PSVAC Training Session

PSVAC Training Session
January 4th, 2009

Agenda Protocol Changes Moshe Karp (30 minutes)
Selective Spinal Immobilization Moshe Karp (30 minutes) Telemetry Contact (15 minutes) RMA policy (15 minutes) ***************** 15 Minute Break ****************** Albuterol Matt Jachyra (30 minutes) Epi Pen Matt Jachyra (40 minutes) New SCAM report Will Tung (10 minutes) MOLST / DNR Orders Will Tung (15 minutes) SAFE Centers Will Tung (10 minutes) Total time: 3 Hours, 30 Minutes January 4th, 2008 PSVAC Training

2009 NYC REMSCO Protocol Changes
Moshe Karp

BLS Changes - GOPs There are just two changes to note within the General Operating Procedures that apply to both BLS and ALS providers: 10 Minute Rule Redefined Signs and Symptoms of Shock January 4th, 2008 PSVAC Training

BLS Changes - GOPs Page A.8 January 4th, 2008 PSVAC Training

BLS Changes - GOPs The result of this protocol can be thought of in terms of this diagram January 4th, 2008 PSVAC Training

BLS Changes - GOPs Page A.11 – A.12
Because pale conjunctiva are a sign of anemia, and not necessarily shock, and because it is a bad idea to ask someone with suspected decompensated shock to stand just to that you can assess for orthostatic vital signs, this wording has been removed from this section of the GOPs. January 4th, 2008 PSVAC Training

BLS Protocols The following BLS Protocols were changed:
400: WMD / Nerve Agent Exposure Protocol 404: Non-Traumatic Chest Pain 407: Asthma 414: Poisoning or Drug Overdose 432: Cold-Related Emergencies 421: Head and Spine Injuries January 4th, 2008 PSVAC Training

BLS Protocols Protocol 400 – WMD / Nerve Agent Protocol
So, particularly during the initial treatment, you can’t give one drug (atropine) without giving the other (2-PAM). For this reason, the portion of the protocol for the treatment of the yellow tag adult patient has been changed – calling for two doses of each agent. January 4th, 2008 PSVAC Training

BLS Protocols Protocol 400 – WMD / Nerve Agent Protocol
The Mark I autoinjector kit that was previously used is no longer available. Instead, the company is now packaging both drugs in a single autoinjector kit –Duodote. January 4th, 2008 PSVAC Training

BLS Protocols Protocol 404 – Non-Traumatic Chest Pain
“Don't take VIAGRA if you take nitrates, often prescribed for chest pain, as this may cause a sudden, unsafe drop in blood pressure.” Though this warning is straight out of the commercial, it also applies to us. January 4th, 2008 PSVAC Training

There are a variety of drugs used to treat erectile dysfuntion: sildenafil (Viagra) tadalafil (Cialis) vardenafil (Levitra) The new protocol requires that 72 hours have passed from the time that a patient takes one of these medications until you can safely administer nitroglycerin without OLMC contact. January 4th, 2008 PSVAC Training

One additional change is the age at which the treatments in the protocol are indicated. Consistent with the American Heart Association recommendations, patients age 33 or older are to be considered “at risk” for heart disease and treated as such. This protocol has been altered to reflect this younger age. January 4th, 2008 PSVAC Training

BLS Protocols Protocol 407 – Asthma Wheezing
The first change to this protocol is right at the top. In fact, it’s the title. Now titled wheezing, this protocol no longer requires that the patient have a history of asthma. Whether their wheezing is due to asthma, COPD, smoke inhalation or anything, you can treat their wheezing with this protocol. January 4th, 2008 PSVAC Training

BLS Protocols Protocol 411 – Poisoning or Drug Overdose
Activated charcoal is not a harmless substance. It can make a patient feel nauseated and, if aspirated, can cause a severe inflammatory reaction in the lungs, leading to lung diseases. Also because its benefit is even questionable for many overdoses, it has been removed from the REMAC protocols. January 4th, 2008 PSVAC Training

BLS Protocols Protocol 432 – Cold-Related Emergencies
Severely hypothermic patients may have very slow heart rates and/or hypotension. And so their pulse can be very difficult to feel. The protocol now reflects that, allowing “at least seconds” to check for a carotid pulse. January 4th, 2008 PSVAC Training

Selective Spinal Immobilization
Moshe Karp

NYS Spinal Update January 4th, 2008 PSVAC Training Objectives
At the completion of this unit, the EMS provider will be able to utilize assessment findings to formulate a field impression and implement a treatment plan for a patient with a suspected spinal injury. Prior to this unit, EMS providers should have an understanding of the anatomy of the spine and spinal cord, trauma assessment, and spinal immobilization. This presentation is to be used as an adjunct to the New York State Department of Health Bureau of EMS trauma curriculum update for the Suspected Spinal Injury protocol published in February of 2008. January 4th, 2008 PSVAC Training

Protocol 421 – Head and Spine Injuries After years of development, the statewide selective spinal immobilization protocol is finally ready for implementation. And, beginning January 1st, it will be incorporated into the NYC REMAC protocols. First, let’s address why this is such an important change. Q: Do you know how long it takes, just lying on a long spine board, to develop the changes consistent with a decubitus ulcer (“bedsore”, “decub”)? A: Just one hour. January 4th, 2008 PSVAC Training

Protocol 421 – Head and Spine Injuries Spinal immobilization, when unnecessary, prolongs scene times, causes undo pain for the patient, and may even worsen some injuries. The problem is figuring out when it is unnecessary. January 4th, 2008 PSVAC Training

Protocol 421 – Head and Spine Injuries Fortunately, this question has been asked and answered. A large study (NEXUS) was performed to identify criteria which could be used to determine who does and does not need x-rays. And, in subsequent studies, it was shown that these same criteria could be used to determine who did and did not need spinal immobilization. January 4th, 2008 PSVAC Training

BLS Protocols

Patients meeting one or more of the following criteria must be immobilized: Altered mental status for any reason, including possible intoxication due to drugs or alcohol. GCS <15 January 4th, 2008 PSVAC Training

Complaint of, or inability of the provider to assess for, neck and/or spine pain or tenderness. Weakness, paralysis, tingling, or numbness of the trunk or extremities at any time since the injury. Deformity of the spine not present prior to the injury. January 4th, 2008 PSVAC Training

Distracting injury or circumstances, including anything producing an unreliable physical exam or history. January 4th, 2008 PSVAC Training

High risk mechanism: axial load such as diving or tackling, high-speed motor vehicle accidents, rollover accidents, falls greater than standing height. Provider concern for potential spinal injury. January 4th, 2008 PSVAC Training

NOTE: ONCE SPINAL IMMOBILIZATION HAS BEEN INITIATED, IT MUST BE COMPLETED. SPINAL IMMOBILIZATION MAY NOT BE REMOVED IN THE PREHOSPITAL SETTING. 3. If necessary to initiate spinal immobilization, utilize the Rapid Takedown technique ONLY if the patient is standing. January 4th, 2008 PSVAC Training

Protocol 421 – Head and Spine Injuries Three final comments on this protocol: 1) Once immobilization is initiated (c-collar, KED, backboard, etc), it may not be removed. 2) The protocol is not meant to identify patients for whom immobilization is needed, only those for who it is not needed. 3) If a patient is found to not need immobilization, all of the criteria that led to this decision must be documented in the PCR narrative. January 4th, 2008 PSVAC Training

Telemetry Contact

Telemetry What is telemetry? For us? OLMC
Greek: tele = remote, metron = measure Remote assessment and reporting For us? OLMC On-Line Medical Control Physician (or Medical Control Officer operating under Physician’s protocol) available 24/7 January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 31 31

When To Call RMA 10-83 Patient lacks Decisional Capability
High Index of Suspicion Unsafe Environment Uncooperative Patient Patient under 6 years old Questions about DNR or MOLST 10-83 Obvious signs of death but CPR in progress DNR or MOLST presented after CPR has been started January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 32

When To Call Medication Orders Transport Epi-pen Administration
Patient requests a hospital outside of “10 minute rule” Absolutely refuses transport to a closer hospital. Patient requests a specialty referral center Memorial Sloan-Kettering Patient requests hospital on diversion January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 33

Methodist Medical Control
Who To Call Methodist Medical Control (718) January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 34

What To Say Identify Yourself Identify Your Patient
{name}, {age}, {gender} “complaining of” or “called 911 for” {reason} State Reason for calling OLMC Patient Information: Past History, Meds, Allergies Physical Assessment: Vital Signs, Skin CTC, etc. Surroundings: good or bad environment Friends / Family members present January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 35

What To Document Always inform your DO of any OLMC contact ACR
Physician name & ID, or MCO name & badge Translator name, address & phone Any OLMC-approved decisions RMA Alternate treatment or transport Approved cessation of resuscitation January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 36

RMA Policy Changes

Definitions Refusal of Medical Aid (RMA): A refusal of emergency medical aid (treatment and/or transport) by a patient or guardian on behalf of a patient. Patient: Any individual for whom an ambulance has been requested for treatment and/or transport. Patient Contact: Any instance in which an emergency medical provider has initiated an assessment or treatment of a patient. Refusal of Medical Aid (RMA) – A refusal of emergency medical aid (treatment and/or transport) by a patient or guardian on behalf of a patient. Patient – Any individual for whom an ambulance has been requested for provision of emergency medical treatment and/or transport. Patient Contact – Any instance in which an emergency medical provider has initiated an assessment or treatment of a patient. Patient Qualified to Request an RMA – A patient qualified to request an RMA must be at least eighteen years of age, or if younger than 18 years of age must be one of the following: A. A patient who is married. B. A patient who is pregnant (for purposes of consenting to medical, dental, health and hospital services related to prenatal care). C. A patient who is a parent. D. A patient who is seeking treatment for HIV or a sexually transmitted disease. E. A patient who is in the military. Minor Patient - A minor patient is any patient under the age of eighteen and who is not qualified to request an RMA. Decisional Capacity – an individual's ability to make an informed decision concerning his or her medical condition or treatment. In order to have decisional capacity, the patient must not be impaired and must demonstrate that s/he understands: The nature of his or her presenting medical condition; The possible risks and consequences of refusing emergency medical treatment and/or transport for his or her acute or presenting medical condition, including where applicable, the risk of serious adverse health consequences or death. Treatment and transportation alternatives. January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 38 38

Definitions Decisional Capacity: An individual's ability to make an informed decision concerning his or her medical condition or treatment. Must understand: Nature of his medical condition Risks and consequences of refusal Treatment and transport alternatives Refusal of Medical Aid (RMA) – A refusal of emergency medical aid (treatment and/or transport) by a patient or guardian on behalf of a patient. Patient – Any individual for whom an ambulance has been requested for provision of emergency medical treatment and/or transport. Patient Contact – Any instance in which an emergency medical provider has initiated an assessment or treatment of a patient. Patient Qualified to Request an RMA – A patient qualified to request an RMA must be at least eighteen years of age, or if younger than 18 years of age must be one of the following: A. A patient who is married. B. A patient who is pregnant (for purposes of consenting to medical, dental, health and hospital services related to prenatal care). C. A patient who is a parent. D. A patient who is seeking treatment for HIV or a sexually transmitted disease. E. A patient who is in the military. Minor Patient - A minor patient is any patient under the age of eighteen and who is not qualified to request an RMA. Decisional Capacity – an individual's ability to make an informed decision concerning his or her medical condition or treatment. In order to have decisional capacity, the patient must not be impaired and must demonstrate that s/he understands: The nature of his or her presenting medical condition; The possible risks and consequences of refusing emergency medical treatment and/or transport for his or her acute or presenting medical condition, including where applicable, the risk of serious adverse health consequences or death. Treatment and transportation alternatives. January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 39 39

High Index of Suspicion – The concern that an individual may have an acute medical,
traumatic, psychiatric, social or other condition that could result in a life–threatening or life-altering outcome. Indications for a high index of suspicion may include, but are not to be limited to: The mechanism of injury; Assessment of injury/illness severity; Abnormal vital signs; A friend, neighbor, co-worker, or family member who has frequent contact with the patient and who expresses concern for the patient’s health, based on a change in the patient’s condition; A caller to 911 who reports expressed or actual suicidal or homicidal behavior by the patient (regardless of whether the caller is on the scene or not). The request for assistance originated with a physician or other health care provider (regardless of whether the caller is on the scene or not) who indicates that there has been a significant change in the patient’s medical condition. 3.7 Low Index of Suspicion – Any condition that does not merit a high index of suspicion. 3.8 Mechanism of Injury/Illness – The way in which traumatic injuries likely occurred. This would include the forces that act on the body to cause damage and/or the mechanism or cause of an illness or symptom. No to Minimal Mechanism of Injury/Illness – where the expectation of injury, physical damage and/or exposure is minimal and there is a low index of suspicion that the patient is at risk for injury/illness. Examples include: A. A vehicle collision where there is no physical damage to the passenger compartment of a vehicle. Damage is limited to scratches, mirrors or fenders. B. Noxious fumes released in the general vicinity of a person without direct exposure. Moderate Mechanism of Injury/Illness – where the expectation of potential injury, physical damage and/or exposure is likely and may have put occupants at risk for injury/illness but, there is a low index of suspicion for injuries/illnesses with life–threatening or life-altering outcomes. Examples include: A. A collision resulting in noticeable damage to a vehicle but where the occupant may or may not have a current complaint or visible injury/illness. B. The release of noxious fumes where an occupant may have been exposed but has no current complaint or visible injury/illness. Severe Mechanism of Injury/Illness - where the expectation of injury, physical damage and/or exposure is strong and there is a high index of suspicion that the patient is at risk for severe injury/illness with the potential for life–threatening or life-altering outcome. Examples include: A. Collisions resulting in major trauma to an occupant in either vehicle. B. The release of noxious fumes where an individual is likely to have been exposed and has current complaints and/or visible injury/illness. C. Exposure to shockwaves from an explosion in a confined space, regardless of current complaint or visible injury. Index of Suspicion High Index of Suspicion: Possible acute medical, traumatic, psychiatric, social condition with possible life–threatening or life-altering outcome. The Mechanism of Injury Severity of Injury or Illness Abnormal Vital Signs Another person who expresses concern based on a change in the PT’s condition Suicidal or Homicidal Behavior A healthcare provider indicates change in PT condition Low Index of Suspicion: Everything else! January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 40 40

Safe Environment No immediate danger to PT health or safety
Adequate supportive resources (or assistance to obtain them) Suspicion of abuse? Automatically unsafe! Undomiciled? Not automatically unsafe. 3.13 Safe Environment – An environment which is not believed to be an immediate danger to the health or safety of a patient who is refusing medical aid. An example of a safe environment would be a setting with adequate supportive care resources for the immediate future, or in its absence, a location with adequate assistance to reasonably ensure the safe return of the patient to such a setting. An example of an unsafe environment would be a setting lacking adequate supportive care resources for the immediate future, or a location without adequate assistance to ensure the safe return to such setting, or where there is a suspicion of abuse (child, spouse or elder). Adequacy of housing or lack of housing should not automatically be considered an unsafe environment January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 41 41

Who Can RMA? PT must be 18, or an Emancipated Minor:
General Operating Procedures page A.14 Is a mother Is married Has left home and is self supporting Is enlisted in the Armed Forces Is requesting treatment for STD, drug abuse, child abuse Guardians may request an RMA for their charges. Parents (including grandparents) School Officials January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 42 42

Who CANNOT RMA? A Minor (under 18 years old) without a guardian
Impairment - A condition in which it is suspected that an individual’s decisional capacity may be compromised as a result of diminished, altered or impaired intellect, reasoning, insight, or judgment; including any diminishment, alteration or impairment associated with: • alcohol, drug or toxic substance use; • head trauma, dementia, encephalopathy, mental retardation, or other central nervous system (CNS) dysfunction (e.g., Alzheimer's disease, CVA with cognitive deficit); • acute or “uncontrolled” chronic psychiatric illness; • medical illness, including but not limited to, metabolic or infectious disorders such as hypoxia, hypotension, severe hyperglycemia, hypoglycemia, and sepsis. The fact that a patient has any of the above conditions does not automatically require that the patient be considered impaired, but if the patient is determined to have decisional capacity, the basis for such conclusion must be clearly documented on the Prehospital Care Report (PCR). Examples: A. A patient who has consumed an alcoholic beverage provided that the individual demonstrates no clinical signs of intoxication. B. A patient with a chronic psychiatric condition who is not exhibiting any impairment. C. A patient who is chronically disoriented as to time but who is able to demonstrate that s/he has decisional capacity with regard to evaluating the risks benefits and consequences of accepting or refusing treatment and transport for his or her presenting condition. Who CANNOT RMA? A Minor (under 18 years old) without a guardian Parent/guardian for a child under 6 years old An impaired patient (or guardian) Substance abuse Clinical signs of intoxication AMS due to: Trauma Psychiatric condition CNS dysfunction Medical condition January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 43 43

Interagency Cooperation
Severe Mechanism of Injury/Illness - where the expectation of injury, physical damage and/or exposure is strong and there is a high index of suspicion that the patient is at risk for severe injury/illness with the potential for life–threatening or life-altering outcome. Examples include: A. Collisions resulting in major trauma to an occupant in either vehicle. B. The release of noxious fumes where an individual is likely to have been exposed and has current complaints and/or visible injury/illness. C. Exposure to shockwaves from an explosion in a confined space, regardless of current complaint or visible injury. The New York City Police Department, New York City Department of Correction and other law enforcement authorities may require, based upon existing protocols for medical care of persons in their custody, and safety and security concerns, that persons in their custody be transported to certain specially designated medical facilities, provided that the facility is a 911 receiving hospital. This is acceptable unless the following exceptions exist: A. A patient with an unmanageable airway MUST be transported to the nearest 911 receiving destination and B. A patient whose medical condition requires immediate medical care from a Specialty Referral Center or other specialized care center (e.g., PCI center for STEMI patient, hypothermia center, hyperbaric center, CETCAN or SAFE center) MUST be transported to the 911 System center. Interagency Cooperation PT in custody of law enforcement may RMA PT has Decisional Capability Must be PT’s decision (i.e. not coerced) Suspect Coercion? Call OLMC or request a Duty Officer! Patient may request specific destination Must be a 911 receiving facility Exception: Critical PT must go to nearest 911 facility Exception: Specialty Referral Centers (STEMI, etc) January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 44 44

OLMC - (718) 780-5555 Required for: Document all OLMC contact!
EMTs and Paramedics MUST contact OLMC prior to accepting an RMA when that the RMA request is from: a minor patient with no parent or guardian present at the scene the parent or guardian of a patient who is 5 years of age or younger. A patient qualified to RMA with decisional capacity, OR the parent or guardian of a minor patient who is 6 years of age or older when following an assessment by EMS personnel it is determined that ANY of the following are present: A. The patient requires immediate medical treatment and transport to an ambulance destination, based on a high index of suspicion B. There has been administration of medication C. The patient is in an unsafe environment A patient qualified to RMA who, although alert, is unable or unwilling to provide sufficient information for EMS personnel to determine his/her decisional capacity, index of suspicion, or whether s/he is in a safe environment. A patient who lacks decisional capacity even if following an assessment by the EMS personnel it is determined that all of the following are present: A. There is a low index of suspicion for conditions requiring immediate treatment and/or transport B. There has been no administration of medication C. The patient is in a safe environment A health care proxy on behalf of a patient lacking decisional capacity, because in New York State, health care proxies cannot be honored by EMS in the prehospital setting. 4.10 When necessary to contact OLMC, EMS personnel shall use ANY means available to them (e.g., radio, telephone, 12 watt) to establish contact. 4.11 When a request is made by EMS personnel for an OLMC physician to speak to a patient and/or other interested party, the OLMC physician MUST speak with the patient and/or other interested party. OLMC - (718) Required for: PT under 6 w/ parent or guardian PT with High Index of Suspicion Medication administered Unsafe environment PT lacking Decisional Capability Unaccompanied minor PT cannot or refuses to provide information Situations where a Health Care Proxy is requesting RMA Questions/concerns with DNR or MOLST Document all OLMC contact! January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 45 45

Medication Administration
Patient Seeking to RMA because of Ambulance Destination - When a patient seeks to RMA solely because s/he wishes transport to an ambulance destination other than the closest appropriate ambulance destination and the requested ambulance destination is no more than 10 minutes additional travel time than would be required to reach the closest 911 ambulance destination shall be honored without requesting permission from either an on-scene EMS Officer or OLMC provided that the patient is stable; does not require treatment at a Specialty Referral or Specialized Care Center; and the requested ambulance destination is not on ambulance redirection or diversion. For all other circumstances (see below) permission for such transport must be requested as follows: If transport time to the requested 911 ambulance destination is expected to be between 10 and 20 additional minutes travel time beyond that required to reach the closest 911 ambulance destination, an on-scene EMS Officer may approve such transport request. In the absence of an on-scene Officer, OLMC contact and approval is required. If transport time to the requested 911 ambulance destination is expected to exceed 20 minutes additional travel time beyond that required to reach the closest 911 ambulance destination, permission for such transport must be requested from OLMC. Permission will only be granted by OLMC if it is determined that the patient’s present medical complaint or condition requires specific immediate knowledge or treatment available exclusively at the specific ambulance destination where the patient receives treatment for that same or related condition. Any transport to a non-911 ambulance destination (e.g., Sloan-Kettering Cancer Center, NY Eye and Ear) requires permission from OLMC. Such transport will be approved ONLY if the patient's present medical complaint or condition requires specific immediate knowledge or treatment available exclusively at the specific ambulance destination where the patient receives treatment for that same or related condition. In the absence of such a need, patients should be transported only to a 911 ambulance destination. A patient request to an ambulance destination that is currently on Ambulance Redirection or Diversion may only be honored with permission from OLMC and permission for such transport will be granted only if it is determined that the patient’s current medical complaint or condition requires specific immediate knowledge or treatment available exclusively at the specific ambulance destination where the patient receives treatment for that same or related condition. Refusal by any patient or his or her guardian to go to a Specialty Referral Center or other specialized care center (e.g., Trauma, Burn, Stroke Centers, hyperbaric, replantation, spinal cord injury, venomous bite centers, PCI center for STEMI patients, hypothermia center for non-traumatic cardiac arrest patients, CETCAN center for child abuse/neglect patients and SAFE center for sexual assault patients) requires OLMC Approval. A. If the patient develops an unmanageable airway while enroute to a Specialty Referral Center or other specialized care center, the ambulance must divert to the closest appropriate 911 ambulance destination and the reasons for such diversion must be documented on the PCR. B. If the patient becomes unstable (other than as a result of an unmanageable airway) while enroute to the ambulance destination but it is determined that the patient would gain immediate medical benefits from care at specialty center (e.g., hypotension or arrhythmias following trauma, STEMI, or carbon monoxide intoxication), the ambulance should continue to transport the patient to the nearest appropriate Specialty Referral Center or other specialized care center (e.g., Trauma center, PCI center for STEMI patient, hypothermia center, or hyperbaric center) and the reason(s) for the continued transport to the Specialty Referral Center or specialized care center must be documented on the PCR. C. If the patient becomes unstable for any reason while enroute to a CETCAN (child abuse and neglect) or SAFE (sexual assault) center, the ambulance must divert to the closest appropriate 911 ambulance destination (nearest hospital or trauma center) and the reasons for such diversion must be documented on the PCR. EMS personnel shall consider overall transport time versus time spent on scene in making a transport determination. The decision process should not unduly delay the patient’s transport. Medication Administration All providers (both EMTs and Paramedics) must contact OLMC when a medication was administered to the patient by EMS or others on scene. Oxygen is only considered a medication if used for the treatment of a patient condition that would be considered a high index of suspicion (e.g., CHF, major trauma). OLMC contact not required when “minor treatment” (Bandages, gauze, icepacks, splints, immobilizers and oxygen) is provided to patients who choose to RMA. 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Alternate Destinations
Patient may RMA due to destination Follow the “10 minute rule”: General Operating Procedures page A.8 You may transport a patient to their hospital of choice as long as Patient is Stable or Potentially Unstable Destination is less than an additional 10 minutes away More than 10 minutes? CO or OLMC may approve up to an additional 20 minutes Usually requires specific need available only at that destination Txp to Hospitals on Diversion need OLMC approval Specialty Referral Centers Require OLMC approval to override May need to continue to SRC even is PT becomes unstable Patient Seeking to RMA because of Ambulance Destination - When a patient seeks to RMA solely because s/he wishes transport to an ambulance destination other than the closest appropriate ambulance destination and the requested ambulance destination is no more than 10 minutes additional travel time than would be required to reach the closest 911 ambulance destination shall be honored without requesting permission from either an on-scene EMS Officer or OLMC provided that the patient is stable; does not require treatment at a Specialty Referral or Specialized Care Center; and the requested ambulance destination is not on ambulance redirection or diversion. For all other circumstances (see below) permission for such transport must be requested as follows: If transport time to the requested 911 ambulance destination is expected to be between 10 and 20 additional minutes travel time beyond that required to reach the closest 911 ambulance destination, an on-scene EMS Officer may approve such transport request. In the absence of an on-scene Officer, OLMC contact and approval is required. If transport time to the requested 911 ambulance destination is expected to exceed 20 minutes additional travel time beyond that required to reach the closest 911 ambulance destination, permission for such transport must be requested from OLMC. Permission will only be granted by OLMC if it is determined that the patient’s present medical complaint or condition requires specific immediate knowledge or treatment available exclusively at the specific ambulance destination where the patient receives treatment for that same or related condition. Any transport to a non-911 ambulance destination (e.g., Sloan-Kettering Cancer Center, NY Eye and Ear) requires permission from OLMC. Such transport will be approved ONLY if the patient's present medical complaint or condition requires specific immediate knowledge or treatment available exclusively at the specific ambulance destination where the patient receives treatment for that same or related condition. In the absence of such a need, patients should be transported only to a 911 ambulance destination. A patient request to an ambulance destination that is currently on Ambulance Redirection or Diversion may only be honored with permission from OLMC and permission for such transport will be granted only if it is determined that the patient’s current medical complaint or condition requires specific immediate knowledge or treatment available exclusively at the specific ambulance destination where the patient receives treatment for that same or related condition. Refusal by any patient or his or her guardian to go to a Specialty Referral Center or other specialized care center (e.g., Trauma, Burn, Stroke Centers, hyperbaric, replantation, spinal cord injury, venomous bite centers, PCI center for STEMI patients, hypothermia center for non-traumatic cardiac arrest patients, CETCAN center for child abuse/neglect patients and SAFE center for sexual assault patients) requires OLMC Approval. A. If the patient develops an unmanageable airway while enroute to a Specialty Referral Center or other specialized care center, the ambulance must divert to the closest appropriate 911 ambulance destination and the reasons for such diversion must be documented on the PCR. B. If the patient becomes unstable (other than as a result of an unmanageable airway) while enroute to the ambulance destination but it is determined that the patient would gain immediate medical benefits from care at specialty center (e.g., hypotension or arrhythmias following trauma, STEMI, or carbon monoxide intoxication), the ambulance should continue to transport the patient to the nearest appropriate Specialty Referral Center or other specialized care center (e.g., Trauma center, PCI center for STEMI patient, hypothermia center, or hyperbaric center) and the reason(s) for the continued transport to the Specialty Referral Center or specialized care center must be documented on the PCR. C. If the patient becomes unstable for any reason while enroute to a CETCAN (child abuse and neglect) or SAFE (sexual assault) center, the ambulance must divert to the closest appropriate 911 ambulance destination (nearest hospital or trauma center) and the reasons for such diversion must be documented on the PCR. EMS personnel shall consider overall transport time versus time spent on scene in making a transport determination. The decision process should not unduly delay the patient’s transport. January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 47 47

What Do You Do? ALWAYS recommend TXP! Full Assessment
PT may have right of refusal, but an MD can provide peace of mind. Never encourage an RMA! Full Assessment Including two sets of vital signs Required for every RMA Determine Index of Suspicion Determine Safe Environment Evaluate Decisional Capacity A patient seeking to refuse medical aid who presents with conditions that may indicate impairment shall not automatically be considered impaired but shall be evaluated to determine if s/he has the decisional capacity to refuse medical aid. 4.6 EMS personnel shall make all reasonable attempts to persuade patients requiring emergency medical treatment and/or transport to accept such aid. Under no circumstances shall any patient be encouraged to refuse medical aid. January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 48 48

What Do You Do? Request Duty Officer to the scene Contact OLMC
Always the first option Contact OLMC Request Police Department Document RMA in PCR if approved A patient seeking to refuse medical aid who presents with conditions that may indicate impairment shall not automatically be considered impaired but shall be evaluated to determine if s/he has the decisional capacity to refuse medical aid. 4.6 EMS personnel shall make all reasonable attempts to persuade patients requiring emergency medical treatment and/or transport to accept such aid. Under no circumstances shall any patient be encouraged to refuse medical aid. January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 49 49

PCR RMA Disposition Code: 005 “Trinity” Sign & Witness! OLMC Contact?
A PCR must be completed for every patient contact. Every RMA situation requires the completion of a PCR, including instances where the patient refuses to cooperate with a physical assessment or respond to questions from EMS personnel. The PCR shall clearly document the patient’s refusal to cooperate. 5.4 Completion of PCR – Obtaining Applicable Signatures - A PCR must be completed for each patient contact, including each RMA and each determination that treatment and/or transport is not required. All information relevant to the RMA shall be fully and legibly documented on the PCR. If the patient is uncooperative in providing information, EMS personnel shall obtain as much information as possible and fully document the circumstances of the call. If the patient demonstrates decisional capacity, EMS personnel shall ensure that the patient and a witness sign the refusal of medical aid acknowledgment (on the back of the PCR). If the patient lacks decisional capacity, the patient should not sign the refusal of medical aid acknowledgement. The emergency medical provider and a witness should sign the refusal of medical aid acknowledgment (on the back of the PCR). The witness may be a family member, friend, bystander, police officer, caregiver or other involved individual. If no witness is available or a witness is present but refuses to sign the PCR, EMS personnel can sign the PCR acknowledgment and fully document in the PCR narrative section the reason(s) that a witness signature could not be obtained. PCR RMA Disposition Code: 005 “Trinity” PT aware of medical condition PT advised of risks & consequences PT advised of alternate destinations & continuance of 911 care Sign & Witness! OLMC Contact? Document physician name & ID Translator used? Document name, address and phone of translator Radio Codes 10-93: Patient with Decisional Capacity 10-93A: Patient without Decisional Capacity; OLMC approval January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 50 50

RMA Flowchart January 4th, 2008 January 4th, 2008 PSVAC Training
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Question to Ask 1. Who called for the ambulance? If not the patient, who and why did they call? 2. Is the patient capable of communicating with the On-Line Medical Control Physician? If not, why not? 3. Why does the patient not want to go to the hospital? What would change the patient's mind (e.g., going to a specific hospital)? 4. What are the signs and symptoms of injury or illness (physical or mental)? 5. What is the patient’s usual health status? 6. Does the patient's chronic/acute medical or psychiatric condition (e.g., diabetes, mental retardation, Alzheimers) lead you to suspect that the patient may not have the appropriate decisional capacity to refuse treatment and/or transport? January 4th, 2008 PSVAC Training

Question to Ask 7. What has changed since the initial call for the ambulance, if anything? 8. Was the patient given all alternatives (e.g., choice of hospitals, seeing private physician)? 9. Does the patient appear to understand the alternatives? 10. Has the patient taken any medications (on their own or provided by EMS) since the onset of their current complaint? 11. Does the patient understand the consequences of their injury or condition and of refusing treatment and or transport to the hospital? (This should include the possibility of death, if the circumstances indicate that it is indeed possible.) 12. Does the patient clearly understand that EMS is still available by calling 911, should the patient desire treatment or transportation to a hospital? 13. Will someone be able to stay with the patient if the RMA is granted by the OLMC physician? January 4th, 2008 PSVAC Training

Sample Case 1 Two teenage boys (both 18) are involved in a car-versus-telephone-pole MVA. Both airbags are deployed and the patients must be extracted. They say they have no neck or back pain, but the driver has cuts on his head and says he “feels a little woozy”. He cannot correctly state today’s date. Neither want to go to the hospital, because their “parents will get angry”. Do you contact OLMC? Why or why not? What if one was 17? What if the passenger was the father of the driver? What if there was only minor damage and no head injury? January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 54

Sample Case 2 911 call to an assisted living facility for a suspected CVA. The PT presents with mild slurred speech, no facial droop, partial weakness and drift in the left arm and leg, strong vitals. The PT has a DNR on file (presented to you by the facility). The caregiver tells you the PT does not want to go to the hospital. Do you write up the RMA? Why or why not? Do you contact OLMC? Why or why not? What if there was no signs of stroke? What if the PT had bedsores, and there is fecal matter on the floor of the PT room? January 4th, 2008 January 4th, 2008 PSVAC Training PSVAC Training 55

B R E A K 15 Minutes

Albuterol Administration
Matt Jachyra

Albuterol Albuterol is a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs. Albuterol is used to treat or prevent bronchospasm in people with reversible obstructive airway disease such as COPD, bronchitis and asthma. Albuterol is also used to prevent exercise-induced bronchospasm. January 4th, 2008 PSVAC Training

Albuterol January 4th, 2008 PSVAC Training

Albuterol 407 Wheezing For patients over one (1) year of age who are experiencing asthma exacerbation or wheezing. 1. Assess the airway 2. Administer oxygen 3. Monitor breathing NOTE: IF PATIENT EXHIBITS SIGNS OF IMMINENT RESPIRATORY FAILURE, REFER TO PROTOCOL #401 – ADULT RESPIRATORY DISTRESS/FAILURE OR #450 – PEDIATRIC RESPIRATORY DISTRESS/FAILURE. January 4th, 2008 PSVAC Training

Albuterol 4. Do not permit physical activity
5. Place the patient in a Fowler’s or Semi-Fowler’s position 6. Assess the following prior to administration of the first nebulized treatment: • Vital signs • Patient’s ability to speak in complete sentences • Accessory muscle use • Wheezing January 4th, 2008 PSVAC Training

Albuterol 7. Administer Albuterol Sulfate 0.083%, one (1) unit dose or 3 cc via nebulizer at a flow rate that will deliver the solution over 5 minutes to 15 minutes. Do not delay transport to complete medication administration. 8. Begin transport. NOTE: FOR PATIENTS IN SEVERE RESPIRATORY DISTRESS, CALL FOR ADVANCED LIFE SUPPORT ASSISTANCE, DO NOT DELAY TRANSPORT. 9. If symptoms persist, Albuterol Sulfate 0.083% may be repeated twice for a total of three (3) doses, with the third occurring during transport. 10. Upon completion of patient treatment or transfer of patient care to an ALS Provider or a 911 Receiving Hospital, reassess the patient. See Step # 6. January 4th, 2008 PSVAC Training

Albuterol MEDICAL CONTROL MUST BE CONTACTED FOR ANY PATIENT REFUSING MEDICAL ASSISTANCE OR TRANSPORT. January 4th, 2008 PSVAC Training

So what is Albuterol and how do I eat it?
January 4th, 2008 PSVAC Training

Albuterol Medication name Generic - Albuterol
1. Actions - Beta agonist bronchodilators Which in plain English means that it dilates bronchioles reducing airway resistance. 2. Side effects: -Increased pulse rate -Tremors -Nervousness -Nausea January 4th, 2008 PSVAC Training

OK! OK! OK! But how do I administer it to my patient??
Albuterol 3. Supplied in 3mm plastic vial in 0.083% concentration. Like with every medication prior to administration please check for expiration, cloudiness of the liquid, proper name, intact medication container and if there is an indication for drug administration. Document properly not only when and how medication was given but also patient response. OK! OK! OK! But how do I administer it to my patient?? January 4th, 2008 PSVAC Training

Albuterol Nebulizer is a device used to administer medication to people in the form of a mist inhaled into the lungs. There are different types of nebulizer, although the most common are the jet nebulizers, which are also called "atomizers". Jet nebulizers are connected by tubing to a compressed air source that causes air or oxygen to blast at high velocity through a liquid medicine to turn it into an aerosol, which is then inhaled by the patient. Nebulizers accept their medicine in the form of a liquid solution, which is often loaded into the device upon use. January 4th, 2008 PSVAC Training

Albuterol 1. Mouthpiece 2. Nebulizer t-piece 3. Nebulizer cap
4. Nebulizer chamber 5. Nebulizer air-inlet connector 6. Nebulizer baffle 7. Tubing January 4th, 2008 PSVAC Training

Albuterol Assemble clean nebulizer parts by placing baffle down
in nebulizer chamber. Holding chamber stationary, screw on nebulizer cap. Add prescribed medication through the opening on cap using a medicine dropper or premeasured dose container. January 4th, 2008 PSVAC Training

Albuterol Assemble mouthpiece and T-piece and insert into the top
of the nebulizer cap. January 4th, 2008 PSVAC Training

Albuetrol Attach tubing to nebulizer air-inlet connector. Set the
LPM flow between 4-6 to deliver medication over 5-15 minutes. January 4th, 2008 PSVAC Training

Albuterol Begin treatment by advising the
patient to place the mouthpiece between their teeth. With mouth closed, pt should inhale deeply and slowly through mouth as aerosol begins to flow then exhale slowly through the mouthpiece. January 4th, 2008 PSVAC Training

Albuterol So how bad your patient can get? - Previous intubations
- Prolonged hospitalizations - Family history - Events leading to the episode - Medications compliance - Inhaled steroids use - Severity of current episode - Patients lifestyle - Combination of all of the above January 4th, 2008 PSVAC Training

Epinepherine Autoinjector
Matt Jachyra

Epinephrine Auto Injector
Anaphylaxis, or anaphylactic shock, is an allergic reaction that can be fatal within minutes, either through swelling that shuts off airways or through a dramatic drop in blood pressure. Anaphylaxis occurs in individuals when they are exposed to an allergen to which they are allergic. An allergen is almost always a protein that is treated by the immune system as a foreign substance. Contact with, or ingestion of this allergen will set off a chain reaction in a person's immune system that may lead to swelling of the airways, loss of blood pressure, and loss of consciousness, resulting in anaphylactic shock. January 4th, 2008 PSVAC Training

Common causes of anaphylaxis include: Food - Peanuts, tree nuts (walnuts, cashews, etc.), shellfish, fish, milk, and eggs commonly cause anaphylactic reactions. Medication - Anaphylactic reactions to medication will typically occur within an hour after taking the drug, however reactions may occur several hours later. Insect stings - The symptoms of anaphylactic reactions to insect stings usually occur within minutes of the sting. Latex - Approximately 10 to 17 percent of those employed in the health care occupations have this allergy. January 4th, 2008 PSVAC Training

Signs and Symptoms of an Allergic Reaction: -Hives -Swelling of the throat, lips, tongue, or around the eyes -Difficulty breathing or swallowing -Generalized flushing, itching, or redness of the skin -Abdominal cramps, nausea, vomiting, or diarrhea -Increased heart rate -Sudden decrease in blood pressure (and accompanying paleness) January 4th, 2008 PSVAC Training

Example of Hives January 4th, 2008 PSVAC Training

It is impossible to predict the severity of future anaphylactic reactions in any particular person. There is no set pattern, but the severity of an allergic reaction is thought to depend on: -The amount of allergen to which a patient is exposed -The individual's degree of hypersensitivity to the allergen -Time elapsed from exposure until your arrvial January 4th, 2008 PSVAC Training

So what can we do??? January 4th, 2008 PSVAC Training

1. Perform initial assessment (your ABC). 2. Perform a focused history and physical exam: -History of allergies -What was the patient exposed to -How were they exposed -What effects -Time of onset -Progression -Interventions January 4th, 2008 PSVAC Training

3. Assess baseline vital signs and SAMPLE history. 4. Administer oxygen if not already done in the initial assessment. 5. Determine if patient has prescribed preloaded epinephrine available. Facilitate administration of preloaded epinephrine. 6. Record and reassess in two minutes. 7. Record reassessment findings. NOW THIS IS WHERE IT GETS TRICKY!!! January 4th, 2008 PSVAC Training

Patient has contact with substance that causes allergic reaction without signs of respiratory distress or shock/hypoperfusion (anaphylactic shock): 1. Continue with focused assessment. 2. Patient is not wheezing or without signs of respiratory distress or hypotension should not receive epinephrine. 3. Transport, reassess, reevaluate and closely monitor. January 4th, 2008 PSVAC Training

Patient has contact with substance that causes allergic reaction with signs of respiratory distress or shock/hypoperfusion (anaphylactic shock): Protocol 410 – Anaphylactic Reaction January 4th, 2008 PSVAC Training

ANAPHYLAXIS CAN BE A POTENTIALLY LIFE THREATENING SITUATION MOST OFTEN ASSOCIATED WITH A HISTORY OF EXPOSURE TO AN INCITING AGENT/ALLERGEN (BEE STING OR OTHER INSECT VENOM, MEDICATIONS/DRUGS, OR FOODS SUCH AS PEANUTS, SEAFOOD, ETC.). THE PRESENCE OF RESPIRATORY DISTRESS (UPPER AIRWAY OBSTRUCTION [STRIDOR], SEVERE BRONCHOSPASM [WHEEZING]) AND/OR CARDIOVASCULAR COLLAPSE/HYPOTENSIVE SHOCK CHARACTERIZE THE CLINICAL FINDINGS THAT AUTHORIZE AND REQUIRE TREATMENT ACCORDING TO THIS PROTOCOL. THIS PROTOCOL APPLIES TO PATIENTS 9 YEARS OF AGE OR OLDER, OR PATIENTS WEIGHING MORE THAN 30 KG (66 LBS). January 4th, 2008 PSVAC Training

Determine that the patient’s history includes a history of anaphylaxis, severe allergic reaction and/or recent exposure to an allergen or inciting agent. NOTE: REQUEST ALS ASSISTANCE, IF AVAILALE. DO NOT DELAY TRANSPORT TO THE HOSPITAL 2. Administer high concentration oxygen. 3. Assess the cardiac and respiratory status of the patient. a. If both the cardiac and respiratory status of the patient are normal, initiate transport. b. If either the cardiac or respiratory status of the patient is abnormal, proceed as follows: January 4th, 2008 PSVAC Training

i. If the patient is having severe respiratory distress or shock and has been prescribed an Epinephrine auto-injector, assist the patient in administering the Epinephrine (0.3 mg via an auto-injector). If the patient’s auto-injector is not available or expired, and the EMS agency carries an Epinephrine auto-injector, administer the Epinephrine (0.3 mg via an auto-injector) as authorized by the agency’s Medical Director. January 4th, 2008 PSVAC Training

ii. If the patient has not been prescribed an Epinephrine auto-injector, begin transport and contact On-Line Medical Control for authorization to administer 0.3 mg Epinephrine via an auto-injector, if available. NOTE: IN THE EVENT THAT YOU ARE UNABLE TO MAKE CONTACT WITH ON-LINE MEDICAL CONTROL (RADIO FAILURE, NO COMMUNICATIONS) AND THE PATIENT IS UNDER 35 YEARS OF AGE, YOU MAY ADMINISTER 0.3 mg EPINEPHRINE (ONE DOSE ONLY) VIA AN AUTO-INJECTOR IF INDICATED. THE INCIDENT MUST BE REPORTED TO ON-LINE MEDICAL CONTROL AND YOUR AGENCY’S MEDICAL DIRECTOR AS SOON AS POSSIBLE January 4th, 2008 PSVAC Training

iii. Contact On-Line Medical Control for authorization to administer a second administration of 0.3 mg Epinephrine via an auto-injector, if needed. iv. Refer immediately to the REMAC Prehospital Treatment Protocol for Respiratory Distress/Failure (#401), Obstructed Airway (#402), or Shock (#415) as appropriate. 4. If cardiac arrest occurs, refer immediately to the REMAC Prehospital Treatment Protocol for Non-Traumatic Cardiac Arrest (#403). January 4th, 2008 PSVAC Training

So what is that magical thing you call Epinephrine and what can I do with it? January 4th, 2008 PSVAC Training

1. Medication name: Generic – Epinephrine Trade - Adrenalin 2. Indications - must meet all of the following three criteria (1) Emergency medical care for the treatment of the patient exhibiting the assessment findings of an allergic reaction IE. Respiratory distress and/or wheezing (2) Medication is prescribed for this patient by a physician (3) Medical direction authorizes use for this patient 3. Contraindications - no contraindications when used in a life threatening situation 4. Medication form - liquid administered via an automatically injectable needle and syringe system January 4th, 2008 PSVAC Training

5. Dosage (1) Adult - one adult auto-injector (0.3 mg) (2) Pediatrics - one pediatrics auto-injector (0.15 mg) 7. Actions (1) Dilates the bronchiole (2) Constricts blood vessels 8. Side effects (1) Increases heart rate (2) Pallor (3) Dizziness, excitability, anxiousness (4) Chest pain (5) Headache (6) Nausea (7) Vomiting January 4th, 2008 PSVAC Training

OK now I know what Epinephrine is and what it does so how do I give it to my patient? January 4th, 2008 PSVAC Training

Administration (1) Obtain order from medical direction either on-line or off-line (2) Obtain patient's prescribed auto injector. Ensure: (a) Prescription is written for the patient experiencing allergic reactions (b) Medication is not discolored, expired, vial is intact (3) Remove safety cap from the auto-injector (4) Place tip of auto-injector against the patient's thigh (a) Lateral portion of the thigh (b) Midway between the waist and the knee (5) Push the injector firmly against the thigh to activate the injector (6) Hold the injector in place until the medication is injected (7) Record activity and time (8) Dispose of injector in biohazard container January 4th, 2008 PSVAC Training

To prepare the EpiPen for use, grasp the auto-injector with the hand (forming a fist around the unit) with the black tip facing downward. Immediately before use, remove the gray activation cap with the other hand, being careful not to touch the black tip, where the needle is located, at any time. January 4th, 2008 PSVAC Training

After uncapping the auto-injector, place the black tip near the fleshy outer portion of the thigh. Instruct the patient that it is not necessary to remove any clothing; the EpiPen auto-injector is designed to work effectively through clothing. Reminded: do not to touch the black tip of the auto-injector at any time. Make a note of the site, which side (R/L) and look for effects of the injection. January 4th, 2008 PSVAC Training

With a quick motion, swing out and jab firmly into the outer thigh, so that the injector is at a 90 degree angle to the thigh. Hold firmly in the thigh for several seconds. During this time, a spring-activated mechanism is released, and a dose of epinephrine is administered. Remove the unit and massage the injection site for an additional few seconds. Once administration is complete, you should check the black tip of the auto-injector. If the needle is exposed, a dose of epinephrine was injected. If not, the above steps should be repeated. Most of the liquid (90%) stays in the auto-injector after the dose is administered and cannot be reused. Dispose used unit in the biohazard sharps container. January 4th, 2008 PSVAC Training

Medical Control Conversation Telemetry: Hello this is Telemetry. PS1:Hi this is Paramedic Jachyra with 93K Park Slope Volunteer Ambulance Corp calling for meds order secondary to anaphylaxis/severe allergic reaction. Telemetry: Stand by for Dr. Silverman 80297 PS1: Good morning doctor this is Paramedic Jachyra. I have a 36 yo female AO3 who after eating peanuts by mistake developed severe allergic reaction. Pt is allergic to nuts and last time she had such reaction she was admitted to the hospital and intubated. Pt speaks in 2-3 word dyspnea and I can see severe accessory muscle use. Vitals are as follow 90/40, 120 heart rate and respirations are 24 labored, I hear bilateral wheezing on expirations, skin is red and pt is covered in hives. Pt has no medical problems and takes over the counter benadryl. So far I’ve trated this patient for shock, gave them oxygen, requested ALS and I’m preparing for transport. I would like to administer Epi Pen Auto-Injector. January 4th, 2008 PSVAC Training

Telemetry: Sure go ahead and administer the Epinephrine and expedite transport to nearest facility. PS1: Repeating orders: I will administer one Auto Injector Epi Pen. Thank you doctor. Telemetry: Ten four goodbye. Be ready to answer additional questions about patient medical history as well as questions about history of present illness. January 4th, 2008 PSVAC Training

Now what about pediatrics? January 4th, 2008 PSVAC Training

ANAPHYLAXIS CAN BE A POTENTIALLY LIFE THREATENING SITUATION MOST OFTEN ASSOCIATED WITH A HISTORY OF EXPOSURE TO AN INCITING AGENT/ALLERGEN (BEE STING OR OTHER INSECT VENOM, MEDICATIONS/DRUGS, OR FOODS SUCH AS PEANUTS, SEAFOOD, ETC.). THE PRESENCE OF RESPIRATORY DISTRESS (UPPER AIRWAY OBSTRUCTION [STRIDOR], LOWER AIRWAY DISEASE/SEVERE BRONCHOSPASM [WHEEZING]) AND/OR CARDIOVASCULAR COLLAPSE/HYPOTENSIVE SHOCK CHARACTERIZE THE CLINICAL FINDINGS THAT AUTHORIZE AND REQUIRE TREATMENT ACCORDING TO THIS PROTOCOL. THIS PROTOCOL APPLIES TO PATIENTS UNDER 9 YEARS OLD OR PATIENTS WEIGHING LESS THAN 30 KG (66 LBS). FOR PATIENTS 9 YEARS OF AGE OR OLDER, OR OVER 30 KG (66 LBS) REFER TO THE ADULT ANAPHYLAXIS PROTOCOL (#410). January 4th, 2008 PSVAC Training

Determine that the patient’s history includes a history of anaphylaxis, severe allergic reaction and/or recent exposure to an allergen or inciting agent. NOTE: DO NOT DELAY TRANSPORT TO THE HOSPITAL 2. Administer high concentration oxygen. 3. Assess the cardiac and respiratory status of the patient. a. If both the cardiac and respiratory status of the patient are normal, initiate transport. January 4th, 2008 PSVAC Training

b. If either the cardiac or respiratory status of the patient is abnormal, proceed as follows: i. If the patient is having severe respiratory distress or shock and has been prescribed a pediatric (0.15 mg) Epinephrine auto-injector, assist the patient in administering the Epinephrine. If the patient’s auto-injector is not available or expired, and the EMS agency carries a pediatric (0.15 mg) Epinephrine auto-injector, administer the Epinephrine as authorized by the agency’s Medical Director. ii. If the patient has not been prescribed a pediatric (0.15 mg) Epinephrine auto-injector, begin transport and contact On-Line Medical Control for authorization to administer a pediatric (0.15 mg) Epinephrine auto-injector, if available. January 4th, 2008 PSVAC Training

NOTE: IN THE EVENT THAT YOU ARE UNABLE TO MAKE CONTACT WITH ON-LINE MEDICAL CONTROL (RADIO FAILURE, NO COMMUNICATIONS), YOU MAY ADMINISTER THE EPINEPHRINE AUTOINJECTOR (0.15 MG) IF INDICATED. THE INCIDENT MUST BE REPORTED TO ON-LINE MEDICAL CONTROL AND YOUR AGENCY’S MEDICAL DIRECTOR AS SOON AS POSSIBLE iii. Contact On-Line Medical Control for authorization to administer a second administration of a pediatric (0.15 mg) Epinephrine auto-injector, if needed. iv. Refer immediately to the REMAC Prehospital Treatment Protocol for Respiratory Distress/Failure (#450), Obstructed Airway (#451), or Shock (#458) as appropriate. 4. If cardiac arrest occurs, refer immediately to the REMAC Prehospital Treatment Protocol for Non-Traumatic Cardiac Arrest (#453) January 4th, 2008 PSVAC Training

EpiPen in Adult and Ped configuration. January 4th, 2008 PSVAC Training

Remember that the best source of information about what’s going on with your patient at present time is your patient himself. Also look for allergy alert tags, bracelets and necklaces. January 4th, 2008 PSVAC Training

New SCAM Report Will Tung

Child Abuse and Neglect
Protocol: General Operating Procedures page A.13 Definition of abuse: improper or excessive action so as to injure or cause harm Definition of neglect: giving insufficient attention or respect to someone who has a claim to that attention You must be able to recognize the problem January 4th, 2008 PSVAC Training

Signs and Symptoms of Abuse
Multiple bruises in various stages of healing Injury inconsistent with mechanism described Repeated calls to the same address Fresh burns Parents seem inappropriately unconcerned Conflicting stories Fear on the part of the child to discuss how the injury occurred Shaken Baby Syndrome January 4th, 2008 PSVAC Training

Signs and Symptoms of Neglect
Lack of adult supervision Malnourished appearance Unsafe living environment Untreated chronic illness; e.g., asthmatic with no medications January 4th, 2008 PSVAC Training

What do you do? Provide appropriate care Do not accuse in the field
Call PD if needed Do not accuse in the field Accusation and confrontation delays transport Report suspicions to the hospital attending physician Reporting: Call NYS Child Abuse/Maltreatment Register File a SCAM Report What you see and what you hear - NOT what you think January 4th, 2008 PSVAC Training

SCAM Report You MUST report suspected child abuse or maltreatment you identify while performing your duties Only reasonable cause needed (no need for proof) Reports to be made: immediately by phone within 48 hours in writing Report must be made even if: only partial information is available there is no reason to suspect parental involvement January 4th, 2008 PSVAC Training

PSVAC Procedures Immediately notify an officer
Try and get as much info as you can while on the call or in the hospital, but don’t delay patient care Complete PCR and SCAM report while at hospital, prior to coming available Return to base and call NYS Child Abuse/Maltreatment Register: (during tour) Send or Fax SCAM Report (within 48 hours) January 4th, 2008 PSVAC Training

Failure to Report We are Mandated Reporters
If you fail to report, you will be: Guilty of Class A misdemeanor Civilly liable for the damages proximately caused by such failure When unsure… REPORT IT. January 4th, 2008 PSVAC Training

New SCAM Report

Sample Case 1 You respond to a baseball field. The coach called when one of his players had trouble catching his breath. The child’s parents were also called, and they arrive at the ball field just after you. You learn that the child has a preexisting asthmatic condition. The parents report that the child sees a specialist regularly. At the scene, the parents administer the child’s inhaler and his breathing becomes less labored. Any need to report this? Why? January 4th, 2008 PSVAC Training

Sample Case 3 You arrive at the home of a grandmother and her 4 year old grandchild. The child appears to have multiple injuries. The grandmother reports that she is babysitting while the child’s mother is at work. The child was difficult to wake from her afternoon nap. The grandmother is concerned about the child. While onscene, the child’s mother arrives to pick up the child. You ask about the child’s injuries and mom says the child is clumsy and frequently falls from her bicycle. Any need to report this? Why? January 4th, 2008 PSVAC Training

Sample Case 2 You respond to a call and find a woman with an injury to her left eye. You see two small children in the room with the woman. The woman reports that she was struck by her drunk boyfriend while the children were cowering behind her. She also states that he told her he would kill her and the two children if she told anyone. Any need to report this? Why? January 4th, 2008 PSVAC Training

Fill Out a SCAM Report Use the last scenario:
Mom: Jane Doe, 32 y/o, Black, Hispanic, Spanish Speaking Boyfriend: John Doe, 30 y/o, Asian, English Speaking Child 1: Junior Doe, 10 y/o, White, Hispanic, Sign Language Child 2: Baby Doe, 4 y/o, Unknown Race, English Speaking January 4th, 2008 PSVAC Training

MOLST / DNR Orders Will Tung

What do we recognize? Protocols: Appendix C What we recognize:
NY State “Out of Hospital” DNR Form Home, hospice, clinic, etc. DNR Bracelet Now: MOLST What we don’t recognize: Living Wills Health Care Proxys Facility DNRs Recognize only for txp from hospital/nursing home January 4th, 2008 PSVAC Training

NYS “Out of Hospital” DNR Form

When is it valid? When presented to EMT
Good faith attempt to identify patient A witness who can reliably identify the patient is useful Out of hospital DNRs do not expire DNR form or bracelet should be taken with the patient January 4th, 2008 PSVAC Training

When is it not valid? If DNR order was revoked or cancelled
The patient states that they wish resuscitative measures A confrontational situation with family A physician directs that the order be disregarded January 4th, 2008 PSVAC Training

What do you treat? If in cardiac or respiratory arrest:
NO chest compressions, ventilation, defibrillation. If not in cardiac or respiratory arrest: full treatment including ventilations If no DNR is presented: Start CPR If DNR is presented after CPR has started, call telemetry For unusual situations or questions Contact officer or telemetry January 4th, 2008 PSVAC Training

Documentation Attach copy of DNR to Patient Care Report
Note on the PCR that a DNR was present Include: physician name, date signed and other pertinent info DNR Form should accompany the patient Leave DOAs onscene January 4th, 2008 PSVAC Training

MOLST Medical Orders for Life-Sustaining Treatment
Completed with the patient or patient’s designee and physician Provide Explicit direction for CPR, mechanical ventilation and other life sustaining treatments January 4th, 2008 PSVAC Training

MOLST Form

When is it important? Most situations: Form will just need to go with the patient to the hospital or back home Look for the form on the refrigerator, the back of the bedroom door or in the patient’s chart No breathing and no pulse: Locate form Determine if it’s valid Follow directions: DNR or CPR Critically ill: Sections on “Life Sustaining Treatments” may apply January 4th, 2008 PSVAC Training

MOLST Characteristics
Original is “MOLST Pink” and printed on heavy stock Copies and Faxes Accepted Do Not Resuscitate or Full CPR is on page 1 Other Care decisions are documented on page 2 An “Out of Hospital DNR Form” is still valid if found Use form with latest date January 4th, 2008 PSVAC Training

MOLST Video Play MOLST Video (7 minutes) January 4th, 2008
PSVAC Training

Sexual Assault Forensic Examiner (SAFE) Centers
Will Tung

SAFE Centers Sexual Assault is any sexual contact without consent
Not just Rape Sexual assault can be perpetrated by anyone, to anyone, and anywhere. Your patient may feel overwhelmed, angry, embarrassed, afraid, numb, in a state of disbelief, or have a sense of profound loss January 4th, 2008 PSVAC Training

SAFE Centers Assume non-authoritative, non-controlling attitude.
Allow your patient to begin to regain control of her/his body: Ask permission to take a history and examine your patient; ask permission to touch your patient Explain all parts of the exam and all procedures Respond to your patient’s wish to talk or not to talk Maintain your patient’s modesty and privacy January 4th, 2008 PSVAC Training

SAFE Centers Tell the patient that you are there to help
“I am sorry for what happened to you.” “No one deserves to be treated as you were.” “Nothing that you could have done or said could possibly justify what has happened to you.” Use a same sex EMT for care whenever possible Be patient; move and act slowly January 4th, 2008 PSVAC Training

SAFE Centers Evidence Collection
If your patient has changed clothing or underwear since the assault, ask her/him to bring this with them in a paper bag (plastic allows degradation of evidence). If possible, ask her/him to bring a change of clothing Discourage your patient from bathing, voiding, or douching as it will destroy evidence If the patient must void, ask them to use a container and bring the urine with them to the hospital Do not allow your patient to drink, brush their teeth, or smoke Do not clean wounds unless necessary January 4th, 2008 PSVAC Training

SAFE Centers Document carefully
Use a diagram to show the location of wounds Keep the written history brief; let the SAFE examiner do the majority of the documentation The slightest misstatement (such as saying “boyfriend” rather than “husband”) could cause significant difficulties at a trial and hurt the legal case Use patient’s statements, if possible NYPD and the SAFE examiner will ask the difficult questions and document them well January 4th, 2008 PSVAC Training

SAFE Centers Upon Arrival at the ED:
Make certain that the triage nurse understands that your patient is a states she was sexually assaulted Be sure to inform staff if weapons and/or other “evidence” has accompanied the patient to the ED (condom, tampon, clothing) You may be asked to take your patient to the “SAFE Room” January 4th, 2008 PSVAC Training

SAFE Centers SAFE Programs allow expert medical management of victims of sexual assault and expert forensic examinations for evidence collection and expert testimony. The 24-hour availability of trained sexual assault examiners, specialized equipment to detect and document injury, dedicated examination and shower rooms, trained advocates and full-time social workers for follow-up counseling services and emotional support allow for seamless integration of all medical, forensic, and counseling care. January 4th, 2008 PSVAC Training

SAFE Centers Upon identification of a stable adult (12 years or older) sexual assault patient (based on patient self-report or bystander/police report): Provide appropriate treatment for any injuries/illnesses in accordance with REMAC Prehospital Treatment Protocols. Physical examination to identify or confirm sexual abuse shall not be performed by EMS healthcare providers. Advise the patient that transportation to an emergency department with a SAFE Program is available and encourage the patient to accept transport to the nearest SAFE facility. If a stable patient accepts transport to a SAFE facility, transport the patient to the nearest (or closest) SAFE hospital. January 4th, 2008 PSVAC Training

Our Closest SAFE Centers
BROOKLYN: Kings County Hospital Center (H 48) Coney Island Hospital (H 42) Woodhull Medical & Mental Health Center (H 45) MANHATTAN: Bellevue Hospital Center (H 02) Beth Israel Medical Center - Petrie Campus (H 03) January 4th, 2008 PSVAC Training

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