2018 ALS/BLS FIELD MANUAL. (Updated 12/01/2017)

Transcription

1 2018 ALS/BLS FIELD MANUAL (Updated 12/01/2017)

2 Sierra-Sacramento Valley EMS Agency Rocklin Office 5995 Pacific Street Rocklin, CA Telephone # (916) Fax # (916) Redding Office 2775 Bechelli Lane Redding, CA Telephone # (530) S-SV EMS/Region III RDMHS Duty Officer (24/7) S-SV EMS Agency Staff Name Title Phone # Victoria Pinette Executive Director Vickie.Pinette@ssvems.com John Lord, RN Associate Director John.Lord@ssvems.com John Poland Associate Director John.Poland@ssvems.com Troy Falck, MD Medical Director Troy.Falck@ssvems.com Michelle Moss Specialty System Coord Michelle.Moss@ssvems.com Patrick Comstock QI Coordinator Patrick.Comstock@ssvems.com Kristy Harlan Contract Manager Kristy.Harlan@ssvems.com Shawn Joyce EP Grant Coordinator Shawn.Joyce@ssvems.com Amy Boryczko Administrative Secretary Amy.Boryczko@ssvems.com Pete Kruse EMS Specialist Pete.Kruse@ssvems.com Allison Kapple Office Assistant Allison.Kapple@ssvems.com Miranda Hill Certification Specialist Miranda.Hill@ssvems.com Includes Policy Manual Update #61 effective 12/01/2017 This field manual is a synopsis of the S-SV EMS Agency Prehospital Care Policy Manual and includes a condensed version of S-SV EMS policies which are specifically related to field care as well as all patient care treatment protocols. The policies and protocols included in this manual are current as of the date listed above. EMS personnel are responsible for all policy and protocol updates released after the printing of this field manual.

3 Field Manual UPDATE SUMMARY Update #61 REF TITLE UPDATE COMMENTS 505-A Hospital Capabilities Reference 803 Paramedic Scope Of Practice Removal of pediatric intubation. Re-designation of Rideout Regional Medical Center as a STEMI receiving center effective, designation of Rideout Regional Medical Center as a Stroke Receiving Center, addition of Colusa Medical Center 837 & 837 A-C Multiple Casualty Incidents (MCI) Revised/streamlined MCI response procedures. 852 Patient Restraint Mechanisms Revised midazolam dose for consistency with other protocols. C-1 Pulseless Arrest Revised termination of resuscitation criteria language & reorganized algorithm. C-5 Return Of Spontaneous Circulation Due for routine review - no significant changes. C-6 Tachycardia With Pulses Revised midazolam dose for consistency with other protocols. C-7 Bradycardia Revised midazolam dose for consistency with other protocols. R-3 Acute Respiratory Distress M-1 Allergic Reaction/Anaphylaxis N-2 Seizure T-2 Tension Pneumothorax Incorporation of BLS epinephrine auto injector. Addition of Ipratropium to asthma/copd mild distress (paramedic personnel). Revised algorithm. Incorporation of BLS epinephrine auto-injector into protocol. Revised definitions in the top informational box on page 1. Reordering of midazolam administration prior to blood glucose check for status epilepticus. Revised midazolam dosing. Revised indications for needle thoracostomy. Revised approved sites and procedure details language. T-8 Hemorrhage Added an additional approved commercial tourniquet device. P-1 General Pediatric Protocol Removal of several outdated tables. Removal of pediatric intubation. P-4 Pediatric Pulseless Arrest P-14 P-16 P-18 Pediatric Respiratory Distress - Wheezing Pediatric Respiratory Distress - Stridor Pediatric Allergic Reaction/Anaphylaxis P-26 Pediatric Seizure 1101 Vascular Access 1104 Advanced Airway Management Additional CPR language & reorganized algorithm. Removal of pediatric intubation. Incorporation of BLS epinephrine auto injector. Addition of Ipratropium to asthma/copd mild distress (paramedic personnel). Revised algorithm. Removal of pediatric intubation. Revised algorithm. Removal of pediatric intubation. Incorporation of BLS epinephrine auto-injector into protocol. Revised definitions in the top informational box on page 1. Removal of pediatric intubation Reordering of midazolam administration prior to blood glucose check for status epilepticus. Revised midazolam dosing. Removal of pediatric intubation. Revised IO insertion procedures. Addition of distal femur IO site for pediatric patients. Replacement of BIG device with NIO device. Revised midazolam dose for consistency with other protocols. Removal of pediatric intubation.

4 Field Manual UPDATE SUMMARY Update #61 REF TITLE UPDATE COMMENTS 1108 Prehospital Blood Draws Due for routine review - no significant changes ALS/LALS Annual Infrequently Used Skills Verification And Regional Training Module Regional training module requirement changed to calendar year, Significant revisions to all infrequently used skills checklists.

5 TABLE OF CONTENTS PROGRAM POLICIES 913 Paramedic Accreditation to Practice Auto Aid/Mutual Aid/Out-Of-Region Response Patient Destination A Hospital Capabilities Reference STEMI Receiving Centers Stroke System Triage & Patient Destination Prehospital Documentation Management of Controlled Substances Paramedic Scope of Practice Base/Modified Base/Receiving Hospital Contact Ventricular Assist Device (VAD) Determination of Death Do Not Resuscitate (DNR) Crime Scene Management Suspected Child Abuse Reporting Guidelines Suspected Elder or Dependent Adult Abuse Reporting Guidelines Active Shooter/Mass Violence Incident Medical Control at the Scene of an Emergency Hazardous Materials Incidents Multiple Casualty Incidents Physician on Scene Medical Control for Transfers Between Acute Care Facilities Paramedic Monitoring of IV Medication Drips During IFTs Paramedic Monitoring of Blood Transfusions During IFTs Paramedic Utilization of ATVs During IFTs ALS/LALS Transfer of Patient Care Cancellation or Reduction of ALS/LALS Response Refusal of EMS Care EMS Care of Minor Patients Patient Restraint Mechanisms

6 853 Tasered Patient Care and Transport Trauma Triage Criteria EMS Aircraft Utilization Prohibition on Carrying of Weapons by EMS Personnel Communication Failure ADULT TREATMENT PROTOCOLS CARDIOVASCULAR C-1 Pulseless Arrest C-5 Return of Spontaneous Circulation (ROSC) C-6 Tachycardia with Pulses C-7 Bradycardia C-8 Chest Pain or Suspected Symptoms of Cardiac Origin RESPIRATORY R-1 Airway Obstruction R-2 Respiratory Arrest R-3 Acute Respiratory Distress MEDICAL M-1 Allergic Reaction/Anaphylaxis M-2 Shock: Non-Traumatic Hypovolemia M-3 Phenothiazine/Dystonic Reaction M-5 Ingestions and Overdoses M-5-A Guidelines for EMS Use of Activated Charcoal M-6 General Medical Treatment M-7 Nausea/Vomiting (From Any Cause) M-8 Pain Management M-9 CO Exposure NEUROLOGICAL N-1 Altered Level of Consciousness N-2 Seizure N-3 Suspected CVA/Stroke

7 OBSTETRIC/GYNECOLOGY OB/G-1 Childbirth ENVIRONMENTAL E-1 Hyperthermia E-2 Hypothermia E-3 Frostbite E-4 Bites and Envenomations E-7 Hazardous Material Exposure E-8 Nerve Agent Treatment TRAUMA T-1 General Trauma Management T-2 Tension Pneumothorax T-8 Hemorrhage T-10 Burns: Thermal & Electrical PEDIATRIC TREATMENT PROTOCOLS P-1 General Pediatric Protocol P-2 Neonatal Resuscitation P-3 Brief Resolved Unexplained Event (BRUE) P-4 Pulseless Arrest P-6 Bradycardia With Pulses P-8 Tachycardia With Pulses P-10 Foreign Body Airway Obstruction P-12 Respiratory Failure/Arrest P-14 Respiratory Distress Wheezing P-16 Respiratory Distress Stridor P-18 Allergic Reaction/Anaphylaxis P-20 Shock P-22 Overdose/Poisoning P-24 Altered Level of Consciousness P-26 Seizure

8 P-32 Nausea/Vomiting (From Any Cause) P-34 Pain Management MISC. POLICIES/PROTOCOLS/DOCUMENTS 1101 Vascular Access Advanced Airway Management Mechanical Chest Compression Devices Prehospital Blood Draws Infrequently Used Skills Helicopter Resource Guide Dopamine Drip Chart

9 S-SV EMS PATIENT CARE POLICIES

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11 Sierra Sacramento Valley EMS Agency Program Policy Paramedic Accreditation To Practice Effective: 12/01/2016 Next Review: 06/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To establish the requirements for obtaining and maintaining accreditation to practice as a paramedic in the S-SV EMS region. AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5, , , , and B. California Code of Regulations, Title 22, Division 9, Chapter A. In order to be eligible for initial paramedic accreditation, an individual shall: 1. Provide a completed S-SV EMS Paramedic Accreditation Application. 2. Provide a copy of a current California Paramedic License. 3. Provide a copy of a current U.S. state-issued driver s license or identification card. 4. Pay the accreditation fee. 5. Complete an S-SV EMS paramedic orientation/accreditation class. 6. Successfully complete a supervised pre-accreditation field evaluation consisting of a minimum of five (5), but no more than ten (10) ALS contacts with an S-SV EMS approved ALS service provider in the S-SV EMS region. This requirement may be met by the submission of actual PCRs, or a letter verifying successful completion of this requirement from a management/qi representative of an S-SV EMS approved ALS service provider. This requirement may be waived in one of the following circumstances: o By providing documentation of five (5) ALS contacts in the S-SV EMS region during the paramedic education program field internship within the previous six (6) months. 1

12 Paramedic Accreditation To Practice 913 o If the paramedic accreditation candidate has been actively employed as a field paramedic in the State of California within the past six (6) months and has a minimum of one (1) years experience as a paramedic. 7. Pass an examination on S-SV EMS policies and protocols with a minimum score of 80%. If the examination is failed twice, the orientation/accreditation class shall be repeated prior to re-testing. 8. If all of the above requirements are not met within 60 days of completion of the orientation/accreditation class, the candidate must repeat all initial paramedic accreditation requirements to be eligible for accreditation. 9. Upon completion of all the above requirements, the individual will be issued an S- SV EMS Paramedic Accreditation Card with the same expiration date as the individual s current California Paramedic License. B. Paramedic accreditation applicant temporary authorization to practice: 1. The paramedic accreditation applicant may practice in the basic scope of practice, with an S-SV EMS approved ALS service provider, as a second paramedic until they are accredited. 2. This temporary authorization to practice shall be valid for a maximum of sixty (60) days, after which time all S-SV EMS paramedic accreditation requirements must be met in order to continue to practice as a paramedic in the S-SV EMS region. C. Critical Care Paramedic (CCP) additional accreditation requirements: In order for an individual to be eligible for accreditation, in the S-SV EMS Agency s CCP scope of practice, the individual must obtain and maintain CCP certification from the Board of Critical Care Transport Certification (BCCTPC). D. Requirements for maintaining/renewing paramedic accreditation: To maintain continuous accreditation, a paramedic shall: 1. Provide a completed S-SV EMS paramedic accreditation application. 2. Provide a copy of a current California Paramedic License. 3. Maintain and provide proof of continuous PALS or PEPP recognition. PALS/PEPP recognition will not be required at the time of initial accreditation, but will be required at the time of paramedic accreditation renewal. 2

13 Paramedic Accreditation To Practice Complete S-SV EMS mandated education. The ALS service provider shall be responsible for ensuring that all paramedic employees are kept current on local policies and procedures. The ALS service provider shall be responsible for ensuring that S-SV EMS mandatory education requirements are completed by their paramedic personnel, including annual infrequently used skills verification of maintenance. 5. Upon completion of all the above requirements, the individual will be issued an S- SV EMS Paramedic Accreditation Card with the same expiration date as the individual s current California Paramedic License. E. Lapse in maintaining paramedic accreditation: A lapse of S-SV EMS paramedic accreditation shall require the following in order to be eligible for renewal: 1. Lapse of less than two (2) years: Meet all requirements listed in the Requirements for maintaining/renewing paramedic accreditation section of this policy. Provide written documentation of completion of orientation/training, by an S-SV EMS approved ALS service provider, to all S-SV EMS policy/protocol updates during the lapse of accreditation. 2. Lapse of more than two (2) years: All requirements for initial accreditation shall be met. F. S-SV EMS paramedic accreditation denial, probation, suspension, or revocation: 1. The S-SV EMS medical director may deny, place on probation, suspend, or revoke accreditation if the paramedic does not maintain current licensure, does not meet local accreditation requirements, or for cause. 2. Due process and appeals procedures specified in S-SV EMS Paramedic Accreditation/Licensure Review Process policy (928) will be followed for any accreditation denial, probation, suspension, and/or revocation. G. ALS provider agency responsibilities: If there is a change in the employment status of an S-SV EMS accredited paramedic employee, the ALS provider agency shall submit a completed S-SV Paramedic Employee Status Report (913-A) to S-SV EMS within 30 calendar days. 3

14 Paramedic Accreditation To Practice 913 APPLICATION PROCESSING: A. A completed and signed application and all required supporting documentation must be submitted to S-SV EMS prior to processing. Incomplete applications will not be processed. B. Incomplete applications will be maintained by S-SV EMS for 60 days awaiting required supporting documentation. All applications not completed within 60 days will be destroyed. C. Completed applications will be processed within 10 business days. CROSS REFERENCES: A. Paramedic Scope of Practice (803). B. EMS Incident Reporting & Investigation (927). C. Paramedic Accreditation/Licensure Review Process (928). D. Infrequently Used Skills: Verification of Maintenance/Regional Training Module (1110). 4

15 Sierra Sacramento Valley EMS Agency Program Policy Automatic Aid/Mutual Aid/Out-Of-Region Response Effective: 06/01/2016 Next Review: 01/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To provide guidelines pertaining to when and under what conditions an EMR, EMT, AEMT or paramedic certified/licensed/accredited in California may legally function in their respective classification during automatic aid, mutual aid and disaster responses. This includes routine automatic aid/mutual aid responses as well as Fireline Paramedic and Ambulance Strike Team activations. AUTHORITY: A. California Health and Safety Code, (b), & B. California Code of Regulations, Title 22, Division 9. C. California Disaster and Civil Defense Master Mutual Aid Agreement, November D. California EMS Authority Ambulance Strike Team/Medical Task Forces (AST) Guidelines #215, July E. California EMS Authority Mutual Aid White Paper Compendium of Statutes and Regulations Related to EMT and Paramedic Scope of Practice During Mutual Aid in California, December F. California Fire Service and Rescue Emergency Mutual Aid System, Mutual Aid Plan, February G. Emergency Management Assistance Compact (EMAC). H. Supplemental Interstate Compact For Emergency Mutual Assistance, July DEFINITIONS: A. Ambulance Strike Team A group of five (5) ambulances of the same type with common communications and a leader. Strike teams may be all ALS or all BLS. 5

16 Automatic Aid/Mutual Aid/Out-Of-Region Response 461 B. Automatic Aid Agreements between two or more jurisdictions where the nearest available resource is dispatched to an emergency irrespective of jurisdictional boundaries, or where two or more agencies are automatically dispatched simultaneously to predetermined types of emergencies. This type of agreement is typically utilized on a routine basis. C. Disaster Assistance Requests for assistance in the event that a disaster overwhelms local resources. These requests may be under existing mutual aid agreements or the result of unforeseen needs arising from a large-scale disaster. D. Fireline Paramedic A paramedic who meets all Firescope requirements, and is authorized by their department to provide ALS treatment on the fireline. E. Medical Task Force Any combination of resources assembled to support a specific medical mission or operational need. All resource elements within a Task Force must have common communications and a designated leader. F. Mutual Aid Agreements between two or more jurisdictions to provide assistance across jurisdictional boundaries, when requested, as a result of the circumstances of an emergency exceeding local resources. PRINCIPLES: POLICY: A. When requested by a recognized automatic aid/mutual aid/disaster assistance requester, EMS personnel may utilize the scope of practice for which they are trained and certified/licensed/accredited according to the California Code of Regulations and the policies and procedures established by the S-SV EMS Agency. B. These guidelines are not intended to replace existing EMS or circumvent the established response of EMS in the local county or EMS region. A. EMR A certified EMR may utilize their scope of practice in a volunteer or paid capacity. There is no requirement for an EMR to be affiliated with a provider. B. EMT 1. A California certified EMT is recognized as an EMT statewide regardless of where in California they are certified. 2. EMTs may utilize their scope of practice in a volunteer or paid capacity. There is no requirement for an EMT to be affiliated with a provider. 6

17 Automatic Aid/Mutual Aid/Out-Of-Region Response During a mutual aid response into another jurisdiction, an EMT may utilize the scope of practice for which they are trained, certified and accredited according to the policies and procedures established by their certifying or accrediting LEMSA. C. AEMT California AEMTs may practice anywhere in California provided all of the following conditions are met: 1. They are in possession of a valid California AEMT Certificate. 2. They are accredited by a LEMSA. 3. They are affiliated with a LALS or ALS provider that is approved by the LEMSA with whom they are accredited. 4. They utilize the scope of practice as defined by the LEMSA with whom they are accredited. D. Paramedic California paramedics may practice anywhere in California provided all of the following conditions are met: 1. They are in possession of a valid California Paramedic License. 2. They are accredited by a LEMSA. 3. They are affiliated with an ALS provider that is approved by the LEMSA with whom they are accredited. 4. They utilize the scope of practice for which they are trained and accredited according to the policies and procedures established by their accrediting LEMSA. E. Out-of-State Response During automatic aid/mutual aid/disaster responses outside of California, EMS personnel are normally approved to utilize the scope of practice for which they are trained and certified/licensed/accredited according to their respective classification. EMS personnel must check in with the Medical Unit Leader or other appropriate representative of the incident for any special restrictions or credentialing requirements. 7

18 Automatic Aid/Mutual Aid/Out-Of-Region Response 461 PROCEDURE: A. Automatic Aid, Mutual Aid and Out-Of-Region Responses: 1. EMS personnel shall follow all S-SV EMS policies/protocols, and shall not administer any medication or perform any procedures listed as Base/Modified Base Hospital Physician Order Only without appropriate approval. 2. Controlled substances shall be obtained, secured and inventoried as indicated in S-SV EMS Management of Controlled Substances policy (710). 3. Documentation of patient care will be completed as indicated in S-SV EMS Prehospital Documentation policy (605). B. Fireline Paramedic Program Additional Requirements: 1. Fireline Paramedic programs shall be reviewed and approved by S-SV EMS. 2. Designation by the paramedic s ALS provider agency as a Fireline Paramedic ensures that the paramedic has completed standard Firescope education. 3. The Fireline Paramedic shall present their credentials to the Medical Unit Leader upon arrival at the incident. 4. S-SV EMS approved Fireline Paramedic personnel shall carry the items listed in S-SV EMS Fireline Paramedic Inventory policy (702) when responding to wildland fires to provide ALS care in such a capacity. C. Ambulance Strike Team Additional Requirements Ambulance providers shall have a fully executed Ambulance Strike Team Memorandum of Understanding (MOU) in place with the California EMS Authority in order to participate in an ambulance strike team/medical task force request. CROSS REFERENCES: A. EMT Scope of Practice (801). B. Advanced EMT Scope of Practice (802). C. Paramedic Scope of Practice (803). D. Emergency Medical Responder (EMR) Scope of Practice (804). 8

19 Sierra Sacramento Valley EMS Agency Program Policy Patient Destination Effective: 06/01/2016 Next Review: 03/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: A. To provide guidelines for determining the appropriate destination of patients transported by ambulance in the S-SV EMS region. B. It is the intent of this policy to ensure that individual patients receive appropriate medical care while protecting the interests of the community at large by making maximum use of available emergency medical care resources. AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5, Chapter & , Chapter & B. California Code of Regulations, Title 13, 1105(c). C. California Code of Regulations, Title 22, Division 9, Chapters 2, 3, 4, & 7. A. Determination of patient destination shall be governed by California Code of Regulations, Title 13, Section 1105 (c): "In the absence of decisive factors to the contrary, ambulance drivers shall transport emergency patients to the most accessible medical facility equipped, staffed, and prepared to receive emergency cases and administer emergency care appropriate to the needs of the patients." B. Hospitals unable to accept patients due to incapacitating internal disaster or S-SV EMS authorized diversion shall be considered not prepared to receive emergency cases. C. In determining the most accessible facility, transport personnel shall take into consideration traffic obstructions, weather conditions, or similar factors which clearly affect transport time. 9

20 Patient Destination 505 D. All hospitals shall maintain the current status of their facility on EMResource, and must update their facility status no less than once every 24 hours. E. All hospitals must respond to EMResource hospital status polls initiated by the S-SV EMS Agency (HAvBED, ED & Census, etc.) within 30 minutes. GUIDELINES: A. The most accessible medical facility shall ordinarily be the nearest licensed healthcare facility that maintains and operates a basic emergency department, except for the following circumstances: 1. The base/modified base hospital may direct that the patient be transported to a further acute care hospital equipped, staffed, and prepared to receive emergency cases, which in the judgment of the base hospital physician or MICN, is more appropriate to the medical needs of the patient. Such direction shall take into consideration the prehospital provider s stated time and/or travel limitations. 2. S-SV EMS policies/protocols governing transport of special category patients to designated special care facilities shall be followed. 3. The Control Facility is responsible for the dispersal of all patients during Multi- Casualty Incidents. 4. In response to an unprecedented demand for medical/health services beyond the capacity of current system providers and resources available through local, regional, state, and/or federal mutual aid, Crisis Standard of Care Procedures may be implemented to include alternate patient transportation/destination orders. B. A member of a health care service plan should be transported to a hospital that contracts with the plan when the base/modified base hospital determines that the condition of the member permits such transport. However, when the prehospital provider agency determines that such transport would unreasonably remove the transport unit from the area, the member may be transported to the nearest hospital capable of providing appropriate treatment. C. When a patient or their legally authorized representative requests transportation to a hospital other than the most accessible, the request should be honored when the base/modified base hospital determines that the condition of the patient permits such transport; except when the prehospital provider agency determines that such transport would unreasonably remove the transport unit from the area. In such cases: 1. Arrangements should be made for alternative transport if possible. 10

21 Patient Destination If such transport cannot be obtained without unacceptable delay, the patient may be transported to the nearest hospital capable of providing appropriate treatment. D. When a private physician requests emergency transportation to a hospital other than the most accessible, the request should be honored unless: 1. The base/modified base hospital determines that the condition of the patient does not permit such transport. In such cases, base/modified base hospital directions shall be followed. If communication with the requesting physician is feasible, the base/modified base hospital should contact the physician and explain the situation. 2. The prehospital provider agency determines that such transportation would unreasonably remove the unit from the area. In such cases: CROSS REFERENCES: Arrangements should be made for alternate transportation if possible. If alternate transportation cannot be arranged without unacceptable delay, and the private physician is immediately accessible, the patient may be transported to a mutually agreed-upon alternate destination. If alternate transportation cannot be arranged without unacceptable delay, and the private physician is not immediately accessible, the patient may be transported to the nearest hospital capable of providing appropriate treatment. A. Hospital Capabilities (505-A). B. Ambulance Patient Diversion (508). C. Base/Modified Base/Receiving Hospital Contact (812). D. Multiple Casualty Incidents (MCI) (837). E. Crisis Standard of Care Procedures (838). F. Trauma Triage Criteria (860). G. Chest Pain/Discomfort of Suspected Cardiac Origin (C-8). H. Suspected CVA/Stroke (N-3). I. Burns: Thermal & Electrical (T-10 & P-28). 11

22 Sierra - Sacramento Valley EMS Regional Hospital Capabilities (505-A) Hospital Type Definitions BASE: Base hospital - medical direction provided to prehospital personnel by MICNs, in consultation with ED MD/DO when necessary MOD: Modified base hospital - medical direction provided directly by ED MD/DO when necessary REC: Receiving hospital - unable to provide any medical direction to prehospital personnel, but able to receive ambulance patients Hospitals Located Within The S-SV EMS Region Hospital Name Telephone Number County Hospital Type Level I/II Trauma Center Level III Trauma Center Level IV Trauma Center Pedi. Trauma Center Labor and Delivery Orchard Hosp. (530) Butte REC X Burn Center STEMI Center Stroke Center Helispot/ Helipad VAD Center Enloe Med. Center (530) Butte BASE X X X X X Feather River Hosp. (530) Butte BASE X X X Oroville Hosp. (530) Butte BASE X X X Colusa Medical Center (530) Colusa MOD X Glenn Med. Center (530) Glenn REC X Sierra Nevada Memorial Hosp. (530) Nevada MOD X X X Tahoe Forest Hosp. (530) Nevada MOD X X Kaiser Roseville Med. Center (916) Placer MOD X X X Sutter Auburn Faith Hosp. (530) Placer MOD X Sutter Roseville Med. Center (916) Placer BASE X X X X X Fairchild Med. Center (530) Siskiyou BASE X X X Mercy Med. Center Mt. Shasta (530) Siskiyou BASE X X X Mayers Memorial Hosp. (530) Shasta MOD X X Mercy Med. Center Redding (530) Shasta BASE X X X X X Shasta Regional Med. Center (916) Shasta BASE X X X St. Elizabeth Community Hosp. (530) Tehama BASE X X X Rideout Regional Med. Center (530) Yuba BASE X X X X X 12 Updated

23 Sierra - Sacramento Valley EMS Regional Hospital Capabilities (505-A) Hospital Name Telephone Number County Hospital Type Level I/II Trauma Center Level III Trauma Center Level IV Trauma Center Pedi. Trauma Center Labor and Delivery Burn Center STEMI Center Kaiser North Sacramento (916) Sac. REC X Kaiser South Sacramento (916) Sac. REC X X X X X Stroke Center Helispot/ Helipad Mercy General Hosp. (916) Sac. REC X X X X Mercy Hosp. Folsom (916) Sac. REC X X X Mercy San Juan Med. Center (916) Sac. REC X X X X X Methodist Hosp. (916) Sac. REC X X Sacramento VA Med. Center (916) Sac. REC Sutter Sacramento Med. Center (916) Sac. REC X X X X X UC Davis Med. Center (916) Sac. BASE X X X X X X X X Hospital Name Telephone Number City Hospital Type Level I/II Trauma Center Level III Trauma Center Level IV Trauma Center Pedi. Trauma Center Labor and Delivery Renown Regional Med. Center (775) Reno REC X X X X X St. Mary's Regional Med. Center (775) Reno REC X X X Providence Med. Center (503) Medford REC X X X X X Rogue Regional Med. Center (541) Medford REC X X X X X Sky Lakes Med. Center (541) Klamath Falls Sacramento County Hospitals Nevada & Oregon Hospitals Burn Center STEMI Center Stroke Center Helispot/ Helipad REC X X X S-SV EMS Designated MCI Control Facilities (CFs) VAD Center VAD Center Control Facility County/Area of Responsibility Enloe Medical Center Rideout Regional Medical Center Sutter Roseville Medical Center Tahoe Forest Hospital (Back-Up: REMSA) Mercy Medical Center Redding Butte, Colusa and Glenn counties Sutter and Yuba counties Western Slope of Nevada and Placer counties Tahoe Basin and Eastern Slope of Nevada and Placer counties Shasta, Siskiyou and Tehama counties 13 Updated

24 Sierra Sacramento Valley EMS Agency Program Policy STEMI Receiving Centers Effective: 06/01/2016 Next Review: 11/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: A STEMI receiving center (SRC) will be the preferred destination for patients who access the 911 system, and who show evidence of a ST-elevation myocardial infarction on a 12- lead electrocardiogram (ECG). AUTHORITY: A. California Health and Safety Code, Division 2.5, Chapter & , Chapter , , & B. California Code of Regulations, Title 13, 1105 (c), Title 22, Division 9, Chapter 4, DEFINITIONS: POLICY: A. STEMI ST Elevation Myocardial Infarction. B. PCI Percutaneous Coronary Intervention. C. STEMI Receiving Center (SRC) S-SV EMS designated facilities that have emergency interventional cardiac catheterization capabilities. D. STEMI Referring Facility (SRF) Facilities that do not have emergency interventional cardiac catheterization capabilities. The following requirements shall be met for a hospital to be designated as a SRC by the S-SV EMS Agency: A. Be licensed by the California Department of Public Health Services as a general acute care hospital. B. Have a special permit for basic or comprehensive emergency medical service pursuant to the provisions of Title 22, Division 5. 14

25 STEMI Receiving Centers 506 C. Be accredited by a Centers for Medicare and Medicaid Services approved deeming authority. D. Licensure as a cardiac catheterization laboratory. E. Intra-aortic balloon pump capability. F. Have a cardiovascular surgical services permit. This requirement may be waived by the S-SV EMS Medical Director when appropriate for patient or system needs. The S- SV EMS medical director will evaluate conformance with existing American College of Cardiology/American Heart Association or other professional guidelines. G. Communication system for notification of incoming STEMI patients, available twenty four (24) hours per day/seven (7) days per week, including a dedicated 12-lead ECG receiving station and in-house paging system. H. Provide CE opportunities, minimum of four (4) hours per year, for EMS personnel in areas of 12-lead ECG acquisition and interpretation, as well as assessment and management of STEMI patients. I. Provide public education about STEMI warning signs and the importance of early utilization of the system. J. The hospital will have the following positions designated and filled prior to becoming a designated SRC, and will maintain such positions at all times while designated: 1. Medical Directors: The hospital shall designate two physicians as co-directors of its SRC program. One physician shall be a board certified/eligible interventional cardiologist with active PCI privileges. The co-director shall be a board certified/eligible emergency medicine physician with active privileges to practice in the emergency department. 2. Nursing Directors: The hospital shall designate two SRC nursing co-directors. One nursing director shall be an RN trained or certified in critical care nursing and affiliated with the cardiac catheterization laboratory. The co-director shall be an RN trained or certified in critical care nursing and affiliated with the emergency department. 3. A daily roster of the following on-call physician consultants and staff must be maintained: 15

26 STEMI Receiving Centers 506 Cardiologist with percutaneous coronary intervention (PCI) privileges. Cardiovascular surgeon, if cardiovascular surgical services are offered. o If cardiovascular surgical services are not available on site, the facility must have a rapid transfer agreement in place with a facility that provides this service. This agreement must be on file with the S-SV EMS Agency. This agreement must include the requirement that the cardiac surgical hospital must agree to accept emergent and non-emergent transfers for additional medical care, cardiac surgery, or intervention. o The facility must have a rapid transport agreement with an S-SV EMS approved transport provider. The expectation will be that the patient will arrive at the cardiac surgical hospital within one (1) hour of the decision to operate, in emergency cases. Cardiac catheterization laboratory team. Intra-aortic balloon pump capabilities 24/7. K. Internal Hospital Policies. The hospital shall develop internal policies for the following situations: 1. Fibrinolytic therapy protocol to be used only in unforeseen circumstances when PCI for a STEMI patient is not possible. 2. Diversion of STEMI patients only during times of an internal disaster or when the cardiac catheterization laboratory is otherwise unavailable. Notification shall be made to the following entities at least 24 hours prior to any planned event resulting in the cardiac catheterization lab being unavailable: o S-SV EMS Agency. o SRC emergency department - to include a status posting on EMResource indicating that the cardiac cath lab is unavailable. o Appropriate adjacent SRC(s). o Appropriate prehospital provider agencies. In the case of an unplanned event, the following entities shall be notified as soon as possible: o SRC emergency department - to include a status posting on EMResource indicating that the cardiac catheterization lab is unavailable. o Appropriate adjacent SRC(s). o Appropriate prehospital provider agencies. All appropriate entities shall be notified as soon as possible when the cardiac catheterization lab is subsequently available. An ambulance patient diversion form describing such events shall be submitted to the S-SV EMS Agency by the end of the next business day. 3. Prompt acceptance of appropriate STEMI patients from other STEMI referral centers that do not have PCI capability. 16

27 STEMI Receiving Centers 506 L. Data Collection, Continuous Quality Improvement and Performance Standards: DESIGNATION: 1. SRC s shall comply with all data collection, continuous quality improvement and performance standards as defined in SRC contracts. 2. These requirements will be the same for each SRC. A. The SRC applicant shall be designated after satisfactory review of written documentation and an initial site survey by S-SV EMS or its designees and completion of a contract between the hospital and the S-SV EMS Agency. B. Initial designation as a SRC shall be for a period of four (4) years. Thereafter, redesignation shall occur every four (4) years, contingent upon satisfactory review. C. Failure to comply with the criteria and performance standards outlined in this policy and/or SRC contracts may result in probation, suspension or rescission of SRC designation. Compliance will be solely determined by the S-SV EMS Agency. PATIENT DESTINATION: A. SRCs should be considered the destination of choice if the following criteria are met: 1. Identified STEMI patients based on machine interpretation of field 12-lead ECG, verified by a paramedic or Advanced EMT II. 2. Total transport time to the SRC is forty-five (45) minutes or less. B. Prehospital personnel shall notify the SRC emergency department of the patient s pending arrival by advising of a STEMI ALERT as soon as possible. C. In the rare instance that the closest SRC cardiac catheterization laboratory is unavailable, the patient shall be transported to the next closest SRC if the total transport time to the alternate SRC is forty-five (45) minutes or less. D. Contact and consultation with the closest base/modified base hospital for appropriate patient destination shall be made in these and similar situations: 1. Patients in cardiac arrest or with an unmanageable airway should be considered for transport to the closest receiving hospital. 2. Patients with unstable ventricular tachycardia, second degree type II or third degree heart blocks, or with obvious contraindications to thrombolytic therapy should be directed to the closest SRC based on specific clinical scenario. 17

28 STEMI Receiving Centers 506 CROSS REFERENCES: A. 12 Lead EKG Program (440). B. Patient Destination (505). C. S-SV EMS Base/Receiving Hospital Capabilities (505-A). D. Interfacility Transport of STEMI Patients (506-A). E. Base/Modified Base/Receiving Hospital Contact (812). F. Chest Pain or Suspected Symptoms of Cardiac Origin (C-8). 18

29 Sierra Sacramento Valley EMS Agency Program Policy Stroke System Triage and Patient Destination Effective: 12/01/2016 Next Review: 07/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: A. To establish stroke receiving center designation criteria, requirements and responsibilities. B. To define the identification, destination and notification criteria of EMS transported suspected stroke patients. AUTHORITY: A. California Health and Safety Code, Division 2.5, Chapter & , Chapter , , , and B. California Code of Regulations, Title 13, 1105(c), Title 22, Division 9. DEFINITIONS: POLICY: A. Acute Stroke Patient A patient who meets assessment criteria for a suspected acute stroke in accordance with S-SV EMS Suspected Stroke Protocol (N-3). B. Stroke Receiving Center An acute care hospital which obtains and maintains Joint Commission Accreditation as a Primary Stroke Center or which has been alternately approved by the S-SV EMS Agency, and enters into a memorandum of understanding (MOU) with the S-SV EMS Agency designating them as a stroke receiving center. A. Acute Stroke Patient Identification and Destination: 1. Criteria for assessment, identification and treatment of a suspected acute stroke patient shall be based on S-SV EMS Suspected Stroke Protocol (N-3). 2. Patients identified by prehospital personnel as having an onset of stroke symptoms or time last seen normal within the past four (4) hours shall be transported to a stroke receiving center if transport time is less than 30 minutes. 19

30 Stroke System Triage and Patient Destination If the onset of symptoms or time last seen normal is unknown or exceeds four (4) hours, the patient shall be transported per routine S-SV EMS destination criteria, unless instructed otherwise by a base/modified base hospital. 4. Patients with an uncontrolled airway or in cardiac arrest shall be transported to the closest receiving facility. B. Stroke Receiving Center Notification: 1. As soon as possible, preferably from the scene, prehospital personnel shall contact the intended stroke receiving center and inform them that a stroke patient is being transported to their facility. The report shall indicate a Stroke Alert, and should include the following minimum information: Pertinent patient assessment information and prehospital treatment provided. The time of onset of symptoms or when patient was last seen normal. The patient s blood glucose reading. Minimum necessary patient identifying information (name, DOB, MR#, etc.) only if requested by the stroke receiving center. 2. When possible, prehospital personnel should obtain and relay to receiving hospital personnel the contact information of the individual(s) who can verify the time of onset of symptoms or when patient was last seen normal. C. Stroke Receiving Center Diversion: Diversion of stroke patients shall only occur during times of an incapacitating internal disaster or when the CT scanner is otherwise unavailable. 1. Notification shall be made to the following entities at least 24 hours prior to any planned event resulting in the CT scanner being unavailable: Stroke receiving center emergency department to include a status posting on EMResource indicating that the CT scanner is unavailable. Appropriate adjacent stroke receiving center(s). Appropriate prehospital provider agencies. 2. All entities listed in this section shall also be notified as soon as possible in the case of an unplanned event causing the CT scanner to be unavailable as well as when the CT scanner is subsequently available. D. Stroke receiving centers shall comply with all data reporting, continuous quality improvement and performance standards required by their stroke receiving center MOU. These requirements will be the same for each stroke receiving center. 20

31 Stroke System Triage and Patient Destination 507 E. S-SV EMS Notification: S-SV EMS shall be notified no later than the end of the next business day if any of the following occur: 1. A patient within the 30 minute catchment area of a stroke receiving center transported by the EMS system is identified as an acute stroke patient by the receiving facility and was not transported to a stroke receiving center. 2. Any instance of diversion of a stroke patient by a stroke receiving center other than the approved instances of diversion indicated in this policy. 3. An EMS field provider fails to leave the minimum required patient care documentation at the receiving facility at the time of initial patient transport. F. Interfacility Transfer of Acute Stroke Patients: 1. In the event that an acute stroke patient requires transfer to a higher level of care the transferring hospital shall follow their patient transfer policies/procedures. 2. The 911 system may be utilized to request an emergent ground ambulance for transport of an acute stroke patient to a stroke receiving facility if necessary. An air ambulance or Critical Care Transport (CCT) ambulance may also be utilized if necessary/appropriate. 3. Transferring hospital staff should provide ambulance personnel with all appropriate patient documentation including a CT scan. Patient transport should not be delayed if complete documentation is not available. If complete documentation is not sent with the ambulance, the sending hospital should fax/electronically transmit the pertinent documentation to the stroke receiving center in sufficient time that it will arrive prior to the patient if possible. CROSS REFERENCES: A. Patient Destination (505). B. Patient Care Documentation (605). C. Base/Modified Base/Receiving Hospital Contact (812). D. Suspected Stroke (N-3). 21

32 Sierra Sacramento Valley EMS Agency Program Policy Prehospital Documentation Effective: 06/01/2017 Next Review: 03/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To define patient care report (PCR) documentation and data submission responsibilities. AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5, , , , and B. California Code of Regulations, Title 22. A. BLS non-transport provider personnel shall, at a minimum, complete a PCR for the following types of incidents: 1. Refusal of EMS care completed by BLS personnel. 2. Utilization of any BLS optional skill. B. LALS/ALS non-transport provider personnel shall, at a minimum, complete PCRs as follows: 1. If the non-transport provider is cancelled prior to arrival at scene, completion of a PCR by the non-transport provider is not required. 2. If a non-transport provider arrives on scene and no patient is identified, a PCR shall be completed indicating a minimum of the reported incident location, incident times and reason why no patient was identified. If the non-transport provider arrives after or simultaneous to the transport provider, a single PCR by either provider is sufficient. 3. If the non-transport provider establishes patient contact prior to the transport provider, the non-transport provider shall complete a PCR for each patient unless contact was limited to a BLS assessment and patient care was assumed by a transport provider. If transfer of care is done within the same agency, a single PCR documenting the care provided by all personnel on scene is sufficient. 22

33 Prehospital Documentation If the non-transport and transport provider establish patient contact simultaneously, or if the non-transport provider establishes patient contact after the transport provider, a single PCR documenting the care provided by all personnel on scene is sufficient. 5. If the non-transport provider arrives on scene after the transport provider and no patient contact is established by the non-transport provider, completion of a PCR by the non-transport provider is not required. C. BLS/LALS/ALS transport provider personnel shall, at a minimum, complete PCRs as follows: 1. If the transport provider is cancelled prior to arrival at scene, completion of a PCR by the transport provider is not required. 2. If a transport provider arrives on scene and no patient is identified, a PCR shall be completed indicating a minimum of the reported incident location, incident times and reason why no patient was identified. If the transport provider arrives after or simultaneous to the non-transport provider, a single PCR documenting this minimum information by either provider is sufficient. 3. The transport provider shall complete a PCR for each patient where patient contact/transport is established. If patient care is maintained by a non-transport provider and both units are from the same agency, a single PCR documenting the care provided by all prehospital personnel is sufficient. 4. If the transport provider arrives on scene after the non-transport provider and no patient contact is established by the transport provider, completion of a PCR by the transport provider is not required. D. Multiple Patient Incidents: 1. During an incident involving two or more patients, the initial LALS/ALS provider who establishes patient contact shall complete a PCR on each patient unless one or more of the following special circumstances apply: Patient contact was limited to triage/basic assessment only, and all pertinent patient assessment and treatment information is documented by the transporting provider. Patient care was transferred to another provider from the same agency, and all pertinent patient assessment and treatment information is documented by the transporting unit. The provider receives approval from S-SV EMS not to complete full PCR documentation on each patient (i.e. large MCI). 23

34 Prehospital Documentation 605 In the event that any of these conditions apply, the initial LALS/ALS provider who establishes patient contact shall complete a minimum of one PCR containing pertinent incident information (incident nature, details, patient count/triage categories, etc.). E. A PCR is a legal medical record. Prehospital personnel are responsible for providing clear, concise, complete, legible and accurate prehospital documentation. Any form of falsification of prehospital documentation shall be considered a serious infraction, subject to possible disciplinary action. PROCEDURE: A. All EMS transport and ALS/LALS non-transport providers shall utilize an electronic PCR software system compliant with the current supported version of NEMSIS for prehospital documentation purposes required by this policy. B. BLS non-transport providers shall utilize either a written PCR or an electronic PCR software system compliant with the current supported version of NEMSIS for prehospital documentation purposes required by this policy. C. When available to prehospital personnel, the following minimum patient care documentation shall be completed by the primary patient care provider and left at the receiving facility at time of patient delivery: 1. Routine incident information (date of incident, incident number, call location, EMS unit number, and hospital arrival time). 2. Patient demographic information (name, sex, age, date of birth, address, city and telephone number). 3. Chief complaint. 4. PQRST/time of symptom onset (including time of incident and mechanism of injury for all trauma patients). 5. Pertinent medical history, medications and medication allergies. 6. Vital signs (including GCS, BP, pulse, respirations, pain scale, cardiac rhythm and Sp02 as appropriate). 7. Treatment rendered (including time, type of treatment, medication, dose, route, response and total IV volume infused). 8. Relevant patient care related documents (DNR/POLST forms, 12 Lead EKGs, cardiac monitor rhythm strips, etc.). 24

35 Prehospital Documentation Name, title and ID of the prehospital provider completing the documentation. Although it is preferred that a completed PCR be left at the receiving hospital at the time of patient delivery, prehospital personnel may satisfy this requirement with the completion of an interim patient care report (605-A or equivalent). D. Completed PCRs shall be distributed as follows: 1. Receiving hospital: When a complete PCR is not left with the patient at the receiving hospital, the PCR shall be provided/available to the receiving hospital within 24 hours. When patient care is transferred from one LALS/ALS provider to another prehospital provider, the non-transport provider shall provide/make available a copy of their completed PCR to the receiving hospital within 24 hours. 2. Base hospital: If a base hospital is utilized for medical control that is not the receiving hospital, a copy of the PCR shall be provided/available to the base hospital within 24 hours. 3. S-SV EMS: If a BLS optional skill is utilized, a copy of the PCR shall be provided/available to S-SV EMS within seven (7) calendar days. E. Completed PCRs for adult and emancipated minor patients shall be preserved for a minimum of seven years. Completed PCRs for unemancipated minor patients shall be preserved for at least one year after such minor has reached the age of 18 years and, in any case, not less than seven years. F. Prehospital providers not utilizing the S-SV EMS selected PCR software system shall submit PCR data to the S-SV EMS data system in a currently supported NEMSIS format. CROSS REFERENCES: A. BLS Optional Skills Utilization Patient Care Report (605-A) B. Interim Patient Care Report (605-B). 25

36 Sierra Sacramento Valley EMS Agency Program Policy Management of Controlled Substances Effective: 06/01/2016 Next Review: 11/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To ensure accountability of all controlled substances obtained, maintained and utilized by paramedic and AEMT II prehospital provider agencies and personnel. AUTHORITY: POLICY: A. Code of Federal Regulations, Title 21. B. California Health & Safety Code, Division 2.5. C. California Health & Safety Code, Division 10. D. California Code of Regulations, Title 22, Division 9, Chapters 3 & 4. A. S-SV EMS approved controlled substances: 1. Fentanyl. 2. Midazolam (Versed). 3. Morphine sulfate. B. Prehospital provider agencies shall obtain controlled substances through one of the following methods: 1. The medical director of the provider agency. 2. The base/modified base hospital shall ensure that a mechanism exists for provider agencies to contract for the provision of controlled substances. C. Prehospital Provider Agency Policies and Procedures: 1. Provider agencies shall ensure that security mechanisms and procedures are established for controlled substances, including, but not limited to: 26

37 Management of Controlled Substances 710 Controlled substance ordering and order tracking. Controlled substance receipt and accountability. Controlled substance master supply storage, security and documentation. Controlled substance labeling and tracking. Controlled substance vehicle storage and security. Controlled substance usage procedures and documentation. Controlled substance reverse distribution. Controlled substance disposal. Controlled substance re-stocking procedures. 2. Prehospital provider agencies shall ensure that mechanisms for investigation and mitigation of suspected controlled substance tampering or diversion are established, including, but not limited to: Controlled substance testing. Controlled substance discrepancy reporting. Controlled substance tampering, theft and diversion prevention/detection. Controlled substance usage audits. D. Security of Narcotics: 1. Paramedic and AEMT II personnel shall be responsible for maintaining the correct inventory of controlled substances at all times. 2. All controlled substances shall be stored/secured in one of the following manners: Preferred: Secured in a commercially developed drug locker specifically designed for controlled substances storage. The drug locker shall be securely mounted to the vehicle to prevent theft and shall have an electronic access keypad with an individual PIN code assigned to each paramedic or AEMT II personnel authorized to access and utilize the controlled substances. The drug locker shall be able to produce an electronic audit trail showing the date, time and PIN code of each instance the locker was opened. The double lock requirement does not apply to providers storing their controlled substance utilizing this method. Alternate: Secured on the vehicle under double lock in an appropriate manner to prevent theft. The vehicles outside driver/passenger/patient access door(s) shall not be considered one of the two locks. 3. Prehospital provider agencies must abide by all Federal, State and local regulations for the storage/security of controlled substances. 27

38 Management of Controlled Substances Each unit shall maintain a standardized written record of the controlled substance inventory. Controlled substance inventory and administration records shall be maintained in accordance with State and Federal Law and Regulation. 5. Controlled substances shall be inventoried any time there is a change in personnel. The key to access controlled substances, if applicable, shall be in the custody of the individual who performed the inventory. 6. Any discrepancies in the controlled substance count shall be reported as soon as possible to the appropriate supervisor and the issuing agent (medical director). The discrepancy report must be appropriately documented. E. Controlled Substances Administered to Patients: 1. Controlled substances are to be administered in accordance with S-SV EMS treatment protocols. 2. The following information must be documented on a controlled substance administration record: Date and time administered. Unit number. Patient name. Drug administered. Amount administered. Paramedic/AEMT II signature and number. 3. If only a portion of the medication was administered to the patient, the remainder shall be wasted in the presence of a registered nurse or physician at the receiving hospital, or the provider s immediate supervisor. Both parties shall document this action on the controlled substance administration form. 4. Controlled substance inventories/logs are subject to inspection by the California Board of Pharmacy, Bureau of Narcotic Enforcement Administration of the Justice Department, Federal Drug Enforcement Administration, the S-SV EMS Agency, the issuing agent, and/or officers of the prehospital provider agency. CROSS REFERENCES: A. Prehospital Provider Agency Inventory Requirements (701). B. AEMT Scope of Practice (802). C. Paramedic Scope of Practice (803). 28

39 Sierra Sacramento Valley EMS Agency Program Policy Paramedic Scope Of Practice Effective: 12/01/2017 Next Review: As Needed 803 Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To establish the paramedic scope of practice in the S-SV EMS region. AUTHORITY: A. California Health and Safety Code, Division 2.5, , , B. California Code of Regulations, Title 22, Division 9, Chapter 4, & PRINCIPLES: A. A paramedic may perform any activity specified in the S-SV EMS EMT Scope of Practice Policy (801), or any activity specified in S-SV EMS AEMT Scope of Practice Policy (802). B. A paramedic shall be licensed in the State of California, accredited by S-SV EMS, and sponsored by an S-SV EMS approved paramedic prehospital service provider agency in order to perform the approved paramedic scope of practice in the S-SV EMS region. C. Advanced life support (ALS) activities carried out by paramedics at the scene of a medical emergency or during transport shall be under the following conditions only: 1. Standing order patient care based on S-SV EMS approved policies/protocols. 2. Direct on-line medical direction by a base/modified base hospital physician or base hospital MICN. Base/modified base hospital contact/approval is required to utilize procedures/ medications that are identified in S-SV EMS policies/protocols as base hospital order only (with the exception of documented communication failure as specified in S-SV EMS Communication Failure Policy 890) or base/ modified base hospital physician order only. 3. Direct medical supervision as specified in S-SV EMS Physician on Scene Policy (839). 29

40 Paramedic Scope Of Practice Interfacility transport (IFT) written orders from a physician as specified in S-SV EMS Medical Control For Transfers Between Acute Care Facilities Policy (840). POLICY: A. A paramedic student or a licensed paramedic, as part of an organized EMS system, while caring for patients in a hospital as part of his/her training or continuing education (CE) under the direct supervision of a physician, registered nurse, or physician assistant, or while at the scene of a medical emergency or during transport, or during interfacility transfer, or while working in a small and rural hospital pursuant to of the Health and Safety Code, may perform the following procedures or administer the following medications: B. Basic Scope of Practice: 1. Utilize electrocardiographic devices and monitor electrocardiograms, including 12- lead electrocardiograms (ECG). 2. Perform defibrillation, synchronized cardioversion, and external cardiac pacing. 3. Visualize the airway by use of the laryngoscope and remove foreign bodies with Magill forceps. 4. Perform pulmonary ventilation by use of lower airway multi-lumen adjuncts, the esophageal airway, perilaryngeal airways, stomal intubation, and adult oral endotracheal intubation. 5. Utilize mechanical ventilation devices for continuous positive airway pressure (CPAP). 6. Institute intravenous (IV) catheters, saline locks, needles, or other cannula (IV lines), in peripheral veins and monitor and administer medications through preexisting vascular access. 7. Institute intraosseous access (IO needles or catheters). 8. Administer IV or IO glucose solutions or isotonic balanced salt solutions, including Ringer's Lactate solution. 9. Obtain venous blood samples. 10. Use laboratory devices, including point of care testing, for prehospital screening use to measure lab values including, but not limited to: glucose, capnometry, capnography, and carbon monoxide. 30

41 Paramedic Scope Of Practice Utilize Valsalva maneuver. 12. Perform percutaneous needle cricothyroidotomy. 13. Perform needle thoracostomy. 14. Monitor thoracostomy tubes. 15. Monitor and adjust IV solutions containing potassium 40 meq/l. 16. Administer approved medications by the following routes: IV, IO, intramuscular, subcutaneous, inhalation, transcutaneous, rectal, sublingual, endotracheal, intranasal, oral or topical. 17. Administer, using prepackaged products when available, the following medications: 10% and 50% dextrose Activated charcoal Adenosine Aerosolized or nebulized beta-2 specific bronchodilators albuterol Amiodarone Aspirin Atropine sulfate Calcium chloride Diphenhydramine hydrochloride Dopamine hydrochloride Epinephrine Fentanyl Glucagon Ipratropium bromide Midazolam Lidocaine hydrochloride Morphine sulfate Naloxone hydrochloride Nitroglycerin preparations, except intravenous Ondansetron Pralidoxime chloride Sodium bicarbonate 31

42 Paramedic Scope Of Practice 803 C. S-SV EMS Optional Scope of Practice: All licensed and S-SV EMS accredited paramedics or supervised paramedic students in the S-SV EMS region may perform the following additional activities in the prehospital setting and/or during interfacility transport: 1. Adult nasotracheal intubation. D. IFT Optional Scope of Practice: Paramedics who have successfully completed S-SV EMS approved training and are functioning under the oversight of an S-SV EMS approved paramedic IFT optional skills ALS ambulance provider may utilize the following IFT optional skills: 1. Monitor preexisting intravenous infusion of magnesium sulfate, nitroglycerin, heparin and/or amiodarone. 2. Monitor blood transfusions. 3. Utilize automatic transport ventilators (ATV s). E. Critical Care Paramedic (CCP) Expanded Scope of Practice: A CCP may utilize the following additional scope of practice during interfacility transports when they have completed a CCP training program as specified in S-SV EMS Paramedic Training Program Requirements and Approval Process Policy (1005), have successfully completed required competency testing, hold a current certification as a CCP from the Board of Critical Care Transport Certification (BCCTPC), and are employed by an S-SV EMS approved CCP prehospital provider: 1. Set up and maintain thoracic drainage systems. 2. Set up and maintain mechanical ventilators. 3. Set up and maintain IV fluid delivery pumps and devices. 4. Blood and blood products. 5. Glycoprotein IIB/IIIA inhibitors. 6. Heparin IV. 7. Nitroglycerin IV. 8. Norepinephrine. 9. Thrombolytic agents. 10. Maintain total parenteral nutrition. 32

43 Sierra Sacramento Valley EMS Agency Program Policy Base/Modified Base/Receiving Hospital Contact Effective: 12/01/2016 Next Review: 07/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To define the circumstances under which prehospital personnel shall establish base, modified base, and/or receiving hospital contact for medical control, patient destination and/or patient notification purposes. AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5, , 1798, , B. California Code of Regulations, Title 22, Division 9, Chapters 2, 3 and 4. A. Prehospital personnel shall make appropriate hospital contact in a timely manner according to the requirements contained in this policy. B. Base/modified base hospital contact is required by prehospital personnel to perform procedure(s) and/or administer medications(s) that are identified in S-SV EMS policies/protocols as Base/Modified Base Hospital Order Only. In the event of communication failure, those procedures/medications may still be utilized if the patient s condition warrants such treatment. C. Base/modified base hospital contact is required by prehospital personnel to perform procedure(s) and/or administer medications(s) that are identified in S-SV EMS policies/protocols as Base/Modified Base Hospital Physician Order Only. In the event of communication failure those procedures/medications shall not be utilized. D. When requesting to speak directly to a base/modified base hospital physician, prehospital personnel shall advise the hospital staff member who initially answers the telephone or radio of the reason for the request. E. Prehospital personnel may provide minimum necessary patient identifying information (name, DOB, MR#, etc.) when requested by the receiving hospital. A secured communication line (e.g. landline, cellular telephone) shall be used if available. 33

44 Base/Modified Base/Receiving Hospital Contact 812 PROCEDURE: A. Prehospital personnel shall contact the base/modified base hospital that is in closest proximity to the incident for any of the following circumstances: 1. For authorization to perform procedures and/or administer medications that are indicated in S-SV EMS policies/protocols as Base/Modified Base Hospital Order Only or Base/Modified Base Hospital Physician Order Only. 2. For patients refusing assessment, treatment and/or transportation as required by S-SV EMS Refusal Of EMS Care Policy (850). 3. For destination consultation on the following types of patients: Burn patients who require destination consultation as required by S-SV EMS Burns Thermal & Electrical Treatment Protocol (T-10). When there is initiation of an ALS/LALS protocol and transport to a facility other than the most accessible is being considered, except for the following types of patients meeting criteria for transport directly to a designated specialty care facility: o STEMI patients If a STEMI patient is within the authorized catchment area of a designated STEMI receiving center, contact shall be made directly with the designated STEMI receiving center. o Stroke patients If a patient is identified as meeting stroke symptom criteria and the patient is within the authorized catchment area of a designated stroke receiving center, contact shall be made directly with the stroke receiving center. o Trauma patients If a patient meets Anatomic and/or Physiologic Trauma Triage Criteria, or meets Mechanism of Injury Trauma Criteria and is within the authorized catchment area of a designated trauma center, contact shall be made with the appropriate designated trauma center. Note: These exceptions do not apply to patients who require transport to the closest facility (i.e. unable to establish an airway, CPR in progress) 4. For any patient who, in the opinion of the prehospital provider, requires the additional input or judgment of the base/modified base hospital for appropriate management. B. Prehospital personnel shall make contact directly with the destination facility, in a timely manner, for any patient who does not meet the above criteria or when base/modified base contact is made and the patient is authorized/directed to be transported to a facility other than the base/modified base hospital initially contacted. 34

45 Base/Modified Base/Receiving Hospital Contact 812 CROSS REFERENCES: A. Patient Destination (505). B. Hospitals Capabilities (505-A). C. STEMI Receiving Centers (506). D. Stroke System Triage and Patient Destination (507). E. Refusal Of EMS Care (850). F. Trauma Triage Criteria (860). G. Communication Failure (890). H. Chest Pain or Suspected Symptoms of Cardiac Origin (C-8). I. Suspected CVA/Stroke (N-3). J. Burns Thermal & Electrical (T-10). 35

46 Sierra Sacramento Valley EMS Agency Program Policy Ventricular Assist Device (VAD) Effective: 06/01/2017 Next Review: 03/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To establish guidelines for prehospital assessment and treatment and transport of patients with a Ventricular Assist Device (VAD). AUTHORITY: A. California Health and Safety Code, Division 2.5, , 1798 and B. California Code of Regulations, Title 22, Division 9. PROCEDURE: A. Follow appropriate S-SV EMS treatment protocol(s) for the patients condition. B. There are no medication contraindications in relation to the VAD. C. Chest compressions are CONTRAINDICATED. Chest compressions and blunt chest and/or abdominal trauma may dislodge the VAD grafts and cause sudden death. D. If defibrillation or cardioversion is necessary, follow the appropriate treatment protocol. The pump is insulated so that electrical therapy should not be an issue. E. A patient with a VAD might not have a palpable pulse as this is a continuous flow device. However, they do have a heart rate and rhythm. The only method to establish the patient s heart rate and rhythm will be by obtaining an EKG as the patient s palpable pulse may not match their true heart rate. Treat arrhythmias according to S- SV EMS protocols, except for chest compressions. F. A patient with a VAD might not have a systolic and diastolic blood pressure obtainable by standard methods using a manual or automatic blood pressure cuff. The mean blood pressure (typical range is mmhg) is typically obtained via doppler, however, auscultation may be possible. G. Pulse oximetry may not be measurable or accurate. 36

47 Ventricular Assist Device (VAD) 818 H. Waveform capnography monitoring is recommended if available. I. Overall clinical assessment is the most important clinical observation (e.g. responsiveness, skin signs and perfusion, respirations, etc.). J. A patient with a VAD may also have an Implanted Cardioverter-Defibrillator (ICD) or a Pacemaker/ICD. K. A patient with a VAD will most likely have a trained companion with them. The companion is familiar with the VAD and emergency troubleshooting. The companion should accompany the patient during transport and be responsible for the VAD whenever possible. L. Patients/companions are taught to call 911 in an emergency then page the on-call VAD Coordinator immediately. The VAD Coordinator will typically be on the telephone to provide additional assistance to prehospital personnel when they arrive. The patient/companion will know how to contact the on-call VAD Coordinator if necessary. In addition, contact information for the VAD Coordinator and VAD Implant Center is usually attached to or located inside the patients VAD equipment bag. M. If transporting a patient to the hospital, the VAD equipment bag, power source, battery and battery charger should be brought with the patient. N. A patient with a VAD should typically be transported to the nearest appropriate VAD center, with preference given to their implanting center whenever possible. The patient and/or their companion should be able to advise prehospital personnel of the requested transport destination. If the patients condition does not warrant transportation to the VAD center, or if there are any questions regarding appropriate destination, the base/modified base hospital shall be contacted for destination consultation. 37

48 Sierra Sacramento Valley EMS Agency Program Policy Determination Of Death Effective: 06/01/2016 Next Review: 03/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To establish criteria for public safety, EMR, EMT, Advanced EMT (AEMT), and paramedic personnel to determine death in the prehospital setting. AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5, and B. California Code of Regulations, Title 22, Division 9. A. CPR need not be initiated and may be discontinued for patients who meet the Obvious Death or Probable Death criteria. B. Public safety, EMR, EMT, AEMT, or paramedic personnel may determine death for patients who meet the following Obvious Death criteria: Patients who, in addition to the absence of respiration, cardiac activity and neurological reflexes have one (1) or more of the following: 1. Decapitation. 2. Decomposition. 3. Incineration of the torso and/or head. 4. Exposure, destruction, and/or separation of the brain or heart from the body. 5. Rigor Mortis. 6. A valid Do Not Resuscitate (DNR) form or medallion in accordance with the S-SV EMS Do Not Resuscitate Policy (823). Note: this applies regardless of the cause of death (e.g. person with a terminal illness who is a trauma victim). 38

49 Determination Of Death 820 C. AEMT II or paramedic personnel may determine death for individuals who Obvious Death criteria do not apply, but who meet the following Probable Death criteria: PROCEDURE: Patients who, in addition to the absence of respirations, pulses and neurological reflexes meet one (1) or more of the following criteria at the time of initial assessment by the AEMT II or paramedic: 1. Lividity or Livor Mortis (discoloration appearing on dependent parts of the body after death as a result of cessation of circulation, stagnation of blood and settling of the blood by gravity) and the cardiac monitor shows asystole in two (2) leads. 2. Victim of cardiac arrest secondary to blunt or penetrating trauma and the cardiac monitor shows asystole in two (2) leads. 3. Victim of cardiac arrest secondary to blunt trauma and the cardiac monitor shows PEA at a rate 40 per minute. A. Patient assessment shall include a visual and physical examination. The examination shall be conducted in close proximity and with sufficient lighting to assure the existence of obvious or probable death criteria. B. If determination of death is based on rigor mortis, all of the following specific assessments shall be completed and documented. 1. Assessment to confirm absence of respiration: Assess the patient s airway. Look, listen and feel for respirations, including auscultation of the lungs for a minimum of 30 seconds. 2. Assessment to confirm absence of pulse: Palpate the carotid pulse for a minimum of 30 seconds. Auscultate the apical pulse for a minimum of 30 seconds. 3. Assessment to confirm absence of neurological response: Check for pupil response with a penlight or flashlight. Check for a response to painful stimuli. A positive response to any of the above assessments requires immediate resuscitative intervention unless the patient has a valid DNR order. 39

50 Determination Of Death Assessment to confirm rigor mortis: Confirm muscle rigidity of the jaw by attempting to open the mouth. Confirm muscle rigidity of one arm by attempting to move the extremity. If any doubt exists as to the presence of rigor mortis, prehospital personnel shall initiate CPR unless the patient has a valid DNR order. C. If there is any objection or disagreement by family members or prehospital personnel regarding terminating or withholding resuscitation for patients who have a DNR or meet probable death criteria, basic life support, including defibrillation, shall continue or begin immediately and EMS personnel shall contact the base/modified base hospital for further directions. Once base contact is initiated, do not stop resuscitation unless directed to do so by the base/modified base hospital. D. The body and scene should be disturbed as little as possible to protect potential crime scene evidence, and an immediate request for law enforcement shall be made. E. EMS personnel shall follow the direction of law enforcement as to who has custody of the body. Note: evidence of a hospice patient receiving care from a physician or registered nurse who is a member of a hospice care team normally does not require coroner notification by prehospital personnel or law enforcement as this notification is the responsibility of hospice personnel. F. Appropriate prehospital personnel shall remain on scene until released by law enforcement. The following minimum information shall be provided to law enforcement prior to leaving the scene: 1. Unit ID. 2. Name and certification or license number of the EMS provider who determined death. 3. Patient demographics and medical history. 4. Determination of death date and time. G. The EMS provider who determined death shall document all relevant facts/findings, including time of determination of death, on the PCR. A minimum six-second cardiac monitor strip of each lead shall be attached to the PCR for all patients where death is determined utilizing probable death criteria. The PCR shall be completed within 24 hours and a copy provided to the coroner upon request. 40

51 Determination Of Death 820 SPECIAL INFORMATION: A. Hypothermia, drug and/or alcohol ingestion/overdose can mask the positive neurological reflexes which indicate life, so it is imperative to be certain no contributing environmental factors exist, such as cold water submersion or cold exposure. If any possibility exists that such conditions could be a factor, resuscitation should be started immediately unless the patient has a valid DNR. B. In the event of a disaster/multi-casualty incident, death may be determined in accordance with START criteria. C. If the base/modified base hospital physician directs EMS personnel to stop resuscitation efforts once ambulance transport has begun, the ambulance will reduce transport code and continue transport to the destination hospital. D. If a patient undergoing resuscitation is transported to rendezvous with an EMS aircraft and determination of death is made at the rendezvous location, the body shall not be moved from the rendezvous location, and an immediate request for law enforcement shall be made. CROSS REFERENCES: A. Do Not Resuscitate (DNR) (823). B. Crime Scene Management (825). 41

52 Sierra Sacramento Valley EMS Agency Program Policy DNR, POLST, End of Life Option (Aid-In-Dying Drug) Effective: 12/01/2016 Next Review: 10/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: A. To provide a mechanism to allow patients to refuse unwanted resuscitation attempts and ensure that patient's rights to control their own medical treatment are honored. B. To establish the criteria, requirements and procedures to withhold resuscitative measures in the prehospital setting. AUTHORITY: A. California Health and Safety Code, Division 1, Part 1.8, B. California Health and Safety Code, Division 2.5, and C. California Code of Regulations, Title 22, Division 9. D. California Probate Code, Division 4.7. E. Guidelines for EMS Personnel Regarding Do Not Resuscitate (DNR) Directives, (EMSA #111), California Emergency Medical Services Authority. DEFINITIONS: A. Advance Health Care Directive (AHCD): A document that allows an individual to provide healthcare instructions and/or appoint an agent to make healthcare decisions when unable or prefer to have someone speak for them. AHCD is the legal format for healthcare proxy or durable power of attorney for healthcare and living will. B. Agent or Attorney-In-Fact: An individual designated in a power of attorney for health care to make a health care decision for the principal/patient, regardless of whether the person is known as an agent or attorney-in-fact, or by some other term. C. Aid-in-Dying Drug: A drug determined and prescribed by a physician for a qualified individual, which the qualified individual may choose to self-administer to bring about his or her death due to terminal illness. The prescribed drug may take effect within minutes to several days after self-administration. 42

53 DNR, POLST, End of Life Option (Aid-In-Dying Drug) 823 D. Basic Life Support (BLS) Measures: The provision of treatment designed to maintain adequate circulation and ventilation for a patient in cardiac arrest without the use of drugs or special equipment (assisted ventilation via a bag-mask device and manual or automated chest compressions). E. Do Not Resuscitate (DNR): A request to withhold interventions to restore cardiac activity and respirations (no chest compressions, defibrillation, advanced airway, assisted ventilation, or cardiotonic drugs). The patient shall receive full palliative treatment for pain, dyspnea, major hemorrhage, or other medical conditions; i.e., oropharyngeal suction and oxygen. Relief of choking caused by a foreign body is appropriate; however, if breathing has stopped and the patient is unconscious, ventilation should not be assisted. F. DNR Wrist or Neck Medallion: A MedicAlert or other EMSA approved wrist or neck medallion, permanently engraved with the words "Do Not Resuscitate - EMS", and a patient identification number. G. Durable Power of Attorney for Health Care (DPAHC): Allows an individual to appoint an agent/attorney-in-fact to make health care decisions if they become incapacitated. The DPAHC must be immediately available. The agent/attorney-in-fact must be physically present and provide adequate identification. Decisions made by the agent/attorney-in-fact must be within the limits set by the DPAHC, if any. H. Emergency Medical Services Prehospital Do Not Resuscitate (DNR) Form: An approved DNR form, developed by the California Emergency Medical Services Authority (EMSA) and the California Medical Association (CMA), that is used statewide for the purpose of instructing EMS personnel to forgo resuscitation attempts in the event of a patient's cardiopulmonary arrest in the out of hospital setting. The form must be signed and dated by a physician and patient/surrogate to be valid. I. End of Life Option Act: A California state law that authorizes an adult, eighteen years or older, who meets certain qualifications, and who has been determined by his or her attending physician to be suffering from a terminal disease to make a request for an aid-in-dying drug prescribed for the purpose of ending his or her life in a humane and dignified manner. J. Physician s Orders for Life Sustaining Treatment (POLST): A physician order form that addresses a patient s wishes about a specific set of medical issues related to end-of-life care. The form must be signed and dated by a physician and patient/surrogate to be valid. 43

54 DNR, POLST, End of Life Option (Aid-In-Dying Drug) 823 POLICY: A. Any one of the following approved DNR orders shall be honored by prehospital personnel in the S-SV EMS region: 1. A fully executed original or photocopy of the Emergency Medical Services Prehospital Do Not Resuscitate (DNR) form. 2. A fully executed original, or photocopy, of the POLST form. 3. The patient is wearing an approved DNR wrist or neck medallion. 4. If the patient's physician is present, they may verbally order DNR and immediately confirm the DNR order in writing. A telephone order by the patient's physician to prehospital personnel is not acceptable. 5. A written or electronic DNR order by a physician. In order to be valid this type of DNR order shall consist of the following: Patient's name. The words "Do Not Resuscitate" (or DNR) or "No Code". The physician's signature or an RN signature verifying a valid verbal order from a physician on a physician order sheet. The date of the order. 6. An AHCD or DPAHC, with the agent/attorney-in-fact physically present, and stating the patient refuses resuscitative measures. The agent/attorney-in-fact must provide adequate identification. B. End of Life Option Act: PROCEDURE: A patient who has obtained an aid-in-dying drug has met extensive and stringent conditions as required by California law. The law offers protections and exemptions for healthcare providers but is not explicit about EMS response for End of Life Option Act patients. A. DNR, POLST, AHCD, DPAHC: 1. All patients shall receive an immediate assessment/medical evaluation. 2. Identify that the patient is the person named on the applicable form. This will normally require either the presence of a witness who can reliably identify the patient or the presence of a form of identification. 44

55 DNR, POLST, End of Life Option (Aid-In-Dying Drug) When the patient is found to be in cardiopulmonary arrest, BLS measures shall be initiated if necessary pending verification of a valid DNR order. 4. When in doubt, resuscitation shall be initiated and the base/modified base hospital physician contacted immediately. 5. If an S-SV EMS approved DNR order is not available, prehospital personnel shall consult with the base/modified base hospital physician to discuss the validity or applicability of forms presented. 6. If there is any objection or disagreement by family members/caretakers regarding withholding resuscitation, or if prehospital personnel have any reservations regarding the validity of the DNR order, BLS resuscitation shall begin immediately and contact with the base/modified base hospital physician shall be made for further direction. 7. If a patient has a valid DNR, but resuscitation was started prior to arrival of the EMS responder, CPR can be discontinued. 8. If the patient is conscious and states that s/he wishes resuscitative measures, then the DNR form shall be ignored. B. End of Life Option Act: The following guidelines are provided for EMS personnel when responding to a patient who has self-administered an aid-in-dying drug: 1. Within 48 hours prior to self-administering the aid-in-dying drug, the patient is required to complete a Final Attestation for an Aid-In-Dying Drug to End My Life in a Humane and Dignified Manner. However, there is no mandate for the patient to maintain the final attestation in close proximity. If a copy of the final attestation is available, EMS personnel should confirm the patient is the person named in the final attestation. This will normally require either the presence of a witness who can reliably identify the patient or the presence of a form of identification. 2. There are no standardized Final Attestation for an Aid-In-Dying Drug to End My Life in a Humane and Dignified Manner forms. If available, EMS personnel should make a good faith effort to review and verify that the document is identified as a Final Attestation for an Aid-In-Dying Drug to End My Life in a Humane and Dignified Manner and includes the patient s name, signature and date. 3. Provide comfort measures (airway positioning, suctioning) when applicable. 4. Withhold resuscitative measures if patient is in cardiopulmonary arrest. If a POLST or AHCD is present, follow the directive as appropriate for the clinical situation. 45

56 DNR, POLST, End of Life Option (Aid-In-Dying Drug) The patient may at any time withdraw or rescind his or her request for an aid-indying drug regardless of their mental state. In this instance, EMS personnel shall provide medical care according to standard treatment protocols. EMS personnel are encouraged to consult with the base/modified base hospital physician in these situations. 6. Family members may be at the scene of a patient who has self-administered an aid-in-dying drug. If there is objection to the End of Life Option Act, inform the family that comfort measures will be provided and consider base/modified base hospital physician consultation for further direction. DOCUMENTATION: A. A copy of any applicable forms (DNR, POLST, AHCD, DPAHC, final attestation, etc.) shall be attached to the prehospital patient care report (PCR) when available. When DNR orders are noted in the patient s written or electronic medical record, a copy of the order shall be attached to the PCR when available. If copies of any applicable forms/orders are unavailable, prehospital personnel shall document in the PCR that such documents were reviewed and verified as valid. Other appropriate information (name of physician who signed the form, date signed, circumstances surrounding the incident, base/modified base hospital physician name if consulted, etc.) shall also be documented in the PCR. B. If the patient is wearing a DNR bracelet or neck medallion, the DNR bracelet or neck medallion number shall be documented in the PCR. C. If patient transport is undertaken, any applicable forms (DNR, POLST, AHCD, DPAHC, final attestation, etc.) shall be taken with the patient to the receiving facility. CROSS REFERENCES: A. EMSA/CMA DNR Form (823-A). B. POLST Form (823-B) C. Base/Modified Base/Receiving Hospital Contact (812). D. Determination of Death (820). 46

57 Sierra Sacramento Valley EMS Agency Program Policy Crime Scene Management Effective: 06/01/2017 Next Review: 05/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To provide guidelines for EMS personnel when patient care is required at the scene of a known or potential crime. AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5, , B. California Code of Regulations, Title 22, Division 9. A. The primary duty of both law enforcement and EMS personnel is to protect and preserve human life. EMS personnel must ensure that patient care is given highest priority, in consideration to the needs of law enforcement (personnel/public safety, crime scene management and evidence preservation). B. In the event that EMS personnel discover a crime scene, or are at a crime scene without law enforcement, an immediate request for law enforcement shall be made. EMS personnel shall assure their own safety and, if possible, attempt to follow the guidelines contained in this policy. C. EMS personnel shall follow the directions of law enforcement with respect to crime scene management. This direction should not prevent or detract from patient care. The following guidelines should be followed: 1. Parking of EMS vehicles should be done to provide adequate access for EMS personnel but with consideration of the crime scene (i.e., do not run over expended shell casings or destroy physical evidence such as tire tracks, foot prints and/or broken glass). 2. Entry to the crime scene should be made by the minimum number of EMS personnel necessary to provide patient care. If possible, entry and exit should be accomplished by the same route. 47

58 Crime Scene Management Care should be taken not to disturb any physical evidence. 4. Removal of the patient's clothing should be kept to a minimum. If necessary, clothing removal should be done in a manner which will minimize the loss of physical evidence (i.e., do not cut clothing through bullet or knife holes). 5. Patient clothing and personal articles are to be left in the possession of law enforcement personnel. Do not discard anything. 6. Place wrappers and other disposable trash items which accumulate as patient care is rendered in a single site away from the patient and/or potential crime scene evidence. Do not pick up trash items and discard because evidence may be destroyed. Law enforcement personnel may suggest a site to be used for trash which would be most ideal to maximize evidence preservation. 7. Determination Of Death (S-SV EMS Determination of Death Policy 820): Patients who meet Obvious Death Criteria do not require cardiac monitor confirmation of asystole. Patients who meet Probable Death Criteria should be assessed utilizing the minimum number of EMS personnel necessary. Law enforcement personnel have the authority to declare death. If this has occurred, medical confirmation procedures by EMS personnel do not need to be performed unless specifically requested by law enforcement. 8. Every effort to cooperate with law enforcement should be made. In the event of disagreement with law enforcement, EMS personnel should document the issue and refer the matter to their supervisor for follow up. If the disagreement involves an issue that could result in patient harm, an immediate request for supervisory personnel to respond to the scene shall be made. CROSS REFERENCES: A. Determination of Death (820) B. Active Shooter/Mass Violence Incident (834) 48

59 SIERRA-SACRAMENTO VALLEY EMS AGENCY PROGRAM POLICY REFERENCE NO. 830 SUBJECT: SUSPECTED CHILD ABUSE REPORTING GUIDELINES PURPOSE: To provide guidelines for the identification of suspected child abuse and the procedure for reporting such suspicions by prehospital care personnel. AUTHORITY: California Penal Code, Chapter 916 (Part 4, Title 1, Chapter 2, Article 2.5), Sections DEFINITIONS: Agencies authorized to accept mandated reports: Police Department, Sheriff s Department, and Child Protective Services (CPS). School District Police and security departments are not included. Child: Any person under the age of eighteen (18). Mandated reporter: Includes, but not limited to: paid firefighters, EMRs, EMTs, AEMTs, paramedics, teachers, peace officers, any healthcare practitioner, clergy member, child care custodian, or an employee of a child protective agency. Neglect: The negligent failure of a parent or caretaker to provide adequate food, clothing, shelter, medical/dental care, or supervision. Physical abuse: A physical injury, including death, to a child that appears to have been inflicted by other than accidental means. Sexual abuse: Sexual assault on, or the exploitation of a minor. Sexual assault includes: rape, rape in concert (aiding or abetting or acting in concert with another person in the commission of a rape), incest, sodomy, oral copulation, penetration of genital or anal opening by a foreign object, and child molestation. It also includes lewd or lascivious conduct with a child under the age of fourteen years, which may apply to any lewd touching if done with the intent of arousing or gratifying the sexual desires of either the person involved or the child. Sexual exploitation refers to conduct or activities related to pornography depicting minors, and promoting prostitution by minors. Effective Date: 12/01/2014 Date last Reviewed/Revised: 09/14 Next Review Date: 09/2017 Approved: SIGNATURE ON FILE S-SV EMS Medical Director 49 SIGNATURE ON FILE S-SV EMS Regional Executive Director

60 SUBJECT: SUSPECTED CHILD ABUSE REPORTING GUIDELINES PRINCIPLES: POLICY: REFERENCE NO. 830 A. The purpose of reporting suspected child abuse/neglect is to protect the child, prevent further abuse of the child and other children in the home, and begin treatment of the entire family. The infliction of injury, rather than the degree of that injury, is the determinant for intervention by CPS and law enforcement. B. California Penal Code, Sections and 11168, requires that mandated reporters promptly report all suspected non-accidental injuries, sexual abuse, or neglect of children to local law enforcement and/or to CPS. C. It is the job of law enforcement, CPS and the courts to determine whether child abuse/neglect has, in fact, occurred. It is not necessary for the mandated reporter to determine child abuse, but only to suspect that it may have occurred. Children under the age of five, especially less than six months, are at highest risk. D. Under current law, all healthcare professionals are mandated to report suspected child abuse/neglect that they have knowledge of or observe in their professional capacity. They are required to sign a statement, for their employer, acknowledging their understanding of this requirement. Any person who fails to report as required may be punished by six months in jail and/or a $1,000 fine. E. When a mandated reporter has knowledge of or has observed child abuse or neglect, that individual is required to report to the local law enforcement and/or to the CPS immediately or as soon as practically possible by telephone and shall complete the suspected child abuse report form within 36 hours. When a mandated reporter is not performing their job duties, they become discretionary reporters and are not required by law to report. F. When two or more mandated reporters are present at scene and jointly have knowledge of a known or suspected instance of child abuse/neglect, the telephone report can be made by a selected member and a single written report may be made and signed by the selected member of the reporting team. Any member who has knowledge that the designated reporter failed to uphold their agreement, shall thereafter make the report. If EMS personnel are not selected as the designated reporter, they shall document the name and agency of the appointed team member in their prehospital documentation to indicate that the reporting obligation has been met. G. Those persons legally required to report suspected child abuse have immunity from criminal or civil liability for reporting as required. A. The primary purpose of the Department of Justice (DOJ) Suspected Child Abuse Report form SS 8572 (Reference No. 830-A) is to make all agencies aware of 50

61 REFERENCE NO. 830 SUBJECT: SUSPECTED CHILD ABUSE REPORTING GUIDELINES possible abuse/neglect. This will lead to a thorough investigation, and protection of the child. In order to facilitate this process, it is recommended that a prompt verbal report be made to both the local county Child Protective Services (CPS) and local law enforcement. However, if the child is in imminent danger, local law enforcement should be notified immediately. B. To make a verbal report to CPS, call the local county CPS office (included in this policy). This should be done as soon as possible. Prehospital care providers should be aware of their local law enforcement reporting procedures and telephone numbers for notification. C. The suspected child abuse/neglect report is to be completed according to the instructions on the back of the form (Reference No. 830-A). The report shall be filled out as completely and clearly as possible using lay terminology. The completed form shall be sent to the local county CPS and local law enforcement within 36 hours. A copy of the report should be retained by the reporting party. An electronic version of the form and instructions can also be obtained at: D. The following information shall be included in the prehospital documentation: 1. The name of the CPS social worker and/or name, department and badge number of the law enforcement officer. 2. Time of notification. 3. Disposition of child if not transported. CHILD ABUSE REPORTING BUTTE COUNTY 24 HOUR TELEPHONE CONTACT NUMBER: (888) Chico Area North County MAIL REPORTS TO (SOUTH COUNTY): MAIL REPORTS TO (NORTH COUNTY): (800) Oroville Area South County Child Protective Services 78 Table Mountain Boulevard Oroville CA, Child Protective Services 2445 Carmichael Drive Chico, CA COLUSA COUNTY 24 HOUR TELEPHONE CONTACT NUMBER: (530) MAIL REPORTS TO: Child Protective Services P.O. Box

62 SUBJECT: SUSPECTED CHILD ABUSE REPORTING GUIDELINES REFERENCE NO. 830 Colusa, CA NEVADA COUNTY 24 HOUR TELEPHONE CONTACT NUMBER: (530) or (888) MAIL REPORTS TO: Child Protective Services P.O. Box 1210 Nevada City, CA FAX REPORTS TO: (530) PLACER COUNTY 24 HOUR TELEPHONE CONTACT NUMBER: (916) or (866) (866) MAIL REPORTS TO: REPORTS TO: Family & Children s Services 101 Cirby Hills Drive, Ste. 5 Roseville, CA pc_scar@placer.ca.gov SHASTA COUNTY 24 HOUR TELEPHONE CONTACT NUMBER: (530) Child Protective Services MAIL REPORTS TO: 1313 Yuba Street Redding, CA SISKIYOU COUNTY 24 HOUR TELEPHONE CONTACT NUMBER: (530) or (530) after hours Child Protective Services MAIL REPORTS TO: 1215 South Main Street Yreka, CA SUTTER COUNTY 24 HOUR TELEPHONE CONTACT NUMBER: (530) Child Protective Services MAIL REPORTS TO: P.O. Box 1599 Yuba City, CA TEHAMA COUNTY 24 HOUR TELEPHONE CONTACT NUMBER: (530) or (800) Child Protective Services MAIL REPORTS TO: 310 South Main Street Red Bluff, CA YUBA COUNTY 24 HOUR TELEPHONE CONTACT NUMBER: (530) Child Protective Services MAIL REPORTS TO: 5730 Packard Avenue, Suite 100 Marysville, CA FAX REPORTS TO: (530)

63 SIERRA-SACRAMENTO VALLEY EMS AGENCY PROGRAM POLICY REFERENCE NO. 832 SUBJECT: SUSPECTED ELDER OR DEPENDENT ADULT ABUSE REPORTING GUIDELINES PURPOSE: To define suspected elder and dependent adult abuse and the required reporting procedures for prehospital care personnel. AUTHORITY: Welfare and Institutions Code Section et seq. California Code of Regulations, Title 22, and DEFINITIONS: Abuse of an elder or a dependent adult means either of the following: Physical abuse, neglect, financial abuse, abandonment, isolation, abduction, or other treatment with resulting physical harm or pain or mental suffering. The deprivation by a care custodian of goods or services that are necessary to avoid physical harm or mental suffering. Dependent adult means any person between the ages of 18 and 64 years who: Resides in this state and who has physical or mental limitations that restrict his or her ability to carry out normal activities or to protect his or her rights, including, but not limited to, persons who have physical or developmental disabilities, or whose physical or mental abilities have diminished because of age; or Is admitted as an inpatient to a 24-hour health facility, as defined in Sections 1250, , and of the Health and Safety Code. Developmentally disabled person means a person with a developmental disability specified by or as described as follows: Developmental disability" means a disability that originates before an individual attains age 18 years, continues, or can be expected to continue, indefinitely, and constitutes a substantial disability for that individual. As Effective Date: 12/01/2014 Date last Reviewed/Revised: 09/14 Next Review Date: 09/2017 Approved: SIGNATURE ON FILE S-SV EMS Medical Director 53 SIGNATURE ON FILE S-SV EMS Regional Executive Director

64 REFERENCE NO. 832 SUBJECT: SUSPECTED ELDER OR DEPENDENT ADULT ABUSE REPORTING GUIDELINES defined by the Director of Developmental Services, in consultation with the Superintendent of Public Instruction, this term shall include mental retardation, cerebral palsy, epilepsy, and autism. This term shall also include disabling conditions found to be closely related to mental retardation or to require treatment similar to that required for individuals with mental retardation, but shall not include other handicapping conditions that are solely physical in nature. Elder means any person residing in this state, 65 years of age or older. Reasonable suspicion means an objectively reasonable suspicion that a person would entertain, based upon facts that could cause a reasonable person in a like position, drawing when appropriate upon his or her training and experience, to suspect abuse. PRINCIPLES: A. EMRs, EMTs, AEMTs, Paramedics, and MICNs, as health care practitioners, are mandated reporters and have a legal obligation to report known or suspected elder or dependent adult abuse under the following circumstances: 1. When the reporter who in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse, or neglect; or 2. When the reporter has observed a physical injury where the nature of the injury, its location on the body, or the repetition of the injury, clearly indicates that physical abuse has occurred; or 3. When the reporter is told by an elder or a dependent adult that he or she has experienced behavior, including an act or omission, constituting physical abuse, abandonment, abduction, isolation, financial abuse, or neglect, or the reporter reasonably suspects that abuse. B. Any mandated reporter who has knowledge, or reasonably suspects, that types of elder or dependent adult abuse for which reports are not mandated have been inflicted upon an elder or dependent adult, or that his or her emotional well-being is endangered in any other way, may report the known or suspected instance of abuse. C. Reports made under this law are confidential. The identity of all persons making reports of elder or dependent abuse is also confidential. This information will be shared only between the investigating and licensing agencies, with the district attorney in a criminal prosecution resulting from the report, by court order, or when the reporter waives the right to remain anonymous. 54

65 REFERENCE NO. 832 SUBJECT: SUSPECTED ELDER OR DEPENDENT ADULT ABUSE REPORTING GUIDELINES POLICY: D. When two or more persons who are required to report are present and jointly have knowledge of a known or suspected instance of abuse of an elder or dependent adult, and when there is agreement among them, the telephone report may be made by a member of the team selected by mutual agreement and a single report may be made and signed by the selected member of the reporting team. Any member who has knowledge that the member designated to report has failed to do so shall hereafter make the report. If EMS personnel are not selected as the designated reporter, they shall document the name and agency of the appointed team member in their prehospital documentation to indicate that the reporting obligation has been met. E. Reporting is the individual responsibility of the mandated reporter. No supervisor or administrator may prohibit the filing of a required report. F. Mandated reporters who report suspected cases of elder or dependent adult abuse, in good faith, have absolute immunity, both civilly and criminally, for making a report of abuse of an elder or dependent adult. This includes taking of photographs of the victim and surroundings to submit with the report. G. Under current law, all healthcare professionals are mandated to report suspected Elder/Dependent Adult Abuse that they have knowledge of or observe in their professional capacity. They are required to sign a statement, for their employer, acknowledging their understanding of this requirement. Failure to report physical abuse, abandonment, abduction, isolation, financial abuse, or neglect of an elder or dependent adult, is a misdemeanor, punishable by not more than six months in the county jail, by a fine of not more than one thousand dollars ($1,000); or both fine and imprisonment. Any mandated reporter who willfully fails to report physical abuse, abandonment, abduction, isolation, financial abuse, or neglect of an elder or dependent adult, where that abuse results in death or great bodily injury, shall be punished by not more than one year in a county jail, by a fine of not more than five thousand dollars ($5,000), or by both fine and imprisonment. A. Reports of physical abuse are to be made immediately, or as soon as possible, by telephone. B. When reporting abuse that allegedly occurred in a long-term care facility or Adult Day Health Care Center, contact either the local law enforcement agency or the local Ombudsman Program. C. When the abuse is alleged to have occurred anywhere else, contact either the local law enforcement agency or the local county Adult Protective Services. 55

66 REFERENCE NO. 832 SUBJECT: SUSPECTED ELDER OR DEPENDENT ADULT ABUSE REPORTING GUIDELINES D. VERBAL REPORT: Verbal reports are to include the following information, unless unavailable: 1. The name, address, telephone number and occupation of the person making the report. 2. The name, address, age and present location of the elder or dependent adult. 3. The names and addresses of family members or any other person responsible for the elder or dependent adult's care. 4. The nature and extent of the elder or dependent adult's condition. 5. Date, time and place of the incident. 6. Any other information, including information that led that person to suspect elder or dependent adult abuse, as requested by the agency receiving the report. E. WRITTEN REPORT: A written Report of Suspected Dependent Adult/Elder Abuse (832-A or ) must be completed and submitted to the agency initially contacted within two (2) working days of the verbal report. F. The following information shall be included in the prehospital documentation: 1. The name of the APS social worker or Local Ombudsman, and/or name, department and badge number of the law enforcement officer. 2. Time of notification. 3. Disposition of Elder or Dependent Adult if not transported. G. VOLUNTARY REPORTS: 1. Any person who is not a mandated reporter, who knows, or reasonably suspects, that an elder or a dependent adult has been the victim of abuse may report that abuse to a long-term care ombudsman program or local law enforcement agency when the abuse is alleged to have occurred in a long-term care facility. 2. Any person who is not a mandated reporter, who knows, or reasonably suspects, that an elder or a dependent adult has been the victim of abuse in any place other than a long-term care facility may report the abuse to the county adult protective services agency or local law enforcement agency. 56

67 REFERENCE NO. 832 SUBJECT: SUSPECTED ELDER OR DEPENDENT ADULT ABUSE REPORTING GUIDELINES ELDER / DEPENDENT ADULT ABUSE REPORTING BUTTE COUNTY LOCAL OMBUDSMAN (530) or (800) APS 24 HOUR CONTACT NUMBER (800) MAIL REPORTS TO Department of Employment & Social Services P.O. Box 1649 Oroville, CA FAX REPORTS TO (530) COLUSA COUNTY LOCAL OMBUDSMAN (530) or (800) APS 24 HOUR CONTACT NUMBER (530) MAIL REPORTS TO Department of Social Services 251 East Webster Street Colusa, CA FAX REPORTS TO (530) NEVADA COUNTY LOCAL OMBUDSMAN (916) or (530) APS 24 HOUR CONTACT NUMBER (888) MAIL REPORTS TO Adult Services 578 Sutton Way, PMB 135 Grass Valley, CA FAX REPORTS TO (530) PLACER COUNTY LOCAL OMBUDSMAN (916) or (530) APS 24 HOUR CONTACT NUMBER (888) MAIL REPORTS TO Adult Protective Services 101 Cirby Hills Drive Roseville, CA FAX REPORTS TO (916) SHASTA COUNTY LOCAL OMBUDSMAN APS 24 HOUR CONTACT NUMBER (530) MAIL REPORTS TO (530) or (530) or (866) Department of Social Services 2460 Breslauer Way, P.O. Box Redding, CA FAX REPORTS TO (530)

68 REFERENCE NO. 832 SUBJECT: SUSPECTED ELDER OR DEPENDENT ADULT ABUSE REPORTING GUIDELINES ELDER / DEPENDENT ADULT ABUSE REPORTING SISKIYOU COUNTY LOCAL OMBUDSMAN (530) or (530) or (866) APS 24 HOUR CONTACT NUMBER (530) MAIL REPORTS TO Adult Services Department 1215 S. Main Street Yreka, CA FAX REPORTS TO (530) SUTTER COUNTY LOCAL OMBUDSMAN (916) or (530) APS 24 HOUR CONTACT NUMBER (530) MAIL REPORTS TO Department of Human Services 1965 Live Oak Blvd. Suite C Yuba City, CA FAX REPORTS TO (530) TEHAMA COUNTY LOCAL OMBUDSMAN (530) or (800) APS 24 HOUR CONTACT NUMBER (800) MAIL REPORTS TO Department of Social Services P.O. Box 1515, Red Bluff, CA FAX REPORTS TO (530) YUBA COUNTY LOCAL OMBUDSMAN (916) or (530) APS 24 HOUR CONTACT NUMBER (866) or (530) MAIL REPORTS TO FAX REPORTS TO (530) Health and Human Services Agency 5730 Packard Avenue, Suite 1000 Marysville, CA

69 Sierra Sacramento Valley EMS Agency Program Policy Active Shooter/Mass Violence Incident Effective: 06/01/2017 Next Review: 05/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To establish guidelines for EMS response to an active shooter/mass violence event. Extraordinary efforts and pre-planned training/coordination with law enforcement (LE) is required prior to and during response to these events in order to rapidly affect rescue, save lives and enable operations with mitigated risk to personnel. The goal is to plan, prepare and respond in a manner that will save the maximum number of lives possible. BACKGROUND: Active shooter/mass violence events are volatile and complex. Research and history have indicated that the active risk at most incidents is over before first responders arrive on scene, or shortly thereafter, but they may also require extended operations. Usually LE resources in the initial moments of an active shooter/mass violence event are focused on locating, containing and eliminating the threat, thus EMS resources should emphasize planning for rapid triage, treatment and extrication of the wounded in coordination with LE and as directed by Unified Command (UC). Tactical EMS support personnel are not a typical resource because they are usually very limited in number, not immediately available, and committed to their tactical team s assignment which may preclude them from casualty care activities until the tactical team s objective is met. Considerations, planning and interagency training should occur around the concept of properly trained and equipped medical personnel who are escorted by LE into areas of mitigated risk, which are cleared but not secured, to execute triage, medical stabilization at the point-of-wounding, and provide for evacuation or sheltering-in-place. AUTHORITY: A. California Health and Safety Code, Division 2.5. B. California Code of Regulations, Title 22, Division 9, Chapter 2, 3 and 4. 59

70 Active Shooter/Mass Violence Incident 834 DEFINITIONS: POLICY: A. Active Shooter An incident involving a suspect or suspects who are actively shooting at victims with the intent to cause the maximum number of casualties in a short amount of time. B. Concealment Anything that obscures you from view of the suspect such as smoke, vegetation, etc. Concealment will not provide ballistic protection. C. Cover Any object that provides ballistic protection, such as a reinforced concrete wall, large dirt mound, etc. D. Cleared An area that has been checked by LE and no apparent threats have been found. E. Secured An area that has been slowly, methodically and deliberately searched by LE and no threats have been found. F. Cold Zone The area surrounding the active shooter incident that is secured by LE. All normal EMS activities should take place in the Cold Zone. G. Warm Zone The area outside of the Hot Zone that has been swept/cleared by LE, but has not been completely secured. Limited numbers of EMS personnel, as determined by UC, may enter the Warm Zone for the purposes of extrication or to establish a Casualty Collection Point. The Warm Zone should be staffed by armed LE when possible for EMS personnel protection. H. Hot Zone The area immediately surrounding the shooter(s) that has not been cleared or secured by LE. Only LE or specially trained and equipped EMS personnel (i.e. tactical medics) should enter the Hot Zone. I. Casualty Collection Point A cleared area located within the Warm Zone where injured patients are brought to begin the process of triage and immediate life-saving treatment, usually limited to controlling massive external hemorrhage, placing occlusive dressings on open chest wounds and basic airway management. A. S-SV EMS policies and treatment protocols shall apply during an active shooter/mass violence event. The utilization of Tactical Emergency Casualty Care (TECC) principals, as indicated in this policy, may initially be necessary at scene depending on specific incident events. B. The Control Facility (CF) should be notified as soon as possible for any active shooter/mass violence incident, and shall be utilized for patient dispersal during any 60

71 Active Shooter/Mass Violence Incident 834 event that meets the Multiple Casualty Incidents declaration threshold (S-SV EMS MCI Policy 837). The CF shall consider trauma triage criteria before directing the transport of trauma patients. Immediate trauma patients shall be transported to designated trauma centers until the trauma centers are unable to accept further trauma patients. C. Incident Command System (ICS) concepts shall be implemented for all active shooter/mass violence incidents. D. Active shooter/mass violence incidents are primarily a LE event but also require coordination with fire/rescue/ems personnel. Therefore, responders should consider establishing UC as soon as possible. E. Consider early ordering of additional triage, treatment and transportation resources. All resources shall be requested through the IC/UC. CONSIDERATIONS: A. While the community-accepted practice has been staging EMS assets at a safe distance (usually out of line-of-sight) until the area is completely secured by LE, considerations should be made for more aggressive EMS operations in areas of higher but mitigated risk to ensure casualties can be rapidly retrieved, triaged, treated, and evacuated. Rapid triage and treatment are critical to survival. B. Utilize staging areas to limit the number of responders. Don t stack up responders and resources in one location as responders may be targets. C. Stage responders for rapid evacuation and always have an escape route open to leave the scene quickly if needed. D. Use a deliberate and cautious approach to the scene. EMS personnel should be escorted by LE whenever possible. E. Use identification that is discernable from a distance. Be aware that responders may be wearing uniforms and civilian attire, so exercise caution in identifying individuals. F. Consider establishing a duress code known to all responder personnel. G. If bystanders become hostile, extricate yourself and advise the IC/UC. H. If exposed to gunfire, explosions or threats, withdraw to a safe area or shelter in place if necessary. I. Consider the use of apparatus solid parts such as motor, pump, water tank and wheels as cover in the Hot Zone. Understand the difference between cover and concealment. 61

72 Active Shooter/Mass Violence Incident 834 J. Consider additional devices and hazards at the main scene and secondary scenes in close proximity to the main scene. Such threats, if identified, would necessitate upgrading the area to a Hot Zone and requiring rapid evacuation of all medical personnel/surviving casualties. K. Communicate with the IC/UC to determine which agency or personnel will locate casualties, triage them, provide point-of-wounding medical stabilization, and/or remove them to a safe location. Be aware that LE officers may bypass casualties in order to eliminate the threat. L. Adopt a "scoop and run" response within the Warm Zone. Treatment, including splinting/spinal immobilization/als procedures, can wait until the victim is in a cleared or secured location. Utilize gurneys to transport multiple patients, and uninjured victims to assist walking wounded patients as appropriate. M. Work as teams or in pairs at a minimum. If possible, assign an extra responder to serve as a team spotter. Their role is to observe, identify and avoid threats while the balance of the team executes their EMS assignment. If resources are available, LE should be assigned as the team spotter. N. Use internal Casualty Collection Points (CCPs) for large facilities with multiple casualties where evacuation distances are long. Point-of-wounding medical stabilization should occur prior to evacuation to the CCP. Identify all responders and casualties at the CCP for accountability and protection/security purposes. O. For larger geographic incidents or incidents with travel barriers, consider the use of multiple staging, triage and other supporting setup areas. P. Events with mobile perpetrators or sequenced attacks may necessitate CCP or staging area relocation and additional protection/security. PROCEDURE: A. Evacuation Care (Hot or Warm Zone): Only LE or specially trained and equipped EMS personnel (i.e. tactical medics) should enter the Hot Zone to provide Evacuation Care. The goal of Evacuation Care is to provide life-saving interventions and to prevent casualties from sustaining additional injuries. Minimal trauma interventions are warranted in this phase of care. 1. Consider quickly placing and/or directing casualties to be placed in position to open or protect their airway if necessary. 2. Consider hemorrhage control and treat according to S-SV EMS Hemorrhage Treatment Protocol (T-8), with the following additional considerations: 62

73 Active Shooter/Mass Violence Incident 834 If required and available, tourniquets should be applied over clothing. Consider moving to safety prior to tourniquet application if the situation warrants. Consider instructing casualties and/or bystanders to apply direct pressure to the wound if no tourniquet is available or application is not feasible. 3. Upon approval of the IC/UC, non-tactical EMS personnel may enter the area once it has been cleared by LE in order to provide Evacuation Care. These personnel should be issued appropriate protective gear, if available, and escorted by LE personnel. 4. Casualty Extraction: If casualties can move to safety, they should be instructed to do so. If casualties are unresponsive, quickly assess for respirations. If they are not breathing, leave them and move on to the next casualty. If casualties are responsive but cannot move, a tactically feasible rescue plan should be devised. Recognize that threats are dynamic and may be ongoing, requiring continuous threat assessments. B. Casualty Collection Point (CCP) Care (Warm Zone): Limited numbers of EMS personnel (as determined by the IC/UC) should enter the Warm Zone for the purposes of patient extrication or to establish a CCP. The goal of CCP Care is to stabilize casualties to permit safe evacuation to dedicated medical treatment and transport assets. 1. LE casualties should have weapons made safe by appropriate personnel once the threat is neutralized or if their mental status is altered. 2. Assess casualties and initiate appropriate life-saving interventions based on the provider s level of training and scope of practice according to S-SV EMS Treatment Protocols (as permitted by personnel/equipment resources). 3. Prevent Hypothermia: Minimize casualties exposure to the elements. Keep protective gear on or with the casualty if feasible. Replace wet clothing with dry if possible. Place casualties onto an insulated surface as soon as possible. 4. Document Evacuation/CCP Care rendered on a Triage Tag. 63

74 Active Shooter/Mass Violence Incident Prepare Casualties for Evacuation: Consider environmental factors for safe and expeditious evacuation. Secure casualties to a movement assist device when available. Appropriate spinal precautions should be implemented as indicated based on S-SV EMS Treatment Protocols (as permitted by personnel/equipment resources). CROSS REFERENCES: A. Tactical Medicine Operational Programs (460). B. Crime Scene Management (825). C. Multiple Casualty Incidents (837). D. General Trauma Management (T-1). E. Hemorrhage (T-8). 64

75 Sierra Sacramento Valley EMS Agency Program Policy Medical Control at The Scene of an Emergency Effective: 06/01/2017 Next Review: 11/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To define patient care responsibilities at the scene of a non-disaster medical emergency when two or more ALS personnel are present from two or more providers and to define the parameters for transferring patient care to another individual in the prehospital setting. AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5, , B. California Code of Regulations, Title 22, Division 9. A. Authority for patient health care management in an emergency shall be vested in that licensed or certified health care professional, which may include any Paramedic, or other prehospital emergency personnel, at the scene of the emergency, who is most medically qualified specific to the provision of rendering emergency medical care. If no licensed or certified health care professional is available, the authority shall be vested in the most appropriate medically qualified representative of public safety agencies who may have responded to the scene of the emergency. B. Notwithstanding the above, authority for the management of the scene of an emergency shall be vested in the appropriate public safety agency having primary investigative authority. The scene of an emergency shall be managed in a manner designed to minimize the risk of death or health impairment to the patient and to other persons who may be exposed to the risks as a result of the emergency condition, and priority shall be placed upon the interests of those persons exposed to the more serious and immediate risks to life and health. Public safety officials shall consult emergency medical services personnel or other authoritative health care professionals at the scene in the determination of relevant risks. Some limited examples are as follows: 1. California Highway Patrol All freeways; all roadways in unincorporated areas to include right-of-way. (CVC 2454) 2. Sheriff s Office Off-highway unincorporated areas (parks, private property, etc.). 65

76 Medical Control at The Scene of an Emergency 835 PROCEDURE: 3. Local Fire/Police Specific areas of authority within their jurisdiction, except freeways. 4. Airport Fire/Police Airports. 5. U.S. Military National Defense Area; a military reservation or an area with military reservation status that is temporarily under military control, e.g., military aircraft crash site. A. Medical management at the scene of a medical emergency includes: 1. Medical evaluation and care. 2. Medical aspects of extrication and movement of the patient(s). 3. Patient destination, in consultation with base/modified base hospital when necessary. 4. Mode of transport (ground or air). 5. Transport code. B. The first on duty ALS licensed and accredited or certified responder on the scene shall assume responsibility for the patient s care. C. Whenever ALS personnel transfer patient care responsibility to another EMS provider, they are responsible for noting such action took place on the patient care report. CROSS REFERENCES: A. Prehospital Documentation (605). B. Base/Modified Base/Receiving Hospital Contact (812). C. Multiple Casualty Incidents (837). D. Physician on Scene (839). E. Communication Failure (890). 66

77 Sierra Sacramento Valley EMS Agency Program Policy Hazardous Materials Incidents Effective: 12/01/2016 Next Review: 07/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To establish guidelines for the response of EMS prehospital personnel to incidents involving hazardous materials. AUTHORITY: A. California Health and Safety Code, Division 2.5, , , , , B. California Code of Regulations, Title 22, and C. OSHA Regulations, CFR D. Applicable County Hazardous Materials Response Plan. DEFINITIONS: A. County Hazardous Materials Response Plan County specific plan defining hazardous materials incident types and establishing response protocols/ responsibilities of agencies within the county. B. Hazardous Materials (Haz Mat) Any material which is explosive, flammable, poisonous, corrosive, reactive, or radioactive, or any combination, and requires special care in handling because of the hazards it poses to public health, safety, and/or the environment. C. Hazardous Materials (Haz Mat) Response Team An emergency team that has received specialized training and equipment for the purpose of protecting the public and the environment in the event of an accidental or intentional release of hazardous materials into the environment. D. Decontamination The process of removing or neutralizing contaminates that have accumulated on a victim to the extent necessary to prevent/alleviate the occurrence of heath and/or environmental effects. 67

78 Hazardous Materials Incidents 836 E. First Responder Awareness Level First responders at the awareness level are individuals who are likely to witness or discover a hazardous substance release and who have been trained to initiate an emergency response sequence by notifying the proper authorities of the release. F. Exclusion Zone (Hot Zone) The contaminated area, Immediately Dangerous to Life and Health (IDLH). G. Contamination Reduction Zone (Warm Zone) The area where decontamination takes place. H. Support Zone (Cold Zone) The uncontaminated area where personnel should not be exposed to hazardous conditions. TRAINING AND COMPETENCY: POLICY: The minimum training for EMS prehospital personnel is Haz Mat First Responder Awareness level. Annual refresher training is required to be provided by the employer to be of sufficient content and duration to maintain competencies or to demonstrate those competencies. Additional training may be required to function at an emergency incident. The responsibility for hazardous material containment, identification, decontamination, and victim evacuation rests with the Incident Commander (IC)/Unified Command (UC). A. Responding ambulances should stage off-site until the IC/UC provides for safety, a clear assignment and approach to scene. B. EMS personnel must avoid contamination and not transport patients until they have been completely decontaminated. (Exception: For radiation contaminated patients that meet immediate triage criteria, treatment and transport should not be delayed for decontamination processes). C. EMS personnel shall not enter or provide treatment in the Contamination Reduction Zone (Warm Zone) or Exclusion Zone (Hot Zone) unless specifically trained, equipped and authorized to do so. D. EMS personnel shall not use Haz Mat specific personal protective equipment (PPE), including self-contained breathing apparatus (SCBA), unless specifically trained, fit tested and authorized to do so. E. EMS personnel shall contact the base/modified base or receiving hospital as soon as possible, so they may prepare to receive victims. The base/modified base hospital may also assist field personnel in determining a decontamination and treatment plan. 68

79 Hazardous Materials Incidents 836 DISPATCH: Ambulances dispatched to a possible hazardous materials incident shall be advised by dispatch of the following additional information when known/available: A. On scene wind direction and recommended approach route (coordinated with IC/UC). B. Staging area location. C. Location of incident command post. D. Communication frequencies. E. Type of hazardous material(s) involved. F. Estimated number of patients. SCENE MANAGEMENT: A. Once cleared to respond into the scene (Support Zone/Cold Zone) from staging, ambulance personnel shall follow directions provided by IC/UC or designee. B. Recognition of a Haz Mat on-scene or during transport: PATIENT CARE: If ambulance personnel become aware of hazardous materials while on scene or during transport, they shall: 1. Consider themselves contaminated and part of the incident (Hot Zone). 2. Evacuate to a safe location (if safe/appropriate to do so) to minimize exposure, and consider self-decontamination. 3. Isolate the scene and deny entry (keep others away!). Move uninvolved victims to a safe zone. 4. Confirm Haz Mat using DOT Emergency Response Guidebook and notify appropriate jurisdictional authorities to respond to the scene for site control and decontamination. A. EMS personnel shall not render medical care beyond the Support Zone (Cold Zone) unless specifically trained, equipped and authorized to do so. 69

80 Hazardous Materials Incidents 836 B. Medical treatment and transportation is secondary to the prevention of spreading the contaminate, and the management of the Haz Mat incident. The IC/UC or designee is responsible for determining the treatment priority for the patient(s). EMS transport personnel may be requested to receive non-ambulatory patients from the Contamination Reduction Zone (Warm Zone) after decontamination has been completed. C. For radiation contaminated patients that meet immediate triage criteria, treatment and transport should not be delayed for decontamination processes. D. Deceased victims shall be left undisturbed at the scene, or moved at the direction of the coroner, IC/UC or designee. E. The use of EMS aircraft for the transport of potentially contaminated Haz Mat patient(s) is generally not appropriate. Patient transport by EMS aircraft shall occur only by direction of the IC/UC or designee. EMS aircraft may be utilized, at the discretion of the IC/UC or designee, to transport immediate radiation contaminated patients under the same criteria as ground based transportation assets. F. If necessary, request CHEMPACK resources utilizing county specific activation procedures (S-SV EMS Nerve Agent Treatment Protocol E-8). G. Treat as directed by specific S-SV EMS protocols, and/or the base/modified base hospital. CROSS REFERENCES: A. Ingestions and Overdoses (M-5). B. Hazardous Material Exposure (E-7). C. Nerve Agent Treatment (E-8). D. Emergency Response Guidebook (ERG). 70

81 Sierra Sacramento Valley EMS Agency Program Policy Multiple Casualty Incidents (MCI) Effective: 12/01/2017 Next Review: 11/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To establish procedures for EMS response/utilization during a multiple-casualty incident (MCI). This policy is intended to be utilized in coordination with applicable regional MCI plans, and to support the operational framework established in the California Public Health and Medical Emergency Operations Manual. AUTHORITY: A. California Health and Safety Code, Division 2.5, , B. California Code of Regulations, Title 22, Division 9. C. California Code of Regulations, Title 19, Division 2, Articles 1-8, 2400 et seq. D. California Public Health and Medical Emergency Operations Manual (July, 2011). E. California Medical and Health Operational Area Coordinator Manual (January, 2017). DEFINITIONS: A. Multiple-Casualty Incident (MCI) An incident which requires more emergency medical resources to adequately deal with victims than those available during routine responses, including an incident that meets any of the following criteria: 1. Five (5) or more IMMEDIATE and/or DELAYED patients, or 2. Ten (10) or more MINOR patients, irrespective of the number of IMMEDIATE and/or DELAYED patients, or 3. At the discretion of prehospital or hospital providers. B. Control Facility (CF) A facility/entity responsible for patient dispersal during an MCI (Designated CFs are listed in Hospital Capabilities Reference Policy No. 505-A). 71

82 Multiple Casualty Incidents (MCI) 837 POLICY: A. The California OES Region III and Region IV MCI Plans, in coordination with S-SV EMS policies, shall be used as a standard for training personnel and managing MCIs within the S-SV EMS region. Provider agencies are responsible for ensuring that their personnel have appropriate knowledge/training to adequately manage MCI s. B. S-SV EMS treatment and destination policies/protocols shall continue to apply during an MCI. The CF shall consider trauma triage criteria before directing the transport of trauma patients. IMMEDIATE trauma patients shall be transported to designated trauma centers until the trauma centers are unable to accept further trauma patients. PROCEDURE: A. MCI Response/Management: EMS personnel shall utilize the following procedures for any event that meets the criteria of an MCI as defined in this policy: 1. CF Notification: CF notification ( pre-alert ) shall be made as soon as possible, by the initial responding medical unit or dispatch center, to allow adequate time for hospital patient receiving capabilities polling. Pertinent updates shall be communicated to the CF in a timely manner (including MCI confirmation/cancellation once on scene and when all patients have been transported and the scene is clear). 2. Establish/Utilize ICS: Once on scene, EMS personnel shall check in with the Incident Commander (IC) and establish medical command. The Medical Branch is responsible for the following: o Resources (Additional resources shall be ordered through the IC). o Assignments* (Refer to MCI Medical Organizational Chart 837-A). o Communications (Establish incident and CF communications). o Ingress/Egress (Determine/communicate best ingress/egress routes). o Name (Confirm/establish incident name). o Geography (Establish staging, triage, treatment and transport areas) *Note: Detailed MCI position checklists are listed in the Region III MCI Plan (Manual 1 Field Operations, appendix A). Appropriate medical position identification vests shall be utilized on scene. o Ground transport providers shall carry a minimum of Medical Group Supervisor and Triage Unit Leader vests on all 911 response units. o Additional position vests should be available on supervisor vehicles and/or disaster/mci support units. 72

83 Multiple Casualty Incidents (MCI) Triage: S.T.A.R.T. triage shall be utilized and should take no longer than seconds per patient. A colored ribbon system may be utilized for initial triage. Approved triage tags shall be utilized on all patients prior to transport. Treatment rendered during initial triage shall be limited to airway repositioning and major hemorrhage control. CPR shall not be initiated on cardiac arrest victims unless there are sufficient personnel on scene to not result in the detriment of care to other patients. Any patient who has a tourniquet or hemostatic dressing applied to control hemorrhage shall be deemed an IMMEDIATE regardless of the START triage algorithm. Patients placed in spinal motion restriction and/or unaccompanied pediatric patients must be categorized as DELAYED at a minimum, as these patients require an ED room/bed upon arrival at the receiving hospital. 4. Treatment: Designate treatment areas and assign staff as needed. Treatment areas should be located in safe locations, large enough to handle the number of victims and easily accessible to patient transport vehicles. Once initial triage has been completed, patients may be moved to appropriate treatment areas. Continuous re-triage and patient evaluation shall occur in treatment areas until the patient is transported. Medical supplies from the first-in ambulance or disaster/mci support units should be used for on scene treatment. 5. Patient Tracking: S-SV EMS approved prehospital patient tracking worksheets (837-B) shall be utilized to track all patients. Copies of the patient tracking worksheets shall be submitted to S-SV EMS as soon as possible (either during or immediately following the conclusion of the event as appropriate). 6. Transportation/CF Communication: If a staging area has been established, transport crews shall remain with their vehicle in the staging area until requested or released. The Patient Transportation Unit Leader (or Medical Communications Coordinator if established) will contact the CF and provide patient information and total number of transport resources available. Patient information provided to the CF will be limited to age, gender, triage category, triage tag number, primary injury type and any special considerations (pregnancy, burns, etc.). 73

84 Multiple Casualty Incidents (MCI) 837 The Patient Transportation Unit Leader/Medical Communications Coordinator will work collaboratively with the CF to ensure appropriate patient distribution based on patient conditions and available transportation resources. IMMEDIATE patients should be transported first. If necessary, patients may be transported by BLS ambulances and/or nontraditional transport resources (e.g. buses, vans) as determined appropriate by the Patient Transportation Unit Leader/Medical Communications Coordinator in consultation with the CF. EMS personnel shall accompany patients transported by non-traditional transport resources. The first-in ambulance should generally be the last ambulance to leave. The Patient Transportation Unit Leader/Medical Communications Coordinator will notify the CF of the following: o When patients are ready for transport (to obtain destinations). o When units depart the scene (with unit # and ETA to receiving hospital). o When all patients are transported and the scene is clear. The CF will relay pertinent patient information to the receiving facilities. 7. S-SV EMS Notification: Prehospital ground transport providers (dispatch, supervisor, manager, etc.) shall notify the S-SV EMS Duty Officer of an MCI as soon as possible, and provide pertinent updates related to the incident and/or other system impacts resulting from the incident. 8. Incident Documentation: A Patient Care Report (PCR) shall be completed for all patients, unless this requirement is waived by S-SV EMS on an incident specific basis. EMS personnel shall complete additional ICS paperwork if requested by the IC based on the nature/size of the incident (medical branch worksheets, ambulance staging logs, 214 logs, etc.). The Medical Group Supervisor is responsible to ensure all paperwork is complete. B. MCI Review: 1. EMS provider agencies should conduct a hotwash as soon as possible after the conclusion of the incident. 2. An MCI Details/Feedback Form shall be submitted to S-SV EMS within seven (7) working days by the following providers: Prehospital ground and air transport providers. Control Facility (CF). Receiving facilities. 74

85 Multiple Casualty Incidents (MCI) 837 Prehospital non-transport/first responder providers (recommended/optional). 3. S-SV EMS will evaluate the incident details/documentation and determine if additional formal after-action review/follow-up is necessary. CROSS REFERENCES: A. Patient Destination (505). B. Hospital Capabilities Reference (505-A). C. Base/Modified Base/Receiving Hospital Contact (812). D. Active Shooter/Mass Violence Incident (834). E. MCI Checklist And Medical Branch Organizational Chart (837-A). F. MCI Prehospital Patient Tracking Worksheet (837-B). G. MCI Support And Transportation Resources (837-C). H. MCI Details/Feedback Form (837-D). 75

86 MCI Checklist And Medical Branch Organizational Chart 837-A MCI CHECKLIST Task Completed 1. Ensure Control Facility (CF) MCI notification (including pre-alert if applicable) 2. Check in with the Incident Commander (IC) and establish Medical Command 3. Establish appropriate roles/functions (Triage, Treatment, Transportation) 4. Don/utilize appropriate MCI vests for identification 5. Order additional transport/medical resources through the IC 6. Ensure that triage tags are utilized on all patients prior to transport 7. Maintain adequate CF communications to ensure appropriate patient distribution 8. Utilize the patient tracking worksheet to adequately track all patients MCI MEDICAL BRANCH ORGANIZATIONAL CHART Medical Branch Director Notes Triage Unit Leader Triage Personnel Morgue Manager Medical Group Supervisor (MGS) Treatment Unit Leader Immediate Treatment Manager Delayed Treatment Manager Minor Treatment Manager Patient Transportation Unit Leader Medical Comm. Coordinator Ambulance Coordinator Positions assigned based on incident size. Medical Branch Director typically only assigned on larger incidents. Smaller incidents may only utilize a MGS and Triage Unit Leader (who are also responsible for Treatment Unit and Patient Transportation Unit duties). Positions should be filled based on personnel qualifications. 76

87 Incident Name/Location Prehospital Patient Tracking Worksheet (837-B) Incident Date Form Completed By Contact Telephone # Triage Status Triage Tag # (Last 4) Patient Name (First & Last) Age Gender Primary Injury Type Ready For Trans. Hospital Destination Trans. Unit ID Trans. Time ETA CF Advised I D M M F I D M M F I D M M F I D M M F I D M M F I D M M F I D M M F I D M M F Instructions: Completed worksheets shall be sent to the S-SV EMS Agency as soon as possible - 1) Take a picture of the completed worksheet with a smartphone and the photograph to RDMHS.Region3@ssvems.com, or 2) Fax completed forms to (916)

88 MCI Support And Transportation Resources 837-C MCI SUPPORT RESOURCES Ambulance resources needed beyond the capacity of local providers and routine mutual aid agreements are requested through the Medical Health Operational Area Coordinator (MHOAC). MCI Local resources sufficient? YES Non-traditional transport resources (buses, vans, etc.) and other MCI resources (MCI trailers/caches, Disaster Medical Support Units, etc.) are requested and coordinated through the IC and/or local OES/ EOC/MHOAC. S-SV EMS will collaborate with the local MHOAC and/or the RDMHS as needed regarding the ordering and coordinating of prehospital EMS resources, and will assist with submission of required OA Resource Request and SITREP forms as needed. Immediate need EMS transport resources may be requested directly from S-SV EMS to reduce response delays in the event that requested resources are available from within the S-SV EMS jurisdiction. Routine MCI events (managed with local/s-sv EMS jurisdictional mutual aid resources) do not involve an expectation of reimbursement from the requesting OA by the EMS mutual aid provider. Large/extended events (including requests for ambulance strike team resources, patient evacuations, etc.) must be requested/authorized by an appropriate OA entity (OES/EOC/ MHOAC). The requesting OA maintains financial responsibility for any EMS resource utilization costs incurred in these situations. NO Routine mutual aid resources sufficient? NO Notify local MHOAC Program and S-SV EMS of request for additional resources S-SV EMS will request and coordinate resources from within the S-SV EMS Jurisdiction S-SV EMS jurisdictional resources sufficient? NO YES YES S-SV EMS will collaborate with the MHOAC Program & RDMHS to request necessary regional &/or statewide resources Incident managed by local EMS resources Provide appropriate incident notification to S-SV EMS S-SV EMS will notify & update the requester, MHOAC Program, and RDMHS 78

89 Sierra Sacramento Valley EMS Agency Program Policy Physician on Scene Effective: 06/01/2017 Next Review: 11/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To define patient care responsibilities when a physician is on the scene of a medical emergency, and one or more EMS personnel are present. AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5, , B. California Code of Regulations, Title 22, Division 9. A. EMS personnel encountering a physician on the scene of a medical emergency shall initiate and maintain responsibility for patient care unless the physician assumes responsibility for patient care and accompanies the patient to the hospital (if required). EMS personnel may assist the physician provided they operate within their applicable S-SV EMS scope of practice. B. If necessary, (outside a licensed healthcare facility, physician is unknown to EMS personnel, etc.) EMS personnel are responsible for confirming that the individual is in fact a California licensed physician. If needed, utilize the EMSA/CMA Physician on Scene Card referenced in this policy. C. In the event of a conflict with a physician on scene, EMS personnel shall follow base/modified base hospital orders and document events appropriately. PROCEDURE: A. Physician is a bystander or outside a licensed/recognized healthcare facility: 1. If the physician wishes to do more than offer assistance: EMS personnel must notify the base/modified base hospital as soon as possible. 79

90 Physician on Scene 839 If there is a conflict between the physician's requested treatment and the EMS personnel s scope of practice, explain that you can legally only treat within the applicable S-SV EMS scope of practice. If necessary, contact the base/modified base hospital and request the physician to discuss any issues directly with base/modified base hospital personnel. The physician must: o Assume responsibility for the patient. o Provide the care s/he wishes. o Accompany the patient to the hospital (if safety allows). B. Physician is patient s physician/patient is located at a licensed/recognized healthcare facility (physician s office, clinic, urgent care, acute care hospital, etc.): 1. The patient's physician may provide treatment prior to transfer of patient care to EMS personnel. 2. If there is a conflict between the physician s requested treatment and the EMS personnel s scope of practice following transfer of patient care, explain that you can legally only treat within the applicable S-SV EMS scope of practice. 3. If necessary, contact the base/modified base hospital and request the physician to discuss any issues directly with base/modified base hospital personnel. 4. Patient responsibility may be transferred to EMS personnel if appropriate. There is no requirement for the physician to accompany the patient to the hospital under these circumstances. EMSA/CMA PHYSICIAN ON SCENE CARD: FRONT NOTE TO PHYSICIANS ON INVOLVEMENT WITH EMS PERSONNEL EMS personnel operate under standard policies and procedures developed by the Local EMS Agency and approved by their Medical Director under Authority of Division 2.5 of the California Health and Safety Code. The drugs they carry and procedures they can do are restricted by law and local policy. If you want to assist, this can only be done through one of the alternatives listed on the back of this card. These alternatives have been endorsed by CMA, State EMS Authority and CCLHO. Assistance rendered in the endorsed fashion, without compensation, is covered by the protection of the Good Samaritan Code (see Business and Professional Code, Sections 2144, and Health and Safety Code, Section ). BACK ENDORSED ALTERNATIVES FOR PHYSICIAN INVOLVEMENT After identifying yourself by name as a physician licensed in the State of California, and, if requested, showing proof of identity, you may choose one of the following: 1. Offer your assistance with another pair of eyes, hands or suggestions, but let EMS personnel remain under base hospital control; or, 2. Request to talk to the base station physician and directly offer your medical advice and assistance; or, 3. Take total responsibility for the care given by EMS personnel and physically accompany the patient until the patient arrives at a hospital (if safety allows) and responsibility is assumed by the receiving physician. In addition, you must sign for all instructions given in accordance with local policy and procedures. 80

91 Sierra Sacramento Valley EMS Agency Program Policy Medical Control for Transfers Between Acute Care Facilities Effective: 06/01/2017 Next Review: 01/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To assure medical control of patients during transfers between acute care facilities. This policy does not exempt any acute care hospital or physician from meeting their statutory or regulatory obligations for patient transfers. The medical/legal responsibility for the patient rests with the transferring physician. AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5, , , , , , , and B. California Code of Regulations, Title 22, Division 9. C. United States Code, Title 42, Section 395dd, EMTALA Statute. D. Code of Federal Regulations 42, Sections and , EMTALA Regulations. A. Prior to accepting an acute care inter-facility transfer patient, EMS personnel shall: 1. Obtain pertinent patient information to include diagnosis, history and any therapies received while in the hospital or the previous four (4) hours, whichever is less. 2. Complete a physical assessment, including vital signs. B. EMS personnel shall follow orders of the transferring physician, however they cannot provide care beyond the S-SV EMS approved scope of practice. Should medical consultation be needed during transport, EMS personnel shall follow S-SV EMS policy for base hospital/modified base hospital contact (Reference No. 812). C. If a patient is to be transferred outside of the S-SV EMS region or base/modified base hospital radio contact range, EMS personnel may provide care according to approved S-SV EMS policies and treatment protocols. 81

92 Sierra Sacramento Valley EMS Agency Program Policy Paramedic Monitoring of Magnesium Sulfate, Nitroglycerin, Heparin, and/or Amiodarone Infusions During IFTs Effective: 12/01/2016 Next Review: 10/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To provide parameters for paramedic monitoring of magnesium sulfate, nitroglycerin, heparin, and/or amiodarone infusions during interfacility transports (IFTs). AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5, B. California Code of Regulations, Title 22, Chapter 4, Article 1, A. Only prehospital provider agencies approved by S-SV EMS to utilize paramedic IFT optional skills are authorized to provide such services. B. Only paramedics who have successfully completed an S-SV EMS approved paramedic IFT optional skills training program will be permitted to monitor magnesium sulfate, nitroglycerin, heparin, and/or amiodarone infusions during IFTs. C. Patients will have pre-existing infusions in peripheral or central IV lines. Paramedics will not initiate infusions. D. The infusion(s) will have been running for at least 10 minutes prior to transport. E. Patients will have maintained stable vital signs for the previous 30 minutes and will not have more than two medication infusions running exclusive of potassium chloride. F. The timeframes listed above will not apply to patients who require immediate transport for critical interventions, when the transferring and/or receiving physician(s) determine that immediate transport is in the best interest of patient care. PROCEDURE: A. All patients shall be maintained on a cardiac monitor and a non-invasive blood pressure monitor. 82

93 Paramedic Monitoring of Magnesium Sulfate, Nitroglycerin, Heparin, and/or Amiodarone Infusions During IFTs 841 B. The paramedic shall receive written orders from the transferring physician prior to leaving the transferring hospital. These orders shall include a telephone number where the transferring and/or base/modified base hospital physician can be reached during transport in addition to the type of solution, dosage and rate of infusion. C. Patients will be hemodynamic stable at time of transport. D. If medication administration is interrupted (infiltration, accidental disconnection, malfunctioning pump, etc.), the paramedic may restart the line as delineated in the transfer orders. E. All medication drips will be in the form of an IV piggyback monitored by a mechanical pump familiar to the paramedic. In cases of pump malfunction that cannot be corrected, the medication drip will be discontinued and the transferring physician and/or base/modified base hospital notified as soon as possible. S-SV EMS shall be notified of the pump malfunction no later than the end of the next business day. F. The paramedic shall document on the PCR the total volume infused throughout the duration of the transport. G. Magnesium sulfate infusions: Authorized paramedics are allowed to transport patients on magnesium sulfate infusions within the following parameters: 1. Infusion fluid will be NS. Regulation of the infusion rate will be within parameters defined by the transferring physician. 2. If the patient develops signs of magnesium toxicity, the medication drip will be discontinued and the transferring physician and/or base/modified base hospital will be notified as soon as possible. Signs of magnesium toxicity include: Thirst Diaphoresis DTR s (Deep Tendon Reflexes) depressed or absent Hypotension Flaccid paralysis Respiratory depression Circulatory depression or collapse CNS depression Urine output < 30 ml/hr Chest pain or pulmonary edema 83

94 Paramedic Monitoring of Magnesium Sulfate, Nitroglycerin, Heparin, and/or Amiodarone Infusions During IFTs Vital signs, including DTR s, shall be monitored and documented every 15 minutes and immediately if there is any change in patient status or medication adjustment. H. Nitroglycerin infusions: Authorized paramedics are allowed to transport patients on nitroglycerin infusions within the following parameters: 1. Infusion fluid will be D5W. 2. Medication concentration will be 50mg/250mL. 3. Regulation of the infusion rate will be within parameters defined by the transferring physician, but in no case will changes be greater than 10mcg/minute increments every 5-10 minutes. In cases of severe hypotension, the medication drip will be discontinued and the transferring physician and/or base/modified base hospital will be notified as soon as possible. 4. Discuss with transferring physician concomitant use of analgesics during transport (i.e. morphine sulfate, fentanyl). 5. Vital signs shall be monitored and documented every 15 minutes and immediately if there is any change in patient status or medication adjustment. I. Heparin infusions: Authorized paramedics are allowed to transport patients on heparin infusions within the following parameters: 1. Infusion fluid will be D5W or NS. 2. Medication concentration shall not exceed 100units/mL of IV fluid (25,000 units/250ml). 3. Infusion rates shall be verified with the sending RN following changeover to the mechanical EMS transport pump, and will remain constant during transport. No regulation of the rate will be performed by the paramedic except to turn off the infusion completely. 4. Vital signs shall be monitored and documented every 15 minutes and immediately if there is any change in patient status. 84

95 Paramedic Monitoring of Magnesium Sulfate, Nitroglycerin, Heparin, and/or Amiodarone Infusions During IFTs 841 J. Amiodarone infusions: Authorized paramedics are allowed to transport patients on amiodarone infusions within the following parameters: 1. Medication concentration must be a minimum concentration of 150mg/250mL (0.6 mg/ml). 2. Infusion rates may vary between mg/min. 3. Infusion rates will remain constant during transport. No regulation of the rate will be performed by the paramedic except to turn off the infusion completely. 4. Vital signs will be monitored and documented every 15 minutes and immediately if there is any change in patient status. 5. Y-Injection incompatibility; the following will precipitate with amiodarone hydrochloride: Heparin Sodium bicarbonate 6. Amiodarone hydrochloride intravenous infusion monitoring is not approved for patients < 14 years old without base/modified base physician contact. 7. For infusions > one hour, amiodarone hydrochloride concentrations should not exceed 2mg/mL unless a central venous catheter is used. CROSS REFERENCES: A. Paramedic IFT Optional Skills: Transferring Hospital Requirements (341). B. Paramedic IFT Optional Skills: Prehospital Provider Agency Application and Approval Process (441). C. Paramedic IFT Optional Skills: Prehospital Provider Agency Requirements and Responsibilities (442). 85

96 Sierra Sacramento Valley EMS Agency Program Policy Paramedic Monitoring of Blood Transfusions During IFTs Effective: 12/01/2016 Next Review: 10/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To provide parameters for paramedic monitoring of blood transfusions during interfacility transports (IFTs). AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5, B. California Code of Regulations, Title 22, Chapter 4, Article 1, A. Only prehospital provider agencies approved by S-SV EMS to utilize paramedic IFT optional skills are authorized to provide such services. B. Only paramedics who have successfully completed an S-SV EMS approved paramedic IFT optional skills training program will be permitted to monitor blood transfusions during IFTs. C. Paramedic monitoring of blood transfusions during IFTs is limited to those circumstances when there are no RN staffed Critical Care Transport (CCT) units available or when air ambulance transport is not appropriate or available. D. Patients will have pre-existing blood transfusions in peripheral or central IV lines. Prehospital personnel will not initiate blood transfusions. PROCEDURE: A. All patients will be maintained on a cardiac monitor and a non-invasive blood pressure monitor. B. The paramedic shall receive written orders from the transferring physician prior to leaving the transferring hospital. These orders shall include a telephone number where the transferring and/or base/modified base hospital physician can be reached during the patient transport in addition to the transfusion rate. 86

97 Paramedic Monitoring of Blood Transfusions During IFTs 842 C. Patients will be hemodynamically stable at the time of transport. D. Paramedic personnel must be knowledgeable in the operation of the specific blood delivery/warming device. E. Regulation of the transfusion rate will be within the parameters defined by the transferring physician. F. Verify the patient and blood with the sending RN by checking the patient ID band against the blood label(s) and blood order for name, blood type and unit identifying number. G. Vital signs will be monitored and documented every 15 minutes and immediately if there is any change in patient status or change in transfusion rate. H. Monitor the patient for any signs and symptoms of a transfusion reaction. Monitor temperature for adverse effects if transport time exceeds 15 minutes. The following are the most common types of transfusion reactions that may occur: 1. Hemolytic reactions: Hemolytic reactions are the most life-threatening. Clinical manifestations may vary considerably: fever, headache, chest or back pain, pain at infusion site, hypotension, nausea, generalized bleeding or oozing from surgical site, shock. The most common cause is from ABO incompatibility due to a clerical error or transfusion to the wrong patient. Chances of survival are dose dependent therefore it is important to stop the transfusion immediately if a hemolytic reaction is suspected. Give a fluid challenge. 2. Febrile non-hemolytic reaction: Chills and fever (rise from baseline temperature of 1 C or 1.8 F). Document and report to hospital on arrival. 3. Allergic reaction: Characterized by appearance of hives and itching. 4. Anaphylaxis: May occur after administration of only a few ml's of a plasma containing component. Symptoms include coughing, bronchospasm, respiratory distress, vascular instability, nausea, abdominal cramps, vomiting, diarrhea, shock, and loss of consciousness. 5. Volume overload: Characterized by dyspnea, headache, peripheral edema, coughing, frothy sputum or other signs of congestive heart failure occurring during or soon after transfusion. Restrict fluid. I. If a suspected transfusion reaction occurs: 1. Interrupt the transfusion immediately. 87

98 Paramedic Monitoring of Blood Transfusions During IFTs Contact the transferring and/or base/modified base hospital physician. 3. Consult appropriate treatment protocol. 4. Document any suspected transfusion reactions. 5. Report to hospital staff immediately upon arrival. J. The paramedic shall document on the PCR the total volume infused throughout the duration of the transport. CROSS REFERENCES: A. Paramedic IFT Optional Skills: Transferring Hospital Requirements (341). B. Paramedic IFT Optional Skills: Prehospital Provider Agency Application and Approval Process (441). C. Paramedic IFT Optional Skills: Prehospital Provider Agency Requirements and Responsibilities (442). 88

99 Sierra Sacramento Valley EMS Agency Program Policy Paramedic Utilization of Automatic Transport Ventilators (ATVs) During IFTs Effective: 12/01/2016 Next Review: 10/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To provide parameters for paramedic utilization of Automatic Transport Ventilators (ATVs) during interfacility transports (IFTs). AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5, B. California Code of Regulations, Title 22, Chapter 4, Article 1, A. Only prehospital provider agencies approved by S-SV EMS to utilize paramedic IFT optional skills are authorized to provide such services. B. Only paramedics who have successfully completed an S-SV EMS approved paramedic IFT optional skills training program will be permitted to utilize an ATV during IFTs. PROCEDURE: A. Paramedics will not initiate ventilator support. B. Written transfer orders from the transferring physician shall be obtained prior to transport. Transport orders must provide for maintaining and adjusting ventilations via ATV settings during transport. C. Ventilator support must be regulated by an ATV familiar to the paramedic. D. If an ATV failure occurs and cannot be corrected, the paramedic shall discontinue use of the ATV, initiate ventilation by bag-valve, and notify the transferring physician and base/modified base hospital as soon as possible. S-SV EMS shall be notified of any ATV failure by the end of the next business day. 89

100 Paramedic Utilization of Automatic Transport Ventilators (ATVs) During IFTs 843 E. Paramedics shall continually observe the patient and document patient response to any changes while the ATV is operational. F. Initial ATV settings and any subsequent changes shall be documented on the patient care report. G. The paramedic is responsible for all airway management and must frequently reassess tracheostomy/endotracheal tube placement, which shall be checked after each patient movement (bilateral breath sounds, end-tidal C02). H. A non-invasive BP monitor device shall be utilized. Vital signs shall be monitored and documented every 15 minutes and immediately if there is any change in patient status or adjustment of the ATV setting. Vital signs shall include pulse oximetry and cardiac monitoring which shall be maintained throughout transport. I. A continuous end-tidal C02 detector device must be employed during transport (capnograph or waveform capnography are preferred). J. The ventilator that the paramedic provider will be using must be able to match the existing ventilator settings and shall include the following minimum device features (including circuit): 1. Modes: Assist Control (AC). Synchronized Intermittent Mandatory Ventilation (SIMV). Controlled Mechanical Ventilation (CMV). 2. Set rate of ventilations. 3. Adjustable delivered tidal volume. 4. Adjustable Fi Positive End-Expiratory Pressure (PEEP). 6. Adjustable Inspiratory and Expiratory ratios (I:E ratio). 7. Peak airway pressure gauge. 8. Alarms: Peak airway pressure. Disconnect. 90

101 Paramedic Utilization of Automatic Transport Ventilators (ATVs) During IFTs 843 K. Prehospital provider agencies approved for utilization of ATVs must follow the manufacturer instructions regarding the use, maintenance, cleaning, and regular testing of the device. At a minimum, ATV equipment shall undergo annual preventative testing and maintenance by qualified manufacturer s representative personnel or designee. L. Paramedics must be thoroughly trained and regularly retrained on the ATVs use. Such training shall occur no less than annually and shall be documented. CROSS REFERENCES: A. Paramedic IFT Optional Skills: Transferring Hospital Requirements (341). B. Paramedic IFT Optional Skills: Prehospital Provider Agency Application and Approval Process (441). C. Paramedic IFT Optional Skills: Prehospital Provider Agency Requirements and Responsibilities (442). 91

102 Sierra Sacramento Valley EMS Agency Program Policy ALS/LALS Transfer Of Patient Care Effective: 06/01/2015 Next Review: 03/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE To provide a mechanism for the appropriate transfer of patient care from ALS/LALS personnel to other prehospital care providers in the prehospital setting. AUTHORITY POLICY A. California Health and Safety Code, Division 2.5, B. California Code of Regulations, Title 22, Division 9, Chapters 3 & 4 A. Patient assessment and care shall be initiated by the first arriving Advanced EMT (AEMT), paramedic, or flight nurse. The first on duty ALS/LALS licensed and accredited or certified responder who makes patient contact at the scene of an emergency shall be the primary care provider for that patient until such responsibility is transferred to another AEMT, paramedic, flight nurse, or EMT partner. B. All ALS/LALS personnel on scene have a duty to provide the primary care provider with recommendations and assistance, to ensure the best possible patient care as logistics permit and circumstances require. C. The primary care provider shall provide other assisting ALS/LALS personnel who arrive on scene with all appropriate patient care information. D. If there are significant differences regarding the transfer of care or correct course of treatment between ALS/LALS providers, base/modified base hospital consultation shall be utilized to determine the appropriate treatment. PROCEDURE A. Paramedic to Paramedic: 1. Paramedics are authorized to transfer primary patient care to another paramedic when the transfer of care is mutually agreed. 92

103 ALS/LALS Transfer Of Patient Care If a paramedic refuses transfer of care due to the patient s condition or complexity of treatment, the initial paramedic shall maintain patient care and accompany the patient to the hospital. 3. Paramedics may not refuse transfer of care in the following situations: Transfer of care from a paramedic functioning in a specialized role (tactical medic, fireline medic, bike medic, standby event, etc.). During a declared Multi Casualty Incident (MCI). Transfer of care from a ground paramedic to ALS EMS aircraft personnel. 4. A paramedic who transfers care to another paramedic shall: Provide complete patient assessment and treatment information to the paramedic accepting responsibility for the patient. Ensure the completion of a patient care record as required by S-SV EMS policy. The patient care record shall include the time of patient care transfer and the name/provider agency of the paramedic accepting transfer. B. AEMT to AEMT: 1. AEMTs are authorized to transfer primary patient care to another AEMT when patient condition permits. 2. The initial AEMT shall maintain the lead responsibility and accompany the patient during transport in the following circumstances: When the patient is determined to be critical When the receiving AEMT refuses transfer of care due to the patient s condition or complexity of treatment. 3. An AEMT who transfers care to another AEMT shall: Provide complete patient assessment and treatment information to the AEMT accepting responsibility for the patient. Ensure the completion of a patient care record as required by S-SV EMS policy. The patient care record shall include the time of patient care transfer and the name/provider agency of the AEMT accepting transfer. C. AEMT to Ground Paramedic: 1. AEMTs shall provide a verbal and written report when able (in some cases a triage tag) to the arriving ground paramedic. 93

104 ALS/LALS Transfer Of Patient Care Patient care shall be transferred to the ground paramedic as soon as possible after their arrival on scene. 3. The ground paramedic shall provide a report and ETA to the receiving hospital staff while enroute. 4. AEMTs shall ensure the completion of a patient care record as required by S-SV EMS policy. The patient care record shall include the time of patient care transfer and the name/provider agency of the paramedic accepting transfer. D. AEMT or Paramedic to ALS Flight Crew: 1. AEMT and paramedic personnel shall provide a verbal and written report when able (in some cases a triage tag) to the arriving flight crew. 2. Patient care may not be transferred to ALS flight personnel until they are ready to accept care of the patient. 3. The ALS flight crew shall provide a report and ETA to the receiving hospital staff while enroute. AEMT and Paramedic personnel shall ensure the completion of a patient care record as required by S-SV EMS policy. The patient care record shall include the time of patient care transfer and the name(s)/provider agency of the ALS flight personnel accepting transfer. E. ALS Flight Crew to a ground EMT, AEMT, or Paramedic: 1. ALS flight crew personnel (including RNs) are authorized to transfer primary patient care to a ground EMT, AEMT, or paramedic when the care does not exceed their scope of practice, and patient condition permits. 2. The flight nurse shall maintain the lead responsibility and accompany the patient during transport in the following circumstances: When the patient is determined to be critical. When the receiving EMT, AEMT, or paramedic refuses transfer of care due to the patient s condition or complexity of treatment. 3. A flight nurse who transfers care to an EMT, AEMT, or paramedic shall: Provide complete patient assessment and treatment information to the EMT, AEMT, or paramedic accepting responsibility for the patient. 94

105 ALS/LALS Transfer Of Patient Care 844 Ensure the completion of a patient care record as required by S-SV EMS policy. The patient care record shall include the time of patient care transfer and the name/provider agency of the AEMT or paramedic accepting transfer. F. AEMT or Paramedic to EMT Partner: 1. The AEMT or paramedic is responsible for initial patient history, assessment and reassessment. The AEMT or paramedic is ultimately responsible for all aspects of patient care rendered. Patient care may be delegated to an EMT partner, pursuant to the requirements listed below. Prior to delegation of patient care to an EMT partner, the AEMT or paramedic shall perform a complete initial assessment and obtain a patient history. Delegation of patient care can only occur if the patient does not meet ALS/LALS treatment criteria including, but not limited to, the following: o Patients refusing EMS care. o Patients where ALS treatment is indicated according to S-SV EMS policies or treatment protocols. o Trauma patients defined by S-SV EMS Trauma Triage Criteria Policy (860). o 5150 patients, with the exception of interfacility transports with a written order requesting BLS transport. o Any patient who, in the opinion of the ALS/LALS provider, requires the additional input or judgment of an AEMT/paramedic or base/modified base hospital for appropriate management. o All patients in active labor or pregnant patients with greater than 20 week s gestation, with an obstetric complaint. 2. The AEMT or paramedic is responsible to ensure that the documentation of his/her initial assessment and patient history is completed on the PCR. CROSS REFERENCES: A. Prehospital Documentation (605). B. Base/Modified Base/Receiving Hospital Contact (812). C. Medical Control at The Scene of an Emergency (835). D. Refusal Of EMS Care (850). E. Trauma Triage Criteria (860). 95

106 Sierra Sacramento Valley EMS Agency Program Policy Cancellation Or Reduction Of ALS Response Effective: 12/01/2016 Next Review: 07/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To establish criteria for BLS personnel reducing or cancelling responding ALS resources. AUTHORITY: A. California Health and Safety Code, Division 2.5, , and B. California Code of Regulations, Title 22, Division 9, Chapter 4, , and DEFINITIONS: POLICY: A. Code 4 or Canceled Call No further assistance is needed by the Incident Commander (IC) or designee. Further responding units are canceled. B. No Patient Contact Arrival at scene and unable to locate any patient. Verbal or physical contact with a patient has not been made. C. Code 2 Proceeding expeditiously but obeying all traffic laws without exception. D. Code 3 Proceeding with red lights and siren according to the vehicle code. E. Competent Person A person with a capacity to understand the nature of his/her medical condition, and not impaired by alcohol, drugs or medications, mental illness, traumatic injury, grave disability or mental abilities diminished because of age. A. Reducing code of responding ALS resources: 1. The IC or designee on the scene of a medical incident may reduce a responding ALS resource from Code 3 to Code 2 upon determination that, in the best judgment of the IC or designee, the illness or injury is not immediately life-threatening and that the difference in Code 3 and Code 2 response time would not likely have an impact on patient safety. 96

107 Cancellation Or Reduction Of ALS Response When an ambulance is reduced to Code 2, it is possible that the resource will be redirected to a different Code 3 call, resulting in a delayed ambulance response. B. Cancellation of responding ALS units: 1. The IC or designee may cancel a responding ALS resource upon determination of the following: That the incident does not involve an injury or illness which would require assessment, treatment or transport by ALS personnel; or, When the patient is a competent adult and is refusing ALS assessment and or transport. 2. Before canceling the ALS resource, consider the medicolegal responsibility involved. 3. ALS personnel should attempt to make patient contact once they have arrived on scene and are in visual range of the patient. C. Incidents when ALS resources should not be canceled by BLS personnel include: 1. Medical: Cardiac arrest with active CPR Cardiac symptoms Difficulty breathing Altered mental status Drug ingestion Seizures Near drowning Hemorrhage All Pediatric patients < 3 years old 2. Patients who meet Trauma Triage Criteria as defined in S-SV EMS Trauma Triage Criteria Policy (860). CROSS REFERENCES: A. Patient Initiated Released at Scene (RAS) or Patient Initiated Refusal of Service (AMA) (850). B. Treatment/Transport of Minors (851). C. Trauma Triage Criteria (860). 97

108 Sierra Sacramento Valley EMS Agency Program Policy Refusal of EMS Care Effective: 06/01/2017 Next Review: 03/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To establish criteria, guidelines and requirements for the refusal of EMS assessment, treatment and/or transportation (collectively referred to in this policy as EMS care ). EMS personnel have a duty to act in the best interest of all patients. No individual shall be encouraged to refuse EMS care. AUTHORITY: A. California Health and Safety Code, Division 2.5, , and B. California Code of Regulations, Title 22, Division 9. C. California Welfare and Institution Code, 5008, 5150 and DEFINITIONS: A. Agent/attorney-in-fact An individual designated in a Durable Power of Attorney for Health Care to make health care decisions for the patient, regardless of whether the person is known as an agent/attorney-in-fact, or by some other term. B. Durable Power of Attorney for Health Care (DPAHC) Allows an individual to appoint an agent or attorney-in-fact to make health care decisions if they become incapacitated. Decisions made by the agent/attorney-in-fact must be within the limits set by the DPAHC, if any. C. Conservatorship A court case where a judge appoints a responsible person or organization (called the conservator ) to care for another adult (called the conservatee ) who cannot care for himself or herself. D. Minor An individual under the age of 18 years. E. Emancipated An individual under the age of 18 years old who is married, on active duty in the military, or emancipated by court declaration. F. Parent The lawful mother or father of a non-emancipated minor. 98

109 Refusal of EMS Care 850 POLICY: G. Legal Guardian An individual who has been granted legal authority to care for another person. Legal guardianship is commonly used for incapacitated seniors, developmentally delayed adults and minors. H. Person An individual who does not have a complaint suggestive of an illness/injury, does not request evaluation of an illness/injury and/or in the judgement of EMS personnel, does not demonstrate a known or suspected illness/injury that requires EMS care. I. Patient An individual who has a complaint suggestive of an illness/injury, requests evaluation of an illness/injury, and/or in the judgment of EMS personnel, demonstrates a known or suspected illness/injury that requires EMS care. J. Patient Representative An individual legally responsible for healthcare decisions involving a patient (parent, legal guardian, conservator, agent/attorney-in-fact). Note: a law enforcement officer may also legally represent a patient who is in their custody if the circumstances warrant. K. Competent Individual An individual who has the capacity to understand the circumstances for which EMS care is indicated, and the risks associated with refusing all or part of such care. They are alert and their judgement is not impaired by alcohol, drugs/medications, illness, injury, or grave disability. A. No individual will be denied EMS care on the basis of age, sex, race, creed, color, origin, economic status, language, sexual preference, disease, or injury. B. Individuals determined by EMS personnel to meet the definition of a person according to this policy do not require EMS care. C. Patient assessment and refusal of EMS care procedures shall be performed by ALS/LALS personnel whenever possible. BLS personnel may only complete the refusal of EMS care procedures if ALS/LALS personnel are not on scene. BLS personnel shall not continue ALS/LALS personnel to scene for the sole purpose of completing the refusal of EMS care documentation. D. A patient, or patient representative acting on behalf of the patient, may decline all or part of EMS care if all of the following actions have taken place: 1. EMS personnel have provided the patient/patient representative enough information about the decision they are making so that there is informed consent. 2. EMS personnel are satisfied that the patient/patient representative is competent and has understood the risk and options concerning their decision. 99

110 Refusal of EMS Care 850 PROCEDURE: 3. EMS personnel have involved law enforcement and/or the base/modified base hospital in situations required by this policy. The highest medical authority on scene shall complete the following procedures for any patient, or patient representative on behalf of the patient, refusing EMS care: A. Perform an adequate patient assessment as indicated by the patient s complaint/condition/presentation. B. Advise the patient/patient representative of their known/suspected condition, or the known/suspected condition of the patient they are representing, and the known/unknown risks and/or possible complications of refusing EMS care. C. Request/involve law enforcement for any of the following patient circumstances: 1. Attempted suicide, verbalized suicidal/homicidal ideations, or on a 5150 hold. 2. Clearly irrational decision making in the presence of a potentially life threatening condition. 3. Concern for patient neglect or endangerment. D. Contact the base/modified base hospital for consultation while in close proximity to the patient for any of the following patient circumstances: 1. New altered level of consciousness. 2. Potentially life threatening condition, including but not limited to, patients meeting STEMI, stroke, or trauma triage criteria. 3. Unstable vital signs. 4. Disagreement between law enforcement and EMS personnel about whether or not the patient requires EMS care. 5. A patient who is not legally responsible for their own healthcare decision making (non-emancipated minor, conservatee, patient with a DPAHC, etc.) being released to self or another individual on scene who is not their legally designated healthcare decision maker (parent, legal guardian, conservator, agent/attorney-in-fact). 6. Any circumstance where EMS personnel believe that the involvement of the base/modified base hospital would be beneficial. 100

111 Refusal of EMS Care 850 In the Event of Communication Failure: Patients who are legally responsible for their own healthcare decision making, or who have a legally designated healthcare decision maker (parent, legal guardian, conservator, agent/attorney-in-fact) on scene with them, may be released after all other requirements are met. EMS personnel must document the method(s) of communication attempted and the reason for the communication failure. Patients who are not legally responsible for their own healthcare decision making (non-emancipated minor, conservatee, patient with a DPAHC, etc.), and who do not have a legally designated healthcare decision maker on scene with them, shall not be released without base/modified base hospital consultation. E. Prior to releasing patients who are not legally responsible for their own healthcare decision making (non-emancipated minor, conservatee, patient with a DPAHC, etc.), EMS personnel shall also attempt to contact the patient s legally designated healthcare decision maker (parent, legal guardian, conservator, agent/attorney infact) if they are not already on scene. Contact details (method of contact, reason for inability to contact if applicable, etc.), as well as information on who the patient was actually released to shall be adequately documented in the patient care report. F. A patient, or patient representative on behalf of the patient, continuing to refuse EMS care, despite the foregoing measures, must sign a Refusal of EMS Care Form (850- A or similar), witnessed by one of the following, in order of preference: 1. Immediate family member. 2. Law enforcement officer. 3. Other EMS personnel. If the patient/patient representative refuses to sign the Refusal of EMS Care Form, EMS personnel shall adequately document this information on both the patient care report and the Refusal of EMS Care Form, and obtain a witness signature (in the same order of preference listed above) attesting to the fact that the patient refused to sign. G. Provider agencies are responsible for routinely auditing refusal of EMS care calls. Random auditing of these type of calls shall occur on a minimum of a monthly basis. CROSS REFERENCES: EMS Care of Minor Patients (851). 101

112 Sierra Sacramento Valley EMS Agency Program Policy EMS Care of Minor Patients Effective: 06/01/2017 Next Review: 03/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To establish criteria, guidelines and requirements for EMS assessment, treatment and/or transport (collectively referred to in this policy as EMS care ) of minor patients. AUTHORITY: A. California Health and Safety Code, Division 2.5. B. California Code of Regulations, Title 22, Division 9. C. California Business and Professions Code D. California Family Code, 6922, 6924, 6925, 6926, 6927, 6928, and E. California Welfare and Institution Code, 305 and 625. DEFINITIONS: A. Minor An individual under the age of 18 years. B. Emancipated An individual under the age of 18 years old who is married, on active duty in the military, or emancipated by court declaration. C. Parent The lawful mother or father of a non-emancipated minor. D. Legal Guardian An individual who has been granted legal authority to care for another person. Legal guardianship is commonly used for incapacitated seniors, developmentally delayed adults and minors. E. Emergency A situation requiring immediate services for alleviation of severe pain or immediate diagnosis of unforeseen medical conditions, which, if not immediately diagnosed and treated, would lead to serious disability or death. 102

113 EMS Care of Minor Patients 851 POLICY: A. Parent/legal guardian consent for EMS care is not required for minor patients meeting any of the following criteria: 1. Has an emergency medical condition and a parent/legal guardian is not available. 2. Is an emancipated minor. 3. Is fifteen (15) years of age or older, living separate and apart from their parents and managing their own financial affairs. 4. Is twelve (12) years of age or older and in need of medical care for an infectious, contagious communicable disease, or for a sexually transmitted disease. 5. Is twelve (12) years of age or older and in need of medical care for drug or alcohol abuse. 6. Is in need of medical care for rape or sexual assault. 7. Is pregnant and requires medical care related to the pregnancy. B. EMS personnel shall make every effort to inform a parent/legal guardian of a nonemancipated minor of the situation requiring EMS care and where their child has been transported. 1. EMS personnel are not permitted to inform a parent/legal guardian without the minor s consent under the following circumstances: Is pregnant and requires medical care related to the pregnancy. Is twelve (12) years of age or older and in need of medical care for an infectious, contagious communicable disease, or for a sexually transmitted disease. 2. EMS personnel are not permitted to inform a parent or legal guardian of a minor who is in need of medical care for rape or sexual assault when they reasonably believe that the parent/guardian committed the rape or assault. C. If EMS personnel believe a parent or legal guardian is making a decision which appears to be endangering the health and welfare of a minor patient, law enforcement involvement shall be utilized. CROSS REFERENCES: Refusal of EMS Care (850). 103

114 Sierra Sacramento Valley EMS Agency Program Policy Patient Restraint Mechanisms Effective: 12/01/2017 Next Review: 07/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To provide guidelines on the use of restraint mechanisms by EMS personnel in the prehospital setting for patients who are violent, potentially violent, or who may harm themselves or others. AUTHORITY: A. California Code of Regulations, Title 22. B. Welfare and Institutions Code, C. Health and Safety Code, Division 2.5, , and PRINCIPLES: A. The safety of the patient, community and responding personnel is of paramount concern. B. Restraint mechanisms are to be used only when necessary in situations where the patient is potentially violent or is exhibiting behavior that is dangerous to self or others. C. Prehospital personnel must consider that aggressive or violent behavior may be a symptom of medical conditions such as seizure, head trauma, hypoxia, alcohol or drug related problems, hypoglycemia or other metabolic disorders, stress or psychiatric disorders. D. The method of restraint used shall allow for adequate monitoring of vital signs and shall not restrict the ability to protect the patient's airway or compromise vascular or neurological status. E. This policy is not intended to negate the need for law enforcement personnel to use appropriate restraint equipment that is approved by their respective agency to establish scene management control. Restraints applied by law enforcement require the officer to remain available at the scene or during transport to remove or adjust the restraints for patient safety. 104

115 Patient Restraint Mechanisms 852 POLICY: A. General Principals: 1. Restrained patients shall not be transported in a prone position. EMS personnel must ensure that the patient's position does not compromise their respiratory/ circulatory systems, and does not preclude any necessary medical intervention to protect or manage the airway should vomiting occur. 2. Monitor vital signs and be prepared to provide airway/ventilation management. 3. The base and/or receiving hospital shall be informed as soon as possible that the patient has been restrained, the type of restraint and the reason for restraint. B. Forms of Restraint: 1. Physical Restraint: Restraint devices applied by EMS personnel must be padded soft restraints that will allow for quick release. Restrained extremities should be evaluated for pulse quality, capillary refill, color, temperature, nerve and motor function immediately following application and every 10 minutes thereafter. It is recognized that the evaluation of vascular and neurological status requires patient cooperation, and thus may be difficult or impossible to monitor. Restraints shall be applied in such a manner that they do not cause vascular, neurological, or respiratory compromise. Any abnormal findings require the restraints to be removed and reapplied or supporting documentation as to why restraints could not be removed and reapplied. Restraints shall not be attached to movable side rails of a gurney. The following forms of restraint shall not be applied/utilized by EMS personnel: o Hard plastic ties or any restraint device requiring a key to remove. o Restraining a patient s hands and feet behind the patient. o Sandwich restraints, using backboard, scoop-stretcher or flats. 2. Chemical Restraint If a patient is combative, such that harm to self or others is likely, consider chemical restraint as follows: o Pediatric patients: Contact base/modified base hospital for consultation. o Adult patients: Midazolam 5 mg IV/IO OR 10 mg IM/IN. 105

116 Patient Restraint Mechanisms 852 C. Law Enforcement Applied Restraints 1. The general principals of this policy shall pertain to patients with restraints applied by law enforcement who are treated/transported by EMS personnel. 2. Restraint devices applied by law enforcement must provide sufficient slack to allow the patient to straighten their abdomen and chest and to take full tidal volume breaths. 3. Restraint devices applied by law enforcement require the officer's continued presence to ensure patient and scene management safety. The officer should accompany the patient in the ambulance. If this is not possible, the officer should follow by driving in tandem with the ambulance on a pre-determined route. A method to alert the officer of any problems that may develop during transport should be discussed prior to leaving the scene. Patients in custody/arrest remain the responsibility of law enforcement. D. Interfacility Transport of Psychiatric Patients A two-point, locking, padded cuff and belt restraint and/or two-point locking, padded ankle restraints may be used only during the interfacility transport of psychiatric patients on a 5150 hold under the following circumstances: 1. Transport personnel must be provided with a written restraint order from the transferring physician or their designee as part of the transfer record. 2. Transport personnel shall have immediate access to the restraint key at all times during the transport. 3. Restrained extremities should be evaluated for pulse quality, capillary refill, color, temperature, nerve and motor function immediately following application and every 10 minutes thereafter. Any abnormal findings require the restraints to be adjusted or removed and reapplied or supporting documentation as to why restraints could not be adjusted or removed and reapplied. E. Documentation The following information shall be documented on patient care report: 1. Reason for restraint. 2. Type of restraint utilized and identity of personnel applying restraint. 3. Assessment of the vascular/neurological status of the restrained extremities and cardiac/respiratory status of the restrained patient. 106

117 Sierra Sacramento Valley EMS Agency Program Policy Tasered Patient Care and Transport Effective: 06/01/2017 Next Review: 01/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To establish guidelines for EMS personnel in the treatment and transportation of patients on whom a Taser has been used. AUTHORITY: A. California Code of Regulations, Title 22, B. Health and Safety Code, , and GENERAL CONSIDERATIONS: POLICY: A. A Taser is designed to transmit electrical impulses that temporarily disrupt the body s nervous system. The Electro-Muscular Disruption (EMD) technology causes an uncontrollable contraction of the muscle tissue, allowing the Taser to physically debilitate a target regardless of pain tolerance or mental focus. B. The scene must be safe and secured by law enforcement before EMS personnel will evaluate or treat the patient. C. Assess the patient for any potential cause of the abnormal or combative behavior such as head trauma, hypoxia, alcohol or drug related problems, hypoglycemia or other metabolic disorders, stress or psychiatric disorders. D. Assess the patient for any potential injury resulting from Taser deployment. A. Taser probes should not be routinely removed by EMS personnel unless they interfere with the treatment or safe transportation of the patient. Only EMT, AEMT and paramedic personnel are approved to remove Taser probes in the prehospital setting. B. If removed by EMS, Taser probes shall be offered to law enforcement prior to disposal. C. Mode of transportation and destination will be determined by law enforcement, in consultation with EMS personnel and/or the base/modified base hospital if necessary. 107

118 Tasered Patient Care and Transport 853 PROCEDURE: A. When safe to do so, patients should be immediately evaluated, with particular attention to signs and symptoms of excited delirium. B. Treat any injuries or medical conditions according to appropriate protocol(s). C. Patient will normally be in custody of law enforcement and require transportation to an emergency department for medical clearance. D. If EMS personnel determine that the patient is a danger to self or others, law enforcement may be requested to accompany the patient during transport. E. Patient should be appropriately restrained if indicated. F. If one or both of the Taser probes requires removal: 1. Verify the wires to the probes have been severed. 2. Use routine biohazard precautions. 3. Place one hand on the patient in the area where the probe is embedded and stabilize the skin surrounding the puncture site between two fingers. Keep your hand away from the probe. With your other hand, in one fluid motion pull the probe straight out from the puncture site. 4. Follow law enforcement direction regarding the preservation or disposal of probes. 5. Apply direct pressure for bleeding, and apply a sterile dressing to the wound site. DOCUMENTATION: The following information shall be documented on the patient care report: A. Patient s presenting behavior or signs/symptoms which resulted in Taser use. B. Baseline patient assessment including, but not limited to, oxygen saturation, blood glucose level, neurological assessment and vital signs. C. Anatomic location of the Taser probes. D. If Taser probes removed by EMS, document time of removal and if probes were intact following removal. 108

119 Sierra Sacramento Valley EMS Agency Program Policy Trauma Triage Criteria Effective: 12/01/2016 Next Review: 07/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To identify individuals who are at greatest risk for severe injury and determine the most appropriate facility to transport patients with different injury types and severities. AUTHORITY: A. California Health and Safety Code, Division 2.5; Chapter 6, Article 2.5, B. California Code of Regulations, Title 22, Division 9, Chapter 7. C. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report (MMWR), Recommendations and Reports, January 13, 2012/Vol. 61/No. RR-01, Guidelines for Field Triage of Injured Patients, Recommendation of the National Expert Panel on Field Triage, PRINCIPLES: Patients meeting trauma triage criteria should be transported as soon as possible. On scene procedures should be limited to triage, patient assessment, airway management, control of external hemorrhage, and immobilization. Additional interventions should be completed enroute with the exception of those incidents requiring prolonged extrication. TRAUMA CENTER LEVELS: A. Level I: A Level I Trauma Center has the greatest amount of resources and personnel for care of the injured patient. Typically, it is also a tertiary medical care facility that provides leadership in patient care, education and research for trauma, including prevention programs. B. Level II: A Level II Trauma Center offers similar resources as a Level I facility, differing only by the lack of research activities for a Level I designation. C. Level I and II Pediatric: Level I and II Pediatric Trauma Centers focus specifically on pediatric trauma patients. Level I Pediatric Trauma Centers require some additional pediatric specialties and are research and teaching facilities. 109

120 Trauma Triage Criteria 860 D. Level III: A Level III Trauma Center is capable of assessment, resuscitation and emergency surgery, if warranted. Injured patients are stabilized before transfer, if indicated, to a facility with a higher level of care according to pre-existing arrangements. E. Level IV: A Level IV Trauma center is capable of providing 24-hour physician coverage, resuscitation and stabilization to injured patients before they are transferred, if indicated. TRAUMA TRIAGE CRITERIA: A. Physiologic Trauma Triage Criteria (one or more of the following): 1. Respiratory rate < 10 or > 29 breaths per minute (< 20 in infants < 1 year of age), or need for ventilatory support. 2. Glasgow Coma Score (GCS) Systolic Blood Pressure < 90. B. Anatomic Trauma Triage Criteria (one or more of the following): 1. All penetrating injuries to the head, neck, chest, torso, and extremities proximal to the elbow or knee. 2. Chest wall instability or deformity (e.g. flail chest). 3. Two or more proximal long-bone fractures. 4. Paralysis. 5. Pelvic fractures. 6. Amputation proximal to wrist or ankle. 7. Crushed, degloved, mangled, or pulseless extremity. 8. Open or depressed skull fracture. C. Mechanism of Injury Trauma Triage Criteria (one or more of the following): 1. High-risk auto crash (one or more of the following): Ejections (partial or complete) from automobile. 110

121 Trauma Triage Criteria 860 Death in the same passenger compartment. Intrusion, including roof: > 12 inches at occupant site or > 18 inches at any site 2. Non-Automotive crash > 20 mph including, but not limited to: motorcycle, ATV, gocart, bicycle, skateboard, watercraft and aircraft. 3. Auto vs Pedestrian/Bicycle: thrown, run over, or with significant (> 20 mph) impact. 4. Adults who fall > 20 feet. 5. Children who fall > 10 feet or three (3) times their height. 6. Other high energy impact. D. Special Considerations Trauma Triage Criteria (any of the following): 1. Adults 65 years of age: Low impact mechanism (e.g. ground level falls) might result in severe injury. SBP < 110 might represent shock. 2. Current patient use of anticoagulation or antiplatelet medication, or history of bleeding disorder. 3. Pregnancy > 20 weeks. 111

122 Trauma Triage Criteria 860 Trauma Patient Destination Unmanageable Airway? YES Transport to closest hospital NO Meets Anatomic &/or Physiologic Criteria? NO YES Adult ( 15 y/o) Pediatric ( 14 y/o) If a level I or II trauma center is closest, transport directly to the level I or II trauma center If a level III trauma center is closest, contact the level III trauma center for destination consultation Transport to a pediatric trauma center if transport time is 45 minutes If patient is too critical for transport to a pediatric trauma center, contact the closest trauma center for destination consultation If transport time to a pediatric trauma center is > 45 minutes, follow adult destination criteria Meets Mechanism of Injury Criteria? YES If transport time to a trauma center is 45 minutes, contact the trauma center for destination consultation If transport time to a trauma center is > 45 minutes, contact the closest base/modified base hospital for destination consultation NO Meets Special Considerations Criteria Only? YES Prehospital personnel shall contact the closest base/modified base hospital for destination consultation when they believe that transport to a trauma center may be in the patient s best interest Prehospital personnel shall notify the receiving trauma center of the patient s pending arrival as soon as possible 112

123 Trauma Triage Criteria 860 TRAUMA REGISTRY: All hospitals receiving trauma patients from the S-SV EMS region shall provide data to the S-SV EMS Trauma Registry. GLASGOW COMA SCALE (GCS): Adult GCS Points Eye Opening Response Verbal Response Motor Response 6 Obeys Commands 5 Oriented & converses Localizes pain 4 Opens spontaneously Disoriented & converses Flexion withdrawal 3 Opens to verbal stimuli Inappropriate words Flexion abnormal (decorticate) 2 Opens to painful stimuli Incomprehensible sounds Extension (decerebrate) 1 No response No response No response Pediatric GCS Points Eye Opening Response Verbal Response Motor Response 6 Normal spontaneous movement 5 Cries appropriate/coos/babbles Withdraws to touch 4 Opens spontaneously Irritable cry Withdraws to pain 3 Opens to verbal stimuli Inappropriate crying/screaming Flexion abnormal (decorticate) 2 Opens to painful stimuli Grunts Extension (decerebrate) 1 No response No response No response CROSS REFERENCES: A. Patient Destination (505). B. Hospital Capabilities (505-A). C. Multiple Casualty Incidents (837). 113

124 Sierra Sacramento Valley EMS Agency Program Policy EMS Aircraft Utilization Effective: 06/01/2016 Next Review: 01/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To identify appropriate and consistent criteria for requesting/utilizing EMS aircraft for prehospital patient care and transport. AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5, , , , , , , and B. California Code of Regulations, Title 22, Division 9, Chapter 8, C. California Code of Regulations, Title 22, Chapter 12, , D. Prehospital EMS Aircraft Guidelines, EMSA Document #144, December A. It is important that EMS personnel utilize consistent and appropriate criteria when requesting an EMS aircraft for assistance with patient care and transport. B. A patient being transported by EMS aircraft should be critically ill and/or injured (life or limb). Special circumstances related to a particular area will drive decisions related to EMS aircraft utilization. C. Utilization should be based upon the time closest/most appropriate level of care. D. Time savings will be influenced by a number of factors, including but not limited to, a patient s condition, the type of aircraft and current environmental conditions. E. The use of EMS aircraft should provide a significant reduction in arrival time to a receiving facility capable of providing definitive care, including designated specialty care centers. If the total estimated receiving facility arrival time for EMS aircraft exceeds the ground ambulance use, air transport should not be used. 114

125 EMS Aircraft Utilization 862 F. Utilization of EMS aircraft should be considered in the following situations: 1. Patients who meet trauma triage criteria. 2. Time critical medical patients. 3. MCI. 4. The patient is inaccessible by any other means. 5. Utilization of existing ground transport services threatens to overwhelm the local EMS system. 6. When additional or specialty care provider resources are needed. G. The decision to cancel a responding EMS aircraft is the discretion of the Incident Commander. The decision should be made collaboratively with on-scene medical personnel, after assessing the scene location and patient needs. H. The pilot shall have the final authority in decisions to continue or cancel the response. The pilot in command may also dictate the need to deviate from destination policy. I. EMS aircraft transportation should not be used for the following patients: 1. CPR in progress. 2. Patient(s) contaminated by hazardous materials that cannot be completely decontaminated prior to transport. 3. Patient(s) who are potentially violent or have behavioral emergencies. However, a patient may be transported at the discretion of the flight crew. CROSS REFERENCES: EMS Prehospital Aircraft Operations Protocol (450). 115

126 Sierra Sacramento Valley EMS Agency Program Policy Prohibition on Carrying of Weapons by EMS Personnel Effective: 06/01/2017 Next Review: 05/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To establish a policy prohibiting the carrying of weapons by on-duty EMS personnel. This policy does not apply to on-duty peace officers or members of an approved Tactical Emergency Medical Support (TEMS) program who may also provide emergency patient care during the course of their assigned duties. This policy also does not apply to EMS supervisor personnel who have a current/valid carrying a concealed weapon (CCW) permit, if the EMS provider agency has a policy specifically addressing this matter (including minimum training requirements, storage, etc.). AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5, , and B. California Code of Regulations, Title 22, Division 9. A. On-duty EMS personnel shall not carry or possess on or about their person, or have in EMS equipment or vehicles, any of the following articles: 1. Firearms or concealed weapons of any sort. 2. Stun guns or Tasers. 3. Night sticks, batons, billy clubs, saps, or lead weighted gloves. 4. Dirk, dagger, or switchblade knife. 5. Any other deadly weapon. 6. Tear gas, mace, pepper spray, or chemical agents. 7. Handcuffs. B. This policy does not include pocket knives or similar tools, instruments/equipment used in EMS rescue operations, or animal repellent. 116

127 Sierra Sacramento Valley EMS Agency Program Policy Communication Failure Effective: 06/01/2017 Next Review: 01/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To define the conditions under which a paramedic or AEMT may utilize Advanced Life Support (ALS) medications/procedures for prehospital patient care in the event of communication failure. AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5, , , , 1798, , and B. California Code of Regulations, Title 22, Division 9. If during the course of patient treatment a paramedic or AEMT attempts direct voice contact with a base/modified base hospital but cannot establish or maintain adequate contact: A. They may initiate necessary ALS procedures specified in approved S-SV EMS policies and protocols. B. Procedures/medications listed in applicable treatment protocols as Base/Modified Base Hospital Order Only may be performed in the event of communication failure if warranted by the patient condition. C. The following procedures/medications listed in applicable treatment protocols as Base/Modified Base Hospital Physician Order Only shall not be performed/administered in the event of a communication failure and without a direct order from a base/modified base hospital physician: 1. Terminating resuscitative efforts utilizing the BLS termination of resuscitation criteria if no ROSC in an adult pulseless arrest patient (Reference No. C-1). 2. Administration of activated charcoal (Reference No. M-5). 3. Activation/utilization of the Nerve Agent Treatment Protocol (Reference No. E-8). 117

128 Communication Failure 890 PROCEDURE: In each instance where ALS procedures are initiated or attempted under the conditions specified for communication failure, the paramedic or AEMT shall: A. Attempt to establish base/modified base hospital contact by telephone and/or radio throughout the call as circumstances permit. B. Immediately upon voice contact, provide a verbal report to the base/modified base hospital MICN or physician. C. Document the existence and reason for the communication failure in the patient care report. 118

129 S-SV EMS ADULT PATIENT TREATMENT PROTOCOLS 119

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131 Sierra Sacramento Valley EMS Agency Treatment Protocol Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director Manual Chest Compressions Rate: /minute Depth: 2 inches - allow full chest recoil Minimize interruptions Rotate compressors every 2 minutes Perform CPR during AED/defibrillator charging Resume CPR immediately after shock Pulseless Arrest Effective: 12/01/2017 Next Review: 07/2020 Mechanical Chest Compression Devices C-1 Indications: 1) Adult pts, 2) Non-traumatic cardiac arrest Contraindications: 1) Pts who do not fit in the device, 2) Known or clinically apparent third trimester pregnancy Apply following completion of at least one 2 minute manual CPR cycle, or at the end of a subsequent cycle. Apply with minimal interruption to chest compressions Waveform Capnography Waveform capnography, if available, shall be used on all patients with an advanced airway in place Persistently low PETCO 2 levels < 10 mm HG suggest ROSC is unlikely ensure chest compressions are adequate or consider termination of resuscitation efforts An abrupt increase in PETCO 2 is indicative of ROSC Treatment on Scene Movement of a patient may interrupt CPR or prevent adequate depth and rate of compressions Consider resuscitative efforts on scene up to 30 minutes to maximize chances of ROSC If resuscitation attempts do not obtain ROSC, consider termination of resuscitation efforts Termination of Resuscitation Criteria Base/Modified Base Hospital Physician Order* BLS termination of resuscitation criteria (all criteria must be present): (1) Arrest not witnessed by EMS, (2) No AED shocks delivered, (3) No ROSC after 3 rounds of CPR & AED analysis ALS Termination of Resuscitation Criteria (all criteria must be present): (1) Arrest not witnessed by EMS, (2) No effective bystander CPR was provided or effective CPR cannot be maintained, (3) No ROSC after full ALS care in the prehospital setting *In the event of communication failure, prehospital personnel may terminate resuscitative efforts without a base/ modified base hospital physician order for patient s who meet the ALS termination of resuscitation criteria. BLS CPR x 2 minutes - with BVM and 100% O 2 - apply AED as soon as possible Consider advanced airway at appropriate time during resuscitation (EMT King Airway providers only) do not interrupt chest compressions to establish an advanced airway Analyze rhythm/check pulse after 2 minutes of CPR If arrest witnessed by EMS and an AED or defibrillator is immediately available, start CPR and utilize the AED/defibrillate as soon as possible NO ROSC? NO Shock advised? YES Deliver AED shock Resume CPR x 2 minutes Analyze rhythm/check pulse after 2 minutes of CPR YES Go to ROSC Protocol C-5 See page 2 for ALS treatment 121

132 Sierra Sacramento Valley EMS Agency Treatment Protocol Pulseless Arrest C-1 Reversible Causes (Contact base/modified base hospital for additional treatment consultation if necessary ) - Hypovolemia - Hypoxia - Hydrogen Ion (Acidosis) - Hypo-/hyperkalemia - Hypothermia - Tamponade, cardiac - Tension pneumo. - Thrombosis, pulmonary - Thrombosis, cardiac - Toxins *Biphasic Manual Defibrillation Detail Manufacturer recommendation (if unknown J). Subsequent doses should be at equivalent or higher ALS ASYSTOLE/PEA Cardiac Monitor VF/VT CPR x 2 minutes IV/IO NS (may bolus up to 1000 ml) Consider advanced airway Analyze rhythm/check pulse after 2 minutes of CPR Defibrillation* CPR x 2 minutes IV/IO NS (may bolus up to 1000 ml) Consider advanced airway Analyze rhythm/check pulse after 2 minutes of CPR ROSC? YES Go to ROSC Protocol C-5 YES ROSC? NO NO Shockable rhythm? YES Go to VF/VT Go to Asystole/ PEA NO Shockable rhythm? NO YES Defibrillation* CPR x 2 minutes Epinephrine every 3-5 mins. - IV/IO: 1 mg (1:10,000) - ET: mg (1:1,000) diluted in 10 ml NS if no IV/IO Analyze rhythm/check pulse after every 2 minutes of CPR CPR x 2 minutes Epinephrine every 3-5 mins. - IV/IO: 1 mg (1:10,000) - ET: mg (1:1,000) diluted in 10 ml NS if no IV/IO Analyze rhythm/check pulse after every 2 minutes of CPR For VF/VT unresponsive to defib/epi: Amiodarone - IV/IO: 300 mg - May repeat 150 mg x 1 in 3-5 mins. 122

133 Sierra Sacramento Valley EMS Agency Treatment Protocol C-5 Return Of Spontaneous Circulation (ROSC) Approval: Troy M. Falck, MD Medical Director Effective: 12/01/2017 Approval: Victoria Pinette Executive Director Next Review: 07/2020 BLS Manage airway/assist ventilations, high flow O 2 Confirm palpable pulse and auscultated BP Monitor for reoccurrence of cardiac arrest ALS NO Pulse < 60/min YES SBP < 90 NO Recurrent non-sustained V-Tach? NO YES YES Atropine 0.5 mg IV/IO or 1 mg ET if no IV/IO access May repeat every 3-5 mins (max total 3 mg) Consider Transcutaneous Pacing Refer to Bradycardia Protocol (C-7) Amiodarone Only If not previously administered during initial resuscitation efforts 150 mg IV/IO over 10 minutes - intermittent IV push or IV infusion in 100 ml D5W at a rate of 15 mg/min If SBP remains < 90, consider: Fluid Bolus ml NS Dopamine 5 10 µg/kg/min to maintain SBP 90 Monitor & reassess 12 Lead EKG Notes SRC = STEMI Receiving Center If acute MI is suspected cause of cardiac arrest, direct transport to a SRC is strongly encouraged STEMI? NO YES Transport to closest SRC YES 45 min to SRC NO Contact closest base/ modified base hospital for destination consultation 123

134 Sierra Sacramento Valley EMS Agency Treatment Protocol C-6 Tachycardia With Pulses Approval: Troy M. Falck, MD Medical Director Effective: 12/01/2017 Approval: Victoria Pinette Executive Director Next Review: 11/2019 Unstable patients with persistent tachycardia require immediate cardioversion It is unlikely that symptoms of instability are caused primarily by the tachycardia if the heart rate is < 150/min; cardioversion is seldom needed for patients meeting this criteria BLS Manage airway and assist ventilations as necessary Assess V/S, including SpO 2 O 2 at appropriate rate (if hypoxemic) ALS Cardiac monitor, 12-lead ECG at appropriate time (do not delay therapy) Establish vascular access at appropriate time (may bolus up to 1000 ml NS) *Cardioversion Information If rhythm is wide irregular or monitor will not synchronize, and the patient is critical, treat as VF with unsynchronized defibrillation doses (C-1) Initial synchronized cardioversion doses: - Narrow regular: J - Narrow irregular: J - Wide regular: 100 J If no response to the initial shock, increase dose in a stepwise fashion for subsequent cardioversion attempts Persistent tachycardia causing (any): Hypotension? Acutely altered mental status? Signs of shock? Ischemic chest discomfort Acute heart failure? NO YES Cardioversion* Pre-cardioversion sedation with one of the following should be used for an awake patient whenever possible: Midazolam: 5 mg IV/IO; OR Morphine: 2 5 mg IV/IO; OR Fentanyl: mcg IV/IO Wide QRS? 0.12 second NO A-Fib, A-Flutter, or S-Tach? NO Valsalva Maneuver YES YES Monitor & reassess Contact base hospital for consultation if necessary If no response to Valsalva Maneuver, consider: Adenosine First dose: 6 mg rapid IV/IO push If rhythm dose not convert within 1 2 minutes: Second dose: 12 mg rapid IV/IO push Flush IV/IO line with 20 ml NS after each dose 124

135 Sierra Sacramento Valley EMS Agency Treatment Protocol C-7 Bradycardia Approval: Troy M. Falck, MD Medical Director Effective: 12/01/2017 Approval: Victoria Pinette Executive Director Next Review: 11/2019 Symptomatic bradycardia is defined as a heart rate <60/min that elicits signs and symptoms. When bradycardia is the cause of symptoms, the rate is generally <50/min Symptomatic bradycardia exists clinically when the following 3 criteria are present: 1.) The heart rate is slow; 2.) The patient has symptoms; and 3.) The symptoms are due to the slow heart rate BLS Manage airway and assist ventilations as necessary Assess V/S, including SpO 2 O 2 at appropriate rate (if hypoxemic) ALS Cardiac monitor, 12-lead ECG at appropriate time (do not delay therapy) Establish vascular access at appropriate time (may bolus up to 1000 ml NS) *Transcutaneous Pacing Information If patient is symptomatic, do not delay pacing to start an IV/IO or wait for atropine to take effect. Set initial rate at 60/min. Set initial current at 10 ma and increase by 10 ma increments while assessing for mechanical capture. Once pacing is initiated (mechanical capture achieved), adjust the rate based on the patient s clinical response. Most patients will improve with a rate of 60-70/min if the symptoms are primarily due to bradycardia. Monitor/re-evaluate patient as needed, and increase current as necessary to maintain mechanical capture. Persistent bradycardia causing (any): Hypotension? Acutely altered mental status? Signs of shock? Ischemic chest discomfort Acute heart failure? NO Monitor and reassess Contact base hospital for consultation if necessary YES Atropine 0.5 mg IV/IO May repeat every 3 5 minutes (max total: 3 mg) If atropine ineffective: Transcutaneous Pacing* Consider sedation with one of the following: - Midazolam: 5 mg IV/IO; OR - Morphine: 2 5 mg IV/IO; OR - Fentanyl: mcg IV/IO May repeat sedation x 1 after 5 minutes If patient remains symptomatic: Dopamine 2-10 µg/kg/min infusion to maintain BP >

136 SIERRA SACRAMENTO VALLEY EMS AGENCY TREATMENT PROTOCOL MEDICAL EMERGENCY CARDIOVASCULAR REFERENCE NO. C-8 SUBJECT: CHEST PAIN OR SUSPECTED SYMPTOMS OF CARDIAC ORIGIN Assessment, treatment and transport destination decision should occur concurrently. A minimum of the pt s last name and first initial shall be entered into the monitor prior to 12-lead acquisition. Any 12-lead consistent with an acute ST elevation MI (computer read out or paramedic interpretation) shall be transmitted to the appropriate facility as soon as possible if transmission capabilities are available. BLS Assess V/S including pulse oximetry Administer O 2 at appropriate rate if dyspneic, signs of heart failure or shock, or SpO2 94% P-Q-R-S-T Aspirin: mg chewable PO (approved/optional for EMT personnel) Should be administered as soon as possible Anticoagulant use by patient is not a contraindication to aspirin administration ALS Cardiac monitor 12-lead ECG as soon as possible prior to NTG administration Establish vascular access at appropriate time during treatment (may bolus up to 1000 ml NS) Nitroglycerin (NTG): 0.4 mg SL tablet or spray Repeat every 5 minutes if discomfort persists Do not administer if SBP < 100 Consider establishing vascular access prior to NTG administration if inferior MI suspected Consult with base/modified base hospital prior to NTG administration if patient takes erectile dysfunction or pulmonary HTN medication Morphine Sulfate 2 mg slow IV/IO OR Fentanyl 25 mcg slow IV/IO Administer if discomfort persists following one or more EMS administered NTG doses, and if all the following are present: - RR > 12 - SBP > GCS = 15 May repeat morphine 2 mg increments or fentanyl 25 mcg increments every 5 minutes as needed if discomfort persists Max total opioid dose = 20 mg morphine equivalent (20 mg morphine, 200 mcg fentanyl, or combination of the two) Zofran (Ondansetron) 4 8 mg slow IV/IO, IM or ODT may be administered prior or concurrent to fentanyl or morphine administration to reduce potential nausea/vomiting See Page 2 for Patient Destination Determination Page 1 Effective Date: 12/01/2015 Date last Reviewed/Revised: 10/2015 Next Review Date: 10/2018 Approved by: SIGNATURE ON FILE S-SV EMS Medical Director 126 SIGNATURE ON FILE S-SV EMS Regional Executive Director

137 SIERRA SACRAMENTO VALLEY EMS AGENCY TREATMENT PROTOCOL MEDICAL EMERGENCY CARDIOVASCULAR REFERENCE NO. C-8 SUBJECT: CHEST PAIN OR SUSPECTED SYMPTOMS OF CARDIAC ORIGIN Patient Destination Determination Pts with a 12-lead ECG computer read out consistent with an acute ST elevation MI (i.e. ***Acute MI Suspected***), shall be transported directly to the closest STEMI receiving center (SRC) if the transport time to that SRC is 45 minutes, and they do not meet any of the critical criteria (indicated below). Prehospital personnel shall contact the closest base/modified base hospital or SRC (as appropriate) for destination consultation on any STEMI pt outside the SRC 45 minute transport catchment area, pts meeting critical criteria (indicated below), or for any suspected STEMI pt without 12-lead ECG computer confirmation. STEMI Confirmed by 12-lead ECG? NO STEMI Suspected? NO Transport to most accessible facility YES YES 45 min to SRC YES Transmit 12-lead ECG to closest SRC if transmission capabilities available Contact closest SRC for destination consultation NO Critical Criteria Cardiac Arrest? Unmanageable Airway? Unstable V-Tach? 2 0 type II or 3 0 Heart Block? YES Contact closest base/modified base hospital for destination consultation NO 45 min to SRC NO YES Transport to SRC Transmit 12-lead ECG to SRC if transmission capabilities available Contact SRC & advise of a STEMI ALERT Page 2 127

138 SUBJECT: AIRWAY OBSTRUCTION SIERRA SACRAMENTO VALLEY EMS AGENCY TREATMENT PROTOCOL MEDICAL EMERGENCY RESPIRATORY REFERENCE NO. R-1 Signs of severe obstruction: Poor air exchange Increased breathing difficulty Silent cough Cyanosis Inability to speak/breathe BLS ABC s High flow O 2 Be prepared to support ventilation with appropriate airway adjuncts YES Signs of severe obstruction? Foreign Body (FB) Consider Causes & Immediate Transport Infection Anaphylaxis NO O 2 at appropriate rate if needed Suction as needed to control secretions ALS Abdominal thrust If patient becomes unresponsive: begin CPR Check mouth for foreign body No blind finger sweep ALS Direct laryngoscopy Remove foreign body with Magill forceps Consider Needle Cricothyrotomy If unable to ventilate by appropriate airway maneuvers If soft tissue of neck begins to balloon, remove catheter Establish vascular access at appropriate time during treatment (may bolus up to 1000 ml NS) Position of comfort Consider humidified O2 Assist ventilation with BVM Avoid visualization Avoid OPA ALS For inadequate ventilation consider: Nebulized epinephrine 1:1,000 5 ml (HHN, mask or BVM) Advanced airway Monitor & Reassess Go to Allergic Reaction/ Anaphylaxis Protocol M-1 Cardiac monitor Establish vascular access at appropriate time during treatment (may bolus up to 1000 ml NS) Monitor & Reassess Needle Cricothyrotomy Indications: Extensive orofacial injuries that make orotracheal intubation impossible Complete airway obstruction with inability to remove FB by other methods Contraindications: Age < 3 yrs or estimated weight < 15 kg Conscious patient Moving ambulance Patient has midline neck hematoma or massive subcutaneous emphysema Page 1 Effective Date: 06/01/2015 Date last Reviewed/Revised: 04/2015 Next Review Date: 04/2018 Approved by: SIGNATURE ON FILE S-SV EMS Medical Director 128 SIGNATURE ON FILE S-SV EMS Regional Executive Director

139 Sierra Sacramento Valley EMS Agency Treatment Protocol Respiratory Arrest Effective: 12/01/2016 Next Review: 07/2019 R-2 Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE BLS Reposition airway (head tilt/chin-lift or jaw thrust) Assess V/S including SpO2 at appropriate time Spontaneous respirations? YES High flow 0 2 Assist ventilations as needed Assess for and treat causes Monitor & reassess NO Ventilate with high flow 0 2 & appropriate airway adjuncts, consider advanced airway ALS Cardiac monitor Establish vascular access at appropriate time (may bolus up to 1000 ml NS) Suspected narcotic overdose? NO YES Naloxone 1 2 mg slow IV/IO May give IM/IN if no IV/IO or SBP >90 May repeat dose every 2 3 minutes x 2 (3 total) if improvement inadequate Use only if RR <12 or respiratory efforts are inadequate Do not administer if advanced airway in place & pt is being adequately ventilated Check blood glucose NO Adequate response? Dextrose 50% 50ml (25gm) IV/IO If no IV/IO or delay anticipated: Glucagon 1 unit (1 mg) IM/IN YES 60 mg/dl? NO YES Monitor & reassess 129

140 Sierra Sacramento Valley EMS Agency Treatment Protocol Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director Acute Respiratory Distress Continuous Positive Airway Pressure (CPAP) BLS Effective: 12/01/2017 Next Review: 09/2020 Indications: - CHF with pulmonary edema - Moderate to severe resp. distress - Near drowning Contraindications: - < 8 years of age - Respiratory or cardiac arrest - Severe decreased LOC - Agonal respirations - Inability to maintain airway - Suspected pneumothorax - SBP < 90 - Major trauma, especially head injury or significant chest trauma Complications: - Hypotension - Pneumothorax - Corneal drying EMT Epinephrine Auto-Injector Administration Criteria (epinephrine auto-injector optional skills providers only) Candidates for administration of auto-injector epinephrine by authorized EMT personnel are patients with suspected asthma, in severe distress (auto-injector epinephrine for asthma is not authorized for PSFA or EMR personnel) Epinephrine should be used cautiously in patients > 35 years old, or with a history of CAD or HTN R-3 Assess respiratory status, administer high flow O 2, manage airway & assist ventilation as appropriate Assess V/S, including SpO 2 Consider CPAP, when appropriate, for moderate to severe distress Assess history and physical, determine degree of illness fever, sputum production, medications, asthma, COPD, CHF, exposures, hypertension, tachycardia, JVD, edema Epinephrine auto-injector provider? NO YES Suspected asthma in severe distress? NO Monitor & reassess YES See page 2 for ALS treatment Epinephrine Adult (> 30 kg) Auto-injector 0.3 mg (0.3 ml) inject deep IM into lateral thigh, midway between waist and knee 130

141 Sierra Sacramento Valley EMS Agency Treatment Protocol Acute Respiratory Distress R-3 Asthma/COPD ALS Mild Distress Mild wheezing Mild shortness of breath Cough Moderate to Severe Distress Cyanosis Accessory muscle use Inability to speak > 3 words Severe wheezing/shortness of breath Decreased or absent air movement Cardiac monitor Consider IV NS (may bolus up to 1000 ml) Cardiac monitor IV/IO NS (may bolus up to 1000 ml) Albuterol 5 mg and Ipratropium 500 mcg Nebulizer May repeat (albuterol 5 mg only) if respiratory distress continues Albuterol 5 mg and Ipratropium 500 mcg Nebulizer/CPAP/BVM May repeat (albuterol 5 mg only) if respiratory distress continues History of asthma with severe distress only Epinephrine 1:1, mg/kg IM (max dose = 0.5 mg) CHF/Pulmonary Edema ALS Mild Signs & Symptoms Moderate to Severe Signs & Symptoms Cardiac monitor IV NS TKO Cardiac monitor Assess BP x 2 to confirm accuracy IV/IO NS TKO *Nitroglycerin 0.4 mg SL May repeat every 5 minutes *Nitroglycerin Notes/Precautions Do not administer if SBP < 100 Do not delay due to difficult vascular access Consult with base/modified base hospital prior to administration for pts taking erectile dysfunction or pulmonary HTN medication *Nitroglycerin titrate dose based on SBP SBP : 0.4 mg SL SBP : 0.8 mg SL SBP > 200: 1.2 mg SL May repeat titrated doses every 5 minutes based on repeat BP 131

142 Sierra Sacramento Valley EMS Agency Treatment Protocol M-1 Allergic Reaction/Anaphylaxis Approval: Troy M. Falck, MD Medical Director Effective: 12/01/2017 Approval: Victoria Pinette Executive Director Next Review: 07/2020 Allergic reaction: Sensitivity to an allergen causing hives, pruritus, flushing, rash, nasal congestion, watery eyes, and/or angioedema not involving the airway High-risk allergic reaction: Allergic reaction with a history of anaphylaxis, or significant exposure with worsening symptoms Anaphylaxis: Severe allergic reaction with 1 or more of the following: respiratory distress, bronchospasm/wheezes/ diminished breath sounds, hoarseness, stridor, edema involving the airway, hypotension (SBP < 90) In extremis: Anaphylaxis with 1 or more of the following: airway compromise, altered mental status, SBP < 70 Epinephrine Auto-Injector Administration Criteria (approved epinephrine auto-injector optional skills providers) Candidates for the administration of auto-injector epinephrine by authorized PSFA, EMR, or EMT personnel are patients in severe distress, who have one or more of the anaphylaxis symptoms listed above Epinephrine should be used cautiously in patients > 35 years old, or with a history of CAD or HTN BLS Assess respiratory status, manage airway and assist ventilations as appropriate Remove antigen source O 2 at appropriate rate Assess V/S, including SpO 2 May assist patient with administration of prescribed EpiPen if necessary Epinephrine auto-injector provider? NO YES Criteria met for epinephrine admin? NO Monitor & reassess YES See page 2 for ALS treatment Epinephrine Adult (> 30 kg) Auto-injector 0.3 mg (0.3 ml) inject deep IM into lateral thigh, midway between waist and knee 132

143 Sierra Sacramento Valley EMS Agency Treatment Protocol Allergic Reaction/Anaphylaxis M-1 ALS Cardiac monitor Advanced airway as needed for severe distress Allergic Reaction Anaphylaxis Diphenhydramine 50 mg PO, IM, or IV Epinephrine 1:1, mg/kg IM (max 0.5 mg) May repeat in 20 min if symptoms persist NO High-risk? IV/IO NS Bolus 1000 ml Titrate to SBP > 90 (max 2000 ml) YES Diphenhydramine 50 mg IV/IO or IM Epinephrine 1:1, mg/kg IM (max 0.5 mg) IV NS TKO May bolus up to 1000 ml For Wheezing/Bronchospasm Albuterol 5 mg & Ipratropium 500 mcg Nebulizer or BVM May repeat (Albuterol 5 mg only) for continued respiratory distress Monitor & reassess NO In extremis? YES Patients On Beta Blocker Medications If inadequate response to epinephrine: Glucagon 1 mg slow IV/IO - may administer IM if no IV/IO or delay anticipated Epinephrine 1:10, mg slow IV/IO over 2 3 minutes May administer via ET if no IV/IO access Repeat every 3 5 minutes if continued airway compromise, altered mental status, or SBP < 70 Discontinue if patient experiences chest pain or life threatening dysrhythmias Max total dose = 0.5 mg For Persistent Hypotension (SBP < 70) Dopamine 10 µg/kg/min 133

144 Sierra Sacramento Valley EMS Agency Treatment Protocol Shock: Non-Traumatic Hypovolemia Effective: 12/01/2016 Next Review: 06/2019 M-2 Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE Shock includes two (2) or more of the following signs/symptoms: - Pale, cool and/or diaphoretic skin signs - Altered mental status - SBP < 90 Initiate early transport and treatment enroute BLS High flow O 2 Assess V/S including SpO2 ALS Cardiac monitor Consider advanced airway if GCS 8 Contact base/modified base for consultation if suspected cardiogenic, distributive, obstructive, or neurogenic shock IV/IO NS If signs/symptoms of blood loss, hypoperfusion, or SBP < 90: administer up to 1000 ml NS bolus, titrate to SBP > 90 If SBP < 70: administer up to 2000 ml NS bolus, titrate to SBP > 90 Monitor & reassess 134

145 SIERRA SACRAMENTO VALLEY EMS AGENCY TREATMENT PROTOCOL MEDICAL EMERGENCY SUBJECT: PHENOTHIAZINE/DYSTONIC REACTION Assessment: - History includes possible ingestion of phenothiazine - Symptoms often mistaken for a seizure disorder or tetany MEDICAL REFERENCE NO. M-3 Signs and Symptoms - Facial grimaces - Anxiety/restlessness - Protruding tongue/jaw muscle spasm - Torticollis (twisting of the neck) - Oculogyric crisis (circular movement of the eyeballs) - Spasms of the back muscles, causing the head and legs to bend backward and the trunk to arch up BLS ABC s Reassure patient, get medication history and collect home meds ALS Consider establishing vascular access Diphenhydramine 50mg IM or IV/IO Monitor and reassess Page 1 Effective Date: 12/01/2015 Date last Reviewed/Revised: 06/2015 Next Review Date: 06/2018 Approved by: SIGNATURE ON FILE S-SV EMS Medical Director 135 SIGNATURE ON FILE S-SV EMS Regional Executive Director

146 Sierra Sacramento Valley EMS Agency Treatment Protocol Ingestions And Overdoses Effective: 12/01/2016 Next Review: 07/2019 M-5 Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE Poison Control Contact Information: or BLS O 2 at appropriate flow rate, manage airway and assist ventilations as necessary Assess V/S including SpO2 Identify substance and time of ingestion: bring sample in original container if safe/possible ALS Cardiac monitor Check blood glucose Establish vascular access at appropriate time (may bolus up to 1000 ml NS) Blood glucose 60 mg/dl? YES NO Hx & clinical picture fits hypoglycemia? NO YES Dextrose 50% 50 ml (25gm) IV/IO If no IV/IO or delay anticipated: Glucagon 1 mg (1 unit) IM/IN Note: If suspected insulin or oral diabetic agent OD, consider need for additional dextrose or glucagon Treat according to specific therapy listed on page 2 BASE/MODIFIED BASE PHYSICIAN ORDER ONLY Activated Charcoal 50gm PO Only give if patient is awake Contraindications - Acids/alkalais - Foreign body ingestions - Corrosives - Prior administration of ipecac 136

147 Sierra Sacramento Valley EMS Agency Treatment Protocol Ingestions And Overdoses M-5 Specific Therapy: Ingestions and Overdoses Narcotics Naloxone 1 2 mg slow IV/IO May give IM/IN if no IV/IO or SBP >90 May repeat dose every 2 3 minutes x 2 (3 total) if improvement inadequate Use only if RR <12 or resp. efforts are inadequate Do not administer if advanced airway in place & pt is being adequately ventilated Tricyclic Antidepressants Sodium Bicarbonate 1mEq/kg IV/IO If any of the following are present: SBP < 90 QRS > 0.12 seconds (3 small boxes) Seizures Beta Blockers Up to 1000 ml NS bolus if SBP < 90 Atropine 1 mg IV/IO Only if HR < 50 and SBP < 90 after NS bolus May repeat every 5 minutes (3 mg max total) Glucagon 1 mg (1 unit) IV/IO Only if HR < 50 and SBP < 90 systolic If no IV/IO or delay anticipated, may administer 1 mg IM/IN Organophosphate Or Carbamate Atropine 2 mg IV/IO Only if HR < 60 May repeat every 3 minutes no max dose If exposed externally: Reference Haz Mat Protocol E-7 Epinephrine 1:10, mg slow IV/IO Only if SBP < 70 May repeat every 3 minutes until SBP > 90 Calcium Channel Blockers Up to 1000 ml NS bolus if SBP < 90 Calcium Chloride 10% 10ml slow IV/IO Only if SBP < 90 Administer no faster than 1ml/minute May repeat every 5 minutes (maximum: 4 total doses) Hydrofluoric Acid Oral ingestions require immediate treatment as hydrofluoric acid (HF) can cause fatal hypocalcemia Early signs of hypocalcemia include: - Tingling sensation around mouth, lips, hands or feet - Hand or foot spasms - QT interval prolongation Calcium Chloride 10% 10ml slow IV/IO Only if signs of hypocalcemia Administer no faster than 1ml/minute If exposed externally: Reference Haz Mat Protocol E-7 137

148 SIERRA-SACRAMENTO VALLEY EMS AGENCY PROGRAM POLICY REFERENCE NO. M-5-A SUBJECT: GUIDELINES FOR EMS USE OF ACTIVATED CHARCOAL PURPOSE: This addendum is intended for the use of the base/modified base hospital in guiding the field use of activated charcoal. Activated charcoal is an agent used for gastric decontamination following overdose ingestion. Its use is somewhat controversial as there is evidence to suggest its ability to absorb toxic agents, but there is little research supporting improvement in clinical outcomes after its administration. Previous clinical research only supports its use when given early after ingestion. Therefore, while activated charcoal may be helpful when given rapidly after an overdose, it is very important to avoid administration in cases where potential contraindications exist. INDICATIONS: A. Early administration within 1 hour of ingestion (agent still in stomach) B. Potentially deadly agent C. No effective antidote D. No contraindications E. Suggested agents where EMS administration of activated charcoal is appropriate: 1. Calcium channel blockers 2. Beta blockers 3. Antidepressants 4. Anticonvulsants 5. Digoxin CONTRAINDICATIONS: A. > 2 hours since ingestion B. Obtunded/altered level of consciousness (aspiration risk) C. Known caustic ingestion (acid or alkali) D. Known hydrocarbon ingestion E. Suspected GI obstruction (vomiting) RELATIVE CONTRAINDICATION: Agent(s) not well absorbed by activated charcoal (examples: lithium, iron, toxic alcohols) Effective Date: 06/01/2015 Date last Reviewed/Revised: 02/2015 Next Review Date: 02/2018 Approved: SIGNATURE ON FILE S-SV EMS Medical Director 138 SIGNATURE ON FILE S-SV EMS Regional Executive Director

149 SIERRA SACRAMENTO VALLEY EMS AGENCY TREATMENT PROTOCOL MEDICAL EMERGENCY SUBJECT: GENERAL MEDICAL TREATMENT Consider the following: Trauma GI Bleeding Abdominal Pain Syncope/Near Syncope Recently Altered BLS MEDICAL REFERENCE NO. M-6 Consider the possibility of sepsis when a combination of the following markers of the Systemic Inflammatory Response Syndrome (SIRS) are present in a patient with suspected infection: Temperature > F or < F RR > 20 HR > 90 ETCO2 25 mm Hg Assess ABC s Consider O 2 at appropriate rate Assess V/S including temp if available Assess history & physical Determine degree of illness ALS Cardiac monitor consider 12-lead Consider establishing vascular access (may bolus up to 1000 ml NS) Consider blood glucose check Blood glucose 60 mg/dl? NO YES Dextrose 50% 50ml (25gm) IV/IO If no IV/IO or delay anticipated: Glucagon 1 unit (1 mg) IM/IN OR Oral Glucose Pre-packaged glucose solution/gel or 2 3 tablespoons of sugar in water/juice ONLY if patient is conscious and able to swallow Hx & clinical picture fits hypoglycemia? YES NO Monitor & reassess Provide early hospital notification for suspected sepsis/sirs patients Page 1 Effective Date: 12/01/2015 Date last Reviewed/Revised: 10/2015 Next Review Date: 10/2018 Approved by: SIGNATURE ON FILE S-SV EMS Medical Director 139 SIGNATURE ON FILE S-SV EMS Regional Executive Director

150 SIERRA SACRAMENTO VALLEY EMS AGENCY TREATMENT PROTOCOL MEDICAL EMERGENCY SUBJECT: NAUSEA/VOMITING (FROM ANY CAUSE) MEDICAL REFERENCE NO. M-7 Nausea and vomiting can be symptoms of a multitude of different causes. If possible, the specific underlying cause should be determined and treated. Providers should realize that the use of an antiemetic may relieve symptoms while leaving the cause untreated, and possibly, more difficult to detect. Providers should weigh the benefits of antiemetic use against the possible risk of making an accurate diagnosis more difficult, and the possible side effects of the antiemetic agent. Treatment of nausea and vomiting is warranted for patients where it may contribute to a worsening of the patient s condition, or where the patient s airway may be endangered. Providers may consider giving Zofran (Ondansetron) prophylactically, prior to or immediately after opioid administration, for a patient with a history of nausea/vomiting secondary to opioid administration. Zofran (Ondansetron) may also be administered prior to transport to a patient with a history of motion sickness. BLS Assess and support ABC s as needed O 2 at appropriate rate if needed Assess and treat as appropriate for underlying cause ALS Cardiac Monitor Consider establishing vascular access (may bolus up to 1000 ml) Check blood glucose if hypoglycemia or hyperglycemia suspected Zofran (Ondansetron) 4 8 mg ODT (Oral Disintegrating Tablet) OR 4 8 mg IM OR 4 8 mg slow IV/IO (over 30 seconds) May repeat as needed to a maximum total dose of 16 mg Base/modified base hospital contact/consultation required prior to administration of Zofran (Ondansetron) to patients during the first 8 weeks of pregnancy Monitor and reassess Page 1 Effective Date: 08/01/2015 Date last Reviewed/Revised: 06/2015 Next Review Date: 06/2018 Approved by: SIGNATURE ON FILE S-SV EMS Medical Director 140 SIGNATURE ON FILE S-SV EMS Regional Executive Director

151 Sierra Sacramento Valley EMS Agency Treatment Protocol Pain Management Effective: 06/01/2016 Next Review: 04/2019 M-8 Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE BLS Assess V/S including SpO2 O 2 at appropriate flow rate, titrate to SpO2 94% Assess/document initial pain score, and reassess/document pain score after each pain management intervention Utilize non-pharmacological pain management as appropriate (psychological coaching, ice packs, immobilization/splinting, etc.) Other Causes of Pain Non-acute injuries Back pain, abdominal pain Sickle cell crisis, cancer, etc. Contact base/modified base hospital for pain management consultation Pain From Acute Injuries Isolated extremity injuries Multi-system trauma Burns Frostbite Bites/envenomations Pain/Discomfort of Suspected Cardiac Origin Go to Protocol C-8 Communication Failure? YES Are all of the following present? Significant pain RR >12 SBP >100 GCS 15 or baseline mental status & no head injury YES ALS NO IV/IO NS TKO (may bolus up to 1000 ml) Cardiac monitor Follow base/modified base hospital orders for pain management * Pain Management Notes/Requirements NO Continuous cardiac and SpO2 monitoring required for all patients receiving pain medication. Titrate medication to a tolerable pain level. Use caution when administering both opioids and midazolam to patients. Max total opioid dose = 20 mg morphine equivalent (20 mg morphine, 200 mcg fentanyl, or a combination of the two). Max total midazolam dose = 4 mg. Each medication dose and patient response (including pain score) must be documented on the PCR. Morphine Sulfate* (every 5 min.) 2 10 mg slow IV/IO, or 2 10 mg IM/SQ OR Fentanyl* (every 5 min.) mcg slow IV/IO, or mcg IM/SQ, or 1.5 mcg/kg IN (max single dose = 100 mcg) Acute Isolated Extremity Injuries Only Midazolam* (every 5 min.) - if necessary 1 2 mg slow IV/IO only 141

152 Sierra Sacramento Valley EMS Agency Treatment Protocol CO Exposure/Poisoning Effective: 06/01/2016 Next Review: 04/2019 M-9 Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE Initial symptoms of CO exposure are insidious, similar to the flu and thus seemingly benign. These symptoms increase in severity as the SpCO level rises and may include one or more of the following: - Confusion - Dizziness/vertigo - Headache - Shortness of breath - Nausea/vomiting - Fatigue - Syncope - Confusion - Tachycardia - Cardiac arrhythmias - Seizures - Shock - Coma - Apnea BLS Remove patient from CO exposure source Assess V/S including SpO2 O 2 at appropriate flow rate, 100% if CO poisoning suspected ALS Measure SpCO with CO-Oximeter device (if available) Cardiac Monitor SpCO 0 3% SpCO 3 12 % SpCO > 12 % Considered a normal reading Treat according to appropriate protocol based on presentation Symptoms of CO exposure? YES 100% 0 2 Treat according to appropriate protocol based on presentation Rapid transport to closest facility NO No further SpCO evaluation needed Treat according to appropriate protocol based on presentation Monitor and reassess 142

153 Sierra Sacramento Valley EMS Agency Treatment Protocol Altered Level Of Consciousness Effective: 12/01/2016 Next Review: 07/2019 N-1 Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE BLS High flow O 2, manage airway and assist ventilations as necessary Assess V/S including SpO2 ALS Consider advanced airway if GCS 8 Cardiac monitor Establish vascular access at appropriate time (may bolus up to 1000 ml) Suspected narcotic overdose? NO YES Naloxone 1 2 mg slow IV/IO May give IM/IN if no IV/IO or SBP >90 May repeat dose every 2 3 minutes x 2 (3 total) if improvement inadequate Use only if RR <12 or respiratory efforts are inadequate Do not administer if advanced airway in place & pt is being adequately ventilated Dextrose 50% 50ml (25gm) IV/IO If no IV/IO or delay anticipated: Check blood glucose NO Adequate response? Glucagon 1 unit (1 mg) IM/IN OR YES 60 mg/dl? Oral Glucose Pre-packaged glucose solution/ gel or 2 3 tablespoons of sugar in water/juice ONLY if patient is conscious and able to swallow NO YES YES Hx & clinical picture fits hypoglycemia? NO Monitor & reassess 143

154 Sierra Sacramento Valley EMS Agency Treatment Protocol N-2 Seizure Approval: Troy M. Falck, MD Medical Director Effective: 12/01/2017 Approval: Victoria Pinette Executive Director Next Review: 07/2020 Status Epilepticus: 2 or more seizures without periods of consciousness, or a single seizure lasting > 5 minutes Transport patients > 20 weeks pregnant in left-lateral position BLS Assess and support ABC s; assess V/S, including SpO 2 High flow O 2 - manage airway and assist ventilations as appropriate ALS Cardiac monitor Establish vascular access at appropriate time (may bolus up to 1000 ml NS) NO Status Epilepticus? YES Midazolam 10 mg IM/IN if vascular access is not already established OR 5 mg IV/IO if vascular access is already established May repeat same dose x 1 after 5 minutes of continued seizure activity Check blood glucose (BG) BG < 60 mg/dl? YES Dextrose 50% 50 ml (25 gm) IV/IO OR Glucagon (if no IV/IO) 1 mg IM/IN NO Monitor & reassess 144

155 Sierra Sacramento Valley EMS Agency Treatment Protocol Suspected Stroke Effective: 12/01/2016 Next Review: 07/2019 N-3 Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE BLS Cincinnati Prehospital Stroke Scale (CPSS) Interpretation: If any 1 of these 3 signs is abnormal, the probability of a stroke is 72% O 2 at appropriate flow rate if dyspneic, signs of heart failure or shock, or SpO2 94% Perform CPSS assessment Suspect stroke for either of the following: New onset symptoms with abnormal CPSS Unexplained new ALOC without response to glucose, glucagon, or naloxone If stroke suspected: Determine time of symptom onset or when patient last seen normal Transport as soon as possible on scene procedures should be limited to critical interventions only ALS Consider advanced airway if GCS 8 Cardiac monitor, consider 12-lead ECG Check blood glucose Obtain blood draw if requested by stroke receiving center IV/IO NS TKO (may bolus up to 1000 ml) Stroke symptoms 4 hours? YES 30 min transport to a stroke receiving center YES Transport to closest stroke receiving center and advise of a Stroke Alert Provide minimum necessary patient identifying information (name, DOB, MR#, etc.) if requested by the stroke receiving center NO NO Transport to closest/most appropriate hospital Contact closest base/modified base hospital for destination consultation if necessary 145

156 SUBJECT: CHILDBIRTH SIERRA SACRAMENTO VALLEY EMS AGENCY TREATMENT PROTOCOL MEDICAL EMERGENCY ABC s Estimate blood loss O 2 at appropriate rate Consider establishing vascular access at appropriate time during treatment (may bolus up to 1000 ml) OBSTETRIC/GYN REFERENCE NO. OB/G-1 Presenting Part Prolapsed Cord Head Breech or Footling Rapid transport & early hospital contact Protect Cord Place mother in knee-chest position Insert gloved hand into vagina & gently push presenting part off the cord Cover the cord with wet saline dressing Allow delivery Dry/provide warmth Assure open airway Evaluate for meconium and clear airway if required Refer to Neonatal Resuscitation Protocol P-2 if necessary APGAR at 1 minute Clamp & Cut Cord Delay clamping of the umbilical cord for 2 minutes for uncomplicated births not requiring resuscitation Double clamp cord, cut with sterile scissors between clamps, 6" from baby Rapid transport & early hospital contact Avoid compression of cord by presenting part Allow delivery to progress passively until baby s waist appears Rotate baby to face down position (do not pull) If head does not deliver in 3 minutes, insert gloved hand into vagina to create an air passage for infant As mother bears down, sweep the head out of the vagina APGAR at 5 minutes Transport Do not wait for placenta After delivery of placenta, gently massage fundus until firm A P G A R Sign/Score Appearance Pulse Rate Grimace Activity Respiration 0 Blue/Pale None None Limp Absent 1 Peripheral cyanosis <100 Grimace Some motion Slow/irregular Pink >100 Cries Active 2 Good/strong cry Page 1 Effective Date: 12/01/2015 Date last Reviewed/Revised: 06/2015 Next Review Date: 06/2018 Approved by: SIGNATURE ON FILE S-SV EMS Medical Director 146 SIGNATURE ON FILE S-SV EMS Regional Executive Director

157 Sierra Sacramento Valley EMS Agency Treatment Protocol Hyperthermia Effective: 12/01/2016 Next Review: 06/2019 E-1 Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE BLS If patient is in extremis, begin treatment prior to secondary survey Immediate rapid transport should be considered for patients in extremis Assess V/S including temperature if thermometer available Move patient to a cool environment, remove excess clothing, begin cooling measures O 2 at appropriate flow rate HEAT CRAMPS Alert Temperature usually normal Sweaty, may be warm or cool to touch Neuro exam is normal except for muscle cramps (usually legs) HEAT EXHAUSTION Temperature normal slightly elevated Sweaty, usually hot to touch Neuro exam: no loss of control of extremities, but feels very weak, with normal neuro function Patient typically feels sick with flu like symptoms HEAT STROKE Altered mental status Core temperature usually 104 Skin usually flushed, hot; may or may not be moist if exercise induced May have persistent seizures Give cool/cold fluids slowly by mouth Rest cramping muscles Monitor and reassess ALS Cardiac monitor IV/IO NS: 1000 ml fluid bolus Give cool/cold fluids slowly by mouth Monitor and reassess ALS Aggressive cooling Cold packs on neck, axilla and inguinal areas; fanning and misting if possible, undress patient, cover with sheet and wet thoroughly Cardiac monitor IV/IO NS: 1000 ml NS bolus - reassess and repeat if indicated for hypotension, SBP < 90, or signs of poor perfusion Continue cooling measures during transport Monitor and reassess 147

158 Sierra Sacramento Valley EMS Agency Treatment Protocol Hypothermia Effective: 12/01/2016 Next Review: 06/2019 E-2 Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE BLS Manage airway and assist ventilations as necessary: 4 6 breaths per minute may be adequate Assess V/S including temperature if thermometer is available: assess pulse for 60 seconds or greater if necessary O 2 at appropriate flow rate: humidified and warmed if possible Move patient to a warm environment exercising extreme care & gentleness (minimize physical movement of the patient): remove wet clothing and cover patient with warmed blankets &/or clothing ALS Cardiac monitor Pulseless v-tach or v-fib? YES Start CPR defibrillate Manual biphasic: 200 J or manufacturer s recommended dose Manual monophasic: 360 J AED: Device specific Resume CPR immediately NO IV/IO NS: 1000 ml NS bolus (warm fluid if available) Check blood glucose Blood glucose 60 mg/dl? YES Dextrose 50% 50 ml (25gm) IV/IO If no IV/IO or delay anticipated: Glucagon 1 unit (1 mg) IM/IN NO Monitor & reassess 148

159 Sierra Sacramento Valley EMS Agency Treatment Protocol Frostbite Effective: 06/01/2016 Next Review: 04/2019 E-3 Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE BLS ABC s Assess V/S O 2 at appropriate flow rate Remove wet clothing Elevate extremity Wrap affected area in dry, sterile gauze Separate affected digits ALS Consider IV/IO NS TKO - if experiencing pain with anticipated need for IV/IO analgesia Pain management necessary? YES Go to Pain Management Protocol (M-8) or (P-34) NO Monitor & reassess 149

160 Sierra Sacramento Valley EMS Agency Treatment Protocol Bites and Envenomations Effective: 06/01/2016 Next Review: 04/2019 E-4 Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE Important Caveats For Medical Responders Ensure the scene is safe. Attempt to determine and differentiate what animal/reptile/insect/etc. the bite or sting is from, however, DO NOT attempt to catch or transport the live animal/reptile/insect/etc. with the patient. A digital photograph is preferred for identification purposes if safe to do so. However, if the animal/reptile/insect/etc. is dead, prehospital personnel may consider bringing it in with the patient for positive identification in a closed solid container. Avoid the head and fangs on pit vipers as they are capable of envenomation even when dead. Black Widow spider bites cause diaphoresis, severe cramping and pain. Most cramping from Black Widow bites occurs in the abdomen, groin, back and legs. Bites from Brown Recluse, Hobo Spiders and others in the sicariidae family, may cause a painless bite with tissue necrosis and clotting disorders developing over several days with little to no immediate symptoms. There are NO Brown Recluse Spiders native to California and they are very rare, usually brought or transported from another state. There is NO current antivenom for this class of spider. Stings from Scorpions may cause pain and red welt at the sting site(s) as well as uncontrolled muscle jerking, pain, eye twitching, hypotension and increased salivation especially in those with significant health history and/or of extremes of age. Bites from Centipedes may cause pain, minor bleeding and red welt at the sting site(s). General first aid is usually all that is needed. Stings from Bees, Wasps and Ants may cause pain, very minor bleeding and red welt at the sting site(s). General first aid is usually all that is needed, however, there is a risk for anaphylaxis, especially in patients with history of reaction or who have received multiple stings. Bites from Pit Vipers and others in the crotalinae family are hemotoxic and cytotoxic and may cause pain, localized tissue destruction and edema. Oral parasthesia or metallic taste in the mouth may represent systemic toxicity. Hypotension may be due to fluid loss as a result of edema and usually resolves with antivenom. However, it may be due to the venom itself if no significant edema is noted. Contact base/modified base hospital for medical consultation if this occurs Bites from Coral Snakes and others in the elapid family, are neurotoxic and lack the impressive signs of envenomation of Pit Vipers, but may cause neuromuscular weakness and rapid respiratory depression and failure. Venomous bites and mammal bites to face, tongue, mouth and neck or direct stings to the tongue and mouth are imminent airway emergencies and will need to be addressed early. BLS Assess ABC s, manage airway and assist ventilations as appropriate O 2 at appropriate flow rate Assess V/S including pulse oximetry Immediate rapid transport should occur for venomous snake bites and/or anaphylaxis related to bites/stings with treatment performed enroute For Specific Treatment See Pages 2 & 3 150

161 Sierra Sacramento Valley EMS Agency Treatment Protocol Bites and Envenomations E-4 Snakebite, Spider/Centipede Bite, Bee/Wasp/Scorpion/Ant Stings BLS Spider/Centipede Bite or Bee/Wasp/Scorpion/Ant Stings Snakebite - Venomous Loosely immobilize or splint injury (if in extremity) in position of comfort at or above heart level Clean wound site and control bleeding Apply ice for pain control as needed Remove any constrictive clothing/jewelry/bands Monitor for signs of anaphylaxis While very rare, severe reactions to Black Widow bites and some Scorpion stings may require antivenom, especially in patients with significant health history and/or in the extremes of age If patient shows potential need for antivenom, contact base/modified base hospital ASAP ALS Cardiac monitor Advanced airway if necessary Consider IV/IO NS TKO: may bolus up to 1000 ml for adults, or 20 ml/kg for pediatrics Loosely immobilize or splint injury (if in extremity) in position of comfort at or above the heart level Remove any constrictive clothing /jewelry/bands Clean wound site and control bleeding DO NOT start IV/IO lines or apply B/P cuff to bitten extremity DO NOT cut or slice wound or use suction on wound to remove venom DO NOT apply ice DO NOT apply tourniquets or lymphatic constriction wraps/banding Document the time of the bite Monitor for signs of anaphylaxis Mark margin of swelling/redness, including time Pre-alert receiving hospital of probable need for antivenom if moderate to severe bite noted If snake bite was from an exotic pet or zoo animal (e.g. coral, cobra, krait, mojave), neurologic and/or respiratory depression may precede local reaction, observe closely for mental status change, respiratory depression, convulsions or paralysis If exotic species, contact base/modified base hospital ASAP as they may need to consult with physician expert and coordinate with Poison Control for specific antivenom Signs of anaphylaxis? NO Nausea/ vomiting? NO Pain management necessary? NO Monitor & reassess YES YES YES Go to Allergic Reaction/ Anaphylaxis Protocol (M-1) Go to Nausea/ Vomiting Protocol (M-7) or (P-32) Go to Pain Management Protocol (M-8) or (P-34) 151

162 Sierra Sacramento Valley EMS Agency Treatment Protocol Bites and Envenomations E-4 Dog/Cat/Other Mammals/Human Bites BLS Dog/Cat/Other Mammals/ Human Bites Loosely immobilize or splint injury (if in extremity) in position of comfort at or above heart level Clean wound site and control bleeding Apply ice for pain control as needed Concern must be considered for rabies, tetanus and high risk of other infections especially in cat and other carnivore bites. Be concerned of bleeding, infection and wound healing complications in patients with significant health history and/or in the extremes of age. Uncontrolled Hemorrhage? YES Go to Hemorrhage Protocol (T-8) NO Pain management necessary? YES Go to Pain Management Protocol (M-8) or (P-34) NO Monitor & reassess 152

163 Sierra Sacramento Valley EMS Agency Treatment Protocol Hazardous Material Exposure Effective: 12/01/2016 Next Review: 07/2019 E-7 Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE Refer to S-SV EMS Hazardous Material Incidents policy (836) Important caveats for medical responders: EMS personnel shall not enter or provide treatment in the Contamination Reduction Zone (Warm Zone) or Exclusion Zone (Hot Zone) unless specifically trained, equipped and authorized to do so. EMS personnel shall not use Haz Mat specific personal protective equipment (PPE), including self-contained breathing apparatus (SCBA), unless specifically trained, fit tested and authorized to do so. Do not transport patients until they have been completely decontaminated. If transport personnel become contaminated, they shall immediately undergo decontamination. Do not delay the treatment or transportation of immediate patients who are contaminated with radioactive material (page 3). Early base/modified base hospital contact, and CHEMPACK activation when appropriate (S-SV EMS Nerve Agent Treatment Protocol E-8), will maximize assistance from necessary resources. Refer to Hazardous Materials Medical Management Reference as appropriate. Information that must be obtained by EMS personnel on every hazardous materials incident: Number of patients. Material involved or DOT 4-digit placard #. Route(s) of exposure for each patient. Signs & symptoms for each patient. Decontamination procedure completed for each patient. Procedure utilized to determine effectiveness of decontamination procedure. Risk of secondary exposure to rescuers. PPE required to transport patient. See Pages 2 & 3 For Specific Treatment 153

164 Sierra Sacramento Valley EMS Agency Treatment Protocol Hazardous Material Exposure E-7 BLS Establish and secure airway as appropriate/necessary O 2 at appropriate flow rate Contact base/modified base hospital for assistance in determining a decontamination/treatment plan if necessary After patient is fully decontaminated, cover with blankets and/or sheets as appropriate If eye exposure occurs, irrigate each exposed eye with NS ensure contact lenses are removed ALS Cardiac Monitor IV/IO NS TKO in non-burned/non-contaminated extremity (may bolus up to 1000 ml) HYDROFLUORIC ACID (HF) Calcium Chloride 10% 10 ml slow IV/IO May repeat every 5 minutes ORGANOPHOSPHATE OR CARBAMATE Atropine 2 mg IV/IO if HR < 60 May repeat every 3 minutes to HR > 80 No maximum dose For HF burns isolated to the hands, fingers, or toes Calcium Chloride 10% Pour contents of one ampule into a sterile glove and immerse affected area into solution If Calcium Gluconate gel has been applied, do not remove - no further treatment is necessary Refer to Nerve Agent Treatment Protocol (E-8) if additional treatment is necessary Note: Skin exposure to HF with a concentration > 20% can cause fatal hypocalcemia and should be treated. Provide continuous EKG monitoring to look for QT-interval prolongation which is an early sign of hypocalcemia Note: Precautions must be taken to prevent direct contact with secretions of a patient who has ingested organophosphates or carbamate pesticides 154

165 Sierra Sacramento Valley EMS Agency Treatment Protocol Hazardous Material Exposure E-7 RADIATION EMERGENCIES Patient care takes priority over radiological concerns - addressing contamination issues should not delay treatment of life-threatening injuries Viable patients are a high priority - rapidly extricate, treat and transport those patients who are most critical and likely to survive It is highly unlikely that the levels of radioactivity associated with a contaminated patient would pose a significant health risk to care providers Body substance isolation clothing (gloves, gowns, N-95 masks, protective eyewear, shoe protectors, and head cap) are recommended, including 2-3 pair of disposable gloves Due to fetal sensitivity to radiation, assign pregnant staff to other duties If time permits, consider the following: Ambulance Preparation Avoid using internal and external compartments - work out of mobile kits as much as possible Close all internal compartments prior to loading patient Cover radio communication microphones with a rubber glove Cover floor of ambulance with disposable papers or pads Patients If oxygen is warranted, use a non re-breather mask if tolerated to provide protection from inadvertent respiratory contamination hazards An N95 mask is appropriate to protect patient from inadvertent respiratory contamination hazards when oxygen is not indicated Frequent glove changes will reduce the spread of contamination and should be considered prior to handling the patient or patient care adjuncts All medical procedures should be utilized to save an immediate patient - if it is medically necessary to intubate a patient that is contaminated, then do so - change gloves prior to intubation and maintain ET tube sterility if possible Patients with limited or no field decontamination Patients with field decontamination Initiate ALS care as necessary Keep patient wrapped (cocoon style) as much as possible to minimize the potential for contamination spread Only expose areas to assess and treat If necessary, cut and remove the patient's clothing away from the body being careful to avoid contamination to the unexposed skin Properly contain all removed clothing by placing it in a sealable bag Continue to reassess/monitor vitals while transporting patient to the appropriate receiving facility Contact with patient may result in transfer of contamination; change gloves as necessary Patients with non life-threatening injuries should have field decontamination prior to removal from the Exclusion (Hot) Zone Patient's condition permits a more thorough radiological survey prior to continued care Conduct a head to toe assessment as the patient s injuries warrant If patients clothing has not been removed during decontamination procedures, keep patient wrapped (cocoon style) as much as possible Expose patient's injuries for assessing and treating only Contact with patient may result in transfer of contamination; change gloves as necessary 155

166 Sierra Sacramento Valley EMS Agency Treatment Protocol Nerve Agent Treatment Effective: 12/01/2016 Next Review: 07/2019 E-8 Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE Refer to S-SV EMS Hazardous Material Incidents policy (836) Important caveats for medical responders: EMS personnel shall not enter or provide treatment in the Contamination Reduction Zone (Warm Zone) or Exclusion Zone (Hot Zone) unless specifically trained, equipped and authorized to do so. EMS personnel shall not use Haz Mat specific personal protective equipment (PPE), including self-contained breathing apparatus (SCBA), unless specifically trained, fit tested and authorized to do so. Do not transport patients until they have been completely decontaminated. If transport personnel become contaminated, they shall immediately undergo decontamination. Treatment notes: Base/Modified Base Hospital Physician order must be obtained prior to utilizing this protocol for patient treatment. Once an order is obtained, the entire protocol becomes a standing order that applies to all authorized/trained EMS personnel operating at the incident. Atropine (2mg) and pralidoxime chloride (600mg) auto-injectors included in MARK I/DuoDote nerve agent antidote kits shall only be used by authorized/trained EMS personnel. Paramedics may administer atropine and/or pralidoxime chloride IM/IV in situations where autoinjector nerve agent antidote kits are not available. EMS personnel may self-administer nerve agent antidote kits when authorized/trained to do so. Adult auto-injectors are not to be used in children under 40 Kg. Nerve agent antidote medications are only given if the patient is showing signs and symptoms of nerve agent poisoning, they are not to be given prophylactically. A decrease in bronchospasm and respiratory secretions are the best indicators of a positive response to atropine and pralidoxime therapy. Signs/Symptoms of Nerve Agent Exposure (mild to severe) 1. Unexplained runny nose 9. Abdominal cramps 2. Chest tightness 10. Involuntary urination/defecation 3. Difficulty breathing 11. Jerking/twitching/staggering 4. Bronchospasm 12. Headache 5. Pinpoint pupils/blurred vision 13. Drowsiness 6. Drooling 14. Coma 7. Excessive sweating 15. Convulsions 8. Nausea/vomiting 16. Apnea Nerve Agent Exposure Mnemonic (SLUDGEM) Salivation Lacrimation Urination Defication GI distress Emesis Miosis/muscle fasciculation 156

167 Sierra Sacramento Valley EMS Agency Treatment Protocol Nerve Agent Treatment E-8 CHEMPACK Description: As an addition to the Strategic National Stockpile (SNS) Program, the Centers for Disease Control and Prevention (CDC) established the CHEMPACK project resulting in the forward placement of sustainable caches of nerve agent antidotes. CHEMPACK caches have been placed at select sites throughout the S-SV EMS region and surrounding areas. Placements were planned according to program requirements and effective transportation alternatives. EMS CHEMPACK caches contain enough antidote to treat approximately 454 patients. These caches contain primarily auto-injectors for rapid administration, but also have some multi-dose vials for variable dosing and prolonged treatment. Authorization to deploy, break the seal on, or move CHEMPACK assets from their designated location will be limited to an event that: 1. Threatens the medical security of the community; and 2. Places multiple lives at risk; and 3. Is otherwise beyond local emergency response capabilities; and 4. Will likely make the material medically necessary to save human life. CHEMPACK requesting/deployment: A requestor is considered to be one of the following at the scene of a suspected nerve agent or organophosphate release with known, suspected, or potential contaminated, exposed, or affected patients: 1. EMS prehospital personnel; or 2. Incident Commander (IC); or 3. Medical Group Supervisor (MGS). Potential requestors should be familiar with and follow their Operational Area (OA)/county specific CHEMPACK plans and procedures The S-SV EMS Duty Officer and MHOAC Program shall be notified as soon as possible in the event of a CHEMPACK request/deployment. 157

168 Sierra Sacramento Valley EMS Agency Treatment Protocol Nerve Agent Treatment E-8 DuoDote Auto-Injector (Atropine 2.1 mg/0.7ml & Pralidoxime Chloride 600 mg/2ml) may be utilized if MARK I kits (Atropine 2mg & Pralidoxime Chloride 600mg) are not available Patient exposed? NO Monitor & Reassess YES Remove all clothing Blot off the agent Flush area with large amounts of water Cover the affected area Exclusion Zone (Hot Zone) Treat only patients with severe signs/symptoms with IM autoinjectors Contamination Reduction Zone (Warm Zone) Mild to severe signs/symptoms Mild Signs/Symptoms Moderate Signs/Symptoms Severe Signs/Symptoms Atropine 2 mg IV/IO or IM OR Administer one (1) atropine auto-injector IM May repeat every 3-5 mins until symptoms improve Atropine 4 mg IV/IO or IM OR Administer two (2) atropine auto-injectors IM May repeat every 3-5 mins until symptoms improve Atropine 6 mg IV/IO or IM OR Administer three (3) atropine auto-injectors IM May repeat every 3-5 mins until symptoms improve Pralidoxime chloride If symptoms do not improve in 5 mins, administer one (1) Pralidoxime chloride auto injector (600 mg) IM, one (1) time only Pralidoxime chloride If symptoms do not improve in 5 mins, administer two (2) Pralidoxime chloride auto injectors (1200 mg) IM, one (1) time only Pralidoxime (2-PAM) Administer three (3) Pralidoxime chloride autoinjectors (1800 mg) IM Establish vascular access (may administer up to 1000 ml NS if SBP < 90) Cardiac Monitor (if possible) If seizures continue: go to Seizure Protocol N-2 158

169 SIERRA-SACRAMENTO VALLEY EMS AGENCY TREATMENT PROTOCOL MEDICAL EMERGENCY SUBJECT: GENERAL TRAUMA MANAGEMENT TRAUMA REFERENCE NO. T-1 Treatment Protocol: A. Airway: 1. Administer oxygen at high flow rate. 2. Be prepared to support ventilation with appropriate airway adjuncts. 3. If Glasgow Coma Scale is 8, ventilate patient with 100% oxygen and consider advanced airway management. B. Spinal Stabilization: 1. Whether or not a backboard is used, attention to spinal precautions among atrisk patients is paramount. These include application of a cervical collar, adequate security to a stretcher, minimal movement/transfers, and maintenance of in-line stabilization during any necessary movement/transfers. 2. This policy is not intended to authorize removal of spinal stabilization once in place. 3. Patients with penetrating trauma to the head, neck or torso and no evidence of spinal injury should not be stabilized on a backboard. 4. Spinal stabilization with a backboard should be implemented for any patient with a history of trauma, or found in the setting of trauma, who meets any of the following criteria: a. Midline spinal pain or tenderness. b. Limited cervical spine active range of motion. c. Gross motor/sensory deficits or complaints. d. High energy impact blunt trauma patients meeting anatomic and/or physiologic trauma triage criteria. Effective Date: 06/01/2015 Date Last Reviewed/Revised: 04/2015 Next Review Date: 04/2018 Approved: SIGNATURE ON FILE SIGNATURE ON FILE S-SV EMS Medical Director S-SV EMS Regional Executive Director 159

170 REFERENCE NO. T-1 SUBJECT: GENERAL TRAUMA MANAGEMENT 5. Spinal stabilization, with or without a backboard, should be considered for any patient with a history of trauma, or found in the setting of trauma, who is determined to have an unreliable history & physical, including but not limited to the following circumstances: a. Altered mental status (i.e. dementia or delirium). b. Intoxicated (drugs or alcohol). c. Injury detracting from or preventing reliable history and exam. d. Language barrier preventing reliable history or exam. e. Extremes of age < 5 or > 65 years old 6. Initiation of spinal stabilization is not necessary for patients who do not meet any of the criteria listed in items 4 and 5 above. 7. Helmet Removal: a. Football helmets should be removed in the field only under the following circumstances (note: if the helmet is removed, the shoulder pads should also be removed and/or the head should be supported to maintain neutral stabilization): If the helmet and chin strap fail to hold the head securely. If the helmet and chin strap design prevent adequate airway control, even after facemask removal. If the facemask cannot be removed. If the helmet prevents adequate proper stabilization for transport. b. Motorcycle, bicycle, and other helmets should be carefully removed in the field. 8. Pregnancy If patient is in third trimester, transport in left-lateral position. C. Transport as soon as possible. Ideally, scene times for patients meeting anatomical and/or physiological trauma criteria should not exceed 10 minutes. D. Vascular Access: 1. Initiate a large bore IV/IO of NS/LR TKO via blood administration or macrodrip tubing on all patients meeting anatomic or physiologic trauma triage criteria. All IV/IO access should be initiated en route, unless adequate personnel are available on scene to allow procedure without causing transport delay. 2. If systolic blood pressure (SBP) is < 90 mmhg, or if thoracic or abdominal pain is present, initiate second line of NS/LR solution with large bore IV (preferably 16 gauge). 160

171 REFERENCE NO. T-1 SUBJECT: GENERAL TRAUMA MANAGEMENT 3. Fluid resuscitation guidelines: a. If signs/symptoms of blood loss, hypoperfusion, SBP < 90: Give up to 1000 ml bolus, titrate to SBP 90. b. If SBP < 70: Give up to 2000 ml bolus, titrate to SBP 90. E. Contact Receiving Hospital as Soon as Possible CROSS REFERENCES: Policy and Procedure Manual Trauma Triage Criteria, Reference No. 860 Advanced Airway Management, Reference No

172 Sierra Sacramento Valley EMS Agency Treatment Protocol T-2 Tension Pneumothorax Approval: Troy M. Falck, MD Medical Director Effective: 12/01/2017 Approval: Victoria Pinette Executive Director Next Review: 07/2020 BLS Assess respiratory status, manage airway and assist ventilations as appropriate High flow O 2 ALS Suspected tension pneumothorax with absent or diminished breath sounds and one of the following: Combined hypotension (SBP < 90) and SpO2 < 94%? Penetrating injury to the thorax? Traumatic cardiac arrest? NO Monitor & reassess YES Approved Sites: Decompress Affected Side (may be performed during transport) Anterior: 2 nd intercostal space mid-clavicular line Lateral: 4 th or 5 th intercostal space mid-axillary line above the anatomic nipple line Procedure Details: Use a minimum 14g x 3.25" catheter specifically designed for needle decompression Insert needle at a 90 0 angle, just over the superior border of the rib, and advance until air is freely aspirated or a rush of air is heard. Remove needle from catheter, attach a stopcock or one-way valve and adequately secure Recheck breath sounds Two (2) attempts allowed on affected side(s) without base/modified base hospital contact Continuously monitor & reassess 162

173 Sierra Sacramento Valley EMS Agency Treatment Protocol T-8 Hemorrhage Approval: Troy M. Falck, MD Medical Director Effective: 12/01/2017 Approval: Victoria Pinette Executive Director Next Review: 11/2020 BLS Assess and support ABC s Assess V/S, including SpO 2 Attempt to control bleeding with direct pressure Uncontrolled Bleeding? NO Monitor and reassess Extremity, area amenable to tourniquet placement and tourniquet available YES Non extremity, area not amenable to tourniquet or tourniquet not available Apply tourniquet* proximal to bleeding site Remove improvised tourniquet devices Reassess for bleeding Consider applying a hemostatic agent** Monitor and reassess Continued Bleeding? NO Transport Time 30 min? YES Reassess tourniquet for removal YES NO Consider placement of 2 nd tourniquet* proximal to 1 st Leave tourniquet(s) in place YES Amputation or near amputation NO *Approved Tourniquet Devices Combat Application Tourniquet Emergency and Military Tourniquet Mechanical Advantage Tourniquet SAM XT Extremity Tourniquet Special Ops. Forces Tactical Tourniquet **Approved Hemostatic Agents QuikClot Emergency 4x4 and/or Combat Gauze Z-Fold HemCon ChitoGauze Pro Z-Fold Monitor and reassess NO Apply pressure dressing & loosen tourniquet Significant Bleeding? YES Tighten tourniquet & leave in place 163

174 Sierra Sacramento Valley EMS Agency Treatment Protocol Burns Effective: 06/01/2016 Next Review: 04/2019 T-10 Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE INFORMATION NEEDED Type and source of burn: chemical, electrical, thermal, steam Complicating factors: exposure in enclosed space, total time of exposure, drug or alcohol use, smoke or toxic fumes OBJECTIVE FINDINGS Evidence of inhalation injury or toxic exposure (carbonaceous sputum, hoarseness, or singed nasal hairs) Extent of burn (depth full or partial thickness and BSA affected) Entrance or exit wounds for electrical or lightning strike Associated trauma from an explosion, electrical shock or fall BLS ABC s - consider BVM early for altered LOC or respiratory distress O 2 at appropriate flow rate Assess V/S including pulse oximetry Remove wet dressings and cover with dry, clean dressings/linen ALS Cardiac monitor Consider early advanced airway if evidence of inhalation injury or compromised respiratory effort IV/IO NS/LR TKO (in non-burned extremity) For 2 o & 3 o burns > 9% BSA, facial burns, or if IV/IO pain management is necessary Administer fluid bolus of 1000 ml for adults or 20 ml/kg for pediatrics (or as directed by the base/ modified base hospital) for 2 o or 3 o burns > 9 % BSA or signs of hypovolemia Albuterol (if wheezes are present) 5 mg in 6 ml NS via HHN, mask or BVM Destination Per Trauma Triage Criteria (860) YES Does pt meet trauma triage criteria? Pain management necessary? YES Go to Pain Management Protocol (M-8) or (P-34) *All patients suffering from an electrical burn shall be transported for evaluation *Patients with the following types of burns require base/modified base hospital transport destination consultation Full thickness (3 o ) burns of the hands, feet, face, perineum, or > 2% of any body surface Partial thickness (2 o ) burns > 9% of body surface Significant electrical or chemical burns When prehospital personnel determine that transport to a burn center may be in the best interest of the patient 164

175 Sierra Sacramento Valley EMS Agency Treatment Protocol Burns T-10 BURN CHART 165

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177 S-SV EMS PEDIATRIC PATIENT TREATMENT PROTOCOLS 167

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179 Sierra Sacramento Valley EMS Agency Treatment Protocol Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director Definitions: General Pediatric Protocol o Neonate An infant during the first 28 days of life. o Pediatric All patients > 28 days old up to and including 14 years of age. Principals: Effective: 12/01/2017 Next Review: 11/2020 o Pediatric protocols shall be utilized for any patient up to and including 14 years of age. Applicable adult protocols (General Trauma Management, Burns, etc.) may be utilized when there is not a pediatric protocol applicable to the patient s complaint/condition. o A length-based pediatric resuscitation tape shall be utilized for determining sizes of equipment, defibrillation/cardioversion doses and medication doses in the prehospital setting. Normal Vital Signs and Definition of Hypotension P-1 Age Normal Pulse Rate Normal Resp. Rate Normal SBP Hypotension Definition Neonate SBP < 60 Infant (1-12 months) SBP < 70 Toddler (1-2 years) Preschooler (3-5 years) School-age child (6-7 years) SBP < 70 + (age in years x 2) Preadolescent (10-12 years) SBP < 90 Adolescent (12-14 years) SBP <

180 Sierra Sacramento Valley EMS Agency Treatment Protocol Neonatal Resuscitation Effective: 6/1/2016 Next Review: 03/2019 P-2 Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE Approximate Time BIRTH Term gestation? Good muscle tone? Breathing or crying? NO YES Routine Care Provide warmth Clear airway* if necessary Dry Ongoing evaluation Provide warmth Clear airway* if necessary Dry, stimulate & reposition NO 30 sec HR <100, gasping, or apnea? NO Labored breathing or persistent cyanosis? YES YES 60 sec Positive-pressure ventilation with room air* Pulse Oximetry Clear airway*/supplemental 0 2 Pulse Oximetry HR <100? YES NO Ongoing evaluation Postresuscitation care Consider endotracheal intubation* NO HR <60? YES CPR Rate 120/min 3:1 compression:ventilation ratio Consider endotracheal intubation* IV/IO NS TKO (may bolus 20 ml/kg) *AIRWAY & VENTILATION INFORMATION See notes on page 2 for clearing the airway of meconium. Convert from room air to high flow O2 for persistent bradycardia or cyanosis. Attempt intubation only if BVM ventilation is unsuccessful or impractical. Consider hypovolemia and/or pneumothorax. HR <60? YES Epinephrine IV/IO: mg/kg 1:10,000 ( ml/kg) ET: 0.1 mg/kg 1:1,000 (0.1 ml/kg) 170

181 Sierra Sacramento Valley EMS Agency Treatment Protocol Neonatal Resuscitation P-2 Clearing the Airway of Meconium Non-vigorous newborns with meconium-stained fluid do not require routine intubation and tracheal suctioning. If you are attempting PPV but the baby is not improving and the chest is not moving despite performing each of the ventilation corrective steps, including intubation, the trachea may be obstructed by thick secretions. Suction the trachea using one of the following methods: o Suction capability 80 mm Hg: Perform direct laryngoscopy immediately after birth for suctioning of the hypo pharynx and intubation/suction of the trachea. Accomplish tracheal suctioning by applying suction directly to the endotracheal tube (utilizing a meconium aspirator), as it is withdrawn from the airway. Repeat intubation and suctioning until little additional meconium is recovered or until the heart rate indicates that resuscitation must proceed without delay. o Suction capability > 80 mm Hg: Do not use an endotracheal tube to suction the trachea. Use a bulb syringe and, if necessary, a suction catheter to thoroughly suction meconium from the nose, mouth and oropharynx. A laryngoscope blade may be inserted to assist in visualization of the oropharynx during suction with the catheter. Intubation may be necessary for respiratory depression. 171

182 Sierra Sacramento Valley EMS Agency Treatment Protocol Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director Brief Resolved Unexplained Event (BRUE) Effective: 06/01/2017 Next Review: 03/2020 Brief resolved unexplained event (BRUE) is an event occurring in an infant younger than one year of age when the observer reports a sudden, brief (lasting <1 minute but typically <20-30 seconds), and now resolved episode (patient returned to baseline state of health after the event) of any of the following: - Cyanosis or pallor - Absent, decreased, or irregular breathing - Marked change in tone (hyper- or hypotonia) - Altered level of responsiveness BRUE should be suspected when there is no explanation for a qualifying event after conducting an appropriate history and physical examination All infants 1 year of age with possible BRUE should be transported by EMS if parent/guardian refuses EMS treatment and/or transport, base/modified base hospital consultation is required prior to release EMS personnel shall make every effort to obtain the contact information of the person who witnessed the event this contact information shall be provided to the receiving hospital upon patient delivery P-3 BLS Determine severity, nature and duration of episode: - Was child awake or sleeping at time of episode? - What resuscitative measures were taken? Obtain a complete medical history including: - Known chronic diseases - Evidence of seizure activity - Current or recent infection - Recent trauma - Medication history - Unusual sleeping or feeding patterns - Known gastroesophageal reflux or feeding problems Assume history given is accurate Perform a comprehensive physical assessment including: - General appearance - Skin color - Evidence of trauma - Extent of interaction with the environment Assess V/S including Sp02 Treat any identifiable causes as indicated ALS Cardiac monitor Check blood glucose level (BG) if hypoglycemia suspected BG < 60 mg/dl? YES Go to ALOC Protocol P-24 NO Transport 172

183 Sierra Sacramento Valley EMS Agency Treatment Protocol P-4 Pediatric Pulseless Arrest Approval: Troy M. Falck, MD Medical Director Effective: 12/01/2017 Approval: Victoria Pinette Executive Director Next Review: 07/2020 Infant CPR 2 finger chest compressions minimize interruptions Rate: /minute Depth: at least 1/3 diameter of the chest (approx. 1 ½ ) Comp./Vent. Ratio: 30/2 (1 rescuer), 15/2 (2 rescuer) Rotate compressors every 2 minutes Perform CPR during AED/defibrillator charging Resume CPR immediately after shock Child CPR 1 or 2 hands as needed to provide adequate depth Rate: /minute Depth: at least 1/3 diameter of the chest (approx. 2 ) Comp./Vent. Ratio: 30/2 (1 rescuer), 15/2 (2 rescuer) Rotate compressors every 2 minutes Perform CPR during AED/defibrillator charging Resume CPR immediately after shock AED Utilization Use child pads, if available, for infants and children less than 8 years old If child pads are not available, use adult pads. Make sure the pads do not touch each other or overlap Adult pads deliver a higher shock dose, but a higher shock dose is preferred to no shock Waveform Capnography Waveform capnography, if available, shall be used on all patients with an advanced airway in place Persistently low PETCO 2 levels < 10 mm HG suggest ROSC is unlikely ensure chest compressions are adequate or consider termination of resuscitation efforts (base/modified physician order only) An abrupt increase in PETCO 2 is indicative of ROSC BLS CPR x 2 minutes - with BVM and 100% O 2 - apply AED as soon as possible Analyze rhythm/check pulse after 2 minutes of CPR If arrest witnessed by EMS and an AED or defibrillator is immediately available, start CPR and utilize the AED/defibrillate as soon as possible) NO ROSC? NO Shock advised? YES Deliver AED shock Resume CPR x 2 minutes Analyze rhythm/check pulse after 2 minutes of CPR YES Monitor & reassess See page 2 for ALS treatment 173

184 Sierra Sacramento Valley EMS Agency Treatment Protocol Pediatric Pulseless Arrest P-4 Reversible Causes (Contact base/modified base hospital for additional treatment consultation if necessary ) - Hypovolemia - Hypoxia - Hydrogen Ion (Acidosis) - Hypo-/hyperkalemia - Hypothermia - Tamponade, cardiac - Tension pneumo - Thrombosis, pulmonary - Thrombosis, cardiac - Toxins First shock 2 J/kg, subsequent shocks 4 J/kg *Manual Defibrillation Detail ALS ASYSTOLE/PEA Cardiac Monitor VF/VT Defibrillation* CPR x 2 minutes IV/IO NS (may bolus 20 ml/kg) Analyze rhythm/check pulse after 2 minutes of CPR CPR x 2 minutes IV/IO NS (may bolus 20 ml/kg) Analyze rhythm/check pulse after 2 minutes of CPR ROSC? YES Monitor & reassess Begin post resuscitation care YES ROSC? NO NO Shockable rhythm? YES Go to VF/VT Go to Asystole/ PEA NO Shockable rhythm? NO YES Defibrillation* CPR x 2 minutes Epinephrine every 3-5 mins - IV/IO: 0.01 mg/kg (1:10,000) Analyze rhythm/check pulse after every 2 minutes of CPR CPR x 2 minutes Epinephrine every 3-5 mins - IV/IO: 0.01 mg/kg (1:10,000) Analyze rhythm/check pulse after every 2 minutes of CPR For VF/VT unresponsive to defib/epi: Amiodarone - IV/IO: 5 mg/kg May repeat every 3-5 mins. x 2 (max total 300 mg) 174

185 SIERRA SACRAMENTO VALLEY EMS AGENCY TREATMENT PROTOCOL MEDICAL EMERGENCY SUBJECT: BRADYCARDIA WITH PULSES BLS PEDIATRIC REFERENCE NO. P-6 Assess & support ABC s as needed/high flow O 2 Assist ventilation with BVM as needed Assess V/S including a palpated and auscultated pulse Pulse Oximetry HR < 60? NO YES CPR if HR <60/min with signs of poor perfusion despite oxygenation and ventilation Support ABC s Continue high flow O 2 Monitor & reassess NO ALS Persistent symptomatic bradycardia? YES Epinephrine IV/IO: 0.01 mg/kg 1:10,000 (0.1 ml/kg) ET: 0.1 mg/kg 1:1,000 (0.1 ml/kg) Repeat q 3 5 minutes If no response to epinephrine: Atropine IV/IO/ET: 0.02 mg/kg Maximum single dose: 0.5 mg Base/Modified Base Hospital Order Only Consider transcutaneous pacing Cardiac Monitor IV/IO NS TKO if appropriate (may bolus 20 ml/kg) Endotracheal intubation as necessary for severe distress if BVM unsuccessful or impractical If pulseless arrest develops go to pulseless arrest protocol P-4 Cardiopulmonary Compromise Hypotension Acutely altered mental status Signs of shock Search for and treat possible contributing factors: Hypovolemia Hypoxia/ventilation problems Hydrogen ion (acidosis) Hypo-/hyperkalemia Hypoglycemia Hypothermia Toxins Tamponade, cardiac Tension pneumothorax Thrombosis Trauma Page 1 Effective Date: 06/01/2015 Date last Reviewed/Revised: 11/2014 Next Review Date: 11/2017 Approved by: SIGNATURE ON FILE S-SV EMS Medical Director 175 SIGNATURE ON FILE S-SV EMS Regional Executive Director

186 SIERRA SACRAMENTO VALLEY EMS AGENCY TREATMENT PROTOCOL MEDICAL EMERGENCY SUBJECT: TACHYCARDIA WITH PULSES PEDIATRIC REFERENCE NO. P-8 BLS Assess & support ABC s as needed High flow O 2 Assess V/S, including Pulse Oximetry ALS *Cardiopulmonary compromise Hypotension Acutely altered mental status Signs of shock Narrow QRS ( 0.08 sec) Cardiac Monitor (12 lead) Wide QRS (> 0.08 sec) Probable Sinus Tachycardia Compatible hx consistent with known cause P waves present & normal Variable R-R & constant P-R Infants: rate usually < 220 bpm Children: rate usually < 180 bpm Probable Supraventricular Tachycardia Compatible hx (vague, nonspecific) P waves absent or abnormal HR not variable Hx of abrupt rate changes Infants: rate usually 220 bpm Children: rate usually 180 bpm Possible Ventricular Tachycardia *Cadiopulmonary compromise? NO Treat underlying cause Consider IV/IO NS TKO (may bolus 20 ml/kg) *Cadiopulmonary compromise? YES YES Base/Modified Base Hospital Order Only NO Vagal Maneuvers Synchronized Cardioversion J/kg If not effective, increase to 2 J/kg Consider sedation Monitor & Reassess YES Successful? NO IV/IO NS TKO (may bolus 20 ml/kg) Contact Base/Modified Base Hospital for Treatment Consultation Base/Modified Base Hospital Order Only Adenosine 0.1 mg/kg rapid IV/IO (max dose 6 mg) If no response, administer second dose after 2 minutes 0.2 mg/kg rapid IV/IO (max dose 12 mg) Effective Date: 06/01/2015 Date last Reviewed/Revised: 11/2014 Next Review Date: 11/2017 Approved by: SIGNATURE ON FILE S-SV EMS Medical Director 176 SIGNATURE ON FILE S-SV EMS Regional Executive Director

187 SIERRA SACRAMENTO VALLEY EMS AGENCY TREATMENT PROTOCOL MEDICAL EMERGENCY SUBJECT: FOREIGN-BODY AIRWAY OBSTRUCTION BLS PEDIATRIC REFERENCE NO. P-10 Signs/symptoms of foreign body airway obstruction (FBAO) sudden onset of respiratory distress with coughing, gagging, stridor, or wheezing. Do not use tongue/jaw lift or perform blind finger sweep Signs of severe obstruction: - Poor air exchange - Increased breathing difficulty - Silent cough - Cyanosis - Inability to speak or breath - Ask patient are you choking? If patient nods yes then act Assess ABC s Reassure patient/encourage coughing O 2 & suction as needed Monitor & reassess Transport NO Signs of severe obstruction? If ALTE go to ALTE protocol P-3 YES If patient < 1 yr old 5 back blows followed by 5 chest thrusts If patient 1 yr old Abdominal thrusts in rapid sequence If ineffective, consider chest thrusts If patient becomes unconscious Begin CPR Check for F.B. remove only if visualized Look into mouth when opening the airway Use finger sweep only to remove visible F.B. ALS Needle Cricothyrotomy Indications Extensive orofacial injuries that make orotracheal intubation impossible Complete airway obstruction with inability to remove F.B. by other methods Contraindications Age < 3 yrs or weight < 15 kg Conscious patient Moving ambulance Pt. has midline neck hematoma or massive subcutaneous emphysema Endotracheal intubation (if BVM unsuccessful or impractical) If seen, remove F.B. with Magill forceps Maintain airway & O 2 Monitor & reassess Transport YES Ventilating adequately? NO Consider Needle Cricothyrotomy Transport Page 1 Effective Date: 06/01/2015 Date last Reviewed/Revised: 01/2015 Next Review Date: 01/2018 Approved by: SIGNATURE ON FILE S-SV EMS Medical Director 177 SIGNATURE ON FILE S-SV EMS Regional Executive Director

188 SIERRA SACRAMENTO VALLEY EMS AGENCY TREATMENT PROTOCOL MEDICAL EMERGENCY SUBJECT: RESPIRATORY FAILURE/ARREST PEDIATRIC REFERENCE NO. P-12 Anticipate respiratory failure & possible respiratory arrest if any of the following are present: Increased respiratory rate, with signs of distress (e.g. increased effort, nasal flaring, retractions, or grunting) An inadequate respiratory rate, effort, or chest excursion (e.g. diminished breath sounds, gasping, and cyanosis), especially if mental status is depressed BLS Assess & support ABC s as needed Positive pressure ventilation with BVM and 100% O 2 Assess V/S (including a palpated & auscultated pulse) & Pulse Oximetry at appropriate time during treatment HR < 60? NO YES Perform CPR if despite O 2 and ventilation HR < 60 with signs of poor perfusion Go to Bradycardia Protocol P-6 ALS Cardiac Monitor IV/IO NS TKO (may bolus 20 ml/kg) Endotracheal intubation if BVM unsuccessful or impractical Suspect Narcotic OD? NO YES Naloxone 0.1 mg/kg IV/IO, or IM/IN (max dose 2 mg) If no improvement, consider repeat dose x 2 (total 3 doses) q 2-3 minutes Do not administer if advanced airway is in place & pt is being adequately ventilated Naloxone is to be given for inadequate respiratory status only Blood Glucose Check Go to ALOC Protocol P-24 YES Results < 60 mg/dl? NO Adequate Response? NO YES Monitor & Reassess Page 1 Effective Date: 06/01/2015 Date last Reviewed/Revised: 01/2015 Next Review Date: 01/2018 Approved by: SIGNATURE ON FILE S-SV EMS Medical Director 178 SIGNATURE ON FILE S-SV EMS Regional Executive Director

189 Sierra Sacramento Valley EMS Agency Treatment Protocol P-14 Pediatric Respiratory Distress Wheezing Approval: Troy M. Falck, MD Medical Director Effective: 12/01/2017 Approval: Victoria Pinette Executive Director Next Review: 09/2020 Refer to Adult Respiratory Distress Treatment Protocol (R-3) for continuous positive airway pressure (CPAP) indications, contraindications and complications information Consider respiratory failure with a history of increased work of breathing and presenting with ALOC and a slow or normal respiratory rate without retractions Do not attempt to visualize the throat or insert anything into the mouth if epiglottitis suspected EMT Epinephrine Auto-Injector Administration Criteria (epinephrine auto-injector optional skills providers only) Candidates for administration of auto-injector epinephrine by authorized EMT personnel are patients with suspected asthma, in severe distress (auto-injector epinephrine for asthma is not authorized for PSFA or EMR personnel) BLS Assess respiratory status, administer high flow O 2, manage airway & assist ventilation as appropriate Assess V/S, including SpO 2 Assess history and physical, determine degree of illness Consider CPAP, when appropriate, for moderate to severe distress (patients 8 years of age only) Epinephrine auto-injector provider? NO YES Suspected asthma in severe distress? NO Monitor & reassess YES Epinephrine Pediatric (15-30 kg) Auto-injector 0.15 mg (0.3 ml) inject deep IM into lateral thigh, midway between waist and knee See page 2 for ALS treatment 179

190 Sierra Sacramento Valley EMS Agency Treatment Protocol Pediatric Respiratory Distress Wheezing P-14 ALS Mild Distress Mild wheezing Mild shortness of breath Cough Moderate Severe Distress Cyanosis Accessory muscle use Inability to speak > 3 words Severe wheezing/shortness of breath Decreased or absent air movement Cardiac monitor Cardiac monitor IV/IO NS (may bolus 20 ml/kg) Albuterol 5 mg and Ipratropium 500 mcg Nebulizer May repeat (albuterol 5 mg only) if respiratory distress continues Albuterol 5 mg and Ipratropium 500 mcg Nebulizer, CPAP, or BVM May repeat (albuterol 5 mg only) if respiratory distress continues Monitor & reassess Epinephrine 1:1,000 (for severe distress only) 0.01 mg/kg IM (max dose = 0.3 mg) 180

191 Sierra Sacramento Valley EMS Agency Treatment Protocol P-16 Pediatric Respiratory Distress Stridor Approval: Troy M. Falck, MD Medical Director Effective: 12/01/2017 Approval: Victoria Pinette Executive Director Next Review: 09/2020 The hallmark of upper airway obstruction (i.e., croup, epiglottitis, foreign body airway obstruction) is inspiratory stridor Do not attempt to visualize the throat or insert anything into the mouth if epiglottitis is suspected BLS Assess respiratory status and administer high flow O 2 Manage airway and assist ventilation as appropriate Assess V/S, including SpO 2 Assess history and physical, determine degree of illness Minimize outside stimulation keep patient calm and allow parent to hold the child and/or O 2 mask if their presence calms the child Suspect Croup or Epiglottitis? NO Go to appropriate protocol YES ALS Cardiac monitor Consider nebulized saline Base/Modified Base Hospital Order Only Nebulized epinephrine 0.5 ml/kg 1:1,000 (max 5 ml) nebulizer or BVM For doses < 5 ml, mix with NS to = 5 ml of volume If full upper airway occlusion suspected Ensure proper airway positioning and BVM seal Attempt to ventilate and reassess Perform needle cricothyrotomy as airway of last resort Monitor & reassess 181

192 Sierra Sacramento Valley EMS Agency Treatment Protocol P-18 Pediatric Allergic Reaction/Anaphylaxis Approval: Troy M. Falck, MD Medical Director Effective: 12/01/2017 Approval: Victoria Pinette Executive Director Next Review: 07/2020 Definitions/Descriptions Allergic reaction: Sensitivity to an allergen causing hives, pruritus, flushing, rash, nasal congestion, watery eyes, and/or angioedema not involving the airway High-risk allergic reaction: Allergic reaction with a history of anaphylaxis, or significant exposure with worsening symptoms Anaphylaxis: Severe allergic reaction with one or more of the following symptoms: abnormal appearance (agitation, restlessness, somnolence), respiratory distress, bronchospasm/wheezes/diminished breath sounds, hoarseness, stridor, edema involving the airway, diminished perfusion In extremis: Anaphylaxis with one or more of the following symptoms: airway compromise, altered mental status, hypotension BLS Epinephrine Auto-Injector Administration Criteria (epinephrine auto-injector optional skills providers only) Candidates for the administration of auto-injector epinephrine by authorized PSFA, EMR, or EMT personnel are patients in severe distress who have one or more of the anaphylaxis symptoms listed above BLS Assess respiratory status, manage airway and assist ventilations as appropriate Remove antigen source O 2 at appropriate rate Assess V/S, including SpO 2 May assist patient with administration of prescribed EpiPen if necessary Epinephrine auto-injector provider? NO YES Criteria met for epinephrine admin? NO Monitor & reassess YES See page 2 for ALS treatment Epinephrine Pediatric (15-30 kg) Auto-injector 0.15 mg (0.3 ml) inject deep IM into lateral thigh, midway between waist and knee 182

193 Sierra Sacramento Valley EMS Agency Treatment Protocol Pediatric Allergic Reaction/Anaphylaxis P-18 ALS Cardiac monitor Allergic Reaction Anaphylaxis Diphenhydramine 1 mg/kg PO, IM, or IV (max = 50 mg) Epinephrine 1:1, mg/kg IM (max = 0.3 mg) May repeat in 20 min if symptoms persist NO High-risk? IV/IO NS Bolus 20 ml/kg May repeat bolus if necessary YES Diphenhydramine 1 mg/kg IV/IO or IM (max = 50 mg) Epinephrine 1:1, mg/kg IM (max = 0.3 mg) Consider IV NS TKO May bolus 20 ml/kg For Wheezing/Bronchospasm Albuterol 5 mg & Ipratropium 500 mcg Nebulizer or BVM May repeat (Albuterol 5 mg only) for continued respiratory distress Monitor & reassess NO In extremis? YES Epinephrine 1:10, mg slow IV/IO over 2 3 minutes (max dose = 0.1 mg) 183

194 SUBJECT: SHOCK SIERRA SACRAMENTO VALLEY EMS AGENCY TREATMENT PROTOCOL MEDICAL EMERGENCY BLS PEDIATRIC REFERENCE NO. P-20 Shock in children may be subtle and difficult to recognize. Tachycardia may be the only sign noted. Hypotension is a late sign of shock. Determining B/P may be difficult and readings may be inaccurate in children < 3 years of age Obtain History Including: - Onset and duration of symptoms - Fluid Loss (vomiting, diarrhea) - Fever, infection, trauma or ingestion - History of: allergic reaction, cardiac disease or rhythm disturbances Important signs to watch for: COMPENSATED SHOCK Tachycardia Cool extremities Capillary refill time > 2 seconds (despite warm ambient temperature) Weak peripheral pulses compared with central pulses Normal blood pressure Perform endotracheal intubation only if BVM ventilation is unsuccessful or impractical DECOMPENSATED SHOCK Hypotension and/or bradycardia (late findings) Decreased mental status Decreased urine output Tachypnea Non-detectable distal pulses with weak central pulses Assess V/S including Pulse Oximetry High flow 0 2 by blow by or mask ventilation, suction as needed Keep child warm Transport as soon as possible ALS Cardiac Monitor IV/IO NS TKO Check Blood Glucose Results 60 mg/dl? YES NO YES Fluid Bolus NS 20 ml/kg Reassess & repeat if necessary for continued signs of shock* *If DKA suspected, contact base/ modified base hospital for consultation prior to repeat fluid boluses Go to ALOC Protocol P-24 Cont. signs of shock? NO Monitor & Reassess Page 1 Effective Date: 06/01/2015 Date last Reviewed/Revised: 01/2015 Next Review Date: 01/2018 Approved by: SIGNATURE ON FILE S-SV EMS Medical Director 184 SIGNATURE ON FILE S-SV EMS Regional Executive Director

195 SUBJECT: OVERDOSE/POISONING SIERRA SACRAMENTO VALLEY EMS AGENCY TREATMENT PROTOCOL MEDICAL EMERGENCY PEDIATRIC REFERENCE NO. P-22 Poison Control Contact Info for Base Physicians or MICN s Voice: / TTY: Note: Perform endotracheal intubation only if BVM ventilation is unsuccessful or impossible Consult with base/modified base if blood glucose reading is > 60 mg/dl but hypoglycemia is suspected BLS Assess & support ABC s, O 2 at appropriate rate Assess V/S including Pulse Oximetry Consider BVM/assist respirations early for ALOC or respiratory distress ALS Cardiac Monitor Monitor & reassess Contact base/modified base hospital if consultation needed YES Ventilating adequately, alert with a good gag reflex? NO Intubate as needed for severe distress if BVM unsuccessful or impossible IV/IO NS TKO (may bolus 20 ml/kg) Suspect Narcotic OD? YES Naloxone 0.1 mg/kg IV/IO, or IM/IN (max dose 2 mg) If no improvement, consider repeat dose x 2 (total 3 doses) q 2-3 minutes Do not administer if advanced airway is in place & pt is being adequately ventilated Naloxone is to be given for inadequate respiratory status only NO Dextrose 10% 5 ml/kg (0.5 gm/kg) IV/IO Max dose = 10 gm (100 ml) If no IV/IO or delay anticipated Glucagon Less than 24 kg: 0.5 mg IM/IN 24 kg or more: 1 mg IM/IN YES Check blood glucose Results 60 mg/dl? NO NO Monitor & Reassess Adequate Response? YES Page 1 Effective Date: 12/01/2014 Date last Reviewed/Revised: 07/14 Next Review Date: 07/2017 Approved by: SIGNATURE ON FILE S-SV EMS Medical Director 185 SIGNATURE ON FILE S-SV EMS Regional Executive Director

196 SUBJECT: OVERDOSE/POISONING SIERRA SACRAMENTO VALLEY EMS AGENCY TREATMENT PROTOCOL MEDICAL EMERGENCY NERVE AGENT/ORGANOPHOSPHATE EXPOSURE PEDIATRIC REFERENCE NO. P-22 All providers will ensure personal safety by assuring adequate decontamination of victims and using appropriate personal protective equipment (PPE). Under no circumstances should responding personnel at any level use personal protective equipment (PPE) or assist in patient decontamination without completing the required training. Only patients with severe exposure will be treated within the Exclusion Zone (Hot Zone) or contaminated area by personnel who have specific training to allow them to function in that area. Patients in the Exclusion Zone (Hot Zone) with severe exposure shall be treated with IM medication only. Auto-injectors are NOT to be used in children < 40 kg. YES Patient decontaminated? NO MILD TO SEVERE EXPOSURE Decontaminate patient NO Severe Exposure? YES Assess and support ABCs as needed 0 2 as needed BVM/assist respirations/advanced airway adjuncts as needed IV/IO NS TKO (may bolus 20 ml/kg) Atropine IV/IO or IM 0.02 mg/kg (minimum dose 0.1 mg) For moderate to severe exposure: repeat q 3 5 minutes as needed until a positive response is achieved Advanced airway adjuncts as needed Atropine IM only 2 years old 0.5 mg IM 2 10 years old 1.0 mg IM Repeat q 3 5 minutes as needed until a positive response is achieved Pralidoxime (2-PAM) IM only: if available from the CHEMPACK 50 mg/kg IM Maximum 1 gram Decontaminate patient Pralidoxime (2-PAM): if available from the CHEMPACK 25 mg/kg IM OR 25 mg/kg slow IV/IO (over 20 minutes) Maximum 1 gram May repeat x 1 for severe exposures If seizures present: Go to Seizure Protocol P-26 Support ABC s/0 2 as needed IV/IO NS TKO (may bolus 20 ml/kg) Page 2 186

197 SIERRA SACRAMENTO VALLEY EMS AGENCY TREATMENT PROTOCOL MEDICAL EMERGENCY SUBJECT: ALTERED LEVEL OF CONSCIOUSNESS PEDIATRIC REFERENCE NO. P-24 Clinical setting and/or medical history may dictate naloxone or dextrose as the initial medication Note: glucose paste or glucose solution, sugared soft drinks, orange juice or other oral glucose may be administered if the patient is: 1) able to maintain their airway; and, 2) able to follow commands Consult with base/modified base if blood glucose reading is > 60 mg/dl but hypoglycemia is suspected BLS Assess & support ABC s as needed/high flow O 2 Assess V/S including pulse oximetry Consider BVM/assist respirations early for respiratory distress ALS Cardiac Monitor Intubate as needed for severe distress if BVM unsuccessful or impractical IV/IO NS TKO (may bolus 20 ml/kg) Naloxone 0.1 mg/kg IV/IO, or IM/IN (max dose 2 mg) If no improvement, consider repeat dose x 2 (total 3 doses) q 2-3 minutes Do not administer if advanced airway is in place & pt is being adequately ventilated Naloxone is to be given for inadequate respiratory status only YES Suspect Narcotic OD? NO Adequate response? YES NO Check Blood Glucose Results < 60 mg/dl? NO YES Dextrose 10% 5 ml/kg (0.5 gm/kg) IV/IO Max dose = 10 gm (100 ml) If no IV/IO or delay anticipated Glucagon Less than 24 kg: 0.5 mg IM/IN 24 kg or more: 1 mg IM/IN Monitor & Reassess * If Signs/Symptoms of ALTE: Go to ALTE Protocol P-3 Page 1 Effective Date: 12/01/2014 Date last Reviewed/Revised: 07/14 Next Review Date: 07/2017 Approved by: SIGNATURE ON FILE S-SV EMS Medical Director 187 SIGNATURE ON FILE S-SV EMS Regional Executive Director

198 Sierra Sacramento Valley EMS Agency Treatment Protocol P-26 Pediatric Seizure Approval: Troy M. Falck, MD Medical Director Effective: 12/01/2017 Approval: Victoria Pinette Executive Director Next Review: 07/2020 Status Epilepticus: 2 or more seizures without periods of consciousness, or a single seizure lasting > 5 minutes Only continuous or repetitive seizure activity requires ALS intervention Cooling measures if febrile: loosen clothing and/or remove outer clothing/blankets BLS Assess and support ABC s; assess V/S, including SpO 2 High flow O 2 manage airway and assist ventilations as appropriate ALS Cardiac monitor Consider vascular access at appropriate time (may bolus 20 ml/kg NS) NO Status Epilepticus? YES Midazolam 0.2 mg/kg IM/IN (max 10 mg) if vascular access is not already established OR 0.1 mg/kg IV/IO (max 5 mg) if vascular access is already established May repeated same dose x 1 after 5 minutes of continued seizure activity Check blood glucose (BG) BG < 60 mg/dl? NO YES Dextrose 10% 5 ml/kg (0.5 gm/kg) IV/IO max 100 ml (10 gm) OR Glucagon (if no IV/IO) < 24 kg: 0.5 mg IM/IN 24 kg: 1.0 mg IM/IN Monitor & reassess 188

199 SIERRA SACRAMENTO VALLEY EMS AGENCY TREATMENT PROTOCOL MEDICAL EMERGENCY SUBJECT: NAUSEA/VOMITING (FROM ANY CAUSE) PEDIATRIC REFERENCE NO. P-32 Nausea and vomiting can be a symptom of a multitude of different causes. If at all possible, the specific underlying cause should be determined and treated. Providers should realize that the use of an antiemetic may relieve symptoms while leaving the cause untreated, and possibly, more difficult to detect. With this in mind providers should weigh the benefits of antiemetic use against the possible risk of making an accurate diagnosis more difficult, and the possible side effects of the antiemetic agent. Treatment of nausea and vomiting is warranted for patients where it may contribute to a worsening of the patient s condition, or where the patient s airway may be endangered. Prehospital personnel may consider giving Zofran (Ondansetron) prophylactically prior to or immediately after opioid administration for a patient who is identified to have a history of nausea/vomiting secondary to opioid administration, or prior to transport for a patient with a history of motion sickness. BLS Assess and support ABC s as needed O 2 at appropriate rate if needed Assess and treat as appropriate for underlying cause ALS Cardiac Monitor Consider establishing vascular access (may bolus 20 ml/kg) Check Blood Glucose if hypoglycemia or hyperglycemia suspected NO Age 4 years old? YES Zofran (Ondansetron) 4 mg ODT (Oral Disintegrating Tablet)/IM OR 4 mg slow IV/IO (over 30 Seconds) Base/modified base hospital contact/consultation required for additional doses or prior to administration of Zofran (Ondansetron) to patients during the first 8 weeks of pregnancy Monitor and reassess Page 1 Effective Date: 08/01/2015 Date last Reviewed/Revised: 06/2015 Next Review Date: 06/2018 Approved by: SIGNATURE ON FILE S-SV EMS Medical Director 189 SIGNATURE ON FILE S-SV EMS Regional Executive Director

200 Sierra Sacramento Valley EMS Agency Treatment Protocol Pain Management (Pediatric) Effective: 06/01/2016 Next Review: 04/2019 P-34 Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE BLS Assess V/S including SpO2 O 2 at appropriate flow rate, titrate to SpO2 94% Assess/document initial pain score, and reassess/document pain score after each pain management intervention Utilize non-pharmacological pain management as appropriate (psychological coaching, ice packs, immobilization/splinting, etc.) Other Causes of Pain Non-acute injuries Back Pain Abdominal Pain Sickle cell crisis Cancer Other Pain From Acute Injuries Isolated extremity injury Multi-system trauma Burns Frostbite Bites/envenomations Contact base/modified base hospital for pain management consultation Follow base/modified base hospital orders for pain management NO Are all of the following present? Age 4 years old Significant pain RR >12 SBP age appropriate GCS 15 & no head injury YES ALS IV/IO NS TKO (may bolus up to 20 ml/kg) Cardiac monitor * Pain Management Notes/Requirements Continuous cardiac and SpO2 monitoring required for all patients receiving pain medication. Titrate medication to a tolerable pain level. Max total opioid dose = 20 mg morphine equivalent (20 mg morphine, 200 mcg fentanyl, or a combination of the two), our four (4) total doses whichever is less. Each medication dose and patient response (including pain score) must be documented on the PCR. Morphine Sulfate* (every 5 min.) 0.1 mg/kg slow IV/IO (max single dose = 5 mg), or 0.2 mg/kg IM/SQ (max single dose = 5 mg) OR Fentanyl* (every 5 min.) 1 mcg/kg slow IV/IO (max single dose = 50 mcg), or 1 mcg/kg IM/SQ (max single dose = 50 mcg), or 1.5 mcg/kg IN (max single dose = 75 mcg) 190

201 S-SV EMS GENERAL POLICIES & INFO SECTION 191

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203 Sierra Sacramento Valley EMS Agency Program Policy Vascular Access Effective: 12/01/2017 Next Review: 09/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To establish vascular access and fluid administration guidelines for prehospital personnel. AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5, and B. California Code of Regulations, Title 22, Division 9, Chapters 3 & 4. A. Vascular Access Guidelines 1. Over-the-needle catheters may be inserted into peripheral veins of the limbs and external jugular vein for administration of intravenous medications/fluid boluses, or the anticipated need to administer intravenous medications/fluid boluses. 2. Avoid more than three (3) attempts at vascular access per patient unless necessary for emergent treatment. 3. Do not establish access in an extremity that has a functioning dialysis shunt. 4. Do not connect the primary IV tubing directly to the IV catheter. IV extension/saline lock tubing shall be utilized between the primary IV tubing and the IV catheter. 5. Saline locks are optional and encouraged when fluid boluses or numerous medication administrations are not expected to be necessary. 6. When large volumes of fluid may be required, large bore catheters (14-18 gauge) should be used, and placed in proximal veins when available. This includes, but is not limited to, patients requiring adenosine, STEMI patients, stroke patients, trauma patients, and patients in cardiac arrest. 7. Consider establishing two (2) IV s in patients who have, or are at risk for decompensation (e.g. hypovolemic shock). Do not delay patient transport to establish additional vascular access. 193

204 Vascular Access TKO indicates a rate of ml per hour (25-30 micro drops per minute, or 5 macro drops per minute). TKO shall be the default rate unless otherwise specified in the applicable treatment protocol. 9. A fluid bolus in an adult patient consists of up to 1000 ml (unless otherwise specified in the applicable treatment protocol) of crystalloid solution delivered as rapidly as possible, with reassessment of hemodynamic parameters, respiratory status and lung sounds before and after administration. 10. A fluid bolus in a pediatric patient consists of 20 ml/kg of crystalloid solution delivered as rapidly as possible, with reassessment of hemodynamic parameters, respiratory status and lung sounds before and after administration. B. External Jugular (EJ) Vein Cannulation 1. EJ vein cannulation may be utilized in any situation where an IO would be acceptable. 2. Contraindications (Relative): Suspected coagulopathy (e.g. advanced liver disease or taking coumadin). Suspected cervical spine injury. Inability to tolerate supine position. Stable patient. 3. Procedure: Place patient in trendelenburg or supine position and elevate shoulders. Turn head 45 to 60 degrees to side opposite of intended venipuncture site. Palpate to assure no pulsatile quality to vessel. Prep site with a recognized antiseptic agent, wipe dry with a sterile gauze pad. Tourniquet vein by placing finger just above clavicle near midclavicular line. Stabilize skin over vein with thumb. Point needle toward shoulder in direction of vein, and puncture vein midway between jaw and clavicle over belly of sternocleidomastoid muscle. Maintain compression of vein at clavicle area until needle is withdrawn and IV tubing has been connected in order to prevent air from entering vein. Secure IV site. 4. Possible Complications: Air embolism. Hematoma requiring compression of neck. Extravasation of fluid or medication, infection, thrombosis. 194

205 Vascular Access 1101 C. Intraosseous Infusion 1. Indications: Emergency situations when lifesaving fluids or drugs should be administered and IV cannulation is difficult, impossible, or too time consuming (if a peripheral IV cannot be established after two (2) attempts or within seconds). For adult (paramedics) and pediatric (paramedic or AEMT) patients, weighing 3 kg, who present with one (1) or more of the following clinical conditions: o Cardiac arrest. o Hemodynamic instability (B/P < 90 mmhg & clinical signs of shock). o Imminent respiratory failure. o Status epilepticus with prolonged seizure activity greater than 10 minutes, and refractory to IN/IM anticonvulsants. o Toxic conditions requiring immediate IV access for antidote. IO placement may be considered prior to peripheral IV attempts in cases of cardiopulmonary or traumatic arrest, in which it may be obvious that attempts at placing a peripheral IV would likely be unsuccessful or too time consuming, resulting in a delay of life-saving fluids or drugs. 2. Contraindications: Fracture or suspected vascular compromise in targeted bone. Excessive tissue or absence of adequate anatomical landmarks. Infection at area of insertion site. Previous significant orthopedic procedure at site (e.g. prosthetic limb/joint). IO access in targeted bone within past 48 hours. 3. Site Selection: Site selection depends on patient age/size/anatomy, presenting condition, ability to locate anatomical landmarks, provider training/experience, and clinical judgment. Site selection is also dependent on the absence of contraindications, accessibility of the site and the ability to monitor and secure the site. Humeral site may be preferred for high volume fluid administration and/or lower extremity trauma (see IO Insertion Site Instructions at the end of this policy). No more than one (1) attempt allowed in each bone. 4. Insertion Procedure: Prep site with a recognized antiseptic agent, wipe dry with a sterile gauze pad. Insert the device according to manufacturer specific directions. Attach primed extension set to needle and secure needle per manufacturer instructions. 195

206 Vascular Access 1101 For patients unresponsive to pain: o Rapid flush with 10 ml of normal saline. For patients responsive to pain: o Prime extension set with 2% lidocaine o Slowly administer 2% lidocaine over 120 seconds. Adult 40 mg. Pediatric 0.5 mg/kg (maximum 40 mg). o Allow lidocaine to dwell in IO space 60 seconds. o Rapid flush with 10 ml of normal saline. o Slowly administer a subsequent ½ dose of 2% lidocaine over 60 seconds. Adult 20 mg. Pediatric ½ the initial dose (maximum 20 mg). Connect fluids to extension set using IV tubing infusion may need to be pressurized to achieve desired rate. Dress site and secure tubing. 5. Possible Complications: Infiltration of fluids/drugs into the subcutaneous tissue due to improper placement. Cessation of the infusion due to clotting in the needle, or the bevel of the needle being lodged against the posterior cortex. Osteomyelitis or sepsis. Fluid overload. Fat or bone emboli. Fracture. 6. S-SV EMS Agency Approved IO Devices: NIO tm EZ-IO. Manual IO device bone marrow type needles, 15 and 18 gauge size. D. Preexisting Vascular Access Device (PVAD) 1. Paramedic personnel may access the following types of PVADs on any patient who is in extremis and no other vascular access is available or appropriate: Indwelling catheter/device exiting externally inserted into the superior vena cava or right atrium (Broviac, Hickman, PICC and others). Hemodialysis shunt (fistulas/grafts). Note: Access that is subcutaneous requiring entry through the skin and special equipment to access is not approved for use by prehospital personnel. 196

207 Vascular Access Indications: In the absence of any other observable vascular access, when the patient has one or more of the following: Cardiopulmonary arrest. Extremis due to circulatory shock. Critical need for pharmacological intervention. 3. Complications: Infection: Due to the location of the catheter, strict adherence to aseptic technique is crucial when handling a PVAD. o Use of sterile gloves is recommended. o Prep injectable port and surrounding skin with chlorhexidine prior to attaching I.V. tubing. o Use new supplies if equipment becomes contaminated. o Re-cover port with sterile dressing and securely tape. Air Embolism: The PVAD provides a direct line into the central circulation; introduction of air into these devices can be hazardous. 4. Approved Infusions: Intravenous solutions. All medications except diazepam (Valium) as it interacts with silicone causing crystallization of the medications and deterioration of the silicone. 5. Procedure: Do not remove injection cap from catheter. Do not use a syringe smaller than 10 ml to prevent catheter damage from excess infusion pressure. Always expel air from syringe prior to administration. Follow all medications with 5 ml of saline to avoid clots. Do not inject medications or fluids if resistance is met when establishing patency. Do not allow I.V. fluids to run dry. Do not manipulate or remove an indwelling catheter under any circumstances. Should damage occur to the external catheter, clamp immediately between the skin exit site and the damaged area to prevent air embolism or blood loss. 197

208 Vascular Access 1101 IO Insertion Site Instructions Proximal Tibia Adults Extend the leg - insertion site is approx. 3 cm (2 finger widths) below the patella and approx. 2 cm (1 finger width) medial, along the flat aspect of the tibia. Proximal Tibia Infants & Small Children Extend the leg - insertion site is just below the patella, approx. 1 cm (1 finger width) and slightly medial, approx. 1 cm (1 finger width) along the flat aspect of the tibia. Pinch the tibia between your fingers to identify the center of the medial and lateral borders. Distal Tibia Adults Approx. 3 cm (2 finger widths) proximal to the most prominent aspect of the medial malleolus. Palpate the anterior and posterior borders of the tibia to assure that your insertion site is on the flat center aspect of the bone. Distal Tibia Infants & Small Children Approx. 1-2 cm (1 finger width) proximal to the most prominent aspect of the medial malleolus. Palpate the anterior and posterior borders of the tibia to assure that your insertion site is on the flat center aspect of the bone. 198

209 Vascular Access Distal Femur Infants & Small Children Secure the leg out-stretched to ensure the knee does not bend. Identify the patella by palpation. The insertion site is just proximal to the patella (maximum 1 cm) and approximately 1-2 cm medial to midline Humerus Adult Only Place pts hand over the abdomen (elbow adducted and humerus internally rotated). Place your palm on the pts shoulder anteriorly. o The area that feels like a ball under your palm is the general target area. o You should be able to feel this ball, even on obese pts, by pushing deeply. Place the ulnar aspect of one hand vertically over the axilla. Place the ulnar aspect of the opposite hand along the midline of the upper arm laterally. Place your thumbs together over the arm this identifies the vertical line of insertion on the proximal humerus Palpate deeply as you climb up the humerus to the surgical neck. o It will feel like a golf ball on a tee the spot where the ball meets the tee is the surgical neck. o The insertion site is on the most prominent aspect of the greater tubercle, 1 to 2 cm above the surgical neck.

210 Sierra Sacramento Valley EMS Agency Program Policy Advanced Airway Management Effective: 12/01/2017 Next Review: 07/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To establish guidelines/requirements for advanced airway management by prehospital personnel in the S-SV EMS region. AUTHORITY: POLICY: A. California Health and Safety Code and B. California Code of Regulations, Title 22, Division 9. A. Prehospital personnel must weigh the benefit of advanced airway placement against the adverse effects of interrupting chest compressions in a cardiac arrest patient. If BVM ventilation is adequate, prehospital personnel may defer insertion of an advanced airway until the patient fails to respond to initial CPR and defibrillation or until spontaneous circulation returns. B. Advanced airway patency must be confirmed with physical assessment in addition to one or more of the following ETCO2 monitoring methods: 1. Waveform capnography (preferred). 2. Esophageal detection device (EDD) and Capnometer. 3. Esophageal detection device (EDD) and colorimetric CO2 detector. C. Paramedic/AEMT personnel must confirm advanced airway patency on any patient where the airway has been established by an EMT, and assume responsibility for the advanced airway once they have established patient care. D. Paramedic/AEMT personnel who establish an advanced airway shall accompany the patient to the hospital if transported. This requirement does not apply to multiple patient incidents or when patient care is transferred to a specialty provider (EMS aircraft, etc.). If patient care is transferred, receiving personnel must re-confirm advanced airway patency immediately upon transfer. 200

211 Advanced Airway Management 1104 E. Advanced airway patency must be confirmed any time there is concern about the patency of the airway or when there is a movement of the patient. F. If the advanced airway is determined to no longer be patent, appropriate measures must be immediately taken to establish the patency of the airway. This may include removal of the advanced airway and utilization of BLS airway measures until an advanced airway can be established. Prehospital personnel shall confirm that the advanced airway remains patent when the patient is transferred from the ambulance gurney to the hospital gurney, and any concerns must be reported immediately to the receiving ED physician. PROCEDURE: A. General Advanced Airway Utilization Procedures: The following procedures should be utilized for the placement of advanced airway devices based on specific patient condition and circumstances: 1. If possible, pre-oxygenate with high flow O2 via NRM or BVM as appropriate for three (3) minutes. 2. Apply high flow NC (10 15 L/min) in addition to NRM or BVM to augment preoxygenation. 3. Position patient in a semi-recumbent or reverse trendelenburg position if possible. 4. Continue utilizing passive oxygenation via NC during intubation attempts. 5. Perform jaw thrust to maintain pharyngeal patency and apply airway. B. Suspected Head/Brain Injury: 1. Consider prophylactic lidocaine for suspected head/brain injury patients. 2. Lidocaine (1.5mg/kg IV/IO) should be administered three (3) minutes prior to intubation whenever possible. C. Orotracheal Intubation and King Airway Device: 1. Indications: Cardiac arrest. Respiratory arrest or severe compromise and unable to adequately ventilate with BVM. 201

212 Advanced Airway Management Relative Indications: Sustained altered mental status with a Glasgow Coma Scale Score 8. Impending airway edema in the setting of respiratory tract burns or anaphylaxis. 3. King Airway Contraindications: Patients under four (4) feet tall. Pediatric patients ( 14 years old). Responsive patient with an intact gag reflex. Patients with known esophageal disease. Patients who have ingested a caustic substance. 4. Notes: A King airway device may be utilized as a primary airway, or after unsuccessful intubation attempts. An intubation attempt is defined as the introduction of an ET tube past the teeth. Make no more than two (2) total attempts per patient at placing an endotracheal tube. Each attempt should last no longer than 30 seconds. Ventilate with 100% oxygen for a minimum of one (1) minute prior to each attempt. Consider utilizing an ET tube introducer for patients with a difficult airway (e.g., suspected spinal injuries, supraglottic or laryngeal edema present, epiglottis can be visualized but vocal cords cannot). If orotracheal intubation is unsuccessful, a King airway device shall be utilized if an advanced airway remains necessary. King airway sizing: o Size 3 Patient between 4 and 5 feet tall (55 ml air). o Size 4 Patient between 5 and 6 feet tall (70 ml air). o Size 5 Patient over 6 feet tall (80 ml air). D. Nasotracheal Intubation: 1. Indications: Hypoxia/hypoventilation refractory to non-invasive airway and respiratory management. Oral anatomy, injury, or jaw clenching preventing orotracheal intubation. Patient nare is able to accommodate size 6.0 or 7.0 Endotrol ET tube. 2. Relative Indications: Sustained altered mental status with a Glasgow Coma Scale Score 8. Impending airway edema in the setting of respiratory tract burns or anaphylaxis. 202

213 Advanced Airway Management Contraindications: Apnea. Pediatric patients ( 14 years old). Suspected basilar skull fracture. Mid-facial injuries with bony instability. Combativeness preventing patient compliance. Anticoagulant use (relative). Orotracheal intubation preferred. E. Needle Cricothyrotomy: 1. Indications: Inability to maintain the airway with standard airway procedures (e.g., BVM ventilation, endotracheal/nasotracheal intubation, King Airway). Typically involves patients with pathologic processes that cause distortion of the upper airway anatomy, including one or more of the following: Airway obstruction by uncontrolled bleeding into the oral cavity and/or vomiting. Severe maxillofacial trauma - blunt, penetrating, or associated with mandibular fracture. Laryngeal foreign body that cannot be removed expeditiously. Swelling of upper airway structures. Infection (e.g., epiglottitis, Ludwig's angina). Allergic reaction or hereditary angioedema. Chemical or thermal burns to the epiglottis and upper airway 2. Contraindications: Age < 3 years or estimated weight < 15 kg. Ability to maintain airway utilizing less invasive procedures. Conscious patient. Moving ambulance Patient has a midline neck hematoma or massive subcutaneous emphysema. F. Advanced Airway Placement Confirmation: 1. If waveform capnography is not available, an esophageal detection device (EDD) shall be used prior to ventilating through the advanced airway device. 2. While ventilating, auscultate both lung fields for breath sounds and confirm chest rise. Listen over left upper quadrant of the abdomen for air in the stomach. 203

214 Advanced Airway Management Attach an ETCO2 monitoring device which must remain in place until arrival at the hospital. Waveform capnography shall be used if available. 4. All devices used to confirm advanced airway placement must be documented on the PCR. G. If the patient regains consciousness while the advanced airway is in place, do not remove the advanced airway. Use restraints as necessary and consider sedation with Midazolam 5 mg IV/IO OR 10 mg IM/IN for adult patients ( 15 years old). 204

215 Sierra Sacramento Valley EMS Agency Program Policy Mechanical Chest Compression Devices Effective: 06/01/2017 Next Review: 05/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: A. Define the approval process for utilization of mechanical chest compression devices in the S-SV EMS region. B. Identify the mechanical chest compression devices approved for use in the S-SV EMS region. C. Establish the criteria for EMS personnel training and utilization of approved mechanical chest compression devices in the S-SV EMS region. AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5. B. California Code of Regulations, Title 22, Division 9. A. EMS provider agencies shall obtain S-SV EMS approval prior to utilizing a mechanical chest compression device in the S-SV EMS region. The request for approval shall include the following minimum information: 1. A letter of request for approval from a chief officer, including justification of the need to utilize the device(s). 2. Proposed number and type of devices to be utilized. 3. Device funding source. 4. Geographical location(s) where the device(s) will be utilized. 5. Anticipated annual number of incidents when the device(s) will be utilized. 6. Proposed initial and ongoing training program, including the anticipated number of personnel to be trained on the use of the device(s). 205

216 Mechanical Chest Compression Devices Proposed plan for notifying appropriate allied agencies and hospitals of the device(s) use prior to implementation. 8. A copy of the provider s Continuous Quality Improvement Program (CQIP), including information on the CQI monitoring of the use of the mechanical chest compression device(s). B. S-SV EMS shall have sole discretion on device approval which will be determined on an individual applicant basis. Approval considerations will be based on the following criteria: 1. Geographical location. 2. EMS response and transport times. 3. Manpower. 4. Anticipated utilization. 5. Device funding source. 6. Personnel maintenance of skills and QI. 7. Other considerations deemed appropriate by the S-SV EMS Agency. C. The following mechanical chest compression devices have been approved for use in the S-SV EMS region: 1. Physio Control LUCAS 2 Chest Compression System. 2. Zoll AutoPulse. D. EMS personnel may utilize an approved mechanical chest compression device for patients in cardiac arrest under the following conditions: 1. They are employed by and on duty with an EMS provider agency approved by S- SV EMS to utilize the device. 2. They successfully complete the approved training prior to utilizing the device. 3. They follow the indications, contraindications and device application procedure indicated in S-SV EMS Agency Pulseless Arrest Treatment Protocols. 4. They accompany any patient who the device is utilized on to the hospital (if transported), even if they are not the primary patient care provider. 206

217 Mechanical Chest Compression Devices 1106 E. Mechanical chest compression device maintenance: 1. All mechanical chest compression device approved providers shall have a maintenance program for the device. 2. The periodic preventative maintenance of all devices shall meet or exceed the criteria recommended by the manufacturer. 3. Individuals performing scheduled maintenance or repair shall possess the necessary credentials recommended by the manufacturer. 4. Providers shall immediately remove from service any device suspected of malfunctioning and manual CPR shall be resumed if necessary. Any malfunctioning device shall not be placed back into service until properly serviced or repaired by the manufacturer or manufacturer s authorized service program. 5. Any device suspected of malfunctioning, that may have adversely affected patient care shall be: Immediately reported to an on-duty provider agency supervisor. Immediately reported to the RN or physician staff at the receiving facility if the malfunctioning device impacted or has a potential to impact patient health and well-being. Reported to S-SV EMS by the end of the next business day. This report shall include the provider s name, date of incident, type/model/serial number of device, patient s name, incident number, description of the incident, effect on patient care, all actions taken at the time of reporting, and current location of device. Reported to the manufacturer by the end of the next business day. The device malfunction report submitted to the manufacturer shall not include any patient identifiable healthcare information. 6. Device maintenance records shall be subject to review and inspection by S-SV EMS upon request. F. Allied agency/hospital notification: Prior to implementation of the device, approved providers shall notify the appropriate allied agencies and local receiving hospitals of the use of the device. G. Records/Data Collection: 1. A patient care report shall be completed for each patient on whom the device is applied. In addition to data normally recorded on the PCR, the report shall include specific information related to the use of the device, including: 207

218 Mechanical Chest Compression Devices 1106 Time of patient collapse. Was cardiac arrest witnessed? Was bystander CPR performed? Total time of manual CPR prior to device application. Time of device application. Total time of device use. Did patient receive any AED or defibrillation shocks? Did the patient experience return of spontaneous circulation (ROSC) in the prehospital setting? 2. Documentation and data related to the use of the mechanical chest compression device(s) shall be made available to S-SV EMS upon request. H. Quality Improvement: 1. All patient contacts involving the use of the mechanical chest compression device shall undergo chart review by provider QI personnel. Chart review shall include evaluation for appropriate clinical use and adherence to S-SV EMS policies and treatment protocols. 2. Any concerns or issues involving the use of the mechanical chest compression device shall be reported to S-SV EMS as soon as possible. I. Prohibited Use: Any EMS provider use of a mechanical chest compression device outside the limitations of this policy are prohibited and shall be reported to S-SV EMS as soon as possible. CROSS REFERENCES: A. Prehospital Documentation (605). B. Continuous Quality Improvement Program (620). C. Pulseless Arrest (C-1). 208

219 Sierra Sacramento Valley EMS Agency Program Policy Prehospital Blood Draws Effective: 12/01/2017 Next Review: 11/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: To allow Advanced EMT (AEMT) and paramedic personnel to perform prehospital venous blood draws on patients for medical reasons or for the purpose of chemical testing as indicated in this policy. AUTHORITY: POLICY: A. California Health and Safety Code, Division 2.5, and B. California Code of Regulations, Title 22, Division 9, Chapter 3 & 4. C. California Code of Regulations, Title 17, D. California Vehicle Code A. When an agreement has been established with a receiving hospital, venous blood draws may be performed by AEMT or paramedic personnel for the following medical reasons: 1. Suspected drug overdose. 2. Unconscious patient, unknown cause. 3. Suspected STEMI or stroke. B. At the direction of a peace officer, venous blood draws may be performed by paramedic personnel for the purpose of chemical testing from persons suspected of driving under the influence under the following circumstances: 1. As indicated in California Vehicle Code, (k), paramedic employees of a fire department are not approved to perform venous blood draws for the purpose of chemical testing. 209

220 Prehospital Blood Draws 1108 PROCEDURE: 2. Paramedic personnel shall not withdraw blood for this purpose unless authorized by his or her employer to do so. 3. An emergency call for EMS services takes precedence over a peace officer s request for a paramedic to withdraw blood. 4. At no time will a peace officer s request for a blood draw for the purpose of chemical testing take precedence over the medical treatment of a patient. A. Select and utilize appropriate blood-drawing devices. B. If drawing blood from an IV, attach blood draw adapter to the hub of the IV catheter and draw blood sample immediately after establishing venous access, prior to IV fluid administration. C. If drawing blood without an IV, select vein and prep site with an appropriate disinfectant agent (note special instructions for chemical testing, as indicated under item H below). D. Allow tubes to fill under their own vacuum. E. Blood tubes for medical reasons shall be drawn in the following order: 1. Blue. 2. Red. 3. Green. 4. Purple. F. After drawing the blood, samples shall be labeled with the following minimum information: 1. Patient name and date of birth. 2. Date and time drawn. 3. EMS unit number. G. Place filled/labeled tubes used for medical blood draws in an appropriate specimen collection bag and turn them over to the receiving RN when you arrive at the hospital. 210

221 Prehospital Blood Draws 1108 H. Special procedures for drawing blood at the request of a peace officer for the purpose of chemical testing: 1. Suspects shall be in law enforcement custody and shall consent to the blood draw. If the suspect refuses or is unable to consent to the blood draw for any reason, the paramedic shall stop the procedure immediately and document such. Paramedics shall not draw blood on a struggling or restrained suspect. The suspect must be cooperative. 2. Blood draw kits shall be supplied by the requesting law enforcement agency. 3. The blood draw procedure will be performed based on standard practice listed in this policy with the following exception: Alcohol or other volatile organic disinfectant shall not be used to clean the skin where a specimen is to be collected. Aqueous benzalkonium chloride (zephiran). Aqueous merthiolate or other suitable aqueous disinfectant (normally included in the blood draw kit supplied by law enforcement) shall be used. 4. The arresting officer must be present when the blood draw is performed. 5. The obtained blood sample will be the property of the arresting officer. I. Documentation: 1. Blood draws performed on patients for medical reasons will be documented appropriately on the patient care record. 2. The following minimum information shall be documented on the patient care record for all blood draws performed on suspects for the purpose of chemical testing: Incident number. Date and time of incident. Incident location or where the blood draw procedure is being performed (i.e. police station, etc.). Suspect or patient name, age and gender. Brief narrative including the requesting peace officers name and badge number, suspect s or patient s consent for the procedure, kit number, skin preparation used, and site of blood draw(s). 211

222 Sierra Sacramento Valley EMS Agency Program Policy ALS/LALS Annual Infrequently Used Skills Verification And Regional Training Module Effective: 12/01/2017 Next Review: 09/ Approval: Troy M. Falck, MD Medical Director Approval: Victoria Pinette Executive Director SIGNATURE ON FILE SIGNATURE ON FILE PURPOSE: A. To identify medical procedures (skills) utilized infrequently by ALS/LALS personnel in the prehospital setting, and provide a standardized method for annual evaluation of all S-SV EMS certified AEMT s and accredited paramedic s ability to safely, efficiently and adequately perform them. B. To establish a standardized method of ensuring that appropriate education and training is provided to all ALS/LALS prehospital personnel in the S-SV EMS region on a regularly scheduled basis. AUTHORITY: A. California Health and Safety Code, Division 2.5, B. California Code of Regulations, Title 22, Division 9, , , , , , and Chapter 12 DEFINITIONS POLICY: A. Infrequently Used Skill Medical procedures that are performed rarely by ALS/LALS personnel in the prehospital setting and/or that may result in serious complications when performed incorrectly. B. Regional Training Module A standardized training module developed by S-SV EMS in conjunction with S-SV EMS Regional Quality Improvement Committee members. A. Prehospital service providers shall verify that every S-SV EMS certified AEMT and accredited paramedic affiliated with their organization has successfully performed all of the skills listed in the applicable Infrequently Used Skills Annual Verification Tracking Sheet (1110-A: AEMT or 1110-B: paramedic) a minimum of once during every 12 month period. Under special circumstances, an extension to the 12 month requirement may be approved by S-SV EMS upon request. 212

223 ALS/LALS Annual Infrequently Used Skills Verification And Regional Training Module 1110 B. All infrequently used skills shall be verified by successful performance in a structured training environment, utilizing the S-SV EMS approved infrequently used skills verification checklists (1110-C through 1110-L). A copy of the completed Infrequently Used Skills Annual Verification Tracking Sheet shall be maintained in the employee s file for a period of not less than four (4) years, and be made available for review by S- SV EMS representatives upon request. The individual infrequently used skills verification checklists are not required to be maintained. C. Skills competency verification shall be conducted by one of the following: 1. Service provider s CQI coordinator or their designee. 2. Service provider s medical director. 3. Base/modified base hospital prehospital coordinator or their designee. D. Regional training modules will be developed and distributed by S-SV EMS on an annual basis. All ALS/LALS service provider agencies are required to deliver these training modules and ensure that their affiliated AEMT and paramedic personnel complete this training no later than the end of the calendar year. PSFA, EMR and EMT personnel are encouraged to complete this training as appropriate, but it is not a mandatory requirement for BLS personnel. Proof of completion of the regional training module (rosters, sign in sheets, etc.) shall be maintained for a minimum if four (4) years, and be made available for review by S-SV EMS representatives upon request. E. Any AEMT or paramedic who is determined to not have current skills verification and/or regional training module completion documentation on file shall not be allowed to function as an AEMT or paramedic in the S-SV EMS region until they complete the required skills verification and/or regional training module. CROSS REFERENCES: A. AEMT Infrequently Used Skills Annual Verification Tracking Sheet (1110-A). B. Paramedic Infrequently Used Skills Annual Verification Tracking Sheet (1110-B). C. Adult Oral Endotracheal Intubation Skills Verification Checklist (1110-C). D. Nasotracheal Intubation Skills Verification Checklist (1110-D). E. King Airway Device Skills Verification Checklist (1110-E). F. Needle Cricothyrotomy Skills Verification Checklist (1110-F). 213

224 ALS/LALS Annual Infrequently Used Skills Verification And Regional Training Module 1110 G. Needle Thoracostomy Skills Verification Checklist (1110-G). H. Adult Cardioversion/Defibrillation Skills Verification Checklist (1110-H). I. Pediatric Cardioversion/Defibrillation Skills Verification Checklist (1110-I). J. Transcutaneous Cardiac Pacing Skills Verification Checklist (1110-J). K. Intraosseous Infusion Skills Verification Checklist (1110-K). L. Multiple Casualty Incident (MCI) Response Procedures Checklist (1110-L). 214

225 Regional EMS Aircraft Resource Guide 215

226 Contact your primary dispatch center to request an EMS aircraft This Helicopter Resource Guide was developed by the EMS Aircraft Committee of the Sierra-Sacramento Valley EMS Agency REVISED APRIL 2017 SIERRA SACRAMENTO VALLEY EMS AGENCY Butte County Colusa County Nevada County Placer County Shasta County Siskiyou County Sutter County Tehama County Yuba County 216

227 TABLE OF CONTENTS PURPOSE... 1 UTILIZATION... 1 ACTIVATION... 3 SAFETY... 4 MULTI-CASUALTY INCIDENT (MCI)... 9 HAZARDOUS MATERIALS (HAZMAT) INCIDENT... 9 CONTACT NUMBERS NORTHERN CALIFORNIA EMS AIRCRAFT GENERAL BASE LOCATIONS MAP

228 PURPOSE The purpose of this handbook is to provide all EMS ground providers standardized guidelines for requesting and utilizing EMS aircraft, within the S-SV EMS region. The primary goal is to minimize loss of life, disability, pain and suffering by ensuring the timely availability of air medical resources in the S-SV EMS region. UTILIZATION A. EMS AIRCRAFT CLASSIFICATIONS: Air Ambulance: Minimum of (2) ALS licensed attendants (normally Paramedic/RN configuration). Generally have an expanded scope of practice. ALS Rescue Aircraft: Primary function is not prehospital emergency medical transport. Minimum of (1) ALS licensed attendant (Paramedic). BLS Rescue Aircraft: Primary function is not prehospital emergency medical transport. Minimum of (1) BLS attendant (EMT). Auxiliary Aircraft: Primary function is not prehospital emergency medical transport. Attendant may or may not have a medical license/certification. B. AIR AMBULANCE: AirLink: CCRN/Paramedic or RRT, Night Vision, VFR AirLink 3 (Klamath Falls), skids, 1 patient capability, side load. Calstar: RN/RN, Night Vision, VFR, IFR Calstar 3 (Auburn), skids, 2 patient capability, rear load. Calstar 6 (South Lake Tahoe), skids, 2 patient capability, rear load. Calstar 1 (Concord), skids, 2 patient capability, rear load. Calstar 12 (Modesto), skids, 2 patient capability, right side load. Care Flight: RN/CCP, Night Vision, VFR, TAWS, NVG Care Flight 1 (Reno), skids, 1 patient capability, left side load. Care Flight 2 (Gardnerville), skids, 1 patient capability, left side load. Care Flight 3 (Truckee), skids, 1 patient capability, left side load. Care Flight 4 (Beckwourth), skids, 1 patient capability, left side load. Enloe Flightcare: CFRN/FP-C, Night Vision, VFR (Chico), skids (with skis for snow landing), 1 patient capability, right side load (primary aircraft), left side load (back-up aircraft). 218

229 LifeNet: RN/Paramedic Night Vision, VFR LifeNet 3-4 (Montague), skids, 1 patient capability, left side load Mercy Flights: CFRN/FP-C, Night Vision, VFR Mercy 105 (Medford, OR), skids, 1 patient capability, left side load. PHI Air Medical: CFRN/FP-C, Night Vision, VFR, IFR Med 4-5 (Susanville), skids, 1 patient capability, left side load. Med 4-3 (Redding), skids, 1 patient capability, VFR, rear load. Med 4-2 (Sonora), skids, 1 patient capability, VFR, side load. Med 4-1 (Modesto), skids, 1 patient capability, IFR, rear load. REACH: RN/Paramedic, Night Vision REACH 7 (Marysville), skids, 1 patient capability, IFR, rear load. REACH 5 (Redding), skids, 1 patient capability, VFR, L side load. REACH 6 (Lakeport), skids, 1 patient capability, VFR, L side load. REACH 17 (Sacramento), skids, 1 patient capability, IFR, rear load. REACH 2 (Stockton), skids, 1 patient capability, VFR, L side load. SEMSA Air 1: CFRN/FP-C, Night Vision, VFR C. AIR RESCUE: Air 1 (Susanville), skids, 1 patient capability, left side load. CHP: Paramedic, Night Vision, VFR, FLIR, Search, Short Haul (1660 Lbs.), External Hoist (450 Lbs.) and technical rescue capable H-20/24 (Auburn), skids, can reconfigure for 1 patient capability, L side load. H-14/16 (Redding), skids, can reconfigure for 1 patient capability, L side load. H-30/32 (Napa), skids, can reconfigure for 1 patient capability, L side load. D. AUXILIARY RESCUE AIRCRAFT: Butte County SO: Regularly staffed May October, otherwise on call 24/7 H-1 and Bravo-1: Short haul, NVG, day & night rescue, 1 patient capability. CAL FIRE: Available during fire season only Vina and Columbia: Short haul, 1 patient capability. Sacramento Metro Fire Department: SAR, external hoist (600 lb.) Fire Copter 1 (Sacramento), 1 patient capability. 219

230 ACTIVATION A. EMS aircraft shall be requested by the Incident Commander (IC), or designee. The request for EMS aircraft shall be made through the IC or designee s primary dispatch. B. An S-SV EMS designated EMS air ambulance coordination center shall be utilized as the coordination center for emergency 911 incidents. C. If more than one (1) patient is identified as needing EMS aircraft transport, multiple EMS aircraft may be requested. D. If needed, request EMS aircraft early or anticipate need for additional EMS aircraft resources to allow sufficient time for response. Requests for EMS aircraft resources may be canceled at any time. E. If public agencies are not available for Search and Rescue (SAR), consider requesting/utilizing an air ambulance. Air ambulances will maintain availability for other EMS calls and their SAR time is limited. F. Based upon the best available evidence, the Greater Sacramento Area Trauma Quality Improvement Committee recommends that patients undergoing active CPR should not be transported by air ambulance to a receiving facility. G. Patients with partial or complete amputation requiring re-implantation or patients requiring hyperbaric treatment must be evaluated at the local hospital prior to being transported to a specialty center. 220

231 SAFETY NEVER APPROACH THE AIRCRAFT WITHOUT THE SIGNAL FROM THE PILOT OR FLIGHT CREW TO COME FORWARD. A. SAFETY ZONES: Safe Zone The two areas at each side of the helicopter s main body the area in full view of the pilot and flight crew. Caution Zone The area that extends from the pilot forward. Hazard Zone The area extending rearward from the main body to the tail rotor. This area should always be avoided and be clear of people, obstacles, and debris. B. EMERGENCY LANDING ZONE (ELZ) REQUIREMENTS: Setting up a SAFE landing zone will insure the safety of the critical care crew as well as all individuals on the ground. 1. Emergency Landing Zone (ELZ) Day and Night: 100 ft x 100 ft or 100 ft in diameter. 2. ELZ area should be a firm, flat landing surface free of obstacles, hazards, and debris. Be prepared for mph winds from rotor wash that would cause debris to be blown around. Consider FIRE POTENTIAL! Always coordinate landing efforts with pilot. 3. If watering a site is required, attempt to use as little as possible to achieve the task. If the ELZ is too slippery to walk in comfortably, it is too slippery to operate in safely. 221