Making Requests for Protocol Changes

[Bieber]

Hi everyone. How are you all doing? I'm well, getting over this bronchitis, working on my schoolwork, and hopefully upgrading to full time employment here soon.

As you all know, I'm not perfectly content with my system's protocols. Thankfully, we've recently gotten a new medical director, one who has previously worked in EMS and one who, from what I've noticed, means to improve the system. However our protocols have to be approved by our very conservative medical society, so I know that we're not going to be changing too drastically. Nonetheless, I remain undiscouraged and in fact challenged by this.

We're a very large system here, and I've never even met our new medical director, let alone all of our employees, and only our EMS director twice. Because of this, it seems like any interaction with them will be very formal, and even if it weren't, I like to be thorough. So I am beginning work on a presentation to try and explain to them what changes I personally think we should implement, and why. Besides having a conservative medical society, many of our paramedics and administrators seem rather conservative as well, and I know that to implement many of these changes (or to even have a chance at getting my voice heard), I will need to come well armed and well prepared, which is why I want to prepare and present to my medical director a very formal, well thought out and well researched presentation.

Unfortunately, even if I succeed in giving the kind of presentation I would like to, I know that I may be denied or even stigmatized for having the audacity, as not only a new paramedic but also possibly as a new full timer or even still just part time at the time of this presentation. All the same, I know the kinds of things I would like to see in my system and I want to give it my best shot.

I've listed below some of the changes I would like to implement, what I am asking from you is your advice on such presentations. If any of you have created such presentations yourselves in the past, I'd love to hear your feedback on how you produced and presented them. Right now my idea is to present each idea, explain why it is superior to the current system, and include studies and references that support it. For the record, I haven't yet gotten into the dirty work of looking up research articles to specifically cite, however on all the applicable issues I have previously read research studies that dealt with them.

Current Ideas:

Field C-Spine clearance (thinking NEXUS, but I need to do my homework).

Eliminating/downgrading the importance of MOI in Trauma Triage.

Eliminating some of the restrictions on EKG/IV application.

Reconsidering mandatory application of EKGs on patients to whom narcotics are administered.

Adding IV locks to our equipment.

Eliminating transport of code blue patients.

Changing cardioversion to standing orders.

Increasing pain management options/dosages, including to multisystem trauma patients.

Adding NSAIDs for mild to moderate pain for whom narcotics may be inappropriate.

Replacing mandatory oxygen therapy with clinically appropriate O2 therapy.

A standing pain/nausea protocol.

Increasing/adding dosage/drugs by standing order to the pediatric protocols.

Adding a protocol for febrile patients.

I'd also like to discuss treat and release options and primary care alternatives (referrals, etc).

Finally, and this is something I've been playing around with in my head, I'd really like to write a textbook/field provider's guide that includes all of those things that we SHOULD have learned in paramedic school. I want it to be a book that covers the full breadth of medicine much more than what we currently learn. I understand that it's arrogant to think that I could write such a text, but with no one else trying to create a book that covers ALL aspects of medicine specifically aimed at paramedics, I feel like this is something I can't wait for a smarter man than I to do.

So, come on. Tear my ideas apart or build them up, either way you'll be helping me.

[Carl Ashman]

Morning Bieber,

Well, I must say that you are very ambitious. One thing you'll have to remember is that Rome wasn't built in a day. If I were you then I would pick out 2 or 3 of these subjects on focus on changing those first. My choice would be c-spine clearance, standing orders for pain management and a reappraisal of dosages in the pediatric patient. You have plenty of other relevant "burning isuues" but these would be my priority. Yours may differ, I don't know.

I'll give you my take on the rest:

MOI in trauma is a good indicator of the types of injury one might expect. Don't forget that if someone does not intially present with symptoms then it's not to say there's nothing going on. There are many cases of particularly splenic and liver injuries with late on-set presentation.

Elimination on restrictions on EKG/IV application. What do you mean?

EKG/BP/Spo2 montoring of patients that have received narcotics or sedatives is good, safe practice. Why would you want to change it? The subtle signs that monitoring shows may alert you far more quickly to a impending problem.

Eliminating transporting Code Blue patients: Here I tend to agree, to a point. We all know the importance of BLS and that massage in a moving truck is pretty ineffectual. However, there is a progression towards automated compression with a Lucas or Zoll. This changes the rules somewhat as there is a growing body of evidence that suggests PCI (angioplasty) in cardiac arrest may have some effect. Also, we are currently trialling a new protocol which indicates transport in potential organ donors.

Cardioversion as a standing order: Agreed! Clinically unstable patients that do not respond to pharmacological agents need treating stat (God, did I just say, STAT? Shoot me..). I would however advise an adjunct protocol for the administration of a benzodiazepine. Cardioversion without Versed on board..Oww!!

Pain management: agreed! Multi-system trauma should not be excluded. If anything, they have more right to be medicated. Pain is a disabilatting factor that leads to higher mortality. Pijn management protocols should be linked to the individual pain score. My personal favorite is a combination of ketamine, midazolam and fentanyl..

NSAIDS? Mmmm.. I have limited experience of these drugs in EMS. The only real benefit I saw was with diclofenac in renal colic patients. Wouldn't be my first choice. Also, there really are not many patients by which opiates are contra-indicated.

O2 therapy only to those who need it: I agree wholeheartedly! By now we all know about the effect of 02 generated free radicals in the MI patient, don't we?

A protocol for febrile patients is actually quite easy: cool em' down and give IV/rectal paracetamol titrated to weight/age.

Treat and release options: One of the problems in US EMS is that most of the ground rules are based on the lowest common denominator. Whilst you come across as being a very engaged practitioner that is hungry for new knowledge, that can't be said of everyone. Can a part-time medic with a certificate from a paramedic mill school be trusted to make that decision? EMS needs to pull up it's boot straps nd make a degree mandatory before we take that route. (Or be a nurse-led profession, but I wouldn't want to offend anyone here..)

Here is the link to a presentation I gave in Pennsylvania last year, there is a relevant section on pain mangement in the middle. You have my blessing to reproduce, should you wish...

https://docs.google.com/present/edit?id=0Adxb-ZUzuZENZGdkendqcG5fMThkenJnZDZkMg&hl=en

Good luck with your crusade!

Carl

Edited to include link

Edited April 6, 2011 by Carl Ashman

[BEorP]

While I applaud your efforts, the first thing I would say is tread very carefully. You mentioned it in your post so you clearly understand the need for it, but it never hurts to emphasize it. This type of thing, not matter how tactfully you approach it, will rub some (many?) people the wrong way.

My main thought after reading through your list is that it may be better to focus on one specific issue for which there is significant literature that your current practice is not what is best. Transporting cardiac arrests may be the best one, but I don't claim to be familiar with all of the literature out there. Asking for protocol changes without evidence seems like it is just asking for trouble. This could be perceived as you (new, cocky paramedic [in their eyes]) thinking you know better than the physician-accepted best practices that have been put into your protocols and that you are better than the other paramedics who have worked under these for years. (It seems like it may be more likely to be interpreted this way when you talk about "conservative" protocols since this makes it seem like you are simply seeking more latitude or skills rather than a shift to evidence-based practice.) If you are able to approach it as wanting to be able to practice in line with what are the best practices based on solid evidence so you can provide the best patient care possible I think you may be received more positively, but you will need to only propose changes that have a true solid backing in the literature.

The next thing that I wanted to comment on is how you plan on getting your message to the medical director. I don't entirely understand the presentation that you are proposing or how exactly you would be presenting it to a medical director you have never met. Though I appreciate your desire to be formal with this, I think going too formal (as in a presentation) risks being perceived as arrogant or something similar. An approach that I might use if I were in your position would be to try to meet the medical director (for example at a recertification or something... hopefully there is at least a bit of an opportunity for some face time with the medical director even if you work for a large service) and even just talk to them to show them that 1. you're not an idiot and 2. you're not an arrogant prick. Making these two things clear from the start is important. This could be done even just by asking an intelligent question after a presentation they give or maybe asking a question about a unique patient presentation on a call. After that initial in person casual meeting, then I might follow up with an email saying how it was nice meeting them in person and I was curious about [insert name of protocol you'd like changed] since I have noticed a lot of literature that seems to point to [whatever] as being the best treatment. I would take the angle of being curious about the reason for our protocols given the evidence to the contrary rather than specifically asking for a change. Now, if your medical director is receptive then the answer may be that you're right and things should be changed. This is just how I would approach it, but of course there are many ways that would work. Just keep in mind that many medical directors have big egos and unfortunately even just asking them questions to try to improve your own knowledge can be perceived as you challenging them if it is not done carefully at least initially until they know the two key things about you.

The last thing I will say is that don't assume that just because you have a protocol that does't line up with the evidence means that your medical director doesn't know better. Especially in your situation where there is some other body that needs to approve the protocols, maybe the medical director has wanted to have field pronouncements since the day he got hired but knows that the other medical body would never approve this. These debates happen all of the time behind the closed doors of base hospitals without most of us ever knowing. The best example I can think of of a case where a known best practice was not used by a medical director was a clinically validated field pronouncement protocol that the medical director knew about that was not in use. How do people know he knew about it? Because he coauthored the paper on it. So just remember there is a lot more at play here. Your medical director may be on your side on this but it may not be worth the fight against other regulators for him.

Please don't let this dampen your enthusiasm. Anyone in EMS who is thinking is a good thing, even if that means questioning. I just know from my own mistakes at times that anything where you might make anyone in EMS feel at all threatened is something that you need to approach very carefully. Best of luck!

[NYCEMS9115]

Its going to be a long battle. You will meet resistant. I've been asking for continuous benzodiazepines for Status Epilepticus. Currently we can give 2 doses without calling OLMC. It used to be all OLMC orders. So, for the 13years I've been a Paramedic in NYC; they've made strives and Protocols have changed for the better or worst, several times. The Status Ep Protocol has changed only once. CPR Guidelines have changed more and our Cardiac Arrest Protocol has changed the most out of all Protocols: Bretylium out, 200 300 360J, 360J stacked, Lidocaine out, Isuprel out, 1:1000 Epi out, Pacing out, Vasopressin in, Amiodarome in, Vaso given no Epi, Vaso given Epi given, therapeutic hypothermia, IO in, ET route out, colorimetric in, colorimetric out, capnography in, D50 out, D50 out, Narcan out, Fluid out, and Procainamide out. These changes were not done on one shot; it changed every year for 5years. I feel NYC EMS Protocols cater to the dead more than the alive.

What I'm saying is, its going to be tough and you need an organization to piggyback on. Be ready to be questioned and your ideas will be debated. All the best.

[Doczilla]

My recommendation, before putting together a formal "presentation", is to look up examples of the protocols you desire in other EMS systems, as well as pull any relevant articles (looks like most of what you want is not really evidence based, but operational preference). Then, have an informal private discussion with the medical director 1 on 1. In my experience, this will allow him to get his head wrapped around it first, and he's in a good position to initiate the changes in the organization with potentially less resistance. If you go with a full on presentation to the MD and command staff all at once, then there may be other players that will want to shoot it down for various reasons such as resistance to change, desire not to do more training, concern for budgeting the training, and equipment, etc. Regarding the medical society that approves the protocols (assuming this is a panel of physicians that makes this call), let the MD handle it. That's his job, and it's better coming from another MD than from outside the panel.

'zilla

[Richard B the EMT]

One thing you'll have to remember is that Rome wasn't built in a day. If I were you then I would pick out 2 or 3 of these subjects on focus on changing those first.

Its going to be a long battle. You will meet resistant......What I'm saying is, its going to be tough and you need an organization to piggyback on. Be ready to be questioned and your ideas will be debated. All the best.

Choose your battles, study up on both pros and cons for whatever you choose to try and change.

[Bieber]

Wow, I'm surprised at how many replies I've already gotten--and I just woke up!

Thanks everyone for the prompt responses. I know, I am very ambitious. Patience has never been one of my defining characteristics, and when I see something I'd like to change, it's hard not to just dive right in both feet forward. I understand that anytime you try to upset the status quo you risk upsetting the wrong people, and that I'm going to have to tread very carefully. I'll try to address each of your posts individually.

Carl Ashman

C-Spine clearance would definitely be on the top of my list, and you're right I may have to condense my list a little bit. I don't expect all of them to get approved even if I am so fortunate to have some of them accepted.

MOI for Trauma Triage

I don't disagree that the MOI can be one indicator of the severity of injuries, but currently it's our only criteria by which we triage trauma patients by standing orders and leaves a lot to be desired.

EKG/IV Application

Currently, if it's one then it must be the other. And if it's either they must be code yellow. To be honest, I can think of a lot of excuses to do an EKG on somebody without necessarily thinking they need an IV as well; and vice versa. I would also like to move our practice to be more in line with that of the local hospitals; and I know that not every patient who gets an IV at the hospital gets put on the EKG as well.

Narcotic Patient Monitoring

This one I don't have so much of a problem with as many of the others, it's more about moving our practice in line with the hospitals. SpO2 monitoring SHOULD remain mandatory with all patients receiving narcs, but I know most of the hospitals around here don't automatically put them on the EKG as well. It's more about narrowing the difference between "EMS medicine" and "hospital medicine". (Don't take this the wrong way, I'm not trying to turn us INTO the hospital, only trying to make our practices more in line.)

Code Blues

I can't see us getting automated compression devices here due to their cost and the fact that we always have plenty of hands on scene to do CPR, to be honest. I hadn't heard about anybody doing PCI in the fully arrested patient, though, and I know they're not doing it around here. Could you share a link with me? In general, however, there's really nothing more the hospital can or will do other than the same stuff we're going to do on scene. Until there's a concrete benefit to transporting code blues to the hospital, which currently there isn't--at least around here--I don't think we ought to be transporting dead people.

Cardioversion

I agree!

Pain Management

Mhm. We certainly shouldn't be giving pain management to hemodynamically unstable patients, but with stable multisystem trauma patients? They deserve to have their pain controlled well.

NSAIDs

I agree. And while I'm more than happy to do what I can to take care of my patient's pain, I also realize that fentanyl may not be appropriate for every patient and I'd like to have some other options. We do have Toradol, but we give that almost solely for kidney stones.

O2 Therapy

Indeed. We're only required to keep sats at >97%, but all chest pains require at least 2 LPM by NC and I think that we can do without that.

Febrile Patients

This one I need to do a bit more homework on, but I think it would be good to have some options, especially for febrile pediatric patients.

Treat and release options

This one isn't going to happen. I know that it won't. But I want to introduce the concept, get it into their heads and make them start thinking about it, and realizing that it's happening in other parts of the world and that for EMS to become sustainable in this changing healthcare environment, we're going to need to really start reexamining our educational standards and our medical schedule of billing.

Thanks so much for your advice, and for sharing that presentation, Carl!

BEorP

Yeah, especially considering we're going to be having a major protocol revision sometime towards the end of this year, it's really hard to say whether or not these issues have already been addressed or if my medical director is already planning to change some of these things. I know that the medical director certainly talks with other physicians in our community, and I'm not sure exactly where those doctors are coming from but I have a premonition that they're not greatly enthused by the idea of changing too much of the status quo for EMS.

NYCEMS9115

Thanks for your advice! We're nowhere near the size of FDNY or even the old NYC*EMS, but we're still running more than a dozen trucks so I have at least of a glimmer of an idea of how tough it must have been for you to make any major changes within your organization.

Doczilla

Thanks, Doc. I've read the protocols of a few services that implement some of these changes I would like to see us have (Wake County EMS, for one), however sharing them with my medical director might be a good idea as well. You're right about meeting the medical director one on one, which is exactly what I was planning to do. I've always found that presenting alternative opinions on a one on one basis to always be better than trying to tackle the entire administration all at once. Thanks for your advice.

(Would have used quotes on all this, but they were giving me trouble.)

[fiznat]

MOI for Trauma Triage.....I don't disagree that the MOI can be one indicator of the severity of injuries, but currently it's our only criteria by which we triage trauma patients by standing orders and leaves a lot to be desired.

I don't know if you were motivated by it or not, but there is actually some recent research on this topic. I can't remember which journal it was in, but we just had a presentation on it and there were several articles which clearly showed that physiologic criteria is much more useful than MOI in determining severity of injury. When I get out of work I'll see if I can find the articles.

SpO2 monitoring SHOULD remain mandatory with all patients receiving narcs, but I know most of the hospitals around here don't automatically put them on the EKG as well. It's more about narrowing the difference between "EMS medicine" and "hospital medicine".

Regardless of what the hospital does or doesn't do, thorough monitoring of patients receiving narcotic intervention is good medicine.

Code Blues.....In general, however, there's really nothing more the hospital can or will do other than the same stuff we're going to do on scene. Until there's a concrete benefit to transporting code blues to the hospital, which currently there isn't--at least around here--I don't think we ought to be transporting dead people.

I think it is generally a dangerous idea to suppose that the hospital has nothing to offer a patient. I am all for a sensible and targeted protocol that eliminates transport of specific kinds of arrests (asystole/rigor/lividity, major trauma, etc), but I think broadly saying "no transporting dead people" is going a little too far.

NSAIDs

I agree. And while I'm more than happy to do what I can to take care of my patient's pain, I also realize that fentanyl may not be appropriate for every patient and I'd like to have some other options. We do have Toradol, but we give that almost solely for kidney stones.

I realize other people may disagree, but my feeling is that if it isn't bad enough for narcotics then it isn't an emergency, and probably doesn't need to be treated immediately in the field.

Febrile Patients

This one I need to do a bit more homework on, but I think it would be good to have some options, especially for febrile pediatric patients.

We have Tylenol for fever where I work, but I never use it. ...For the same reason as above.

[Paramagic]

Good work pushing for change. I agree that small steps are probably a good start, pick a topic, research it carefully and present it well. I would suggest picking one that has a really good evidence base, and that other services have demonstrated can be used without exposing the service to greater risk. C-Spine might be a good way to go, there is a lot of evidence for this.

MOI for Trauma Triage

I don't disagree that the MOI can be one indicator of the severity of injuries, but currently it's our only criteria by which we triage trauma patients by standing orders and leaves a lot to be desired.

MOI is a very poor predictor of injury, it's a good one to at least downgrade. I suspect you will never get rid of it entirely, but at least minimize the sillyness that goes with "OMG look at that MOI!!" There is a reasonable amount of evidence for how bad MOI is at predicting anything.

EKG/IV Application

Currently, if it's one then it must be the other. And if it's either they must be code yellow. To be honest, I can think of a lot of excuses to do an EKG on somebody without necessarily thinking they need an IV as well; and vice versa. I would also like to move our practice to be more in line with that of the local hospitals; and I know that not every patient who gets an IV at the hospital gets put on the EKG as well.

I don't know what code yellow means, I assume it is some type of triage category? If so, just doing an ECG or starting an IV should not be a reason for upgrading a triage category, that is just ridiculous! However I suspect you will not be able to find papers on this, so maybe leave it until you have been able to effect change elsewhere and maybe gained the trust of your MD.

Narcotic Patient Monitoring

This one I don't have so much of a problem with as many of the others, it's more about moving our practice in line with the hospitals. SpO2 monitoring SHOULD remain mandatory with all patients receiving narcs, but I know most of the hospitals around here don't automatically put them on the EKG as well. It's more about narrowing the difference between "EMS medicine" and "hospital medicine". (Don't take this the wrong way, I'm not trying to turn us INTO the hospital, only trying to make our practices more in line.)

As above, absurd, but if it's ingrained it will be hard to change. If a 22 year old basketballer lands akwardly and fractures his ankle, I will give him opioid analgesia, but why would I need to monitor his EKG or SpO2? Those are just surrogates for good patient care and monitoring by the provider.

Code Blues

I can't see us getting automated compression devices here due to their cost and the fact that we always have plenty of hands on scene to do CPR, to be honest. I hadn't heard about anybody doing PCI in the fully arrested patient, though, and I know they're not doing it around here. Could you share a link with me? In general, however, there's really nothing more the hospital can or will do other than the same stuff we're going to do on scene. Until there's a concrete benefit to transporting code blues to the hospital, which currently there isn't--at least around here--I don't think we ought to be transporting dead people.

There is actually a lot of research into the futility of transporting cardiac arrests to hospital, and there are papers that address specific criteria for field termination. However, this is perhaps an emotive issue, so maybe hang back as well on this one. I think it should change, it's futile, dangerous and absurd, but establish your "credentials" first. I'm not aware of any data on doing PCI during cardiac arrest, everything I have read is regaring PCI after successful resuscitation, so I would like to see some papers also.

Pain Management

Mhm. We certainly shouldn't be giving pain management to hemodynamically unstable patients, but with stable multisystem trauma patients? They deserve to have their pain controlled well.

Sorry, I strongly disagree on this one. If a patient is hemodynamically unstable it doesn't mean that they shouldnt get pain relief, it just means that you should adjust either how you give pain relief or what you give. Ketamine is ideal. Witholding pain relief to anyone who needs it is criminal in my opinion. Carl already touched on this, but there is ample evidence of the deleterious effects of untreated acute pain in the long term.

NSAIDs

I agree. And while I'm more than happy to do what I can to take care of my patient's pain, I also realize that fentanyl may not be appropriate for every patient and I'd like to have some other options. We do have Toradol, but we give that almost solely for kidney stones.

More options are always good

O2 Therapy

Indeed. We're only required to keep sats at >97%, but all chest pains require at least 2 LPM by NC and I think that we can do without that.

I won't flog this dead horse further but good luck!

Febrile Patients

This one I need to do a bit more homework on, but I think it would be good to have some options, especially for febrile pediatric patients.

Definitely do a fair bit of research for this, what you find may surprise you. Treatment of fever in pediatrics is quite possibly for the parents benefit than the childs. Anti-pyretics don't do much good for kids, they don't reduce the likelihood of febrile convulsions and should possibly only be given to patients who are actually distressed. Even then it is not clear that the fever is actually the culprit, rather the myalgia or other issues that accompnay or cause the fever. Don't forget that fever is a normal, healthy response.

Treat and release options

This one isn't going to happen. I know that it won't. But I want to introduce the concept, get it into their heads and make them start thinking about it, and realizing that it's happening in other parts of the world and that for EMS to become sustainable in this changing healthcare environment, we're going to need to really start reexamining our educational standards and our medical schedule of billing.

A worthy aim, good luck.

[usalsfyre]

Your two best bets are titrated oxygen therapy (sats >97%? That's absurd!) and transporting cardiac arrest. The AHA backs you on these issues.

You might find out how many accidents have occurred in the last five years during emergency transport. If you can't get them to stop transporting cardiac arrest, at least see if they'll reduce transport priority. Carflite and MedStar in the DFW metroplex recently did this.