Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

What Do I Want to See Under My Tree from EMS Santa

Image credit.

There is one change to my protocols that probably would not be used often, but when used would more than make up for the lack of use.

What would a rogue want? It isn’t an EMS helicopter.

I have written about so many things that are really nice treatments.

High-dose IV (IntraVenous) NTG (NiTroGlycerin or GTN – GlycerylTriNitrate in Commonwealth countries)?

I am fortunate to have state protocols that include this, although not where I work. I can give multi-dose SL (SubLingual) NTG where I work. I can do enough with that and the short transport times, that this is not at the top of my list.

Remove furosemide (Lasix) from the paramedic scope of practice?

It has been moved to requiring medical command permission. This is one case of the Just-Say-No aspect of on line medical command that is not horrible. Still, the better thing to do is to just trash the furosemide. Maybe with the next protocol revision it will be as the medical directors realize that it is not a good drug.

Full standing orders for everything I have with no need to call for any dose, no matter how high, or for any mixture of opioids and sedatives at any dose?

Again, that would be nice, but it is not at the top of my list, because I already have pretty liberal standing orders and the medical command doctors have not refused any dose for me in years. Part of that is just knowing the doctors, but this would be a really good present for a lot of the medics who are new, or are new to an EMS service.

The standing orders are for musculoskeletal pain, no longer just for isolated extremity trauma (and burns and chest pain).

Droperidol (Inapsine)?

I have written a lot about droperidol, and I will write a lot more, but I think that this is something that needs to develop a comfort level among the ED (Emergency Department) physicians before they will be comfortable allowing EMS to use droperidol. Once the doctors realize how useful it is, again (or for the first time, for the newer doctors), then it should be quickly made available to EMS.

RSI (Rapid Sequence Induction/Intubation)?

We have etomidate (Amidate) available for services that will have at least 2 paramedics on scene, but this is not RSI. The state calls it DFI (Drug Facilitated Intubation). The dose is 0.3 mg/kg with a maximum of 30 mg. Why? Obviously, patients weighing more than 100 kg are too easy to intubate, so we will use lower per/kg doses for them. 😳

DFI? No this is CFI – Charlie Foxtrot Intubation. It is unreasonable for me to expect anything to change with this until medical oversight becomes better. When paramedics develop some real skill at intubation, then RSI may become available to EMS in Pennsylvania.

As much as I don’t like the choice of medication, or the dosing, the biggest problem is the competence of the medics attempting intubation – averaging one per year and not practicing in between.

What about real medical oversight?

Yes. That would be a great present – for medical directors in the area to understand how to provide oversight and to be aggressive in encouraging EMS to be better. There is already some of that, but there are other medical directors who have a long way to go. I was tempted to make this my choice, but I want to be more realistic.

Realistic in EMS? In a post about Santa?

Just more realistic. Besides, as I have already pointed out, I have a lot of what I would want, now. I am very pleased with the progress made in Pennsylvania. When I was on our county protocol committee, we had none of the things I mentioned that we have now.

So what do I want?

I’ll tell you after I open my presents tomorrow.


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