ALL WESTCHESTER REMAC'D MEDICS MUST READ - NOW

[WAS967 97]

http://www.wremsco.org/protocols-drafts.htm

New Paramedic Protocols go into effect in less than ONE MONTH - On July 1st, 2009.

All Paramedics credentialed by the Westchester REMAC have until JUNE 30th (That's 26 days from now) to be in-serviced on the new protocols or your credentials will be SUSPENDED until you are properly in-serviced.

Everyone who dislikes the short notice given by the county should call them and voice their complaints (914-231-1616). Perhaps the date will be pushed back. While you're at it, be sure to ask why we have one month notice when the Protocols were approved by SEMAC SIX MONTHS AGO.

Points of interest:

-Etomidate now on standing order for MAI

-Morphine on standing order for pain control

-Elimination of Nitro Paste

-Elimination of Thiamine

-Addition of Dobutamine and Dexamethasone

Points of distress:

-Not enough stress RE: Not using Etomidate in instances involving trismus (clenching).

-Still no standing order sedation for Pacing/Cardiioversion

-Still no antiemetics

-CPAP should be mandatory

Edited June 4, 2009 by WAS967

[x635 4,066]

I can't believe Westchester is STILL not using CPAP!!!!

[WAS967 97]

They ARE as of the new protocols. Problem is, it's still optional. IMHO it should be mandatory. Go big or go home.

Edited June 4, 2009 by WAS967

[Goose 188]

I can't believe Westchester is STILL not using CPAP!!!!

There are agencies that have CPAP....but it's (disturbingly) by no means a mandatory therapy.

[WAS967 97]

Someone pointed out to me earlier the lack of any sort of mention of ETT medication administration. Perhaps this can be used as fuel to light fires under people's butts to get real IO guns/drills on the units.

[ny10570 745]

Someone pointed out to me earlier the lack of any sort of mention of ETT medication administration. Perhaps this can be used as fuel to light fires under people's butts to get real IO guns/drills on the units.

Now this I would call distressing. CPAP is great, and decreases intubation rates and hospital stays. I haven't seen anything where it makes a major impact on fatalities. ETT drug administration results in a zero save rate in cardiac arrest.

A quick comment about using etomidate. Why not use etomidate in the presence of trismus? I've heard of it causing trismus, but haven't seen anything in the last 10 years telling you not to use etomidate in the presence of trismus. If your agency does not use paralytics and the trismus is not as a result of an injury to the cranial nerve there is a reasonable chance that the etomidate will facilitate an otherwise impossible intubation.

[medic25 0]

Now this I would call distressing. CPAP is great, and decreases intubation rates and hospital stays. I haven't seen anything where it makes a major impact on fatalities. ETT drug administration results in a zero save rate in cardiac arrest.

A quick comment about using etomidate. Why not use etomidate in the presence of trismus? I've heard of it causing trismus, but haven't seen anything in the last 10 years telling you not to use etomidate in the presence of trismus. If your agency does not use paralytics and the trismus is not as a result of an injury to the cranial nerve there is a reasonable chance that the etomidate will facilitate an otherwise impossible intubation.

Actually the most recent study out of Canada showed at 21% reduction in mortality after the introduction of CPAP in the field to EMS (Annals of Emergency Medicine last year, don't remember which issue).

I'm a little surprised to see etomidate-only intubation being done. The research on that is far less favorable; for the most part you either need to go all in and give the paralytic as well, or don't give anything. The problem with just sedating the patient is that you can frequently go from a bad SOB'er who can't be intubated to an unconscious bad SOB'er who's jaw is still clenched. Not really what you want, especially if they start vomiting.

[Skooter92 7]

I'm a little surprised to see etomidate-only intubation being done. The research on that is far less favorable; for the most part you either need to go all in and give the paralytic as well, or don't give anything. The problem with just sedating the patient is that you can frequently go from a bad SOB'er who can't be intubated to an unconscious bad SOB'er who's jaw is still clenched. Not really what you want, especially if they start vomiting.

My experience in CT with etomidate is that frequently you don't need the paralytic to complete the intubation. The etomidate usually relaxes the patient enough to gain atraumatic access and visualization. Great stuff.

[WAS967 97]

A quick comment about using etomidate. Why not use etomidate in the presence of trismus? I've heard of it causing trismus, but haven't seen anything in the last 10 years telling you not to use etomidate in the presence of trismus. If your agency does not use paralytics and the trismus is not as a result of an injury to the cranial nerve there is a reasonable chance that the etomidate will facilitate an otherwise impossible intubation.

I've had numerous discussions with a colleague about this and the paramedic protocols he helped develop specifically consider trismus an absolute contraindication to the use of Etomidate for MAI. I'm trying to get more information - stay tuned. Google hasn't turned up much information about it so I'm curious to learn more.

[ny10570 745]

Actually the most recent study out of Canada showed at 21% reduction in mortality after the introduction of CPAP in the field to EMS (Annals of Emergency Medicine last year, don't remember which issue).

I'm a little surprised to see etomidate-only intubation being done. The research on that is far less favorable; for the most part you either need to go all in and give the paralytic as well, or don't give anything. The problem with just sedating the patient is that you can frequently go from a bad SOB'er who can't be intubated to an unconscious bad SOB'er who's jaw is still clenched. Not really what you want, especially if they start vomiting.

In nearly everything I've read etomidate is universally a better induction agent than benzos, ketamine, and nitrous. While RSI does provide better success rates, I haven't seen anything that makes etomidate only dangerous. Mostly the percentages I've seen are mid to high 90's for RSI and mid 80's to 90 for etomidate only. While not an ideal trade off, depresed cortisol production vs paralysis is a fair deal in a service as large as FDNY or a quieter agency with only a couple of intubations per medic.