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PSVAC Training Session

PSVAC Training Session. January 4 th , 2009. Agenda. Protocol Changes Moshe Karp (30 minutes) Selective Spinal Immobilization Moshe Karp (30 minutes) Telemetry Contact (15 minutes) RMA policy (15 minutes) ***************** 15 Minute Break ******************

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PSVAC Training Session

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  1. PSVAC Training Session January 4th, 2009

  2. Agenda • Protocol Changes Moshe Karp (30 minutes) • Selective Spinal Immobilization Moshe Karp (30 minutes) • Telemetry Contact (15 minutes) • RMA policy (15 minutes) ***************** 15 Minute Break ****************** • Albuterol Matt Jachyra (30 minutes) • Epi Pen Matt Jachyra (40 minutes) • New SCAM report Will Tung (10 minutes) • MOLST / DNR Orders Will Tung (15 minutes) • SAFE Centers Will Tung (10 minutes) Total time: 3 Hours, 30 Minutes PSVAC Training

  3. 2009 NYC REMSCO Protocol Changes Moshe Karp

  4. 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 PSVAC Training

  5. BLS Changes - GOPs • Page A.8 PSVAC Training

  6. BLS Changes - GOPs • The result of this protocol can be thought of in terms of this diagram PSVAC Training

  7. 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. PSVAC Training

  8. 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 PSVAC Training

  9. 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. PSVAC Training

  10. 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. PSVAC Training

  11. 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. PSVAC Training

  12. 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. PSVAC Training

  13. 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. PSVAC Training

  14. 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. PSVAC Training

  15. 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. PSVAC Training

  16. 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. PSVAC Training

  17. Selective Spinal Immobilization Moshe Karp

  18. NYS Spinal Update PSVAC Training

  19. 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. PSVAC Training

  20. 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. PSVAC Training

  21. 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. PSVAC Training

  22. BLS Protocols

  23. Selective Spinal Immobilization Patients meeting one or more of the following criteria must be immobilized: • Altered mental status for any reason, including possible intoxication due to drugs or alcohol. • GCS <15 PSVAC Training

  24. Selective Spinal Immobilization • Complaint of, or inability of the provider to assess for, neck and/or spine pain or tenderness. • Weakness, paralysis, tingling, or numbness of the trunk or extremities at any time since the injury. • Deformity of the spine not present prior to the injury. PSVAC Training

  25. Selective Spinal Immobilization • Distracting injury or circumstances, including anything producing an unreliable physical exam or history. PSVAC Training

  26. Selective Spinal Immobilization • High risk mechanism: • axial load such as diving or tackling, • high-speed motor vehicle accidents, • rollover accidents, • falls greater than standing height. • Provider concern for potential spinal injury. PSVAC Training

  27. 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. PSVAC Training

  28. 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. 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 PSVAC Training 31

  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 PSVAC Training 32

  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 PSVAC Training 33

  33. Who To Call Methodist Medical Control (718) 780-5555 January 4th, 2008 PSVAC Training PSVAC Training 34

  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 PSVAC Training 35

  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 PSVAC Training 36

  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 PSVAC Training 38

  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 PSVAC Training 39

  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 PSVAC Training 40

  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 PSVAC Training 41

  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 PSVAC Training 42

  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 PSVAC Training 43

  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 PSVAC Training 44

  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 PSVAC Training 45

  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 PSVAC Training 46

  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 PSVAC Training 47

  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 PSVAC Training 48

  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 PSVAC Training 49

  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 PSVAC Training 50

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