New Protocols

[Jamie Davis, the Podmedic]

What new protocols have you seen added recently or do you think will be added soon? As our treatments change and the expectations for patient care continue to rise. A lot of new protocol changes are in the pipeline and I wonder what are the new skills or meds you are looking forward to and which ones you are dreading? I talked about the recent changes in my protocols for Respiratory Distress related to Pulmonary Edema on the blog here.

[Scott Stewart]

This is the CPG used by Victorian, Australia Paramedics.

http://www.rav.vic.gov.au/Media/docs/40-CPG-A0701-Pulmonary-Oedema-...

[Jamie Davis, the Podmedic]

Scott,

Thanks for posting that link. We can start having a real discussion of the differences and similarities in our practices and maybe take some knowledge from another region and work to get a new protocol added to our own!

[Scott Stewart]

Re the MAS/RAV protocol, our treatment for APO has moved away from large doses of Lasix to focus on PEAP & GTN. This has meant less patients ending up intubated. My understanding is that this is in line with published evidence.

Scott

[Jamie Davis, the Podmedic]

I'm thinking that by APO you mean something like acute pulmonary edema? We, too have moved away from lasix and to using CPAP (continuous positive airway pressure) It has cut down on our respiratory distress intubations by quite a bit. We just had a class on CPAP and Capnography. I'm planning on a few features in upcoming episodes on both for the MedicCast.

How is capnography catching on in Australia? Here it is growing slowly but steadily in the EMS setting but many docs and nurses don't quite understand how much you can get from a good capnography waveform (just like an ECG).

[Dale]

Hi,

I'm just an EMT-B that volunteers for two different, very small rural communities. One in the small town I live in, and the one in the even smaller town I work in. I live in west central Minnesota. We've just recently added baby aspirins for suspected cardio problems. I know not a real big step.

But the most important thing for us out in these boonies, is to start treating these people more like major trauma cases. We have no level 1 hospitals for trauma or cardiology treatment. So everything much worse than a bruise or scrape has to be flown 100 miles or more to get appropriate care. So faster diagnosis for chest pains has become critical. The target is 90 minutes or less from dispatch to a table with a cardiologist 100 miles away. Paramedic intercept for many areas can be 20 to 60 minutes out. And only the 'Medics have a 12 lead. My home town service has a 3 lead, but that's not really good enough. And most services don't even have that. What we seem to be headed to is for every service to be equipped with 12 leads with built in tele-faxs. We would hook up the patient, push a button and fax the data right to the Doctor in the ER. The Doctor could then make the call that much sooner on the helicopter, while still getting his 'Medics rolling to us and hopefully make pre-hospital treatment plans. The only trouble is, money. Not every service would be able to afford it without a grant covering most or all of the cost.

Dale

[Jamie Davis, the Podmedic]

Dale,

Thanks for joining the discussion here at the MedicCast Forums. I consider myself in a Rural area (and I am for the Mid Atlantic region) but with distances like you mentioned, you win out over me. In cases like yours, good assessment skills and history taking are key to providing the best care and making the right choices for your patients.

What kind of additional skills do your EMT-Bs have vs the NREMT standard? For instance, can you start IVs or insert a combitube?

[Dale]

Hi,

We carry and use the combi-tube. Though not often. I've used one in the last two years. Due to distances and the fact we come from our homes or jobs to the firehall and then get going, means we might not be able to get to you fast enough. Sadly, we don't get many saves if we need to go far out of town.

We don't do IVs. That's a job for the 'Medics. And it's not just the extra training that we would all need. The real problem with us doing IVs is we just wouldn't do it often enough to stay good at it. And as you know there is a big difference between poking holes in the training dummy and trying to run a line on an 80 yr old patient with bad veins in the back of the rig going down the road at 80 mph. I'll happily let you 'Medics do that!

Otherwise we're pretty much a standard BLS. With variances for Epi-Pens and Glucagon and baby aspirin. We perhaps stress even more on CPR than most. But then, doing chest compressions for 30miles isn't for sissies, LOL! Due to the rural nature of the area, off road agricultural accidents are a concern. The patient can be a mile from the road. With fuel and chemical spills possible primary/secondary mechanisms of injury in addition to mechanical injuries and scene safety problems. And this being Minnesota, Land of 10,000 Lakes, boating accidents can happen in the summer. In the winter we have snowmobiles and ice fishing. In fact we'll be putting on the "gumby suits" and practicing cold water rescues next month.

dale

[0311_DoC]

Well here are ours. I don't think they are very progressive.

http://www.southernnevadahealthdistrict.org/ems/regs-manuals.htm

[Jamie Davis, the Podmedic]

Thanks for that link. You may not believe that your protocols are very aggressive but what specifically would you add that isn't there now? I think that maybe I need to add that to the to the topics list or start a new discussion. If you want to chime in live, join the discussion at the next MedicCast Live! in January (mediccastlive.com).
--
Jamie Davis, NREMT-P "the Podmedic"
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[EMT424]

Our region went to CPAP 8 months ago and we find it too new to look or morbidity/mortality results. I have used CPAP in conjunction with meds twice. Other than the patient freaking out about feeling like you put their face outside the window of a car moving 90 mph, the effects are great at our altitude (8,500 feet plus) and have really improved the pt. with minimum medication. CPAP is a better airway based treatment for PE and allows medications to be nebulized with good results of deeply-driven med's. I am less impressed with CPAP for severe asthma--the results are questionable if it really assisted those with a respiratory exhalation-type effect and barrelled-chest patients like COPD/Cor-pulmonae type pt.

[easi822]

Does anyone else have Asprin in your stroke protocol? We have it here in Alabama and I really like the idea. You obviously don't give it if you suspect a bleed, but if you suspect an ischemic stroke you use Asprin here and it does have a good positive outcome on the patients as to lenght of stay in the hospital and recovery time according to the work we are getting from our directors down in Montgomery.

[Paul Bond]

Easi822:
That's an interesting protocol. I'd be curious to see it (the protocol) and how the training is set up for the crews to recognize and differentiate bleed v. ischemia.
I'm all for expanding what EMS does. I'm also curious how it's mapped out and how the QA/QI/PI (or whatever buzz words your system is currently using for improvement and oversight) is done. Are your protocols available online? I'd enjoy reading through them.
Feel free to email me through here if you'd like.