# Most Progressive Protocols 2017



## michael150 (Sep 24, 2017)

Hey all. I am going to be doing a final essay in paramedic school and I just wanted to post on this forum to see what everyone thought. I am interested in progressive protocols and perhaps sometime in my career, be involved or start a movement for a nationwide set of protocols and more training for EMS. So, what EMS system, to you guys, have the most progressive protocols? Can you also post a link to your protocols?

Any help would be most appreciated and thanks in advance!


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## Tigger (Sep 25, 2017)

If you can find a copy of Presido TX, you'll probably be done.


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## michael150 (Sep 25, 2017)

Tigger said:


> If you can find a copy of Presido TX, you'll probably be done.


Thank you so much! I will look into that!


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## DesertMedic66 (Sep 25, 2017)

A nationwide set of protocols is not going to be a realistic option. Our county is too varied for that to work or at least work effectively. 

In Los Angeles you need different protocols since you have 5 hospitals on every street corner compared to another area where your closest hospital is 3 hours away.


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## michael150 (Sep 25, 2017)

DesertMedic66 said:


> A nationwide set of protocols is not going to be a realistic option. Our county is too varied for that to work or at least work effectively.
> 
> In Los Angeles you need different protocols since you have 5 hospitals on every street corner compared to another area where your closest hospital is 3 hours away.


I really appreciate the response and I realize that as of right now, it is basically impossible. Maybe not a set of protocols that are nationwide but I do believe that we can have a nationwide scope of practice (I realize that is a lot different than a set of protocols). I just do not agree with the fact that from state to state, we have different scope of practices and allowed to do different things or not do different things....


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## Tigger (Sep 25, 2017)

DesertMedic66 said:


> A nationwide set of protocols is not going to be a realistic option. Our county is too varied for that to work or at least work effectively.
> 
> In Los Angeles you need different protocols since you have 5 hospitals on every street corner compared to another area where your closest hospital is 3 hours away.


Why can we not have nationwide protocols that everyone is accountable for? If you don't want to use every part of it, don't.


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## DesertMedic66 (Sep 25, 2017)

Tigger said:


> Why can we not have nationwide protocols that everyone is accountable for? If you don't want to use every part of it, don't.


Systems are different and have different issues/objects to deal with. Is RSI needed in LA when you are right around the corner from a hospital? Is RSI needed when you have a 2 hour transport to the closest ED? Do you need a ventilator in LA with the ED right around the corner? Do you need the ventilator when you are several hours from the closest ED? 

Is it up to the individual provider to decide what protocols he wants or wants to use or is it up to his system to decide? 

Fire departments vary on their policies and tactics nationwide (there are a lot of things that are in common but still a lot that are different). You are going to fight a high rise fire in NY different then you are going to fight a fire in some town of 500. 

Police departments vary on their policies and tactics. LA county does not allow officers to use the PIT  maneuver where as CHP does. 

Even our local hospitals have different policies and procedures based on what works best for them.


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## Tigger (Sep 25, 2017)

DesertMedic66 said:


> Systems are different and have different issues/objects to deal with. Is RSI needed in LA when you are right around the corner from a hospital? Is RSI needed when you have a 2 hour transport to the closest ED? Do you need a ventilator in LA with the ED right around the corner? Do you need the ventilator when you are several hours from the closest ED?
> 
> Is it up to the individual provider to decide what protocols he wants or wants to use or is it up to his system to decide?
> 
> ...


I understand that not every area needs the same things. In fact I actually work for a city service and one in the boonies, I see it every week and the guidelines reflect it. You can what if to death. Doesn't get around the point that the baseline education in this country for paramedics is woefully inadequate to practice in many areas. If an area doesn't want to use a provider's full education, that is fine, but forcing employers to bring their employees up to speed is backwards. 

It is much more nuanced than your examples, some of which are a stretch. I work for a tiny fire district that's primary hazard is wildland interface. Yet we still train for high rise fires, just as the city trains for wildland. It is not emphasized as much, but we are exposed to it.


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## DesertMedic66 (Sep 25, 2017)

Tigger said:


> I understand that not every area needs the same things. In fact I actually work for a city service and one in the boonies, I see it every week and the guidelines reflect it. You can what if to death. Doesn't get around the point that the baseline education in this country for paramedics is woefully inadequate to practice in many areas. If an area doesn't want to use a provider's full education, that is fine, but forcing employers to bring their employees up to speed is backwards.
> 
> It is much more nuanced than your examples, some of which are a stretch. I work for a tiny fire district that's primary hazard is wildland interface. Yet we still train for high rise fires, just as the city trains for wildland. It is not emphasized as much, but we are exposed to it.


Educational standards and a national set of protocols are completely different. I am all in favor of a national educational standard. 

The odds are you guys train in high rise fires differently from a fire department where that is a real possibility. The odds are you guys train wildland fires differently than the US Forest service. Yes, a lot of things may be similar however there is not one policy/protocol for all the different departments. As another poster on here has said “once you have seen one EMS system, you have seen one EMS system”.


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## Summit (Sep 25, 2017)

@DesertMedic66  already pointed out that appropriate protocols for Urban areas differ greatly from Rural areas.

There are also regional environmental problems:

Does Montana need a Marine Envenomation protocol?
Does Alaska need a Snakebite protocol?
Does Florida need a Frostbite Protocol?
Does Georgia need an AMS/HACE or HAPE protocols?
Does Alabama need an Avalanche Resuscitation protocol?

Protocols are need based and need is population and practice environment based.

In nursing, where the education is generalist and then specialization occurs, you see different protocols at every hospital and in every unit.

@Tigger How about a broad national scope? Not as long as EMS education is technician/skills based... how do you choose what skills and meds to put in it without running into the same population/environment problems?

Even nurses vary their scope... between RNs! They have such a broad scope as determined by population and practice environment, it is totally impractical to generate multipage lists of skills and medications like you find for EMS in each state. Scope is usually nonspecific, being more like "Is something in scope? Did you learn it in school or is it a best practice that you receive specialized training on? And does your agency allow it? If yes, then it is in YOUR scope." Here is an example from your state: https://www.colorado.gov/pacific/dora/Nursing_Laws

@michael150 : make sure you figure out what a "progressive protocol" really means.
Is it the longest list possible of no-call-in protocols and whizbang skills like central lines and pericardialcentesis?
Is it appropriate evidenced based guidelines and independence matched to the provider skillset, patient population, and practice environment location?
Is "most progressive" for one agency really the "most progressive" for everyone?


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## michael150 (Sep 25, 2017)

Summit said:


> @DesertMedic66  already pointed out that appropriate protocols for Urban areas differ greatly from Rural areas.
> 
> There are also regional environmental problems:
> 
> ...


I think what I mean by "most progressive protocol" would mean that we are allowed to operate fully and completely with our scope of practice as paramedics with more than one choice of medication to give for a procedure like...RSI. When a service has just one set of drugs for RSI like Midazolam and Succs, it takes away the option to give something else if there is a contraindication for either (ie. Hyperkalemia or a known sensitivity for either drugs). It comes down to as my instructor says: "We are at a crossroads in EMS, where we make the decision to either become a profession or skilled labor". Furthermore, I work with a nurse that worked Burning Man this year. When he came back, he was very blunt in the fact that he had no idea what he was doing there or what they needed him for. Even with his TNCC, CEN, and CCRN certifications, he felt like since they allowed medics to operate almost fully (if not fully) at their scope of practice, it was unnecessary for him to help staff the "emergency tent". I also think it heavily comes down to schooling and training. School needs to be longer than a single year with core pre-requisites like A&P, micro, patho, and pharm. Those are just my opinions and I know that I am very new to this. Thanks for any responses and I look forward to all of your input from everyone!


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## GMCmedic (Sep 25, 2017)

Why do we need to carry more meds for a procedure that we do 1% of the time? 

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## michael150 (Sep 25, 2017)

GMCmedic said:


> Why do we need to carry more meds for a procedure that we do 1% of the time?
> 
> Sent from my SAMSUNG-SM-G920A using Tapatalk


RSI was just an example I was using. I apologize and do realize that RSI is not a commonly used tool in EMS.


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## GMCmedic (Sep 25, 2017)

michael150 said:


> RSI was just an example I was using. I apologize and do realize that RSI is not a commonly used tool in EMS.


Understood. 

Just FWIW I did the math for funzies and we intubate with drug assistance in less than 1% of our runs at this service. That number is probably fairly close across the country. 

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## TXmed (Sep 25, 2017)

My problem isnt about the number of times performed, its about the number of times practiced compared to performed. That 1% (or less) is with a critical patient whose outcome depends on how this procedure goes. Yet ems services rarely practice this, and if they do its a good'ole boy "ehh you got it" system. 


Progressive and evidemce based are different things. If evidence comes out that the new progressive drug youve been giving has an imcreased mortality, how would that look to the 100's of patients youve been giving too?


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## michael150 (Sep 25, 2017)

@GMCmedic understood completely and I also want to point out that on my ride-time, I have found that in instances that we should have RSId a patient due to losing an airway, we did not. I work at the L1 Trauma Center here that sees well over 250 patients a day (and it is primarily the point of transport for most critically sick and injured patients) and even the ED attendings/residents will point out that the patient should have been tubed. If we can do it in the field when we know that it is going to be done at the hospital anyway, why not do it? Like I said, I know that I am new at this but I just don't see how holding off things like that where it is either they have a patent airway or not, is arguable. 

@TXmed I completely agree. It seems like we only do it that one time in the field every once in a while but when it needs to be done, it is emergent. Additionally, just with our luck it is a difficult airway like a pedi or an extremely obese patient with airway compromise. What drug are you specifically talking about may I ask?


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## TXmed (Sep 25, 2017)

No particular drug or procedure.


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## GMCmedic (Sep 25, 2017)

michael150 said:


> @GMCmedic understood completely and I also want to point out that on my ride-time, I have found that in instances that we should have RSId a patient due to losing an airway, we did not. I work at the L1 Trauma Center here that sees well over 250 patients a day (and it is primarily the point of transport for most critically sick and injured patients) and even the ED attendings/residents will point out that the patient should have been tubed. If we can do it in the field when we know that it is going to be done at the hospital anyway, why not do it? Like I said, I know that I am new at this but I just don't see how holding off things like that where it is either they have a patent airway or not, is arguable.
> 
> @TXmed I completely agree. It seems like we only do it that one time in the field every once in a while but when it needs to be done, it is emergent. Additionally, just with our luck it is a difficult airway like a pedi or an extremely obese patient with airway compromise. What drug are you specifically talking about may I ask?


Because sometimes the patient needs an airway, but they also need more hands. 

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## TXmed (Sep 25, 2017)

Well in speakong with field RSI (which i am a fan of) alot of patients need to be rescusitated first. 

Say for instance the trauma patient with a shock index of 0.9 or greater. Sure they may need an airway but what is worse for THIS particular patient. The questionable airway or post intubation hypotension ? Sometimes forgoimg the procedure so patients can be adequetly rescusitated BEFORE RSI can make a significant difference in the patient. So passing the buck to an ER or flight crew isnt necessarily a bad thing.


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## VentMonkey (Sep 25, 2017)

@michael150 I see you're from Omaha, and can't help but wonder if you're a Creighton paramedic student. If so, when I was in Omaha last year it seemed to be a heavily fire-based EMS city. 

I talked with one of their former students who said Omaha Fire still utilizes MS for pain management with no other option. In short, the impression left regarding the city's EMS system was hardly a progressive one.

With all of that said, kudos to you for wanting to push for higher educational standards. Just know that as everyone else has mentioned, _progressive_ is definitely subjective. Having chosen a field that is chocked full of "strong-minded" individuals you definitely have your work cut out for you, so good luck.

As far as RSI goes, not to thread derail too much, but it really is best left in the hands of those that possess the crux of airway management, from alpha to omega.


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## michael150 (Sep 25, 2017)

VentMonkey said:


> @michael150 I see you're from Omaha, and can't help but wonder if you're a Creighton paramedic student. If so, when I was in Omaha last year it seemed to be a heavily fire-based EMS city.
> 
> I talked with one of their former students who said Omaha Fire still utilizes MS for pain management with no other option. In short, the impression left regarding the city's EMS system was hardly a progressive one.
> 
> ...



I actually go to the community college for paramedic. As much as I wish I had the money to go to Creighton, it's 2x the cost of tuition where I go. In addition, I'm going to be getting my associates and not just the certificate. Moving on to your comments about OFD. It is completely fire based as the two private companies only run IFTs and no 911 whatsoever. They now have Fentanyl for analgesia but those are the only two. They also now have Ketamine to be used for combative patients and they have to provide a RASS score first. We have the saying in class that Omaha EMS is 10-15 years behind everyone else protocol wise. 

It is a very non-progressive city when it comes to EMS and it still blows my mind the amount of hospitals they have here. Coming from Las Vegas, we don't even have 2 trauma centers (just UMC whereas Omaha has UNMC and now Bergan Mercy). I definitely have my work cut out for me and I can see the difficulty and amount of time it's going to take to get there. What I want to use this essay for in school is to start building a platform for the future! 



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## michael150 (Sep 25, 2017)

TXmed said:


> Well in speakong with field RSI (which i am a fan of) alot of patients need to be rescusitated first.
> 
> Say for instance the trauma patient with a shock index of 0.9 or greater. Sure they may need an airway but what is worse for THIS particular patient. The questionable airway or post intubation hypotension ? Sometimes forgoimg the procedure so patients can be adequetly rescusitated BEFORE RSI can make a significant difference in the patient. So passing the buck to an ER or flight crew isnt necessarily a bad thing.



I don't seem to be understanding. I apologize. 


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## VentMonkey (Sep 25, 2017)

michael150 said:


> I don't seem to be understanding. I apologize.


With due respect, he's referring to things typically not taught in the standard DOT paramedic curriculum. It goes back to my point about the crux of airway management.

Also, I thought Creighton was a Level 1 trauma center out there? I can see it being a bit steep. I did their critical care course, and it wasn't cheap, but definitely well worth it.


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## michael150 (Sep 25, 2017)

VentMonkey said:


> With due respect, he's referring to things typically not taught in the standard DOT paramedic curriculum. It goes back to my point about the crux of airway management.
> 
> Also, I thought Creighton was a Level 1 trauma center out there? I can see it being a bit steep. I did their critical care course, and it wasn't cheap, but definitely well worth it.



I need to do some research into that. We didn't learn anything about post-intubation hypotension, just the possibility of vagaling out our patients. Creighton University Medical Center was closed as of the beginning of June I believe. Bergan Mercy was completely remodeled and now serves as the CHI L1 and Nebraska Medicine as the other! 


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## Carlos Danger (Sep 25, 2017)

michael150 said:


> Hey all. I am going to be doing a final essay in paramedic school and I just wanted to post on this forum to see what everyone thought. I am interested in progressive protocols and perhaps sometime in my career, be involved or start a movement for a nationwide set of protocols and more training for EMS. So, what EMS system, to you guys, have the most progressive protocols? Can you also post a link to your protocols?
> 
> Any help would be most appreciated and thanks in advance!



I appreciate your enthusiasm and desire to help change EMS for the better. A common theme of the discussion on this forum is dissatisfaction with the educational standards of EMS in the US. We pretty much all agree that EMS education in general should be more rigorous. 

If you really want to start working towards this, I would start by thinking about what you mean by "progressive". It might be tempting to use that term to describe protocols that are more comprehensive than most, or that include more "advanced" interventions than is typical, but I don't think having protocols for chest tubes and field amputations (merely as examples) necessarily makes an agency progressive. It could actually make them regressive, depending on certain factors, including the simple fact that there are good reasons why you rarely see those things done in the field. Just something to think about.


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## Carlos Danger (Sep 25, 2017)

michael150 said:


> I need to do some research into that. *We didn't learn anything about post-intubation hypotension, just the possibility of vagaling out our patients. *Creighton University Medical Center was closed as of the beginning of June I believe. Bergan Mercy was completely remodeled and now serves as the CHI L1 and Nebraska Medicine as the other!



This would be a good topic to discuss in a separate thread.


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## michael150 (Sep 25, 2017)

Remi said:


> I appreciate your enthusiasm and desire to help change EMS for the better. A common theme of the discussion on this forum is dissatisfaction with the educational standards of EMS in the US. We pretty much all agree that EMS education in general should be more rigorous.
> 
> If you really want to start working towards this, I would start by thinking about what you mean by "progressive". It might be tempting to use that term to describe protocols that are more comprehensive than most, or that include more "advanced" interventions than is typical, but I don't think having protocols for chest tubes and field amputations (merely as examples) necessarily makes an agency progressive. It could actually make them regressive, depending on certain factors, including the simple fact that there are good reasons why you rarely see those things done in the field. Just something to think about.



I appreciate that! From the reading I've been doing on the forum, I am starting to see the general consensus that education needs to be more rigorous and more in depth. That's fantastic because we as providers are the ones that determine the fate and track that EMS takes. 

I also see what all of you mean by deciding what I mean by "progressive". To me, it was always being able to work with a certain autonomy with the skills I was taught to do. It's critical thinking to figure out the issue and fixing it to the best of my ability. No, field amputations would probably not be included in what I would describe as the perfect protocol list; however, if it was, critical thinking would need to take place on the ALS level to determine necessity or not. 


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## VentMonkey (Sep 25, 2017)

michael150 said:


> Creighton University Medical Center was closed as of the beginning of June I believe.


That's too bad, I enjoyed my clinical time there.


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## johnrsemt (Sep 28, 2017)

GMCmedic said:


> Why do we need to carry more meds for a procedure that we do 1% of the time?
> 
> Sent from my SAMSUNG-SM-G920A using Tapatalk


So for that theory; we have only had 3 cardiac arrests here in 9 years (only 1 workable) so why carry ACLS meds?


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## johnrsemt (Sep 28, 2017)

There needs to be a Nationwide BLS protocol;  and basic ALS protocol:  then you can add or subtract as needed:   Add Altitude and avalanche protocols or subtract them.
Worked a place in July (different state) that had an 84 page BLS protocol.  Everywhere else I worked figured that you learned BLS in school and didn't need a written protocol to do that.


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## GMCmedic (Sep 28, 2017)

johnrsemt said:


> So for that theory; we have only had 3 cardiac arrests here in 9 years (only 1 workable) so why carry ACLS meds?


Because nobody has been brave enough to start working codes without them in a prehospital setting, but that's apples and oranges. I didn't say we shouldnt carry any meds, we just don't need to carry multiple options.

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## GMCmedic (Sep 28, 2017)

As far as National protocols.....well, States Rights. Ill leave it at that.

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## Carlos Danger (Sep 28, 2017)

johnrsemt said:


> So for that theory; we have only had 3 cardiac arrests here in 9 years (only 1 workable) so why carry ACLS meds?


Honestly, I would say good question. It seems like any setting that only handles one workable arrest per decade could easily get by with BLS services.


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## EpiEMS (Sep 28, 2017)

johnrsemt said:


> So for that theory; we have only had 3 cardiac arrests here in 9 years (only 1 workable) so why carry ACLS meds?



Well, first, there's little evidence that those meds actually make a difference (to important metrics like neurologically intact survival).



johnrsemt said:


> Everywhere else I worked figured that you learned BLS in school and didn't need a written protocol to do that.



Defining BLS is part of the problem. Is glucometry BLS? CPAP? How about EpiPens? I'd say all three are BLS measures, but ought to have a protocol, no?


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## Summit (Sep 28, 2017)

johnrsemt said:


> There needs to be a Nationwide BLS protocol;  and basic ALS protocol:  then you can add or subtract as needed:   Add Altitude and avalanche protocols or subtract them.


The end product of this is exactly what we have now.


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## Pond Life (Sep 28, 2017)

Perhaps progressive should encompass the freedom to act autonomously across the whole of the paramedic scope of practice. Or maybe it could mean that the paramedics develop their own areas of practice. Perhaps even allow the paramedic to make the decision not to transport to ED in all but the most serious of cases.


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## Gurby (Sep 28, 2017)

Summit said:


> @michael150 : make sure you figure out what a "progressive protocol" really means.
> Is it the longest list possible of no-call-in protocols and whizbang skills like central lines and pericardialcentesis?
> Is it appropriate evidenced based guidelines and independence matched to the provider skillset, patient population, and practice environment location?
> Is "most progressive" for one agency really the "most progressive" for everyone?


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## RocketMedic (Sep 29, 2017)

We (and ESD-48) transfuse blood into people on the regular here in North Harris County (Houston).


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## EpiEMS (Sep 29, 2017)

RocketMedic said:


> We (and ESD-48) transfuse blood into people on the regular here in North Harris County (Houston).


Is that part of a research project, or regular ol' protocol?


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## RocketMedic (Sep 29, 2017)

Regular protocols. But we're always researching too.


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## Summit (Sep 29, 2017)

RocketMedic said:


> Regular protocols. But we're always researching too.


What is the criteria for blood?


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## TXmed (Sep 29, 2017)

RocketMedic said:


> Regular protocols. But we're always researching too.




As in published research or internal ? Does the info get forwarded to either of the trauma centers in H-town ? 

Not to seem like a prick, but alot of places claim research when in reality they look at their own numbers for self-falacio rather than reporting to an entity to make it public and therefore furthering general knowledge. Im a huge advocate for EMS research but it rarely gets pushed unless a resident or fellow gets the ball rolling.


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## RocketMedic (Sep 29, 2017)

I honestly don't know. For all I know our Docs might be wallpapering a bathroom.


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## RocketMedic (Sep 29, 2017)

Adult and pediatric criteria


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## StCEMT (Sep 29, 2017)

RocketMedic said:


> Adult and pediatric criteria


Has it seemed like a beneficial addition in your experience? I've yet to run into a situation I could have used it, but I seem to be a medical **** magnet and haven't done a legit trauma assessment in some time.


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## agregularguy (Sep 29, 2017)

We also are supposed to be getting blood out here in SC. Was originally supposed to get in October, now not entirely sure when, still within next few months is what I was last told. ( In addition to push dose pressors, doc was on board with them!)


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## SAREMT (Sep 30, 2017)

I think another thing to consider with the definition of "progressive" is the autonomy of decision making with regard to treatment, transport, and referral. 

I come from a system that only recently began dispatching nonemergent calls as code 2 and does not enable any sort of community paramedicine as the money is not there. I would argue that a factor in progressiveness is the recognition that not every single patient needs a code 3 response and transport to the hospital meanwhile enabling the field paramedics to critically evaluate and field triage patients. This could mean a referral to primary care physician, secondary means of transport to the ED if necessary, or dare I say a field prescription.


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