Toronto Fire Services Standard Operating Guideline - Emergency Medical Responses PDF

STANDARD OPERATING GUIDELINE EMERGENCY MEDICAL RESPONSES Date Issued: July 9, 2024 Rescinds: May 1, 2024 Section: Incident and Emergency Operations File Code: G-EMRS PURPOSE To provide all Toronto Fire Services (TFS) personnel with a guideline when responding to medical incidents, including expecta...

STANDARD OPERATING GUIDELINE EMERGENCY MEDICAL RESPONSES Date Issued: July 9, 2024 Rescinds: May 1, 2024 Section: Incident and Emergency Operations File Code: G-EMRS PURPOSE To provide all Toronto Fire Services (TFS) personnel with a guideline when responding to medical incidents, including expectations while working alongside Paramedic Services from Toronto and surrounding regions. RESPONSIBILITY All TFS personnel are responsible for understanding and following guidelines for responses with Paramedic Services. Company Officers are responsible for providing the TFS Communication Centre with radio updates regarding the status or location of a patient, if different from the initial dispatch, prior to the arrival of Paramedic Services. Company Officers are responsible for announcing by radio when they have arrived at patient by announcing “Arrived at the Patient Location”. Company Officers are responsible for announcing by radio when Paramedic Services have arrived on scene by announcing “Paramedics on Scene”. District Chiefs shall ensure crews adhere to this guideline. GUIDELINES 1. Paramedic Services Personnel Responsibilities At emergency incidents, in addition to patient care, Paramedic Services personnel are responsible for the following: (a) Coordinating pre-hospital emergency medical care within the limitations posed by scene safety (e.g., risk of hazardous exposure, contamination, etc.). (b) Removing patients from scene and transporting to hospital facility. (c) Assisting other emergency agencies as required. (d) Assuming responsibility for patient care from TFS crews. 2. TFS Crews at Medical Incidents After dropping off the fire crew as close and safe as possible to the location of the patient, the driver shall safely position the apparatus so as not to obstruct the most convenient point of patient access and egress by the ambulance unit and paramedics but shall not reverse the apparatus without a File Code: G-EMRS Page 1 of 15  STANDARD OPERATING GUIDELINE TFS spotter. Once the apparatus is safely parked, the driver shall be out of the apparatus at medical incidents and shall assist with Exterior Access or Egress. Patient assessment and treatment shall be in accordance with TFS training and approved protocols. The TFS Company Officer shall be responsible for ensuring that on scene TFS crews perform designated functions in priority order (i.e., 1, 2, 3): 1. Patient Care: Usually consists of two (2) firefighters and the Company Officer. Responsible for the assessment and treatment of the patient, according to approved TFS standards and protocols. 2. Interior Patient Access and Egress: One of the two firefighters on the Patient Care Team, or the Company Officer once the patient has been stabilized either before or after the arrival of paramedics. Functions could include summoning an elevator, clearing obstructions in a doorway, moving furniture to allow movement of the patient or placement of the stretcher, monitoring CO levels etc. 3. Exterior Access and Egress: Usually assigned to the firefighter driving the apparatus. The firefighter should not leave the sight line of the apparatus. Facilitates paramedic access and egress to and from the patient to the best pf their abilities. This could involve, but is not limited to, holding open doors and gates, propping apartment/ condo doors open for paramedic access, moving shoes and other obstructions from the stretcher path, summoning elevators, or clearing obstructive snow. Firefighters should be familiar in the use of Paramedic Services patient lifting and securing devices such as the following: (a) Stretcher and ambulance power load system (b) Stair Chair (c) Backboard (d) Scoop Stretcher File Code: G-EMRS Page 2 of 15  STANDARD OPERATING GUIDELINE (e) All related spinal immobilization equipment (f) Manta Tarp Firefighters shall get verbal confirmation from a paramedic before undertaking actions involving a stretcher. Company Officers shall clearly document the physical findings that fulfill the requirements of the TFS FireRMS. 3. At Scene Report from TFS to Paramedic Services When paramedics arrive at scene after the arrival of TFS, they should be provided a brief, succinct and relevant update specifying the following: (a) Safety issues (if any). i. Animals, weather, vehicle stabilization, airbags, gas tanks, chemicals, weapons, structural concerns etc. (b) At Scene Report from TFS to Paramedic Services. i. Patient’s approximate age ii. Chief complaint iii. Brief incident history iv. Medical history v. Examination findings, including vital signs vi. Treatment rendered vii. Approximate time on scene 4. Updates via TFS Communications Centre The Company Officer shall ensure updates are communicated to the TFS Communications Centre including the following: (a) Patient Contact. i. When crews make patient contact, they shall announce over the radio that they have “Arrived at the Patient Location.” (b) Safety issues (if any). (c) Medical update when appropriate: i. The chief complaint and incident type ii. The patients approximate age iii. Level of responsiveness/alertness iv. Breathing, or difficulty breathing v. Is there uncontrollable bleeding (d) Entry issues (e.g., entry codes). (e) Action underway by TFS crews. (f) Approximated rescue duration time. After receipt of an update from on scene crews, TFS Communications Centre personnel shall immediately forward the information to the Toronto Paramedic Services Central Ambulance Communications Centre (CACC). File Code: G-EMRS Page 3 of 15  STANDARD OPERATING GUIDELINE 5. Communications During all communication between Paramedic Services and TFS crews, whether at an incident scene or during radio or telephone transmission, personnel shall use clear language. The Paramedic Services CACC shall be responsible for the following: (a) Notifying the TFS Communications Centre for TFS response. i. As per the Tiered Response Agreement. ii. For other incidents where Paramedic Services arrival is expected to be delayed. (b) Confirming with TFS Communication Centre that TFS crews are responding as per Tiered Response Agreement and all rescues, fire or other emergency calls received from any source other than TFS (on the direct telephone line) where a TFS response is required. For all medical, rescue, fire, or other emergency situations (example: hazardous materials incidents) that are not received from Paramedic Services CACC, the TFS Communications Centre shall be responsible for notification of the Paramedic Services as follows: (a) For emergency events where the TFS Communications Centre receives information regarding a potential patient (person trapped, smoke inhalation, etc.), TFS will notify the Paramedic Services CACC immediately. (b) For fire events where the TFS Communication Centre receives information of a known or suspected person in a confines space with smoke or flames, or if a person or persons have been exposed to smoke or heat, TFS will notify the Paramedic Services CACC immediately. (c) For fire events where TFS has not received information regarding a potential patient, TFS will notify the Paramedic Services CACC of active fire conditions once on scene. When a call is received for medical assistance, unless from Paramedic Services CACC, TFS Communications Centre personnel shall determine relevant information including the following: (a) Number of patients at the scene. (b) Safety issues (if any). (c) Medical information including: i. The chief complaint and incident type ii. The patient’s approximate age iii. Conscious (yes/no, alert?) iv. Breathing (yes/no, difficulty breathing?) v. Entry issues (e.g., entry codes) File Code: G-EMRS Page 4 of 15  STANDARD OPERATING GUIDELINE After relevant information has been determined, the TFS Communications Centre shall: (a) Dispatch the appropriate apparatus. (b) Confirm with Paramedic Services CACC that Paramedic Services are responding. 6. Toronto Fire Services First on Scene The provision of additional patient information assists the Paramedic Services CACC in prioritizing responses and upgrading Paramedic response. Patient updates shall be immediately relayed to Paramedic Services CACC by the TFS Communications Centre if different from initial dispatch. Requests by TFS crews at scene for a high priority response by Paramedic Services should include an appropriate update. On scene TFS crews shall conduct a scene survey (EMCAP: Environment, Mechanism of Injury, number of Casualties, Additional resources, Personal Protective Equipment) and search of the scene to ensure no patients are missed (e.g., child or infant thrown from car). The TFS resources needed solely for patient care, are two (2) trained and certified crew members for every patient. Additional apparatus should be requested as necessary by the Company Officer/Incident Commander. Assessment and treatment of the patient(s) shall be carried out according to approved TFS training, medical directives, and protocols. Additional TFS resources for other purposes (e.g., extrication, fire suppression) shall be requested by the Company Officer/Incident Commander as required. When Paramedic Services arrive, Paramedic services personnel shall assume responsibility for the patient. Firefighters shall continue to provide treatment until otherwise directed by Paramedic Services personnel. When a firefighter accompanies a patient in an ambulance unit to the hospital, the apparatus that the firefighter was aboard may proceed to the hospital for retrieval of the firefighter, provided it is within the response district of the apparatus and the TFS Communications Centre is notified and approves. If outside of the apparatus response district, the Company Officer shall contact the TFS Communications Centre to arrange pickup and transportation by other means. File Code: G-EMRS Page 5 of 15  STANDARD OPERATING GUIDELINE NOTE: The primary assessment is intended to assess and intervene rapidly for life- threatening conditions in critically ill or injured patients. This includes determining the adequacy of airway, breathing and circulation, as well as the acquisition of the patient’s oxygen saturation (SpO2), blood pressure and tympanic temperature. 7. Riding in the Back of Ambulances “A paramedic or any other person transported in the patient’s compartment of an ambulance is exempt from subsection 106 (3) of the Ontario Highway Traffic Act – Use of Seatbelt Assembly by Passenger, where attendance to a patient makes it impracticable to wear a seatbelt assembly.” TFS personnel riding in the back of ambulances are to follow the same policy as Paramedic Services: (a) If seated in the rear facing seat providing patient care, seatbelt yourself in. (b) If performing CPR, brace yourself as best as possible to prevent being thrown. NOTE: If a higher medical authority, having assumed care of the patient, requests that a TFS crew modify their patient care procedures (e.g., refrain from rotating during compressions) to ensure responder safety, TFS crews shall comply with the recommendation. 8. Patient Management TFS crews responding to medical emergencies assume responsibility for patient care. TFS crews are responsible for the patient until responsibility has been taken over by a higher medical authority. TFS crews shall not leave patients who indicate they do not want or need medical attention; Company Officers shall update TFS Communications Centre regarding the patients concerns and status. Municipal Paramedic Services personnel have the authority to leave a patient only once their “refusal of care” documentation and a detailed examination of the patients status has been completed. TFS crews shall wait with the patient until Paramedic Services personnel assume responsibility for the care of the patient and indicate that they no longer require our services. If for some reason the patient specifically demands that the firefighters leave the premises, or if there is any concern File Code: G-EMRS Page 6 of 15  STANDARD OPERATING GUIDELINE for the personal safety of the firefighters, it is expected firefighters will wait nearby and advise paramedics of the patient’s status once paramedics arrive on scene. These rare incidents will require documentation via the FireRMS report for the incident and completion of witness statement by all TFS crews who made patient contact. TFS Communications Centre, at the request of senior management, may redirect apparatus from a medical call once a patient assessment has been completed and an update (including vital signs) has been provided to TFS Communications. The TFS Communications Centre shall provide all patient updates to Paramedic Services CACC. NOTE: When a sharp is exposed, the treating paramedic will announce, “sharps out.” TFS crews should then repeat this phrase aloud to ensure everyone on scene is fully aware of the potential hazard. 9. Call Cancellation While En Route Paramedic Services CACC may contact the TFS Communications Centre to indicate that they will no longer be sending their personnel to a previously dispatched tiered response. When notified by Paramedic Services CACC of a call cancellation, the TFS Communications Centre is notified by Paramedic Services CACC that the priority for a previously dispatched event has been downgraded, TFS apparatus will continue to respond. If TFS crews have made patient contact prior to this notification occurring, TFS crews are expected to: (a) Complete an assessment and communicate findings to the TFS Communications Centre. (b) Determine if a request for a Paramedic Services’ response should be considered. TFS Company Officers shall detail in their FireRMS the sequence of events in these situations. 10. Responding to Calls Involving Non-Obvious Patients (Medical Assist / Medical Check Call / Medical Other / Medical Assist Non-Emergency Call types pertaining to this standard are defined as follows: (a) MEA – Medical Assist – This event type is used for emergency responses for falls, lift assists or access problems. (b) MECC – Medical Check Call – This event type is used by TEMS when they receive a medical alarm from an alarm company and want TFS to File Code: G-EMRS Page 7 of 15  STANDARD OPERATING GUIDELINE check on the patient before they dispatch an ambulance. (c) MEO – Medical Other – This event type is used when there is a medical call, but it is unknown what symptoms the person has. (d) MEANE – Medical Assist Non-Emergency – A response initiated by a request from paramedics on scene or through TEMS Communications where no medical emergency has been reported, but TFS is required for a lift assist, or an access problem. When dispatched as primary responder to non-obvious patients (such as call types listed above or a “lift assist”), TFS crews will conduct a thorough primary and secondary assessment of the patient, take initial and follow-up vital signs, and ascertain specific details about the patients situation: (a) Are there any injuries? (b) What caused the fall? (c) Are they confused? (d) Do they have gait stability? (e) Does the patient want to seek further assessment or go to the hospital? (f) Is this a common occurrence? (g) Is there any indication of head trauma? (h) Was there a loss of consciousness? (i) Are there C-spine considerations? (j) History of diabetes? (k) Does the patient admit to taking any medications/drugs/alcohol? Update TFS Communications with pertinent vital signs and details attained. Paramedics will respond, even if no Paramedic unit is initially assigned, TFS crews will remain on scene, update TFS Communications, and monitor patient condition. NOTE: Vital Signs to be reassessed at a MINIMUM of every 30 minutes, if the patient meets any medical directive (i.e., oxygen therapy or anaphylaxis – severe allergic reaction), reassessment shall be done every 10 minutes. If patient adamantly refuses treatment and/or assessment, update TFS Communications. Advise TFS Communications that TFS crews will be staging and advise the on-duty Platoon Chief. Documentation should include ALL patient findings, details and circumstances surrounding the call but exclude patient names as is consistent with all medical calls. File Code: G-EMRS Page 8 of 15  STANDARD OPERATING GUIDELINE NOTE: Since private health information of the patient is being entered in FireRMS, DO NOT enter the patients name in the FireRMS report. At an incident where multiple patients are involved, they will be populated in FireRMS numerically as 1, 2, 3, and so on. TFS crews shall remain on scene and wait with the patient until Paramedic Services personnel arrive, assume responsibility for the patient care, and clear TFS crews. This does not apply if one of the following occurs: (a) Should the response be secondary to an accidental alarm activation (i.e., a medic alert), and you are able to verify with the potential patient that it was indeed an accidental activation, the Company Officer shall update the TFS Communications Centre and clear the scene. Ensure that thorough documentation is included in the Company Officer’s narrative to indicate due diligence done to determine that it indeed was accidental. (b) Should your patient abandon the scene, please follow the “G-EMRS – 19, No Patient Found on Scene” procedure. (c) If Paramedic Services are no longer responding to an event, and the TFS crew does not have grounds to advocate for the patient or insist that paramedics attend (via assessment, patient history, or on-scene findings), then the TFS crew can update TFS Communications Centre and clear the scene. (d) If TFS crews respond to an event initiated by a third-party caller (e.g., Check Call) and determine there was no medical cause for concern after acquiring a patient history and attempting an assessment, the Company Officer shall inform the TFS Communications Centre, who will then update Paramedic Services CACC. TFS will stay on scene if Paramedic Services are still responding to the event; however, if Paramedic Services decide to cancel the call based on the provided information, TFS crews may clear the call. NOTE: If Paramedic Services have not assigned a unit to an incident, due to the incident being deemed low priority, TFS Communications Centre shall dispatch this event as a non-emergency response. When Paramedic Services CANCEL an event, TFS is no longer required and shall not respond. 11. Toronto Paramedic Services First on Scene After patient contact is made, Paramedic Services may cancel a TFS response through notification of the TFS Communications Centre if assistance is not required. File Code: G-EMRS Page 9 of 15  STANDARD OPERATING GUIDELINE If Paramedic Services are on the scene and have made patient contact, when TFS crews arrive, the Company Officer shall offer assistance (e.g., providing an egress route, provide a blocker vehicle, setting up stretcher etc.). If no assistance is needed, the TFS crews may clear immediately. If Paramedic Services have not made patient contact, TFS crews shall accompany Paramedic Services to the patient’s side. If the patient can be optimally treated by Paramedic Services alone, TFS crews may clear the incident. NOTE: Personal Health Information Protection Act (PHIPA) classifies paramedics and their employers as Health Information Custodians and as such are responsible for keeping private patient information. PHIPA does not consider police or firefighters to be Health Information Custodians. PHIPA does allow paramedics to share patient information when agencies are providing care for the patient. NOTE: TFS crews not providing any patient care are not entitled to any patient information by law. It is reasonable for Paramedic Services personnel to not share patient information if TFS is not involved in patient care. If TFS crews provide care, it is reasonable for TFS to gather approximate age, vital signs, actions taken, and services provided as part of the continuity of care. TFS crews remain responsible for documenting their actions and indicate “Unknown” or “CNO” (could not obtain) when completing reports that are part of their normal course of duties (e.g. should the patient have a fistula or injuries making it unsafe to obtain a blood pressure, it shall be entered as CNO). 12. Patient Transport Patient transport is the responsibility of Paramedic Services utilizing a provincially regulated Paramedic Services unit. NOTE: TFS staff are not permitted to transport patients in TFS apparatus. It is the responsibility of the Company Officer to provide relevant updates through the TFS Communications Centre to Paramedic Services CACC on the condition of the patient. File Code: G-EMRS Page 10 of 15  STANDARD OPERATING GUIDELINE 13. Other Healthcare Workers on Scene Several healthcare providers (e.g., doctors, nurses, Hatzoloh) operate in the greater Toronto area. On scene healthcare providers are not a replacement for the Regional Paramedic Services. It is important that patients should receive the highest level of care available to be provided at the scene. If the healthcare providers have identified themselves as such and are administering or are intent on administering care without the presence of a regional Paramedic Services provider, TFS crews shall not prevent the delivery of that care when indications suggest their care will exceed the standard that can be delivered by TFS crews. TFS should cooperatively assist the healthcare providers with patient care. This assistance will not exceed the level to which the firefighter has been trained (e.g., use of unfamiliar medical devices, use of medications in which the firefighter has not been trained etc.). TFS crews shall wait with the patient until Regional Paramedic Services arrive at the patient and assume responsibility for the care of the patient, indicating that TFS crews are no longer required. 14. Do Not Resuscitate Incidents All TFS crews shall be familiar with Ontario Office of the Fire Marshall/Ontario Ministry of Health and Long-Term Care – Do Not Resuscitate Confirmation (DNRC) forms. It is the responsibility of all TFS personnel to be fully aware of protocols to be followed at “Do Not Resuscitate” (DNR) incidents. Company Officers shall ensure TFS crews under their command make all reasonable efforts to provide the expected levels of emergency medical care without compromising the dignity of all persons concerned. A DNR order expresses the patient’s wish to not be resuscitated in the event of a cardiac arrest. Firefighters shall honour a DNR order only when presented with a valid DNR Confirmation (DNRC) form. When TFS crews become aware of the existence of a DNRC at the scene, they shall immediately obtain the form from the patient’s family member or caregiver. File Code: G-EMRS Page 11 of 15  STANDARD OPERATING GUIDELINE The Company Officer shall review it to ensure it is valid. A valid DNRC contains a unique serial number, the OFM logo, the Ministry of Health and Long-Term care logo and has the following fields completed: (a) The patient’s correct name (b) A tick box that has been checked to indicate that one of the two conditions has been met with respect to the need for CPR (c) A signature by a physician or nurse (RN, RN (EC) or RPN) and the date the form was completed A photocopy of the original form is acceptable. TFS crews shall perform a patient assessment and confirm the physical condition of the patient. If the patient is not VSA, provide all appropriate medical care. If the patient is confirmed to be VSA, take appropriate steps to ensure the dignity of the patient is maintained and the family or caregivers are informed in a suitable manner. Assist responding Paramedic Services personnel and police as required. The Company Officer shall document the event in the narrative of the FireRMS Report and document the unique DNRC serial number. At the discretion of the Company Officer, DC or PC, TFS crews attending the incident shall complete a Witness Statement (refer to Standard Operating Guideline G-SECU - Firefighter Observations for the Office of the Fire Marshall Form) to document their actions and observations. NOTE: TFS crews MUST provide all appropriate patient assessment and medical care including the cardiac arrest directive until the DNRC is deemed valid by the Company Officer. 15. Obvious Death Incidents TFS crews shall perform a patient assessment and confirm the physical condition of patient. This MUST include a hands-on ABC assessment to confirm absence of Vital Signs AND confirmation the patient has one or more of the following finding: (a) Decapitation (b) Transection (c) Decomposition (putrefaction) (d) Gross Charring or Incineration (e) Gross Rigor Mortis i. Stiffness of ALL limbs and body File Code: G-EMRS Page 12 of 15  STANDARD OPERATING GUIDELINE ii. Coolness to touch of all parts of the body (especially the patients core) iii. Dependent or Fixed Lividity TFS crews must transfer care of a deceased patient only to the coroner or regional Paramedic Service staff. This does not include Hatzoloh, event medical personnel, TCHC staff, or security guards. After transferring care, the Company Officer shall notify the TFS Communications Centre identifying which agency the deceased patient was left in the care of. The Company Officer shall document the specific criteria that was met to utilize the Obvious Death Medical Directive. NOTE: If there is any doubt as to whether the patient meets the obvious death medical directive criteria, err on the side of caution, and treat as per the appropriate cardiac arrest protocol. 16. Hazardous Materials Incidents Paramedic Services provide medical care and transportation to persons who have been, or are suspected to have been, exposed to hazardous materials, within the limitations expressed in Section 1.0 of this guideline. TFS crews are responsible for providing the applicable and sufficient level of patient decontamination. At any hazardous materials incident, Paramedic Services shall assume responsibility for the following: (a) Providing dedicated operational response. (b) Responding Paramedic Services will be directed to the designated staging area as established by TFS. The designated staging area shall be communicated to Paramedic Services CACC by TFS following site assessment and determination of environmental and health hazards. (c) In the absence of specific staging information, Paramedic Services will be directed to stage at a safe distance upwind of at least 500m until advised to move forward. (d) Providing baseline medical monitoring for TFS crews if requested. (e) Providing equipment, advice, and expertise to on scene TFS crews requesting guidance for treatment of patients or persons who are suspected to have injuries or are contaminated with hazardous materials and remain within the hot zone. (f) Initiating contact with the necessary medical support services able to provide specific guidance to all emergency responders regarding related health issues. (g) Providing treatment and transportation of patients as necessary. File Code: G-EMRS Page 13 of 15  STANDARD OPERATING GUIDELINE 17. Command The Incident Commander should make every effort to coordinate unified command with Paramedic Services for incidents such as the following: (a) Automobile and other accident extrications (b) Hazardous materials incidents (c) Mass casualties 18. Securing Patient Information From Toronto Hospitals To secure patient information from a Toronto Hospital, TFS personnel should refer to the Standard Operating Guideline G-SECU – Securing Patient Information from Hospitals. 19. No Patient Found on Scene If a patient or person cannot be found on scene at the address or location dispatched to, TFS Communications Centre must be updated and will call the initial contact number back to ascertain the exact location. TFS crews will begin their search with the initial location information, while awaiting a call back from the TFS Communications Centre. A reasonable search shall be conducted for the patient or person and will be detailed in the Company Officer’s narrative in FireRMS. The narrative in FireRMS will outline the efforts the crew took to find the patient or person (e.g., “travelled 100 metres in all directions from the location on the street, searched the entire floor of the high-rise as well as the floor above and below including all stairways.”). If a new exact address or location is attained, it must be searched as per 19.1. This continued search MUST be included in the Company Officer’s narrative in Fire RMS. Once the search is complete, and no patient or person is located, the TFS Communications Centre will be updated. 20. Personal Protective Equipment (PPE) Requirements Any tiered response with patient contact including procedures involving active airway management or likely to cause vigorous coughing in the patient such as administration of a nebulized medication by paramedics or suctioning: Level 3 PPE: Safety eye wear, disposable medical examination gloves, NFPA certified fatigue pants, shirt and safety shoes or bunker pants and bunker boots and an N95 respirator mask. File Code: G-EMRS Page 14 of 15  STANDARD OPERATING GUIDELINE Patient assessment or care procedures of a patient who has active and copious blood loss, vomiting or diarrhea: Level 4 PPE: Safety eye wear, disposable medical examination gloves, NFPA certified fatigue pants, shirt and safety shoes or bunker pants and bunker boots, N95 respirator mask and non-permeable disposable gown or bunker coat. NOTE: Safety eye wear is considered safety googles alone, or safety glasses with disposable face shield. NOTE: The minimum PPE requirements for tiered response (medical) calls: bunker pants, boots or NFPA approved station wear, and disposable medical exam gloves, safety glasses and N95 mask. Gowns or bunker coats are an additional requirement in the following conditions: - Patients with possible communicable illness - Body fluid splash - Outbreak conditions ATTACHMENT(S) N/A RELATED SOGS G-SECU – Securing Patient Information from Hospitals G-FFOF – Incident Observation Form G-NOER – Non-Emergency Event Type File Code: G-EMRS Page 15 of 15