Q: I work for a service that spends far too much time on scene and worse yet, they have sometimes delayed transport to wait for ALS! Is there anything in the protocols that relates to delaying patient transport?
A: EMTs at all levels are trained naot to delay transport; this is a standard of care. Under EMS System Regulations 105 CMR 170.940(C), EMTs are held to that knowledge base and must exercise reasonable care, judgment, knowledge and ability and perform their duties in accordance with their training and the Statewide Treatment Protocols.
Until 2014, the Statewide Treatment Protocols included, in each and every specific protocol, a statement about not delaying transport. When the Protocols were overhauled and redesigned, all the repetitive standard instructions were removed from each protocol and put in a Routine Care Protocol which is applicable to every patient encounter. The language about not delaying transport was accidentally omitted, but will be restored as part of the Routine Care Protocol in next year's (2015) update to the Statewide Treatment Protocols.
It is important to note that EMTs at all levels are still required to carry out their duties without delay, including not delaying transport, even though this statement isn’t spelled out in the 2014 protocols.
Q: Is it acceptable to immobilize a patient with a c-collar on an ambulance cot with the 5 point stretcher harness instead of using a backboard? Do the current OEMS protocols allow providers to avoid use of KED, short board, and long board? What is the proper spinal immobilization procedure today?
A: It’s not only acceptable to immobilize a patient with a c-collar on an ambulance cot and 5 point stretcher restraint instead of using a backboard, it's consistent with Protocol 4.8 Spinal Column/Cord Injuries. Refer to Protocol 6.4 Selective Spinal Assessment for details allowing EMTs to forgoe a c-collar in certain circumstances.
The long board as simply an extrication device when needed to move a patient downstairs, or out of a vehicle. A short board can be used for CPR if a patient suffers a cardiac arrest during transport in the back of the ambulance and you need to place a hard surface behind them. The KED is optional (see AR 5-401 Ambulance Equipment List: BLS).
Q: I heard the new protocols restrict the use of lights and sirens when transporting a stable patient to the hospital. Is that true?
A: This is not new. The old protocols worded it as “Remember that ambulance crashes are a threat to both crew and patients: use lights and sirens only when indicated due to patient condition or circumstances.” It’s now worded more clearly “Use of lights and sirens should be justified by the need for immediate medical intervention that is beyond the capabilities of the ambulance crew using available supplies and equipment.”
You may be interested in: The Truth About Using Lights & Sirens
Q: Do all levels of pre-hospital providers need to have Protocol Update training when the protocols are released, even if they just finished the National Registry exam and are newly certified?
A: Yes, the service must ensure their EMTs have current training in the state protocols before they may operate as an EMT on an ambulance. A protocol course (not just the update) is especially important for new EMTs because the initial EMT course and certification exam is much more general and not focused on the details of the state protocols which should be viewed as a “living” document that is ever changing as new science is adopted. In addition, MA EMS regulations (specifically 105 CMR 170.333) requires that “Each service shall operate, and shall ensure that its agents operate, in accordance with MGL c. 111C, 105 CMR 170.000, all other applicable laws and regulations, the Statewide Treatment Protocols, where relevant, administrative requirements of the Department, and the service’s established policies and procedures that are consistent with 105 CMR 170.000”
Q: AR 5-500 (7/2013) advises that “chemical restraint” is not authorized…but in the new protocol paramedics have standing orders for benzo’s and Haldol?
A: Chemical restraint is NOT authorized. Benzo’s and Haldol are to be used when patients need relief from severe agitation. They are NOT to be sedated to the point of immobility.
Q: What do I do if I am on-scene and a physician tells me to do something contrary to the statewide treatment protocols?
A: EMTs operate under "off-line" medical control through the MA EMS pre-hospital treatment protocols while "punched in" at a licensed ambulance service. (EMT certification doesn't apply "off-duty").
If an EMT is working for a service and is assigned to cover a football game with instant radio communication for immediate ambulance dispatch, and a physician on-scene wants to provide advice that conflicts with the current MA EMS pre-hospital treatment protocols; the EMT should contact medical control (the Affiliate Hospital Medical Director for an ALS level service, the service medical director for a BLS level service, or an ED physician at a hospital licensed to provide medical control to which the patient will likely be transported). This communication should be facilitated through CMED to ensure the transmission is recorded. Bear in mind that the physician on-line will likely ask how the EMT knows they are dealing with an MD, so the EMT should ask for proof beforehand that the individual is, in fact, a physician with training in Emergency Medicine.
If, in extenuating circumstances, there is a communications failure (see Communication Failure Policy) and medical control is not reached; the EMT should tell the physician on scene that s/he will need to accompany the EMT/patient to the hospital if the EMT accepts the advice given by the physician on scene.
As with all calls, the EMT should carefully document everything that transpired on the patient care report.
Q: You respond to a single-vehicle MVA with minor damage and find two patients ambulatory outside of the vehicle. One is walking around and the other has fled the scene on foot but is caught by police a 1/4 mile away and returned for EMS evaluation. Upon patient assessment, both patients adamantly refuse treatment or transport. It is noted that both patients have a strong odor of alcohol on their breath and both admit to heavy drinking. Neither have any apparent injuries but both have a staggering gate and inappropriate responses to questions. After a lengthy assessment, one patient accepts transport, but the other still refuses. What are the protocols for a patient such as this?
A: Any patient that provides inappropriate responses to assessment questions should be considered in a state of altered mental status and Protocol 2.3 Altered Mental/Neurological Status should be followed. Explain to the patient that you are required to treat and transport based on your assessment findings and ask for police assistance if needed.
Q: What is the policy on TASER dart removal? I have been asked by our local police department if we will remove the darts. I did not think we are allowed, since I would consider it an impaled object. The police chief said that they were allowed, after training, to remove them from anywhere but the head and neck.
A: You are correct; impaled probes (such as the dart-like electrodes fired from a TASER device) are impaled objects and shall not be removed by EMS personnel unless their removal is necessary to provide life- or limb-saving treatment (see OEMS Advisory “TASERs and EMS Response" 9/1/2006)
Q: How should an EMT handle a patient with a tracheostomy tube?
A: See Tracheostomy Tube Obstruction Management within Protocol 5.3 Tracheostomy Tube Obstruction Management Adult & Pediatric.
Q: If you are transporting a patient with a valid CC/DNR or MOLST, and during the transport the patient dies; where should the patient be transported?
A: According to the MDPH/OEMS, the patient should be transported to the nearest hospital emergency department in all cases, which may or may not be (depending on distance) the initial sending facility.
Q: Are EMS providers required to pass a protocol update exam?
A: All services need to ensure their EMTs, AEMTs, and Paramedics are aware of changes to the protocols as they occur and whenever a new version of the protocols is released (every calendar year). A service may also require that their providers successfully complete a protocol update exam as a condition of employment.
Q: In the "Routine Patient Care" section of the State EMS Pre-Hospital Treatment Protocols, reference is made under "Transport Decision" to Department (meaning OEMS) approved regional Point-of-Entry Plans. Where can I locate these?
A: Region II's Point-of-Entry (POE) Plans are located under the CMED heading on this website's homepage or by clicking here.
Q: What happened to the "Hypertensive" protocol?
A: Hypertensive Emergencies was eliminated when version 12.03 was released. The content from this protocol was incorporated into the "Routine Patient Care" section and within the Cardiac Protocols.
Q: The Newly Born Care Protocol (2.11) reads “If the pulse is <100 bpm and not increasing, proceed to 2.12 Newborn Resuscitation.” Does that mean I should begin compressions when the pulse is less than 100 bpm?
A: No. The Newly Born Care Protocol (2.11) directs the EMT to Resuscitation of the Newly Born (2.12) at that critical point, but the EMT should then FOLLOW the protocol which reads “For heart rate less than 60, institute positive pressure ventilation with 100% oxygen for 1 minute and if heart rate remains at 60 start chest compressions.”
Newly Born Care Protocol (2.11) directs the EMT to Resuscitation of the Newly Born (2.12)
