Adult ALS Protocols apply to adult patients age 18 and over.
A. Remember: Courtesy to the patient, the patient's family and other emergency care personnel is of utmost importance.
B. A Willmar Ambulance Services report form must be completed on all patients and a copy left with the patient at the hospital. Specific prehospital care information must also be recorded on all patient contacts as part of the System data collection program.
C. The specific conditions listed for treatment in this document, although frequently stated as medical diagnoses, are operational diagnoses to guide the paramedic in initiating appropriate treatment. This document is to be used as consultative material in striving for optimal patient care. It is recognized that specific procedures or treatments may be modified depending on the circumstances of a particular case. Also, a medical control physician, when consulted, will either concur or further evaluate the paramedic's clinical findings and suggest an alternate diagnosis and treatment.
D. In all circumstances, physicians have latitude in the care they give and may deviate from these Medical Protocols if it is felt such deviation is in the best interest of the patient. Nothing in these protocols shall be interpreted as to limit the range of treatment modalities available to medical control physicians to utilize, other than the modalities and the medications used must be consistent with the paramedic's training.
A medical control physician should be contacted as specified in these protocols. Whenever possible, medical control should be obtained from the hospital of destination requested by the patient. Medical control as required by protocol for cardiac and other non-trauma patients should be established immediately upon completion of necessary ALS procedures. If no request for medical control has been made before three minutes from hospital arrival, patient information only should be communicated (for hospital notification) in lieu of medical control. Except for load-and-go situations with short transport times, any such delay in establishing medical control will be explained in an Incident Report submitted by paramedics. This policy in no way precludes establishment of medical control at any time during the run to obtain physician advice or assistance.
In the occurrence of communication failure, paramedics may perform those orders outlined in the ALS Medical Protocols under "After Obtaining Verbal Orders" for patients with life-threatening or potentially life-threatening conditions. Initiation and performance of these orders must be in accordance with the paramedic's training and must be carried out as written in these Medical Protocols. Any instance of communications failure where procedures are carried out without a physician's verbal order must be reported in an Incident Report within 48 hours.
If a physician is present and wishes to assume
responsibility for the patient's care:
A.
If the patient's personal physician is present and wishes to assume
responsibility for the patient's care:
1. The paramedic should defer to the orders of the personal physician as long as those orders are appropriate and not in conflict with ALS Medical Protocols. (Paramedics should establish radio medical control any time they are uncomfortable with carrying out orders from a patient's physician.)
2. Orders given by the personal physician should be written on the EMS report form and signed by the physician.
3.
The paramedic should contact the medical control physician during
transport to report treatment given and to obtain further orders if the personal
physician does not accompany the patient.
B.
If a System Medical Directoror
medical control physician is present and wishes to assume responsibility for the
patient's care, the same guidelines apply as in 1. above.
C.
If any other intervening physician wishes to assume responsibility for
the patient when no radio medical control exists, the paramedics should
relinquish responsibility for patient management if the physician:
1. Can show appropriate identification (or is known to the paramedics); and
2. Agrees in advance to accompany the patient to the hospital (exception: major multiple casualty incident); and
3.
Signs the EMS report form assuming responsibility and verifying orders.
a. If radio medical control exists, the intervening physician should be allowed to communicate with the medical control physician prior to the paramedics accepting orders. If there is any disagreement between the two physicians, the paramedics will follow the orders of the medical control physician and allow the physicians to continue their communication.
b. In the case of multiple intervening physicians at the scene, the paramedics should request the physicians designate one physician to direct patient care.
D. An intervening physician not wishing to assume responsibility for care and accompanying the patient to the hospital may be asked to assist the paramedics and/or act as a medical consultant to them and to the medical control physician.
Whenever an ambulance is
requested for a patient, it is the responsibility of the EMS system to treat and
transport that patient with his/her consent. Transport by ambulance should
always be offered to a patient. If a competent patient or parents of a minor
refuse treatment or transportation, they should sign the refusalstatement on the ambulance report form. If they refuse to sign,
this should be documented, including witnesses' names if possible. In general,
a person is mentally competent if he/she:
A. is capable of understanding the nature and consequences of the proposed treatment; and
B. has sufficient emotional control, judgment, and discretion to manage their own affairs; and
C.
is not impaired by drugs or alcohol.
Emergency care for life-threatening conditions should never be delayed or withheld to carry out legal consent procedures. Any time contact with the patient occurs and the patient is not transported, the run is a "left," not a "cancel," and requires full documentation on the ambulance report form including what the patient (or parent) was told at the scene regarding non-transport and any other follow-up advice or information given at the scene.
Adults: A mentally competent adult has the right to refuse treatment and/or transport; however, the paramedic and/or medical control physician (by phone or radio) should explain thoroughly the alternatives and potential consequences of this action. A medical control physician should always be consulted if in doubt as to the mental competency of a patient, or if the paramedic feels it is detrimental to leave the patient.
Minors: Consent or refusal of treatment/transport of minors (less than 18 years) must be given by the child's parent or legal guardian. Although less desirable, consent or refusal may be given by a responsible adult (over 18) caretaker if the parent has deliberately left the minor in the care of this adult, and the adult is competent and capable. If unsure whether it is appropriate to allow someone to give consent or refuse treatment of a minor, a medical control physician should be consulted.
All equipment appropriate to the nature of the call for assessment, treatment and transport should be taken to the site of the patient at the time of initial patient contact.
Cardiopulmonary resuscitation will be promptly instituted
for all patients found in cardiac arrest unless reliable criteria for the
determination of death are present, or a valid DNR
or No CPR order exists.
A. Reliable criteria for the determination of death include:
1. Lividity
2. Rigor
3. Obviously fatal trauma
4. Absence of vital signs in a trauma victim upon arrival of EMS personnel despite a patent airway
B. Do Not Resuscitate(DNR, No CPR) orders are orders issued by a patient's physician to refrain from initiating resuscitative measures in the event of a cardiopulmonary arrest. Patients with DNR orders may receive vigorous medical support, including all interventions specified in the ALS Medical Treatment Protocols, up to the point of cardiopulmonary arrest.
In the nursing home, a DNRorder is valid if it is written in the order section of the patient chart (or on a transfer form) and is signed by a physician. Copies of the order are valid. In a private home, the standard DNR form (see Appendix F, page 3) must be signed by the patient or proxy, the physician, and a witness in order to be valid. No validation stamp or notarization is necessary, and a legible copy is acceptable.
If possible, the DNRorder or copy should accompany the patient to the hospital. Pertinent documentation should be included on the ambulance report form for the run. In the event of confusion or questions regarding the DNR order, resuscitation should be initiated and a medical control physician should be consulted.
Health Care Declarations and living wills should not be interpreted at the scene, but conveyed to the physicians in the receiving Emergency Department.
Complete DNR guidelines are found in this document in Appendix F, page 3.
Patients should be transported to the hospital of their choice (or family's or physician's choice) unless the gravity of the patient's condition warrants transport to the nearest hospital capable of immediately handling the emergency. The decision to transport to the nearest facility or the decision to change destination en route is ultimately the responsibility of the medical control physician. Also, in the case of critical trauma, the paramedic may independently decide to divert to the nearest hospital appropriate for major trauma if the patient meets one or more of the following trauma triagecriteria:
|
· Systolic blood pressure less than 90 |
· Glasgow coma score of 13 or less |
|
· Penetrating trauma to head, neck or trunk |
· Respiratory rate of less than 10 or greater than 30 |
|
· Less than "A" on the AVPU scale |
· Prolonged extrication |
|
· Death of occupant in same vehicle |
|
Whenever circumstances are such that the paramedic must make a diversion decision independently, the original receiving hospital should be notified by the paramedics or service dispatcher as soon as possible.
Paramedics may also consider the need for transport to a closer hospital per service medical director.
A. Exposure to blood should be minimized.
When the possibility of exposure to blood or other body fluid exists, gloves are required. During extrication, or when broken glass is present, leather gloves or fire fighter gloves should be used. If hands accidentally become contaminated with blood, they should be washed thoroughly as soon as possible.
When there is risk of eye or
mouth contamination (for example, the patient is vomiting bloody material or
there is arterial bleeding), protective eyewear and masks are required.
B.
Needles and other sharp objects should be considered as potentially
infective and be handled with extraordinary care. Needles should not be
recapped. If it is absolutely necessary to recap a needle, use the appropriate
technique prescribed by local EMS policies. Needles, syringes and broken glass
vials should be immediately placed in puncture-proof containers after use.
C.
Pocket masks with one-way valves or positive pressure ventilators should
be used for artificial respiration whenever possible. Masks should be worn by
the paramedic or patient (See D) for those infectious agents known to be
transmitted by the airborne route (i.e., tuberculosis, chicken pox, measles,
etc.).
D.
Sufficient information should be obtained to determine if a patient might
have active tuberculosis (TB), recent history of TB, HIV infection, fever,
recent weight loss or cough. If there is a history suggestive of active TB,
paramedics should wear masks compatible with OSHA guidelines and take other
specific precautions in accordance with their individual ambulance service
Respiratory Protection Plan. Albuterol nebulizations should not be administered in the ambulance to
patients with a history or symptoms suggestive of active TB; subcutaneous
terbutalineor epinephrineshould be considered instead. Ventilation should be maximized in
the patient compartment during transport of patients known to have active
tuberculosis.
E.
Equipment should be thoroughly cleaned per protocol after each use.
Disposable equipment should be considered for use whenever appropriate.
F.
In the event of significant exposure to blood or body fluids, supervisory
personnel should be promptly informed.
G.
Significant exposure is defined as follows:
1. Any puncture of the skin by a needle or other sharp object that has had contact with patient's blood or body fluids or with fluids infused into the patient.
2. Blood spattered onto mucous membranes (e.g. mouth) or eyes.
3.
Contamination of open skin (cuts, abrasions, blisters, open dermatitis)
with blood, vomitus, saliva, amniotic fluid or urine. Bite wound to providers
would be included in this category.
H.
Local ambulance service policies should define a plan of action in the
event of a significant exposure of an emergency responder to blood or body
fluids.
A.
When working at a Hazardous Materials Incident, Willmar Ambulance Service
paramedics should station themselves in the Haz Mat cold zone. Paramedics should
operate in the cold zone unless they have adequate training and personal
protective equipment for operation in the warm zone. H.E.A.T. will contact you
on scene.
B.
Patients who have been exposed to a hazardous material should be
appropriately decontaminated by qualified personnel. Considerations during
decontamination should include:
1. Weather and other limiting elements.
2. The patient's level and severity of exposure.
3. Condition of the victim. Transport those patients who cannot wait for a complete decontamination due to life-threatening injuries or condition.
4. No invasive procedures without medical control orders, unless the patient is critical.
5.
Contaminated patients being transported for further evaluation or
treatment need to be appropriately cocooned to contain any remaining
contaminates, and paramedics should limit exposure to themselves using
appropriate available protective equipment.
C.
Early hospital notification is important to allow appropriate preparation
for the patient.
In special incidents with potential for multiple
casualties, resources of the Willmar Ambulance Service may be temporarily
overwhelmed or extended to their limits. A System Plan for EMS Response to
Multiple Casualty Incidents establishes a framework for coordinating resources
during incidents requiring various ambulance providers, hospitals and public
safety agencies to work together to optimize patient care and transportation
with the given resources of the community. The goals of the system plan are to:
A.
Recognize and maintain operations of ambulance providers, hospitals, and
other agencies as close to normal as possible;
B.
Utilize the incident command structure to allow flexibility for effective response to a variety
of hazards most likely to occur within the County, including natural disaster,
hazardous material exposure, urban fire, air crash, civil unrest or any incident
with actual or potential multiple casualties; and
C. Set system standards to aid individual agencies when developing policies and procedures.
(See Appendix D, page 11)
Critical Incident Stress Debriefing (CISD) and Peer Counseling: Paramedics and other EMS personnel are encouraged to familiarize themselves with the causes and contributing factors of critical incident and cumulative stress, and learn to recognize the normal stress reactions that can develop from providing emergency medical services.
A Southwest Region CISD Peer Counseling Program is available to paramedics and other EMS personnel. The program consists of mental health professionals, chaplains and trained peer support personnel who develop stress reduction activities, provide training, conduct debriefings, and assist EMS personnel in locating available resources. The team will provide voluntary and confidential assistance to those wanting to discuss conflicts or feelings concerning their work or how their work affects their personal lives.