EMS Protocol Changes

[Alex Woo]

Theses were the references; I see what happened.... Sorry about that....

Reference:1. http://store.emsinnovations.com/p-527-tracheostomy-kit-mini-trach-ii.aspx2. http://www.uptodate.com/patients/content/topic.do?topicKey=~WzGGul1rLjg2rmR3. http://www.medicinenet.com/congestive_heart_failure/page5.htm4. http://www.mayoclinic.com/health/pulmonary-edema/DS00412/DSECTION=treatments-and-drugs5. http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_WhatIs.html6. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH00007217. 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

I know what all the medications and procedures I have mentioned. I am fully aware.... I am just tired of the Doctors and Members of REMSCO just sitting around and doing almost nothing on a monthly basis. I want to throw something at them; so a dialogue can start. Maybe then things will change. I want others to see the problems we have in NYC and see something be done. It doesn't have to be anything I've mentioned but if I can provide the spark, then so be it.... NYC EMS is not the best service; we're only recognize because we are the largest and service the most people. Many EMS people come to NYC and visit; ask what we can do and we are not as advanced as they thought. I want NYC EMS to be the leader and the pioneer to EMS change. If I can get NYC EMS up to par with other services; I will but I will lead NYC EMS to be the best EMS service in the nation. I will.... Thank you everyone on this forum. Whether you agree with me or not; you all have helped my cause.... Happy New Year....

[p3medic]

NYC, tough nut to crack. You have FDNY, the death of NYC*EMS, multiple vollies, a medical directory who probably doesn't know any of you by name, a huge range of clinical abilities which makes most MD's write protocols directed to the lowest common denominator.

First, break away from FDNY back into a 3rd service model and let vollies take care of contracted facilities, leave 911 to a single agency with a group of associate medical directors (doctors) that are actively involved in the education and review of the city medics.

Next, pay a living wage.

Finally, admit the Yankees suck and join RED SOX NATION.

That is all.

Edited January 2, 2011 by p3medic

[paramedicmike]

Alex,

I seriously doubt you're trying to start a dialogue. You've done nothing but demonstrate that you're not willing to listen to advice if it doesn't support what you're already saying. You have, repeatedly, demonstrated that you're unwilling to accept advice and constructive criticism in an effort to help you improve your presentation. You have, repeatedly, demonstrated that you don't know what you're talking about in terms of medications and why they're on or not on the ambulance. You have repeatedly demonstrated either complete ignorance of, or an unwillingness to engage in, research to support your position.

You have received an awful lot of good advice from many people here. Most of that advice has been pretty consistent in its content. You've received an awful lot of patience from people who've responded to your posts. If you're only interested in having people agree with the manner in which you're going about this, this might not be the best place to continue posting. It seems pretty clear that while people don't disagree with what you're trying to do, there seems to be pretty consistent disagreement with both how you're going about getting it done and your qualifications to get it done.

If you're interested in pursuing this issue, please heed the advice you've been given so far in your multiple threads here. If you're interested in only listening to people agree with your methods and practices, it seems pretty evident that this isn't it.

Please. Get a clue.

[Alex Woo]

Thank you. I understand and I appreciate what everyone has said; good or bad. I've moved pass this; I've heard a lot of things from all angles and I will use what others have said and regroup and come back when I've done all the research possible but then this goes beyond making a dialogue. Like you've said; its cost money and many won't bother with it. So why would I? I am doing as must as I can with NYC REMSCO as I physically can; its not my job to change it; I can only comment and bring suggestions. That being said; NYC Protocols will change someway, somehow; for the sake of the patient, the medic, & the system.

If you worked NYC; you would understand my fustration because you would have it too... Until one walks in one's shoes, one can't comment. That is why I started a dialogue to hear what others are going through. I appreciate the service & system but there is no merit for striving to be the best in NYC; if you were in NYC; you would know what I'm talking about. Its an, us versus them, mentality. FDNY EMS isn't as good as they claim to be. This what all non FDNY 911 members have to deal with; FDNY making rules as it comes along. Hospitals won't back you thru the threat of patient steering & selective dispatching. Things FDNY do to make a point is unbelievable to others but for us; its reality. We have no say; non FDNY EMS. The NYC REMSCO liason to NYS Dept of Health has and will always be the Chief of FDNY EMS. Its the way it is... I want change and its come to a point were it must change or it'll break. NYC/FDNY EMS will break come 1/12...

[Paramagic]

I've done my best to be polite, respectful and helpful, but I seem to be coming up against a wall here.

I will use what others have said and regroup and come back when I've done all the research possible

I would like to think that is true, but a really have my doubts. If you were really interested in obtaining data I would have thought that you might like to know where I source my statements from. I'd be happy to furnish you with references, but it does not appear to be important to you, and while you are happy to agree with me without question when my statements correspond to your desires, you are also happy to dismiss out of hand any contrary position. It seems to me that you are interested in getting more "toys" rather than improving patient care.

Improving patient care has little to do with how many drugs you carry, and even less to do with what other services carry, but everything to do with the judicious application of best available evidence by well educated and experienced providers as an integrated part of the health system at large. I hope you come to this realization sooner rather than later.

[mobey]

Improving patient care has little to do with how many drugs you carry, and even less to do with what other services carry, but everything to do with the judicious application of best available evidence by well educated and experienced providers as an integrated part of the health system at large.

Quoted for relevance.

Possibly one of the most inteligent statements posted on this forum.

[fiznat]

I have to commend Mr. Woo on his ability to remain calm, relaxed, and consistently respectful throughout this thread. A lot of people have been pretty aggressive in their criticism of him here, and I am surprised each time he posts that the he hasn't blown up in anger or frustration. Well done for that.

For the OP: I understand your intent, but as I said about 4 pages back you really are going about this the wrong way. Passion is good, but you need to understand that the language doctors speak is the language of science. Linking to opinion pieces and web definitions shows doctors (and us!) that you're really not understanding how decisions are made in the field of medicine. In addition to that, your grasp on English writing is not good. It sounds like English isn't your first language. I don't mean that as an insult, but I think we've seen enough here to know that it is true. If you expect to be taken seriously, you need to have someone proofread your material before you send it out. Even the best ideas will be cast aside if they aren't presented in a coherent manner. If you care whether people pay attention to your ideas, you need to make some efforts on your side of the fence first.

Oh and by the way:

Improving patient care has little to do with how many drugs you carry, and even less to do with what other services carry, but everything to do with the judicious application of best available evidence by well educated and experienced providers as an integrated part of the health system at large. I hope you come to this realization sooner rather than later.

Nicely put, sir. Hats off.

Edited January 3, 2011 by fiznat

[Kiwiology]

We have unlimited drug dosages (within good clinical reasoning and prudent praxis) and no medical control whatsowever ... never have, never will

[NYCEMS9115]

I believe protocols need to reflect the needs of patients. We're hearing a lot on TBI and the NFL has big rules on Head Injuries and not allowing a player to come back until he's thoroughly examined and cleared. In NYS, we have a click it or tic-ket slogan to prevent MVA deaths; so why doesn't NYS/NYC push for helmet or ticket laws. We know the cost to treat TBI is staggering...

I've heard from one MD; that's right, one MD who gave a CME lecture on TBI at NY Weill Cornell; he was the Chair of Neurology at NY Columbia Presby. He was surprised that we couldn't give Mannitol; he believes & studies have shown its a great edema reducer & for the TBI pt with increased ICP; it works wonders; it is a mainstream medication. This lecture was given 9/10. Also, reverse tredelenberg also helps to lower ICP. I've done 8hrs CME on TBI after that one and each one MD who gave the lecture said the same thing. I've relayed lectures from these CMEs to NYC REMSCO; they haven't responded neither. I requested Mannitol to be in our head injury protocol and the notation about placing the pt into a reverse trendelenberg for moderate to severe TBI pts. It has been 2 months since I've sent emails to the region.

That being said; Mr. Woo, I hear you and I am also fustrated w/ NYC REMSCO. I agree that they do little to hear what providers say. Its a sad time in NYC EMS.

See:

http://emedicine.medscape.com/article/433855-overview

Updated 11/1/2010, so its pretty current..

We as EMS providers can guessimate the CPP. We can formulate the MAP by: (2x diastolic + systolic) / 3.... If the MAP is low (normal 70-110) then the CPP will be low. MOI and S/S will let you know that there's a TBI. Mannitol must be given; it takes 2-8hrs to work. Dose is 0.25-1g/kg q 4-6hrs. Its pricey but so are the cost for TBI pts....

[chbare]

However, you have not looked at the other side of the issue. You state that mannitol must be given, yet you do not provide a compelling case IMHO.

The evidence you presented actually presents a compelling case against pre-hospital mannitol administration in many cases.

Quoted from the article:

"Because mannitol causes significant diuresis, electrolytes and serum osmolality must be monitored carefully during its use. In addition, careful attention must be given to providing sufficient hydration to maintain euvolemia. The limit for mannitol is 4 g/kg/d. At daily doses higher than this, mannitol can cause renal toxicity. Mannitol should not be given if the patient's serum sodium level is greater than 145 or serum osmolality is greater than 315 mOsm."

Are you able to monitor labs in field? Are you able to assess or calculate serum osmolality in the field? Could you manage an electrolyte derangement if one occurred?

"Boluses of mannitol can generate a dramatic diuresis, resulting in rapid intravascular depletion and potential kidney damage. Mannitol can cause as much as 1500 cc of fluid to diurese in the space of 2 hours, as intravascular fluid depletion occurs, hematocrit can rise, blood viscosity can increase, and cloning is enhanced. This makes the area of brain irritation much more amenable to stroke."

Are you able to place urinary catheters and adequately monitor input and output?

We must be able to appreciate the benefits and pitfalls of implementing modalities. Physicians as well must decide what risks and benefits are associated with a specific modality and ultimately decide if a modality can be implemented in a way where benefits outweigh the risks.

Can you provide good, peer reviewed evidence that implementing a mannitol protocol in a system similar to your system leads to clear benefits in patient morbidity and mortality? If so, you should use this evidence, but also acknowledge the risks and find evidence or methods that will minimalise these risks. Unfortunately, a link to emedicine and a paragraph stating that mannitol must be given is less than compelling. It's great when casually discussing topics on this site, but inadequate when you are approaching medical direction or a committee about changing policy, procedure and/or protocol.

I have actually been involved in this process and failed miserably. At one point I really wanted my company to have a ketamine protocol. However, during my research, I could not find any compelling evidence that using ketamine was better than our current protocols. I wanted to use it, had good anecdotal experiences with it, but the reality was that the evidence was less than compelling to support company wide policy and protocol changes.

Take care,

chbare.