16. Increased Standing Orders

I have made my list of the 16 biggest EMS treatment changes over my twenty-year career as a paramedic. I will be posting my list in reverse order over the coming weeks.

16. Increased Standing Orders

When I started as a paramedic 20 years ago, we had to call medical control for permission to give medications far more than we do today, including anytime we wanted to give controlled substances. If a patient was in status epilepticus or had bones sticking out of their leg, we had to call to talk to a doctor for permission to give Valium for the seizure or morphine for the broken leg. What doctor would say no? We did this because at the time in Connecticut there was a law requiring “simultaneous communication” with a physician for a paramedic to give controlled substances.

We had also had to call in many other situations. often whether you got permission or not depended on which doctor answered the phone. Some moonlighters or new doctors didn’t even know our guidelines or would tell us to give drugs we didn’t carry. Recently we had torodol as a medical control option. The problem was some doctors said no to torodol no matter the scenario, while others thought ti was a great drug and always said yes. There was little consistency. In the end, we decided to remove the drug altogether and just up the amount of fentanyl and morphine would could give instead.

We hardly ever have to call for anything now. Our region has decided that if our guidelines are reasonable, we ought to be able to lay out situations where paramedics can do what they need to do on standing orders. For instance, if a medic needs to call in for permission to give a drug like dopamine, he likely has a patient sick enough to demand his full attention and requiring him to get on the phone to talk a doctor, who likely is busy himself, is not an ideal situation. While medics are always encouraged to call if they have any question, as long as they are within our general guidelines they are free to follow them on their own. The only two major situations we call for now are for STEMI alerts to get the doctor to activate the cath lab and on cardiac arrests if we want permission to cease a resuscitation on scene. Overall, the standing order system works great and is a vast improvement over the old “Mother, May I?” days.


  • Zina says:

    My mother fell and banged head pretty bad,she was taking a low does of pain meds also as she has been taken for years.she also has other health issues.she mas been to emergency room on numerous actions for a little confusion or kiney infection ,she is 74,this particular time I made clear she had fallen a few days ago and banged head pretty bad so I had advised her not to take her sleeping pills ,so bye the 3rd day she was very exhausted , when ambulance took her to hospital they immediately did narcan and she became more alert.she had never over dosed and was awake to start just a little confused.i am very upset the way the hospital uses narcan they give to anybody wether needed or not and all it has done was made a bad mark on her name.they found out she had crushed vertibra sbs severe kidney infection beside not sleeping that was probably why she was somewhat confused,the infection an no sleep.but because the use of narcan she is having a hard time getting pain meds.not right ,I thought narcan was supposed to be for over dosing she was never and had never over dosed in her life.she has cancer , fybromyalga,and other painful health issues and they are refusing to help her.im sorry but narcan doesn’t help everyone


    • medicscribe says:

      Narcan in our state is only supposed to be given by EMS for depressed respirations in a pain who is known to have used opiates. It used to be, but is no longer used for coma of unknown etiology. Sometimes, medics give Narcan to patients with altered mental status in the belief that opioids have caused the altered mental status, which sounds like what happened in your mother’s case. This would not be considered appropriate in our state.

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