MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 EMT-BASIC PROTOCOLS MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 TABLE OF CONTENTS Statement of purpose
Certification and Inservice requirements
MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 STATEMENT OF PURPOSE
The purpose of the protocols in this document is to provide the affiliated EMT-Basic with off-line medical direction when rendering pre-hospital emergency care. Some procedures are performed upon assessment of the patient by the EMT-Basic and others may be performed only after contact with the Base Physician. The Base Physician is the on-duty emergency physician at the receiving hospital. EMT-Basic personnel affiliated with Saint Joseph Regional Medical Center, Plymouth Campus, and Culver-Union Township EMS will be expected to follow these protocols as written and medical control orders as given. It is understood, however, that situations may arise where protocols will not conform to the patient’s needs. In these cases the EMT-Basic should consult with the Base Physician. If this is not possible, the EMT- Basic should utilize other BLS personnel on the scene and decide on the appropriate course of action. National Standard EMS Curriculums should be the Standard of Care for all conditions not directly addressed in these protocols or by the Physician. It should also be understood the on-duty Physician has the authority and privilege to give orders based upon their own judgment, which may or may not be in conjunction with a written protocol. These protocols recognize your ability to perform as a trained professional. They do not “step you through” all of your skills. Where the word “CONSIDER” is used in conjunction with an intervention, it is meant that it is your option based upon the situation. These protocols have been provided to all providers in CD ROM format; updates will be distributed periodically as needed, with the revision date at the top of each page. It is the individual's responsibility to keep a current protocol binder. Concerns or suggestions for revision or addition to these protocols should be submitted to the Medical Director or Tri County Ambulance Service, Inc. training officers. MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 MEDICAL CONTROL
ASSESSMENT Patient requires treatment/transport, and medical direction is sought by the EMT-Basic or is offered by a physician at the scene. MANAGEMENT The EMT-Basic may accept medical direction as follows:
Patient’s private physician, when present at the scene and in physical contact with the patient, after CONTACT BASE PHYSICIAN for confirmation, if possible.
System Medical Director, when present at the scene and in physical contact with the patient.
Base Physician at the receiving hospital, by radio, landline, or cellular telephone.
Base Physician at Saint Joseph Regional Medical Center, Plymouth Campus or the transferring facilitywhen transport is to another facility and communication is not possible with a physician at the receivingfacility.
Physician intervenor, other than #1 or #2 above, present at the scene and in physical contact with the patient. Direction may be accepted from this physician ONLY AFTER THE FOLLOWING CRITERIA HAVE BEEN MET: a.
intervenor provides appropriate identification;
confirmation has been received from the Base Physician;
communication between intervenor and Base Physician has taken place by radio, land line, or cellular telephone.
intervenor agrees to accompany patient IN THE AMBULANCE to the hospital.
Base Physician may resume control at any time.
The EMT-Basic MUST NOT serve as a mediator between intervenor and Base Physician. MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 REFUSAL OF EVALUATION / CARE / TRANSPORT
ASSESSMENT A patient, who initially requests emergency medical services, or demonstrates potential for injury based on the mechanism of the event, has the right to terminate his/her own treatment if he/she is competent and is not suicidal, self destructive, or a threat to others. Patient must be 18 years of age or older. A parent or proven legal guardian may refuse on behalf of a minor. MANAGEMENT
Determine the patient’s airway, respiratory, and circulatory status.
Assess the scene for any mechanism of injury.
Determine if the patient can converse in a clear and appropriate manner, is aware of their surroundings and situation, is oriented to person, place, and date, and that there is no evidence of consumption or suspicion of influence by alcohol or other substance.
Advise the patient you will transport if they so desire. If the patient refuses, have patient sign release, witnessed by bystanders, if possible.
If the patient refuses to sign or has consumed alcohol, CONTACT BASE PHYSICIAN for order to transport. Request law enforcement assistance. Note why patient is incompetent or unable to make decision based on illness or mental status.
Complete a run report on this (and all releases) patient, including all discussion between the caregiver and the patient. A copy of this run report is to be turned in to the EMS Coordinator within 24 hours of the call.
If you deem a scene to be a mass casualty incident, all victims will be offered assessment; if any or all victims deny injury and there is no obvious mechanism for injury, document the call on a run report and you may list the names of all individuals who denied injury and refused assessment. MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 D.N.R. PRESENTATION ASSESSMENT This protocol applies only to situations in which the paramedic is presented with or finds an EMS-DNR form or equivalent. The EMS-DNR form serves as an advance directive to limit the scope of EMS care for individuals with a terminal illness and those suffering from a severe chronic illness and/or disease who do not wish for life-sustaining treatment in the event of a cardiopulmonary arrest. This protocol will become effective when responding EMS personnel are presented with the documentation indicating the patient does not wish to be resuscitated. MANAGEMENT AIRWAY
Determine the patient has an airway without obstruction.
Determine the patient is pulseless by checking both carotid and radial pulses.
Assess the scene for any mechanism of injury.
Obtain a history from family/bystanders regarding the nature of the call.
Carefully review the EMS-DNR form. It must meet ALL of these criteria: a.
Must be directly identifiable with the patient.
Must include signature of the patient or authorized decision-maker.
Must have the physician’s name, signature, and license number.
If the DNR meets all the criteria above, do not initiate care. If there are any doubts to any criteria: a.
Contact Base Physician. Advise them of the DNR and the criteria in question. Follow base physician’s recommendation, and explain decision to family.
If the EMS emergency IS NOT related to the terminal/chronic illness identified by the DNR form, routine medical care and management must be provided as dictated by on or offline medical control.
Complete a run report on this patient, including all discussion between caregiver, bystanders, Base Physician, etc. A copy of this run report is to be turned in to the Base Hospital within 24 hours of the call.
If the nature of the EMS call is not clearly applicable to the terminal illness and/or chronic disease, resuscitation/treatment must be performed. If there is family conflict at the scene over whether the patient should or should not be resuscitated, EMS will err in favor of treating the patient. Once resuscitation has begun, it cannot be suspended without specific instruction from the Base Physician.
Under the law, the patient has the right to revoke the DNR at any time, either by verbal intent to revoke or by destruction of the document. In such a case, care must then be administered.
MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 STANDARD CARE PROTOCOL
ASSESSMENT Patient presents as candidate for basic life support intervention. This protocol serves as a basis for all patients requiring BLS. The following should be considered CRITICAL PATIENTS:
1. Situations which have a reasonable chance of compromising airway, breathing, or
2. Unresponsive patients 3. Premature or multiple childbirth.
Paramedic intercept should be initiated for these patients as in “Interventions” #2 below. MANAGEMENT AIRWAY
Establish and support the airway as necessary. If the patient is unable to maintain and protect their airway, insert oropharyngeal or nasopharyngeal airway. Oral airways should not be used on infants less than 12 months of age. Insert non-visualized airway when appropriate.
Apply appropriate oxygen therapy in relationship to the assessment of the patient. If the patient is apneic, initiate bag-valve-mask resuscitation at the rate of 20 8 to 12 ventilations per minute. (One ventilation every 5 to 6 seconds.)
If breathing is present, monitor and record rate every 5 minutes in an unstable patient, or every 15 minutes in a stable patient.
Palpate and record a pulse rate every 5 minutes in an unstable patient or every 15 minutes in a stable patient.
Monitor and record patient’s blood pressure every 5 minutes in an unstable patient or every 15 minutes in a stable patient. If unable to continuously monitor blood pressure, obtain a base reading by auscultation and document. Follow with palpated reading as possible. Blood pressure is not a priority at an accident scene in multi-system trauma patients.
If patient is pulseless, initiate external cardiac compressions at a rate of 100 per minute.
INTERVENTIONS CONTACT BASE PHYSICIAN if questions or situations arise not addressed in these protocols. CALL FOR PARAMEDIC INTERCEPT as soon as it is recognized that advanced skills may benefit the patient. This may be based on dispatch information alone. Intercept will be initiated if the paramedic unit can reach you before you reach the hospital. Paramedic intercept may include, but is not limited to any situation which may compromise A, B, C’s, unresponsiveness, premature childbirth or multiple births. MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 ABANDONED INFANTS
Description To provide appropriate care and chain of custody for infants left with or found by EMS providers. Procedure
An emergency medical services provider shall, without a court order, take custody of a child who is, or appears to be, not more than 45 days of age if: a.
the child is voluntarily left with the provider by the child’s parent; and
the parent does not express an intent to return for the child.
An emergency medical services provider who takes custody of a child under this section shall perform any act necessary to protect the child’s physical health or safety.
Any person who in good faith voluntarily leaves a child with an emergency medical services provider is not obligated to disclose the parent’s name or their name.
Immediately after an emergency medical services provider takes custody of a child under section 1, the provider shall notify the local child protection service that the provider has taken custody of the child.
The local child protection service shall: a.
Assume the care, control, and custody of the child immediately after receiving notice under section 4; and
Not later than 48 hours after the local child protection service has taken custody of the child, contact the Indiana clearinghouse for information on missing children to determine if the child has been reported missing.
MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 ALTERED MENTAL STATUS
ASSESSMENT Patient presents with an altered mental status of unknown etiology. This includes, but is no limited to, totally unresponsive, responsive to pain only, awake but non- communicative. MANAGEMENT
If the patient has a known diabetic history and the patient has the ability to swallow, administer 1 tube of oral glucose between the cheek and gum.
Monitor the airway and reassess the patient.
MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 ASSESSMENT Patient presents with signs and symptoms of respiratory distress. MANAGEMENT
If the patient has a prescribed inhaler, and has not taken the maximum prescribed dosage, assist the patient up to the maximum prescribed dosage.
Transport as soon as possible in the most comfortable position.
MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 SUSPECTED ACUTE CORONARY SYNDROME ASSESSMENT Patient presents complaining of substernal pain or discomfort, possibly radiating to or originating in left shoulder, neck, or jaw. Determine whether there are findings typical of angina or myocardial infarction including history of CAD or risk factors, chest pain with typical characteristics (dull ache or pressure rather than sharp and stabbing), associated dyspnea, nausea, or diaphoresis. Patient may have a previous history of angina or myocardial infarction. MANAGEMENT
If the patient has findings typical of angina or myocardial infarction, and is not allergic to aspirin, administer four 81 mg (324 mg) chewable aspirin orally. Instruct patient to chew them.
If systolic blood pressure is 100mmHg or greater and patient is awake and alert, administer patient’s prescribed nitroglycerin tablet sublingually every 5 minutes until pain is relieved or a maximum of three tablets have been given. If blood pressure falls below 100 at any point, do not administer further prescribed nitroglycerin.
Contraindication: DO NOT administer nitroglycerin if patient has taken Viagra (sildenafil) or Levitra (vardenafil) within the last 24 hours, or Cialis (tadalafil) within the last 48 hours. MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 SUSPECTED ACUTE ISCHEMIC STROKE ASSESSMENT Patient presents with signs and symptoms of an acute CVA. Assessment reveals the patient has one-sided facial drooping, unequal grip strengths, is unable to hold arms out equally with eyes closed, is unable to verbalize “you can’t teach an old dog new tricks” without slurring, or is unable to speak at all. Some patients with recent onset of symptoms will be candidates for fibrinolytic therapy. Every effort should be made to transport rapidly to allow early evaluation and therapy. MANAGEMENT
Assess and record Glasgow Coma Scale score.
Determine exact onset of symptoms if possible. a. If onset of symptoms is less than 2 hours, provide safe and rapid
transport to the nearest facility. Do not delay scene time for treatments or assessments that can be performed enroute. Contact receiving facility early to alert the base physician of acute symptoms.
b. If onset of symptoms is greater than 2 hours, or you are unable to
determine onset of symptoms, provide supportive care and transport.
MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 CARDIAC ARREST ASSESSMENT Patient presents unresponsive, apneic, or without pulses. Patient does not display signs of obvious death, such as rigor mortis, dependent lividity, decapitation, transection at midline or catastrophic head injury. Patients displaying the above signs should be considered non-viable. MANAGEMENT
Attach automated defibrillator. Allow machine to analyze rhythm.
Defibrillate at 360 joules or equivalent biphasic setting if indicated.
Perform CPR for two minutes. Insert non-visualized airway if not done during this two minutes.
Allow machine to analyze patient two minutes after last defibrillation.
Defibrillate at 360 joules or equivalent biphasic setting as indicated. Perform CPR for 2 minutes. Repeat steps 5 and 6 as necessary.
CONTACT BASE PHYSICIAN.
If at any point the defibrillator advises “no shock”, resume CPR.
MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 MEDICAL DEVICE-DEPENDENT PATIENTS
DESCRIPTION To outline what type of care is required for medical device-dependent patients.
1. EMT-Advanced personnel are allowed to transport any of the following under this
protocol, following the standard care protocol, providing that the EMT-Advanced has been trained to do so.
PCA pump with any medication or fluid infusing through a peripheral IV.
Medication infusing through a peripheral IV or continuous subcutaneous catheter via a closed, locked system.
A central catheter that is clamped off (subclavian, Hickman, PICC, Passport.) (EMT-Basic)
A patient with a feeding tube that is clamped off. (EMT-Basic)
A patient with a peripheral IV infusing vitamins.
IV fluids through a peripheral IV via gravity or an infusing system that allows the technician to change the rate of infusion are limited to D5%W, lactated ringers, sodium chloride (0.9% or less), potassium chloride 40 mEq or less.
2. Long-term care providers should stop central venous and enteral ongoing
infusions prior to transport by EMT-Advanced or EMT-Basic personnel. EMT-Advanced or EMT-Basic personnel shall not manipulate these devices unless directed to do so by medical control.
3. The following require a paramedic level transport.
Medication infusing through a peripheral or central IV, or fluid infusing through a central IV via gravity or an infusing system that allows the operator or assistant to change the rate of infusion.
A patient with a continuous feeding tube.
MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 ALLERGIC REACTION ASSESSMENT Patient presents with signs/symptoms consistent with an allergic reaction. Patient may or may not have a history of anaphylaxis. Remember that persons may suddenly be sensitive to allergens previously unknown, such as bee venom. MANAGEMENT
CATEGORIZE PATIENT UNDER “A” OR “B” BELOW A. Asymptomatic / Urticaria or “rash” only. 1. CONTACT BASE PHYSICIAN if an unusual situation exists (delayed transport time, severe past reaction to the same allergen.) Signs and symptoms of severe allergic reaction (Anaphylaxis.) Including respiratory distress and/or shock (hypoperfusion), wheezing, stridor, hypotension, and/or altered mental status. 1.
If the patient presents as a “B”, administer Epinephrine Auto-Injector (Epi-Pen) in lateral thigh, midway between waist and knee.
If the patient is a 10 year-old child or less, presents as a “B”, and weighs less than 45 kg, administer Epinephrine Auto-injector (Epi-Pen Jr.) in lateral thigh, midway between the waist and knee.
MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 POISONING ASSESSMENT Patient has recent history of poisoning by ingestion, inhalation, or absorption. History may not be available, but mechanism at the scene as well as signs and symptoms may create a high index of suspicion. Signs/symptoms include: signs of shock, drooling, nausea and vomiting, burns about the nose or mouth, odor of poison on the breath, altered mental status, convulsions, reddening or burns on the skin, empty medication or poison containers. MANAGEMENT
Attempt to determine type of agent involved and report to Base Physician Bring container along if appropriate. Bring material safety data sheet (MSDS) if readily available.
If poisoning appears to be by absorption, use caution in touching the patient or any garments which may be contaminated. Use personal protective clothing and equipment as needed to avoid contact. Begin flushing affected area by steady water stream for at least fifteen minutes. Do not allow run-off to further contaminate the victim or clothing. If clothing is contaminated, remove and isolate.
If poisoning appears to be by inhalation, remove victim from the source and begin high-flow oxygen. USE CAUTION FOR PERSONAL SAFETY WHEN ENTERING A POTENTIALLY HAZARDOUS ENVIRONMENT.
If Poison Control has been contacted, document all information received and convey to the Base Physician as soon as possible. DO NOT PERFORM ANY MANAGEMANT UNTIL AUTHORIZED BY THE BASE PHYSICIAN. MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 ASSESSMENT Patient presents with burns resulting from chemical or thermal injury. Determination should be made of approximate surface area involved. SEVERITY OF BURNS MAY NOT BE APPARENT INITIALLY AS THE INJURY MAY PROGRESS DURING TRANSPORT. TREAT FOR WORST CASE WHEN IN DOUBT. MANAGEMENT
If the patient has active burning, extinguish with water or saline. (For chemicals, remove as appropriate. This usually entails a 20-minute water flushing.)
FOLLOW STANDARD CARE PROTOCOL. Note: If evidence of airway burns, be alert to the need for rapid airway control.
Remove all clothing and jewelry, if possible. If clothing adheres to skin, remove surrounding cloth. Do not attempt to soak adhered clothing off of skin.
Using aseptic technique, drape the victim in a clean, dry sheet. Avoid wetting the patient due to the danger of advancing body heat loss.
MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 ASSESSMENT Patent presents as victim of multi-system trauma. Patient may be awake and alert or unresponsive. Mechanisms of injury at scene may suggest a high index of suspicion of internal injuries. Patient may have external signs consistent with multi-system trauma. Signs of shock may or may not be present. MANAGEMENT
Consider pneumatic anti-shock garment for stabilization of suspected pelvic or lower-extremity fractures. Use adequate pressure to stabilize the injury.
Completely immobilize patient if any mechanism of injury leads to suspicion of spinal compromise.
Limit scene time to ten minutes or less unless entrapment delays transport. Document reasons for any scene time over ten minutes on run sheet and notify Base Physician of delay.
Do not delay transport of multi-system trauma patients for any treatment except spine immobilization, securing an airway, ensuring breathing and circulation.
Consider helicopter evacuation of severe multi-system trauma, if scene time is prolonged, and especially if there are multiple victims. Requesting the helicopter to FLY early will be beneficial in response time. MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 BACKBOARD PROTOCOL Mechanism Positive of Injury Positive spinal injury Uncertain IMMOBILIZE Positive Mechanisms:
High speed MVCFalls >three times patient heightAxial loadDiving accidents
Spinal pain or tenderness?
spinal columnSports injury to head or neck
Motor and sensory Reliable: Reliable patient? Negative spinal Positive spinal Unreliable: IMMOBILIZE Note: If any doubt exists, immobilize the cervical spine
Intoxication with drugs or alcoholOther distracting injuries
MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 MEDICATION LIST
Specified quantities represent the minimum to be carried on-board affiliated EMT-Basic units. MEDICATIONS MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 CERTIFICATION AND IN-SERVICE REQUIREMENTS
EMT-Basic certifications are valid for a period of 2 years. During this period, all affiliated EMT-Basic personnel are required to complete and/or maintain the following: 1.
Basic Cardiac Life Support (CPR-Healthcare)
Minimum of 40 hours of didactic continuing as stated in your book.
Minimum number hours of Audit & Review per your hospital requirement.
All skills listed in the CEU book (which must be assessed in a “skill test” format.)
Items 1-3 above must be signed by the person responsible for or conducting the program. Individuals can only sign for the skills that do not exceed their certification level. The following persons are approved to sign for EMS skills: MEDICAL DIRECTOR: Dr. George Restrepo, DO CULVER-UNION TOWNSHIP AMBULANCE SERVICE DIRECTOR
CULVER-UNION TOWNSHIP AMBULANCE SERVICE TRAINING OFFICER
MARSHALL COUNTY EMERGENCY MEDICAL SERVICES EMT-B PRE-HOSPITAL MANAGEMENT EFFECTIVE JANUARY 1, 2007 SIGNATURE PAGE The following signatures stand as approval for the entire content of these protocols. This document is effective January 1, 2007.
MEDICAL DIRECTOR ________________________________________________ Dr. George Restrepo, DO
Medical Director, Saint Joseph Regional Medical Center, Plymouth Campus
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