Making Requests for Protocol Changes

[Paramagic]

That's a good point, being able to point to AHA recommendations will carry a fair bit of weight for your argument.

[Bieber]

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.

I did read an article regarding it recently, as a matter of fact. Most likely the same one as you.

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

I think appropriate monitoring is (as you might guess) more appropriate than "thorough" monitoring. By that logic, we should put everyone on the monitor simply to be thorough. I don't think that SpO2 monitoring is, in general, too little when it comes to the administration of narcotics.

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.

Could you offer some examples of treatments the hospital might, could or would do for patients in cardiac arrest that we are unable to perform in the field? Furthermore, what's the point of transporting someone to the hospital if in doing so you greatly decrease the efficacy of the one thing that's one hundred percent certain to actually stand a chance of making a difference in cardiac arrest?

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.

The thing is, we're not emergency providers. We're primary care providers who occasionally dabble in emergencies, and as such, as need to equip ourselves to more appropriately manage primary care conditions. Treating minor to moderate pain with the appropriate pain management is part of that.

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.

Sorry. It would be intermediate level triage. And yes, it is a ridiculous, but currently if we do an EKG or start an IV, they're a yellow; and if they're a yellow, they get an EKG and an IV.

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.

I don't think SpO2 monitoring is inappropriate, however I don't think that an EKG is necessarily necessary.

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.

The truth is there is nothing more vital than CPR during cardiac arrest, and trying to perform just about any other treatment besides CPR during cardiac arrest risks interrupting it, which defeats the purpose all together. The science is clear, CPR is what saves lives, everything else is just the butter on the toast.

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.

Ketamine would be ideal, however I don't know if ANYONE around here is using it, not even in the hospitals. I don't really think fentanyl or morphine would be appropriate for a patient who is hemodynamically unstable.

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.

Yeah, that's true. I'm surprised that antipyretics don't help to reduce the incidence of febrile seizures, though. I really need to look up the standard model of care for sepsis and SIRS with regards to this protocol.

A worthy aim, good luck.

Thank you!

[Paramagic]

On my iPhone so quoting is a bit if a pain, so I'll just do my best.

Regarding SpO2 in patients with opioid analgesia on board, it really depends on what you want it to tell you an how it is used. If you are using it to identify hypoventilation, you will be well behind the 8 ball by the time the SpO2 starts to fall as the sats will hold for a remarkably long time in most patients who are hypoventilating or even apneic. In some circumstances it may be useful, but it is no substitute for eyeballing the patient. However, it doesn't really matter, it's non-invasive and cheap so as long as the limitations are recognized it is fine.

Anti-pyretics don't really have any role to play in the management of true sepsis.

For a polytrauma patient who is 'unstable' fentanyl is a good option for pain relief as it comes without the hemodynamic compromise associated with morphine.

[Bieber]

Anti-pyretics don't really have any role to play in the management of true sepsis.

Yeah, I know. I meant more of having a generalized protocol for patients presenting with a fever and/or SIRS/sepsis.

For a polytrauma patient who is 'unstable' fentanyl is a good option for pain relief as it comes without the hemodynamic compromise associated with morphine.

It's better than morphine, that's for sure. I think it can still cause a bit of hypotension, though nothing major.

[Carl Ashman]

Morning all,

Well, this has turned into a great discussion on myths in EMS.

FIrst of all, Here's the link about automated compressions in PCI (not exactly convincing results, but it's a start).

To adress some other points that have cropped up during the discussion:

Could you offer some examples of treatments the hospital might, could or would do for patients in cardiac arrest that we are unable to perform in the field? Furthermore, what's the point of transporting someone to the hospital if in doing so you greatly decrease the efficacy of the one thing that's one hundred percent certain to actually stand a chance of making a difference in cardiac arrest?

I already touched on this, potential organ donation is one issue.

. I'm surprised that antipyretics don't help to reduce the incidence of febrile seizures, though. I really need to look up the standard model of care for sepsis and SIRS with regards to this protocol.

Well, actually, the jury is out on this one. There is a body of evidence that would suggest there's no benefit. One of the inital problems is that paracetamol is often used incorrectly by parents in terms of dosages. Sponging the child has proven to work faster than paracetamol but the effect of the drug lasts longer. However it's benefit lies within symtomatic relief, something which you would hard-pressed to deny a child. As EMS providers we would nood see the long-term benefit of sustained administration but it is not necessarily bad practice to iniate it. As far as anti-pyretics are concerned in sepsis, I agree, there is little benefit as these pts need far more aggressive therapies like parenteral antibiotics and fluid monitoring and management strategies (basically an ICU bed).

Ketamine would be ideal, however I don't know if ANYONE around here is using it, not even in the hospitals. I don't really think fentanyl or morphine would be appropriate for a patient who is hemodynamically unstable.

Ketamine is a great drug and I am so glad to have it in my arsenal. However, it is not good practice to give it stand-alone. Ketamine works differently to other analgesic/anesthetic agents. It's a NMDA receptor agonist. It only shuts down those receptors that are responsible for conscious thought but not all senses. It can lead to intense dreams or nightmares and the so-called re-emergence phenomenon. This is where the patient literally screams his or her way back into consciousness. However, there is good news, this effect can be greatly reduduced by a co-commitent dose of a benzodiazepine. My personal choice is midzolam. I have recently been trying new options in pain management strategies (I have a very liberal protocol with lots of room for manoeuvre and a willing Medical Director). I recently attended an MVA with a young adult with multiple fractures. With a combination of ketamine 0.5mg/kg and fentanyl 0.01mg/kg topped off with a 2mg bolus of midzolam the pain score went from 9 to zero in less than a minute. Without snowing the patient under, either. She remained reasonably stable throughout the whole process. As far as I am concerned, ketamine has a great future in EMS.

Carl.

Edited April 7, 2011 by Carl Ashman

[Paramagic]

Morning all,

Well, this has turned into a great discussion on myths in EMS.

Ketamine is a great drug and I am so glad to have it in my arsenal. However, it is not good practice to give it stand-alone. Ketamine works differently to other analgesic/anesthetic agents. It's a NMDA receptor agonist. It only shuts down those receptors that are responsible for conscious thought but not all senses. It can lead to intense dreams or nightmares and the so-called re-emergence phenomenon. This is where the patient literally screams his or her way back into consciousness. However, there is good news, this effect can be greatly reduduced by a co-commitent dose of a benzodiazepine. My personal choice is midzolam. I have recently been trying new options in pain management strategies (I have a very liberal protocol with lots of room for manoeuvre and a willing Medical Director). I recently attended an MVA with a young adult with multiple fractures. With a combination of ketamine 0.5mg/kg and fentanyl 0.01mg/kg topped off with a 2mg bolus of midzolam the pain score went from 9 to zero in less than a minute. Without snowing the patient under, either. She remained reasonably stable throughout the whole process. As far as I am concerned, ketamine has a great future in EMS.

Carl.

Actually the suppression of emergence phenomenon with benzodiazepines is a myth. There are two direct studies into this, neither found a difference in the emergence phenomenon when midazolam was adminstered concurrently. Well, one did, but it was not powered to detect a significant difference. Certainly midazolam is recommended if emergence occurs, but it won't stop it occurring.

Wathen JE, Roback MG, Mackenzie T et al. Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double blind randomized controlled emergency department trial. Ann Emerg Med 2000;36:579-588.

Sherwin TS, Green SM, Khan A et al. Does adjunctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? A randomized double blind placebo controlled trial. Ann Emerg Med 2000;35:229-238.

McCarty EC, Mencio GA, Walker LA, Green NE. Ketamine sedation for the reduction of children's fractures in the emergency department. J Bone Joint Surg Am 2000;82-A:912-18

Green SM, Rothrock SG, Lynch EL, et al. Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases. Ann Emerg Med 1998;31:688-97

Green SM, Johnson NE. Ketamine sedation for pediatric procedures. Part 2: review and implications. Ann Emerg Med 1990;19:1033-46.

Green SM, Kuppermann N, Rothrack SG, Hummel CB, Ho M. Predictors of adverse events with intramuscular ketamine sedation in children. Ann Emerg Med 2000;35:35-42.

Edited April 7, 2011 by Paramagic

[Carl Ashman]

Actually the suppression of emergence phenomenon with benzodiazepines is a myth. There are two direct studies into this, neither found a difference in the emergence phenomenon when midazolam was adminstered concurrently. Well, one did, but it was not powered to detect a significant difference. Certainly midazolam is recommended if emergence occurs, but it won't stop it occurring.

Wathen JE, Roback MG, Mackenzie T et al. Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double blind randomized controlled emergency department trial. Ann Emerg Med 2000;36:579-588.

Sherwin TS, Green SM, Khan A et al. Does adjunctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? A randomized double blind placebo controlled trial. Ann Emerg Med 2000;35:229-238.

McCarty EC, Mencio GA, Walker LA, Green NE. Ketamine sedation for the reduction of children's fractures in the emergency department. J Bone Joint Surg Am 2000;82-A:912-18

Green SM, Rothrock SG, Lynch EL, et al. Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases. Ann Emerg Med 1998;31:688-97

Green SM, Johnson NE. Ketamine sedation for pediatric procedures. Part 2: review and implications. Ann Emerg Med 1990;19:1033-46.

Green SM, Kuppermann N, Rothrack SG, Hummel CB, Ho M. Predictors of adverse events with intramuscular ketamine sedation in children. Ann Emerg Med 2000;35:35-42.

Hello Paramagic,

Thanks for talking the time to reply.

I am aware of the problem in children, that's why I tend to steer away from ketamine in this patient group. My opinion was based upon administration to adults. I have never taken part in a study, so my evidence is anecdotal, but I have never seen a serious form of re-emergenge phenomenon in subjects that have been given supplemental midazolam in the 10 years I have been using it. I have, however, seen it in patients that were given just ketamine.

Carl.

[Bieber]

Okay, just to clarify, I'm well aware that septic patients don't get antipyretics as the standard care. I guess I should have said I would like to have a protocol for febrile (non-septic) patients AND a protocol for specifically septic patients.

Carl, you've offered one possible in-hospital treatment, PCI with continuous mechanical compressions. The studies I've read show that while it is possible, it's still an emerging science and I haven't seen any that directly address PCI following out-of-hospital cardiac arrests on their own. The fact is still the same that if you can't do adequate CPR while en route to the hospital, what's the point in getting them to a PCI center so they can have their heart revascularized and wake up with massive neurological deficits? I think that trying to get a return of spontaneous circulation on scene followed by PCI after transport to the hospital would hold more positive outcomes than transporting those patients before they've attained ROSC.

The second thing you've suggested is organ donation, and to be honest I'm a little appalled by that. Not because I'm against organ donation, because I'm not, but look at it this way. You want us to transport patients who are still in arrest, something which is known to greatly decrease their chances of survival, as well as put every provider in the back of the ambulance in harm's way (we, like most services in this country, don't have seating which allows providers to remain seat belted in while doing CPR), not for the purpose of saving the patient, but to save his or her organs. I'm all for organ donation, but our role is to try and save our patients, and to keep ourselves safe in the process.

[Carl Ashman]

Okay, just to clarify, I'm well aware that septic patients don't get antipyretics as the standard care. I guess I should have said I would like to have a protocol for febrile (non-septic) patients AND a protocol for specifically septic patients.

Carl, you've offered one possible in-hospital treatment, PCI with continuous mechanical compressions. The studies I've read show that while it is possible, it's still an emerging science and I haven't seen any that directly address PCI following out-of-hospital cardiac arrests on their own. The fact is still the same that if you can't do adequate CPR while en route to the hospital, what's the point in getting them to a PCI center so they can have their heart revascularized and wake up with massive neurological deficits? I think that trying to get a return of spontaneous circulation on scene followed by PCI after transport to the hospital would hold more positive outcomes than transporting those patients before they've attained ROSC.

The second thing you've suggested is organ donation, and to be honest I'm a little appalled by that. Not because I'm against organ donation, because I'm not, but look at it this way. You want us to transport patients who are still in arrest, something which is known to greatly decrease their chances of survival, as well as put every provider in the back of the ambulance in harm's way (we, like most services in this country, don't have seating which allows providers to remain seat belted in while doing CPR), not for the purpose of saving the patient, but to save his or her organs. I'm all for organ donation, but our role is to try and save our patients, and to keep ourselves safe in the process.

Looking at it from your point of view I would be appalled too. My personal safety is of paramount importance, always. However, we work differently to you guys. The code is worked onscene according to protocol. Then, a decision is made to transport if the patient falls into the trial category (<75yrs and no other medical conditions that contraindicate) The service in question then uses an automated compression device and a transport ventilator (as opposed to a BVM). The drugs would have been drawn up before hand and would be given whilst in a belted, sitting position. The monitor is also so positioned that it can be used from a sitting position. Organ donation is not the primary aim, by the way. Of course we are far more focused upon making a save but we also realise that we can't save them all and so try and make the best of a bad situation.

Here's a pic of the inside of the vehicle for you to understand a little better what I mean:

Carl

[island emt]

Excellent thread so far folks:

Bieber our young Jedi Knight

While we understand your thirst for being at the top of your game when it comes to prehospital care, you should not take the shotgun approach to changing everything all at once.

Treatment protocols have evolved over many years and most changes taking place now, are due to evidence based medicine as a direct result of honest studies being done in many places around the world.

I applaud you for your vigor in wanting to be the best you can be.

Addressing one of your requests : Selective spinal immobilization.

We have been developing this for many years and it has been a part of our protocol since the mid 90's. There have been several changes in the algorithm since version 1 which was developed by the wilderness medicine folks here. Then along came the NEXUS study with our then state medical director Dr. John Burton as one of the authors.

We learned that EMS has a very low <1% miss rate when this protocol algorithm is follow properly. Very similar to what the ER staff physicians have.

Here is a link to our state website with the selective spinal immobilization protocol and training material.

http://www.state.me.us/dps/ems/training_materials.html#spinal

My advice would be the same as others, Pick one or two items from your bucket list, do the research and then present them to your medical director for consideration.

Don't go in with the shotgun approach that someone else is doing XXXX so we should be also.

You youngsters are the future of EMS and soon will be taking over the reigns from us old timers.