EMS Protocol of the Week - General Cardiac Arrest Care (Non-Traumatic) (Adult)

The prehospital approach to general cardiac arrest care is a good introduction to the progression of responsibilities from one level of training to the next. We get a large number of OLMC calls from our own paramedics requesting physician input in arrest cases, so it’s always good to refresh ourselves on what they can or cannot do in these instances.

Note that everything in the attached protocol is Standing Order, which, as a reminder, consist of the steps that EMS providers should be performing by default without any additional physician input.

At the CFR level, providers who encounter a patient in arrest will initiate CPR and apply an Automated External Defibrillator, following the AED’s instructions until backup arrives.

BLS providers (EMTs) will request ALS backup if not already present, but will otherwise begin to transport the patient to the hospital after 3 rounds of CPR/AED analysis.

It’s not until the ALS (paramedic) level that an actual cardiac monitor will be applied, giving a specific rhythm underlying the arrest. It’s for this reason that you might hear something from the paramedics like “our initial rhythm was asystole; patient was shocked 2 times (by AED) prior to our arrival.” From there, paramedics will branch off into separate protocols based on the specific type of arrest, each consisting of their own Standing Orders and Medical Control Options.

Can’t wait to find out more specifics? Tune in next week for more cardiac arrest talk! Or, for spoilers, there’s always www.nycremsco.org and the protocol binder!

Dave

EMS Protocol of the Week - Introduction

Another year, another trip around the sun, and just as the sun rises and falls, just as the seasons change, so too do you have another EMS PoTW email gracing your mailbox. 

Interns, fellows, and new faculty, welcome to the Maimo fam! These emails, while destined to be your favorite part of every week, will start to make more and more sense after you get your lecture and hands-on time with the On-Line Medical Control (OLMC) phone. Until then, use these emails as a reference going forward!

Everyone else, welcome back! This week feels as good a time as any to reinforce some OLMC basics, starting with how to read these protocols (found here, at www.nycremsco.org, and the protocols binder next to the phone [you know, the one you always pick up by mistake]). Take a look at the attached pdf for a refresher on protocol formatting, but here are the big points:

1. Each protocol is divided into dedicated sections for CFR (firefighters), BLS (EMTs), and ALS (paramedics).

2. Each protocol reads top to bottom, in sequential order, but each section builds on the section before it (remember, “Good ALS care starts with good BLS care”). CFRs will stop at the end of their section, EMTs will cover everything between the CFR section and the BLS section, and paramedics will cover everything from the CFR, BLS, and ALS sections.

3. Standing Orders (SO) describe everything explicity written in each of these sections that EMS providers are expected to do by default. Medical Control Options (MCOs) are found at the end of each protocol and describe what providers (usually paramedics) can do after calling OLMC for physician approval; the most common example of this would be paramedics requesting to give calcium chloride and sodium bicarbonate during a cardiac arrest.

   1. Discretionary Orders (DO) are those that you, as the OLMC physician, are requesting the providers to perform but are not explicitly written in the protocols as either SO or MCO. The order must be for something that the crew already carries and is trained in using; a common example for this is having our paramedics use ketamine for intubation, because they use it in another protocol (Excited Delirium), and it’s not currently listed as a sedation option for airway management. On the flip side, you cannot ask the crew to give propofol as a Discretionary Order, as this is not a medication that they carry or know how to use. Discretionary Orders highlight the importance of having a general understanding of what EMTs and paramedics can do and how their ambulances are stocked.

   2. While we use 18 as the age cutoff for whether or not a patient is a minor, for the purposes of these protocols, the NYC REMAC defines pediatric patients as up to 15 years of age.

Let all of that simmer like a nice, hot, mid-July soup, and we’ll see it put into practice next week! Until then, don’t forget about www.nycremsco.org and the protocols binder.

Dave

EMS Protocol of the Week - Drowning/Decompression Illness (Adult and Pediatric)

It’s summertime! Which means it’s hot out! Which means people are going swimming! Which means people are drowning!

Not a ton unexpected out of the protocol for drowning and decompression illness. ABCs again, with a reminder for spinal precautions as needed. The protocol refers out to the previously discussed section on Cold Emergencies for suspected hypothermia and reminds providers to initiate CPR on pulseless hypothermic patients. For suspected decompression illness, EMTs will place the patient left side down in case of air emboli. Most importantly, they are instructed to transport the patient and any companion divers to the nearest appropriate hospital (in this case, one with hyperbarics). The attached appendix is a list of facilities with specialty care capabilities, including hyperbarics.

That’s it! ABCs, protect the spine, know where to look up the closest dive tank, and you’re not dead til you’re warm and dead!

See you all next week! www.nycremsco.org and the protocol binder for more.

 Dave