medic182

Does a lactate level effect the way you treat a patient. I know it is a great indicator of cellular hypoxia and mortality, but is there a set protocol you follow. I.E. patient with stable vital signs but a lactate level of 5.0 would it change your treatment, or would you just treat more aggressively. Just thoughts I am putting out there. Donnie, RN, CEN, EMT-P

I am wondering if any ERs out there are doing bedside lactate monitoring via capillary to venous sample. Our flight crews do it, but we are not doing it in the ER, in fact it's not routinely ordered on patient's, even critical patients. If your ER is doing them are you finding it useful or not? I have researched lactate monitoring quite a bit and it is a really good measure of cellular hypoxia and a great indicator of mortality. Just wanted to get some feedback from everyone. Thanks Donnie RN, CEN, EMT-P

The patient should have been tested. The gold standard of care is a rapid HIV test and you should have results in less than 12 hours, usually with in an hour. If the source patient is HIV positive then starting on the anitretrovirals is extremely important. There has actually been no documented case of HIV transmission to a health care worker who started on meds right away. One week out is a little late I would think. I would attempt to find out what the source patient's results were and if they were negative I would just continue to with the labs. You should have labs at exposure, one month, three months, six months, and one year.

First things first. You can only do much with a code like this, so congrats on doing what you can do. Let's tackle one thing at a time. Difficult IV access. Gotta love the IV drug users with no veins, then with nothing circulating only makes things worse. IO was definately a good idea here. I have 10+ years as a pre-hospital medic and almost a year as an ER RN. The Narcan is the first thing I would have done, followed by epi and atropine. I would have considered hypoglycemia possibly late in the arrest, but it would not have been one of the first things I would have checked. It possible that the patient, and actually likely, was hypoglycemic secondary to respiratory depression s/p opiate overdose. The body was trying to get energy from anywhere and would burn glucose in the process. But be reminded, that though a blood glucose level of 37 is low, it is not likely to cause aystole. As far as blood from the ETT, it could be anything. If it was a bad intubation and in the belly then varcies is likely. If it was in the lungs then a pulmonary injury could have been the cause. I agree with someone who asked did the attending see blood in the airway, that would be a key piece of information. Well there is my two cents. Sounds like it was a bad code, but unfortunately with greater than 10 minutes of downtime without CPR, that patient was dead before they hit your back door. Keep you chin up, you did fine. Donnie

I agree.. I have been a medic for 7 years and now an ER RN. there is a huge difference! never in a hospital based setting should an EMT-P outrank an RN, that is the simple truth. Look at flight programs, they are required to have an RN on board to give blood, titrate drips, do assessments. Having evaluated paramedic throughout the country, precepted for many programs, there is no scenario that a paramedic should be doing the things listed by others in thsi thread, for example, chest tube insertion, RX writing, patient assessment, treatment plans, that is ridiculous and a huge liability, and to be quite honest, I think it might be an little white lie. This is NOT part of any paramedic's education or scope of practice. Mid-level providers should be CRNP or PAC only. From a logical stand point both CRNP and PAC have a minimum of masters level education, compared to a paramedic certification or an associates degree in paramedicine. Which brings me to a final resting point, RNs have a license, paramedic's have a certification. According to the DEA you must possess a license to write perscriptions, therefore, I call ******** on the paramedic being a mid-level provider. Here is the simple truth. Been a medic, Been a RN. There is a huge difference in teh amount of education and the scope of practice. I think both a medic and RN should be paid more; however, I think that the difference in pay is adequate. Though when I was a medic I didn't think so, but now being an RN, it is approriate. Ok I'm done now :)

I am trying to find information about triage regulations in the state of PA or anywhere really and I am unable to find anything concrete. Here is the situation our ER is in. We are a small community ER (11 beds), see an average of 70 patient's per day. Our previous process was this. A patient would come in the waiting room, sign in at the triage desk. The triage nurse would take there slip and give it to registration (on the other side of the waiting room) registration would register teh patient, the triage nurse would take the patient back to a room and finish their triage at bedside. (just to note, every single patient that comes into our ER, even a simple laceration, has to have a total of 11 pages of paperwork filled out including an entire database prior to the nurse or physician seeing them.) the triage nurse would hten go back out to their office and wait for the next patient and start over. If someone signed in with chest pain, SOB, CVA, etc they were brought right back, and registration was also completed at bedside. This process actually worked really well for our ER. Here is the problem. Senior adminsitration is now sayign that the triage nurse is not allowed to leave their office at all and then all paperwork should be completed at the bedside by the primary nurse. Senior administration is saying it is a law that the triage nurse is not allowed to leave the office and that the first person the patient is the triage RN. The only thing I can find is the EMTALA regulations that state a medical screenign exam has to be preformed prior to discharge, leaving AMA, or transfer, nothing that regulates the traige process. Any help would be great. Thanks