NYS Collaborative Protocol Rollout

[NomadicMedic]

Threads take twists and turns here. (That's one the cool things about a threaded message board.)

Delaware uses a statewide ALS protocol set, with some sections marked "for agencies that participate in...". Not every county does RSI or POC lactate testing, however the protocols are there.

I found one set of BLS/ALS protocols to bulky and confusing. I'd rather just work with my standing orders, knowing that I'm expected to do all the BLS stuff too.

 

[Tigger]

You asked for comments, likes, dislikes, and hates. I'd say you got them. The thing with protocol changes is understanding why they were changed, and if it actually made sense to do so.

 

[firecoins]

This protocol is mostly for paramedics. BLS is minor and should never get to the point of using epi pens for asthma. ALS should be there or the bls crew should be at the ER. I hate these protocols. They have eliminated D50 from the diabetic/ams protocols for d10.

 

[Carlos Danger]

BLS is minor and should never get to the point of using epi pens for asthma. ALS should be there or the bls crew should be at the ER.

Perhaps in your perfect world everything would be handled by ALS, but the reality is that much of NYS is very rural and some places are quite remote and doesn't have either ALS or a hospital right around the corner.

I hate these protocols. They have eliminated D50 from the diabetic/ams protocols for d10.

Why, what is wrong with D10?

 

[Medic Tim]

This protocol is mostly for paramedics. BLS is minor and should never get to the point of using epi pens for asthma. ALS should be there or the bls crew should be at the ER. I hate these protocols. They have eliminated D50 from the diabetic/ams protocols for d10.

any reason besides we have always done it that way to not like D10. I use it over d50 on all of my diabetic wake ups. It is just as fast and less likely to harm the pt.

there are also rural services that may have extended transport time where an EMT may be the highest cert taking care of the pt for a good amount of time.(I am un-familiar with NY so I am speaking in general terms as many areas in the US are only covered by BLS) While research shows inhaled beta agonists are just as effective as epi in most ped asthma attacks, there are times that epi could and should be used

 

[NomadicMedic]

This protocol is mostly for paramedics. BLS is minor and should never get to the point of using epi pens for asthma. ALS should be there or the bls crew should be at the ER. I hate these protocols. They have eliminated D50 from the diabetic/ams protocols for d10.

And WHY is d10 as opposed to d50 a bad thing?

 

[Wheel]

Perhaps in your perfect world everything would be handled by ALS, but the reality is that much of NYS is very rural and some places are quite remote and doesn't have either ALS or a hospital right around the corner.



Why, what is wrong with D10?

We've had a hard time getting d50, so we're using d10. I love it. I'd much rather hang a bag and let it work than try to push d50 through the fragile veins of a diabetic, especially the ones where you're lucky to get a 20g in them.

 

[Eddie2170]

You asked for comments, likes, dislikes, and hates. I'd say you got them. The thing with protocol changes is understanding why they were changed, and if it actually made sense to do so.

Fair enough

 

[Eddie2170]

Perhaps in your perfect world everything would be handled by ALS, but the reality is that much of NYS is very rural and some places are quite remote and doesn't have either ALS or a hospital right around the corner.

And yes, im in a semi-rural area but with all my available ALS being privates i've been dispatched to AMS with a quote of no ALS available from dispatch & a ~20 minute ETA to the hospital after getting the pt in the ambulance

& a few months prior to that we had a coach bus mci with a 30 min ETA for an ALS unit, the first patient to receive any ALS care was when he was getting in the helicopter
that time dispatch stated there were no units from our ALS provider on this side of the Hudson River, I didn't take to kindly to that :angry:

Unfortunately once your 45 minutes outside of the greater metropolitan areas (NYC/Albany etc.) NYS becomes very Rural with much longer transport & intercept times

So while most of the protocol changes are geared towards ALS, it is nice to have a little more BLS level intervention ability for when the pt truly requires ALS, while yes its rare & not often, ill take what I can get

 

[usalsfyre]

No obviously if your an AEMT you dont need to call for the bls stuff before your AEMT interventions can be done etc.

& i really just posted the actual protocols because i was getting annoyed reading peoples responses to what was stupid and arguing over stuff they obviously didnt read or know anything about, completely basing their opinion on prior posters interpretation of what i said which was strictly changes

And im so glad my thread turned from a protocol thread to an asthma treatment argument when I expected answers like this

This still doesn't really answer my question. Epi is indicated well before steroids in the asthma patient in extremis, but should be skipped otherwise. Can you bypass the epi or not?

 

[Carlos Danger]

And yes, im in a semi-rural area but with all my available ALS being privates i've been dispatched to AMS with a quote of no ALS available from dispatch & a ~20 minute ETA to the hospital after getting the pt in the ambulance

& a few months prior to that we had a coach bus mci with a 30 min ETA for an ALS unit, the first patient to receive any ALS care was when he was getting in the helicopter
that time dispatch stated there were no units from our ALS provider on this side of the Hudson River, I didn't take to kindly to that :angry:

Unfortunately once your 45 minutes outside of the greater metropolitan areas (NYC/Albany etc.) NYS becomes very Rural with much longer transport & intercept times

So while most of the protocol changes are geared towards ALS, it is nice to have a little more BLS level intervention ability for when the pt truly requires ALS, while yes its rare & not often, ill take what I can get

Yeah, people who aren't familiar with NYS tend to think it's all high rises and subways.

I remember once launching from Canandaigua (near Rochester) on a scene call for an entrapment up near Gouverneur (I think). When we landed on scene almost 1.5 hours after being dispatched, the patient had just been extricated and we were the first ALS there. I've also been to quite a few snowmobile and hunting mishaps where the only people on scene before us were volunteer firefighters on their personal 4-wheelers. Even in the Finger Lakes and Southern Tier, we would sometimes beat the fly car to the scene.

 

[Eddie2170]

This still doesn't really answer my question. Epi is indicated well before steroids in the asthma patient in extremis, but should be skipped otherwise. Can you bypass the epi or not?

As a bls provider definitely not

An ALS provider, I dont know, I dont think so, however a call to the receiving MD med control could always change that

 

[Onsite Innovations Medic]

This protocol is mostly for paramedics. BLS is minor and should never get to the point of using epi pens for asthma. ALS should be there or the bls crew should be at the ER. I hate these protocols. They have eliminated D50 from the diabetic/ams protocols for d10.

Depending on your transport distance and times in your region. If you look at some departments on long island or upstate NY a transport can take upwards of an hour.

 

[Onsite Innovations Medic]

As a bls provider definitely not

An ALS provider, I dont know, I dont think so, however a call to the receiving MD med control could always change that

I think EPI has been used in the BLS setting in NYC for a few years now with great success. NYS copies NYC usually they are just 2 or 3 years behind.

 

[Christopher]

Giving epinephrine before solumedrol for pediatric asthma is stupid.

The standard of care for pediatric asthma is rapid acting beta agonist first followed by IV/IM steroids. PERIOD.

Epinephrine is a distant 3rd/4th option along with mag sulfate.

Wikipedia usually has a "citation needed" for this sorta thing...sigh.

You've conflated early initiation of longer term systemic treatment with early management of moderate to severe exacerbations refractory to inhaled beta agonists.

Yes, oral/IV corticosteroids are a Class I treatment (IM is not a Class I prehospital Rx), but only for those who are failing initial treatment with inhaled beta agonists. This is not a "wait to see response" step and characterizing it as a serial step is a complete misunderstanding of the evidence for its indication for use.

Parenteral magnesium, epinephrine, and terbutaline are all indicated in moderate to severe exacerbations with minimal or no response to beta agonists and ipratropium. These range from Class I to Class III, with the exception of epinephrine which only has "expert consensus" evidence.

Why does epinephrine have such poor evidence in asthma? For the same reason it has poor evidence in anaphylaxis...nobody does randomized controlled trials.

 

[Christopher]

They have eliminated D50 from the diabetic/ams protocols for d10.

Smartest thing they ever did! I don't even miss D50 in the slightest and adore my D10. Better than half the meds in my truck!