# San Diego protocol regarding BP



## brachialbabies (Feb 18, 2011)

So I've heard from a couple sources that it's actually illegal for a San Diego County EMT to transport anyone with a BP lower than 100 on scene. Is this true, and if so would it be appropriate to transport anyways if the patient has a signed DNR?


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## dixie_flatline (Feb 18, 2011)

brachialbabies said:


> So I've heard from a couple sources that it's actually illegal for a San Diego County EMT to transport anyone with a BP lower than 100 on scene. Is this true, and if so would it be appropriate to transport anyways if the patient has a signed DNR?



Sorry, but your post doesn't make a whole lot of sense.

Unless a local provider can give more details, you're going to need to cite something more concrete than "I've heard".  I know a few marathon regulars whose systolic is at or below 100 most of the time.  Plus I just can't think of any case where it makes sense to refuse transport due to hypotension?

Regardless, if the pt has a signed DNR it only goes into effect for live-saving efforts.  Even with a signed, verified, notarized DNR being presented by a power of attorney, you still have to provide some type of care (maximal or palliative only depending on the DNR) until arrest occurs.  I'm not sure how that factors in to your question about transporting a hypotensive pt at all?


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## adamjh3 (Feb 18, 2011)

It depends on the circumstances. 

I'll generally start to consider calling ALS if the patient has a systolic BP under 90 WITH other S/S, because they can perform interventions to raise BP that I as a BLS provider cannot. 

But again, it all depends on the circumstances. If you're not sure, there's no shame in calling a BH to find out what you should do. As basics we don't have the education to trust ourselves.


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## JPINFV (Feb 18, 2011)

dixie_flatline said:


> Regardless, if the pt has a signed DNR it only goes into effect for live-saving efforts.  Even with a signed, verified, notarized DNR being presented by a power of attorney, you still have to provide some type of care (maximal or palliative only depending on the DNR) until arrest occurs.  I'm not sure how that factors in to your question about transporting a hypotensive pt at all?


Why does the power of attorney have to present the DNR?

What if the patient is A/Ox4 with capacity and hands you the DNR?


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## dixie_flatline (Feb 18, 2011)

JPINFV said:


> Why does the power of attorney have to present the DNR?
> 
> What if the patient is A/Ox4 with capacity and hands you the DNR?



.... 

It was a joke.  Discussion of DNRs always engenders a spirited debate about making sure the DNR is legitimate.  For the point of my question, the DNR is undeniably valid.

My main problem there was just that a DNR (in my experience) specifies what level of care should be provided for live-saving efforts (both kinds of DNR, at least in Maryland, result in hands-off at time of arrest).  If the pt has a systolic below 100 (but still a pulse), unless there are other related issues, I failed to see how the DNR would factor into a transport decision.


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## brachialbabies (Feb 18, 2011)

To clarify I guess my post was actually two separate questions.. 

Can BLS in SD County transport patients with a blood pressure less than a 100? Obviously if you arrived on scene you wouldn't leave the patient. But would it be more appropriate to stay on scene and turn over to ALS? 

Scenario: non-trauma patient only responding to pain, has a BP less than 100, but is still breathing. Would ALS provide any sort of interventions apart from O2 in this case in the presence of a DNR? I would assume not. So would it matter at that point if BLS did the transport or not?


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## adamjh3 (Feb 18, 2011)

There are still too many open questions in that scenario. Is this their normal mental status? What are the pt's other VS? Why are you there? Where are they going?

A DNR is exactly what it says it is Do Not RESUSITATE. They have a BP so they obviously still have a pulse, they're not dead yet, so you're going to do what you can to keep them alive. However once they die (pulseless and apenic) that's where your interventions are limited or removed depending on the exact verbage of the DNR

ETA: Is it possible you're confusing a DNR with an advance directive?


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## Sandog (Feb 18, 2011)

To OP
I think you may have some misconceptions about a DNR, you should reacquaint yourself with this order as it may become pertinent some day. 

Below is sample text I found on a written DNR. It may help clarify.



> I have discussed my health status with my physician, _________________.
> I request that *in the event my heart and breathing should stop*, no person shall
> attempt to resuscitate me.


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## Monkey (Feb 19, 2011)

I've NEVER seen that in the protocol book.  I would say that you are possibly hearing a specific agencies policy.  

If you're on a medical aid, and the pt is below 100, then decide to upgrade or make base hospital contact and get their input as to upgrading or doing the transport yourself. 

The only protocol regarding a BP below 100, that I can think of, that is written is assisting with NTG when a pt has a systolic sub 100.


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## EMS49393 (Feb 19, 2011)

My systolic blood pressure hovers between 90 and 96 regularly.   There is really no such thing as a "normal" blood pressure.   There is such a thing as a "normal" blood pressure for each individual person.  It seems odd to base a transport decision on one assessment finding that may in fact be a completely normal finding for the patient.  

You do need to be familiar with how to handle a patient with a DNR in your jurisdiction because most areas handle them differently.  As Dixie stated, Maryland has a special DNR protocol, so special that it takes up several pages in our protocol book.   My state has a specific EMS DNR form that allows for two options, (A) for advanced life support, everything up to and including medications, EKG, and airway control minus intubation, until arrest.  After arrest, no heroic measures, and (B) for basic life support, palliative care only.  Until a few years ago, the only form EMS was allowed to honor was the state EMS form.  They have since changed and we can now honor every states DNR form as a form B.  If you do not know your jurisdiction regulations, you need to make the effort and find out who to contact in regards to your specific protocols.


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## certguy (Feb 19, 2011)

*b/p policy*

If you think about it the rumor you heard makes no sense.Playing murphy,if medics are unavailable,coming from a distance,or you have a short transport time you're supposed to wait???????


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## Monkey (Feb 19, 2011)

certguy said:


> If you think about it the rumor you heard makes no sense.Playing murphy,if medics are unavailable,coming from a distance,or you have a short transport time you're supposed to wait???????



Many local agencies have their own weird policies, although I cannot figure out why this would be one of them.  It is NOT San Diego protocol, (I've looked several times to see if I could find it since reading this post).

As was stated, some BP's run low... putting that kind of restriction on transporting a pt, whether it be a GT or Medical Aid, sounds rediculous to me, but oh well.


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## certguy (Feb 19, 2011)

*San Diego protocal*

When I get the computer up again,I'll do a post on how DNR's evolved im San Diego.It was interesting,yet frustrating.


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## jjesusfreak01 (Feb 20, 2011)

EMS49393 said:


> Until a few years ago, the only form EMS was allowed to honor was the state EMS form.  They have since changed and we can now honor every states DNR form as a form B.  If you do not know your jurisdiction regulations, you need to make the effort and find out who to contact in regards to your specific protocols.



I will happily honor another state's DNR form, providing I have handed off responsibility to MC, otherwise, thats a shade of grey I don't want to get involved with. Also, in NC we have a DNR and a MOST form (specifically details what is/is not wanted), so its always quite clear. 

Back to the thread. I have transported patients with BPs below 100sys, pts with heplocks, and a patient who had just been given 15mg MS immediately prior to transport. This is as a basic. Of course, you make exceptions for hospice patients with DNRs. If 15mg of MS sends them into respiratory arrest, I am going to do nothing, which is exactly what a medic is going to do.


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## Monkey (Feb 20, 2011)

jjesusfreak01 said:


> ...and a patient who had just been given 15mg MS immediately prior to transport. This is as a basic.



That IS against county protocol.  However most private BLS agencies don't pay attention to it.


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## TransportJockey (Feb 20, 2011)

Monkey said:


> That IS against county protocol.  However most private BLS agencies don't pay attention to it.



In NM it was not against any protocols... but then again NM basics can give IN/IM/SQ Narcan, so it wasn't a major deal.


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## Monkey (Feb 20, 2011)

Yeah, true, but he started with San Diego Protocols which are about as tight as they get.


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## JPINFV (Feb 20, 2011)

jtpaintball70 said:


> In NM it was not against any protocols... but then again NM basics can give IN/IM/SQ Narcan, so it wasn't a major deal.



It's rather irrelevant anyways since most DNR orders call for pain management even if it quickens death.


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## JPINFV (Feb 20, 2011)

Monkey said:


> That IS against county protocol.  However most private BLS agencies don't pay attention to it.




Just curious, do you have a reference. In general, just because a medication was administered prior to transport by a health care facility does not mean that it's automatically a paramedic level call.


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## TransportJockey (Feb 20, 2011)

JPINFV said:


> It's rather irrelevant anyways since most DNR orders call for pain management even if it quickens death.



Whoops, missed the DNR reference. Sorry.


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## Monkey (Feb 20, 2011)

JPINFV said:


> Just curious, do you have a reference. In general, just because a medication was administered prior to transport by a health care facility does not mean that it's automatically a paramedic level call.



It's not an ALS call...  Protocol states that any meds given that are non standard or narcotic, a BLS unit must wait at least 30 mins from time given to transport.  The only time it must be upgraded to ALS in San Diego is if the facility refuses to d/c an IV that is anything more than NS, but that rarely if ever happens.

And again, that is San Diego Protocol, not state or NREMT.


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## JPINFV (Feb 20, 2011)

Ok... Which section of the protocol is the 30 minute rule found in?

Link to San Diego County LEMSA protocol:

http://www.co.san-diego.ca.us/hhsa/programs/phs/documents/EMS-PolicyProtocolManual_2010online.pdf


Also, pg. 331-333 includes the scope of practice for EMTs in San Diego LEMSA, which incldues the following about IVs:

"B. A supervised EMT student or certified EMT may monitor and transport patients with
peripheral lines delivering IV fluids under the following circumstances:

...

The fluid infusing is a glucose solution or isotonic balanced salt solution, including
Ringer's Lactate."

So, you can transport patinets on more than just NS.


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## Monkey (Feb 20, 2011)

S-135, "check for prior IV, IM, SC, and non routine PO medication delivery to assure minimum wait period of 30"..."

No wait time is necessary for routine oral/dermal medications or completed aerosol treatments.

and you're right, NS isn't the only IV you can transport, as long as no added meds are added, and the rate is maintainable without having to adjust.


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## JPINFV (Feb 20, 2011)

Ah, gotcha. Thanks for the reference.

I bet either hospitals, SNFs, ambulance services, and dialysis clinics either absolutely hate it or routinely ignore it. Dialysis patient had a little extra taken off the top and got a little IV saline? 30 minute wait. 

Patient received some anti-nausea medication? 30 minute wait. 

Interfacility psychatric patient who was just given some valium? 30 minute wait. 

Interhospital transfer of patient who just recieved pain meds? 30 minute wait. 

Now, does the ambulance company just have a crew sitting for 30 minutes, or do they cancel and send the next available crew with the possibility of having to repeat this...


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## Monkey (Feb 20, 2011)

Normally the facilities are pretty good about it.  an IFT from say, ER to another hospital, sometimes is the only snag.  

And yes, i've sat in the ER breakroom for 20-30 minutes before transporting.

It doesn't happen often, and yes, some private companies do not enforce it/ignore it.


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## jjesusfreak01 (Feb 20, 2011)

Monkey said:


> That IS against county protocol.  However most private BLS agencies don't pay attention to it.



This was a transport to a hospice facility, and the patient was a DNR. The patient needed no monitoring or IV, and since they were a DNR, no medical professional, whether EMT or MD, was going to do anything if the patient went into respiratory arrest. Also, the 15mg barely touched him.

That said, I wouldn't transport a non-DNR patient on heavy narcs with no way to reverse it (we are an IFT company and our BLS units don't carry Naloxone).


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## johnrsemt (Feb 21, 2011)

Am I reading this right?  (From JPINV):  San Diego EMS Protocol is over 330 pages long?  (I couldn't download it).   I think that is crazy,   how do you read and remember that much.

  I though ours were bad at 70 odd pages full of info:   my old area was 70 pages, but most were half page or less.


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## johnrsemt (Feb 21, 2011)

What is wrong with transporting a patient with heavy narcotics on a BLS level?  if they stop breathing  or the resp effort slows down,  bag them.   
   On an ALS level if I give Narcan, it cancels the effect of the pain meds, and makes it so they feel everything til the Narcan wears off;  (If I remember right, it takes about 2 hours for it to wear off).    It only takes 10-15 min for the Morphine to wear off so they start breathing again on their own.


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## Monkey (Feb 21, 2011)

hahahaha... i'm waiting for us to get a protocol on applying an adhesive bandage, but yeah, it's thick.

San Diego EMS is a VERY conservitive system. It's a "Mother, may I?" system.  It's mainly targeted at ALS, but that trickles down to BLS.  CYA is the name of the game.


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## EMS49393 (Feb 21, 2011)

Maryland's protocol book is over 500 pages.  Of course there is a lot more information in that book then protocols.  There is a section on drug information, wilderness EMS, pilot programs, inter-facility transport programs, phone numbers, procedures for attempting to implement a new protocol, and many other things.

The protocols themselves are a few hundred pages long, but they are really easy to remember, especially if you already know what you are doing.

Most protocols should be pretty easy to remember if you had a strong education.  The hardest thing I have to remember is when I can give a medication without consult.  I was a boarder medic in MO/AR and they were VERY different.  I'm a boarder medic here in PA/MD and they are somewhat different.  Other then that, I've never had problems moving from system to system.

Keep a copy handy, go over it now and again, and you'll be surprised just how much of that 330 pages you actually really do know.


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## JPINFV (Feb 21, 2011)

johnrsemt said:


> Am I reading this right?  (From JPINV):  San Diego EMS Protocol is over 330 pages long?  (I couldn't download it).   I think that is crazy,   how do you read and remember that much.
> 
> I though ours were bad at 70 odd pages full of info:   my old area was 70 pages, but most were half page or less.



It's not just medical protocols. It's protocols and system policies, so it includes unit inventory and county discipline process, and education requirements, and scope of practice, and everything else that's normally separate from the actual treatment protocols.


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## johnrsemt (Feb 21, 2011)

that sounds better;  thank you for the info


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