Operations

  • Introduction
  • Philosophy
  • General Guidelines
  • Communications & Orders
  • Facility Handoff Report / MIST Report
  • Verification of Medical Personnel on the Scene
  • ALS and BLS Team Approach
  • Transportation/Destination
  • Non-Transported Patient
  • Safe Transport of Pediatric Patients
  • Language Considerations
  • Guidelines for Initiating Resuscitation Efforts
  • Guidelines for Termination of Resuscitation Efforts
    (For Patients > 15 y/o)
  • Guidelines for DNR/POST/Advanced Directives
  • Traumatic Cardiac Arrest Resuscitation
  • Medical Alert Criteria
  • Major Trauma Criteria
  • Trauma Alert Criteria
  • Adult GCS
  • Peds GCS
  • Mass Casualty Procedures
  • Applied Ballistics Triage
  • START Triage
  • Jump START Triage
  • Decontamination of Patients
  • Universal Precautions
  • Blood & Body Fluid Exposure of EMS Personnel
  • Infection Control Procedures
  • Post Exposure Protocol
  • Provider Credentialing and Authorized Procedures
  • Request for New or Changed Protocol/Equipment

Introduction

The following protocols have been developed to provide standardized guidelines for patient care in particular critical situations. In some circumstances it is necessary to abbreviate or shorten terms to provide the most concise set of guidelines possible. When "ALS" appears in this document, we refer to Paramedic procedures, care, or transport as outlined by the Emergency Medical Services Branch, Fire and Building Safety Division of the Indiana Department of Homeland Security. When "BLS" appears in this document, we refer to Emergency Medical Technician (EMT) procedures, care, or transport as defined by the Emergency Medical Services Branch, Fire and Building Safety Division of the Indiana Department of Homeland Security. Throughout this document the terms "guidelines", "protocols", and "directives" may be used interchangeably.

 

The following protocols are guidelines to be used in patient care management. These medical guidelines are not intended to be all-inclusive and may not necessarily have covered every situation which may be encountered by the Paramedic/EMT. These guidelines are not meant to serve as a teaching tool, but are written with the understanding that the EMT or Paramedic knows how to perform the procedures. If there are references to procedures, medications, or conditions to which the Paramedic/EMT is not familiar, it is his/her responsibility to attain the appropriate guidance and/or education prior to performing such procedures or using such medications.

 

The protocols are designed to guide the Paramedic/EMT through the continuity of care for the out-of-hospital patient. ALS procedures are contained within the same protocol as the BLS procedures. This is intended to allow both the EMT and Paramedic to understand where ALS intervention is involved as part of the team of out-of-hospital care providers and where ALS intervention may be necessary in the out-of-hospital care. Some protocols are specific to ALS care as the treatment provided to the patient evolves beyond the BLS level of care.

 

The protocols are to provide guidelines in the treatment of patients of all ages. Where necessary, protocols unique for specific ages those ages are noted. For the purposes of these protocols, an adult is over the age of 15 years, a child is ages 1 to 15 years, an infant is 1 month to 1 year, and a newborn is from time of delivery up to 28 days (less than 1 month). When certain procedures are contrary to these ages, they are noted in the specific protocol.

 

Written protocols are not a substitute for direct physician orders and will always be superseded by on-scene EMS Medical Directors/Fellows or on-line medical control. As with all aspects of health care, these patient care protocols should be considered dynamic and will thus be continually evolving.

 

The Operational Guidelines Section contains guidelines for all affiliates. Some guidelines have specific notations for Indianapolis Emergency Medical Services (IEMS) personnel. These IEMS guidelines are in addition to, NOT substitution for, other guidelines in this section.

 

These protocols are reviewed and affirmed or revised annually. New or substantially changed material for this year is highlighted in red text.

 

These protocols are to be used by all affiliates. Except where indicated, affiliating agencies may not alter, add to or delete any portion of these protocols without written permission from their Medical Director.

Philosophy

Marion County Advanced and Basic Life Support Protocols are designed to allow pre-hospital care to begin immediately upon arrival of EMS personnel. If the advanced life support provider believes it is appropriate to provide ALS treatment beyond the contents of these protocols, the provider must establish on-line medical control and receive orders for such additional care.

 

Realizing that each patient's presentation is unique, the EMS provider’s care should be stylized for the patient's needs. EMS personnel should take the time for an appropriate and accurate assessment. Most patients will tell the provider what is wrong with them. EMS personnel should take the time to listen. All patients require initial and on-going assessments. Making the assumption that everything is abnormal until proven normal by exam will minimize errors. Communication with the physician or nursing staff as a consult is encouraged. It is all right not to know everything. It is unacceptable not to ask questions. When specifically noted, communication is mandatory for medical direction. Medical control means interaction with a physician either through direct communication or via a nurse or paramedic who has questioned a physician regarding the requested order.

 

The sequence of care outlined may vary according to the patient's condition and the resources available. Documentation in the patient care report of decisions made is required. EMS providers can accept reasonable and appropriate orders from physicians. They can also refuse orders which do not seem right for the situation. The EMS provider is the individual assessing the patient and further discussion can always occur.

 

Incident reports by receiving facilities or by the EMS provider should be viewed as quality assurance issues not punishment. Growth and improvement can occur only with a continuous examination of this system and its needs. Concerns and issues that are not directly related to patient care should be documented via an incident report. Patient care reports should be reserved for patient care documentation only.

 

It is the goal of the Marion County Advanced and Basic Life Support System to provide the best possible care to all patients. The paramedics and EMTs within this system should view themselves as responsible professionals committed to others through service and example. Through their dedication, knowledge, and essential prehospital patient management, the patient's chances for a positive outcome can only be enhanced.

General Guidelines

    Affiliating services, departments, and agencies may not alter any portion of these protocols without written permission from the Medical Director.

     

    These protocols are not intended to be all-inclusive and may not have covered every situation potentially encountered by EMS personnel. An on-line ED physician must order any other skills or therapies and the EMS provider must have been trained in the skill or therapy.

     

    This is NOT meant to be a teaching tool. EMS personnel are expected to know how to perform the therapies and procedures. If an EMT or Paramedic is unfamiliar with any condition, treatment, medication, skill, or procedure contained herein, it is that individual’s responsibility to seek the needed education.

     

    Once contact is made with a patient, the patient remains the EMS provider’s responsibility until one of the following occurs:

     

      Care is transferred to receiving facility staff
       Care is transferred to an appropriate level healthcare provider
       The patient is deemed non-viable
       A valid Signature of Release (refusal of transport) is obtained

     

    Transfer of care at the receiving facility is not complete until a verbal report is given to the medical care provider. It is also required that a written patient care report be submitted to the ED staff unless the EMS provider is sent on an emergency response. When this occurs, the written patient care report must be made available as promptly as possible.

     

    Throughout these protocols unless otherwise specified:

     

      Adult is over 15 years old
      Child is 1 to 15 years old
      Infant is 1 month to 1 year of age
      Newborn is birth to 1 month old.

     

    Throughout these protocols, interventions are listed by certification level. BLS (EMT) personnel may only provide therapies listed as BLS, and Paramedics may provide all therapies listed. When appropriate, the Paramedic may elect to provide a Paramedic level intervention instead of an EMT level intervention (i.e. – Endotracheal intubation instead of placing a non-visualized airway).

     

    Cases of suspected abuse must be reported according to law.

     

      1-800-800-5556 is the Indiana Child Abuse and Neglect Hotline

       

      1-800-992-6978 is the Indiana Adult Protective Services Hotline

     

    In the event of the death of a child less than 1 year of age the Sudden Unexpected Infant Death (SUID) form will be filled out and faxed to coroner’s office (317) 327-4563.

     

    Anywhere throughout this protocol manual where medications are to be administered at the BLS or the ALS level, it is required that the medication be verified prior to administration.

Communications & Orders

  1. Establish communications with the intended receiving hospital when:
  2.  

    1. Patient’s condition is unstable
    2. Patient requires specialized care
    3. Requesting orders
    4. Consulting MD regarding a refusal of transport

     

  3. Radio or phone report should be brief and generally follow the MIST format:
  4.  

    1. Provide Age/Gender
    2. Mechanism of Injury or Medical Complaint
    3. Injuries or Illness Identified
    4. Symptoms/ Vital Signs
    5. Treatments Rendered
    6. Request orders (when appropriate)

       

      Note: Patient names are not to be given over the radio-patient initials and/or last 4 digits of social security number are permissible if requested by receiving facility

     

    Hospital communication or request for orders should be made on a recorded line whenever possible.

     

  5. Repeat any orders received exactly as heard for confirmation.
  6.  

  7. If, based upon the EMS provider’s training, the orders received are inappropriate and/or dangerous, question the orders three times then verbally refuse to act. Continue to treat the patient according to these protocols.
  8.  

  9. If an order for therapy is denied and the EMS provider believes it to be life-saving, verbally request it three times. The EMS provider may then contact their supervising hospital for further instructions. Continue to treat the patient according to appropriate protocols.

 

  M  
Mechanism of Injury
or
Medical Complaint
Mechanism: Speed, Vehicle Type, Restraints, Protective Equipment, Weapon Type

Medical: Onset, duration, other pertinent history
I
Injuries
or
Illness Identified
Injuries – Head to Toe
Illnesses – STEMI - EKG Findings, Stroke – Scale Positive/Negative
S
Symptoms
&
Vital Signs
Current vitals, any prior abnormal vital signs
(HR, BP, SPO2, RR, ETCO2, Blood Glucose)
GCS: Eyes:____ Motor: ______ Verbal: ______ (Total: _______ )
T
Treatments
Rendered
Airway placement – What Type
Tourniquets / Needle Decompression
Defibrillator shocks
IV or IO Access
Medications Given + Responses

 

An incident of refusal of orders must be brought to the attention of the appropriate leader at the service, agency, or department and the Medical Director within 48 hours.

Facility Handoff Report / MIST Report

When patient care is transitioned at the hospital, a face-to-face verbal handoff must be provided to the receiving facility staff. Use the MIST format:

 

  1. Mechanism of Injury or Medical Complaint
  2. Injuries or Illness Identified
  3. Symptoms/ Vital Signs
  4. Treatments Rendered

 

  M  
Mechanism of Injury
or
Medical Complaint
Mechanism: Speed, Vehicle Type, Restraints, Protective Equipment, Weapon Type

Medical: Onset, duration, other pertinent history
I
Injuries
or
Illness Identified
Injuries – Head to Toe
Illnesses – STEMI - EKG Findings, Stroke – Scale Positive/Negative
S
Symptoms
&
VitalSigns
Current vitals, any prior abnormal vital signs
(HR, BP, SPO2, RR, ETCO2, Blood Glucose)
GCS: Eyes:____ Motor: ______ Verbal: ______ (Total: _______ )
T
Treatments
Rendered
Airway placement – What Type
Tourniquets / Needle Decompression
Defibrillator shocks
IV or IO Access
Medications Given + Responses

Verification of Medical Personnel on the Scene

  1. The EMS provider is operating under the supervision of “medical control”. Medical control is defined as the Medical Director or an on-line ED physician.
  2.  

  3. In general, on scene physicians will be courteously dissuaded from participating in patient care.
  4.  

    1. This and sections C and D do not apply to the agency’s EMS Medical Director(s), the IUSM Out-of-Hospital Care (EMS) Fellow(s), and the IUSM Emergency Medicine residents when in IEMS vehicles.

     

  5. The paramedic on the scene with the patient will have medical control of the patient except when:
  6.  

    1. A physician identifies him/herself as a physician and can produce a State of Indiana Professional Licensing Agency license and is willing to assume in advance ALL medical and legal responsibilities for the patient. The physician:
    2.  

      1. Must be willing to sign the run sheet for all orders given.
      2. Must be willing to sign a required provider specific form (when applicable)
      3. Must make radio or telephone contact with the emergency department physician at the receiving facility and be willing to accompany the patient to the hospital in the ambulance.

       

    3. The paramedic feels the physician may be helpful in rendering care to the patient within the scope of the ALS protocols or if the physician possesses special knowledge about the patient or can perform special skills the patient may need.

     

  7. If the physician requests an intervention that according to prehospital standards of care is inappropriate or detrimental to the patient, the paramedic will treat the patient as outlined by the appropriate protocols. The paramedic will then refer the on-scene physician to the physician at the receiving hospital.
  8.  

  9. At no time should lifesaving medical care be delayed in order to establish identities or medical control. It is the responsibility of the paramedic to institute appropriate medical care ASAP.

ALS and BLS Team Approach

  1. The EMS provider with the highest level of certification is responsible for the initial assessment of all patients unless the number of patients or the severity of injuries makes this impossible.
  2.  

  3. In the event of a non-transport (refusal or non-viability), the EMS provider with the highest level of certification is responsible for the assessment and documentation unless the number of patients and the severity of injuries make this impossible.
  4.  

  5. In situations where a BLS crew has requested a paramedic for assistance and the paramedic feels BLS transport is indicated, the paramedic will continue to assist the BLS crew throughout the transport.
  6.  

  7. Patient care may be delegated from the Paramedic to the EMT under the following conditions:
  8.  

    1. The patient is stable and does not meet any of the criteria for ALS transport listed below.
    2.  

    3. The Paramedic fully informs the EMT of assessment findings and anticipated patient needs.
    4.  

    5. The EMT is comfortable with accepting responsibility for treatment and transport.
    6.  

    7. The patient has not received any ALS treatment (i.e. – IV therapy, intubation, etc.)
    8.  

    9. The Paramedic fully documents assessment findings and treatment up to the point of delegation of patient care to the EMT.

 

ALS treatment and transport is indicated if the patient has one or more of the following conditions. If the BLS crew is able to deliver the patient to an emergency department in less time than it would take for the ALS crew to make contact, the BLS crew should complete transport. Waiting for ALS to arrive should not cause delays in transporting the patient.

    Shortness of breath or acute dyspnea
    Chest pain or anginal equivalent
    New onset altered level of consciousness
    Uncontrollable bleeding
    Unconsciousness
    Seizures
    Patient meets Trauma Alert Criteria
    Patient meets Medical Alert Criteria
    Shock signs/symptoms (unstable patient)
    OB at > 20 weeks with contractions and:
              - Evidence of meconium staining
    or

              - Vaginal Bleeding
    Childbirth prior to 38 weeks gestation
    Syncope or near-syncope
    Symptomatic with abnormal vital signs
    Any uncertainty about the patient’s status

Any time the EMS provider believes the patient’s condition warrants ALS treatment and care.

Transportation / Destination

  1. A patient is anyone who has either requested an ambulance or has had an ambulance requested for them. All patients who have activated the EMS system will be transported to a hospital campus with EMS radio communication capabilities unless patient refuses transport. (See Non-Transported Patient)
  2.  

  3. Patients will be transported to the patient's hospital of choice when their condition is stable and they do not meet a special needs situation. The EMS provider is responsible for informing the patient that transport to a specific hospital may be better for their specific medical situation.
  4.  

  5. Special needs considerations for hospital choice include:
  6.  

    1. Patients with multi-systems trauma → Trauma Center
    2.  

    3. Patients with serious burns → Burn Center (in case of burn diversion closest appropriate trauma center) – See Burn Center criteria
    4.  

    5. OB in 2nd and 3rd trimester → Hospital with Labor and Delivery
    6.  

    7. STEMI / CVA → Hospital with resources for that specialty
    8.  

      1. Patients with ROSC following cardiac arrest should be transported to a PCI-capable facility

       

    9. Children with known or suspected button battery ingestion should be transported to Peyton Manning CHildren's Hospital or Riley Children’s Hospital.

     

  7. If there is an immediate threat to loss of life or limb, the EMS provider may use their judgment and transport the patient to the nearest or most appropriate facility. The EMS provider will advise the patient and the family of this decision. The EMS provider will make every effort to explain the rationale behind the decision.
  8.  

  9. In the interest of safety and well being for EMS providers, patients, and community members, it is realized that red lights and sirens must be used appropriately when transporting to the hospital. If, in the judgment of the EMS provider, there is a "time critical" threat to life or limb, red lights and sirens are appropriate.
  10.  

  11. Special Considerations for Pediatric Trauma Pediatric Trauma Transport Destination Protocol:
  12.  

    1. Patients with multi-system trauma → trauma center
    2.  

      1. Patients under the age of 15 should be transported to Riley Hospital for Children.
      2.  

      3. If adults and children from the same family meet major trauma criteria, children should be transported separately to the Riley Hospital for Children. If the injured adult refuses to be separated from the child, the adult should be informed of the risks of taking the child to a non-pediatric trauma center and both should be taken to a trauma center with capabilities for both age groups.
      4.  

      5. In the case of Pediatric MCI, activate the MedMACC. In these cases, some children may need to be transported to non-pediatric specific trauma centers. This should occur with the following considerations:
      6.  

        1. In MOST cases Riley Hospital for Children estimates that they can take 4 RED, 8 YELLOW, and 30 GREEN
        2.  

        3. In situations in which injured children need to be triaged to hospitals OTHER than Riley, the sickest and youngest of the injured children should be preferentially taken to Riley. The other critically injured should be dispersed equitably and with primary consideration to travel distance to the following trauma centers:
        4.  

             Eskenazi Hospital
             Methodist Hospital
             Peyton Manning Children’s Hospital, (while not a pediatric trauma center, they may accept up to 2 reds, 6 yellow and unlimited green in the setting of DECLARED Pediatric MCI only.)

Non-Transported Patient

  1. Transportation of the patient for additional evaluation and care should always be the goal of EMS providers regardless of the acuity of the patient’s complaint. Should the patient state that they are refusing transportation, the EMS provider will enlist the aid of the patient’s friends and family members present to encourage the patient to agree to additional treatment and transportation. Any fears or concerns the patient might have should be discussed.
  2.  

  3. Medical control must be consulted when a patient is refusing transport and any of the following applies:
  4.  

    1. Patient has an abnormal mental status, indicated by:
    2.  

      1. Slurred or abnormal speech
      2. Disorientation to person, place, or time
      3. Inappropriate or irrational thinking

       

    3. Patient is less than 1 year old.
    4.  

    5. There are any historical data, symptoms, or signs suggestive of a potentially life threatening illness or injury.
    6.  

    7. Patient does not have access to a phone or “significant others” to aid in getting further care if needed.

     

  5. When Medical Control is contacted, the physician will be apprised of the situation and whether the SOR is against the EMS personnel’s medical advice. The physician will be asked for recommendations, and may ask to speak directly to the patient. The EMS provider should record the hospital, physician’s name, and the recommendations on the patient care report of the Refusal of Transport or Signature of Release form.
  6.  

  7. To accept the patient’s decision not to receive treatment and/or transportation, the following must be performed:
  8.  

    1. The patient or the patient’s guardian is informed:
    2.  

      1. That transport is indicated for further evaluation and care by an emergency department physician.
      2. That the patient has not been evaluated by a physician.
      3. That significant medical problems may exist and that these potential problems cannot be fully described at this time, but may possibly lead to significant disability or even death.
      4. To seek follow-up medical care as soon as possible.
      5. That 911 may be called at any time should they change their mind and wish to be transported to a hospital emergency department.

       

    3. The patient is asked if they understand the risks in refusing further medical care, and additional explanation is provided as needed.
    4.  

    5. The refusal form is signed by the patient or their guardian after they read (or have read to them) the statement of refusal.
    6.  

    7. A complete patient care report with all assessment findings and vital signs must be completed by the highest medical authority on scene in addition to the refusal-specific documentation.

     

  9. In the event the patient is less than 18 years old, these persons may take responsibility for the child:
  10.  

    1. Parent or legal guardian
    2. Individual in loco parentis (someone who assumes the duties and responsibilities in place of a parent, e.g., grandparent, aunt, uncle, babysitter, principal, police officer) if:
    3.  

      1. There is no parent or legal guardian present; or
      2. The parent or legal guardian is not reasonably present or declines to act; or
      3. The existence of the parent or legal guardian is unknown to the health care provider.

       

    4. Adult sibling of the minor if:
    5.  

      1. There is no parent, legal guardian, or individual in loco parentis present; or
      2. The parent, legal guardian, or individual in loco parentis is not reasonably present or declines to act; or
      3. The existence of the parent, legal guardian, or individual in loco parentis is unknown to the health care provider.

       

    6. The minor patient if there is compelling evidence of emancipation as defined under Indiana Code 16-36-1-3(a)(2)(A)-(E):
    7.  

      1. At least 14 years of age; and
      2. Not dependent on a parent for support; and
      3. Living apart from the minor’s parents or from an individual in loco parentis; and
      4.  

        1. Managing the minor’s own affairs; or
        2. Is or has been married; or
        3. Is in the military service of the United States; or
        4. Is authorized to consent to health care by any other statute.

     

  11. If the patient is a minor and none of the above can be contacted, the patient should be transported to the closest, most appropriate facility.

Safe Transport of Pediatric Patients

  1. These guidelines apply to every EMS response resulting in the need to transport pediatric patients and require the use of a safety seat or restraint (as defined below). Pediatric patients that do not require a child safety seat or restraint should be transported following the same procedure as adult patients. Unlike other situations, choice of safety restraints are directly related to the child’s size. Therefore, for the purposes of this protocol, child specific safety seats or restraints are required until the child has reached adult size by provider judgment (As a general guide, greater than 5 feet tall and 100 lbs. ).
  2.  

  3. These guidelines offer recommendations, as published by NHTSA, for the transportation of children in five (5) different possible situations:
  4.  

    1. A child who is not injured or ill.
    2. An ill or injured child whose condition does not require continuous and/or intensive medical monitoring/intervention.
    3. An ill or injured child who does require continuous and/or intensive monitoring/intervention.
    4. A child whose condition requires spinal motion restriction and/or lying flat.
    5. A child or children who require transport as part of a multiple patient transport (newborn with mother, multiple children, etc.).

     

  5. General Guidelines
  6.  

    1. Each agency is responsible for providing child restraint options that are compatible with their transporting vehicles. These guidelines do not comprehensively cover all possible situations and EMS provider judgment should be used if a situation is presented that is not addressed below.
    2.  

    3. The child’s age and weight shall be considered when determining an appropriate restraint system. Child seat models offer a wide range of age/weight limits, so each individual device must be evaluated to determine the appropriateness of use.
    4.  

    5. The child’s own safety seat is the preferred device unless the device has been involved in a motor vehicle crash, cannot be safely secured in the vehicle or the child needs care and monitoring that cannot be delivered with the child in the car seat.
    6.  

      1. With the exception of a minor vehicle crash (e.g. “fender-bender”), avoid using the child’s own safety seat if the seat was involved in a motor vehicle crash. However, using the child’s own seat can be considered if no other restraint systems are available and the seat shows no visible damage/defect.

       

    7. Transportation of a child in any of the following ways is NEVER appropriate:
    8.  

      1. Unrestrained;
      2. On a parent/guardian/other caregiver’s lap or held in their arms;
      3. Using only horizontal stretcher straps, if the child does not fit according to cot manufacturer’s specifications for proper restraint of patients;
      4. On the multi-occupant bench seat or any seat perpendicular to the forward motion of the vehicle, even if the child is in a child safety seat.

       

  7. Situation Guidelines
  8.  

    *Ideal transport method is in bold & highlighted, with acceptable alternatives listed.

     

    1. The uninjured/not ill child shall be transported:
    2.  

      1. In a vehicle other than a ground ambulance using a properly installed, size-appropriate child restraint system.
      2. In a size-appropriate child seat properly-installed in the front passenger seat of the ambulance with the airbags off or in another forward-facing seat.
      3. In a size-appropriate child seat properly-installed on the rear-facing EMS provider’s seat.
      4. Consider delaying the transport of the child (ensuring appropriate adult supervision) until additional vehicles are available without compromising other patients on the scene. Consult medical direction/operations.

       

    3. The ill/injured child not requiring continuous intensive monitoring/interventions, shall be transported:
    4.  

      1. In a size-appropriate child restraint system secured appropriately on the cot.
      2. In the EMS provider’s seat (captain’s chair) in a size-appropriate restraint system.
      3. On the cot using three horizontal straps (chest, waist, knees) and one vertical restraint across each shoulder (X formation).

       

    5. The ill/injured child whose condition requires continuous intensive monitoring or intervention, shall be transported:
    6.  

      1. In a size-appropriate child restraint system secured appropriately to cot.
      2. On the cot using three horizontal straps (chest, waist, knees) and one vertical restraint across each shoulder (X formation). If assessment/intervention requires the removing of restraint strap(s), restraints should be re-secured as quickly as possible.

       

    7. The ill/injured child who requires SMR or lying flat, shall be transported:
    8.  

      1. Secured to a size-appropriate LBB, then secure the LBB to the cot, head first, with a tether at the foot (if possible) to prevent forward movement, and three horizontal restraints (chest, waist, and knees) and a vertical restraint across each shoulder (X formation).
      2. Secured to a standard LBB with padding added as needed and secure using the strap configuration listed above.

       

    9. The child or children requiring transport as part of a multiple patient transport.
    10.  

      1. If possible, for multiple patients, transport each as a single patient according to the guidance provided for situations 1 through 4. For mother and newborn, transport the newborn in an approved size-appropriate restraint system in the rear-facing EMS provider seat with a belt-path that prevents both lateral and forward movement, leaving the cot for the mother.
      2. Consider the use of additional units to accomplish safe transport, remembering that non-patient children should be transported in non-EMS vehicles, if possible.
      3. When available resources prevent meeting the criteria for situations 1 through 4 for all child patients, transport using space available in a non-emergency mode, exercising extreme caution and driving at a reduced speed.
      4. Note: Even with childbirth in the field, it is NEVER appropriate to transport a child held in the parent/guardian/caregiver’s arms or on a parent/guardian/caregiver’s lap.

       

      Reference: Working Group Best-Practice Recommendations for the Safe Transportation of Children in Emergency Ground Ambulances. National Highway Traffic Safety Administration (NHTSA), September 2012, available at www.ems.gov

Language Considerations

Communication is a key to a thorough evaluation of the patient’s condition and determining necessary treatment. All services, agencies, and departments are strongly encouraged to have interpretation services available for EMS personnel to contact in the event of a language barrier.

 

English/Spanish Translations

 

 I am a paramedic  Soy paramédico.
 How are you?  Cómo se siente?
 What's the matter?  Qué le ocurre?
 Speak slowly please.  Hable despacio, por favor.
 You must go to the hospital.  Tiene que ir al hospital.
 We're going to take you to the hospital, OK?  Vamos a llevarle al hospital. ¿De acuerdo?
 Understand?  ¿Me comprende?
 What is your name?  Cómo se llama?
 What is your age?  Cuántos años tiene?
 Where do you live?  Dónde vive?
 Are you allergic to medicine?  Sufre de alguna alergia a las medicinas?
 Where does it hurt?  Dónde le duele?
 Does it hurt here?  Le duele aquí?
 How much does it hurt? Bad? Mild? Little?  Quanto duele? Malo? Suave? Poco?
 Do you take medications?  Toma usted medicamentos?
 Do you have insurance?  Tiene seguro médico?
 What hospital do you want to go to?  A qué hospital quiere ir?
 Sign here please.  Firme aquí, por favor.
 Do you feel better?  Se encuentra mejor?
 Do you take Viagra?  Toma Viagra o otra?
 Please don't move.  No se mueva, por favor.
 Any questions?  Tiene alguna pregunta?

Refusal of Transportation Statements

 Emergency personnel have offered to transport me to the hospital for further evaluation and care. I refuse this service.  Aunque el personal de emergencia se ha ofrecido a llevarme al hospital para que me realicen más pruebas y para recibir más atención médica, yo rechazo este servicio.
 I understand that I have not been evaluated by a physician and that serious medical problems may still exist which may result in disability or death.  Yo comprendo que no me ha examinado un médico y que posiblemente tenga problemas de salud graves que puedan causarme incapacidad o incluso la muerte.
 I understand that I may call 911 or an ambulance at any time if I change my mind and wish to be taken to a hospital.  Entiendo que puedo llamar al 911 o a una ambulancia en cualquier momento si cambio de opinión y deseo que me lleven al hospital.
 I understand that I am assuming full responsibility for my continuing medical care.  Yo asumo toda la responsabilidad de buscar atención médica

Guidelines for Initiating Resuscitation Efforts

  1. Basic and/or Advanced cardiac life support must be started on all patients who are found apneic and pulseless, UNLESS meets Dead On Arrival (DOA) Criteria:
  2.  

    1. Valid DNR (see below)
    2.  

    3. Obvious signs of prolonged death such as rigor mortis, dependent lividity, or decomposition
    4.  

    5. Injury that is incompatible with life (i.e. decapitation, or burned beyond recognition without detectable signs of life, gross dismemberment including crushing of head or torso)

     

  3. If any of the above applies, do not start CPR. Contact the appropriate authorities and complete a patient care report.
  4.  

  5. Resuscitation efforts should begin immediately in all other cases. If in doubt, start resusucitation. CPR shall be performed according to current AHA standards. The appropriate protocol shall be followed for further treatment.

Guidelines for Termination of Resuscitation Efforts
(For Patients > 15 y/o)

Termination of Resuscitation for Medical Cardiac Arrest:

 

  1. Termination of resuscitation may be appropriate for victims of medical cardiac arrest who have no return of spontaneous circulation after 30 minutes of advanced life support. This therapy should include, at a minimum, CPR with minimal interruptions, ventilation with oxygenation, intravenous or intraosseous access, and administration of fluids and/or appropriate medications per protocol.
  2.  

  3. Resuscitation may also be terminated by contacting intended receiving facility.
  4.  

  5. If ROSC is achieved but cardiac arrest re-occurs, the patient should be transported. Do not reset or restart the 30-minute resuscitation time.

Termination of Resuscitation for Traumatic Cardiac Arrest:

 

  1. Resuscitative efforts should be withheld for trauma patients that meet DOA criteria. See above guidelines.
  2.  

  3. Resuscitation may be terminated for blunt or penetrating traumatic arrest found pulseless and apneic (without agonal respirations) and without organized electrical activity (must be asystolic or other rhythm with rate less than 40/min). Patients with ventricular fibrillation, ventricular tachycardia or organized rhythms with rate greater than 40/min should have resuscitation continued with prompt transport.
  4.  

  5. When the mechanism of injury does not correlate with the clinical condition, suggesting a non-traumatic cause of cardiac arrest, standard resuscitative measures should be followed.
  6.  

  7. If an adult patient was asphyxiated by hanging, initiate on-scene resuscitation care for 30 minutes or ROSC. Terminate if no ROSC after 30 minutes of resuscitation. If ROSC occurs, transport to a trauma center and identify as a trauma alert.

 

Exemptions: Standing termination protocols do not apply for patients under 15 years of age, females with known pregnancy >24 week or uterine fundus palpable above the umbilicus, victims of lightning strikes, victims of cold water drowning (unless known submersion time greater than 30 minutes in adults or 90 minutes in children), or victims with hypothermia as suspected etiology of cardiac arrest. Please refer to appropriate protocols.

Guidelines for DNR/POST/Advanced Directives

  1. If persons present at the scene of a patient in cardiopulmonary arrest request that resuscitative measures be withheld, request to see a DNR/POST order which has been signed by the attending physician or chart order (if an ECF patient).
  2.  

  3. If the DNR/POST order is presented and resuscitative efforts are not attempted, complete a patient care report with assessment findings, contact the attending physician, and contact the appropriate authorities.
  4.  

  5. In the event the documents cannot be produced immediately, begin resuscitative efforts in accordance with the appropriate protocol and contact the receiving facility for further orders.
  6.  

  7. If the paramedic questions the validity of the DNR order, resuscitative efforts should be initiated. Contact the emergency department physician at the intended receiving facility for further orders. These guidelines do not apply to a Living Will

Traumatic Cardiac Arrest Resuscitation

  1. If patient is unresponsive and has no palpable pulse with evidence of trauma being most likely cause of cardiac arrest and does not meet DOA criteria:
  2.  

    1. Position patient in position where resuscitation efforts can be initiated
    2. Apply manual c-spine stabilization or c-collar if situation allows
    3. Apply cardiac monitor and treat displayed rhythm
    4.  

      1. Asystole or PEA with rate < 40
        1. Terminate resuscitation
      2. PEA with rate > 40
        1. Prompt transport to nearest trauma center with continued resuscitation
      3. VFib/VTach
        1. Defibrillate per protocol
        2. Prompt transport to nearest trauma center with continued resuscitation

       

    5. Control obvious external hemorrhage by application of direct pressure and/or tourniquet as needed.
    6. Start chest compressions at rate 100 per minute with minimal interruptions
    7. Provide oxygenation and ventilation by BVM or advanced airway as indicated.
    8. If mechanism of injury was blunt or penetrating trauma to chest, strongly consider bilateral needle thoracostomy.
    9. Obtain vascular access by IV or IO and initiated fluid resuscitation.

     

  3. Transport to nearest trauma center
  4.  

    1. Transport if ROSC achieved
    2.  

    3. Transport if PEA (organized rhythm) with rate > 40 or persistent VF/VT
    4.  

    5. Penetrating or blunt trauma with witnessed cardiac arrest by EMS provider
    6.  

    7. Females with known pregnancy > 24 weeks or uterine fundus palpable above the umbilicus

Medical Alert Criteria

    Suspected acute MI
    Suspected Sepsis
    Acute neurological deficits of < 6 hours duration
    Inspiratory stridor

 

Physiological

 

    Systolic BP (SBP) < 90 mmHg or vital signs outside of physiologic ranges for pediatrics
    GCS < 13
    Respiratory rate < 10 or > 30 (adults), < 15 or > 45 (peds)
    Heart rate < 40 or > 120
    Temp < 92°F or > 105°F
         - Usually determined in the transferring ED
    Oxygen saturation < 88%
Healthcare provider discretion

Major Trauma Criteria

Physiologic

 

    Systolic BP < 90 mm Hg or vital signs outside of physiologic ranges for pediatrics
    Glasgow Coma Scale (GCS) ≤ 13
    Respiratory rate < 10 or > 29
    Patient receiving blood to maintain vital signs
    Airway or respiratory compromise as defined by:

      BVM, Intubation, adjunct airway, or cricothyroidotomy in the field
      Needle chest decompression

 

Anatomic

 

    Penetrating trauma to the head, neck, chest, abdomen, or extremities proximal to the knees and elbows
    Traumatic amputation proximal to the wrist or ankle
    Burns > 15% or high voltage (>1000 volts) electrical injury
    Any crushed, degloved, pulseless, or mangled extremity
    Pelvic fracture
    Two or more long bone fractures (tibia/fibula or radius/ulna count as only 1 bone)
    Flail chest
    Extremity paralysis suggestive of spinal cord injury
    Open or depressed skull fracture
    Victim of hanging who meet above criteria

 

Healthcare provider discretion

Trauma Alert Criteria

Mechanism of Injury
    Ejection from vehicle
    Vehicle roll-over
    Prolonged extrication from vehicle
    Pedestrian struck by vehicle at speed > 20 MPH
    Falls > 20 feet (adults) or > 3x the child’s height

 

Healthcare provider discretion

Glasgow Coma Scale

Eye Opening Spontaneous
4
To Voice
3
To Pain
2
None
1
Verbal Response Oriented
5
Confused
4
Inappropriate Words
3
Incomprehensible Sounds
2
None
1
Verbal Response Obeys Commands
6
Purposeful Movement to Pain
5
Withdraw to Pain
4
Flexion to Pain
3
Extension to Pain
2
None
1
Total  
3 - 15

Pediatric
Glasgow Coma Scale

(for use with children less than school age)
Eye Opening Spontaneous
4
To Sounds
3
To Painful Stimuli
2
None
1
Verbal Response Appropriate Words or Social Smile
5
Cries but Consolable
4
Persistently Irritable
3
Restless, Agitated
2
None
1
Verbal Response Spontaneous Movement
6
Localizes to Pain
5
Withdraw to Pain
4
Flexion to Pain
3
Extension to Pain
2
None
1
Total  
3 - 15

Mass Casualty Procedures

Critical Actions Upon Arrival

    Don appropriate protective equipment
    Report to assigned staging area/ group leader
    Park vehicle at location directed by Staging Officer – avoid blocking street
    Verify you are on the proper radio channel
    Transporting Units:
      → Notify Transport Officer of arrival
      → Remain in vehicle and await assignment from Transport Officer
      → When parking for patient transport, park using “Drive Through Loading” (preferred) or Back in to allow for quicker driving out
      → If Level 1 MCI, mark in service after transport. If Level 2 or 3 MCI return to staging emergent unless released by command.
EMS Roles to be filled by priority

 

1st Arriving:
Medical Group Leader

 

2nd Arriving:
Transport Officer

 

3rd Arriving:
Triage/Treatment Officer

 

4th Arriving:
Staging
(Consider off site)

 

  1. During a declared Mass Casualty Incident:
    1. The hospital destination will be determined by the on-scene Transport Officer.
      If Transport Officer not yet designated, the role will be the responsibility of the Medical Group leader.
    2. The Transport Officer has the authority to require an ambulance transport more than one patient at a time in the same ambulance, if sufficient seat restraints are available.

  2. During an Active Shooter/Hostile Event causing a declared Mass Casualty Incident:
    1. The primary goal is rapid extraction and transport of patients – do not delay transport for on-scene treatment.
    2. Use modified “Applied Ballistics” Triage System instead of START Triage

  3. During a Mass Casualty Incidents caused by a lightning strike
    1. Use “reverse triage” – treat patients who are pulseless or apneic first. CPR and defibrillator use is appropriate.

  4. During other types of Mass Casualty Incidents:
    1. Use START/JumpSTART Triage

Applied Ballistics Triage

Use during declared Mass Casualty Incident from an Active Shooter/Hostile Event.

 

  1. Perform life-saving interventions, which include:
    1. Tourniquet Application/Hemorrhage Control
      Opening airway
      Needle decompression (if paramedic)

  2. Patients that have penetrating wounds to the head/torso/abdomen/proximal extremities and still are breathing should be considered “red/immediate” and prioritized for trauma center transport.

  3. Patients with penetrating wounds that are distal to the elbow or knee without a tourniquet in place should be considered “yellow/delayed” and taken to non-trauma centers.

If no
tourniquet
required

Can go to any
hospital -
avoid
trauma centers.

START Triage

Marion County EMS providers have adopted a simple system for triaging patients in a multiple-patient scenario or a mass casualty incident. It is acknowledged that, under these circumstances, some patients that EMS could potentially save if encountered individually will not be given the benefit of all necessary resources.

Criteria
Tag
Move the walking wounded
Minor
No resp after head tilt - jaw thrust
Dead / Dying
Respirations > 30
Immediate
Pulse: No radial puls (least injured arm)
Immediate
Mental status: Unable to follow simple commands
Immediate
Otherwise
Delayed
Developed by the Newport Beach, CA Fire & Marine Dept., and the current DOT Standard for EMS providers.

Jump START Triage

Jump-START is a modification of the START triage guidelines for pediatric patients and takes into account the normal variation in respiratory rate on the basis of age, and the fact that primary respiratory failure can be corrected easily.

 

An apneic child is more likely to have a primary respiratory problem than an adult. Perfusion may be maintained for a short time and the child may be salvageable.

 

A respiratory rate of 30 may either over-triage or under-triage a child, depending on age.

 

Capillary refill may not adequately reflect peripheral hemodynamic status in a cool environment.

 

Obeying commands may not be an appropriate gauge of mental status for younger children.

 

Criteria (Ages 1 - 8)
Tag
Move the walking wounded
Minor
Apneic or irregular respirations: Open airway
Resume breathing?
Immediate
Still apneic and no peripheral pulse?
Dead / Dying
Still apneic but has a peripheral pulse
Mouth-toMask for 15 seconds (4-5 breaths)
Resume breathing?
Immediate
Still apneic?
Dead / Dying
Respirations < 15 or > 45
Immediate
Pulse: No peripheral pulse (least injured extremity)
Immediate
Mental status: Unresponsive or responsive to pain only
Immediate
Otherwise
Delayed
Age < 1:
If all Jump-START “delayed” criteria are satisfied and there are no significant external injuries, the child may be classified as “ambulatory” and tagged.
Minor
Developed by Lou Romig MD, FAAP, FACEP at Miami Children’s Hospital

Decontamination of Patients

To decrease potential exposure of emergency and health care personnel, patients exposed to hazardous materials should be decontaminated at the scene as indicated by the exposure, given resources and patient condition. This guideline is for the medical treatment and transportation aspects of these patients, and does not encompass the hazardous materials response or mitigation.

 

  1. Ensure that each receiving hospital is notified as early as possible of
  2.  

    1. suspected agent(s),
    2. route of exposure (e.g., skin vs. inhalation), and
    3. estimated number of patients.

     

  3. Ensure that the Indiana Poison Center (IPC) is notified as early as possible of the suspected agent(s) and likely receiving hospital(s). Med-1 or the IHERN is preferred; the IPC is also available at (317) 962-2323 or (800) 222-1222.
  4.  

  5. Perform decontamination as indicated by the exposure.
  6.  

    1. Upon completion of decontamination and/or removal of contaminated clothing, patients should be covered (including feet).
    2.  

    3. If the patient’s clothing is removed, it should remain at the scene; valuables may come with the patient sealed in a plastic bag.

     

  7. Treat and transport patients per appropriate out-of-hospital care guidelines. Utilize appropriate personal protective devices to decrease likelihood of EMS personnel exposure.
  8.  

  9. For each patient transported, notify the receiving hospital en route of the patient’s medical and/or trauma issues, condition, and the type of decontamination performed.
  10.  

  11. Deliver patients to the appropriate area at the Emergency Department.
  12.  

    1. If additional decontamination is needed, this will typically not be directly into the ED, but rather to the adjacent decontamination area.
    2.  

    3. Unless otherwise directed, do not drive the ambulance into an enclosed area (e.g., garage)

     

  13. At the conclusion of all out-of-hospital patient assessment and transport activities, ensure that each hospital contacted in #1 and the IPC is notified of
  14.  

    1. The total number of patients transported (or if no patients are coming).
    2. The conclusion (“all clear”) of out-of-hospital EMS activity at the scene.

Universal Precautions

SINCE MEDICAL HISTORY AND EXAMINATION CANNOT RELIABLY IDENTIFY ALL PATIENTS INFECTED WITH BLOOD BORNE PATHOGENS, BLOOD AND BODY FLUID, UNIVERSAL PRECAUTIONS SHALL BE USED FOR ALL PATIENTS.

 

  1. Universal blood and body fluid precautions (the use of barriers) shall be used for all patients if contact with blood or body fluids is possible regardless of whether a diagnosis is known. EMS providers are responsible to use the personal protective equipment (PPE) made available by their employer.
  2.  

  3. PPE should be removed immediately after patient contact to avoid contamination of other surfaces (i.e. – steering wheel, door handles, clip boards, pens, etc.)
  4.  

  5. Personnel with patient contact responsibilities, who have any open lesions, cuts, or skin conditions such as eczema, should report such conditions to management personnel prior to beginning their scheduled shift. Management may consult the Medical Director or Occupational Health physician when appropriate.
  6.  

  7. Personnel should have been assessed for the need for immunization against the Hepatitis B Virus.
  8.  

  9. Personnel will, upon hire and annually thereafter receive education and training pertaining to infection control guidelines to be observed for their service.
  10.  

  11. Body fluids include: saliva, sputum, gastric secretions, urine, feces, CSF, breast milk, serosanguineous fluid, semen, or any drainage.
  12.  

  13. Immediately after use, sharps will be disposed of in provided biohazard, puncture resistant containers. Containers will be replaced when 3/4 full. Used needles shall not be sheared, bent, broken, recapped, or resheathed by hand. Used needles shall not be removed from disposable syringes. Do not lay or stick used needles in seat cushions.
  14.  

  15. Exposure to Blood and/or Body fluids:
  16.  

    1. Personnel sustaining an exposure (needle stick, mucous membrane, or skin contact) to blood and/or body fluids shall immediately cleanse the contaminated area with soap and water. If these are not immediately available, waterless hand cleaner shall be used.
    2.  

    3. In cases of splattering of blood or body fluids to the eyes and/or mouth, flush with copious amounts of water for 15 minutes.
    4.  

    5. Notify the employee’s appropriate leadership personnel.
    6.  

    7. Complete the Indiana State Board of Health REPORT OF BLOOD OR BODY FLUID EXPOSURE form and leave a copy of this at the receiving facility with any other paperwork left following patient care. Remaining copies shall be turned over to Management per the Department policy. This form must be filled out completely and accurately within twenty-four (24) hours.

     

  17. Hand washing is the most important infection control procedure. EMS providers should wash their hands:
  18.  

    1. after removing PPE
    2. after each patient contact
    3. after handling potentially infectious material
    4. after cleaning/decontaminating equipment
    5. after using the restroom
    6. before eating or preparing food

Blood & Body Fluid Exposure of EMS Personnel

Background:

 

The Ryan White Care Act of 1990 and amended in 1996 contains provisions for the notification of emergency response personnel exposed to infectious diseases while attending, treating, assisting, or transporting a victim. In Indiana, IC 16-41-10 provides for an emergency medical services provider (a firefighter, a law enforcement officer, a paramedic, an emergency medical technician, a physician or nurse licensed in Indiana, or other persons who provider emergency medical services in the course of their employment) who is exposed to potentially infectious blood or body fluids to get this notification in the following manner:

 

  1. EMS Provider must notify provider’s employer within 24 hours of the exposure on a form designated by the EMS Commission and the State Health Department. A copy of the form goes to:
  2.  

    1. The Medical Director of the health care facility to which the patient was taken following the exposure OR in the health care facility where the patient was located at the time of exposure, AND
    2.  

    3. The EMS provider’s employer, AND
    4. The State Health Department.

     

  3. A patient (including those unable to consent due to physical or mental incapacity) to whose blood or body fluids the EMS provider is exposed is considered to have consented to:
  4.  

    1. Testing for the presence of dangerous communicable diseases. These diseases are only those which are life-threatening by carrying a substantial risk of death if acquired by a healthy, susceptible host, and the disease can be transmitted from person to person. The diseases are:
    2.  

      1. Infectious pulmonary tuberculosis
      2. Hepatitis B, C
      3. HIV
      4. Diphtheria
      5. Hemorrhagic fevers
      6. Meningococcal disease
      7. Plague
      8. Rabies

       

    3. Release of the testing results to the Medical director of the health care facility (or other designated physician).
    4.  

    5. However, a medical facility may not restrain a patient in order to test the patient for dangerous communicable diseases, and nothing in the law prohibits a patient from being discharged from the medical facility before such testing is performed or the results of the tests are released.
    6.  

    7. A provider or a facility that tests patient for the presence of a dangerous communicable disease under this law is immune from liability for the performance of the test over the patient’s objections or without the patient’s consent.

     

  5. Within 72 hours of being notified of the exposure, the Medical director of the health care facility (or other designated physician) must notify the Medical Director of the EMS provider’s employer (or other physician designated in writing by the EMS provider) of the results of the test(s).
  6.  

  7. Within 48 hours of being notified of the results of the test(s), the Medical Director of the EMS provider’s employer (or other physician designated by the EMS provider) will
  8.  

    1. Explain, without disclosing information about the patient, the presence or absence of dangerous communicable disease(s) to which the provider was suspected to have been exposed, if any.
    2.  

    3. Provide any medically necessary treatment and/or counseling to the EMS provider. Expenses of testing, treating, or counseling the EMS provider are the responsibility of the EMS provider or the provider’s employer.

Infection Control Procedures

 

  1. All body fluids from all patients will be considered potentially to be infectious. All emergency response employees are to use the personal protective equipment (PPE) made available by their employer. It is the employee's responsibility to wear the appropriate PPE in order to have maximum protection against infectious disease.
  2.  

  3. Handwashing is the most important infection control procedure! Emergency response employees will wash hands:
  4.  

    1. after removing PPE
    2. after each patient contact
    3. after handling potentially infectious materials
    4. after cleaning or decontaminating equipment
    5. after using the bathroom
    6. before eating
    7. before and after handling or preparing food

     

  5. Handwashing will be performed for at least 10-15 seconds, utilizing soap and water or an alcohol-based solution.
  6.  

  7. Eating, drinking, smoking, handling contact lenses, or applying cosmetics or lip balm is prohibited at the scene of EMS operations.
  8.  

  9. Disposable resuscitation equipment and supplies will be used whenever possible. For CPR, the order of preference is:
  10.  

    1. Disposable bag-valve mask
    2. Disposable pocket mask with one-way valve
    3. Mouth-to mouth resuscitation

     

  11. After use, all PPE and contaminated disposable patient care materials will be placed in leak proof bags, color coded and marked as a biohazard for disposal as soon as possible.
  12.  

  13. Contaminated work clothes will be removed and exchanged for clean clothes as soon as possible. The crew member will shower if body fluids were in substantial contact with skin under work clothes.

Post Exposure Control

 

  1. Any employee exposed to potentially infectious material will immediately wash the exposed area with soap and water or an alcohol-based solution (saline wash if the eyes are involved.)
  2.  

  3. Any employee having an occupational communicable disease exposure will immediately report the exposure to his/her supervisor. Needle stick injuries will be reported to the designated officer immediately.
  4.  

  5. The emergency response employee will fill out the appropriate exposure report forms at the soonest possible time after any exposure occurs.
  6.  

  7. All exposures to infectious or potentially infectious materials should be medically evaluated within the first hour after exposure as some prophylactic treatments are only effective if initiated within that time period. The following events will be considered potentially high risk exposures:
  8.  

    1. Hollow needle stick injuries.
    2. Breaks in the skin caused by potentially contaminated objects.
    3. Splash of blood or other potentially infectious material onto eyes, mucous membranes, or non-intact skin.

     

  9. All potentially high risk exposures will immediately be evaluated by a qualified medical care provider and a plan for prophylactic treatment will be initiated if deemed appropriate:
  10.  

    1. Blood (and urine sample for UPT, if applicable) may be obtained to establish a baseline.
    2. The decision to initiate anti-retroviral therapy is made without waiting for lab test results.
    3.  

      1. Current treatment guidelines will be followed.
      2. The patient will be referred to Occupational Health, Infectious Disease, and/or their private physician as appropriate.

       

    4. Whenever possible, the source patient will be traced to the receiving facility by the designated officer. The designated officer will notify the receiving facility that a communicable disease exposure has taken place, and request an infectious disease determination as provided for in IC 16-41-10.

Provider Credentialing and Authorized Procedures

 

  1. The EMS Agency’s medical director must authorize the credentialing of individuals to practice as an EMS provider at their agency, as well as the maintenance of said credentials.
  2.  

  3. The EMS Agency’s medical director has the authority to determine which clinical procedures are authorized within the scope of practice of each EMS provider.
  4.  

  5. The EMS Agency may remove a provider’s credentials, and therefore the provider from active duty as an EMS provider, to ensure patient safety and/or professional standards are met.

Request for New or Changed Protocol/Medical Equipment

 

  1. Documentation of the following information should be submitted to the agency’s EMS Medical Director for review:
  2.  

    1. Executive Summary (one-paragraph summary of everything below)
    2.  

      1. Define the problem.
      2.  

      3. How commonly is the problem encountered (e.g., cases per week, month, or year)
      4.  

        1. This should be data-based – either retrospectively (looking at patient care records) or prospectively (using a survey after calls)

         

      5. What is the proposed solution?
      6.  

        1. Provide a copy of the new protocol (in the usual format) and/or Identify all protocols that will require a change.
        2. What are the benefits? (e.g., reduced morbidity/mortality, increased patient comfort, increased patient care efficiency or effectiveness)
        3. What are the risks (e.g., side effects, complications)?
        4. What is the cost?
        5.  

          1. Direct costs (e.g., to supply all vehicles/kits plus spare supplies at station(s), how soon will it expire/become obsolete?

           

        6. Will special storage be necessary (e.g., refrigeration)?
        7. Indirect costs (e.g., education)

         

      7. What alternatives were considered? Why is the proposed solution the best choice?

     

  3. Include a list of the keywords used for the medical literature search, and a copy of the salient literature.