So how does ALS work in California?

[NPO]

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?

I recently listened to a podcast about it, and it was very intriguing. Mostly for fluid and trains trauma identification.

 

[VentMonkey]

Yeah, we covered it in my CCP course in terms of indications and key points on where to look and what indicated what (e.g., any free fluid in a space called "Morrison's Pouch" which I believe is perihepatic? Indicates at least ~200-250 cc's of free fluid).

I'm curious to see and know how these progressive systems across the nation have found them to be. Things such as experience in finding a positive FAST in the field etc. can be the difference in activating a true trauma alert or not. What was their training? How high is their success rate from a prehospital standpoint? This is something that is still fairly new to EMS and may, or may not be yet another "flash in the pan" of things that come and go in our line of work.

 

[RocketMedic]

We're still trying to get it. Life-flight and a few services north of usage it and love it.

 

[VentMonkey]

How about your ABX? How does this work? Is this part of a sepsis protocol? I would imagine it to be perhaps some sort of broad spectrum push dose such as Ancef?

 

[RocketMedic]

Galveston is apparently implementing Ancef for suspected sepsis, possibly pneumonia and/or UTI, and trauma with open wounds. @TransportJockey , can you clarify?

 

[Bullets]

Man, i thought NJ had a weird system.

 

[EpiEMS]

Man, i thought NJ had a weird system.

California might be worse...

 

[CALEMT]

California is worse...

Fixed it for you.

 

[wtferick]

 

[CALEMT]

View attachment 2973

I retort:

 

[VentMonkey]

Lol, like I stated earlier in this thread, I would not give up my job as a paramedic in another state such as say Texas, or Delaware to move either to, or back to California.

We do what we can in our county, and obviously every county has its issues, but ultimately, yes California at least from an EMS standpoint in my perspective is plagued with politics, and very powerful fire, and nursing unions, which in my opinion seem to have a palpable amount of clout hindering those that only wish to provide cutting edge, up to date, and progressive prehospital care.

It definitely is harder to function as a single role paramedic in California than the above mentioned states, for example. I chose to seek the (continuing) education needed to put myself in a position in this state that would allow me to practice as I saw fit.

Do I envy some of those on this forum who practice paramedicine outside of this state? Yeah, I do, but at the end of the day this is where my family seems to enjoy, so if it means I have to search a little harder throughout this state to remedy my "career" dilemma, then so be it.

In summary, it is why I chose to finally suck it up, and join the social media craze these "wild and crazy kids" talk about these days. So that I could meet, and talk with like minded individuals from all over the world regarding what we do, and how we do it where we do it.

 

[CALEMT]

Plus its Commiefornia... the gun nazi state.

 

[NPO]

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.

Follow-up:
The sepsis protocol trial went live Sept 1st and is being done by Liberty Ambulance in cooperation with Ridgecrest Regional.

They are using nasal ETCO2 to detect sepsis early. The metric is ETCO2 <25mmHg, which has a 90% rate of correlation to a lactate of 4. Treatment under the protocol is 250ml bolus for SBP <90mmHg up to 2 liters, with special consideration for renal failure and CHF patients, those patients max at 500ml before you start Dopamine.

Expect to see something added to protocols in 1-2 years following the trial. They plan on adding the protocol regardless of what the trial shows, they just are doing to trial to get the protocol started and track any improvements in patient outcomes prior to a county wide approved protocol.

 

[VentMonkey]

Follow-up:
The sepsis protocol trial went live Sept 1st and is being done by Liberty Ambulance in cooperation with Ridgecrest Regional.

They are using nasal ETCO2 to detect sepsis early. The metric is ETCO2 <25mmHg, which has a 90% rate of correlation to a lactate of 4. Treatment under the protocol is 250ml bolus for SBP <90mmHg up to 2 liters, with special consideration for renal failure and CHF patients, those patients max at 500ml before you start Dopamine.

Expect to see something added to protocols in 1-2 years following the trial. They plan on adding the protocol regardless of what the trial shows, they just are doing to trial to get the protocol started and track any improvements in patient outcomes prior to a county wide approved protocol.

That's good to know and hear. Ironically enough, I just got my latest Jems issue yesterday, and it is all about sepsis, and various sepsis protocols/ alerts in several systems both nationally, and internationally.

I'll take a gander in a bit, but do recall flipping through it yesterday and seeing one of the systems abiding by the ETCO2 of (<) 25mmHG as a guideline for field diagnosis, and work ups.

In a perfect world we would be given iSTAT's, but meh, so is life.

 

[VentMonkey]

Also, as an addition, I really wish this county would move away from Dopamine and strictly use Norepinephrine, not just for our CCT division.

 

[NPO]

Also, as an addition, I really wish this county would move away from Dopamine and strictly use Norepinephrine, not just for our CCT division.

I asked about that. They said their hands are tied by the state. They used to use norepinephrine many moons ago, but it lots favor when people started calling it Leave-em-dead. Turns out it wasn't the drug that was bad, it was the patients!

He (George Baker at EMS, you'll know him) said theoretically we could gang up on Lyon and get him to add it to an optional scope.

George is the one heading up the sepsis package, so that's why I talked to him.

 

[VentMonkey]

Lol, yep, I know George. Yes, the problem was not only the stigma Levo developed along with the name, but also the fact that many patients were being given incorrect doses.

My CCP instructor was HUGE on emphasizing that Levo is turning out to be more effective that initially thought, as are many other clinicians.

And, yes, you are correct, the state does quite often tie the hands of individual county EMS agencies, which brings us right back to the ops original question...sadly.

 

[dutemplar]

Also, as an addition, I really wish this county would move away from Dopamine and strictly use Norepinephrine, not just for our CCT division.

We are just starting with phenylephrine now.

ŸŸSTART INFUSION AS SOON AS PRACTICAL:
ŸŸAdd 10mg to 100ml Saline or 5% dextrose bag
ŸŸDraw up 50 ml of solution and infuse at 60 ml/h (100 mcg/min) initially and monitor BP
closely every 2 minutes.
ŸŸSTOP infusion temporarily if BP > 190 mmHg systolic or sudden bradycardia
ŸŸOnce BP starts to recovers reduce rate to 30 ml/h (50 mcg/min)
ŸŸThe objective is to keep BP relatively constant
ŸŸReduce by 2.5 - 5ml/h (4.15 - 8.3mcg/min) if BP remains elevated above desired level.
ŸŸIncrease infusion by 5 ml/h (8.3 mcg/min) to 10 ml/h (16 .6 mcg min) increments if BP
below desired level
ŸŸIF STARTING INFUSION IS NOT PRACTICAL OR IMMEDIATE ACTION IS REQUIRED
e.g. RSI:
ŸŸGive 0.5 ml – 1 ml (50 - 100 mcg) every 2-5 min, duration 10-20 min

 

[VentMonkey]

We are just starting with phenylephrine now.

ŸŸSTART INFUSION AS SOON AS PRACTICAL:
ŸŸAdd 10mg to 100ml Saline or 5% dextrose bag
ŸŸDraw up 50 ml of solution and infuse at 60 ml/h (100 mcg/min) initially and monitor BP
closely every 2 minutes.
ŸŸSTOP infusion temporarily if BP > 190 mmHg systolic or sudden bradycardia
ŸŸOnce BP starts to recovers reduce rate to 30 ml/h (50 mcg/min)
ŸŸThe objective is to keep BP relatively constant
ŸŸReduce by 2.5 - 5ml/h (4.15 - 8.3mcg/min) if BP remains elevated above desired level.
ŸŸIncrease infusion by 5 ml/h (8.3 mcg/min) to 10 ml/h (16 .6 mcg min) increments if BP
below desired level
ŸŸIF STARTING INFUSION IS NOT PRACTICAL OR IMMEDIATE ACTION IS REQUIRED
e.g. RSI:
ŸŸGive 0.5 ml – 1 ml (50 - 100 mcg) every 2-5 min, duration 10-20 min

Where is it exactly that you practice?

Do you guys have a broad spectrum antibiotic in your protocol as well?

How have you, or anyone in your system, found that it works for this patient population?

Thanks.

 

[dutemplar]

Doha, Qatar. Currently no antibiotics - they are actually more regulated here than narcs. This is the only GCC state I know of with medics carrying narcs. We also do not have drug resistance either. Anyone coming here to work or live has to be screened for STDs, tuberculosis, etc.

That part's new, the CPGs (protocols) were rolled out a month ago, but with the schedule not everyone is 100% up to speed yet and pharmacy is still stocking everything.