# Protocol question



## BadCowboy0716 (Apr 6, 2013)

If you could change one protocol in the book which one would it be and why? I'm looking a paper subject. I was thinking about writing about RSI because we currently don't do it here being as we run in the city and we are only 5-15 minutes from like 5 different hospitals.


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## NomadicMedic (Apr 6, 2013)

Which book are you talking about? All of us have very different protocols. 

In my case, I'd like to have Lasix removed from our CHF protocols and CPAP added as a BLS skill for everyone.


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## BadCowboy0716 (Apr 6, 2013)

I mean our list of protocols on the truck. We have our BLS able to do Cpap here.


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## JPINFV (Apr 6, 2013)

I'd add a line to the intro stating that the protocol is a guide, but any intervention provided is done under the paramedic's own judgement.


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## Scott33 (Apr 6, 2013)

Just one? IV nitro.


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## usalsfyre (Apr 6, 2013)

Long Spine Boards are only to be used for extrication and movement and the patient immediately removed once on the stretcher.


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## Milla3P (Apr 6, 2013)

usalsfyre said:


> Long Spine Boards are only to be used for extrication and movement and the patient immediately removed once on the stretcher.



LBB at providers discretion, not for twisted ankles.


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## Carlos Danger (Apr 6, 2013)

I would add Ketamine for sedation, intubation, and analgesia in certain cases.

I would also take spine boards out of the protocols completely.




Scott33 said:


> Just one? IV nitro.



I hear a lot of paramedics say this and I always wonder why IV nitro would be better than SL?


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## VFlutter (Apr 6, 2013)

Halothane said:


> I hear a lot of paramedics say this and I always wonder why IV nitro would be better than SL?



Unless they are planning on initiating a Tridil drip I do not really see much of an advantage.


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## Carlos Danger (Apr 6, 2013)

Chase said:


> Unless they are planning on initiating a Tridil drip I do not really see much of an advantage.



As you know, setting up and titrating a drip is infinitely more time consuming and infinitely more of a hassle than popping SL's. 

Yet I often hear paramedics say they want to include IV nitro in their protocols, and I always wonder why.


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## Medic Tim (Apr 6, 2013)

Halothane said:


> I would add Ketamine for sedation, intubation, and analgesia in certain cases.
> 
> I would also take spine boards out of the protocols completely.
> 
> ...



I have the choice of ketamine , morphine and fent for RSI, procedural sedation and analgesia. It is a great drug. I would not remove boards completely. They make for decent extrication and carrying device. I prefer the scoop versions. 

I also have iv nitro for acs and Chf if the transport time is greater than 20 min or if I am in the clinic.


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## Scott33 (Apr 6, 2013)

Halothane said:


> Yet I often hear paramedics say they want to include IV nitro in their protocols, and I always wonder why.



More a case of not having to break the seal on a CPAP mask for the CHF patient, and to provide a nice steady drip for both CHF and ACS patients for those of us not restricted to a max of 3 doses. Also requires no coaching in how to expose the frenulum of the tongue. Easily titrated with a short half life.


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## Carlos Danger (Apr 6, 2013)

Medic Tim said:


> I would not remove boards completely. They make for decent extrication and carrying device. I prefer the scoop versions.



I agree they can be handy, so I wouldn't take them off the ambulances, I would just remove the protocol requirement for their use.


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## Carlos Danger (Apr 6, 2013)

Scott33 said:


> *More a case of not having to break the seal on a CPAP mask for the CHF patient, *and to provide a nice steady drip for both CHF and ACS patients for those of us not restricted to a max of 3 doses. Also requires no coaching in how to expose the frenulum of the tongue. Easily titrated with a short half life.



The CPAP think is a decent point, but even considering that, I think the time and hassle of setting up a drip and the time a titration cycle takes makes an infusion only worth it if you have a pretty long transport time.


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## Epi-do (Apr 6, 2013)

I can only pick one?  I don't even know where I would start, since most of them are out dated and need to be updated.


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## phideux (Apr 7, 2013)

At the place I left recently, Get rid of the Mast Trousers. They were the best thing since sliced bread in the 70s, things have changed since then.


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## Handsome Robb (Apr 7, 2013)

RSI for medics that prove themselves proficient and competent. I know plenty of medics that have no business pushing paralytics.

Take nasotracheal intubation out. We carry the kits, are trained to do it but the ERPs here would blow a gasket if you brought a patient in with a nasal tube and QA/I wouldn't be far behind. If you don't want us doing it then don't give us the protocol, supplies and training to perform it...


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## MackTheKnife (Apr 7, 2013)

phideux said:


> At the place I left recently, Get rid of the Mast Trousers. They were the best thing since sliced bread in the 70s, things have changed since then.



I've been out of the scene for awhile. What's wrong with MAST?


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## chaz90 (Apr 7, 2013)

MackTheKnife said:


> I've been out of the scene for awhile. What's wrong with MAST?



In short, they don't help and actually appear to hurt. Also, you'd end up screwing around on scene putting them on sick patients rather than transport to definitive care.


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## NomadicMedic (Apr 7, 2013)

Uhh, how long have you been out of the scene? It's been over 20 years since I've seen a PASG on a truck.


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## Trashtruck (Apr 7, 2013)

Take long backboards out of the protocols. Treat them like the Reeves...use them for a carrying device, but don't put them in the protocols.

Does anybody use nitropaste for CHFer's?


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## Medic Tim (Apr 7, 2013)

Trashtruck said:


> Take long backboards out of the protocols. Treat them like the Reeves...use them for a carrying device, but don't put them in the protocols.
> 
> Does anybody use nitropaste for CHFer's?



It is available for Intermediates and medics in Maine .


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## chaz90 (Apr 7, 2013)

Robb said:


> RSI for medics that prove themselves proficient and competent. I know plenty of medics that have no business pushing paralytics.
> 
> Take nasotracheal intubation out. We carry the kits, are trained to do it but the ERPs here would blow a gasket if you brought a patient in with a nasal tube and QA/I wouldn't be far behind. If you don't want us doing it then don't give us the protocol, supplies and training to perform it...



I agree with the need for RSI with rigorous training and oversight. 

I also think nasotracheal intubation has a place though. They shouldn't be common, but it can be used in rare cases where the orotracheal route is anticipated to be too difficult to push paralytics or where a rapid airway is necessary without vascular access.


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## chaz90 (Apr 10, 2013)

Trashtruck said:


> Take long backboards out of the protocols. Treat them like the Reeves...use them for a carrying device, but don't put them in the protocols.
> 
> Does anybody use nitropaste for CHFer's?



Delaware uses Nitropaste with CHF patients in addition to 0.8 mg SL every 5 minutes. We also use Nitropaste on ACS patients, for better or for worse.


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## STXmedic (Apr 10, 2013)

chaz90 said:


> Delaware uses Nitropaste with CHF patients in addition to 0.8 mg SL every 5 minutes. We also use Nitropaste on ACS patients, for better or for worse.



Same here, and throw in nitro for infusion as well.


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## Carlos Danger (Apr 10, 2013)

chaz90 said:


> I agree with the need for RSI with rigorous training and oversight.



RSI should not, IMO, be a standard paramedic skill. A very large percentage of paramedics (if not a significant majority) simply do not have the airway experience or judgement to do it safely, and it has not been shown to improve outcomes in most patients, anyway. In fact many studies indicate more harm than benefit.

RSI should be reserved for EMS systems that have uncommonly strong education and QI programs, and that can show that it does, in fact, improve outcomes in their system.

Heck, intubation itself is in question....



chaz90 said:


> I also think nasotracheal intubation has a place though. They shouldn't be common, but it can be used in rare cases where the orotracheal route is anticipated to be too difficult to push paralytics or where a rapid airway is necessary without vascular access.



The problem is, blind NTI isn't "rapid", unless you get lucky, or perhaps if you practice it a lot. But it's not really an easy procedure, and it's impossible to practice it on real people. There's a reason why it went by the wayside quite a while ago.

I suppose there are times when an attempt isn't going to hurt anything. So I wouldn't necessarily take it out of the protocols, I guess. 



PoeticInjustice said:


> Same here, and throw in nitro for infusion as well.



I wonder how many people who think they want to do nitro infusions in the field have ever set one up or titrated it?

I don't think it offers the advantages you guys think it does, and I don't think it is time effective unless you have pretty long transport times.


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## Carlos Danger (Apr 10, 2013)

Airway algorithm:


 "RSI is only indicated in the patient whom, because of impending respiratory failure, you do not expect to survive transport to the closest ED; there is no such thing as 'elective intubation' in the prehospital setting"


 "Bag-mask ventilation will not be done in any case, unless the Sp02 drops below 90 and airway placement is not imminent"

Protocol:
Placement of high-flow NC
Pre-oxygenation with NRB
IO or IV placement
Induction with ketamine (preferably) or etomidate (only where ketamine is contraindicated) 
Relaxation with succinylcholine (preferably) or rocuronium (only where succinylcholine is contraindicated)
ONE look (which shall be terminated at 60 seconds, or when the Sp02 drops below 93) via VL or DL (+/- bougie) --> ETI. 
If unsuccessful at ETI --> supraglottic airway --> done
If unsuccessful at SGA placement --> cric --> done


Only allowing RSI to be done when it is truly necessary, and placing a "hard stop" at 1 ETI attempt would eliminate the vast majority of the problems that I have seen with prehospital RSI.

The goal is to ventilate the lungs, not to place plastic between the cords.


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## truetiger (Apr 10, 2013)

Out in the rural setting, hauling it the the local ED usually isn't an option in most cases of RSI, many times the doctors at these facilities are less familiar with intubation than the medics.


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## PNW EMT (Apr 11, 2013)

DEmedic said:


> Uhh, how long have you been out of the scene? It's been over 20 years since I've seen a PASG on a truck.



Pierce County, WA requires them on all trucks BLS and ALS. There's like one place on earth you can buy them from and when you do they always say "ah you must be from Pierce County!"


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## medicdan (Apr 11, 2013)

PNW EMT said:


> Pierce County, WA requires them on all trucks BLS and ALS. There's like one place on earth you can buy them from and when you do they always say "ah you must be from Pierce County!"


apparently RI still requires MAST pants statewide as well... I'd love someone else to confirm. Remember, this is the state that has non-ACLS cardiacs...


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## Handsome Robb (Apr 11, 2013)

Trashtruck said:


> Take long backboards out of the protocols. Treat them like the Reeves...use them for a carrying device, but don't put them in the protocols.
> 
> Does anybody use nitropaste for CHFer's?



Nitropaste for both CHF and ACS, no infusions. Transport times are too short generally.


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## TheLocalMedic (Apr 11, 2013)

1.  Get rid of Lasix.  It's not a good pre-hospital drug.

2.  No board unless obvious c-spine deformity/tenderness or neuro deficit.

3.  Haldol + Ativan dart guns should be on every ambulance!


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## Amberlamps916 (Apr 11, 2013)

Lactate testing......


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## 18G (Apr 11, 2013)

To give atrovent without calling Medical Command.


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