NY Protocol Updates

[Goose 188]

So work informed me of two new protocol updates coming down the line.

The first, i'm told, is BLS administration of 2 81mg (baby) aspirin to chest pain patients - assuming they have not taken any prior to EMS arrival. This, according to those who told me, is to go into effect July 1, 2007. I haven't seen the actual protocol itself, i should be getting a copy tomorrow.

The second applies to ALS providers and is in the process of coming down the line, unaware of its approval status, but i was told its "probably" going to be passed. That is the helicopter transport of an MI patient with ST elevation. Essentially, the way it was explained to me, was that the idea is that patients who can get cathed and administered thrombolitics within 1 hour of onset have the best chance for survival. There seems to be a number of schools of thought on this subject, which may explain why it hasn't become official yet.

So far i know of Vassar and Westchester that have Cath labs and i'm told St. Francis is due to open theirs by the end of this year/beginning of next. Any other EDs with this capability?

[Guest partyrock]

If its going to be like FDNY's ASA administration then it'll be 162 mg reguardless of what they took prior unless they have a clotting dissorder or allergic (of course).

I had heard a while ago Northern Westchester was trying to get a Cath-Lab some joint project with Presby.

Edited June 8, 2007 by partyrock

[RWC130 594]

NYS DOH EMS Protocol Update - Administration of Aspirin

http://www.health.state.ny.us/nysdoh/ems/p...ion_2007-01.pdf

HVREMSCO Protocol Update -Administration of Aspirin

http://www.hvremsco.org/Aspirin/Aspirin%20...AQs%20feb07.pdf

Yes, 81 mg

[fitzjr11 17]

The asprin protocol was sent out several months ago, and as per the state- emts that do not have the update can not ride ambulances w/ asprin on it.

We had our state inspection this week and that's what we were told

[Oswegowind 17]

St John's is getting a non emergency cath lab in Yonkers...is still in the works though...and as for riding on an ambulance with aspirin which is so potentially harmful that the state feels they have to limit units as to who can ride with it in their possession is so ridiculous! It is not a controlled substance...if you aren't trained on how to give it (haha) then don't touch it (haha). Enjoy!

[Guest alsfirefighter]

Oswego I agree with you totally.

I'm actually a bit surprised that they allowed a dose option in the protocol. Especially when most doctors that I have heard speak on the subject and fellow paramedic educators I associate with have spoken about how ineffective administering 162mg of Aspirin basically is. In my ALS protocol, it allows me up to 4 tablets of 81mg chewable ASA PO if they haven't taken aspirin that day. I give the max dose to all my patients, based on these lectures and conversations. I've also in my experience very rarely find a patient whom isn't take "an aspirin a day" which is 325mg. If they have taken an aspirin and its later in the day or at night, I will "contact" medical control and request a simple 162 mg dose to increase the therapuetic index of the original aspirin taken that day.

[Goose 188]

If its going to be like FDNY's ASA administration then it'll be 162 mg reguardless of what they took prior unless they have a clotting dissorder or allergic (of course). 

I had heard a while ago Northern Westchester was trying to get a Cath-Lab some joint project with Presby.

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the NYS protocol states that "if they have not taken aspirin and have no history of aspirin allergy and no history of gastrointestinal bleeding" then give asprin. Funny thing is, the PSE sheet for aspirin admin. doesn't require you ask if the patient has taken aspirin. lol

[Oswegowind 17]

That is probably because you are supposed to canvass the patient as to what medications they take during your history questions. I.e. Do you take medication? What are they? Did you take your normal dose today? What other medical conditions do you have?

Why test it twice? You should already be doing this, and now you have just another minor option to assist someone in their time of need. I had hoped that by 2007 EMT's would be starting lines and drawing bloods on a regular basis...don't know it that is ever going to happen but it would be great...just make everyone Intermediate and up.

[ex-commish 490]

the NYS protocol states that "if they have not taken aspirin and have no history of aspirin allergy and no history of gastrointestinal bleeding" then give asprin. Funny thing is, the PSE sheet for aspirin admin. doesn't require you ask if the patient has taken aspirin. lol

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I am going to assume that the state is assuming ( does that sound right?) that the EMT or Medic will question the p/t's hx which would include medications and past medical hx.

[Guest partyrock]

Never assume, and the state usually doesn't. It's been a while since I looked over the BLS protocols down here, but I'm pretty sure we give the asprin reguardless of previous intake. I know the state doesn't assume because they have us repeating the allergy question. I know I never assume because no matter how thourough I am patients still spontaniously develop new ailments and allergies in the ER.

Oswego, I love your pipe dream. I bought into it as well a few years ago and was all excited when the state made CFR almost as well trained as EMT's. This was explained to me as the begining of the great transformation where BLS would get IV fluids and the combi tube. ALS would get more advanced standing orders with a pilot study for treat and release. Now I don't see any indication that its comming anytime soon. From what I understand my beloved FDNY was instumental in shooting those changes down when they realised they would be removing medics from most trauma calls. They were affraid they wouldn't be able to get people to upgrade. There were also cost concerns. Would EMT's be paid more? How are they going to recoup the increased costs of training and equipment if this becomes the new standard of BLS care? What about the decrease in ALS billed jobs? Now that the state is keeping BLS where it is, there's rumors of in house upgrade service wide to Intermediate where you can bill many more jobs for ALS without using medics.

I'm done rambling.

[Guest]

If its going to be like FDNY's ASA administration then it'll be 162 mg reguardless of what they took prior unless they have a clotting dissorder or allergic (of course). 

I had heard a while ago Northern Westchester was trying to get a Cath-Lab some joint project with Presby.

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Just a point of clarification: FDNY does not make protocol in NYC. It is the REMAC Committee of REMSCO. FDNY follows them just like all the other hundred or so agencies.

Mike

[mlfcemt093 0]

Just a point of clarification:  FDNY does not make protocol in NYC.  It is the REMAC Committee of REMSCO.  FDNY follows them just like all the other hundred or so agencies.

Mike

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Yes you are correct, however, the emt/paramedic instructors and bosses @ the FDNY EMS academy are extremely instrumental w/ presenting to the region changes that they are feel are needed, for example if not for FDNY EMS there would be no albuterol admin in the state because it was FDNY EMS who did the pilot study and achieved positive feed back for asthmatics therefore it was put to practice and i'm sure sooner or later more and more positive things will come to fruition especially due to the fact that FDNY EMS recently obtained uniformed status so we will all hopefully see some new and interesting changes being made like what partyrock brought up about all emts being upgraded to "I" status i'm certainly looking foward to those changes.

[Guest]

Yes you are correct, however, the emt/paramedic instructors and bosses @ the FDNY EMS academy are extremely instrumental w/ presenting to the region changes that they are feel are needed, for example if not for FDNY EMS there would be no albuterol admin in the state because it was FDNY EMS who did the pilot study and achieved positive feed back for asthmatics therefore it was put to practice and i'm sure sooner or later more and more positive things will come to fruition especially due to the fact that FDNY EMS recently obtained uniformed status so we will all hopefully see some new and interesting changes being made like what partyrock brought up about all emts being upgraded to "I" status i'm certainly looking foward to those changes.

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That is not entirely correct. When albuterol was being studied, there were two simultaneous pilot programs, one by FDNY which required the patient to have a history of asthma and one by REMSCO that allowed for any patient with bronchospasm to be treated. Both programs demonstrated sucessfully, but the one that "won out" was the FDNY one mainly because the REMAC docs were uncomfortable that the EMTs would be able to assess bronchospasm.

As one of the instructors who rolled out the REMSCO program to EMS agencies, I can tell you that the REMSCO program would have been the better one to implement and would have better served a larger group of patients because not everyone who could benefit from albuterol has a history of asthma.

[Goose 188]

Allot of things would be nice...5 year certification or even licensing , the move towards making the "I" the base level of care. These steps would not only improve patient care, but surely weed out those who don't belong in EMS but have managed to skate through a "B" class.

Whatever the case may be, its nice to have a few extra tools (albuterol, asprin, accucheck, nitro) in my bag, now i actually feel like i have a chance at making a difference.

I had heard a rumor that the reason NY state never went with a combi tube was because FDNY EMTs were having some issues using it. Just curious if this is true?

[Guest partyrock]

You guys carry nitro?? FDNY has a BLS 5 year recert trial running right now. The current plan as I understand it is to offer the 5 year recert to agencys with a certain minimum of calls so it won't be open to everyone.

FDNY still hasn't even tried to start a field trial of combi-tubes for bls. Hopefully its in the works soon, but who knows when.

[Guest alsfirefighter]

Combi tube trial?....wow. For the life of me I still can't figure out why it works sooo many other places for BLS but of course it doesn't in NY that all this stupidity has to be added on. Other then remembering how much air to put into each tube, there is only 1 hole it goes in. If you can't figure that out you need more than just help.

I also don't understand why things get limited by call volume. I don't care if you run 10 calls a year...every person should have the same quality of care regardless of where you live. This is a huge problem through the EMS service all over the state.

As far as albuterol I'll keep some comments to myself..however I have seen the misuse of it by BLS more then I've seen appropriate useage. Administering it without assessing lung sounds...no hx of any form of COPD illness and the time honored favorite of slapping it on someone whom is simply hyperventilating from an anxiety attack or with full pulmonary edema.

[mlfcemt093 0]

As one of the instructors who rolled out the REMSCO program to EMS agencies, I can tell you that the REMSCO program would have been the better one to implement and would have better served a larger group of patients because not everyone who could benefit from albuterol has a history of asthma.

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OK I don't mind being corrected thanks for the xtra info

[Guest partyrock]

I'm not saying its right, but the argument was an EMT on the slowest bus is going to see at least 250 jobs a year while the average tech sees over 600. The idea is they get enough hands on with all their skills that monthly peer to peer training and 16 hours of instructor led training a year will be enough to keep them sharp. The real test will be the pass rate on the refresher after 5 years.

[WAS967 97]

The first, i'm told, is BLS administration of 2 81mg (baby) aspirin to chest pain patients - assuming they have not taken any prior to EMS arrival. This, according to those who told me, is to go into effect July 1, 2007. I haven't seen the actual protocol itself, i should be getting a copy tomorrow.

Technically the new protocol has been in effect since it was released by the state back around February. July 1st is the date that all agencies are required to be compliant with the new protocols, carry the ASA, and have their people in serviced. HOW they are in serviced is left entirely up the the medical director of the agency. Paperwork is the key here as that is what the state will be looking at during site inspections.

The second applies to ALS providers and is in the process of coming down the line, unaware of its approval status, but i was told its "probably" going to be passed. That is the helicopter transport of an MI patient with ST elevation. Essentially, the way it was explained to me, was that the idea is that patients who can get cathed and administered thrombolitics within 1 hour of onset have the best chance for survival. There seems to be a number of schools of thought on this subject, which may explain why it hasn't become official yet.

Haven't heard of this one until now. I'll have to look into it. Probably won't affect us as much in Westchester since a majority of the time it's quicker to go by ground to WMC. I'd be more interested in seeing a statewide protocol for diversion to a heart center for any case of 12-lead identified STEMI, regardless of mode of transport. The fact that we can divert to designated stroke centers, burn centers, and trauma centers but not heart centers is ridiculous.

The asprin protocol was sent out several months ago, and as per the state- emts that do not have the update can not ride ambulances w/ asprin on it.

Sounds about right. And since it is a statewide protocol, EVERY ambulance SHOULD have it. And here is the kicker - the training is agency specific. So if you take an ASA update at XVAC, it doesn't AUTOMATICALLY apply to YVAC. HOWEVER, with the proper paperwork from the in-service that you DID complete, your other agency medical director can approve of the training you took elsewhere, and waive training at the second agency. It all comes down to what your medical director allows. Confused? So are a lot of people. Get even more confusing when, TECHNICALLY, the medics are supposed to do the ASA update also!

I'm actually a bit surprised that they allowed a dose option in the protocol. Especially when most doctors that I have heard speak on the subject and fellow paramedic educators I associate with have spoken about how ineffective administering 162mg of Aspirin basically is. In my ALS protocol, it allows me up to 4 tablets of 81mg chewable ASA PO if they haven't taken aspirin that day. I give the max dose to all my patients, based on these lectures and conversations. I've also in my experience very rarely find a patient whom isn't take "an aspirin a day" which is 325mg. If they have taken an aspirin and its later in the day or at night, I will "contact" medical control and request a simple 162 mg dose to increase the therapuetic index of the original aspirin taken that day.

Right there with you on the dose option. In fact the dose option is incorrect. It should be 162 mg, not 160mg, but hey. Who's checking? (Not the SEMAC docs apparently). The reason we were told that they put the dose option in there is (supposedly) for agencies that, for one reason or another - don't ask why - only have the 325mg ASA dosage. However, in the letters from the SEMAC, it states that your SUPPOSED to carry the 81mg Chewable tablets. So no idea why they would only have the 325mgs.

As far as efficacy of a 162mg dose, thats quite controvertible. There are some "camps" that have been teaching that 81mg dosage for MOST patients is adequate enough to eliminate the aggregation of 90% of your platelets, and 162mg will be fine for most. Ergo why most patients take 81mg a day. You get a leap frog effect. (If that makes sense). Many would actually argue that 325mg is overkill. But who the heck knows? In the end, erring on the side of caution and giving a full 325mg, regardless of prvious intake, won't harm them in the absense of complications (sensitivity, GI bleed, etc).

Funny thing is, the PSE sheet for aspirin admin. doesn't require you ask if the patient has taken aspirin. lol

The PSE sheet is only meant as a guideline for what agencies should use as practical testing for their people. If an agency feels the need to add a point for specifically asking about previous intake, they may. And techincally it DOES ask, as it requires the candidate to state the indications and contraindications for ASA administration, one of which is ASA intake within the past 24-48 hours.