We can’t wait to see you next year at Fire Rescue 2018 at our stomping grounds in Columbia. If you haven’t been to an event at the Colonial Life Arena and Metro Convention Center here in the Vista, you’re in for a real treat. This year’s theme of FR 2017 was “Racing to the Future” – a very apropos theme for this month’s column as we “race to the future” of medicine with our newly released South Carolina State EMS Protocols!
New Protocols Are On The Street
The bureau would like to share some insight and squash a few rumors about our newly released EMS protocols. First and foremost, we can’t thank doctor’s DesChamps and Clanton for their countless hours of review, correction, and quality assurance oversight they contributed to the DHEC team as we went through more than a year of revision. Without their support and guidance you would not have access to the extremely comprehensive set of protocols we have assembled for you. Some changes will be discussed briefly as to clinical additions and subtractions, but one of the most requested modifications was provided and we are hearing some great feedback from the community on it. This revision cycle, the protocols were done in editable PDF versions, Vice Visio so that they are a bit easier to access and modify for most agencies. Embedded within each protocol is a fillable page for you or your Medical Control Physician (MCP) to add some more guidance, PEARLS, etc. without having to create a new document. Also, on the pages where a medication is indicated for use, only the medication is listed; however, there is an editable field attached to it so that once you and your MCP agree to the dose of that medication to give in that particular situation, you can just plug it in and save it. On the technical side, we had several requests for PDF versions of the protocols to be put out because, according to the requestors, they are easier to plug in to an app creation tool. Yes, that’s right; some agencies are creating an app for the protocols. Pretty neat, huh? A current copy of the PDF version of the S.C. State Protocols can be found at www.scemsportal.org.
The 2017 update expands on the 2010 version and continues to incorporate evidence-based guidelines, expert opinion and historically proven practices meant to ensure that the nearly five million citizens and 12 million visitors to South Carolina will continue to be provided the highest quality pre-hospital patient care available. The South Carolina Department of Health and Environmental Control Bureau of EMS Medical Control Committee provide final approval for these protocols. The purpose of the protocol section is to provide treatment protocols outlining permissible and appropriate assessment, delivery of care, reassessment and procedures which may be rendered by pre-hospital providers. The protocols also outline which medical situations require direct voice communication with medical control. In general treatment protocols are specific orders which may and should be initiated prior to contact with Medical Control. Whereas a Protocol (guideline or algorithm) guides decisions and criteria for diagnosis, management, and treatment of specific cases, a Standing Order is a specific written policy that prescribes a definitive action to be taken for a particular condition or situation. Standing Orders include medication dosages, routes of administration, therapeutic procedures, etc. to be implemented. Standing Orders are often included within Protocols.
How Do They Do That?
These protocols have been developed and implemented through the combined efforts of the S.C. DHEC Bureau of EMS, the S.C. EMS Advisory Committee, the S.C. Trauma Advisory Committee, the S.C. Stroke Advisory Committee, the S.C. EMS for Children’s Committee, and other specialty groups and providers. They have been approved by the Bureau of EMS Medical Control Committee. In developing these protocols input was sought from all the committees listed above, EMS field personnel, as well as private and academic specialists in areas related to specific protocols. These then are consensus protocols.
The question often arises as to why a specific protocol does not follow verbatim a similar protocol published by a national body. For example, why does the South Carolina protocol on Asystole/Pulseless Electrical Activity not follow the AHA/ECC Protocol of similar title exactly? This is a reasonable question and has been much debated.
Why Did They Do That?
First, all protocols are consensus documents and this applies to national organization protocols as much as it does to state or local protocols. The goal of the protocol is to utilize the best information known at the time and to account for generally accepted medical practice. Often the final answer is based on the precept of will this activity harm the patient versus the less defined, will this activity possibly help the patient. In the case of life threatening situations we tend to err on the side of activities that may possibly help the patient, even if evidence to that result is not firm.
Second, often conclusions regarding the benefit (or lack of benefit) are gathered from large, combined meta-studies where the application of that particular intervention was not directly studied, but the results were inferred.
Third, national guidelines generally reflect the most basic, minimum care that we expect to be provided to a patient in a certain situation. National guidelines are not intended to be promoted as a rule to limit what can be done for patients and should not be thought of as such.
Finally, national guidelines often err on the side of not including an intervention where there is inadequate evidence to support its inclusion. This does not equate to the statement that the intervention will not work or is harmful – only that to date, evidence is lacking to support its use. It may be that studies have not yet been done — or cannot be done — to determine the efficacy of a specific intervention. Some typical interventions that are not yet incorporated into national guidelines include double sequence defibrillation, the use of lipid infusion therapy for toxicologic cardiovascular collapse codes, the use of albuterol and/or insulin for hypercalcemia – and the list goes on. These are all utilized in the practical real-world scenario and within the Emergency Medicine specialty.
Similarly, interventions such as transcutaneous pacing or the use of atropine are still being utilized by Emergency Medicine practitioners – even though they are no longer reflected within Authors Statement. (Rev: 20170401 Introduction - Authors Statement (Page AS 2 of 3) 2017 the AHA/ECC National Guideline.) The reasons for this are varied, but are often anecdotal. In an extreme life-threatening situation where previous interventions have not resulted in a positive outcome, we feel that it is not unreasonable to try such interventions.
These are situations where there is truly nothing to lose and a small chance of monumental life-restoring results. Currently the medical literature tends to grade the strength of evidence for an intervention based upon the perceived or documented Benefit:Risk ratio. A Class 1 recommendation generally means that the benefits of the intervention far outweigh the risks of the intervention — with that ratio reversing for a Class 3 recommendation (i.e. the risks of the intervention outweigh the benefits). The Level of Certainty of the recommendation varies from Level A, where large populations have been studied in randomized clinic trials, to Level C, where there is very limited populations which have been studied. Level C also includes consensus opinion of experts or standard of care.
A copy of the Standard Level of Evidence Nomogram is attached to the protocols to help you understand the medical literature as you review it.
Do We You Have To Follow
The S.C. DHEC Bureau of EMS does not mandate the use of all the protocols we produce. Since the cost of doing business is not what you could consider “cheap” in any field of medicine, let alone EMS, we have provided assistance on many levels to help a new EMS system (First Responder or Transport) to make it as easy and inexpensive as possible. The PreMIS, soon to be Continuum system allows a new agency to not have to purchase a records management system. The state protocols provide a nearly all encompassing set of guidelines where you and your MCP can sit down and adopt (or rule out) individual protocols and have a working set in no time at all.
That being said, there are a few protocols that are either mandatory or must be used ONLY as outlined in the State Protocols. The two Protocols that are MANDATED by the Bureau of EMS: Protocol 37 — Field Triage and Bypass. ALL EMS Services MUST adopt this protocol. It is contingent upon the Service Medical Control Physician – in consultation with the Service Director — to specify which facilities within their area meet the criteria for Trauma Centers and to determine to which of these facilities the EMS Service WILL transport patients who meet the appropriate criteria as outlined.
In addition, Protocol 20b – SC R.A.C.E. Tool (Rapid Arterial oCclusion Evaluation Scale) is mandated per statute [“The Department shall adopt and distribute a nationally recognized, standardized stroke-triage assessment tool. Each licensed emergency medical services provider must establish a stroke assessment and triage system that incorporates the department approved stroke-triage assessment tool.”] There has been some confusion on Protocol 20b, as some agencies believe they must follow this protocol and the enclosed transport guidelines verbatim. Currently, you must ONLY include, utilize, and report the S.C. R.A.C.E. score/tool in your protocol. You are not mandated to follow the transport guidelines; they are only guidelines at this time.
As always, we recommend you transport your patients to the closest appropriate facility for their specific malady, but understand that may not be accomplished 100 percent of the time. All other protocols are optional to be chosen and utilized by the EMS Service in consultation with and approval from their local MCP. However, within the remaining protocols there are three protocols – which if adopted by the service - MUST be followed as written. These Protocols are:
- Protocol 9 – Rapid Sequence Intubation
- Protocol 16 – Adult: Pain Management
- Protocol 45 – Pediatric: Pain Control
We have done our best to provide the most accurate, up to date clinically protocols for your use, if you so choose. No group is infallible and we certainly do not claim to be. There were many bleary eyed nights of diet Mountain Dew and designer pizzas that went in to the production of these documents for you. Should you review the protocols and have a specific question or comment, there is a dedicated email address for just such a purpose. Please direct your inquiries to [email protected].
These medical treatment protocols are established to ensure safe, efficient and effective interventions to relieve pain and suffering and improve patient outcomes without inflicting harm. They also serve to ensure a structure of accountability for Medical Directors, EMS agencies, pre-hospital providers and facilities to provide continual performance improvement. A recent report of the Institute of Medicine calls for the development of standardized, evidence-based pre-hospital care protocols for the triage, treatment and transport of patients.
To summarize: These protocols establish current recommendations of pre-hospital care in South Carolina, these protocols are a consensus document, and these protocols will be frequently revised and updated. There is no single way to provide good medicine.