Why do people hate on LA County protocols?

ParamedicStudent

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Why? I don't get the hate for it.
Is it because you need a base order for most treatments?
I hear you can't perform ALS interventions unless there are two medics on scene. Is this right?
What else? Thanks
 

luke_31

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Cause for years the protocols were not much better then when they started even though medicine had advanced beyond them. That you have to call for just about everything and it didn't matter how critical the patient was, all the boxes had to be checked before the MICN would issue orders. Limitations on scope of practice and pharmaceuticals carried. All the stuff you learn as a paramedic student about half isn't allowed in LA county. That they focus on there being a hospital within 10mins from wherever you are, even though some of the county it can take at least twice that time to get to a hospital. With that focus they don't have good protocols or pharmaceuticals to go beyond first and second line treatments for some conditions and you can't get past first line on some. If you were an IFT ALS unit that needed to actually treat a patient you would spend half the time explaining who the f--k you were and then it's a toss up of getting the orders that you need. As a IFT paramedic you are basically a BLS transfer truck with a monitor, you can't transport any truly critical patients in the IFT setting. The closest you get is if you happen to be going from an urgent care to an ER and even then it was sketchy at best as to whether some of the transports were appropriate under LA County protocols. Basically any medicine that requires a pump automatically makes it a RN transfer because paramedics are too incompetent to use a pump (don't know about this, as I now use a pump on transfers where I work and they aren't that complicated). I got out of the system about six years back and where I'm at now we actually practice as paramedics with more autonomy and work directly with the ER doctors when we need to do something outside protocols or have reached the end of the protocol and need to ask for orders for one of the very few medicines or procedures that need orders ( all of which are high risk and not like getting permission for use of narcotics for pain management).
 

DesertMedic66

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Luke did a pretty good job at summing it up. Unless you want to be a FF/PM there is no way to be a paramedic on an 911 ambulance. The majority of FF/PM that I deal with focus solely on the FF aspect and only do the bare minimum PM training.

I don’t have any experience with LA county personally but I know several people who work in the system who hate it. The girlfriend is a TICU nurse who sometimes works in the ED with her father being an ED doctor (both at the same hospital in LA county) and they find LA county EMS a complete joke.
 

CALEMT

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People hate on LACo protocols because they want robot medics instead of actual clinicians and critical thinkers.
 

VentMonkey

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Firsthand experience here...it seems as though it’s more of an overall cultural issue than it is a protocol issue. I would even go so far as to say that the archaic set of protocols are by and large, a result of the culture itself.

Now don’t be mistaken, EMS and it’s overall culture is not exactly stellar, nor do we have the best track record when it comes to throwing words around such as “profession” or “professional”, but the pockets of providers and systems that do reflect a desire to see it through with regard to change and progress are clearly abundant.

With that, as I’ve mentioned in the past, even the most prudent clinicians can stand out in a sea of androids. If you can get past being a pariah in your line of work, with a short check-off list, and embrace a culture of tradition that’s designed to bestow little to no faith in your judgments as a field clinician—you’ll do great!

As an aside, accreditation as an IFT paramedic without a fire departments endorsement is absolutely deplorable, and quite frankly, depressing. It doesn’t (didn’t) seem like anyone wanted to be there, not even those who were going to be entrusted to provide “911” care, i.e., the FFPM’s. But again, remember, short check-off lists and traditions...
 

RocketMedic

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I laugh at SoCal EMS protocols (especially LACo) because they don't allow you to actually treat your patient effectively in many cases. No matter who you are (fire or private), you're not actually able to take care of your patients anywhere near as effectively as most of the rest of us can, and you don't really have revolutionary research, new ground or much of anything other than an overpriced, undertrained, disinterested squad of firefighters that can ask permission for some common treatments if they're so inclined (*which they are likely not) and a herd of BLS transports. Even in a state like CA, where we're subordinated to nurses and the whims of the nursing unions, LA County has terribly inadequate protocols.

Are patients harmed by being minimally treated? I don't know, to be honest, and there's not a lot of data in the wild for us field medics in Texas to get our teeth into yet regarding the long-term effects on morbidity, mortality and patient experience of screamingly advanced care vs minimalistic BLS care or "an IV" yet. To be honest, I don't know if the stable A-fib RVR I converted with diltiazem yesterday would have been harmed by waiting until we got to the hospital, or if her outcome would have been any different had I had to ask a nurse or a physician. I don't think she would have died on the ten-minute ride to the ED, and even a LACo medic can start a line, so in some ways, I can't directly claim the protocols I operate under are any better. People don't seem to drop dead in LACo that frequently for lack of fentanyl, and a lot of the more 'exotic' things we do are both really rare and can be diverted or otherwise done, and some of the most important things we do are basic, fundamentals that don't really need protocol wars to dictate. Frankly, I suspect that the vast majority of patient outcomes would look identical when compared between LACo and anywhere else.

However
Ours are a lot more accepting of perceived risk, in that we do a lot of things that would get my card shredded in CA/LACo (like field blood transfusions). Sure, risk might not be your cup of tea, but accepting risk also allows us to do helpful things for people, like provide effective pain management or more lifesaving things like emergent airway management via RSI. We can also do things more safely and are far faster to adapt to changes in medicine, especially because many of us can be actively engaged and involved in what we do without having to rassle with nursing and fire unions and all of that madness. It also allows us to try and do a lot more good work for our patients, which adds value to our services and provides us with a whole lot of new opportunities for patient care, professional personal and industrial development, and gets us paid more, better and treated as professional paramedics, not the hired help. Look at the fire departments in CA. Yes, they've got tradition and great marketing and American Heroes and all, but they're also the product of diversification of services into EMS. Their leadership saw the wave, started paddling, and they're at least pretending to surf it. If it wasn't for the EMS services that LACoFD / other FD provides the community (as weak as they are from my perspective), they would likely look a lot like CalFire or a Fire-only department like Kern County FD if they didn't provide those services, which are generally paid less, staffed at lower levels and face far more budgetary scrutiny than their larger, more mission-diverse siblings.

From a patient perspective, I'd way rather be in Texas, in a system that lets medics 'swing for the fences', than LACo for the vast majority of what I need. I want to be in a system/treated by a culture where paramedics understand 12-leads, where I can get ketamine and a tube to breathe for me, and where they can put in blood to replace the blood I've misplaced. I'd way rather get pain meds than not if I am hurting. From the patient/clinical perspective of a paramedic, it is way better to work in aggressive, progressive systems than archaic 1970s-land EMS.

Lastly, the culture. There's really no comparison. I have literally gone years before calling for orders.

@ParamedicStudent

If you're interested, download the PPP app (Paramedic Protocol Provider) and check out some protocols from other places. You'll be very surprised at the differences and similarities. For example, Houston Fire is pretty much exactly like LACo, with a few differences, but practically the same...but immediately to their north/west are four extremely progressive services where we do things like RSI, field blood transfusions, etc.

That's right. We put blood back into people. In ambulances. Without nurses, doctors, or a crusty MICN. On standing orders. #lifechanging

Also, our EMS culture is way more demanding and professional.
 
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Uclabruin103

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They hate because they don't fully understand. LA County has most of the standard treatments prior to base contact that most system have. It's not as if you have to call base prior to giving epi to an anaphylaxis. And if you need something off kilter, then call base and ask .

Yes, it's annoying to call base when you want to just give zofram and start a line, but whatever. You get used to it. And some departments have standard field treatment protocols where you can do even more before base, then you just give a very brief report.
 

medichopeful

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They hate because they don't fully understand. LA County has most of the standard treatments prior to base contact that most system have. It's not as if you have to call base prior to giving epi to an anaphylaxis. And if you need something off kilter, then call base and ask .

Yes, it's annoying to call base when you want to just give zofram and start a line, but whatever. You get used to it. And some departments have standard field treatment protocols where you can do even more before base, then you just give a very brief report.

I'm sorry, but any system that requires their medics to ask permission to start an IV has some serious issues.
 

CALEMT

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So starting a line is an automatic base hospital contact?
 

Uclabruin103

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Yes, so...

Age, weight, severity, cc, HAM, vitals and physical assessment, treatment, closest hospital.

So for a general ALS it'd take me easily less than 3-4 minutes to do .
 

VentMonkey

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They hate because they don't fully understand.
Pretty sure this isn’t the why, but ok. @RocketMedic summed up a stance for a more inclined pro-paramedic system. Might I ask— your profile states you’re an EMT, how well do you fully understand them?
It's not as if you have to call base prior to giving epi to an anaphylaxis.
Perhaps, or even better (and a real-life scenario) do what they did to a family member of my wife’s and misdiagnose the anaphylaxis as general malaise, BLS the patient, and skip the protocol altogether.
Yes, it's annoying to call base when you want to just give zofram and start a line, but whatever. You get used to it.
aaaand here’s a perfect example of my point regarding culture in my OP on this thread. You and I both know, firsthand, the majority of the departments can’t even be trusted with something as basic as IV administration, and an antiemetic. IMO? Hardly “whatever”.
And some departments have standard field treatment protocols where you can do even more before base, then you just give a very brief report.
The SFTP’s are for the more “clinically inclined” departments...of Los Angles, if that says anything.

When I studied for my protocol test there years ago I had to dig through the two binders they gave us to locate what the specific SFTP’s were. They’re nothing short of unimpressive, and laughable by just about every other state’s guidelines.

My county’s protocols aren’t anything to write about either, but we’re at least somewhere in between California and the norm. LA? Very sub-norm.
So starting a line is an automatic base hospital contact?
Unless they changed the protocol, I believe he’s misinformed.

It’s once you start a line, the patient is now an “ALS” patient, and requires a paramedic to follow in, and subsequently make base contact for whatever protocol hit the patient may have entered by paramedic discretion.

There’s no flipping back and forth between protocols though, you’re typically committed to it. “Pick and stick” to your treatment tree. IIRC, San Diego operates similarly.
 
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DesertMedic66

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They hate because they don't fully understand. LA County has most of the standard treatments prior to base contact that most system have. It's not as if you have to call base prior to giving epi to an anaphylaxis. And if you need something off kilter, then call base and ask .

Yes, it's annoying to call base when you want to just give zofram and start a line, but whatever. You get used to it. And some departments have standard field treatment protocols where you can do even more before base, then you just give a very brief report.
No, but if you want to give Benadryl to that allergic reaction that does require base contact...
 

Uclabruin103

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Pretty sure this isn’t the why, but ok. @RocketMedic summed up a stance for a more inclined pro-paramedic system. Might I ask— your profile states you’re an EMT, how well do you fully understand them?

Perhaps, or even better (and a real-life scenario) do what they did to a family member of my wife’s and misdiagnose the anaphylaxis as general malaise, BLS the patient, and skip the protocol altogether.

aaaand here’s a perfect example of my point regarding culture in my OP on this thread. You and I both know, firsthand, the majority of the departments can’t even be trusted with something as basic as IV administration, and an antiemetic. IMO? Hardly “whatever”.

The SFTP’s are for the more “clinically inclined” departments...of Los Angles, if that says anything.

When I studied for my protocol test there years ago I had to dig through the two binders they gave us to locate what the specific SFTP’s were. They’re nothing short of unimpressive, and laughable by just about every other state’s guidelines.

My county’s protocols aren’t anything to write about either, but we’re at least somewhere in between California and the norm. LA? Very sub-norm.

Unless they changed the protocol, I believe he’s misinformed.

It’s once you start a line, the patient is now an “ALS” patient, and requires a paramedic to follow in, and subsequently make base contact for whatever protocol hit the patient may have entered by paramedic discretion.

There’s no flipping back and forth between protocols though, you’re typically committed to it. “Pick and stick” to your treatment tree. IIRC, San Diego operates similarly.

Medic for just over 5 years. Never bothered to look at my forum profile since making the account. Every system has misdiagnosis issues, so generalizing to all medics is not fair to do.

I don't feel it's a lack of trust by having to make base after giving zofran. Otherwise you would need a base order for it.

Regardless of what county I work in, I always would advocate for my patients and treat them appropriately. No, I don't have blood transfusion or RSI. But I'm also not more than 30 minutes from a hospital, and if I need those I'll get an airship. And have them there sooner than that.
 

CALEMT

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It’s once you start a line, the patient is now an “ALS” patient, and requires a paramedic to follow in, and subsequently make base contact for whatever protocol hit the patient may have entered by paramedic discretion.

So excuse my ignorance but up until my internship where I work all 3 hospitals are base hospitals.

I’m my internship say I run a abd pain. Nausea and vomiting is associated with the pain. I start a line and give zofran IVP. I transport to the closest facility (in my internship it being a non base hospital). In LACo does this constitute a base contact?
 

Uclabruin103

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So excuse my ignorance but up until my internship where I work all 3 hospitals are base hospitals.

I’m my internship say I run a abd pain. Nausea and vomiting is associated with the pain. I start a line and give zofran IVP. I transport to the closest facility (in my internship it being a non base hospital). In LACo does this constitute a base contact?
Yes it would.
 

medichopeful

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Yes it would.

A base contact for permission to do the treatment? Or a simple entry note saying that "hey, this is what we have, this is what we did, we'll be at your facility in 5."
 

CALEMT

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Yes it would.

A base hospital order to give zofran IVP? You serious?

Come April I’ll have the ability to give fentanyl (already a standing order) OR Ketamine (trial drug, also a standing order).
 
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