# Why do people hate on LA County protocols?



## ParamedicStudent (Feb 16, 2018)

Why? I don't get the hate for it.
Is it because you need a base order for most treatments?
I hear you can't perform ALS interventions unless there are two medics on scene. Is this right?
What else? Thanks


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## luke_31 (Feb 16, 2018)

Cause for years the protocols were not much better then when they started even though medicine had advanced beyond them.  That you have to call for just about everything and it didn't matter how critical the patient was, all the boxes had to be checked before the MICN would issue orders.  Limitations on scope of practice and pharmaceuticals carried.  All the stuff you learn as a paramedic student about half isn't allowed in LA county. That they focus on there being a hospital within 10mins from wherever you are, even though some of the county it can take at least twice that time to get to a hospital. With that focus they don't have good protocols or pharmaceuticals to go beyond first and second line treatments for some conditions and you can't get past first line on some. If you were an IFT ALS unit that needed to actually treat a patient you would spend half the time explaining who the f--k you were and then it's a toss up of getting the orders that you need. As a IFT paramedic you are basically a BLS transfer truck with a monitor, you can't transport any truly critical patients in the IFT setting.  The closest you get is if you happen to be going from an urgent care to an ER and even then it was sketchy at best as to whether some of the transports were appropriate under LA County protocols. Basically any medicine that requires a pump automatically makes it a RN transfer because paramedics are too incompetent to use a pump (don't know about this, as I now use a pump on transfers where I work and they aren't that complicated).  I got out of the system about six years back and where I'm at now we actually practice as paramedics with more autonomy and work directly with the ER doctors when we need to do something outside protocols or have reached the end of the protocol and need to ask for orders for one of the very few medicines or procedures that need orders ( all of which are high risk and not like getting permission for use of narcotics for pain management).


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## DesertMedic66 (Feb 16, 2018)

Luke did a pretty good job at summing it up. Unless you want to be a FF/PM there is no way to be a paramedic on an 911 ambulance. The majority of FF/PM that I deal with focus solely on the FF aspect and only do the bare minimum PM training. 

I don’t have any experience with LA county personally but I know several people who work in the system who hate it. The girlfriend is a TICU nurse who sometimes works in the ED with her father being an ED doctor (both at the same hospital in LA county) and they find LA county EMS a complete joke.


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## CALEMT (Feb 16, 2018)

People hate on LACo protocols because they want robot medics instead of actual clinicians and critical thinkers.


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## VentMonkey (Feb 17, 2018)

Firsthand experience here...it seems as though it’s more of an overall cultural issue than it is a protocol issue. I would even go so far as to say that the archaic set of protocols are by and large, a result of the culture itself.

Now don’t be mistaken, EMS and it’s overall culture is not exactly stellar, nor do we have the best track record when it comes to throwing words around such as “profession” or “professional”, but the pockets of providers and systems that do reflect a desire to see it through with regard to change and progress are clearly abundant.

With that, as I’ve mentioned in the past, even the most prudent clinicians can stand out in a sea of androids. If you can get past being a pariah in your line of work, with a short check-off list, and embrace a culture of tradition that’s designed to bestow little to no faith in your judgments as a field clinician—you’ll do great!

As an aside, accreditation as an IFT paramedic without a fire departments endorsement is absolutely deplorable, and quite frankly, depressing. It doesn’t (didn’t) seem like anyone wanted to be there, not even those who were going to be entrusted to provide “911” care, i.e., the FFPM’s. But again, remember, short check-off lists and traditions...


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## truetiger (Feb 19, 2018)

Because they're ****?


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## RocketMedic (Feb 20, 2018)

I laugh at SoCal EMS protocols (especially LACo) because they don't allow you to actually treat your patient effectively in many cases. No matter who you are (fire or private), you're not actually able to take care of your patients anywhere near as effectively as most of the rest of us can, and you don't really have revolutionary research, new ground or much of anything other than an overpriced, undertrained, disinterested squad of firefighters that can ask permission for some common treatments if they're so inclined (*which they are likely not) and a herd of BLS transports. Even in a state like CA, where we're subordinated to nurses and the whims of the nursing unions, LA County has terribly inadequate protocols.

Are patients harmed by being minimally treated? I don't know, to be honest, and there's not a lot of data in the wild for us field medics in Texas to get our teeth into yet regarding the long-term effects on morbidity, mortality and patient experience of screamingly advanced care vs minimalistic BLS care or "an IV" yet. To be honest, I don't know if the stable A-fib RVR I converted with diltiazem yesterday would have been harmed by waiting until we got to the hospital, or if her outcome would have been any different had I had to ask a nurse or a physician. I don't think she would have died on the ten-minute ride to the ED, and even a LACo medic can start a line, so in some ways, I can't directly claim the protocols I operate under are any _better_. People don't seem to drop dead in LACo that frequently for lack of fentanyl, and a lot of the more 'exotic' things we do are both really rare and _can_ be diverted or otherwise done, and some of the most important things we do are basic, fundamentals that don't really need protocol wars to dictate. Frankly, I suspect that the vast majority of patient outcomes would look identical when compared between LACo and anywhere else.

*However*
Ours are a _lot_ more accepting of perceived risk, in that we do a lot of things that would get my card shredded in CA/LACo (like field blood transfusions). Sure, risk might not be your cup of tea, but accepting risk _also_ allows us to do helpful things for people, like provide effective pain management or more lifesaving things like emergent airway management via RSI. We can _also_ do things more safely and are far faster to adapt to changes in medicine, especially because many of us can be actively engaged and involved in what we do without having to rassle with nursing and fire unions and all of that madness. It _also_ allows us to _*try and do a lot more good work for our patients, which adds value to our services and provides us with a whole lot of new opportunities for patient care, professional personal and industrial development, and *__*gets us paid more, better and treated as professional paramedics, not the hired help.*_ Look at the fire departments in CA. Yes, they've got tradition and great marketing and American Heroes and all, but they're _also_ the product of diversification of services into EMS. Their leadership saw the wave, started paddling, and they're at least pretending to surf it. If it wasn't for the EMS services that LACoFD / other FD provides the community (as weak as they are from my perspective), they would likely look a lot like CalFire or a Fire-only department like Kern County FD if they _didn't_ provide those services, which are generally paid less, staffed at lower levels and face far more budgetary scrutiny than their larger, more mission-diverse siblings.

From a patient perspective, I'd way rather be in Texas, in a system that lets medics 'swing for the fences', than LACo for the vast majority of what I need. I want to be in a system/treated by a culture where paramedics understand 12-leads, where I can get ketamine and a tube to breathe for me, and where they can put in blood to replace the blood I've misplaced. I'd way rather get pain meds than not if I am hurting. From the patient/clinical perspective of a paramedic, it is way better to work in aggressive, progressive systems than archaic 1970s-land EMS.

Lastly, the culture. There's really no comparison. I have literally gone years before calling for orders.

@ParamedicStudent

If you're interested, download the PPP app (Paramedic Protocol Provider) and check out some protocols from other places. You'll be very surprised at the differences and similarities. For example, Houston Fire is pretty much exactly like LACo, with a few differences, but practically the same...but immediately to their north/west are four extremely progressive services where we do things like RSI, field blood transfusions, etc.

That's right. We put blood back into people. In ambulances. Without nurses, doctors, or a crusty MICN. On standing orders. #lifechanging

Also, our EMS culture is _way_ more demanding and professional.


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## Uclabruin103 (Feb 21, 2018)

They hate because they don't fully understand. LA County has most of the standard treatments prior to base contact that most system have. It's not as if you have to call base prior to giving epi to an anaphylaxis. And if you need something off kilter, then call base and ask .

Yes, it's annoying to call base when you want to just give zofram and start a line, but whatever. You get used to it.  And some departments have standard field treatment protocols where you can do even more before base, then you just give a very brief report.


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## medichopeful (Feb 21, 2018)

Uclabruin103 said:


> They hate because they don't fully understand. LA County has most of the standard treatments prior to base contact that most system have. It's not as if you have to call base prior to giving epi to an anaphylaxis. And if you need something off kilter, then call base and ask .
> 
> Yes, it's annoying to call base when you want to just give zofram and start a line, but whatever. You get used to it.  And some departments have standard field treatment protocols where you can do even more before base, then you just give a very brief report.



I'm sorry, but any system that requires their medics to ask permission to start an IV has some serious issues.


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## Uclabruin103 (Feb 21, 2018)

medichopeful said:


> I'm sorry, but any system that requires their medics to ask permission to start an IV has some serious issues.



You don't have to get permission to do it, you just make base on your way to the hospital .


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## CALEMT (Feb 21, 2018)

So starting a line is an automatic base hospital contact?


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## Uclabruin103 (Feb 21, 2018)

Yes, so...

Age, weight, severity, cc, HAM, vitals and physical assessment, treatment, closest hospital. 

So for a general ALS it'd take me easily less than 3-4 minutes to do .


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## VentMonkey (Feb 21, 2018)

Uclabruin103 said:


> They hate because they don't fully understand.


Pretty sure this isn’t the why, but ok. @RocketMedic summed up a stance for a more inclined pro-paramedic system. Might I ask— your profile states you’re an EMT, how well do you fully understand them?


Uclabruin103 said:


> It's not as if you have to call base prior to giving epi to an anaphylaxis.


Perhaps, or even better (and a real-life scenario) do what they did to a family member of my wife’s and misdiagnose the anaphylaxis as general malaise, BLS the patient, and skip the protocol altogether.


Uclabruin103 said:


> Yes, it's annoying to call base when you want to just give zofram and start a line, *but whatever. You get used to it*.


aaaand here’s a perfect example of my point regarding culture in my OP on this thread. You and I both know, firsthand, the majority of the departments can’t even be trusted with something as basic as IV administration, and an antiemetic. IMO? Hardly “whatever”.


Uclabruin103 said:


> And some departments have standard field treatment protocols where you can do even more before base, then you just give a very brief report.


The SFTP’s are for the more “clinically inclined” departments...of Los Angles, if that says anything.

When I studied for my protocol test there years ago I had to dig through the two binders they gave us to locate what the specific SFTP’s were. They’re nothing short of unimpressive, and laughable by just about every other state’s guidelines.

My county’s protocols aren’t anything to write about either, but we’re at least somewhere in between California and the norm. LA? Very sub-norm.


CALEMT said:


> So starting a line is an automatic base hospital contact?


Unless they changed the protocol, I believe he’s misinformed.

It’s once you start a line, the patient is now an “ALS” patient, and requires a paramedic to follow in, and subsequently make base contact for whatever protocol hit the patient may have entered by paramedic discretion.

There’s no flipping back and forth between protocols though, you’re typically committed to it. “Pick and stick” to your treatment tree. IIRC, San Diego operates similarly.


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## DesertMedic66 (Feb 21, 2018)

Uclabruin103 said:


> They hate because they don't fully understand. LA County has most of the standard treatments prior to base contact that most system have. *It's not as if you have to call base prior to giving epi to an anaphylaxis.* And if you need something off kilter, then call base and ask .
> 
> Yes, it's annoying to call base when you want to just give zofram and start a line, but whatever. You get used to it.  And some departments have standard field treatment protocols where you can do even more before base, then you just give a very brief report.


No, but if you want to give Benadryl to that allergic reaction that does require base contact...


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## Uclabruin103 (Feb 21, 2018)

VentMonkey said:


> Pretty sure this isn’t the why, but ok. @RocketMedic summed up a stance for a more inclined pro-paramedic system. Might I ask— your profile states you’re an EMT, how well do you fully understand them?
> 
> Perhaps, or even better (and a real-life scenario) do what they did to a family member of my wife’s and misdiagnose the anaphylaxis as general malaise, BLS the patient, and skip the protocol altogether.
> 
> ...



Medic for just over 5 years. Never bothered to look at my forum profile since making the account.  Every system has misdiagnosis issues, so generalizing to all medics is not fair to do. 

I don't feel it's a lack of trust by having to make base after giving zofran.  Otherwise you would need a base order for it.  

Regardless of what county I work in, I always would advocate for my patients and treat them appropriately. No, I don't have blood transfusion or RSI. But I'm also not more than 30 minutes from a hospital, and if I need those I'll get an airship. And have them there sooner than that.


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## CALEMT (Feb 21, 2018)

VentMonkey said:


> It’s once you start a line, the patient is now an “ALS” patient, and requires a paramedic to follow in, and subsequently make base contact for whatever protocol hit the patient may have entered by paramedic discretion.



So excuse my ignorance but up until my internship where I work all 3 hospitals are base hospitals. 

I’m my internship say I run a abd pain. Nausea and vomiting is associated with the pain. I start a line and give zofran IVP. I transport to the closest facility (in my internship it being a non base hospital). In LACo does this constitute a base contact?


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## Uclabruin103 (Feb 21, 2018)

CALEMT said:


> So excuse my ignorance but up until my internship where I work all 3 hospitals are base hospitals.
> 
> I’m my internship say I run a abd pain. Nausea and vomiting is associated with the pain. I start a line and give zofran IVP. I transport to the closest facility (in my internship it being a non base hospital). In LACo does this constitute a base contact?


 Yes it would.


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## medichopeful (Feb 21, 2018)

Uclabruin103 said:


> Yes it would.



A base contact for permission to do the treatment?  Or a simple entry note saying that "hey, this is what we have, this is what we did, we'll be at your facility in 5."


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## CALEMT (Feb 21, 2018)

Uclabruin103 said:


> Yes it would.



A base hospital order to give zofran IVP? You serious? 

Come April I’ll have the ability to give fentanyl (already a standing order) OR Ketamine (trial drug, also a standing order).


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## Uclabruin103 (Feb 21, 2018)

medichopeful said:


> A base contact for permission to do the treatment?  Or a simple entry note saying that "hey, this is what we have, this is what we did, we'll be at your facility in 5."


After your treatments.


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## Uclabruin103 (Feb 21, 2018)

CALEMT said:


> A base hospital order to give zofran IVP? You serious?
> 
> Come April I’ll have the ability to give fentanyl (already a standing order) OR Ketamine (trial drug, also a standing order).


Cool, but if it's like our ketamine trial then it'll be in a 100cc bag with no IM dosing. 

Zofran is a standing order in LA.  You just have to make base contact on the way to the hospital


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## medichopeful (Feb 21, 2018)

Uclabruin103 said:


> After your treatments.



That's not as bad as I thought.  Most places have to make an entry note, but that's completely different from a radio consult/medical direction or whatever you want to call it.

So walk me through a patient contact complaining of a fractured ankle and pain (if you decide to give a narcotic, let's say they become nauseous for discussion purposes).  Let's say it's an isolated injury.  Include when you would call the hospital and what you would say/do.


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## Uclabruin103 (Feb 21, 2018)

medichopeful said:


> That's not as bad as I thought.  Most places have to make an entry note, but that's completely different from a radio consult/medical direction or whatever you want to call it.
> 
> So walk me through a patient contact complaining of a fractured ankle and pain (if you decide to give a narcotic, let's say they become nauseous for discussion purposes).  Let's say it's an isolated injury.  Include when you would call the hospital and what you would say/do.


I'd give zofran, and fent. Then call base.

UCLA base ra62 with a medical.  Called to the home of a 35 male weighing 70 kg in a mild level of distress, complaining of ankle pain. Was jumping, landing wrong, and felt a snap 10/10 pain.  No history, no allergies, no med.  Hr 76, 120/80, 100%, 18 rr, gcs 15, clear lungs, normal skins, perrl pupils. Obvious deformity with bruising, swelling, no other trauma, good CMS, no head/neck/back pain. Started a 20g left at, 50mcg ivp fent, 4mg zofran, splinted with ice pack. 5 minutes from marina del Rey, 20 minutes from you. Requesting additional doses of fent up to 200mcg for pain .


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## RocketMedic (Feb 21, 2018)

That's not terrible. Not great (unless your ketamine trial is for pain as well) but not terrible. Welcome to mediocre! I do think that you are correct in that I don't understand the protocols- namely, why they are so convoluted and silly. I really don't understand that. 

Do you have to have a life-saving fire-medic there or is it private BLS or what?

What gets ALS?

FWIW, I literally just call the hospital and let them know what we're bringing them as a courtesy. The only thing I don't necessarily agree with is the practice of "delegated medical orders" that allows our paramedic supervisors to function as medical control should you call them- to be honest, on the occasions that I call medical control, it's because I want a doctor, not a nurse or paramedic.

If you're interested, here's a direct link to our protocols.
https://drive.google.com/drive/folders/0Bzpa1B5BQ5OFYThRT3EtX0FpazQ


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## medichopeful (Feb 21, 2018)

Uclabruin103 said:


> I'd give zofran, and fent. Then call base.
> 
> UCLA base ra62 with a medical.  Called to the home of a 35 male weighing 70 kg in a mild level of distress, complaining of ankle pain. Was jumping, landing wrong, and felt a snap 10/10 pain.  No history, no allergies, no med.  Hr 76, 120/80, 100%, 18 rr, gcs 15, clear lungs, normal skins, perrl pupils. Obvious deformity with bruising, swelling, no other trauma, good CMS, no head/neck/back pain. Started a 20g left at, 50mcg ivp fent, 4mg zofran, splinted with ice pack. 5 minutes from marina del Rey, 20 minutes from you. Requesting additional doses of fent up to 200mcg for pain .



As @RocketMedic said, definitely not terrible.  Thanks for the description!


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## Uclabruin103 (Feb 21, 2018)

Destination


RocketMedic said:


> That's not terrible. Not great (unless your ketamine trial is for pain as well) but not terrible. Welcome to mediocre! I do think that you are correct in that I don't understand the protocols- namely, why they are so convoluted and silly. I really don't understand that.
> 
> Do you have to have a life-saving fire-medic there or is it private BLS or what?
> 
> ...


I feel they're the easiest to read.  Much easier than mine. 
http://dhs.lacounty.gov/wps/portal/dhs/ems/prehospitalcaremanual/?????????????#tabs-13

What needs ALS and what can be BLS is stated in policy 808.


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## aquabear (Feb 22, 2018)

So some background on my perspective on this: I started my EMS as an EMT in LA County, first working for an IFT company and then with a 911 transport provider. I had to learn LA County protocols when I attened UCLA/Daniel Freeman, but opted to intern out of county. I worked briefly as a paramedic in LA County before moving to Santa Barbara and then Texas. After moving to Texas and operating under physician delegated authority, I’ve formed a few opinions about their protocols.

The first problem is the system is so large (and in my opinion unmanageable) that you cannot ensure a consistent quality of care across a system with thousands of paramedics. Since there isn’t a good way to manage QA/QI for a system that large without a sizable outlay in money and trained personnel, you are forced to operate accounting for the “lowest common denominator.” When you have agencies “drafting” people to go to paramedic school, (who usually don’t want to be there) you are forced to limit their scope. This causes the medical director to put policies like 806 and 808 in place, which dictate what you can and can’t do prior to base contact and what chief complaints medics can’t “ship” with a BLS crew.

The second issue is the culture that has developed in the prehospital community. The excuse of “the hospital is only 5 minutes away” is constantly pounded into medic’s heads. It’s my opinion that if a patient needs a critical treatment, you do the treatment in the field. There is a delay in starting treatment in an ER: you have to wait for for a bed, transfer care, get orders from a MD, get meds, and finally do your treatment. Best case, a couple minutes. Worst case? Who knows... depending on how long you have to hold the wall. Another cultural problem I saw is the willingness to “punt” those borderline ALS calls. I can remember numerous calls as an EMT where I got, “you got the story?” or joking about the phrase “ship it” with “anxiety” or “chest wall pain” patients. I’m not saying all medics do it, but it does happen (and is another reason for 806 and 808 to exist).

The third issue is the way the state setup the EMS regulatory system. I think if individual departments could set their own scopes of practice, you would have better protocols. Unfortunately in California, you have LEMSAs (Local EMS Authorities) that set the protocols for an entire region, not individual agencies and their medical directors. Since scopes of care can’t be tailored to each agency, you end up with this limited scope that everyone has to follow.


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## RocketMedic (Feb 22, 2018)

^this. Any system with that many people long ago abandoned any reasonable span of control and became effectively unmanageable beyond policing out the actively negligent and abusive.


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## RocketMedic (Feb 23, 2018)

So what is this ketamine study?


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## DesertMedic66 (Feb 23, 2018)

RocketMedic said:


> So what is this ketamine study?


At least the one we are doing (Riverside and San Bernardino county, not sure about LA) is just attempting to show CA state that our paramedics can use Ketamine correctly and that it should be added to the state list of approved medications. 

It’s not a normal study that looks at if it works or any factors like that. For CA we are not allowed to carry any medications that is not on the state approved list. So we have to do a trial study to get the medication and then report to the state the  conclusion/results of the study and then hopefully the state will say “hey, our medics can handle having this medication”. Welcome to CA...


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## DrParasite (Feb 23, 2018)

aquabear said:


> The first problem is the system is so large (and in my opinion unmanageable) that you cannot ensure a consistent quality of care across a system with thousands of paramedics. Since there isn’t a good way to manage QA/QI for a system that large without a sizable outlay in money and trained personnel, you are forced to operate accounting for the “lowest common denominator.” When you have agencies “drafting” people to go to paramedic school, (who usually don’t want to be there) you are forced to limit their scope. This causes the medical director to put policies like 806 and 808 in place, which dictate what you can and can’t do prior to base contact and what chief complaints medics can’t “ship” with a BLS crew.


which is absolutely a fair statement, one that applies to all large systems.  if the system has 1 paramedic unit, operating 12 hour shifts, on a pittman schedule, than you have 8 full time paramedics.  lets add 2, to be supervisors and fill in when people are out, bringing the total to 10.  It's really easy for a medical director to get to know those 10 people really well, know their competency levels, etc.  After all, you only need to monitor 4 crews.  Now compare that to NYC, which runs 227 DAILY crews, and you see how you can't maintain that closeness that you had with a small agency.

But even with that being said, with enough levels of middle management, with multiple levels of QA/QI, you can do a halfway decent job of it.  And if your existing medics can't follow the rules that you give them, or can't maintain the agency's clinical standards, and re-educating them hasn't worked, than get rid of them.  It's not really rocket science.


aquabear said:


> The second issue is the culture that has developed in the prehospital community. The excuse of “the hospital is only 5 minutes away” is constantly pounded into medic’s heads. It’s my opinion that if a patient needs a critical treatment, you do the treatment in the field. There is a delay in starting treatment in an ER: you have to wait for for a bed, transfer care, get orders from a MD, get meds, and finally do your treatment. Best case, a couple minutes. Worst case? Who knows... depending on how long you have to hold the wall. Another cultural problem I saw is the willingness to “punt” those borderline ALS calls. I can remember numerous calls as an EMT where I got, “you got the story?” or joking about the phrase “ship it” with “anxiety” or “chest wall pain” patients. I’m not saying all medics do it, but it does happen (and is another reason for 806 and 808 to exist).


I remember being dispatched to a fall victim at a train station that was a block from the hospital.  We were dispatched BLS, as are most fall victims, but when we arrived and assessed the patient, we found him to have a skull fracture (fluids coming out of the ears, AMS, etc).  My fill in partner for the day (a paramedic supervisor who was great 20 years ago, but now, ehhh, he's better behind a desk than on a truck) and i requested ALS, applied a collar and secured the PT to a LSB, and carried him down two flights of stairs to the ambulance stretcher, and placed him in the back of the truck and requested a trauma team activation.  our ALS unit arrived, hopped in our truck, and began their assessment.  Realistically, I could be at the Level 1 trauma center door in about a minute (and 30 seconds of that is backing in the ambulance, we were that close).  What was ALS going to do, when the patient needed "definitive care?"

That all being said, even in the urban areas, you still need to do your job.  If you have an ABC issue, fix the issue.  if you have clinical indications for an issue you can fix, than fix the issue.  The "holding the wall" situations that SoCal is infamous for (and an accepted practice too, which blows my mind) is a new one, but that only means you need to do more to treat the patient since you might be waiting an hour or more in the ER waiting for a bed.  If it's a medical call that you can fix using something in your med box, than it's malpractice not to, especially knowing it will be a while until you get a bed.  

When you say punt, do you mean turf the call to BLS?  because if those calls the medic won't do anything other than the stare of life, than BLS can stare just as good as ALS.  But if you have a sick patient, and they will be waiting to get a bed because SoCal ER's treat EMS as free labor so they don't need to hire more staff, than that's a good reason to keep those borderline patients with ALS.



aquabear said:


> The third issue is the way the state setup the EMS regulatory system. I think if individual departments could set their own scopes of practice, you would have better protocols. Unfortunately in California, you have LEMSAs (Local EMS Authorities) that set the protocols for an entire region, not individual agencies and their medical directors. Since scopes of care can’t be tailored to each agency, you end up with this limited scope that everyone has to follow.


are you talking about individual departments in the same town, county and region?  or each individual agency that is running 911 calls in LA all running with different protocols?  Because the first one might be doable, the second one scares me.


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## RocketMedic (Feb 23, 2018)

DesertMedic66 said:


> At least the one we are doing (Riverside and San Bernardino county, not sure about LA) is just attempting to show CA state that our paramedics can use Ketamine correctly and that it should be added to the state list of approved medications.
> 
> It’s not a normal study that looks at if it works or any factors like that. For CA we are not allowed to carry any medications that is not on the state approved list. So we have to do a trial study to get the medication and then report to the state the  conclusion/results of the study and then hopefully the state will say “hey, our medics can handle having this medication”. Welcome to CA...



Like for sedation or pain management or both? To me, the bag of 100 suggests pain management, which it is super effective at.

@DrParasite , it is my understanding that everone in CA plays by their county LEMSA's protocols, regardless of specific agency. Here in Texas, we each have our own different ones, which literally means where you are determined level of care.


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## CALEMT (Feb 23, 2018)

RocketMedic said:


> pain management



This.


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## RocketMedic (Feb 23, 2018)

Oh you will love it


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## DesertMedic66 (Feb 23, 2018)

RocketMedic said:


> Oh you will love it


I plan on using it as much as I can. It is our only option for trauma that is not on the arms or legs. From talking around it sounds like a decent amount of medics (too many for my liking) are scared to use it because we actually have to do math since its weight based.


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## CALEMT (Feb 23, 2018)

DesertMedic66 said:


> I plan on using it as much as I can. It is our only option for trauma that is not on the arms or legs. From talking around it sounds like a decent amount of medics (too many for my liking) are scared to use it because we actually have to do math since its weight based.



Not gonna lie, I’ll have to revamp my med math skills. But in all reality the only real mathematical part is the dosing of 0.3mg/kg.


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## RocketMedic (Feb 23, 2018)

It is amazing for ortho trauma too. I am known for my ketamine + fentanyl on dislocated knees, shoulders, etc


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## FrostbiteMedic (Feb 23, 2018)

RocketMedic said:


> The only thing I don't necessarily agree with is the practice of "delegated medical orders" that allows our paramedic supervisors to function as medical control should you call them- to be honest, on the occasions that I call medical control, it's because I want a doctor, not a nurse or paramedic.



I'm 100% certain that if I am calling medical control that I want an MD on the other end of the line. I won't even allow a nurse to relay the orders, I have to speak with the MD directly. And should I ever be a supervisor, I'm 100% sure I wouldn't be comfortable acting as medical control. That's way, way, WAY too much liability for my taste.


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## RocketMedic (Feb 23, 2018)

Basically, fentanyl obtunds mu receptors, ketamine keeps them from resetting. I like.


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## ArizonaEMT (Jul 24, 2018)

Come to Az, Nm, Tx you will never go back....... In my system in AZ no base hospital contact at all to start all procedures or meds.


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## VentMonkey (Jul 24, 2018)

ArizonaEMT said:


> In my system in AZ no base hospital contact at all to start all procedures or meds.


In my system—in California—none really either.

Here’s a more important question:

Is there ever a time when we should seek _expert_ consultation?


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## RocketMedic (Jul 25, 2018)

I think so. Weird cardiac things (weird high-degree blocks, med. interactions, etc), overdoses, and I'm OK with calling in to bounce *elective* RSI off of an MD.

Urgent interventions ought to be treated as standing orders though.

The shame of it is that CA's med-control heavy system has the skeleton of greatness underneath it. Need a weird field intervention like lab interpretation and whole blood? You can bring the MD in on that, maybe even remote-issue an Rx. But it's easier to build floors than ceilings....


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## Jim37F (Jul 25, 2018)

Can't comment on Paramedic level stuff, but at the EMT level, well...

At my current FD, we're only EMR level medical first response (we're trained to NREMT, but not to state certified EMT), and yet I'm doing almost exactly the same, no loss in skills than when I was an EMT-B in LA Co. 

In other words, LA Co protocols leave EMTs so shackled that they're no more than EMR's in the rest of the country based on what they're actually able to do. It's not tough to imagine how similarly restrictive ALS is in LA Co to the rest of the country.


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## StCEMT (Jul 25, 2018)

I started seeking consult yesterday on a 38wk pregnant lady with a heart rate of 200+ to verify med interactions and if they had any requests since she was maintaining pressures in 140's and I very rarely give meds to people who are pregnant. Converted before I finished my initial report to the comm room folks when my partner stuck her with an IV.

Outside of that, it's been a long time since I have called. I am pretty well equipped to handle most situations and have permission to color outside of my lines a little if needed.


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## DrParasite (Jul 25, 2018)

Jim37F said:


> At my current FD, we're only EMR level medical first response (we're trained to NREMT, but not to state certified EMT), and yet I'm doing almost exactly the same, no loss in skills than when I was an EMT-B in LA Co.


from a practical side, the skills for EMR are pretty much the same as an EMT, at least from the NREMT perspective.  If you look at the skill sheets for testing, they are nearly identical.  

There are occasionally some drugs that EMTs can give by EMRs can't, but from a "skill" point of view, they are very similar.  the difference is in the knowledge and education that an EMT has vs an EMR.  I've long said that EMRs are great on the engine for the first time 10 minutes to make sure the patient doesn't die until EMS arrives, but you are going to want someone with a little more knowledge who is going to know what is going on with the patient during transport.

And yes, some states  (like Colorado) do give EMTs even more drugs to give and skills to perform.  But I wouldn't trust more than a handful of people on my department to do that, much more comfortable waiting for the ambulance to arrive.


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