Protocols

[Bieber]

Hi everyone,

Well, it seems a cold day in hell has come upon us and I, of all people, have been offered the chance to write a set of protocols for a small and rural EMS service. The opportunity landed in my lap after a former classmate and colleague who works for this service (one of their only two paramedics) mentioned they were in the process of revising the protocols and asked me if I would like to write them for that service. I have been interested in this particular service for a while and had even been tempted to work for them, but for one problem: their protocols are absolutely atrocious. Not in that they're particularly bad in se, but only that the way in which they are written is completely incomprehensible. They include drugs not carried and exclude drugs that are carried. Because I don't think I could make heads or tails of their protocols if I tried, and because I refuse to work ALS if I can't or don't understand the protocols, I have thus far not sought employment with them. But thankfully, they've made the wise decision to clean up their protocols and I've been given a rare opportunity to take part in it, and though I am certainly not the appropriate person to do so I would like to give it my best shot.

I asked for a list of drugs they carried and was told that I could select whatever drugs I wanted, citing that with the new protocols they would adjust their drug stock as needed.

Now, I know the drugs used by the service I currently work for well, and I'm familiar with other drugs that we learned about during paramedic school, but having never administered many of them, I have less experience with them as many of you however there are several drugs of which I've heard good things and I'd like to get your input on them and on these protocols in general. I'm going to do some further reading on each and every one of these drugs, but I'm looking less for a textbook answer from you guys and more of your own personal experiences with these drugs and your opinions of them as clinicians.

As I develop these protocols, I'll add more to this thread and address each section individually, but for now I'd like to stick to the drugs alone. And so, without further ado, let's begin!

Pain Management

-Fentanyl - We carry this drug at my service and I'm a big fan of it, so I would definitely like to keep it here however I oftentimes feel frustrated by how limited we are in terms of providing pain management on a wider scale so I would like to consider some other options and get your feedback on them.

-Morphine - Though it's popularity seems to be fading, I still feel like there seems to be an appropriate time and place for this drug. As the service in question is about an hour away from the nearest hospital, and because if I recall correctly morphine lasts longer than fentanyl, it seems like it would be a good option to have. I know it's use in MI has been called into question, but what about for general pain management and its use in conditions such as pulmonary edema? I've heard from at least one paramedic that he's never seen anyone in acute CHF dry up as quickly as they did with morphine.

-Ketorolac - I've given it a couple of times, including once for kidney stones and though I haven't ever seen its effects firsthand (too short of a transport time), how do you feel it stands for mild to moderate pain and also, do you feel it's useful in the relief of pain secondary to kidney stones?

Antiemetics

-Reglan - Another drug we carry at my service, and one with which I've never had any problems but as a drug that I know seems to be falling out of favor, I would like to know where it ranks alongside two other drugs:

-Zofran - I've given it during clinicals and it seemed to work well. I know of a neighboring service that carries it and everyone there seems to be a big fan of it.

-Phenergan - Given it during clinicals, don't recall much about it to be quite honest. Between these three, which do you feel has the greatest effect on nausea with the fewest side effects and associated risks?

Bronchospasm

-Albuterol - Use it at my service, I'm used to it, seems to work fine for me. But (and this is for those guys who are big on RT) what about some other drugs such as...

-Xopenex - I've heard good things about it, never used it.

-Combivent - I know the hospitals around here seem to use it a lot. I know it's albuterol + ipratropium. Is there a big benefit to this over albuterol?

Sedatives

-Ativan - Real familiar with this drug. It's what we carry and it seems to work pretty good. But, having never used or administered any other sedative, I'd like to know how it stacks up against a couple of others:

-Valium - My service used to have it before I was here, don't know why they got rid of it to be honest. I know it has a pretty short half-life compared to the others, which may or may not be good for a service an hour away from the nearest hospital.

-Versed - The one experience I've had with Versed was not a good one. We had a transfer patient who was tubed and the doctor wouldn't give him anything more than some Versed and refused to give us an order for Ativan. The guy was bucking the tube by the time we got to the receiving hospital twenty minutes later.

Nitroglycerin

-Tablets - This is the way I've always given nitro, it works fine but it's not very controlled.

-Paste - I've heard this route is even less controlled than the tablets.

-IV Infusion - Don't know of any services around here that use it, but I've heard from a lot of paramedics that it's by far the most controlled way of giving nitro.

Those are the main drugs I'm curious about, but if anyone would like to throw in some other drugs for consideration or some ideas for these protocols, I'd be really interested in knowing your guys' opinion. There's no guarantee that my protocols will be approved, or even that I'm competent enough to make a decent set of protocols, but like I said I would like to try and hope I can do a half-way decent job of this.

[paramedicmike]

Where are you? "The Midwest" is a pretty big place. Are there state or regional protocols to which you may be bound? Or is each service allowed to create their own protocols with the approval of the medical director? Just thinking out loud.

Fentanyl: I like this drug. I haven't seen the problems others outlined in another recent thread. It's potent and works without the cardiovascular effects that morphine can bring. It is a bit shorter acting than morphine so having an extra dose or two can be beneficial if you have long transport times.

Morphine: Sometimes fentanyl doesn't work. Backups are nice to have. Especially considering that we should be aggressively attempting to manage patient pain. Morphine is a tried and true drug. Just make sure you have an anti-emetic handy for those who get nauseous with this drug.

Ketorolac: No experience with this.

I've used both Reglan and Zofran. They both work but not always that quickly. The earlier you can give it the better. In fact, if you think they may get nauseous later give it early.

Phenergan: I really like phenergan. I had a lot of success with the drug when we carried it. I know, too, that it worked exceptionally well for me with a food poisoning experience a few years ago. My vomiting stopped immediately. The nausea went away and it made me drowsy which was exactly what I needed at the time. The FDA had to step in, however, and require a warning for this medication as there were several cases of adverse outcomes. If you search for this drug it'll turn up a lot of info about the problems and the FDA's involvement. As a result of the required warnings it was removed as an option. I think you'll find this to be common in more and more places.

-Albuterol - Use it at my service, I'm used to it, seems to work fine for me. But (and this is for those guys who are big on RT) what about some other drugs such as...

-Xopenex - I've heard good things about it, never used it.

-Combivent - I know the hospitals around here seem to use it a lot. I know it's albuterol + ipratropium.

My experiences exactly.

Ativan and Versed I like and have found both to be very effective. Versed even has some nice synergistic effects with another drug that can do wonders with keeping a patient comfortable. I've never had any luck with valium. Ever.

NTG paste: We use this at one service for CHF patients we have on CPAP. That way we're not taking the mask off to squirt it under their tongue. It's slow but it works.

NTG infusions: Glass bottles are not very friendly to an EMS environment. That's all I'll say about that.

Instead of NTG tablets, consider the NTG spray. I've found that it's easier to administer than the tablets and works just as well.

Don't forget to use your current medical director as a resource. Good luck.

[Bieber]

I don't have time to respond to your thread in its entirety, but answering your question about where I am, that would be Kansas.

[crotchitymedic1986]

You have a golden opportunity that I hope you do not let slip by. Find the "best" most aggressive service in your state, get a copy of their protocols, and then go a little better with yours. Liberal protocols can be used as a recruitment tool to attract medics to this service, and whats wrong with being able to brag that you have the best protocols (plus, you may not have to recreate the wheel too much if the other service has a really good set). I have always preferred the "flow chart" style of protocols, similar to ACLS.

[tcripp]

What a great opportunity! Working in a rural service with transport times up to 1/2 hour to a local facility and 1.5 hours to a level I trauma, PCI, stroke center; I'll share what we use.

1. Pain management - we carry both fentanyl and morphine.
2. Antiemetics - Zofran.
3. Bronchospasm - We carry albuterol, xopenex and ipratroprium.
4. Sedatives - valium and versed. We also carry etomidate for RSI. Versed is the only drug we have IM for those occasions when we can't get an IV established.
5. Nitroglycerin - we carry paste, tablets and spray. I am currious why you say a tablet isn't very controlled? I'd think you'd say that about the spray.

Depending on how rural you are, in addition to these, might I suggest you also look at STEMI protocols (plavix, metaprolol and heparin), labetelol for hypertensive crisis, and RSI protocols.

Edited February 12, 2011 by tcripp

[fiznat]

This seems just bizarre to me. Why don't you have your medical director writing your protocols? Around here, protocols are written by a panel of doctors and are reviewed annually to keep up with the latest research. These kinds of decisions need to be based on science and come from a background of experience and education. I don't mean to say anything negative about you specifically, but it seems to me that there is *no way* a single paramedic should be given this kind of responsibility.

[Bieber]

Real quickly to clarify to everyone: the service for which I am writing these protocols is NOT the service I work for, nor do I have any formal affiliation with them at this time. I would LIKE to work for them, pending a protocol revision, however at this point in time I am ONLY writing their protocols for them. The reason for this is that their director is only an EMT and they only have two part time paramedics, one of whom approached me to write their protocols for them.

This seems just bizarre to me. Why don't you have your medical director writing your protocols? Around here, protocols are written by a panel of doctors and are reviewed annually to keep up with the latest research. These kinds of decisions need to be based on science and come from a background of experience and education. I don't mean to say anything negative about you specifically, but it seems to me that there is *no way* a single paramedic should be given this kind of responsibility.

The service I work for (not the service I'm writing the protocols for) has a protocol committee which submits protocol revisions to the medical director who must approve them and then they must be approved by the local medical society. The medical director of the service I am writing the protocols for, I can't speak for; however I assume that their standard is to write the protocols which must then be submitted to and approved by the medical director.

Also, with all due respect, while I agree that were this a larger service the protocols ought not come from a single paramedic, I do respectfully disagree that the protocols should not come from paramedics in general. I feel very strongly that in order for EMS to come into its own as a profession we MUST, absolutely MUST be the creators of our own destiny. As I've said before, I don't feel that I am the best person to write these protocols, but I have been offered the opportunity to do so and I won't shy away from it; and though I may be inadequate I intend to do my very best to provide a set of protocols that are grounded firmly in science (I've already included in my rough draft that oxygen is NOT to be given wantonly or arbitrarily) and that they are representative of the "best practice" and highest standards I can accomplish.

Paramedics ought to be the leaders in the field of paramedicine, and though I feel we will always need medical oversight, I also believe that we should be the ones creating our own protocols (to be approved by a physician) and not simply sit back and have no hand or no guiding hand in the practice of paramedicine. We need to be reviewing the current research and our current protocols and be able to justify everything that we do, and I feel that, though I may not be deserving or capable of this, I will surely try and in doing so play some small part in turning paramedics from "the guys who get their protocols from people who've reviewed the research" to "the guys who review the research and write their own protocols to be further approved by their medical director".

[paramedicmike]

Real quickly to clarify to everyone: the service for which I am writing these protocols is NOT the service I work for, nor do I have any formal affiliation with them at this time. I would LIKE to work for them, pending a protocol revision, however at this point in time I am ONLY writing their protocols for them. The reason for this is that their director is only an EMT and they only have two part time paramedics, one of whom approached me to write their protocols for them.

If you're writing protocols for them you're working for them. If you're not being compensated by this organization to do work for them then under no circumstances should you hand *anything* over to them.

If you're seriously interested in working for them then this could be your foot in the door. Even if it's only a contractual position you can still claim ownership of the work produced and be fairly compensated, by your own agreement, for the work you're doing. It'll also help prevent them from taking the work you've done and then deny you credit for the work which could cause problems should you claim the work on a resume and they dispute it.

Also, with all due respect, while I agree that were this a larger service the protocols ought not come from a single paramedic, I do respectfully disagree that the protocols should not come from paramedics in general. I feel very strongly that in order for EMS to come into its own as a profession we MUST, absolutely MUST be the creators of our own destiny. As I've said before, I don't feel that I am the best person to write these protocols, but I have been offered the opportunity to do so and I won't shy away from it; and though I may be inadequate I intend to do my very best to provide a set of protocols that are grounded firmly in science (I've already included in my rough draft that oxygen is NOT to be given wantonly or arbitrarily) and that they are representative of the "best practice" and highest standards I can accomplish.

I like the way you're thinking here. To a large extent I agree. But I hope you also realize that EMS as a whole doesn't have the educational foundation to do anything like what you're describing here. Of all people here on this forum you're one of the few who I know I don't have to explain the importance of obtaining such education.

As an aside, if there's any research you're dying to do this might be the perfect opportunity to start working on it. EMS is in dire need of evidence based medicine. You could be on the cutting edge, so to speak.

Just make sure you're being fairly compensated for your work. Doing it for free because the "experience is invaluable" unfairly puts you in a position to let them take advantage of you. There's a reason the word in the quoted phrase is "invaluable".

[HellsBells]

A few quick notes here:

Antiemetics- I would suggest stocking dimenhydrinate. It works very well for nausea related to motion sickness and narcotic admin.

ACS- Why not include a nitro patch? It is applied to the skin and gives a specific dose per hour.

I also agree with the previous poster. DONT do this work for free.

[Paramagic]

What a great opportunity! You will have a hard time finding a lot of research specific to out-of-hospital care, but search long and hard and present a compelling case for everything you can. In some cases you won't necessarily find any research, so it pays to think long and hard about why you may want to include certain drugs/interventions and to be able to present a clear and rational case for their inclusion when the RCTs don't exist.

With regards to specific stuff mentioned (and based on not much more than my personal preferences!) :

Morphine/Fentanyl: Have both, there is no real reason not to. Some people like one, others like the other, give them (and the patient) the choice. It also allows opiod coverage when someone is allergic to morphine. Consider ketamine if you can. It is an absolutely wonderful drug; safe, effective, can be given IV, IO, IM, Oral, won't knock off respiratory drive or airway reflexes and can be used as part of an induction for RSI as well (especially useful in patients with tenuous perfusion)

On RSI, if you are going to include a protocol, take a look at the Ambulance Victoria (Australia) protocol for this. To date they are the only people to carry out a high quality intention to treat study and show a benefit. RSI is a wonderful tool, but it has to be done perfectly or not at all. To my knowledge they do not include ketamine as an induction agent, but this can be included in yours (really, ketamine rocks!)

If you really wantt to be cutting edge, DON'T include heparin, plavix or beta-blockers for ACS. They cause nothing but harm (discussed briefy here by DP Gumby and I)

Good luck!