EMS Protocol Changes

[Alex Woo]

Because I want change I am retarded.... Change starts with ideas.... I am making an idea... This does not change with one person; it changes with a collection of ppl.... There are many who will be against it but there will be some who'll agree.... I am sorry if you believe my ideas are not valid and there is no science.... I reference the sources; who agree with what I am saying... Medicine is a practice and what paramedics know is just the tip of this iceberg.... So relax...

7. http://www.nlm.nih.gov/medlineplus/seizures.html

8. http://www.scdhec.gov/health/ems/rsi.pdf

9. http://medind.nic.in/iad/t05/i4/iadt05i4p263.pdf Page 3

These were the links that were broken... I apologize for that; I uploaded from my cellphone... These sites are respectable; written by physicians... Not all physicians agree; so your Medical Director might not agree with my Medical Director.... We don't have to agree but we must respect one's idea... I am looking at the big picture,... NYC EMS services millions of ppl; I am lookin out for the best interests for them...

My proposal is having options; when communication with telemetry has been a everyday problem for many Paramedics in NYC.... However, I do appreciate all the negative comments. It only makes my quest stronger....

Happy New Year....

[mobey]

Because I want change I am retarded....

Get off your pity pot.

No-one has critisized you for wanting change. Stop putting words in our mouth or you will be labeled a troll.

This does not change with one person; it changes with a collection of ppl....

Perfect... So you understand why we use studies rather than one MD's opinion.

I am sorry if you believe my ideas are not valid and there is no science.... I reference the sources; who agree with what I am saying... Medicine is a practice and what paramedics know is just the tip of this iceberg.... So relax...

This is not a case of us needing to relax. This is case of you getting off your goddam pillar and opening your frickin mind up to what actually works. You see, some of us have actually been educated in how to propose protocols to Med Directors. I have been about as patient as I can with you, and trying to help you understand what it takes to prove medicine, but to no avail. You continue to pout and reject reality to take the easy way out, and send off rediculously unprofessional emails to a MD, who probably shows it to his cohorts, so they too can laugh at you.

These sites are respectable; written by physicians... Not all physicians agree; so your Medical Director might not agree with my Medical Director....

You don't get my point; No one cares what 1 physician has to say. Medicine is proven by peer reviewed studies... studies..... studies!

Do you know what they call the student physician who got the lowest marks in class? DOCTOR. That is why no one changes thier practice on one MD's opinion.

Good Luck banging your head against the wall, and looking like an idiot.

[Alex Woo]

Thank you.... I'm done banging my head.

Its not that I'm not getting what you or others are saying but I was immediately criticized but that's fine. We can agree to disagree. My proposal is an infant propping its head up. My idea hasn't learned to put itself on its belly; it has not learned to sit up; it hasn't pulled itself up onto its feet...

I wanted to hear other fellow paramedics' treatment modalities in their respected region. I was insulted because I used abbreviations and that they were abbreviations for texting. Others commented on the grammar; I accepted that & I apologized and rephrase my question. I gave reasons why; I can show proof. I have life experience in NYC EMS; so I understand the system along with its drawbacks. I'm not changing other's protocols. I'm trying to change mine for the good of the patients. I am not asking for something we don't have or have not done before.

I'm also certified in Westchester & the Hudson Valley (HV) to work; the protocols there in HV allow for continued administration of NTG w/o calling the MD. We have Thiamine and Lidocaine: which NYC has eliminated. We have RSI and NYC has just benzo's & etomidate. It has Lasix in Standing Order(SO) but in NYC we have to call for it; when 1 year ago it was SO. I'm not proposing to change because others are doing it but in America when MD's argue about something that's not mainstream or FDA approved; they go with studies done overseas. Looking at other's success or method is done all the time; we all do it. Yet, I was insulted because I asked what others do. When ppl cross into one state from another; they are the same person; so why are treatment so different?

So, if I ask what others do; its to see how I can incorporate that, to make it better. That's what research is for; finding all variables and eliminate ones that do not belong. Its been beaten down on me in these posts; I shouldn't use this forum for question asking, when I can simply google it.

So, I am going to pound my head on the wall; since I'm an idiot. I've been pounding my head for years with the way NYC and NYS has handle its EMS affairs. I promised myself that I will make positive change in EMS & I will. Look at the Red Sox in 2004; they were referred to, as idiots but with hard work; they became the 2004 World Series Champions. Every dog has its day; the day so far belongs to the nay sayers but it due time I will have my day...

Thank you and hope your New Year will be prosperous. I do appreciate all the comments...

[Richard B the EMT]

In a small piece of defence for Mr Woo, he may have the same lack of spell check on his computer (can't seem to reactivate mine, either), and/or while a good Paramedic and administrator, has difficulty typing (I am just a fast and possibly prolific 4 finger typist, myself).

Inability to type, or use a computer, doesn't indicate lack of ability to formulate ideas that, while some here may or may not support, are genuinely believed to be as an improvement to all in our field.

[Alex Woo]

Thank you Richard B....

If anyone or any organization was to agree and want to assist in this sensitive matter. Many will proof-read before submitting. If I spell something wrong or use improper english; there is no defense. However, I reply from my cell and there is no spell or grammar check in this screen. No excuses; I phrase my question and points improperly; thus causing a snowball of insults. I am fine with all that...

I just hope my message, subliminal as it was, gets through to some and hopefully the some; are ones who can do something. I am just one person; I'd hope this forum would have helped my cuase, which I believe is just. However, most don't. That is what makes a person unique. If I cared what others said or felt; I wouldn't be where I am in life....

Thank you all.... Happy New Year.....

Also, thank you all who gave me a negative reputation; I see I have a -7. Really do not know what that is. If it was something really that would have affected me; then it would be bad. However, if it was; because I believe something that was not mainstream, I get a negative rating.... Awesome.... I am not offended; this just makes me more hungry for EMS change in NYC, NYS, and the USA..... I will continue to be contraversial; if that is what is necessary; then I will be the contraversial person....

Please really look at the whole picture... I am asking to change a protocol for the benefit of the patient... I've experience the Status Epilepticus; who seized for awhile prior to arrival and due to the thicknees of the walls, I had no cell phone coverage. We got him out of the apt in 25 minutes. We gave him 20mg of Valium; we didn't carry Ativan and 20mg was all we carried. We couldn't get a hold of the MD. He seized all the way to the hospital and seized 30 minutes more; the ER gave hime addt'l 20mg Valium and 8mg Ativan before he stopped. He seized for over 1hr and 15minutes. He ended up in the ICU. This prompt the EMS dept to have the medics carry more Valium and introduced Ativan to the EMS Dept. Before this, I'd asked the EMS Director; we needed to carry more Valium and we needed Ativan. Reason for not carrying more Valium and having Ativan. The closest hosptials are all w/in 10 minutes and Ativan wasn't cheap and it was not EMS compatible. Because we didn't get orders; we had no cell coverage; we were restricted. The General Operating Procedures (GOP); clearly states that if the medic is out of contact with Telemetry; they can only perform Standing Orders and transport. Easy on paper but not practical. The GOP also stated that the protocols are to be used with good clinical judgment. Many will argue that we broke protocol and deserved the restriction, regardless of the reason.

I do not want my medics or any medic to have to be place in this or any situation similiar to my experience. I believe that if the medications are standing orders; then to repeat or max out must be in standing orders. Ex. Nitroglycerin, Albuterol, and Benzodiazepine...

[Paramagic]

Ok, I'll try again. It is admirable to want to change your practice or the practice of your service for the benefit of the patient. However, there is little that you have put forward that is of benefit to the patient. Continuous nebulized albuterol probably is, and in some situations (such as your seizure example) it may be useful to have further options for seizure management. But, as I tried to point out, it is not necessarily just a matter of everyone getting all the new toys. If you look at the big picture (as you ask us to do) the service has to train everyone in the use of these treatment modalities, have continuing education on them and supply the drugs or equipment (and possibly thow away a large amount of what they supply if it is something that doesn't get used often).

All of this costs money; sometimes a lot of money. A sad reality of the world we live in is that we have to consider the cost versus the benefits in anything we would like to see instituted, as there is nevere (particularly for EMS) a bottomless pool of money to spend. When it comes to things like nitrates for ACS, which have been shown to have no impact on mortality and morbidity, or furosemide for acute cardiogenic pulmonary edema which has been shown to be bad for patients, it would seem pointless to lobby for spending more money on things that don't help. Hell, we are currently lobbying to have furosemide removed from our formulary because it never gets used any more!

Now, when we start looking at things like RSI (as an extreme example, although this holds true for all interventions) we have to start looking at not just the cost to implement and continue with the treatment modality, but also the risk involved versus the potential benefits. With RSI the risk is enormous, and thus far (certainly until the publication of Bernard's trial last month) there has been no benefit to the patient demonstrated. I would have thought that as an ambulance manager this would be something that you would have a good grasp of.

Now, with reference to your letter to the medical director: Not withstanding any issues there are with grammar, there is certainly nothing in this letter that would make me even consider changing any protocols. The sole reference you have provided that comes from a medical journal is from the Indian Journal of Anaesthetics, which does not rate very highly on impact factor. The article also doesn't actually address in any relevant way the issues you have put forward, so I'm not even sure why it is there. The rest of the references that are accessible are from websites dedicated to providing largely generic information to lay-people. Providing such links to your medical director is unlikely to impress him/her. You need to provide some decent references from peer reviewed medical journals to be able to support your requests, not consumer health advice from the internet.

It really isn't relevant what other services are doing, what is relevant is what is the best for the patient that can be sustained by the service. If you really want to effect change you need to be prepared to support it with evidence and clear rationales.

[medicgirl05]

My protocols allow for 3 NTG SL sprays as long as the BP is ^90 systolic. If the pain is not relieved then we move to morphine.

We administer 2 doses of Atrovent before calling medical director for direction.

Valium is administered as we see fit.

We carry thiamine but I have never used it or seen it used.

I am lucky that our medical director is always a phone call away. We have 2 medical directors and we have both of their personal cell numbers and home numbers. For the most part I am able to do whatever I ask for as trust has been established in the 5 years that I've worked here.

I am at least 30 minutes from a hospital with the possibilty of being over an hour away depending what part of the county the call originates in and the level of care required for the patient.

Hope this helps.

[Alex Woo]

Thx medicgirl05.... Can you tell me what county and state you're from?

Happy New Year....

[Alex Woo]

Thx Paramagic... If that's the case; let's get rid of all treatment. We'll be Ambulance Drivers... I'm starting a dialogue. I'm just throwing out an idea. I am one person; I believe as Paramedics; don't just tell me the STEMI; give my NTG drip, Heparin, ARB, ACE Inhibitor, Clorigel; these reduce mortality and morbity. We can't; so we need to do the next best think; vasodilation and reduce preload until pt is at the ER, triaged, and a stretcher found. This can take time in NYC. We are always delayed triage and stretcher. So what can we do? Continuing NTG SL q 5mins if Chest Pain persists and patient remains hemodynamically stable. We used to give Nitropaste but they took it out over 1 year ago. As for Albuterol your probably write; Epinephrine, Magnesium, Solu-Medrol are all standing orders. I want continuing Albuterol as an option. Seizures; we can give 2 doses of one Benzo; Valium, Ativan, & Versed. You can't used another Benzo; you must stick for one under SO. I want the medic to continue to give or max out w/o callin; along with alternating between Valium and Ativan... Your right I need science; won't need studys if we mirrored Emergency Medicine.... Diuretics.are the cornerstone in treating APE. We have to be careful of mineral loss.

I'm just saying. NYC will conform to change.... I wish EMS/PHC could mirror Emergenncy Medicine. We should follow ACLS, PALS, AMLS, PHTLS, etc. What's the point when we can't do most of what's in the ABC courses. Its a nice to know but you can't do....

[Alex Woo]

Thx Paramagic... If that's the case; let's get rid of all treatment. We'll be Ambulance Drivers... I'm starting a dialogue. I'm just throwing out an idea. I am one person; I believe as Paramedics; don't just tell me the STEMI; give my NTG drip, Heparin, ARB, ACE Inhibitor, Clorigel; these reduce mortality and morbity. We can't; so we need to do the next best think; vasodilation and reduce preload until pt is at the ER, triaged, and a stretcher found. This can take time in NYC. We are always delayed triage and stretcher. So what can we do? Continuing NTG SL q 5mins if Chest Pain persists and patient remains hemodynamically stable. We used to give Nitropaste but they took it out over 1 year ago. As for Albuterol your probably write; Epinephrine, Magnesium, Solu-Medrol are all standing orders. I want continuing Albuterol as an option. Seizures; we can give 2 doses of one Benzo; Valium, Ativan, & Versed. You can't used another Benzo; you must stick for one under SO. I want the medic to continue to give or max out w/o callin; along with alternating between Valium and Ativan... Your right I need science; won't need studys if we mirrored Emergency Medicine.... Diuretics.are the cornerstone in treating APE. We have to be careful of mineral loss.

I'm just saying. NYC will conform to change.... I wish EMS/PHC could mirror Emergenncy Medicine. We should follow ACLS, PALS, AMLS, PHTLS, etc. What's the point when we can't do most of what's in the ABC courses. Its a nice to know but you can't do....