EL DORADO COUNTY EMS AGENCY FIELD POLICIES

Transcription

1 EL DORADO COUNTY EMS AGENCY FIELD POLICIES Effective: July 1, 2017 Reviewed: February 8, 2017 Revised: February 8, 2017 EMS Agency Medical Director ALS UNIT MINIMUM EQUIPMENT INVENTORIES PURPOSE: A standardized inventory control program will ensure that effective levels of ALS equipment and medications are maintained and carried on approved ALS units. DEFINITIONS: Minimum Equipment Inventory - A minimum inventory of equipment and medication that is required to be carried on approved Advanced Life Support (ALS) units. More equipment may be carried if deemed appropriate by an ALS contractor. ALS Transporting Unit Means an ALS ambulance that is capable of transporting patients. ALS Non-Transporting Unit Means an engine, squad, truck, or other type of response unit that is capable of providing full ALS on a full or part time basis. ALS Assessment Unit Means an engine, squad, truck, or other type of response unit that is capable of providing limited ALS on a full or part time basis. POLICY: 1) The EMS Medical Director has the authority to set the minimum standard for ALS equipment and medications that are to be maintained. This standard shall meet State and local policies, protocols and regulations, and shall ensure the capability to provide an ALS level of patient care. Each ALS provider shall implement an inventory control program to ensure that all ALS units have appropriate ALS equipment and that medications are stocked to at least the minimum level inventory required. 2) When determining what inventory your unit(s) will carry, keep in mind the potential for multiple patients and/or multiple calls before restocking. For non-transporting and assessment units this limited inventory may necessitate restocking from the ALS transporting unit prior to transport of the patient in order for the non-transporting unit to stay in-service. 3) Records of daily inventory shall be retained by the ALS contractor for a minimum of twenty-four (24) months. 4) For non-transporting and assessment units: Contractors with issues in regards to controlled substances (morphine sulfate, Fentanyl, and midazolam) may request an exception to this equipment inventory by submitting a letter to the EMS Agency Medical Director requesting that they not be required to carry morphine sulfate or midazolam. This letter must describe the reason(s) that the contractor desires to exclude these medications from their inventory. The EMS Agency Medical Director will either approve or deny the exception and will notify the contractor in writing of his or her decision.

2 ALS TRANSPORTING UNIT ALS NON- TRANSPORTING UNIT ALS ASSESSMENT UNIT ALS UNIT MINIMUM EQUIPMENT INVENTORIES AIRWAY Needle Thoracotomy Kits Consisting of: 3 1/4 10 Gauge Cath (For adults) 2 14 Gauge Cath (For pediatrics) Chlorhexidine Prep/Swab Needle Cricothyroidotomy Kits Consisting of: ENK Flow Modulator Reinforced Gauge Cath (At least 2 ½ long) Chlorhexidine Prep/Swab 5 ml Syringe Normal Saline Acorn or Vial Twill Tape 1 N/A N/A Main Oxygen Tank w/2 Flow Meters (Minimum oxygen level of 750 PSI) Portable Oxygen Tanks (Minimum oxygen level of 500 PSI) Portable Oxygen Regulator 2 Opt. Opt. Oxygen Humidifier 1* 1* Opt. N2O2/CPAP Adapter (Pigtail) * Optional if N202 not used and disposable CPAP is used Adult BVM w/mask &O2 Supply Tubing Child BVM w/mask & O2 Supply Tubing Infant BVM w/mask & O2 Supply Tubing 2 1 Opt. Peep Valves Adult Nasal Cannulas 2 1 Opt. Pediatric Nasal Cannulas Adult Non-Rebreather Masks Pedi Non-Rebreather Masks 2 1 Opt. Infant Non-Rebreather Masks 2 1 Opt. AeroEclipse Nebulizers Nebulizers for Inhaled Meds 2* 1* Opt. Nebulizer Mask (*optional if non-re-breather mask can be converted to nebulizer mask) 2 1 Opt. Nebulizer BVM Adapters Key: Opt. = Optional N/A = Not applicable * = See notes for special information 2

3 ALS TRANSPORTING UNIT ALS NON- TRANSPORTING UNIT ALS ASSESSMENT UNIT ALS UNIT MINIMUM EQUIPMENT INVENTORIES AIRWAY continued Intubation Kit(s) Consisting of: Oropharyngeal Airways Sizes #1 thru #6 Nasopharyngeal Airways Sizes 20 FR 36 FR Uncuffed Endotracheal Tubes Sizes (including half sizes) Cuffed Endotracheal Tubes Sizes (half sizes are optional) Endotrol Endotracheal Tubes Sizes 6.0, 7.0, and 8.0 Adult Laryngoscope Handle (pediatric sized handle is optional) Full Set of Disposable Laryngoscope Blades (straight and curved) ml Syringe Stylettes (1 adult and 1 pediatric) 2 ET Securing Devices Magil Forceps (1 adult and 1 pediatric) Spare Laryngoscope Batteries (1 set for each handle) BAAM Device 4 Water Soluble Lubricating Jelly Packets End Tidal CO2 Detectors (1 adult and 1 pediatric)) ET Tube Introducer (ETTI)/Bougie Opt. Opt. Opt. Video Intubation Device (Non-brand specific) King Airway Device Set Consisting of: King LT or LTS-D Airways in sizes 2, 2.5, 3, 4*, & 5* Water based lubricant 60 cc or 90 cc syringe (If a 60 cc syringe is used, multiple fillings may be required) Pulse Oximeter 1 Opt. Opt. Spare SPO2 Sensor 2 Opt. Opt. Pedi Pulse Oximetry Sensors Opt. Opt. Opt. Nitrous Delivery System: 1 Matrx Unit/ 1 Mask/ 5 Mouthpieces 1* 1* Opt. O2 Max (Pulmodyne ) Fixed System Or Equivalent Single Use Disposable Model With prepackaged nebulizer kit 1* 1* Opt. Male Adapted Oxygen Hose (*Not req. if disposable model is used) Key: Opt. = Optional N/A = Not applicable * = See notes for special information 3

4 ALS TRANSPORTING UNIT ALS NON- TRANSPORTING UNIT ALS ASSESSMENT UNIT ALS TRANSPORTING UNIT ALS NON- TRANSPORTING UNIT ALS ASSESSMENT UNIT ALS UNIT MINIMUM EQUIPMENT INVENTORIES SUCTION 1 NA NA On Board Suction Unit 1 1 Opt. Battery Operated Portable Suction Unit 3 Opt. Opt. Spare Suction Canisters/Bags W/ Lids 3 1 Opt. Suction Connecting Tubing 3 1 Opt. Yankauer/Tonsil Tip Catheters 2 1 Opt. #10 French Suction Catheters 2 1 Opt. #14 French Suction Catheters 2 1 Opt. #16 French Suction Catheters 1 1 Opt. Meconium Aspirator 1 1 Opt. 60 cc Syringe (Luer tapered style tip) 2 1 Opt. #8 French Pediatric Feeding Tubes 2 Opt. Opt. #14 French Salem Sump NG Tube Opt. Opt. 1* Hand Held Suction Device (*Optional if battery powered suction is carried) EKG 1 Opt. Opt. 12 Lead/ETCO2 Capable Biphasic Monitor/Defibrillator w/pacing (Test to manufacturers specifications) N/A 1 1 Biphasic Monitor/Defibrillator w/pacing (Test to manufacturers specifications ) 1 Opt. Opt. 12 Lead Cables ECG Leads (Cables) Spare ECG Paper Adult Electrode Sets Pediatric Electrode Sets Pedi Multi-Function Defibrillation/Pacing Pads Spare Monitor Batteries 1 Opt. Opt. ETCO2 Set (cable and adult and pediatric adapters) Key: Opt. = Optional N/A = Not applicable * = See notes for special information 4

5 ALS TRANSPORTING UNIT ALS NON- TRANSPORTING UNIT ALS ASSESSMENT UNIT ALS UNIT MINIMUM EQUIPMENT INVENTORIES IV Normal Saline IV Solutions 1000 ml Opt. Opt. Opt. Normal Saline IV Solution 100 ml IV Administration Sets (Macro-Drip) Opt. Opt. Opt. Adjustable IV drip tubing may be used in lieu of macro/micro drip tubing. If used, the inventory of all drip tubing may be reduced by 50%. 2 1 Opt. IV Administration Sets (Micro-Drip) Saline Locks 2 Opt. Opt. Buretrol Sets (150 ml each) Normal Saline Vials or Preloaded Syringes 5-10mL 2 Opt. Opt. Dial-A-Flows 2 Opt. Opt. 3 Way Valve w/extensions Blood Tube Sets Vacutainer Barrels Vacutainer Luer Adapters Blood Glucose Meter (Calibrate weekly and upon opening a new box of test strips) Box of Glucose Meter Test Strips Glucose Meter Testing Solution (High and Low) Must be replaced 90 days after initial opening Lancets Isopropyl Alcohol Preps Chlorhexidine Preps/Swabs Prep Razors Penrose Drains/Tourniquets (Latex Free) Rolls of Transpore Tape Sterile IV Site Covers 6 2 Opt. 14 ga. IV Catheters ga. IV Catheters ga. IV Catheters ga. IV Catheters ga. IV Catheters 1.25 Opt. Opt. Opt. 23 ga. Butterfly Catheter Key: Opt. = Optional N/A = Not applicable * = See notes for special information 5

6 ALS UNIT MINIMUM EQUIPMENT INVENTORIES Opt. Opt. Opt. 25 ga. Butterfly Catheter 1 1 1* 4 2 Opt. Twin Catheters ml Syringes ml Syringes ml Syringes ml Syringes 3 1 Opt. 20 ml Syringes IO Kit (Either Brand): 1 EZ-IO Bag with the Following Supplies: 1 EZ-IO Driver 2 EZ-IO LD Needles (Large Adult) 2 EZ-IO Adult Needles 2 EZ-IO Pediatric Needles 2 EZ-Connect Tubings 1 Pressure Bag 1 Lidocaine HCI 2%/100 mg. Pre-Load (Recommended) 2 10 ml Normal Saline Preloaded Syringes (Recommended) 1 EZ-IO Wristband 4 Chlorhexidine Preps/Swabs 2 Sterile 4x4 Dressings 1 EZ-Stabilizer *Assessment units may use EZ-IO needle manually without the driver and only carry one of each needle size and other supplies * 18 ga. Transfer or Injection Needles *Assessment units may carry either 18 or 20 ga. 4 2 Opt. 20 ga. Transfer or Injection Needles 5* 2* Opt.* Filter Needles in Assorted Sizes (*mandatory if carrying ampules) MAD Intranasal Atomizers Key: Opt. = Optional N/A = Not applicable * = See notes for special information 6

7 ALS TRANSPORTING UNIT ALS NON- TRANSPORTING UNIT ALS ASSESSMENT UNIT ALS UNIT MINIMUM EQUIPMENT INVENTORIES MEDs 147 ml (5 oz) 100 G 36 mg 15 mg Opt. Opt. Acetaminophen 160 mg/5ml (Liquid ) 50 G 18 mg 5 mg Opt. 6 mg Opt. Activated Charcoal (without Sorbitol) Adenocard Albuterol Sulfate Albuterol / Atrovent Mixed (DuoNeb) 1200 mg 1 bttl 3 mg 16 mg 2 G 450 mg 1 bttl 2 mg 8 mg 1 G 300 mg 1 bttl 1 mg Opt. Opt. Amiodarone in 150 mg Preloaded Syringes or 3 ml Vials Aspirin (Chewable 80 mg.) Atropine Sulfate/1 mg. Pre-Load Syringes Atropine Sulfate/8 mg. Vial Calcium Chloride 10%/1 G. Pre-Load Syringes Opt. Opt Opt. 50% Dextrose/25 G. Pre-Load Syringes % Dextrose/25G (250cc NS) G G G Diphenhydramine 50 mg Vials or Pre-load Syringes mg mg mg 2 1 Opt. Dopamine 400 mg in 250 ml (Plus Drip Chart) bags bag Epinephrine 1:10,000 Pre-Load Syringes 1 mg/10 ml Epinephrine 1:1000 Multi-Dose 30 ml Vials (*may use ampules) Fentanyl (100 mcg/2 ml Carpujets or vials) (*Optional w/ Medical Director s mcg mcg* mcg* approval) Glucagon 120 ml Opt. Opt. Ibuprofen 100 mg/5ml (4 oz) Opt. Opt. Opt. Inhalation Solution In 3 ml Acorns/Pillows (must have saline in 10 cc syringes) Lidocaine HCI 2%/100 mg. Pre-Load Opt. Lidocaine Viscous* 2%/15 ml (*Lidocaine Jelly 2% may be substituted) 6 2 Opt. Magnesium Sulfate mg mg mg mg ml mg mg mg mg ml mg mg* mg mg Key: Opt. = Optional N/A = Not applicable * = See notes for special information 7

8 ALS TRANSPORTING UNIT ALS NON- TRANSPORTING UNIT ALS ASSESSMENT UNIT ALS TRANSPORTING UNIT ALS NON- TRANSPORTING UNIT ALS ASSESSMENT UNIT ALS UNIT MINIMUM EQUIPMENT INVENTORIES g 24 mg g 8 mg* 8 mg* Morphine Sulfate (Supplied in 4 mg Carpujets) (*Optional w/ Medical Director s approval) ONLY REQUIRED IF FENTANYL IS NOT AVAILABLE MEDs continued Narcan mg mg mg Neosynephrine Spray (up to a 1% solution) Nitroglycerine 1/150 SL Spray or Tablets bttl bttl bttl 3 1 Opt. Nitro Bid Ointment (NTG Paste) 2% (30g tube or 1g packets) G G Opt. Opt. Opt. Nitronox (*at least one completely full) Opt. Ondansetron Oral Dissolving Tablets (4 mg or 8 mg each) Ondansetron Vials or Pre-load Syringes 4 mg/2 ml Oral Glucose 15 g Opt. Sodium Bicarbonate/50 meq. Pre-Load Syringes Versed (5 mg/ml concentration) (*Optional w/ Medical Director s approval) mg mg G meq mg mg mg G meq mg* mg G mg* INFECTION CONTROL 1* 1* 1* Hepa (P100) Masks. N95 mask may also be carried, but a minimum of one P100 mask *PER EMT-P is required for high level procedures such as intubation Disposable Gowns Hand Cleaner Bottle/ Wipes 2 1 Sharps Containers Protective Eye Glasses Per Paramedic Opt. Opt. Opt. Spit Sock Hood 1 Opt. Opt. Disinfectant Spray Large Bio-Hazard Bags 2 sets Opt. Opt. Non-Latex Sterile gloves ( XL, L, M) Non-Latex gloves only Non-Latex Protective Gloves (*1 box sized for each crewmember) Non-Latex gloves only Emesis Bag/Basin 1 Opt. Opt. Post Exposure Kit, containing: 2 Red Top and 1 Purple Top Blood Tube(s), and set of instructions Key: Opt. = Optional N/A = Not applicable * = See notes for special information 8

9 ALS TRANSPORTING UNIT ALS NON- TRANSPORTING UNIT ALS ASSESSMENT UNIT ALS UNIT MINIMUM EQUIPMENT INVENTORIES TRAUMA Sterile 4x4 Dressings 4 Opt. Opt. Non-Sterile 4x4 Dressings stack Roller Gauze Combine Dressings 5 x Multi Trauma Dressings Petroleum Gauze Adhesive Bandages QuickClot Combat Gauze Z-Fold Dressing or QuickClot 1 st Response TM 5 clotting sponge dressing pack Israeli/Pressure Bandage 4 (without mobile pad) 1 box 1 1 Triangular Bandages Burn Kit consisting of: *Face Mask *2 - Sheets *2-15 x20 Dressings 1 1* 1* 2-12 x15 Dressings 2-12 x12 Dressings *Only items with an asterisk are required on non-transporting and assessment units ml Sterile Irrigation Solution Cloth Tape Rolls Elastic Bandages Trauma Shears Tourniquet (SWAT-T, C-A-T, or SOF Tactical Tourniquets are approved brands) Hot Packs Cold Packs Backboards 1 Opt. Opt. Scoop Stretcher X-Collar (or equivalent) Infant Cervical Collars Head Immobilizer Sets Backboard Straps 1 Opt. Opt. KED 2 Opt. 1 Sam Splints 2 2 Opt. Cardboard Arm Splints 2 2 Opt. Cardboard Leg Splints Adult Traction Splint (Sager, Hare, or Kendrick) 1 1 Opt. Pediatric Traction Splint (Kendrick Traction Device) 1 Opt. Opt. Pediatric Immobilizer Opt.* Opt. Opt. Pelvic Immobilization Device (T-Pod or SAM Sling) * Required if no linen sheet. Opt Opt. Opt. Full or Half Body Vacuum Splint Key: Opt. = Optional N/A = Not applicable * = See notes for special information 9

10 ALS TRANSPORTING UNIT ALS NON- TRANSPORTING UNIT ALS ASSESSMENT UNIT ALS UNIT MINIMUM EQUIPMENT INVENTORIES MISCELLANEOUS OB Kit Penlight 2 NA NA Blankets 6 NA NA Sheets 1 NA NA Pillow 4 NA NA Pillow Cases Opt. NA NA Rain Cover 2 2 Opt. Emergency/CHP Blankets 1 NA NA Bedpan 1 NA NA Urinal 2 NA NA Soft Restraint Sets 1 NA NA Hard Leather or Other Hard Padded Restraint Set 1 NA NA Med Net Radio Opt. Opt. Opt. Stuffed Animal MCI Triage Kit Consisting of: MEDIC UNIT 1- Triage Ribbon Dispenser Person Go Kit ENGINE 1- Triage Ribbon Dispenser Opt. Opt. Opt. Clipboard 1* 1* 1* Patient Care Protocols 5* 3* 2* PCR Forms 2* 2* 1* PCR Continuation Forms Notice of Privacy Rights (HIPAA) Forms Weight Based Resuscitation tool Ring Cutter 1 N/A N/A Child Car Seat/Restraint System 1 Opt. Opt. Hand Cuff Key Opt. Opt. Opt. Automatic CPR Device (Lucas or AutoPulse) Nose clips for epistaxis Thermometer- Temporal or Tympanic Mobile EPCR Platform Key: Opt. = Optional N/A = Not applicable * = See notes for special information 10

11 EL DORADO COUNTY EMS AGENCY FIELD POLICIES Effective: July 1, 2011 Reviewed: N/A Revised: July 1, 2016 Scope: BLS Personnel EMS Agency Medical Director BLS MEDICATION ADMINISTRATION POLICY: BLS personnel are authorized to administer only oxygen and oral glucose according to County protocol. BLS personnel may assist a patient for whom a physician has prescribed medication in the administration of his/her own medications such as nitroglycerin, epinephrine, albuterol, etc. Information regarding administration of the following medications: NITROGLYCERIN (NTG) General Info: NTG is a vasodilator taken as a sublingual tablet or spray to treat angina pectoris and myocardial infarction. NTG may have a hypotensive effect. Considerations: a. Take blood pressure (BP) before and after each administration of NTG. b. If BP is less than 120 systolic, discourage patient use unless the patient s physician gives verbal orders to the patient knowing the BP is less than 120 systolic. c. NTG tablets should be placed under the patient s tongue and be allowed to dissolve; NTG sprays can be sprayed anywhere in the patient s mouth (1 spray equals 1 dose); do not shake spray canister. Limit doses of NTG to three. Indications for BLS Personnel: Chest pain in patients with known coronary artery disease Side effects: Hypotension /Flushing Headache Nausea/Vomiting Dizziness Contraindications: Blood pressure < 120 systolic Patients taking erectile dysfunction medications (i.e., Viagra, Cialis, or Levitra) within the last 48 hours Precautions: Monitor the patient s vital signs closely Limit doses to 1 every 5 minutes unless otherwise directed by a physician (Max. of 3) If side effects become severe, have patient discontinue use EPINEPHRINE (Epi-Pen, Adrenaline) General Info: Epinephrine (Adrenaline) is a naturally occurring chemical in the human body that increases the heart rate, respirations, blood pressure, and dilates the bronchioles in the lungs. During anaphylaxis, massive amounts of histamine are released into the body causing hypotension, bronchospasm and/or laryngeal edema; epinephrine can reverse these potentially fatal effects. Epinephrine is prescribed to people who have had previous allergy problems to a specific allergen. It comes in the form of an automatic injecting syringe that will inject a pre-

12 BLS MEDICATION ADMINISTRATION measured dose. The preferred location for injecting epinephrine is the patient s thigh, although the deltoid (shoulder/upper arm) muscle may also be used if the thigh is inaccessible. Indications for BLS Personnel: Severe anaphylaxis Signs and symptoms of severe anaphylaxis may include: Severe dyspnea Severe hypotension Difficulty swallowing/hoarseness with upper airway swelling Side effects of epinephrine: Cardiac arrhythmias /Tachycardia/ Tremors Hypertension INHALERS/BRONCHODILATORS General Info: There are many different types of inhalers used by respiratory patients in the field; typically these inhalers are either bronchodilators or steroid type medications. BLS personnel may encounter patients, who for physical reasons cannot self-administer these medications. It is allowable that if a patient is unable to self-administer a physician prescribed medication the BLS personnel may assist. Indications for inhaler assistance by BLS personnel: Severe dyspnea secondary to asthma or chronic obstructive pulmonary disease (COPD) Precautions: Avoid over-usage of inhaler by patient Side effects: Cardiac arrhythmias/tachycardia/palpitations Tremors Contraindications: Known over-usage of inhaler ASPIRIN (ASA) General Info: In cardiac patients low doses of aspirin can thin the blood and improve coronary perfusion. Studies have shown that in the acute stages of myocardial infarction the administration of aspirin may reduce mortality by as much as twenty-three percent. Doses are normally 1-2 baby aspirin tablets (80 mg each) taken once a day. Indications for BLS Personnel: Chest pain of suspected cardiac origin Side Effects: Nausea/Vomiting Exacerbation of gastric ulcer Contraindications: Patients with a known sensitivity or allergy to aspirin 2

13 BLS MEDICATION ADMINISTRATION Administration of aspirin within the last twelve (12) hours History of gastric/peptic ulcers ORAL GLUCOSE SOLUTION General Info: In known diabetic patients who have an altered level of consciousness who are suspected to be hypoglycemic oral glucose can provide a rapid source of cell saving blood sugar. A single 15 gram tube may be given if the patient can self administer. Repeat with a second 15 gram tube if patient doesn t respond to the first tube in 10 minutes. Indications for BLS personnel: Known or suspected diabetics who are conscious but confused, lethargic, irritable, or dizzy Side Effects: Nausea Contraindications: Patients who cannot self administer Patients with an impaired gag reflex Unresponsive patients 3

14 EL DORADO COUNTY EMS AGENCY FIELD POLICIES Effective: July 1, 2011 Updated: July 12, 2012 Revised: July 1, 2016 Scope: ALS Personnel EMS Agency Medical Director CONTROLLED SUBSTANCES PURPOSE: This policy outlines the process used by ALS contractors to: obtain an initial stock, maintain the current stock, provide security for, and document controlled substances(fentanyl/morphine Sulfate/Versed). AUTHORITY: Code of Federal Regulations, Title 21, California Health & Safety Code, Division 10 California Health & Safety Code, Division 2.5 California Code of Regulations, Title 22, Division 9, Chapters 3 & 4 POLICY: 1) Restock A. In order to restock controlled medications, the ORIGINAL controlled substance logs must be presented to the hospital or pharmacy staff. B. New medication supply will be signed into stock by 2 paramedics or 1 paramedic and 1 company officer. In circumstances where the afore mentioned staff are not available, an EMT signature may be used. C. Once controlled substances are obtained and prior to dispersion to field units a tamper proof holographic seal with an individual serial number shall be placed over the metal end (the end without a factory applied paper seal) of the individual pre-loaded controlled substance tamper proof container. The responsibility to place and track the holographic seals rests with each ALS contractor. Holographic seals can be obtained from the JPA. D. Holographic seals must also be placed on each individual vial of Versed for tracking purposes. Place the holographic seal so that it completely affixes the plastic tab to the vial on two (2) sides, but doesn t cover the expiration date or the lot number. 2) Tracking A. Each individual preload, vial, and cylinder must be tracked on the controlled substance tracking/usage log. The tracking/usage log shall be initially completed on the first day of the month and must contain the following information: I. Unit number II. Month III. Date received IV. Medication type: M = Morphine, V = Versed, N = Nitronox, F = Fentanyl V. Serial numbers (stamped on the cylinders) VI. Lot numbers VII. Expiration dates VIII. Date used (if applicable) IX. Incident number (if applicable)

15 CONTROLLED SUBSTANCES X. Amount used (For Nitronox refer to Nitronox Section below*) XI. Amount wasted (if applicable) XII. Paramedic name/signature XIII. Witness name/signature The controlled substance tracking/usage log shall be updated any time a controlled substance is used or wasted. If a medication is restocked at any point during the month it must be added to the controlled substance tracking log. This log does NOT need to be updated daily, only when there are changes to the inventory. Names and signatures are only required when a medication has been used or removed from service. * Nitronox information: The tracking/usage log will only be updated for each Nitronox cylinder when the cylinder is completely empty. The incident number of the last usage should be entered in the appropriate section. A note that includes the incident number and how many minutes the Nitronox was used must be made in the comments section of the daily log (or on the back of the daily log if space is an issue) for each usage. Nitronox cylinders should be used until they are completely empty before restocking. If in doubt about whether a cylinder is empty, simply open the valve and allow a small amount of product to escape. Note: If during administration to a patient it becomes apparent that the Nitronox is not working, check the cylinder (using the above method) to make certain it is not empty. B. Daily (every 24 hours) inspection of the controlled substances shall include: I. Security tag and container intact without evidence of tampering II. Contents intact and no visible leaks III. Presence of correct quantity of medications and verification that there is an appropriate amount of fluid IV. Completion of the Controlled Substance Daily Log, which includes: a. Date b. Time c. Paramedic s legible signature d. Witnesses legible signature, either paramedic or company officer. In circumstances where the afore mentioned staff are not available an EMT signature may be used. e. Morphine** f. Versed** g. Nitronox** h. Fentanyl** i. Security tag number This is the tag that secures the controlled substances in the tamper proof container j. Comments If you have any brief comments such as restocked or tag damaged you would enter those in this section. This section is also used to document Nitronox use and must include an incident number. Comments may be continued on the back side of the daily log if you run out of space ** Start How much medication or how many cylinders of Nitronox (full or partially full) were on the unit at the start of shift Used If any medication was used, how much? For Nitronox how many minutes was it used? End How much medication or cylinders of Nitronox (full or partial) remain (if restocked this number may be higher). 2

16 CONTROLLED SUBSTANCES 3) Storage Medications: A. Controlled substances shall be kept in a clear tamper resistant box or bag that must be securely closed shut with a numbered security tag. The numbered security tag must be secured in such a manner that no medications may be removed from the LOCKED BOX or bag without removing the numbered security tag. For zippered pouches fasten the numbered security tag around the base of the zippers vs. the zipper handles. B. The numbered security tag must be replaced when damaged, broken, or removed. Document such a change in the comments section of the daily log; if additional space is needed write on the back of the daily log. C. The sealed container must be then kept in a secondary secure locked box, cabinet, or container. D. Controlled substances must be stored in an environmentally controlled environment. Nitronox: A. It is permissible to keep a single cylinder of Nitronox in the rapid deployment bag to expedite its use. B. All additional cylinders of Nitronox must be kept in a locked cabinet or box. 4) Verification/Documentation Procedures A. Monthly or Opened Security Tag Verification: I. At the beginning of each month, or any time the numbered security tag is removed, the medications must be thoroughly inspected. This thorough monthly inspection shall include: 5) General Information a. Check for visible damage/tampering of tamper proof seals or containers b. Make sure there is appropriate amount of liquid inside the medication containers c. Check expiration dates d. Confirm correct medication, concentration, and dose e. Replacing the numbered security tag with a new one. Documentation of this new security tag will be verified on the daily log at the beginning of the next shift. A. The controlled substance inventories shall be verified by two paramedics (or 1 paramedic and 1 EMT or supervisor if a second paramedic is not available). B. Once the numbered security tag is in place it does not need to be removed until the medications are needed for patient treatment or the next monthly inspection, whichever comes first. C. For situations where there is some controlled medication left over after administration to a patient or when a medication expires*, the medication must be wasted in front of a witness. This witness should be another healthcare provider (i.e., a registered nurse, physician, or another paramedic) whenever possible. Medications shall be wasted into a sharps container that is partially filled with a 1/2 of saw dust, kitty litter, or some other absorbent material. WASTING EXCEPTION: a single cylinder of Nitronox may be used for more than one patient. A minimum of at least one (1) completely full cylinder of Nitronox shall be maintained at all times on transporting medic units. 3

17 CONTROLLED SUBSTANCES *CSA 3 personnel to follow hospital pharmacy policy on expiring medications. 6) Administration A. In order to be eligible to carry controlled substances, applicants shall first submit verification of the following items to the El Dorado County EMS Agency Medical Director for initial approval: I. An internal process to: II. III. a) obtain an initial stock of controlled substances for each ALS unit in service; b) provide adequate security for all controlled substances (meeting the above listed requirements); c) restock controlled substances following administration to a patient during prehospital care; d) restock controlled substances following loss or breakage of a controlled substance container; e) maintain records of controlled substances (records must be retained by the contractor for a period of not less than three (3) years) An orientation program to be used for new employees and on-going training as per the County s paramedic accreditation packet. An internal program to monitor the administration, security, and restock of controlled substances. B. Any unresolved discrepancy in a unit s controlled substance log or inventory shall be documented in an incident report and forwarded to the EMS Agency and the appropriate JPA Executive Director within twenty-four (24) hours. Immediately notify your supervisor if there is a discrepancy. Any suspected theft or loss of any controlled substance must also be reported on a DEA form 106. C. Each ALS contractor shall show documentation of an agreement with a California licensed physician to provide necessary prescribing and oversight as required by the United States Drug Enforcement Administration. 4

18 EL DORADO COUNTY EMS AGENCY FIELD POLICIES Effective: July 1, 2017 Reviewed: February 8, 2017 EMS Agency Medical Director DETERMINATION OF DEATH PURPOSE: To provide criteria for prehospital personnel to determine when a patient is obviously dead and when resuscitative efforts should be instituted or discontinued. PROCEDURE: 1. The patient is to be determined obviously dead upon meeting the following criteria: a. The patient has suffered one of the following: 1) Decapitation. 2) Decomposition of body tissue. 3) Incineration. 4) Known submersion for 90 minutes or longer. 5) Functional separation from the body of the heart, brain, or lungs. 6) Pulseless and apneic and all of the following physical exam findings are present*: - Rigor mortis as indicated by stiffness in jaw - Cold skin (in a warm environment) - Pupils dilated and non responsive - Asystole noted on EKG in two leads (ALS personnel), or; - No palpable carotid pulse is felt and no breath or apical heart sounds are heard after a minimum 60 seconds of auscultation and palpation (BLS personnel only). 7) Adult patient with major blunt trauma that is pulseless and the monitor shows: asystole or wide complex PEA with a rate of 40 or less in at least two (2) leads. (ALS personnel only) 8) The patient is in cardiac arrest and has a reliable history of no vital signs for 20 minutes and presents with asystole in at least two (2) leads on the monitor. If a reliable history is not readily available or if there is evidence of pregnancy, hypothermia, drug ingestion or electrocution begin BCLS/ACLS procedures and contact base station for further instructions. (ALS personnel only) 2. When an obvious death is determined in the field: a. A Prehospital Care Report (PCR) shall be completed with all appropriate patient information. It shall describe the patient assessment and the time the patient was determined to be obviously dead. b. Base station contact is not required for patients determined obviously dead unless otherwise specified in this policy. 3. For patients who do not meet the obviously dead determination of death criteria appropriate treatment measures shall be instituted: a. The base station physician may determine that resuscitative interventions are futile or not indicated, and may authorize the discontinuation of resuscitative efforts with reasonable attempts and an assessment of all the following: i) No spontaneous respirations are present after: Assuring the patient has an open airway

19 DETERMINATION OF DEATH ii) Looking, listening, and feeling for respirations including chest auscultation for lung sounds for a minimum of 60 seconds, and; No pulses are present after: palpation of the carotid pulse for a minimum of 60 seconds and/or auscultation of the apical pulse for a minimum of 60 seconds The adult patient is in pulseless arrest (asystole, PEA, refractory VT/VF) for more than 20 minutes despite (on-scene) ACLS resuscitative measures, assuming the patient has an effective BLS or ALS airway and a patent IV/IO in place. There is no suspected history of pregnancy, drug ingestion, hypothermia, or electrocution The Paramedic determines the scene to be appropriate for termination of resuscitative measures b. Following an order by the base station physician to discontinue resuscitative measures, a PCR shall be completed. All appropriate patient information must be included, and a description of all resuscitative efforts employed, criteria outlining discontinuation of resuscitative efforts, and the time the base station physician determined the patient to be dead. c. BLS personnel may determine a patient to be dead if patient is pulseless and apneic as defined in section 1 of this policy after twenty minutes of CPR (unless there is evidence of pregnancy, hypothermia, drug ingestion, or electrocution). d. In the event that radio contact cannot be made with the base station the Paramedic may make a determination of death in pulseless, apneic patients as described above. Paramedics must make base station contact once radio contact can be made. An EMS Event Analysis form shall be submitted to the EMS Agency Medical Director within 24 hours in all cases where resuscitative measures were discontinued during radio failure. e. Prehospital emergency medical care personnel shall notify the County Coroner or the appropriate law enforcement agency when a patient has been determined to be dead. The most appropriate EMS unit (may be the first responders) shall remain on scene until released by the coroner or law enforcement agency. In the event that the deceased subject is in a public occupancy, the body may be transported to the nearest medical facility depending on the circumstances and the ETA of the County Coroner/law enforcement. Leave all IV/IO lines and airway adjuncts in place. 4. Transport of deceased patients: a. Patients who are dead at the scene should not be transported by ambulance; however, for patients that collapse in public locations it may be necessary to transport to the hospital or other location in order to move the body to a place that provides the family with more privacy. b. When resuscitative measures have begun and the decision is made to transport OR if resuscitation begins en route, Do Not discontinue measures, continue to destination hospital or divert to nearest hospital. Policies and procedures relating to medical operations during declared disaster situations or multiple casualty incidents will supersede this policy. Reference(s): A proposed decision-making guide for the search, rescue and resuscitation of submersion (head under) victims based on expert opinion Original Research Article 2

20 DETERMINATION OF DEATH Resuscitation, Volume 82, Issue 7, July 2011, Pages Michael J. Tipton, Frank St. C. Golden 3

21 EL DORADO COUNTY EMS AGENCY FIELD POLICIE Effective: July 1, 2017 Reviewed: December 14, 2016 Revised: December 14, 1016 EMS Agency Medical Director DO NOT RESUSCITATE (DNR)/ DYING WITH DIGNITY PURPOSE: To establish criteria for a Do Not Resuscitate (DNR) Order and to thereby permit EMS Personnel to withhold resuscitative measures and medical interventions from patients in accordance with their wishes. DEFINITIONS: Do Not Resuscitate (DNR) - No chest compressions, no defibrillation, no assisted ventilation, no endotracheal intubation, and no cardiotonic medications. This does not exclude treatment for airway obstruction, pain, dyspnea, or major hemorrhage. DNR Form - Official State document developed by the California EMS Authority and the California Medical Association which allows a patient with a life threatening illness or injury to forgo resuscitative measures that may keep them alive. Physician Orders for Life-Sustaining Treatment (POLST) - Official State document developed by the California State EMS Authority and the California Coalition for Compassionate Care, which allows a patient with a life threatening illness or injury to specify a type of intervention(s) or forgo specific resuscitative or life-sustaining measures that may keep them alive. EMS providers should be aware of different levels of care in Sections A and B. Section C does not apply to EMS personnel. DNR Medallion - Medic Alert medallion which states Do Not Resuscitate - EMS or similar medallion as approved by the California EMS Authority. Advanced Health Care Directive (AHCD) - An advance directive established in conformance with California statutory law by which an individual may give specific instructions about healthcare and/or name an agent to make health care decisions in the event the individual becomes unable to make such decisions for them self. Aid in Dying Drug A drug (or combination of drugs) 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 a terminal illness. The prescribed drug(s) may take effect within minutes to several days after self-administration. End of Life Act A California state law 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 from an authorized physician, prescribed for the purpose of ending his or her life in a humane and dignified manner. PROCEDURE: All patients with rapidly deteriorating vital signs or absent vital signs and who do not meet the determination of death criteria shall be resuscitated unless the field personnel are presented with: Statewide Standards A completed and signed Prehospital DNR Request Form. See Appendix A A completed and signed POLST form. See Appendix B The patient is wearing a DNR medallion. See Appendix C

22 DO NOT RESUSCITATE (DNR) Medical Director Approved Documents A written, signed DNR order in the patient s medical record stating Do Not Resuscitate, No Code, or No CPR signed by a physician, with the patient s name and date A paper copy of the electronic medical record (EMR) order for DNR containing the physician name and date. See Appendix D An Advanced Health Care Directive. See Appendix E A verbal order from the patient s physician provided the physician immediately contacts and advises the base station EMS field personnel may discontinue resuscitation if the previously stated requirement(s) are satisfied If the paramedic is presented with any other type of written medical directive (not signed by physician) indicating patient s DNR request and/or family verbally states patient s DNR request, paramedics will contact base station for further direction EMS field personnel shall attempt to comply with partial or limited DNR orders (such as basic CPR, but no intubation, no drugs, or chemical code only) when such actions would not contradict other provisions of this policy Base station contact by the field personnel is not necessary prior to complying with a DNR order, but the base station should be informed as soon as possible. Base Hospital Physicians retain the authority for determining the appropriateness of resuscitation If a valid DNR order is present and the family requests resuscitation, begin resuscitation until the situation can be clarified. Usually discussions with the family will make attempted resuscitation unnecessary, contact base station for assistance If for any reason the DNR order does not seem to apply to the situation, resuscitation should be initiated and the base station contacted immediately Patients who are dead at the scene should not be transported by ambulance; however, for patients that collapse in public locations it may be necessary to transport to the hospital or other location in order to move the body to a place that provides the family with more privacy When resuscitative measures have begun and the decision is made to transport OR if resuscitation begins enroute, Do Not discontinue measures, continue to destination hospital or divert to nearest hospital Verification shall be accomplished by the following: a. The presence of a DNR order, the physician s name signing the order, and the date of the order are to be documented on the Prehospital Care Report (PCR). b. The DNR form (original or copy), DNR medallion, AHCD, POLST form, or a copy of the valid DNR order from the patient s medical record shall be taken with the patient. There is no date of expiration for DNR. END OF LIFE OPTION ACT A person who has obtained an aid-in dying drug has met extensive and stringent California state law requirements. The law offers protections and exemptions for healthcare providers but is not clear or explicit regarding EMS responses to patients who have initiated the End of Life Option. The following guidelines are provided for EMS personnel when responding to a patient who has self-administered an aid-in-dying drug.

23 DO NOT RESUSCITATE (DNR) 1. Within 48 hours of self-administrating 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 for directly or to keep it in close proximity to their person. Of a copy of the final attestation is available, EMS personnel should confirm the patient is the person identified in the final attestation. This will normally require the presence of a form of identification or a person who can reliably identify the patient. 2. There are no standardized Final Attestation forms, but the law has required specific information that must be on the Final Attestation: The document is identified as a Final Attestation For An aid-in-dying Drug to End My Life in a Humane and Dignified Manner Patient s name and signature The form is dated 3. Provide comfort measures and/or airway ventilation measures when applicable. 4. Withhold resuscitative measures if the patient is in cardiopulmonary arrest. 5. The patient may at any time withdraw or rescind his or her request fo an aid-in-dying drug regardless of the patient s mental status. In this instance, EMS personnel shall provide medical care as per standard protocols. EMS personnel are encouraged to contact their base Hospital for further direction or concerns. REFERENCES: 1) Recommended Guidelines for EMS Personnel regarding DNR and other Patient-Designated Directives Limiting Prehospital Care, EMSA # 311, Fifth Edition, October ) Coalition for Compassionate Care of California; 3) Advance Healthcare Directive;

24 DO NOT RESUSCITATE (DNR) Appendix A EMSA/CMA APPROVED PREHOSPITAL DNR FORM 1. Under the EMSA/CMA approved Prehospital DNR Form, do not resuscitate (DNR) means no chest compressions, defibrillation, endotracheal intubation, assisted ventilation, or cardiotonic drugs. 2. The patient should receive all other care not identified above for all other medical conditions according to local protocols. 3. Relief of choking caused by a foreign body is usually appropriate, although if breathing has stopped and the patient is unconscious, ventilation should not be assisted. 4. Requests must be signed and dated by a physician. No witness to the patient's or surrogate's signature is necessary. Ensuring appropriate informed consent is the responsibility of the attending physician, not the EMS system or prehospital provider. 5. The DNR Form should be clearly posted or maintained near the patient in the home. A typical location might be in an envelope in a visible location near the patient's bed. Copies of the form are valid and will be honored. The patient or family should be encouraged to keep a copy in case the original is lost. The copy should be taken with the patient during transport. 6. In general, EMS personnel should see the written prehospital DNR Form unless the patient's physician is present and issues a DNR order. 7. Correct identification of the patient is crucial, but after a good faith attempt to identify the patient, the presumption should be that the identity is correct if documentation is present and the circumstances are consistent. There should be a properly completed standard EMSA/CMA DNR Form available with the patient. A witness who can reliably identify the patient is valuable.

25 DO NOT RESUSCITATE (DNR)

26 DO NOT RESUSCITATE (DNR) EMSA APPROVED POLST FORM Appendix B EMS personnel who encounter the EMSA approved POLST form in the field should be aware of the different levels of care in Sections A and B of the form (Section C does NOT apply to EMS personnel). Section A Section A applies only to individuals who do NOT have a pulse and are NOT breathing upon arrival of EMS personnel. 1. If an individual has checked Attempt Resuscitation/CPR, then EMS personnel should treat the individual to the fullest extent possible according to local protocols regardless of what may be checked in Section B. For this individual this form as filled out does NOT constitute a DNR. 2. If the individual has checked Do Not Attempt Resuscitation/DNR, then no attempts should be made to resuscitate the individual and the EMS personnel should follow their local policies, procedures and protocols for declaration of death. Section B Section B applies only to individuals who have checked Do Not Attempt Resuscitation/DNR in Section A AND who have a pulse and/or are breathing upon the arrival of EMS personnel. 1. If an individual has checked Full Treatment then they should be treated to the fullest extent possible. This includes, but is not limited to, intubation and other advanced airway interventions, mechanical ventilation and defibrillation/cardioversion. Should the individual s condition deteriorate after EMS personnel have arrived and they have indicated DNR in Section A, then resuscitation efforts should be attempted up to, but NOT including, chest compressions. Then EMS personnel should follow local protocols regarding declaration of death. EMS personnel shall ignore the check box marked Trial Period of Full Treatment as it is not applicable to pre-hospital care. 2. If an individual has checked Selective Treatment the following care may be provided (in addition to the care outlined below): Administration of IV fluids May use non-invasive positive airway pressure to include: continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), and bag valve mask (BVM) assisted respirations according to local protocols. This does NOT include intubation EMS personnel shall ignore the subjective phrase avoid burdensome measures when considering treatment options for the patient. EMS personnel shall follow

27 DO NOT RESUSCITATE (DNR) their local protocols, policies and procedures regarding patient treatments and if necessary contact medical control for further guidance EMS personnel shall ignore the check box marked Request transfer to hospital only if comfort needs cannot be met in current location. EMS personnel shall follow their local protocols, policies and procedures regarding patient transport 3. If an individual has checked Comfort-Focused Treatment the following care may be provided: The patient should receive full palliative treatment for pain, dyspnea, major hemorrhage, or other medical conditions (includes medication by any route) according to local protocols Relief of choking caused by a foreign body is usually appropriate, although if breathing has stopped and the patient is unconscious, ventilation should not be assisted EMS personnel shall ignore the statement Request transfer to hospital only if comfort needs cannot be met in current location. EMS personnel shall follow their local protocols, policies and procedures regarding patient transport 4. EMS personnel shall obtain online medical control prior to following any orders listed under Additional Orders. EMSA approved POLST forms must be signed and dated by a physician and the patient or legally recognized decision-maker. No witness to the patient's or legally recognized decision-maker's signature is necessary. Ensuring appropriate informed consent is the responsibility of the attending physician, not the EMS system or prehospital provider. The EMSA approved POLST form should be clearly posted or maintained near the patient. A typical location might be in an envelope in a visible location near the patient's bed. Copies of the form are valid and will be honored. The patient or family should be encouraged to keep a copy in case the original is lost. The copy should be taken with the patient during transports. In general, EMS personnel should see the written EMSA approved POLST form unless the patient's physician is present and issues a DNR order. Correct identification of the patient is crucial, but after a good faith attempt to identify the patient, the presumption should be that the identity is correct if documentation is present and the circumstances are consistent. There should be a properly completed EMSA approved POLST form available with the patient. A witness who can reliably identify the patient is valuable.

28 DO NOT RESUSCITATE (DNR)

29 DO NOT RESUSCITATE (DNR) Appendix C DNR MEDALLION

30 DO NOT RESUSCITATE (DNR) Appendix D EXAMPLES OF APPROVED ELECTRONIC DNR ORDERS

31 EL DORADO COUNTY EMS AGENCY FIELD POLICIE Effective: July 1, 2017 Reviewed: December 14, 2016 Revised: December 14, 1016 EMS Agency Medical Director Appendix E EXAMPLES OF ADVANCED HEALTH CARE DIRECTIVE

32 DO NOT RESUSCITATE (DNR)

33 EL DORADO COUNTY EMS AGENCY FIELD POLICIES Effective: July 1, 2009 Reviewed: N/A Revised: July 2012, July 1, 2016 Scope: BLS and ALS Personnel EMS Agency Medical Director EMS AIRCRAFT AUTHORITY: Division 2.5 of the Health and Safety Code, Section , California Code of Regulations, Title 22., Prehospital Emergency Medical Services, Chapter 8., Prehospital EMS Aircraft Regulations, Title 21, Public Works Chapter 2.5 Division of Aeronautics (Department of Transportation), Public Utilities Code Section , and Federal Aviation Regulations. PURPOSE: The purpose of the Air Ambulance Dispatch Policy is to quickly summon an air ambulance to the scene of an emergency or to a medical facility for an interfacility transport. DEFINITIONS: AAMS- Association of Air Medical Services. A non-profit trade association committed to representing and advocating for the Air Medical and the Critical Care Ground Transport Industry. Air Ambulance- Any aircraft specially constructed, modified or equipped, and used for the primary purpose of responding to emergency calls and transporting critically ill or injured patients whose medical flight crew has a minimum of two (2) attendants certified in advanced life support. Aircraft Type- Particular make and model of aircraft. Authorization- The process required by Title 22, Chapter 8 of the California Code of Regulations that local EMS agencies must follow in order to allow EMS aircraft services to provide service within an EMS agency s local jurisdiction. Authorizing EMS Agency- The local EMS Agency, which approves utilization of specific EMS Aircraft within its jurisdiction. C.A.M.T.S. - The Commission on Accreditation of Medical Transport Systems. A national independent commission dedicated to improving the quality of patient care and safety of the transport environment for services providing rotor wing, fixed wing and ground transport systems. Classifying EMS Agency- Shall be the local EMS Agency in the jurisdiction of origin except for aircraft operated by the California Highway Patrol, the California Department of Forestry, or the California National Guard, which shall be classified by the EMS Authority. County- El Dorado County. Emergency Medical Services Aircraft- Any aircraft utilized for the purpose of prehospital emergency patient response and transport. EMS aircraft includes air ambulances and all categories of rescue aircraft. IFR- Instrument Flight Rules.

34 EMS AIRCRAFT Medical Flight Crew- The individuals(s), excluding the pilot, specifically assigned to care for the patient during aircraft transport. Rescue Aircraft- An aircraft whose usual function is not prehospital emergency patient transport but which may be utilized, in compliance with local EMS policy, for prehospital emergency patient transport when use of an air or ground ambulance is inappropriate or unavailable. Rescue aircraft includes: ALS Rescue Aircraft (ALSRA) - has medical crew with a minimum of one attendant certified or licensed in advanced life support. BLS Rescue Aircraft (BLSRA) - Has medical crew with a minimum of one attendant certified in basic life support as identified in Chapter 8, Title 22. Auxiliary Rescue Aircraft (ARA) - does not meet the minimum requirements established for a BLSRA. VFR- Visual Flight Rules. POLICY: 1) REQUEST AND RESPONSE a) Upon request for medical response, the requested air ambulance agency and its designated dispatch center shall immediately notify the requester of their status: If immediately available, the aircraft will lift off as soon as is safely possible and the estimated time of arrival will be relayed to the requester If the aircraft is committed to another response, the EMS aircraft dispatch center will so state and give an estimate of when the aircraft will be available for another mission If the aircraft is on a delay (i.e., maintenance or weather), the EMS aircraft dispatch center shall inform the requester of the nature of the delay and give an estimated time the aircraft will be available If unavailable due to maintenance, weather, or for some other reason for an indeterminate time period, the EMS aircraft dispatcher will so state b) No air ambulance shall respond to the scene of an emergency without formal request from an El Dorado County designated dispatch center. c) The designated dispatch centers for the East and West Slopes of El Dorado County shall dispatch the closest air ambulance at the request of the Incident Commander. The designated dispatch centers may also dispatch an air ambulance whenever the patient condition may be ascertained and presents with one or more of the following: Unresponsive Spinal cord injury Significant head, neck, or chest injury Burns > 15% surface area Any other incident where the designated dispatching agency deems it beneficial to the patient(s), or responding emergency personnel d) Transport via air ambulance is the preferred method of air transport for critical patients; however an ALS air rescue helicopter may be utilized for prehospital emergency patient transport, when in the opinion of the on scene medical personnel, transport via ALS air 2

35 EMS AIRCRAFT rescue helicopter would be in the patient s best interest. Consideration must be given to the need for higher-level medical procedures (e.g., RSI, surgical cricothyrotomy, surgical chest tube, etc.) that can be performed by an air ambulance flight crew vs. speed of transport to definitive care by an air rescue helicopter. e) Simultaneous response of a rescue helicopter and an air ambulance is permissible with the ALS rescue helicopter being utilized as the first responder. f) For interfacility transfers the selection of a specific EMS aircraft is at the discretion of the transferring physician/facility. For patients requiring rapid sequence induction (RSI), the patient s weight in kilograms and the anticipated need for RSI should be relayed to the air ambulance crew as soon as possible in order to facilitate preparation of medications while the air ambulance is still en route to the scene. 2) ON-LINE MEDICAL CONTROL a) On-line medical control for the scene of a medical emergency where both ground and EMS aircraft personnel are present shall be conducted by the base station contacted by the ground unit(s). b) Once the transfer of patient care has been accomplished between the ALS ground unit and the EMS aircraft personnel the EMS aircraft crew will assume the responsibility for the care of the patient. c) The flight crew shall notify the receiving facility physician of the patient s condition and the estimated time of arrival. LANDING ZONE SCENE SAFETY CONSIDERATIONS: Select accessible site Determine proper size 100 X 100 Walk perimeter looking for wires or hazards Observe for drones operating in the area Evaluate ground slope Determine wind direction Establish latitude/longitude Wet down dusty areas Mark L.Z. for identification Secure loose equipment and perimeter Remain on radio frequency For landing/departure Evaluate environmental conditions for snow, dust, grass, sand Maintain own safety first, and at all times 3

36 EL DORADO COUNTY EMS AGENCY FIELD POLICIES Effective: July 1, 2017 Reviewed: February 8, 2017 EMS Agency Medical Director EXPOSURE DETERMINATION, TREATMENT AND REPORTING PURPOSE: Preventing exposures to blood and body fluids is the most important strategy for preventing occupationally acquired infection. Prehospital care providers and the departments that employ them should work to ensure adherence to the principles of Standard Precautions, including ensuring access to and consistent use of appropriate work practices, work practice controls, and personal protective equipment (PPE). When an occupational exposure has occurred, appropriate post-exposure management is an important element of workplace safety. POLICY: 1. Protection All prehospital care providers should receive the HepBV vaccine series. a. Frequent hand washing. b. Use PPE including gloves, gowns, eyewear and masks. c. Use sharps with caution, do not recap needles, dispose of in appropriate receptacle immediately after use. 2. Treat Exposure Site a. Use soap and water to wash areas exposed to potentially infectious fluids as soon as possible after exposure. b. Flush exposed mucous membranes with water. c. Flush eyes with saline solution or water. 3. Report and Document a. Report occupational exposures immediately to supervisor and/or designated officer. b. Complete the appropriate employee exposure reporting forms. c. Document the incident, including: i. Date and Time of incident. ii. Details of where and how exposure occurred. iii. Exposure site, type and amount of fluid or material, severity of exposure. iv. Details about exposure source including history of HIV, HepCV, HepBV. 4. Evaluate the Exposure For transmission of blood borne pathogens (HIV, HepBV and HepCV) to occur, an exposure must include both of the following: Infectious body fluid Blood, semen, vaginal fluids, amniotic fluids, breast milk, cerebrospinal fluid, pericardial fluid, peritoneal fluid, pleural fluid and synovial flood can transmit HIV, HBV and HCV A portal of entry Percutaneous, mucous membrane, cutaneous with non-intact skin. If both of these factors are not present, there is no risk of transmission and further evaluation is not required. Note: Saliva, vomitus, urine, feces, sweat, tears and respiratory secretions DO NOT transmit HIV (unless visibly bloody). The risk of HepBV and HepCV transmission from non-bloody saliva is negligible. Factors to consider in assessing need for evaluation of the exposure:

37 EXPOSURE DETERMINATION, TREATMENT, AND REPORTING a. Type of exposure: i. Percutaneous injury ii. Mucous membrane iii. Non-intact skin iv. Bites resulting in blood exposure b. Type and amount of fluid/tissue c. Infectious status of source patient d. Optimal time to start prophylaxis is within hours of exposure. Go to the closet ER if immediate treatment is needed or return to the base hospital for further evaluation. Bring any legally obtained source patient samples with you. 5. Evaluate the Exposure Source a. Request testing of source patient following state regulations related to informed consent and confidentiality if the source is known. b. For patients who cannot be tested, consider medical diagnoses, clinical symptoms and history of risk behaviors. Note: California Health and Safety Code Allows an exposed provider to request an evaluation in writing within 72 hours to determine if there is a significant exposure, be counseled regarding the need for testing, treatment options and follow-up. 2. The source patient or legal representative will be given the opportunity to consent for testing. If a good faith effort to notify source is unsuccessful or if the source refuses consent within 72 hours, any available blood or patient sample that was legally obtained in the course of giving care (routine blood draw) may be tested. 3. An exposed provider shall be prohibited from directly obtaining informed consent for testing from the source patient. 6. Follow-Up testing: All high risk exposures require 6 week re-testing to be done through your department s occupational health provider. 2

38 EL DORADO COUNTY EMS AGENCY FIELD POLICIES Effective: July 1, 2017 Reviewed: December 14, 2016 EMS Agency Medical Director FIRELINE PARAMEDIC PURPOSE: To establish procedures for Fireline Paramedic response from and to Agencies within or outside (local) EMS Agency jurisdiction when requested through the Statewide Fire And Rescue Mutual Aid System, to respond to and provide Advanced Life Support (ALS) care on the fireline at wildland fires. AUTHORITY: California Health and Safety Code, Division 2.5, Sections , v California Code of Regulations, Title 22, Division 9, Sections and California Fire Service and Rescue Emergency Mutual Aid System, Mutual Aid Plan, (3-2002). POLICY: 1) El Dorado County Accredited Paramedics may function within their scope of practice, when serving in an authorized capacity assignment, as an agent of their authorized ALS service fire agency. 2) Fire service providers shall establish non-medical qualifications in order to serve as a Fireline Paramedic (e.g., fitness requirements, minimum experience requirements, etc.) 3) Under the authority of State regulations, a paramedic may render ALS care during emergency operations as long as the following conditions are met: a. The paramedic is currently licensed by the State of California and is accredited by a County EMS Agency within California. b. The paramedic is currently employed with an ALS provider and possesses the requisite wildland fireline skills and equipment. c. The paramedic does not exceed the scope of practice or medical control policies from their county of origin. Paramedics operating in the capacity of a Fireline Paramedic (FEMP) shall follow established LEMSA standing or communication failure protocols. 4) The FEMT-P is expected to check in and obtain a briefing from the Logistics Section Chief, or the Medical Unit Leader (MEDL) if established at the Wildfire Incident. 5) Documentation of patient care will be completed on any significant patient contact (beyond basic first aid). Documentation of Patient Care will be submitted to incident host agencies and a legible copy of the Patient Care Record (PCR) will be forwarded to the El Dorado County EMS Agency 6) Continuous Quality Improvement activities shall be in accordance with EDCEMS policy in concert with provider agency CQI procedures. 7) County accredited paramedics shall carry the ALS/BLS inventory consistent with the FIRESCOPE FEMP Position Description. Reasonable variations may occur; however, any exceptions shall have prior approval of the EMS Agency. The equipment lists are a minimalist scaled down version of standard inventory in order to meet workable/packable weight limitations (45 lbs. including wildland safety gear). 8) For controlled substance security a FEMP shall keep all controlled medications in his or her immediate possession (in the same room, vehicle, etc.) at all times. During FEMP deployment

39 FIRELINE PARAMEDIC where a FEMP is alone and no witnesses are available, a single signature on the controlled substance log is acceptable; however upon return to the station a second witness signature verifying the contents of the controlled substance pouch is required. FEMP MINIMUM INVENTORY: Airway, Oral Pharyngeal Kit Biohazard Bag (2) Bag Valve Mask (1) Space Blanket (2) Bandage, Sterile 4 x 4 (6) Bandage, Triangular (2) Cervical Collar, Adjustable Cold Pack (3) Dextrose Oral (1) Dressing, Multi-Trauma (4) Eye Wash (1 bottle) Pen Light (1) Exam Gloves Coban Wraps/Ace Bandage (2 ea.) Kerlix, Kling, 4.5, Sterile (2) Mask, Face, Disposable w/eye shield (1) BLS EQUIPMENT* (FEMT) Pad, Writing (1) Pen and Pencil (1 ea.) Triangular Dressing with Pin (2) Splinter Kit (1) Scissors, Medic (1) Sheet, Burn or equivalent (2) Stethoscope (1) Sphygmomanometer (1) Splint, Moldable Suction, Manual Device (1) Tape, 1 inch, Cloth (2 rolls) Petroleum Dressing (2) Thermometer, Digital (1) Triage Tags (6) Israeli Bandage (1) Combat Gauze/Sponge (1 ea) ALS EQUIPMENT (FEMP) *BLS equipment is also required for FEMP ALS AIRWAY: Endotracheal Intubation Equipment (6.0, 7.5 ET Mac 4, Miller 4, stylette and handle-pedi recommended for weight) Rescue Airway (1) ETT Restraint End Tidal CO2 Detector ETT Verification Device Needle Thoracostomy Kit (1) BIOMEDICAL EQUIPMENT: Compact AED/SAD (waveform display preferred) (1) AED/SAD Patches (2) Pulse Oximeter (1 Optional) Glucometer or Equivalent (1) MISC: Sharps Container (1) Narcotic Storage (per local protocol)* FEMP Pack Inventory Sheet (1) PCR (6) MEDICATIONS: Aerosolized Beta 2 Specific Bronchodilator (4) Lidocaine 100 mg Pre-loads (2) or Amiodarone 300 mg (1) Aspirin-Chewable 80 mg (1 bottle) Atropine Sulfate 1 mg (2) Dextrose 50% 25 G. Pre-Load (1) Diphenhydramine 50 mg (4) Epinephrine 1 10,000 1mg (2) Epinephrine 1 1,000 1 mg (4) Glucagon 1 mg/unit (1) Versed 20 mg Morphine Sulfate 10 mg/ml (6), OR; Fentanyl 600 mcg Naloxone 2 mg (2) Nitroglycerin 1/150 gr (1) Saline 0.9% IV 1,000 ML Can be configured into two 500 cc or 4 250cc 2

40 FIRELINE PARAMEDIC IV/MED ADMIN: IV Administration Set-Macro-Drip (2) Venaguard (2) Alcohol Preps (6) Betadine Swabs (4) Tourniquet (2) Razor (1) Transpore Tape (1) 14 ga. IV Catheter (2) 16 ga. IV Catheter (2) 18 ga. IV Catheter (2) 20 ga. IV Catheter (2) 10 cc Syringe (2) 1 cc TB Syringe (2) 18 ga. Needle (4) 25 ga. Needle (2) Glucometer Test Strips (4) Lancet (4) 3

41 EL DORADO COUNTY EMS AGENCY FIELD POLICIES Supersedes: Policy dated July 1, 2011 Effective: July 1, 2012 Reviewed: April 2012 Revised: July 1, 2016 Scope: ALS Personnel EMS Agency Medical Director GUIDELINES FOR INTERFACILITY TRANSFER OF 5150 PATIENTS PURPOSE: All psychiatric patients who present to an El Dorado County hospital emergency department must be seen by an emergency department physician and have a medical screening examination. The patient will undergo a psychiatric evaluation by the El Dorado County Psychiatric Evaluation Staff member once they are deemed medically stable by the emergency physician. DEFINITIONS: When any person is determined by law enforcement or Psychiatric Emergency Services staff to be a danger to self, others, or gravely disabled as a result of a mental disorder, that person may be detained for up to 72 hours for evaluation and treatment in a 5150-designated psychiatric facility. Psychiatric Emergency Services Staff (PES staff) Trained mental health staff designated by the County s Health Services - Mental Health Division to provide 24/7 mental health crisis services including evaluation for a 5150 hold. POLICY: 1) Patients are considered to be ready for transfer when: a. The patient has been assessed by the treating emergency physician and determined to have no underlying organic basis for the presenting psychiatric symptoms. b. The patient is determined by PES Staff to be of danger to themselves or others or is gravely disabled as a result of a mental disorder. Patient is placed under c. The receiving in-patient psychiatric facility has accepted the 5150 patient in transfer. d. The patient is placed in approved hard leather restraints, or equivalent, as per the EDCEMSA Physical Restraint Policy*. e. Upon implementation, the attitude portrayed in approaching the patient is of paramount importance. Convey to the patient that the purpose of extremity restraints is both required by policy and intended for patient safety during transport as with any other gurney security systems (i.e. seatbelt and gurney locking mechanism to ambulance floor.) *Transferring base physician may order a waiver of restraints for patients who are stable and represent no risk of violence or flight. Both the transporting paramedic and the base physician must be in agreement and the order for unrestrained transfer must be written in the transfer orders. Adverse Reactions to physical restraint: Severe emotional, psychological, and potentially lethal physical injury may occur in restrained patients The patient may become agitated if the restraints are uncomfortable or severely limit movement Request assistance from transferring ED staff for proper application of restraints and

42 GUIDELINES FOR INTERFACILITY TRANSFER OF 5150 PATIENTS medical intervention 2) Guidelines for Transfer: a. All 5150 psychiatric patients requiring an ambulance for transport shall have the following: All patients will have the appropriate restraints in place The ambulance paramedic will follow the written guidelines or EMS protocol for further sedation of the patient as needed while en route to the receiving facility The emergency physician will initiate reasonable pharmacologic therapy as indicated for patient prior to departure from the emergency department If present, the paramedic will d/c the IV upon arrival to the psychiatric facility b. Patients with known allergy to benzodiazepines and are anticipated to require sedation will require CCT (Critical Care Transport). Justification: An R.N. may be required to administer alternative sedation on transport as ordered by the sending emergency physician. c. Consideration will be given for bad weather conditions as to timing of transport. An effort will be made to avoid risk to ambulance personnel during these situations. d. If there is a request for a chaperone to accompany the patient, the decision will be made in concert with Mental Health personnel and the Attending Physician to determine the necessity of the request. The responsibility for providing a chaperone, when indicated, will rely on the requesting agency. 3) Documentation considerations: a. When a non-emergency transport is scheduled or unscheduled, the ambulance crew must obtain all the appropriate paperwork and forward to the Ambulance Billing Office with the PCR. b. Documentation of the transfer on the PCR shall include the patient s diagnosis; the term 5150 will not be accepted as a medical diagnosis. 2

43 EL DORADO COUNTY EMS AGENCY FIELD POLICIES Effective: July 1, 2017 Reviewed: December 14, 2016 EMS Agency Medical Director HOSPICE PATIENTS DEFINITIONS: Allow Natural Death Order- A hospice form that is interchangeable with a DNR and is used for terminally ill patients currently under hospice care. This form must be completed and signed to be considered valid. See Appendix A. for example Respite Care- is the term used to refer to the act of leaving a loved one with special needs in the temporary care of another party. General Inpatient Care term used for an increased level of hospice care requiring Pt. to be transported to an inpatient facility ( specific hospital or SNF) for short term management of symptoms not manageable in the current place of residence. PURPOSE: To provide guidance for prehospital personnel in situations involving patients in hospice care. PROCEDURE: 1. Patients who are terminally ill and under hospice care as evidenced by the initiation of call for service by hospice personnel may be transported from one care facility to another for the means of respite or other necessary care or procedures. 2. If at any time, a patient or a patient s legal representative request transport to the nearest emergency department, the prehospital personnel will comply with the request. The Base Station shall be contacted and apprised of the situation and will notify initiating hospice of the change in transport destination 3. If there is any question in either of the above items the prehospital personnel shall contact hospice at (West-Slope Only). For hospice situations on the East Slope contact the Base Station.

44 HOSPICE PATIENTS 2

45 EL DORADO COUNTY EMS AGENCY FIELD POLICIES Effective: July 1, 2008 Reviewed: April 2009, July 2016 Revised: N/A Scope: ALS Personnel EMS Agency Medical Director INTER-COUNTY EMT-PARAMEDIC RESPONSE AND TRANSPORT PURPOSE: This policy shall be followed when an on-duty El Dorado County EMT-Paramedic is dispatched to an emergency outside the boundaries of El Dorado County. POLICY: 1) Should an EMT-Paramedic be dispatched across the County line, that EMT-Paramedic shall: a. Maintain responsibility for the call. b. Follow the policies, procedures, and protocols of the El Dorado County EMS Agency. c. Follow the medical control of the EMT-Paramedic s base station. 2) If EMT-Paramedics from another county are dispatched to the same incident, the first EMT- Paramedic to arrive on scene shall maintain authority over the medical management of the patient unless there are compelling reasons to turn care over to another EMT-Paramedic. 3) In cases where ALS first responders are dispatched into another county, care may be transferred to an equally trained transporting EMT-Paramedic or may be retained by the first responder EMT- Paramedic who must then accompany the patient to the hospital.

46 EL DORADO COUNTY EMS AGENCY FIELD POLICIES Effective: July 1, 2017 Reviewed: February 8, 2017 EMS Agency Medical Director MALFUNCTIONING ICD PURPOSE: To allow a patient with a physician prescribed ICD deactivating magnet to temporarily deactivate a malfunctioning ICD while in the presence of paramedics with continuous cardiac monitoring capabilities. DEFINITIONS: Implantable Cardioverter Defibrillator (ICD) - is a device that monitors heart rhythms, and delivers shocks if ventricular tachycardia or ventricular fibrillation is detected. POLICY: 1) In the event of a malfunctioning ICD as evidenced by cardiac monitoring, paramedics may allow a patient or a patient s family member, if so trained, to place an ICD deactivating magnet on the patient s chest directly over the ICD. This may only be performed by the patient or other authorized party and must be in compliance with orders from the patient s physician. 2) At no time shall the paramedic personally place the ICD deactivating magnet on the patient. 3) Once the ICD deactivating magnet is in place cardiac monitoring shall be continuous. 4) If at any time the patient goes into ventricular fibrillation or ventricular tachycardia the paramedic shall immediately remove the ICD deactivating magnet. 5) In cases where an ICD is delivering inappropriate shocks to a patient and for whatever reason they cannot utilize the ICD deactivating magnet, the paramedic may treat the patient If the ICD deactivating magnet does not function properly or if you encounter a patient who does not have an ICD deactivating magnet, or no one is trained in its use, then the paramedic may consider the following treatment options: Refer to Formulary for pain management.

47 EL DORADO COUNTY EMS AGENCY FIELD POLICIES Effective: July 1, 2017 Reviewed: February 8, 2017 EMS Agency Medical Director MANAGEMENT OF PRE-EXISTING MEDICAL INTERVENTIONS PURPOSE: To provide guidelines for dealing with pre-existing medical devices and/or medications outside of the EMT-Paramedic scope of practice. I. PRE-EXISTING TRANSDERMAL MEDICATIONS: Leave patches in place, except in the following situations: Nitroglycerine patches prior to cardioversion/defibrillation Clonidine (Catapress) or nitroglycerine patches should be removed if patient is exhibiting signs of shock (systolic BP <90) Fentanyl patches in patients exhibiting respiratory depression Nicotine patches in patients exhibiting chest pain If patches are removed, wipe any remaining medication from the skin with a towel or cloth. Contact base station for consultation regarding other medications. II. PRE-EXISTING VENTILATORY SUPPORT: Do not disconnect the ventilation device if the device is portable and the person normally responsible for operating the device is present and able to monitor and control the ventilation device during transport. Disconnect the ventilation system and ventilate the patient using a BVM if the ventilation device is: 1) not portable, 2) malfunctions, or 3) the person normally responsible for its operation is not able to monitor and control the ventilation device during transport. Ventilations should be delivered at the rate and volume pre-determined by the patient s physician. Contact the base station for direction if necessary. III. VENTRICULAR ASSIST DEVICE (VAD): INFORMATION: Blood flow is determined by the set pump speed. It is afterload dependent (elevated blood pressure will decrease the flow) and preload sensitive (assess for dehydration, right ventricular failure, fluid overload). A patient with a VAD will typically have no palpable pulse but they do have heart rate and rhythm. Determine what rhythm the patient is in as soon as possible. BP usually cannot be auscultated and pulse oximetry may not be measurable or accurate. VAD PROCEDURE: 1. Follow appropriate EDCEMS treatment protocol (treat underlying rhythm) for the patient s condition. If any questions or concerns contact the local VAD center the patient is linked to. Phone number is located with the equipment bag. 2. Chest compressions are contraindicated. DO NOT PERFORM COMPRESSIONS. Follow all

48 MANAGEMENT OF PRE-EXISTING MEDICAL INTERVENTIONS other EDCEMS protocols including pacing/defibrillation for patient condition. 3. VAD patients should be assessed for signs of circulation via capillary refill, skin color, and temperature. 4. Most patients with a VAD will also have an ICD or pacemaker ICD. 5. Most patients have a trained companion accompanying them. Utilize their knowledge to assist with any troubleshooting. All VAD patients have a coordinator s number attached somewhere on the machine or carry bag. 6. If transporting this patient bring the power source (A/C)/batteries and chargers with the patient to the hospital. 7. A patient with a VAD should typically be transported to the nearest appropriate VAD center. The patient and/or their companion will be able to advise prehospital personnel of the requested transport destination. Trauma of any kind even a fall could be reason enough to take the patient to a VAD center. If the patients condition does not warrant transportation to the VAD center or if there are any questions regarding appropriate destination, the base hospital shall be contacted for destination decision. 8. Take visiting/out of area patients to the closest VAD Center: UCDMC Sutter Medical Sacramento Mercy General 9. Trouble shooting the device: Battery/Power a. Replace the battery. b. Place patient on home battery power (A\C) assure it is plugged into the wall. c. Do not delay transport if the controller reads low battery or has the minute countdown that is low. Controller Related a. Assure all cables are attached. b. If all cables are attached and Controller is failing have the patient change the controller. You may need to assist patient with changing the controller. c. Auscultate over the heart to evaluate for humming. The humming sound indicates the pump is running. Internal Device Related a. Take patient to VAD Center 10. VAD patients should be assessed for signs of circulation via capillary refill, skin color, and temperature. 11. When consulting with ER staff from a VAD Center inform them you have a VAD patient and what the situation is. In most cases you will be required to call back or give a return phone number for the cardiologist to get on the phone. Contact the base station for direction if necessary. 2

49 MANAGEMENT OF PRE-EXISTING MEDICAL INTERVENTIONS VAD Example: 3