Introduction to Advanced Out-of-Hospital Care

1. Introduction to Advanced Out-of-Hospital Care Ray Taylor Valencia College Department of Emergency Medical Services

2. Topics • Introduction • Role and Duties of the Paramedic • Paramedicine as a Profession • Common Interventions in the Out-of-Hospital Setting • Expanding Scope of Practice • Advantages of Nonphysician Paramedical Personnel

3. Introduction • Role of paramedic today is quite different today from the “ambulance driver” of yesterday • Emergency medical services has made significant advances over the last 30 years • Roles and responsibilities of the paramedic have advanced accordingly • Modern rescue or ambulance vehicle is a mobile emergency department (MICU)

4. The paramedic of today provides a comprehensive level of prehospital emergency care.

5. Description of the Profession • The paramedic is a highly trained health care professional • Possess the greatest training in the out-of-hospital setting • The primary task of a paramedic is to provide emergency medical care in the out-of-hospital setting. • Comprehensive, compassionate and efficient care • All paramedics must be licensed, registered, or otherwise credentialed.

6. The paramedic of the 21st century is highly trained in both medical and trauma care

7. Description of the Paramedic Profession • Part of the continuum of patient care • Responsibility to provide the best possible care regardless of the patient’s ethnic, religious, race or ability to pay • Roles and responsibilities encompass • Health care • Public health • Public safety • Responsibility to act in the best interest of the patient • Paramedic will function as a facilitator of access to care as well as an individual treatment provider

8. EMS (paramedic) has become the focal point of entry into the health care system

9. Introduction • Description of the Profession • Levels of EMS Providers • Emergency Medical Responder (EMR): immediate lifesaving care to critical patients. • Emergency Medical Technician (EMT): basic emergency medical care; transportation for critical and emergent patients.

10. Introduction • Description of the Profession • Levels of EMS Providers • Advanced Emergency Medical Technician (AEMT): basic and limited advanced emergency medical care; transportation for critical and emergent patients. • Paramedic: highest level of prehospital care provider; leader of prehospital care team.

11. Description of the Profession • Patient advocacy • Paramedics are responsible to the system medical director, their employer, the public, and their peers

12. Introduction • The Modern Paramedic • Combination of public health, public safety, health care • Provides emergency medical care in out-of-hospital setting • Makes accurate independent judgments • Has appropriate licensing or credentialing

13. Modern EMS is a combination of public health, public safety, and health care.

14. Introduction • The Modern Paramedic • Link between health resources • Maintains high-quality health care at reasonable cost • Advocates for patient • Ensures patient receives best possible care without regard to ability to pay or insurance status

15. Description of the Profession • To function as a paramedic: • Licensing or credentialing • Fulfilled requirements of licensing body • Register with area they work in • Medical Direction • You must recognize that you are an essential component in the continuum of care

16. Paramedics must possess knowledge, skills, and attitudes consistent with the expectations of the public and the profession.

17. Characteristics of the Paramedic • Changes in U.S. health care system • Technology, costs, and patient population trends are forcing change • Today’s role is much different than 10 years ago • Research driven

18. Paramedic Characteristics As a paramedic you should: • Flexible • Confident leader • Excellent judgment • Prioritizes decisions • Has rapport with wide variety of patients • Functions independently

19. Paramedic: A True Health Professional • Emergency medical services are now recognized as an important part of the health care system. • Paramedics are now highly respected members of the health care team. • Do not take professionalism for granted • Strive to maintain your professional status

20. Paramedic: A True Health Professional • The completion of your initial paramedic course is the start of your professional education. • Continuing education programs • Reviews skills and procedures • Peer evaluation • Active role in professional and community organizations

21. Public education is an important part of the paramedic's job.

22. Paramedic: A True Health Professional • Need for research • Little or no scientific data to support many of our prehospital practices • Adherence to a code of professional ethics and etiquette • Ethics are standards of right or honorable behavior • Etiquette refers to good manners

23. Introduction • Paramedic: A True Health Professional • National Emergency Medical Services Education Standards: Paramedic Instructional Guidelines • Participates in research • Acceptance of and adherence to code of professional ethics and etiquette

24. Paramedic Characteristics • Many different types of EMS system designs and operations • Fire department • Private ambulance service • Third city service • Hospital service • Police department • Regardless of type of service, your success as a paramedic will depend upon your having or developing certain professional characteristics

25. Common Procedures and Interventions Performed in the Out-of-Hospital Setting

26. COMMON PROCEDURES AND INTERVENTIONS • Airway Management, Ventilation and Oxygen Therapy • Oral and nasopharyngeal airways • Nasal cannula, non-rebreather masks • Bag-Valve-Mask device • Endotracheal intubation (oral and nasal) • LMA • Rapid Sequence Induction and Intubation • Cricothyrodomy

27. COMMON PROCEDURES AND INTERVENTIONS • Intravenous Access • Basic skill allowing paramedics to provide drug and fluid therapy • Vascular access • Peripheral (14-24 gauge) • External jugular • Intraosseous • No central lines • Fluids employed • Normal Saline, Lactated Ringers, 5% Dextrose in Water, Combination Solutions

28. COMMON PROCEDURES AND INTERVENTIONS • Pharmacotherapy • First began in early 1970s with agents used to treat cardiac problems • Agents are AHA (ACLS) and U.S.D.O.T. standards: • Epinephrine Calcium Thiamine • Atropine NaHCO3 Haldol • Lidocaine Benadryl Morphine • Vasopressin ProventilNubain • Magnesium Nitrous Oxide Narcan • Adenosine Dextrose 50% Tagamet • Valium/AtivanLasix/BumexCardizem • Amiodarone ASA Dopamine

29. COMMON PROCEDURES AND INTERVENTIONS • Defibrillation • Most positive impact in the outcome of out-of-hospital patients • Correctly performed defibrillation in combination with bystander CPR, produces overall community survival rates in excess of 20% (ECG presentation of V-Fib) • AED’s and first responders • Cardiac Monitoring and Diagnostic Electrocardiography

30. ADDITIONAL PROCEDURES AND THERAPIES • Transcutaneous Pacemakers (TCP) • Oximetric monitoring • Capnograpy • Nebulization therapy • CPAP • Special Procedures • Glucometer blood sugar assay • Needle thoracostomy

31. Capnography(Quantitative EtCO2 Detectors) • Capnography is a form of noninvasive monitoring of the end-tidal carbon dioxide (EtCO2) levels in the patient’s exhaled breath. • Capnography refers to a unit that displays both a numeric EtCO2 value and a CO2 waveform (capnograph).

32. Definitions • Capnography is the measurement of exhaled CO2 • Capnometer gives a numerical or qualitative measure of exhaled CO2 • Capnograph gives both a numerical reading of exhaled CO2 plus a tracing • End-tidal CO2 (EtCO2) is the measurement of CO2 at the end of exhalation

33. End-tidal CO2 • The peak partial pressure of CO2 during exhalation (the highest level of expired CO2 reached during exhalation) is known as the end-tidal CO2 (EtCO2). • Normally occurs at the end of the alveolar plateau • EtCO2 is a reflection of alveolar ventilation, CO2 production and pulmonary blood flow. • Can be thought of as the blood pressure of metabolism

34. OUT-OF-HOSPITALELECTROCARDIOGRAPHY • 12 Lead-Diagnostic Electrocardiography • Revolutionizing standard of care within ALS systems • Prehospital acquisition and detection of MI offers opportunity to decrease time delays associated with delivery of definitive intervention

35. Out-of-Hospital12-Lead Electrocardiography • Four large scale studies evaluated the use of 12-Lead electrocardiography in the out-of-hospital setting • European Myocardial Infarction Project • MITI in Seattle Washington • Canadian and Israeli studies • 99% of 12-lead ECG’s were diagnostic quality • Average additional on scene time for acquisition of 12-lead ECG is 5 minutes

36. BENEFITS OF OUT-OF-HOSPITAL 12-LEAD ELECTROCARDIOGRAPHY • Improved paramedic diagnosis of myocardial ischemia and/or infarction • Early warning of receiving medical facility • Reduced in-hospital delays for • Mechanical or chemical reperfusion • Early catheterization • “Cardiac Alert” • CLOT teams

37. Benefits of Prehospital 12-Lead Electrocardiography • Localization and anticipation of complications • IWMI and RVI • AWMI and high degree heart block and cardiogenic shock • Improved treatment strategies regarding pain relief, AV block, and hypotension • Allows for the future out-of-hospital delivery of thrombolitic therapy

38. Expanded Scope of Practice • 911 response • Critical care transport • Helicopter EMS • Tactical EMS • Primary care • Industrial medicine • Sports medicine • Corrections medicine • Hospital emergency department

39. Expanded Scope of Practice • Critical care transport: vehicles to move patients between facilities. • Specialized ground ambulances • Fixed-wing aircraft • Helicopters • Large vehicles mounted on truck chassis

40. The modern critical care transport vehicle provides virtually all the capabilities of the hospital intensive care unit.

41. Expanded Scope of Practice • Helicopter EMS (HEMS) • Staff: two medical crew members; often paramedics. • Education: flight physiology, aircraft operations, flight safety.

42. The helicopter has become an important part of the modern EMS system.

43. Expanded Scope of Practice • Tactical EMS • Enhance safety of special operations personnel and public • Cross trained as police officers; carry weapons • Lifesaving care (dangerous environments); patient safely evacuated to EMS

44. Expanded Scope of Practice • Primary Care • Care at scene without transport to hospital • Specialized crews periodically assess and monitor high-risk patients.

45. Expanded Scope of Practice • Industrial Medicine • Safety inspection • Accident prevention • Medical screening of employees • Vaccinations and immunizations • Increased employee safety • Decreased time lost from work

46. The industrial paramedic provides several important services in addition to emergency care.

47. Expanded Scope of Practice • Sports Medicine • Injury prevention • Injuries specific to sports • Corrections Medicine • Initial prisoner medical intake assessment • Oversee medical needs of prison population; emergencies

48. Expanded Scope of Practice • Hospital Emergency Departments • Role varies state to state • Assist medical and nursing staff with skills and responsibilities within scope of paramedicine

49. ADVANTAGES OF NON-PHYSICIAN PARAMEDICAL PERSONNEL • Cost containment • Success of treatment interventions • Cardiac resuscitation • Endotracheal intubation • Resuscitation skills involve hand-eye coordination • Electrical therapy • IV access • Intubation • Dr. Leonard Cobb’s experience in Seattle • Mentorship/Apprenticeship • Strategic location of fire departments to provide rapid response and intervention

50. Summary • EMS recognized as staple in health care system. • Paramedics identified as underutilized medical experts. • As scope of practice for paramedicine continues to expand, so will demand for skilled practitioners.