CPAP and EMS in NYS

[ems-buff 81]

I know that this may be old news to some ALS providers on the board here, but I found something very interesting. I know for a fact that Empress EMS was one of the first in the Hudson Valley to use CPAP in the EMS setting, and I must say, for the CHF and COPD'er out there, it is a great tool to have in our bag of tricks. I know that the Town of Mamaroneck is starting to look into it, and I was wondering once the Westchester County REMAC approve's it. How many people out there would use it, or would you think it's to time consuming not to metion it suck O2 like a hurricane...( I thought that was funny ) Also I was doing some research on the subject, and found that PA already has this in use, as well as letting EMT-B use it as part of there BLS protocols... Here's a copy of it, and I must say they are very detailed on what an EMT can and can't do, among other things...

Pennsylvania Department of Health Respiratory 421 – BLS – Adult/Peds

Effective 11/01/08 421-1 of 4 RESPIRATORY DISTRESS/RESPIRATORY FAILURE STATEWIDE BLS PROTOCOL

Criteria: A. Shortness of breath or difficulty breathing.

1. Conditions which produce SOB from bronchoconstriction that may respond to bronchodilators. These conditions generally are associated with wheezing. a. COPD (emphysema, chronic bronchitis)

b. Asthma

c. Allergic reaction d. Respiratory infections (pneumonia, acute bronchitis)

2. Conditions which produce SOB without bronchoconstriction that do not respond to bronchodilators. These conditions usually are not associated with wheezing.

a. CHF

b. Pulmonary embolism Exclusion

Criteria: A. None.

System Requirements: A. Only an EMT that has completed the bronchodilator module through the EMT curriculum or continuing education may assist the patient with administration of a bronchodilator.

B. CPAP may only be administered by an EMT that has completed the DOH BLS CPAP training and has been approved to administer CPAP by the service medical director.

C. [Optional] BLS services may carry CPAP devices for use by the service’s EMTs.

1. These services must assure that all EMTs using CPAP have completed the DOH BLS CPAP training and have been approved by the service medical director.

2. These services must carry a CPAP device that has a manometer (or other means to provide specific CPAP pressure) and meets any other specifications required by the DOH.

3. These services must be approved to carry pulse oximeters – See Protocol #226.

4. The service medical director must oversee the CPAP training, use of CPAP, and quality improvement audits. Treatment: A. All patients:

1. Initial Patient Contact – see Protocol # 201.

a. Consider call for ALS if available. See Indications for ALS Use protocol #210

2. If allergic reaction is suspected and patient meets criteria, proceed with Allergic Reaction / Anaphylaxis protocol #411.

B. Pediatric patients:

1. NOTE: If child is sitting in a tripod position with excessive drooling this may be epiglottitis, transport immediately. Do not lay the patient flat and do not attempt to visualize the throat.

C. All patients:

1. Apply high concentration oxygen. If necessary, assist respirations with a bag-valve-mask, but avoid overzealous hyperventilation.

2. Monitor pulsoximetry1 [OPTIONAL – MANDATORY IF USING CPAP]

3. Continuous Positive Airway Pressure (CPAP) [OPTIONAL]: a. Apply CPAP to adult patient if patient does not have any contraindication to CPAP 2 AND has at least TWO of the following after high concentration oxygen:

1) Pulse oximetry < 90%

2) Respiratory rate > 25 bpm

3) Use of accessory muscles during respiration

b. If CPAP is applied 3:

1) Titrate pressure up until either improvement or maximum of 10 cm H2O pressure.

2) Remove CPAP if respiratory status deteriorates and assist with BVM ventilation if needed.

[Guest]

I stand behind CPAP 110%. Although FDNY does not equip their ALS units with it, we at NY Presbyterian do; both 911 and transport. I have seen it work wonders on pt's in the past and will not hesitate to use it in the future. If it is used properly O2 consumption isn't that much of an issue. Oxygen isn't the major concern as much as flow is. With a minimal O2 setting, one can usually bring the SPO2 up fairly high without having to raise the O2 inputs.

Side note (and not to thread jack): FDNY EMS just in serviced and equipped their BLS units with Epi-Pens, which had been in the making for years. Meanwhile most voluntary participating BLS units have carried them for years. (if that sheds any light on how long it might take for FDNY to get CPAP)

[Goose 188]

It's been a proven therapy for years...never understood why it took some of our local MACs so long to buy into it. A number of Westchester agencies already use it.

As far as BLS getting it...i'm not too sure how i feel about that. I doubt the region will buy into it. My reservation is that there are so many BLS providers that have difficulty doing the job as is and are completely incapable of operating without a paramedic...ie: cannot identify a candidate for BLS albuterol.

I suppose it would be nice...but given the conservative nature of the MAC and the patchwork of BLS agencies we have countywide i don't see it happening anytime soon.

[medic929 0]

I understand that Rockland Paramedic Service is using CPAP now

[Jybehofd 85]

i wish westchester would get CPAP or RSI.. or something anything would help..

[Goose 188]

i wish westchester would get CPAP or RSI.. or something anything would help..

There are agencies that have it. There is also RSI...but i think only Empress is allowed to preform it because of the high volume of tubes that occur down there. Besides, i recall hearing that RSI is being phased out by a lot of EMS agencies nationwide due to a combination of low success rate and the danger.

Edited May 8, 2009 by Goose

[WAS967 97]

Westchester HAS RSI. It's up the agencies to utilize it. If their medical control doctor is stuck in the stone ages then there isn't much that can be done other than beat a dead horse.

I know that the Town of Mamaroneck is starting to look into it, and I was wondering once the Westchester County REMAC approve's it.

The REMAC has approved it. The SEMAC has approved it. The proposed protocols cleared SEMAC late last year, yet mysteriously have disapeard from the REMAC website. Supposedly it is just waiting on people to get off their asses and get the education part of it going.

If people are really motivated to get this off the ground, call the REMAC and ask what the hold up is. Then call the education committee of the REMAC and ask them too. Then call the protocol committee and ask them. Get answers. Don't let patients suffer because of red tape.

Edited May 8, 2009 by WAS967

[ny10570 745]

NYC only got epi pens because of a slow news day. CPAP constantly comes up but gets beaten back as part of cost benefit. Along with the monetary cost, there is the time lost to restock O2 and equipment, time on scene in a short transport system, and additional training. For the money that would be spent on CPAP there are other things I would rather see purchased.

[JBE 328]

So would it be a thread jack to say that I have used a CPAP for my own medical condition(Sleep Apnea) and I have torn the thing off my face at least twice and I didn't sleep any better with it than I have without?? The concept of using it is actually pretty interesting in the applications described above.

[chovesh 1]

I tried to do a clinical study with BLS CPAP. I had a few doctors who were interested in doing the study but none of them came through in the end. Anyway, in my research leading up to the study that never was I found there are something like 5 states that have BLS CPAP. (Here is a very good Powerpoint on it: www.paramountems.com/hospitals/CPAP%20for%20Medical%20Directors.ppt) The goal of our study that never was, was to analyze ALS calls where CPAP was used and to see if BLS providers could handle calls alone that would otherwise be ALS thereby freeing up ALS units for other calls. (This would obviously only be useful in very busy places like NYC and yonkers where ALS providers are a rare and precious commodity.) I know I'm going to be attacked for suggesting EMTs can "handle" an ALS call without medics, and I know people will say they lack the assessment skills that ALS providers bring. I understand. However, I've seen studies that showed EMTs and Paramedics were equally able to assess patients for CPAP eligibility (I'm sorry I don't remember where the study was, I'll post an addendum if I do find it).

As far as CPAP in our area is concerned: I believe it is definitely worthwhile from a patient-care perspective. It maybe expensive to train providers and outfit ambulances with CPAP but when you think about it you are saving the patients and insurance companies thousands of dollars. The goal of CPAP, when you boil it down, is to keep patients from being intubated. The first day of intubation costs $8,000! Not to mention the high rate of infection amongst intubated patients (the rate of infection is even higher amongst those intubated in the field). Patients treated with CPAP spend less time in the hospital, have a 45% lower morbidity rate, avoid the dangers of sedation, and are most comfortable (that's got to count for something.

A few agencies in the city have adopted CPAP (NYP-EMS, Hatzalah, ??) in Westchester I heard Empress has it. In Rockland County, RPS just started using it. I heard a rumor Westchester EMS was looking into it, I don't know if they got it.

If you want my powerpoint or sources PM me.

[chovesh 1]

As far as BLS getting it...i'm not too sure how i feel about that. I doubt the region will buy into it. My reservation is that there are so many BLS providers that have difficulty doing the job as is and are completely incapable of operating without a paramedic...ie: cannot identify a candidate for BLS albuterol.

In response to that: I agree. As is evident from my previous response, I am a HUGE fan of CPAP. Even I, however, have my reservations about BLS CPAP in Westchester. For certain agencies (empress) it may be beneficial but we have to take it on an agency by agency basis. For example, Mamaroneck probably doesn't need BLS CPAP because they have medics on every call (and if the MEMS medic is unavailable, LVAC is just down the road). [i don't mean to pick on MEMS, it's just the first agency that came to mind because this thread was created by a MEMS member. MEMS here = any VAC in westchester county]

[EJS1810 7]

I looked at the topic too quickly and thought it said CRAP and EMS. I said, here we go again..........................

Edited May 10, 2009 by EJS1810

[EFFD4091-MLSS emt 13]

Mobile Life uses CPAP as well as RSI

[ems-buff 81]

I have split the questions about EMT being to Medic depenant have been move to the following topic.

EMT's being Medic depenant

Please use the link above for futher disscussion.

Thank You