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PSVAC Training Session January 4th, 2009 1 Agenda Protocol Changes Selective Spinal Immobilization Telemetry Contact RMA policy Moshe Karp (30 minutes) Moshe Karp (30 minutes) (15 minutes) (15 minutes) ***************** 15 Minute Break ****************** Albuterol Epi Pen New SCAM report MOLST / DNR Orders SAFE Centers Matt Jachyra (30 minutes) Matt Jachyra (40 minutes) Will Tung (10 minutes) Will Tung (15 minutes) Will Tung (10 minutes) Total time: 3 Hours, 30 Minutes January 4th, 2008 PSVAC Training 2 2009 NYC REMSCO Protocol Changes Moshe Karp 3 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 4 BLS Changes - GOPs Page A.8 January 4th, 2008 PSVAC Training 5 BLS Changes - GOPs The result of this protocol can be thought of in terms of this diagram January 4th, 2008 PSVAC Training 6 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 7 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 8 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 9 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 10 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 11 BLS Protocols Protocol 404 – Non-Traumatic Chest Pain 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 12 BLS Protocols Protocol 404 – Non-Traumatic Chest Pain 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 13 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 14 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 15 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 30-45 seconds” to check for a carotid pulse. January 4th, 2008 PSVAC Training 16 Selective Spinal Immobilization Moshe Karp 17 NYS Spinal Update Suspected Spinal Injury New York State Department of Health Bureau of Emergency Medical Services January 4th, 2008 PSVAC Training 18 Selective Spinal Immobilization 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 19 Selective Spinal Immobilization 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 20 Selective Spinal Immobilization 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 21 BLS Protocols Selective Spinal Immobilization Patients meeting one or more of the following criteria must be immobilized: i. Altered mental status for any reason, including possible intoxication due to drugs or alcohol. ii. GCS <15 January 4th, 2008 PSVAC Training 23 Selective Spinal Immobilization iii. Complaint of, or inability of the provider to assess for, neck and/or spine pain or tenderness. iv. Weakness, paralysis, tingling, or numbness of the trunk or extremities at any time since the injury. v. Deformity of the spine not present prior to the injury. January 4th, 2008 PSVAC Training 24 Selective Spinal Immobilization vi. Distracting injury or circumstances, including anything producing an unreliable physical exam or history. January 4th, 2008 PSVAC Training 25 Selective Spinal Immobilization vii. High risk mechanism: • • • • axial load such as diving or tackling, high-speed motor vehicle accidents, rollover accidents, falls greater than standing height. vii. Provider concern for potential spinal injury. January 4th, 2008 PSVAC Training 26 Selective Spinal Immobilization 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 27 Selective Spinal Immobilization 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 29 Telemetry Contact 30 Telemetry What is telemetry? – 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 PSVAC Training 31 When To Call RMA – – – – – – 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 PSVAC Training 32 When To Call Medication Orders – Epi-pen Administration Transport – 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 PSVAC Training 33 Who To Call Methodist Medical Control (718) 780-5555 January 4th, 2008 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 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 PSVAC Training 36 RMA Policy Changes 37 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. January 4th, 2008 PSVAC Training 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 January 4th, 2008 PSVAC Training 39 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 PSVAC Training 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. January 4th, 2008 PSVAC Training 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 PSVAC Training 42 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 PSVAC Training 43 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 PSVAC Training 44 OLMC - (718) 780-5555 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 PSVAC Training 45 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. January 4th, 2008 PSVAC Training 46 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 January 4th, 2008 PSVAC Training 47 What Do You Do? ALWAYS recommend TXP! – 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 January 4th, 2008 PSVAC Training 48 What Do You Do? Request Duty Officer to the scene – Always the first option Contact OLMC Request Police Department Document RMA in PCR if approved January 4th, 2008 PSVAC Training 49 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 PSVAC Training 50 RMA Flowchart January 4th, 2008 PSVAC Training 51 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 52 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 53 Sample Case 1 Two teenage boys (both 18) are involved in a carversus-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 What if What if What if January 4th, 2008 contact OLMC? Why or why not? one was 17? the passenger was the father of the driver? there was only minor damage and no head injury? 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 PSVAC Training 55 B R E A K 15 Minutes 56 Albuterol Administration Matt Jachyra 57 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 58 Albuterol January 4th, 2008 PSVAC Training 59 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 60 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 61 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 62 Albuterol MEDICAL CONTROL MUST BE CONTACTED FOR ANY PATIENT REFUSING MEDICAL ASSISTANCE OR TRANSPORT. January 4th, 2008 PSVAC Training 63 Albuterol So what is Albuterol and how do I eat it? January 4th, 2008 PSVAC Training 64 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 65 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 66 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 67 Albuterol 1. 2. 3. 4. 5. Mouthpiece Nebulizer t-piece Nebulizer cap Nebulizer chamber Nebulizer air-inlet connector 6. Nebulizer baffle 7. Tubing January 4th, 2008 PSVAC Training 68 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 69 Albuterol Assemble mouthpiece and T-piece and insert into the top of the nebulizer cap. January 4th, 2008 PSVAC Training 70 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 71 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 72 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 73 Epinepherine Autoinjector Matt Jachyra 74 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 75 Epinephrine Auto Injector 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 76 Epinephrine Auto Injector 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 77 Epinephrine Auto Injector Example of Hives January 4th, 2008 PSVAC Training 78 Epinephrine Auto Injector 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 79 Epinephrine Auto Injector So what can we do??? January 4th, 2008 PSVAC Training 80 Epinephrine Auto Injector 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 81 Epinephrine Auto Injector 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 82 Epinephrine Auto Injector 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 83 Epinephrine Auto Injector 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 84 Epinephrine Auto Injector 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 85 Epinephrine Auto Injector 1. 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 86 Epinephrine Auto Injector i. If the patient is having severe respiratory distress or shock and has been prescribed an Epinephrine autoinjector, 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 autoinjector) as authorized by the agency’s Medical Director. January 4th, 2008 PSVAC Training 87 Epinephrine Auto Injector 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 88 Epinephrine Auto Injector 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 89 Epinephrine Auto Injector So what is that magical thing you call Epinephrine and what can I do with it? January 4th, 2008 PSVAC Training 90 Epinephrine Auto Injector 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 91 Epinephrine Auto Injector 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 92 Epinephrine Auto Injector 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 93 Epinephrine Auto Injector 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 94 Epinephrine Auto Injector 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 95 Epinephrine Auto Injector January 4th, 2008 PSVAC Training 96 Epinephrine Auto Injector 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 97 Epinephrine Auto Injector January 4th, 2008 PSVAC Training 98 Epinephrine Auto Injector 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 99 Epinephrine Auto Injector January 4th, 2008 PSVAC Training 100 Epinephrine Auto Injector 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 101 Epinephrine Auto Injector 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 102 Epinephrine Auto Injector Now what about pediatrics? January 4th, 2008 PSVAC Training 103 Epinephrine Auto Injector 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 104 Epinephrine Auto Injector 1. 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 105 Epinephrine Auto Injector 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 autoinjector 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 106 Epinephrine Auto Injector 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 107 Epinephrine Auto Injector EpiPen in Adult and Ped configuration. January 4th, 2008 PSVAC Training 108 Epinephrine Auto Injector 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 109 New SCAM Report Will Tung 110 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 111 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 112 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 113 What do you do? Provide appropriate care – 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 114 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 115 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: 1-800-635-1522 (during tour) Send or Fax SCAM Report (within 48 hours) January 4th, 2008 PSVAC Training 116 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 117 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 119 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 120 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 121 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 122 MOLST / DNR Orders Will Tung 123 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 124 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 126 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 127 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 128 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 129 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 130 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 132 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 133 MOLST Video Play MOLST Video (7 minutes) January 4th, 2008 PSVAC Training 134 Sexual Assault Forensic Examiner (SAFE) Centers Will Tung 135 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 136 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 137 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 138 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 139 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 140 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 141 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 142 SAFE Centers 1. Upon identification of a stable adult (12 years or older) sexual assault patient (based on patient self-report or bystander/police report): a. 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. b. 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. c. 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 143 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 144