*

>>>> ultimately reduce the cost of health care in most of those folks.

>>>>

>>>> I'd have to see a better argument than the one you have advanced, Mr.

>>>

>>>> before I condemned Ms. Woods' idea.

>>>>

>>>> I will admit that I was a bit unusual, being a physician who 'came up

>>>> through the ranks' and actually tended to listen to the reports of the

>>> Basics

>>>> and Medics (many of whom I helped train in my early career) that I

>> worked

>>>> with.

>>>>

>>>> That being said, even someone who 'felt normal' but had a field BG of

>> 500

>>>> would deserve at least a referral for follow up after evaluation in the

>>>> ED....and even someone who 'feels normal,' but has a BG that high

>> should

>>> be

>>>> considered for transport.

>>>>

>>>> ck

>>>>

>>>>

[Guest guest]

Policy states we are to use CareFusion to print and scan patient specific labels

at bedside in the ED as well. That doesn't really explain all the labels stuck

around the tech's computer monitor nor all the unlabeled tubes in biohazard bags

with a admissions label on them. Whether you believe that policies can be

" stupid " or not (which is not to insult you, but some people believe there are

no bad policies--usually in nursing administration), noone here honestly can say

they believe that 100% of policies are observed 100% of the time.

With regards to identifying blood tubes from prehospital folk, I believe that

verbally identified, in a biohazard bag, and handed to the nurse accepting

report is acceptable. Once admission labels are printed it can be appropriately

and individually labeled. I think it's ridiculous to expect a paramedic to do

something (individually hand-label tubes) that your average nurse wouldn't do.

Prior to them going to the lab, they can be labeled according to lab's standards

by hospital staff (which was going to do it anyway if the labs weren't drawn

with the EMS IV) and voilà--prehospital blood, sent to the lab, and noone was

inconvenienced.\

Austin

On Sep 1, 2010, at 10:33 AM, rick.moore@...> rick.moore@...>

wrote:

> It may be pointless but we have to label the samples at the bedside in the ED

as well and in most emergency conditions we do not have pre-printed labels yet

when blood is drawn. I have been involved in mix-ups that resulted in failure to

label the tubes at the bedside in the ED. Tubes can be labeled in the room by

the medic prior to handing them over. This eliminates the bouncing of the truck

issue.

> As you stated we are held hostage to the lab standards and they are in place

largely because there have been issues. As someone once told me, for every

policy written there is someone's name in invisible ink on the bottom of it.

> Rick

>

> From: texasems-l [mailto:texasems-l ] On Behalf

Of B. Austin

> Sent: Wednesday, September 01, 2010 10:29 AM

> To: texasems-l

> Subject: Re: D-Sticks As A Baseline Vital Sign

>

>

>

> Which is completely valid, in my opinion. Most hospitals have either automated

systems (such as those annoying scanners/printers) or use hospital labels. Many

ERs are held (hostage) to laboratory standards such as the direction of labels,

information contained, or the need for barcode labels, etc. The reason for

bedside labeling in the hospital is to attempt to eliminate the many mistakes

made by phleb techs (or nurses) who are doing a dozen draws in an hour for

morning labs. While it has some relevancy to all other hospital settings, it is

much less necessary for EMS. Not to mention, who would actually be able to read

the handwritten labels anyway? My handwriting is illegible anyway, then add in

the curved surface of the tube, trying to use a grease pen (or stay on the tiny

label), the bouncing of the truck, etc. It's pointless.

>

> Austin

>

> On Sep 1, 2010, at 10:12 AM,

rick.moore@...> wrote:

>

>> The typical reason given for not accepting EMS blood tubes is that they are

hemolyzed and require a redraw. JEMS published a study a few months back that

indicates that hospital drawn samples are found hemolyzed more often than EMS

samples. The most common issue I find with EMS drawn samples is related to

identification of the samples. Most facilities require the sample (each tube) be

labeled with patient name, dob and the date time and initials of the person

drawing. EMS seems to like to draw the tubes and place them in a ziplock bag and

label the bag with the patient's name or pull the tubes from a shirt pocket and

indicate they belong to the patient they are delivering.

>> Rick

>>

>> From: texasems-l

[mailto:texasems-l ] On

Behalf Of mark_opian@...

>> Sent: Wednesday, September 01, 2010 9:57 AM

>> To: texasems-l

>> Subject: Re: D-Sticks As A Baseline Vital Sign

>>

>>

>>

>> most will not take our blood draws. Because they want to draw the blood them

self for bill and to make sure it do right.

>> Sent from my Verizon Wireless BlackBerry

>>

>> Re: D-Sticks As A Baseline Vital Sign

>>

>> Quick question -- do any of the hospitals you transport to routinely accept

blood draws done in the prehospital setting?

>>

>> Wes Ogilvie

>>

>> Sent from my iPad

>>

>> On Sep 1, 2010, at 9:49, " B. Austin "

abaustin+yahoogroups@...

> wrote:

>>

>>>

>>> I wasn't going to comment on this topic, because I think it's more a matter

of opinions rather then actually affecting patient care, but since it's already

a discussion ...

>>>

>>> I think a much more useful thing to do prehospitally is draw a full rainbow

of blood when you start the IV. That gives a lot more data then just a single

blood stick, potentially saves the patient some pain later on, and may speed up

their hospital process significantly. Of course, this is dependent on the ED

accepting your tubes, which many don't (stupidly.)

>>>

>>> For the " average " paramedic system in the U.S. (outside of those with truly

extended transport times) I don't see the benefit in doing routine fingersticks.

If you have an indication, by all means. I regularly do them by venous blood but

fortunately I'm using a glucometer that is calibrating correctly for venous

blood (as I hadn't even considered the reading may be wrong otherwise.) Of

course, if the causation of the incorrect reading is due to the tourniquet, I

would imagine it would still give an incorrect reading regardless of the unit

used.

>>>

>>> Austin

>>>

>>> On Aug 31, 2010, at 12:55 AM,

wegandy1938@...

wrote:

>>>

>>>> While I don't recall it ever being mandated by protocol, it has always been

my practice to do a D-stick on every patient unless emergency interventions and

time prevented it. I recognize that sometimes your hands are so full just

keeping the patient alive with airway and other mandatory interventions that you

don't have enough hands to do it. But even in codes, I have always tried to do

it if there is enough personpower. We don't hear much about hypoglycemia's role

in cardiac arrest, but I have had some patients who arrested and were seriously

hypoglycemic. Also hyperglycemic.

>>>

>>>

[Guest guest]

Looking back on it, I was more acerbic with my comment than I should have been.

I apologize and did not mean to offend anyone. Looking forward to more

discussions with you on this and other clinical issues.

Rick

Re: D-Sticks As A Baseline Vital Sign

> > >

> > > In a message dated 08/31/10 20:10:46 Central Daylight Time,

> > > rick.moore@...

rick.moore%40stdavids.com >

40stdavids.com>

> > rick.moore%40stdavids.com > writes:

> > >

> > > Using your logic every time someone seeks medical care the care

> provider

> > > should run every diagnostic test available just in case they have some

> > > process that may or may not be related to the chief complaint. That

> > should

> > > reduce the cost of health care nicely.

> > > You should treat the patient based on recognized standard of care as

> > > dictated by the chief complaint. And say you do find a normally

> > responding

> > > patient with a BGL of 500. What are you going to do about it Alyssa?

> It's

> > not

> > > your job to diagnose the worlds ills. Even Internal Medicine docs don't

> > run

> > > every test every time.

> > >

> > > Rick

> > >

> > > that being said, I could justify at least a finger stick BG on any

> > patient

> > > I saw in the ED based on any complaints of weakness (global or

> specific),

> > > mental status change from slurred speech to loss of consciousness, loss

> > of

> > > energy, depression, anxiety, fall, blurred vision, headache,

> nausea.....

> > >

> > > So how many patients do you think that I saw didn't need a BG?

> > >

> > > you check blood pressure, pulse and respirations on every patient, even

> > if

> > > they don't have a history of hypertension, irregular heart beat or lung

> > > problems...

> > >

> > > the triage nurses ask about safety at home (including questions

> designed

> > to

> > > identify abuse)...won't that also increase the cost of health care by

> > > identifying people who need social service intervention?

> > >

> > > There are good arguments about using a blood glucose as a screening

> tool

> > to

> > > identify folks who need further evaluation for diabetes....in order to

> > > catch them earlier, before significant end organ damage is done, which

> > *will*

> > > ultimately reduce the cost of health care in most of those folks.

> > >

> > > I'd have to see a better argument than the one you have advanced, Mr.

> >

> > > before I condemned Ms. Woods' idea.

> > >

> > > I will admit that I was a bit unusual, being a physician who 'came up

> > > through the ranks' and actually tended to listen to the reports of the

> > Basics

> > > and Medics (many of whom I helped train in my early career) that I

> worked

> > > with.

> > >

> > > That being said, even someone who 'felt normal' but had a field BG of

> 500

> > > would deserve at least a referral for follow up after evaluation in the

> > > ED....and even someone who 'feels normal,' but has a BG that high

> should

> > be

> > > considered for transport.

> > >

> > > ck

> > >

> > >

[Guest guest]

Over the years I have worked in 4 hospitals and in each of those ED nurses hand

labeled blood tubes at the bedside of patients whose blood was drawn prior to

the printing of labels. I do work in nursing administration and I do not believe

that 100% of the policies are followed 100% of the time and don't expect that

they will. I have also labeled EMS blood tubes with hospital labels on more than

one occasion but I was careful to maintain custody of the tubes from the time

the medic handed them to me and the time the labels were affixed.

Rick

From: texasems-l [mailto:texasems-l ] On Behalf

Of B. Austin

Sent: Wednesday, September 01, 2010 12:15 PM

To: texasems-l

Subject: Re: D-Sticks As A Baseline Vital Sign

Policy states we are to use CareFusion to print and scan patient specific labels

at bedside in the ED as well. That doesn't really explain all the labels stuck

around the tech's computer monitor nor all the unlabeled tubes in biohazard bags

with a admissions label on them. Whether you believe that policies can be

" stupid " or not (which is not to insult you, but some people believe there are

no bad policies--usually in nursing administration), noone here honestly can say

they believe that 100% of policies are observed 100% of the time.

With regards to identifying blood tubes from prehospital folk, I believe that

verbally identified, in a biohazard bag, and handed to the nurse accepting

report is acceptable. Once admission labels are printed it can be appropriately

and individually labeled. I think it's ridiculous to expect a paramedic to do

something (individually hand-label tubes) that your average nurse wouldn't do.

Prior to them going to the lab, they can be labeled according to lab's standards

by hospital staff (which was going to do it anyway if the labs weren't drawn

with the EMS IV) and voilà--prehospital blood, sent to the lab, and noone was

inconvenienced.\

Austin

On Sep 1, 2010, at 10:33 AM,

rick.moore@...>

rick.moore@...> wrote:

> It may be pointless but we have to label the samples at the bedside in the ED

as well and in most emergency conditions we do not have pre-printed labels yet

when blood is drawn. I have been involved in mix-ups that resulted in failure to

label the tubes at the bedside in the ED. Tubes can be labeled in the room by

the medic prior to handing them over. This eliminates the bouncing of the truck

issue.

> As you stated we are held hostage to the lab standards and they are in place

largely because there have been issues. As someone once told me, for every

policy written there is someone's name in invisible ink on the bottom of it.

> Rick

>

> From: texasems-l

[mailto:texasems-l ] On

Behalf Of B. Austin

> Sent: Wednesday, September 01, 2010 10:29 AM

> To: texasems-l

> Subject: Re: D-Sticks As A Baseline Vital Sign

>

>

>

> Which is completely valid, in my opinion. Most hospitals have either automated

systems (such as those annoying scanners/printers) or use hospital labels. Many

ERs are held (hostage) to laboratory standards such as the direction of labels,

information contained, or the need for barcode labels, etc. The reason for

bedside labeling in the hospital is to attempt to eliminate the many mistakes

made by phleb techs (or nurses) who are doing a dozen draws in an hour for

morning labs. While it has some relevancy to all other hospital settings, it is

much less necessary for EMS. Not to mention, who would actually be able to read

the handwritten labels anyway? My handwriting is illegible anyway, then add in

the curved surface of the tube, trying to use a grease pen (or stay on the tiny

label), the bouncing of the truck, etc. It's pointless.

>

> Austin

>

> On Sep 1, 2010, at 10:12 AM,

rick.moore@...

> wrote:

>

>> The typical reason given for not accepting EMS blood tubes is that they are

hemolyzed and require a redraw. JEMS published a study a few months back that

indicates that hospital drawn samples are found hemolyzed more often than EMS

samples. The most common issue I find with EMS drawn samples is related to

identification of the samples. Most facilities require the sample (each tube) be

labeled with patient name, dob and the date time and initials of the person

drawing. EMS seems to like to draw the tubes and place them in a ziplock bag and

label the bag with the patient's name or pull the tubes from a shirt pocket and

indicate they belong to the patient they are delivering.

>> Rick

>>

>> From:

texasems-l

[mailto:texasems-l

] On Behalf Of

mark_opian@...

>> Sent: Wednesday, September 01, 2010 9:57 AM

>> To:

texasems-l

>> Subject: Re: D-Sticks As A Baseline Vital Sign

>>

>>

>>

>> most will not take our blood draws. Because they want to draw the blood them

self for bill and to make sure it do right.

>> Sent from my Verizon Wireless BlackBerry

>>

>> Re: D-Sticks As A Baseline Vital Sign

>>

>> Quick question -- do any of the hospitals you transport to routinely accept

blood draws done in the prehospital setting?

>>

>> Wes Ogilvie

>>

>> Sent from my iPad

>>

>> On Sep 1, 2010, at 9:49, " B. Austin "

abaustin+yahoogroups@...

\

> wrote:

>>

>>>

>>> I wasn't going to comment on this topic, because I think it's more a matter

of opinions rather then actually affecting patient care, but since it's already

a discussion ...

>>>

>>> I think a much more useful thing to do prehospitally is draw a full rainbow

of blood when you start the IV. That gives a lot more data then just a single

blood stick, potentially saves the patient some pain later on, and may speed up

their hospital process significantly. Of course, this is dependent on the ED

accepting your tubes, which many don't (stupidly.)

>>>

>>> For the " average " paramedic system in the U.S. (outside of those with truly

extended transport times) I don't see the benefit in doing routine fingersticks.

If you have an indication, by all means. I regularly do them by venous blood but

fortunately I'm using a glucometer that is calibrating correctly for venous

blood (as I hadn't even considered the reading may be wrong otherwise.) Of

course, if the causation of the incorrect reading is due to the tourniquet, I

would imagine it would still give an incorrect reading regardless of the unit

used.

>>>

>>> Austin

>>>

>>> On Aug 31, 2010, at 12:55 AM,

wegandy1938@...<\

mailto:wegandy1938%40aol.com> wrote:

>>>

>>>> While I don't recall it ever being mandated by protocol, it has always been

my practice to do a D-stick on every patient unless emergency interventions and

time prevented it. I recognize that sometimes your hands are so full just

keeping the patient alive with airway and other mandatory interventions that you

don't have enough hands to do it. But even in codes, I have always tried to do

it if there is enough personpower. We don't hear much about hypoglycemia's role

in cardiac arrest, but I have had some patients who arrested and were seriously

hypoglycemic. Also hyperglycemic.

>>>

>>>

[Guest guest]

I wasn't trying to be insulting, for reference. If any animosity is or was

received, please disregard as it was not my intention.

Did you find the process of labeling the tubes yourself with stickers (instead

of the paramedic hand labeling them) particularly burdensome? Did you feel that

the blood tubes were significantly at risk of being misidentified in that

process?

Lastly, I would hope you will acknowledge that it is just as likely that ED

nurses aren't labeling at bedside as that they are. It depends on the facility

and what policies administration " cares about " at the time. Your anecdotal

experience has been that nurses are always(?) labeling at bedside, where mine is

that those policies are more honored in the breach than in the observance.

Austin

> Over the years I have worked in 4 hospitals and in each of those ED nurses

hand labeled blood tubes at the bedside of patients whose blood was drawn prior

to the printing of labels. I do work in nursing administration and I do not

believe that 100% of the policies are followed 100% of the time and don't expect

that they will. I have also labeled EMS blood tubes with hospital labels on more

than one occasion but I was careful to maintain custody of the tubes from the

time the medic handed them to me and the time the labels were affixed.

> Rick

>

> From: texasems-l [mailto:texasems-l ] On Behalf

Of B. Austin

> Sent: Wednesday, September 01, 2010 12:15 PM

> To: texasems-l

> Subject: Re: D-Sticks As A Baseline Vital Sign

>

>

>

> Policy states we are to use CareFusion to print and scan patient specific

labels at bedside in the ED as well. That doesn't really explain all the labels

stuck around the tech's computer monitor nor all the unlabeled tubes in

biohazard bags with a admissions label on them. Whether you believe that

policies can be " stupid " or not (which is not to insult you, but some people

believe there are no bad policies--usually in nursing administration), noone

here honestly can say they believe that 100% of policies are observed 100% of

the time.

>

> With regards to identifying blood tubes from prehospital folk, I believe that

verbally identified, in a biohazard bag, and handed to the nurse accepting

report is acceptable. Once admission labels are printed it can be appropriately

and individually labeled. I think it's ridiculous to expect a paramedic to do

something (individually hand-label tubes) that your average nurse wouldn't do.

Prior to them going to the lab, they can be labeled according to lab's standards

by hospital staff (which was going to do it anyway if the labs weren't drawn

with the EMS IV) and voilà--prehospital blood, sent to the lab, and noone was

inconvenienced.\

>

> Austin

>

> On Sep 1, 2010, at 10:33 AM,

rick.moore@...>

rick.moore@...> wrote:

>

>> It may be pointless but we have to label the samples at the bedside in the ED

as well and in most emergency conditions we do not have pre-printed labels yet

when blood is drawn. I have been involved in mix-ups that resulted in failure to

label the tubes at the bedside in the ED. Tubes can be labeled in the room by

the medic prior to handing them over. This eliminates the bouncing of the truck

issue.

>> As you stated we are held hostage to the lab standards and they are in place

largely because there have been issues. As someone once told me, for every

policy written there is someone's name in invisible ink on the bottom of it.

>> Rick

>>

>> From: texasems-l

[mailto:texasems-l ] On

Behalf Of B. Austin

>> Sent: Wednesday, September 01, 2010 10:29 AM

>> To: texasems-l

>> Subject: Re: D-Sticks As A Baseline Vital Sign

>>

>>

>>

>> Which is completely valid, in my opinion. Most hospitals have either

automated systems (such as those annoying scanners/printers) or use hospital

labels. Many ERs are held (hostage) to laboratory standards such as the

direction of labels, information contained, or the need for barcode labels, etc.

The reason for bedside labeling in the hospital is to attempt to eliminate the

many mistakes made by phleb techs (or nurses) who are doing a dozen draws in an

hour for morning labs. While it has some relevancy to all other hospital

settings, it is much less necessary for EMS. Not to mention, who would actually

be able to read the handwritten labels anyway? My handwriting is illegible

anyway, then add in the curved surface of the tube, trying to use a grease pen

(or stay on the tiny label), the bouncing of the truck, etc. It's pointless.

>>

>> Austin

>>

>> On Sep 1, 2010, at 10:12 AM,

rick.moore@...

> wrote:

>>

>>> The typical reason given for not accepting EMS blood tubes is that they are

hemolyzed and require a redraw. JEMS published a study a few months back that

indicates that hospital drawn samples are found hemolyzed more often than EMS

samples. The most common issue I find with EMS drawn samples is related to

identification of the samples. Most facilities require the sample (each tube) be

labeled with patient name, dob and the date time and initials of the person

drawing. EMS seems to like to draw the tubes and place them in a ziplock bag and

label the bag with the patient's name or pull the tubes from a shirt pocket and

indicate they belong to the patient they are delivering.

>>> Rick

>>>

>>> From:

texasems-l

[mailto:texasems-l

] On Behalf Of

mark_opian@...

>>> Sent: Wednesday, September 01, 2010 9:57 AM

>>> To:

texasems-l

>>> Subject: Re: D-Sticks As A Baseline Vital Sign

>>>

>>>

>>>

>>> most will not take our blood draws. Because they want to draw the blood them

self for bill and to make sure it do right.

>>> Sent from my Verizon Wireless BlackBerry

>>>

>>> Re: D-Sticks As A Baseline Vital Sign

>>>

>>> Quick question -- do any of the hospitals you transport to routinely accept

blood draws done in the prehospital setting?

>>>

>>> Wes Ogilvie

>>>

>>> Sent from my iPad

>>>

>>> On Sep 1, 2010, at 9:49, " B. Austin "

abaustin+yahoogroups@...

\

> wrote:

>>>

>>>>

>>>> I wasn't going to comment on this topic, because I think it's more a matter

of opinions rather then actually affecting patient care, but since it's already

a discussion ...

>>>>

>>>> I think a much more useful thing to do prehospitally is draw a full rainbow

of blood when you start the IV. That gives a lot more data then just a single

blood stick, potentially saves the patient some pain later on, and may speed up

their hospital process significantly. Of course, this is dependent on the ED

accepting your tubes, which many don't (stupidly.)

>>>>

>>>> For the " average " paramedic system in the U.S. (outside of those with truly

extended transport times) I don't see the benefit in doing routine fingersticks.

If you have an indication, by all means. I regularly do them by venous blood but

fortunately I'm using a glucometer that is calibrating correctly for venous

blood (as I hadn't even considered the reading may be wrong otherwise.) Of

course, if the causation of the incorrect reading is due to the tourniquet, I

would imagine it would still give an incorrect reading regardless of the unit

used.

>>>>

>>>> Austin

>>>>

>>>> On Aug 31, 2010, at 12:55 AM,

wegandy1938@...<\

mailto:wegandy1938%40aol.com> wrote:

>>>>

>>>>> While I don't recall it ever being mandated by protocol, it has always

been my practice to do a D-stick on every patient unless emergency interventions

and time prevented it. I recognize that sometimes your hands are so full just

keeping the patient alive with airway and other mandatory interventions that you

don't have enough hands to do it. But even in codes, I have always tried to do

it if there is enough personpower. We don't hear much about hypoglycemia's role

in cardiac arrest, but I have had some patients who arrested and were seriously

hypoglycemic. Also hyperglycemic.

>>>>

>>>>

[Guest guest]

I am not insulted and did not perceive any animosity. I don't think that nurses

do this every time, just indicating that it happens. No I did not feel that the

tubes were at risk of being mis-handled.

From: texasems-l [mailto:texasems-l ] On Behalf

Of B. Austin

Sent: Wednesday, September 01, 2010 12:53 PM

To: texasems-l

Subject: Re: D-Sticks As A Baseline Vital Sign

I wasn't trying to be insulting, for reference. If any animosity is or was

received, please disregard as it was not my intention.

Did you find the process of labeling the tubes yourself with stickers (instead

of the paramedic hand labeling them) particularly burdensome? Did you feel that

the blood tubes were significantly at risk of being misidentified in that

process?

Lastly, I would hope you will acknowledge that it is just as likely that ED

nurses aren't labeling at bedside as that they are. It depends on the facility

and what policies administration " cares about " at the time. Your anecdotal

experience has been that nurses are always(?) labeling at bedside, where mine is

that those policies are more honored in the breach than in the observance.

Austin

On Sep 1, 2010, at 12:33 PM,

rick.moore@...> wrote:

> Over the years I have worked in 4 hospitals and in each of those ED nurses

hand labeled blood tubes at the bedside of patients whose blood was drawn prior

to the printing of labels. I do work in nursing administration and I do not

believe that 100% of the policies are followed 100% of the time and don't expect

that they will. I have also labeled EMS blood tubes with hospital labels on more

than one occasion but I was careful to maintain custody of the tubes from the

time the medic handed them to me and the time the labels were affixed.

> Rick

>

> From: texasems-l

[mailto:texasems-l ] On

Behalf Of B. Austin

> Sent: Wednesday, September 01, 2010 12:15 PM

> To: texasems-l

> Subject: Re: D-Sticks As A Baseline Vital Sign

>

>

>

> Policy states we are to use CareFusion to print and scan patient specific

labels at bedside in the ED as well. That doesn't really explain all the labels

stuck around the tech's computer monitor nor all the unlabeled tubes in

biohazard bags with a admissions label on them. Whether you believe that

policies can be " stupid " or not (which is not to insult you, but some people

believe there are no bad policies--usually in nursing administration), noone

here honestly can say they believe that 100% of policies are observed 100% of

the time.

>

> With regards to identifying blood tubes from prehospital folk, I believe that

verbally identified, in a biohazard bag, and handed to the nurse accepting

report is acceptable. Once admission labels are printed it can be appropriately

and individually labeled. I think it's ridiculous to expect a paramedic to do

something (individually hand-label tubes) that your average nurse wouldn't do.

Prior to them going to the lab, they can be labeled according to lab's standards

by hospital staff (which was going to do it anyway if the labs weren't drawn

with the EMS IV) and voilà--prehospital blood, sent to the lab, and noone was

inconvenienced.\

>

> Austin

>

> On Sep 1, 2010, at 10:33 AM,

rick.moore@...

>

rick.moore@...

> wrote:

>

>> It may be pointless but we have to label the samples at the bedside in the ED

as well and in most emergency conditions we do not have pre-printed labels yet

when blood is drawn. I have been involved in mix-ups that resulted in failure to

label the tubes at the bedside in the ED. Tubes can be labeled in the room by

the medic prior to handing them over. This eliminates the bouncing of the truck

issue.

>> As you stated we are held hostage to the lab standards and they are in place

largely because there have been issues. As someone once told me, for every

policy written there is someone's name in invisible ink on the bottom of it.

>> Rick

>>

>> From:

texasems-l

[mailto:texasems-l

] On Behalf Of B. Austin

>> Sent: Wednesday, September 01, 2010 10:29 AM

>> To:

texasems-l

>> Subject: Re: D-Sticks As A Baseline Vital Sign

>>

>>

>>

>> Which is completely valid, in my opinion. Most hospitals have either

automated systems (such as those annoying scanners/printers) or use hospital

labels. Many ERs are held (hostage) to laboratory standards such as the

direction of labels, information contained, or the need for barcode labels, etc.

The reason for bedside labeling in the hospital is to attempt to eliminate the

many mistakes made by phleb techs (or nurses) who are doing a dozen draws in an

hour for morning labs. While it has some relevancy to all other hospital

settings, it is much less necessary for EMS. Not to mention, who would actually

be able to read the handwritten labels anyway? My handwriting is illegible

anyway, then add in the curved surface of the tube, trying to use a grease pen

(or stay on the tiny label), the bouncing of the truck, etc. It's pointless.

>>

>> Austin

>>

>> On Sep 1, 2010, at 10:12 AM,

rick.moore@...

> wrote:

>>

>>> The typical reason given for not accepting EMS blood tubes is that they are

hemolyzed and require a redraw. JEMS published a study a few months back that

indicates that hospital drawn samples are found hemolyzed more often than EMS

samples. The most common issue I find with EMS drawn samples is related to

identification of the samples. Most facilities require the sample (each tube) be

labeled with patient name, dob and the date time and initials of the person

drawing. EMS seems to like to draw the tubes and place them in a ziplock bag and

label the bag with the patient's name or pull the tubes from a shirt pocket and

indicate they belong to the patient they are delivering.

>>> Rick

>>>

>>> From:

texasems-l

[mailto:texasems-l

] On Behalf Of

mark_opian@...

>>> Sent: Wednesday, September 01, 2010 9:57 AM

>>> To:

texasems-l

>>> Subject: Re: D-Sticks As A Baseline Vital Sign

>>>

>>>

>>>

>>> most will not take our blood draws. Because they want to draw the blood them

self for bill and to make sure it do right.

>>> Sent from my Verizon Wireless BlackBerry

>>>

>>> Re: D-Sticks As A Baseline Vital Sign

>>>

>>> Quick question -- do any of the hospitals you transport to routinely accept

blood draws done in the prehospital setting?

>>>

>>> Wes Ogilvie

>>>

>>> Sent from my iPad

>>>

>>> On Sep 1, 2010, at 9:49, " B. Austin "

abaustin+yahoogroups@...

\

> wrote:

>>>

>>>>

>>>> I wasn't going to comment on this topic, because I think it's more a matter

of opinions rather then actually affecting patient care, but since it's already

a discussion ...

>>>>

>>>> I think a much more useful thing to do prehospitally is draw a full rainbow

of blood when you start the IV. That gives a lot more data then just a single

blood stick, potentially saves the patient some pain later on, and may speed up

their hospital process significantly. Of course, this is dependent on the ED

accepting your tubes, which many don't (stupidly.)

>>>>

>>>> For the " average " paramedic system in the U.S. (outside of those with truly

extended transport times) I don't see the benefit in doing routine fingersticks.

If you have an indication, by all means. I regularly do them by venous blood but

fortunately I'm using a glucometer that is calibrating correctly for venous

blood (as I hadn't even considered the reading may be wrong otherwise.) Of

course, if the causation of the incorrect reading is due to the tourniquet, I

would imagine it would still give an incorrect reading regardless of the unit

used.

>>>>

>>>> Austin

>>>>

>>>> On Aug 31, 2010, at 12:55 AM,

wegandy1938@...<\

mailto:wegandy1938%40aol.com> wrote:

>>>>

>>>>> While I don't recall it ever being mandated by protocol, it has always

been my practice to do a D-stick on every patient unless emergency interventions

and time prevented it. I recognize that sometimes your hands are so full just

keeping the patient alive with airway and other mandatory interventions that you

don't have enough hands to do it. But even in codes, I have always tried to do

it if there is enough personpower. We don't hear much about hypoglycemia's role

in cardiac arrest, but I have had some patients who arrested and were seriously

hypoglycemic. Also hyperglycemic.

>>>>

>>>>

[Guest guest]

I am not insulted and did not perceive any animosity. I don't think that nurses

do this every time, just indicating that it happens. No I did not feel that the

tubes were at risk of being mis-handled.

From: texasems-l [mailto:texasems-l ] On Behalf

Of B. Austin

Sent: Wednesday, September 01, 2010 12:53 PM

To: texasems-l

Subject: Re: D-Sticks As A Baseline Vital Sign

I wasn't trying to be insulting, for reference. If any animosity is or was

received, please disregard as it was not my intention.

Did you find the process of labeling the tubes yourself with stickers (instead

of the paramedic hand labeling them) particularly burdensome? Did you feel that

the blood tubes were significantly at risk of being misidentified in that

process?

Lastly, I would hope you will acknowledge that it is just as likely that ED

nurses aren't labeling at bedside as that they are. It depends on the facility

and what policies administration " cares about " at the time. Your anecdotal

experience has been that nurses are always(?) labeling at bedside, where mine is

that those policies are more honored in the breach than in the observance.

Austin

On Sep 1, 2010, at 12:33 PM,

rick.moore@...> wrote:

> Over the years I have worked in 4 hospitals and in each of those ED nurses

hand labeled blood tubes at the bedside of patients whose blood was drawn prior

to the printing of labels. I do work in nursing administration and I do not

believe that 100% of the policies are followed 100% of the time and don't expect

that they will. I have also labeled EMS blood tubes with hospital labels on more

than one occasion but I was careful to maintain custody of the tubes from the

time the medic handed them to me and the time the labels were affixed.

> Rick

>

> From: texasems-l

[mailto:texasems-l ] On

Behalf Of B. Austin

> Sent: Wednesday, September 01, 2010 12:15 PM

> To: texasems-l

> Subject: Re: D-Sticks As A Baseline Vital Sign

>

>

>

> Policy states we are to use CareFusion to print and scan patient specific

labels at bedside in the ED as well. That doesn't really explain all the labels

stuck around the tech's computer monitor nor all the unlabeled tubes in

biohazard bags with a admissions label on them. Whether you believe that

policies can be " stupid " or not (which is not to insult you, but some people

believe there are no bad policies--usually in nursing administration), noone

here honestly can say they believe that 100% of policies are observed 100% of

the time.

>

> With regards to identifying blood tubes from prehospital folk, I believe that

verbally identified, in a biohazard bag, and handed to the nurse accepting

report is acceptable. Once admission labels are printed it can be appropriately

and individually labeled. I think it's ridiculous to expect a paramedic to do

something (individually hand-label tubes) that your average nurse wouldn't do.

Prior to them going to the lab, they can be labeled according to lab's standards

by hospital staff (which was going to do it anyway if the labs weren't drawn

with the EMS IV) and voilà--prehospital blood, sent to the lab, and noone was

inconvenienced.\

>

> Austin

>

> On Sep 1, 2010, at 10:33 AM,

rick.moore@...

>

rick.moore@...

> wrote:

>

>> It may be pointless but we have to label the samples at the bedside in the ED

as well and in most emergency conditions we do not have pre-printed labels yet

when blood is drawn. I have been involved in mix-ups that resulted in failure to

label the tubes at the bedside in the ED. Tubes can be labeled in the room by

the medic prior to handing them over. This eliminates the bouncing of the truck

issue.

>> As you stated we are held hostage to the lab standards and they are in place

largely because there have been issues. As someone once told me, for every

policy written there is someone's name in invisible ink on the bottom of it.

>> Rick

>>

>> From:

texasems-l

[mailto:texasems-l

] On Behalf Of B. Austin

>> Sent: Wednesday, September 01, 2010 10:29 AM

>> To:

texasems-l

>> Subject: Re: D-Sticks As A Baseline Vital Sign

>>

>>

>>

>> Which is completely valid, in my opinion. Most hospitals have either

automated systems (such as those annoying scanners/printers) or use hospital

labels. Many ERs are held (hostage) to laboratory standards such as the

direction of labels, information contained, or the need for barcode labels, etc.

The reason for bedside labeling in the hospital is to attempt to eliminate the

many mistakes made by phleb techs (or nurses) who are doing a dozen draws in an

hour for morning labs. While it has some relevancy to all other hospital

settings, it is much less necessary for EMS. Not to mention, who would actually

be able to read the handwritten labels anyway? My handwriting is illegible

anyway, then add in the curved surface of the tube, trying to use a grease pen

(or stay on the tiny label), the bouncing of the truck, etc. It's pointless.

>>

>> Austin

>>

>> On Sep 1, 2010, at 10:12 AM,

rick.moore@...

> wrote:

>>

>>> The typical reason given for not accepting EMS blood tubes is that they are

hemolyzed and require a redraw. JEMS published a study a few months back that

indicates that hospital drawn samples are found hemolyzed more often than EMS

samples. The most common issue I find with EMS drawn samples is related to

identification of the samples. Most facilities require the sample (each tube) be

labeled with patient name, dob and the date time and initials of the person

drawing. EMS seems to like to draw the tubes and place them in a ziplock bag and

label the bag with the patient's name or pull the tubes from a shirt pocket and

indicate they belong to the patient they are delivering.

>>> Rick

>>>

>>> From:

texasems-l

[mailto:texasems-l

] On Behalf Of

mark_opian@...

>>> Sent: Wednesday, September 01, 2010 9:57 AM

>>> To:

texasems-l

>>> Subject: Re: D-Sticks As A Baseline Vital Sign

>>>

>>>

>>>

>>> most will not take our blood draws. Because they want to draw the blood them

self for bill and to make sure it do right.

>>> Sent from my Verizon Wireless BlackBerry

>>>

>>> Re: D-Sticks As A Baseline Vital Sign

>>>

>>> Quick question -- do any of the hospitals you transport to routinely accept

blood draws done in the prehospital setting?

>>>

>>> Wes Ogilvie

>>>

>>> Sent from my iPad

>>>

>>> On Sep 1, 2010, at 9:49, " B. Austin "

abaustin+yahoogroups@...

\

> wrote:

>>>

>>>>

>>>> I wasn't going to comment on this topic, because I think it's more a matter

of opinions rather then actually affecting patient care, but since it's already

a discussion ...

>>>>

>>>> I think a much more useful thing to do prehospitally is draw a full rainbow

of blood when you start the IV. That gives a lot more data then just a single

blood stick, potentially saves the patient some pain later on, and may speed up

their hospital process significantly. Of course, this is dependent on the ED

accepting your tubes, which many don't (stupidly.)

>>>>

>>>> For the " average " paramedic system in the U.S. (outside of those with truly

extended transport times) I don't see the benefit in doing routine fingersticks.

If you have an indication, by all means. I regularly do them by venous blood but

fortunately I'm using a glucometer that is calibrating correctly for venous

blood (as I hadn't even considered the reading may be wrong otherwise.) Of

course, if the causation of the incorrect reading is due to the tourniquet, I

would imagine it would still give an incorrect reading regardless of the unit

used.

>>>>

>>>> Austin

>>>>

>>>> On Aug 31, 2010, at 12:55 AM,

wegandy1938@...<\

mailto:wegandy1938%40aol.com> wrote:

>>>>

>>>>> While I don't recall it ever being mandated by protocol, it has always

been my practice to do a D-stick on every patient unless emergency interventions

and time prevented it. I recognize that sometimes your hands are so full just

keeping the patient alive with airway and other mandatory interventions that you

don't have enough hands to do it. But even in codes, I have always tried to do

it if there is enough personpower. We don't hear much about hypoglycemia's role

in cardiac arrest, but I have had some patients who arrested and were seriously

hypoglycemic. Also hyperglycemic.

>>>>

>>>>

[Guest guest]

Which is why he is your apprentice....

ck

In a message dated 09/01/10 19:38:14 Central Daylight Time, wegandy@...

writes:

Hey, I'm the attending curmudgeon here! Wesley is still a resident.

GG

-----Original Message-----

From: krin135@...

To: texasems-l

Sent: Wed, Sep 1, 2010 7:00 am

Subject: Re: D-Sticks As A Baseline Vital Sign

Time out!

Alyssa: I think that Wes' finger was firmly in his cheek when he wrote

that.

Rick: Since Alyssa seems to have been responding to Wes, and not you, your

response is a bit beyond measured, ESPECIALLY since Alyssa has proposed a

research project evaluating the use of the FSBG as a reasonable additional

'vital sign' in a population suspected of a significant underdiagnosis of

diabetes. She's trying to replace 'best opinions' and 'dogma' with

research/science.

and anyone who knows Wes (and his apprenticeship with Mr. Grady) would

expect something like his response.

ck

In a message dated 09/01/10 08:40:58 Central Daylight Time,

rick.moore@... writes:

" But no, really - *I'm* the immature and inexperienced person here. "

If you are considering this a personal attack on you and not an attack on

the fact that we in EMS depend more on dogma than science then I would

agree with the sentence above.

Rick

Re: D-Sticks As A Baseline Vital Sign

> >

> > In a message dated 08/31/10 20:10:46 Central Daylight Time,

> > rick.moore@...

rick.moore%40stdavids.com > writes:

> >

> > Using your logic every time someone seeks medical care the care

provider

> > should run every diagnostic test available just in case they have some

> > process that may or may not be related to the chief complaint. That

> should

> > reduce the cost of health care nicely.

> > You should treat the patient based on recognized standard of care as

> > dictated by the chief complaint. And say you do find a normally

> responding

> > patient with a BGL of 500. What are you going to do about it Alyssa?

It's

> not

> > your job to diagnose the worlds ills. Even Internal Medicine docs

don't

> run

> > every test every time.

> >

> > Rick

> >

> > that being said, I could justify at least a finger stick BG on any

> patient

> > I saw in the ED based on any complaints of weakness (global or

specific),

> > mental status change from slurred speech to loss of consciousness,

loss

> of

> > energy, depression, anxiety, fall, blurred vision, headache,

nausea.....

> >

> > So how many patients do you think that I saw didn't need a BG?

> >

> > you check blood pressure, pulse and respirations on every patient,

even

> if

> > they don't have a history of hypertension, irregular heart beat or

lung

> > problems...

> >

> > the triage nurses ask about safety at home (including questions

designed

> to

> > identify abuse)...won't that also increase the cost of health care by

> > identifying people who need social service intervention?

> >

> > There are good arguments about using a blood glucose as a screening

tool

> to

> > identify folks who need further evaluation for diabetes....in order to

> > catch them earlier, before significant end organ damage is done, which

> *will*

> > ultimately reduce the cost of health care in most of those folks.

> >

> > I'd have to see a better argument than the one you have advanced, Mr.

>

> > before I condemned Ms. Woods' idea.

> >

> > I will admit that I was a bit unusual, being a physician who 'came up

> > through the ranks' and actually tended to listen to the reports of the

> Basics

> > and Medics (many of whom I helped train in my early career) that I

worked

> > with.

> >

> > That being said, even someone who 'felt normal' but had a field BG of

500

> > would deserve at least a referral for follow up after evaluation in

the

> > ED....and even someone who 'feels normal,' but has a BG that high

should

> be

> > considered for transport.

> >

> > ck

> >

> > [Non-text portions of this message have been removed]

> >

> > [Non-text portions of this message have been removed]

> >

> >

>

> [Non-text portions of this message have been removed]

>

>

>

[Non-text portions of this message have been removed]

------------------------------------

Yahoo! Groups Links

------------------------------------

Yahoo! Groups Links

[Non-text portions of this message have been removed]

[Non-text portions of this message have been removed]

------------------------------------

Yahoo! Groups Links

[Guest guest]

Which is why he is your apprentice....

ck

In a message dated 09/01/10 19:38:14 Central Daylight Time, wegandy@...

writes:

Hey, I'm the attending curmudgeon here! Wesley is still a resident.

GG

-----Original Message-----

From: krin135@...

To: texasems-l

Sent: Wed, Sep 1, 2010 7:00 am

Subject: Re: D-Sticks As A Baseline Vital Sign

Time out!

Alyssa: I think that Wes' finger was firmly in his cheek when he wrote

that.

Rick: Since Alyssa seems to have been responding to Wes, and not you, your

response is a bit beyond measured, ESPECIALLY since Alyssa has proposed a

research project evaluating the use of the FSBG as a reasonable additional

'vital sign' in a population suspected of a significant underdiagnosis of

diabetes. She's trying to replace 'best opinions' and 'dogma' with

research/science.

and anyone who knows Wes (and his apprenticeship with Mr. Grady) would

expect something like his response.

ck

In a message dated 09/01/10 08:40:58 Central Daylight Time,

rick.moore@... writes:

" But no, really - *I'm* the immature and inexperienced person here. "

If you are considering this a personal attack on you and not an attack on

the fact that we in EMS depend more on dogma than science then I would

agree with the sentence above.

Rick

Re: D-Sticks As A Baseline Vital Sign

> >

> > In a message dated 08/31/10 20:10:46 Central Daylight Time,

> > rick.moore@...

rick.moore%40stdavids.com > writes:

> >

> > Using your logic every time someone seeks medical care the care

provider

> > should run every diagnostic test available just in case they have some

> > process that may or may not be related to the chief complaint. That

> should

> > reduce the cost of health care nicely.

> > You should treat the patient based on recognized standard of care as

> > dictated by the chief complaint. And say you do find a normally

> responding

> > patient with a BGL of 500. What are you going to do about it Alyssa?

It's

> not

> > your job to diagnose the worlds ills. Even Internal Medicine docs

don't

> run

> > every test every time.

> >

> > Rick

> >

> > that being said, I could justify at least a finger stick BG on any

> patient

> > I saw in the ED based on any complaints of weakness (global or

specific),

> > mental status change from slurred speech to loss of consciousness,

loss

> of

> > energy, depression, anxiety, fall, blurred vision, headache,

nausea.....

> >

> > So how many patients do you think that I saw didn't need a BG?

> >

> > you check blood pressure, pulse and respirations on every patient,

even

> if

> > they don't have a history of hypertension, irregular heart beat or

lung

> > problems...

> >

> > the triage nurses ask about safety at home (including questions

designed

> to

> > identify abuse)...won't that also increase the cost of health care by

> > identifying people who need social service intervention?

> >

> > There are good arguments about using a blood glucose as a screening

tool

> to

> > identify folks who need further evaluation for diabetes....in order to

> > catch them earlier, before significant end organ damage is done, which

> *will*

> > ultimately reduce the cost of health care in most of those folks.

> >

> > I'd have to see a better argument than the one you have advanced, Mr.

>

> > before I condemned Ms. Woods' idea.

> >

> > I will admit that I was a bit unusual, being a physician who 'came up

> > through the ranks' and actually tended to listen to the reports of the

> Basics

> > and Medics (many of whom I helped train in my early career) that I

worked

> > with.

> >

> > That being said, even someone who 'felt normal' but had a field BG of

500

> > would deserve at least a referral for follow up after evaluation in

the

> > ED....and even someone who 'feels normal,' but has a BG that high

should

> be

> > considered for transport.

> >

> > ck

> >

> > [Non-text portions of this message have been removed]

> >

> > [Non-text portions of this message have been removed]

> >

> >

>

> [Non-text portions of this message have been removed]

>

>

>

[Non-text portions of this message have been removed]

------------------------------------

Yahoo! Groups Links

------------------------------------

Yahoo! Groups Links

[Non-text portions of this message have been removed]

[Non-text portions of this message have been removed]

------------------------------------

Yahoo! Groups Links

[Guest guest]

Hey, I'm the attending curmudgeon here! Wesley is still a resident.

GG

Re: D-Sticks As A Baseline Vital Sign

> >

> > In a message dated 08/31/10 20:10:46 Central Daylight Time,

> > rick.moore@...

rick.moore%40stdavids.com > writes:

> >

> > Using your logic every time someone seeks medical care the care

provider

> > should run every diagnostic test available just in case they have some

> > process that may or may not be related to the chief complaint. That

> should

> > reduce the cost of health care nicely.

> > You should treat the patient based on recognized standard of care as

> > dictated by the chief complaint. And say you do find a normally

> responding

> > patient with a BGL of 500. What are you going to do about it Alyssa?

It's

> not

> > your job to diagnose the worlds ills. Even Internal Medicine docs don't

> run

> > every test every time.

> >

> > Rick

> >

> > that being said, I could justify at least a finger stick BG on any

> patient

> > I saw in the ED based on any complaints of weakness (global or

specific),

> > mental status change from slurred speech to loss of consciousness, loss

> of

> > energy, depression, anxiety, fall, blurred vision, headache,

nausea.....

> >

> > So how many patients do you think that I saw didn't need a BG?

> >

> > you check blood pressure, pulse and respirations on every patient, even

> if

> > they don't have a history of hypertension, irregular heart beat or lung

> > problems...

> >

> > the triage nurses ask about safety at home (including questions

designed

> to

> > identify abuse)...won't that also increase the cost of health care by

> > identifying people who need social service intervention?

> >

> > There are good arguments about using a blood glucose as a screening

tool

> to

> > identify folks who need further evaluation for diabetes....in order to

> > catch them earlier, before significant end organ damage is done, which

> *will*

> > ultimately reduce the cost of health care in most of those folks.

> >

> > I'd have to see a better argument than the one you have advanced, Mr.

>

> > before I condemned Ms. Woods' idea.

> >

> > I will admit that I was a bit unusual, being a physician who 'came up

> > through the ranks' and actually tended to listen to the reports of the

> Basics

> > and Medics (many of whom I helped train in my early career) that I

worked

> > with.

> >

> > That being said, even someone who 'felt normal' but had a field BG of

500

> > would deserve at least a referral for follow up after evaluation in the

> > ED....and even someone who 'feels normal,' but has a BG that high

should

> be

> > considered for transport.

> >

> > ck

> >

> > [Non-text portions of this message have been removed]

> >

> >

[Guest guest]

Hey, I'm the attending curmudgeon here! Wesley is still a resident.

GG

Re: D-Sticks As A Baseline Vital Sign

> >

> > In a message dated 08/31/10 20:10:46 Central Daylight Time,

> > rick.moore@...

rick.moore%40stdavids.com > writes:

> >

> > Using your logic every time someone seeks medical care the care

provider

> > should run every diagnostic test available just in case they have some

> > process that may or may not be related to the chief complaint. That

> should

> > reduce the cost of health care nicely.

> > You should treat the patient based on recognized standard of care as

> > dictated by the chief complaint. And say you do find a normally

> responding

> > patient with a BGL of 500. What are you going to do about it Alyssa?

It's

> not

> > your job to diagnose the worlds ills. Even Internal Medicine docs don't

> run

> > every test every time.

> >

> > Rick

> >

> > that being said, I could justify at least a finger stick BG on any

> patient

> > I saw in the ED based on any complaints of weakness (global or

specific),

> > mental status change from slurred speech to loss of consciousness, loss

> of

> > energy, depression, anxiety, fall, blurred vision, headache,

nausea.....

> >

> > So how many patients do you think that I saw didn't need a BG?

> >

> > you check blood pressure, pulse and respirations on every patient, even

> if

> > they don't have a history of hypertension, irregular heart beat or lung

> > problems...

> >

> > the triage nurses ask about safety at home (including questions

designed

> to

> > identify abuse)...won't that also increase the cost of health care by

> > identifying people who need social service intervention?

> >

> > There are good arguments about using a blood glucose as a screening

tool

> to

> > identify folks who need further evaluation for diabetes....in order to

> > catch them earlier, before significant end organ damage is done, which

> *will*

> > ultimately reduce the cost of health care in most of those folks.

> >

> > I'd have to see a better argument than the one you have advanced, Mr.

>

> > before I condemned Ms. Woods' idea.

> >

> > I will admit that I was a bit unusual, being a physician who 'came up

> > through the ranks' and actually tended to listen to the reports of the

> Basics

> > and Medics (many of whom I helped train in my early career) that I

worked

> > with.

> >

> > That being said, even someone who 'felt normal' but had a field BG of

500

> > would deserve at least a referral for follow up after evaluation in the

> > ED....and even someone who 'feels normal,' but has a BG that high

should

> be

> > considered for transport.

> >

> > ck

> >

> > [Non-text portions of this message have been removed]

> >

> >