Revised: November 2017

Transcription

1 Sacramento County EMS Agency Orientation Revised: November 2017

2 The material provided in this presentation is an overview of selected Sacramento County EMS policies, procedures, and protocols. The presentation of this material may not be considered a substitute for your complete review and understanding of all materials regulating paramedic practices in Sacramento County - prior to functioning in that capacity. Sacramento County EMS Policies and Procedures

3 EMS Laws and Regulations California Health and Safety Code, Division 2.5 Statutes Regulating how EMS is delivered in California leginfo.ca.gov California Code of Regulations, Title 22 State EMSA clarifies the regulations ccr.oal.ca.gov

4 ANY OF THE FOLLOWING ACTIONS BY PREHOSPITAL CARE PERSONNEL SHALL BE CONSIDERED EVIDENCE OF A THREAT TO PUBLIC HEALTH AND SAFETY Fraud in procurement of certification Gross Negligence Repeated negligence Incompetence Fraudulent, dishonest, or corrupt act Conviction of any crime Violating any provision of this division or the authority Violating statute regulating narcotics or controlled substances Addiction/excessive use of alcohol, narcotics, etc. Functioning outside the field of Medical Control

5 Sacramento County EMS Agency David Magnino Emergency Medical Services Administrator 1.0 FTE Stephanie Mello Administrative Services Officer II Ben Merin EMS Coordinator 1.0 FTE Hernando Garzon MD Medical Director 0.23 FTE (Contract) Amanda Morse Office Assistant II 1.0 FTE Dorthy Rodriguez EMS Specialist II 1.0 FTE Stephen Harrington EMS Specialist II 1.0 FTE Kathy Ivy EMS Specialist II 1.0 FTE EMS Community Leaders Trauma/Medical/Operations Oversight Committees

6 Sacramento County EMS Philosophy The driving force behind the production of this document has been the Paramedics, Physicians, and Nurses from local emergency medical service providers. These healthcare professionals and the County of Sacramento, are dedicated to a coordinated, medically driven EMS system, which provides high quality emergency care for all residents and visitors to Sacramento County.

7 Various Local EMS Agency Responsibilities Provide For Physician Medical Control Maintain a State Approved EMS/Trauma System Plan Designate/Monitor Trauma Centers Develop/Maintain EMS System Treatment Protocols Designate/Monitor Paramedic/ALS Service Providers Approve/Monitor EMS Training Programs Certify EMTs and MICNs Accredit Paramedics Investigate Medical Care Complaints/Deficiencies

8 Sacramento County EMS System Hospitals 9 General Acute Care Hospitals 300 ED Beds/3000 Staffed Beds 3 Base Hospitals Kaiser South, Mercy San Juan and UCDMC. 3 Trauma Base Hospitals Kaiser South, Mercy San Juan and UCDMC

9 Sacramento Area Hospitals In County (KHN) Kaiser Hospital North (KHS) Kaiser Hospital South (MSJ) Mercy San Juan (MHF) Mercy Hospital Folsom (MGH) Mercy General Hospital (MHS) Methodist Hospital (SMCS) Sutter Medical Center, Sacramento (UCD) UC Davis Medical Center Veterans Hospital (VA) Out of County (KHR) Kaiser Hospital Roseville (SRH) Sutter Roseville Med Center

10 Approved Paramedic Service Providers PRIVATE AlphaOne Ambulance American Medical Response Bay Medic CALSTAR(Air) Medic Ambulance NorCal Ambulance ProTransport-1 REACH (Air) Sacramento Valley Ambulance TLC Falck/Verihealth PUBLIC Cosumnes Fire Folsom City Fire Sacramento City Fire Sacramento Metropolitan Fire

11 County EMS Medical/Operational Advisory Committees Open Meeting Chaired by the County Medical Director EMS Policies/Procedures are discussed EMTs, Paramedics, Nurses and Physicians provide input for revising treatment protocols Field personnel are welcome to attend Submit agenda items 15 working days prior to meeting CEU Available

12 County EMS Trauma Review Committee Closed Meeting Trauma Surgeons, Emergency Physicians, County Pathologists and EMS Staff review individual surgical cases to identify opportunities for improving trauma care

13 EMS System Policy Updates COUNTY OF SACRAMENTO EMERGENCY MEDICAL SERVICES AGENCY Document # PROGRAM DOCUMENT: Draft Date: 10/26/94 Overdose and/or Poison Ingestion Effective: 05/01/15 Revised: 01/08/15 Review: 05/01/16 Updates are effective May 1 st and November 1 st. Updates are available on the website approximately 6 weeks prior to scheduled update, but cannot be used until the effective date. Policies change between effective dates so keep current by communicating with your provider.

14 November 1, 2017 Updates This is just a overview of the most significant updates, go to SCEMSA website for full overview of updates. Policy Patient Initiated Refusal of EMS Assessment, Treatment and/or Transport: Policy was completely revised to a more legal definition. Please read the policy in it s entirety. Policy EMS Patient Care Report: Completion and Distribution: What communication needs to occur to the receiving hospital staff prior to leaving the patient to ensure that information needed for continuing care of the patient has been provided. This includes: Date of incident and incident number Call location Unit number Agency name Patient name, sex, age and DOB Chief complaint PQRST/time of symptom onset (including time of incident and mechanism of injury for trauma patients Pertinent medical hx Medications Vital signs (including GCS, BP, pulse, respiration, pain scale, cardiac rhythm and SpO2 as appropriate Tx rendered(including time, type of tx, medication, dose, route, response and total IV volume ECG left with patient

15 Policy 2525-EMS Radio Report Format: New Policy to provide a standardized and consistent approach to prehospital radio notifications. One for medical report and one for MCI alerts/reports. Please see policy for complete details Policy Paramedic Accreditation to Practice: New requirements that are effective May 1, 2018 and May Please review policy. Policy Discomfort/Pain of Cardiac Origin: Updated language allowing administration of ASA in BLS section. Policy Stroke: Language added, last seen normal time (time patient was witnessed by another party to have been at their prior baseline.

16 ?? QUESTION?? Who is SCEMSA s Medical Director? Dr. Garzon

17 Policies 2000 Series EMS System Policy 2001 thru 2520

18 PD# 2032 CONTROLLED SUBSTANCE All controlled substances will be stored in a secure and accountable manner Oncoming and off-going Paramedic will jointly count, date, time, and sign a Controlled Substance Signature Log. All wastage will be witnessed by a second person that documents it in accordance with a provider-developed procedure. Revision Effective 05/01/2015

19 PD # 2033 Obvious Death EMT or Paramedic Visual Examination of the Remains: viewing of the body with sufficient proximity and lighting to assure existence of death determining condition. DECAPITATION INCINERATION DECOMPOSITION SEPARATION OF BRAIN OR HEART RIGOR MORTIS (Physical examination of the jaw/limb) Revision: Effective: 05/1/2015

20 Determination of Death- Paramedic ONLY Physical exam indicates Livor Mortis ASYSTOLE 2 LEADS Rigor/Livor Mortis cannot be assessed - ASYSTOLE 2 LEADS AMBIENT TEMPERATURE SKIN Traumatic Injuries - PULSLESS, ASYSTOLE 2 LEADS, PEA RATE LESS THAN OR EQUAL TO 40/MIN Documented submersion greater than or equal to 60 minutes.

21 Notification of Death In all cases when death has been determined, notify the Coroner's office or investigating agency. Follow the direction of the Coroner's office/investigative agency as to who has custody of the body. Evidence of a hospice patient receiving care from a physician or registered nurse, who is a member of a hospice care interdisciplinary team, within twenty (20) days before death does not require coroner notification. When the investigating agency releases prehospital personnel, they may depart the scene. In all cases, documentation will be forwarded to the Coroner's office within 72 hours or sooner if requested by the Coroner's office.

22 PD# 2039 Physician/Nurse at Scene Present your State CMA card to the MD or RN Licensed Physician Option 1: Physician acts as an observer. Option 2: Contact base hospital to allow the on-scene Physician to speak with Base Hospital Physician. The onscene Physician chooses to offer medical advice and assistance. Option 3: Take total responsibility. Revision: Effective: 02/09/2015

23 Option 2 or 3: On-scene Physician Desires option 2 or 3: Paramedic will ask to see the Physician s medical license, noting his/her name, license number and date of expiration on PCR. Contact Base and ask to speak with Base Physician. Paramedic should have the on scene physician speak directly w/the Base Hospital Physician. The Base Hospital Physician may, request the on scene doctor to function as an observer capacity only (option 1). Retain medical control but consider suggestion offered by the physician on scene (option 2) Delegate Medical control to the Physician on the scene (option 3). If this occurs then the Paramedic will:

24 Physician on scene Make ALS equipment and supplies available to the Physician and offer assistance but continue to practice within the SCEMSA scope of practice. Ensure the Physician accompanies the patient to the receiving hospital in the ambulance. Ensure that the physician signs for all instructions and medical care given on the PCR. Keep Base Hospital advised. Complete an ALS service provider incident report and forward a copy to SCEMSA w/in 72 hours.

25 CMA STATE OF CALIFORNIA cma California Medical Association NOTE TO PHYSICIAN ON INVOLVEMENT WITH EMT- IIs AND EMT-Ps (PARAMEDIC) A life support team [EMT-II or EMT-P (Paramedic) operates under standard policies and procedures developed by the local EMS agency and approved by their Medical Director under the 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, CCLHO, and BMQA. Assistance rendered in the endorsed fashion, without compensation, is covered by the protection of the Good Samaritan Code (see Business and Professions Code, Sections 2144, and Health and Safety Code, Section ). (over) 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 to do one of the following: 1. Offer your assistance with another pair of eyes, hands, or suggestions, but let the life support team remain under base hospital control; or, 2. Request to talk to the base station physician and directly offer your medical advise and assistance; or, 3. Take total responsibility for the care given by the life support team and physically accompany the patient until the patient arrives at a hospital and responsibility is assumed by the receiving physician. In addition, you must sign for all instructions given in accordance with local policy and procedures. (Whenever possible, remain in contact with the base station physician). (REV. 7/88) Provided by the Emergency Medical Services Authority

26 Registered Nurse On-Scene Recognition by Paramedic OR Valid California RN License OR Valid SCEMSA MICN Certification. Paramedic can request that the RN perform BLS procedures. MICN may assist but not provide Base Hospital Orders.

27 Policy # 2050 Direct Admit Patient Transports In no circumstances shall patient care be compromised or adversely affected by waiting to deliver a patient to another department... ( Example; L&D) Contact receiving facility prior to arrival Request an escort Bring all necessary equipment This policy is not intended for the purposes of inter-facility transfers. Revision: Effective: 05/01/15

28 Policy # 2055 On-Viewing Medical Emergencies Notify Sacramento Regional Fire Emergency Communications Center if you come upon the scene of a medical/traumatic emergency or flagged down by bystanders. Unit must STOP and render aid including transport Unless en route to another emergency or transporting a patient Revision: Effective: 6/1/2013

29 Hospital Services PD# 2060 Revision: Effective: 06/01/16 SERVICE Emergency Department MSJ MHS MHF MGH SMCS KHN KHR KHS UCD SRMC VAMC Base Hospital Labor and Delivery Orthopedics Trauma Base Hospital * Interventional Cardiac Catheterization Services ** Burn Center Primary Stroke Center Ventricular Assist Device

30 Hospital Services Policy # 2060 Sacramento County ALS Service Providers may contact Sutter Roseville Medical Center for direct medical control for Trauma Patients. Sutter Roseville Medical Center may NOT be utilized by Sacramento County ALS Service Providers as a BASE hospital for medical (non-trauma ) patients. ALS personnel can contact UCDMC, MSJ, or KHS on all Trauma Triage patients refusing treatment and or transportation. Patients requiring Interventional Cardiac Catheterization Services as indicated by a 12-lead ECG consistent with an acute myocardial infarction, who requests a Kaiser Facility should be directed to a Kaiser or Dignity Health Catheterization facility. Revision: Effective:05/01/17

31 Non-trauma patients under CPR transport to most accessible destination Trauma patients with unstable airway transport to most accessible destination Law enforcement shall be responsible for patient in custody

32 PD# 2085 Do Not Resuscitate (DNR) Partial DNR orders require a consult with medical oversight. Medical oversight should be consulted with questions regarding a valid DNR. Prehospital personnel should provide comfort measures including BLS CPR until questions are resolved. Revision: Effective: 02/09/2017

33 Documentation The presence of a DNR order, the Physician, PA or NP s name signing the order and the date of the order is to be documented on the Patient Care Report. The DNR form (original or copy), DNR medallion, or a copy of the valid DNR order from the patient s medical record shall be taken with the patient.

34 DNR FORM Must be readily available to be honored They re only two (2) venders in California that are currently approved to produce Statewide approved prehospital DNR medallions. Medic Alert Foundation & Caring Advocates.

35 Signatures Required

36 PD# 2101 Patient Initiated Refusal of Service/Transport Person An individual, who, who is alert cooperative and can demonstrate capacity who does not have a complaint suggestive of an illness/injury, does not request evaluation of an illness/injury, nor has suffered a mechanism that has a reasonable likelihood to cause injury and/or in the judgement of EMS personnel, does not demonstrate a known or suspected illness/injury that requires EMS care. Follow provider policies Patient An individual who has a complaint suggestive of an illness/injury, or has suffered a mechanism reasonably likely to cause 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. A PCR shall be completed on all PATIENT contacts

37 Patient assessment and refusal, of EMS care shall be performed by ALS personnel whenever possible. BLS personnel may only complete the refusal of EMS care procedures if ALS personnel are not on scene and do not meet criteria as listed under Procedure A (4). BLS personnel shall not continue ALS personnel to scene for the sole purpose of completing the refusal of EMS care documentation. A4. Base hospital consultation shall be done by an ALS provider while in close proximity to the patient for any of the following patient circumstances: a. Complaint of new onset of altered level of consciousness (LOC). b. A patient, assessed by EMS personnel to have impaired capacity. c. Potentially life threatening condition, including but not limited to, patients meeting STEMI, stroke, or trauma triage criteria. d. Unstable vital signs. e. Disagreement between law enforcement and EMS personnel about whether or not the patient requires EMS care. f. 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, and agent/attorney-in-fact). g. Any circumstance where the patient s capacity is unclear or EMS personnel believe that the involvement of the base hospital would be beneficial.

38 Base hospital consultation shall be done by an ALS provider while in close proximity to the patient for any of the following patient circumstances (Cont.): h. Patients in law enforcement custody or under 5150 hold do not require consent for transport. However, patients in law enforcement custody or under 5150 hold may decline treatment unless, in the prehospital provider s discretion, withholding treatment could potentially cause harm to either the patient or providers. i. Patients who are not legally responsible for their own healthcare decision making (nonemancipated minor, concervatee, patient with a DPHC, etc.), and who do not have a legally designated healthcare decision maker on scene with them, shall not be released without base hospital consultation. j. Base hospital contact for pediatric trauma patients shall be to UC Davis Medical Center

39 Paramedic Scope of Practice PD# 2221 and Paramedic Scope of Practice Utilization PD# 2223 Utilization of the Sacramento County Paramedic Scope of Practice is allowed only when employed by a designated ALS provider as a Paramedic & when ALS equipment is available. A California state licensed Paramedic who is employed as a Paramedic at the time of an incident, by a locally designated ALS provider with a current Sac County accreditation and ALS equipment is not available may provide the State of California EMT Scope of Practice.

40 PD# 2200 Medical Oversight Standing Orders SCEMS PD# Base Hospital Orders: Can be given by MICNs or BHPs Base Physician Orders: Shall not exceed SCEMS SOP or EMSA SOP Revision: Effective: 11/01/15

41 DMO (direct medical oversight) SHALL BE UTILIZED TO AID IN DESTINATION DECISION WITH THE FOLLOWING: Assessment indicates condition unstable and destination is not the most accessible Special Triage Policy differs from requested destination by patient, family, MD, etc. Control Facility makes decision on expanded emergency levels II, III or IV

42 PD# 2305 Patient Care Report Completion and Distribution Completion of a PCR when more than one provider is on scene will be as follows: 1. If a non-transporting ALS provider arrives on scene prior to the transporting ALS unit, the non-transporting ALS provider will generate a PCR, even if nothing more than a primary assessment has been done. 2. In the event that a non-transporting and transporting Advanced Life Support (ALS) provider make patient contact simultaneously, the transporting provider shall complete the PCR. 3. If the transfer of care is done within the same agency, one PCR is sufficient, as long as it specifies which prehospital care personnel performed what care. 4. If a non-transporting unit arrives prior to the transporting unit and non-transporting personnel maintain patient care, the non-transporting unit personnel shall complete the PCR.

43 The completion and delivery of PCRs to hospitals: Except during extenuating circumstances, it is the expectation that patient care reports will be completed and made available to hospital staff shortly after transfer of care to facilitate continuity of care. The service provider shall make available an electronic PCR (via web portal accessible by the receiving hospital) or deliver a hard copy (fax acceptable) within one (1) hour for a minimum of > 90% of all transported patients, and cannot exceed twentyfour (24) hours for any patient. Transporting ALS Service Providers shall make available an electronic PCR to the base hospital or deliver a hard copy PCR (fax acceptable) to the Base Hospital within seventy-two (72) hours when a Base Hospital is utilized for medical control, whether the patient is transported or not. All patient contacts that do not result in transportation to a hospital (AMA, DOA, transfer of patient care to transporting ALS unit), shall have an epcr completed and submitted within twenty-four (24) hours

44 In what circumstances shall a base hospital consult occur when the patient refuses EMS assessment, treatment and/or transport? Complaint of new onset of ALOC Impaired capacity Potentially life threatening conditions Unstable vitals Disagreement between Law and EMS personnel about whether or not the patient requires EMS care Pt. not legally responsible for their own healthcare decision making Patient capacity is unclear and base hospital consultation would be beneficial 5150 where pts refuses care but in the providers discretion withholding tx could potentially cause harm to either the patient or providers Pts not legally responsible for their own healthcare decision making and don t have anyone else to make their decisions on scene with them Any pedi trauma pt. shall have base hospital contact to UC Davis

45 Policies 4000 Accreditation/Certification Programs Approval Policies center around reporting responsibilities of relevant employers, criminal background checks, EMT & MICN certification, Paramedic accreditation, AED oversight standards and all training programs.

46 PD# 4400 Paramedic Continuous Accreditation To maintain continuous Paramedic accreditation an individual must: To be eligible for Continuous Paramedic: At accreditation, an individual must: 1. Have no lapse in California Paramedic licensure or County Accreditation. 2. Apply online at no less than thirty (30) days prior to last day of the current accreditation period. Paramedics waiting for their State Paramedic license should apply to avoid late fees. Once State license is verified, or received, the application for continuous accreditation will be completed. 3. Indicate an affiliation with a Sacramento County ALS provider and provide a current dated letter on official letter head of affirmation of employment or affiliation. 4. Upload evidence of a renewed and valid California Paramedic license before the current Paramedic license expires. 5. *Copy (front and back) of a valid American Heart Association BLS Healthcare Provider, American Red Cross Professional Rescuer CPR card or equivalent. 6. *Copy (front and back) of a valid American Heart Association Advanced Cardiac Life Support (ACLS) card or equivalent.

47 7. *Copy (front and back) of a valid American Heart Association Pediatric Advanced Life Support (PALS) or Pediatric Education for Prehospital Professionals (PEPP) card or equivalent. 8. **Copy of (front and back) of a current ITLS/PHTLS card, and 9. Verification of Skills Competency is completed every two years (see SCEMSA skill form)*. 10. Upload government issued ID *Effective May 1, 2018 **Effective May 1, 2019

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50 Your accreditation expires May 31 st and you start and complete your application on June 1 st are you continuous? NO $$You are now reaccrediting$$

51 Policies 5000 Transportation/Patient Destination covers transfer of care, destination, trauma criteria & destination, hospital diversion, interfacility transfers and emerging viruses.

52 PD# 5010 Transfer of Care: Non-Transporting Paramedic to Transporting Paramedic. A non-transporting Paramedic may transfer to a transporting Paramedic if the transporting Paramedic Agrees to assume responsibility for the patient. All assessment and care provided by the nontransporting Paramedic must be relayed to the transporting Paramedic. A transporting Paramedic may refuse to assume care for a patient they feel has not been adequately treated or stabilized for the given circumstances. Revision: Effective: 5/1/2016

53 Revision: Effective: 05/01/16 PD# 5050 Destination Multiple patients will be off-loaded at the hospital for evaluation UNLESS directed otherwise by Control Facility during a declared MCI or area-wide emergency

54 PD# 5050 Destination If there exist no medical condition that the Paramedic believes is unstable and no special triage policy applies, then the patient shall be taken to the facility based on the following decisive factors: Special Triage Criteria Special Triage Polices Patients request Trauma Cardiac Family/Guardian Pediatric Stroke Private Physician VAD Burns EMS Resources availability Obstetric Law Enforcement Revision:

55 Question?? If you have a patient who meets Trauma Triage Criteria but also is a VAD patient which hospital should the patient go to? UC DAVIS A VAD center and Trauma Center

56 PD# Trauma Triage Criteria (CTP) Trauma Triage Criteria PD# 5053 shall be applied by prehospital personnel to any patient suffering from suspected acute injury. CTP s shall be transported to the time closest appropriate designated trauma center. Direct Medical Oversight (DMO) shall be obtained from a Trauma Base Hospital for any CTP refusing to be transported to a trauma center to guide prehospital personnel in making a destination decision. CTP without an effective airway will be transported to most accessible ER Any Patient with a tourniquet in place shall be transported to the nearest appropriate trauma center.

57 Pediatric Trauma Destination All CTPs 14 years of age will be transported to UCDMC if they meet ANY trauma triage condition with the following exceptions: 1. Pediatric Critical Trauma patients with no effective established airway may be transported to the closest available facility. 2. Traumatic CPR - transport to the time closest designated trauma center. Pediatric pts with tourniquet in place should be transported to UCDMC

58 PD# 5053-Trauma Destination Revision: Effective: 11/01/2015

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60 PD# 5060 Hospital Diversion Advisory CT scanning not available Will transport a non-immediate patient to the next most appropriate facility with any of the following signs or symptoms: New onset lateralizing neurological signs Sudden onset worst headache of their life ALOC with GCS<12 refractory to treatment Diversion Receiving only IMMEDIATE patients Revision: Effective: 11/01/16

61 CLOSED TO ALL AMBULANCE TRAFFIC Internal Hospital Disaster

62 Policies 7500 Disaster Medical Services Plan Addresses Disaster Medical Services Plan MCI Critique START/JumpSTART Out of County Responses

63 PD# 7500 Disaster Medical Services Every out-of-hospital provider agency in Sacramento County shall be responsible for implementing the OES4 MCI plan within their organization. The provider shall require that all out-of-hospital personnel be familiar with the OES4 MCI plan as a minimum. Formal OES4 MCI training is highly recommended.

64 Mutual Aid Region Map

65 CF Utilization *see PD# 7500* Once an MCI has been declared contact Control Facility (CF) for all designation decisions The CF shall be utilized when: a. When the number of patients meeting critical trauma criteria equals four (4) or more. b. The total number of immediate and/or delayed patients equals five (5) or more for a unifocal incident, or c. when the total number of minors exceeds ten (10) irrespective of the numbers of immediate and delayed, or d. at the discretion of the Provider

66 Policy MCI Patient distribution shall be as follows: Once an MCI Trauma has be declared the provider may disperse up to 1 pt. that meets trauma triage criteria to each open trauma center while simultaneously contacting the CF. The filed will report these pt. dispersals to the CF who will make all subsequent pt. dispersals. Level 1 & 2 MCIs: prehospital personnel will report to the CF the START triage level (immediate, delayed, minor) as well as whether the pts. meets trauma criteria. Level 3 & 4 MCIs: prehospital personnel will report to the CF only the START triage level (immediate, delayed, minor) for each pt.

67 Policy 7500-Disaster Medical Services Plan Who is responsible for direct medical control and the dispersal of patients during all declared Multi-Casualty Incidents (MCI)? The Control Facility Who is the Control Facility? UC DAVIS

68 PD# 7500 MCI/Disaster Medical Services Plan Field Triage- Standard field triage shall be utilized until it can no longer meet the needs to triage all pts. in a timely & effective manner. A mass casualty triage algorithm shall be utilized when standard field triage can no longer meet then needs to triage all pts. in a timely and effective manner (START/JumpSTART). Initial triage should take 30 seconds or less.

69 Policy START/JumpSTART Once all immediate pts have been assigned destination facilities, all delayed and minor pts shall receive secondary triage to determine if they meet trauma triage criteria. This information shall be reported to the CF when seeking appropriate destination. Secondary Triage on delayed and minor pts may be abbreviated or eliminated ONLY when very large pt. numbers would prevent timely distribution of pts to hospitals.

70 Policy 7508

71 For pts. 1-8 yrs. of age. Policy 7508

72 Initial triage should take 30 seconds or less per patient. Initial triage shall utilize the START method *Refer to Program Document (PD) # 7508* Black Red Yellow Green Clinically Dead Critical Life Threatening Serious May Be Life Threatening Walking wounded

73 Policy 7500-Disaster Medical Services Plan What are the three (3) types of MCIs? MCI Trauma MCI Medical- no decon required MCI HazMat- decon required

74 Policies 8000 Adult Treatment Policies

75 PD# 8001 Allergic Reaction/Anaphylaxis This is a standing protocol except what particular medication dose and route? Epinephrine 1:10,000 IV push is a BASE HOSPITAL ORDER ONLY. 0.1mg increments of 1:10,000, slow IV push, for stridor and hypotension, until a systolic B/P > 90mm Hg OR a total of 0.5 mg. is given.

76 PD# 8017 Dystonic Reaction How can you give Diphenhydramine? 50mg IV/IM (IV preferred route)

77 PD# 8018-Overdose and/or Poison Ingestion Treatment for beta blocker overdose? 500cc fluid bolus When can you give Atropine? Heart rate < 50 and SBP < 90 If maxed out on Atropine what else can you give? Glucagon 4 mg

78 Policy 8026-Respiratory Distress What is the TX protocol for patients with Moderate/Severe Asthma and/or COPD? Albuterol 5mg via neb CPAP IV access Epi 1: mg IM (severe asthma/bronchospasm only)

79 Policy 8026-Respiratory Distress Your patient in moderate/severe Asthma/COPD is 40 or older, do you need a base hospital order for Epi 1: mg IM? YES

80 Selective Spinal Immobilization PD # 8044 All pts. suffering traumatic injuries shall be assessed for the possibility of spinal injury. Unless pts. meet some other criteria for spinal immobilization, pts. sustaining stab/gunshot wound, or any penetrating injury, to any body site, do not require spinal immobilization, unless prehospital providers elect to immobilize them based on their clinical assessment.

81 Selective Spinal Immobilization Flow Chart

82 Policy 8063-Nausea/Vomiting What treatment do you want to consider after cardiac monitoring? IV NS and titrate to SBP of mmhg Ondansetron 4mg PO/SL/IM/IV/IO What is the max dose for Ondansetron? 8 mg

83 Policies 8800 Skills Focus on Cricothyrotomy, Needle w/jet Insufflation, IO, stomal intubation, IV access, TCP, COMBITUBE, MARK 1 Nerve Agent Antidote Kit, 12 lead EKG, CPAP, King Tube, VAD, Intranasal Medication, Amiodarone administration and DuoDote Auto-Injectors

84 PD# 8801 Cricothyrotomy Indications: Older than three (3) years or greater than fifteen (15) kilograms on whom other airway methods have failed. Have orofacial injuries or partial airway obstruction that preclude orotracheal intubation. Effective May 1, 2018 Percutaneous Cricothyrotomy & high flow intermittent ventilation for those with complete obstructions Absolute Contraindications: DO NOT perform on a conscious patient. DO NOT perform on a patient with a complete airway obstruction DO NOT perform on patients with an anterior neck hematoma or with massive subcutaneous emphysema

85 PD# 8802-Intraosseous Infusion IO lines will NOT be established as precautionary. Only patients who have an IMMEDIATE need for an IO medication and who are in extremis when peripheral venous access cannot be obtained shall undergo intraosseous cannulation. All other uses of the IO route require a base hospital order. In a conscious adult patient with a response to pain, flush the IO with 2 ml of 2% Lidocaine (40mg) slowly at a rate of 1-2 minutes. 1. Wait 60 seconds then give 10cc Normal Saline flush via IO. 2. 1ml of 2% Lidocaine (20mg) via IO. In a conscious pediatric patient responsive to pain, administer 0.5 mg/kg of 2% preservative free Lidocaine, not to exceed 40mg, via IO slowly over 1-2 minutes. 1. Flush with 5 ml saline.

86 PD# 8808 Intravenous Access INTRAVENOUS ACCESS SHALL NOT BE ESTABLISHED UNDER THE TERM PRECAUTIONARY. 2 attempts by 2 different paramedics, max 4 attempts. Base hospital contact must be established for further IV attempts Paramedics may access pre-existing vascular devices for cardiac arrest or pending cardiac arrest only; access in other situations requires BASE HOSPITAL ORDER. Saline locks shall be used when only administration of medication is indicated. If fluids are needed an IV line will be connected to the saline lock Revision: Effective: 05/01/16

87 Indications of CPAP PD#8829 CPAP Adult pts in moderate to severe respiratory distress who are spontaneously breathing, conscious and no suspicion of pneumothorax. Contraindications: Apneic, Pediatric, Cardiac and/or respiratory arrest, suspected pneumothorax, vomiting, unconscious, uncooperative pts even after coaching, and inability to achieve good seal with the CPAP facemask. Notify the receiving hospital that CPAP is in use.

88 Policies 9000 Pediatric Treatment Policies

89 PD# 9005 Pediatric Decreased Sensorium Rule out Hypoglycemia- check blood sugar Narcotic overdose- check pupils, respiratory depression/insufficiency, bradycardia or hypotension Seizure- active and continuous-consider Midazolam IV- 0.1mg/Kg (max dose 4 mg) slow IM-0.1mg/kg (max dose 4 mg) IN 0.2 mg/kg (max dose 6 mg)

90 PD#9016 Pediatric Parameters Unless otherwise stated, pediatric protocols will apply to pts 14 years of age or whose weight is 36 kg as determined by a length-based resuscitation tape - Broselow Pediatric Emergency tape or equivalent may still be considered pediatric patients; however weights will then need to be estimated and adult dosages should be used.

91 9018 Pediatric Pain Management Every patient deserves to have their pain managed. Consider reassurance, adjusting position of comfort, ice or heat, and gentle transport before deciding to treat with narcotics. Fentanyl can be given IV/IO/IN Document pain scale with initial assessment/vital signs, after each administration of medication and after all procedures.

92 9019 Brief Resolved Unexplained Event (BRUE) An episode involving an infant less than twelve (12) months of age that is frightening to the observer and there is no explanation for a qualifying event after conducting an appropriate hx and physical exam. A qualifying event is characterized by one or more of the following: Apnea (central or obstructive) Color change (cyanosis, pallor) Marked change in muscle tone Unexplained choking or gagging ALOC

93 PD#9020 Pediatric Nausea and/or Vomiting Assess and support ABC s, supplemental O2 to maintain 94%. Treat as appropriate for underlying cause Suction if needed Check blood glucose Cardiac monitoring Consider IV NS 20ml/kg if VS/exam suggest volume depletionrecheck vitals Consider Ondansetron Patients 40kg, 4mg POx1; Max 4mg Patients 40kg 0.1 mg/kg slow IV push x1 Max dose 4mg Effective 05/01/16

94 Disaster Healthcare Volunteers

95 Continuing Education for EMS

96 Prehospital Continuing Education

97 Public Counter Hours: Tuesday- Thursday 8:00am 12:00pm Phone: Fax:

98 EMS Specialist Contact Info Stephen Harrington- ALS Liaison Specialist Kathy Ivy- Prehospital Education Specialist Dorthy Rodriguez- Quality Improvement & Data Specialist