IYO: Which EMS system has the most strict vs most laxed protocols?

[ParamedicStudent]

In your opinion, which systems have you worked for or have information about that offers the strictest protocols vs more flexible protocols?

Most strict meaning by the book, do this and this, in this order. Ask for a base order before doing anything.

Flexible meaning more control/autonomy, protocols uses key phrases such as "use clinical decision/judgement", " if possible" , "at paramedic's discretion" etc.

Please and thank you.

 

[NomadicMedic]

It'll be very different based on every system. Something that may be standing orders for me is a med control contact for another guy and vice versa.

The tricks and tools aren't as important as you may think.

That kind of stuff really only makes a difference when you're brand new. The important stuff is work/life balance, pay, call volume and retirement.

 

[VFlutter]

That kind of stuff really only makes a difference when you're brand new. The important stuff is work/life balance, pay, call volume and retirement.

Psh I don't care if I have to live off Ramen noodles as long as I get to do a pericardiocentesis at work.

 

[mgr22]

ParamedicStudent, you'd probably get a more comprehensive answer to your question if you Googled the protocols for, say, 10 major EMS systems. Many EMS web sites allow access to their protocols. Maybe pick five common presenting problems and compare what each system lets you do. I went through an exercise like that for some research I was doing. It wasn't hard.

 

[Summit]

Psh I don't care if I have to live off Ramen noodles as long as I get to do a pericardiocentesis at work.

milk... nose...

 

[aquabear]

Psh I don't care if I have to live off Ramen noodles as long as I get to do a pericardiocentesis at work.

We’ve got standing orders for pericardiocentesis (I’ve only done it once in two years) and they pay us enough to live off of Campbell’s soup too!

 

[SpecialK]

I can't see a need for writing down "use clinical judgement" that's kind of fairly screamingly obvious.

New CPGs are published every two years (so there are only twelve months between reviews) and I cannot say there's want of anything; even in some of the older versions, maybe a couple of minor things but they've been taken care of.

Looking into the future I can see two things: firstly, going totally electronic so small incremental add-ins can happen on a rolling basis rather than waiting because there would be a need to publish several thousand new copies (or stickers to replace pages) and the second being a move towards perhaps a single Australasian set of CPGs where at least an agreed core set is defined; which is pretty much the case anyway but something like that would be nice I think. I think registration may help with that.

And of course there are always certain things you must do in a specific order such as RSI or pacing or non-transport checklists and those are specified as such; which is not a bad thing either. The rest is entirely down to clinical judgement and I'm not sure how it is possible for it to be any other way? I'm not sure how you could effectively function if it was not?

 

[Bullets]

We’ve got standing orders for pericardiocentesis (I’ve only done it once in two years) and they pay us enough to live off of Campbell’s soup too!

Come to Camden, NJ. We get Campbells Soup for FREE!!!!

 

[VentMonkey]

@Bullets does your system do ALS intercept, and if so is it in a fly car or ambulance?

 

[RocketMedic]

Our protocols are pretty aggressive, but they're also pretty strict- to the point of management arguing that heat stroke can't be heat stroke due to not meeting an arbitrary temperature that was so dumb I don't remember it.

 

[DrParasite]

@Bullets does your system do ALS intercept, and if so is it in a fly car or ambulance?

If I'm not mistaken, his system does ALS intercept using fly car ambulances........

meaning the ALS shows up in an ambulance, but transports in the BLS truck if needed. It's standard practice throughout NJ (although most non-transport ALS agencies respond in SUVs instead of ambulances)

 

[VentMonkey]

If I'm not mistaken, his system does ALS intercept using fly car ambulances........

meaning the ALS shows up in an ambulance, but transports in the BLS truck if needed. It's standard practice throughout NJ (although most non-transport ALS agencies respond in SUVs instead of ambulances)

So most ALS intercepts in NJ are ALS ambulances? Interesting.

Do they carry two sets of ALS gear in the event that the ALS ambulance is diverted to another call while their partner rides in with the other (BLS) ambulance?

 

[DrParasite]

So most ALS intercepts in NJ are ALS ambulances? Interesting.

No..... back in the day, only New Brunswick, Newark and Jersey City were "legally" allowed to transport in an ALS ambulance; the justification for this was in those cities, both the ALS and BLS were ran by the same hospital based agency. So in those three cities, and only those three cities, you would find paramedics riding in ambulances. The theory was, both an ALS and BLS truck showed up; if the patient required ALS, the paramedic truck transported and BLS went back in service, and if the patient did not require ALS, the EMT truck transported and ALS went back in service. and if the patient was really sick, the patient was usually transported in the BLS truck, with both medics in the back, and the EMTs drove both vehicles to the hospital.

In the rest of the state, ALS is in a flycar (usually some type of SUV), from a hospital based regional system, while the BLS was ran by the municipality. So if the patient is BLS, the paramedics go available, and if the patient is ALS, one medic treats while the other follows in the SUV, while the BLS ambulance transports. This was a political decision that started before I became involved in EMS.

10-15 years ago (maybe it's closer to 25 years now), some hospital based systems (which had previously only ran ALS units) added CCT units, and added BLS divisions. This allowed them to create non-emergency divisions to get in on the lucrative hospital discharge and inter-facility market, as well as bid on 911 contracts for municipalities. They staffed their CCT unit with an RN, a Paramedic, and an EMT, so if the CCT unit wasn't on a CCT run, they could be sent on ALS requests when the primary unit was tied up. In theory, the CCT unit could transports, but legally they were only able to transport with the BLS unit. So agencies could apply for waivers to the "only BLS can transport" if they chose too, and it was up the the dept of health to approve or deny it.

I have heard people say that the ALS agency for Bullet's area had such a waiver, but I have also heard that they were told a waiver exists, but no one has actually seen it. So they are pretty much going on "well, since those guys could do it based on their criteria, and we meet the same criteria, then so will we, and we can beg for forgiveness if we get caught." and last I heard others were following their trend. It's a political headache that predates me.

I heard RWJUH/NB have moved their paramedics out of ambulances, and moved them to SUVs to save money (well, for RWJ they had 6 medic trucks; they all used to be in ambulances, located throughout the county; now only the ones stationed in New Brunswick are still in an ambulance, but the out stations are in SUVs).

Do they carry two sets of ALS gear in the event that the ALS ambulance is diverted to another call while their partner rides in with the other (BLS) ambulance?

yes and no. Some trucks will carry two sets of gear. two monitors, two drug bags, two airway bags etc, so if they needed to split up (all paramedic units in NJ are dual ALS provider by state law) and each take an ALS patient to the hospital in a separate ambulance, they could. But no, once they are assigned to an assignment, unless some weird thing happens, they are committed to that assignment until the crew turns over patient care.

a BLS ambulance (typically based in the municipality) is sent to EVERY request for an ambulance that comes through the 911 system. ALS are only sent on calls that meet ALS criteria per EMD guidelines. In theory, ALS should only be treating and transporting patient that meet ALS criteria. At least that's how the system is set up to function.

 

[Bullets]

@Bullets does your system do ALS intercept, and if so is it in a fly car or ambulance?

My specific area does ALS intercept in Type 3s but this may be changing as paid BLS becomes more prevalent.

Camden now does ALS intercept primary in Type 2s and their backup is Pickups with SpaceKaps.

NJ is a mixed bag of ALS in fly cars or type 3s

 

[DrParasite]

Camden now does ALS intercept primary in Type 2s and their backup is Pickups with SpaceKaps.

I suggested this to my former ALS operations coordinator: take the medics out of the type 3s, and put them in them in the type 2s to save on funds. They rarely transport in them, and if they needed to, it was only one provider in the back. The response was a resounding no.....

But it was ok to put BLS in type 2s, and put them and a medic in the back on a sick ALS patient.....

Is Camden EMS transporting in their ALS units?

 

[Bullets]

I suggested this to my former ALS operations coordinator: take the medics out of the type 3s, and put them in them in the type 2s to save on funds. They rarely transport in them, and if they needed to, it was only one provider in the back. The response was a resounding no.....

But it was ok to put BLS in type 2s, and put them and a medic in the back on a sick ALS patient.....

Is Camden EMS transporting in their ALS units?

Yup, they run just like University used to