# BS protocol updates



## Cake (Jul 8, 2010)

great.  they just upgraded our BLS pharmacology to allow administration of Acetaminophen.... Tylenol!!!  so now we're going to get calls for stubbed toes and hangovers.  and are we really going to stay on scene for the 30 min or so for it to kick in and get results?  i just dont understand the point of this.  now im really starting to feel like an underpaid babysitter


----------



## reaper (Jul 8, 2010)

Is the protocol for pain or Fever?

Liquid Tylenol is very common for pedi fevers. Sooner it is administered, the sooner the fever will start to break.


----------



## WolfmanHarris (Jul 8, 2010)

We have a protocol for PO tylenol, benadryl and polysporin for special events. (As approved by the service.) Nothing for day to day operations.

Really though, do you think the people who call for total bull, pay attention to what's in your scope? I don't think you'll see any significant change in call volume.


----------



## Cake (Jul 8, 2010)

we'll only have it in pill form. x2 325mg tablets for adult. no where in the protocols does it mention fever, only for pain.  i wonder if we'll be using it for fevers as well...

im hoping its the case that no one will really know..  lets hope the word doesnt get out


----------



## JPINFV (Jul 8, 2010)

Holy hell, I think this is the first time I've seen an EMT against increasing a scope of practice sans the education argument. Are you really arguing that you want to do less because doing more might increase your work load?


----------



## MrBrown (Jul 8, 2010)

We have been dishing out panadol and leaving people at home for 30 years, great stuff, love it to bits


----------



## Cake (Jul 8, 2010)

JPINFV said:


> Holy hell, I think this is the first time I've seen an EMT against increasing a scope of practice sans the education argument. Are you really arguing that you want to do less because doing more might increase your work load?




here's my confusion- if a patient is in pain a) and its minor enough to be helped with a tylenol, why couldn't they just take one themselves being that its such a common medication? b) if its serious pain/trauma then i doubt a tylenol will matter, and its most likely going to be an ALS call where they can work with a bit more. How long does it take for tylenol to kick in?  As an emergency responder, don't you think we're going for more immediate treatments?

I know I'm still new, but I feel things like tylenol and bandaids dont belong on an ambulance.  These are common, available items that don't warrant the dispatch of an ambulance.  It has EMERGENCY on the side for a reason.  


As far as education goes, I don't think one has to be any more educated to administer tylenol than the next guy.  We've been taking it ourselves since adolescents.  I sure don't feel any more educated after this protocol update.  

You say that I'm against increasing the scope of practice, and I see your point- baby steps baby steps- but in a way I feel that this cheapens our position even more.


----------



## TransportJockey (Jul 8, 2010)

Never have I seen APAP in a protocol for minor pain... NM is was ONLY in the protocols for pedi fever.


----------



## mycrofft (Jul 8, 2010)

*Legalities and situations*

Legalities: At least in Calif.,without an order, even in the form of a protocol, a RN cannot give oral medication. An OTC topical like ABX oint is a fencestraddler, and if there is a bad side effect (allergy?), someone can get in trouble. Where can an EMT do something a pharmacy-trained RN can't?

Situations: you are doing standby at the company picnic and someone has a headache or a muscle pain from an activity. Or they have indigestion from the rancid egg salad. They probably did not bring anything, or its been sitting in their car cooking at 135deg F for years.

The kicker for these cases is if you are doing SOAPIE documentation, you are supposed to truthfully re-asses and describe the outcome of your treatment.
Spare me.

Oh, by the way...make sure that indigestion isn't an MI or acute food poisoning, the muscle ache isn't a stree fx, and that headache isn't an incipient CVA or dehydration.


----------



## TransportJockey (Jul 8, 2010)

mycrofft said:


> Legalities: At least in Calif.,without an order, even in the form of a protocol, a RN cannot give oral medication. An OTC topical like ABX oint is a fencestraddler, and if there is a bad side effect (allergy?), someone can get in trouble. Where can an EMT do something a pharmacy-trained RN can't?
> 
> Situations: you are doing standby at the company picnic and someone has a headache or a muscle pain from an activity. Or they have indigestion from the rancid egg salad. They probably did not bring anything, or its been sitting in their car cooking at 135deg F for years.
> 
> ...



What do the I and the E stand for at the end of SOAP?


----------



## abckidsmom (Jul 8, 2010)

jtpaintball70 said:


> What do the I and the E stand for at the end of SOAP?



Intervention and Evaluation

I would never call an ambulance for tylenol, but I would approach a standby unit for some.  For bandaids, too.

We used to have a favorite spot to sit while we were posted where the people all played in the river, sliding on rocks in the rapids.  Bandaid central!  

If ERs can be used for tylenol, so can ambulances.


----------



## Cake (Jul 8, 2010)

abckidsmom said:


> Intervention and Evaluation
> 
> I would never call an ambulance for tylenol, but I would approach a standby unit for some.  For bandaids, too.
> 
> ...




As a standby unit, or working events then it makes a lot of sense, and I think its a worthy idea. 

I was thinking more towards the emergency response side of things.  Lets give this guy a tylenol for his amputated leg?? <_<


----------



## abckidsmom (Jul 8, 2010)

Cake said:


> As a standby unit, or working events then it makes a lot of sense, and I think its a worthy idea.
> 
> I was thinking more towards the emergency response side of things.  Lets give this guy a tylenol for his amputated leg?? <_<



It's within the scope.  I don't think I'd give anybody anything PO who was headed for the OR.  

Tylenol for fever is a good tool to have in the box.  Cheap, low-risk, and effective.


----------



## Veneficus (Jul 8, 2010)

It is humane to give tylenol after a nitro if you are not administering ASA with it.

Don't use a cannon to kill a mosquito. If a patient has mild pain and tylenol will do, why start an IV or inject somebody with something?

Tylenol works really well for fever. (I like ibuprofin for kids better though)

Not to mention once you have given morphine for break through you can use an nsaid for maintenence. 

Lets not forget, if you are a basic, what other pain options do you even have? Better to do something than nothing right?


----------



## octoparrot (Jul 8, 2010)

to the OP, what state is this in? I'm curious to read up on it.


----------



## mgr22 (Jul 9, 2010)

Cake said:


> I know I'm still new, but I feel things like tylenol and bandaids dont belong on an ambulance.  These are common, available items that don't warrant the dispatch of an ambulance.  It has EMERGENCY on the side for a reason.
> 
> As far as education goes, I don't think one has to be any more educated to administer tylenol than the next guy.  We've been taking it ourselves since adolescents.  I sure don't feel any more educated after this protocol update.
> 
> You say that I'm against increasing the scope of practice, and I see your point- baby steps baby steps- but in a way I feel that this cheapens our position even more.



Did they cover how toxic Tylenol can be, and how often people OD on it? If so, how much of that did you already know? Just because a drug is available OTC, it doesn't mean it's benign. As a healthcare provider, you've got a higher level of responsibility when you start handing out meds.

I think we "cheapen our position" when we apply our own definitions of emergencies to everyone else.


----------



## lampnyter (Jul 9, 2010)

wow thats almost lucky, here EMTs cant even give aspirin. all we can do is glucose, epipen, activated charcoal and nitro, thats it...


----------



## TransportJockey (Jul 9, 2010)

lampnyter said:


> wow thats almost lucky, here EMTs cant even give aspirin. all we can do is glucose, epipen, activated charcoal and nitro, thats it...



CAn't give ASA but can give NTG? I'm hoping you can't just hand it out to whomever you want to

EDIT: Exactly what Lights said. As an EMT-B in NM I was expected to have the 324mg of ASA on board before a medic unit arrived (if I wasn't riding with one or an intermediate) and if they had NTG they got some of that before too.


----------



## lightsandsirens5 (Jul 9, 2010)

lampnyter said:


> wow thats almost lucky, here EMTs cant even give aspirin. all we can do is glucose, epipen, activated charcoal and nitro, thats it...



What the h***? NTG but no ASA? Even as an I85 in WA, I'm supposed to give ASA before NTG, assuming ASA is not contraindicated. That just makes sense. Suspected MI/possible cardiac chest pain; "You allergic to this? No?" 325 mg chweable ASA. (well, actually 324 mg, but I won't get into that. 81x4=324. Lol)

What state are you in?


----------



## lampnyter (Jul 9, 2010)

i dont like to give out that information but yes, we can give NTG but not aspirin.

EDIT: and no, they have to have their own nitro


----------



## Cake (Jul 9, 2010)

octoparrot said:


> to the OP, what state is this in? I'm curious to read up on it.



Maryland


----------



## lightsandsirens5 (Jul 9, 2010)

lampnyter said:


> i dont like to give out that information but yes, we can give NTG but not aspirin.
> 
> EDIT: and no, they have to have their own nitro



Don't like to give what info? Your state? Why not?

And so you are saying that you can only assist with nitro, not give it?


----------



## lampnyter (Jul 9, 2010)

yes, we can only assist.

we have to go by the 5 rights very strictly


----------



## JPINFV (Jul 9, 2010)

lampnyter said:


> yes, we can only assist.
> 
> we have to go by the 5 rights very strictly



I've always found "assisting" someone in taking their own prescription a stretch too far to consider it administering. You aren't really giving anyone anything in that case. You're essentially allowing them to take their own prescription. Now if you were administering it from your own stock based on your own assessment (instead of allowing a patient to take a medication from their on stock on their physician's prescription), then this conversation would make a lot more sense.


----------



## Cake (Jul 10, 2010)

lets say a guy gets hurt, and as the on scene EMT, I want to give him tylenol for the pain.  His buddy comes up and hands him a vicodin instead.  I could advise against it, but there is nothing that I can do to prevent him from taking it?   Or an asthmatic who wants an extra does of their own abeuterol?  He or she has already had their allotted 2 doses per protocol, but they're not feeling it, and want more.  Can I keep them from their meds, or do I hand it over and tell em you're on your own?


----------



## JPINFV (Jul 10, 2010)

Basically, yea. Unless the patient is suicidal, I can't think of a reason why you could keep anyone from self administering prescribed medications. The vicodin is illegal, but I doubt anyone would care provided abuse isn't suspected.


----------



## PrincessAnika (Jul 15, 2010)

> CAn't give ASA but can give NTG? I'm hoping you can't just hand it out to whomever you want to



nope, here in PA NTG (and epi-pen) are pt assisted meds, and you do actually "give" it meaning you do the placement of the tab under the tongue or activate the spray (provided of course your 6Rs are in place) - think about it, you really want a diaphoretic cardiac pt holding their own nitro to place it under their tongue?  it'll be all but gone by the time they get it there...then what good does it do?   can give one dose, then CMC, if unable to contact may give one extra dose as outlined in protocol 501.



Cake said:


> lets say a guy gets hurt, and as the on scene EMT, I want to give him tylenol for the pain.  His buddy comes up and hands him a vicodin instead.  I could advise against it, but there is nothing that I can do to prevent him from taking it?   Or an asthmatic who wants an extra does of their own abeuterol?  He or she has already had their allotted 2 doses per protocol, but they're not feeling it, and want more.  Can I keep them from their meds, or do I hand it over and tell em you're on your own?



on the asthma....and this is just a thought....but the albuterol in the inhaler is less potent than the albuterol in a nebulizer treatment (i think thats what i'm trying to say)....as a pt i've already OD'd on my inhaler to the point of not being able to take anymore, including not being able to do a nebulizer treatment (6 doses, 2puffs each dose, in 90mins...oops).  one extra inhaler dose i wouldn't really worry about (but watch vitals etc!) but after that i would tell the pt they can't take it any more or the medic/ER won't be able to give them the nebulizer they need.  granted this is also a pt by pt decision, if they are crashing.....though granted an inhaler in a pt who is getting worse to the point of very limited air exchange (who has most likely already used the inhaler a few times before calling!) is not going to do much by this point if i did not already have ALS on scene i would be on the phone with the dr - he gets paid the big bucks to make those decisions 
on the vicodin - i would do my best to prevent it, as it is technically illegal to share medication with someone for whom the med is not prescribed, and you don't know if your pt is allergic to it or not...they may not even know....and if they are then you have a bigger problem on your hands....


----------



## WolfmanHarris (Jul 15, 2010)

PrincessAnika said:


> n the albuterol in the inhaler is less potent than the albuterol in a nebulizer treatment


Salbutamol (albuterol) is most effectively delivered by MDI w/ spacer. The belief that nebulized is more effective is not supported in the literature.

Closa, RM et. al. 1998, "Efficacy of Bronchodialators Administered by Nebulizers Vs Spacer Devices in Infant with Acute Wheezing" Pediatric Pulmonology, vol 26. pp. 344-348

Deerojanawong, J. et. al. 2005. "Randomized Controlled Trial of Salbutamol Aerosol Therapy Via MDI-Space Vs. Jet Nebulizer in Young Children With Wheezing." Pediatric Pulmonology, vol 39 pp. 466-472.

Rubilar, L. et. al. 2000. "Randomized Trial of Salbutamol via MDI-Spacer Vs. Nebulizer for Acute Wheezing in Children Less Than Two Years of Age." Pediatric Pulmonology. vol 29. pp 264-269.



> but after that i would tell the pt they can't take it any more or the medic/ER won't be able to give them the nebulizer they need.



This is probably is a jurisdiction thing, but here all my doses are irregardless of previous self-medication.



> granted this is also a pt by pt decision, if they are crashing.....though granted an inhaler in a pt who is getting worse to the point of very limited air exchange (who has most likely already used the inhaler a few times before calling!) is not going to do much by this point if i did not already have ALS on scene i would be on the phone with the dr - he gets paid the big bucks to make those decisions



If they're crashing they likely don't have the tidal volume to draw the salbutamol into the bronchial tree. Pouring more bronchodialator into respiratory dead space isn't going to help. They need epi at this point concurrently with careful PPV.


----------



## PrincessAnika (Jul 15, 2010)

WolfmanHarris said:


> Salbutamol (albuterol) is most effectively delivered by MDI w/ spacer. The belief that nebulized is more effective is not supported in the literature.
> 
> Closa, RM et. al. 1998, "Efficacy of Bronchodialators Administered by Nebulizers Vs Spacer Devices in Infant with Acute Wheezing" Pediatric Pulmonology, vol 26. pp. 344-348
> 
> ...




~ what i meant (and i apologize for not explaining it better - baby brain) is that the dosage is different.  neb of 2.5mg alb in 3ml nss is not the same as 90mcg inhaler - or am confused?   on those studies - do you have any that aren't pediatric?  i don't know too many adults that are even given spacers to use, let alone use them on a per/dose basis....

~ so if a pt has OD'd on albuterol (meaning showing S/S of having too much in their system) you give them more?  :huh:

~ thanks for explaining what i was trying to say better.  i don't always use the right words to get my point across...lol


----------



## WolfmanHarris (Jul 15, 2010)

PrincessAnika said:


> ~ what i meant (and i apologize for not explaining it better - baby brain) is that the dosage is different.  neb of 2.5mg alb in 3ml nss is not the same as 90mcg inhaler - or am confused?   on those studies - do you have any that aren't pediatric?  i don't know too many adults that are even given spacers to use, let alone use them on a per/dose basis....



A single 100mcg spray is not considered a dose. At least not under my medical directives. A dose is 900 mcg (9 sprays) delivered one spray every 10 seconds. All our dose are delivered with spacer.

In a nebulized dose a very large portion of the drug is lost to room air.

As far as research, I don't have any readily available (as in, in a document I had on my desk) sources from other journals. What other than where they were published potentially calls their validity into question for you?



> ~ so if a pt has OD'd on albuterol (meaning showing S/S of having too much in their system) you give them more?  :huh:



The most common side effects of salbutamol are going to be pretty hard to pick out in a patient in severe respiratory distress, unresponsive to medication, that may be progressing to failure. Tachycardia, palpitations, headache, etc. may be present anyways. These are the effects of the drug on the sympathetic nervous system, which will already be stimulated. Hypokalemia is something to be worried about later.

Let's examine why this Pt. might have self-administered salbutamol with no relief? The most common problem is likely they're doing it wrong and not drawing their medication in deep enough. In which case a properly administered dose may clear up the problem. The other is that they're in status asthmaticus and are not responding to salbutamol, in which case, go right to epi and PPV and consider salbutamol after the epi has begun to work.


----------



## PrincessAnika (Jul 15, 2010)

WolfmanHarris said:


> A single 100mcg spray is not considered a dose. At least not under my medical directives. A dose is 900 mcg (9 sprays) delivered one spray every 10 seconds. All our dose are delivered with spacer.



never heard of that dose (only standard 1-2 puffs PRN q4-6h), and we don't carry spacers on the ambo.  as a pt i've never been scripted a spacer for albuterol inhaler (got one once for flovent but was specifically told NOT to use it for albuterol).  do ya'lls carry MDI on the truck as well?  just curious bc we do not (only neb)...



> As far as research, I don't have any readily available (as in, in a document I had on my desk) sources from other journals. What other than where they were published potentially calls their validity into question for you?



just was looking for something directed at/researched in adults, not infants/very young children/children under 2 - not doubting their validity as pertained to those age grps at all since a majority of children that age are unable to follow commands of breath in and hold it, just curious if they had studied it in pts who were capable of (and did) follow proper dosing etc.



> The most common side effects of salbutamol are going to be pretty hard to pick out in a patient in severe respiratory distress, unresponsive to medication, that may be progressing to failure. Tachycardia, palpitations, headache, etc. may be present anyways. These are the effects of the drug on the sympathetic nervous system, which will already be stimulated. Hypokalemia is something to be worried about later.



i was referring to the fact that OD may cause seizures, or be fatal, per the medication sheet that the pts get....and etc.



> Let's examine why this Pt. might have self-administered salbutamol with no relief? The most common problem is likely they're doing it wrong and not drawing their medication in deep enough. In which case a properly administered dose may clear up the problem. The other is that they're in status asthmaticus and are not responding to salbutamol, in which case, go right to epi and PPV and consider salbutamol after the epi has begun to work.



true, the first is a common problem.  there is a significant lack of education, i have found, for pts with any medical problem (not just asthma), and/or lack of understanding and retaining that understanding should they get it the first time around....a good example is myself - fortunately i have a medical background and know something of what i am dealing with (though my brain is quite fuzzy ATM coming off of being sick and really dehydrated)...but when i was dx'd with asthma a few years ago all i was told was "you have asthma.  take this med (flovent) this way and take this one (albuterol) that way.  bye."  :angry::blink:


----------

