PATIENT CARE GUIDELINES

Transcription

1 PATIENT CARE GUIDELINES

2 TABLE of CONTENTS Introduction Required Supply Lists ALS Supplies BLS Supplies Standing Orders Guidelines Transport Destination TSAQ Diversion Guidelines Medical / Legal Considerations Duty to Act Consent/Refusal Documentation Physician Assistance Individuals on Scene Confidentiality Out of Hospital Do-Not-Resuscitate (OOH DNR) General Protocols Airway C-Spine Clearance Chemical Restraint Dead On Arrival Failed Airway IV Access Multiple Patient Triage Pain Management Police Custody Universal Patient

3 Medical Protocols Abdominal Pain Allergic Reaction Altered Mental Status Asystole / PEA Atrial Fibrillation with RVR Behavioral Bradycardia Cardiac Arrest Cerebrovascular Accident Chest Pain Diabetic Complications Fever / Infection Control Hypertension Hypotension Induced Hypothermia Nausea / Vomiting Overdose / Toxic Exposures Post Resuscitation Pulmonary Edema Respiratory Distress Seizure Supraventricular Tachycardia Ventricular Tachycardia / PVC V-Fib / Pulseless V-Tach TABLE of CONTENTS Trauma Protocols Bites / Stings Burns Drowning / Diving Head Trauma Hyperthermia Hypothermia Multiple Trauma Skeletal Trauma Traumatic Arrest Uncontrollable Hemorrhage Pediatric / Obstetrical Protocol Childbirth / Labor Newborn Obstetrical Emergency Pediatric Bradycardia Pediatric Respiratory Distress Pediatric Seizure

4 Procedures 12 Lead EKG AED Airway: Obstruction Airway: Surgical Cric Airway: CPAP Airway: Blind Insertion Airway Device Airway: Nebulizer Airway: Orotracheal Intubation Airway: Suctioning Assessment: Adult Assessment: Pediatric Blood Draw Blood Glucose Analysis Capnography Chest Decompression Childbirth Difficult Airway Evaluation External Pacing Gastric Tube Intranasal Administration Manual Defibrillation Pharmacological Assistance Intubation Pulse Oximetry Spinal Immobilization Splinting SQ and IM Injections Synchronized Cardioversion Taser Probe Removal Termination of Resuscitation Venous Access: Existing Catheter Venous Access: External Jugular Venous Access: Extremity Venous Access: Intraosseous Wound Care: General Wound Care: Tourniquet TABLE of CONTENTS

5 Medications Activated Charcoal Adenosine (Adenocard) Albuterol Sulfate (Proventil) Amiodorone (Cordorone) Aspirin Ativan (Lorazepam) Atropine Sulfate Atrovent (Ipratropium) Benadryl (Diphenhydramine) Calcium Chloride Cardizem (Diltiazem) Dextrose Dopamine (Intropin) Epinephrine (Adrenalin) Etomidate (Amidate) Fentanyl (Sublimaze) Ketamine (Ketalar) Labetalol (Normodyne) Lidocaine (Xylocaine) Magnesium Sulfate Morphine Sulfate Narcan (Naloxone) Nitroglycerine (spray and paste) Oral Glucose Rocuronium Sodium Bicarbonate Solumedrol (Methylprednisolone) Tranexamic Acid (TXA) Tylenol (Acetaminophen) Versed (Midazolam) Zofran (Ondansetron) TABLE of CONTENTS Charts and Formulas Glasgow Coma Scale Infant Glasgow Coma Scale APGAR Score Dopamine Infusion Epinephrine Infusion Lidocaine Infusion Drug Calculations

6

7 Required ALS Supply List The following is a minimum standard of supplies to be carried on all WCEMS ambulances while operating at ALS level or above. It is encouraged that all units consider increased supplies based on need and call volume. In some circumstances, the fluid and drugs on this page may be supplied in concentrations or amounts other than those listed. It is the ALS provider's responsibility to ensure all equivalent total amounts are present and that correct dosages are administered to patients. Medications may be supplied in generic or brand name, and are considered interchangeable. ITEM QTY ITEM QTY All BLS Equipment Requirements As Listed Pedi IV Arm Board 1 Cardiac Monitor with AED capabilities 1 PEEP Valve 1 Batteries (spare) 1 Pre-Filled Saline Flush 4 EKG Paper 1 Saline Lock 4 EKG Electrodes 10 Syringes (1cc, 3cc, 5cc, 10cc, 20cc) 1 of each size Razor or equivalent 1 60cc Tonsil Tip Syringe 1 Pulse Oximeter 1 Adenosine 30mg Chest decompression catheter 1 Amiodarone 600mg ET Tube Securing Device (Pediatric and adult 1 of each size size) Ativan 4mg CPAP mask and hose w/ applicable equipment for operation 1 Atropine 3mg Cricothyrotomy Kit or equivalent 1 Benadryl 50mg Defibrillator Pads (Pediatric and Adult size) 1 of each size Calcium Chloride 1000mg Endotracheal Tube Inducer (Pediatric and Adult size) 1 of each size Cardizem 75mg Inline ETC02 for advanced airway 2 Dextrose 50% 50g Side stream ETCO2 cannula 2 Dopamine 1600mcg ET Tubes or equivalent (2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6.0, 6.5, 7.0, 7.5, 8.0, 8.5) 1 of each size Epi 1:10,000PFS 6mg Electric or manual IO 1 Epinephrine 1:1000 2mg Needles (Pedi / Adult / Lg Adult) 1 of each size Etomidate 30mg Pressure Bag 1 Fentanyl 300mcg Stabilizer 1 Ketamine 500mg Injection Needles (18g, 25g) 1 Labetalol 40mg IV Catheters: 14g, 16g, 18g, 20g, 22g, 24g 4 each Lidocaine 300mg IV Start Kits 4 Lidocaine Premix 2000mg Laryngoscope Blades: Magnesium Sulfate 2gm Miller (1, 2, 3, 4) 1 of each size Morphine 20mg Macintosh (1, 2, 3, 4) 1 of each size Narcan 4mg Laryngoscope Handle (Small and Large Handle) 1 of each size Rocuronium 100mg IV Fluid Drip Set 4 Sodium Bicarb 4.2% 5meq Mucosal Atomization Device 2 Sodium Bicarb 8.4% 150meq Nasogastric Tube (14fr and 16fr size) 1 of each size Solumedrol 125mg Normal Saline Bags: Tranexamic Acid (TXA) 1g 100cc, 250cc,500cc, or 1,000cc any combination 6 liters Versed 20mg *Video Laryngoscope 1 Zofran 8mg * Items with an (*) are only available on first out units

8 Required BLS Supply List The following is a minimum standard of supplies to be carried on all WCEMS ambulances while operating at ALS level or above. It is encouraged that all units consider increased supplies based on need and call volume. In some circumstances, the fluid and drugs on this page may be supplied in concentrations or amounts other than those listed. It is the ALS provider's responsibility to ensure all equivalent total amounts are present and that correct dosages are administered to patients. Medications may be supplied in generic or brand name, and are considered interchangeable. ITEM QTY ITEM QTY 2 Way Communication Adjustable C-Collars (Pediatric and Adult Sizes) 1 NPA set 1 2 of each size OPA set NRB (Pediatric and Adult Sizes) 2 of each size Pedi SPO2 Probe or equivalent 1 Traction Splint (Pediatric and Adult Size) 1 of each size Penlight 1 BVM (Neonate, Infant, Pediatric, Adult) 1 of each size Personal Skin Cleanser 1 Alcohol Preps 5 Portable O2 Bottle with regulator 1 Ammonia Inhalants 2 Protective Eyewear 2 Backboards 2 Protective Gowns 2 Bandaging Roll or equivalent 2 Protective N95 Masks 2 Biohazard Bags 2 Rectal Thermometer Attachment 1 BP Cuff (Infant, Pediatric, Adult) 1 of each size Reflective Road Triangles 2 Pediatric Pharmaceutical Measuring device 1 Rigid Suction Device w/ Tubing 2 Topical Burn Gel 2 packages Saline for Irrigation 1 Burn Sheet 1 Scoop Stretcher 1 Splints (Various Sizes) 1 Sharps Container (mounted) 1 Vehicle Child Safety Restraint 1 Sharps Shuttle (portable) 1 Tourniquet 1 Nebulizer 2 Disinfectant Spray or equivalent 1 Soft Suction Catheter (8fr, 12fr, 14fr) 1 of each size Emergency Blanket 1 Stair Chair 1 Emergency Response Guide 1 Sterile Water for Irrigation 1 Fire Extinguisher 1 Stethoscope 1 Flashlight 1 Stretcher 1 Gloves (Small, Medium, Large, X-Large) 1 box of each size Suction Canister 2 Glucometer 1 Tape (1" and 2") 1 of each Glucometer Strips 2 *Thermometer (Oral or Temporal) 1 Head Blocks 2 *Thermometer Probes (if oral is present) 2 Heat pack 2 Trauma Shears 1 Cool pack 2 Trauma Tape or equivalent 1 Hydrogen Peroxide 1 Triangular Bandage 2 KED 1 Webbing or equivalent 2 No Smoking Signs (cab and box) 1 each Activated Charcoal 50gm Lancets 1 Albuterol 4 doses Lubrication Gel or equivalent 1 Aspirin 324mg Map Book 1 Atrovent 3 doses Portable Mounted Suction 1 Nitroglycerine Paste 2 doses Vehicle Mounted Suction 1 Nitroglycerin Spray 1 bottle Mounted Onboard O2 Cylinder 1 Oral Glucose 30g Multi-Trauma Pad or equivalent 2 Tylenol 480mg Nasal Cannula 2 Occlusive dressing 2 Blind Insertion Airway Device (Size 3, 4, 5) 1 of each size * Mechanical CPR device 1 Non-Adhesive Non-Sterile Bandage 2 OB Kit 1 Non-Adhesive Sterile Bandage 2 1 * Items with an (*) are only available on first out units

9 The listed ALS / BLS drugs and supplies are required to be available on all in-service WCEMS ambulances. This list is mandated by medical direction. Effective date: August 24, 2016 Expiration Date: March 31, 2017

10 Required ALS Supply List The following is a minimum standard of supplies to be carried on all WCEMS ambulances while operating at ALS level or above. It is encouraged that all units consider increased supplies based on need and call volume. In some circumstances, the fluid and drugs on this page may be supplied in concentrations or amounts other than those listed. It is the ALS provider's responsibility to ensure all equivalent total amounts are present and that correct dosages are administered to patients. Medications may be supplied in generic or brand name, and are considered interchangeable. ITEM QTY ITEM QTY All BLS Equipment Requirements As Listed Pedi IV Arm Board 1 Cardiac Monitor with AED capabilities 1 PEEP Valve 1 Batteries (spare) 1 Pre-Filled Saline Flush 4 EKG Paper 1 Saline Lock 4 EKG Electrodes 10 Syringes (1cc, 3cc, 5cc, 10cc, 20cc) 1 of each size Razor or equivalent 1 60cc Tonsil Tip Syringe 1 Pulse Oximeter 1 Adenosine 30mg Chest decompression catheter 1 Amiodarone 600mg ET Tube Securing Device (Pediatric and adult 1 of each size size) Ativan 4mg CPAP mask and hose w/ applicable equipment for operation 1 Atropine 3mg Cricothyrotomy Kit or equivalent 1 Benadryl 50mg Defibrillator Pads (Pediatric and Adult size) 1 of each size Calcium Chloride 1000mg Endotracheal Tube Inducer (Pediatric and Adult size) 1 of each size Cardizem 75mg Inline ETC02 for advanced airway 2 Dextrose 50% 50g Side stream ETCO2 cannula 2 Dopamine 1600mcg ET Tubes or equivalent (2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6.0, 6.5, 7.0, 7.5, 8.0, 8.5) 1 of each size Epi 1:10,000PFS 6mg Electric or manual IO 1 Epinephrine 1:1000 2mg Needles (Pedi / Adult / Lg Adult) 1 of each size Etomidate 30mg Pressure Bag 1 Fentanyl 300mcg Stabilizer 1 Ketamine 500mg Injection Needles (18g, 25g) 1 Labetalol 40mg IV Catheters: 14g, 16g, 18g, 20g, 22g, 24g 4 each Lidocaine 300mg IV Start Kits 4 Lidocaine Premix 2000mg Laryngoscope Blades: Magnesium Sulfate 2gm Miller (1, 2, 3, 4) 1 of each size Morphine 20mg Macintosh (1, 2, 3, 4) 1 of each size Narcan 4mg Laryngoscope Handle (Small and Large Handle) 1 of each size Rocuronium 100mg IV Fluid Drip Set 4 Sodium Bicarb 4.2% 5meq Mucosal Atomization Device 2 Sodium Bicarb 8.4% 150meq Nasogastric Tube (14fr and 16fr size) 1 of each size Solumedrol 125mg Normal Saline Bags: Tranexamic Acid (TXA) 1g 100cc, 250cc,500cc, or 1,000cc any combination 6 liters Versed 20mg *Video Laryngoscope 1 Zofran 8mg * Items with an (*) are only available on first out units

11 Required BLS Supply List The following is a minimum standard of supplies to be carried on all WCEMS ambulances while operating at ALS level or above. It is encouraged that all units consider increased supplies based on need and call volume. In some circumstances, the fluid and drugs on this page may be supplied in concentrations or amounts other than those listed. It is the ALS provider's responsibility to ensure all equivalent total amounts are present and that correct dosages are administered to patients. Medications may be supplied in generic or brand name, and are considered interchangeable. ITEM QTY ITEM QTY 2 Way Communication Adjustable C-Collars (Pediatric and Adult Sizes) 1 NPA set 1 2 of each size OPA set NRB (Pediatric and Adult Sizes) 2 of each size Pedi SPO2 Probe or equivalent 1 Traction Splint (Pediatric and Adult Size) 1 of each size Penlight 1 BVM (Neonate, Infant, Pediatric, Adult) 1 of each size Personal Skin Cleanser 1 Alcohol Preps 5 Portable O2 Bottle with regulator 1 Ammonia Inhalants 2 Protective Eyewear 2 Backboards 2 Protective Gowns 2 Bandaging Roll or equivalent 2 Protective N95 Masks 2 Biohazard Bags 2 Rectal Thermometer Attachment 1 BP Cuff (Neonate, Infant, Pediatric, Adult) 1 of each size Reflective Road Triangles 2 Pediatric Pharmaceutical Measuring device 1 Rigid Suction Device w/ Tubing 2 Topical Burn Gel 2 packages Saline for Irrigation 1 Burn Sheet 1 Scoop Stretcher 1 Splints (Various Sizes) 1 Sharps Container (mounted) 1 Vehicle Child Safety Restraint 1 Sharps Shuttle (portable) 1 Tourniquet 1 Nebulizer 2 Disinfectant Spray or equivalent 1 Soft Suction Catheter (8fr, 12fr, 14fr) 1 of each size Emergency Blanket 1 Stair Chair 1 Emergency Response Guide 1 Sterile Water for Irrigation 1 Fire Extinguisher 1 Stethoscope 1 Flashlight 1 Stretcher 1 Gloves (Small, Medium, Large, X-Large) 1 box of each size Suction Canister 2 Glucometer 1 Tape (1" and 2") 1 of each Glucometer Strips 2 *Thermometer (Oral or Temporal) 1 Head Blocks 2 *Thermometer Probes (if oral is present) 2 Heat pack 2 Trauma Shears 1 Cool pack 2 Trauma Tape or equivalent 1 Hydrogen Peroxide 1 Triangular Bandage 2 KED 1 Webbing or equivalent 2 No Smoking Signs (cab and box) 1 each Activated Charcoal 50gm Lancets 1 Albuterol 4 doses Lubrication Gel or equivalent 1 Aspirin 324mg Map Book 1 Atrovent 3 doses Portable Mounted Suction 1 Nitroglycerine Paste 2 doses Vehicle Mounted Suction 1 Nitroglycerin Spray 1 bottle Mounted Onboard O2 Cylinder 1 Oral Glucose 30g Multi-Trauma Pad or equivalent 2 Tylenol 480mg Nasal Cannula 2 Occlusive dressing 2 Blind Insertion Airway Device (Size 3, 4, 5) 1 of each size * Mechanical CPR device 1 Non-Adhesive Non-Sterile Bandage 2 OB Kit 1 Non-Adhesive Sterile Bandage 2 1 * Items with an (*) are only available on first out units

12

13 STANDING ORDERS GUIDELINES FOR UTILIZING STANDING ORDERS The following standing orders are meant to serve as guidelines for patient care. It is impossible to outline treatment sequences for every situation you will encounter. Each patient should be treated individually and appropriately, utilizing sound clinical judgment and these protocols as guidelines. The receiving hospital should be notified as soon as practical; however, this practice is a courtesy and should never interfere with patient care. If the clinical picture is clouded or complicated, and/or Medical Control consultation is needed, contact the On-Duty Supervisor. The receiving emergency department physician may also be used as Medical Control in the event the Supervisor is unable to be contacted. Therapies are to be utilized at WCEMS protocol level, not state certification level. The following is a brief summary of skills allowed at each level. APPROVED ECA PROVIDERS can: Scene survey and request additional resources Triage and assessment Basic airway management including adjuncts, O2 administration, suctioning, Blind Insertion Airway Device placement, and bag valve mask ventilations CPR and AED use Basic patient assessment Assess vital signs, blood glucose levels and pulse oximetry Assist in delivery of the newborn Basic intervention in bleeding control/burn management Musculoskeletal movement restriction Vehicle rescue Documentation of patient care Verbal patient care reports to receiving hospital staff Rehabilitation of ambulance/infection control Wound care Assist advanced provider with skills as requested (within basic scope of practice) APPROVED EMT-BASIC PROVIDERS can: Perform all of the functions listed above for ECA providers Administer Aspirin, Albuterol, Atrovent, Nitroglycerine spray, and Oral Glucose, assist patient with selfadministration of an Epi-pen or metered dose inhaler Administer Tylenol PO Administer CPAP Administer Epinephrine 1:1000 IM for severe respiratory distress APPROVED EMT-INTERMEDIATE PROVIDERS can: Perform all of the functions listed above for EMT-Basic providers Administer Tylenol PR Intravenous cannulation and fluid administration including adult and pediatric IO Administration of Dextrose IV/IO/PR in hypoglycemic patients Administration of Epinephrine IV/IO in pulseless patients Endotracheal intubation Administration of Narcan IV/IO/IM/IN in patients suspected to be under the influence of narcotics Insertion of Nasogastric Tube

14 APPROVED EMT-PARAMEDIC TRAINEES (P1) can: Perform all of the functions listed above for EMT-Intermediate providers Perform all functions up to the level of the trainer supervising them APPROVED EMT-PARAMEDIC PROVIDERS (P2) can: Perform all of the functions listed above for EMT-Intermediate providers Apply and interpret electrocardiographic assessment (4, 12, and 15-lead) Administer appropriate pharmacological therapy for assessed conditions in symptomatic patients Intramuscular administration of all approved medications Intranasal administration of all approved medications Perform Pleural Needle Decompression Perform pain and sedation management with approved medications Perform Blood collection at request of Law Enforcement and/or Search Warrant APPROVED SENIOR PARAMEDICS / SUPERVISORS can: Perform all of the functions listed above for EMT-Paramedic providers Perform Pharmacologically Assisted Intubations (P3) Perform Field Termination of Resuscitation (P4) Perform Surgical Cricothyrotomy (P3) Authorize extended transport destinations (P4) Provide On-Line or On-Scene Medical Control as needed. TRANSPORT DESTINATION CRITERIA All Patients requesting ambulance transport will be transported by ambulance. The medical and/or surgical needs of the critically ill or injured patient are always the primary consideration in determining transport destination. In general, critically ill medical and trauma patients should be transported to the closest appropriate facility unless the patient s condition can be best treated at another facility and the patient s condition is stable enough for the longer transport distance. Critically injured patients require rapid transport to the closest hospital capable of handling the multiple trauma patients. Determination of appropriate transport destination should be based upon the patient s immediate condition, location of the call, possible traffic delays and the needs of the patient in the critical first hour of trauma. When in doubt, refer to TSAQ GUIDELINES. Transport of the urgent and/or non-urgent patient shall be to the hospital of the patient s choice with regards to current system status and the capabilities of the hospital. If the patient insists on being transported to a facility that is not capable of treating their injury/illness, they must sign a waiver stating they understand the risks of their decision. Should the system be stressed at the time of the transport, or the requested destination is outside of the normal transport area, consult the on-duty supervisor for further guidance.

15 TSA-Q FACILITY DIVERSION GUIDELINES SUBJECT: PURPOSE: Diversion of Emergency Medical Services (EMS) traffic from emergency facilities. To define uniform system guidelines for a hospital requesting diversion of EMS traffic to an alternate hospital. ACKNOWLEDGMENTS: System hospital facilities, both Trauma Centers and non-trauma Centers, should request diversion activation only when the resources and capabilities of that facility have been exhausted to the point that further ambulance traffic would jeopardize the care and treatment of patients at that facility as well as any subsequent patient transported to that facility by an ambulance. It is recognized in advance that no diversion strategy can guarantee total compliance with these guidelines and it is likely that ambulances will deliver patients to hospitals which have requested diversion activation. It is further understood that a request for diversion activation is honored as a courtesy by the local EMS system. Each facility is responsible for defining facility-specific policies and procedures for implementation of these guidelines. Diversion activation by a facility is understood to be a request applicable to all ambulance traffic regardless of a patient s injury or illness and regardless of the diversion activation rationale. It is understood that EMS personnel will not attempt to screen patients transported to a facility based upon the diversion categories identified hereunder. DEFINITIONS: Transfer: Bypass: Diversion: Appropriate Facility: Movement of a patient from one hospital to another based upon the patient s need (inter-hospital transport) Intentional movement of a patient from the scene to a specific hospital, not necessarily the nearest hospital, based upon the patient s medical need. Intentional movement of a patient from the scene to an alternate hospital capable of providing appropriate care at the request of the nearest hospital due to lack of available resource or capability. A hospital, not necessarily the nearest hospital, with the resources and capability to care for a patient based upon the patient s medical needs. DIVERSION ACTIVATION CATEGORIES; ED saturation ICU saturation OR saturation Internal disaster AUTHORIZATION FOR DIVERSION STATUS IMPLEMENTATION AND DEACTIVATION: Hospital administrator or designee; and Trauma Director or designee

16 COMMUNICATION OF DIVERSION STATUS A hospital must notify the local EMS system dispatch and on-line medical direction source of a request for diversion activation and deactivation A hospital must provide the local EMS system with the applicable diversion activation category identified previously A hospital must provide the local EMS system dispatch and on-line medical direction source the names of the administrator or designee and Trauma Director or designee authorizing diversion implementation and deactivation. TIME PERIOD FOR DIVERSION STATUS; Diversion request will be in allotment up to eight (8) hours. A hospital may deactivate a diversion request at any time. A hospital must notify the local EMS system dispatch and on-line medical direction source to request an extension beyond each eight (8) hour allotment. Neglect or failure of a hospital to notify the local EMS system dispatch and on-line medical direction source at the end of the requested eight (8) hour allotment will result in automatic deactivation of that hospital s diversion request. AUTHORIZATION FOR OVER-RIDE OF DIVERSION STATUS: The on-line medical direction source may over-ride a diversion status after consideration of the following: Severity of the patient Distance and estimated time to an alternate appropriate facility Inclement weather conditions Resource availability and capability of the transporting pre-hospital provider All potential receiving facilities within a 15 minute radius of the patient location have requested diversion consideration Patient refuses transport to another designated facility. SYSTEM MONITORING AND QI Each hospital will be requested to document and report diversion activities to the SETRAC QI Committee on a quarterly basis. Each EMS system will be requested to document and report to the SETRAC QI Committee those situations where a diversion request has not been honored or has been over-ridden by the on-line medical direction source.

17 MEDICAL / LEGAL CONSIDERATIONS DUTY TO ACT Waller County EMS (WCEMS) has a duty to respond to all calls for medical aid within the geographical boundaries of our service area and, when resources are available, to recognized mutual aid agencies. Once treatment is rendered, WCEMS personnel have a duty to care for that patient until there is a transfer of care to someone of appropriate medical training according to patient condition. PATIENT CONSENT / REFUSAL OF TREATMENT Implied consent is used for any patient that is unable to communicate their wishes due to an injury, accident, illness or unconscious/altered mental status or suffering from what reasonably appears to be a life threatening injury or illness. 1. If a patient (or legal patient representative) requests evaluation and treatment from WCEMS, they will be actively encouraged to seek evaluation by a physician. If they consent, they will be transported to the appropriate acute care facility. Under no circumstances will WCEMS refuse or deny treatment to any patient who requests medical assistance. 2. Minor patients (under the age of 18 years old) shall not be permitted to consent or refuse to medical care or EMS transport without first obtaining permission from the parent, legal guardian, or other authorized family members or caregivers UNLESS: (1)patient resides separate from parents and maintains their own financial affairs, (2) legally married, (3)member of Armed Forces, (4)requests pregnancy related treatment other than abortion, (5)has a disease that is required by law to be reported to Health Department, or (6) is legally emancipated. No prior consent is required if the delay for consent could worsen the present condition or cause loss of life or limb to the minor patient. If guardian/caregiver cannot be reached after all efforts have been exhausted, contact on-duty supervisor for further instructions. If the parent or legal guardian refuses needed medical care for their child and EMS feels the child is in danger of losing life or limb, contact law enforcement and the on-duty supervisor. 3. Any patient who appears to be impaired or have altered mental status cannot be permitted to decline or refuse medical care or transportation. When orientation is questionable, opt for treatment and transport. 4. Patients who present with the following will be strongly discouraged from declining/refusing EMS transport: Chest pain or symptoms of ischemic heart disease. Dyspnea/respiratory distress Hypertension Seizures Abdominal pain with significant findings (orthostatic changes, guarding, rigidity, hematemesis, melena, rebound tenderness, abdominal surgery within last year). Overdoses / Poisonings accidental or intentional. Any complaint or abnormal finding possibly related to a known or suspected pregnancy including abdominal pain of unknown etiology in a female of childbearing potential. Any evidence of injury to the head, spine, chest, abdomen or pelvis. Known or suspected abuse victims child or adult. Contact CPS / APS, and law enforcement if care is refused. Any patient that receives advanced and/or invasive treatment then refuses further care or transport. This includes medications of any type. 5. Any patient refusing treatment or transport against medical advice will be informed of EMS findings and that further harm could result without appropriate treatment. This will constitute an informed refusal, will be considered Against Medical Advice (AMA) and will be documented as such. The on-scene EMS providers have the option to request the on-duty supervisor to witness a potential AMA refusal. All AMA refusals will be documented and completed thoroughly by the on-scene Paramedic.

18 DOCUMENTATION In all cases where an ambulance is dispatched, whether patient contact is established or not, a report must be completed. All transports/refusals must contain all pertinent information detailing response to incident, patient contact, assessment, treatment, response to therapy and any events at the receiving facility as applicable. Records will include: Dispatched complaint Actual C/C and reason EMS called. Level of consciousness including GCS (minimum of baseline and ending) Physical exam findings. Complete set of vital signs upon arrival on scene, during care, and upon discharge. (at least 2 sets), Any diagnostic findings (ECG, blood glucose, SpO2, etc.). Any attempts and number of attempts offering EMS transport including any outside assistance. Condition of patient at presentation and discharge. Reason patient is refusing and patient understands the risks of such a refusal. Patient s plans for seeking physician evaluation. Signature of personnel present who witnessed patient s refusal and your attempt to encourage the patient to seek follow-up care (non-ems if possible). All EKG tracings and Vital signs trending page. Pain scale if applicable (minimum of baseline and ending and after each pain management attempt) All applicable signatures. Hospital Face Sheet. Demographics and insurance information. PHYSICIAN ASSISTANCE PHYSICIAN ON SCENE Occasionally a physician will attempt to provide assistance at the pre-hospital scene. When this occurs, if this physician is an emergency physician or a physician adequately trained in emergency medical care, every attempt should be made to utilize the physician appropriately. The following provides guidelines for a physician at the prehospital emergency scene. THE GOOD SAMARITAN PHYSICIAN This physician has no previous connection or relationship with the patient. The doctor should be courteously informed that you are functioning under delegated practice of a licensed physician Medical Director. To take control of the scene, the physician must: 1. Submit verification of physician status by providing proof of medical licensure or verifiable personal identification by personnel on scene. If this status cannot be verified, assistance should be courteously declined. 2. The physician must be willing to assume responsibility for the patient at the scene, in transport and until relieved by another physician in the emergency department. This physician must accompany the crew and patient to the hospital and sign the patient care report as the in charge health care provider. 3. WCEMS personnel will not perform any treatments or procedures that are not in their scope of practice. PHYSICIAN IN HIS/HER OFFICE OR OTHER MEDICAL FACILITY: 1. The physician in his/her office may elect to take charge and supervise the EMS management of the patient provided they will be physically present in the transporting ambulance. 2. If the physician is not willing to be present during transport, EMS crews will revert to WCEMS protocols for appropriate therapy.

19 INDIVIDUALS ON SCENE CERTIFIED/LICENSED INDIVIDUALS ON SCENE Individuals that possess a valid EMS certification and/or other healthcare license but are not members of WCEMS may be allowed to assist Waller County EMS personnel in rendering patient care under the following conditions: 1. The individual may only provide basic care under the direct supervision of a Waller County EMS In-charge or Supervisor on scene 2. The individual may not administer any advanced or invasive treatment even if they possess an advanced certification. BYSTANDERS ON SCENE Non-Certified bystanders may not render patient care. Bystanders whom are approved First Responders for Waller County EMS may render patient care within their approved level and/or as deemed necessary by the on-scene WCEMS in-charge personnel. LAW ENFORCEMENT PERSONNEL ON SCENE Medically certified/licensed law enforcement personnel may assist WCEMS with basic care as deemed necessary by the on-scene WCEMS in-charge personnel. Law Enforcement personnel whom are approved First Responders for Waller County EMS may render patient care within their approved level and/or as deemed necessary by the on-scene WCEMS in-charge personnel. FIRE DEPARTMENT PERSONNEL ON SCENE Medically certified/licensed fire department personnel may assist WCEMS with basic care as deemed necessary by the on-scene WCEMS in-charge personnel. Fire department personnel whom are approved First Responders for Waller County EMS may render patient care within their approved level and/or as deemed necessary by the on scene WCEMS in-charge personnel. CONFIDENTIALITY All information regarding patient information is protected under the Health Insurance Portability and Accountability Act (HIPAA). The exception to this is in the event that a criminal act has been committed or is confessed to the crew. In this case, law enforcement officials will be notified. Do not release a patient report to anyone except for the receiving ER. All others need to request a copy from the Executive Director in person. Ensure all reports are completed, synced from laptop, proofread for accuracy, locked, and faxed with all documents attached upon return to station.

20 OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDERS (OOH DNR) IDENTIFYING OOH DNR FORM AND ID DEVICES There are two devices approved by Texas Department of Health to identify that a patient has an advanced directive in the form of a Do-Not-Resuscitate order: Texas OOH-DNR Form An original Texas OOH DNR form can be identified by a red symbol in the shape of the State of Texas in the upper left hand corner with the word STOP imposed over it and the words DO NOT RESUSCITATE beside it. An original or photocopy of this form shall be honored by all WCEMS personnel. Photocopies of this form are to include page 2 (instructions) either copied onto the back of page 1 or attached to page 1. Page 2 does not have to be included for photocopy to be valid as long as page 1 appears to be properly completed. Texas OOH DNR ID Necklace or Bracelet The following shall be honored by WCEMS personnel in lieu of the original or copy of OOH DNR form:an intact, unaltered, easily identifiable plastic identification OOH DNR bracelet, with the word "Texas" (or a representation of the geographical shape of Texas and the word "STOP" imposed over the shape) and the words "Do Not Resuscitate. OR An intact, unaltered, easily identifiable metal bracelet or necklace inscribed with the words, "Texas Do Not Resuscitate - OOH". PROPERLY COMPLETED TEXAS OOH DNR The following sections must be completed in order for a Texas OOH DNR to be valid: Section 1: Patient s name and date of birth Section 2: Signatures, dates and appropriate boxes marked in either box A, B, or C (one only). Section 3: Witnesses signatures and dates signed. Witnesses signatures are not required if form is signed by two physicians (Section 2, Box C completed). Section 4: Physician s signature, printed or typed name, license number, date Section 5: Signatures of all persons who have signed the Texas OOH DNR in the above sections and the date the order was issued. DOCUMENTATION OF OOH DNR ORDERS BY WCEMS PERSONNEL In the event of an OOH DNR order or identification device is encountered or if any other situations as noted above occur, the following information will be documented in addition to the standard demographic information: 1. History and assessment of the patient s physical condition. 2. Name of the patient s attending physician or physician on scene 3. Full name, address, telephone number, and relationship to patient of any witness used to identify the patient. 4. Unique identification number on the DNR form or identification device. 5. Situations or conflict at scene and the resolution.

21 HONORING AN OOH DNR When presented with a patient who has Out of Hospital Do Not Resuscitate order, the protocol outlined below shall be followed. Honoring an OOH-DNR in the presence of a pulseless, apneic patient: 1. Verify that the patient is the person named on the OOH-DNR form. If the patient is wearing an OOH- DNR ID device, it shall be honored with or without the form being present. 2. Cease all resuscitation efforts. 3. Notify law enforcement of the patient s death. 4. Attach a copy of the OOH-DNR to the call report. Treatment to be withheld in the presence of an OOH-DNR form: Cardiopulmonary resuscitation Advanced airway management Artificial ventilation Defibrillation External Pacing Palliative Care If the patient is not in cardiac arrest, requires care, and has a properly completed OOH DNR form or ID device, provide care needed and transport both the patient and the OOH DNR form to the hospital. Out of state OOH DNR If an OOH DNR order is presented from another state, territory, or possession of the United States, WCEMS will honor only the original DNR form if there is no reason to question the authenticity of the order or device. Do not honor an OOH-DNR if: 1. There is a suspicion of suicide, homicide or other non-natural cause of death. 2. The patient is known to be pregnant. 3. The OOH-DNR or ID device has been destroyed or revoked according to Texas Health and Safety Code Sec : a. A declarant may revoke an out-of-hospital DNR order at any time without regard to the declarant s mental state or competency. An order may be revoked by: 1. The declarant or someone in the declarant s presence and at the declarant s direction destroying the order form and removing the DNR identification device, if any; 2. a person who identifies himself or herself as the legal guardian, as a qualified relative, or as the agent of the declarant having a medical power of attorney who executed the out-ofhospital DNR order or another person in the person s presence and at the person s direction destroying the order form and removing the DNR identification device, if any; 3. the declarant communicating the declarant s intent to revoke the order, or; 4. a person who identifies himself or herself as the legal guardian, relative, or the agent of the declarant having a medical power of attorney who executed the out-of-hospital DNR order orally stating the person s intent to revoke the order. CONFLICT RESOLUTION PROCEDURE In the event the scene situation is unclear or conflict at the scene occurs, personnel will: 1. Initiate Basic Life Support procedures during the resolution process. 2. Consult with the family members to resolve the conflict. 3. WCEMS will transport with CPR in progress and full ALS skills if the conflict cannot be resolved.

22 GENERAL EMERGENCIES Patient Care Guidelines

23 AIRWAY UNIVERSAL PATIENT PROTOCOL Assess ABCs Rate, effort and adequacy Pulse Oximetry ETCO2 If adequate Give supplemental O2 with appropriate device as needed Reassess If inadequate Continue with protocol Open airway Head tilt-chin lift or jaw thrust Remove obstructions as needed AIRWAY: OBSTRUCTION PROCEDURE AIRWAY:SUCTIONING PROCEDURE Insert adjuncts as needed OPA / NPA Assist or ventilate with supplemental O2 using appropriate device as needed Reassess ABCs If adequate Continue actions If inadequate Continue with protocol AIRWAY:OROTRACHEAL INTUBATION PROCEDURE (option) PHARMACOLOGICAL ASSISTED INTUBATION PROCEDURE as needed Bougie required GASTRIC TUBE PROCEDURE If 3 failed attempts (1 by P4) at Orotracheal Intubation, or airway efficiency is still inadequate FAILED AIRWAY PROTOCOL NOTES Capnography required with any / all intubations. Also include at least 4 other methods of confirmation. Any of the above airways are considered acceptable as long as they maintain ETCO2 at and pulse oximetry > 92%. An intubation attempt is defined as any time the bougie passes the teeth. External Laryngeal Manipulation (ELM) should be employed as needed on all intubations. Allow person intubating to guide your position and pressure. AIRWAY

24 C-SPINE CLEARANCE Altered Mental Status? Any evidence of alcohol or drug use that is interfering with judgment? Are there extremes of age that may be interfering with the patient s judgment? Does patient have any injuries that may be distracting them from other injuries? This can be a more painful injury or an injury that is particularly grotesque or visible to the patient. Proximity injuries should raise suspicion Upper Torso Injury Long Bone Fx Stress of situation and MOI should raise suspicion for decreased sensitivity also. Any neurologic deficits noted? Any point tenderness or complaint of pain during spinal assessment? If NO to all of the above, complete Range of Motion Test. Any tenderness or pain? If NO to all of the above No immobilization required. If YES to any of the above Spinal immobilization is required. SPINAL IMMOBILIZATION PROCEDURE If patient refuses Refusal waiver signature required. NOTES Range of Motion Test includes look fully upwards, downwards and side to side without assistance and without any spinal process pain. The decision to NOT implement spinal immobilization is the responsibility of the Paramedic. If you feel spinal immobilization is needed, but patient refuses any/all of it, a waiver must be signed before transport of patient that documents what is refused and releasing responsibility of WCEMS crews of injuries caused by this refusal of care. C-SPINE CLEARANCE

25 CHEMICAL RESTRAINT TO BE USED ONLY AFTER ALL OTHER ATTEMPTS TO CALM / RESTRAIN PATIENT HAVE FAILED SCENE SAFETY!! Ensure law enforcement on scene as applicable Ensure Supervisor contacted as soon as possible UNIVERSAL PATIENT PROTOCOL Safety will take precedence over all individual procedures. For methamphetamine, cocaine or PCP overdoses whom are NOT violent but are symptomatic {hyperthermia, HTN, tachycardia, agitation, and/or restlessness} ATIVAN (option) VERSED (option) If combative AND physical restraint is unsuccessful, AND Suspected Alcohol intoxication KETAMINE IM/IV only No suspected Alcohol Intoxication ATIVAN (option) VERSED (option) If no response after 5 minutes KETAMINE After successful chemical sedation Ensure proper physical restraint in place RESTRAINT PROCEDURE EKG and Vital signs Continual monitoring is required AIRWAY PROTOCOL Continuous ETCO2 and SPO2 monitoring mandatory IV ACCESS PROTOCOL 1000cc Fluid bolus If patient experiences laryngospasm after Ketamine use OPA/NPA with BVM until laryngospasm subsides If prolonged laryngospasm AIRWAY:OROTRACHEAL INTUBATION PROCEDURE NOTES Be prepared to treat hypotension and/or respiratory depression as soon as sedation is affected. Do not treat tachycardia during use of Ketamine unless it becomes a non-sinus type tachycardia. Expect rates as high as 170. Signs/symptoms of Excited Delirium: o Aggressive, threatening, combative behavior. o Extreme agitation or excitement. o Unusual strength, sweating and tachypnea. CHEMICAL RESTRAINT

26 DEAD ON ARRIVAL Does person meet any of the following criteria: Decapitation Decomposition Rigor Mortis Dependent lividity, venous pooling Injuries incompatible with life Pulseless/Apneic with valid OOH-DNR Pulseless and/or Apneic in a MCI where EMS resources are required for stabilization of living persons If patient meets criteria Do not attempt resuscitation Document any / all criteria Contact supervisor and law enforcement Remain on scene until released If patient does not meet criteria Attempt resuscitation following appropriate protocols NOTES Be mindful and aware of situations that may be considered a crime scene and coordinate with Law Enforcement. Honoring an OOH-DNR does not require asystole. It only requires the absence of spontaneous respirations and/or pulse. DEAD ON ARRIVAL

27 FAILED AIRWAY AIRWAY PROTOCOL Total of (3) failed Orotracheal intubation attempts (with at least 1 attempt by P4 if available) will constitute a failed airway SPO2 is greater than 90% with supplemental O2 via appropriate delivery device continue actions SPO2 is less than 90% and falling with supplemental O2 via appropriate delivery device or becoming difficult to ventilate Blind Insertion Airway Device (BIAD) AIRWAY:BLIND INSERTION AIRWAY DEVICE SPO2 is greater than 90% with BIAD and good compliance Continue actions SPO2 is less than 90% and falling See AIRWAY: SURGICAL CRIC PROCEDURE Contact Supervisor NOTES If first intubation attempt fails, make adjustments and consider the following; o Different Blade o Different size tube o Change head position o Change person o ELM Continuous SPO2 and ETCO2 should be applied to all patients. If SPO2 is low, but all other indications show that ETT is patent, continue actions. Notify Supervisor of Failed Airway immediately. FAILED AIRWAY

28 IV ACCESS UNIVERSAL PATIENT PROTOCOL Assess need for IV access Emergent or potentially emergent medical or traumatic condition Peripheral site Upper extremities preferred but not mandatory VENOUS ACCESS:EXTREMITY PROCEDURE External jugular site Greater than 8 years of age For life threatening event VENOUS ACCESS:EXTERNAL JUGULAR PROCEDURE Intraosseous For life threatening event and/or unable to cannulate peripheral site on critical patient in 2 attempts VENOUS ACCESS:INTRAOSSEOUS PROCEDURE Monitor lock Monitor infusion Monitor fluid bolus as needed. Maximum 20ml/kg Monitor ABCs and lung sounds for signs of fluid overload NOTES Any fluids or medications approved for IV use may also be used IO. All IVs should have a saline lock or set at a rate of TKO unless administering a fluid bolus. In life threatening situations, only 2 IV attempts maximum allowed before using IO. In life threatening situations, any pre-existing external venous catheter may be accessed. In post-mastectomy patients, avoid IV, blood draws, injections or blood pressure analysis in arm of affected side. IV ACCESS

29 MULTIPLE PATIENT TRIAGE ABLE TO WALK? YES MINOR NO BREATHING? NO POSITION AIRWAY BREATHING IMMEDIATE APNEIC PEDI ADULT YES PULSE NO PULSE DECEASED 5 BREATHS APNEIC BREATHING IMMEDIATE RESPIRATORY RATE > 30 (ADULT) < (PEDI) < 30 (ADULT) (PEDI) IMMEDIATE PERFUSION NO PALPABLE PULSE MENTAL STATUS DOESN T OBEY COMMANDS (ADULT) POSTURING, "U" OR "P" (PEDI) OBEYS COMMANDS (ADULT) "A", "V", OR "P" (PEDI) DELAYED

30 PAIN MANAGEMENT UNIVERSAL PATIENT PROTOCOL Patient care using appropriate protocols Pain scale 4/10 or less Make patient comfortable Reassess Pain scale 5/10 or greater EKG IV ACCESS PROTOCOL Treat pain appropriately If IV access unsuccessful or hazardous FENTANYL IM / IN If IV access successful FENTANYL (option) MORPHINE (option) Repeat medications as needed for pain management Do not exceed medication maximum dosages Reassess after each dose to determine need for additional doses NAUSEA/ VOMITING PROTOCOL NOTES The goal for Pain Management is to take the edge off the pain and make it tolerable. Complete pain relief is unrealistic in our setting and could cause further complications. Pain severity must be recorded pre and post analgesic administration. Be cautious of narcotic use with hypotension, head injuries or respiratory distress. Document all allergies prior to medication administration. Document reasoning of any pain 5/10 or greater that was not treated appropriately. Vital signs must be documented within 15 minutes post administration. Pain 4/10 or less may be treated if you feel it is detrimental to patient or patient does not understand pain scale. Document reasoning. PAIN MANAGEMENT

31 POLICE CUSTODY UNIVERSAL PATIENT PROTOCOL Evidence of traumatic injury or medical illness Use appropriate protocol and transport as needed Pepper spray Irrigate eyes Remove contaminated clothing. If patient is wheezing RESPIRATORY DISTRESS PROTOCOL Transport as needed Taser If significant injury from Taser probe, from fall after taser use, or patient complains of chest pain with cardiac history Appropriate protocol Transport as needed For probe removal TASER PROBE REMOVAL PROCEDURE Blood Draw BLOOD DRAW PROCEDURE Combative or violent patient CHEMICAL RESTRAINT PROTOCOL RESTRAINT PROCEDURE Jail Call If life threatening emergency, transport patient immediately to closest appropriate facility with jail staff or deputy onboard All other decisions to transport will be made by jail doctor Have jailers contact the jail doctor, give him your assessment findings over the phone, and follow his directions for transport or refusal No orders for medicine will be taken from the doctor. Only the jailers or the nurse are to take medication orders from jail doctor NOTES Any patient who is handcuffed or in custody by Law Enforcement and transported by EMS must be accompanied by Law Enforcement during transport. If patient with history of Asthma was pepper sprayed and released back to Law Enforcement, ensure they understand to call EMS immediately if patient begins wheezing or develops difficulty breathing. POLICE CUSTODY

32 UNIVERSAL PATIENT Scene survey PPE Be professional and courteous at all times Conduct appropriate assessments ASSESSMENT: ADULT ASSESSMENT: PEDIATRIC Consider C-SPINE CLEARANCE PROTOCOL Airway management including oxygen using appropriate devices AIRWAY PROTOCOL Vital signs Blood pressure Pulse rate, rhythm and quality Respiratory rate, rhythm and quality PULSE OXIMETRY PROCEDURE BLOOD GLUCOSE ANALYSIS PROCEDURE Temperature CAPNOGRAPHY PROCEDURE Glascow Coma Scale Pain scale EKG {3 lead and/or 12 lead} 12 LEAD PROCEDURE Treat per appropriate protocols based on assessments and vital signs Transport to closest appropriate facility NOTES Pediatric patient is defined by the length of the Broselow-Luten Tape. If the patient is longer than the tape, they are considered an adult. Temperature, EKG, and ETCO2 use are to be based on patient presentation, age, history and complaint. Never transport in prone position. This protocol may also be used for any patient that does not meet criteria for any other protocol. Perform the sections of this protocol as needed based on or part of assessment. UNIVERSAL PATIENT

33 Medical Emergencies Patient Care Guidelines

34 ABDOMINAL PAIN UNIVERSAL PATIENT PROTOCOL 12 lead EKG IV ACCESS PROTOCOL Consider NAUSEA/VOMITING PROTOCOL Consider PAIN MANAGEMENT PROTOCOL Consider OB and Trauma related protocols based on assessment NOTES Ensure all trauma to abdomen has been rules out. Do not overly palpate abdominal area once pain is registered. Any patient with severe pain that precedes vomiting and is longer than 6 hours in duration is likely to be caused by a surgically correctable illness, Also, any patient with signs of distention, rigidity or pulsatile masses should be transported to facility with surgical capabilities. Document Vital signs and GCS prior to administering anti-emetics. Consider the following in women of child bearing age and refer to OB section. o Abortion o Ectopic pregnancy (until proven otherwise) o Uterine Rupture o Abruptio Placenta o Ovarian Cyst Document all referred / radiating pain sites, presence or lack of bowel sounds and last bowel movements. ABDOMINAL PAIN

35 ALLERGIC REACTION UNIVERSAL PATIENT PROTOCOL 12 lead EKG as patient severity allows If only hives and/or rash with no respiratory involvement IV ACCESS PROTOCOL BENADRYL Continue to reassess airway If signs of impending respiratory involvement or shock AIRWAY PROTOCOL EPINEPHRINE 1:1000 IM IV ACCESS PROTOCOL BENADRYL ALBUTEROL SOLUMEDROL Reassess airway If condition worsens EPINEPHRINE 1:10000 IV/IO Reassess airway If Anaphylaxis refractory to above treatments EPINEPHRINE INFUSION Consider RESPIRATORY DISTRESS PROTOCOL PEDIATRIC RESPIRATORY DISTRESS PROTOCOL NOTES The shorter the onset from cause to symptoms, the more severe the reaction is. When giving Epinephrine to patients over 50 years, or patients with known cardiac history, ensure 12 lead is completed prior to medication as time and severity allows. Give Epinephrine IV if IM dose is ineffective or perfusion is severely diminished. The effect of IV is faster, but IM is safer. To administer Epinephrine by IV/IO, inject 1cc of 1:10,000 into 100cc saline and administer through 60 gtts set. ALLERGIC REACTION