# Does Kern County Still Have Good Protocols?



## AlexTheChamberlain (Jan 20, 2019)

So, I’ve just been looking over the protocols for Kern, and was curious about the “Paramedic Level I” and “Paramedic Level II” section. I was just wondering about these two because a lot of people who used to work in Kern, and now work somewhere else, say it used to be great, and you’d pretty much only have to call base for a STEMI or to pronounce. I’m just curious how things have changed, because reading this, sounds like I have to call base to give versed to an active seizure, or glucagon to a diabetic. 
Feedback from anyone working in Kern would be great. Thanks!


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## gonefishing (Jan 20, 2019)

AlexTheChamberlain said:


> So, I’ve just been looking over the protocols for Kern, and was curious about the “Paramedic Level I” and “Paramedic Level II” section. I was just wondering about these two because a lot of people who used to work in Kern, and now work somewhere else, say it used to be great, and you’d pretty much only have to call base for a STEMI or to pronounce. I’m just curious how things have changed, because reading this, sounds like I have to call base to give versed to an active seizure, or glucagon to a diabetic.
> Feedback from anyone working in Kern would be great. Thanks!


No...........


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## NPO (Jan 20, 2019)

At the very beginning of the protocols there is a statement that says something along the line of "If making base contact will delay necessary treatment, do not make base contact first."

You are correct that many medications and procedures are Level II, however it is the expectation of the medical director that you use any skill or medication in the protocols when it's an emergency.

Now. That has nothing to do with "Good Protocols". There are strong and weak parts of the Kern County protocols, but the gap between Kern and many other counties has narrowed considerable in recent years.


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## DesertMedic66 (Jan 20, 2019)

After working for some time in the Kern system I will also admit that they are falling behind. They have yet to get some medications that other counties have been using for a while now (TXA and Ketamine). I also am not a fan of the level I and II medications/procedures however at least they include a statement that allows you to override contacting base. Riverside county has been stepping up their game in recent years and has been a part of several trial studies and in April will be putting push dose epi into the protocols as well. 

At the MICN class I went to, they admitted they were behind on the times and said it’s going to take a while to recover.


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## VentMonkey (Jan 20, 2019)

DesertMedic66 said:


> After working for some time in the Kern system...


Define “some time”...

OP, I have no clue what you get by meaning “good protocols”. Are you a paramedic? Are you—like many people—going off of others opinions to form yours?

Most of what you’ve heard sounds like a hodgepodge of others accounts and experiences with this system. You don’t have to call for about anything, but why does that make them “good”?

Now all jokes aside @DesertMedic66 and @NPO are right. 

The county has very much fallen behind with EBM delivery. My personal opinion is that it has more to do with the “Good Ole’ Boy” era and the impact that it’s had on everything up to, and including its EMS-delivery model.


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## AlexTheChamberlain (Jan 20, 2019)

NPO said:


> At the very beginning of the protocols there is a statement that says something along the line of "If making base contact will delay necessary treatment, do not make base contact first."
> 
> You are correct that many medications and procedures are Level II, however it is the expectation of the medical director that you use any skill or medication in the protocols when it's an emergency.
> 
> Now. That has nothing to do with "Good Protocols". There are strong and weak parts of the Kern County protocols, but the gap between Kern and many other counties has narrowed considerable in recent years.



Mind if I ask exactly which area of the protocols you're referring to? Unless you're talking about this line in the paramedic 101 protocols: "If necessary based on physiological justification, a paramedic may modify protocol treatment sequence." 

In regards to good protocols, I just like the idea of being able to be trusted to make decisions on your own, and not have it say say "if pt has this, call base to unlock the next step". I much rather love the idea of base being used as needed, when you have a question.


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## AlexTheChamberlain (Jan 20, 2019)

DesertMedic66 said:


> After working for some time in the Kern system I will also admit that they are falling behind. They have yet to get some medications that other counties have been using for a while now (TXA and Ketamine). I also am not a fan of the level I and II medications/procedures however at least they include a statement that allows you to override contacting base. Riverside county has been stepping up their game in recent years and has been a part of several trial studies and in April will be putting push dose epi into the protocols as well.
> 
> At the MICN class I went to, they admitted they were behind on the times and said it’s going to take a while to recover.



Yeah that is something I've noticed in regards to Kern's protocols; they give you freedom to decide what to do, but use drugs that are pretty outdated. I really love their pain management protocol leaving a lot up to discretion, but if it had the options like SSVEMS with ketorolac, acetaminophen, fentanyl, morphine, ketamine, and versed for pain (which when I was reading, I couldn't believe was in California) they'd be perfect. That's just one example though. 

And FINALLY pressors! Mind if I ask where you got the news from?


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## AlexTheChamberlain (Jan 20, 2019)

VentMonkey said:


> Define “some time”...
> 
> OP, I have no clue what you get by meaning “good protocols”. Are you a paramedic? Are you—like many people—going off of others opinions to form yours?
> 
> ...



Yes, there has been a little hodgepodging going on from talking to the 15+ year medics about their time in Kern, when I was still in elementary school. But maybe good wasn't the best word, since yes, they are a little behind (like still using dopamine over push-dose epi, the lack of TXA, and Ketamine), but I really like the idea of point blank "you know what to do, just do it" rather than asking to unlock the next level.


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## DesertMedic66 (Jan 20, 2019)

AlexTheChamberlain said:


> Yeah that is something I've noticed in regards to Kern's protocols; they give you freedom to decide what to do, but use drugs that are pretty outdated. I really love their pain management protocol leaving a lot up to discretion, but if it had the options like SSVEMS with ketorolac, acetaminophen, fentanyl, morphine, ketamine, and versed for pain (which when I was reading, I couldn't believe was in California) they'd be perfect. That's just one example though.
> 
> And FINALLY pressors! Mind if I ask where you got the news from?


Riverside county approved it back in November. I was talking to some members of the committee who passed it. All employees are having training on it between now and April. We start with the new protocol on April 1st.


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## RocketMedic (Jan 20, 2019)

AlexTheChamberlain said:


> Yeah that is something I've noticed in regards to Kern's protocols; they give you freedom to decide what to do, but use drugs that are pretty outdated. I really love their pain management protocol leaving a lot up to discretion, but if it had the options like SSVEMS with ketorolac, acetaminophen, fentanyl, morphine, ketamine, and versed for pain (which when I was reading, I couldn't believe was in California) they'd be perfect. That's just one example though.
> 
> And FINALLY pressors! Mind if I ask where you got the news from?


SSVEMS?


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## DesertMedic66 (Jan 20, 2019)

RocketMedic said:


> SSVEMS?


Sierra-Sacramento Valley EMS


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## VentMonkey (Jan 21, 2019)

AlexTheChamberlain said:


> I really like the idea of point blank "you know what to do, just do it" rather than asking to unlock the next level.


Fair enough. It’s indirectly built this way. In short, many of the MICN’s aren’t too versed on our protocols, coupled with the way that they’re written makes them indirectly autonomous. 

With that, there are still plenty of providers who aren’t exactly honed with the protocols and will ask for orders for very basic Level 2 delineation. When this happens, oftentimes, the nurse has to then turn to the doc or give the generic “follow your protocols” reply. 

After a while it just made me realize what I can, and cannot do without orders, which really isn’t much.

I don’t know that I’d consider them at one time great, or even good. I think they were, and still are a loose set of protocols that by and large will get you through a standard shift. 

Structurally, I also don’t think our county’s paramedics in general are adequately trained enough to appreciate cutting-edge EBM. This comment may seem harsh, but honestly? Meh.


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## NPO (Jan 21, 2019)

I agree with @VentMonkey. Unfortunately, Kern County continuing education has been, for the most part, completely absent for the last several years. 

Your cook book classes (ACLS, PALS) we're PowerPoints with a test. There wasn't even a formal education person at Hall ambulance for the last several years. Management made it clear through their actions that education was not a priority for them, which for me was very disheartening.

But back to the "asking for permission", when I worked there, many MICNs had the like of thought that if you were asking for an order, you wanted it denied (for example, don't want to give activated charcoal, but it's indicated and is a level 2 medication) or that if you were asking you weren't confident enough to just do it, and therefore probably shouldn't be doing it anyway. Maybe not the best line of thought, but that was my experience.

In my time as a medic in Kern County, I remember only a SMALL handful of calls where I felt like my protocols had my hands tied. And the medical director is pretty loose with "do it if you can justify it"


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## DrParasite (Jan 22, 2019)

I'll never understand the MICN concept... you call someone who likely has similar education to you, for their permission to give a drug that you think will help the patient?   and if you didn't sound confident, they would deny it?  I'm so glad every place I have ever worked when paramedics needed a consult or orders, they spoke to someone with MD after their name every time.

I think one question I have is what makes protocols good?  Is it having a lot of drugs to give?  or having a smaller number of drugs that work better and are easier to use (such as epi drip vs dopamine)?  I have never heard of Versed for pain control, but since it's used for so many other things....

Also, why is changing protocols so difficult?  our medical director can change them with the stroke of a pen.  Is there evidence behind the change?  would it be good for the patient?  Or are your protocols need to be approve by someone besides the medical director? I know nothing about Kern or Hall, I'm trying to understand how thinks work out west.


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## Peak (Jan 22, 2019)

I don't really understand why systems would have nurses giving orders anyway. Since I'm not a licensed medical provider I wouldn't feel comfortable having my name on an order anyway, let alone through a phone on a patient I've never seen. I get that these are probably through standing orders or protocols from the medical director, but it just seems weird that one non-LIP is requesting an order from another non-LIP. 

Occasionally our nurses may ask for a 12 lead , BGL, specific assessment, and so on (especially for some of the lower acuity/volume services); but we are just discussing an assessment that I would think is beneficial and is within their scope and standing orders already. When we request these though it is in the same nature of a medic asking another medic their thoughts on a case. The moment an EMT, medic, or flight nurse asks for an order I had the phone over to one of our PEMs or adult attendings. 

The reality is that most nurses, even those with extensive ED experience, don't really understand the nature of pre-hospital care; especially so in 911 systems.


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## DesertMedic66 (Jan 22, 2019)

DrParasite said:


> I'll never understand the MICN concept... you call someone who likely has similar education to you, for their permission to give a drug that you think will help the patient?   and if you didn't sound confident, they would deny it?  I'm so glad every place I have ever worked when paramedics needed a consult or orders, they spoke to someone with MD after their name every time.
> 
> I think one question I have is what makes protocols good?  Is it having a lot of drugs to give?  or having a smaller number of drugs that work better and are easier to use (such as epi drip vs dopamine)?  I have never heard of Versed for pain control, but since it's used for so many other things....
> 
> Also, why is changing protocols so difficult?  our medical director can change them with the stroke of a pen.  Is there evidence behind the change?  would it be good for the patient?  Or are your protocols need to be approve by someone besides the medical director? I know nothing about Kern or Hall, I'm trying to understand how thinks work out west.


In CA the protocols are decided by the county. So there is a committee in every county that is formed who looks into everything. It’s not as simple as “I want ketamine so let’s carry it”. If the medication is not in our state approved list of medications we must now go through the process to do a trial study of the drug. For that we need to file a bunch of paperwork, write very specific protocols for what exactly we are studying and how we are going to measure success. Once we get approval from state we must now open it up for each department that uses paramedics to see if they want in the study. Once we get all that set up then each employee will get mandatory training/education on the medication. We have to wait for the trial to end and then we make the results all fancy and present it to the state. The state then makes the decision to allow us to use it or not. Now since it is approved each individual county can decide if they want to carry/use that medication. They have to announce what they are planning to do and then open it up for public comment since it is a county change. 

TLDR: in CA it takes a long time and is a huge process to add a new medication into our response bags.


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## NPO (Jan 22, 2019)

The long process of adding a medication or skill is preciously why the Kern County medical director hasn't done many of the things he would like to. He's explained to be the laborious process to MAYBE get something added. 

It all goes back to the very bureaucratic process in California. The state medical director is very hesitant to add anything.

Also (and this is more my opinion) the largest lobbying voices in California EMS are metropolitan fire departments. The biggest voice gets what they want. If they don't want *INSERT PROTOCOL HERE* then the little voices of other EMS agencies are told the state as a whole doesn't need it, and since it has to be approved at a state level, it won't happen.


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## RocketMedic (Jan 23, 2019)

Another thing to consider: a lot of the (inadequate) research that _has_ been done has pointed us _away _from pharmacological solutions to a lot of problems, _away _from endotracheal intubation, etc. The procedures may be indicated and helpful, but in aggregate, consensus seems to be that less-invasive alternatives and alternative therapies (ie electrical vs chemical cardioversion) are effective as well. In the limited field-medical context of EMS, I can understand wanting to keep it simple but be good at those things.

With that being said, I also think California went too far.


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## NPO (Jan 23, 2019)

I rarely use the "cool" and "advanced" things in my scope of practice. On a day to day basis, I rarely get further than one or two steps into a protocol.

But when you need those other interventions, you are glad you have it.

RSI is an easy example. I rarely use it. And a lot of places (one near me) tend to over-use it. But when I really need it, I'm glad I have it.


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## DrParasite (Jan 24, 2019)

RocketMedic said:


> Another thing to consider: a lot of the (inadequate) research that _has_ been done has pointed us _away _from pharmacological solutions to a lot of problems, _away _from endotracheal intubation, etc. The procedures may be indicated and helpful, but in aggregate, consensus seems to be that less-invasive alternatives and alternative therapies (ie electrical vs chemical cardioversion) are effective as well. In the limited field-medical context of EMS, I can understand wanting to keep it simple but be good at those things.


IIRC, the research to go away from ET said we should go away from it because we suck at it, with the primary reason being we don't do it enough, particularly on real patients.  Not that it wasn't effective.  Had that research been done in an area that didn't have 6 paramedics on a cardiac arrest (3 on the engine, 2 on the ambulance, and a supervisor), and was in an area where paramedics intubated patients at least every two weeks, those results were likely to have been different.

 What research says we shouldn't give meds to treat patients?  I can understand simply monitoring a stable patient vs treating an issue that has no patient complaint, but I haven't read anything that says we shouldn't give zofran to help make the vomiting person feel better.

On the topic of RSI: most of NJ allows it, while many medical directors in NC don't, including my former one.  It's not something that should be used all the time, but there is absolutely a time and place to use it, and if you don't have that option, well, you aren't giving the patient the best chance for success and survival


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## wtferick (Feb 8, 2019)

Peak said:


> I don't really understand why systems would have nurses giving orders anyway. Since I'm not a licensed medical provider I wouldn't feel comfortable having my name on an order anyway, let alone through a phone on a patient I've never seen. I get that these are probably through standing orders or protocols from the medical director, but it just seems weird that one non-LIP is requesting an order from another non-LIP.
> 
> Occasionally our nurses may ask for a 12 lead , BGL, specific assessment, and so on (especially for some of the lower acuity/volume services); but we are just discussing an assessment that I would think is beneficial and is within their scope and standing orders already. When we request these though it is in the same nature of a medic asking another medic their thoughts on a case. The moment an EMT, medic, or flight nurse asks for an order I had the phone over to one of our PEMs or adult attendings.
> 
> The reality is that most nurses, even those with extensive ED experience, don't really understand the nature of pre-hospital care; especially so in 911 systems.


I would rather trust a Nurse with little to no pre-hospital experience than a Paramedic in all reality.


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## Tigger (Feb 8, 2019)

DrParasite said:


> On the topic of RSI: most of NJ allows it, while many medical directors in NC don't, including my former one.  It's not something that should be used all the time, but there is absolutely a time and place to use it, and if you don't have that option, well, you aren't giving the patient the best chance for success and survival


Hot take: if you can provide a surgical airway, you don't truly "need" RSI.


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## DesertMedic66 (Feb 9, 2019)

Tigger said:


> Hot take: if you can provide a surgical airway, you don't truly "need" RSI.


Yeah, I’m not gonna be cutting on a trauma patient who has a GCS of 7 with an expected easy intubation. That would very quickly be flagged in hopefully all systems.


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## Peak (Feb 9, 2019)

wtferick said:


> I would rather trust a Nurse with little to no pre-hospital experience than a Paramedic in all reality.



I just don't think that nurses should be giving medical orders. I assume that this is delagation from a set of standing orders from the medical director, but it still seems a bit odd. 

Also, I certainly wouldn't trust nurses who don't have EMS experience, or at least really strong ED background. In reality nursing school doesn't teach a whole lot in the way of critical care, let alone the unique challenges of EMS. Nurses are held liable for failure to rescue, but typically that is calling 911 or a code/rapid response in the hospital and letting someone else fix it.


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## DrParasite (Feb 9, 2019)

Tigger said:


> Hot take: if you can provide a surgical airway, you don't truly "need" RSI.


Ummmm, I guess?  I've seen several patient's receive RSI in the field.  I've never seen a surgical airway performed, despite the paramedics having that capability.  

I mean, I guess you're right.... no need to RSI someone to ensure a patent airway, if you can just cut a hole in in the neck and have them breath that way..... RSI still sounds like a safer option to me though.

In my current EMS system, surgical airways are in the paramedic scope of practice, but if you do one, you need to call the medical director immediately afterwards and explain your actions.  their thinking is you have enough tools in your toolbox that you shouldn't need to do a surgical airway, but you have it available should you need it.


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## Tigger (Feb 9, 2019)

DesertMedic66 said:


> Yeah, I’m not gonna be cutting on a trauma patient who has a GCS of 7 with an expected easy intubation. That would very quickly be flagged in hopefully all systems.


This was recently brought up by our education captain and medical director. I'm with you, if the patient needs to be intubated, do it when conditions are optimal. I think their point was more to emphasize that it is a legitimate airway strategy especially if the patient is not an RSI candidate and other means are not providing adequate ventilation.


DrParasite said:


> In my current EMS system, surgical airways are in the paramedic scope of practice, but if you do one, you need to call the medical director immediately afterwards and explain your actions.  their thinking is you have enough tools in your toolbox that you shouldn't need to do a surgical airway, but you have it available should you need it.


What a great way to discourage people from doing the right thing.


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## DrParasite (Feb 9, 2019)

Tigger said:


> What a great way to discourage people from doing the right thing.


Above my paygrade.  I guess (and this is only a guess) is that the situation should never get bad enough when you have to do a surgical airway, but if it does, he wants to hear about it.  I guess he doesn't consider a surgical airway to be the right thing, but since he has MD after his name, he's in a better position to make that statement than i am.


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## aquabear (Feb 14, 2019)

So are counties in California using push dose pressors as a bridge to a drip, or have they just gotten rid of prehospital vasopressor drips all together and using just PDP instead?


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## DesertMedic66 (Feb 14, 2019)

aquabear said:


> So are counties in California using push dose pressors as a bridge to a drip, or have they just gotten rid of prehospital vasopressor drips all together and using just PDP instead?


That’s a good question haha. The only pressor that is/was available in CA to use is dopamine. A lot of counties are starting to phase it out. 

There are talks about possibly trying to do a trial study for Levophed but one major issue is that only a super small percentage of companies carry pumps. So for the time being it seems as if push dose is the safer option.


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## MedicEducate4Life (Feb 21, 2019)

California has a wide array of protocols since we have a great variance in the geographical areas that are also regulated by a multitude of Local Emergency Medical Service Agencies (LEMSA).  With 58 counties and around 33 LEMSAs (all with different protocols) research outcomes and data are not always representative of the "State".  One of the biggest difficulties is writing a protocol that is functional for all the areas served, not just the metropolitan areas but the rural and remote areas.

Skills that are not used and never reviewed and competency tested are likely to have failure rates that are high.  Larger organizations and entities have greater expenses to maintain competency testing let alone add a procedure or medication that comes with an added cost.  So they often fight changes preventing budget increases, preventing compliance and skill testing, and preventing other medical directors to pioneer a change on their own.  California has many medical directors who do not want to increase their liability.


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