Appendix V!

Friday afternoon while I was checking my email I that I had a new e-mail from the Commonwealth of Massachusetts’ Office of Emergency Medical Services.  Every year around this time they like to send out any pending protocol changes that are being released with the annual March 1^st updates.  Version 10.01, due go into effect on March 1, 2012 has a great new edition that I am very excited about.

On the summary sheet of expected changes, protocol 1.6 for Post Resuscitative Care had the following addition:

Mandating therapeutic hypothermia do not delay transport.  hyperlinked to Appendix V.

While the state might need some work on their punctuation and capitalization, I was excited to see that Therapeutic Hypothermia was being added to our scope of practice.  I moved down to Appendix V to see what was in store for me in the coming year.  The new protocol describes the implementation, necessity and reasoning for the use of prehospital hypothermia in the following way:

Cardiac arrest patients of medical etiology, who have responded to ACLS resuscitation efforts of any rhythm and demonstrate restored cardiac output and hemodynamic stability, but subsequently display signs of severe ischemic brain injury or coma, are candidates for instituting therapeutic hypothermia. Statistics show a significant number of those who survive out of hospital sudden cardiac arrest suffer from residual ischemic brain injury following cardiopulmonary resuscitation. The return of spontaneous circulation (ROSC), while resulting in the reperfusion of vital organs and the re-oxygenation of tissue, is thought to trigger destructive chemical reactions within brain cells limiting neurological recovery. The process of instituting early external and internal cooling efforts and maintaining mild hypothermia (32-34° C) in the first 12- 24 hours has been demonstrated to be a beneficial treatment adjunct in protecting the neurological function of cardiac arrest victims and improving patient outcomes.  Therapeutic induced hypothermia has been shown to be of significant benefit to select patients; continuation in-hospital is essential to its benefit, and may be a factor in hospital destination decisions by medical control.

They get it.  All of the work done by services such as Wake County EMS, MedStar in Fort Worth, Texas and countless others is finally making a difference in some of the hardest to reach places.  While Massachusetts is not at the back of the back when it comes to EMS interventions, we certainly are pretty close to it, and seeing this bold declaration from the state’s EMS Office not only that this bold step forward for prehospital care might work, but they expect it to be used state wide.  No special project waivers, no medical control consultation, but a blatant but all-too-necessary stomp on the gas pedal.

Indications are outlined as the following:

• Age 16 or older, patients age <16(pediatric patient) contact medical control

• ROSC – patient demonstrates no purposeful movement to sternal rub or response to commands 5 minutes into ROSC, and

• Palpable Carotid pulse with a stable cardiac rhythm, and

• Patient does not have existing hypothermia (< 34º C), and

• Patient is intubated or appropriate rescue airway.

• Post-cardiac arrest with return of spontaneous circulation (ROSC)

• Post-cardiac arrest in setting of STEMI

All perfectly reasonable, however I have read in a study by Wake County that initial neurological checks have proven to be all but useless and doing them only delays what the patient really needs: induced hypothermia.

The state’s listed contraindications again are no big surprise:

• Traumatic arrest, or

• Hypothermia exists (< 34° C) by core temperature

• Identified Pregnancy, or

• Respiratory arrest

The last one, “respiratory arrest” I can only assume means respiratory arrest in the absence of a previous cardiac arrest.  That is to say, Mr. Jones just stopped breathing, but never has a pulse, so let’s make sure we don’t cryogenically freeze him in the back of our ambulance.

Moving down now past the BLS and ILS requirements, I wanted to touch briefly on the ALS interventions listed.  They are, by far, some of the most liberal protocols I’ve ever seen written by the state, and they give the paramedic exactly what they need: the discretion to care for their patient appropriately.

5. ALS STANDING ORDERS

a.  Initiate endotracheal intubation or appropriate rescue airway according to protocol prior to initiating cooling. Do not hyperventilate; goal is an ETCO2 of around 40mmHg

b. Obtain finger stick glucose and initiate IV Normal Saline. Titrate IV to patient’s hemodynamic status.

c.   Cardiac Monitor: (12 lead ECG where appropriate) manage dysrhythmias per protocol. If STEMI present, transport to nearest STEMI Center.

d.  Place esophageal thermometer probe to establish patient’s baseline body temperature (34º C or greater). (IF AVAILABLE)

e.  Place ice packs or equivalent in armpits, neck, torso and groin areas. Commonwealth of

f.  Establish 1 or 2 peripheral IV / or IO lines to infuse chilled normal saline (2 – 4º C) wide open @ 500ml increments  to a max of 2000ml or 30  ml/kg to a max of 2L monitoring for CHF. Target cooling body to temperatures 32-34º C.(If refrigerated saline available)

g. If patient has significant shivering, you may administer:

lorazepam 2.0 – 4.0 mg or

morphine 2.0 mg every 5 minutes up to 10.0 mg max or 

fentanyl 50 mcg every 5 minutes to max. 200 mcg or

midazolam 0.15 mg/kg to max of 10 mg IV Push

Let’s start with the all too frequently used two word phrase “If Available.”  The state is recognizing that not every prehospital service has the funds to purchase a refrigerator for each of their ambulances or an esophageal probe, yet they are still giving every service the ability to push forward with or without each of these pieces of equipment.

And then there is treatment “g” where the state says to the paramedic “go ahead, pick a narcotic that YOU think will work and use it to benefit your patient.”  I am sure as more research is done, this list will drill down from the four to just lorazepam and midazolam but the sheer fact that the paramedic is given the choice of the four is remarkable.  They are letting us think for ourselves and expanding our scope of practice rather than dumbing it down to the lowest denominator.

Way to go, Massachusetts.  You are starting to realize that the paramedics you train and oversee are actual patient care practitioners and not just “get them to the closest hospital as fast as possible” ambulance drivers.  Let’s hope that this is the first of many positive changes to come down the line over the next couple of years.

To read the summary of upcoming protocol changes, follow this link:

http://www.mass.gov/eohhs/docs/dph/emergency-services/treatment-protocols-1001-edits.pdf

To read the entire 271 page Massachusetts treatment protocols, go here:

http://www.mass.gov/eohhs/docs/dph/emergency-services/treatment-protocols-1001.pdf