MLREMS BLS Protocols

2.37 Ventricular Assist Devices (LVADs)

***UNSURE CARE LEVEL*** CRITERIA Any request for service that requires evaluation and transport of a patient with a Left Ventricular Assist Device (VAD). 1. Assess airway and breathing. Treat airway obstruction or respiratory distress per protocol. Treat medical or traumatic condition per protocol. 2. Assess pump function and circulation: • Listen to motor of pump over heart and observe green light on system control device. • Assess perfusion based on mental status, capillary refill, and skin color. The absence of a palpable pulse is normal for patients with a functioning VAD. They may not have a blood pressure. • DO NOT PERFORM CPR unless there is no evidence of the pump functioning (no motor noise) and the person is unresponsive and without a pulse. 3. Perform secondary assessment, treat per protocol. 4. Notify URMC Heart Failure Coordinator ASAP, regardless of the patient's complaint. Call 1-800-892-4964 and declare a "VAD EMERGENCY" 5. Bring patient's power unit and batteries to the Emergency Department. Unless otherwise directed by Medical Control or the Heart Failure Coordinator, transport patient to URMC-Strong Memorial Hospital. 6. Trained support member must remain with patient. 7. Do not delay transport to hospital.

1. Routine Medical Care

1. Determine if patient has capacity to make decisions. For patients without capacity, EMS providers should perform care under the concept of implied consent. Patients without capacity cannot refuse medical treatment. Capacity Assessment Criteria: a. Ability to clearly demonstrate awareness of person, place, period of time and problem b. Ability to clearly demonstrate "decisional capacity" by expressing understanding of the situation, being able to explain their decision to consent or refuse in rational terms, and demonstrating an understanding of the risks and benefits of a decision or action c. Not suicidal and not a threat of harm to others 2. Appropriate equipment to provide oxygenation, ventilation and patient assessment should be brought to the patient, along with an AED or cardiac monitor and the means (stairchair, backboard, or stretcher) to appropriately move the patient from the scene to the ambulance. Equipment should be specific for the size and age of the patient. ALS should also bring medications and advanced airway equipment as appropriate. 3. At least one full set of vital signs should be taken on all patients. If the patient refuses, document at least the patient's respiratory rate and quality, and any other assessment parameters such as skin color, neurologic assessment and GCS. 4. Serial vital signs including pulse oximetry and pain scale should be completed every 15 minutes for non-critical patients and every 5 minutes for critical patients whenever possible. Document vital signs and patient response after any medication administration. If patient care or other extenuating circumstances do not allow for this frequency, the reason should be documented on the PCR. 5. Oxygen therapy, suction, and ventilatory assistance as needed per protocol and to the provider's training level. Administer oxygen via appropriate oxygen delivery device (nasal cannula or non-rebreather mask) only to patients with dyspnea, hypoxia (O2 sat <94%), or signs of heart failure at a rate to keep O2 saturation ≥94%. If unable to obtain accurate pulse oximeter reading, apply non-rebreather mask with appropriate flow rate. If patient has history of COPD or is on home oxygen, continue home oxygen flow rate and delivery device unless contraindicated by patient's presentation. 6. Trauma patients meeting New York State Major Trauma Criteria (see Appendix) should be transported to the nearest regional trauma center unless the patient has an unmanageable airway or is in cardiac arrest, in which case the patient should be transported to the nearest emergency department. 7. Contact with the receiving hospital should be made per receiving hospital guidelines and as soon as possible in the following circumstances: a. Patients meeting trauma triage criteria b. Patients with evidence of an acute stroke or myocardial infarction c. Patients in cardiopulmonary or respiratory arrest d. Any unstable patient 8. Should the ALS provider not have the ability to call Medical Control, another provider or dispatcher should contact the receiving hospital to notify the physician/staff of a patient's unstable condition. 9. Timely transport to the receiving hospital should occur in all cases. Use of lights and sirens on such calls should be at the discretion of the provider in charge, and should be based on the stability of the patient, the need for stabilizing procedures such as airway management or drug administration at the scene, the need for procedures/medications available only at the hospital, etc. The provider in charge should also consider the possibility of increased risk to patient and crew in deciding on use of lights and sirens. 10. Crew safety during transport is a high priority. Crews should stage per agency policy when a concern for scene safety exists. All crew and patients should be secured by a seat belt while the vehicle is in motion. Patient care providers should only move freely to provide critical patient care interventions such as CPR, airway management, and medication administration. All patient care equipment should be secured by a strap, clip, or mount or placed within a cabinet. 11. When possible, transport pediatric patients in car seats appropriate for age. 12. Provide patient care consistent with NYS BLS Protocols and for the patient's specific complaint using the appropriate protocol included herein. 13. The patient care interaction and all procedures performed and medications given must be documented in the PCR. 14. Blood glucose determination is mandatory for patients with diabetes, seizure disorder, syncope, and any patient with altered mental status when cared for by an ALS provider. It is recommended for all other patient presentations as time and patient condition allows. Blood Glucose monitoring can only be done using a Blood Glucometer. Chemstrips are not allowed.

2.0 Airway Management - Adult

1. Establish a patent BLS airway. • Manually open airway as needed • Head tilt / chin lift (non-trauma) • Modified jaw thrust (trauma) 2. Suction as needed. 3. Oropharyngeal or nasopharyngeal airway as needed unless contraindicated. 4. If ventilation status is inadequate, use positive pressure ventilation utilizing BVM with high concentration oxygen to ventilate at a rate of 10-12 breaths per minute. Support spontaneous ventilations at an appropriate rate. EMT STOP

2.1 Airway Management - Pediatric

1. Establish a patent airway. • Manually open airway as needed • Head tilt / chin lift (non-trauma) • Modified jaw thrust (trauma) 2. Suction as needed. 3. Oropharyngeal or nasopharyngeal airway as needed unless contraindicated. 4. If ventilation status is inadequate, use positive pressure ventilations utilizing BVM with high concentration oxygen to ventilate at a rate of 12-20 breaths per minute. Support spontaneous ventilations as necessary.

3.1 Ventricular Fibrillation & Pulseless V-Tach

1. Follow Adult Cardiac Arrest - General Procedures Protocol (3.0) EMT STOP

3.3 Asystole/Pulseless Electrical Activity (PEA)

1. Follow Adult Cardiac Arrest - General Procedures Protocol (3.0) EMT STOP

4.3 Asystole/Pulseless Electrical Activity (PEA)

1. Follow General Procedures Protocol (4.0) EMT STOP

4.1 Ventricular Fibrillation/Pulseless V-Tach

1. Follow Pediatric Cardiac Arrest, see General Procedures Protocol (4.0) EMT STOP

2.19B Hypothermic Cardiac Arrest

1. Institute CPR. NOTE Pharmacological and electrical interventions are often ineffective in severe hypothermia, and should be used only with extreme caution. 2. Defibrillate once if shock advised. EMT STOP

2.33 Suspected Spinal Injuries

1. Patients with mechanism capable of producing spinal injuries meeting any of the following criteria must immediately receive spinal immobilization: Age Patients < 8 or > 65 years old Medical History Patient's with Down Syndrome History of spinal tumors History of degenerative bone disorders History of spina bifida Mechanism of Injury Death of passenger in same compartment Motorcycle crash Falls greater than standing height Vehicle versus bicycle >5 mph Vehicle-pedestrian collision Axial load (diving injury, spearing tackle) Patient ejection Vehicle rollover Collision >20 mph with 12 inches deformity to vehicle Physical Findings HR < 50 or > 120 bpm SBP < 90 mmHg RR < 10 or > 28 bpm GCS < 15 Burns >15% BSA or facial/airway burns Two or more proximal long bone fractures Trauma of two or more body systems Flail Chest Amputation (except digits) 2. Patients not meeting any of the above criteria should be assessed for the following. If any are present, the patient must receive spinal immobilization. • Altered Mental Status for any reason, including possible intoxication from alcohol or drugs (signs of poor judgment, GCS <15 or AVPU other than A). • Complaint of neck and/or spine pain or tenderness. • Weakness, tingling, or numbness of the trunk or extremities at any time since the injury. • Deformity of the spine not present prior to this incident. • Distracting injury or circumstances (i.e. anything producing an unreliable physical exam or history). 3. Provide routine care per relevant protocol. NOTE Once spinal immobilization has been initiated (i.e. extrication collar placed on patient) spinal immobilization MUST be completed and may not be removed in the prehospital setting.

2.9 Burns

1. Remove patient from source of burn - heat source, chemicals, electricity source etc. Precautions should be taken to prevent injury to the rescuers. Only trained personnel should perform high-risk rescue procedures as appropriate. Decontamination measures should be taken as appropriate. 2. Assure airway patency and administer high flow oxygen. 3. Stop burning process by application of water, except in case of elemental metal burn. Dry chemicals should be brushed away as much as possible before water is applied. In most cases 5-10 minutes is sufficient, although longer periods may be needed for hot grease, asphalt or chemicals. Burns from sodium metal, potassium metal, phosphorus, etc. should not be flushed with water, but instead should be covered with dry sterile dressings to prevent both air and water from making contact with the area. Remove jewelry and clothing as appropriate. 4. Apply dry sterile dressings. Take other measures to keep the patient warm as needed. 5. Timely transport with early notification to emergency department if patient unstable, possibility of airway obstruction exists, or extensive burns. Transport to burn center for: • Burns compromising patient's airway • Burns of face, hands, feet, joints, perineum or genitalia • Circumferential burns • 20% total of 2nd / 3rd degree burns • 5% 3rd degree burns • Significant chemical burns

2.32 Stroke

1. Routine medical care with evaluation of the Cincinnati Stroke Scale, which includes: (CSS - If any of the following tests positive, stroke is possible) • Facial droop during smile Normal = equal smile Abnormal = one side moves less • Arm drift (arms held straight for 10 seconds with eyes closed) Normal = no movement or equal movement Abnormal = 1 arm drifts or cannot lift arm against gravity • Speech ("You can't teach an old dog new tricks") Normal = correct words/ no slurring Abnormal = slurred words / wrong words / no speech Determine the time at which the patient's symptoms began (abnormal speech, extremity weakness, numbness, paralysis, facial droop, etc.) 2. Assure airway patency and administer oxygen per protocol. 3. Consider other causes for altered mental status - refer to Altered Mental Status Protocol (2.4). 4. Assess blood glucose (BLS if available). If hypoglycemic, refer to Diabetic Emergencies Protocol (2.14). Do not withhold treatment for hypoglycemic patients who present with stroke-like symptoms 5. Timely transport. If patient fulfills following criteria, contact Medical Control of a Stroke Center* and advise of a "Stroke Alert" by providing appropriate clinical information to the Medical Control Physician: • One or more abnormal findings on Cincinnati Stroke Scale (see above) AND • Symptoms for <5 hours AND • Blood Glucose >80 mg/dl EMT STOP

2.11 Chest Trauma

1. Routine medical care. 2. Assure airway patency and administer high flow oxygen. 3. Stabilize but do not remove penetrating objects. Use occlusive dressing to seal sucking wounds on 3 sides only - leave open on 4th side. Stabilize flail segments. 4. If signs/symptoms of tension pneumothorax present: Remove occlusive dressing from sucking wound (if present). 5. Timely transport with early notification to hospital EMT STOP

2.14 Diabetic Emergencies

1. Routine medical care. 2. Assure airway patency and administer oxygen per protocol. 3. Assess signs, symptoms, medical history, and blood glucose (BG), if available. 4. If patient has BG < 80 mg/dL, appears hypoglycemic, or if you are unsure if patient is hypoglycemic: If patient is able to speak coherently, offer any form of available sugar (non-diet soda, candy, orange juice, granular sugar, or glucose gel). 5. All patients on oral hypoglycemic medications or long-acting insulin, who have been treated for potential hypoglycemia, should be transported. 6. Treatment should not be withheld from patients with a stroke-like presentation, as this is likely due to hypoglycemia.

2.21 Near-Drowning

1. Routine medical care. 2. Assure airway patency, and administer oxygen per protocol. 3. If patient is pulseless and apneic, refer to Cardiac Arrest Protocols (3.0, 3.1, 4.0 and 4.1). 4. Initiate spinal immobilization precautions and trauma care as appropriate; see Spinal Immobilization Protocol (2.33). 5. Treat hypothermia (even in warm water drowning or warm environmental conditions) - see Hypothermia Protocol (2.19A). 6. All patients should be transported for evaluation. 7. Unless contraindicated, transport patient in lateral recumbent position. NOTE Heimlich maneuver is contraindicated for the removal of water from the lungs

2.16 Head Trauma

1. Routine medical care. 2. Spinal immobilization. Patient's head should not be lower than the body. 3. Assure airway patency and administer oxygen per protocol. 4. If BVM ventilation needed, ventilations should be slow and steady at a constant rate of 10 breaths per minute. 5. Timely transport with early notification to emergency department.

2.31 Seizures

1. Routine medical care. 2. Assure airway patency and administer oxygen per protocol. 3. Assess signs, symptoms, and medical history. 4. Consider possible causes: • Existing seizure disorder • Toxic ingestion - see Poisoning / Overdose Protocol (2.25) • Head Injury - see Head Trauma Protocol (2.16) • Hypoglycemia - see Diabetic Emergencies Protocol (2.14) • Eclampsia (if maternity patient beyond 20 weeks or up to 6 weeks after delivery) 5. If seizing, begin timely transport. 6. Assess BG (BLS, if available; mandatory for ALS) - If hypoglycemic, see Diabetic Emergencies Protocol (2.14). EMT STOP

2.23 Obstetric Emergencies

1. Routine medical care. Administer oxygen per protocol. 2. Assess signs, symptoms, and obstetric history. 3. If delivery imminent: • Allow baby to deliver spontaneously. • Support infant, but do not attempt to retard or hasten delivery. • Begin timely transport with ALS transport/intercept if possible, but do not delay transport to wait for ALS. • Contact Medical Control as necessary for instructions and destination. • For routine deliveries, preference hospital affiliated with maternal Ob/Gyn physician 4. Check for nuchal cord. 5. Clamp cord in two places 8-12" from infant; cut cord between clamps. 6. Assess infant and proceed with neonatal resuscitation - see Neonatal Resuscitation Protocol (2.22) 7. Do not wait for delivery of placenta to begin transport. If the placenta delivers spontaneously, bring to hospital in plastic bag. Do not pull on cord under any circumstances. 8. After delivery of placenta, massage uterus as needed for control of maternal hemorrhage. 9. If mother is hypotensive, refer to Hypotension/Shock Protocol (2.18) as needed.

2.24 Pain Management

1. Routine medical care. If pain is secondary to a burn, refer to Burn Protocol (2.9). 2. Assure airway patency. Administer oxygen per protocol. 3. Apply pain relief measures such as splinting, positioning, ice packs, etc. as appropriate.

4.0 Pediatric Cardiac Arrest

1. Verify patient is pulseless and apneic. 2. Initiate or continue CPR. CPR is to be continued at all times as is practical. 3. Assure airway patency and begin use of BVM. Provide initial BLS airway management, including Oropharyngeal or Nasopharyngeal Airway. 4. Apply AED or SAED if available. If switching to a different AED/monitor you may use previously applied patches if compatible with new unit. If patient ≥ age 8 - Automatic external defibrillator may be used as appropriate. If patient < age 8 - Use pediatric cables, if not available may use adult cables. 5. Follow prompts provided by AED/SAED device. 6. Utilize ALS, or initiate timely transport toward ALS (ALS intercept or hospital if closer). If ALS not available, no more than 3 shocks should be delivered at the scene. Defibrillation should not be performed in a moving ambulance. EMT STOP

3.0 Cardiac Arrest - General Procedures

1. Verify patient is pulseless and apneic. 2. Initiate or continue CPR. CPR is to be continued at all times as is practical. 3. Assure airway patency and begin use of BVM. Provide initial BLS airway management, including Oropharyngeal or Nasopharyngeal Airway. 4. Apply AED or SAED if available. If switching to a different AED/monitor you may use previously applied patches if compatible with new unit. 5. Follow prompts provided by AED/SAED device. 6. Utilize ALS, or initiate timely transport toward ALS (ALS intercept or hospital if closer). If ALS not available and transport ambulance is available, no more than 3 shocks should be delivered at the scene. Defibrillation should not be performed in a moving ambulance. 7. Advise receiving hospital ASAP. EMT STOP

1.5 Obvious Death

1.5 OBVIOUS DEATH CRITERIA • CPR and ALS treatment are to be withheld only if the patient is obviously dead or has a valid Do Not Resuscitate order, refer to Do Not Resuscitate Protocol (1.3). • If the patient has no pulse and meets one or more of the following criteria for obvious death, CPR and ALS therapy need not be instituted: • Body decomposition • Rigor mortis with warm air temperature • Dependent lividity • Injury not compatible with life (i.e. decapitation, burned beyond recognition, massive open or penetrating trauma to the head or chest with obvious organ destruction) • All cases of hypothermia should receive full resuscitative efforts, refer to Hypothermia Protocol (2.19A or B). 1. Verify apnea and pulselessness 2. Verify that the patient meets obvious death criteria as defined above If doubt exists, start resuscitation immediately. Once initiated continue resuscitation efforts until one of the following occurs: • Resuscitation efforts meet criteria for Field Termination Protocol (1.4). • Patient care responsibilities are transferred to the transporting provider or the destination hospital staff. • Return of spontaneous pulse. Medical Control must be contacted in the following circumstances before following the Obvious Death Protocol: • If a bystander or first responder has initiated CPR or Automatic External Defibrillation prior to EMS arrival and any of the obvious death criteria are present. • If the patient was submerged for greater than one hour in any water temperature

2.12 Conducted Energy Weapons

CRITERIA Conducted Energy Weapons (also referred to as Electronic Control Devices, Conducted Energy Devices, etc) are used by law enforcement as an alternative to ballistic devices and other physical force in order to gain compliance with a noncooperative person. These devices send an electrical charge of up to 50,000 volts per pulse with 12 to 20 pulses per second up to five seconds per cycle. The electrical current is about 2.1-3.5 milliamps. The delivered energy is between 0.7 to 1.76 joules. The number of discharges and the duration of discharges can be controlled by the operator. The discharge can either be through probes fired from the device with a range of up to 35 feet or with a contact discharge where the device is held against the subject. Either method will work through clothing. Either method uses electricity to cause the skeletal muscles between the probes to contract and release rapidly preventing voluntary control of the affected muscles. The device may cause a brief altered mental status, but subjects regain normal mentation and muscle control almost immediately, although some subjects may take up to a minute to recover. 1. Assure patient is appropriately restrained and not a danger to care providers. 2. Assess patient for problems and treat as per appropriate protocol. The device does not cause an altered mental status. Any altered level of consciousness must be assessed and treated in accordance with the Altered Mental Status Protocol (2.4). 3. Assess patient for high-risk criteria. Most patients who have been exposed to a CED will be in police custody and treatment decisions should be a cooperative venture. Presence of one or more of the following risk factors indicates need for an ALS response and transport to an Emergency Department is encouraged: • Known cardiac history including pacemaker/implantable defibrillator • Known seizure disorder • Pregnancy • Altered mental status • Extended physical struggle including multiple discharges or cycles 4. The barbs that contact the patient have an end that is similar to a fishhook and may imbed as much as 1.5 cm. To remove the probe, stabilize the soft tissue around area with a gloved hand and remove the probe by pulling outward. If there is resistance when removing the probe, leave the probe in place and transport to the Emergency Department. Clean the area and dress appropriately

2.38 Crush Injuries

CRITERIA • Crushed extremities distal to the axilla and iliac crest. • Entrapped body parts may not have suffered crush injuries • Prolonged and continuous heavy pressure to any portion of the body ALL LEVELS 1. Routine Care (1.0) 2. Ensure patent airway and support oxygen/ventilation per protocol 2.0 or 2.1 3. Spinal Immobilization as indicated per protocol 2.33 4. Consider Pelvic splinting 5. Conserve Body Heat 6. Consider placement, but not tightening of tourniquet on extremity a. Be prepared for significant bleeding b. Tighten if directed by Medical Control or Paramedic 7. Hypotension and shock treatment per protocol 2.18 BLS STOP

2.39 Cyanide

CRITERIA • Known or suspected exposure to cyanogenic compound due to combustion or chemical process. • Signs and symptoms including any of the following: a. Tachypnea b. Tachycardia c. Central and peripheral cyanosis d. Throbbing headache e. Hypotension f. Syncope g. Weakness h. Agitation i. Seizures j. Cardiac arrest 1. Routine Standing Orders. 2. Rapid transport once necessary decontamination completed. Transport patients who have ingested cyanide salts in vehicles with windows open and/or good ventilation. 3. Mild exposures with conscious and alert patients should be given oxygen and observed for signs and symptoms. No antidotes should be administered for mild exposure. EMT-B STOP

2.30 Sedation

CRITERIA Any adult or pediatric patient who requires a painful therapeutic procedure or whose condition is interfering with their clinical management including: • Synchronized cardioversion • Transcutaneous pacing • Post-intubation sedation CONTRAINDICATIONS • Known history of hypersensitivity or other adverse reactions to the required medications • Clinical condition or vital signs contraindicate the use of sedative medications NOTE For extremely agitated or combative patients, refer to Behavioral Emergencies Protocol (2.8) All Sedation and Analgesia medications should be used with caution if MAP < 65 mmHg EMT STOP

2.8 Behavioral Emergencies

CRITERIA Any patient who demonstrates potentially violent behavior regardless of underlying diagnosis, who continues to resist against appropriately applied restraints, and needs facilitation of physical restraint. In all cases, consider staging until law enforcement is present. CAUTION Agitation may signal a physiologic deterioration of the patient and accompany hypoxia, hypoglycemia, cerebral edema, or other medical problems. Treatment of medical disorders should always be done prior to any chemical restraint. 1. Assess mental, emotional, and physical status thoroughly including all other potential causes of aggressive behavior. Other causes should be treated first, which may be sufficient to resolve the aggressive behavior. 2. Attend to medical or trauma needs as per protocol. No patient will be transported without law enforcement presence if his or her emotional or mental status poses a threat to patient or crew safety. Follow 'Management of Violent and Potentially Violent Behavior' procedures (Policy 9.3). If unable to manage with physical restraints, consider chemical restraints below. EMT STOP

2.10 Chest Pain/Threatened Myocardial Infarction

CRITERIA Patient with non-traumatic chest pain or other indications of possible Myocardial Infarction (shortness of breath, nausea, diaphoresis, etc) 1. Routine medical care. 2. If systolic BP > 120 mmHg and HR > 50 and < 130 bpm, may assist patient with taking own nitroglycerin tablets. If systolic BP remains > 120 mmHg, one tablet may be taken sublingually every 3-5 minutes up to total of 3 doses. CAUTION Avoid Nitroglycerin in patients who have taken erectile dysfunction medication (Viagra™, Levitra™, or Cialis™) in the past 72 hours 3. Aspirin 324 mg (if not already taken or contraindicated by allergy or active bleeding): 4 tablets 81 mg each should be chewed and swallowed for total dose of 324 mg.

2.20 Nausea/Vomiting

CRITERIA Patient with uncontrolled nausea/vomiting and no evidence of head injury: 1. Attempt to treat cause of the nausea. EMT STOP

4.2 Return of Spontaneous Circulation

CRITERIA The following is for a patient with Return of Spontaneous Circulation (ROSC) as evidenced by a palpable pulse following CPR, electrical, or drug therapy for a patient previously pulseless. • Post-conversion treatment of VF or VT should only be started if the patient has regained a pulse of adequate rate (>60). If not, refer to other cardiac protocols as appropriate. 1. Routine medical care. EMT STOP

2.28 Re-establishing Patient Medication IV

CRITERIA • Adult or Pediatric patient with life-sustaining IV treatment which cannot be discontinued for a brief time without major consequences (See list of allowed drugs below) • IV/Central line infiltrated or pulled out with no other means of rapid IV access 1. Routine medical care as appropriate and transport to appropriate hospital. Bring bag of patient medication to hospital if available and alert Medical Control that patient is en route. EMT STOP

2.6 Apparent Life Threatening Event

CRITERIA • An episode in an infant or child less than 2 years old which is frightening to the observer and is characterized by one or more of the following: • Apnea (central or obstructive) • Skin color change: cyanosis, erythema (redness), pallor, plethora (fluid overload) • Marked change in muscle tone • Choking or gagging not associated with feeding or a witnessed foreign body aspiration • Seizure-like activity 1. Routine medical care. 2. Assure airway patency and administer oxygen per protocol. 3. Timely transport to the emergency department. If the parent or guardian refuses medical care or transport, the provider must contact Pediatric Medical Control. BLS cannot cancel ALS for ALTE.

2.19A

CRITERIA • Body temperature < 35 °C (95 ° F) • Do not use tympanic thermometers. 1. Routine medical care. 2. Move out of cold environment. Gently remove wet clothing, cover with blankets and otherwise protect from further heat loss. 3. Assure airway patency and administer oxygen per protocol (with warm moist air if possible). 4. Maintain horizontal position. 5. Avoid rough handling during patient movement. 6. Timely transport (goal of <15 minute scene time). 7. Monitor temperature; assess cardiopulmonary status, and presence of other factors such as trauma, drug usage, etc. Heart rates should be assessed for at least 1 full minute. 8. If temp is 30-35°C (86 - 95°F), gentle re-warming measures may be instituted (heated ambulance). 9. Assess BG (BLS if available). If hypoglycemic, see Diabetic Emergencies Protocol (2.14).

2.17 Hyperthermia/Heat Exhaustion/Heat Stroke

CRITERIA • Body temperature > 40.6 °C (105 ° F). Do not use tympanic thermometers. • Infants and children, and frail, elderly, or chronically ill adults may show symptoms of hyperthermia at lower temperatures than listed above. Patients on anticholinergic medications (Benadryl, Ditropan, Detrol, haloperidol, amitriptyline, nortriptyline, etc) are prone to hyperthermia due to an inability to perspire. • May be accompanied by CNS dysfunction (delirium, psychoses, coma, seizures), absence of sweating, pallor, tachycardia, hypotension, cramping or tingling, nausea /vomiting, headache, dizziness. 1. Routine medical care. 2. Assure airway patency and administer oxygen per protocol. 3. Assess signs, symptoms. 4. Remove patient from hot environment. Remove clothing. 5. Cool patient using whatever means immediately available: • sprinkle or spray with fine water mist • air conditioned ambulance, or fanning CAUTION Rapid cooling may cause shivering and vomiting Wet sheets without air circulation will retain heat rather than dissipate it Do not use alcohol to lower temperature Do not delay transport to the hospital 6. Continue to monitor body temperature.

3.4 Bradycardia

CRITERIA • Bradycardia may be absolute (HR <60 bpm) or relative, which is a rate slower than expected for the patient's condition. Bradycardia may be normal status for patient on beta blockers or with an athletic life style. • Treatment listed to be used only if one or more of these conditions exist: • altered mental status • severe chest pain • lightheadedness, dizziness, nausea • systolic BP <90 mmHg, or relative hypotension for patient • frequent PVCs 1. Routine medical care EMT STOP

4.4 Bradycardia

CRITERIA • Bradycardia may be absolute or relative, which is a rate slower than expected for the patient's condition and is almost always the result of hypoxia in children. • Treatment listed to be used only if one or more of these conditions exist: • altered mental status • severe chest pain • lightheadedness, dizziness, nausea • systolic BP <80 mmHg, or relative hypotension for patient's expected normal • frequent PVCs 1. Routine medical care and begin timely transport. For newborns, refer ro Neonatal Resuscitation Protocol (2.22). 2. Assure airway patency and administer high flow oxygen. Bag-valve mask assisted ventilation should always be done for children < 8 yrs of age with bradycardia with poor perfusion. 3. Administer chest compressions if, despite ventilation and oxygenation, pulse remains < 60 bpm with poor perfusion. EMT STOP

2.4 Altered Mental Status

CRITERIA • Decreased level of consciousness from all causes should be treated using protocol below. • An ALS evaluation (including BG, SPO2, and ECG) should be performed on all patients whose mental status is decreased and on all patients over the age of 35 who have had a syncopal episode. 1. Routine medical care. 2. Assure airway patency and administer oxygen per protocol. 3. Assess signs, symptoms, hemodynamic status, medical history, possibility of poisoning, etc. 4. Consider need for spinal immobilization as appropriate. 5. Assess Blood Glucose (BLS if available) and refer to Diabetic Emergencies Protocol (2.14) if BG < 80 mg/dl. 6. All patients with an altered mental status should have timely transport to the hospital. 7. Consider other possible causes of decreased level of consciousness and refer to the appropriate protocol: • head trauma - refer to Head Trauma Protocol (2.16) • postictal - refer to Seizure Protocol (2.31) • meningitis or other infectious processes - refer to agency infectious disease plan • hypoxia - refer to Airway Management Protocols (2.0-2.3) • stroke - refer to Stroke / CVA Protocol (2.32) • overdose - refer to Poisoning / Overdose Protocol (2.25)

2.26 Pulmonary Edema/CHF

CRITERIA • Dyspnea/Tachypnea • Rales/wheezing • Pink, frothy sputum may be present or absent 1. Routine medical care. 2. Assess signs, symptoms and hemodynamic status. 3. Position patient with head elevated (High Fowlers). 4. Initiate oxygen therapy. 5. If inadequate respirations or decreased level of consciousness, consider use of BVM. 6. Begin timely transport.

1.4 Termination of Resuscitation

CRITERIA • For patient's meeting Do Not Resuscitate criteria, refer to Do Not Resuscitate Protocol (1.3). • For patients with obvious death, refer to Obvious Death Protocol (1.5). • Patient's must meet all of the following requirements for termination of resuscitative efforts to occur: • Age 18 or older • Non-traumatic, non-hypothermic • ECG is asystole confirmed in three leads, ventricular standstill, or pulseless idioventricular rhythm with a rate < 10 beats per minute • Cardiac arrest protocols have been followed for at least 25 minutes, including successful intubation or advanced alternate airway, IV/IO access, adequate CPR, and appropriate pharmacologic therapy • There has been no return of a perfusing cardiac rhythm at any time during at least 25 minutes of resuscitative measures • Patient is not in a public place • Appropriate emotional support by family, neighbors, clergy, or policeis available at the scene if the family is present ABSOLUTE ONLINE 1. Follow cardiac arrest protocols for at least 25 minutes. 2. Assure all of the above criteria have been met. 3. Obtain authorization from Medical Control to terminate resuscitative efforts. 4. Terminate resuscitative efforts. 5. Contact Medical Examiner /Coroner through police officer, telephone, or other appropriate means. Do not remove endotracheal tubes, king airways or IV/IO tubing. The patient may be covered, and may be moved back onto a bed or sofa if appropriate. TRANSPORT TO THE HOSPITAL SHOULD BE INITIATED IF ANY OF THE ABOVE CRITERIA ARE NOT MET, OR IF THE FAMILY OR THE PATIENT'S PRIVATE PHYSICIAN (if contacted) DISAGREE WITH TERMINATION OF EFFORTS AT THE SCENE. PATIENTS ALREADY MOVED TO AN AMBULANCE ARE NOT ELIGIBLE FOR TERMINATION OF RESUSCITATION IN THE FIELD, AND MUST BE TRANSPORTED TO THE HOSPITAL.

2.13 Croup

CRITERIA • History consistent with upper respiratory infection • Difficulty / inability to speak or presence of stridor 1. Routine medical care. 2. Assure airway patency and administer humidified high flow oxygen. CAUTION If possibility of epiglottitis, airway should not be stimulated or examined and Medical Control should be contacted before other treatment is undertaken. 3. Timely transport.

4.7 Stable Wide Complex Tachycardia

CRITERIA • If patient has wide complex tachycardia and is pulseless, refer to VF / Pulseless VT Protocol (4.1) • Stable VT protocol - Asymptomatic or minor symptoms (palpitations, heart racing, etc.) • Unstable VT protocol - HR >150 bpm with altered mental status change or shock symptoms (hypotension, poor peripheral pulses, cool distal extremities). 1. Routine medical care. 2. Assure airway patency and administer high flow oxygen. EMT STOP

3.7 Stable Wide Complex Tachyardia

CRITERIA • If patient has wide complex tachycardia and is pulseless, refer to VF/ Pulseless VT Protocol (3.1) • Stable VT protocol - Asymptomatic or minor symptoms (palpitations, heart racing, etc.) • Unstable VT protocol - HR >150 bpm with altered mental status changes or evidence of shock (hypotension, poor peripheral pulses, cool distal extremities). 1. Routine medical care. EMT STOP

2.18 Hypotension/Shock

CRITERIA • Inadequate tissue perfusion as evidenced by one or more of the following: • poor peripheral pulses, or capillary refill > 2 sec • altered mental status • cyanosis, pallor, diaphoresis, cool skin • dizziness, light-headedness, nausea or vomiting • tachycardia (in conjunction with one or more other symptoms and suggestive history) SHOCK MAY BE PRESENT EVEN IN THE PRESENCE OF A NORMAL BLOOD PRESSURE, PARTICULARLY IN CHILDREN AND YOUNG ADULTS 1. Routine medical care. 2. Assure airway patency and administer oxygen per protocol. 3. Assess signs, symptoms, and medical history. 4. Consider treatable causes: • Anaphylaxis - see Anaphylaxis Protocol (2.5) • Dysrhythmia - see appropriate Protocol (Section 3 or 4) • Hypoglycemia - see Diabetic Emergency Protocol (2.14) • Hypovolemia - see #5-6 below • Hypoxia - see Airway Management Protocol (2.0, 2.1) • Neurogenic or septic shock - see # 5-7 below • Trauma - see appropriate Trauma Protocol (Chest - 2.11, Head - 2.16) 5. Timely transport in supine position, or shock position if appropriate. Keep the patient warm by passive measures including warm ambulance compartment temperature, but avoid hyperthermia.

2.7 Avulsed Tooth Reimplantation

CRITERIA • Only reimplant permanent teeth • Best chance for success is when reimplantation occurs less than 5 minutes from injury • Do not reimplant if the alveolar bone / gingiva are missing or if the root is fractured • Do not reimplant if the patient is immunosuppressed or reports having cardiac issues that require antibiotics prior to procedures • Do not reimplant if the patient requires spinal immobilization • If not candidate for reimplantation, place tooth in interim storage media (low fat milk, patients' saliva, or saline) and keep cool. Avoid tap water storage but do not allow the permanent tooth to dry. 1. Routine medical care 2. Assure airway patency and administer oxygen per protocol 3. Assess signs, symptoms, hemodynamic status, and medical history 4. Consider need for spinal immobilization as appropriate (if spinal immobilization needed, do not reimplant) 5. Patients with an altered mental status should not be considered candidates for dental reimplantation 6. Hold the tooth by the crown 7. Quickly rinse the tooth with saline before reimplantation but do not brush off or clean tooth of tissue 8. Rinse and suction the clot from the socket 9. Reimplant tooth firmly into socket with digital pressure 10. Have the patient hold tooth in place using gauze and bite pressure 11. Report to hospital staff the efforts made to reimplant tooth

2.29 Respiratory Distress/Bronchospasm

CRITERIA • Oxygen saturation < 92% • Cyanosis • Respiratory rate < 8 rpm or > twice normal for age • Use of accessory muscles for respiration • Auscultation of adventitious breath sounds (wheezing, stridor), or markedly decreased air movement 1. Routine medical care including ensuring airway patency and administering high flow oxygen. 2. Assess signs, symptoms and hemodynamic status including vital signs, ability to speak in sentences, presence of accessory muscle use or wheezing. 3. If patient has own inhaler / nebulizer, may assist patient to use the device. 4. If patient is between 1 and 65 years of age and • has physician diagnosed asthma with previously prescribed use of Albuterol, and • agency approved for Albuterol use with a provider trained in Albuterol administration: Albuterol 5 mg by nebulizer, if available, may repeat x1 if ALS still en route or not available Albuterol 2.5 mg by nebulizer, if available, may repeat x1 if ALS still en route or not available CAUTION Medical Control should be contacted first (BLS Only) if patient has cardiac history (CHF, angina, arrhythmias, previous AMI, etc) 5. Timely transport with ALS if available. (ALS can not release to BLS for transport after medication administration.) EMT STOP

2.5 Anaphylaxis/Allergic Reaction

CRITERIA • Respiratory distress (wheezing, stridor, or use of respiratory accessory muscles) • Tongue, oropharynx, or uvular swelling • Hives, itching, or flushing • Signs of shock • Auscultation of unusual/abnormal breath sounds (wheezing, stridor), or markedly decreased movement of air 1. Routine medical care including oxygen saturation if available. 2. Assure airway patency and administer oxygen per protocol. 3. Assess signs, symptoms, and hemodynamic status. 4. If symptoms of shock, airway swelling or respiratory distress are present and: • The patient has their own anaphylactic emergency kit, the provider may assist the patient in administering the kit's contents or • If the BLS agency has completed registration as an EpiPen agency, the provider has been trained in its use and an auto injector Epinephrine device (0.3 mg IM) is available, the provider may administer the device's contents. If the patient has not had an epinephrine autoinjector previously prescribed, Medical Control must be contacted before BLS may administer. Use EpiPen Jr./Pediatric auto-injector (0.15 mg IM) for children under 30 kg (66 lbs). 5. Begin timely transport. If Epinephrine has been giv

3.5 Unstable Tachycardia (Wide or Narrow Complex)

CRITERIA • Stable Tachycardia - Asymptomatic or minor symptoms (palpitations, heart racing, etc.) • Unstable Tachycardia - HR > 150 bpm with mental status change or evidence of shock (hypotension, poor peripheral pulses, cool distal extremities) 1. Routine medical care. EMT STOP

4.5 Unstable Tachycardia (Wide or Narrow Complex)

CRITERIA • Stable Tachycardia - Asymptomatic or minor symptoms (palpitations, heart racing, etc.) • Unstable Tachycardia - HR > 150 bpm with mental status change,or evidence of shock (hypotension, poor peripheral pulses, cool distal extremities) 1. Routine medical care. 2. Assure airway patency and administer high flow oxygen. 3. Timely transport. EMT STOP

3.6 Stable Narrow Complex Tachycardia

CRITERIA • Supraventricular is defined as non-sinus, narrow complex tachycardia with HR usually > 150 bpm. • If ECG complex > 0.12 seconds, refer to Wide Complex Tachycardia Protocol (3.7), especially if patient > 50 years of age, or has a history of previous MI, coronary artery disease, or CHF. • Stable Narrow Complex Tachycardia protocol - asymptomatic or minor symptoms (palpitations, heart racing, etc.) • Unstable Narrow Complex Tachycardia protocol - HR >150 bpm with mental status change or evidence of shock (hypotension, poor peripheral pulses, cool distal extremities) 1. Routine medical care. EMT STOP

4.6 Stable Narrow Complex Tachycardia

CRITERIA • Supraventricular is defined as non-sinus, narrow complex tachycardia with HR usually > 160 bpm. If ECG complex > 0.12 seconds, refer to Wide Complex Tachycardia Protocol (4.7) • Stable Narrow Complex Tachycardia protocol - Asymptomatic or minor symptoms (palpitations, heart racing, etc.) • Unstable Narrow Complex Tachycardia protocol - HR >150 bpm with mental status change, or shock symptoms (hypotension, poor peripheral pulses, cool distal extremities) 1. Routine medical care. 2. Assure airway patency and administer high flow oxygen. 3. Timely transport. EMT STOP

2.25 Poisoning/Overdose

CRITERIA • Suspected or actual overdose of patient's prescribed medications - accidental or intentional. • Suspected or actual ingestion/injection of non-prescribed medications - accidental or intentional. • Exposure to potentially toxic substance - ingestion, inhalation, dermal contact, etc. 1. Routine medical care with transport in left lateral recumbent position if oral ingestion. 2. Assure airway patency and administer oxygen per protocol. CAUTION If carbon monoxide inhalation or inhalation injury, patient must be on 100% oxygen 3. Assess signs, symptoms, hemodynamic status, type, time and amount of poisoning. If possible, bring poison container to hospital. 4. Poison control may be contacted for management advice, however all treatment orders must come from on-line Medical Control. 5. If orally ingested poison less than one hour old in an alert patient who is able to protect their airway AND if directed by Medical Control: Sorbitol-free Activated Charcoal 50 g PO Sorbitol-free Activated Charcoal 2 g/kg PO (Max 50 g)

3.2 Return of Spontaneous Circulation (ROSC)

CRITERIA • The following is for a patient with Return of Spontaneous Circulation (ROSC) as evidenced by a palpable pulse following CPR, electrical, or drug therapy for a patient previously pulseless. • Post-conversion treatment of VF or VT should only be started if the patient has regained a pulse of adequate rate (>60). If not, refer to other cardiac protocols as appropriate. 1. Routine medical care. EMT STOP

2.22 Neonatal Resuscitation

CRITERIA • The primary concerns of newborn resuscitation are adequate oxygenation, airway patency, and warmth. • Signs of inadequate oxygenation include: • Quiet, not crying • No response to tactile stimulation • Diffuse, dark cyanosis over entire body (Initial cyanosis should "pink up" rapidly) • Respiratory rate < 20 rpm • Pulse rate < 100 bpm • Flaccid, non-moving extremities • Supplemental oxygenation (when needed) may be provided by holding mask near or on face: 1. Suction only if BVM is used. 2. Keep baby at level of vagina until umbilical cord is cut. Cord should be clamped and cut 30-45 seconds after birth. 3. Dry baby, warm with blankets, provide tactile stimulation. Environment should be warm. 4. If respirations < 30 rpm or heart rate < 100 bpm Ventilate with 100% oxygen using neonatal or small child bag-valve mask at a rate of 40-60 breaths per minute. 5. If heart rate < 60 bpm Begin chest compressions at rate of 120 per minute utilizing a compression/ventilation ratio of 3:1. Begin timely transport. EMT STOP

2.15 Fluid Challenge/Replacement

CRITERIA • Medical hypovolemia due to dehydration: • history consistent with decreased fluid intake and/or increased fluid loss • decreased skin turgor or sunken eyeballs • sinus tachycardia not clearly explained by other causes • orthostatic changes: either patient becomes dizzy when standing, or pulse increases by >20 bpm • Shock due to trauma or other causes (see appropriate protocol)

2.2 Airway Obstruction - Adult

Conscious patient Adequate air exchange (able to cough, speak, or breathe) 1. Reassure patient and place in position of comfort. 2. Encourage coughing. Clear oropharynx as needed. 3. Administer high flow oxygen. Inadequate air exchange (cannot cough, speak, or breathe) 4. Administer continuous abdominal thrusts (Heimlich Maneuver; chest thrusts on pregnant patient) until adequate air exchange is restored or the patient loses consciousness. Unconscious patient 5. Manually open airway, attempt to ventilate with 2 breaths. If unable to ventilate, reposition and reattempt to ventilate. 6. Administer CPR. 7. Suction and finger sweep only if object visible. 8. Repeat this sequence from #5 as needed and begin timely transport.

2.3 Airway Obstruction - Pediatric

Conscious patient: Airway should not be unnecessarily stimulated or examined in the situation of possible epiglottis or croup. Adequate air exchange (able to cough, speak, breathe, or cry) 1. Reassure patient and place in position of comfort. 2. Encourage coughing. Clear oropharynx as needed. DO NOT PERFORM BLIND FINGER SWEEPS. 3. Administer high flow oxygen. Inadequate air exchange (cannot cough, speak, breathe, or cry) 4. Age <1 yr: Administer 5 back slaps with head lower than body Administer 5 chest thrusts Repeat as necessary Age >1 yr: Administer continuous abdominal thrusts (Heimlich maneuver) until adequate air exchange is restored, or patient loses consciousness. Unconscious patient: 5. Manually open airway, attempt to ventilate with 2 breaths. If unable to ventilate, reposition and reattempt to ventilate. 6. Administer CPR. 7. Suction and finger sweep only if object visible. 8. Repeat this sequence from #5 as needed and begin timely transport.

2.34 Vascular Access

EMT STOP

2.35 Ventilator Management - Emergent Prehospital

PARAMEDIC ONLY

2.36 Ventilator Management - Stable Outpatient

PARAMEDIC ONLY

1.2 On Scene Medical Personnel

PATIENT'S PERSONAL PHYSICIAN If the patient's personal physician is on the scene, they may assume responsibility for the patient. The physician wishing to assume responsibility for the patient must: 1. Write and sign for all orders for the EMS provider. 2. If the physician refuses to sign, Medical Control is to be contacted. Unless the physician accompanies the patient to the hospital, standard operating procedures and standing orders will prevail if the patient's condition deteriorates and/or other procedures are required. If the patient's personal physician accompanies the patient to the hospital, he/she continues to assume full responsibility for all orders and patient care decisions. The EMS provider will decline any orders that are contrary to, or exceed the level of their training. BYSTANDER PHYSICIAN A bystander physician wishing to assume responsibility for a patient may do so only after approval from the Medical Control Physician. If a bystander physician wishes to assume responsibility for the patient, they must: 1. Write and sign for all orders for the EMS provider. 2. Accompany the patient to the hospital. If the physician does not agree to accompany the patient to the hospital, standard operating procedures and standing orders will prevail both on scene and during transport. If the physician accompanies the patient to the hospital, he/she continues to assume full responsibility for all patient care decisions. The EMS provider will decline any orders that are contrary to or exceed the level of their training. The EMS provider should make reasonable effort to verify the credentials and qualifications of the bystander physician prior to involving them in patient care. If doubt exists, Medical Control should be contacted and system protocols shall dictate patient care. If approval from Medical Control cannot be obtained, the bystander physician may not assume responsibility for the patient, and the EMS provider will follow system protocols. REGISTERED NURSE, PHYSICIANS ASSISTANT, LICENSED PRACTICAL NURSE, ETC. Non-physician medical personnel may assist with patient care under direction of the EMS provider, but may not be in charge of, or assume responsibility for patient care. OTHER PRE-HOSPITAL CARE PROVIDERS Off-Duty EMS personnel and On-Duty personnel from a lower scope of practice agency may assist with patient care under the direction of the EMS providers on scene but may not be in charge of, or assume responsibility for patient care.

9.3 Management of Violent and Potentially Violent Behavior

PURPOSE To define the techniques that may be used for the management of violent and potentially violent patients. Underlying this policy is the expectation that the safety of pre-hospital personnel is paramount and at no time should the provider put their safety in jeopardy. POLICY 1. Responders should apply the following techniques on every call to promote their safety and the safety of those around them: Use an established panic code with a communications center and other responders when in a lifethreatening circumstance to summon rapid law enforcement response. Have two means of communication with a communications center at all times Ensure that location changes are reported to a communications center Be aware of an exit route from the scene Have a plan for an alternate source of cover or concealment Have dogs and other potentially hostile animals secured Scan the scene for improvised weapons Be alert to the body language of all persons on the scene Treat the patient in an alert posture to be able to defend or escape 2. Law Enforcement should be requested for situations where EMS providers have a high index of suspicion that violence may occur. 3. Patient contact may be delayed if the responders believe the scene may be unsafe based on either dispatch information or a scene size up. EMS units should stage out of sight from any potential hostile incident and notify the communications center of their staging location. 4. If patient contact is delayed due to a potentially dangerous environment, it should be reported to the communications center and documented on the PCR with both the reason and the time. 5. If an EMS provider is already on the scene and the situation becomes hostile, the providers should exit the situation to a safe area until law enforcement can establish order on the scene. 6. EMS personnel should consider potential medical causes for the hostile reaction including hypoxia, hypoglycemia, and postictal state. The causes, once identified, should be treated according to the Standards of Care. 7. If exit is not practicable, the providers should verbally direct the hostile party(ies) to stop their actions. These directions should be specific, direct, and respectful. Responders should be prepared to seek exit or refuge, and should request expedited assistance from law enforcement. 8. Physical confrontations between EMS providers and the public should be avoided. EMS providers should exit the situation expeditiously should the situation escalate to violence. It is acceptable to leave behind equipment and the patient if necessary to ensure scene safety. The EMS providers should reengage in patient care as soon as the scene is safe. 9. If a physical confrontation can not be avoided, EMS providers may defend themselves, the other responders, and the patient. The confrontational physical contact must be limited to the amount of force reasonably expected to ensure the safety of everyone on scene and the physical contact should be defensive in nature. The use of improvised weapons (such as large metal objects including flashlights and oxygen cylinders) must only be in defense of responders or civilians on scene, when one reasonably believes there is an imminent danger of death or serious physical injury. On duty possession or use of traditional weapons (pepper spray or similar, TASER, firearm, bludgeons, or edged weapons) are strongly discouraged and must be conducted only within a specific written policy approved by the agency operations staff and medical director. If there is any physical contact resulting from a confrontation with a violent person, the EMS responders must document the situation thoroughly and report it as per the agency's policies. Incidents resulting in physical injury to the patient must be reported to the New York State Bureau of EMS consistent with the policies outlined in Part 800.21. 10. Patient restraint may be performed with law enforcement personnel or under the order of a Medical Control Physician. Assess the patient's need for restraint in collaboration with the on-scene police agency. Prior to restraining a patient, explain to the patient and patient's significant other(s) the reason for restraint use. Select the least restrictive device possible, but one that will ensure the patient cannot harm themselves or others. Maintain constant, direct supervision of the restrained patient 11. Patients must be restrained in a supine or lateral recumbent position. Patients must be restrained using a soft restraint (such as a cravat or spiral gauze) or handcuffs provided by law enforcement. Handcuffs or plastic bands should be replaced with cloth or leather restraints if feasible. A means for removing the handcuff (keys) or plastic band (removal device) must be present at all times to allow removal. The restraints should be secured to a non-moving portion of the patient carrying device. All limbs should be restrained. It may be appropriate to place a belt around the patient's thighs, pelvis, and chest however these belts must not restrict chest expansion. 12. Once restraints are applied, the EMS providers must regularly reassess vital signs, and circulatory, motor, and sensory status distal to the restraints. Restrained extremities must be monitored for constriction, ischemia, or other signs of injury. The patient's medical status must be continuously monitored. The patient must never be left alone. 13. If the patient is spitting, it is appropriate to apply a "Spit Sock" or non-rebreather mask with flaps and reservoir removed. The EMS provider must constantly monitor the patient's airway, respiratory status, and level of consciousness. 14. Depending on the situation, law enforcement may follow the ambulance to the hospital. If at any time the provider in charge of patient care is not comfortable in transporting a patient alone in the back of the ambulance, law enforcement should be requested to ride along. 15. Advanced Life Support and pharmacological intervention may be indicated. Refer to the MLREMS Standards of Care for indications and dosage. 16. Documentation is expected to include the following: Steps taken to control patient prior to use of physical restraints, including the reasons restraints were needed and why less restrictive measures were unable to be utilized. Baseline skin color and integrity prior to application of restraints. The time restraints were applied. Pertinent observations including vital signs and any changes in behavior. Name of police agency, and if possible, name of police officer. Vital signs and patient evaluation must be documented every

9.23 Life Threatening Hemmorrhage

PURPOSE Controlling life threatening hemorrhage is a primary goal of emergency medical care. This policy authorizes the use of either a tourniquet or hemostatic gauze to gain rapid hemorrhage control and minimize blood loss from external life threatening hemorrhage. POLICY This procedure may be used by any level provider who is trained on and authorized to use a tourniquet and/or hemostatic gauze by their Agency Medical Director. INDICATIONS 1. Life threatening hemorrhage is indicated by arterial hemorrhage or massive venous hemorrhage as a result of blunt or penetrating trauma. CONTRAINDICATIONS 1. Tourniquets should not be used on limbs with a dialysis fistula, except in cases of traumatic penetration, amputation, or crush injury without response to a pressure dressing. 2. Never apply tourniquet over a joint. PROCEDURE Hemorrhage from an extremity: 1. In cases where life threatening hemorrhage to a limb cannot be controlled with a pressure dressing, apply tourniquet 2 inches above wound. 2. Tighten tourniquet until bleeding has stopped. 3. Record time that tourniquet was applied. 4. Tourniquet shall remain on until hospital arrival. 5. Inform all subsequent care providers of the location of the tourniquet, its effectiveness, and time of application. Hemorrhage from axilla, groin, neck, or large scalp wounds: 1. Clear pooled blood from the wound. 2. Pack with hemostatic gauze and maintain direct pressure for at least 3 minutes. CONSIDERATIONS: • A tourniquet may be placed over clothing however it does not work well over leather coats or bulky clothing. • When a tourniquet is placed over clothing, it should be placed as close to the torso as possible. • If tourniquet placement exceeds 2 hours, contact medical control. • The tourniquet and hemostatic gauze should be re-evaluated every time there is a change in the patient's status, or the patient is moved.

9.10 Care and Transport of Minors

PURPOSE EMS providers are occasionally called to treat and transport minors. New York State does not allow a person under age 18, unless emancipated, to assume responsibility for their medical care. This policy defines an emancipated minor and outlines the treatment expectations of minors and emancipated minors. POLICY 1. Definition of emancipation shall be a person between the ages of 16 and 18 who: a. Live separate and apart from their parents b. Do not receive any financial support from them c. Live beyond the parent's custody and control d. Are not in foster care 2. An emancipating event includes: a. Marriage b. Pregnancy (only for prenatal care) c. Parenthood d. Degree/Diploma e. Military service 3. If a minor is ill or injured in any way, they should be transported to a medical facility. 4. If a minor is between the ages of 16 and 18 and relates an emancipating event, they may make their own decisions regarding treatment and transport to include refusing such care. 5. If a minor is not injured use the following guidelines: a. A law enforcement officer has the legal authority to assume responsibility for a minor who is not injured until a parent/guardian can be located. If willing, the officer must sign the refusal form in the area for guardian. b. Make reasonable efforts to contact parent/guardian. Document who you spoke with and their treatment decision for the minor. Care and treatment should never be delayed to accomplish this. c. If contact with a parent/guardian cannot be made, contact Medical Control.

9.2 ALS Release to BLS

PURPOSE On occasion, an ALS provider is dispatched to a call that does not require ALS. Although these instances may be infrequent, the patient should receive an assessment by the ALS provider and the release to BLS must be properly documented and mutually agreed upon by both the ALS and BLS provider. This policy applies to all patients where patient contact has been made and the ALS provider desires to release the patient to a BLS provider or the BLS provider feels ALS is not indicated. Patient contact is defined by the provider's visual contact with the patient. POLICY An ALS unit (i.e. an ambulance or first response unit staffed by an EMT-CC or EMT-P technician and certified to operate at the ALS level) who makes patient contact may transfer care of a patient to a BLS unit according to the following procedure: 1. The ALS technician will complete a focused assessment on the patient. This will include: a. Focused subjective assessment including history of the problem. b. Complete medical history including current medications, allergies, and recent hospitalizations. c. Assessment of all pertinent systems. d. A complete set of vital signs including blood pressure, pulse, respirations, level of consciousness, and skin color/temperature. 2. The ALS technician will assure that the patient's condition does not currently, and will likely not in the reasonably near future, warrant pre-hospital ALS-level care (to include pain control). 3. The ALS technician will assure through verbal conference with the BLS crew that they are comfortable assuming care of the patient. 4. The ALS technician will complete a PCR which includes full documentation of the assessment performed, physical findings, pertinent negatives, and vital signs. In cases where both the BLS unit and the ALS provider are from the same agency, it is acceptable for the ALS assessment to be completed as an addendum on the transporting provider's PCR. Considerations 1. The ALS technician must accompany the patient to the hospital if the BLS crew expresses any discomfort with assuming care for the patient. This is regardless of whether or not the ALS technician believes any ALS procedures are warranted. However, it is the obligation of the BLS crew to state if they are not comfortable with managing the patient. 2. The ALS provider may not use tests to rule out pathology. For example, a normal 3 or 12 lead EKG does not rule out the presence of myocardial infarction or other cardiac emergency. Acquisition of an EKG should not be used as a determining factor for whether a patient may be released to BLS care. Similarly, normal SpO2 or EtCO2 do not rule out respiratory disorders. 3. It is the responsibility of the ALS technician on scene to contact Medical Control if there is any debate as to the appropriateness of the release to BLS.

9.5 Refusal of Treatment/Transport Policy

PURPOSE This policy outlines the evaluation of a patient refusing treatment or transport and the documentation expected when obtaining such a refusal. POLICY I. Overview A patient is defined as a person encountered by EMS personnel with an actual or potential injury or medical problem. "Encountered" refers to visual contact with the patient. These persons may have requested an EMS response or may have had an EMS response requested for them. Due to the hidden nature of some illnesses or injuries, an assessment should be performed on all patients. For patients initially refusing care, an attempt to evaluate the individual, even if only by visual assessment, is expected and must be documented. II. Evaluation The evaluation of any patient refusing medical treatment or transport should include the following: 1. Visual Assessment - To include responsiveness, level of consciousness, orientation, obvious injuries, respiratory distress, and gait. 2. Initial Assessment - Airway, breathing, circulation, and disability. 3. Vital Signs - Pulse, blood pressure, respiratory rate and effort. Pulse oximetry and/or blood glucose when clinically indicated. 4. Focused Exam - As dictated by the patient's complaint (if any). 5. Medical Decision Making Capacity Determination - As defined below. Patients at the scene of an emergency who demonstrate capacity for medical decision making shall be allowed to make decisions regarding their medical care, including refusal of evaluation, treatment, or transport. In order to ensure that a patient exhibits the capacity for medical decision making, the patient must have the ability to understand the nature and consequences of their medical care decision. A patient, who is evaluated and found to have any one of the following conditions, shall be considered incapable of making medical decisions regarding care and/or transport and should be transported to the closest appropriate medical facility under implied consent: 1. Altered mental status from any cause including altered vital signs, intoxication from drugs and/or alcohol, presumed metabolic causes (ingestion, hypoglycemia, stroke, etc), head trauma, or dementia. 2. Age less than 18 unless an emancipated minor or with legal guardian consent. 3. Attempted suicide, danger to self or others, or verbalizing suicidal intent. 4. Acting in an irrational manner, to the extent that a reasonable person would believe that the capacity to make medical decisions is impaired. 5. Severe illness or injury to the extent that a reasonable and medically capable person (or, for a pediatric patient, the parent/guardian) would seek further medical care. 6. When appropriate documents are signed and patient is placed under involuntary commitment pursuant to Article 9 of the New York State Mental Hygiene Law. Patient consent in these circumstances is implied, meaning that a reasonable and medically capable adult would allow appropriate medical treatment and transport under similar conditions. Providers who identify a patient requiring transport under implied consent and are refusing to do so may require Medical Control consultation and Law Enforcement involvement to ensure the patient is transported to an appropriate emergency facility for evaluation. Medical care should be provided according to the most recent edition of the Monroe-Livingston Regional EMS Standards of Care. Once a patient assessed to lack decisional capacity is transported under implied consent to the appropriate emergency facility, another determination of decisional capacity may be required for continued involuntary care and treatment. Patients exhibiting the following at risk criteria should receive particular attention to an appropriate evaluation and risk/benefit discussion prior to not transporting and the EMS provider should consider medical control consultation prior to obtaining a refusal: 1. Age greater than 65 years or less than 2 months. 2. Pulse > 120 or <50. 3. Systolic blood pressure >200 or <90. 4. Respirations >29 or <10. 5. Serious chief complaint (chest pain, SOB, syncope). 6. Significant mechanism of injury or high suspicion of injury. Patients exhibiting medical decision making capacity and wishing to refuse care/transport may do so after the provider has assured the following have been completed: 1. Determined the patient exhibits decisional capacity to refuse care/transport. 2. Offered transport to a hospital. 3. Explained the risks of refusing care/transport. 4. Explained that by refusing care/transport, the possibility of serious illness of death may increase. 5. Advised the patient to seek medical attention and gave instructions for follow-up care. 6. Confirmed that the patient understands these directions. 7. Ensured that the patient signed the Refusal of Treatment/ Transport Form or documented why it was not signed. 8. Left the patient in the care of a responsible adult when possible. 9. Advised the patient to call 911 with any return of symptoms or if they wish to be re-evaluated and transported to the hospital. III. Medical Control The EMS provider should consider consulting Medical Control if the patient does not wish transport. The purpose of the consultation is to obtain a "second opinion" with the goal of helping the patient realize the seriousness of their condition and accept transportation. Medical consultation is highly recommended for the following: 1. The provider is unsure if the patient is medically capable to refuse treatment and/or transport. 2. The provider disagrees with the patient's decision to transport due to unstable vital signs, clinical factors uncovered by the assessment, or the provider's judgment that the patient is likely to have a poor outcome if not transported (See at risk criteria, above). Medical Control consultation is required for the parent or legal guardian refusing transport of a child being evaluated for an Acute Life Threatening Event (ALTE). IV. Documentation Patient refusals are the highest risk encounters in clinical EMS. Careful assessment, patient counseling, and appropriate Medical Control consultation can decrease non-transport of high-risk refusals. Paramount to the decision-making involved in a patient refusal of treatment and/or transport is the documentation of that refusal. Documentation is expected to include: 1. Documentation of the provider's assessment, the treatment provided, reasons for refusal, and Medical Control consultation as appropriate on the Prehospital Care Report. 2. Completion of the Monroe-Livingston EMS Region Refusal of Treatment/Transport Form: a. Identify the agency name. b. Identify the date of the incident. c. Identify the PCR associated with the refusal. d. Appropriately mark the boxes indicating Medical Decision Making Capacity Determination. Any boxes checked "yes" indicate that the patient cannot refuse treatment and/or transport as they lack decision making capacity. e. Identify any Absolute On-Line Medical Control criteria and any high risk criteria that may benefit by Medical Control Consultation. f. Identify the reason for refusal of care and/or transport and directions for follow-up care in the PCR. g. Print, sign, and indicate the provider's EMT number after completing the items on the Patient Refusal Checklist. h. Have the patient print, sign, date, and time the release form. Should the patient refuse to sign, check the "Patient refused to sign" box. A witness should still sign. i. Have a witness sign the release form. 3. Provide the patient with a Patient Refusal Information Card (If available) 4. Attach the refusal form to the PCR (electronically or paper) For agencies using an electronic medical record and a device capable of capturing patient and provider signatures electronically in the field, the agency may use a modified Monroe-Livingston EMS Region Refusal of Treatment/Transport Form for use on such an electronic device as approved by the Regional Medical Director or his/her designee. Associated Documents: 1. MLREMS Refusal of Treatment/Transport Form 2. MLREMS Refusal of Treatment/Transport Information Card

9.15 Access to Emergency Psychiatric Services

PURPOSE To define a decision tree for accessing hospital based emergency psychiatric services. NOTE: This policy applies to patients not presenting with a primary medical or traumatic condition. If the patient has a presenting medical or traumatic condition requiring immediate treatment, follow the appropriate MLREMS Standard of Care. In all cases clinical continuity and safety for patients and providers should be considered. POLICY For patients requiring emergency department based psychiatric services, the following guidelines should be followed: Transport the person to the destination noted on the transport papers, regardless of both Code Red status and the patient's preference. In the absence of written transport papers, transport the person to the Article 9.39 hospital where current psychiatric treatment is being provided. If the intended destination is Code Red, the patient should be taken to the nearest non-Code Red Article 9.39 hospital If the person is not in a current treatment program (at a 9.39 facility), they should be taken to the nearest Article 9.39 hospital that is not Code Red. NOTE: Article 9.39 Hospitals in the Monroe-Livingston area include: Monroe County Rochester General Hospital University of Rochester Medical Center - Strong Memorial Hospital St. Mary's (Unity) Surrounding Counties Clifton Springs Hospital (Clifton Springs) Newark-Wayne Community Hospital (Newark) St. James Mercy Hospital (Hornell) Wyoming County Community Hospital (Warsaw)

9.17 On-line Medical Control Requirements

PURPOSE To define the requirements of facilities and physicians providing on-line medical control to EMS providers in the Monroe-Livingston Region. DEFINITION On-Line Medical Control (OLMC) is the advice and direction through a direct, live communication link (two-way radio or telephone) from a physician to certified first responders, emergency medical technicians or advanced emergency medical technicians who are providing medical care at the scene of an emergency. POLICY Facility Requirements To be a considered an OLMC facility in the Monroe-Livingston Region, the facility must: 1. Have an emergency department meeting all standards for emergency department/service as defined in Section 405 of the NYS Hospital Code. 2. Have a physician staff member physically present in the emergency department and immediately available 24 hours a day that is credentialed by the Monroe-Livingston REMAC to provide OLMC. 3. Provide on-line medical direction for BLS and ALS agencies that transport patients to their facility and to facilities not able to provide OLMC. 4. Accept patients requiring BLS and or ALS services who may have received EMS care under physician direction originating from another medical control hospital. 5. Maintain direct two-way radio and/or compatible telephones connected to regional communications systems to communicate with BLS and ALS units and medical control hospitals. 6. Use only Monroe-Livingston REMAC approved medical control logs and maintain them for a minimum of 7 years. 7. Record all audio from direct two-way radio and/or compatible telephones providing OLMC and maintain them for a minimum of 7 years. 8. Assume the responsibility for the care and maintenance of necessary communications equipment within the institution. 9. Familiarize staff members with approved regional and state protocols. 10. Participate in local and or regional EMS planning activities as appropriate. 11. Participate in quality improvement activities as defined in Part 405.19 item (f) of the NYS Hospital Code. 12. Participate in quality improvement activities as requested by the Monroe-Livingston REMAC or System Medical Director as they relate to the provision of OLMC. 13. Designate a Hospital Medical Control Director to be in charge of overall coordination of medical control in that facility. Physician Requirements To be credentialed as an On-Line Medical Control Physician in the Monroe-Livingston Region, the physician must: 1. Be licensed to practice medicine or osteopathy in New York 2. Be Board Certified/Board Eligible by the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine or be credentialed in basic and advanced cardiac life support, and Advanced Trauma Life Support, or equivalent. 3. Physicians-in-training must be credentialed in basic and advanced cardiac life support and Advanced Trauma Life Support, or equivalent, and be at the PGY2 or higher training level. 4. Be trained in and thoroughly familiar with the following: a. Regional and state BLS and ALS protocols b. Communication systems c. EMS levels of training and responsibilities d. Medical control system and responsibilities of a medical control physician 5. Successfully complete (80% or better) an open book, written OLMC Test administered by the Monroe- Livingston REMAC. 6. Review, and as directed, complete re-training regarding the provision of OLMC as regional protocols and policies are updated. Hospital Medical Control Director Requirements Each OLMC hospital is to identify one physician as the Hospital Medical Control Director whose duty is the overall coordination and medical accountability of the medical control system in his/her facility. The Hospital Medical Control Director is responsible to the Regional Medical Director for all functions of the medical control system in that hospital. The Hospital Medical Control Director must meet all requirements of an OLMC Physician. Additionally, the Hospital Medical Control should be familiar with the Monroe-Livingston BLS and ALS protocols, system configuration, and communication, and have a thorough knowledge of and strong dedication to the support and improvement of emergency medical services. The Hospital Medical Control Director will: 1. Maintain knowledge levels appropriate for an EMS medical director through continued education. 2. Sit as a member of the Monroe-Livingston REMAC and participate regularly in its functions, or appoint a suitable physician alternate. 3. Ensure adequate training and familiarity of all emergency department physician and nursing staff with: a. Pre-hospital medical control system and issues b. Training and responsibilities of all levels of pre hospital EMS providers c. Quality improvement concerns d. Monroe-Livingston REMAC protocols e. Pre-hospital/hospital interface and cooperation 4. Develop and implement an effective quality improvement program for continuous system and patient care improvement. a. EMS call audits shall be conducted at a minimum of twelve (12) hours per year. 5. Direct and facilitate an on-going review of the medical control system and quality improvement program. Mediate pre-hospital issues and problems concerning medical control, as appropriate. 6. Report any EMS personnel or ALS Agency complaint, protocol violation, or lack of cooperation with other aspects of medical control and or quality improvement activities, to the Monroe-Livingston REMAC. 7. Maintain Monroe-Livingston REMAC protocols and appropriate policies immediately available at the medical control telephone/radio base station. Note: Medical Control facilities will have until September 1, 2009 to meet physician credentialing requirements and will have until January 1, 2009 to meet audio recording requirements.

9.14 Emergency Incident Rehabiliation

PURPOSE To ensure the physical and mental condition of responders operating at the scene of an emergency or training exercise does not deteriorate to a point that affects the safety and health of the responder, fellow responders, or the safety and integrity of the operation. Agency leadership are strongly encouraged to review the United States Fire Administration guide to Emergency Incident Rehabilitation (February 2008 revision) and the National Fire Protection Association Standard 1584 to assist in placing this policy into context. Regardless of how rehabilitation is implemented, it is absolutely crucial that all responders follow this policy. No one, including officers, should be allowed to skip the rehabilitation process as enforcement of this policy will have a measurable affect on the long-term well-being of all responders. POLICY The following policy is strongly recommended for events, including training, fireground operations, hazardous materials incidents, prolonged extrication, and any other event where emergency response personnel are engaged in activities that pose a risk of exceeding a safe level of physical or mental endurance. This policy defines the minimum expectations of Emergency Incident Rehabilitation in the Monroe/Livingston Region, however agencies may, upon approval of their Medical Director, choose to implement additional criteria for rest, re-hydration, or physiologic measures provided they are not less than the minimum expectations set forth herein. Expectations 1. It is the responsibility of all responders at the scene to monitor themselves and their personnel to ensure the safety, health, and welfare of all responders by ensuring adequate rest and hydration following the recommendations as set forth in this policy. 2. All providers are encouraged to participate in self-rehabilitation. This should ideally include 10 minutes between work periods and/or SCBA exchanges whereby the provider is allowed to rest and consume appropriate fluids while awaiting reassignment. 3. The Incident Commander shall consider the circumstances of each incident or training exercise early in the evolution of the incident or exercise, and make adequate provisions for the rest and rehabilitation for all personnel operating at the scene. 4. For any event where the above criteria are met, it is recommended that the Incident Commander or their designee (Incident Safety Officer or Logistics Section Chief) establish the following minimum: a. Rehabilitation Area Ample space with preference to seating for responders Protection from the elements, fumes, or hazards Accessible by EMS Clearly identified Temperature control including active cooling and re-warming of responders as indicated by environmental conditions Re-hydration to include water and electrolyte replacement Nutrition (as appropriate for the duration of the incident) Staffing should include at least one Rehabilitation Officer/Manager with training of at least the NYS EMT-B and BLS equipment to include oxygen, blood pressure cuff and pulse oximeter. Availability of an AED in proximity to the Rehabilitation Area is strongly encouraged. Pulse co-oximetry is optional, but encouraged. b. Treatment Area Separate from the rehabilitation area In close proximity to a transporting ALS ambulance and the rehabilitation area Staffing should include a fully-staffed ALS transporting ambulance 5. There should be at least one rehabilitation staff member trained to at least the EMT-B level for every 5 responders in the Rehabilitation Area. 6. For large incidents, it may be advisable to have more than one Rehabilitation and/or Treatment Area established. This decision should be made by the Incident Commander or their designee. 7. For incidents greater than a single alarm, it is recommended that a minimum of one fully staffed ALS transporting ambulance is available per alarm assignment. Additional transporting ambulances may be required depending on the type of operation, environmental conditions, and number of responders involved. 8. No personnel should enter the warm or hot zone of a declared Hazardous Materials Incident unless the Rehabilitation and Treatment areas have been established and staffed according to the policies and procedures of the respective Hazardous Materials Team. This must include an ALS transporting ambulance and a regionally credentialed Tox-Medic. 9. It is advised that pre-hydration, when possible, occurs to include a minimum of 16 ounces of non-caffeinated fluids over the two hours prior to scheduled events, such as training exercises. Protocol 1. Responders should be detailed to the Rehabilitation Area by the Incident Commander or their designee after every 45 minutes of continuous hard labor, one 45 minute or 60 minute rated SCBA cylinder, two, thirty-minute rated SCBA cylinders, or after being decontaminated. The Incident Commander or Incident Safety Officer may direct personnel to the Rehabilitation Area at any time for reasons not mentioned above. 2. All responders must be decontaminated (if necessary) and remove personal protective equipment prior to entering the Rehabilitation Area. 3. All responders must follow their agencies accountability system when entering/departing the Rehabilitation and/or Treatment Areas. 4. Upon entering the Rehabilitation Area, the responder is expected to do the following: a. Drink at least 16 ounces of fluid (water first, then half-strength electrolyte solution). b. No tobacco use in the Rehabilitation or Treatment Areas. c. Heed the directives of the Rehabilitation Officer/Manager with regards to their disposition to the manpower/staging or the treatment areas. 5. The responder will be assessed by the Rehabilitation Officer/Manager or other qualified medically trained personnel. 6. Any responder entering the rehabilitation area with complaints of chest pain, shortness of breath (beyond normal exertion), or altered mental status will be immediately moved to the Treatment Area and may not return to duty for the duration of the incident. This shall be immediately reported to the individual(s) responsible for scene safety, accountability and/or command. 7. Every responder will be assessed for presence of other symptoms to include dizziness, weakness, nausea, headache, cramps, aches or pain, changes in gait, speech or behavior, mental/physical stress, exhaustion, and symptoms of heat or cold-related stress. These symptoms do not require immediate removal to the Treatment Area, but must resolve prior to returning to manpower/staging. b. Treatment Area Separate from the rehabilitation area In close proximity to a transporting ALS ambulance and the rehabilitation area Staffing should include a fully-staffed ALS transporting ambulance 5. There should be at least one rehabilitation staff member trained to at least the EMT-B level for every 5 responders in the Rehabilitation Area. 6. For large incidents, it may be advisable to have more than one Rehabilitation and/or Treatment Area established. This decision should be made by the Incident Commander or their designee. 7. For incidents greater than a single alarm, it is recommended that a minimum of one fully staffed ALS transporting ambulance is available per alarm assignment. Additional transporting ambulances may be required depending on the type of operation, environmental conditions, and number of responders involved. 8. No personnel should enter the warm or hot zone of a declared Hazardous Materials Incident unless the Rehabilitation and Treatment areas have been established and staffed according to the policies and procedures of the respective Hazardous Materials Team. This must include an ALS transporting ambulance and a regionally credentialed Tox-Medic. 9. It is advised that pre-hydration, when possible, occurs to include a minimum of 16 ounces of non-caffeinated fluids over the two hours prior to scheduled events, such as training exercises. Protocol 1. Responders should be detailed to the Rehabilitation Area by the Incident Commander or their designee after every 45 minutes of continuous hard labor, one 45 minute or 60 minute rated SCBA cylinder, two, thirty-minute rated SCBA cylinders, or after being decontaminated. The Incident Commander or Incident Safety Officer may direct personnel to the Rehabilitation Area at any time for reasons not mentioned above. 2. All responders must be decontaminated (if necessary) and remove personal protective equipment prior to entering the Rehabilitation Area. 3. All responders must follow their agencies accountability system when entering/departing the Rehabilitation and/or Treatment Areas. 4. Upon entering the Rehabilitation Area, the responder is expected to do the following: a. Drink at least 16 ounces of fluid (water first, then half-strength electrolyte solution). b. No tobacco use in the Rehabilitation or Treatment Areas. c. Heed the directives of the Rehabilitation Officer/Manager with regards to their disposition to the manpower/staging or the treatment areas. 5. The responder will be assessed by the Rehabilitation Officer/Manager or other qualified medically trained personnel. 6. Any responder entering the rehabilitation area with complaints of chest pain, shortness of breath (beyond normal exertion), or altered mental status will be immediately moved to the Treatment Area and may not return to duty for the duration of the incident. This shall be immediately reported to the individual(s) responsible for scene safety, accountability and/or command. 7. Every responder will be assessed for presence of other symptoms to include dizziness, weakness, nausea, headache, cramps, aches or pain, changes in gait, speech or behavior, mental/physical stress, exhaustion, and symptoms of heat or cold-related stress. These symptoms do not require immediate removal to the Treatment Area, but must resolve prior to returning to manpower/staging 18. All personnel should be encouraged to hydrate with at least 36 ounces of appropriate fluids over two hours after the conclusion of the incident. Interpreting CO Values During Incident Rehabilitation 1. The use of hand-held pulse co-oximetry devices is optional, and not required for Incident Rehabilitation. 2. The SpCO reading is to be used as a screening measure. Definitive carboxyhemoglobin determinations are performed via blood draw in the hospital setting. Any patient with complaints of chest pain, shortness of breath, or altered mental status should receive oxygen by a non-rebreather mask and moved to the Treatment Area, regardless of SpCO reading. 3. The following CO treatment guidelines will pertain to the asymptomatic emergency responder on entry to the Rehabilitation Area. a. If SpCO <5% and vital signs are within normal limits, the provider is encouraged to drink at least 16 ounces of fluid and may return to manpower/staging after a minimum of 10 minutes rest. b. If SpCO ≥5% and <12%, the responder may breathe ambient air and may not leave the rehabilitation area until their CO level is below 5%. c. If SpCO ≥12% the responder should be moved to the Treatment Area and receive high-flow oxygen until the SpCO is <5%. d. If SpCO ≥25%, the responder will be moved to the Treatment Area and transported with high-flow oxygen to an emergency department. Documentation 1. All responders entering the Rehabilitation Area should have their name, vital signs, and disposition recorded on the Rehabilitation Log (Attached). This Log should be attached and stored with the stand-by PCR associated with the incident and a copy given to the Incident Commander or Incident Safety Officer. 2. A separate PCR must be completed for any responder referred to the Treatment Area, regardless of whether the responder was transported by EMS. Should the responder not wish transport, a MLREMS Refusal Form must be completed and the individual(s) responsible for scene safety, accountability and/or command shall be notified.

9.8 Use of Emergency Medical Dispatch

PURPOSE To establish the recommended standard with which emergency requests for emergency medical service are processed. POLICY 1. All telephone requests for emergency medical care received in Monroe or Livingston Counties should be processed using an Emergency Medical Dispatch (EMD) program. Such a program should assure the following: a. EMD is used as an integral part of every EMS call receipt and dispatch process. b. Emergency Medical Dispatchers handle all calls and are trained in the principles and procedures of EMD following the standards of a recognized curriculum. c. A nationally recognized EMD reference system is used which includes standardized caller interrogation and pre-arrival instructions. d. There are written policies and procedures for call receipt, call processing, and dispatch of resources based on the identified patient need. This should include the time frames for call processing, a priority assignment of resources based on need and availability, simultaneous dispatch of resources, ALS intercept, mutual aid, Mass Casualty Incidents, etc. e. There are written policies for maintaining documentation including voice and text records compliant with state requirements. f. There are written policies and procedures for variance investigation and an EMD quality improvement program. g. There is an identified physician Medical Director who is an active participant in the regional EMS system and is familiar with EMD dispatch principles and the local EMS system. This physician shall also be responsible for the medical component and quality improvement of the EMD program. h. Emergency Medical Dispatch should be used to determine the level of response and that level should balance the need of the patient and risk to the community. 2. Any public safety agency (law enforcement, fire, and emergency medical service) that does not refer calls for emergency medical care to an EMD-enabled Public Safety Answering Point should have in place a written policy outlining the process used to handle telephone requests for emergency medical care and providing pre-arrival instructions. This policy should be written with and approved by the agency Medical Director.

9.6 Agency Policy Expecations

PURPOSE To identify the written policies expected of EMS agencies that serve the Monroe-Livingston Region. POLICY All agencies should have internal policies that address the following (NYS DOH BEMS Policy numbers are listed if available): 1. Vehicle Safety (07-07, 00-13) a. Requirements and eligibility for driving an emergency vehicle b. Initial and recurrent training c. Use of safety restraints by crew, patients, passengers, and equipment d. Expected speeds and use of emergency response mode e. Idling of ambulances (05-01) f. Vehicle preventive maintenance (02-11) 2. Infectious Disease (02-09, 99-06, SARS 05-01, 03-11) (OSHA 1910.1030 Blood borne pathogens standard). a. Prevention and use of universal precautions b. Disposal of contaminated supplies c. Cleaning of contaminated durable equipment d. Disinfection of contaminated vehicles including the process and schedule for monthly deep-cleaning e. Exposure reporting f. Initial and recurrent training requirements 3. Mandatory Reporting a. Child Abuse (02-01) b. AED use (PAD Agencies only) 4. Sexual Harassment (00-11) 5. Smoking (00-07) 6. Hazardous Materials Response Plan (OSHA 1910.120, 1910.1200) 7. Quality Assurance (QA) (NYS Workbook and Guidance Document Version 1, 2007) a. Composition of QA Committee b. Procedure for referral and evaluation of care provided c. Procedure for corrective action/remediation d. Procedure for complaint tracking and resolution e. Procedure for vehicle and equipment failure reporting 8. Medical Equipment a. Durable medical equipment preventive maintenance (02-11) b. Training and quality assurance for BLS determination of BG (05-04) c. Process for vehicle equipment checking d. Storage of medications (00-15, 00-14, 00-06) i. Maximum/minimum temperature ranges and policy for their documentation and replacement. ii. For controlled substances, the means of accountability and secure storage as well as compliance with all parts of NYS Part 80.

9.0 Basic Providers Assisting on Advanced Procedures

PURPOSE To outline duties that an ALS provider may delegate to a BLS provider during patient care. POLICY 1) A BLS provider may set up the following equipment after successful completion of a training program as approved by the Agency Medical Director: a) Assembly of IV/IO fluid administration sets to include: Saline lock Fluids and drip sets b) Assembly of medication administration devices to include: Nebulizer devices c) Application of ALS monitoring equipment to include: Monitoring leads 12-Lead Electrocardiogram Noninvasive automatic blood pressure devices Continuous pulse oximetry devices Continuous waveform capnography devices 2) A BLS provider may use an ALS provider's blood glucose monitor to determine a patient's blood glucose if so trained. BLS providers may independently determine blood glucose only if so trained and the agency for which they are practicing under has approval to carry and use point-of-care blood glucose testing equipment. 3) Under no circumstances shall a BLS provider perform IV cannulation or diagnose electrocardiograms. 4) Even after the completion of any "ALS assistant" program (also known as Assist-A-Tech), the BLS EMT is not certified to practice beyond the scope of the NYS BLS curriculum. 5) BLS providers shall have the responsibility to decline requests for assistance if they have not been trained or are not comfortable in providing the assistance.

9.26 Management of Pelvic Fractures

PURPOSE To outline the indications and applications for use of a pelvic immobilization device (Traumatic Pelvic Orthotic Device [T-POD]®, SAM Sling®, sheet, or similar). POLICY This procedure may be used by any level provider (EMT-B and up) who is trained on and authorized to use a pelvic immobilization device by their Agency Medical Director. INDICATIONS The pelvic immobilization device should be applied to those patients that clinically present with one of the following: 1. Suspected pelvic fracture with hypotension 2. Suspected pelvic fracture with severe pain and high energy mechanism (fall from significant height or high speed MVC/MCC) 3. Known "open book" fracture CONTRAINDICATIONS 1. Evisceration of abdominal contents in the area of pelvic immobilization device placement. PROCEDURE 1. Routine medical care. 2. Apply device according to manufacturer instructions being sure to place at the level of the greater trochanters. 3. Note time of placement and contact receiving facility with relevant patient information and to advise of pelvic immobilizer placement.

9.1 Cancellation of ALS by BLS

PURPOSE To outline the procedure by which Advanced Life Support (ALS) providers are cancelled appropriately. POLICY 1. Any individual certified at the First Responder or higher level shall have the authority to request the response of an ALS unit if it has not been dispatched. 2. A responding Advanced Life Support unit may be canceled by an Emergency Medical Technician - Basic or higher trained pre-hospital provider on scene under the following circumstances: a. The provider has personally assessed the patient, and; b. The patient does not require evaluation or management by an ALS provider based on potential injury, medical condition, or complaint, and; c. The ALS unit is not the only responding transporting unit if the patient will need to be transported. 3. The provider canceling the ALS unit will be responsible for completing appropriate prehospital documentation, including documenting the cancellation of the ALS unit. 4. Paramedics providing service with a non-transport/non-ALS service shall have the authority to supersede the BLS provider's decision to cancel a responding ALS unit. 5. Once the ALS provider has made visual contact with a patient, he/she shall follow the "ALS Release to BLS" policy. 6. The transporting EMT is ultimately responsible for patient care and may call back a cancelled ALS unit if they are uncomfortable caring for the patient, regardless of who cancelled the ALS unit.

9.9 Public Access Defibrillation

PURPOSE To outline the responsibilities of Public Access Defibrillation (PAD) agencies and NYS certified agencies that own or operate an AED. POLICY 1. Definition a. Certified Agency - Any transporting agency or any agency that is an ILS/ALS first response agency. b. PAD Agencies - All others, including BLS first-response agencies, physicians' offices, health clubs, public meeting places, etc. 2. Event Reporting a. PAD Agencies are required to fill out an event form and forward it to the MLREMS Program Agency along with a copy of the AED report within 48 hours of its use. b. Certified Agencies are not required to fill out an event form but must complete requisite prehospital documentation (eg a PCR). 3. Regulations a. PAD Agencies are required to post a sign at their front entrance that states they have an AED and where it is located inside the building. b. PAD Agencies are required to fill out a new Notice of Intent when significant changes are made to the original application. c. PAD Agencies and Certified Agencies are required to have written policy for the use of AEDs to include: i. Training requirements ii. Routine inspection of the AED iii. Regular maintenance of the AED d. PAD Agencies must participate in a regionally approved QA/QI program. e. PAD Agencies must have a collaborative agreement with a physician.

2.27 Rapid Sequence Intubation

RSI PARAMEDICS ONLY

1.1 Radio/Phone Failure

Situations may occur where communications with Medical Control cannot be established due to one or more of the following: 1. The crew does not have cellular service and no telephones or radios are available at the scene 2. No physician is available at the Medical Control base station 3. EMS providers are operating as part of a mutual aid disaster response outside of the Monroe-Livingston region In the event of the above, all protocols listed in this document become standing orders for use by the EMT-I, EMT-CC or EMT-P with the exception of those orders so identified as "Absolute Online". Absolute Online orders may only be performed by a direct verbal order from a physician and may not be performed on standing orders under any circumstances. Any instance of radio/phone failure must be documented. Further, the event must be reported to the Agency Director of Operations, the Agency Medical Director, and the Monroe-Livingston Program Agency by the next business day.

1.3 Do Not Resuscitate Orders

The following procedure is to be used in determining course of action for all patients. For conscious, alert patients, their wishes are to be followed according to standard consent procedures. For unconscious patients, the following steps should be followed: 1. Determine presence of valid DNR at the scene: a. Signed New York State approved document, bracelet, or necklace; b. Properly documented nursing home or hospital DNR form; c. Properly completed Medical Orders for Life Sustaining Treatment (MOLST) form. 2. If DNR document, bracelet or necklace is not present - begin standard treatment per protocol 3. If DNR document, bracelet or necklace is present, and is valid for the patient's condition, check presence of pulse: If pulse is present: Provide comfort measures such as oxygen, airway suctioning, and transport as requested by patient, family, or patient's private physician. If additional care is specified on a properly completed MOLST form, follow those instructions. If pulse not present: Contact local police, who will contact the Medical Examiner/Coroner

5.2 Albuterol (Proventil, Ventolin)

a) Indications (1) Signs and symptoms of respiratory distress (2) Bronchospasm/wheezing associated with Asthma b) Adverse Effects (1) Tachycardia/ Palpitations (2) Hypertension (3) Angina (4) Nervousness/ Anxiety (5) Tremors (6) Dizziness (7) Headache (8) Sweating (9) Nausea/ Vomiting (10) Sore throat c) Precautions (1) May cause severe bronchospasm from repeated excessive use. (2) Patient must have his/her own physician-prescribed hand-held aerosol inhaler. d) Contraindications (1) Known hypersensitivity (2) Albuterol not prescribed for the patient e) Preparations 2.5mg/3mL (0.083%) solution f) Dosage (1) Adult: 5 mg via nebulizer may repeat once (2) Pediatric: 2.5 mg via nebulizer may repeat once

5.4 Epinephrine Auto Injector

a) Indications Moderate to severe allergic reaction with respiratory distress, shock or airway swelling b) Adverse Effects (1) Tachycardia / Palpitations (2) Angina (3) Headache (4) Nausea / vomiting (5) Dizziness (6) Hypertension (7) Nervousness / Anxiety (8) Tremors c) Precautions Unless in severe allergic reaction or severe asthma, medical consultation should be obtained before administering to pregnant or cardiac patients d) Contraindications None in the presence of anaphylaxis e) Preparations Epinephrine Auto-injector only (Patient prescribed or EMS service authorized) (1) Adult: 0.3 mg (EpiPen) (2) Pediatric: 0.15 mg (EpiPen Jr.) f) Dosage (1) Patients greater or equal to 30 kg (66lbs): Adult Auto-injector: 0.3 mg IM (2) Patients less than 30 kg (66lbs): Pediatric Auto-injector: 0.15 mg IM

5.3 Aspirin

a) Indications Non-traumatic chest pain b) Adverse Effects (1) Heartburn (2) Nausea and vomiting (3) Wheezing c) Precautions GI bleeding and upset d) Contraindications Known hypersensitivity e) Preparations 81 mg tablets f) Dosage (1) Adult: 324 mg chewed (4 tablets) (2) Pediatric: Not Indicated

5.1 Activated Charcoal (WITHOUT SORBITOL)

a) Indications Poisoning by mouth b) Adverse Effects May indirectly induce vomiting and cause nausea c) Precautions Does not absorb all drugs and toxic substances d) Contraindications (1) Altered mental status (2) Patients who have received an emetic e) Preparations (1) 25 grams/125 mL bottle (2) 50 grams/250 mL bottle f) Dosage (1) Adult: Administer 50 grams (2) Pediatric: Administer 2 grams/kg (Max 50g)

5.6 Oral Glucose

a) Indications (1) Altered mental status with patent airway and known diabetic history b) Adverse Effects Not clinically significant c) Precautions Patient without gag reflex may aspirate. d) Contraindications Inability to speak e) Preparations 10-15 grams of glucose (contained in 24, 30, or 37.5 gram tube) f) Dosage (1) Adult: Administer 10-15 grams of glucose paste between the gum and cheek. (2) Pediatric: Administer 10-15 grams of glucose paste between the gum and cheek; this may be accomplished through several small administrations.

5.5 Nitroglycerin

a) Indications (1) Patient must have own prescribed sublingual nitroglycerin. (2) Chest pain b) Adverse Effects (1) Hypotension (2) Headache (3) Dizziness (4) Tachycardia c) Precautions (1) Reassess blood pressure before and after administration. (2) If systolic blood pressure drops more than 20 mmHg, obtain medical consultation before further administration. d) Contraindications (1) Blood pressure below 120 mmHg systolic (2) Heart rate less than 50 bpm or greater than 130 bpm (3) Medication not prescribed for the patient (4) Pediatric patient (5) Any patient having taken medication for erectile dysfunction (e.g., Viagra™, Levitra™, or Cialis™) within the past 72 hours. Medical consultation is required to override this contraindication. e) Preparations 0.4 mg sublingual tablet f) Dosage (1) Adult: One tablet sublingually (a) Repeat in 3 to 5 minutes if chest pain persists (b) Maximum of three doses (a combination of patient-administered and EMT-B-administered) (2) Pediatric: Not Indicated

5.7 Oxygen

a) Indications All medical and trauma patients b) Adverse Effects High concentrations of oxygen will reduce the respiratory drive in some COPD patients; these patients should be carefully monitored. c) Precautions (1) Never withhold oxygen from those who need it. (2) Oxygen should be given with caution to patients with COPD. (3) Nasal cannula should not be used with more than 6 lpm. (4) Non-rebreather face masks must be supplied with a minimum 12 lpm. d) Contraindications None e) Dosage (1) Adult: Administer per protocol (2) Pediatric: Administer per protocol