EMS-PoW BONUS - RMA Refresher

Hey all, I’m going to copy and paste a few points from a recent RMA call as a refresher, because there have been several recent calls with similar opportunities for improvement. Please keep them in mind for your next call!

For context, the call was for a 95F with ESRD whose daughter called EMS because she was “spitting up,” but the daughter was now requesting to RMA after speaking with the patient’s nephrologist, who wanted the patient to go to dialysis instead.

1. You asked EMS if the patient “has capacity,” which is language that is important to avoid. EMS responded by saying “yes – she’s alert and oriented x3.” This is inappropriate – decisional capacity is not the same as level of orientation. EMS can determine orientation on their own, and in simple cases they may gauge patients to have capacity on their own, but if EMS is calling OLMC, it is the OLMC doc’s responsibility to determine decisional capacity.

2. Determining decisional capacity – much like obtaining informed consent – requires having a detailed conversation with the patient or HCP discussing the risks, benefits, and alternatives to refusing transport and ensuring understanding of that conversation, often by having the patient repeat back what you have explained. If you do not speak with the patient or HCP, you cannot determine decisional capacity.

3. Again, if you do not speak with the patient or HCP, you cannot determine decisional capacity.

4. This is particularly important when you consider the big picture of this call. All we know about this patient is that she is elderly, “spitting up,” and due for dialysis today. Does she have hyperkalemia? ACS? Pneumonia? SBO? Just because the nephrologist wants the patient to go to dialysis doesn’t mean that that’s what’s best for the patient. The nephrologist cares about the kidneys. We care about the emergencies. And again, this doesn’t mean that the patient/HCP couldn’t RMA to go to dialysis, but they would need to understand that they’d be risking missing those other potentially fatal diagnoses. Once more for the rafters: if you do not speak with the patient or HCP, you cannot determine decisional capacity.

Hope these points make sense! Reach out with any questions.\

And good luck to all taking the ITE!

Dave

EMS Protocol of the Week - Head, Neck, and Spine Injuries (Adult and Pediatric)

One of the nice things about the newly formatted protocols is that they start to eliminate some of the confusing redundancy with certain medications. A great example of this was for seizures. Under the old formatting, there was a dedicated seizure protocol, but there were also instances, like with the old head injury protocol, where the same seizure medications were described, often leading to inconsistencies if, say, dosages were inadvertently changed for one but not the other. Now, a sweeping change was made to the new protocols, placing topics like seizure management in a single space, with other protocols referring to that space as needed. 

The new protocol for Head, Neck, and Spine injuries is one such example of this. Remember that, like with other trauma protocols, the focus is on good BLS care. In this case, that means ABCs, hemorrhage control, and C-spine stabilization with collar if indicated. ALS care covers advanced airway management and seizure control as needed, with reference to the specific seizure protocol for medication options. Stay tuned for a future email with updates specific to the seizure protocol, but broadly, you’re looking at Standing Order midazolam, lorazepam, or diazepam for adults, with repeat doses as Medical Control Options; or weight-based midazolam as SO for peds, with MCOs also allowing for weight-based lorazepam or diazepam. 

Even though this new formatting may lead to you flipping between a couple different protocols, I think that overall, it helps streamline care in the field and eliminate opportunities for error. Disagree? Reach out! In the meantime, www.nycremsco.org or the protocols binder for more.

Dave

EMS Protocol of the Week - Burns (Adult and Pediatric)

The prehospital burn protocol for NYC is an interesting combination of scene safety, resuscitation, analgesia, and specialty care systems, making it a nice example of all the interplay between the operational and medical aspects of EMS. 

First step at the CFR level is to “stop the burning process,” which, remembering that CFRs are FDNY firefighters, is very funny to me. Beyond that, they’ll remove any clothing, accessories, etc. that may be contributing to injury, start to dress some wounds, initiate eye irrigation, and divert to procedures for carbon monoxide exposure, if indicated. BLS will continue with local wound care and initiate transport.

At the ALS level, paramedics will secure an advanced airway if necessary, obtain IV access, and begin fluid resuscitation. For patients in severe pain, they will administer weight-based morphine or fentanyl by Standing Order in up to 2 doses, to a maximum total of 10mg morphine or 200mcg fentanyl. Importantly, even though those medications are Standing Order, the paramedics require OLMC approval for their use if there is any burn that involves the airway, so be sure to discuss this with crews that call. Other ALS considerations include cardiac monitoring for electrical burns, and topical analgesics for chemical eye exposures.

The Key Points/Considerations section, while probably not directly impactful to OLMC, nevertheless contains some interesting tidbits, ranging from decontamination guidance, to burn center criteria, to references to Burn MCIs, which invoke citywide disaster plans in case of a sudden surge of patients requiring burn center beds. Worth a quick read for a little bit of insight.

Keep it up, OLMC pros! You’re all…on…fire! Ha ha ha, do you get it?

Anyway, www.nycremsco.org or the protocol binder for more protocols (and less jokes).

Dave