INTEGRITY AMBULANCE SERVICE ADVANCED-EMT
STANDI NG ORDERS / TRAINING MANUAL - VERSIO N January 1, 2013
Adult : Patients 16 Years Old and Above
Pediatric : Patients 16 Years old w ill be shaded in gray and Bulleted with a “ P ”
ADULT and PEDIATRIC ORDERS INDEX
TOPIC / PAGE / TOPIC / PAGEIntroduction to SOPs / 2 / Fever / 36
Protocols and Procedures Guidelines / 3 / Field Termination / 7
Abbreviations / 42 / Frostbite / 27
Abdominal Pain / 33 / GCS / 25
Airway Maintenance / 8 / Hazardous Drug Exposure / 41
Allergic Reactions / 29 / HAZ-MAT / 39
Altered Level of Consciousness / 30 / Head Injury / 25
APGAR Chart / 35 / Heat Exposure / 28
Asthma/Emphysema/COPD / 29 / Hemorrhage Control / 24
BAAM / 10 / Hypothermia / 26
Bradycardia / 17 / Initial Care / 8
Burns/Smoke Inhalation / 27 / Internal Dialysis Fistula / 13
Carbon Monoxide Poisoning / 28 / Intubation / 10
Cardiac Arrest—Asystole/PEA / 16 / IO Insertion / 11
Cardiac Arrest—BLS / 14 / Maintenance of Existing IV Pump / 11
Cardiac Arrest--PATH Protocol / 16 / Major Trauma / 24
Cardiac Arrest—Renal Dialysis Patient / 15 / Nebulized Meds / 11
Cardiac Arrest—VFIB/Pulseless VT / 15 / Newborn Resuscitation / 25
Cardiovascular Emergencies / 14 / Non-Initiation of Care / 5
Central Venous Catheters / 13 / Non Traumatic Shock / 19
Chest Pain / 17 / Obstetrical Emergencies / 33
Child Abuse / 36 / Pain Control / 19
Childbirth / 34 / Poisoning and Overdose / 32
Combative Patient / 37 / Prehospital Field Triage / 21
Communicating with the Hospital / 4 / Pulmonary Edema / 29
CPR Chart / 14 / Respiratory Distress / 28
Crisis Standards of Care / 40 / Rights of Medications / 45
CVA/TIA Checklist / 46 / Safe Harbor / 36
Delivery Complications / 34 / Seizures / 31
DNR-Comfort Care/Comfort Care Arrest / 6 / Selective Spinal Immob. Form / 45
Drowning / 26 / Shock / 19
Drug Bag Program / 84-90 / Skills Sheets / 72 - 84
Drug Sheets / 48 - 71 / Spinal Immobilization / 38
EDD / 10 / START Triage / 39
Elder Abuse / 36 / Stipulations / 3
End Tidal CO2--Colorimetric / 9 / Stroke / 20
Exsanguinating Hemorrhage / 24 / Tachycardia / 18
Extrapyramidal Reactions / 31 / Tension Pneumothorax / 11
Extremity Injuries / 26 / Transport Guidelines / 23
Eye Injuries / 28 / Trauma Criteria / 22
Trauma Emergencies / 21
INTEGRITY AMBULANCE STANDARD OPERATING PROTOCOLS
The protocols contained herein are to be utilized for each and every patient transport as the patient’s condition determines. These protocols are not solely for the transport of patients to an emergency department or emergency room. These protocols may be applied to any patient under the care of an Integrity Ambulance Service EMS provider. EMS providers are reminded that when utilizing these protocols that they are to remain within the confines of the State of Ohio EMS Scope of Practice for their particular EMS certification level.
Integrity Ambulance Service recognizes that there is a role for all levels of Emergency Medical Technician Certification. Not every function defined by the State of Ohio is approved under specific medical directors. Patient care should always be delivered at the highest level of EMS available. Every EMS provider must be aware of the State of Ohio requirements for recertification, and each individual is responsible for personally fulfilling these requirements. Those seeking to fulfill National Registry of Emergency Medical Technician (NREMT) requirements may do so under their own individual responsibility.
Continuing Education certifications must be received through an approved or accredited Continuing Education site with a valid accreditation number noted, and must be filed properly. Each EMS provider must maintain his/her own personal records for CEUs, and be responsible for his/her own Continuing Education Status.
Parmedic certifications for CPR and Advanced Cardiac Life Support must be received through an approved AHA or ASHI education site and must be filed properly. Each Paramedic must maintain his/her own personal records for BLS/ACLS and be responsible to maintain certification in both areas.
Quality Assurance Run Reviews are completed monthly and documented in conjunction with the Medical Director, Kindra C. Engle, D.O. and Director of Operations, Derrick Marple, EMT-P, EMSI. Run reviews are mandatory with Integrity Ambulance Service. Provider problems will be addressed promptly upon recognition and documented in the provider’s personnel file. A plan to resolve identified problems will be implemented. The Medical Director has the right to remove an EMS provider from actively functioning under their Medical Control, either temporarily or permanently, through reduction in care level or complete revocation of active status.
STIPULATIONS
· This protocol is for use by those individuals operating in and under the authority of Integrity Ambulance Service, LLC and certified by the State of Ohio as a Paramedic.
· This protocol is to be used in the field only. Communications must be attempted as soon as practical for potentially unstable patients, or for hospitals that request contact on all patients being transferred to their facility.
· Procedures marked with a diamond (¨) are never to be performed without a physician's order.
The diamond provides identification of procedures and medications that require on-line medical control authorization.
· No procedures, techniques, or drugs will be used without the proper equipment or beyond the training or capabilities of the prehospital personnel. Nothing in this protocol may be used without specific pre-approval of Kindra C. Engle, D.O.
· Items enclosed in braces ({ }) are at the option of the department and its medical director.
· EMS personnel of any level are not authorized to intubate, unless they have and can use appropriate confirmation devices: End tidal carbon dioxide (EtCO2) detectors or monitors, or Esophageal Detection Devices (EDD).
· Infrequently, stepwise adherence to specific protocols may not be in the patient’s best interest. No protocol can substitute for the EMS professional’s judgment. However, at no time should treatment options exceed those authorized without direct consultation with the Medical Control Physician (MCP). In all such cases, contact with MCP should be considered as soon as possible.
· The Adult and Pediatric Orders (“Peds”) are combined.
A Sections that apply only to Adults are bulleted with an “A”.
R All Pediatric treatments will be in Pink and bulleted with a “P”.
· Sections which apply to both Adult and Peds are indicated with standard bullets.
G There are also sections which apply to only Geriatric patients and are bulleted with a bold “G.”
MEDICAL CONTROL PROTOCOLS AND PROCEDURES GUIDELINES
1. In patients with non-life-threatening emergencies who require IV’s, only two attempts at IV insertion should be attempted in the field, additional attempts must be made en route.
2. Patient transport, or other needed treatments, must not be delayed for multiple attempts at endotracheal intubation.
3. Verbally repeat all orders received before their initiation.
4. Any patient with a cardiac history, irregular pulse, unstable blood pressure, dyspnea, or chest pain must be placed on a cardiac monitor and a copy of the EKG must be attached to the EMS Run Sheet.
5. When transferring lower level pre-hospital care to a higher level of pre-hospital care, a thorough consult should be performed between caregivers describing initial patient presentation and care rendered to the point of transfer.
6. If the patient’s condition does not seem to fit a protocol or protocols, contact Medical Control for guidance.
7. All trauma patients with mechanisms or history for multiple system trauma will be transported as soon as possible. The scene time should be 10 minutes or less.
8. Medical patients will be transported in the most efficient manner possible considering the medical condition. Advanced life support therapy should be provided at the scene if it would positively impact patient care. Justification for scene times greater than 20 minutes should be documented.
COMMUNICATING WITH HOSPITAL OR MEDICAL CONTROL
· There are several reasons to contact the hospital.
o To notify the hospital when time is needed to set-up for the patient. Examples include major trauma, cardiac arrest, hazardous materials, bedbugs, and Cardiac or Stroke Alerts
o Hospitals that request to be notified on every patient transported to their facility are:
· Bay Park
· Blanchard Valley
· Bluffton Hospital
· Children’s Medical Center
· Flower Hospital
· Fostoria Community Hospital
· Grandview Medical Center
· Greene Memorial Hospital
· Huber Heights ER
· Joint Township District Memorial Hospital
· Kettering Medical Center
· Lima Memorial
· McCullough-Hyde Hospital
· Mary Rutan Hospital
· Maternity at Miami Valley Hospital
· Mercer County Community Hospital / Coldwater
· Miami Valley South
· St. Anne’s ER
· St. Charles’ ER
· St. Luke’s ER
· St. Rita’s ER
· St. Vincent’s ER
· Soin Medical Center
· Southview Hospital
· Springfield Regional Medical Center
· Sycamore
· Toledo Hospital
· University Toledo Medical Center
· Upper Valley Medical Center
· Van Wert County Hospital
· Veterans Adm. Medical Center
· Wayne Hospital
· Wilson Memorial Hospital
· Wood County
· Wyandot Memorial
· WPAFB Medical Center
o To obtain orders, such as for procedures or medications indicated by the diamond in these
Standing Orders
o To obtain advice. For example, guidance from the MCP might be needed before a medication is given, even though Standing Orders allow it to be used without permission. Another situation could be a patient with an unfamiliar condition.
· When contacting the hospital, make sure a clear picture is painted. The crew can see the patient; the hospital personnel cannot. The ability to communicate findings will directly impact the hospital’s response.
· When calling about a trauma patient, include MIVT, ETA, the components of the GCS, and patient assessment findings, especially those relevant to the decision to transport to a Trauma Center.
· If consultation with a physician is desired, the medic should specifically request Medical Control. Crews cannot take medical orders from a Registered Nurse only. Contact for Medical Control must come from a physician. The nurse can provide the orders verbally, but the crew MUST have a physician’s name to attribute the orders to.
· When calling with an alert (Trauma, Cardiac, or Stroke) say, “We recommend a Alert.”
· Remember that the hospital may have more information, and may or may not decide to act on your recommended alert. Examples:
o Patients who meet Trauma Destination Protocols do NOT always warrant the hospital calling in a surgical team immediately.
o A patient who meets Cardiac Alert criteria may have prior EKGs in their hospital record that indicate that the alert is unnecessary.
Non-Initiation of Care
NON-INITIATION OF CARE
· Resuscitation will not be initiated in the following circumstances:
o Burned beyond recognition
o Decapitation
o Deep, penetrating, cranial injuries
o Massive truncal wounds
o DNR Order—present and valid
o Frozen body
o Hemicorporectomy (body cut in half).
o Rigor mortis, tissue decomposition, or severe dependent lividity
o Triage demands
o Blunt trauma found in cardiac arrest unless one of the following conditions is present:
§ Patient can be delivered to an emergency department within 5 minutes.
§ The arrest is caused by a medical condition
§ Focused blunt trauma to the chest (such as a baseball to the chest)
· An example is Commotio cordis, a form of sudden cardiac death seen most often in boys and young men playing sports. It occurs as the result of a blunt, non-penetrating impact to the precordial region from a ball, bat or other projectile.
o Penetrating trauma found in cardiac arrest when the patient cannot be delivered to an emergency department within 15 minutes.
§ Resuscitation will be initiated on victims of penetrating trauma who arrest after they are
in EMS care.
· Once en route, continue care even if the above time limits cannot be met.
NOTE: Pediatric patients may meet non-initiation of care criteria.
DNR: COMFORT CARE/COMFORT CARE ARREST
ONLY DNR ORDERS WITH THE FOLLOWING SYMBOL / LOGO
WILL BE FOLLOWED OR ACCEPTED:
DNR
COMFORT CARE
Do Not Resuscitate-Comfort Care (DNR-CC)
(Permits any medical treatment to diminish pain or discomfort that is not used to postpone the patient’s
death)
· The following treatments are permitted:
o Suctioning
o Oxygen
o Splinting/immobilization
o Bleeding control
o Intravenous Access
o Pain control/Comfort Positioning
· The following treatments are not permitted:
o Chest compressions
o Artificial Airway adjuncts
o Initiate Resuscitative IV (Large-bore, high-volume flow)
o Resuscitative drugs (Drugs used during resuscitation – “Code Drugs”)
o Defibrillation/cardioversion/monitoring
o Respiratory assistance (oxygen, suctioning are permitted)
Do Not Resuscitate-Comfort Care Arrest (DNR-CCA)
· Permits any Standing Orders treatment until cardiac or respiratory arrest or agonal breathing occurs.
NOTE: When a Durable Power of Attorney for Healthcare (DPA-HC) is present AND the “Living Will and Qualifying Condition” box is checked, the DPA-HC cannot override the patient’s DNR status. A patient may change their DNR status at anytime verbally, in writing or by action. This MUST be documented on the Patient Care Report.
FIELD TERMINATION OF RESUSCITATION EFFORTS
R FIELD TERMINATION DOES NOT APPLY TO PEDIATRICS
¨ When a patient in cardiac arrest has failed to respond to Advanced Life Support (ALS), it may be decided to terminate the effort and not transport the patient to the hospital. For the paramedic to determine that this option is appropriate, the following criteria must be met:
A The victim must:
o Be 18 years or older
o Be in PEA or asystole
o Not be in arrest due to hypothermia
o Have an advanced airway
o Have vascular access
A PEA rate of higher than 40 should be given additional consideration before field termination is
initiated. Pre-hospital care providers should be aware that patients in PEA with a rate equal to or greater than 40 may not be in true cardiac arrest. The patient may not have palpable pulses due to being hemodynamically unstable. MCP may not approve field termination of a patient in PEA based on these criteria.