Draft PA statewide protocols

[Medic26]

OK for anyone that is interested......these are the new draft statewide protocols. They are currently in the final stage of the approval process.

http://www.dsf.health.state.pa.us/health/l...protocols05.pdf

Any of the yellow boxes are optional areas that each region can modify. For some of us this is a step up and others a step backwards. But at least we have a starting point to even the level of care offered and maybe be able to move forward.

[fiznat]

haha yeah I was going to look through it ....till I found out it was a 106 page .pdf file haha. Lazyness has taken hold.

Anything you can pick out thats particurally controversial or that youd like to discuss?

[Medic26]

Not really....

But this has been a long effort from what we where informed. Currently each region in the state has designed its own protocols and practices from them. Some of these are VERY different with regards to where the command line is. Some services have had protocols where they NEVER contact medical command, these are the folks (as we are told) that have held up progress with regards to state-wide uniformity.

Improvements for our region is the addition of pain control above the command line in ACS and extremity trauma, the adition of phenergan, and the use of etomidate in leu of versed for sedated intubation (we hear its a much better drug). On the other hand, a few drugs we did not need command to give orders on before have to be given with medical control orders now. Most notable of these changes is in pulmonary edema......patients who are not normally taking lasix will now have to wait until we can get orders, instead of us being able to administer. We frequently have transport times > 30 minutes, so this will be an issue for us due to poor radio communications in some area's with no cell service for contacting medical control.

Oh yeah....almost forgot. The state has added the King LT airway as an approved rescue-airway. This is big news.

[1EMT-P]

I like their draft, I think they did a good job given the fact that some agencies are more advanced than others!

[fiznat]

Yikes.. you'll be needing on-line medical control to give lasix to patients without a previous Rx for it? Thats kinda scary! Whats the reason for that, has there been evidence of abuse/misuse of the drug? ...Are they not sure you folks can tell the difference between rhonchi and rales or something? ...Not like on-line medcon is going to help that at all. I dont get it.

Etomidate is a sweet drug. In my system, medics arent even allowed to sedate prior to intubation, but are given standing orders for versed once the tube has already been placed. Odd, I know.

[Medic26]

Yikes.. you'll be needing on-line medical control to give lasix to patients without a previous Rx for it? Thats kinda scary! Whats the reason for that, has there been evidence of abuse/misuse of the drug? ...Are they not sure you folks can tell the difference between rhonchi and rales or something? ...Not like on-line medcon is going to help that at all. I dont get it.

I have been told that this was a problem somewhere else in the state, as with everything else with progress comes headaches.

Regarding the sedated intubation, we've had that protocol in our region for about 5 years but using versed 5 mg withed mixed results. I also now see that they have written in a requirment for capnography effective in 2008, another smart move.

[Spock]

I've spent some time on these protocols and have mixed feelings. The capnography requirement is a good thing but there is alot of opposition because of the cost. As I have said before, if you do not have electronic capnography you should not be intubating. Etomidate will be more effective than versed for intubation but any medication assisted intubation must be reviewed by the local, regional, and state medical directors. I think the state does not trust the local docs to keep a close eye on this protocol. Strong medical oversight and QA is important for the success of any medication assisted intubation protocol but three levels might be a bit much.

The King LT has been approved and will be official as soon as it is published in the Pennsylvania Bulletin (a legal requirement) which will be before the protocols are approved. I'm on the agenda for our command system meeting next week and the medical directors support the King so we will start the training as soon as possible. I have an interest in getting the King in our trucks because I'm tired of having to change a combitube in the trauma bay. The King will be easier and safer. The last combitube I had to change was put in by a flight crew.

The lasix restriction may have been caused by idiots in my area giving it to patients with pneumonia. They changed the protocol instead of educating the idiots. I would mention that nitrates are considered more effective for emergency management of CHF than lasix. You have to give the lasix eventually but NTG will help more readily.

Live long and prosper.

Spock

[Medic26]

Spock,

I was surprised to read the requirement of 2 ALS providers in order to use the facilitated intubation protocol, ours is and always has been written for a single provider....Then again our region has not had many issues with bad tubes or poor providers. Combitube use is almost non-existant but we look forward to the King airway being added to our units.

The lasix thing was just a WTFO, we have CPAP anyway....used in conjunction with NTG we should have no problems.

The only question I have now after reading them agian is.......why are we giving suspected stroke patients a NSS bolus? Maybe I missed some new study, but wouldn't this promote more intracranial bleeding in the patients who are having hemorrhagic stroke?

[stcommodore]

I haven't been through it all but I think the Etomidate is a huge step foward, and hopefully a good one for the patients that require it.

[Spock]

I missed the NSS bolus for stroke patients. I'll have to look into it and talk to the state medical director if I see him this weekend. Perhaps it is to prevent hypotension? Hypotension is very bad since it decreases cerebral perfusion pressure (CPP=MAP - ICP) and causes ischemia in unaffected areas. When I give anesthesia for acute stroke patients in the angio suite I frequently have to run a vasopressor to keep the BP up. I usually use neosynephrine to keep the BP > 150 systolic. I don't think a fluid bolus would increase bleeding by itself unless you gave a couple of liters.

CPAP is a much better choice than intubating. Glad you have it up there because we can't get it down here. I think it is a good idea to require two ALS providers for the medication assisted intubation protocol. Nothing wrong with a back up plus one person can give the drugs and watch the monitor (pulse oximeter) while the other concentrates on the airway. I've done both in the back of a truck and would have appreciated having help.

Live long and prosper.

Spock.