EMS Protocol Changes

[Alex Woo]

I am not building a case with protocols. It was a like to know for me; so I can see how systems really differ. I like to find out from others; like if I was at an EMS Convention speaking to you. I just wanted to hear it from people in the same field instead of reading it off the computer. I guess I have to do more that apologize and rephrase.

As for google; yes I do. If someone asked if I can give a medication or not; can I treat and how. I would answer it regardless of their intentions. I can google it but what would be the point. Everyone on this forum ask others and they probably can google it. Its a regional question I'm asking, which is unique to that region.

So, I quess I don't need to ask since I can google it and this forum is not for asking peers anything. I guess I'm learning new things on this forum.

Thank you all. Have safe and wonderful New Year...

[paramedicmike]

This forum is absolutely directed towards asking questions. However, when undertaking a research project, I think you'll find people are more receptive to your inquiries if you demonstrate that you've done some basic research on your own before demanding help.

The information you're looking for is easily accessible on the web. If you had come here and said something to the effect of, "Hey guys. I'm looking for info related to this particular region and can't find it online. Can anyone help?" I think you would have gotten a much better response than what you've received from the demanding tone present in both your text message style and sentence fragment style posts.

Pick an area you want to research and then go to Google. If you still can't find it, then ask. But expecting people to do your research legwork for you is both disingenuous and irresponsible.

[Alex Woo]

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This was one of the emails sent to NYC REMSCO...

Ms. Diglio,???? ??

I am emailing you regarding our current ALS Protocols. I want to see more changes; which will benefit the Prehospital Provider, the Region, and foremost the patients. See my proposal.?? ??

502: Obstructed Airway. I understand why Cricothyriodotomy was taken out. The procedure is time consuming for something that barely provides any air to the choking patient. I worked upstate and we had the Quick Mini Trach Kit 1. It works and its quick.?? ??

504A: DRUG THERAPY OF MYOCARDIAL ISCHEMIA. Other than the STEMI and the requirement for 12 Lead; this Protocol has been stagnant. I believe that and its a Medical consensus, that NTG is every beneficial medication for ACS 2. I feel that SL NTG should be given every 5 minutes until the Chest Pain has been relieved or until care is transferred to a appropriate health facility without calling Medical Control. Calling can waste valuable time; time is heart.?? ??

506: Acute Pulmonary Edema. Currently Lasix is a Medical Control Option D. We all believe that Lasix's effectiveness is related to Renal functions. Lasix can take a while before the positive effects occur. However, Lasix is an important part in treatment of CHF 3. Lasix should be back in Standing Orders. In addition, NTG should be given every 5 minutes without calling Medical Control to reduce Cardiac Preload 4.?? ??

507: Asthma. Currently, ALS Providers must call Medical Control for more Albuterol/Atrovent after 3 Tx's. At the recommend O2 flow rate of 6LPM to produce the inhalable mist; the medication last about 10 minutes. It all depends on flow rate; which is dependant on patient's condition. Asthma (COPD) is an incurable; which causes narrowing of your respiratory airways and can lead to death 5. Regardless of transport time and the proximity of the hospital; the Unit could be extended triage and would need to continue to give the Beta2 Agonists/Bronchodilators while in the Ambulance Triage Area. I believe that continuous Albuterol/Atrovent Tx's should be Standing Orders.?? ??

508: COPD. Same as 507 rationale.?? ??

511: Altered Mental Status. Thiamine was taken out. Thiamine is Vitamin B1, virtually no side effects, necessary for sugar breakdown, and helps to correct nerve and cardiac problems for patient's whose diet doesn't contain enough Thiamine 6.?? ??

513: Seizures. Benzodiazepines are the mainstream medication for prolong seizures. If time is brain; then why do ALS Providers only given 1 dose with 1 repeat; Medical Control must be contacted for continuous Benzo's. We know if seizures last more than 5 minutes; it is classified as Status Epilepticus and this is a medical emergency; brain damage may result 7. If that's the case; then continuous Benzo's need to be Standing Orders.?? ??

GOP; Prehospital Sedation, Page 19. We need to incorporate RSI are part of the Sedation Protocol prior to intubation. It is an intense 10 hour course 8; which can be introduced into the NYS DOH EMT-P curriculum. Patients who need intubation, need to be sedated 9.  Complications may arise, where the EMT-P can not intubate but as long as mask ventilations is maintained, the problem is not emergent 9. ?? ??

I've emailed you my ideas on changing the EMT-P to an AAS only with CCEMTP training. I was wondering if you can bring all this, to the next REMSCO/REMAC Meeting. I am available to assist in this change. Thank you for your attention.?? ??

Reference:??

1. http://store.emsinnovations.com/p-527-tracheostomy-kit-mini-trach-ii.aspx??

2. http://www.uptodate.com/patients/content/topic.do?topicKey=~WzGGul1rLjg2rmR??

3. http://www.medicinenet.com/congestive_heart_failure/page5.htm??

4. http://www.mayoclinic.com/health/pulmonary-edema/DS00412/DSECTION=treatments-and-drugs??

5. http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_WhatIs.html??

6. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000721?? ?

7. http://www.nlm.nih.gov/medlineplus/seizures.html8. http://www.scdhec.gov/health/ems/rsi.pdf9. http://medind.nic.in/iad/t05/i4/iadt05i4p263.pdf page 3 

Regards,

Alexander G. Woo

[mobey]

I dunno man.

I don't buy it. Alot of the links were broken, and your protocol changes are full of questions and opinion.

507/508 you seem to equate Asthma and COPD as the same illness? Do you know the difference?

Why did you link to websites?

In healthcare we use studies to prove or disprove theories.

Perhaps I am too thorough, but the any protocol change I have seen has been a few pages of narrative, with multiple studies backing it up. If I were a Med Director and I got this email I would delete it, post haste.

I realize this is not an answer to your question directly, but if you are looking to improve your chances of these changes, a little critisism from those who know what it takes to be takes seriously can't hurt.

[paramedicmike]

My comments from your thread on proposed changes to the provider structure in New York are valid here.

Your grammar is atrocious.

Your inability to write complete sentences is embarrassing.

Your failure to create any kind of logical argument to support your position is laughable.

Your failure to offer any kind of current medical literature to support your missing arguments is... well, given your history here so far... is not unexpected.

The links you provide are either broken or are so generic as to immediately label your message not worthy of the attention of the reader.

Your desire to implement change is laudable. But based on everything you've presented here so far you don't stand a chance to change anything.

My suggestion, aside from what I wrote in your provider overhaul thread, is to go back to grammar school and start there. I think you'd be much better off in achieving your goals if you just started over.

[Alex Woo]

You all are right. I just wanted to start a discussion. I am no one; I'm just one person. This is not an overnight battle. Its a long time war. I appreciate all the comments, mostly bad. If I'm dumb to question something then I'm stupid for trying. I wanted to hear from others. I am really sorry to have brought it up. I'm in the beginning stages but obviously, I started it all wrong. This is going somewhere it doesn't need to go....

[mobey]

You all are right. I just wanted to start a discussion. I am no one; I'm just one person. This is not an overnight battle. Its a long time war. I appreciate all the comments, mostly bad. If I'm dumb to question something then I'm stupid for trying. I wanted to hear from others. I am really sorry to have brought it up. I'm in the beginning stages but obviously, I started it all wrong. This is going somewhere it doesn't need to go....

Jeez, I have tried to be really patient with you, and offer some constructive tips/feedback. But dude, you MUST show some dignity. When you post responces like this, it not only ends a good learning thread, but makes you look like a complete loser.

Don't sulk, chin up and find some studies that backup your requests. You should be learning about evidence based medicine and how it applies to protocols, that way MD's will take you seriously. This new position you have taken will get you nowhere.

[Alex Woo]

Thank you for your input; happy new year....

[scott33]

----------------------------

This was one of the emails sent to NYC REMSCO...

Ms. Diglio,???? ??

These question marks were not in the original email I hope.

504A: DRUG THERAPY OF MYOCARDIAL ISCHEMIA. Other than the STEMI and the requirement for 12 Lead; this Protocol has been stagnant. I believe that and its a Medical consensus, that NTG is every beneficial medication for ACS 2. I feel that SL NTG should be given every 5 minutes until the Chest Pain has been relieved or until care is transferred to a appropriate health facility without calling Medical Control. Calling can waste valuable time; time is heart.?? ??

No mention of hemodynamic parameters when giving NTG. You may find that after your first few doses of NTG, if the pain hasn't resolved, it probably isn't going to. Is your suggestion to keep dumping nitrates, or look at another treatment option? When you say it is a "medical consensus", you should provide a citation which backs it up.

506: Acute Pulmonary Edema. Currently Lasix is a Medical Control Option D. We all believe that Lasix's effectiveness is related to Renal functions. Lasix can take a while before the positive effects occur. However, Lasix is an important part in treatment of CHF 3. Lasix should be back in Standing Orders. In addition, NTG should be given every 5 minutes without calling Medical Control to reduce Cardiac Preload 4.?? ??

Wrong. Concrete wrong! Lasix has proven itself to be a terrible medication for use in prehospital care and REMAC are quite right to bin it. Studies have shown (see link) that the average paramedic cannot differentiate between wet sounding lungs of CHF, and that of pneumonia. That's the sad truth and if you give it for the latter, all you will create is a drier mucous plug which will be harder to treat. Additionally, many patients in CHF are not fluid overloaded. They just have a fluid distribution problem due to a decrease in LV function. Many a "CHF" patient has to get fluid boluses in the ER, due to field misdiagnosis by the paramedic. CPAP is the way ahead for the prehospital treatment of CHF - if you were current with EBM you would know this.

http://www.ncbi.nlm.nih.gov/pubmed/16531376

507: Asthma. Currently, ALS Providers must call Medical Control for more Albuterol/Atrovent after 3 Tx's. At the recommend O2 flow rate of 6LPM to produce the inhalable mist; the medication last about 10 minutes. It all depends on flow rate; which is dependant on patient's condition. Asthma (COPD) is an incurable; which causes narrowing of your respiratory airways and can lead to death 5. Regardless of transport time and the proximity of the hospital; the Unit could be extended triage and would need to continue to give the Beta2 Agonists/Bronchodilators while in the Ambulance Triage Area. I believe that continuous Albuterol/Atrovent Tx's should be Standing Orders.?? ??

And once again, after 3 treatments with no relief, shouldn't you be looking at some other interventions (mag, epi, CPAP)?

513: Seizures. Benzodiazepines are the mainstream medication for prolong seizures. If time is brain; then why do ALS Providers only given 1 dose with 1 repeat; Medical Control must be contacted for continuous Benzo's. We know if seizures last more than 5 minutes; it is classified as Status Epilepticus and this is a medical emergency; brain damage may result 7. If that's the case; then continuous Benzo's need to be Standing Orders.?? ??

No mention of the dangers involving continued benzo administration may cause.

GOP; Prehospital Sedation, Page 19. We need to incorporate RSI are part of the Sedation Protocol prior to intubation. It is an intense 10 hour course 8; which can be introduced into the NYS DOH EMT-P curriculum. Patients who need intubation, need to be sedated 9. Complications may arise, where the EMT-P can not intubate but as long as mask ventilations is maintained, the problem is not emergent 9. ?? ??

Forget RSI. It involves more than just sedating the patient. You are taking away their ability to breathe by paralyzing them. This is not a procedure without its many dangers, and not one to be taken lightly. RSI will be reserved for certain progressive systems, transport, flight and other countries. Everyone else will may just be left with intubating the dead, or even seeing a push towards the use of supraglottic devices in the years ahead.

I am sorry, but your email makes for painful reading. It seems that you just want to repeat standing orders ad-nauseum and limit contact time with MC. Reading your posts there may be a language barrier that has prompted all this, but nothing is going to change. NYC MAC protocols are becoming more simplified with each rollout. As I said before, there is a reason for that, and it begins with the level of provider in the system.

Edited December 30, 2010 by scott33

[NYCEMS9115]

I totally agrre with the change.... I hate having to be on hold with the MD.... I concur; good luck with this....