Why do people hate on LA County protocols?

[Uclabruin103]

A base hospital order to give zofran IVP? You serious?

Come April I’ll have the ability to give fentanyl (already a standing order) OR Ketamine (trial drug, also a standing order).

Cool, but if it's like our ketamine trial then it'll be in a 100cc bag with no IM dosing.

Zofran is a standing order in LA. You just have to make base contact on the way to the hospital

 

[medichopeful]

After your treatments.

That's not as bad as I thought. Most places have to make an entry note, but that's completely different from a radio consult/medical direction or whatever you want to call it.

So walk me through a patient contact complaining of a fractured ankle and pain (if you decide to give a narcotic, let's say they become nauseous for discussion purposes). Let's say it's an isolated injury. Include when you would call the hospital and what you would say/do.

 

[Uclabruin103]

That's not as bad as I thought. Most places have to make an entry note, but that's completely different from a radio consult/medical direction or whatever you want to call it.

So walk me through a patient contact complaining of a fractured ankle and pain (if you decide to give a narcotic, let's say they become nauseous for discussion purposes). Let's say it's an isolated injury. Include when you would call the hospital and what you would say/do.

I'd give zofran, and fent. Then call base.

UCLA base ra62 with a medical. Called to the home of a 35 male weighing 70 kg in a mild level of distress, complaining of ankle pain. Was jumping, landing wrong, and felt a snap 10/10 pain. No history, no allergies, no med. Hr 76, 120/80, 100%, 18 rr, gcs 15, clear lungs, normal skins, perrl pupils. Obvious deformity with bruising, swelling, no other trauma, good CMS, no head/neck/back pain. Started a 20g left at, 50mcg ivp fent, 4mg zofran, splinted with ice pack. 5 minutes from marina del Rey, 20 minutes from you. Requesting additional doses of fent up to 200mcg for pain .

 

[RocketMedic]

That's not terrible. Not great (unless your ketamine trial is for pain as well) but not terrible. Welcome to mediocre! I do think that you are correct in that I don't understand the protocols- namely, why they are so convoluted and silly. I really don't understand that.

Do you have to have a life-saving fire-medic there or is it private BLS or what?

What gets ALS?

FWIW, I literally just call the hospital and let them know what we're bringing them as a courtesy. The only thing I don't necessarily agree with is the practice of "delegated medical orders" that allows our paramedic supervisors to function as medical control should you call them- to be honest, on the occasions that I call medical control, it's because I want a doctor, not a nurse or paramedic.

If you're interested, here's a direct link to our protocols.
https://drive.google.com/drive/folders/0Bzpa1B5BQ5OFYThRT3EtX0FpazQ

 

[medichopeful]

I'd give zofran, and fent. Then call base.

UCLA base ra62 with a medical. Called to the home of a 35 male weighing 70 kg in a mild level of distress, complaining of ankle pain. Was jumping, landing wrong, and felt a snap 10/10 pain. No history, no allergies, no med. Hr 76, 120/80, 100%, 18 rr, gcs 15, clear lungs, normal skins, perrl pupils. Obvious deformity with bruising, swelling, no other trauma, good CMS, no head/neck/back pain. Started a 20g left at, 50mcg ivp fent, 4mg zofran, splinted with ice pack. 5 minutes from marina del Rey, 20 minutes from you. Requesting additional doses of fent up to 200mcg for pain .

As @RocketMedic said, definitely not terrible. Thanks for the description!

 

[Uclabruin103]

Destination

That's not terrible. Not great (unless your ketamine trial is for pain as well) but not terrible. Welcome to mediocre! I do think that you are correct in that I don't understand the protocols- namely, why they are so convoluted and silly. I really don't understand that.

Do you have to have a life-saving fire-medic there or is it private BLS or what?

What gets ALS?

FWIW, I literally just call the hospital and let them know what we're bringing them as a courtesy. The only thing I don't necessarily agree with is the practice of "delegated medical orders" that allows our paramedic supervisors to function as medical control should you call them- to be honest, on the occasions that I call medical control, it's because I want a doctor, not a nurse or paramedic.

If you're interested, here's a direct link to our protocols.
https://drive.google.com/drive/folders/0Bzpa1B5BQ5OFYThRT3EtX0FpazQ

I feel they're the easiest to read. Much easier than mine.
http://dhs.lacounty.gov/wps/portal/dhs/ems/prehospitalcaremanual/?????????????#tabs-13

What needs ALS and what can be BLS is stated in policy 808.

 

[aquabear]

So some background on my perspective on this: I started my EMS as an EMT in LA County, first working for an IFT company and then with a 911 transport provider. I had to learn LA County protocols when I attened UCLA/Daniel Freeman, but opted to intern out of county. I worked briefly as a paramedic in LA County before moving to Santa Barbara and then Texas. After moving to Texas and operating under physician delegated authority, I’ve formed a few opinions about their protocols.

The first problem is the system is so large (and in my opinion unmanageable) that you cannot ensure a consistent quality of care across a system with thousands of paramedics. Since there isn’t a good way to manage QA/QI for a system that large without a sizable outlay in money and trained personnel, you are forced to operate accounting for the “lowest common denominator.” When you have agencies “drafting” people to go to paramedic school, (who usually don’t want to be there) you are forced to limit their scope. This causes the medical director to put policies like 806 and 808 in place, which dictate what you can and can’t do prior to base contact and what chief complaints medics can’t “ship” with a BLS crew.

The second issue is the culture that has developed in the prehospital community. The excuse of “the hospital is only 5 minutes away” is constantly pounded into medic’s heads. It’s my opinion that if a patient needs a critical treatment, you do the treatment in the field. There is a delay in starting treatment in an ER: you have to wait for for a bed, transfer care, get orders from a MD, get meds, and finally do your treatment. Best case, a couple minutes. Worst case? Who knows... depending on how long you have to hold the wall. Another cultural problem I saw is the willingness to “punt” those borderline ALS calls. I can remember numerous calls as an EMT where I got, “you got the story?” or joking about the phrase “ship it” with “anxiety” or “chest wall pain” patients. I’m not saying all medics do it, but it does happen (and is another reason for 806 and 808 to exist).

The third issue is the way the state setup the EMS regulatory system. I think if individual departments could set their own scopes of practice, you would have better protocols. Unfortunately in California, you have LEMSAs (Local EMS Authorities) that set the protocols for an entire region, not individual agencies and their medical directors. Since scopes of care can’t be tailored to each agency, you end up with this limited scope that everyone has to follow.

 

[RocketMedic]

^this. Any system with that many people long ago abandoned any reasonable span of control and became effectively unmanageable beyond policing out the actively negligent and abusive.

 

[RocketMedic]

So what is this ketamine study?

 

[DesertMedic66]

So what is this ketamine study?

At least the one we are doing (Riverside and San Bernardino county, not sure about LA) is just attempting to show CA state that our paramedics can use Ketamine correctly and that it should be added to the state list of approved medications.

It’s not a normal study that looks at if it works or any factors like that. For CA we are not allowed to carry any medications that is not on the state approved list. So we have to do a trial study to get the medication and then report to the state the conclusion/results of the study and then hopefully the state will say “hey, our medics can handle having this medication”. Welcome to CA...

 

[DrParasite]

The first problem is the system is so large (and in my opinion unmanageable) that you cannot ensure a consistent quality of care across a system with thousands of paramedics. Since there isn’t a good way to manage QA/QI for a system that large without a sizable outlay in money and trained personnel, you are forced to operate accounting for the “lowest common denominator.” When you have agencies “drafting” people to go to paramedic school, (who usually don’t want to be there) you are forced to limit their scope. This causes the medical director to put policies like 806 and 808 in place, which dictate what you can and can’t do prior to base contact and what chief complaints medics can’t “ship” with a BLS crew.

which is absolutely a fair statement, one that applies to all large systems. if the system has 1 paramedic unit, operating 12 hour shifts, on a pittman schedule, than you have 8 full time paramedics. lets add 2, to be supervisors and fill in when people are out, bringing the total to 10. It's really easy for a medical director to get to know those 10 people really well, know their competency levels, etc. After all, you only need to monitor 4 crews. Now compare that to NYC, which runs 227 DAILY crews, and you see how you can't maintain that closeness that you had with a small agency.

But even with that being said, with enough levels of middle management, with multiple levels of QA/QI, you can do a halfway decent job of it. And if your existing medics can't follow the rules that you give them, or can't maintain the agency's clinical standards, and re-educating them hasn't worked, than get rid of them. It's not really rocket science.

The second issue is the culture that has developed in the prehospital community. The excuse of “the hospital is only 5 minutes away” is constantly pounded into medic’s heads. It’s my opinion that if a patient needs a critical treatment, you do the treatment in the field. There is a delay in starting treatment in an ER: you have to wait for for a bed, transfer care, get orders from a MD, get meds, and finally do your treatment. Best case, a couple minutes. Worst case? Who knows... depending on how long you have to hold the wall. Another cultural problem I saw is the willingness to “punt” those borderline ALS calls. I can remember numerous calls as an EMT where I got, “you got the story?” or joking about the phrase “ship it” with “anxiety” or “chest wall pain” patients. I’m not saying all medics do it, but it does happen (and is another reason for 806 and 808 to exist).

I remember being dispatched to a fall victim at a train station that was a block from the hospital. We were dispatched BLS, as are most fall victims, but when we arrived and assessed the patient, we found him to have a skull fracture (fluids coming out of the ears, AMS, etc). My fill in partner for the day (a paramedic supervisor who was great 20 years ago, but now, ehhh, he's better behind a desk than on a truck) and i requested ALS, applied a collar and secured the PT to a LSB, and carried him down two flights of stairs to the ambulance stretcher, and placed him in the back of the truck and requested a trauma team activation. our ALS unit arrived, hopped in our truck, and began their assessment. Realistically, I could be at the Level 1 trauma center door in about a minute (and 30 seconds of that is backing in the ambulance, we were that close). What was ALS going to do, when the patient needed "definitive care?"

That all being said, even in the urban areas, you still need to do your job. If you have an ABC issue, fix the issue. if you have clinical indications for an issue you can fix, than fix the issue. The "holding the wall" situations that SoCal is infamous for (and an accepted practice too, which blows my mind) is a new one, but that only means you need to do more to treat the patient since you might be waiting an hour or more in the ER waiting for a bed. If it's a medical call that you can fix using something in your med box, than it's malpractice not to, especially knowing it will be a while until you get a bed.

When you say punt, do you mean turf the call to BLS? because if those calls the medic won't do anything other than the stare of life, than BLS can stare just as good as ALS. But if you have a sick patient, and they will be waiting to get a bed because SoCal ER's treat EMS as free labor so they don't need to hire more staff, than that's a good reason to keep those borderline patients with ALS.

The third issue is the way the state setup the EMS regulatory system. I think if individual departments could set their own scopes of practice, you would have better protocols. Unfortunately in California, you have LEMSAs (Local EMS Authorities) that set the protocols for an entire region, not individual agencies and their medical directors. Since scopes of care can’t be tailored to each agency, you end up with this limited scope that everyone has to follow.

are you talking about individual departments in the same town, county and region? or each individual agency that is running 911 calls in LA all running with different protocols? Because the first one might be doable, the second one scares me.

 

[RocketMedic]

At least the one we are doing (Riverside and San Bernardino county, not sure about LA) is just attempting to show CA state that our paramedics can use Ketamine correctly and that it should be added to the state list of approved medications.

It’s not a normal study that looks at if it works or any factors like that. For CA we are not allowed to carry any medications that is not on the state approved list. So we have to do a trial study to get the medication and then report to the state the conclusion/results of the study and then hopefully the state will say “hey, our medics can handle having this medication”. Welcome to CA...

Like for sedation or pain management or both? To me, the bag of 100 suggests pain management, which it is super effective at.

@DrParasite , it is my understanding that everone in CA plays by their county LEMSA's protocols, regardless of specific agency. Here in Texas, we each have our own different ones, which literally means where you are determined level of care.

 

[CALEMT]

pain management

This.

 

[RocketMedic]

Oh you will love it

 

[DesertMedic66]

Oh you will love it

I plan on using it as much as I can. It is our only option for trauma that is not on the arms or legs. From talking around it sounds like a decent amount of medics (too many for my liking) are scared to use it because we actually have to do math since its weight based.

 

[CALEMT]

I plan on using it as much as I can. It is our only option for trauma that is not on the arms or legs. From talking around it sounds like a decent amount of medics (too many for my liking) are scared to use it because we actually have to do math since its weight based.

Not gonna lie, I’ll have to revamp my med math skills. But in all reality the only real mathematical part is the dosing of 0.3mg/kg.

 

[RocketMedic]

It is amazing for ortho trauma too. I am known for my ketamine + fentanyl on dislocated knees, shoulders, etc

 

[FrostbiteMedic]

The only thing I don't necessarily agree with is the practice of "delegated medical orders" that allows our paramedic supervisors to function as medical control should you call them- to be honest, on the occasions that I call medical control, it's because I want a doctor, not a nurse or paramedic.

I'm 100% certain that if I am calling medical control that I want an MD on the other end of the line. I won't even allow a nurse to relay the orders, I have to speak with the MD directly. And should I ever be a supervisor, I'm 100% sure I wouldn't be comfortable acting as medical control. That's way, way, WAY too much liability for my taste.

 

[RocketMedic]

Basically, fentanyl obtunds mu receptors, ketamine keeps them from resetting. I like.

 

[ArizonaEMT]

Come to Az, Nm, Tx you will never go back....... In my system in AZ no base hospital contact at all to start all procedures or meds.