Hello! Dr Fink here.

Welcome to the inaugural Protocol Update email. If you’re thinking to yourself, “wait, I never signed up for this!”, you can blame management, who provided me with the email roster. This email has been added to the email list for Patroller.Ski so that I can notify you all when I update protocols or feel like there’s a need for clarification or education.

This first email is long. I apologize. In the future, I’ll try to keep them short and sweet.

You’re currently subscribed to both the protocol updates emails, which will contain everything important, as well as a separate channel for medical education emails, which will be sporadic and not critical. You can manage your subscription preferences using the link at the bottom of any of the emails, and you can unsubscribe if you like. The onus is then on you to make sure you check the change log periodically for updates to the protols.

You can also reply directly to these emails if you have any questions. Those questions will go straight to my inbox.

Contents:

1. ALS: Ketamine Protocol Update
2. Pain Control Protocol Education
3. Clinic Collaboration and Shared Space
   1. Clinic Capabilities
   2. Clinic Staff Education
   3. Clinic Doesn’t Yet Have Controlled Substances
   4. A message from Bryce Campbell, Clinic Director
4. Closing Thoughts

ALS: Ketamine Protocol Update

The ketamine that was available for order this season was limited, so we have vials which are 500 mg / 10 ml, or 50mg/ml. This is a great concentration for IM or IN use, but poses risk of accidental overdose when given IV. I have added to the ketamine protocol page:

“Administration:IV/IO: Dilute ketamine to 10 mg/ml concentration. For 500mg/10ml (50mg/ml) concentration vial,  remove 2ml saline from a 10ml flush. Draw up 2 ml (100 mg) into the flush for a total of 10 ml. Agitate to mix. This makes 10 mg/ml solution. Label the syringe to avoid confusion.”

Pain Control Protocol Education

This isn’t an update to the protocols since I became director, but it is a change compared to how Dr. Mitchell was directing you. In the past, it was policy that any patient given narcotics on the hill was transported by EMS to hospital.

In the new protocols for this season, it is also acceptable to transport patients who receive narcotic pain meds to the clinic as well. We just don’t want these patients to be treated with narcotics and be released to private vehicle. This gives our ALS providers the opportunity to offer pain control to more patients who otherwise might suffer without it. 

Clinic Collaboration and Shared Space

There have been some concerns voiced by patrollers about the clinic space not feeling like shared space and some also have been getting the feeling that the clinic is wanting to approach patients who are either going by EMS or to private vehicle to try to get them to check in. I’ve spoken with the patrollers involved in a few cases and with the clinic director Bryce Campbell, and I have his thoughts below. The high points are these:

Clinic Capabilities

The clinic can handle more types of patients than Summit was able to. We may want to delay calling an ambulance for simple suspected fractures, knee injuries needing pain control, dislocated shoulders, etc. If an X-Ray or pain control could change whether or not that patient needs to go to the ER, it may be worth going to clinic rather than ambulance. Please see Bryce’s message below. This will remain a work in progress as we all figure out how to work together.

Clinic Staff Education

The clinic is going to educate its nurses and providers that if you have requested an ambulance, they shouldn’t be trying to persuade you or the patient to check in. It’s your decision. You can always decide to cancel an ambulance and have the patient check in if your evaluation in the clinic changes your or your patient’s take on the situation. 

Clinic Doesn’t Yet Have Controlled Substances

In the box of things that are beyond anyone’s control, the DEA ordering forms that they ordered and that were sent to the mountain for them are MIA. The hunt for missing mail is on, and they’ve been reordered. For the moment, this means that the clinic doesn’t have controlled substances! Fun for all.

For the time being, ALS providers maybe asked to come to meet the patient and provide a dose of pain control before the patient is transferred into the care of the clinic.

We should not:

• Provide any medications to the clinic provider to administer themselves. This isn’t legal under our kind of DEA license.
• Administer medications to clinic patients after the clinic has assumed responsibility for them. Meds immediately prior to handoff are ok. After is not. We are not clinic providers.

If you have any weird situations or encounters, please request OLMC or contact me after. Don’t do anything you’re not comfortable with.

A message from Bryce Campbell, Clinic Director

From Bryce:

We’re pleased to be open and operational, and we appreciate everyone’s flexibility as we refine workflows, educate providers, and strengthen collaboration. Patrick mentioned that you requested a list of conditions appropriate for clinic care. While it’s difficult to create an exhaustive list due to case-by-case nuance, the following points should provide helpful clarity.

First, the clinic is part of the St. Charles Health System, not a standalone facility. This allows access to broader resources than previously available. Patients evaluated in clinic may be discharged home, referred to the ED, or scheduled directly for orthopedic follow-up—often avoiding an ED visit altogether.

Second, the clinic can perform X-rays, reductions, splinting, and provide pain control. Many isolated orthopedic injuries—such as suspected fractures, knee injuries, and dislocations of fingers, patellae, or shoulders—can receive definitive initial care in clinic, frequently eliminating the need for ED transfer. We appreciate the patrol’s focus on avoiding unnecessary clinic visits that simply add cost before an inevitable ED transfer. In many cases, however, urgent care is substantially less expensive than ambulance transport or ED care and may allow direct orthopedic referral, appropriate stabilization and analgesia, or safe transport to the ED by private vehicle rather than ambulance. While some patients will still require ambulance transfer from clinic, we believe this model provides net benefit and higher-value care for most patients, often reducing total cost of care.

Given these expanded capabilities, please consider bringing patients with isolated orthopedic injuries to the clinic for evaluation, pain control, diagnosis, and treatment—even in cases that may previously have defaulted to ambulance transport. We believe the clinic can meaningfully support care for many of these patients.

The important take away from my perspective is – If you encounter a patient who you believe may ultimately require evaluation in the emergency department but is hemodynamically stable, please consider having the patient first evaluated in the urgent care clinic prior to activating an ambulance from the hill.

Obviously, this is not a policy and still leaves room for clinical judgment. 

-Bryce

Closing Thoughts

I’m so glad that we’re finally open and you’re all out there doing it. I have a ton of respect for everything you do and the different jobs that you juggle. Figuring out how to deal with new clinic providers while chainsawing trees and getting ready to evac Cloud is a job that’s hard to explain to anyone who hasn’t done it.

Managing patients in collaboration with the clinic is something we’re figuring out on both sides. I hope that you’ll consider these three things:

• We should all assume positive intent. I think that the clinic is trying to nose into things when they think they can help. Clinic providers are hourly– nobody is getting paid more for pulling in patients.
• The clinic is more capable and plugged in than in the past. Consider transporting more stable injuries there to be evaluated and treated, as in many cases they can have faster pain control and may be able to avoid an ambulance or ER visit.
• Your judgment is first. If you think that a patient should go by ambulance to the ER, you should trust your judgment. I do. I have asked the clinic to respect that, and I will keep working with them if we have issues.

I look forward to seeing you all on the hill soon. Reach out if you have concerns or questions.

-Patrick