California Paramedic Regulations are Open for Public Comment

Posted by Patrick Lickiss on Sep 21, 2011 in Current Events, EMS 2.0, General, Treatment | 26 comments

Did you hear that?  That was the sound of my brain exploding.  Seriously.  If you’ve read this blog for any length of time, you’ll know that I’m a huge advocate for expanding the role, educational requirements and scope of practice of prehospital practitioners.  I may finally get my vindication.

The State of California is looking at revising their scope of practice to fall in line with the National Scope of Practice Model.  This can’t happen soon enough.  There are three main areas of focus:  additions to the paramedic scope, establishing a standard for Critical Care Transport Paramedics (CCT-P) and Advanced Prehospital Paramedics (APP) and revising minimum standards for controlled substances management.  Since narcotic control is a dissertation in itself, I’ll focus on the first two topics today.

BASIC PARAMEDIC SCOPE
Alameda County readers of this blog will note that many of the changes detailed below represent medications we already give and treatments we already perform.  It’s important to note that local medical directors ultimately control what happens in their system and that many counties have requested permission from the state to incorporate these treatments already.  Adding these to the state scope means that special permission won’t be necessary and that local medical directors can add these items to their protocols with ease.

Medications

• Amiodarone
• Dextrose 10%
• Diltiazem
• Fentanyl
• Ipratropium
• Lorazepam
• Magnesium Sulfate
• Ondansetron (Zofran)
• Potassium up to 40 meq

Procedures

• External pacing
• Perilaryngeal airways and pediatric endotracheal intubation
• CPAP/BiPAP
• Intraosseous Insertion
• Prehospital lab tests including capnography and carbon monoxide monitoring
• Naso and orogastric insertion and suctioning
• Intranasal medication administration

Not a bad list of additions if you ask me.  I’m glad to see a move towards fentanyl for pain management and I think that lorazepam is better suited for sedation than the midazolam most of us are using now.   Standardizing CPAP and IO usage is a great idea as well.  We’ve had excellent results here with both and I think those skills will serve other systems as well.

CCT-P/APP
Now this is what I’m really excited about.  Several counties in the Bay Area have implemented CCT-P programs but this opens that idea up to the rest of the state and expands to allow advanced ALS practitioners.  The state would standardize the training programs for both designations and allow local medical directors to authorize these levels of care without additional state approval.  Let’s start with the CCT-P scope:

• Set up, maintain and troubleshoot thoracic drainage system.
• Set up, maintenance and troubleshooting of a mechanical ventilator.
• Set up, maintenance and troubleshooting of fluid delivery pumps and devices.
• Administer medication infusions during interfacility transports including, Heparin, blood and blood products, Glycoprotein IIB/IIIA inhibitors, nitroglycerine, norepinephrine, TPN, and thrombolytics.

Not too shabby.  This allows systems to develop CCT-P level interfacility units with the ability to backup the 911 system, or to train a portion of their 911 responders to perform these transfers, depending on the volume of either type of call.  I’m actually an advocate for the second option.  By providing advanced training to interested 911 responders, you not only obtain the ability to utilize them for complex transfers (which likely have a higher reimbursement success rate than 911 calls) but you also win on the 911 side by having better trained providers caring for your emergent patients.  Everyone wins.

Now, on to the coup de gras…Advanced Prehospital Paramedics:

• Perform digital and nasotracheal intubation procedure.
• Surgical cricothyrotomy.
• Perform procedure for facilitated intubation using sedation and neuromuscular blockade.
• Set up, maintenance and troubleshooting of a mechanical ventilator.
• Administer medication including succinylcholine and etomidate.
• Administer OTC medications.
• Assess and refer patients, and assess and provide treatment without transport.

Now the likelihood is that I’ll be writing about this level of care for some time to come so let’s start with the big one:  ”Assess and refer patients, and assess and provide treatment without transport.”  Simply awesome.

One of the biggest roadblocks to APP programs is the inability to bill for services.  State and Federal insurance programs (and most privates) reimburse for transport only.  The addition of treat and release/treat and refer to the state scope is a huge step towards advocating for EMS reimbursement for those programs.  Making those programs sustainable means that they can be rolled out on a state-wide basis.  Now you see why I’m so excited about this and I hope you are too!

If you’re interested in reading the regulations in their entirety or making your voice hear during the public comment period, head over to the EMSA website. The period for public comment ends October 24th!

What are you looking forward to in the future of EMS?  Were any of those addressed in this scope update?  What are your next steps towards making your EMS dreams a reality?

Image via Flickr

Upcoming Randomized Trial of Assessment and Referral by Paramedics

Posted by Patrick Lickiss on Aug 17, 2011 in Assessment, EMS 2.0, General, Research, Treatment | 2 comments

By far, one of the possibilities for the future of EMS which excites me the most is generally characterized as “community paramedicine”.  The idea that paramedics will be placed in a position to treat and release and treat and refer in the field, diverting patients from the local emergency rooms is an exciting one to be sure.  The first step in rolling out a system like that, however, is determining whether or not paramedics can safely determine which patients don’t actually need an ambulance transport.  Published recently in BMC Emergency Medicine (PDF link) was the study protocol for just such an experiment in Perth, Western Australia ^[1].

INCLUSION/EXCLUSION CRITERIA
Patients will be considered for the trial if they are suffering from the following conditions:

• Isolated minor injury
• Simple infection
• Hardware problem (like issues with a urinary catheter)

The exclusion criteria are:

• Younger than 16
• Third trimester pregnancy
• Not in the patient’s residence
• Residence is unsafe
• GCS < 15
• SpO2 < 95% on room air
• Heart rate > 100
• Systolic BP < 100
• Pain requiring narcotics
• Patient unable to wait four hours for further treatment

STUDY DESIGN
For patients meeting the eligibility criteria, the paramedics will call in, provide enrollment information and be told if the patient is randomized into the control arm (transport by ambulance to the ED) or the intervention arm (referral to the in-home hospital service).  Within four hours, a home hospital service nurse or nurse practitioner will respond to the patient’s residence for evaluation and treatment.  The patient might be treated and then released from the service, enrolled into ongoing care or referred to the ED.  As a side note for US readers, check out the website for Silver Chain, the home hospital service.  This is an amazing concept.

OUTCOMES
The primary outcome focus of the researchers is the proportion of patients needing unplanned medical care within 48 hours of enrollment.  The secondary outcome focuses include a variety of clinical, operational and investigatory measures.  Additionally, cost benefit and patient satisfaction data will be collected and analyzed.

ESTIMATED OUTCOMES
With an annual transport volume of approximately 100,000, researchers estimate that they can enroll roughly 10% of their total patient base in the study.  With a goal of 940 patients in both the control and intervention arms, it is estimated that patient enrollment will be completed within a year.

DISCUSSION
As I mentioned earlier, this is a truly exciting possibility.  If paramedics can be shown to safely determine whether or not a patient can be treated at home, it opens the door to diverting at least a portion of patients from overwhelmed Emergency Departments.  As the researchers note, there have been mixed messages in the literature about the ability of paramedics to safely evaluate patients for non-transport.  This study seems well designed and isn’t biting off too much at once.  By focusing on one piece at a time, the researchers appear to be approaching this type of program the right way.  I’ll keep an eye out for the completed study and will let you know the results when it is published, likely next year.

CITED ARTICLES
[1]- Arendts G, et al.: “ParaMED Home: A protocol for a randomised controlled trial of paramedic assessment and referral to access medical care at home”. BMC Emergency Medicine 2011; 11:7.

Image via Flickr

Evaluation of the Canadian C-Spine Rule Continues

Posted by Patrick Lickiss on Jul 27, 2011 in Assessment, General, Research, Treatment | 2 comments

In an article published in February in the BioMed Central of Emergency Medicine (an OPEN journal by the way, not charging $85/article!) a study protocol was laid out for the next phase in the evaluation of the safety of the Canadian C-Spine Rule (CCR).  The full text of the article may be found here (PDF link).

For those not familiar, the CCR is a spinal clearance tool which is basically a cross between the State of Maine and the NEXUS criteria you’ve likely seen physicians use in the ED.  There’s a nice flow chart in the article, but the basics are as follows:

• Does the patient have a high risk factor indicating immobilization?
  • Older than 64 years
  • Dangerous mechanism
  • Numbness/tingling
• Does the patient have one low risk factor?
  • Minor rear-end MVC
  • Ambulatory on scene
  • No neck pain when asked
  • No neck pain with palpation
• Can the patient rotate their own head, left and right, to 45 degrees, regardless of pain

I really like this technique because it just makes sense:  Do they have any big things to worry about?  No.  Do they have something which indicates they’re uninjured? Yes.  Can they move their head? Yes.  Fantastic, don’t c-spine!

A BRIEF HISTORY OF THE CCR
The researchers in Canada have clearly been doing their due diligence.   This project has been on going, in one form or another, for the past 10+ years.  The CCR was first written about in 2001 and was compared at the time to both the standard NEXUS exam and radiological results.  Since then, the procedure has been validated amongst physician, ED triage nurse and paramedic level practitioners.  During the phase I and II trials, the CCR demonstrated a 99.7% sensitivity ^[1].

The researchers have since implemented the protocol amongst physicians in  multiple hospitals and are studying implementation amongst ED triage nurses as well.  One line in the article really stuck in my head after reading it:  ”While we hope to demonstrate that ED triage nurses can safely remove patient’s cervical immobilization devices, it would be significantly more valuable if we could empower the paramedics to selectively forgo immobilization in the first place, and avoid great discomfort to patients.” ^[1] Simply put, I love this idea!  If we have access to a tool which can benefit our patients, why don’t we give it to everyone involved in patient care, so that we can significantly benefit our patients more often!

Additionally, I love the idea of standardizing something like ruling out spinal immobilization across all levels of care from pre-hospital to in-hospital.  The main thing holding this article/study back from being one of the most ground breaking in EMS is the actual statement that spinal immobilization is not, in fact, beneficial and actually harms our patients.  But that might be asking too much.

At any rate, check out the article and stay tuned, the idea of standardizing care across practitioner levels is an interesting one that bears more reflection.

ARTICLE CITED
[1] - Vaillancourt C, et. al: “Evaluation of the safety of C-spine clearance byparamedics: design and methodology”. BMC Emergency Medicine 2011 11:1.

Image via Flickr

Does Real-Time Feedback During CPR Affect Outcome?

Posted by Patrick Lickiss on Jul 20, 2011 in General, Research, Treatment | 4 comments

Today’s ECG monitors are amazing pieces of equipment.  Between transmitting 12 leads over a Bluetooth connection to tracking an entire cardiac arrest from start to finish, there is little these monitors can’t do.  One recent addition (that I’ve seen on Zoll and Phillips monitors) is real-time audible and visual feedback with regard to the quality of compressions and ventilation.  At first glance, this seems like a great idea.  The more compliant the resuscitation, the more likely a positive outcome right?  Well a recent article in the British Medical Journal looks at precisely this relationship ^[1].

BACKGROUND
This study enrolled 1586 patients in cardiac arrest spread over three Resuscitation Outcomes Consortium sites.  Each site used the Philips MRx monitor with the Q-CPR software and force transducer.  Field crews were trained in a manner consistent with their local requirements and worked for three months to familiarize themselves with the monitor.

The monitor provides visual and audible feedback about the frequency, depth and release of chest compressions as well as the ventilation rate.

Philips MRx Monitor/Defibrillator with Q-CPR

DESIGN
After a period of familiarization, groups were created within the study area and were assigned to start with “feedback on” or  ”feedback off”.  All groups used the Q-CPR software and hardware to track CPR quality regardless of feedback status.  After a period of time (ranging from two to seven months) each group changed to the other arm of the study.  This rotation back and forth continued for the remainder of the study.

PATIENT POPULATION
Of the 1586 patients, 771 were enrolled into the “feedback off” group and 815 were enrolled in the “feedback on” group.  Demographic information was roughly the same for each group with about 60% of the patients being male, 10% suffering cardiac arrest witnessed by responders, 40% arresting while witnessed by bystanders and 50% receiving bystander CPR.  The most common presenting rhythm was asystole and all patients received ALS care on scene.

Patients were left out of the study if they were known to be incarcerated, pregnant, had a DNR or suffered cardiac arrest from primarily traumatic causes.

FINDINGS
The researchers began by analyzing quality of CPR provided.  When comparing the codes in each group, they found that compression rate, depth and full release were all closer to the AHA guidelines (specific values can be found in the full text (PDF link) of the article) when feedback was “on”.   There was no significant difference in ventilatory rate noted.

The study authors then looked at prehospital ROSC, presence of pulse at the ED, survival to discharge and discharge awake.  Interestingly enough, they found no difference between the group “with feedback” and “without feedback” despite the fact that the feedback group did “better” CPR.

SO WHAT?
The study authors state that improved CPR has indeed been linked to improved patient outcomes.  They also note that visual and audible feedback improved CPR performance.  So why didn’t these patients do better in the short or long term when the providers were given feedback?  The researchers suggest that perhaps the improvements in CPR noted here were not sufficient enough to improve outcomes.  Perhaps, they suggest, real-time feedback makes the most difference in situations were CPR is poor (rather than adequate) to begin with.

Another idea is that the feedback is only given by the monitor when CPR performance falls below the standard.  A better form of feedback may be goal directed, like a tone at 100 beats per minute rather than an audible feedback of “speed up” or “slow down” when quality suffers.

Ultimately, high performance CPR is what is improving our patient outcomes.  Whether real-time feedback helps accomplish that goal remains to be seen.  Does your system use real-time feedback for cardiac arrest?  What about feedback for the crew after the call during the QA/QI process?  What works?  What doesn’t?  Drop me a line in the comments.

NOTE: This article is not an endorsement or review of the Philips MRx.  This product is mentioned only because it was the specific device used by the study designers.

CITED ARTICLES
[1] - Hostler D, et al.: “Effect of real-time feedback during cardiopulmonary resuscitation outside hospital:  prospective, cluster-randomised trial”. BMJ 2011; 342: d512.

Image via USAF

Pediatric Poisoning Refresher

Posted by Patrick Lickiss on Jul 13, 2011 in Assessment, General, Research, Treatment | 2 comments

While browsing through recent journal articles, I came across a retrospective study published by the University of California at San Diego Emergency Medicine Department ^[1]. Looking back at eight years worth of EMS documentation (this is one of the limitations of a retrospective study) the researchers attempted to quantity particular information about pediatric poisonings in that time period.  I say that this is a limitation of a retrospective study because the validity of the research relies on the quality of documentation performed before the study was designed.  This can prove to be time consuming and may not yield useful results.

THE FINDINGS

There were more than 40,000 paramedic transport calls for patients 5 years and younger over the study period; 996 (2.5%) of these calls had the chief complaint of poisoning. Of the calls classified as poisonings, 38% involved a 1-year-old and 35% involved a 2-year-old. Fifty-six percent of these poisonings involved either prescription or over-the-counter medications. An additional 16% were due to household cleaners. Eighty-eight percent of all calls were classified as mild in acuity, with 13% of poisoning calls for children under a year of age classified as moderate or acute; 50% of moderate or acute poisoning calls were to children 2 years of age. July and March were the months with the highest incidence of poisoning calls. The fewest calls were received on Saturdays and Sundays^[1].

There are a few items of interest in these findings.  First of all, the vast majority (over 70%) of poisonings take place with patients 2 years old and younger.  It seems like a lot of presentations in that population should including poisoning as a potential differential diagnosis, particularly if you are struggling to find a cause for the symptoms.  Next, the majority of poisoning calls for pediatrics involve medications.  Keep in mind that therapeutic effects in adults are potentially fatal in pediatrics.  This is especially true with regards to medications targeted at the cardiovascular system like digoxin and beta-blockers.  Finally, “moderate” or “acute” poisonings were more likely to occur with patients two years of age.  This is logical as these patients are becoming more active and mobile.  When responding to patients in this age group (for other calls, not for poisonings) take a quick look around on scene and see if there are medications or household cleaners in easy reach of children.  This is the perfect opportunity to provide some education to the family, particularly if you’re not the primary caregiver.

NATIONAL STATISTICS
According to the American Association of Poison Control Centers,  over 52% of poisonings in 2009 occurred in patients aged 0-5 years.  Since 2006, the pediatric ingestion of analgesics has seen a particularly marked increase ^[2].  According to the CDC, children are twice as likely to be seen in the Emergency Department for medication poisoning as they are for poisonings from household cleaners ^[3].

ACTIONS WE CAN TAKE
We discussed earlier about maintaining an elevated index of suspicion for poisoning in pediatric patients.  We also discussed gently providing education to caregivers when an unsafe situation is discovered on scene (though not necessarily during a response for poisoning).  What about treatment options?  Poison Control is a valuable resource and every EMS practitioner should have the number in his or her cell phone.  Poison Control is staffed by medical providers who are able to provide you with valuable information, even if you do not know the exact toxin which has been ingestion.  Often, the individual answering the phone will be able to determine the substance based on partial labels, color, uses, etc.  I have had excellent luck with identifying myself as a paramedic on scene of a 911 call after the line is answered.  I am often transferred to a pharmacist right away and have been able to get treatment suggestions as well as findings (including ECG changes) to watch out for.  After that, it’s as easy as contacting my base hospital, letting them know that I contacted poison control and getting an order to treat as suggested by the pharmacist.

I encourage everyone reading this to stop for a moment and put the following number in your phone:  (800)222-1222.  You can call that number from anywhere in the U.S. and you will be connected to your local poison control center.

So how about it?  Have you used Poison Control on duty?  What about off duty?  What was your experience like?  Are you taught about using Poison Control during annual training?  Let me know in the comments.

CITED ARTICLES
[1] - Vilke GM: “Pediatric Poisonings in Children Younger than Five Years Responded to by Paramedics”. J Emerg Med 2011 Jan 5, [Epub ahead of print].

[2] – American Association of Poison Control Centers – 2009 Detailed Statistics (PDF Link)

[3] – Centers for Disease Control and Prevention – Poisoning Factsheet

Image via Flickr

AHA Bradycardia Algorithm – Pacing or 12 Lead?

Posted by Patrick Lickiss on Jun 15, 2011 in Assessment, General, Treatment | 7 comments

I was e-mailed a few weeks ago by a friend of mine who had a question about the wording in the AHA guidelines with regards to symptomatic bradycardia and whether it was appropriate to perform a 12 lead ECG before pacing.  He described a patient who presents as hypotensive and diaphoretic with a three lead ECG showing a 2nd degree type II AV block at a rate in the 30s.  The other provider on scene performed a 12 lead ECG before pacing and found that the patient was experiencing an inferior wall MI with elevation in leads II, III and avF.  Excerpted (with permission) are a few lines from that e-mail:

In this case, the 12 lead prior to pacing was very useful, as the hospital used it to make a cath lab decision…but they still took another 12 lead as we switched monitors and before they started pacing again.  ACLS says ‘immediate’ cardioversion or pacing for symptomatic patients.  It doesn’t say anything about getting a 12 lead first.  Had it been my call, I would have been pacing a few minutes earlier and would have never bothered with a 12 lead.  What do you think?

This is a sticky situation.  In reviewing the 2010 AHA guidelines for bradycardia, the statement is made under the heading “Identify and treat underlying cause” to perform a “12 lead ECG if available; don’t delay therapy” ^[1].  Now that seems pretty cut and dry:  If a patient is bradycardic and is symptomatic, treat them as such and figure the rest out later.  I have another thought, however.

What does a patient in symptomatic bradycardia ultimately need?  They need the cause of their altered heart rhythm fixed.  In the scenario presented to me, that cause was a STEMI.  Is a basic ED going to be able to fix that underlying cause?  Nope.  What are they going to do for that patient?  Probably IV fluids, pacing and dopamine, all of which can be accomplished in the back of your ambulance.  If your closest ED happens to be a STEMI specialty center then your destination won’t change regardless of the reading on the monitor.  But what if you have a basic ED 10 minutes away and a STEMI center 15 minutes away?  Suddenly that ECG is potentially pretty important.

In my opinion, one of the most important things we do in the field is make destination decisions.  At the end of the day, our job is to get the patient to definitive care.  The decision of where to take a patient is an important one and cannot be made without thorough assessment.  In this case, I believe that “thorough assessment” includes a 12 lead ECG.  With proper team work, that 12 lead can be performed while someone else sets up pacing.

Another common scenario in the field is whether to give nitroglycerine for chest pain before a 12 lead is performed.  While less emergent than pacing, the thought process is similar.  Why would you perform a treatment that could obstruct your ability to determine what the underlying cause of the patient’s condition is?  This negatively impacts your ability to get the patient to the correct destination.  Tom Bouthillet over at EMS 12 Lead has a great case study about this exact phenomenon.

Again, the decision to pace a symptomatic patient is very different than the decision to administer nitrates for chest pain.  Consider, however, the implication of performing that 12 lead ECG while pacing is being set up, particularly if it may alter your destination decision.  Be sure to consult with your medical director before making treatment decisions like this.  I think it’s a worthwhile conversation for us to have with our directors, what do you think?

CITED ARTICLES
[1] - Neumar RW, et al.: “Part 8:  Adult Advanced Cardiovascular Life Support:  2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation 2010; 122: S729-67.