OCMCA Education Task Force. Practical Skill Guide

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1 OCMCA Education Task Force Practical Skill Guide MFR & Basic MFR/EMT Epinephrine Study (MABEES) Practical Component In-service training: MFR & Basic MFR/EMT Epinephrine Study (MABEES) Purpose: Every licensed BLS unit in Michigan must carry pediatric and adult epinephrine auto-injectors. The Michigan Department of Health and Human Services (MDHHS) has approved a special study that allows participants to draw up and administer epinephrine via intramuscular (IM) injection in place of an epinephrine auto-injector. This EMS CE is necessary to assure that the study participants are able to properly draw up and administer epinephrine via intramuscular injection, when indicated. Contact the W/L MCA by at with any questions regarding MABEES or the contents of this Practical Skill Guide.

2 Table of Contents Lesson Plan (page 1) and CE Outline (page 2) If CE is desired, agencies will need to make application to the MDHHS for credit. CE Content (page 3-6) The information found within the CE Content section of this guide is designed to assist instructors in completing the objectives found in the approved Lesson Plan and CE Outline. Practical Skill Assessment Forms Adult (page 7) Pediatric (page 8) Sample Scenarios (pages 9-10) Multiple scenarios and a Practical Skill Assessment Form have been included with this guide. These resources will assist instructors to objectively identify correct and incorrect actions taken by the learner. MABEES Special Study Protocols (pages 12-24) Multiple protocols have been modified by the W/L MCA for MABEES. The Michigan EMS Quality Assurance Task Force (QATF) has approved the following special study protocols for use by MABEES participating LSAs: 1-4 Adult Anaphylaxis/Allergic Reaction 1-15 Adult Respiratory Distress 3-2 Pediatric Anaphylaxis/Allergic Reaction 3-4 Pediatric Bronchospasm 6M-1 BLS Medication Kit Contents and Exchange Procedure

3 Lesson Plan: Specific Topic Title: Basic MFR/EMT Epinephrine Study (MABEES) - Practical Credit Category: Medical Projected Credits: MFR: 0 MFR/EMT: 1 P SPEC: 1 P MFR/EMT-P: 1 P I/C: 0 Format: Practical Presenter: TBD Date: TBD Time Duration: 1 hour CE Description: The purpose of this EMS continuing education (CE) session is for MABEES participants to practice drawing up and administering epinephrine via intramuscular injection in place of an epinephrine auto-injector. Students must appropriately assess and treat the patients with an indication for epinephrine administration during simulated scenarios. Rationale: Every licensed BLS unit in Michigan must carry an epinephrine auto-injector. The Michigan Department of Health and Human Services (MDHHS) has approved a special study that allows participants to draw up and administer epinephrine via intramuscular injection in place of an epinephrine auto-injector. This EMS CE is necessary to assure that the study participants understand how to properly draw up and administer epinephrine via intramuscular injection when indicated. Objectives: Given a scenario, students will complete the following: Correctly identify a patient that should be receiving epinephrine via intramuscular injection. Draw up epinephrine using the Epi-Kit contents. Administer simulated epinephrine (normal saline solution) to a simulated patient. Demonstrate how to correctly complete all necessary documentation and steps to exchange the Epi- Kit.

4 CE Outline: CE Outline: 1. Introduction (5 minutes) a. List learning goals and objectives to the students. b. State safety considerations during training. c. Describe the format of the practical skills that will be assessed during this CE session. 2. Scenario #1 - Anaphylaxis (15-20 minutes) a. Given a scenario students will: i. Manage ABCs ii. Call for ALS as needed iii. Identify patients that require epinephrine IM 1. List and describe indications iv. Administer epinephrine IM using simulated epinephrine (normal saline) into a simulated patient. v. Reassess the patient for desired effect b. Post scenario, the instructor will list all correct and incorrect actions taken by the students. The instructor will provide strategies to eliminate incorrect actions made by the students. 3. Scenario #2 Asthma (15-20 minutes) a. Given a scenario students will: i. Manage ABCs ii. Call for ALS as needed iii. Identify patients that require epinephrine IM 1. List and describe indications iv. Administer epinephrine IM using simulated epinephrine (normal saline) into a simulated patient. v. Reassess the patient for desired effect b. Post scenario, the instructor will list all correct and incorrect actions taken by the students. The instructor will provide strategies to eliminate incorrect actions made by the students. 4. Scenario #3 - Anaphylaxis or Asthma (15-20 minutes) a. Given a scenario students will: i. Manage ABCs ii. Call for ALS as needed iii. Identify patients that require epinephrine IM 1. List and describe indications iv. Administer epinephrine IM using simulated epinephrine (normal saline) into a simulated patient. v. Reassess the patient for desired effect b. Post scenario, the instructor will list all correct and incorrect actions taken by the students. The instructor will provide strategies to eliminate incorrect actions made by the students. 5. W/L MCA Epi-Kit Exchange Procedure (5 minutes) a. Complete all necessary documentation and paperwork.

5 CE Content 1. Introduction a. List learning goals and objective to the students. Given a scenario, students will complete the following: Correctly identify a patient that should be receiving epinephrine via intramuscular injection. Draw up epinephrine using the Epi-Kit contents. Administer simulated epinephrine (normal saline solution) to a simulated patient. Demonstrate how to correctly complete all necessary documentation and steps to exchange the Epi-Kit. b. State safety considerations during training. Safety is of the utmost importance throughout this training session. The needles utilized for intramuscular injection present a risk of exposure from a needle stick injury. MFR/EMTs should strictly adhere to the needle stick safety techniques taught and demonstrated in the lecture portion of this class. Any unsafe practices will be grounds for the instructor to halt the scenario and correct the practice before the scenario is allowed to continue. c. Describe the format of the practical skills that will be assessed during this CE session. MFR/EMTs participating in this CE session will be provided with three scenarios. Multiple scenarios and Adult/Pediatric Practical Skill Verification Forms have been included with this guide. These resources will assist instructors to objectively identify correct and incorrect actions taken by CE participants. After completion of the scenarios, MFR/EMTs will demonstrate completion of the W/L MCA MFR or BLS Medication Replacement Form.

6 2. Scenario #1 - Anaphylaxis An Adult/Pediatric Practical Skill Assessment Form (see pages 9 & 10) and sample scenarios (see pages 11 & 12) will assist in completion of the following: a. Given a scenario students will: i. Manage ABCs ii. Call for ALS as needed iii. Identify patients that require epinephrine IM 1. List and describe indications iv. Administer epinephrine IM using simulated epinephrine (normal saline) into a simulated patient. v. Reassess the patient for desired effect b. Post scenario, the instructor will list all correct and incorrect actions taken by the students. The instructor will provide strategies to eliminate incorrect actions made by the students. 3. Scenario #2 Asthma An Adult/Pediatric Practical Skill Assessment Form (see pages 9 & 10) and sample scenarios (see page 11 & 12) will assist in completion of the following: a. Given a scenario students will: i. Manage ABCs ii. Call for ALS as needed iii. Identify patients that require epinephrine IM 1. List and describe indications iv. Administer epinephrine IM using simulated epinephrine (normal saline) into a simulated patient. v. Reassess the patient for desired effect b. Post scenario, the instructor will list all correct and incorrect actions taken by the students. The instructor will provide strategies to eliminate incorrect actions made by the students.

7 4. Scenario #3 - Anaphylaxis or Asthma An Adult/Pediatric Practical Skill Assessment Form (see pages 9 &10) and sample scenarios (see pages 11 & 12) will assist in completion of the following: a. Given a scenario students will: i. Manage ABCs ii. Call for ALS as needed iii. Identify patients that require epinephrine IM 1. List and describe indications iv. Administer epinephrine IM using simulated epinephrine (normal saline) into a simulated patient. v. Reassess the patient for desired effect b. Post scenario, the instructor will list all correct and incorrect actions taken by the students. The instructor will provide strategies to eliminate incorrect actions made by the students.

8 5. W/L MCA BLS Medication Kit Contents and Exchange Procedure (6M-1) & W/L MCA MFR Medication Kit Contents and Exchange Procedure (6M-6) a. Complete all necessary documentation and paperwork MFR/EMTs participating in the MABEES study are responsible for completing the W/L MCA MFR or BLS Medication Kit Exchange Form, and ensuring the contents of the kit, including the BEES Dosing Card, are returned to their agency s designee for exchange later at their Medical Control Hospital. The W/L MCA MFR or BLS Medication Kit Replacement Form is used to track Epi-Kit use in the field and must be completed each time the kit is used in the field. This form is used to track Epi-Kit use in the field. The W/L MCA MFR or BLS Medication Kits containing the Epi-Kit does NOT have to be exchanged immediately after an EMS call. Each LSA may keep extra kit(s) available for restocking. However, MFR/EMTs must ensure that all active MFR or BLS licensed units are always stocked with a MFR or BLS Medication Kit. Follow the exchange procedure as is done now. Ensure the MFR or BLS Medication Kit Exchange Form, and the BEES Dosing Card is returned with the used Epi-Kit. The following should be completed after the W/L MCA Epi-Kit has been used, or opened in the field: 1. Fill out the MFR or BLS Medication Kit Exchange Form. a. Complete the following fields: I. Agency/Unit II. Date III. Incident # IV. EMS Crew (Names) b. Indicate all items Used from the kit c. Input patient name (first and last) d. Input the Receiving hospital I. The Receiving hospital is defined as the Emergency Facility where the patient was transported. e. Complete the MFR/EMT-B Statement Section I. Input the MFR or BLS Medication Kit Number found on the pharmacy sticker on the kit. f. Complete the table at the bottom of the form to document medication that has been opened and used or opened and wasted. g. Sign and date the form A copy of the W/L MCA MFR or BLS Medication Kit Exchange Form and a copy of the corresponding PCR must be submitted to the W/L MCA within 72 hours after an Epi-Kit is used in the field. Each LSA should develop a strategy to assure that these documents are submitted to the W/L MCA. The W/L MCA will use these documents to compile data for this special study. W/L MCA will accept the documents by Fax or Fax:

9 Adult Practical Skill Assessment Form Name: IM Administration - Epinephrine 1 mg/ml Tasks: Correctly identify a patient that should be given epinephrine. Specific and measurable Draw up epinephrine using the Epi-Kit contents. actions/objectives Administer simulated epinephrine (normal saline solution) to a simulated patient (manikin or other training device) via the Conditions: Variables that contribute to completion of the tasks Standard: Protocols that are applicable to completion of the tasks intramuscular route. Given, a simulated patient with signs of anaphylaxis or impending respiratory failure due to asthma or COPD; EMS partner(s); an applicable scenario; the Epi-Kit; and additional EMS equipment provided by the instructor. Applicable protocols: Anaphylaxis/Allergic Reaction (Adult Treatment 1-4) Respiratory Distress (Adult Treatment (1-15) Task EMS provider(s) should begin by completing an initial patient assessment of a patient with signs of anaphylaxis or asthma/copd. The EMS provider must identify and treat all life threats and request additional resources (ALS and/or PD) prior to drawing up, and administering epinephrine IM. 1. Determine that epinephrine IM is indicated by patient presentation and W/L MCA Protocol. (Utilize BEES Card for IM injection overview) 2. Remove clothing to expose the patient s thigh. 3. Locate the correct injection site in the vastus lateralis. 4. Cleanse the site with alcohol prep. 5. Using a needle connected to a 1 ml syringe, draw up 0.3 mg (.3 ml) epinephrine from a vial containing 1 mg/ml. (Utilize BEES Card for dosing) a. Attach the needle to a 1 ml syringe. b. Pull the plunger of the 1 ml syringe so that it rests at the.3 ml mark. c. Puncture the vial with the needle attached to the syringe, and then flip the vial upside down. d. Push the plunger so that.3 ml of air is injected into the vial. e. Draw up.3 ml of epinephrine. f. Verify medication and dosage with a partner. 6. Squeeze the muscle to increase the size and depth of the injection site. 7. Insert the needle in a smooth motion at a 90 angle. 8. Draw back on the syringe and verify that blood is not present. 9. Administer the medication. 10. Remove the needle and place it directly into a sharps container. 11. Place a bandage over the site 12. Reassess the patient 3 to 5 minutes later for the desired effect. Complete Incomplete Evaluator s Name: Date:

10 Pediatric Practical Skill Assessment Form Name: IM Administration - Epinephrine 1 mg/ml Tasks: Correctly identify a patient that should be given epinephrine. Specific and measurable Utilize standardized length based tool to accurately estimate weight. actions/objectives Draw up epinephrine using the W/L MCA Epi-Kit contents. Administer simulated epinephrine (normal saline solution) to a simulated patient (manikin or other training device) via the Conditions: Variables that contribute to completion of the tasks Standard: Protocols that are applicable to completion of the tasks intramuscular route. Given, a simulated patient with signs of anaphylaxis or impending respiratory failure due to bronchospasm; EMS partner(s); an applicable scenario; the Epi-Kit; and additional EMS equipment provided by the instructor. Applicable protocols: Pediatric Anaphylaxis (Pediatric Treatment 3-2) Pediatric Bronchospasm (Pediatric Treatment 3-4) Task Complete Incomplete EMS provider(s) should begin by completing an initial patient assessment of a patient with signs of anaphylaxis or bronchospasm. The EMS provider must identify and treat all life threats and request additional resources (ALS and/or PD) prior to drawing up, and administering epinephrine IM. 1. Determine that epinephrine IM is indicated by patient presentation and W/L MCA Protocol. Utilize standardized length based tool to accurately estimate weight. Utilize BEES Card for IM injection overview. 2. Remove clothing to expose the patient s thigh. 3. Locate the correct injection site in the vastus lateralis. 4. Cleanse the site with alcohol prep. 5. Using a needle connected to a 1 ml syringe, draw up the appropriate dose of epinephrine from a vial containing 1 mg/ml. (Utilize BEES Card for dosing) a. Attach the needle to a 1 ml syringe. b. Pull the plunger of the 1 ml syringe so that it rests at the.15 ml mark. c. Puncture the vial with the needle attached to the syringe, and then flip the vial upside down. d. Push the plunger so that.15 ml of air is injected into the vial. e. Draw up.15 ml of epinephrine. f. Verify medication and dosage with a partner 6. Squeeze the muscle to increase the size and depth of the injection site. 7. Insert the needle in a smooth motion at a 90 angle. 8. Draw back on the syringe and verify that blood is not present. 9. Administer the medication. 10. Remove the needle and place it directly into a sharps container. 11. Place a bandage over the site 12. Reassess the patient 3 to 5 minutes later for the desired effect. Evaluator s Name: Date:

11 Sample Scenarios Instructors must complete 3 scenarios with their personnel in order to complete the Lesson Plan and CE Outline. Instructors may use any scenario listed below, or they may develop their own scenarios. Scenarios must include one asthma patient and one anaphylaxis patient. In addition, instructors must utilize one adult scenario and one pediatric scenario. Sample Scenario 1: You are dispatched to an 8 y/o male patient that is suffering an allergic reaction from peanuts. You arrive to find an 8 y/o male patient alert to verbal stimuli in the care of a babysitter. The babysitter states the patient ate a Snickers bar he stole from her purse and then developed hives. The babysitter states the patient has a known peanut allergy. The babysitter did not have access to the patient s Epi-Pen Junior but knows the patient is supposed to receive epinephrine if he consumes peanuts. The babysitter states the patient weighs 22 kg. Initial patient assessment reveals hives all over the patient s torso. The patient presents in severe respiratory distress, cannot speak in complete sentences, and is very lethargic. The patient has an audible wheeze that is confirmed in all fields through auscultation. Vital Signs: BP 60/40, HR 160, Respirations: 44, Pulse Oximetry: 85% Sample Scenario 2: You are dispatched to an elementary school for shortness of breath. You arrive to find a 6 y/o male patient alert on the playground sitting in the tripod position. The patient s teachers state that the patient has a history of asthma. The patient has self-administered an albuterol rescue inhaler with no relief. The patient has no allergies and weighs 19 kg. Initial patient assessment reveals wheezes in all lung fields. The patient is in severe respiratory distress with retractions of the intercostal muscles. The patient again administers his own rescue inhaler. This does not appear to help the patient. The patient becomes increasingly agitated and is unable to speak. It appears that the patient is experiencing impending respiratory failure. Vital Signs: BP 90/40, HR 130, Respirations: 40, Pulse Oximetry 80%

12 Sample Scenarios (continued) Sample Scenario 3: You are dispatched to a 76 y/o female patient with shortness of breath. The patient s husband greets you at the door and states the patient has been having an asthma attack for 2 hours without relief. The husband states that the patient is healthy other than her asthma. The husband reports the patient was intubated once for an asthma attack. The patient s asthma is normally well controlled with her rescue inhaler. The patient has no allergies. The patient is found sitting on the edge of her bed in severe respiratory distress. Initial patient assessment reveals retractions of the intercostal muscle and diminished lung sounds in all fields and wheezing in all lung fields. The patient cannot speak more than one word at a time. The patient denies any chest pain by shaking her head. The patient attempts to administer her rescue inhaler but is not able to administer the medication. The patient appears to be deteriorating rapidly. Vital Signs: BP 148/90, HR 122 regular, Respirations 44 and labor, GCS 15 Sample Scenario 4: You are dispatched to an unknown medical at Billy s Seafood Hut. You arrive to find a 20 y/o female patient that presents with an allergic reaction to shellfish. The patient s friend states she began having an allergic reaction after sampling the seafood surprise. The patient s friend attempted to administer the patient s Epi-Pen but managed to inject the epinephrine into the patient s belt. Your partner confirms this statement by inspecting the patient s belt. Initial assessment reveals oral swelling and an audible wheeze. The patient reports vomiting prior to EMS arrival and feeling nauseous. The patient reports that she has an anaphylactic reaction every time she is exposed to shellfish. Vital Signs: BP 90/60, HR 140 regular, Respirations 36 and labored, GCS 15.

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