# So how does ALS work in California?



## RocketMedic (Aug 17, 2016)

I was browsing a few protocols from the Golden State and I was wondering something: do y'all literally have to Johnny-and-Roy every single intervention that you do or what? What is a MICN? And what is your workflow like? Can you autonomously do things or what?


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## NPO (Aug 17, 2016)

Well, unfortunately you're question is poorly formed. Our protocols are not state wide, they are county by county. But, I'll do the best I can to address your questions.

*Do we Johnny and Roy everything?*
I don't know what this means. But LACo hasn't changed much since that show aired, so for them at least, probably. (I have a great distaste for LACo EMS)

*What is an MICN*
Mobile Intensive Care Nurse. I'm not aware of anywhere that uses MICNs out of the hospital, despite the name MOBILE. Everywhere I know of, the MICN is who answers your radio call in. MICNs received additional training on prehospital protocols to help them help us. 

*Can we autonomously do things?*
We have standing orders just like anyone else. What we have standing orders for varies by county.

Places like LA County offer very little in the way of interventions before making base contact and asking for permission.

Where I work, we have much more leeway. For example, we have Level 1 protocols, and Level 2 protocols.

I can preform any Level 1 protocol prior to base contact. I am supposed to make base contact before initiating Level 2 protocols unless...

_"In the event a paramedic at the scene of an emergency or during transport ... reasonably determines that a delay in treatment may jeopardize the patient, the paramedic is authorized to provide any LEVEL I Paramedic treatment protocol as well as any LEVEL II Paramedic treatment protocol."_

Our medical director also allows us to use clinical judgement, rather than being a robot paramedic with the following excerpt from the opening pages of our protocols...

_"If necessary based on physiological 
justification, a paramedic may modify protocol treatment sequence. Any variation from 
treatment sequence shall be thoroughly documented on the PCR Narrative."_


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## DesertMedic66 (Aug 17, 2016)

RocketMedic said:


> I was browsing a few protocols from the Golden State and I was wondering something: do y'all literally have to Johnny-and-Roy every single intervention that you do or what? What is a MICN? And what is your workflow like? Can you autonomously do things or what?


Going to depend on the area. For my area we can do the majority of interventions without having to contact the hospital. 

MICN = Mobile Intensive Care Nurse. They are the only medical provider (aside from doctor) who is able to answer a radio call from the ambulance. They are familiar with our protocols and have the ability to direct us to a different hospital if needed. They are able to authorize a small amount of treatments for us (for example for SVT in my area we are only able to give one dose of 12mg of Adenosine. If that doesn't convert and we want to give an additional 12mg then we have to get the ok from the MICN). We also have orders that have to be given by the doctor directly (if the patient was given morphine by Fire and we want to give Fent, for example). 

What do you mean by workflow?

As far as can we do things autonomously, it's going to depend on the county you are in. For example in my area we do not have a "Chest Pain" protocol. So not all chest pain gets an IV, O2, 12-lead, NTG, ASA. It prevents the "if chest pain then do this". 

While we don't have an exact protocol for "I need an order for this but I'm in an area where I can't contact the Doctor" we have to use our best judgement on what to do.


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## RocketMedic (Aug 17, 2016)

So it's dependent on the county you're in to determine what you can do? 

Do y'all have PAI (I know RSI is a no-go in CA), video laryngyscopes, ventilators, etc?


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## NPO (Aug 17, 2016)

RocketMedic said:


> So it's dependent on the county you're in to determine what you can do?
> 
> Do y'all have PAI (I know RSI is a no-go in CA), video laryngyscopes, ventilators, etc?


That's all dependant on the county. The state has very little to do with what we do. The state sets the state scope, and then each county adds or subtracts to meet their needs/wishes. 

For example, LACo barely has intubation. 

Kern county has Ventilator protocols, and video laryngoscopes.

The vent is new, and is only for transfers, and no one uses video laryngoscopes except Hall CCT, but they're allowed. 







I had to look up PAI. So no, not exactly. We are allowed to use Versed under two protocols, but only after intubation, which is... well... Ya. Our medical director is new, and is working on that.


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## DesertMedic66 (Aug 17, 2016)

CA state sets the limit for what we can do. Counties can subtract skills if they wish (for example in my county we took out pedi intubation because we had providers killing kids from not checking the tube). 

If a county wishes to add something to the state scope it's not as easy as "we want RSI so we are going to do it". It normally starts off with a trial study of the drug or intervention (we are in the middle of doing a TXA study to see if it if actually beneficial. If it is then we will make a proposal to the state to include it in the scope). 

I don't know of any county that has RSI or PAI. I have not heard of any medic services carrying vents in CA.


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## NPO (Aug 17, 2016)

DesertMedic66 said:


> CA state sets the limit for what we can do. Counties can subtract skills if they wish (for example in my county we took out pedi intubation because we had providers killing kids from not checking the tube).
> 
> If a county wishes to add something to the state scope it's not as easy as "we want RSI so we are going to do it". It normally starts off with a trial study of the drug or intervention (we are in the middle of doing a TXA study to see if it if actually beneficial. If it is then we will make a proposal to the state to include it in the scope).
> 
> I don't know of any county that has RSI or PAI. I have not heard of any medic services carrying vents in CA.


We're getting a ventilator protocol, but just for transfers. I doubt you'll see ALS units carrying vents because they'll just take the hospital's, and any 911 patient that needs ventilation and is rural enough to need a vent should be flown, and they have vents.


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## DesertMedic66 (Aug 17, 2016)

NPO said:


> We're getting a ventilator protocol, but just for transfers. I doubt you'll see ALS units carrying vents because they'll just take the hospital's, and any 911 patient that needs ventilation and is rural enough to need a vent should be flown, and they have vents.


We have one flight option for critical patients that doesn't have vents which is the CHP airship.


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## NPO (Aug 17, 2016)

DesertMedic66 said:


> We have one flight option for critical patients that doesn't have vents which is the CHP airship.


Taxi


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## DesertMedic66 (Aug 17, 2016)

NPO said:


> Taxi


I prefer uber


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## Bullets (Aug 17, 2016)

If you don't have RSI what do you do if the patient needs an airway but is still conscious or has a gag?

If you can only push 12 of adenosine and they don't convert you can't just push another 12 or cardiovert without calling?


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## DesertMedic66 (Aug 17, 2016)

Bullets said:


> If you don't have RSI what do you do if the patient needs an airway but is still conscious or has a gag?
> 
> If you can only push 12 of adenosine and they don't convert you can't just push another 12 or cardiovert without calling?


1.) call an airship since they can RSI, transport to the closest ED so they can RSI, or wait until we can intubate. 

2.) For my area we have to call and get an order for a second 12mg adenosine. We can cardiovert without calling (unless it's a pedi patient).


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## NPO (Aug 17, 2016)

DesertMedic66 said:


> 1.) call an airship since they can RSI, transport to the closest ED so they can RSI, or wait until we can intubate.
> 
> 2.) For my area we have to call and get an order for a second 12mg adenosine. We can cardiovert without calling (unless it's a pedi patient).


What if you can't call? That seems silly, like, if I need to cardiovert, it's got to be bad. I ain't got time to call!


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## DesertMedic66 (Aug 17, 2016)

NPO said:


> What if you can't call? That seems silly, like, if I need to cardiovert, it's got to be bad. I ain't got time to call!


Based on some of the medics we have in our system it is a safe plan to have us contact base for pedi drugs. I've had the joy of a medic wanting to cardiovert a 2 year old who has been vomiting and has had diarrhea for 4 days who was altered with a HR of 160.


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## RocketMedic (Aug 17, 2016)

I don't get the aversion to vents. They're pretty common here in Texas.


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## NPO (Aug 17, 2016)

DesertMedic66 said:


> Based on some of the medics we have in our system it is a safe plan to have us contact base for pedi drugs. I've had the joy of a medic wanting to cardiovert a 2 year old who has been vomiting and has had diarrhea for 4 days who was altered with a HR of 160.


Well I mean cause it's over 150 so you've got no choice!


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## gonefishing (Aug 18, 2016)

LA county is talking about getting rid of intubation entirely.

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## NomadicMedic (Aug 18, 2016)

gonefishing said:


> LA county is talking about getting rid of intubation entirely.
> 
> Sent from my SM-G920P using Tapatalk



Probally not a bad idea.


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## NPO (Aug 18, 2016)

DEmedic said:


> Probally not a bad idea.


Reeducation or separation of EMS from Fire would be better.


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## EpiEMS (Aug 18, 2016)

DesertMedic66 said:


> Based on some of the medics we have in our system it is a safe plan to have us contact base for pedi drugs. I've had the joy of a medic wanting to cardiovert a 2 year old who has been vomiting and has had diarrhea for 4 days who was altered with a HR of 160.



Wow -- just....wow. I imagine that person got remediated?



DEmedic said:


> Probally not a bad idea.



Removing intubation seems reasonable if folks aren't getting enough practice, I'd wager.



NPO said:


> Reeducation or separation of EMS from Fire would be better.



This +1000.


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## NomadicMedic (Aug 18, 2016)

Removing intubation from a system that really only intubates dead people is a no brainer. If they were practing advanced airway managemnnt, I'd say it would be more of an issue, but they tube arrests. Use an SGA.

http://file.lacounty.gov/dhs/cms1_206321.pdf


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## EpiEMS (Aug 18, 2016)

DEmedic said:


> Removing intubation from a system that really only intubates dead people is a no brainer. If they were practing advanced airway managemnnt, I'd say it would be more of an issue, but they tube arrests. Use an SGA.
> 
> http://file.lacounty.gov/dhs/cms1_206321.pdf



I'm not really clear if they are even intubating arrests very much -- or at least not until the first round drugs are in (if I'm not mistaken): http://file.lacounty.gov/dhs/cms1_206097.pdf

Seems like they may as well just use rescue airways...


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## NPO (Aug 18, 2016)

EpiEMS said:


> I'm not really clear if they are even intubating arrests very much -- or at least not until the first round drugs are in (if I'm not mistaken): http://file.lacounty.gov/dhs/cms1_206097.pdf
> 
> Seems like they may as well just use rescue airways...


I don't intubate until well after my first round of drugs are in.... By choice.

But they consider a King an advanced airway, so they often use that instead of an ETT.


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## Handsome Robb (Aug 20, 2016)

EpiEMS said:


> I'm not really clear if they are even intubating arrests very much -- or at least not until the first round drugs are in (if I'm not mistaken): http://file.lacounty.gov/dhs/cms1_206097.pdf
> 
> Seems like they may as well just use rescue airways...



We can't intubate arrests until they've been receiving oxygen for 6 minutes. They either get an OPA and NRB or BVM until then. 


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## MonkeyArrow (Aug 20, 2016)

Handsome Robb said:


> We can't intubate arrests until they've been receiving oxygen for 6 minutes. They either get an OPA and NRB or BVM until then.
> 
> 
> Sent from my iPhone using Tapatalk


You don't ventilate arrests at all for six minutes if using the adjunct/NRB combo?


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## gotbeerz001 (Aug 20, 2016)

MonkeyArrow said:


> You don't ventilate arrests at all for six minutes if using the adjunct/NRB combo?


http://www.ncbi.nlm.nih.gov/m/pubmed/19660833/

I was in San Joaquin Conand they had a presentation regarding Passive Oxygenation Insufflation and they had pretty remarkable numbers regarding improved outcomes in areas that switched from BVM ventilation


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## Handsome Robb (Aug 20, 2016)

MonkeyArrow said:


> You don't ventilate arrests at all for six minutes if using the adjunct/NRB combo?



Nope. If it's a presumed hypoxic etiology they are ventilated with a BVM or if fire is already using a BVM when we arrive we continue to use it otherwise it's passive oxygenation for 6 minutes.


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## EpiEMS (Aug 21, 2016)

Handsome Robb said:


> Nope. If it's a presumed hypoxic etiology they are ventilated with a BVM or if fire is already using a BVM when we arrive we continue to use it otherwise it's passive oxygenation for 6 minutes.
> 
> 
> Sent from my iPhone using Tapatalk



From a purely operational perspective, do you find it easier/keeps your mind on the compressions + electricity?


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## Handsome Robb (Aug 21, 2016)

EpiEMS said:


> From a purely operational perspective, do you find it easier/keeps your mind on the compressions + electricity?



We run dual medic and pit crew CPR so they're covered pretty well. To be honest I haven't run an arrest since I moved here outside of scenarios. With that said they do our scenarios as realistic as possible and it definitely made it easier to focus on the most important parts being optimized. 


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## Tigger (Aug 22, 2016)

EpiEMS said:


> From a purely operational perspective, do you find it easier/keeps your mind on the compressions + electricity?


It does for me. It requires little effort to set up and prevents gastric inflation which is appreciated.


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## EpiEMS (Aug 23, 2016)

Tigger said:


> It does for me. It requires little effort to set up and prevents gastric inflation which is appreciated.



Makes good sense to me. If I were working a BLS-only arrest, and I had the option, I'd probably throw on the NRB and NC, with an OPA + bilateral NPAs til ALS showed up (<10min in my PSA).


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## Handsome Robb (Aug 23, 2016)

The idea is that good CPR creates enough chest compression/expansion to cause a large enough pressure gradient to make passive oxygenation effective. 


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## EpiEMS (Aug 23, 2016)

Handsome Robb said:


> The idea is that good CPR creates enough chest compression/expansion to cause a large enough pressure gradient to make passive oxygenation effective.
> 
> 
> Sent from my iPhone using Tapatalk


So no need to apply an NRB and/or NC? Or are they still going to (plausibly) have some benefit?


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## dutemplar (Aug 23, 2016)

Courtesy of a quick google... some light reading.

http://www.jems.com/articles/2010/01/study-compares-passive-oxygen.html
http://www.resuscitationjournal.com/article/S0300-9572(12)00792-7/fulltext
http://www.cathlabdigest.com/Cardia...ssive-Oxygen-Flow-Better-Assisted-Ventilation
http://www.hindawi.com/journals/bmri/2014/376871/
http://www.ncbi.nlm.nih.gov/pubmed/19660833


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## EpiEMS (Aug 23, 2016)

dutemplar said:


> Courtesy of a quick google... some light reading.



Good stuff -- I suppose my main concern would be the "hyperoxia," if you will. Then again, some quick GoogleFu showed me that (maybe) my concerns aren't valid (http://circ.ahajournals.org/content/126/Suppl_21/A41.short).


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## CALEMT (Aug 23, 2016)

Lol you could create a whole separate thread on passive oxygenation for full arrests.


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## dutemplar (Aug 23, 2016)

Nah, I'm bored to (bleeeeep) at work tonight and have 7 hours to go...

But I'm not "new thread" bored.


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## Tigger (Aug 23, 2016)

EpiEMS said:


> Makes good sense to me. If I were working a BLS-only arrest, and I had the option, I'd probably throw on the NRB and NC, with an OPA + bilateral NPAs til ALS showed up (<10min in my PSA).


We do the "superplug" here, which is two NPAs and an OPA. No one can prove its actually more effective than an OPA and proper positioning but I do as I am told and it makes intuitive sense I suppose.


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## Handsome Robb (Aug 23, 2016)

EpiEMS said:


> So no need to apply an NRB and/or NC? Or are they still going to (plausibly) have some benefit?



It's NRB only. We place an EtCO2 cannula but no O2 source to it.  


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## RocketMedic (Aug 24, 2016)

I'm somewhat curious about SoCal EMS lol. Do I really want to trade my Texas medicking for AMR-San Bernadino County or Hall or Liberty-Ridgecrest or something? I mean, I haven't called for orders in two years.

I mean, I grew up out there, and I do miss it. But I also like guns and freedom and no state taxes.


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## NPO (Aug 24, 2016)

RocketMedic said:


> I'm somewhat curious about SoCal EMS lol. Do I really want to trade my Texas medicking for AMR-San Bernadino County or Hall or Liberty-Ridgecrest or something? I mean, I haven't called for orders in two years.
> 
> I mean, I grew up out there, and I do miss it. But I also like guns and freedom and no state taxes.


I only call for orders if I don't want to give a drug, but I'm supposed to, so I can say I called and they said no. I phrase it in such a way they know to say no.


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## RocketMedic (Aug 24, 2016)

Can yall, hypothetically, use vents on 911 calls, or do you need an rn?


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## DesertMedic66 (Aug 24, 2016)

NPO said:


> I only call for orders if I don't want to give a drug, but I'm supposed to, so I can say I called and they said no. I phrase it in such a way they know to say no.


We can just withhold the drug without calling haha


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## DesertMedic66 (Aug 24, 2016)

RocketMedic said:


> Can yall, hypothetically, use vents on 911 calls, or do you need an rn?


For Riverside and San Bernardino counties vents are only carried on CCT units who only run IFTs and are staffed with 2 EMTs and an RN.


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## kev54 (Aug 24, 2016)

RocketMedic said:


> I'm somewhat curious about SoCal EMS lol. Do I really want to trade my Texas medicking for AMR-San Bernadino County or Hall or Liberty-Ridgecrest or something? I mean, I haven't called for orders in two years.
> 
> I mean, I grew up out there, and I do miss it. But I also like guns and freedom and no state taxes.



Why not work for a company like Remote Medical International so you can live anywhere for most of the year?


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## NPO (Aug 24, 2016)

DesertMedic66 said:


> We can just withhold the drug without calling haha


We can too, locally, but our QA is now doing some kind of state-level audit, so if I can get base to say no, my patient is excluded from the audit, meaning because I didn't give the 23 year old anxiety patient ASA, we won't get docked.


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## RocketMedic (Aug 24, 2016)

DesertMedic66 said:


> For Riverside and San Bernardino counties vents are only carried on CCT units who only run IFTs and are staffed with 2 EMTs and an RN.



I'm guessing ALS transfers are pretty limited in CA?


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## RocketMedic (Aug 24, 2016)

kev54 said:


> Why not work for a company like Remote Medical International so you can live anywhere for most of the year?



Eh, I like what I do and don't really want to travel a lot for work.


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## NPO (Aug 24, 2016)

RocketMedic said:


> I'm guessing ALS transfers are pretty limited in CA?


What makes you say that? The majority of transfers here are BLS or ALS. We have one CCT unit which has an EMT, a Paramedic and an RN. The medic also has to be CCEMT-P or FP-C certified within 2 years.


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## RocketMedic (Aug 24, 2016)

NPO said:


> What makes you say that? The majority of transfers here are BLS or ALS. We have one CCT unit which has an EMT, a Paramedic and an RN. The medic also has to be CCEMT-P or FP-C certified within 2 years.



That's what I mean, I guess. Here in Texas, a lot of what y'all would call CCT (intubated, multiple drips, etc) is still a paramedic-level transfer. I've got CCEMT-P and am pondering taking FP-C, and I enjoy those calls, but I still like 911 more and I like being able to apply the knowledge and tools to both.


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## NPO (Aug 24, 2016)

RocketMedic said:


> That's what I mean, I guess. Here in Texas, a lot of what y'all would call CCT (intubated, multiple drips, etc) is still a paramedic-level transfer. I've got CCEMT-P and am pondering taking FP-C, and I enjoy those calls, but I still like 911 more and I like being able to apply the knowledge and tools to both.


The only thing we don't do ALS is drips. We are allowed to take K+ (40meq), nitro, heparin, and blood. That's it. But we can take vents starting next month.


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## RocketMedic (Aug 24, 2016)

We generally don't start putting on nurses in my neck of the swamps until there's balloon pumps, ECMO or some other treatment going on that's so far out of normal that it demands its own minder.


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## RocketMedic (Aug 24, 2016)

NPO said:


> The only thing we don't do ALS is drips. We are allowed to take K+ (40meq), nitro, heparin, and blood. That's it. But we can take vents starting next month.



I'm guessing propofol drips, ABX infusions, etc are excluded and still require an RN?


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## NPO (Aug 24, 2016)

RocketMedic said:


> We generally don't start putting on nurses in my neck of the swamps until there's balloon pumps, ECMO or some other treatment going on that's so far out of normal that it demands its own minder.


It's kinda silly here, I told a hospital a heparin drip could go ALS. They were blown away. It still went CCT because they couldn't wrap their heads around it.


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## NPO (Aug 24, 2016)

RocketMedic said:


> I'm guessing propofol drips, ABX infusions, etc are excluded and still require an RN?


Yes. Anything other than those I listed are not ALS in my County.


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## DesertMedic66 (Aug 24, 2016)

RocketMedic said:


> That's what I mean, I guess. Here in Texas, a lot of what y'all would call CCT (intubated, multiple drips, etc) is still a paramedic-level transfer. I've got CCEMT-P and am pondering taking FP-C, and I enjoy those calls, but I still like 911 more and I like being able to apply the knowledge and tools to both.


Generally speaking intubated patients are taken CCT unless the transport is short and the patient doesn't need to be kept on any drips. This is a list of the only things medics in Riverside county are able to transport: 
	

		
			
		

		
	






	

		
			
		

		
	
So the vast majority of the ALS IFTs are cardiac monitor, O2, and IV.


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## RocketMedic (Aug 24, 2016)

I don't think I'd be happy there. What about rural CA, like way up north or out east?


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## EpiEMS (Aug 24, 2016)

Tigger said:


> We do the "superplug" here, which is two NPAs and an OPA. No one can prove its actually more effective than an OPA and proper positioning but I do as I am told and it makes intuitive sense I suppose.


The more the merrier. I take my guidance from Mr. Oto, and as he says:
If "_you place a BLS airway, the only breathable passage you’re really guaranteed is the lumen enclosed by the device itself: the central hole or grooves. And that’s not very much room. Our goal isn’t to create a tiny breathing tube, it’s to maximize the amount of usable airway — we’d like to be able to ventilate through as large a diameter as possible. That means using everything we can."



Handsome Robb said:



			It's NRB only. We place an EtCO2 cannula but no O2 source to it.
		
Click to expand...

Gotcha. I figure the NC couldn't hurt, so I was curious.



RocketMedic said:



			I don't think I'd be happy there. What about rural CA, like way up north or out east?
		
Click to expand...


Seems like there's wide variation in scope by county: http://www.emsa.ca.gov/Media/Default/PDF/ParamedicBasicSOPChart3-2013.pdf_


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## dutemplar (Aug 24, 2016)

I know more people looking to eject from Californistan for Texas than vice-versa...


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## CTMD (Aug 27, 2016)

RocketMedic said:


> Can yall, hypothetically, use vents on 911 calls, or do you need an rn?



In San Bernardino County we can use transport vents for 911 scene calls. Almost all the transporting agencies except for AMR have them. (County Fire, Desert, MBA)


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## DesertMedic66 (Aug 27, 2016)

CTMD said:


> In San Bernardino County we can use transport vents for 911 scene calls. Almost all the transporting agencies except for AMR have them. (County Fire, Desert, MBA)


I have yet to see an MBA unit with a vent


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## CTMD (Aug 27, 2016)

DesertMedic66 said:


> I have yet to see an MBA unit with a vent


I was told that they do but I know County has them. They're allowed in the optional equipment list for ICEMA


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## VentMonkey (Aug 27, 2016)

While I don't know much about ICEMA anymore, as it has been some time since I worked there, I can offer up a little something in regards to Kern County...

I am currently a paramedic with our critical care division, and hopefully I can expand and/ or clarify on some of what NPO has touched on already regarding our division.

Since we are a different division altogether we do in fact work _under _our nurses protocols. Anything that is within our normal (Kern County) paramedic scope of practice, our nurses can do, so in theory this includes giving them the ability to intubate, which to my knowledge is not that uncommon in the rest of the country where paramedics seem to be given much more responsibility (and credit). We are allowed RSI both on our ground unit, and obviously our HEMS as well. We do utilize the King Vision as shown by NPO, and there is talks about us hopefully getting Ketamine back for RSI, possibly adding surgical cricothyrotomy to our nurses scope, and perhaps eventually a sepsis protocol for our division, which to my knowledge is actually required, or requested by CAMTS.

As far as the ventilators being used, I am aware of a protocol in the works, but can't really specify for sure the time frame as to when it will be approved (perhaps NPO knows first hand). What I can say is that for our division we are now to use in on _all patients _requiring mechanical ventilatory support; this includes IFT and scene (911) calls.

To the op, to be completely honest between us both, I would not wager my paramedic career in Texas to move back here. I grew up here as well, and this is home for my family, but from a career standpoint it is so much more limited, particularly for someone seeking to provide a level of paramedicine that isn't typically taught in the average American paramedic curriculum. The scope you mentioned in a previous post in regards to the meds allowed by ground paramedics in your state is a testament (IMO) to the level of trust given to prehospital providers elsewhere, and fortunately for you, it's much easier to implement your scope of practice as a true critical care paramedic. I am by no means bickering FWIW, as I really enjoy what I do, and do indeed work for (again, in my opinion) the best private ambulance provider in the state.


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## CTMD (Aug 27, 2016)

VentMonkey said:


> While I don't know much about ICEMA anymore, as it has been some time since I worked there, I can offer up a little something in regards to Kern County...
> 
> I am currently a paramedic with our critical care division, and hopefully I can expand and/ or clarify on some of what NPO has touched on already regarding our division.
> 
> ...




Interesting insight into Kern County's protocols/operations. Do you work for Hall and if so is the critical care side totally seperate from the 911 side or do you still have scene calls? I didn't know that your guys ground CCT was that advanced. Thats pretty awesome that you guys have all that. Since it is CCT does that mean you run EMT Medic Nurse or is it just EMT/Medic?


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## VentMonkey (Aug 27, 2016)

Yes, I work for Hall. The critical care division is technically separate from our ground division, however, we do run 911 calls. We have one ground CCT unit, and a helicopter, and our program is CAMTS accredited.

While the majority of our workload is intended to focus on critical care transport, we do run a good amount of 911 calls especially currently given our call volume in the metro area, which is where our ground ops is; it's within our metro EOA. For California, I guess it is considered advanced, but again, remember we (paramedics) function under our nurses scope, as it's often easier to grant them protocols that we as paramedics in this state would otherwise have to fight tooth and nail for with the state, and/ or possibly the county itself.

It definitely is a bit different from AMR's CCT ops as I remember them being way back when. We are a P/B/RN configuration on the ground, and our helicopter is P/RN respectively. Both ground, and flight ops are held to the same protocols, which means RSI if needed is allowed on the ground at our discretion. Many people seem to shy away from, or not fully understand what we do because the bulk of our work load, especially on the ground, are LDT's (which I have personally come to enjoy), but it can be anything from 1 LDT, to multiple LDT's in a shift, to a mix of LDT/ IFT/ 911, to only 911 calls. Both ground, and air are 24 hours on a rotating schedule that correlates with Bakersfield Fire Departments.


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## NPO (Aug 27, 2016)

CTMD said:


> Interesting insight into Kern County's protocols/operations. Do you work for Hall and if so is the critical care side totally seperate from the 911 side or do you still have scene calls? I didn't know that your guys ground CCT was that advanced. Thats pretty awesome that you guys have all that. Since it is CCT does that mean you run EMT Medic Nurse or is it just EMT/Medic?


Hall CCT air and ground run both IFT and 911, and are EMT, Medic, RN.

Also, as an additional, the RN Intubation is kind of an 'earned' skill. They have to preform 8 successful Intubation under the direction of the paramedic before they can do it autonomously. At least that was the rule last I checked, unless it's changed.

Also, a sepsis protocol is in the works at the LEMSA level for 911.


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## VentMonkey (Aug 27, 2016)

It is hit or miss, as some of our nurses are a tad apprehensive, so yes, the airway is our primary skill, hence my interest in ventilator management; sort the "omega" to the "alpha" of airway management for us prehospital folk. Really, it should be mandated for any, and all advanced airways in the prehospital setting in my mind.


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## CTMD (Aug 27, 2016)

VentMonkey said:


> Yes, I work for Hall. The critical care division is technically separate from our ground division, however, we do run 911 calls. We have one ground CCT unit, and a helicopter, and our program is CAMTS accredited.
> 
> While the majority of our workload is intended to focus on critical care transport, we do run a good amount of 911 calls especially currently given our call volume in the metro area, which is where our ground ops is; it's within our metro EOA. For California, I guess it is considered advanced, but again, remember we (paramedics) function under our nurses scope, as it's often easier to grant them protocols that we as paramedics in this state would otherwise have to fight tooth and nail for with the state, and/ or possibly the county itself.
> 
> It definitely is a bit different from AMR's CCT ops as I remember them being way back when. We are a P/B/RN configuration on the ground, and our helicopter is P/RN respectively. Both ground, and flight ops are held to the same protocols, which means RSI if needed is allowed on the ground at our discretion. Many people seem to shy away from, or not fully understand what we do because the bulk of our work load, especially on the ground, are LDT's (which I have personally come to enjoy), but it can be anything from 1 LDT, to multiple LDT's in a shift, to a mix of LDT/ IFT/ 911, to only 911 calls. Both ground, and air are 24 hours on a rotating schedule that correlates with Bakersfield Fire Departments.




Interesting. So when running 911 calls does the RN sit back and assist or do they try and take the lead on scene? Besides having RSI do you have an expanded formulary? Are your LDTs working calls or is it pretty much BLS with a monitor and a pump? Do you recieve a pay increase for being CCT or is still standard medic pay?


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## VentMonkey (Aug 27, 2016)

NPO said:


> Hall CCT air and ground run both IFT and 911, and are EMT, Medic, RN.
> 
> 
> Also, a sepsis protocol is in the works at the LEMSA level for 911.


A sepsis protocol would be great, I have had scattered luck with call ins, and advising of sepsis work ups over the past few years, but to have a set plan, with sepsis bundles awaiting patients at the hospital, and parameters for field providers to follow similar to our STEMI, and stroke alerts is way overdue, I think.


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## NPO (Aug 28, 2016)

CTMD said:


> Interesting. So when running 911 calls does the RN sit back and assist or do they try and take the lead on scene? Besides having RSI do you have an expanded formulary? Are your LDTs working calls or is it pretty much BLS with a monitor and a pump? Do you recieve a pay increase for being CCT or is still standard medic pay?



On 911 the paramedic is primary, but with the added benefit of having the knowledge, education and scope of a nurse. The nurse may still function on 911 calls; for example administer RSI medications.

Yes, there is a pay incentive. As he alluded to earlier, CCT is a separate division at our company. Not anyone can simply go in and pick up a CCT shift on your weekend. All CCT crew members apply, and are picked and 'interviewed' for the position. There is also a 3 year minimum experience requirement. I only say 'interviewed', because after three years, the CCT manager probably knows you well enough not to have to ask what your life goals are, your prior experience, etc. 



VentMonkey said:


> A sepsis protocol would be great, I have had scattered luck with call ins, and advising of sepsis work ups over the past few years, but to have a set plan, with sepsis bundles awaiting patients at the hospital, and parameters for field providers to follow similar to our STEMI, and stroke alerts is way overdue, I think.



I agree. I think it's just taking a change of view point as a profession. Since sepsis generally doesn't "look" lethal in most stages, we tend to treat it as such. We're finally starting to get around to prehospital, aggressive sepsis treatment. I'd like to get to a point where we call code sepsis, just the way we do with stroke and stemi.


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## CTMD (Aug 28, 2016)

NPO said:


> On 911 the paramedic is primary, but with the added benefit of having the knowledge, education and scope of a nurse. The nurse may still function on 911 calls; for example administer RSI medications.
> 
> Yes, there is a pay incentive. As he alluded to earlier, CCT is a separate division at our company. Not anyone can simply go in and pick up a CCT shift on your weekend. All CCT crew members apply, and are picked and 'interviewed' for the position. There is also a 3 year minimum experience requirement. I only say 'interviewed', because after three years, the CCT manager probably knows you well enough not to have to ask what your life goals are, your prior experience, etc.
> 
> ...


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## VentMonkey (Aug 28, 2016)

CTMD said:


> Interesting. So when running 911 calls does the RN sit back and assist or do they try and take the lead on scene?
> 
> The rule of thumb is the paramedic "leads" the 911 calls, and the RN the transfers, but a good provider will delegate as an effective team leader with CRM regardless of the call. The RN is med pushing while the paramedic sets up to, then intubates. Again, it's most importantly a team approach particularly when dealing with high acuity patients.
> 
> ...


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## VentMonkey (Aug 28, 2016)

The nurse is essentially the med pusher with the exception of perhaps Zofran. Ironically enough we carry vials on our CCT units, but only ODT Zofran in our ground division. Again, if the nurse so chooses, and assuming they have met said requirement, then by all means, the airway is theirs. They are essentially the higher level of care within our unit/ division.

Do I enjoy it? Yes, very much so. I was getting pretty tired of routine medicals, and even true traumas which are often very basic, and have a pretty dismal outcome for the patients, so I felt I needed a changed and craved the opportunity to put my FP-C to use.


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## CTMD (Aug 28, 2016)

Wow that's crazy you guys don't carry IV zofran for your standard 911 units. Do you guys also only carry 1 analgesic and 1 benzo or do you carry both MS and Fent as well as Versed and Valium (for the 911 non CCT units)?
It sounds like you guys have a nice little CCT operation going on up there.
Do the ground 911 units carry vents or just the CCT with possible protocols in the future for all transporting units to have vents?


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## NPO (Aug 28, 2016)

VentMonkey has posted good info, which I would all agree with. Sure some CCT calls may be benign, (TPN transfers, MD req RN, etc...) but there are plenty of 'real' CCT calls that get your brain moving. I still enjoy 911 but also enjoy a good CCT IFT too.



CTMD said:


> Wow that's crazy you guys don't carry IV zofran for your standard 911 units. Do you guys also only carry 1 analgesic and 1 benzo or do you carry both MS and Fent as well as Versed and Valium (for the 911 non CCT units)?
> It sounds like you guys have a nice little CCT operation going on up there.
> Do the ground 911 units carry vents or just the CCT with possible protocols in the future for all transporting units to have vents?


ALS can give IV zofran, but we only carry ODT on ALS units. I'm sure it's a cost thing. We only had zofran added to protocols a few years ago as it is.

ALS carries morphine, fentanyl, versed, and valium. We used to carry Ativan until a recent letter from the manufacturer said it needed to be refrigerated. I don't know if anyone knows this, but Bakersfield is hot. 

As of now, ALS units do not carry vents. I'm not sure we will see them start to soon, even with the new protocols. Most hospitals will likely prefer a vented patient go with an RN, heck, they call CCT for nitro and heparin drips, which are both specifically ALS. I foresee the vent protocol designed for outlying hospitals to transfer patients into Bakersfield for higher level of care, as the protocol states vents will only be used for IFT, I imagine they'll just take the hospital one. But that's speculation.


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## VentMonkey (Aug 28, 2016)

The ventilator is only for our CCT division. I don't know that company wide we will be implemting them anytime soon, though crazier things have happened I am sure.

Both our ambulance and CCT divisions carry Versed/ Valium as our Benzo's, and Fent/ MS for pain management with the latter two falling out of favor much like anywhere else there's been much talk about removing them altogether from our scope which I believe our county EMS director plans on doing, again, how soon is anyone's guess.


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## VentMonkey (Aug 28, 2016)

Sorry I had misunderstood the question regarding formulary earlier. 

Yes, our nurses carry a handful of other medications on top of what is carried on every ALS rig. The meds themselves can be worked into the protocols that they have written specifically for our division/ program.


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## RocketMedic (Aug 28, 2016)

I think my California phase has passed lol. We're talking about nerve blocks, ultrasound and field ABX here lol.


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## RocketMedic (Aug 28, 2016)

I think my California phase has passed lol. We're talking about nerve blocks, ultrasound and field ABX here. 

I do miss CA the state, but I don't think I would be happy with CA EMS.


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## VentMonkey (Aug 28, 2016)

Prehospital U/S sounds interesting especially after learning the criteria to ruling in, and out thoracic and abdominal trauma.

What are your guys' guidelines? And what does your training entail?


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## NPO (Aug 28, 2016)

VentMonkey said:


> Prehospital U/S sounds interesting especially after learning the criteria to ruling in, and out thoracic and abdominal trauma.
> 
> What are your guys' guidelines? And what does your training entail?


I recently listened to a podcast about it, and it was very intriguing. Mostly for fluid and trains trauma identification.


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## VentMonkey (Aug 28, 2016)

Yeah, we covered it in my CCP course in terms of indications and key points on where to look and what indicated what (e.g., any free fluid in a space called "Morrison's Pouch" which I believe is perihepatic? Indicates at least ~200-250 cc's of free fluid).

I'm curious to see and know how these progressive systems across the nation have found them to be. Things such as experience in finding a positive FAST in the field etc. can be the difference in activating a true trauma alert or not. What was their training? How high is their success rate from a prehospital standpoint? This is something that is still fairly new to EMS and may, or may not be yet another "flash in the pan" of things that come and go in our line of work.


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## RocketMedic (Aug 28, 2016)

We're still trying to get it. Life-flight and a few services north of usage it and love it.


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## VentMonkey (Aug 28, 2016)

How about your ABX? How does this work? Is this part of a sepsis protocol? I would imagine it to be perhaps some sort of broad spectrum push dose such as Ancef?


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## RocketMedic (Aug 28, 2016)

Galveston is apparently implementing Ancef for suspected sepsis, possibly pneumonia and/or UTI, and trauma with open wounds. @TransportJockey , can you clarify?


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## Bullets (Aug 29, 2016)

Man, i thought NJ had a weird system.


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## EpiEMS (Aug 29, 2016)

Bullets said:


> Man, i thought NJ had a weird system.


California might be worse...


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## CALEMT (Aug 29, 2016)

EpiEMS said:


> California is worse...



Fixed it for you.


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## wtferick (Aug 29, 2016)




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## CALEMT (Aug 29, 2016)

wtferick said:


> View attachment 2973



I retort:


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## VentMonkey (Aug 29, 2016)

Lol, like I stated earlier in this thread, I would not give up my job as a paramedic in another state such as say Texas, or Delaware to move_ either to_, or _back to _California.

We do what we can in our county, and obviously every county has its issues, but ultimately, yes California at least from an EMS standpoint in my perspective is plagued with politics, and very powerful fire, and nursing unions, which in my opinion seem to have a palpable amount of clout hindering those that only wish to provide cutting edge, up to date, and _progressive _prehospital care.

It definitely is harder to function as a single role paramedic in California than the above mentioned states, for example. I chose to seek the (continuing) education needed to put myself in a position in this state that would allow me to practice as I saw fit.

Do I envy some of those on this forum who practice paramedicine outside of this state? Yeah, I do, but at the end of the day this is where my family seems to enjoy, so if it means I have to search a little harder throughout this state to remedy my "career" dilemma, then so be it.

In summary, it is why I chose to finally suck it up, and join the social media craze these "wild and crazy kids" talk about these days. So that I could meet, and talk with like minded individuals from all over the world regarding what we do, and how we do it where we do it.


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## CALEMT (Aug 29, 2016)

Plus its Commiefornia... the gun nazi state.


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## NPO (Sep 9, 2016)

VentMonkey said:


> A sepsis protocol would be great, I have had scattered luck with call ins, and advising of sepsis work ups over the past few years, but to have a set plan, with sepsis bundles awaiting patients at the hospital, and parameters for field providers to follow similar to our STEMI, and stroke alerts is way overdue, I think.


Follow-up:
The sepsis protocol trial went live Sept 1st and is being done by Liberty Ambulance in cooperation with Ridgecrest Regional. 

They are using nasal ETCO2 to detect sepsis early. The metric is ETCO2 <25mmHg, which has a 90% rate of correlation to a lactate of 4. Treatment under the protocol is 250ml bolus for SBP <90mmHg up to 2 liters, with special consideration for renal failure and CHF patients, those patients max at 500ml before you start Dopamine.

Expect to see something added to protocols in 1-2 years following the trial. They plan on adding the protocol regardless of what the trial shows, they just are doing to trial to get the protocol started and track any improvements in patient outcomes prior to a county wide approved protocol.


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## VentMonkey (Sep 9, 2016)

NPO said:


> Follow-up:
> The sepsis protocol trial went live Sept 1st and is being done by Liberty Ambulance in cooperation with Ridgecrest Regional.
> 
> They are using nasal ETCO2 to detect sepsis early. The metric is ETCO2 <25mmHg, which has a 90% rate of correlation to a lactate of 4. Treatment under the protocol is 250ml bolus for SBP <90mmHg up to 2 liters, with special consideration for renal failure and CHF patients, those patients max at 500ml before you start Dopamine.
> ...


That's good to know and hear. Ironically enough, I just got my latest Jems issue yesterday, and it is all about sepsis, and various sepsis protocols/ alerts in several systems both nationally, and internationally.

I'll take a gander in a bit, but do recall flipping through it yesterday and seeing one of the systems abiding by the ETCO2 of (<) 25mmHG as a guideline for field diagnosis, and work ups.

In a perfect world we would be given iSTAT's, but meh, so is life.


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## VentMonkey (Sep 9, 2016)

Also, as an addition, I really wish this county would move away from Dopamine and strictly use Norepinephrine, not just for _our _CCT division.


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## NPO (Sep 9, 2016)

VentMonkey said:


> Also, as an addition, I really wish this county would move away from Dopamine and strictly use Norepinephrine, not just for _our _CCT division.


I asked about that. They said their hands are tied by the state. They used to use norepinephrine many moons ago, but it lots favor when people started calling it Leave-em-dead. Turns out it wasn't the drug that was bad, it was the patients!

He (George Baker at EMS, you'll know him) said theoretically we could gang up on Lyon and get him to add it to an optional scope.

George is the one heading up the sepsis package, so that's why I talked to him.


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## VentMonkey (Sep 9, 2016)

Lol, yep, I know George. Yes, the problem was not only the stigma Levo developed along with the name, but also the fact that many patients were being given incorrect doses.

My CCP instructor was HUGE on emphasizing that Levo is turning out to be more effective that initially thought, as are many other clinicians.

And, yes, you are correct, the state does quite often tie the hands of individual county EMS agencies, which brings us right back to the ops original question...sadly.


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## dutemplar (Sep 9, 2016)

VentMonkey said:


> Also, as an addition, I really wish this county would move away from Dopamine and strictly use Norepinephrine, not just for _our _CCT division.



We are just starting with phenylephrine now.

START INFUSION AS SOON AS PRACTICAL:
Add 10mg to 100ml Saline or 5% dextrose bag
Draw up 50 ml of solution and infuse at 60 ml/h (100 mcg/min) initially and monitor BP
closely every 2 minutes.
STOP infusion temporarily if BP > 190 mmHg systolic or sudden bradycardia
Once BP starts to recovers reduce rate to 30 ml/h (50 mcg/min)
The objective is to keep BP relatively constant
Reduce by 2.5 - 5ml/h (4.15 - 8.3mcg/min) if BP remains elevated above desired level.
Increase infusion by 5 ml/h (8.3 mcg/min) to 10 ml/h (16 .6 mcg min) increments if BP
below desired level
IF STARTING INFUSION IS NOT PRACTICAL OR IMMEDIATE ACTION IS REQUIRED
e.g. RSI:
Give 0.5 ml – 1 ml (50 - 100 mcg) every 2-5 min, duration 10-20 min


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## VentMonkey (Sep 9, 2016)

dutemplar said:


> We are just starting with phenylephrine now.
> 
> START INFUSION AS SOON AS PRACTICAL:
> Add 10mg to 100ml Saline or 5% dextrose bag
> ...


Where is it exactly that you practice?

Do you guys have a broad spectrum antibiotic in your protocol as well?

How have you, or anyone in your system, found that it works for this patient population?

Thanks.


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## dutemplar (Sep 9, 2016)

Doha, Qatar.  Currently no antibiotics - they are actually more regulated here than narcs.  This is the only GCC state I know of with medics carrying narcs.   We also do not have drug resistance either.  Anyone coming here to work or live has to be screened for STDs, tuberculosis, etc.  

That part's new, the CPGs (protocols) were rolled out a month ago, but with the schedule not everyone is 100% up to speed yet and pharmacy is still stocking everything.


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## LACoGurneyjockey (Sep 9, 2016)

NPO said:


> Follow-up:
> The sepsis protocol trial went live Sept 1st and is being done by Liberty Ambulance in cooperation with Ridgecrest Regional.
> 
> They are using nasal ETCO2 to detect sepsis early. The metric is ETCO2 <25mmHg, which has a 90% rate of correlation to a lactate of 4. Treatment under the protocol is 250ml bolus for SBP <90mmHg up to 2 liters, with special consideration for renal failure and CHF patients, those patients max at 500ml before you start Dopamine.
> ...



Pretty much nailed it. The criteria is 2 or more of the following: new onset aloc, bgl>300 in non diabetic, HR>90, RR>20, Temp>100.9 or <97.1, or NC ETCO2 <25, and the unwritten key is with an identifiable source of infection, uti, respirstory, wounds etc. But that hasnt been written into the protocols yet, just voiced by Ridgecrest Regional. If they meet sepsis alert criteria they want any hypotension treated aggressively like you said, and bilateral large bore IVs regardless of BP. It's going pretty good so far, there's been a few legitimate sepsis alerts, but the criteria needs some tweaking so that every tachy diff breather doesn't fall into it.


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## VentMonkey (Sep 9, 2016)

LACoGurneyjockey said:


> Pretty much nailed it. The criteria is 2 or more of the following: new onset aloc, bgl>300 in non diabetic, HR>90, RR>20, Temp>100.9 or <97.1, or NC ETCO2 <25, and the unwritten key is with an identifiable source of infection, uti, respirstory, wounds etc. But that hasnt been written into the protocols yet, just voiced by Ridgecrest Regional. If they meet sepsis alert criteria they want any hypotension treated aggressively like you said, and bilateral large bore IVs regardless of BP. It's going pretty good so far, there's been a few legitimate sepsis alerts, but the criteria needs some tweaking so that every tachy diff breather doesn't fall into it.


Any critical, or potentially critical patient should and/ or will get two B/L IV's by me, or my nurse, if at all possible regardless of the nature or mechanism.


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## TransportJockey (Sep 9, 2016)

RocketMedic said:


> Galveston is apparently implementing Ancef for suspected sepsis, possibly pneumonia and/or UTI, and trauma with open wounds. @TransportJockey , can you clarify?


We are? Since when? I had that in my protocol in Pecos, but hadn't heard that its official for us yet. 

Sent from my SM-N920P using Tapatalk


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## VentMonkey (Sep 9, 2016)

Ancef? 

Was is a simple push dose gram? 

How did you guys go about giving it and foregoing the need for cultures?


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## Handsome Robb (Sep 9, 2016)

TransportJockey said:


> We are? Since when? I had that in my protocol in Pecos, but hadn't heard that its official for us yet.
> 
> Sent from my SM-N920P using Tapatalk



That's pretty entertaining right there. 

We have a Sepsis protocol but the lack of an FDA approved POC lactate monitor is holding it back from actually allowing us to call "Sepsis Alerts". Our criteria is pretty standard, known or presumed infection with 2 of the three criteria. 

HR >90, RR >20 (or EtCO2 <32 <-sounds like this will be changing to 25) or temp >100.4/<96.8. 2 of those plus a lactate >4 makes for a Sepsis Alert. 

Word on the street is once we have the lactate meters we'll be administering antibiotics as well. 


Sent from my iPhone using Tapatalk


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## Tigger (Sep 9, 2016)

Do we need to draw lactates in order to give antibiotics? There are several screening tools that correlate well to elevated lactate levels.


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## ParamedicStudent (Sep 10, 2016)

DesertMedic66 said:


> 1.) call an airship since they can RSI, transport to the closest ED so they can RSI, or wait until we can intubate.
> 
> 2.) For my area we have to call and get an order for a second 12mg adenosine. We can cardiovert without calling (unless it's a pedi patient).



Just a question: do we ever intubate breathing patients? Wasnt given clear instructions on if the pt is breathing vs not breathing. As in breathing, but wont support their airway much longer, or barely breathing, etc.


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## NomadicMedic (Sep 10, 2016)

ParamedicStudent said:


> Just a question: do we ever intubate breathing patients? Wasnt given clear instructions on if the pt is breathing vs not breathing. As in breathing, but wont support their airway much longer, or barely breathing, etc.



 Depending on the service, paramedics may intubate breathing patients frequently.  RSI, rapid sequence intubation, is the process in which you sedate and paralyze a breathing patient and then intubate them.


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## VentMonkey (Sep 10, 2016)

As a whole I don't know how realistic it is, or how ready we are as prehospital providers to up and administer antibiotics.

Granted there are tons of intelligent providers capable of exhibiting sound clinical judgement, but my take is that it takes a bit more insight, and willingness to learn and understand why it is we would give "X" patient "Y" antibiotic.

Can we? Sure, but I would think the proper training be in order prior to implementing this in a protocol. This is why I am so interested in knowing if there are any systems out there that have implemented an antibiotic, and if so what are their parameters, and outcomes.


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## VentMonkey (Sep 10, 2016)

ParamedicStudent said:


> Just a question: do we ever intubate breathing patients? Wasnt given clear instructions on if the pt is breathing vs not breathing. As in breathing, but wont support their airway much longer, or barely breathing, etc.


You may also find an occasional service that still allows their paramedics to perform nasal intubations.


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## Handsome Robb (Sep 10, 2016)

ParamedicStudent said:


> Just a question: do we ever intubate breathing patients? Wasnt given clear instructions on if the pt is breathing vs not breathing. As in breathing, but wont support their airway much longer, or barely breathing, etc.





DEmedic said:


> Depending on the service, paramedics may intubate breathing patients frequently.  RSI, rapid sequence intubation, is the process in which you sedate and paralyze a breathing patient and then intubate them.



All but one of the patients that have gotten intubated by my partner and I have been breathing. Like DE said, some services allow Paramedic's to sedate and paralyze people to intubate them. 


Sent from my iPhone using Tapatalk


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## NomadicMedic (Sep 10, 2016)

VentMonkey said:


> You may also find an occasional service that still allows their paramedics to perform nasal intubations.



Nasal tubes have been in my protocols at everyplace I've worked. Finding a trigger tube and a BAAM, now that's another story.


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## NPO (Sep 10, 2016)

ParamedicStudent said:


> Just a question: do we ever intubate breathing patients? Wasnt given clear instructions on if the pt is breathing vs not breathing. As in breathing, but wont support their airway much longer, or barely breathing, etc.



Yes, we do. At least here, because we don't have RSI. You just have to time it right; when they take a breath the cords open and you slide it in. Depending what protocol you're operating under you can give versed after passing the tube.


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## VentMonkey (Sep 10, 2016)

DEmedic said:


> Nasal tubes have been in my protocols at everyplace I've worked. Finding a trigger tube and a BAAM, now that's another story.


Our NTI procedure was removed about a year ot two ago. Our medical director sited that there had only been 2 performed in the previous year.

Ironically, I was one of the two, the successful one I might add, but CPAP's all but done away with it in the eyes of many medical directors.

I think I would rather have RSI, personally, but the handful of times I used it, it came in handy, and worked well. I do miss the sound of the BAAM "whistling" at me.


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## DesertMedic66 (Sep 10, 2016)

ParamedicStudent said:


> Just a question: do we ever intubate breathing patients? Wasnt given clear instructions on if the pt is breathing vs not breathing. As in breathing, but wont support their airway much longer, or barely breathing, etc.


Yes. We don't have RSI where I am at however. We had a trauma patient about a year ago with a GCS of 3-4 breathing on her own kinda. Trauma center was about 45 minutes away with no airships available. We ended up tubing her.


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## VentMonkey (Sep 11, 2016)

The "poor man's RSI", or MAI/ DAI is just not the way to go, IMO.

I once sat in on an ACLS class where another paramedic remarked how in Kern County we're "allowed to snow" our patients with MS/ sedatives to intubate (thankfully no longer common practice in our county). This did not sit well with me, and just shows such lack of forward thinking, progression, and overall clinical knowledge, but I digress...

RSI requires a lot of understanding and perhaps also an understanding that the word "rapid" doesn't mean we are to always rush through this procedure post haste.


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## VentMonkey (Sep 11, 2016)

Tigger said:


> Do we need to draw lactates in order to give antibiotics? There are several screening tools that correlate well to elevated lactate levels.


https://www.scemsportal.org/sites/default/files/GCEMS Sepsis.pdf
http://www.jems.com/articles/print/...s-in-hospital-sepsis-care-into-protocols.html
I found this interesting and good read.


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## Tigger (Sep 11, 2016)

My medic program had us do a few research papers and this is what I focused on. Greenville County seems to have figured it out.


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## VentMonkey (Sep 11, 2016)

Tigger said:


> My medic program had us do a few research papers and this is what I focused on. Greenville County seems to have figured it out.


I found it interesting that the article used Epinephrine for anaphylaxis as a comparison for a life-saving procedure.

It's my opinion that many paramedics neglect this medication for allergic reactions as it currently stands, so to say that antibiotics and proper identification utilizing SIRS criteria _may _take a bit more convincing to general paramedics as a whole on just how life-threatening sepsis can be is, well, frankly an understatement to me.

I have met, and spoken to more than one who didn't even know what MODS was. Kinda scary, I think.


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## NPO (Sep 11, 2016)

VentMonkey said:


> I have met, and spoken to more than one who didn't even know what MODS was. Kinda scary, I think.



Those are the guys who message you and tell you to settle down on the forum.


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## VentMonkey (Sep 11, 2016)

So is life...


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