# What would you change about your protocols?



## NUEMT (Sep 14, 2017)

Anything. Everything. You and your medical director are eating pizza and he/she asks you honestly and you answer like you actually care.  What would you say?

Trends, wishlist, out of box ideas welcome. Post references if you got em.


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## Summit (Sep 14, 2017)

All protocols end with: providers get cookies, fresh fruit, free coffee (good coffee), and 15 minute break.

Pt/no pt protocol states patients presenting with suitcases at the curb get dispo'd to Uber.

GI bleed protcol: Add vicks vapor rub and coffee grounds to the formulary

Use of sirens not allowed

Wilderness protocol: Add LiOH scrubbed rebreather


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## NomadicMedic (Sep 14, 2017)

a real pain management protocol, with a paramedic decision tree.

sedation on standing orders

transport of 'general malaise' patients to urgent care, not an ED


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## EpiEMS (Sep 14, 2017)

Oh, I love a good wishlist. I'm going to restrict my wishlist to things that are things I might use relatively frequently like @NomadicMedic has, rather than the "sexy stuff".
 1) Zofran for BLS providers
 2) Methoxyfluorane or something along those lines 
 3) Transport to a non-ED facility for patients with coryzal symptoms, minor trauma, etc.
 4) Somebody supervising to make sure that people don't drive like maniacs (50 in a 45, sure - but not 65)


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## GMCmedic (Sep 14, 2017)

Ill stay realistic. 

1. Push dose pressor

2. Get rid of nimbex 

3. Remove line that says check a BGL on any known diabetic. 

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## MonkeyArrow (Sep 14, 2017)

NomadicMedic said:


> transport of 'general malaise' patients to urgent care, not an ED


I don't know about this one. The general malaise patients are often pretty sick people that end up getting admitted, especially in the older patient population.


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## StCEMT (Sep 14, 2017)

In no particular order

1. Get rid of the damn backboard protocol in it's current state

2. Ketamine for so many reasons.

3. If you are gonna let me intubate, actually give me a sedative.

4. Give me more pain control options. I like Fentanyl, but I would like a little more flexibility in options. 

5. I haven't had a need (yet), but it would be nice to have a better a fib RVR protocol other that A. Watch B. Shock

That's all that comes to mind for now, at least for protocol related ideas.


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## Carlos Danger (Sep 14, 2017)

GMCmedic said:


> Ill stay realistic.
> 
> 1. Push dose pressor
> 
> ...


You guys have nimbex? I never heard of that in EMS. It's a great drug. Why do you carry it instead of roc or vec? What don't you like about it?


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## GMCmedic (Sep 14, 2017)

Remi said:


> You guys have nimbex? I never heard of that in EMS. It's a great drug. Why do you carry it instead of roc or vec? What don't you like about it?


I dont mind it, but for whatever reason we have Roc and Nimbex. The Nimbex is our "long acting" paralytic. Since we added Roc last year, weve given it 53 times and given Nimbex 14 (likely cookbook medics giving it). 

Nimbex cost 10 times what Roc does. If we added maintenance dosing of Roc we could save a lot of money each year on a drug we never use. 

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## VFlutter (Sep 14, 2017)

We currently have Succ, Vec and Nimbex until Roc becomes readily available again. Nimbex's onset of action is too long for a RSI paralytic IMO. You can make it work it is just not ideal. Luckily we have not had to use it for RSI yet since we had a pretty good stock of Roc and Vec and most of the patients we intubate are trauma so Succ isn't an issue.


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## Carlos Danger (Sep 14, 2017)

I am really surprised to hear about cisatracurium in the prehospital world at all. I think it is a great drug, but is very expensive, and outside of certain populations, the clinical differences between it and roc or vec are minor.

I still think that, when the chips are down and you really need the best intubating conditions possible as quickly as possible, succinylcholine is the best drug available, and it is dirt cheap. Barring sux for whatever reason, either roc or vec are decent substitutes.


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## GMCmedic (Sep 14, 2017)

I absolutely love ketamine and roc paired. 

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## VFlutter (Sep 14, 2017)

Remi said:


> I am really surprised to hear about cisatracurium in the prehospital world at all. I think it is a great drug, but is very expensive, and outside of certain populations, the clinical differences between it and roc or vec are minor.



Have you used Nimbex for RSI outside of a routine induction? As opposed to emergent.


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## GMCmedic (Sep 15, 2017)

Now that I have a moment to write this out. 

Our current protocol has 3 weight categories, 50kg, 100kg, and 150kg. 

Its broken down as follows. 

Ketamine 100mg, 200mg, 300mg
Rocuronium 50mg, 100mg, 150mg

Either 100mcg fentanyl or 1mg dilaudid, I prefer fentanyl in this setting. 

Then we have the choice of redosing ketamine or versed if we need more sedation, I never have.

If we need it we have Nimbex broken down as 5mg, 10m, 15mg. 

Our protocol is not all or nothing. If the patient is adequately sedated and paralyzed to optimize first pass success and patient comfort, you stop, though analgesics are not optional. 

I believe that the 14 administrations of Nimbex are likely cook book medics that go through the protocol line for line. Why we still have Nimbex I dont know, it carried over from when we had succs. 

Nimbex is ~$30 a vial, Roc is ~$3

What I plan to propose at the upcoming protocol meeting is adding a 4th 50mg vial of Roc, if we maintenance dose at 0.1 mg/kg the doses will be 5mg, 10mg, 15mg and the dosages on the last line of the protocol remain the same (yay, no new numbers to memorize!!).  

AND save the service over $1000 a year in the process. 

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## Carlos Danger (Sep 15, 2017)

Chase said:


> Have you used Nimbex for RSI outside of a routine induction? As opposed to emergent.


Like in the field or the ED? No. I use sux pretty exclusively in those scenarios, or I try to keep them breathing and don't use any NMB at all. Just depends.

In the OR, the way I practice there's really no difference between RSI and non-RSI inductions, meaning I don't usually ventilate after I give the induction agent. There are exceptions, of course. But I also don't usually wait for the NMB to take full effect, unless I'm using sux. Pretty much anytime I use a non-depolarizer, I am passing the tube while the cords are still moving. So to me personally, onset time means little.  

We don't have cis anymore where I work now. But I used it quite a bit in the past.


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## SpecialK (Sep 15, 2017)

Bring back entonox; generally much easier than MOF!

Apart from that ... I honestly can't think of anything.  The CPGs have expanded so greatly in the past two to three revisions it really is amazing.  

The comprehensive edition is here if you want to have a read and see if you would like to take anything from them http://www.wfa.org.nz/file/933/WFACPG_Comprehensive_LQ170228.pdf


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## RocketMedic (Sep 15, 2017)

I'd steal the old Presidio protocols and be Captain Amazing. Also, give me a field termination criteria that one can actually use to field terminator.


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## NomadicMedic (Sep 15, 2017)

MonkeyArrow said:


> I don't know about this one. The general malaise patients are often pretty sick people that end up getting admitted, especially in the older patient population.



 I just wrote that quick, so I didn't add any qualifiers. Obviously, the paramedic should use clinical judgment to determine proper transport decision. I forget that not every paramedic possesses a well-rounded set of clinical acumen.  Obviously, taking a 70-year-old patient who is borderline septic to the doc in a box is a bad idea, However, I don't think there's anything wrong with taking a 23-year-old who's got a stuffy nose and sore throat to the urgent care.


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## NUEMT (Sep 15, 2017)

EpiEMS said:


> Oh, I love a good wishlist. I'm going to restrict my wishlist to things that are things I might use relatively frequently like @NomadicMedic has, rather than the "sexy stuff".
> 1) Zofran for BLS providers
> 2) Methoxyfluorane or something along those lines
> 3) Transport to a non-ED facility for patients with coryzal symptoms, minor trauma, etc.
> 4) Somebody supervising to make sure that people don't drive like maniacs (50 in a 45, sure - but not 65)



+1 for the green whistle


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## VentMonkey (Sep 15, 2017)

GMCmedic said:


> Remove line that says check a BGL on any known diabetic.


I'm not quite sure I follow.

As far as wish lists? Eh, I just wished we all stopped "wishing" for items that make little differences in the majority of our patients outcomes.

All the fancy gadgets, gizmos, and toys that make for "sexy medicine", but that have yet to _consistently_ provide positive outcomes has done nothing for me but make me want to bury my head in the proverbial sand around many of my peers.


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## RocketMedic (Sep 15, 2017)

I'd protocol in a pay raise.


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## GMCmedic (Sep 15, 2017)

VentMonkey said:


> I'm not quite sure I follow.
> 
> As far as wish lists? Eh, I just wished we all stopped "wishing" for items that make little differences in the majority of our patients outcomes.
> 
> All the fancy gadgets, gizmos, and toys that make for "sexy medicine", but that have yet to _consistently_ provide positive outcomes has done nothing for me but make me want to bury my head in the proverbial sand around many of my peers.


We have a "general considerations" section. 

One portion of that says we are supposed to check a blood sugar on any known diabetic that hasnt checked their own sugar within the last hour, regardless of complaint or signs and symptoms. 

I would like to see that line removed from the protocols. 

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## NomadicMedic (Sep 15, 2017)

GMCmedic said:


> We have a "general considerations" section.
> 
> One portion of that says we are supposed to check a blood sugar on any known diabetic that hasnt checked their own sugar within the last hour, regardless of complaint or signs and symptoms.
> 
> ...




So, don't do it. What'll happen?


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## GMCmedic (Sep 15, 2017)

NomadicMedic said:


> So, don't do it. What'll happen?


Well I don't do it, but just maybe itll help in a culture change. 

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## luke_31 (Sep 16, 2017)

I'd change protocols to be guidelines instead and add in the caveat of use provider judgement as to what is appropriate for each patient.  Maybe just go with a list of all approved procedures and guide of medications and accepted doses for the age groups both children and adult. Let the provider determine what needs to be done for the patient and not have to justify why X was done instead of Y and the time frame for doing the procedures


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## medichopeful (Sep 16, 2017)

Oh this could be fun.  I'm not currently working in the EMS field but will be soon (hopefully), provided I pass my NRP practical.  With that being said, I'm pretty familiar with the MA state protocols, and these are the things I'd change:

-Implementation of a hospice/comfort care protocol, with very liberal use of sedatives, benzos, narcotics, antiemetics, and ketamine.  Also, the addition of scopalamine patches for the protocol.
-Additional options for antiemetics, including phenergan and reglan.  
-Additional pain management options, including dilaudid, ketamine, toradol, ibuprofen, tylenol, and entonox.  In addition, the ability to provide adequate pain relief without having to call medcon for higher doses or adjunct medications.
-RSI for a small subset of medics, with appropriate paralytic reversal drugs.  Dantrolene as well if carrying meds that can cause MH, because it's a wish-list, right? 
-Propofol or precedex infusion capability
-Requirement to have both CPAP and BiPAP capability for ALS level services.
-Push dose pressors, along with more options for pressors (neo, vasopressin would be nice).  Make it so you don't have to call for medcon orders for pressors.
-Octreotide and the ability to infuse blood products
-Nitro infusions for CHF and (possibly) chest pain
-Prehospital antibiotics and the ability to draw blood cultures
-More fluid options than just NS.
-iStats and the ability to provide electrolyte replacement.
-Insulin for severe hyperkalemia
-Alternative point of entry protocols (detox, psych), or alternative modes of transport protocols (chair car, taxi vouchers, etc).

Seeing as it is a wishlist, why not go all out?!


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## TXmed (Sep 16, 2017)

Serious question, is there any evidence for non-anesthesia using push-dose pressors ? Any evidence that they improve patient outcomes ? For RSi or whatever other reason people are using them ? 

I think it is a noval idea and i wanna support it, but every instance i come across people using them in the pre-hospital or emergency setting its  done poorly and inapproprietly.


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## StCEMT (Sep 17, 2017)

TXmed said:


> Serious question, is there any evidence for non-anesthesia using push-dose pressors ? Any evidence that they improve patient outcomes ? For RSi or whatever other reason people are using them ?
> 
> I think it is a noval idea and i wanna support it, but every instance i come across people using them in the pre-hospital or emergency setting its  done poorly and inapproprietly.


I think Weingart was/is working on one, I'm not 100% sure though.


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## VFlutter (Sep 17, 2017)

TXmed said:


> Serious question, is there any evidence for non-anesthesia using push-dose pressors ? Any evidence that they improve patient outcomes ? For RSi or whatever other reason people are using them ?
> 
> I think it is a noval idea and i wanna support it, but every instance i come across people using them in the pre-hospital or emergency setting its  done poorly and inapproprietly.



I do not think there is strong evidence out side of the OR. Same problem we have, sounds like a great idea but hard to prove. Unfortunately may people use it as a bandaid to inadequately resuscitate a patient which usually has bad outcomes. But for peri-intubation hypotension and for bridge to drip is great.


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## medichopeful (Sep 17, 2017)

Chase said:


> But for peri-intubation hypotension and for bridge to drip is great.



^this. Push pressors have their place, and long-term use isn't it.


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## GMCmedic (Sep 22, 2017)

GMCmedic said:


> Ill stay realistic.
> 
> 1. Push dose pressor
> 
> ...


Well, I got 2 of my 3 wishes. I didnt actually go to the meeting so I left #3 alone. 

I dont know all of the details surrounding the push dose pressors yet,  but our MD was not on board with mixing it so itll be 1ml of 1:10,000............

She apparently uses this dose regularly in the ED. 

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## StCEMT (Sep 22, 2017)

GMCmedic said:


> Well, I got 2 of my 3 wishes. I didnt actually go to the meeting so I left #3 alone.
> 
> I dont know all of the details surrounding the push dose pressors yet,  but our MD was not on board with mixing it so itll be 1ml of 1:10,000............
> 
> ...


What's so hard about taking 1ml of epi (10k) and mix it with 9ml NS to fill up a pretty little 10ml syringe nice and evenly? That's about as easy as drug dose calcs get.


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## NomadicMedic (Sep 23, 2017)

StCEMT said:


> What's so hard about taking 1ml of epi (10k) and mix it with 9ml NS to fill up a pretty little 10ml syringe nice and evenly? That's about as easy as drug dose calcs get.


That's how we do it. Easy peasy.


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## GMCmedic (Sep 23, 2017)

StCEMT said:


> What's so hard about taking 1ml of epi (10k) and mix it with 9ml NS to fill up a pretty little 10ml syringe nice and evenly? That's about as easy as drug dose calcs get.


I dont know. 

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## Tigger (Sep 24, 2017)

TXmed said:


> Serious question, is there any evidence for non-anesthesia using push-dose pressors ? Any evidence that they improve patient outcomes ? For RSi or whatever other reason people are using them ?
> 
> I think it is a noval idea and i wanna support it, but every instance i come across people using them in the pre-hospital or emergency setting its  done poorly and inapproprietly.


I am curious what your misadventure experiences are, I don't want to repeat. Our primary pressor is now epi (the "dirty epi drip). 1mg in 1000ml (1ml=1mcg) in 50 mcg increments until improvement (ie MAP of 65). I think this probably a good post ROSC procedure for the profoundly hypotensive (and it's easy to draw out 10mcg as a push dose), but when facing a long transport I am not sure this such a good idea.


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## TXmed (Sep 24, 2017)

Tigger said:


> I am curious what your misadventure experiences are, I don't want to repeat. Our primary pressor is now epi (the "dirty epi drip). 1mg in 1000ml (1ml=1mcg) in 50 mcg increments until improvement (ie MAP of 65). I think this probably a good post ROSC procedure for the profoundly hypotensive (and it's easy to draw out 10mcg as a push dose), but when facing a long transport I am not sure this such a good idea.




Well i have seen alot of people become overzealous using these push-dose pressors or use it as an excuse to not set up a drip. Example: septic patient has a SBP <80 and requires intubation, paramedic or physician has the ability to set up a drip prior to intubation but instead uses a push dose pressor prior to and then just continue the push-dose method until they forget to do a dose and then the patient crashes. I have also seen people just go with 100mcg-200mcg boluses. All they are focused on is the numbers but what is this overzealous use of a pressor doing for cerebral blood flow, renal blood flow, coronary blood flow? Often times prior to intubation there is time to mitigate these problems with a more accurate intervention than a bolus, but some people get this mindset of why workout decimals when i can give a lump sum. People talk about evidence based medicine but where is this evidence in the ER/pre-hospital literature? ive only seen evidence about how bad post-intubation hypotension can be but havent yet come across evidence that a slug of epi has a mortality benefit.


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## StCEMT (Sep 24, 2017)

That sounds more like an education problem tough, not a concept problem? I've never seen anyone that regularly uses it pretend it's anything but a bridging method to a long term solution when needed. Nor do I see them advocating dosing in that manner either.


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## TXmed (Sep 24, 2017)

StCEMT said:


> That sounds more like an education problem tough, not a concept problem? I've never seen anyone that regularly uses it pretend it's anything but a bridging method to a long term solution when needed. Nor do I see them advocating dosing in that manner either.



And that  is one of the reasons i come to this forum to gauge other peoples experiences. Mine have not been exclusive to one poor department or service but rather pretty wide spread.


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## Tigger (Sep 25, 2017)

I have not ever seen it done in the hospital. Usually they just rush to set up a levo drip. It's something I am trying to add to my own practice but I am still trying to figure out when it's a bail out and when it's correct.


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## phideux (Oct 11, 2017)

I'd wish for a Paramedic Initiated Refusal protocol. No more free Medicaid taxi.


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## VFlutter (Oct 17, 2017)

Tigger said:


> I have not ever seen it done in the hospital. Usually they just rush to set up a levo drip. It's something I am trying to add to my own practice but I am still trying to figure out when it's a bail out and when it's correct.



Anesthesia frequently uses push dose pressors in the OR/GI/CCL. The anesthesia cart is usually stocked with premixed Neosynpehrine syringes.


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## Tigger (Oct 20, 2017)

Chase said:


> Anesthesia frequently uses push dose pressors in the OR/GI/CCL. The anesthesia cart is usually stocked with premixed Neosynpehrine syringes.


Oops kinda forgot about that. Watching their ability keep hemodynamics right in a prescribed range is fascinating. However in the ED, I can't say I've ever seen anyone prepare that. Every now and again things go sideways and someone remembers to mix it up and give it.


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