Protocols.

[Jdorr817]

Hello all,

My name is Jacob, and I am new to the site. Figured I get a post out there. My background; I'm 19 and I am an EMT-Intermediate in Virginia. I'm a employed with Campbell Cojnty Public Saftey, and I will be continuing on this fall for my Paramedic.

So here's what this post is about. My OMD is pretty aggressive. I have spoken with a few providers from different surrounding EMS regions and their protocols don't seems to be nearly as in depth as the ones I follow. So, how aggressive are your protocols? Do you wish they were more or less aggressive? What would you change?

 

[DesertMedic66]

My protocols right now are not very aggressive however they are slowly changing. I would like to see them be much more aggressive however I would like to see much more mandatory training for all providers. Our county is staffed with a lot of paramedics so our medical director is not able to see all of us, teach all of us, and test all of us.

 

[Jdorr817]

Where do you think it's necessary to draw the line with aggressiveness? My region has Advanced Practice Paramedics, and they carry drugs for DAI/RSI, Nitro Drips, Ativan, extra Versed, Fentnyl, Labetelol, Ketamine, and Cardizem. (which I's and P's just got ketamine available for pain management, but APs have it for fracture/dislocation reductions)

 

[Clare]

We have one national set of Clinical Procedures and Guidelines.

This contains both "procedures" which must be followed in a certain order; for example, cardioversion or pacing, as well as guidelines which should be followed but clinical judgement is required. For example if there is a good reason to do something different, omit something or add something else in then it can be done at the discretion of the Officer treating the patient.

An example of this would be giving high flow oxygen and beginning an IV adrenaline infusion on somebody with life-threatening asthma before starting nebulised salbutamol and ipratropium. Another example would be giving aspirin to somebody who you were not sure if they had myocardial ischaemia but the "overall clinical picture" did not lead you to diagnose myocardial ischaemia. There is no need to go all the way down the myocardial ischemia guideline. These are examples of modifying treatment for the benefit of the patient by using your clinical judgement.

It's a fairly comprehensive juggernaut at near on 300 pages and having used it for almost two years I still can't remember half the stuff in it

Regardless, the basic premise when attending a patient is: diagnose what is wrong, determine their healthcare needs and how best to meet them then having done that decide if the patient needs either a) treatment or b) referral to another health care provider from ambulance personnel and then if they need referral, how quickly and do they require transport by ambulance to get them there or not?

The CPGs are just a tool to help achieve that but you still need to apply clinical judgement at the end of the day.

 

[triemal04]

I'm sorry, but what part was aggressive? The part where your department created "advanced practice" paramedics to do the things that can and are done by many paramedics across the country as routine care?

You definitely should learn about what is and isn't "aggressive" patient care or protocols, what type of medical care is received prehospitally across the country, and more importantly, why things are this way and what is really best for the patient (despite what some people think).

Quick question for you: do you think that it is appropriate for paramedics to have access to dozens of drugs and the ability to use each of those drugs for multiple illnesses and in multiple ways?

Personally speaking, I would rather see someone with more limited options but who was well educated on those drugs, really knew when it was appropriate to use them, and did in fact have enough legitimate opportunities to use them to become well versed in the all aspects of their administration versus someone with a gargantuan drug box, no education on what they carry, and such limited opportunities to give them that they rarely do and have to manufacture reasons.

That's just me though.

 

[TransportJockey]

I used to run under some of the broadest SOP and guidelines in the country, and I do miss them sometimes... But where I am now is faily well in the middle of TX agencies in terms of aggressive, with things being set up to add more aggressive steps in the future with a credentialing proccess.

 

[Jdorr817]

I'm sorry, but what part was aggressive? The part where your department created "advanced practice" paramedics to do the things that can and are done by many paramedics across the country as routine care?

You definitely should learn about what is and isn't "aggressive" patient care or protocols, what type of medical care is received prehospitally across the country, and more importantly, why things are this way and what is really best for the patient (despite what some people think).

Quick question for you: do you think that it is appropriate for paramedics to have access to dozens of drugs and the ability to use each of those drugs for multiple illnesses and in multiple ways?

Personally speaking, I would rather see someone with more limited options but who was well educated on those drugs, really knew when it was appropriate to use them, and did in fact have enough legitimate opportunities to use them to become well versed in the all aspects of their administration versus someone with a gargantuan drug box, no education on what they carry, and such limited opportunities to give them that they rarely do and have to manufacture reasons.

That's just me though.

This post was by no means meant to make it seem that my region is the Alpha of EMS. In fact I'm quite ignorant to the amount of information out there, which is the actual purpose of this post. I'm a young ALS provider, and want to expand my knowledge on the abilities across the country. To answer you question, I don't believe that a Paramedic should carry around a pharmacy, however I think flexibility and options should be available.

 

[Carlos Danger]

Where do you think it's necessary to draw the line with aggressiveness? My region has Advanced Practice Paramedics, and they carry drugs for DAI/RSI, Nitro Drips, Ativan, extra Versed, Fentnyl, Labetelol, Ketamine, and Cardizem. (which I's and P's just got ketamine available for pain management, but APs have it for fracture/dislocation reductions)

Draw the line at what works and what you actually have the knowledge to safely implement.

To the greatest extent possible, protocols should be written with the goal of resulting in an improvement in the patient's eventual outcome, as indicated by the best available research. Research is how we know what works and what doesn't work.

Of course, sometimes it makes good sense to do things that either haven't been studied well, or aren't well supported by the research. Protocols should be written with this in mind. Some flexibility and latitude is important, but not too much flexibility, or otherwise why even have protocols at all?

"Aggressiveness", or "doing as much as possible" should never be an end in itself. The end we are after is an improved patient, not giving as much medication or performing as many procedures as possible.

Evidence-based protocols actually don't usually appear very "aggressive", and the things we think of when we hear the term "aggressive" are, in most examples that I can think of off the top of my head, not well supported by research.

 

[akflightmedic]

So following evidence based medicine which means sometimes actually doing less in reality is more PROGRESSIVE than aggressive?

We should be thinking how to provide the best care possible with the least invasive skills possible...that sounds very progressive to me. I think I like this...however it does sound like more knowledge/education is in order...progressiveness as opposed to aggressiveness. I dig it!

And friendly piece of advice...while you are happy to put your name out there and who you currently work for...I caution against it as it is not best practice. Sure you have nothing to hide and no issues, but there may come a day when you want to vent or speak not entirely positive things about your service or area...and having your name as a profile and your service listed for all could be bad mojo.

This has been proven many times over....now, will you be "progressive" and change it in the early stage following evidence based practice or you will be "aggressive" and throw caution to the wind?

 

[Jdorr817]

Maybe aggressive isn't the word I should have used. Sorry.

 

[NomadicMedic]

Maybe the question you want to ask is, "how much latitude do you have in creating an individualized treatment plan based on situation and presentation."

As a new medic, I worked in a system that had multiple analgesics, multiple benzo's, different drugs for RSI and a large amount of leeway in the practice. I moved to a system that had tighter protocols and fewer drugs. I found that my patient care was better when I wasn't trying to consider different drugs and treatment modalities for simple cases.

 

[medicsb]

As pointed out, there is a big difference between aggressive and progressive and they are not one and the same. You want to be progressive? Throw out ET tubes and laryngoscopes, throw out paralytics, throw out epi for cardiac arrest, throw out anti-arrhytmics aside from adenosine. Fire most paramedics. Fire ALL paramedics on fire apparatus. Most paramedic don't get enough experience to justify "aggressive" protocols that many have. An EMS system could provide great care with aspirin, albuterol, adenosine, SL nitro, epi 1:1000, morphine, versed, D10, NS, IVs no larger than 18g, O2, CPAP, BVMs (maybe an SGA, too), TCP, cardioversion/defib. Progressive, aggressive, etc. is largely about stroking egos. Anyways, I'm pretty ok w/ paramedics being able to do much more, but there is often as much regressive as there is progressive within a given EMS system.

 

[Carlos Danger]

^^ Very well put.

Exactly what I am always saying, but more concise than I usually put it.

 

[medichopeful]

As pointed out, there is a big difference between aggressive and progressive and they are not one and the same. You want to be progressive? Throw out ET tubes and laryngoscopes, throw out paralytics, throw out epi for cardiac arrest, throw out anti-arrhytmics aside from adenosine. Fire most paramedics. Fire ALL paramedics on fire apparatus. Most paramedic don't get enough experience to justify "aggressive" protocols that many have. An EMS system could provide great care with aspirin, albuterol, adenosine, SL nitro, epi 1:1000, morphine, versed, D10, NS, IVs no larger than 18g, O2, CPAP, BVMs (maybe an SGA, too), TCP, cardioversion/defib. Progressive, aggressive, etc. is largely about stroking egos. Anyways, I'm pretty ok w/ paramedics being able to do much more, but there is often as much regressive as there is progressive within a given EMS system.

I think that adding in some more opioid and non-opioid pain meds would be beneficial to patient care and comfort too. Having no options except morphine is pretty limiting, and I think that patient comfort is somewhere that EMS can really make a difference. I'd love to see APAP, Motrin, Toradol, and Dilaudid in that list!

 

[medichopeful]

Disregard. Double post