On the second Tuesday of every month, I spend four hours at our regional educational standards and medical advisory meetings. I am not a meeting guy, but we have a good group of people and we get things accomplished, although as with any group sometimes it seems we are always rearguing the same issues.
In the educational standards meeting the discussion has been about our yearly skill sessions which each medic is required to take. We have sessions scattered throughout the year — usually one in April, one in June, one in September and one in December — but inevitably people wait until the last one in December. This year we had to add a third session to the two we already had scheduled to accommodate the stragglers. Each session is limited to 40 people.
Each year we try to figure out how to avoid the December rush and how to hold people accountable for getting the sessions taken. My position has always been whatever we do, we have to let the paramedics know what is expected of them. Too often we make decisions, but neglect to tell anyone. We had a big arguement about paramedic accountability. I argued that instead of trying to create hoops for paramedics, we should try to make it easier for them. What is wrong with just having an extra session in December? Other people wanted to assign people to specific sessions based on their birthdays. I made the motion we keep the setup the same. I lost. While we didn’t vote on what the new system would be, the new system proponents will have to come up with a plan for a new system. We’ll see if anything happens. We have the same vote every year.
We also have the same periodic discussion as to the purpose of the skill sessions — are they to be used to teach people or to drill people. We usually have six or seven stations — a megacode, an airway station that includes use of the bougie, combitube, LMA, an IV station that includes an IVs and the IO, a crich station, a BLS station that has spinal immobilization and KED, and then specialty sessions such as child birth, and the one I taught this year, which was the AHA update. Most people feel the skill sessions are pointless — why do I need to stick a needle in an IV arm when I do it everyday on real people? One arguement has been this is neccessary so the MDs can sign off on people’s National Registry forms. Some say we need to prove people can do the skills, yet I believe the way we do them anyone who sleeps at a Holiday Inn Express can walz through. No one has ever failed a skills session. I prefer to think of the skill sessions as a chance to learn new information or to practice skills we don’t do much such as the needle crich.
We argue back and forth each year. Sometimes some of us switch sides of the arguement, and we always end up doing it the same way.
Still, we do get work accomplished. The education group is made up of the clinical coordinators from each hospital in the region, and a couple educators and myself.
The Medical Advisory or MAC also includes the medical directors from each hospital. For the last three meetings we have been redoing our protocols, which is a very tedious process. We go page by page, arguing over every little wrinkle and wording. Each year the pressure that we can give Nitro at changes or at least is discussed. Its 100 now. It has been as high as 120 and as low as 90. This year we moved the blood glucose number for “low blood sugar” from 80 down to 70, although since these are guidelines, you can still give D50 to someone with an altered Mental status and a Blood glucose of 73.
I don’t mean to be critical because all of the discussion is neccessary and I think we have decent protocols, but like I said, the discussion can get tiresome. Whenever the debate gets too heated, we just table the topic to the next meeting when either side of the arguement will have either cooled down or not been able to attend due to other committments. Sometimes we pass a measure easily one meeting, and then it gets brought up and vigorously redebated the next. This has happened repeatedly with morphine for abdominal pain this year. We couldn’t give it, then it was on standing orders, and now it is requires online control. In the end it is all about consensus. We never meet our rollout deadline on January 1, but we get it done.
Here are some of the changes we have agreed on at least for now:
Incorporating the new AHA Cardiac guidelines.
Increasing dose for morphine we can give on standing orders from 0.1 mg/kg to 0.15mg/kg.
Permitting MS on standing orders for certain back pain.
Adding undifferentiated abdominal pain as an indication for medical control orders for MS.
Adding torodol as a medical control option.
Putting Solumedrol on standing orders for asthma and allergic reactions.
IV Magnesium for severe asthma.
Putting epi on standing orders for asthma if the patient is under 50 and has no cardiac history.
Putting up to 2 mg of Ativan on standing order for nonviolent anxiety.
Putting Dopamine and fluid boluses on standing order for cardiogenic shock (None of us had realized medics required online medical control to do either in this scenario.)
Clarifying the indications for narcan to a person with altered mental status with RR less than 10, who is hypoventilating.
Increased use of capnography.
Changing eye irrigation from NS to Lactated Ringers
We are able to now mix Haldolol and Ativan in the same syringe for violent psychs.
Standing orders for nitro paste for pulmonary edema.
We have also done a lot of language change in the guidelines, and reordering steps.
Some things still being debated, include:
Adding zofran for nausea.
A Taser policy
Relooking at indications for spinal immobilization
Adding some new procedure sheets.
Changing fluid thresholds for Trauma patients.
I think we have a few more months of meetings until we are done.
What I like about the committee and the process is that in the end our work hits the street and makes a difference to the patients.