Progressive EMS Ideas and/or Protocols

[Jersey]

Hey All,

I was curious, and wanted to start one thread in one place, as to what "progressive" (purposefully left vague) ideas your agency or an agency you've heard of is using.

For example:

Advanced Care Paramedics capable of providing "non traditional" services such as suturing, anti-biotic perscriptions etc. Please feel free to elaborate on any of these programs you know of!

Specific advanced medical programs such as ground 911 chest tubes, thrombos etc. All of these, of course, are open to debate.

The purpose of this thread is to hopefully share nationally and internationally what the "cutting edge" of EMS care is, and how are colleagues are using different procedures and protocols beyond the average 911 ALS unit.

 

[DrParasite]

The problem with "progressive" EMS is that the idea is to bring the ER to the patient, but you don't have all the resources of the ER.

Take thrombolitics. Now I think they would be a great help to CVA patients, but do you really want to push them without a CAT scan? To clarify further, would you want to administer someone who has a brain bleed?

Suturing and prescriptions are two great examples. but lets also ask how many paramedics want the liability when something goes wrong? or when they get sued, how much will their malpractice insurance increase? And are doctors going to take the liability upon themselves to trust the paramedics to write scripts? also, will the DEA allow this?

One thing everyone needs to remember is that EMS is not definitive care; that status is reserve for an MD. if you are going to change that concept then you probably need to redo the entire paramedic training program from the ground up.

 

[piranah]

my service a few years ago was involved with a program to determine the success rate of TPA for CVA's in the pre-hospital setting. My service had a 100% success rate but one of the other services in the country didnt do so hot. RI is having the protocols change to add Standing orders for pain management and adding fentanyl,ativan and a few others..(my service hasn't gotten the printouts yet).

 

[reaper]

The majority of Thrombolitic use in the field is for STEMI's, not for CVA's. For STEMI's the use is great with long transports. Shorter Transports with access to a CATH lab, They are not really needed.

Did have one Flight service that was studying Thrombilitic use, along with Factor VII for CVA's in the field. They were having a lot of success with it, but I never found out the outcome of the study.

 

[Veneficus]

The majority of Thrombolitic use in the field is for STEMI's, not for CVA's. For STEMI's the use is great with long transports. Shorter Transports with access to a CATH lab, They are not really needed.

Did have one Flight service that was studying Thrombilitic use, along with Factor VII for CVA's in the field. They were having a lot of success with it, but I never found out the outcome of the study.

As in Clotting factor VII?

How did they find out if the CVA was ischemic or not? Especially considering that roughly only 20% of CVAs are bleeds?

Both the Army and Civillian trauma services found restricting who could give factor VII to trauma docs/intensivists improved outcomes. (for the type of bleeding it was designed for)

Not attacking you, but I am very surprised anyone would let such a study go forward. The risk/benefit on a potentially uninformed patient is substantial.

 

[Jersey]

Dr. Parasite,

Everything I mentioned is in use around the country, I did not pull it from thin air.

I'm looking for an informed, rather than condescending, conversation about different field treatment protocols.

A program in North Carolina has been using Advanced Care Paramedics to provide advanced level skills on critical calls as well as "preventative maintenance" type services for the chronically ill to reduce the number of ambulance utilizations and ER visits.

SWITCHING GEARS, I'd love to hear the discussion about field thrombos play out. It's a huge debate, but make sure to differentiate whether we're talking about MI or Neuro thombolytics. In addition, anyone from a program or service that IS using thrombolytics, post a copy of your specific protocol or research that backs up your point of view.

That way, we wont have a heresay back and forth, but rather an informed conversation based on facts and peer reviewed research.

The problem with "progressive" EMS is that the idea is to bring the ER to the patient, but you don't have all the resources of the ER.

Take thrombolitics. Now I think they would be a great help to CVA patients, but do you really want to push them without a CAT scan? To clarify further, would you want to administer someone who has a brain bleed?

Suturing and prescriptions are two great examples. but lets also ask how many paramedics want the liability when something goes wrong? or when they get sued, how much will their malpractice insurance increase? And are doctors going to take the liability upon themselves to trust the paramedics to write scripts? also, will the DEA allow this?

One thing everyone needs to remember is that EMS is not definitive care; that status is reserve for an MD. if you are going to change that concept then you probably need to redo the entire paramedic training program from the ground up.

 

[Jersey]

For instance, please post research links if you have them. Here's one to start off with:

http://www.medscape.com/viewarticle/409729

 

[reaper]

As in Clotting factor VII?

How did they find out if the CVA was ischemic or not? Especially considering that roughly only 20% of CVAs are bleeds?

Both the Army and Civillian trauma services found restricting who could give factor VII to trauma docs/intensivists improved outcomes. (for the type of bleeding it was designed for)

Not attacking you, but I am very surprised anyone would let such a study go forward. The risk/benefit on a potentially uninformed patient is substantial.

Vene,

This study was done by UF. It was a few years back. They were giving thrombolitics and factor VII at the same time. I could never figure out how they were getting it to work. Thrombolitics to bust a clot and factor VII to induce one, for bleeds.

I will see if I can dig up anything on the study.

 

[Needles17]

My favorite one is we have a hypothermia protocol for ROSC. We cool the body temp to 32 - 34c. It is accomplished with a max of 2 liters of cold NS and 60 of Roc. It is performed only for non-trauma codes.

 

[LucidResq]

Finger stick lactate meters and prehospital sepsis alerts.

 

[Melclin]

Suturing and prescriptions are two great examples. but lets also ask how many paramedics want the liability when something goes wrong? or when they get sued, how much will their malpractice insurance increase? And are doctors going to take the liability upon themselves to trust the paramedics to write scripts? also, will the DEA allow this?

No one is going to be giving Captain Patch Medic a prescription pad anytime soon. The leading thinking in this field at the moment is that prehospital practitioners would have a Masters-PhD level of qualification in the same sense as a nurse practitioner. There is a push here for national registry and recognition of skills with the extension of that idea being that we could start prescribing paramedic type drugs on our own authority.

One thing everyone needs to remember is that EMS is not definitive care; that status is reserve for an MD. if you are going to change that concept then you probably need to redo the entire paramedic training program from the ground up.

Yeah you do, but you need to do that anyway. Besides, the idea that an MD is the only person capable of providing definitive care in all cases is absurd.

LucidResq: I love the idea of finger stick lactate measuring. I think prehospital sepsis management is awful and algorithms for care in the future I think are going to need to involve prehospital lactate measurement and possibly blood cultures. http://www.emtlife.com/showpost.php?p=212114&postcount=19 - for my tirade on sepsis management.

I think the future lays also in alternative referral pathways and/or extended care models.

- Brittish paramedic guru Malcolm Woollard on "The Role of the Paramedic Practitioner in the UK" http://www.jephc.com/full_article.cfm?content_id=337 -

- The emergency care practitioner report which is guiding the development and justifications of ECPs - http://www.dh.gov.uk/prod_consum_dh...@dh/@en/documents/digitalasset/dh_4093088.pdf

-Example of ECP guidelines for alternative referal. I believe all paramedics should be working from algorithms like this to make sure people get the care they actually need. http://www.swast.nhs.uk/clinical/pdf/ECPGuidelines.pdf

-Also of interest to me are extended ideas of referral for blood tests, xrays etc. EG: Johnny has twisted his ankle, and called the ambulance, its appears to be relatively okay, but it requires an x-ray and medical consultation. So you drop him off at a clinic with a slip for an appropriate xray and appointment to see a GP. EG(2): Fred is having chest pains, it doesn't appear cardiac, but he needs to go to ED to make sure. You drop him off with the first (and second?) 12 lead, a vial or two of blood and an order for troponin, U/E and FBE or whatever. These would be predetermined patterns for specific problems, we wouldn't actually be ordering blood tests in the same sense as a doctor, otherwise we may as well trot off to medical school. The idea being that it will expedite the care process in our already overcrowded (and soon to be worse, with an aging population) EDs.

 

[FLEMTP]

Our system is very progressive.. we dont even have protocols.. we have guidelines. Basically.. you can do what you see fit for the patient. if it goes outside those "guidelines" then you should be able to justify what you do.

Some of the neat things we've had or have:

Tridal drips (current)

subclavian central lines (current)

propofol for post RSI maintenance (past/current for HEMS)

fentanyl for both pain management and post RSI maintenance (current)

versed

ativan

post cardiac arrest hypothermia

King tubes

LMA supremes

bougies

SALT airways

Alternative paralytics (Rocuronium)

EZ-IO's

pericardiocentesis

Thats all I can think of off the top of my head for now... I'll add more as I can think of them or after I review our guidelines for something I may have missed!

 

[Veneficus]

I could never figure out how they were getting it to work. Thrombolitics to bust a clot and factor VII to induce one, for bleeds

Life is never that simple

primary ischemic strokes can induce secondary hemorrhagic ones.

To complicate the matters more, the thrombolytic can play havoc on the total systemic ability to clot, so replacing factors is sometimes beneficial. depending largely on the nature of the disease process and other comorbities.


Not really related to stroke

I have to say, as much as I like procedures and instant gratification treatments, factor VII is tricky stuff.

It was originally developed for severe hemophilia, but rumor has it so few people had the condition with such severity (I heard 7 world wide) that it could never hope to break even for the research cost.

The Israeli Army was the first to start using it for trauma, followed by a large purchase by the US Army for the current conflicts. There are pages and pages of what the results were, and it wasn't until a study out of Ramstein came out that its use was more strictly limited. At one point during the last 5 years, civillian trauma specialists were going crazy over its widespread use and labeled it a treatment of last resort.

However, once there was more restriction in patient population and dosages and monitoring procedures improved, some are saying it can work rather well. (but the documentation is rather limited)

 

[Melclin]

Our system is very progressive.. we dont even have protocols.. we have guidelines. Basically.. you can do what you see fit for the patient. if it goes outside those "guidelines" then you should be able to justify what you do.

Some of the neat things we've had or have:

Tridal drips (current)

subclavian central lines (current)

propofol for post RSI maintenance (past/current for HEMS)

fentanyl for both pain management and post RSI maintenance (current)

versed

ativan

post cardiac arrest hypothermia

King tubes

LMA supremes

bougies

SALT airways

Alternative paralytics (Rocuronium)

EZ-IO's

pericardiocentesis

Thats all I can think of off the top of my head for now... I'll add more as I can think of them or after I review our guidelines for something I may have missed!

First of all ...wow.

TC pacing? Noradrenaline? Nitro infusion? Blood alchohol measurement? Midaz for pain? Mag sulphate? Dopamine? Etomidate, sux, midaz, fent, roc Gycoprotein inhibitors? Heparin? Umby vein canulation? Am I reading these guidelines right? Why do you bother with an ED ? Honestly, that's amazing mate.

 

[MrBrown]

I would not call our service progressive by any stretch of the immigination, but then agian, what you may consider progressive I think of as normal way of operating.

What we have recently introduced are

- EZ IO to replace Cooks/BIG
- Rapid sequence intubation nationally after successful pilot program
- Ondansterion (zofran) to replace maloxon (metaclopramide)
- Combat application toruniquet

What we are introducing

- Bachelors Degree for anybody above BLS
- Post Graduate Certificate for ALS

What we are trialing
- Thrombolysis

What I would like us to get
- Boussignac CPAP
- Ceftriaxone/finger stick lactate
- Midaz at Paramedic level IM/IN for seizures rather than Intensive Care only

 

[FLEMTP]

First of all ...wow.

TC pacing? Noradrenaline? Nitro infusion? Blood alchohol measurement? Midaz for pain? Mag sulphate? Dopamine? Etomidate, sux, midaz, fent, roc Gycoprotein inhibitors? Heparin? Umby vein canulation? Am I reading these guidelines right? Why do you bother with an ED ? Honestly, that's amazing mate.

we are very fortunate that our medical director here believes in us actually treating the patient and giving us the tools to do what needs to be done!

Most of the US has been in a budget crunch as far as governmental agencies, but once things improve I would like to see something along the lines of an advanced practice paramedic developed (suturing, antibiotic administration, follow up appts, and certain prescriptions written) and eventually a social service type medic to check on frequent flyers and help them with medications, dr appts and such so that we are not seeing as many of the frequent flyer type 911 calls for things that could have been resolved with a medication refill or a trip to their primary care.


The only problem i see with these services is attempting to bill medicare and medicaid and 3rd party insurance for these services when in the past there has been no reimbursement of this type allowed to EMS.

 

[fma08]

Here's a radical idea for progressive ems. Instead of adding more and more toys and procedures, try revamping the education guidelines and curriculum first. Then, work on adding other stuff.

 

[Jersey]

Here's a radical idea for progressive ems. Instead of adding more and more toys and procedures, try revamping the education guidelines and curriculum first. Then, work on adding other stuff.

Ah, I knew someone was going to say it. I completely agree with you that the education system needs to be revamped. However, that has been discussed extensively on other threads. I think it might be a little unfair to suggest that forward thinking systems simply want more toys. In fact, all of the "progressive" EMS agencies that I've come into contact with also seem to have the highest standards for their ALS practitioners and have some of the best overall providers around. Anyone else with me on that?

Now, once again back on topic.

Does anyone know of a system that is using portable lactate meters? Seems like an excellent concept. Here is the link to the PubMed article about the primary device that seems to be going around:

http://www.ncbi.nlm.nih.gov/pubmed/16151900?dopt=Abstract

Second, does anyone have names of systems either in the US or abroad that are using the advanced care paramedic model? (non-emergent home visits etc)

Third, a number of you mentioned pericardial centesis, what are your guidelines for initiating? What additional training is provided? Do you have copies of protocols/guidelines?

GREAT discussion, lets keep it rolling!

 

[FLEMTP]

Third, a number of you mentioned pericardial centesis, what are your guidelines for initiating? What additional training is provided? Do you have copies of protocols/guidelines?

This is taken from our treatment guidelines:

PERICARDIOCENTESIS
INDICATIONS:
• When a Cardiac Tamponade represents an immediate threat to life including:
• Cardiac arrest (most often with PEA)
• Shock or severe cardiovascular collapse
• Look for Jugular vein distention, muffled heart sounds and hypotension (Beck’s Triad)
• An elevated Central Venous Pressure is the single best way to distinguish pericardial tamponade from
hemorrhagic shock
CONTRAINDICATIONS / PRECAUTIONS:
• Beck’s Triad is only present in 30% of patients with Pericardial Tamponade
• Watch for re-developing signs / symptoms and repeat procedure as necessary
EQUIPMENT NEEDED:
• 60cc syringe
• 18 ga X 3 ½” spinal needle
PROCEDURE:
1. Attach the syringe and needle
2. Locate the xiphoid process
3. Insert the needle just to the left of the patient’s xiphoid and inferior to the left rib
4. At a 45° angle to the patient, advance the syringe and needle slowly, aiming toward the patient’s
left mid-clavicle
5. While advancing slowly, apply negative pressure to the syringe
6. Once fluid is encountered, stop advancing the needle and continue aspirating
7. Aspirate up to 60cc, then remove needle and syringe
8. Reassess for improvement
9. Repeat process as necessary

I was taught pericardiocentesis in paramedic school, and it is reviewed here periodically with our training department.

We are expected as a standard of care here anytime we decide to work a traumatic arrest to perform a bilateral chest decompression and a pericardiocentesis.

If this is not performed, you are expected to show a good reason why.

 

[MrBrown]

Here's a radical idea for progressive ems. Instead of adding more and more toys and procedures, try revamping the education guidelines and curriculum first. Then, work on adding other stuff.

You have got to stop saying things like that, my doctor said those types of subjects are not good for my blood pressure honestly, the sph....sshygno.......spigmono.....eh thing you put round the patients arm and pump up runs away in fear!