Most Progressive Protocols 2017

[michael150]

Hey all. I am going to be doing a final essay in paramedic school and I just wanted to post on this forum to see what everyone thought. I am interested in progressive protocols and perhaps sometime in my career, be involved or start a movement for a nationwide set of protocols and more training for EMS. So, what EMS system, to you guys, have the most progressive protocols? Can you also post a link to your protocols?

Any help would be most appreciated and thanks in advance!

 

[Tigger]

If you can find a copy of Presido TX, you'll probably be done.

 

[michael150]

If you can find a copy of Presido TX, you'll probably be done.

Thank you so much! I will look into that!

 

[DesertMedic66]

A nationwide set of protocols is not going to be a realistic option. Our county is too varied for that to work or at least work effectively.

In Los Angeles you need different protocols since you have 5 hospitals on every street corner compared to another area where your closest hospital is 3 hours away.

 

[michael150]

A nationwide set of protocols is not going to be a realistic option. Our county is too varied for that to work or at least work effectively.

In Los Angeles you need different protocols since you have 5 hospitals on every street corner compared to another area where your closest hospital is 3 hours away.

I really appreciate the response and I realize that as of right now, it is basically impossible. Maybe not a set of protocols that are nationwide but I do believe that we can have a nationwide scope of practice (I realize that is a lot different than a set of protocols). I just do not agree with the fact that from state to state, we have different scope of practices and allowed to do different things or not do different things....

 

[Tigger]

A nationwide set of protocols is not going to be a realistic option. Our county is too varied for that to work or at least work effectively.

In Los Angeles you need different protocols since you have 5 hospitals on every street corner compared to another area where your closest hospital is 3 hours away.

Why can we not have nationwide protocols that everyone is accountable for? If you don't want to use every part of it, don't.

 

[DesertMedic66]

Why can we not have nationwide protocols that everyone is accountable for? If you don't want to use every part of it, don't.

Systems are different and have different issues/objects to deal with. Is RSI needed in LA when you are right around the corner from a hospital? Is RSI needed when you have a 2 hour transport to the closest ED? Do you need a ventilator in LA with the ED right around the corner? Do you need the ventilator when you are several hours from the closest ED?

Is it up to the individual provider to decide what protocols he wants or wants to use or is it up to his system to decide?

Fire departments vary on their policies and tactics nationwide (there are a lot of things that are in common but still a lot that are different). You are going to fight a high rise fire in NY different then you are going to fight a fire in some town of 500.

Police departments vary on their policies and tactics. LA county does not allow officers to use the PIT maneuver where as CHP does.

Even our local hospitals have different policies and procedures based on what works best for them.

 

[Tigger]

Systems are different and have different issues/objects to deal with. Is RSI needed in LA when you are right around the corner from a hospital? Is RSI needed when you have a 2 hour transport to the closest ED? Do you need a ventilator in LA with the ED right around the corner? Do you need the ventilator when you are several hours from the closest ED?

Is it up to the individual provider to decide what protocols he wants or wants to use or is it up to his system to decide?

Fire departments vary on their policies and tactics nationwide (there are a lot of things that are in common but still a lot that are different). You are going to fight a high rise fire in NY different then you are going to fight a fire in some town of 500.

Police departments vary on their policies and tactics. LA county does not allow officers to use the PIT maneuver where as CHP does.

Even our local hospitals have different policies and procedures based on what works best for them.

I understand that not every area needs the same things. In fact I actually work for a city service and one in the boonies, I see it every week and the guidelines reflect it. You can what if to death. Doesn't get around the point that the baseline education in this country for paramedics is woefully inadequate to practice in many areas. If an area doesn't want to use a provider's full education, that is fine, but forcing employers to bring their employees up to speed is backwards.

It is much more nuanced than your examples, some of which are a stretch. I work for a tiny fire district that's primary hazard is wildland interface. Yet we still train for high rise fires, just as the city trains for wildland. It is not emphasized as much, but we are exposed to it.

 

[DesertMedic66]

I understand that not every area needs the same things. In fact I actually work for a city service and one in the boonies, I see it every week and the guidelines reflect it. You can what if to death. Doesn't get around the point that the baseline education in this country for paramedics is woefully inadequate to practice in many areas. If an area doesn't want to use a provider's full education, that is fine, but forcing employers to bring their employees up to speed is backwards.

It is much more nuanced than your examples, some of which are a stretch. I work for a tiny fire district that's primary hazard is wildland interface. Yet we still train for high rise fires, just as the city trains for wildland. It is not emphasized as much, but we are exposed to it.

Educational standards and a national set of protocols are completely different. I am all in favor of a national educational standard.

The odds are you guys train in high rise fires differently from a fire department where that is a real possibility. The odds are you guys train wildland fires differently than the US Forest service. Yes, a lot of things may be similar however there is not one policy/protocol for all the different departments. As another poster on here has said “once you have seen one EMS system, you have seen one EMS system”.

 

[Summit]

@DesertMedic66 already pointed out that appropriate protocols for Urban areas differ greatly from Rural areas.

There are also regional environmental problems:

Does Montana need a Marine Envenomation protocol?
Does Alaska need a Snakebite protocol?
Does Florida need a Frostbite Protocol?
Does Georgia need an AMS/HACE or HAPE protocols?
Does Alabama need an Avalanche Resuscitation protocol?

Protocols are need based and need is population and practice environment based.

In nursing, where the education is generalist and then specialization occurs, you see different protocols at every hospital and in every unit.

@Tigger How about a broad national scope? Not as long as EMS education is technician/skills based... how do you choose what skills and meds to put in it without running into the same population/environment problems?

Even nurses vary their scope... between RNs! They have such a broad scope as determined by population and practice environment, it is totally impractical to generate multipage lists of skills and medications like you find for EMS in each state. Scope is usually nonspecific, being more like "Is something in scope? Did you learn it in school or is it a best practice that you receive specialized training on? And does your agency allow it? If yes, then it is in YOUR scope." Here is an example from your state: https://www.colorado.gov/pacific/dora/Nursing_Laws

@michael150 : make sure you figure out what a "progressive protocol" really means.
Is it the longest list possible of no-call-in protocols and whizbang skills like central lines and pericardialcentesis?
Is it appropriate evidenced based guidelines and independence matched to the provider skillset, patient population, and practice environment location?
Is "most progressive" for one agency really the "most progressive" for everyone?

 

[michael150]

@DesertMedic66 already pointed out that appropriate protocols for Urban areas differ greatly from Rural areas.

There are also regional environmental problems:

Does Montana need a Marine Envenomation protocol?
Does Alaska need a Snakebite protocol?
Does Florida need a Frostbite Protocol?
Does Georgia need an AMS/HACE or HAPE protocols?
Does Alabama need an Avalanche Resuscitation protocol?

Protocols are need based and need is population and practice environment based.

In nursing, where the education is generalist and then specialization occurs, you see different protocols at every hospital and in every unit.

@Tigger How about a broad national scope? Not as long as EMS education is technician/skills based... how do you choose what skills and meds to put in it without running into the same population/environment problems?

Even nurses vary their scope... between RNs! They have such a broad scope as determined by population and practice environment, it is totally impractical to generate multipage lists of skills and medications like you find for EMS in each state. Scope is usually nonspecific, being more like "Is something in scope? Did you learn it in school or is it a best practice that you receive specialized training on? And does your agency allow it? If yes, then it is in YOUR scope." Here is an example from your state:

@michael150 : make sure you figure out what a "progressive protocol" really means.
Is it the longest list possible of no-call-in protocols and whizbang skills like central lines and pericardialcentesis?
Is it appropriate evidenced based guidelines and independence matched to the provider skillset, patient population, and practice environment location?
Is "most progressive" for one agency really the "most progressive" for everyone?

I think what I mean by "most progressive protocol" would mean that we are allowed to operate fully and completely with our scope of practice as paramedics with more than one choice of medication to give for a procedure like...RSI. When a service has just one set of drugs for RSI like Midazolam and Succs, it takes away the option to give something else if there is a contraindication for either (ie. Hyperkalemia or a known sensitivity for either drugs). It comes down to as my instructor says: "We are at a crossroads in EMS, where we make the decision to either become a profession or skilled labor". Furthermore, I work with a nurse that worked Burning Man this year. When he came back, he was very blunt in the fact that he had no idea what he was doing there or what they needed him for. Even with his TNCC, CEN, and CCRN certifications, he felt like since they allowed medics to operate almost fully (if not fully) at their scope of practice, it was unnecessary for him to help staff the "emergency tent". I also think it heavily comes down to schooling and training. School needs to be longer than a single year with core pre-requisites like A&P, micro, patho, and pharm. Those are just my opinions and I know that I am very new to this. Thanks for any responses and I look forward to all of your input from everyone!

 

[GMCmedic]

Why do we need to carry more meds for a procedure that we do 1% of the time?

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[michael150]

Why do we need to carry more meds for a procedure that we do 1% of the time?

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RSI was just an example I was using. I apologize and do realize that RSI is not a commonly used tool in EMS.

 

[GMCmedic]

RSI was just an example I was using. I apologize and do realize that RSI is not a commonly used tool in EMS.

Understood.

Just FWIW I did the math for funzies and we intubate with drug assistance in less than 1% of our runs at this service. That number is probably fairly close across the country.

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[TXmed]

My problem isnt about the number of times performed, its about the number of times practiced compared to performed. That 1% (or less) is with a critical patient whose outcome depends on how this procedure goes. Yet ems services rarely practice this, and if they do its a good'ole boy "ehh you got it" system.


Progressive and evidemce based are different things. If evidence comes out that the new progressive drug youve been giving has an imcreased mortality, how would that look to the 100's of patients youve been giving too?

 

[michael150]

@GMCmedic understood completely and I also want to point out that on my ride-time, I have found that in instances that we should have RSId a patient due to losing an airway, we did not. I work at the L1 Trauma Center here that sees well over 250 patients a day (and it is primarily the point of transport for most critically sick and injured patients) and even the ED attendings/residents will point out that the patient should have been tubed. If we can do it in the field when we know that it is going to be done at the hospital anyway, why not do it? Like I said, I know that I am new at this but I just don't see how holding off things like that where it is either they have a patent airway or not, is arguable.

@TXmed I completely agree. It seems like we only do it that one time in the field every once in a while but when it needs to be done, it is emergent. Additionally, just with our luck it is a difficult airway like a pedi or an extremely obese patient with airway compromise. What drug are you specifically talking about may I ask?

 

[TXmed]

No particular drug or procedure.

 

[GMCmedic]

@GMCmedic understood completely and I also want to point out that on my ride-time, I have found that in instances that we should have RSId a patient due to losing an airway, we did not. I work at the L1 Trauma Center here that sees well over 250 patients a day (and it is primarily the point of transport for most critically sick and injured patients) and even the ED attendings/residents will point out that the patient should have been tubed. If we can do it in the field when we know that it is going to be done at the hospital anyway, why not do it? Like I said, I know that I am new at this but I just don't see how holding off things like that where it is either they have a patent airway or not, is arguable.

@TXmed I completely agree. It seems like we only do it that one time in the field every once in a while but when it needs to be done, it is emergent. Additionally, just with our luck it is a difficult airway like a pedi or an extremely obese patient with airway compromise. What drug are you specifically talking about may I ask?

Because sometimes the patient needs an airway, but they also need more hands.

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[TXmed]

Well in speakong with field RSI (which i am a fan of) alot of patients need to be rescusitated first.

Say for instance the trauma patient with a shock index of 0.9 or greater. Sure they may need an airway but what is worse for THIS particular patient. The questionable airway or post intubation hypotension ? Sometimes forgoimg the procedure so patients can be adequetly rescusitated BEFORE RSI can make a significant difference in the patient. So passing the buck to an ER or flight crew isnt necessarily a bad thing.

 

[VentMonkey]

@michael150 I see you're from Omaha, and can't help but wonder if you're a Creighton paramedic student. If so, when I was in Omaha last year it seemed to be a heavily fire-based EMS city.

I talked with one of their former students who said Omaha Fire still utilizes MS for pain management with no other option. In short, the impression left regarding the city's EMS system was hardly a progressive one.

With all of that said, kudos to you for wanting to push for higher educational standards. Just know that as everyone else has mentioned, progressive is definitely subjective. Having chosen a field that is chocked full of "strong-minded" individuals you definitely have your work cut out for you, so good luck.

As far as RSI goes, not to thread derail too much, but it really is best left in the hands of those that possess the crux of airway management, from alpha to omega.