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THIS PRESENTATION IS NOT A SUBSTITUTE FOR READING THE MARIN COUNTY POLICY AND PROTOCOL MANUAL IN ITS ENTIRETY. IT IS AN INTRODUCTION TO THE POLICY AND PROTOCOL UPDATES TAKING EFFECT ON JULY 1, 2016. EMS SYSTEM EVENT REPORTING FORM • • • • • • Replaces EMS Notification Form Includes instruction for completion No “levels” of events Initiators may be anonymous Initiators must reference pertinent P&P Includes opportunity for sharing an interesting case for education purposes PARAMEDIC INTERNSHIP *NEW* • Provides guidance and establishes minimum standards for paramedic internships. • Preceptor Requirements: • 2 years experience as California EMT-P • Current and active (non-probationary) California EMT-P license and local accreditation in Marin County for one year. • Completed training as outlined/required by the Provider Agency and/or Paramedic Training Program. • Formal preceptor designation by the Provider Agency. PARAMEDIC INTERNSHIP *NEW* • Paramedic Interns • Work only in basic scope of practice, unless approved for optional scope procedures. • Work only under direct supervision of their assigned preceptor(s). • In the absence of their preceptor(s), student works in basic EMT scope. UNIFIED RESPONSE TO VIOLENT INCIDENTS *NEW* • To provide triage, medical care and extrication to patients in an incident involving an active shooter/violent incident or other hazardous incident being primarily managed by law enforcement agencies/departments UNIFIED RESPONSE TO VIOLENT INCIDENTS *NEW* • Education, training and joint exercises with Law Enforcement, Fire and EMS must be conducted before Fire and EMS providers are allowed to enter an active scene UNIFIED RESPONSE TO VIOLENT INCIDENTS *NEW* • All law enforcement, fire and/or EMS provider shall have department policies regarding entry of responders into warm zones or secure areas as described in this policy UNIFIED RESPONSE TO VIOLENT INCIDENTS *NEW* • The EMS response to violent encounter/active shooter incidents should be coordinated utilizing ICS, SEMS, NIMS and Unified Command with on scene Law Enforcement/ Fire / EMS/ Facility Cooperator UNIFIED RESPONSE TO VIOLENT INCIDENTS *NEW* • Law Enforcement will be responsible for patient extrication if other first responders are not able to enter the scene. Patient extrication will be initiated at the earliest possible opportunity after the scene is relatively secured and/or the threat is neutralized UNIFIED RESPONSE TO VIOLENT INCIDENTS *NEW* • The on scene Incident Commander/ Unified Command, in addition to departmental policies, will determine PPE requirements for entry into any warm zones TACTICAL PARAMEDIC *NEW* • Tactical Paramedic– A paramedic who meets all established prerequisites and is authorized to provide medical support services for law enforcement operations. TACTICAL PARAMEDIC *NEW* • Must be an accredited Marin County paramedic with successful completion of a Tactical Medicine Course that is certified by the Peace Officers Training and Standards (POST) and approved by the California EMS Authority. TACTICAL PARAMEDIC *NEW* • Tactical paramedics must be sworn peace officers in order to carry a firearm PREHOSPITAL/HOSPITAL CONTACT • Policy Section and Physician Consultation sections were reorganized and cleaned up. • Patient identification information added for STEMI and STROKE patients during early notification process. PREHOSPITAL/HOSPITAL CONTACT Patient Identifying Information • Kaiser STROKE/STEMI Patients – Give Kaiser # (Give Name and DOB if unknown Kaiser #) • MGH STROKE/STEMI Patients – Give Name and DOB • NCH STROKE Patients – Give Name and DOB PREHOSPITAL/HOSPITAL CONTACT • Do not delay care or dedicate excessive time to phonetically spelling out a complicated name. • e.g. Zachary Galifianakis FIELD TRANSFER FORM • New fields added • Focus is to provide the hospitals the necessary information when a PCR is not able to be completed at the hospital. • Requires initiator to provide a phone number for significant other/care provider. • Must be legible and signed! FIELD TRANSFER FORM • Updated FIELD TRANSFER FORM • Updated FIELD TRANSFER FORM • Updated ALL TREATMENT POLICIES • Changed from “Body Substance Isolation” to “Always Use Standard Precautions” PROCEDURE FOR INTRANASAL MEDICATIONS MIDAZOLAM (VERSED) & NARCAN • INDICATION – Removed RR < 8 12-LEAD ECG PROCEDURE • CONTRAINDICATION section removed. DETERMINATION OF DEATH – ALS • Indication definition changed. • Medical indications revised with addition of potentially reversible cause of death added. • Under medical indications revised to replace “nonperfusing wide ventricular complex” with PEA. DETERMINATION OF DEATH – ALS • Removal of “three rounds of medication appropriate for presenting rhythm have been administered.” • Additional language: “If determination of death can still not be made for medical arrests, continue resuscitation for ten additional minutes (30 minutes total) at which point resuscitation may be discontinued and determination of death made if ROSC has not occurred. • IF patient in recurring or refractory VF, continue resuscitation and transport the patient. DETERMINATION OF DEATH – ALS • Physician consult box reworded. • Notification of Law Enforcement and filing out DOD form moved to below Physician consult box. ADULT MEDICATIONS AUTHORIZED/STANDARDIZED DOSE • Removal of D50 • Addition of D10 • 125 ml bolus IV/IO over 10 minutes; recheck BG and repeat as needed • Narcan concentration corrected to 2mg/2ml PATIENT TRANSFER AND TRANSPORTATION • Additions on hemorrhage control • Control significant external bleeding using direct pressure. If bleeding remains uncontrolled, apply gauze or hemostatic dressing and/or tourniquet. • Limb with the tourniquet must remain exposed • Hemostatic dressing must be approved by California EMS Authority • https://www.youtube.com/watch?v=-NgfgofN6-M&feature=youtu.be VENTRICULAR FIBRILLATION/ PULSELESS VENTRICULAR TACHYCARDIA • Revisions made to follow AHA 2015 changes. • Addition to refer to Cardiac Arrest Policy. • Statement that manual CPR is preferred over mechanical. VENTRICULAR FIBRILLATION/ PULSELESS VENTRICULAR TACHYCARDIA • BLS airway management is preferred in the first 5 minutes of CPR. • If NO ventilation occurring with basic maneuvers, proceed to advanced airway. PULSELESS ELECTRICAL ACTIVITY AND ASYSTOLE • Reference to Cardiac Arrest Policy added. WIDE COMPLEX TACHYCARDIA • Biphasic language removed ST ELEVATION MYOCARDIAL INFARCTION (STEMI) • Provide Early STEMI Notification with identifying patient information. COLD INDUCED INJURY • If there are no signs of life and asystole remains after 60 seconds, ventilate for three minutes; auscultate for heart rate and assess for electrical activity for 60 seconds. COLD INDUCED INJURY • If still asystolic and no pulse, begin CPR; if VF/VT defibrillate once @ 200J or 360J (depending on manufacturer) and if no change, begin CPR. COLD INDUCED INJURY • If PEA (even very slow); withhold CPR; continue warming measures; begin transport, continue IV fluid boluses (as above); handle gently and manage airway. • Withhold ACLS medications until core temperature reaches 86F/30C. COLD INDUCED INJURY • Hypothermia from submersion: Based on reliable report or witness, if submersion is<60 minutes, attempt resuscitation/active rewarming. • If submersion is known to be >60 minutes, resuscitation should not be initiated (see Determination of Death Policy, ATG6). COLD INDUCED INJURY • Overhauled COLD INDUCED INJURY • Subtler presentations exist in the elderly, newborns, chronically ill, patients taking medications and alcohol. • Handle the patient gently for all procedures; physical manipulations have been reported to precipitate ventricular fibrillation. COLD INDUCED INJURY • Continue re-warming in patients with temperature < 35C (95°F) with known or suspected hypothermia (hypothermia from submersion <60 minutes) as the primary cause or significant contributor of death, unless obvious death or valid DNR are present ADULT CARDIAC ARREST • Removed “Guideline” from title of policy. • Incorporates AHA 2015 changes • Clarifies when transport of a patient in cardiac arrest is warranted. ADULT CARDIAC ARREST • Regardless of achieving ROSC on scene, transportation is warranted in the following situations: • • • • • Refractory VF Unsafe Scene Conditions Unstable Airway Hypothermia as a primary cause of arrest (<95F/35C) Any patient pulled from a fire in cardiac arrest ADULT CARDIAC ARREST • Manual CPR is not optimal in the back of a moving ambulance. If transporting a patient needing CPR, consider using mechanical CPR if available. SPINAL MOTION RESTRICTION (SMR) • Includes info on athletic equipment removal. • Athletic Equipment (football helmet and shoulder pads; lacrosse helmet and shoulder pads; baseball/softball catcher’s helmet) SPINAL MOTION RESTRICTION (SMR) • In event of suspected spine injury during participation in equipment-intensive sport, removal of equipment is recommended prior to application of SMR. • Equipment should be removed by the rescuers most familiar with the equipment (i.e. Athletic Trainers when present). • Removal of helmet and/or shoulder pads provides early access to the patient’s airway/chest. COMA/ALTERED LEVEL OF CONSCIOUSNESS • Removed D50, added D10 • If BS < 60 or immeasurable: Dextrose 10% 25GM/250ml: 125 ml bolus IV/IO over 10 minutes; recheck BG and repeat as needed SEIZURES • Removed reference to D50 • Added language to treat hypoglycemia according to N1 COMA/ALOC policy SYNCOPY • Removed reference to D50 • Added language to treat hypoglycemia according to N1 COMA/ALOC policy CEREBROVASCULAR ACCIDENT (STROKE) • Rewritten to provide clarity on when to activate as an Early Stroke Notification. • Provide patient identifying information during notification. • Extends LKW to 4.5 hours. • Includes more anticoagulant examples. CEREBROVASCULAR ACCIDENT (STROKE) • Provide Early Stroke Notification if all of the following are true: • Abnormal Cincinnati Prehospital Stroke Scale (CPSS) Score • Last known well < 4.5 hours • Symptoms are most likely due to stroke and not a stroke mimic (see special considerations) • Blood glucose level >70 CEREBROVASCULAR ACCIDENT (STROKE) • Obtain name and contact information for patient family member/decision maker and/or those who had last seen the patient normal (e.g., skilled nursing personnel). ALL PEDIATRIC POLICIES • Measure with color-coded resuscitation tape and treat according to the Pediatric Dosing Guide (P18A). Apply Corresponding wrist band. NEWBORN RESUSCITATION • Added language to now clearly state, “3:1 ratio” above bullet point for “90 compressions / 30 ventilations per minute” • If HR remains < 60/MIN perform BVM with chest compressions at 3:1 ratio PEDIATRIC RESPIRATORY DISTRESS • Clarified Epinephrine dosage for Lower Airway Obstruction/Wheezing: • 2015: “If response inadequate, Epinephrine 1:1,000 (0.1 mg/kg) IM, max. single dose 0.3 mg; maximum dose = 0.6 mg.” • 2016: “If response inadequate, Epinephrine 1:1,000 (0.01 mg/kg) IM, maximum single dose 0.3 mg; MR x 1.” PEDIATRIC TACHYCARDIA POOR PERFUSION • Under Critical Information, removed “Monophasic and biphasic doses are the same” PEDIATRIC SHOCK, SEIZURE, ALOC, ALTE • Removed D25/D50 and replaced with D10. • Treat Blood Glucose if < 60 mg/dl (<40 mg/dl neonate): • Neonate: D10W 2ml/kg IV/IO over 10 minutes • > Neonate: D10W 5 ml/kg IV/IO over 10 minutes PEDIATRIC PAIN MANAGEMENT • Added Zofran • If nausea/vomiting, consider Ondansetron (Zofran) • Ages 2-3: 2mg ODT or slow IV/IO over 30 seconds; MR x1 in 10 minutes • Ages ≥4: 4mg ODT or slow IV/IO over 30 seconds; MR x 1 in 10 minutes PEDIATRIC MEDICATIONS AUTHORIZED/STANDARD INITIAL DOSE • Dextrose 10% replaced D25 and D50. • Epinephrine 1:1,000 – As stated in P3. PEDIATRIC PATIENTS NOTE • Remember to use pediatric colored bands. PEDIATRIC INTRAOSSEOUS INFUSION PROCEDURE • Added Lidocaine if patient is awake or responds to pain. • For patients >3kg: If awake and/or responsive to pain, infuse 2% Lidocaine 0.5mg/kg slowly (max dose = 40mg; treat according to the Pediatric Dosing Guide P18A). Allow the Lidocaine to work 30-60 seconds prior to administering fluids. 2015-2016 MARIN COUNTY PHYSICIANS ADVISORY COMMITTEE • • • • • Dustin Ballard, MD – Marin County EMS Agency Jonathan Vlahos, MD – San Rafael Fire Zita Konik, MD – Novato Fire Vicki Martinez, MD – Corte Madera Fire Mark Bason-Mitchell – Marin County Fire/RVPA/SMEMPS 2015-2016 MARIN COUNTY P&P COMMITTEE • • • • • • • • Karrie Groves - Marin County EMS Agency Randy Saxe – Marin County EMS Agency Bridget Peterson – Marin County Fire/RVPA/SMEMPS Heather Price-Fair – Marin County Fire/RVPA/SMEMPS Brett McTigue – Marin County Fire/RVPA/SMEMPS Mike Gianini – Marin County Fire/RVPA/SMEMPS Liz Froneberger – Corte Madera Fire/Kaiser San Rafael Dan Reese – Corte Madera Fire 2015-2016 MARIN COUNTY P&P COMMITTEE • • • • • • • • Fred Maru – San Rafael Fire Shawn Gordon – San Rafael Fire Aaron Hakenen – Novato Fire Kim Lesik – Novato Fire Maureen Stull – Marin General Hosptial Jeff Cress – Reach Air Chris LeBaudour – Falck/Veri-Health Steven Coleman – NORCAL Ambulance THE END…