EMS Protocol Changes

[Alex Woo]

I am petitoning for change in NYC; I've sent emails and letters to NYCREMSCO, the governing body for the 5 Boro's of NYC EMS. I'm asking for several revisons of our ACS, APE, Asthma/COPD, Seizures, & AMS Protocols. I want vast changes but baby steps first. I've been reaching deaf ears when it comes to EMS change.

I'm asking for continued (ACS/APE) SL NTG w/o calling Med Control; we can give 3 SL in S.O.. (Asthma/COPD) Continued Albuterol/Atrovent w/o calling; we can give 3 Combi in S.O.. (Sz) Continued Benzo's w/o calling Med Control; we can given 2 doses in S.O.. (AMS) Putting back Thiamine; it was taken out over 1 year ago.

What are ur S.O. & Med Control. I want to know the limit on Benzo's, NTG, Neb, & do u have Vit B1? Thanks in advance....

[Chief1C]

Is there like a glossary for abbreviation translation? Maybe it's just b/c I've been up all night.

Penna

http://www.portal.st...ve_11-01-08_pdf

NYC

http://www.nycremsco...intArticleID=81

Edited December 29, 2010 by 4c6

[RomeViking09]

I am petitoning for change in NYC; I've sent emails and letters to NYCREMSCO, the governing body for the 5 Boro's of NYC EMS. I'm asking for several revisons of our ACS, APE, Asthma/COPD, Seizures, & AMS Protocols. I want vast changes but baby steps first. I've been reaching deaf ears when it comes to EMS change.

I'm asking for continued (ACS/APE) SL NTG w/o calling Med Control; we can give 3 SL in S.O.. (Asthma/COPD) Continued Albuterol/Atrovent w/o calling; we can give 3 Combi in S.O.. (Sz) Continued Benzo's w/o calling Med Control; we can given 2 doses in S.O.. (AMS) Putting back Thiamine; it was taken out over 1 year ago.

What are ur S.O. & Med Control. I want to know the limit on Benzo's, NTG, Neb, & do u have Vit B1? Thanks in advance....

1 - Under what case would you need MORE than 3 NTGs in a pre-hospital setting without starting a nitro drip (in ACS if 3x NTG does not work go to morphine, in PE same thing)

2 - Continuous A/A is not of benefit (think about the effect the atrovent has on the body), 1 A/A followed by continuous Albuterol can be of benefit also long as you watch the HR & BP.

3 - Unless you want your patient to stop breathing continuous benzos are not a good thing if you can protect the airway and get them to the ER.

4 - Thiamine in AMS is 6 to 1/ half dozen to be given with D50 or other dextrose/glucose drugs. Not a bad thing to have but not something major your missing.

I think people get worked up over protocols sometime and forget we are not doctors and there are time when we should call for orders (not saying we need to go back to the days of Emergency and calling for IVs or Oxygen), basic immediate and lifesaving care needs to be standing orders, continued treatment with possible long term side effects needs to be run by a doc.

Lets play the what if game, say I have a patient who is having chest pain, I give them 4x 81MG ASA, 3x NTG SL (5 min apart), and they still have pain and a BP of around 105/palp. Now say we have your continued SL NTG in protocol and I give 1 more NTG they vasodilate again (remember they have had 3 NTG before this) and the BP bottoms out, they have poor cerebral perfusion to the point of stroke and I have just made my patient worse. NTG is a bit (not much) stronger vasodilator than morphine when used as most EMS protocols call for (3x NTG 0.4mg SL, 2-4MG Morphine then titrate to effect). By giving the morphine I can slowly vasodilate (and reverse it with narcan & benadryl if I do not get the desired effect)

Before talking up a strom about wanting change look at the change you want and if your in the right to start with.

Just my 2cents.

Edited December 29, 2010 by RomeViking09

[Alex Woo]

We can't give NTG drips; all SL. Paste was taken out 2 yrs ago. I've asked for NTG Drip. On all ACS calls; I've given more than 3; due to hemodynamic CP w/ ECG changes. Ntg sl q 5 minutes; until CP is relived, as long as hemodyn stable: until pt is at ER. Pt will receive more than 5 sl ntg; avg time from onscene to hospital is >30mins. That's 6 SL ntg on an avg; if time is heart?

As for benzo; stat ep; time is brain. 2 doses of benzo may not be enuff. I've given total 25mg of valium and the ER gave add'l 10mg valium and 8mg ativan. The pt was Sz'ing for over an hour b4 it was stopped by benzo's...

I'm asking to not having to call. In NYC 911; there's 1 MD on telemetry w/ 1 EMT-P answering the phone. I've been on hold for the MD for Stat Eps; up to 10 minutes & we're packaging the pt; moving the pt onto the stretcher; mind u Sz'ing w/ no backup. Gave the benzos anyway w/o pernission; by the time the MD was on the line; the pt rec'd add'l 10mg of Valium. My partner and I was restricted for the day but our Medical Director backed us up and pushed the restriction to be lifted... Time is brain and brain; that's what I learned.

Plz tell me ur protocol, ur city, state, website for ur Regional Advisory board. That's what I really need; not on why the med is good, not good, or how it works and can cause side effects. I know all that already. Thx....

[Chief1C]

How many hospitals are there in NYC? Cardiac centers? Are you ever an extensive distance from one, not taking traffic into consideration?

[rock_shoes]

Plz tell me ur protocol, ur city, state, website for ur Regional Advisory board. That's what I really need; not on why the med is good, not good, or how it works and can cause side effects. I know all that already. Thx....

Please stop mutilating the English language! The occasional spelling or grammatical error is one thing but treating the forums like a text message is something else altogether.

I think you'll find other forum members will be much more receptive to you and your ideas if you clean up this aspect of your posts.

[Alex Woo]

Alright. We need to comment on grammatical errors.

Please tell me your protocol, your city, your state, & website for your Regional Advisory board. That's what I really need; not on why the medication is good & not good or how it works and can cause side effects. I know all that already. Thank you....

Is this better?

That's why EMS won't progrees; nothing has been said to help me out. I'm asking for your treatment and I've told you mine. I want to make EMS care better. I've been fighting for positive change in NYC for years. I need to know how other areas are. That's why I posted this. I rather not hear that what I wrote is not grammatically correct... They're for the most part; acceptable abbreviations....

[fiznat]

...Because you are going about this the wrong way. If you are interested in influencing a protocol change in your region, you need EVIDENCE that the changes you are proposing will be efficacious, practical, and safe. That evidence cannot be found by simply referencing protocol in other regions and saying "but they get to do it." You need scientific research. Start here: http://www.ncbi.nlm.nih.gov/pubmed/

I can save you the trouble though. NTG has not been shown to be cardioprotective in any setting, by any route, or by any dose. We use it because the mechanism seems to make sense, and it decreases pain (and therefore anxiety) in ACS patients. Increasing dosing to infinity will increase risk without increasing benefit. Its a no-win, and no matter how many copies of protocols you get from EMT City members, the docs just aren't going to go for it.

Edited December 29, 2010 by fiznat

[Alex Woo]

Its not about how close a hospital is... Many hospital have closed. We have high rises and where I worked; I worked the Lower East Side; many project bldgs... Many of the time elevators are not working. Also, many of these apts are not clean and full of clutter. Onscene time is usually 20+ minutes; then you have to move the pt to the stetcher; if it took you 10mins to make it to the apt; it'll probably be 10mins to get to ambulance.

I never just look at the proximaty of hospitals. You have to look at the egress of the street, bldg, and apt. That alone adds time onscene; time doesn't stop for the patient; they still need Tx.

Lastly, with many NYC hospital closed; ER wait/triage time is at an all time high; it was high before the closures. Your responsibilty is not relieved until the pt is on their strtcher. So, if that's the case; I want the S.O. changed, to allow the Medic to continue to give the drg until their's relief, adverse reactions, or relief by equal or higher medical personnel. (The six rights of medication administration) Continued NTG, Albuterol/Atrovent, & Benzodiazepines administration.

Please tell me your protocol in regards. The city and state your from. The website to your Advisory Board. This will assist in making the needed changes to NYC EMS. Many thanks. Happy New Year.

[spenac]

The easiest way is to just research online for service protocols. Just type in various city names with EMS protocol and you can find many examples. Here to get you started are 3.

http://www.lubbockems.org/file_library

http://www.mchd-tx.org/clinical/documents/USEAUG2010PROTOCOLREV8-2010.pdf

http://www.wakegov.com/NR/rdonlyres/3BD4E0B0-1A9C-40FC-A73B-A622A332CCAD/0/WakeCounty2010ClinicalOperatingGuidelines.pdf