Advanced Protocols?

[BrandonDrew87]

Hey guys, I know at my department we have the most advanced protocols within the area. Here is a list of some of the non common stuff we carry. Please let me know if this normal in other areas or just for us...

Levophed

Lisinopril

Plavix

tenecteplase

Thiamine

Romazicon

Terbutaline

Labetalol

Versed

Hydromorphone

Sublimaze

Nitro gtt

Vecuronium

Rocuronium

Succinicholyine

Amidate

Lopressor

Cardizem

Naloxane

Decadron

Again some of these drugs might be common in your area. But Id just like an idea of whats on other peoples trucks around the world...

[chbare]

Romazicon? You guys doing procedural sedation on benzo naive patients or something like that?

[paramedicmike]

Yeah. I stopped at the Romazicon, too. That's a scary drug to be carrying prehospitally. Dangerous, too.

I'm curious. You mentioned that these were the "non-common stuff" you carried. If these items were normally carried in other areas would that still make them "non-common"? Not trying to pick apart your words. Are you saying that these aren't common items to agencies surrounding yours? Or are you under the impression that these aren't common medications anywhere other than within your agency?

What kind of educational requirements do you guys have in order to maintain proficiency in the use of these meds? Do you have routinely scheduled (monthly, quarterly, yearly etc...) competencies that are mandated by your agency and/or medical director?

[Kiwiology]

Welcome to our community, mind the Kiwi and please, no flash photography, keep your hands, arms and cameras inside the vehicle at all times and listen to the instructions from your waiter.

I wouldn't consider many of those drugs necessary pre-hospital to be honest; quality (how you can use what you have) is almost, if not more important, than what you have, but that's just in my readings.

More is not always better; beta blockers and calcium channel blockers I don't think are something useful to Paramedics; certainly I understand the rationale behind it but I am not aware of any evidence that shows improvements in morbidity and mortality in the pre-hospital environment.

Flumazanil is not necessary, its nasty evil muck that we carried very briefly in the 1980s I believe and quickly threw it away

Thiamine falls into the same category as flumazanil; I really can't see a role for it in the pre-hospital setting

Naloxone is probably not necessary either; ensure adequate oxygenation and transport to hospital. It may have some role in chronic pain patients who have accidently scoffed down a few too many oromorph and can be left at home once we wake them up.

Etomidate, suxamethonium, rocuronium and vecuronium; good to see somebody doing RSI but I am concerned if you are doing it properly or just dishing it out to everybody who only gets 2 tubes a year anyway and letting them have at it

Fentanyl and midazolam are standard drugs carried most places in the world

If you have plavix and tenecteplase you must be doing thrombolysis/ reperfusion, interesting

There are much better analgesics than hydromorphine, like ketamine, which can also be used instead of etomidate for RSI

In case you are interested, here is what each of our levels can do; we have unlimited drug dosages in line with prudent professional practice and work autonomously with no "online control"

Emergency Medical Technician (mostly volunteers, some paid - one year course)

LMA, 12 lead ECG acquisition, tourniquet, PEEP, oxygen, aspirin, GTN, salbutamol, ipatropium, oral glucose, glucagon, nebulised adrenaline, oral ondansetron, paracetamol. entonox (or methoxyflurane where carried), loratadine

Paramedic (Bachelors Degree)

EMT + 12 lead ECG interpretation, cardioversion, sodium chloride 0.9%, D10, adrenaline, amiodarone (cardiac arrest), morphine, fentanyl, IV ondansetron, naloxone, ceftriaxone, midazolam (seizures)

Intensive Care Paramedic (Graduate Certificate)

Paramedic + intubation, intraosseous access, pacing, atropine, adenosine, ketamine, midazolam (sedation), amiodarone (fast AF/VT), suxamethonium, vecuronium

Thrombolysis is coming nationwide at some point too, some areas have it

Edited February 16, 2012 by kiwimedic

[BrandonDrew87]

Wow, thanks for the replys guys. I am going to try to get a copy of our protocols and post them somehow.

@paramedicmike, Most of the items listed are not carried buy any surrounding agencies.

Everybody, We do carry all of these meds but most are rarely used. Ive been a PMD for 3 years and have never given several. Alot of the officers here are also PMD instructors, and my LT's dad is the medical diretor. But as far as training we have a four day hands on training in the summer and we use EMSjane throughout the rest of the year. We have a pretty good group of people and the Med Director knows. He just wants the best for his friends and family I would imagine. (My countys population is only 50,000)

[BrandonDrew87]

@kiwimedic

Wow thats a lot of training, My PMD course was 18 months and my EMT was only 9... LOL. But you said you guys use the amiodarone for AF with RVR (rapid ventricular rate) It is in our protocols to do the same but only for PT's with WPW syndrome. I have had great success with the diltiazem for controlling the rate. Used the amio once with poor results.

What is the dose you are using for rate control?

[DwayneEMTP]

I can't help but think Kiwi whenever you mention that 'we have NO online medical control!" that that is held up as a standard of excellence, when in fact the Afghanis I worked with, as well as the Mongolians, and certainly the Papuan's don't have it either, yet I wouldn't really want to send them to do my recerts...

Just a thought... :-)

[Kiwiology]

Wow thats a lot of training,

By American standards yes, by international standards such a level of education is becoming the standard.

Australia requires a Bachelors Degree and Graduate Certificate, just like we do as they do not have the Technician grade

UK requires a two year FdSc for State Registered Paramedic

Canada requires three years of education for Advanced Care Paramedic

South Africa has a two year CertTech educated Emergency Care Technician and a four year BTech educated Emergency Care Practitioner

Rettungsassistent ("Paramedic" loose translation) in Germany is two years of education

What is the dose you are using for rate control?

150mg as a drip given over 30 minutes

I can't help but think Kiwi whenever you mention that 'we have NO online medical control!" that that is held up as a standard of excellence, when in fact the Afghanis I worked with, as well as the Mongolians, and certainly the Papuan's don't have it either, yet I wouldn't really want to send them to do my recerts...

Just a thought... :-)

Again, such a standard is increasingly common around the world;

We do not have any online control i.e. do not have to "seek permission" to do anything, neither do Australia, nor South Africa, nor the UK, in Canada there is some which was a real surprise given the high standard of education.

[chbare]

However, you have a well defined scope of practice and adhere to those standards as I understand?

[DwayneEMTP]

I think you missed my point Kiwi...The fact that there is no medical control is often held up by you as a standard of excellence, yet in nearly every instance that I've see it that has not been the case.

And also, listing degrees for medical cert is not comparing apples to apples. Just as the standards of medicine vary, so do the standards for education.

We're all very proud of your brains and logic, and I mean that with complete sincerity, but I've spent quite a bit of time now working with Aussie, South African, Indian, British, etc medics/nurses/doctors, those with the education and lack of oversight that you speak of, yet have spent almost none of that time thinking, "Holy shit! They are so much smarter, and more confident, and more professional that I am!" as you would seem to lead us to believe that I should.

I'm not bagging on you brother, only your oft spoken implication that working autonomously is a a sign of increased competency, as that's not been my experience. No more so than a drug box full of advanced pharmaceuticals indicates an advanced provider. Should it? Sure. Does it? Not in most of my experience, nor according to the comments here, the experience of others.

I went through orientation with a couple of Aussie medics that I'm confident couldn't find their asses with both hands and radar. And our Kiwi nurse and doc in Kandahar were such complete douchebags that it was nearly impossible to even get them to comprehend their mistakes. Not to mention a UK and American doctors that weren't any better.

I had to fight the Kiwi doc off of a patient that I was trying to cut the clothes off. Because the pt was shivering and the doc was fighting me trying to cover him with a blanket and take his temperature despite the patient having 4 gunshot wounds.

We argued with the Kiwi nurse one night about the error of giving a 140kilo make with a near complete degloving of of one lower leg and tib/fib fracture of the other 3mg or morphine before a 20 minute transport over rough roads. After an hour of James' and my best effort he still felt that that was an appropriate treatment despite the trauma bay immediately giving him 30mg upon handover. Why? "Because I didn't want him to stop breathing."

Lack of oversight doesn't necessarily indicate increased competence, in fact in my limited experience it often seems to signify a lack of quality improvement as the detection of errors and reporting seems substandard.

Point being that you hold up these standards as accepted benchmarks, which they may be, but in my opinion shouldn't be, as they don't hold true for much of the world, nor, even your part in some, if not many cases.

Dwayne