Region X SOP Review

1. Region X SOP Review March 2013 CE Condell Medical Center EMS System Site Code: 107200E-1213 Prepared by: Sharon Hopkins, RN, BSN, EMT-P Rev 3.12.13

2. Objectives Upon successful completion of this CE, the EMS provider will be able to: 1.Understands the responsibilities of the EMS provider within the EMS System 2. Actively discuss various Region X SOP’s. 3. Understand the rationale for why a certain medication is used and dosing schedule. 4. Understand when consultation with Medical Control would be necessary.

3. Objectives cont’d 5. State indications for CPAP in pulmonary edema following the Region X SOP’s. 6. Actively participate in case scenario discussion. 7. Actively participate in review of assembling of CPAP. 8. Successfully complete the post quiz with a score of 80% or better.

4. EMS – Systems within Systems • The Condell Medical Center EMS System functions under the direction of Dr. M. Pearlman • The CMC EMS System functions collaboratively within Region X • Includes HPH, North Lake County, and St. Francis Systems • HPH = Northshore University Health System • North Lake County = Vista Health System • St. Francis = Resurrection Saint Francis Hospital • Region X oversight provided by IDPH

5. Certification vs Licensure • Certification • Process to grant recognition to an individual who has met certain qualifications • CPR, ACLS, PALS, ITLS • Licensure • Process of occupational regulation • Permission granted to engage in a given trade or profession based on the degree of competency demonstrated • A method to ensure public’s safety

6. Accreditation • Process to ensure that a program meets minimal guidelines • Faculty, facilities, equipment, medical oversight, clinical affiliations, financial stability • National oversight to the process • State of Illinois EMS Systems working on the process of accreditation (including CMC) • Accreditation via CoAEMSP • Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions

7. Reciprocity • Process by which an agency grants automatic certification or licensure to an individual who has comparable certification or licensure from another agency • To move State to State, contact the respective Department of Public Health • To move from one System to another, contact the Resource Hospital for requirements • Able to move within Region X departments based on mutual respect for reciprocity and use of standardized SOP’s

8. Scope of Practice • Range of duties and skills paramedics and other levels of EMS are allowed and expected to perform • Example: Your scope of practice allows you to assess patients, bandage wounds, splint injuries, start IV’s, and intubate (based on level of EMS provider) • You must always function within your scope of practice • When performing as an ED tech, must function in that role and NOT perform EMS skills not approved for the tech job

9. Standard of Care • The degree of care, skill, and judgment that would be expected under like or similar circumstances by a similarly trained, reasonable paramedic in the same community • Judged by how a prudent, similarly trained EMS professional in your area would perform • Example: If you have VF on the monitor, the patient would be defibrillated, receive CPR, and supportive therapies including medication.

10. On-line Medical Direction • Orders given directly to a prehospital provider by radio or telephone • Function may be delegated to the ECRN • Registered nurse who has completed a specialized course • Approved to monitor telecommunications from and give voice orders to EMS personnel under the authority of the EMS Medical Director following System protocols • As a nurse, the ECRN can only give orders as stated in the SOP’s • Additional orders must come from a physician as a nurse cannot give medical orders without direction

11. Off-line Medical Direction • Medical policies, procedures, and practices established in advance of a call • Includes pre and post call oversight and activity on: • Training and education • Auditing, peer review, and other quality assurance processes • Conflict resolution • Choice of equipment used • Clinical protocols - SOP’s policies, and procedures

12. Emergency Medical Dispatch • EMD • A method to assign and direct emergency medical care following pre-arrival directions • Direction oversight provided by the Medical Director • Involvement of the EMS System personnel • Includes annual training and education

13. Initial Education • Course material presented following National EMS Education Instructional Guidelines published by US DOT • Minimum content established • EMS Systems may add to the minimum guidelines • Uses 3 learning domains • Cognitive – facts, information, knowledge • Affective – assign emotions, values, attitudes • Psychomotor – hands-on skills learned in a lab or clinical setting

14. Continuing Education • Used to keep EMS personnel current • Medicine is a dynamic process – always changing • Process can be offered in a variety of mediums • Lectures • Observation vs active participation • Return demonstration of skills • Review/critique of activity

15. Evidence-Based Medicine • The practice of following current best scientific evidence when making decisions regarding the care of patients • Clinical evidence used to replace invalid previously accepted treatments and procedures with new ones that are more appropriate • i.e.: Sodium bicarbonate is no longer automatically administered to every arrested patient • CPR rate of compressions is now at least 100 per minute

16. System Operating Protocols • Also referred to as Standing Orders • Purpose • Provide preauthorized policies and procedures to be followed based on the patient assessment • Allows for swift initiation of appropriate interventions • EMS provider needs to apply critical thinking skills based on assessment, observation, education, and training

17. SOP’s • EMS cannot blindly follow the SOP’s in exact detail – need critical thinking skills • It is the EMS provider’s responsibility to know when the SOP is followed as printed and when deviation is appropriate • i.e.: NTG is not given blindly to every patient with chest pain • The blood pressure must be evaluated • A 12 lead EKG needs to be obtained observing for ST elevation in the inferior leads II, III, aVF • EMS must screen for use of Viagra type medications

18. “Contacting Medical Control” • Certain situations are listed in the SOP’s when Medical Control is contacted • For example: • Whenever the EMS provider is unsure of which way to proceed on the call • For consideration of additional medication orders • To provide advanced notification to facilitate rapid patient intervention (i.e.: patients with ST elevation on 12 lead EKG’s and patients with suspected acute stroke) • To terminate/withdraw resuscitative efforts

19. Scenario Review • Review the following case presentations • They are provided as a means to stimulate discussion • Determine your general impression • This drives your choice of SOP to follow • Discuss which SOP is appropriate • Discuss the questions posed • Use critical thinking skills • Determine any opportunities for improvement noted

20. Scenario #1 • Called to the scene for a 55 year-old male who passed out • Upon arrival patient lying on kitchen floor unresponsive, apneic and pulseless (0-0-0) • History of lung cancer and an old stroke • Wife states patient hasn’t taken meds for past week • Patient in terminal stages of cancer • What would you do?

21. Scenario #1 • Do you start CPR or withhold it? • You need to ask if the patient has a valid DNR • The wife states they have a DNR but it was to be signed by the doctor at their visit later that week • In this patient’s terminal condition, do you start or withhold CPR? • Without a valid DNR and in absence of obvious irreversible death like lividity or rigor mortis CPR must be started (SOP page 87)

22. Scenario #1 • CPR is initiated • 30:2 one and two man CPR for adults • Compressions are 2 inches deep delivered at a rate of at least 100 compressions per minute • What’s the first piece of equipment that should be used on a full arrest after CPR initiated? • Get the monitor on the patient • The rhythm drives the treatment decision

23. Scenario #1 • The monitor shows: • What’s the rhythm? • Asystole • What treatment is administered and why?

24. Scenario #1 • Treatment for asystole • CPR • To provide artificial circulation/perfusion • Keep interruptions to compressions under 10 seconds • Establish IV/IO access • Airway already covered under CPR; need access established to administer medications • Search for treatable causes • The H’s and T’s

25. Scenario #1 – For Asystole • NO defibrillation!!! • Defibrillation results in asystole • Allows opportunity for the dominant pacemaker site (SA node) to take over with an organized rhythm • NO pulse checks at the 10 second pause in CPR!!! • Pulse checks are to be performed ONLY when the rhythm viewed is one that should produce a pulse • i.e.: VT or any organized rhythm • In asystole and VF, would unnecessarily waste too much time feeling for a pulse

26. Scenario #1 – Why Epinephrine? • A vasopressor category medication • Stimulates vasoconstriction • When the hose gets smaller, pressure goes up • First category of drug to give to all arrested patients • 1st dose 1:10,000 1 mg IVP/IO • 1 mg repeated every 3-5 minutes • Epinephrine has a relatively short half life • Did you know – Epinephrine can add strain to the heart by increasing the work load – a negative effect you take with the good • This is why there is cautious use in setting of a patient with cardiac history (think 1:1000 strength for allergic reaction)

27. Scenario #1 – Look for the Causes • H’s • Hypovolemia • Listen for clear breath sounds • Then administer fluid challenges • Hypoxia • Administer supplemental oxygen via BVM • Acidosis (Hydrogen ion) from retained carbon dioxide • Ventilate / breath for patient to rid body of retained CO2 • Hypothermia • Cannot be cold and dead; must be warmed up • Hyper/hypokalemia • Consider potassium problem if on renal dialysis or extremely high blood sugar levels and in DKA

28. Scenario #1 Additional Causes • T’s • Toxins • Consider the young child exposed to others drug sources • Tamponade, cardiac • Difficult to look for signs and symptoms in arrest • Any history? • Tension pneumothorax • What’s the history? • Having trouble ventilating patient? • Is there equal rise and fall of chest? • Thrombosis – coronary or pulmonary • What’s the history?

29. Withdrawing Resuscitative Efforts • You have arrived on the scene • The patient was an unwitnessed arrest and found to be in asystole and remains in asystole • These are generally not considered potentially viable patients • Or perhaps, as in scenario #1, the family does not wish to have resuscitative measures started but does not have a valid DNR in possession Have you considered contacting Medical Control for withdrawing resuscitative efforts???

30. Withdrawing Resuscitative Efforts Once started, you need to consult Medical Control to terminate resuscitation efforts • Medical Control to be contacted while continuing care • Report events of the call including duration of cardiac arrest and treatments rendered

31. Withdrawing Resuscitative Efforts • Reaffirm all of the following • Patient is normothermic adult • Patient experienced an unwitnessed arrest • Airway is secured and IV/IO placement confirmed • Patient remains in asystole • and • No response to al least 20 minutes of ALS care

32. Withdrawing Resuscitative Efforts • If the physician orders termination of efforts, note time or withdrawal of efforts and physician name on run report • Notify Coroner or Medical Examiner • Scene can be turned over to police • Appropriate communication, support and comfort should be offered to the family • What are your department resources to help with this?

33. Scenario #1 Documentation • Points to cover • Condition of patient when found • Supporting documentation available or lacking (i.e.: valid DNR) • If assisting ventilation, what rate and what method? • If invasive equipment used • What size (i.e.: airway, IV)? • Confirmation of appropriate insertion (i.e.: airway)? • If withdrawing resuscitation efforts, what time and physician’s name giving the order • If scene turned over then document to who • Notification of coroner if applicable

34. Scenario #2 • EMS was called to the scene for a patient that has been stabbed • How would EMS approach this scene? • Scene safety important - Is the scene safe? • What is your policy for coordinating with the police? • Can you determine field triage criteria for trauma yet? • Need to know anatomical location of stab wound and stability of vital signs if in a non-vital area

35. Scenario #2 • Patient is 35 year-old female stabbed in left upper quadrant • Wound appeared “superficial” and ½ inch wide • VS: B/P 132/72; P – 108; R – 24; SpO2 96% awake/alert/cooperative; GCS 15 (4/5/6) • Weapon no longer impaled in wound • Bleeding minimal; controlled with 4x4 • Patient report called to hospital as a “category II trauma” • Is this a category II trauma patient?

36. Scenario #2 – EMS Perspective • EMS felt they could “see” the depth of the wound • As wound determined by EMS to be superficial, EMS downgraded category of the trauma • Can EMS determine the depth of a wound in the field? • No, the physician would need to probe wound – may be bedside or wait until patient in surgery • What organ lies in the left upper quadrant that may have been involved? • Major organ is spleen • Remember: It may be hard to determine if there is isolated abdominal or chest wound or combination

37. Review:Patient Categorization for Trauma • Category I trauma • Based on patient being unstable and/or anatomical injuries with highest risk to life and/or limb • Category II trauma • Based on mechanism of injury • Significant transfer of energy where the risk for injury is high but the patient is stable at this point in time • Patient deserves frequent reassessment and close observation should they become a Category I trauma patient

38. Review – Trauma Category I • Criteria for Category I level trauma • Unstable vital signs • GCS <13 with blunt head injury • Attempt to eliminate Category I trauma activation on the person with an altered level of consciousness due to high alcohol levels – not trauma • Anatomical injuries • Penetration to head, neck, torso, groin • EMS does not explore the depth in the field • These are high risk areas if penetration due to presence of organs or vessels

39. Category I Trauma cont’d • Anatomy of Injury cont’d • Combination trauma with burns >20% • 2 or more proximal long bone fractures • 2 or more body regions with potential of life/limb threat • Unstable pelvis • Potential for large amounts of hidden blood loss • Flail chest • Chest wall unstable or with deformity’ • High risk for respiratory inadequacy

40. Category I Trauma cont’d • Anatomy of Injury cont’d • Limb paralysis &/or sensory deficits above the wrist or ankle • Open or depressed skull fracture • Amputation proximal to wrist or ankle

41. Review: Category II Trauma • Mechanism of injury • Partial or complete ejection • Death in same passenger compartment • Motorcycle crash >20 mph or with separation of rider form bike • Rollover (unrestrained) • Falls >20 feet (Peds > x3 body length) • Pedestrian thrown or run over • Auto vs pedestrian/bicyclist with > 5 mph impact

42. Category II Trauma cont’d • Extrication > 20 minutes • High speed MVC • Speed > 40 mph • Intrusion > 12 inches • Major deformity > 20 inches • Co-morbid Factors (increases the risks) • Age <5 without car/booster seat • Bleeding disorders or on anticoagulants • Pregnancy > 20 weeks • Renal disease requiring dialysis

43. Review: Transport Destinations • Category I trauma patient • Highest level trauma center within 25 minute transport time • Category II trauma patient • Closest trauma center • Traumatic arrest • Closest trauma center • No airway • Closest comprehensive ED (includes free standing facilities)

44. Scenario #2 • Is spleen a hollow or solid organ? • Solid • What is the danger of injury to a solid organs? • Injured organ has the potential for blood loss • What is the danger of injury to a hollow organs? • Contents would spill and contaminate the peritoneum or surrounding area

45. Abdominal Contents • Ribs overlie the spleen • Damage to ribs could cause damage to spleen

46. Retroperitoneal Organs

47. Defining Location in Abdomen • The abdominal area is defined by the quadrants and related to the patient's right or left

48. Reporting and Documenting Chest Injuries • There are NO quadrants in the chest • “Quadrants” is a term for describing the location of the abdominal assessment • Describe locations in the chest wall related to: • Clavicular line • Nipple line • Axilla reference – anterior, mid, posterior axillary • Intercostal spacing

49. Scenario #3 • Called to the scene for a 74 y/o male with weakness; unable to get out of bed • Weakness started “Thursday” • Hx: AMI 2 years ago, pacemaker 1 year ago • Meds: Metoprolol, Plavix, Levothyroxine, Losartan, ASA • GCS: 4/5/6 (total 15) • What are you thinking as a general impression?

50. Scenario #3 • Weakness, dizziness, wooziness, can’t get out of bed, don’t feel right • Consider an abnormal presentation of a stroke • At minimum perform the Cincinnati Stroke Scale and document results • Consider that this could also be the presentation of an acute MI • Obtain a 12 lead EKG • If the level of consciousness is altered, obtain a glucose level