So how does ALS work in California?

RocketMedic

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I was browsing a few protocols from the Golden State and I was wondering something: do y'all literally have to Johnny-and-Roy every single intervention that you do or what? What is a MICN? And what is your workflow like? Can you autonomously do things or what?
 

NPO

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Well, unfortunately you're question is poorly formed. Our protocols are not state wide, they are county by county. But, I'll do the best I can to address your questions.

Do we Johnny and Roy everything?
I don't know what this means. But LACo hasn't changed much since that show aired, so for them at least, probably. (I have a great distaste for LACo EMS)

What is an MICN
Mobile Intensive Care Nurse. I'm not aware of anywhere that uses MICNs out of the hospital, despite the name MOBILE. Everywhere I know of, the MICN is who answers your radio call in. MICNs received additional training on prehospital protocols to help them help us.

Can we autonomously do things?
We have standing orders just like anyone else. What we have standing orders for varies by county.

Places like LA County offer very little in the way of interventions before making base contact and asking for permission.

Where I work, we have much more leeway. For example, we have Level 1 protocols, and Level 2 protocols.

I can preform any Level 1 protocol prior to base contact. I am supposed to make base contact before initiating Level 2 protocols unless...

"In the event a paramedic at the scene of an emergency or during transport ... reasonably determines that a delay in treatment may jeopardize the patient, the paramedic is authorized to provide any LEVEL I Paramedic treatment protocol as well as any LEVEL II Paramedic treatment protocol."

Our medical director also allows us to use clinical judgement, rather than being a robot paramedic with the following excerpt from the opening pages of our protocols...

"If necessary based on physiological
justification, a paramedic may modify protocol treatment sequence. Any variation from
treatment sequence shall be thoroughly documented on the PCR Narrative."
 

DesertMedic66

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I was browsing a few protocols from the Golden State and I was wondering something: do y'all literally have to Johnny-and-Roy every single intervention that you do or what? What is a MICN? And what is your workflow like? Can you autonomously do things or what?
Going to depend on the area. For my area we can do the majority of interventions without having to contact the hospital.

MICN = Mobile Intensive Care Nurse. They are the only medical provider (aside from doctor) who is able to answer a radio call from the ambulance. They are familiar with our protocols and have the ability to direct us to a different hospital if needed. They are able to authorize a small amount of treatments for us (for example for SVT in my area we are only able to give one dose of 12mg of Adenosine. If that doesn't convert and we want to give an additional 12mg then we have to get the ok from the MICN). We also have orders that have to be given by the doctor directly (if the patient was given morphine by Fire and we want to give Fent, for example).

What do you mean by workflow?

As far as can we do things autonomously, it's going to depend on the county you are in. For example in my area we do not have a "Chest Pain" protocol. So not all chest pain gets an IV, O2, 12-lead, NTG, ASA. It prevents the "if chest pain then do this".

While we don't have an exact protocol for "I need an order for this but I'm in an area where I can't contact the Doctor" we have to use our best judgement on what to do.
 
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RocketMedic

RocketMedic

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So it's dependent on the county you're in to determine what you can do?

Do y'all have PAI (I know RSI is a no-go in CA), video laryngyscopes, ventilators, etc?
 

NPO

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So it's dependent on the county you're in to determine what you can do?

Do y'all have PAI (I know RSI is a no-go in CA), video laryngyscopes, ventilators, etc?
That's all dependant on the county. The state has very little to do with what we do. The state sets the state scope, and then each county adds or subtracts to meet their needs/wishes.

For example, LACo barely has intubation.

Kern county has Ventilator protocols, and video laryngoscopes.

The vent is new, and is only for transfers, and no one uses video laryngoscopes except Hall CCT, but they're allowed.



I had to look up PAI. So no, not exactly. We are allowed to use Versed under two protocols, but only after intubation, which is... well... Ya. Our medical director is new, and is working on that.
 

DesertMedic66

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CA state sets the limit for what we can do. Counties can subtract skills if they wish (for example in my county we took out pedi intubation because we had providers killing kids from not checking the tube).

If a county wishes to add something to the state scope it's not as easy as "we want RSI so we are going to do it". It normally starts off with a trial study of the drug or intervention (we are in the middle of doing a TXA study to see if it if actually beneficial. If it is then we will make a proposal to the state to include it in the scope).

I don't know of any county that has RSI or PAI. I have not heard of any medic services carrying vents in CA.
 

NPO

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CA state sets the limit for what we can do. Counties can subtract skills if they wish (for example in my county we took out pedi intubation because we had providers killing kids from not checking the tube).

If a county wishes to add something to the state scope it's not as easy as "we want RSI so we are going to do it". It normally starts off with a trial study of the drug or intervention (we are in the middle of doing a TXA study to see if it if actually beneficial. If it is then we will make a proposal to the state to include it in the scope).

I don't know of any county that has RSI or PAI. I have not heard of any medic services carrying vents in CA.
We're getting a ventilator protocol, but just for transfers. I doubt you'll see ALS units carrying vents because they'll just take the hospital's, and any 911 patient that needs ventilation and is rural enough to need a vent should be flown, and they have vents.
 

DesertMedic66

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We're getting a ventilator protocol, but just for transfers. I doubt you'll see ALS units carrying vents because they'll just take the hospital's, and any 911 patient that needs ventilation and is rural enough to need a vent should be flown, and they have vents.
We have one flight option for critical patients that doesn't have vents which is the CHP airship.
 
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Bullets

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If you don't have RSI what do you do if the patient needs an airway but is still conscious or has a gag?

If you can only push 12 of adenosine and they don't convert you can't just push another 12 or cardiovert without calling?
 

DesertMedic66

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If you don't have RSI what do you do if the patient needs an airway but is still conscious or has a gag?

If you can only push 12 of adenosine and they don't convert you can't just push another 12 or cardiovert without calling?
1.) call an airship since they can RSI, transport to the closest ED so they can RSI, or wait until we can intubate.

2.) For my area we have to call and get an order for a second 12mg adenosine. We can cardiovert without calling (unless it's a pedi patient).
 

NPO

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1.) call an airship since they can RSI, transport to the closest ED so they can RSI, or wait until we can intubate.

2.) For my area we have to call and get an order for a second 12mg adenosine. We can cardiovert without calling (unless it's a pedi patient).
What if you can't call? That seems silly, like, if I need to cardiovert, it's got to be bad. I ain't got time to call!
 

DesertMedic66

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What if you can't call? That seems silly, like, if I need to cardiovert, it's got to be bad. I ain't got time to call!
Based on some of the medics we have in our system it is a safe plan to have us contact base for pedi drugs. I've had the joy of a medic wanting to cardiovert a 2 year old who has been vomiting and has had diarrhea for 4 days who was altered with a HR of 160.
 
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RocketMedic

RocketMedic

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I don't get the aversion to vents. They're pretty common here in Texas.
 

NPO

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Based on some of the medics we have in our system it is a safe plan to have us contact base for pedi drugs. I've had the joy of a medic wanting to cardiovert a 2 year old who has been vomiting and has had diarrhea for 4 days who was altered with a HR of 160.
Well I mean cause it's over 150 so you've got no choice!
 

gonefishing

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LA county is talking about getting rid of intubation entirely.

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EpiEMS

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Based on some of the medics we have in our system it is a safe plan to have us contact base for pedi drugs. I've had the joy of a medic wanting to cardiovert a 2 year old who has been vomiting and has had diarrhea for 4 days who was altered with a HR of 160.

Wow -- just....wow. I imagine that person got remediated?

Probally not a bad idea.

Removing intubation seems reasonable if folks aren't getting enough practice, I'd wager.

Reeducation or separation of EMS from Fire would be better.

This +1000.
 

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