Does Kern County Still Have Good Protocols?

[wtferick]

I don't really understand why systems would have nurses giving orders anyway. Since I'm not a licensed medical provider I wouldn't feel comfortable having my name on an order anyway, let alone through a phone on a patient I've never seen. I get that these are probably through standing orders or protocols from the medical director, but it just seems weird that one non-LIP is requesting an order from another non-LIP.

Occasionally our nurses may ask for a 12 lead , BGL, specific assessment, and so on (especially for some of the lower acuity/volume services); but we are just discussing an assessment that I would think is beneficial and is within their scope and standing orders already. When we request these though it is in the same nature of a medic asking another medic their thoughts on a case. The moment an EMT, medic, or flight nurse asks for an order I had the phone over to one of our PEMs or adult attendings.

The reality is that most nurses, even those with extensive ED experience, don't really understand the nature of pre-hospital care; especially so in 911 systems.

I would rather trust a Nurse with little to no pre-hospital experience than a Paramedic in all reality.

 

[Tigger]

On the topic of RSI: most of NJ allows it, while many medical directors in NC don't, including my former one. It's not something that should be used all the time, but there is absolutely a time and place to use it, and if you don't have that option, well, you aren't giving the patient the best chance for success and survival

Hot take: if you can provide a surgical airway, you don't truly "need" RSI.

 

[DesertMedic66]

Hot take: if you can provide a surgical airway, you don't truly "need" RSI.

Yeah, I’m not gonna be cutting on a trauma patient who has a GCS of 7 with an expected easy intubation. That would very quickly be flagged in hopefully all systems.

 

[Peak]

I would rather trust a Nurse with little to no pre-hospital experience than a Paramedic in all reality.

I just don't think that nurses should be giving medical orders. I assume that this is delagation from a set of standing orders from the medical director, but it still seems a bit odd.

Also, I certainly wouldn't trust nurses who don't have EMS experience, or at least really strong ED background. In reality nursing school doesn't teach a whole lot in the way of critical care, let alone the unique challenges of EMS. Nurses are held liable for failure to rescue, but typically that is calling 911 or a code/rapid response in the hospital and letting someone else fix it.

 

[DrParasite]

Hot take: if you can provide a surgical airway, you don't truly "need" RSI.

Ummmm, I guess? I've seen several patient's receive RSI in the field. I've never seen a surgical airway performed, despite the paramedics having that capability.

I mean, I guess you're right.... no need to RSI someone to ensure a patent airway, if you can just cut a hole in in the neck and have them breath that way..... RSI still sounds like a safer option to me though.

In my current EMS system, surgical airways are in the paramedic scope of practice, but if you do one, you need to call the medical director immediately afterwards and explain your actions. their thinking is you have enough tools in your toolbox that you shouldn't need to do a surgical airway, but you have it available should you need it.

 

[Tigger]

Yeah, I’m not gonna be cutting on a trauma patient who has a GCS of 7 with an expected easy intubation. That would very quickly be flagged in hopefully all systems.

This was recently brought up by our education captain and medical director. I'm with you, if the patient needs to be intubated, do it when conditions are optimal. I think their point was more to emphasize that it is a legitimate airway strategy especially if the patient is not an RSI candidate and other means are not providing adequate ventilation.

In my current EMS system, surgical airways are in the paramedic scope of practice, but if you do one, you need to call the medical director immediately afterwards and explain your actions. their thinking is you have enough tools in your toolbox that you shouldn't need to do a surgical airway, but you have it available should you need it.

What a great way to discourage people from doing the right thing.

 

[DrParasite]

What a great way to discourage people from doing the right thing.

Above my paygrade. I guess (and this is only a guess) is that the situation should never get bad enough when you have to do a surgical airway, but if it does, he wants to hear about it. I guess he doesn't consider a surgical airway to be the right thing, but since he has MD after his name, he's in a better position to make that statement than i am.

 

[aquabear]

So are counties in California using push dose pressors as a bridge to a drip, or have they just gotten rid of prehospital vasopressor drips all together and using just PDP instead?

 

[DesertMedic66]

So are counties in California using push dose pressors as a bridge to a drip, or have they just gotten rid of prehospital vasopressor drips all together and using just PDP instead?

That’s a good question haha. The only pressor that is/was available in CA to use is dopamine. A lot of counties are starting to phase it out.

There are talks about possibly trying to do a trial study for Levophed but one major issue is that only a super small percentage of companies carry pumps. So for the time being it seems as if push dose is the safer option.

 

[MedicEducate4Life]

California has a wide array of protocols since we have a great variance in the geographical areas that are also regulated by a multitude of Local Emergency Medical Service Agencies (LEMSA). With 58 counties and around 33 LEMSAs (all with different protocols) research outcomes and data are not always representative of the "State". One of the biggest difficulties is writing a protocol that is functional for all the areas served, not just the metropolitan areas but the rural and remote areas.

Skills that are not used and never reviewed and competency tested are likely to have failure rates that are high. Larger organizations and entities have greater expenses to maintain competency testing let alone add a procedure or medication that comes with an added cost. So they often fight changes preventing budget increases, preventing compliance and skill testing, and preventing other medical directors to pioneer a change on their own. California has many medical directors who do not want to increase their liability.