If you could have anything you wanted…

I have a question for all of you out there:

A few recent situations have arisen for me that have essentially… wait for it… Removed almost all of the barriers. The sky is the limit and the future looks amazingly bright. I can’t tell you how good it feels to have my potential back.

And for one of those things, I’ve got a question for all of you out there.

In December, my EMS system is reviewing their protocols. We have a lot now and the protocols are extremely liberal. However, I’ll be expected to ask for new things like I always do, and right now I haven’t really given it as much serious thought as I need to in order to argue my case. Because of that, I’m kicking it out to you with this question.

Within the boundaries of what we can do legally within the regulations of the Wisconsin EMS system and within the realities of the current economy, if you were me and could ask for whatever you wanted from your amazingly progressive Medical Director and your amazingly energetic and supportive EMS coordinator…

What would you ask for? Toradol for pain control? Induced hypothermia (already have it), RSI? (got it too), CCR? (yep, we started it),  Mag Sulfate drips for anaphylaxis? (Have it), Glucagon IV for beta blocker ODs? (uh huh). Cardiazem? (yep)…

and Etcetera, etcetera, etc…

So I’m in a progressive system. The question is… what do I ask them for now?

What do you think?

  • Right of refusal. Sounds like you have ll the tools for the sick folk, do you have the power to refuse transport to those who abuse your system? Or is that not such a big issue where you are?

    On the other side…
    IN Narcan and Valium, anything that removes needles when possible,
    Surgical cric (yes we’re still using needle cric)

    good question…

    • Aren’t paramedic initiated refusals one of those things that looks good on paper, but as soon as it is put into practice falls apart with the studies showing that paramedics are poor are predicting which patients need hospitalization?

      • There’s a difference between determining the need for hospital admission and for ambulance transport.

        • Too Old To Work

          I agree with Joe and Timothy on this subject. There is a huge difference between deciding someone does not need ALS, which my system allows, and deciding that they don’t need to go to the hospital at all, which my system does NOT allow.

          Remember that discharges to home from EDs for patients with many of the complaints that we commonly see are a huge area of litigation.

          If you need more convincing, look at the litigation history of the Dallas FD for paramedic initiated refusals.

          We’d need a lot better EDUCATION of paramedics before we even start that conversation.

  • End Tidal Capnography
    CO monitoring
    KingLTD back-up airway
    Adult IO protocol? (we use EasyIO, have used BIG)
    Toradol is nice – to really push the envelope get it for a fever protocol
    HyperK+ protocol with D50/Insulin IV and Albuterol
    QuikTrach (easy as a needle, but a much bigger airway)
    I like Happy Medic’s ideas – a thrombolytic would be nice, as would IN drugs (and those two would be good to have)
    What’s your violent patient protocol? Ativan/Haldol?
    If you’re getting money, go for StatLabs (especially Troponin’s) or Doppler, maybe a GlideScope
    Termination of Resuscitation protocol
    CSpine clearance in the field

    • Jake

      What could you possibly want Insulin in a pre-hospital emergency setting for? It takes weeks to get patients in DKA, or any from of hyperglycemia that is, at the time, life threatening to a normal sugar. It has to be titrated and monitored. It is not something we would ever need in an ambulance.

      • Bill C

        The first line treatment in severe hyperkalemia is calcium, insulin, d50 (if not diabetic) to start returning the patient’s action potential across the cellular membrane back into a more normal range…

        • For EMS, calcium alone should be enough to treat hyperkalemia. The bigger problem is that too many people start with the treatments that do not work quickly.

          Calcium works very quickly. When treating life threatening hyperkalemia, why use a treatment that might not even take effect until after the patient is dead?

          I don’t see insulin improving the care we deliver.


    Physical/chemical restraint protocol to make what we’re already doing legal and give us more options, increase the offline pain management doses (triple would be nice), make carrying pain management and sedation meds mandatory so the privates can’t get away with not having any anymore, Selective Spinal Immobilization, take Bicarb and CaCl offline, hypothermia, field termination of cardiac arrest… I’m sure there’s some others I’m forgetting but you get the idea.

    • Too Old To Work

      You have some decent protocols, but haven’t mention CPAP. I’m guessing that’s because it’s so routine that you didn’t feel the need to mention it. If not, that should be high on your list. If you have it, put what I have on my “wish list” your wish list. That’s IV NTG to go with the CPAP.

      Do you have some sort of transport ventilator? Even with short transport times, those are nice because they free up a set of hands.

      I’m shocked you don’t have field termination of cardiac arrest. We’ve had that for over 20 years.

      • More sedation and pain management treatment options – all on standing orders.

        IV NTG and CPAP – also on standing orders.

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  • – IN Fentanyl for peds and adults (we’re pushing for this now)
    – High dose NTG for pulmonary edema (1.2mg-2mg q 5 mins)

  • Jared Priddy

    I’m not a medic so my ideas on meds is very limited however being a BLS provider the following ideas come to mind
    IV start for BLS providers
    the ability for BLS providers to start nebs and give SL nitro or maybe give D50 in emergencies.

    In my system Chesterfield County VA we carry albuterol, bromide, nitro, ASA, and D50 in an out of box kit. This would allow BLS providers to give some meds without getting into the secure meds. I think that with the proper training BLS providers could be taught to give these meds and start IV’s thus helping with a few of the normal “ALS” calls.

    • CPAP for BLS, if you don’t already have it.

  • Tmd757

    Right now, I’d be happy if the state of NH would re-consider the removal of the cricothyrotomy of all types that takes effect at the end of the year…..and propofol would be AWESOME!!!!!!! Its addition would eleminate the need for paralytics most of the time….

  • Guest

    Top 2:
    1)Waveform capnography – no one will ever say a tube is no good again (as long as ya’ll learn to use it right)
    2)Mechanical compression device – do the history on it and watch the trends away from believing that manual compression in moving ambulance actually work. I’m actually surprised the recent AHA update was not more strongly in favor of them… need some more studies. If that’s too much $, go for pocketCPR or similar metronome/quality assurance device.

    Others in random order:
    IN Narcan & Valium, Pertrach Cric kits (awesome!!), AirTraq (also awesome!), full body vacuum splints (much better than backboards), Adult IO (EzIO is great!)
    Avoid SALT airways (don’t work)

    • We’ve had mechanical compression devices (lucus) and in practice they were horrendous to use. Ours were oxygen driven so O2 usage tripled overnight. I realise there are other systems on the market and would be interested in other users experiences.

    • We’ve had mechanical compression devices (lucus) and in practice they were horrendous to use. Ours were oxygen driven so O2 usage tripled overnight. I realise there are other systems on the market and would be interested in other users experiences.

  • Pshe

    Honestly, I would like my state to get off it’s ass and set-up a proper “bridge program” to bring us up to paramedic training and education level without having to start from zero when most of us have over a decade of doing ALS and the education to match. Why must they insist in being “different”. Oh and maybe, just maybe, break the strangle hold some “organizations” *cough* unions *cough* have on the EMS field.

  • Nritchey84

    IN everything do u have EZ-IO? CPAP if its not there already

  • Well, for starters, I want to come work for you already. You have a MUCH wider scope of practice than we do here as paramedics, certainly as far as drugs are concerned. We can’t RSI (a particular irritant of mine), and slowly but surely they don’t want us intubating at all. Having said that, it seems that EMTs over in your part of the world (or at least the BLS ambulances) aren’t allowed to do anything, whereas here they’re much more free to administer certain drugs.
    That as may be, I’d like to second HM and his right of refusal. There is no reason that paramedics are not capable of telling someone who clearly only wants a taxi ride that they can’t have one.
    And at risk of sounding controversial – how about trialling a lone-responder model, such as here in the UK (see 999medic for example and soon in London too). Send out a paramedic to do an initial assessment, and then request the appropriate back up, or none at all…
    Good luck!

  • Ask for competency based continuing education and license renewal. Instead of a mandatory 2 year refresher that rehashes paramedic class in 48 hours ask for a refresher that evaluates what you have done in the field in the past year – skill successes, skill failures, assessments, refusals as well as any continuing education and design a custom education plan for each individual.

    For example, If you have successfully assessed heart failure and applied CPAP appropriately two times a month then you might be considered competent. And your custom refresher education plan would not need a 1 hour Heart Failure/CPAP module and that hour could be spent on another topic.

    • Excellent point. We probably do not need to work on the things we are already doing regularly and doing well.

      We need to work on the things we do not do often.

  • Stovelegs

    High-dosage NTG protocol for CHF/pulmonary edema Pt’s.

    1 spray then simply paste after placing CPAP just isn’t hacking it.

  • I am with HM on this! Go for the big one, the right of refusal! It may take some work to align the optional resources to get the patient the appropriate care, whether it be a cab ride to the clinic, or a helicopter(Which we are not allowed to call for in my system, we have to wait for the paramedic supervisor) to a trauma center.

    If you are going to tilt at windmills, go for the biggest one you can see and give it your best charge!!

  • Parody pay and benefits commensurate with other public safety/public health services.

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