Q&A with Susan Lewis, NRP, Director of the Office of Emergency Medical Services (OEMS)
1. What are the biggest changes in these new protocols that EMTs and paramedics need to know before their next shift?
Each year, the Massachusetts Department of Public Health’s (Department) Office of Emergency Medical Services (OEMS) releases, and sends out to all ambulance services, a Change Memo along with the updated Statewide Treatment Protocol (STP). Both documents can be accessed via the OEMS webpage. All services, EMTs and paramedics are encouraged to review that Change Memo and to use it as a reference for our STP changes.
https://www.mass.gov/doc/changes-memo-ems-statewide-treatment-protocols-version-20262/download
Included within the September STP release are multiple medication additions and deletions. These medication changes affect all levels of EMS personnel, not just paramedics. Examples include that all levels of EMS personnel may now use epinephrine/surfactant nasal preparation to treat anaphylaxis. Diphenhydramine was removed from that same protocol, and Cetirizine was added in its place for mild reactions. Epinephrine IV/IO was moved from paramedic level to Advanced EMT level of care for all cardiac arrest protocols. Vasopressin has been removed completely from the protocols. The dose of TXA was also consolidated from a split dose to a one-time administration dose of TXA 2 mg IV/IO.
2. There are some significant medication changes. Can you share the process for making those changes?
Medication changes are proposed and discussed in the Medical Services Committee (MSC) meetings. MSC meeting dates are posted on the OEMS website. These meetings are held virtually and are open to the public. In accordance with Open Meeting Law, MSC members participate in discussions and vote, when appropriate, to make recommendations to OEMS. MSC members discuss proposed medication changes to the STPs, weighing clinical utility, risk, and the current science related to the use of medication within EMS and emergency medicine practice. MSC makes a recommendation for proposed STP updates to OEMS; the final determination for all changes to the STPs is made by the Department and its OEMS.
3. Advanced EMTs can now administer IV/IO epinephrine during cardiac arrest and IV acetaminophen for pain. What does that expanded scope mean in practice, and what additional training will AEMTs need?
These updates are consistent with recent national practice. Service-level training is required by regulation before implementation. That training must include indications, contraindications, dosing, and administration. During re-licensure inspections, OEMS inspectors verify that services have policies for training and implementing STP updates, including but not limited to, any new equipment prior to it being placed in-service. Department-accredited EMT training institutions (ATIs) are also required to include the most current STPs, along with the National Highway Traffic Safety Administration (NHTSA) National EMS Education Standards, as implemented by the Department within their curriculum.
4. The protocols now say BiPAP/CPAP is no longer indicated for pediatric patients of any age. What prompted that change, and how should crews approach pediatric respiratory distress differently?
There are logistical challenges with pediatric BiPAP/CPAP. Some services were unable to obtain the required equipment. Some hospitals reported that they are unable to continue pediatric CPAP initiated by EMS. As the availability of pediatric BiPAP/CPAP devices and delivery systems increases, for both EMS and hospital use, OEMS will once again explore adding pediatric BiPAP/CPAP to the STPs. EMS still has many options for treating pediatric patients experiencing increasing respiratory distress. Bronchodilators and Epinephrine should be used appropriately. An appropriately sized bag valve mask with a PEEP device can
also be used to achieve some measure of CPAP. Providers using this technique should be mindful of compliance along with the volume and rate of ventilation.
5. The refusal protocol no longer automatically requires a call to medical control for certain high-risk refusals and instead says to call when EMS personnel have concerns about the appropriateness of the refusal. How should providers exercise that judgment, and what should they document to protect both the patient and themselves?
EMS personnel should thoroughly document the factors/criteria in STP 7.5 for refusals, as well as the procedures followed as set out in that STP, such as documenting their attempts to get the patient to be transported to the emergency department. If they call medical control, they should document the conversation, including the name of the physician. In addition, ambulance services should have a policy requiring their EMS personnel to always call medical control for high-risk refusals.
6. The TXA protocol now calls for a single 2-gram IV push for certain adult trauma and obstetrical patients. What should paramedics know about the new dosing and when to administer TXA?
Surgical/trauma care adapts as more data become available. Current literature for both in and out-of-hospital use of TXA is trending toward a one-dose administration over the conventional split dose of half via IV/IO push followed by an infusion within an hour. The common rationale for why this is done is that it is simply easier and avoids the potential for missing the second dose. Paramedics should keep in mind that the main risk of TXA administration is hypotension, but that is rare and offset by resuscitation measures and must be balanced against the benefit of hemostasis. The TXA 2 gram dose should be given over about a minute IV/IO push. You can expect STPs involving TXA to again be revised in the near future as the surgical literature and national protocols regarding TXA are further updated.
7. The protocols expand the use of ultrasound for appropriately trained paramedics, including abdominal and pulmonary scans. How can ultrasound be most useful in the field, including in community paramedicine, and what are its limitations?
Ultrasound in emergency medicine is an expanding field, and the techniques used are also commonly accepted as required for bedside diagnostics. As ultrasound equipment becomes more affordable, smaller, lighter, and easier to use, it makes sense that its use will transition into the pre-hospital environment. There is a learning curve with ultrasound, and the more practiced a provider is in its use, the value increases with better scan results. It should be stressed that ultrasound is currently an adjunct and should not be used by paramedics for diagnostics. Current emergency medicine and EMS use for ultrasound includes, but is not limited to, lung slide for pneumothoraces, cardiac standstill and causes of PEA, fluid status both in and exterior of the vascular space (FAST), and to assist in the location of collapsed veins for IV placement. Affiliate hospital medical directors and services need to work together to establish which studies may be of use in their areas based upon their personnel and patient mix.