EMERGENCY MEDICAL TECHNICIAN

1. EMERGENCY MEDICAL TECHNICIAN Lisa Cookston ROP Career Specialist Orange County Emergency Medical Services

2. EMT Externship • Goal to understand and participate in supplementing current EMT curriculum with new nationwide standards. • I chose to explore Orange County’s EMT program because I work with many students who are interested in EMT and Fire service. • I also work with Coastline Regional Occupational Program’s EMT courses scheduling EMT students for their clinical experiences.

3. OCEMS • Patrick Powers Paramedic BLS Program Coordinator ppowers@ochca.com 714-834-6233

4. OCEMS • 405 w. Fifth Street Suite 301A Santa Ana, Ca 92701 714-834-3500 • Monthly Meetings April 2009-July 2009

5. EMT Classes • EMT classes are offered through out Orange County through community colleges and ROP programs. • The curriculum for these classes encompassed 12 basic life support skills. To meet Orange County Emergency Services accreditation 6 new skills were added to the EMT curriculum.

6. EMT Existing Skills 1.  Cardiac arrest management/ AED 2.  Bag Valve Mask apenic patient 3.  Spinal immobilization supine patient 4.  Spinal immobilization seated patient 5.  Immobilization skills log bone 6.  Immobilization skills joint injury

7. Existing Skills continued 7.  Immobilization skills traction splinting 8.  Bleeding control/shock management 9.  Airway, oxygen and ventillation skills upper airway adjuncts and suction 10.Mouth to mask with supplemental oxygen 11.Oxygen administration 12.Ventilatory management endotracheal intubation (discussed with students but did not test on this

8. EMT Curriculum New Skills • MDI Assistance • IV Set-up/Monitoring • Endotracheal Tube and Tracheostomy Tube Suctioning • Glucose Monitoring • Epinephrine Auto – Injector • 12-Lead Placement

9. OCEMS EMT “Accreditation” Curriculum Intro to OCEMS Facilities (base stations, trauma centers, PRCs, CVRCc, Neuro Centers, Burn, etc…) Destination decisions (I-40 Transport Guidelines) The 13 ALS Providers The 1 air transport provider (Mercy Air), Orange County Fire Authority Air Rescue occasion may be available OCEMS approved CE providers with contact information OCEMS approved/accredited educational programs

10. EMT Scope of Practice • Handout of review of basic EMT State scope of practice • Specific Orange County EMS EMT scope of practice adds: Glucometer Tourniquet Interfacility Transport

11. Interfacility Transport • Intravenous: LR, TPN, < 20 mEq KCL/1000ml, additional other basic solutions per OCEMS medical director • Preset self-contained medication infusion pumps for IV, SQ routes • Chest tubes • Home ventilators and home CPAP

12. Interfacility Transport continued Central Lines: • Okay to Transport: Any central vascular access line that does not require a constant infusion to keep the line open. • Cannot Transport: Any patient with a central vascular access line that is presently being used to monitor the patient’s condition, status, and or signs of life – requires ALS for transport. • Cannot Transport: Any patient with an arterial line – requires ALS for transport.

13. Interfacility Transport Continued 6. Preset enteric feeding 7. Foley Catheter 8. Gastrostomy, colostomy and urostomy

14. Policies and Procedures • Provide handout of policy 300 and I-40 procedure • Review of I-40 Procedure, specifically transport information • Provide handout on OCEMS BLS treatment guidelines • Review of OCEMS DNR policy and California State POLST

15. Skills • Regarding Skills Competency Testing: • Skills competency checklist • Each training program shall use a common OCEMS approved skill checklist • Each student shall have a checklist completed for each skill that requires competency validation • Skills Testing • Each training program may choose to validate skills individually or in a group setting • If skills testing is performed in a group setting the proctor student ration shall not exceed 6 students for each proctor • Definitions: • Administer: A medication carried on a BLS ambulance (Medication brought to the scene by the EMT and stored in the ambulance) • Assist: A medication that is the patient’s own prescribed medication • Reinforce/review 7 patients rights of medication administration • Right Patient • Right Medication • Right Dosage • Right Route • Right Time (expiration, not exceeding maximum dose, etc…) • Right Documentation • Right Response (Proper reassessment and re-evaluation of patient)

16. CONTACT ALS and RAPID TRANSPORT (refer to I-40) for ALL of the Patients below: • Use of auto-injector • Epinephrine Auto-Injector • Review of Patient’s own epinephrine auto-injector • Medication administration technique • Proper disposal • Reassessment after interventions (oxygen, positioning, patient’s own epinephrine auto-injector, pulse oximetry monitoring, etc…) • Documentation of all of the above • Proficient student return demonstration of administration of a prop/trainer epinephrine auto-injector to a mock patient • Mark One® and Duodote® Auto-Injector for self administration • Review of S-L-U-D-G-E-M (salivation, lacrimation, urination, defecation, gastroinstestinal, emesis, muscle twitching) symptoms consistent with known or suspected exposure to an organophosphate

17. Mark One® and Duodote® Auto-Injector for self administration 2.Review of the types of antidote auto-injectors available for self administration 3.Review of technique for self administration 4.Reassessment of self looking for S-L-U-D-G-E-M symptoms or other changes to consider repeating auto-injector dose one time 5.Seek further medical care and documentation 6.Discuss limiting spread of nerve agent/organophosphate compound by speaking with public safety personnel on scene 7.Proficient return student demonstration of self administration of a prop auto-injector

18. Use of metered-dose-inhaler • Albuterol or Atrovent • Review of patient’s own metered-dose-inhaler (MDI) • Medication administration technique • Spacers • Reassessment after interventions (oxygen, positioning, patient’s own MDI, pulse oximetry monitoring, respiratory rate, tidal volume, effort quality, etc…) • Documentation of all of the above • Proficient student return demonstration of administration of a prop metered-dose-inhaler to a mock patient

19. Nitroglycerine – tablet and spray • Contraindications: • Systolic blood pressure less than 90 • Recent head injury • Recent use of medications to treat erectile dysfunction such as Viagra®, Levitra® or Cialis® • Nitroglycerine tablets • Review of patient’s own sublingual nitroglycerine tablets • Reassessment after interventions (oxygen, positioning, patient’s own nitroglycerine, pulse oximetry, pain scale, respiratory status, etc…) • Documentation of all of the above • Proficient student return demonstration of administration of a prop sublingual nitroglycerine tablet to a mock

20. Nitroglycerine – tablet and spray continued • Nitroglycerine Spray • Review of patient’s own sublingual nitroglycerine spray • Reassessment after interventions (oxygen, positioning, patient’s own nitroglycerine, pulse oximetry, pain scale, respiratory status, etc…) • Documentation of all of the above • Proficient student return demonstration of administration of a prop sublingual nitroglycerine spray to a mock patient

21. FDA® approved oral glucose agents – gels, tablets, liquid Contraindications: • Unresponsiveness • Inability to swallow or control own airway Oral Glucose Gel, Tablets and Liquids • Review of oral glucose gel, tablets and liquids and appropriate administration techniques • Reassessment after interventions (oxygen, positioning, oral glucose gel, pulse oximetry, mental status, etc…) • Documentation of all of the above • Proficient student return demonstration of prop oral glucose gel to a mock patient

22. 12-lead placement • Review of anatomical landmarks, intercostal spaces, and midclavicular line. • Demonstration of proper lead placement using anatomical landmarks • Discuss patient privacy/modesty and appropriate lead placement and techniques on women. • Proficient return student demonstration indicating proper placement of leads on either a manikin or other appropriate model

23. Pulse Oximetry Use • Review of proper application and placement of probe to assure reliable readings • Treat patient’s symptoms, not the pulse oximeters reading • Documentation of pulse oximeters readings • Care and maintenance of common pre-hospital pulse oximeters per manufacturer’s recommendations • Proficient return student demonstration of pulse oximetry use and documentation on a mock

24. Tourniquet application • Discuss and review control of hemorrhage to an extremity • Direct pressure • Demonstrate control of external hemorrhage to an extremity using an OCEMS approved tourniquet (proper placement in relation to wound and joints) • Demonstrate and discuss proper assessment of circulation, sensation and motor of the extremity before and after placement of the tourniquet and ongoing assessment • Documentation of tourniquet application • Proficient student return demonstration of application of an OCEMS approved tourniquet or simulated tourniquet to control hemorrhage to an extremity with proper assessment of circulation, sensation and motor before and after tourniquet application on a mock patient

25. Glucometer use • Review of aseptic technique, BSI and required equipment • Review of the steps of the procedure • Demonstration of the use of an FDA approved glucometer to obtain a fingerstick serum glucose value, including care of the wound and disposal of the sharp • Discuss and/or demonstrate the care, cleaning and routine calibration of a common FDA approved glucometer per manufacturer’s guidelines. • Proficient student return demonstration of obtaining a fingerstick serum blood glucose value and documentation of the results on a mock patient, with proper wound care, and sharps disposal

26. Monitoring IV site • Reference OCEMS intravenous policy ## • Review of types of IV tubing • Micro tubing • Macro tubing • Buretrol • Explanation of TKO (to-keep-open) or KVO (keep-vein-open) rate and how to calculate this by counting the drops per minute • Demonstrate how to prepare an IV bag and tubing for administration

27. Monitoring IV site continued • Discuss different types of common IV dressing and when it is appropriate to reinforce a dressing, such as when an IV site is leaking or bleeding • Discuss integrity of IV flow and common causes of occlusions • Monitoring the IV site • Signs and symptoms of IV site infiltration • Signs and symptoms of IV site infection • When to shut off the IV infusion by clamping the tubing and how • Discussion of types of preset infusion pumps

28. Student assessment • Final written exam standardized between all accreditation classes • 10 questions maximum

29. Addendum • Please see email attachments for skill sheets

30. Implementation • Fall 2009 EMT are including new accredited skills curriculum. • In the position of Career Specialist I will use information from externship to prepare students for EMT course. • I will provide an outline of skills so students are aware of what skills they will learn and be certified for.

31. Implementation continued • In recruiting students I will share skills that are taught in EMT course, informing them that with certification in these skills they will be prepared to test in the EMS field.

32. Lessons Learned & Highlights • One of the most profound lessons was how labor intensive and time consuming it is to review, coordinate, and implement class curriculum. • The EMT curriculum task force was made up of representatives from Saddleback College, Santa Ana College, Orange County Fire Authority, Care Ambulance, Coastline Regional Occupational Program, and Orange County Emergency Medical Services.

33. Lessons & Highlights continued • Addition to the current EMT curriculum allows for standardization throughout Orange County • A definite highlight is actually seeing the new skills taught in our current EMT classes and realizing the standard of education and medical services has improved.