So how does ALS work in California?

CTMD said:
In San Bernardino County we can use transport vents for 911 scene calls. Almost all the transporting agencies except for AMR have them. (County Fire, Desert, MBA)
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I have yet to see an MBA unit with a vent
 
While I don't know much about ICEMA anymore, as it has been some time since I worked there, I can offer up a little something in regards to Kern County...

I am currently a paramedic with our critical care division, and hopefully I can expand and/ or clarify on some of what NPO has touched on already regarding our division.

Since we are a different division altogether we do in fact work under our nurses protocols. Anything that is within our normal (Kern County) paramedic scope of practice, our nurses can do, so in theory this includes giving them the ability to intubate, which to my knowledge is not that uncommon in the rest of the country where paramedics seem to be given much more responsibility (and credit). We are allowed RSI both on our ground unit, and obviously our HEMS as well. We do utilize the King Vision as shown by NPO, and there is talks about us hopefully getting Ketamine back for RSI, possibly adding surgical cricothyrotomy to our nurses scope, and perhaps eventually a sepsis protocol for our division, which to my knowledge is actually required, or requested by CAMTS.

As far as the ventilators being used, I am aware of a protocol in the works, but can't really specify for sure the time frame as to when it will be approved (perhaps NPO knows first hand). What I can say is that for our division we are now to use in on all patients requiring mechanical ventilatory support; this includes IFT and scene (911) calls.

To the op, to be completely honest between us both, I would not wager my paramedic career in Texas to move back here. I grew up here as well, and this is home for my family, but from a career standpoint it is so much more limited, particularly for someone seeking to provide a level of paramedicine that isn't typically taught in the average American paramedic curriculum. The scope you mentioned in a previous post in regards to the meds allowed by ground paramedics in your state is a testament (IMO) to the level of trust given to prehospital providers elsewhere, and fortunately for you, it's much easier to implement your scope of practice as a true critical care paramedic. I am by no means bickering FWIW, as I really enjoy what I do, and do indeed work for (again, in my opinion) the best private ambulance provider in the state.
 
VentMonkey said:
While I don't know much about ICEMA anymore, as it has been some time since I worked there, I can offer up a little something in regards to Kern County...

I am currently a paramedic with our critical care division, and hopefully I can expand and/ or clarify on some of what NPO has touched on already regarding our division.

Since we are a different division altogether we do in fact work under our nurses protocols. Anything that is within our normal (Kern County) paramedic scope of practice, our nurses can do, so in theory this includes giving them the ability to intubate, which to my knowledge is not that uncommon in the rest of the country where paramedics seem to be given much more responsibility (and credit). We are allowed RSI both on our ground unit, and obviously our HEMS as well. We do utilize the King Vision as shown by NPO, and there is talks about us hopefully getting Ketamine back for RSI, possibly adding surgical cricothyrotomy to our nurses scope, and perhaps eventually a sepsis protocol for our division, which to my knowledge is actually required, or requested by CAMTS.

As far as the ventilators being used, I am aware of a protocol in the works, but can't really specify for sure the time frame as to when it will be approved (perhaps NPO knows first hand). What I can say is that for our division we are now to use in on all patients requiring mechanical ventilatory support; this includes IFT and scene (911) calls.

To the op, to be completely honest between us both, I would not wager my paramedic career in Texas to move back here. I grew up here as well, and this is home for my family, but from a career standpoint it is so much more limited, particularly for someone seeking to provide a level of paramedicine that isn't typically taught in the average American paramedic curriculum. The scope you mentioned in a previous post in regards to the meds allowed by ground paramedics in your state is a testament (IMO) to the level of trust given to prehospital providers elsewhere, and fortunately for you, it's much easier to implement your scope of practice as a true critical care paramedic. I am by no means bickering FWIW, as I really enjoy what I do, and do indeed work for (again, in my opinion) the best private ambulance provider in the state.
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Interesting insight into Kern County's protocols/operations. Do you work for Hall and if so is the critical care side totally seperate from the 911 side or do you still have scene calls? I didn't know that your guys ground CCT was that advanced. Thats pretty awesome that you guys have all that. Since it is CCT does that mean you run EMT Medic Nurse or is it just EMT/Medic?
 
Yes, I work for Hall. The critical care division is technically separate from our ground division, however, we do run 911 calls. We have one ground CCT unit, and a helicopter, and our program is CAMTS accredited.

While the majority of our workload is intended to focus on critical care transport, we do run a good amount of 911 calls especially currently given our call volume in the metro area, which is where our ground ops is; it's within our metro EOA. For California, I guess it is considered advanced, but again, remember we (paramedics) function under our nurses scope, as it's often easier to grant them protocols that we as paramedics in this state would otherwise have to fight tooth and nail for with the state, and/ or possibly the county itself.

It definitely is a bit different from AMR's CCT ops as I remember them being way back when. We are a P/B/RN configuration on the ground, and our helicopter is P/RN respectively. Both ground, and flight ops are held to the same protocols, which means RSI if needed is allowed on the ground at our discretion. Many people seem to shy away from, or not fully understand what we do because the bulk of our work load, especially on the ground, are LDT's (which I have personally come to enjoy), but it can be anything from 1 LDT, to multiple LDT's in a shift, to a mix of LDT/ IFT/ 911, to only 911 calls. Both ground, and air are 24 hours on a rotating schedule that correlates with Bakersfield Fire Departments.
 
CTMD said:
Interesting insight into Kern County's protocols/operations. Do you work for Hall and if so is the critical care side totally seperate from the 911 side or do you still have scene calls? I didn't know that your guys ground CCT was that advanced. Thats pretty awesome that you guys have all that. Since it is CCT does that mean you run EMT Medic Nurse or is it just EMT/Medic?
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Hall CCT air and ground run both IFT and 911, and are EMT, Medic, RN.

Also, as an additional, the RN Intubation is kind of an 'earned' skill. They have to preform 8 successful Intubation under the direction of the paramedic before they can do it autonomously. At least that was the rule last I checked, unless it's changed.

Also, a sepsis protocol is in the works at the LEMSA level for 911.
 
It is hit or miss, as some of our nurses are a tad apprehensive, so yes, the airway is our primary skill, hence my interest in ventilator management; sort the "omega" to the "alpha" of airway management for us prehospital folk. Really, it should be mandated for any, and all advanced airways in the prehospital setting in my mind.
 
VentMonkey said:
Yes, I work for Hall. The critical care division is technically separate from our ground division, however, we do run 911 calls. We have one ground CCT unit, and a helicopter, and our program is CAMTS accredited.

While the majority of our workload is intended to focus on critical care transport, we do run a good amount of 911 calls especially currently given our call volume in the metro area, which is where our ground ops is; it's within our metro EOA. For California, I guess it is considered advanced, but again, remember we (paramedics) function under our nurses scope, as it's often easier to grant them protocols that we as paramedics in this state would otherwise have to fight tooth and nail for with the state, and/ or possibly the county itself.

It definitely is a bit different from AMR's CCT ops as I remember them being way back when. We are a P/B/RN configuration on the ground, and our helicopter is P/RN respectively. Both ground, and flight ops are held to the same protocols, which means RSI if needed is allowed on the ground at our discretion. Many people seem to shy away from, or not fully understand what we do because the bulk of our work load, especially on the ground, are LDT's (which I have personally come to enjoy), but it can be anything from 1 LDT, to multiple LDT's in a shift, to a mix of LDT/ IFT/ 911, to only 911 calls. Both ground, and air are 24 hours on a rotating schedule that correlates with Bakersfield Fire Departments.
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Interesting. So when running 911 calls does the RN sit back and assist or do they try and take the lead on scene? Besides having RSI do you have an expanded formulary? Are your LDTs working calls or is it pretty much BLS with a monitor and a pump? Do you recieve a pay increase for being CCT or is still standard medic pay?
 
NPO said:
Hall CCT air and ground run both IFT and 911, and are EMT, Medic, RN.


Also, a sepsis protocol is in the works at the LEMSA level for 911.
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A sepsis protocol would be great, I have had scattered luck with call ins, and advising of sepsis work ups over the past few years, but to have a set plan, with sepsis bundles awaiting patients at the hospital, and parameters for field providers to follow similar to our STEMI, and stroke alerts is way overdue, I think.
 
CTMD said:
Interesting. So when running 911 calls does the RN sit back and assist or do they try and take the lead on scene? Besides having RSI do you have an expanded formulary? Are your LDTs working calls or is it pretty much BLS with a monitor and a pump? Do you recieve a pay increase for being CCT or is still standard medic pay?
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On 911 the paramedic is primary, but with the added benefit of having the knowledge, education and scope of a nurse. The nurse may still function on 911 calls; for example administer RSI medications.

Yes, there is a pay incentive. As he alluded to earlier, CCT is a separate division at our company. Not anyone can simply go in and pick up a CCT shift on your weekend. All CCT crew members apply, and are picked and 'interviewed' for the position. There is also a 3 year minimum experience requirement. I only say 'interviewed', because after three years, the CCT manager probably knows you well enough not to have to ask what your life goals are, your prior experience, etc.

VentMonkey said:
A sepsis protocol would be great, I have had scattered luck with call ins, and advising of sepsis work ups over the past few years, but to have a set plan, with sepsis bundles awaiting patients at the hospital, and parameters for field providers to follow similar to our STEMI, and stroke alerts is way overdue, I think.
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I agree. I think it's just taking a change of view point as a profession. Since sepsis generally doesn't "look" lethal in most stages, we tend to treat it as such. We're finally starting to get around to prehospital, aggressive sepsis treatment. I'd like to get to a point where we call code sepsis, just the way we do with stroke and stemi.
 
NPO said:
On 911 the paramedic is primary, but with the added benefit of having the knowledge, education and scope of a nurse. The nurse may still function on 911 calls; for example administer RSI medications.

Yes, there is a pay incentive. As he alluded to earlier, CCT is a separate division at our company. Not anyone can simply go in and pick up a CCT shift on your weekend. All CCT crew members apply, and are picked and 'interviewed' for the position. There is also a 3 year minimum experience requirement. I only say 'interviewed', because after three years, the CCT manager probably knows you well enough not to have to ask what your life goals are, your prior experience, etc.

Makes sense. So the medic can not adminster the RSI meds? What if it was reversed and the RN was going to intubate? Could the medic push the meds then or does the RN still have to adminster the Meds?
How do you like CCT? Is it as "exciting" and diverse as being on a 911 rig only or is it pretty montonous with not a whole lot to do as the medic?
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CTMD said:
Interesting. So when running 911 calls does the RN sit back and assist or do they try and take the lead on scene?

The rule of thumb is the paramedic "leads" the 911 calls, and the RN the transfers, but a good provider will delegate as an effective team leader with CRM regardless of the call. The RN is med pushing while the paramedic sets up to, then intubates. Again, it's most importantly a team approach particularly when dealing with high acuity patients.


Besides having RSI do you have an expanded formulary?

Our RSI meds are expanded for the paramedic yes, but similar to what you would find with any other HEMS agency in our state, and from my knowledge pretty basic (Atropine/ Lido though Lido has generally fallen out of favor, and questionably effective--->Etomidate--->Sux/ Roc--->intubate--->Vec/ Roc (if you so chose post intubation paralysis; most scene flights/ 911 calls seem to just focus on pain management without the continued paralysis, as it should be)--->Fentanyl/ Versed.

Are your LDTs working calls or is it pretty much BLS with a monitor and a pump?

Not 100% sure what you mean by working calls, but they can be anything from a standard TPN drip, to meds that a paramedic may be able transport but not realize, to vented with multiple drips, to LVAD, or IABP patients. Most vented patients have the standard "players" of either Diprivan, or Fentanyl/ Versed depending on their condition and/ or referring physicians preference.

Do you recieve a pay increase for being CCT or is still standard medic pay?

Yes, as NPO stated their is an increase in pay. In my opinion our CCT division is a little known secret that many pawn off as "I don't want to get stuck doing transfers all shift.", but as I frequently explain to some of our crews, often times these patients can, and will present much more urgently than your standard 911 call, even some of the ones people may consider a "good call"; all in one's perspective I suppose...
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The nurse is essentially the med pusher with the exception of perhaps Zofran. Ironically enough we carry vials on our CCT units, but only ODT Zofran in our ground division. Again, if the nurse so chooses, and assuming they have met said requirement, then by all means, the airway is theirs. They are essentially the higher level of care within our unit/ division.

Do I enjoy it? Yes, very much so. I was getting pretty tired of routine medicals, and even true traumas which are often very basic, and have a pretty dismal outcome for the patients, so I felt I needed a changed and craved the opportunity to put my FP-C to use.
 
Wow that's crazy you guys don't carry IV zofran for your standard 911 units. Do you guys also only carry 1 analgesic and 1 benzo or do you carry both MS and Fent as well as Versed and Valium (for the 911 non CCT units)?
It sounds like you guys have a nice little CCT operation going on up there.
Do the ground 911 units carry vents or just the CCT with possible protocols in the future for all transporting units to have vents?
 
VentMonkey has posted good info, which I would all agree with. Sure some CCT calls may be benign, (TPN transfers, MD req RN, etc...) but there are plenty of 'real' CCT calls that get your brain moving. I still enjoy 911 but also enjoy a good CCT IFT too.

CTMD said:
Wow that's crazy you guys don't carry IV zofran for your standard 911 units. Do you guys also only carry 1 analgesic and 1 benzo or do you carry both MS and Fent as well as Versed and Valium (for the 911 non CCT units)?
It sounds like you guys have a nice little CCT operation going on up there.
Do the ground 911 units carry vents or just the CCT with possible protocols in the future for all transporting units to have vents?
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ALS can give IV zofran, but we only carry ODT on ALS units. I'm sure it's a cost thing. We only had zofran added to protocols a few years ago as it is.

ALS carries morphine, fentanyl, versed, and valium. We used to carry Ativan until a recent letter from the manufacturer said it needed to be refrigerated. I don't know if anyone knows this, but Bakersfield is hot.

As of now, ALS units do not carry vents. I'm not sure we will see them start to soon, even with the new protocols. Most hospitals will likely prefer a vented patient go with an RN, heck, they call CCT for nitro and heparin drips, which are both specifically ALS. I foresee the vent protocol designed for outlying hospitals to transfer patients into Bakersfield for higher level of care, as the protocol states vents will only be used for IFT, I imagine they'll just take the hospital one. But that's speculation.
 
The ventilator is only for our CCT division. I don't know that company wide we will be implemting them anytime soon, though crazier things have happened I am sure.

Both our ambulance and CCT divisions carry Versed/ Valium as our Benzo's, and Fent/ MS for pain management with the latter two falling out of favor much like anywhere else there's been much talk about removing them altogether from our scope which I believe our county EMS director plans on doing, again, how soon is anyone's guess.
 
Sorry I had misunderstood the question regarding formulary earlier.

Yes, our nurses carry a handful of other medications on top of what is carried on every ALS rig. The meds themselves can be worked into the protocols that they have written specifically for our division/ program.
 
I think my California phase has passed lol. We're talking about nerve blocks, ultrasound and field ABX here lol.
 
I think my California phase has passed lol. We're talking about nerve blocks, ultrasound and field ABX here.

I do miss CA the state, but I don't think I would be happy with CA EMS.
 
Prehospital U/S sounds interesting especially after learning the criteria to ruling in, and out thoracic and abdominal trauma.

What are your guys' guidelines? And what does your training entail?
 
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