Sunday, February 15, 2009

Protocols


PDXEMT asked a questions about my protocols regarding terminating a field resuscitation. As luck would have it, we just received our 2009 protocol book at the beginning of the month. I'd thought maybe I'd share a few of my favorite tidbits.

First, a little background. I've been working for my company for almost 5 years, since just before we were bought out by the Big Ambulance Company in the Valley. When I started as part timer, our protocol book was a 12-page, photocopied, stapled packet of typewritten (yes, from an actual TYPEWRITER) material. It barely talked about drug doses and said little more than things like "follow current ACLS protocols."

Our current version of the protocols is a 3/4", color-coded by section, spiral bound tome of medical knowledge with such classic protocols as Epistaxis, Anxiety/Stress, and Vomiting. So, on the topic of cardiac arrests, we work everything but the obvious exclusions (dependent lividity, cold in a warm environment, injuries not compatible with life, etc.). Our physician adviser asks that we work everything to the hospital, regardless of rhythm and non-response to drugs. That's what he wants, so that's what we do. There has to be a set of extenuating circumstances for us to call it in the field and working a code on the beach doesn't fit that.

The protocols are extensive and comprehensive and often give us latitude to approach a problem from different directions.
  • Under Pain Control, we can use Morphine, Dilaudid, or Demerol at our discretion without contacting OLMC.
  • For pre-sedation in RSI, we have the option of using Versed or Etomidate.
  • In Hypovolemia/Shock, if we are unable to establish peripheral vascularl access, we are directed to start a central line in the femoral vein.
  • Under Ventricular Ectopy, we have the option of Lidocaine or Amiodarone, at Paramedic preference.
Our Paramedics use RSI in the field, quantitave capnography, and have recently added CPAP and EZ-IO s to our toolboxes. We are only required to contact OLMC for one circumstance: administering magnesium to a pregnanct seizure patient. There are only 6 other circumstances where it is recommended that we call in.

The protcols that we work under imply a large amount of trust being our physician advisors into the abilities of the medics and EMTs. And while I enjoy working in such a liberal system, I know that there's a huge amount of responsibility in this skill set and that I need to represent my physicians well in the field.

5 comments:

medicblog999 said...

Im not sure if I was completely wrong or whether your Medical Directors are exceptional in the States?
I was under the impression that most paramedic services in the US had to gain permission for a lot of interventions. Your post certainly paints a very different picture (in a good way).
We dont have alot of options that you have over there, such as RSI, CPAP, the variation of analgesia available etc.
I would love to have the choices that you have, it would make things alot more manageable in some cases.

Thanks for the insight.

Anonymous said...

hell would love to work where you do

PDXEMT said...

Wow! Those are some impressive protocols! I think I'd be hard-stretched to find any that are more permissive in the area.

Thanks for posting all this info. I think that it shows your doc has a huge amount of trust in you as providers.

My feeling is that medical directors are taking on a lot of risk and liability supervising us, and if they have quirks -- whether it's your doc wanting every code worked, or mine wanting medics to take his own RSI class before getting paralytics, no matter what -- we should be accepting of them, given everything else they do for us.

I have my own feelings about resuscitations and the termination thereof, but those have been informed by my protocols and experience. I think it's interesting that I have protocols that are more permissive in that area, but you have protocols that are more permissive in a variety of other areas (femoral lines, medication choices, etc).

steve whitehead said...

Once upon a time, I worked with very similar, very liberal protocols. I do miss those days. Now I write a lot of variance reports. I have no aversion to calling and consulting with the Doc. I just forget. After so many years of being held 100% accountable for all the drugs in my box without a required contact I often trip over a designated "base contact" treatment and need to go back and say sorry.

Star of Life Law said...

Wow. Just, wow.