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 - Traumatic Cardiac Arrest (Adult and Pediatric)

There aren’t many huge differences between prehospital protocols for traumatic cardiac arrest compared to non-traumatic arrest within NYC. As you might imagine, ambulances in the city aren’t equipped to crack chests or initiate MTP when they’re likely a stone’s throw away from a trauma center. As such, the protocol puts a heavy emphasis on rapid transport, beginning at the BLS level of care. Until the patient has gotten to the ED, much of the arrest care is otherwise the same – CFRs will start CPR and apply an AED, and BLS will request ALS backup (although if they are able to get the patient into the ambulance and transport before ALS arrives, they will – hence why you may receive such patients without vascular access or an airway, so be prepared!). 

Once you get to the ALS level, the patient will get a definitive airway, as well as a needle decompression if there is concern for a tension pneumothorax. Paramedics will start cardiac monitoring and adjust their management based on the presenting rhythm – namely, whether or not defibrillation is indicated. Otherwise, crystalloid fluid resuscitation will be initiated – up to 3 liters for adults, or up to 40 mL/kg for pediatrics. 

That’s really it as far as the prehospital traumatic arrest toolbox. Given the proximity of trauma centers in the city, “scoop and run” tends to be the name of the game rather than “stay and play.” There aren’t big pushes for things like prehospital TXA or blood products at this point, although I’m happy to hear people’s thoughts on that if anyone disagrees. Just remember that at least this way you’re left with something to do once the patient gets to the ED!

Happy resuscitating! www.nycremsco.org for more!

Dave