EMT Patient Care Protocols

General Patient Care

• The General Patient Care section applies to all patient encounters unless otherwise noted in a specific treatment protocol.
• Response:
  • Review dispatch information and select an appropriate response.
  • Consider Body Substance Isolation (BSI) and Personal Protective Equipment (PPE).
  • Evaluate scene safety and determine the number of patients.
  • Consider the need for additional resources.
• Scene Arrival and Size-up:
  • Determine the Mechanism of Injury (MOI) or Nature of Illness (NOI).
  • Begin triage and initiate Mass Casualty Incident (MCI) procedures if appropriate.

Initial Assessment

• Rapidly develop a general impression of the patient on first contact.
• Identify critically unstable patients (e.g., those with altered mental status, airway compromise, acute respiratory distress, signs of poor perfusion, or any patient judged to be in extremis or at risk for deterioration to cardiac arrest).
• If a critically unstable patient is identified:
  • Stop all movement of the patient.
  • Do not initiate transport.
  • Proceed to the Critically Unstable Patient Protocol immediately.

Patient Assessment

• Assess mental status:
  • Alert.
  • Responds to verbal stimuli.
  • Responds to painful stimuli.
  • Unresponsive.
• Assess airway:
  • Stabilize cervical spine when appropriate.
  • Open and establish airway using appropriate adjunct.
  • Place patient in an appropriate position.
  • Suction airway as needed.
  • If a patent airway cannot be established, transport the patient to the closest appropriate hospital-based emergency department or designated freestanding emergency medical facility.
• Assess breathing:
  • Determine if breathing is adequate and assess oxygen saturation (SpO2) with a pulse oximeter.
  • Provide assistance with 100% oxygen using a Bag-Valve-Mask (BVM) if needed.
  • Titrate oxygen to maintain an SpO2 level of 94% or higher.
• Assess circulation:
  • Assess pulse.
  • Manage profuse bleeding using appropriate methods (e.g., direct pressure, wound packing, hemostatic gauze, tourniquet, or junctional tourniquet).
  • Assess skin color, temperature, and capillary refill.
• Assess disability:
  • Assess pulse, motor, and sensory function in all extremities.
  • Assess Glasgow Coma Scale (GCS) for trauma patients.
  • Determine the need for Spinal Motion Restriction.
• Assess exposure:
  • Remove clothing as necessary to assess patient's injuries, considering the patient's condition and environment.

Clinical Priority

• Assign a clinical priority:
  • Priority 1: Critically ill or injured patients requiring immediate attention.
  • Priority 2: Less serious conditions yet potentially life-threatening, requiring emergency medical attention.
  • Priority 3: Non-emergent conditions requiring medical attention but not on an emergency basis.
  • Priority 4: Does not require medical attention.

Treatment Protocols

• Refer to all appropriate protocols.
• Patients who have had an impaled conducted electrical weapon used on them will be transported to the nearest appropriate facility without dart removal.
• Clinicians may assist the patient or primary caregiver in administering prescribed rescue medication.
• For patients with fever documented by EMS as greater than 100.4°F (38°C), clinicians may treat with acetaminophen.

History and Physical Examination/Assessment

• Conduct a focused examination/detailed examination/ongoing assessment.
• Collect and transport documentation related to the patient's history.
• Obtain a contact telephone number for one or more individuals who have details about the patient's medical history.

Communications

• Hospital notification:
  • A brief communication to the ED for notification of an inbound patient.
  • All Priority 1, Priority 2, and Specialty Alert patients require hospital notification via EMRC.
• Medical consultation:
  • A bi-directional communication via EMRC between an authorized hospital-based physician and prehospital EMS clinician.
  • Obtain medical consultation when required by a specific protocol or when a clinician has reached the end of their therapeutic or diagnostic capabilities.

Destination

• Priority 1 patients shall be triaged to the closest appropriate hospital-based emergency department, designated trauma, or designated specialty referral center.

• Priority 2 patients shall be triaged to the closest appropriate hospital-based emergency department, designated trauma, or designated specialty referral center unless otherwise directed by EMS system medical consultation.

• Stable Priority 3 or 4 patients who do not need a time-critical intervention may be transported to the local emergency department or freestanding emergency medical facility.### General Patient Care

• Receiving hospital notification of suspected PUI patients should be done as early as possible to allow hospital staff to prepare.

Transport Priorities

• For Priority 2 and Priority 3 patients not meeting specialty center destination care protocol, EMS clinicians should ask if the patient has had a hospital admission within the last 30 days.
• If the patient has had a hospital admission within the last 30 days, transport them to that hospital as long as it's not more than 15 minutes further than the nearest hospital.

Mode of Transport

• Medevac patients with indications for specialty referral center should be flown to the appropriate type of specialty center if not more than 10-15 minutes further than the closest trauma center.
• Consider using a helicopter when the patient's condition warrants transport to a trauma or specialty referral center and would result in a clinically significant reduction in time compared with driving.
• All requests for scene helicopter transports should be made through SYSCOM.

Helicopter Transport

• If the time of arrival at the trauma or specialty referral center via ground unit is less than 30 minutes, there is generally no benefit in using a helicopter.
• Refer to the Trauma Decision Tree when considering use of aeromedical transport.
• Provide SYSCOM with the patient's category (Alpha, Bravo, Charlie, or Delta).

Patient Categories

• Pediatric Trauma Patients: Indications as per the pediatric section of the Trauma protocols.
• Spinal Trauma Patients: Indications as per Spinal Motion Restriction protocol.
• Burn Patients: Indications as per Burn protocol.
• Hand Injury Patients: Indications as per Hand Trauma protocol.

Status Evaluation

• Evaluate the need for emergent versus non-emergent transportation.
• Do not wait on-scene for advanced life support.
• Attempt to rendezvous en route to the hospital.

Transfer of Care/Rendezvous

• The ALS clinician-patient relationship is established when the ALS clinician initiates patient assessment, administers ALS medication, or performs an ALS procedure.
• ALS clinicians may only terminate their EMS clinician-patient relationship when they are assured that the patient will continue to receive care at the same or greater level.

Documentation

• A Patient Care Report (PCR) will be completed and delivered to the receiving facility as soon as possible.
• If this is not immediately possible, clinicians must provide documentation of the patient's prehospital care on a template and in a format provided or approved by MIEMSS.

Confidentiality

• Patient confidentiality must be maintained at all times.

Professional Conduct

• All patients should be treated with dignity and respect in a calm and reassuring manner.

History and Physical Examination

• Detailed and ongoing assessments are necessary for general patient care.

Triage Algorithm

• START triage algorithm is used to assess patients.
• JumpSTART triage algorithm is used for pediatric patients.

Critically Unstable Patients

• Indications for critically unstable patients include:
• New onset altered mental status
• Airway compromise
• Acute respiratory distress
• Signs of poor perfusion
• Any other patient judged by the clinician to be in extremis or at risk for deterioration to cardiac arrest
• BLS treatments for critically unstable patients include:
• Ceasing all efforts at patient movement
• Obtaining a complete patient assessment
• Controlling life-threatening external hemorrhage
• Managing the patient's airway and ventilation
• ALS treatments for critically unstable patients include:
• Initiating ETCO2 monitoring
• Obtaining 12-lead EKG
• Obtaining vascular access and supporting perfusion with IV fluids and vasopressors as indicated.

General Patient Care

• The General Patient Care section applies to all patient encounters unless otherwise noted in a specific treatment protocol.
• Response to patient encounters involves:
  • Reviewing dispatch information and selecting an appropriate response
  • Considering Body Substance Isolation (BSI) and Personal Protective Equipment (PPE) at the scene
  • Evaluating scene safety and determining the number of patients
  • Considering the need for additional resources

Patient Approach

• Determine the Mechanism of Injury (MOI) or Nature of Illness (NOI)
• Initiate triage and Mass Casualty Incident (MCI) procedures if necessary

Initial Assessment

• Rapidly develop a general impression of the patient on first contact
• Identify critically unstable patients:
  • New onset of altered mental status
  • Airway compromise
  • Acute respiratory distress
  • Signs of poor perfusion
  • Other patients judged to be in extremis or at risk for deterioration to cardiac arrest
• Stop all movement and do not initiate transport if a critically unstable patient is identified
• Proceed to the Critically Unstable Patient Protocol immediately

Assessment

• Assess mental status:
  • Alert
  • Responds to verbal stimuli
  • Responds to painful stimuli
  • Unresponsive
• Assess airway:
  • Stabilize cervical spine when appropriate
  • Open and establish airway using appropriate adjunct
  • Place patient in appropriate position
  • Suction airway as needed
• Assess breathing:
  • Determine if breathing is adequate
  • Assess oxygen saturation (SpO2) with pulse oximeter
  • Provide assistance with 100% oxygen using Bag-Valve-Mask (BVM) if necessary
• Assess circulation:
  • Assess pulse
  • Assess for and manage profuse bleeding
  • Assess skin color, temperature, and capillary refill
  • Initiate cardiac monitoring as appropriate
• Assess disability:
  • Assess pulse, motor, and sensory function in all extremities
  • Assess GCS for trauma patients
  • Determine the need for Spinal Motion Restriction

Exposure

• Assess patient's injuries and remove clothing as necessary

Clinical Priority

• Assign clinical priority based on the patient's condition:
  • Priority 1: Critically ill or injured patients requiring immediate attention
  • Priority 2: Less serious conditions yet potentially life-threatening
  • Priority 3: Non-emergent conditions
  • Priority 4: Does not require medical attention

Treatment Protocols

• Refer to all appropriate protocols
• Patients with impaled conducted electrical weapon darts will be transported to the nearest appropriate facility without dart removal
• Clinicians may assist patients or primary caregivers in administering prescribed rescue medications
• For patients with fever, clinicians may treat with acetaminophen

History and Physical Examination/Assessment

• Conduct a focused examination/detailed examination/ongoing assessment
• Collect and transport documentation related to patient history
• Obtain and document a contact telephone number for individuals with details about the patient's medical history

Communications

• Hospital notification: A brief communication to the ED for notification of an inbound patient
• Medical consultation: A bi-directional communication via EMRC between an authorized hospital-based physician and prehospital EMS clinician
• If medical consultation is unavailable, clinicians shall proceed with additional protocol-directed care

Reassessment

• Reassess unstable patients frequently (recommended every 5 minutes)
• Reassess stable patients at a minimum of every 15 minutes

Disposition

• Priority 1 patients shall be triaged to the closest appropriate hospital-based emergency department or designated trauma or specialty referral center

• Priority 2 patients shall be triaged to the closest appropriate hospital-based emergency department or designated trauma or specialty referral center

• Stable Priority 3 or 4 patients may be transported to the local emergency department or freestanding emergency medical facility### General Patient Care

• Receiving hospital notification of suspected PUI patients should be done as early as possible to allow for hospital staff to prepare.

Priority 2 and 3 Patients

• For patients not meeting a specialty center destination care protocol, EMS clinicians should ask if the patient has had a hospital admission within the last 30 days.
• If the answer is yes, the EMS clinician should transport the patient to that hospital as long as it's not more than 15 additional minutes further than the nearest hospital.

Mode of Transport

• Medevac patients with indications for specialty referral center should be flown to the appropriate type of specialty center if not more than 10-15 minutes further than the closest trauma center.
• Consider utilizing a helicopter when the patient's condition warrants transport to a trauma or specialty referral center and would result in a clinically significant reduction in time compared to driving.
• All requests for scene helicopter transports should be made through SYSCOM.
• For Trauma Decision Tree category Charlie or Delta, receiving trauma center medical consultation is required when considering whether helicopter transport is of clinical benefit.

Time of Arrival

• If the time of arrival at the trauma or specialty referral center via ground unit is less than 30 minutes, there is generally no benefit in using a helicopter.

Special Patient Considerations

• Pediatric Trauma Patients: Indications as per the pediatric section of the Trauma protocols.
• Spinal Trauma Patients: Indications as per Spinal Motion Restriction protocol.
• Burn Patients: Indications as per Burn protocol.
• Isolated burn patients without airway injury or other associated trauma should normally be flown to a burn center, regardless of the location of the closest trauma center.
• Hand Injury Patients: Indications as per Hand Trauma protocol.
• Medevac patients with appropriate indications for hand center referral should normally be flown to the hand center, regardless of the location of the closest trauma center.

Status Evaluation

• Evaluate the need for emergent versus non-emergent transportation.
• Do not wait on-scene for Advanced Life Support; attempt to rendezvous en route to the hospital.

Transfer of Care/Rendezvous and Transition of Patient Care

• ALS clinicians may only terminate their EMS clinician-patient relationship when they are assured that the patient will continue to receive care at the same or greater level, or when they have documented with on-line medical direction that the patient's condition has improved.
• BLS clinicians have the right to decline the transition of patient care.

Documentation

• A Patient Care Report (PCR) will be completed and delivered to the receiving facility as soon as possible, ideally upon transfer of care.
• If this is not immediately possible, clinicians must provide documentation of the patient's prehospital care on a template and in a format provided or approved by MIEMSS for inclusion in the patient care record before leaving the receiving facility, then deliver the completed PCR within 24 hours after dispatch.

Confidentiality

• Patient confidentiality must be maintained at all times.

Professional Conduct

• All patients should be treated with dignity and respect in a calm and reassuring manner.

History and Physical Examination

• General Patient Care involves taking a detailed history and performing a thorough physical examination.

Detailed and Ongoing Assessments

• Perform detailed and ongoing assessments of the patient's condition.

START Triage Algorithm

• Use the START Triage Algorithm to assess the patient's condition and prioritize care.

JumpSTART Triage Algorithm

• Use the JumpSTART Triage Algorithm for pediatric patients.

Critically Unstable Patients

• Identify patients who are in extremis or at risk for deterioration to cardiac arrest.
• Indications for critically unstable patients include:
  • New onset altered mental status (AVPU – not alert)
  • Airway compromise
  • Acute respiratory distress
  • Signs of poor perfusion
  • Any other patient judged by the clinician to be in extremis or at risk for deterioration to cardiac arrest

Triage Algorithm

Triage Categories

• Immediate (Red): Life-threatening injuries/conditions requiring immediate attention, e.g. severe bleeding, breathing difficulties, cardiac arrest
• Delayed (Yellow): Serious injuries/conditions requiring prompt attention, but not life-threatening, e.g. broken bones, severe lacerations
• Minor (Green): Non-life-threatening injuries/conditions treated on a non-urgent basis, e.g. minor lacerations, sprains
• Expectant (Black): Injuries/conditions unlikely to survive even with immediate medical attention, e.g. severe head trauma, catastrophic injuries

Triage Process

Prioritization

• Primary triage: Initial assessment and categorization of patients based on severity of injuries/conditions
• Secondary triage: Re-assessment of patients after initial treatment to re-prioritize and allocate resources
• Re-triage: Ongoing reassessment of patients to adjust priorities and resource allocation as needed

Emergency Response

Scene Management

• Scene safety: Ensuring safety of responders and patients at the scene of the emergency
• Patient extraction: Safely removing patients from the scene and transporting them to a medical facility
• Communication: Coordinating with emergency services, hospitals, and other responders for effective response and resource allocation

Patient Assessment

Initial Assessment

• Primary survey: Initial assessment of patient's airway, breathing, circulation, disability, and exposure (ABCDE)
• Secondary survey: Detailed physical examination and medical history to identify all injuries or conditions
• Vital signs: Monitoring patient's vital signs (e.g. pulse, blood pressure, respiratory rate) to track changes and prioritize care

Resource Allocation

Resource Management

• Resource matching: Allocating available resources (e.g. personnel, equipment, transportation) to meet needs of prioritized patients
• Resource optimization: Managing resources for efficient use of available assets
• Dynamic resource allocation: Continuously reassessing and adjusting resource allocation to respond to changing patient needs and priorities