What would you change about your protocols?

NUEMT

Forum Lieutenant
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Anything. Everything. You and your medical director are eating pizza and he/she asks you honestly and you answer like you actually care. What would you say?

Trends, wishlist, out of box ideas welcome. Post references if you got em.
 

Summit

Critical Crazy
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All protocols end with: providers get cookies, fresh fruit, free coffee (good coffee), and 15 minute break.

Pt/no pt protocol states patients presenting with suitcases at the curb get dispo'd to Uber.

GI bleed protcol: Add vicks vapor rub and coffee grounds to the formulary

Use of sirens not allowed

Wilderness protocol: Add LiOH scrubbed rebreather
 

NomadicMedic

I know a guy who knows a guy.
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a real pain management protocol, with a paramedic decision tree.

sedation on standing orders

transport of 'general malaise' patients to urgent care, not an ED
 

EpiEMS

Forum Deputy Chief
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Oh, I love a good wishlist. I'm going to restrict my wishlist to things that are things I might use relatively frequently like @NomadicMedic has, rather than the "sexy stuff".
1) Zofran for BLS providers
2) Methoxyfluorane or something along those lines
3) Transport to a non-ED facility for patients with coryzal symptoms, minor trauma, etc.
4) Somebody supervising to make sure that people don't drive like maniacs (50 in a 45, sure - but not 65)
 

GMCmedic

Forum Deputy Chief
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Ill stay realistic.

1. Push dose pressor

2. Get rid of nimbex

3. Remove line that says check a BGL on any known diabetic.

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MonkeyArrow

Forum Asst. Chief
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transport of 'general malaise' patients to urgent care, not an ED
I don't know about this one. The general malaise patients are often pretty sick people that end up getting admitted, especially in the older patient population.
 

StCEMT

Forum Deputy Chief
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In no particular order

1. Get rid of the damn backboard protocol in it's current state

2. Ketamine for so many reasons.

3. If you are gonna let me intubate, actually give me a sedative.

4. Give me more pain control options. I like Fentanyl, but I would like a little more flexibility in options.

5. I haven't had a need (yet), but it would be nice to have a better a fib RVR protocol other that A. Watch B. Shock

That's all that comes to mind for now, at least for protocol related ideas.
 

Carlos Danger

Forum Deputy Chief
Premium Member
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Ill stay realistic.

1. Push dose pressor

2. Get rid of nimbex

3. Remove line that says check a BGL on any known diabetic.

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You guys have nimbex? I never heard of that in EMS. It's a great drug. Why do you carry it instead of roc or vec? What don't you like about it?
 

GMCmedic

Forum Deputy Chief
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You guys have nimbex? I never heard of that in EMS. It's a great drug. Why do you carry it instead of roc or vec? What don't you like about it?
I dont mind it, but for whatever reason we have Roc and Nimbex. The Nimbex is our "long acting" paralytic. Since we added Roc last year, weve given it 53 times and given Nimbex 14 (likely cookbook medics giving it).

Nimbex cost 10 times what Roc does. If we added maintenance dosing of Roc we could save a lot of money each year on a drug we never use.

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VFlutter

Flight Nurse
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We currently have Succ, Vec and Nimbex until Roc becomes readily available again. Nimbex's onset of action is too long for a RSI paralytic IMO. You can make it work it is just not ideal. Luckily we have not had to use it for RSI yet since we had a pretty good stock of Roc and Vec and most of the patients we intubate are trauma so Succ isn't an issue.
 

Carlos Danger

Forum Deputy Chief
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I am really surprised to hear about cisatracurium in the prehospital world at all. I think it is a great drug, but is very expensive, and outside of certain populations, the clinical differences between it and roc or vec are minor.

I still think that, when the chips are down and you really need the best intubating conditions possible as quickly as possible, succinylcholine is the best drug available, and it is dirt cheap. Barring sux for whatever reason, either roc or vec are decent substitutes.
 

VFlutter

Flight Nurse
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I am really surprised to hear about cisatracurium in the prehospital world at all. I think it is a great drug, but is very expensive, and outside of certain populations, the clinical differences between it and roc or vec are minor.

Have you used Nimbex for RSI outside of a routine induction? As opposed to emergent.
 

GMCmedic

Forum Deputy Chief
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Now that I have a moment to write this out.

Our current protocol has 3 weight categories, 50kg, 100kg, and 150kg.

Its broken down as follows.

Ketamine 100mg, 200mg, 300mg
Rocuronium 50mg, 100mg, 150mg

Either 100mcg fentanyl or 1mg dilaudid, I prefer fentanyl in this setting.

Then we have the choice of redosing ketamine or versed if we need more sedation, I never have.

If we need it we have Nimbex broken down as 5mg, 10m, 15mg.

Our protocol is not all or nothing. If the patient is adequately sedated and paralyzed to optimize first pass success and patient comfort, you stop, though analgesics are not optional.

I believe that the 14 administrations of Nimbex are likely cook book medics that go through the protocol line for line. Why we still have Nimbex I dont know, it carried over from when we had succs.

Nimbex is ~$30 a vial, Roc is ~$3

What I plan to propose at the upcoming protocol meeting is adding a 4th 50mg vial of Roc, if we maintenance dose at 0.1 mg/kg the doses will be 5mg, 10mg, 15mg and the dosages on the last line of the protocol remain the same (yay, no new numbers to memorize!!).

AND save the service over $1000 a year in the process.

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Carlos Danger

Forum Deputy Chief
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Have you used Nimbex for RSI outside of a routine induction? As opposed to emergent.
Like in the field or the ED? No. I use sux pretty exclusively in those scenarios, or I try to keep them breathing and don't use any NMB at all. Just depends.

In the OR, the way I practice there's really no difference between RSI and non-RSI inductions, meaning I don't usually ventilate after I give the induction agent. There are exceptions, of course. But I also don't usually wait for the NMB to take full effect, unless I'm using sux. Pretty much anytime I use a non-depolarizer, I am passing the tube while the cords are still moving. So to me personally, onset time means little.

We don't have cis anymore where I work now. But I used it quite a bit in the past.
 

RocketMedic

Californian, Lost in Texas
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I'd steal the old Presidio protocols and be Captain Amazing. Also, give me a field termination criteria that one can actually use to field terminator.
 

NomadicMedic

I know a guy who knows a guy.
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I don't know about this one. The general malaise patients are often pretty sick people that end up getting admitted, especially in the older patient population.

I just wrote that quick, so I didn't add any qualifiers. Obviously, the paramedic should use clinical judgment to determine proper transport decision. I forget that not every paramedic possesses a well-rounded set of clinical acumen. Obviously, taking a 70-year-old patient who is borderline septic to the doc in a box is a bad idea, However, I don't think there's anything wrong with taking a 23-year-old who's got a stuffy nose and sore throat to the urgent care.
 
OP
OP
NUEMT

NUEMT

Forum Lieutenant
210
29
28
Oh, I love a good wishlist. I'm going to restrict my wishlist to things that are things I might use relatively frequently like @NomadicMedic has, rather than the "sexy stuff".
1) Zofran for BLS providers
2) Methoxyfluorane or something along those lines
3) Transport to a non-ED facility for patients with coryzal symptoms, minor trauma, etc.
4) Somebody supervising to make sure that people don't drive like maniacs (50 in a 45, sure - but not 65)

+1 for the green whistle
 

VentMonkey

Family Guy
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Remove line that says check a BGL on any known diabetic.
I'm not quite sure I follow.

As far as wish lists? Eh, I just wished we all stopped "wishing" for items that make little differences in the majority of our patients outcomes.

All the fancy gadgets, gizmos, and toys that make for "sexy medicine", but that have yet to consistently provide positive outcomes has done nothing for me but make me want to bury my head in the proverbial sand around many of my peers:(.
 
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