What would you change about your protocols?

[RocketMedic]

I'd protocol in a pay raise.

 

[GMCmedic]

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.

We have a "general considerations" section.

One portion of that says we are supposed to check a blood sugar on any known diabetic that hasnt checked their own sugar within the last hour, regardless of complaint or signs and symptoms.

I would like to see that line removed from the protocols.

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[NomadicMedic]

We have a "general considerations" section.

One portion of that says we are supposed to check a blood sugar on any known diabetic that hasnt checked their own sugar within the last hour, regardless of complaint or signs and symptoms.

I would like to see that line removed from the protocols.

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So, don't do it. What'll happen?

 

[GMCmedic]

So, don't do it. What'll happen?

Well I don't do it, but just maybe itll help in a culture change.

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[luke_31]

I'd change protocols to be guidelines instead and add in the caveat of use provider judgement as to what is appropriate for each patient. Maybe just go with a list of all approved procedures and guide of medications and accepted doses for the age groups both children and adult. Let the provider determine what needs to be done for the patient and not have to justify why X was done instead of Y and the time frame for doing the procedures

 

[medichopeful]

Oh this could be fun. I'm not currently working in the EMS field but will be soon (hopefully), provided I pass my NRP practical. With that being said, I'm pretty familiar with the MA state protocols, and these are the things I'd change:

-Implementation of a hospice/comfort care protocol, with very liberal use of sedatives, benzos, narcotics, antiemetics, and ketamine. Also, the addition of scopalamine patches for the protocol.
-Additional options for antiemetics, including phenergan and reglan.
-Additional pain management options, including dilaudid, ketamine, toradol, ibuprofen, tylenol, and entonox. In addition, the ability to provide adequate pain relief without having to call medcon for higher doses or adjunct medications.
-RSI for a small subset of medics, with appropriate paralytic reversal drugs. Dantrolene as well if carrying meds that can cause MH, because it's a wish-list, right?
-Propofol or precedex infusion capability
-Requirement to have both CPAP and BiPAP capability for ALS level services.
-Push dose pressors, along with more options for pressors (neo, vasopressin would be nice). Make it so you don't have to call for medcon orders for pressors.
-Octreotide and the ability to infuse blood products
-Nitro infusions for CHF and (possibly) chest pain
-Prehospital antibiotics and the ability to draw blood cultures
-More fluid options than just NS.
-iStats and the ability to provide electrolyte replacement.
-Insulin for severe hyperkalemia
-Alternative point of entry protocols (detox, psych), or alternative modes of transport protocols (chair car, taxi vouchers, etc).

Seeing as it is a wishlist, why not go all out?!

 

[TXmed]

Serious question, is there any evidence for non-anesthesia using push-dose pressors ? Any evidence that they improve patient outcomes ? For RSi or whatever other reason people are using them ?

I think it is a noval idea and i wanna support it, but every instance i come across people using them in the pre-hospital or emergency setting its done poorly and inapproprietly.

 

[StCEMT]

Serious question, is there any evidence for non-anesthesia using push-dose pressors ? Any evidence that they improve patient outcomes ? For RSi or whatever other reason people are using them ?

I think it is a noval idea and i wanna support it, but every instance i come across people using them in the pre-hospital or emergency setting its done poorly and inapproprietly.

I think Weingart was/is working on one, I'm not 100% sure though.

 

[VFlutter]

Serious question, is there any evidence for non-anesthesia using push-dose pressors ? Any evidence that they improve patient outcomes ? For RSi or whatever other reason people are using them ?

I think it is a noval idea and i wanna support it, but every instance i come across people using them in the pre-hospital or emergency setting its done poorly and inapproprietly.

I do not think there is strong evidence out side of the OR. Same problem we have, sounds like a great idea but hard to prove. Unfortunately may people use it as a bandaid to inadequately resuscitate a patient which usually has bad outcomes. But for peri-intubation hypotension and for bridge to drip is great.

 

[medichopeful]

But for peri-intubation hypotension and for bridge to drip is great.

^this. Push pressors have their place, and long-term use isn't it.

 

[GMCmedic]

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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Well, I got 2 of my 3 wishes. I didnt actually go to the meeting so I left #3 alone.

I dont know all of the details surrounding the push dose pressors yet, but our MD was not on board with mixing it so itll be 1ml of 1:10,000............

She apparently uses this dose regularly in the ED.

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[StCEMT]

Well, I got 2 of my 3 wishes. I didnt actually go to the meeting so I left #3 alone.

I dont know all of the details surrounding the push dose pressors yet, but our MD was not on board with mixing it so itll be 1ml of 1:10,000............

She apparently uses this dose regularly in the ED.

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What's so hard about taking 1ml of epi (10k) and mix it with 9ml NS to fill up a pretty little 10ml syringe nice and evenly? That's about as easy as drug dose calcs get.

 

[NomadicMedic]

What's so hard about taking 1ml of epi (10k) and mix it with 9ml NS to fill up a pretty little 10ml syringe nice and evenly? That's about as easy as drug dose calcs get.

That's how we do it. Easy peasy.

 

[GMCmedic]

What's so hard about taking 1ml of epi (10k) and mix it with 9ml NS to fill up a pretty little 10ml syringe nice and evenly? That's about as easy as drug dose calcs get.

I dont know.

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[Tigger]

Serious question, is there any evidence for non-anesthesia using push-dose pressors ? Any evidence that they improve patient outcomes ? For RSi or whatever other reason people are using them ?

I think it is a noval idea and i wanna support it, but every instance i come across people using them in the pre-hospital or emergency setting its done poorly and inapproprietly.

I am curious what your misadventure experiences are, I don't want to repeat. Our primary pressor is now epi (the "dirty epi drip). 1mg in 1000ml (1ml=1mcg) in 50 mcg increments until improvement (ie MAP of 65). I think this probably a good post ROSC procedure for the profoundly hypotensive (and it's easy to draw out 10mcg as a push dose), but when facing a long transport I am not sure this such a good idea.

 

[TXmed]

I am curious what your misadventure experiences are, I don't want to repeat. Our primary pressor is now epi (the "dirty epi drip). 1mg in 1000ml (1ml=1mcg) in 50 mcg increments until improvement (ie MAP of 65). I think this probably a good post ROSC procedure for the profoundly hypotensive (and it's easy to draw out 10mcg as a push dose), but when facing a long transport I am not sure this such a good idea.

Well i have seen alot of people become overzealous using these push-dose pressors or use it as an excuse to not set up a drip. Example: septic patient has a SBP <80 and requires intubation, paramedic or physician has the ability to set up a drip prior to intubation but instead uses a push dose pressor prior to and then just continue the push-dose method until they forget to do a dose and then the patient crashes. I have also seen people just go with 100mcg-200mcg boluses. All they are focused on is the numbers but what is this overzealous use of a pressor doing for cerebral blood flow, renal blood flow, coronary blood flow? Often times prior to intubation there is time to mitigate these problems with a more accurate intervention than a bolus, but some people get this mindset of why workout decimals when i can give a lump sum. People talk about evidence based medicine but where is this evidence in the ER/pre-hospital literature? ive only seen evidence about how bad post-intubation hypotension can be but havent yet come across evidence that a slug of epi has a mortality benefit.

 

[StCEMT]

That sounds more like an education problem tough, not a concept problem? I've never seen anyone that regularly uses it pretend it's anything but a bridging method to a long term solution when needed. Nor do I see them advocating dosing in that manner either.

 

[TXmed]

That sounds more like an education problem tough, not a concept problem? I've never seen anyone that regularly uses it pretend it's anything but a bridging method to a long term solution when needed. Nor do I see them advocating dosing in that manner either.

And that is one of the reasons i come to this forum to gauge other peoples experiences. Mine have not been exclusive to one poor department or service but rather pretty wide spread.

 

[Tigger]

I have not ever seen it done in the hospital. Usually they just rush to set up a levo drip. It's something I am trying to add to my own practice but I am still trying to figure out when it's a bail out and when it's correct.

 

[phideux]

I'd wish for a Paramedic Initiated Refusal protocol. No more free Medicaid taxi.