NYC REMAC PUBLIC NOTICE PROPOSED REVISIONS PREHOSPITAL TREATMENT PROTOCOLS THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC.

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1 THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC. NYC REMAC PUBLIC NOTICE PROPOSED REVISIONS PREHOSPITAL TREATMENT PROTOCOLS The Regional Emergency Medical Advisory Committee (REMAC) of New York City Prehospital Treatment Protocols define the minimum standard of care provided to patients by Certified First Responders (CFRs), Emergency Medical Technicians (EMTs), and Advanced Emergency Medical Technicians-Paramedic (AEMT- Ps) in New York City. These protocols reflect both the curriculum and certification requirements of the New York State Department of Health Bureau of Emergency Medical Services and the Regional Emergency Medical Advisory Committee (REMAC) of New York City. The REMAC of New York City has proposed revisions to the current regional Prehospital Treatment Protocols. Deleted language is BOLD RED AND STRUCK-OUT --- DELETED New language is BOLD BLUE AND UNDERLINED --- NEW In order to meet regional needs, the REMAC of New York City is conducting a public notice and is requesting comments from the Emergency Medical community. Comments must be submitted in writing on the attached Comment Form or via to mdiglio@nycremsco.org. If available, appropriate supporting documentation should also be submitted. Comments must be received no later than May 3, Draft revised protocols can be reviewed on-line at (under News and Announcements ). All NYC REMAC Protocols can be accessed in their entirety at Date Distributed/Posted: April 3, 2018 DIRECT ALL INQUIRES AND COMMENTS TO: Jessica van Voorhees, MD Chair, Protocol Committee Regional Emergency Medical Advisory Committee of New York City c/o Regional EMS Council of NYC 475 Riverside Drive, Suite 1929 New York, New York mdiglio@nycremsco.org PLEASE BE ADVISED THAT pursuant to Section 3004-A of Article 30 of the Public Health Law of the State of New York, the Regional Emergency Medical Advisory Committee (REMAC) of New York City is responsible to develop prehospital triage, treatment, and transportation protocols that are consistent with the standards of the State Emergency Medical Advisory Committee and that address specific local conditions with regards to the provision of prehospital medical care rendered by NYS Department of Health certified First Responders, Emergency Medical Technicians and Advanced Emergency Medical Technicians within the City of New York. April 3, 2018 Public Notice

2 THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC. Regional Emergency Medical Advisory Committee (REMAC) of New York City Protocol Revision Comment Form Name: Mailing Address: Telephone Number: Fax Number: Title (e.g., MD, DO, EMT, EMTP, RN, etc.): Protocol Number: N/A Protocol Title: 412: Suspected Stroke Includes: General Operating Procedures Transportation Procedures and Decisions, and Appendix R: Stroke Patient Assessment Triage and Transportation Comments: (Please Type) (Continue on additional sheet if necessary) If available, appropriate supporting documentation should be submitted Comments must be received no later than May 3, 2018 to: Jessica van Voorhees, MD Chair, Protocol Committee Regional Emergency Medical Advisory Committee of New York City c/o Regional EMS Council of NYC 475 Riverside Drive, Suite 1929 New York, New York Draft revised protocols can be reviewed on-line at (under News and Announcements ). All NYC REMAC Protocols can be accessed in their entirety at This form may be duplicated as needed April 3, 2018 Public Notice

3 GENERAL OPERATING PROCEDURES TRANSPORTATION PROCEDURES AND DECISIONS Acute Stroke If the historical/physical findings indicate an acute stroke, transport the patient to the closest appropriate Stroke Center as determined by Appendix R, unless: Patient is in cardiac arrest or has an unmanageable airway Patient has other medical conditions that warrant transport to the nearest appropriate New York City 911 system ambulance destination emergency department as per protocol. If the patient has a LAMS+Speech score of 3, transport patient to the closest Primary Stroke Center (PSC). If the patient has a LAMS+SPEECH score of 4, contact OLMC for Transport Decision to the closest Thrombectomy-Capable Stroke Center (TSC) / Comprehensive Stroke Center (CSC) *, unless Stroke Exclusion Criteria are met : Total time from onset of patient s symptoms to EMS patient contact is greater than 5 (five) hours Patient is wheelchair or bed-bound Seizure is cause of symptoms Loss of Consciousness (LOC) Trauma is cause of symptoms Transport time to TSC/CSC is > 30 minutes and not approved by Online Medical Control. * See Appendix Q/H for list of TSC/CSC/PSC designated hospitals.

4 Protocol Appendices Appendix R: Stroke Patient Assessment Triage and Transportation 1. LAMS+Speech Scale LAMS + Speech Element Finding Score Facial Droop Absent 0 Present 1 Arm Drift Absent 0 Drifts Down 1 Falls Rapidly 2 Speech Deficit Absent 0 Present 1 Grip Strength Normal 0 Weak Grip 1 No Grip 2 Total Score Stroke Exclusion Criteria for LAMS+Speech 4 If any of the criteria to the right are present on a patient with LAMS+Speech score 4, transport should be to the closest New York City 911 system ambulance Primary Stroke Center. Total time from onset of patient s symptoms to EMS patient contact is greater than 5 (five) hours Patient is wheelchair or bed-bound Seizure is cause of symptoms Loss of Consciousness (LOC) Trauma is cause of symptoms Transport time to TSC/CSC is > 30 minutes and not approved by Online Medical Control.

5 3. Stroke Triage & Transportation Algorithm NYC Stroke Triage Protocol Assess LAMS + Speech EMS Arrives to Patient NEW neurological deficit Administer oxygen Check for, and treat, FSBG < 60 mg/dl Facial Droop 0 : Absent 1 : Present Arm Drift 0 : Absent 1 : Drifts Down 2 : Falls Rapidly Speech Deficit 0 : Normal 1 : Abnormal Grip Strength 0 : Normal 1 : Weak Grip 2 : No Grip NEW neurological deficit and FSBG 60 mg/dl? Yes Yes Exclusion Criteria Met? Exclusion Criteria Trauma Cause Wheelchair/Bedbound Loss of Consciousness (LOC) Seizure Cause Last Known Well (LKW)>5 Hours No Transport to PSC or to appropriate ED** No Transport to approved CSC/ TSC* * Per OLMC direction if transport time 30 min ** e.g., trauma, treated hypoglycemia with resolved symptoms

6 THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY BASIC EMERGENCY MEDICAL TECHNICIAN PROTOCOLS 412: Suspected Stroke 1. Monitor the airway. 2. Administer oxygen. 3. Use Glucometer to measure blood glucose level. a. If 60 mg/dl, proceed to LAMS+Speech evaluation. b. If <60 mg/dl, treat hypoglycemia. Conscious & swallowing patient: if the conscious patient can swallow, and can drink without assistance then provide a glucose solution, fruit juice, or non-diet soda by mouth. Conscious / not-swallowing patient: if the conscious patient cannot drink without assistance or tolerate oral glucose, call ALS for further treatment. Do not give oral solutions to patients who cannot swallow. Unconscious patient: call ALS for further treatment. Do not give oral solutions. c. If neurologic deficits have resolved after treatment, transport patient to closest appropriate 911-receiving hospital. d. If neurologic deficits persist after treatment and FSBG 60 mg/dl, proceed to LAMS+Speech evaluation per Appendix R. 4. Document LAMS+Speech score in the prehospital care report. 5. Transport per Appendix R: a. If score is 0-3, transport to the closest NYC 911 system Primary Stroke Center (PSC). b. If score is 4 or greater, and the patient does not meet the specific Stroke Exclusion Criteria for this score, contact OLMC for Transport Decision to the closest NYC 911 system Thrombectomy-Capable Stroke Center (TSC) / Comprehensive Stroke Center (CSC). 6. Do not delay transport.