EMS Protocol Changes

[Richard B the EMT]

If you can get Drs. Kelly and Kaufman behind you, FDNY EMS protocols might get changed.

I'm going to expand on something Alex mentioned. Sometimes time is waiting for the one elevator working in a 26 story "Project" building to first get you up to the patient, then get back up to get you down. We've had number of good (and not so good, yet functional) hospitals close in the last few years. Once you get back in the ambulance, usually you're within 15 minutes travel time, nonetheless.

Then, you have road conditions like we've had from Sunday December 26, 2010, as we've been hit by a 20 inch deep blizzard, with some 6 foot drifts in some spots, Roads have not been plowed out, and our crews are carrying equipment in, and equipment and patients back out to the ambulance, covering several blocks on foot. We're trying not to have an episode like that one in "Philly" last year (think we had one, anyway, someone will post if the case).

[Alex Woo]

Thank you very much......

Thx Richard B. Its like when there's a big disaster; the cell phones are out and landlines are met w/ busy tones. S.O. needs to be expanded to help pts and the medic.....

[Paramagic]

I'm afraid I have to agree with Rock_Shoes: When the written form is the only means of communication you have, it is important that it is clear. Please remember that this board is accessed by health care professionals from all over the world, so "standard" abbreviations may not, in fact, be standard to them. You may not want to hear it, but it is clearly making it difficult for people to understanyd you, so you are hamstringing your own efforts by not observing proper grammar.

As to your questions, there are a number of things that need to be addressed when looking to change protocol. As fiznat has pointed out, you need ot be able to provide good evidence that the change you have mooted is going to be beneficial to the patient, and that the benefits will outweigh the risk. However, it doesn't end there. You also need to demonstrate that the treatment will be both clinically effective and cost effective. No EMS agency will institute change to protocol if you have a drug with NNT=5000 and a high cost to buy, store and maybe throw away.

Now, as for the specifics:

Nitrates for Acute Coronary Syndrome (ACS) or Acute Cardiogenic Pulmonary Edema (ACPE) - You will probably find this one difficult for ACS, but maybe easier to get in for ACPE. As has been pointed out, there is no benefit in terms of morbidity or mortality when using nitrates for ACS. That said, I disagree with RomeViking: Whilst an IV infusion is definitely easier to titrate, it is more costly to equip and run, and has no added benefit. In the scenario given, I would simply not give more nitrates. Just because you have it, doesn't mean you have to give it. Now, personally I can give as much SL nitrate as I feel is necessary, and I often do go above 3, especially in those Killip I ACS patients with big blood pressures, as we think it is probably important to reduce myocardial workload by reducing pre-load (with the understanding that evidence is lacking, as above) I certainly don't give morphine to vasodilate as morphine's vasodilatory effects are unpredictable.

However, for ACPE, nitrates and CPAP are the treatments of choice, and I think you could mount a much stronger case to continue with SL nitrates in these patients.

Albuterol/Atrovent. I thnk you could mount a reasonable case for continuous nebulized albuterol in moderate to severely unwell asthmatic patients, as it has been shown to be slightly more effective than intermittent nebulized albuterol and to have a good safety profile. Atrovent has a very long duration of action and you do not get much, if any added effect, so a single dose, or maybe two doses is ample.

Benzodiazepines for status epilepticus: If a patient does not respond to appropriate doses of benzodiazepines, it may be that they are not going to, and that a second line agent should be used. However, if you were to be giving repeated or large doses, I would suggest that some definitve airway care (such as Rapid Sequence Induction and intubation) may be required to be able to continue with treatment without needing to worry about airway/breathing. This obviously introduces a whole new level of potential complication. You might need to do a patient care record review to see how often your agency attends status epilepticus patients who do not respond to the doses of benzo that you have already. If it is a large number, it may be worth pursuing, if not, then I would expect the risk would outweigh the benefit.

Thiamine: Sorry, can't really get excited about this, maybe you can find some evidence somewhere that it is useful. I have my doubts though.

Finally, I don't think that physical distance to hospital is an excuse for not providing appropriate patient care. It's not mandatory to finish a protocol before getting to the ER, but you should always have to options, even for day to day business, not just extremes as we have been seeing lately.

[scott33]

...Because you are going about this the wrong way. If you are interested in influencing a protocol change in your region, you need EVIDENCE that the changes you are proposing will be efficacious, practical, and safe. That evidence cannot be found by simply referencing protocol in other regions and saying "but they get to do it." You need scientific research. Start here: http://www.ncbi.nlm.nih.gov/pubmed/

What fiznat said.

Alex.

Whereas your intentions may be commendable, your approach is really not. You seem to be clutching at straws here, and have yet to provide any evidence as to why you are asking for these changes. "What ifs" and "because other systems do it" do not count. You need to get your head into the books and come up with something that you could submit for professional peer review. If you want the powers that be to take note of your proposal, there is no point beating it to death here - why not look to get something published in a professional journal? The point is valid, that you should also be able to formulate your argument without reference to other systems. Just know that the northeast is not at the cutting edge of EMS.

NYC protocols are, and always will be, geared towards the most incompetent medic in the system, and we both know there are a lot of them around. The oral and written MAC exams allow no room for lateral clinical judgment or reasoning. It is a test in memorization. Pure and simple.

http://nycremac.com/2010/07/the-answers-to-the-test/

Good luck anyway, but I do think you are putting the cart before the horse.

[island emt]

Alex: If you can not form a simple sentence in the English language, how do you expect to have medical professionals that make protocol decisions to take you seriously?

If it wasn't for Richard's translation of your post, I still wouldn't be sure what you were talking about.

If you want to bring about change study all the current medical research and make a pitch based on evidence , not speculation or because someone else can do it.

[mobey]

That's why EMS won't progrees; nothing has been said to help me out. I'm asking for your treatment and I've told you mine. I want to make EMS care better. I've been fighting for positive change in NYC for years. I need to know how other areas are. That's why I posted this. I rather not hear that what I wrote is not grammatically correct... They're for the most part; acceptable abbreviations....

Sorry to sound like an a$$ here, but I just gotta say it: Part of progressing my profession is exposing incompetence, and keeping those who are not high functioning individuals out of the public eye.

To put it simply: I am not answering your questions directly because I do not want you going to MD's, Polititians, or media representing EMS because you present yourself like an uneducated, unprofessional, 16 year old girl texting her new boyfriend.

So I guess by holding you back, we are in fact, progressing our profession.

[Richard B the EMT]

Hmmm, I had not thought about it until just now, but someone pointed out that just because another area's protocols and/or guidelines says you can do something, does not have proof that the "whatever" is solid medical practice. Witness what happened during the NYC HHC EMS days: Brian Watkins, from Utah.

For blood loss, protocols stated to use the Medical Anti Shock Trousers, commonly called MAST. The device worked as advertised, but noone had thought about deep penetrating chest wounds, such as Mr. Watkins received during a mugging in NYC (He and his family were in town for the US Tennis Open). Theory was, the device would slow or prevent blood flow to the lower extremities and abdominal cavity, and keep the blood more into the heart/pulmonary/brain circuits. Mr.Watkins, through the use of the MAST, had blood available, but it was also available to be pumped out the penetrating chest wound. He exanguenated, the family sued EMS, the hospital where he had been taken, and, of course, the city. EMS changed the protocols from the then national standards, and started calling penetrating chest wounds a contra-indicator for MAST use. Eventually, MAST were removed from all NYC EMS vehicles, even if the state still has the protocols as manditory to be taught.

[Alex Woo]

Thank you all. The people that have commented that my message was done improperly. Obviously, it confused most. I apologize if that offended you. I am sorry that my message was unclear. So, I will re-phrase the question.

I have sent several requests for changes to the NYC REMSCO (The governing body for NYC EMS), regarding Protocols for Acute Coronary Syndrome (ACS), Acute Pulmonary Edema (APE), Asthma, Chronic Obstructive Pulmonary Disease (COPD), Seizures (Sz) and Altered Mental Status (AMS). Currently we have to call for more nitroglycerin (NTG) after 3 doses for ACS and APE patients. We have to call for more Albuterol for Asthma and COPD patients; after the standing order (SO) of 3.

After 2 doses of Benzodiazepine for Status Epilepticus patients, we must call for more. Thiamine (Vitamin B1) has been removed from AMS protocol.

I want the SO to change where the Paramedic can continue to give the medication without calling Medical Control. The reason is that there's only 1 Doctor and 1 Paramedic on Telemetry for the 5 Boroughs (NYC). In my experience working in NYC; I have been on hold for several minutes; there has been times where I waited 10 minutes or longer for the doctor. We learned time is heart and time is brain; so there should be no limit on the Standing Order NTG, Albuterol, and Benzodiazepines. We know that Vitamin B1 helps in breakdown of glucose. It also helps to correct nerve & heart promblems associated with Thiamine defficiancies. We learned the 6 rights of medication administration; this will prevent errors. Travel times can be underestimated depending on the hour and day. In addition, pedestrian and motor vehicle congestion can assist in the travel time being delayed and egress to and from the scene. Also, the triage times can take up to 25 minutes in the ER especially with several hospitals closed in all boroughs which has effected the remaining hospitals. Lastly, care does not cease when you pull up to the Hospital ER bay. I feel my proposal will help the NYC(FDNY) EMS system, the receiving hospitals, the medics, and foremost the patients.

Please provide me the treatment for the said conditions, your city, state, & the website for your EMS Advisory Board. Thank you. Happy New Year.

[paramedicmike]

Does Google not work in New York City?

[mobey]

+1 from me for the re-write.

To be fair.

Sorry I am in Canada and cannot really help with your question though. Although I will say this; Rather than building your case on a foundation of "Ya but they can do it", use google scholar, and find studies that backup what you want to change. If Thiamine is important to you, research studies linking Thiamine to Wernickes and korsakoff's and present them with a well written request for prototocol change.

Then just repeat for the rest.

I doubt any MD will take you seriously if you just bring him print-offs of other services protocols. We in EMS are famous for complaining about other services having more "fun". If you just bring a piece of paper and say "This is what they get to do in Allentown.... why can't we?" You risk getting chalked up to another whiney Paramedic that is jealous of thier neighbors.