Suspected Stroke Destination

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Re: Medication Shortages (Replaces 2012-02) Effective Date: Current

EMS continues to face series of medications shortages. Federal and State authorities are working to address this issue, but there will be ongoing problems that will need to be managed on a local basis. The REMAC and REMO will assist as needed with operational questions including potential medication substitutions, alternative sources or other ideas.

To remain operationally sound, agencies may review medication usage, modify their formularies, and reduce quantities based on historical usage patterns. Medication quantities may be reduced and medication concentrations may be changed as needed. No medication substitutions may be made without the approval of the Medical Advisory Committee.

Agency ALS Coordinators must notify REMO with any changes to the approved Regional formulary. All Controlled Substance formulary changes must be approved by the DOH.

Some immediate shortages:Problem: Diltiazem may be only available in alternative vial sizes and concentrations

Solution: Please be certain to train staff about the medication change and notify REMO. Do not substitute drip formulations for single dose vials because of the potential for medication error. Contact medical control for consideration of metoprolol or amiodarone. _________________________________________________________________________________________________

Problem: Controlled Substances are intermittently in short supply.


Solution: Notify REMO as soon as a problem is recognized so that we may assist in researching a solution and guide your agency through the process of amending your controlled substance plan if needed. Do not alter from your controlled substance plan without contacting the Department of Health.


Problem: IV fluids may be in short supply.

Solution: Please check the FDA website for fluids that have been given extended expiration. If still short of normal saline, lactated ringers may be substituted as written in the collaborative protocols.


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Re: REMO Regional Stroke Destination
Distribution: All EMS Providers, REMO Physicians, Emergency Department nursing and provider staff Effective Date: Current

Policy: Providers should use FAST-ED to determine stroke destination. Patients with FAST-ED score >3 should go directly to comprehensive stroke center if estimated transport time is not more than 30 minutes farther than primary stroke center. Please review and follow attached algorithm.

Stroke care has been rapidly advancing over the last few years. In particular, care of the most severe strokes, large vessel occlusion strokes (LVO), has improved dramatically. Not only are these patients given thrombolytic medications, but physicians with special training and equipment can remove clots that are blocking blood flow. Removal of these clots if clinically appropriate can lead to dramatic improvements in outcomes. Centers that perform these procedures are termed “Comprehensive Stroke Centers”.

A REMAC subcommittee developed an algorithm to follow based on the FAST-ED stroke score. This score is available as an app for either the iPhone or Android. We recommend that all REMO physicians and REMO EMS providers download this and practice using it. A score of greater than 3 predicts a high likelihood of an LVO. Patients that do not have a FAST-ED score greater than 3 may be taken to any stroke center based on the algorithm.

Patients suffering suspected stroke, or their families, may request to go to centers that cannot perform endovascular care even when appropriate – however in these cases, call a REMO physician at the hospital the patient requested and have that physician evaluate the case and discuss with the family. Remember, patients and families may still request other facilities including hospitals that are not DOH approved Stroke Centers. The goal is to assure that our patients are given the opportunity to get care at the right hospitals to assure they have the best outcomes.

Training will be forthcoming through your agencies and the Region. We wanted to issue this advisory before the training was completed to assure the best possible outcomes for our patients.

Comprehensive Stroke Center: Albany Medical Center
NYS Primary Stroke Centers: Albany Memorial, Columbia Memorial, Ellis, Samaritan, St. Peters FAST-ED App Article: Apple: Google:

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Patella Reduction Training

Link to Patella Reduction Training Video:

Link to Post-procedure Patella Reduction Survey: Survey

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REMAC Advisory

Naloxone and the REMO EMS System

Effective date: Current

Update for Law Enforcement

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Proximal Humerus EZ-IO Placement

​See attached PDF for information regarding placement of EZ-IO in Proximal Humerus

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