Many years ago here in Connecticut each of the hospitals in the state had their own set of treatment guidelines for the paramedics they sponsored. In our company some of our medics were sponsored by Hartford Hospital, others by Saint Francis Hospital.* Each hospital had a different set of guidelines, even though their medics worked the same basic territory. Due to the nature of EMS in Connecticut, and the multiple number of ambulance services at the time, some medics worked for three or more services and had to keep all the different guidelines in mind.
About twenty years ago, the hospitals in our region got together and agreed on a single set of guidelines that are reviewed and updated annually. Our regional guidelines became somewhat of a model for the state, and large portions of them have been incorporated by other regions or hospitals. We were early adopters of controlled substances on standing orders with generous analgesia doses (eventually up to the current total of 300 mcgs Fentanyl), selective spinal immobilization, cessation of resuscitation on scene (yes, we used to transport all codes we worked), CPAP, and eliminating Lasix. More recently, we adopted high benzo doses for seizures (10 mg of Versed IM or 4 mg of Ativan IV), as well as for violent psychs, high dose NTG for CHF (0.8 SL), and D10 for hypoglycemia instead of D50.
You can read our guidelines here:
We have long had a statewide EMS Medical Advisory Committee. Years ago, the group meetings were referred to as “Adventures at the Star Wars Bar” because of their contentiousness. Many of the medical directors were old school and did not have a great deal of respect for paramedics (or for the opinions of other physicians). As time went by a new breed of EMS physician arrived on the scene, doctors who either had been paramedics themselves or who had ridden with medics as part of their medical training. These new EMS physicians are pro paramedic and they stay up on the latest research. In recent years we have adopted several statewide guidelines, including being the first state in the country to outlaw long boards for spinal immobilization and one of the first to make cardio cerebral resuscitation the standard for the state.
Over the last year, the state committee, under the leadership of the statewide OEMS Medical Director, has been working on not just unified statewide paramedic treatment guidelines, but eventually uniting with the rest of the New England states in having New England wide guidelines. We have been using New Hampshire as our role model.
Take a look at the New Hampshire guidelines here:
They are very progressive. In our meetings to review the guidelines we adopted the mantra â€œTie Goes to New Hampshire.â€ If the guideline was close enough, then we would go with what New Hampshire had. The committee reviewed the entire set of guidelines, and then distributed them to each of the regions to review and comment on. We just finished our regional review of them. The state is now taking all the regional comments and forging them into a new consensus document that will be forwarded back to the statewide medical committee to review in open committee. The final document will still allow individual regions or hospitals to differ, but if they do differ, they will have to report their differences to the state committee and monitor those differences closely. Likewise, if a region or hospital wants to pilot a new guideline, they will let the state know and then come back with a report on its effectiveness. As I understand it, the states will get together and mold their documents together so there will eventually be one document for all the states.
I like many of the changes made, and am hopeful that two of my pet guidelines â€“ high dose benzos for violent patients (we have a lot of crazed PCP patients in Hartford) and high dose NTG for CHF (it works!) will make it into the final document, but I recognize that for the document to succeed, all will have to agree. There will inevitably be some compromise. I trust there will also be a process for annual review and input. Having all the states working together, with their progressive medical directors, will likely lead to the best evidenced based guidelines and ultimately the best patient care.
This is a great news for us in EMS.
*In our state, EMS services are affiliated with sponsor hospitals that provide the medical control for the serviceâ€™s paramedics to practice. Our company, the Professional Group, was actually an amalgam of four different acquired ambulance companies, Professional, L&M, Trinity, and Maple Hill. L&M, whose uniform I wore, and Trinity were sponsored by Saint Francis Hospital, Professional and Maple Hill were sponsored by Hartford. While Saint Francis paramedics had to ride in either L&M or Trinity Ambulance, and the Hartford paramedics had to ride in the pro or Maple Hill Ambulances, company EMTs could ride in any of them. My first partner wore the light blue Pro uniform, while I wore the dark navy blue L&M shirt. What was great about the setup was that if a nursing home got upset about the service of Professional Ambulance, they would call L&M, or one of the other three. There were four different numbers, and all were answered by the same dispatcher. The other ambulance company in town was outnumbered four to one. That was the old days, of course, before we were acquired by a nationwide company.
For True to Life EMS Fiction about Hartford EMS in the 1990’s(during the Latin gang wars), order Mortal Men Today.