New CFHS protocols-PCP and Adv Emerg Care

[Donut]

Anybody else seen them? I haven't had a chance to look through them yet, but a quick glance through looked decent.  They look awfully familiar though, almost identical to the JIBC's PCP protocols, with a couple of "good" modifications, such as IM Benadryl with anaphylaxis vs the PO we use here.

On another note, another paramedic on the bus to the cenotaph yesterday raised a good question:

why is that immediately after we manage to get consensus that there are 4 levels of prehospital provider, everyone has to rush off and create another one "in between" two others? 

DF

 

[Brad Sallows]

Creeping credentialism and "turf wars".

 

[starlight_745]

Any chance you could post a link or at least give us a run down on the general outline?

 

[Donut]

My IC Clinic printed them off, I don't know if they're online, but I think they went out by email to concerned parties. 

If they're along the same lines as the JI's PCP ones, there should be about 11 symptom relief protocols, as well as a hypovelemia, ALOC NYD, etc. I did note a psych protocol (haldol, love the H), and saw the combitube mentioned at least once, I think with the AED.

Looking at the PCP protocol guide:

Chest pain-NTG w/ ASA
AED
D/C resuscitation
SOB with asthma and or COPD --Ventolin and Atrovent
Analgesia (we use Entonox, didn't see if the CF had anything for PCP)
Hypovlemia-NS 500 ml bolus to BP 100, max 2L without orders
Anaphylaxis--Epi & Benadryl
ALOC NYD--NS, Naloxone Hcl, D10w, thiamine, Glucagon as indicated/ IV access
Narc OD--Naloxone
Hypoglycemia-D10W, glucagon, gluca-goo depending.

This what you were looking for?

DF

 

[starlight_745]

Cool, thanks those actually sound fairly broad for PCP level protocols.  I suspect that the CF has created in "in between" level since there really would not be enough exposure to maintain the ACP competencies.  Not to many unstable tachycardias or CHFers in the military.  We also have PA's and MO's at the UMS level who are capable of an advanced life support level of care.  That as well as that most ACP programs are at least a year and mucho dinaro to put people through no matter how you slice it.  That's my thoughts anyways.

 

[Donut]

Those are the JIBC PCP protocols, not the CF ones.  Ask me later in the week, I'll make a copy and take a look at it closer for you.

Starlight, I agree with you in the CF's case, as to their reasoning behind it.

Overall, in the big picture, I think Mr Sallows has it right.

And I think it's a bad thing, and a mistake.  Why have NOCP's and PAC if it's being undermined by everybody off the LOD?

 

[Donut]

Here's the list of protocols.   There's a cover letter from the Br CWO, too.   Looks like the intention is to bring all Reg F 737 QL3 to PCP, and then add the AEC stuff at the QL5 level


Drug Protocols:
Cardiac chest pain O2, Ntg, ASA (AEC get MS or Demerol, & gravol)
Post arrest stabilization                 ET /Combitube, NS 100ml/Hr (OG tube, Foley Catheter for AEC)
SOB w/ COPD/ Asthma                 Ventolin (single 5 mg dose without orders)
Anaphylaxis Epi, Benadryl, IV, Ventolin
Tension Pneumo AEC only
Hypovelemia 500ml NS in bolus to max of 2L or BP of 90mmHg
Burns NS 4mg/kg x %BSA (Parkland formula?)
Pain   AEC only MS 2.5 mg   IV q10 minutes to a max of 10 mg OR
                   Demerol 25 mg IV q 10 min max 75 mg
ALOC NYD Reverse low volume, low sugars, Narc OD
Narc OD 0.4 Mg Narcan IV/ 0.8 Mg IM, NS IV prn
Seizures AEC only, diazepam 10 mg IV q 10 min to max of 30 mg
Abx for open wounds and delayed tpt, cefazolin 1 gm IM/IV or clindamycin 600mg IM
Hostile Pt Haldol 5mg IM benadryl 25 mg IM, may rpt haldol in 30 mins


Other ones for hypothermia & diving emergencies, too, but not very comprehensive.

Procedures:

ET intubation, no meds for a RSI, so only for a limited number of patient
Urinary cath
Spinal injury clearance
Saline lock
Needle Thoracentesis

So, it looks like a relatively comprehensive list, as others have pointed out there aren't a lot of CHFers in the CF.   Did notice there's nothing for the morphine autoinjectors, for either standard of care. Have they gone the way of the MAST?

 

[Fraser.g]

D,

Yeah they have finally gotten rid of MAST. As a matter of fact they have re-called them so you should not even have them in stock (in case you wanted to use them).

As for the MS auto injectors... the rational for taking them off line is that if you have a trauma patient that requires analgesic on the battle field the are probably in a shalk state. With this goes the peripheral circulation shunting.
The argument goes (and I have seen it in the ED) that IM does not provide adequate coverage. The temptation is to use more IM if that is the only protocol that you have. Once you get to a point where fluid recitation takes place all the MS that is now docked in the muscle tissue is flushed out at once causing an OD or at least respiratory suppression. This is not a big deal when you have a vent available or a BVM for that matter but I have not seen many medics that carry Narcan in their bags with the Morph.

GF

 

[tacmed2007]

OK I have to say that this in my humble view is just dangerous Medicine waiting to happen,  I looked at the protocols and being a Paramedic from AB and seeing all tho MD's after the names I wonder how this happened? To start the very first protocol is your chest pain and your first action BLS and consider attaching and AED lead...how many AED's that have leads do you know of? better yet how many AED's that the CF has bought come with leads? then lets bash into the Nitrates maybe an IV and then consider MS??? where is the standard of Cardiac care there?? no non-dianostic or diagnostic monitoring( my exp to date is no PCP out of the JI can interp ECG's and its not covered in the 5's) no 12 lead which is the standard in ACLS which drives your Tx...or maybe ID the RVI before you dump their BP with a blind trial of Nitro... and that's it. There is no further cardiac Tx protocols except for the Arrest protocol and there they mention again to ID your rhythm so I guess if they present in a PEA or maybe a fine V-Fib there is a protocol for that somewhere?
Then there is the mention of Airway management and the talk of ETT with no adjuncts, no meds...again how much airway management is a JI PCP going to know? And to hear medic coming back and saying" I can intubate" is far from the truth, so you can pass a tube in a OR under strict control with an uncompromised Pt...so could my 9yo if I taught her. Point is they get an opportunity that will not happen again outside a hospital because no where else are they going to maintain a skill they hardly grasp. Look at Tacmed when that came out, most could not grasp the combi tube let alone what was envolved with a cric, and most admitted tat they where not comfortable with that skill set even after grad!


So what are we doing but setting up for failure??? I will be honest I stopped reading the AEC protocols after the first 4 pages but i will go back and read again...but I doubt if I will ever be conviced that this is a good thing

 

[PMedMoe]

tacmed2007, you do realize you replied to a post that's almost six years old, right?

 

[Armymedic]

Before I respond to your somewhat coherent rant, who are you; as in, are you in the CF and do you actually know what CF medics can and can not currently do?

 

[tacmed2007]

ya I know but in my serach for other things I found this and did go on a rant, and yeah I know what the CF medics do because I have done 2 tours in the snad box and I am a medic.

 

[Armymedic]

First, please try to write and communicate appropriately in one of the two national official languages. MSN speak is not appreciated here.

Secondly, if your a recent CF medic and have done tours then you know that those protocols from 2004 are out to lunch and not the ones currently practiced.

Even though your individual points are valid, i.e. medics "intubating", you make yourself seem foolish to those who might not understand what you are trying to say.

 

[Armymedic]

Now that I had a chance to look at the newest QL5 protocols (Apr 2010) and the SAR Tech medical protocols, here is the response to your rant:

1. ACLS- re nitro. The protocol is a spray of nitro if systolic BP is >90 mmHg, and then after 3 nitros (30 mins apart with SBP>90mmHg and no relief of chest pain) then you may give Morphine IV if SBP is still above >90 mgHg. Considering most people with known angina give themselves up to 3 sprays of nitro without checking their own BP, then it is a reasonable protocol, and in line with current ACLS 2009 algorithms.

2. AED- Algorithm indicates if no shock indicated then CPR is to be continued until a MO/PA is contacted, or indications for the discontinue resuscitation algorithm are met. Obviously, if there is a shockable rhythm, then either the rhythm will be refractory or not, and the med tech will seek direction from a MO/PA for further treatment options

2. Airway - in the new protocols, there is no ET intubation. The maximum advance adjuncts for QL5 is a LMA or combitube, or cric as a final adjunct.

If you are going to rant, please at least be current in your complaints.

edit to add: If any Med Techs want them, I have those QL5 protocols on PDF. They are unclassified. If you want a copy pm me with your email address, and I may send them to you.

 

[tacmed2007]

That’s great that you went to all that trouble to look for those protocols, because I was looking at the same protocols a medic sent me.

1. It is great in the world of sugar plum's that our Pt may go into Nitro induced Syncope all on their own, and yeah for them, it is great that our medics that will tell you from their vast JI training that you give Nitro because that’s what the protocol said to do. Clearly you are missing the point of my rant. It is by every Paramedic in Alberta wrong, misguided and just wrong to do any sort of cardiac care without doing proper BLS( that would include Cardiac Monitoring in a 3-5 lead that allows for diagnostic mode) a confirmation of the ABC's a 12 lead ( medics can do those, just not interp them, wait most cant interp 3 leads) then we will have a line started PRIOR to Nitrates and start with the first Nitro regardless of what the Pt did or did not do and then consider MS if we are failing to correct the Chest pain that is likely cardiac in nature. We have a clear understanding with our 12 lead what is involved, where the suspected MI is and if the Pt meets the Thrombolytic checklist to thrombolise in the field with the Cardiac consult. It is not a "reasonable" protocol for a CF medic that has (with exception to a small percentage) little Pre hospital Exp or Car time that did not involve a preceptor holding their hands, or clinical time with a MO/PA hovering and making the call for them or because they aced the sim center.
And if you want to go the ACLS route why is it we have 3's and 5's as a card carrying ACLS provider that could not run a code if the Pt's life depended on it?? Current ACLS has lost its way in the view of my peers and does not correctly address the pre hospital aspect as it has rarely done in its history. It is also dependent on who funded it, and I am betting Lidocain will be back as first line over Amiodarone.

2. AED or Automatic External Defibulators are a single unit strictly to function on an apnic& pulseless Pt, so going back to the Chest pain protocol and the first step is to place said unit on the Pt...Well those made me wonder what the hell?  The AED protocol as a whole is a mirror of just about any EMR or lay rescuer protocol. Again my question is A: you give adjuncts or bits of ALS level skill sets to the Medic and/ or they are ACLS providers already. B: you now have provided in the view of most coming back from the AEC course as able to "Intubate" or can go straight to a surgical airway. C: there is not always a PA/MO around when you need them and seeing as this is for line medics at any time again I wonder.
My point here I will close with.

3. Airways the book states Advance airway, well any airway that is a blind insertion is certainly NOT an advance airway, yet the medics are being allowed to Intubate in theatre? If this is going to be the trend then why not teach them Advance airway management and have that tool present, the argument then will be how to defeat skill fade?? Well I ask how many MO/PA's have tubed someone lately. Of course they have the option of an OR rotation within their scope. I submit that there is clear evidence that our Allies in fact have Snr Sgt's (lacking a Mcpl Equiv) that are practicing Paramedics with Civy accreditation. Both the UK Army and Air force use Paramedics in theatre as do the US SOF community, Air force PJ's on a Medivac in theatre as well as the Aussies and a few other European countries.

So with the that I put forward with the input of some very skilled Paramedics and MO/PA's that our Snr Medic position that is NOT a PA but a QL5 be trained as a Paramedic(ACP) and have that skill under the Lic body of the prov in which they practice. I restate my previous opening of my rant that this is "Dangerous Medicine" and I do not think I would need to provide the empirical data to show that our current medics do not have the fundamental Education to provide solid Core knowledge, Critical thinking in a Pre hospital environment or the depth of understanding the Pharmokentics or dynamics of the drugs of the ALS level tier. So why do we not provide them with that knowledge, we have sent them to the JI (all be it the worst school in the country) but have started them down the road to solid prehospital skill sets and treatment that will adjunct clinical skills. We work in a prehospital environment at the medic level both in country and in theatre, we provide mentoring to ANSF that have Medications that are ALS level or drugs that provide similar qualities to North American drugs and to be able to provide evidence based or knowledge based arguments to their Medics or "doctors" would be very valuable (knowing that the ANA currently use Metoprolol as their first line head ache med) how many would know that it is a Beta blocker???

I personally enjoy heated arguments that involve medicine or the emergent prehospital aspect, I do not enjoy nor make an Unprofessional remark's or comment aimed at a peer.
 

 

[old medic]

2. AED or Automatic External Defibulators are a single unit strictly to function on an apnic& pulseless Pt, so going back to the Chest pain protocol and the first step is to place said unit on the Pt...Well those made me wonder what the hell?  The AED protocol as a whole is a mirror of just about any EMR or lay rescuer protocol.

I'm still confused here.

Are you complaining about the Lifepacks, Zoll M series SAED's,
or are you complaining about the little PAD machines in the system - The Zoll aed plus ?
or are you talking about something else?

Again my question is A: you give adjuncts or bits of ALS level skill sets to the Medic and/ or they are ACLS providers already. B: you now have provided in the view of most coming back from the AEC course as able to "Intubate" or can go straight to a surgical airway. C: there is not always a PA/MO around when you need them and seeing as this is for line medics at any time again I wonder.

I still can't find a question in that.


 

 

[Armymedic]

First, I apologize for the perceived personal attack. I was attempting to point out the expectation we have here as to how we communicate with each other.

Secondly, I fundamentally agree with what you say. The CFHS seems to have a habit of hamstinging the med techs as to what they are allowed and not allowed to do. That being said there are certain things that they do that make sense and others that absolutely do not. I understand why you think it is dangerous medicine, but I would counter that it is not dangerous at all, but quite conservative, perhaps even timid, as there is no place where clinical decisions by the QL 5 is made. A couple of my peers call it "monkey medicine", cause you could teach a monkey to do it.

In agreement: AED/ACLS/ACS - a QL 5 med tech should be taught and tested the big 3 (unstable VT/VF, PEA, Ustable narrow Tach) algorythms and be able to know the medications used, and then have the protocols to allow them to do it. They also should be equiped with a Zoll as a minimum on every amb. They should also have the ability to read 3 lead ECGs. I agree though that thrombolitics is a protocol/skill that is best left above the Med Tech levels.

So with the that I put forward with the input of some very skilled Paramedics and MO/PA's that our Snr Medic position that is NOT a PA but a QL5 be trained as a Paramedic(ACP) and have that skill under the Lic body of the prov in which they practice.

I also agree with your thought that a QL6 Sgt Med Tech should be ACP...but the remainder of the statement is a nice thought, but impractical. Because of our postings, you cant have the English language skills and protocols being dictated by 9 different regions. It is unfortunate that they chose BC and not AB or Ont (where the majority of Med Techs are stationed), but they had the choose one.

Now for picking pepper out of fly turds: I disagree about your semantics of "advanced airways". I, now a bit more educated than before because of time we spend with anesthesia and trauma services, do consider LMA and combitube as advanced airways. Basic airways, as I consider them are manual, NPA and OPA, and ET intubation and cricothyroidotomy are considered definitive airways. As the advisors are all MO and PAs, this is likely where they get the title from, as that is now the common nomenclature used. But as far as the skill of ET intubation, medics should know who to do it (so they can effectively assist me when I am trying to place a tube), but until there is significant improvement in the kit we have (i.e. glidescopes, fibreoptic blades) then no medic should attempting live intubation, especially in trauma , as it is a skill difficult even for skilled doctors.

All in all, good thoughts. Keep bringing them up to those who where crowns, wreaths and coats of arms...that way things will continue to improve. And thank you for giving me your perspective. 

 

[mariomike]

That’s great that you went to all that trouble to look for those protocols, because I was looking at the same protocols a medic sent me.

I enjoy collecting them too. Here is an incomplete list:
http://forums.milnet.ca/forums/threads/94469.0.html

This is the official electronic version of the Standard Operating Procedures (SOP) of Toronto EMS:
http://torontoems.ca/edu-site/dloader.php?download_file=TEMS-SOPs-v-2010-3.pdf

Although from Ontario, as a practicing Paramedic in Alberta, you may find it of educational interest.

I didn't exactly set the world on fire, as I was just a PCP-Ontario ( as most at T-EMS are ) on the Multi-Patient Units MPU's when I retired. The ACPs used to say, "We are the chefs. You are the potatoes!"  ;D 

A couple of my peers call it "monkey medicine", cause you could teach a monkey to do it.

One of our Deputy Chief's allegedly said that at an arbitration. Whether he did or not, it soon became part of our folklore.

"Paramedic says monkeys could be trained to perform medical procedures":
http://www.telegraph.co.uk/news/uknews/6816919/Paramedic-says-monkeys-could-be-trained-to-perform-medical-procedures.html

So why do we not provide them with that knowledge, we have sent them to the JI (all be it the worst school in the country) but have started them down the road to solid prehospital skill sets and treatment that will adjunct clinical skills. 

It is unfortunate that they chose BC and not AB or Ont (where the majority of Med Techs are stationed), but they had the choose one.

Provincial standards:
http://forums.milnet.ca/forums/threads/199/post-972837.html#msg972837

I submit that there is clear evidence that our Allies in fact have Snr Sgt's (lacking a Mcpl Equiv) that are practicing Paramedics with Civy accreditation. Both the UK Army and Air force use Paramedics in theatre as do the US SOF community, Air force PJ's on a Medivac in theatre as well as the Aussies and a few other European countries.

Specially trained municipal Paramedics take care of the Emergency Task Force ETF "Gun Team":
http://www.torontoems.ca/main-site/service/etf.html

 

[tacmed2007]

Rider I do agree with what you said with respect to the Cardiac Care and I have found to date that there are few that can ID beyond Vfib, Tac or asystole; it is every rhythm after that where it stops cold. I remember doing a Pre ACLS intro for medics prior to 1-08 and not one medic could tell me what Afib is!! Now I have looked at what could be done in house and what I have found is that most new medics are either very keen and wish to learn or they have somehow developed the GOD complex and know everything or simply don’t care. So how do you get around that?
I also question the direction of the ACLS for Providers course as the last time I did ACLS was in 2006-07 and have to go recert, where did all the drugs go? Yet when I asked a peer today about the ALCS crs they are about to do and they got on the topic of a SVT and mentioned Adenosine and that it never works I stated that it very rarely works at the 6mg dose and you will normally see a conversion in the second round of 12mg, however I asked what they will do should that fail to correct and they shrugged…I added you may consider the Shock or Block yet they had no idea what the drugs would be for either and simply put “its not in the book I read” and this is a QL6 talking…. So as a whole how do you combat a system that as you stated has a habit of hamstringing ALS level skills in a predominately BLS crew?
So we look back at the AEC course and I was told that the simple fact is that they want to push this so that 50% of the trade is qualified to get the spec pay??? Is that really the reason? Again I try to wrap my head around this and I can’t seem to find a clear answer.
MarioMike my beef if you will on the whole gambit of Cardiac monitoring devices at the CF disposal in a field unit or ambulance is simply put horrid. We have what 4 machines that can be replaced by one. For argument sake you could replace them with the LP12 or LP15 (over kill) that would not only bring standard 4 lead non diagnostic monitoring and 12/15 lead diagnostic monitoring but also have SPO2, ETCO2, NIBP, Invasive BP, provide trend data and print out on a larger paper that eliminates the 6 feet worth of strip that the Zoll currently provides. I believe that the LP12 is the best choice for the CF simply because it provides better monitoring, it gives advance providers the ability to provide ALS level care forward where it typically cannot be done as the current equipment is not portable nor practical in that setting. When it comes to a field unit and we have broken down between UMS and Amb pl’s the focus in Amb should be prehospital with the proper utilization of Ambs and crew (EMS model).
I was also taking aim at the AEC protocol for Cardiac chest pain where it suggested to monitor the Pt with the leads from a AED, well no AED comes with that function (take in to account we don’t even have a standard for AED’s on a given base) only the Zoll or LP12 with SAED mode can do that, however you need to switch to manual mode to monitor. What I also brought forward is the fact that no medic I have talked to knew how to actually use the Propack for instance in a field unit, not one could show me the functions or menu select to switch modes for monitoring. The concern that I have is that we don’t even seem to have a solid game plan for the Equipment we have in stock
Rider I was looking at your definition of Advance airway and I agree that ETT and Surgical airways are definitive and ET is the golden standard for management. I look at LMA, Combi and King LT as a blind airway and thus not advance. I do not have the exposure as you have had in the OR and using those adjuncts as regularly, so I can appreciate your view of that topic. I wish that we had more Cadaver labs in the UofA to review airway management prior to going to a theatre, I am not aware of any agreement with a faculty that could allow for this. What I do wonder and would like your thoughts is the place of a surgical airway in Tactical field care verses ET intubation? My position is that I can get a tube faster than I could do a cric, I could also look at things such as a retrograde intubation or simply use a Bouiges tube. I always carry one and it was a simple yes or no that decided what went first… is there actually strong evidence that supports one over the other? I have not been able to find any and can’t find links to US OIF data to support either way.
Thank you for the valued input.

 

[tacmed2007]

Sorry I ment to address that last bit on the AED to OldMedic...sorry again