2021 Plano Protocols - Version 2 PDF

PLANO FIRE-RESCUE EMERGENCY MEDICAL SERVICES TREATMENT PROTOCOLS Mark A. Gamber, DO, MPH Effective Date: 04/30/2024 EMS Medical Director  Table of Contents of EMS Protocols AUTHORIZATION TO PRACTICE UNIVERSAL GUIDELINES U 1 Scope of Practice U 2 General In...

PLANO FIRE-RESCUE EMERGENCY MEDICAL SERVICES TREATMENT PROTOCOLS Mark A. Gamber, DO, MPH Effective Date: 04/30/2024 EMS Medical Director  Table of Contents of EMS Protocols AUTHORIZATION TO PRACTICE UNIVERSAL GUIDELINES U 1 Scope of Practice U 2 General Instructions/Special Considerations U 3 Universal Patient Care Guidelines – Medical U 4 Universal Patient Care Guidelines – Trauma U 5 Patient Transport Guidelines U 6 Patient Transport Reference U 7 Patient Care Reports (PCR) U 8 Medical Director Notification U 9 Authority for Control of Medical Services at an Emergency Scene U 10 Disaster Response U 11 Use of Expired Medications and Supplies RESPIRATORY R 1 Difficulty Breathing/Respiratory Distress R 2 Airway Management Reference Guidelines R 3 Pharmacologically Assisted Intubation (PAI) R 4 Rapid Sequence Intubation (RSI) R 5 Advanced Airway Confirmation Protocol R 6 I-Gel Airway Reference R 7 King Airway Reference R 8 Positive End Expiratory Pressure (PEEP) Valve Use R 9 End-Tidal CO2 Detection and Monitoring Reference R 10 Continuous Positive Airway Pressure (CPAP) R 11 Tracheostomy and Stoma Management CARDIAC C 1 Acute Coronary Syndrome (ACS) C 2 Right Sided (V4R) and Posterior ECG Reference C 3 Atrial Fibrillation/Atrial Flutter CARDIAC (continued) C 4 Bradycardia C 5 Transcutaneous Pacing C 6 Narrow Complex Tachycardia C 7 Wide Complex Tachycardia – With a Pulse C 8 Arrhythmia Reference Guidelines C 9 Cardiac Arrest – AED/No Monitor C 10 Cardiac Arrest – Asystole/PEA C 11 Cardiac Arrest – Ventricular Fibrillation/Pulseless Ventricular Tachycardia C 12 Cardiac Arrest Reference Guidelines MEDICAL M 1 Allergic Reaction/Anaphylaxis M 2 Anxiety M 3 Behavioral Emergencies M 4 Behavioral Emergencies Reference M 5 Diabetic – Glucose Emergencies M 6 Drowning – Submersion Injuries M 7 Heat and Cold Related Disorders M 8 Nausea and Vomiting M 9 Non-traumatic Shock M 10 Pain Management M 11 Seizures M 12 Sepsis/Septic Shock M 13 Stroke M 14 Toxicological Emergencies M 15 Toxicological Emergencies Reference OB/GYN OB 1 General OB/GYN Treatment OB 2 Pre-Eclampsia/Eclampsia OB 3 Childbirth OB 4 Childbirth Associated Complications OB 5 Neonatal Resuscitation OB 6 (Placeholder for Future Use) OB/GYN (continued) OB 7 “Baby Moses” Law Guidelines TRAUMA T 1 General Trauma Management T 2 Amputations T 3 Burns T 4 Sexual Assault T 5 Selective Spinal Motion Restriction T 6 Tourniquets T 7 TXA/Hemorrhagic Shock T 8 Prehospital Amputation Team T 9 Pelvic Binder STANDARD OPERATING GUIDELINES SOG 1 Consent and Patient Refusal SOG 2 Do Not Resuscitate (DNR)/Termination of Resuscitation (TOR) Guidelines SOG 3 Patient in Law Enforcement Custody SOG 4 Abuse and Neglect Reporting SOG 5 Body Vacuum Splint SOG 6 Domestic Violence SOG 7 External Jugular Venous Cannulation SOG 8 Intraosseous Access SOG 9 Medication Administration Cross Check SOG 10 Medication Policy SOG 11 Nasal Drug Delivery Device SOG 12 Needle Thoracostomy SOG 13 Nerve Agent Exposure SOG 14 Radio Report Guidelines SOG 15 Surgical Cricothyrotomy SOG 16 Taser Removal SOG 17 Ventricular Assist Devices SOG 18 Epistaxis Control SOG 19 PICC Line and Central Line Access SOG 20 Needle Cricothyrotomy TACTICAL EMS (TEMS) & SPECIAL EVENT (SEMS) TEMS 1 Dental Block (If Credentialed) TEMS 2 Dislocation Reduction (If Credentialed) TEMS 3 Incision/Drainage of Superficial Abscess (If Credentialed) TEMS 4 Minor Wound Repair (If Credentialed) TEMS 5 Instrument/Finger Thoracostomy (If Credentialed) TEMS 6 Regional Anesthesia (If Credentialed) TEMS 7 Truncal Tourniquet Device (If Credentialed) TEMS 8 First Aid Care TEMS 9 Plasma-Lyte/TXA Administration (If Credentialed) DRUG REFERENCES APPENDICES Appendix A Medication List Appendix B Medical Equipment and Supply List Appendix C Out-of-Hospital Do-Not-Resuscitate Order (for reference) Appendix D House Bill 624 Flow Chart  Authorization to Practice Delegation of practice is defined as “the transfer of responsibility for the medical performance of one individual to another, while retaining accountability for the outcome”. A physician that pro- vides the medical delegation to, and medical supervision of, an EMS system or program, is referred to as a Medical Director. As per Texas Department of State Health Services regulations and the Texas Medical Practice Act, all emergency medical care is performed under the auspices of the EMS Medical Director. All rights and privileges granted to pre-hospital medical providers operating within this system are granted with the requirement that each individual provider maintain all mandated National, State, Medical City Plano EMS Medical Director and their EMS Provider’s system standards, certifications, and licenses. These protocols were developed and approved by the Medical City Plano EMS Medical Director in accordance with the statues outlined within Texas Health and Safety Code and Emergency Medical Services Act. These protocols may be amended only with the written approval of the Medical Director. January 1, 2017 Authorization Universal Guidelines U.1 Scope of Practice 04/30/2024 U.2 General Instructions / Special Considerations 01/11/2023 U.3 Universal Patient Care Guidelines – Medical 01/11/2023 U.4 Universal Patient Care Guidelines – Trauma 01/11/2023 U.5 Patient Transport Guidelines 04/30/2024 U.6 Patient Transport Reference 04/30/2024 U.7 Patient Care Reports (PCR) 04/01/2020 U.8 Medical Director Notification 01/01/2017 U.9 Authority for Control of Medical Services at an Emergency Scene 01/01/2017 U.10 Disaster Response 04/30/2024 U.11 Use of Expired Medications and Supplies 01/11/2023  Scope Of Practice – Plano Fire-Rescue INTERVENTION, PROCEDURE, THERAPY EMT-B PARAMEDIC AT&C TEMS/SEMS ADVANCED CARDIAC LIFE SUPPORT X AUTOINJECTOR USE FOR EPINEPHRINE OR NERVE AGENT ANTIDOTE X X BAG-VALVE-MASK VENTILATION X X BASIC LIFE SUPPORT (CARDIAC COMPRESSIONS) & AED USE X X BLEEDING CONTROL AND BANDAGING X X BLOOD GLUCOSE ASSESSMENT X X CARDIOVERSION AND/OR MANUAL DEFIBRILLATION X* X CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE (CPAP) X* X DEEP TRACHEAL SUCTIONING X DENTAL BLOCK X DISLOCATION REDUCTION X DUAL SEQUENTIAL EXTERNAL DEFIBRILLATION X* X ECG INTERPRETATION (INCLUDING 12-LEAD) X EMERGENCY CHILDBIRTH X X END-TIDAL CO2 DETECTION/MONITORING X X EPISTAXIS CONTROL X* X EXTERNAL JUGULAR VEIN CANNULATION X FIELD THORACOSTOMY X FIRST AID CARE X X X GASTRIC SUCTIONING VIA THE SUPRAGLOTTIC AIRWAY X HEMOSTATIC AGENT APPLICATION AND WOUND PACKING X X INCISION/DRAINAGE SUPERFICIAL ABSCESS X INTRAOSSEOUS ACCESS WITH NS FLUSH X* X** INTUBATION (ORAL, STOMAL) w/ USE OF THE BOUGIE INTRODUCER X IV ACCESS (PERIPHERAL) WITH NORMAL SALINE ADMINISTRATION X** MAGILL FORCEPS X MANUAL AIRWAY MANEUVERS (JAW THRUST, CHIN LIFT, ETC.) X X MEDICATION ADMINISTRATION: IM, SQ, IV/IO, IN, PO X X X *EMT may utilize the IM or IN routes as per the medication scope of practice PO only MINOR WOUND REPAIR (TISSUE ADHESIVE, STAPLES, SUTURES) X NEBULIZER ADMINISTRATION OF EPINEPHRINE X* X NEBULIZER SET-UP AND USE X X NEEDLE CRICOTHYROTOMY X NPA OR OPA AIRWAY INSERTION X X OROPHARYNGEAL & NASOPHARYNGEAL SUCTIONING X X (INCLUDING TRACHEOSTOMIES/STOMAS) PHARMACOLOGICALLY ASSISTED INTUBATION (PAI) X PICC LINE/CENTRAL LINE ACCESS X PLEURAL DECOMPRESSION (NEEDLE CHEST DECOMPRESSION) X POSITIVE END EXPIRATORY PRESSURE (PEEP) VALVE USE X* X PULSE OXIMETRY AND VITAL SIGN ASSESSMENT X X RAPID SEQUENCE INTUBATION (RSI) X REGIONAL ANESTHESIA X SPINAL MOTION RESTRICTION X X SPLINTING X X SUPRAGLOTTIC AIRWAY (I-GEL, KING, ETC.) X* X SURGICAL CRICOTHYROTOMY X TERMINATION OF RESUSCITATION – ONLINE (WITH OLMCP) X TERMINATION OF RESUSCITATION –OFFLINE X TOURNIQUETS X X TRANSCUTANEOUS PACING X TRUNCAL TOURNIQUET DEVICE X USE OF ULTRASOUND TECHNOLOGY X VENTILATOR X X * - May only perform under the direction of a Paramedic ** - New hire Paramedics may perform this skill upon field assignment, prior to completion of the Paramedic Internship Process April 30, 2024 Universal 1.1  Scope of Practice – Plano Fire-Rescue MEDICATION EMT-B PARAMEDIC AT&C TEMS/SEMS ADENOSINE HYDROCHLORIDE X AFRIN (OXYMETAZOLINE) NASAL SPRAY** X* X ALBUTEROL SULFATE X* X AMIODARONE HYDROCHLORIDE X ANTISEPTIC SPRAY** X ASPIRIN X* X ATROPINE SULFATE X CALCIUM CHLORIDE X CEFEPIME X CETIRIZINE/ZYRTEC** X DEXAMETHASONE X DEXTROSE 50%, DEXTROSE 25%, DEXTROSE 10%** X DILTIAZEM/CARDIZEM** X DIPHENHYDRAMINE/BENADRYL X X EPINEPHRINE 0.1 MG/ML (1:10,000) IV X EPINEPHRINE 1 MG/ML (1:1000) IM X X EPINEPHRINE AUTO INJECTOR IM X X FENTANYL CITRATE** X FEXOFENADINE WITH PSEUDOEPHEDRINE/ALLEGRA-D** X HYDROXOCOBALAMIN** X IPRATROPIUM BROMIDE/ATROVENT X* X KETAMINE** X LIDOCAINE HYDROCHLORIDE X LOPERAMIDE/IMODIUM** X MAGNESIUM SULFATE X MELOXICAM/MOBIC** X MIDAZOLAM HYDROCHLORIDE/VERSED X MORPHINE SULFATE** X NALOXONE/NARCAN X (IN only) X NERVE AGENT ANTIDOTE KIT** X X NORMAL SALINE ADMINISTRATION X* X ONDANSETRON/ZOFRAN X* X ORAL GLUCOSE (GLUTOSE) X* X OTC ANALGESICS (ACETAMINOPHEN AND IBUPROFEN)** X OXYGEN X X BISMUTH SUBSALICYLATE/PEPTO BISMOL** X PLASMA-LYTE** X PREDNISONE** X RANITIDINE/ZANTAC** X ROCURONIUM/ZEMURON** X SODIUM BICARBONATE X TETRACAINE OPTHALMIC SOLUTION** X TRANEXAMIC ACID/TXA** X X TRIPLE ANTIBIOTIC OINTMENT ** X VACCINE ADMINISTRATION** X X VECURONIUM/NORCURON** X ** Optional medication, use only if authorized by the EMS Medical Director. See approved medication list for drugs to be carried/used by this agency. * - May only administer under the direction of a Paramedic Those Paramedics who have received ADVANCED TRAINING & CREDENTIALING (AT&C) may only perform the skills and administer the medications listed in the “AT&C” column which they have been credentialed for by the EMS Medical Director. TACTICAL EMS (TEMS) Paramedics may perform all skills and administer all medications listed in the “PARAMEDIC” column. In addition, they may perform or administer those skills and medications listed in the column associated with their special assignment if credentialed by the EMS Medical Director, but ONLY in situations where they are functioning under these special assignments. April 30, 2024 Universal 1.2  General Instructions Regarding All Protocols Use of Protocols These protocols are only authorized for use by EMS personnel approved by the EMS Medical Director. Furthermore, these protocols are only authorized for use during the performance of medical treatment while such personnel are acting within the course and scope of employment within their department’s 911 service area, mutual-aid, or transfer service area as defined by local statute, contract, or any combination thereof. Protocol Format Protocols may be narrative, outline or list format. When referring to a specific protocol, all formats and any additional text contained under that protocol heading should be considered a part of that protocol. On-Line Medical Control There are times when the EMT or Paramedic in the field encounters a situation where on-line consultation with the EMS Medical Director or his designee is desired. There are also times when the protocols designate a provider to consult the EMS Medical Director or his designee, based upon the situation or the patient’s physical examination. Medical City Plano EMS Medical Control utilizes the designation of OLMCP (On-Line Medical Control Physician) as the term for those physicians authorized by the EMS Medical Director to provide guidance to our EMS Providers in the field. This term is utilized throughout these protocols. EMS Providers should contact MCP MED-COM, the EMS Communications Center, via their designated telephone line (preferred) or radio channel (if available) for OLMCP support. The provider will be connected to an authorized physician in the Emergency Department or an EMS Medical Director for consultation. In the rare event the provider is unable to reach the OLMCP or the EMS Medical Director, the protocol in its entirety shall become standing orders, especially if a delay in treatment could threaten life and/or limb. Allied Health Providers (Other than MCP Authorized EMS Personnel) Allied healthcare providers (CNA, LVN, RN, NP, PA, etc.) may assist MCP EMS Medical Direction personnel/providers in accordance with MCP EMS Treatment Protocols up to their respective skill level and competency, only at the discretion of the in-charge Paramedic. Should no MCP EMS Medical Direction guided Advanced Life Support (ALS) providers be on-scene, non-EMS certified health care professionals must first contact MCP EMS On-Line Medical Control Physician (OLMCP) prior to initiating any ALS interventions. Universal Precautions/Body Substance Isolation Mandate Throughout the course of patient assessment and treatment, uniform compliance with universal blood and body fluid precautions is mandated. Federal laws require this proper management of patients such that the patient and the provider(s) are protected from undue exposure to communicable diseases. On-Scene Dispute Between EMS Providers Disagreements about patient care are to always be handled in a professional manner, away from the patient when possible, and should not detract from or reduce the quality of patient care. The MCP EMS Treatment Protocols, Suggested Operating Guidelines, and/or Appendices can/should be consulted first in order to help resolve disputes; however should a dispute remain unresolved, or if a protocol/guideline/appendix does not specifically address an issue, then the MCP OLMCP MUST be contacted for dispute resolution. Disputes should not be mentioned in patient care reports. A separate written report is to be completed for any unresolved dispute arising at the scene which requires physician intervention. Please remember to January 11, 2023 Universal 2.1  General Instructions Regarding All Protocols include your full name, certification/licensure level, name of your organization/agency, and a detailed description of the incident. The written report should be submitted by fax to (469) 484-0616 or by email to [email protected]. Scene Times Scene times should be kept to the minimum, particularly in trauma patients. While most protocols will contain directions to transport the patient towards the end of the protocol, transport should begin as soon as possible after primary assessment of the patient and, as indicated, performance of immediate airway, respiratory, or cardiac interventions. Trauma patients should have appropriate spinal motion restriction prior to transport. One exception to absolute minimum scene times is the case of the non-traumatic cardiopulmonary arrest victim. Immediate and maximum efforts will usually be necessary prior to rapid transport in order to best achieve stable cardiac rhythms. Patient Definition(s) A patient can be defined as “any person who, upon contact with an EMS system, presents with a complaint, circumstance, and/or condition that might require further assessment or treatment.” The Medical City Plano EMS Medical Control recognizes three specific patient categories: a. Neonate: From birth to 28 days old b. Pediatric: 1. Medical: Patients under 14 years old 2. Trauma: Patients under 14 years old c. Adult: 1. Medical: Patients 14 years and older should be treated using the adult dosing within the protocols; patients less than 18 with medical complaints should be transported to a “pediatric” facility as per the Patient Transport Guidelines. 2. Trauma: Patients 14 years and older Patient Confidentiality MCP EMS Medical Control Providers have a legal and ethical responsibility to handle all information and documentation regarding a patient with the utmost degree of confidentiality. Information obtained during the course of patient contact is not to be disclosed and/or used in any form (verbal/written/electronic, etc.) that might identify the patient without his or her consent. Patient information is only to be shared with those individuals considered part of the continuity of care, or those personnel assigned to the QA/QI process, or law enforcement/state protective agencies when required by law. Every effort should be made to ensure that the record will not be left unattended, open for public view, or stored in such a way as to compromise patient confidentiality. Interfacility Transfers All pre-hospital treatment occurring during transfer shall comply with established EMS Treatment Protocols, or have specific written physician orders from the transporting or receiving facility. A written physician order (from current hospital chart or specific to EMS) must accompany the patient for any intervention, treatment, medication, and/or therapy that is not covered in a specific EMS Treatment Protocol. If an EMS provider is unfamiliar with a given intervention, treatment, medication, and/or therapy; the provider must first consult with the transferring hospital staff, followed by consultation with an OLMCP for transfer approval. The transferring facility should be requested to provide staff clinically capable of supporting any intervention, treatment, medication, and/or therapy that is beyond the scope, training, certification and/or licensure of EMS providers. Should the transferring facility be unwilling or unable to provide staff during transport, the EMS providers must contact the OLMCP for consultation and guidance before they can accept the patient for transport. January 11, 2023 Universal 2.2  General Instructions Regarding All Protocols An accompanying health care provider may assist with patient care within their respective scope practice while under written orders of the transferring physician. The transporting EMS providers and the accompanying staff are both responsible for the management of the patient during transport; however, should the patient decompensate during transport, EMS providers shall assume all primary patient care responsibilities with assistance from accompanying staff. Transport of the Patient Receiving Blood Products Blood Products are substances normally comprising the circulatory volume of the body and provide transport of nutrients, waste products, and clotting properties. Blood Products include: (a) whole blood; (b) packed red cells; (c) platelets; and/or (d) plasma. General guidelines for the transport of patients receiving Blood Products: These patients require continuous ECG monitoring by EMS providers who are capable of handling an acute reaction; therefore, only Paramedics may transport a patient receiving Blood Products. All blood products MUST be initiated by the transferring facility. Paramedics are not authorized to start, hang, and/or initiate any infusion of Blood Products unless credentialed by the Medical Director. Paramedics shall request a written order from the transferring facility as to the infusion rate and total amount to be infused during transport. A copy of this order is to be attached to the PCR and transferring-facility charts. Paramedics shall record a complete set of vital signs (pulse, respirations, systolic & diastolic blood pressure, temperature, etc.) prior to initiating transport; and obtain a complete set of vital signs every ten minutes during transport. If the patient develops any signs of allergic reaction and/or transfusion reaction (described below), immediately stop the infusion and initiate a normal saline infusion (using new tubing) in its place. The Blood Product is not to be thrown away and must be turned over to the receiving facility for evaluation. Allergic reactions: Immediate anaphylactic reactions are characterized by skin flushing, hives, laryngeal edema, chills and hypotension. In the majority of cases, anaphylactic reactions occur before 10 mL of blood has been infused. When an immediate allergic/hypersensitivity reaction occurs, the transfusion is to be terminated and treatment for the allergic response implemented as per the Allergic Reaction Protocol. Hemolytic transfusion reactions (HTR): An adverse reaction that has symptoms of burning at the IV site, restlessness and apprehension, chest tightness, joint and /or back pain, fever, chills, flushing, and/or nausea/vomiting. The treatment of patients with an HTR focuses on the prevention of shock and maintaining renal perfusion to prevent kidney failure. If a hemolytic transfusion reaction is suspected, the transfusion must be terminated immediately. Contact the OLMCP for guidance (if needed.) Mass Casualty Incident (MCI) A Mass Casualty Incident (MCI) will be defined as any incident in which the on-scene providers establish a treatment area to care for multiple victims. A MCI may overwhelm response capabilities and may or may not require assistance from outside agencies. Medical City Plano EMS providers: Shall follow their department’s MCI SOP for actions to be taken in the presence of a MCI May contact Medical City Plano EMS’s MED-COM for assistance with regional placement of patients so as to not overwhelm local area facilities. January 11, 2023 Universal 2.3  Universal Patient Care Guidelines – MEDICAL Patients The following will outline the approach to the General Medical Treatment of the patient in our EMS System. Refer also to the General Trauma Treatment protocol as appropriate. 1. Scene Size-Up: A. As you approach the scene, assure safety for yourself and the patient. B. Consult/follow your department-specific Incident Management System as needed. 2. Universal Precautions/Body Substance Isolation: A. Prior to patient assessment, employ universal precautions to prevent contact with potentially infectious materials and/or hazardous materials. B. EMS personnel should wear all appropriate Personal Protective Equipment (PPE), including protection for eyes and gloves. Regarding the use of face masks:  Personnel should follow the mask policy in place at the location of patient care and any healthcare facility they enter. Please use good judgement and be respectful  Masks should be worn in the following situations: If a patient has or is suspected to have COVID-19 or other airborne transmitted infectious disease If you enter a home and the family is wearing masks During airway treatments including CPAP, BVM use, advanced airway placement, and nebulizer use C. Use proper specialized PPE when there is potential for contact with biological or hazardous materials. Patients should be approached and assessed in ABC order (except for suspected cardiac arrest): 1. Airway Management A. The endotracheal tube or supraglottic airway are the advanced airways of choice. B. Consider advanced airway management for respiratory failure or airway protection. Consider factors such as altered mental status (GCS Score < 8), respiratory rate, spontaneous effort, pulse oximetry, and EtCO2 readings in making this complex clinical decision. C. See also the Airway Management, King Airway or I-Gel, and Confirmation of Advanced Airway protocols. 2. Breathing A. Expose the chest as required; note rate, depth, and pattern of respirations. Obtain pulse oximetry reading on all patients. B. Administer oxygen to ease pain and/or respiratory distress. Titrate to a pulse oximetry reading of at least 94% as appropriate. C. If patient has history of COPD, use lowest concentration of oxygen to achieve SpO2 > 90% while also relieving dyspnea. Never withhold oxygen for fear of depressing respiratory drive. D. Ventilate apneic patients using appropriate adjuncts and high concentration oxygen. E. See also the Respiratory Distress protocol, as well as Capnography and CPAP protocols. 3. Circulation A. Adequacy of circulation is best assessed first by assessing level of consciousness and mental status. Then check the location, rate, and character of the pulse. Capillary refill in pediatric patients is a useful tool. Follow this with a manual assessment of the blood pressure and application of the cardiac monitor. January 11, 2023 Universal 3.1  Universal Patient Care Guidelines – MEDICAL Patients i. Hypotension is a systolic blood pressure < 90 mmHg in the adult or < 70 + (2 x age in years) in the pediatric patient. B. Perform a 12-lead ECG on any patient who may have a cardiac cause for their complaint. Do not delay emergent interventions in an attempt to obtain the 12-lead. C. Treat identified circulatory deficiencies via the Non-Traumatic Shock protocol as appropriate. If the issue is primarily cardiac related, treat in this order: Rate – Rhythm – Blood Pressure. D. Refer to the Cardiac Protocols to address specific rhythm abnormalities. E. Cardiac arrest is an exception. Do not follow the usual ABC order. Follow CAB or Compressions, Airway, Breathing. Continuous compressions with little or no interruption is very important. Aggressively search for and treat VF and VT in these patients. 4. Vascular Access/Fluids/Medications A. Vascular access can be achieved using the following: i. Saline lock, if available: for patients with stable vital signs and not needing volume replacement. ii. Peripheral IV (to include External Jugular access): for administration of fluids and medications. iii. IO route: used in cardiac arrest patients (adult & pedi), or when vascular access is critical and peripheral sites are unavailable. B. Fluid administration is at the following rates (any patient as needed): i. TKO – slow drip for patients who may need medication or fluid bolus. ii. Fluid replacement – refer to specific protocols. If in doubt as to volume needed, contact OLMCP. iii. Always follow medication administration with a 10 to 20 mL bolus. C. Medications – i. Ensure the patient is receiving the correct medication and dose by announcing the name and dose of the medication being administered. Furthermore, announce the name of any medication being handed off. Refer to SOG 9. ii. In the absence of vascular access, certain medications may be administered via the intranasal (IN) route. Refer to specific protocols for appropriate medications and dosages. 5. History and Examination A. After addressing the ABCs and any life-threatening conditions, complete the assessment of the patient. i. History (SAMPLE and OPQRST) ii. Complete set of vital signs with first blood pressure assessed manually iii. Physical exam (Evaluate blood glucose and cardiac rhythm for altered mental status) B. Continue to assess and treat the patient based on the appropriate protocol(s) and standing order(s). C. Vital signs and reassessment should be performed at least every five minutes on unstable patients and every 10 minutes on stable patients. January 11, 2023 Universal 3.2  Universal Patient Care Guidelines – MEDICAL Patients 6. On-Line Medical Control Physician (OLMCP) A. Contact the OLMCP for all non-standing order interventions. B. Never hesitate to contact OLMCP if you have questions or the patient’s course causes you to feel uncomfortable or need guidance. Do not hesitate to call even for interventions that are standing orders if you feel you need the help. 7. Pediatric Dosing Guidelines A. Pediatric medical patients, as defined by these protocols, are any patient under 14 years old. B. Providers may reference the Hantevy application or the provided Pediatric Quick Reference (PQR) guide for dosing guidelines in pediatric patients up to the age of 14. C. Patients ages 14 and over should be treated using the adult dosing guidelines within the protocols. January 11, 2023 Universal 3.3  Universal Patient Care Guidelines – TRAUMA Patients The following will outline the approach to the General Trauma Treatment of the patient in our EMS System. Refer also to the General Medical Treatment protocol as appropriate. 1. Scene Size-Up: A. As you approach the scene, assure safety for yourself and the patient. B. Consult/follow your department-specific Incident Management System as needed. C. Consider mechanism of injury, number of patients, and special equipment/extrication needs. 2. Universal Precautions/Body Substance Isolation: A. Prior to patient assessment, employ universal precautions to prevent contact with potentially infectious materials and/or hazardous materials. B. EMS personnel should wear all appropriate Personal Protective Equipment (PPE), including protection for eyes and gloves. Regarding the use of face masks:  Personnel should follow the mask policy in place at the location of patient care and any healthcare facility they enter. Please use good judgement and be respectful  Masks should be worn in the following situations: If a patient has or is suspected to have COVID-19 or other airborne transmitted infectious disease If you enter a home and the family is wearing masks During airway treatments including CPAP, BVM use, advanced airway placement, and nebulizer use C. Use proper specialized PPE when there is potential for contact with biological or hazardous materials. 3. General Guidelines: A. Do not prolong scene times and/or delay transport time in order to perform procedures for non-immediately life-threatening injuries. B. The survival of trauma patients is dependent upon Rapid Transport for surgical intervention. C. Treat signs and symptoms according to their respective protocols (e.g. seizures, pain, etc.) Patients should be approached and assessed utilizing Primary, Secondary, and Reassessment surveys: 1. Primary Survey A. Designed to rapidly identify life-threatening or potentially life-threatening injuries B. Should be completed within 2 minutes of patient contact. THE PRIMARY SURVEY IS ONLY INTERRUPTED FOR AIRWAY OBSTRUCTION OR RESPIRATORY/CARDIAC ARREST. C. Steps of the Primary Survey include: i. Manually control the cervical spine ii. Assess the airway, breathing and circulation and intervene as necessary iii. Control external hemorrhage iv. Assess mental status using AVPU scale D. See also the Airway Management, King Airway or I-Gel, Confirmation of Advanced Airway, and General Trauma Management protocols. E. Perform procedures to seal an open chest wound, treat a tension pneumothorax, oxygen administration, and provide fluid resuscitation to counter hypoperfusion. January 11, 2023 Universal 4.1  Universal Patient Care Guidelines – TRAUMA Patients 2. Secondary Survey A. Should be completed enroute to the receiving facility for critical patients B. For non-critical patients this can be completed on scene and should be completed within 5 minutes of the Primary Survey C. Steps of the Secondary Survey include: i. Obtain a full set of vital signs (Heart Rate, Respirations, Blood Pressure & SpO2). The initial blood pressure should be assessed manually. ii. Obtain a SAMPLE history iii. Perform a head-to-toe exam, looking for DCAP-BLS in every body area iv. Determine GCS and RTS scores v. Perform indicated bandaging and splinting. Assess neurovascular status before and after bandaging and splinting. vi. Obtain vascular access as indicated 3. Reassessment Survey A. An abbreviated exam performed after interventions and done at least every 5 minutes for critical patients B. Steps of the Reassessment survey include: i. Repeat the Primary Survey ii. Repeat vital signs and GCS iii. Reassess all injuries and interventions. Look for improvement or deterioration. General management of the trauma patient includes the following: 1. Oxygen/Fluid Therapy/Pain Management A. Administer oxygen to ease pain and/or respiratory distress. Titrate to a pulse oximetry reading of at least 94% as appropriate. B. Fluid administration is guided by the patient’s systolic blood pressure i. All patients with significant or multi-system trauma should have two large-bore IV’s initiated ii. Patients with minor trauma should have one, preferably large-bore, IV started iii. IV’s should be at TKO rate unless the SBP is < 90 mmHg in the adult or < 70 + (2 x age in yrs.) in the pediatric patient. 1. Adults: give NS 500 ml bolus if SBP < 90 mmHg. May repeat NS 500 ml bolus once if SBP remains below criteria after initial bolus. 2. Pediatrics: give NS bolus per LBRT if SBP < 70 + (2 x age in years). May repeat same bolus once if SBP remains below criteria after initial bolus. iv. If the patient is hypotensive/hypoperfused and IV access cannot be obtained after 2 attempts in 90 seconds, consider intraosseous (IO) access for fluid administration. See Intraosseous Access procedure document. FOR HYPOTENSION REFRACTORY TO FLUID ADMINISTRATION, CONTACT THE OLMCP C. See the Pain Management protocol for relief of the trauma patient’s pain 2. On-Line Medical Control Physician (OLMCP) A. Contact the OLMCP for all non-standing order interventions. B. Never hesitate to contact OLMCP if you have questions or the patient’s course causes you to feel uncomfortable or need guidance. Do not hesitate to call even for interventions that are standing orders if you feel you need the help. January 11, 2023 Universal 4.2  Universal Patient Care Guidelines – TRAUMA Patients 3. Pediatric Dosing Guidelines A. Pediatric trauma patients, as defined by these protocols, are any patient under 14 years old. B. Providers may reference the Hantevy application or the provided Pediatric Quick Reference (PQR) guide for dosing guidelines in pediatric patients up to the age of 14. C. Patients ages 14 and over should be treated using the adult dosing guidelines within the protocols. January 11, 2023 Universal 4.3  Plano FD Patient Transport Guidelines STEMI/Cardiac LVAD FACILITY TRAUMA** PSYCHIATRIC MEDICAL** MEDICAL** PEDIATRIC HOSPITAL BURNS** STROKE MAJOR ADULT Baylor S&W Centennial Medical Center 3        Pt > 18 yrs Carrollton Regional Medical Center         Baylor S&W Medical Center - Plano         Children’s Medical Center Plano (Legacy) 3        Pt < 14 yrs Children’s Medical Center Dallas 1        Pt < 14 yrs HEART HOSPITAL at Baylor Plano         Medical City Dallas / Medical City Children’s 3        Medical City Frisco 3        Pt > 18 yrs Medical City Heart & Spine - Dallas         Medical City McKinney 2        Pt > 15 yrs Medical City Plano 1        Pt > 14 yrs Pt > 1yrs Methodist Richardson - Campbell         Methodist Richardson - Renner 3        Pt > 18 yrs Parkland Hospital 1        Pt > 14 yrs Texas Health Allen 4        Pt >18 yrs Texas Health Dallas 1        Pt > 14 yrs Texas Health Frisco 3        Pt > 18 yrs Texas Health Plano 2        Pt > 14 yrs April 30, 2024 Universal 5.1  Plano Patient Transport Guidelines If the patient/family requests transport to any facility not in the primary destination chart, the transporting paramedic must seek approval from the on scene OIC and the OLMCP or EMS Medical Director. Contact with the OLMCP or EMS Medical Director should be via the Medical City Plano MED-COM EMS Communications Center. **MAJOR BURNS = Patients with burns > 10% TBSA of partial thickness (2nd degree) or full thickness (3rd degree), including face, hands, feet, and/or genitalia. Any burns from electrical or chemical causes. Any burns also associated with other traumatic injuries. **AMPUTATION = Refer to Trauma 2: Amputations for guidance **STROKE – All suspected stroke patients should be transported to a Comprehensive Stroke Center (CSC). **MEDICAL = Any adult or pediatric patient being transported to the hospital for reasons not related to trauma. **TRAUMA = See Trauma Field Triage Guidelines. A trauma center may receive trauma patients in accordance with the level at which they are functioning. *PEDIATRIC CARDIAC ARREST = Children’s Medical Center Plano and Medical City Children’s are the preferred facilities for patients < 18 years of age in cardiac arrest. January 11, 2023 Universal 5.2  Patient Transport Reference PATIENT RESTRAINT DURING TRANSPORT Adult Patients: Adult patients should be secured to the cot using the three (3) belt system with the shoulder harness provided with the cot. The cot head should be elevated to a sitting or semi- sitting position to prevent forward or backward movement. If the patient condition prevents elevation of the cot head, vertical (shoulder) straps shall be used. Pediatric Patients: Pediatric patients (< 37 kg/81 lbs.) shall be secured using an appropriate Child Restraint System (CRS) affixed to the cot or rear facing attendant seat. The Pedi-Mate is a CRS approved for patients from 4.5 – 18 kg/10 – 40 lbs. In the absence of a 5-point restraint system or car seat, larger children (20 – 37 kg) may be transported utilizing the adult guidelines. Neonatal Patients: Newborns may be transported skin to skin with their mother. We acknowledge the NHTSA recommendations, however we feel the benefit of skin to skin transport for the newborn, in combination with local EMS driver safety record, outweighs the risk of unsecured transport. The local NICU and obstetric communities support our approach. If skin to skin is not appropriate, then the neonate shall be secured using an appropriate CRS affixed to the cot or rear facing attendant seat. SPECIAL SITUATIONS Specialty Facilities: Baylor Medical Center – Frisco: EMS transport to this facility should be limited to pregnant patients only Facilities requesting to NOT receive EMS patients to their Emergency Department: o Methodist Medical Center – McKinney and Addison campuses Transports to THR-Prosper, Baylor Scott & White Emergency Hospital in Murphy, or the Baylor Scott & White Emergency Hospital in Aubrey: Due to the limited services available at these facilities, the following criteria should be adhered to when determining if it is appropriate to transport a patient to one of these destinations. o The patient must be alert, oriented to person, place, time and event (x4); have a GCS of 15; and have vital signs within the refusal guidelines criteria o Their chief complaint must be limited to musculoskeletal back pain; ground level fall orthopedic injuries (with no head strike); soft tissue injuries with controlled bleeding; trauma patients not meeting trauma center criteria; or minor medical Basic Life Support (BLS) patients not requiring Advanced Life Support (ALS) monitoring or intervention (no cardiac monitoring or IV medications). o A patient who requires the administration of a controlled substance (Versed for seizures, Fentanyl for pain, or Ketamine for pain or excited delirium) will be considered an ALS patient. Patients experiencing significant pain should be offered pain medication prior to leaving scene in order to facilitate the destination decision making for BLS vs. ALS patients. o If a patient has a change of events enroute to one of these destinations and requires an ALS intervention, then patient transport will be according to Universal 5: Patient Transport Matrix. April 1, 2020 Universal 6.1  Patient Transport Reference Freestanding Emergency Departments: EMS should not typically transport patients to freestanding ED’s. However, if the patient adamantly requests transport to a freestanding ED, advise the patient that the facility may not be able to manage their care and that they may be transferred. This could make them responsible for another ambulance bill and ED charges for both facilities. Contact OLMCP for assistance/guidance. o Unstable patients should not be transported to freestanding ED’s o In the event inclement weather makes transport to a full service hospital extremely hazardous, EMS may consider transporting patients to a FSED if the transport time to the FSED is significantly less than that of going to a full service facility. Hyperbaric Chambers: Consider these facilities if you have a suspected CO poisoning: o Medical City Plano o Texas Health Dallas (Presbyterian) o Baylor University Medical Center – Dallas Psychiatric Patients: Communicate with the police department (PD) on transporting psychiatric patients. For any psychiatric patient where there is an allegation or suspicion of an overdose or other significant medical issue, the patient should be transported to the closest emergency department by EMS. If there is no cause to suspect significant medical illness or overdose, PD may choose to transport the patient directly to a psychiatric facility. Only PD may transport patients to a psychiatric facility that does not have an emergency department attached (i.e. Green Oaks, Seay Center). Medically unstable psychiatric patients should be taken to the closest appropriate facility. Medically stable psychiatric patients age 18 or older transported by EMS should preferentially be transported to the emergency department at either Methodist Richardson Campbell, Medical City McKinney, Medical City Frisco or Texas Health Plano. These facilities have psychiatric hospitals on campus, mitigating the need for double transport. All psychiatric patients under age 18 should be transported to a pediatric facility, if possible. Follow Behavioral Emergencies Protocol and Reference for a patient who needs to be transported and is refusing or who requires the use of any type of restraints. Contact the MCP OLMCP or EMS Medical Director for additional help on difficult situations or if clearance for PD transport is required by the Consent/Patient Refusal protocol. EMS “Superutilizers”: In the best interest of patient continuity of care, patients who call 911 and are transported more than 5 times in one month or 15 or more times in 6 months may have a care plan constructed that includes transport only to the closest appropriate hospital. Emergency Department Saturation: MCP EMS system providers will only deliver patients to “patient care areas” of the destination Emergency department. This includes the Triage area. EMS will not offload patients in the ED waiting room. April 30, 2024 Universal 6.2  Patient Transport Reference Pediatric Helicopter Activation Criteria: Consider Helicopter activation for the presence of 1 RED or 2 BLUE Criteria Red Criteria (any one): Advanced airway required Deep penetrating injury to head, neck, torso, or proximal to elbow or knee. Suspected spinal cord injury (paralysis, sensory loss) Amputation proximal to wrist or ankle Flail chest 2+ proximal long bone fractures Pelvic fracture Open or depressed skull fracture Pulseless injured extremity Burns: > 10% BSA of 2nd or 3rd degree burns Blue Criteria (two or more): GCS < 14 due to trauma GCS < 10 in non-trauma situations Reliable loss of consciousness > 5 minutes Sustained respiratory rate > 40/minute in pediatrics Sustained heart rate > 150/min in pediatrics Blood pressure < 70 + (2 x age in years) mmHg in pediatrics Adult Helicopter Activation Criteria Amputation proximal to the wrist or ankle PEARLS: The decision to activate a helicopter response should be based upon the initial patient assessment, mechanism(s) of injury, anticipated scene time and anticipated ground transport time to an appropriate hospital Utilize the criteria above to determine if helicopter activation is in the best interest of the patient. If uncertain, consult the OLMCP. Consider the use of air medical transport for UNSTABLE pediatric drowning patients If the estimated time of helicopter arrival to the landing area exceeds 20 minutes beyond the time of estimated patient extrication, the patient should be ground transported to the nearest appropriate hospital. Traffic patterns related to construction or time of day may be considered in this decision. Once a helicopter is responding to the scene, it is generally unwise to cancel that response Helicopters should not be activated for traumatic arrest or non-traumatic cardiac arrest patients April 1, 2020 Universal 6.3  Patient Transport Reference TRAUMA FIELD TRIAGE GUIDELINES Level I or Level II Trauma Center Advanced airway or airway compromise Glasgow Coma Scale < 14 due to trauma All blunt or penetrating trauma with unstable vital signs: o Age 10-64 years SBP < 90 mmHg or HR > 130 bpm o Age > 64 years SBP < 100 mmHg or HR > 120 bpm o Age 0-9 years SBP < 70 + (2 x age in years) o Respiratory rate < 10 or > 29 (< 20 in infants less than one year old) All penetrating injuries to the head, neck, torso, groin and extremities proximal to the elbow or knee Chest wall instability or deformity (e.g. flail chest) Penetrating trauma CPR Significant fractures involving the pelvis or two or more proximal long bones Crushed, degloved, or mangled extremity Open or depressed skull fracture Acute Traumatic Paralysis (not numbness) or Hanging injuries Profuse, uncontrollable bleeding or tourniquet applied to stop bleeding Level I, Level II, or Level III Trauma Center Falls > 10 feet High-Risk Auto Crash: o Intrusion > 12 inches into occupant site or > 18 inches into any site o Ejection (partial or complete) from automobile o Death in same passenger compartment o Vehicle rollover Auto vs. pedestrian/bicyclist thrown, run over or with significant (> 5 mph) impact Motorcycle or bicycle crash > 5 mph or with separation of bike and rider Pregnancy > 20 weeks Older adults: Risk of injury and death increases after age 55 Anticoagulation and bleeding disorders, specifically with head trauma. Have a high index of suspicion of internal bleeding with these patients. Level IV Trauma Center or non-trauma designated facilities Stable traumatic injuries not addressed by previously listed criteria  When in doubt, transport to a Level 1 or 2 trauma center  Refer to Adult and Pediatric flight criteria for use of air medical transport  Blunt traumatic CPR patients should be transported to the closest hospital April 1, 2020 Universal 6.4  Patient Care Reports (PCR) Documentation is a crucial component of patient care, and effective communication of information is vital. Improper and/or poor communication can result in confusion and/or complications in delivery of patient care. Regardless of the method of documenting information, patient care records should include, at a minimum, the following patient care date (when the data is available): Patient name, age, and sex Approximate weight in pounds or kg. Chief complaint, nature of illness and/or mechanism of injury. Patient history, medications prescribed, medications taken, and any drug hypersensitivities/allergies. Pre-arrival care provided by bystanders or other medical personnel. Neurological assessment, including a GCS score. Physical assessment of the patient including at least 2 complete sets of vital signs if the patient is transported. Pertinent ECG findings or patient exam findings including acute changes in cardiac rate or rhythm. All care provided to the patient including any negative or positive responses to medical therapy, as well as the time an intervention was initiated or a medication was administered. Basic Guidelines for Pre-Hospital Documentation A PCR should be completed on every patient with an injury, illness, and/or medical complaint. The Joint Commission forbidden or “do not use” abbreviations are not to be used. See chart on page 2 of this guideline. A separate PCR should be completed for each patient seen, Example: a mother and her newborn are transported together, or a delivery takes place enroute to the hospital. A separate PCR is needed on each (one for the mother and another for child). A PCR shall be completed for each encounter of the same patient on a new and separate call. Example: diabetic seen and treated by EMS who refuses transport, but who requests EMS later for the same complaint or worsening of their symptoms. ECGs obtained during the course of patient assessment or treatment must be attached (or captured if electronic reporting is used) to EMS and hospital copies of PCR. A receiving staff signature should be obtained on the PCR for all transported patients. Texas Department of State Health Services Rule The Texas Department of State Health Services (TDSHS) requires EMS personnel to provide a written or computer generated PCR to the receiving facility on all transports. Failure to provide appropriate documentation allows TDSHS to suspend or decertify an EMS certificant, or suspend or revoke a licensed pre-hospital healthcare provider entity/agency/organization for failing to make complete, accurate, and/or clearly written patient care reports that fully document: (a) a patient’s condition upon arrival at the scene; (b) the pre-hospital care provided; and (c) the patient’s status during transport, including signs, symptoms, and responses to interventions, procedures, medications, and/or therapies utilized before and/or during transport. In the event EMS is in response-pending status, or was called out prior to PCR completion, the PCR shall be delivered to the receiving facility within 24 hours of the call. It is the responsibility of the April 1, 2020 Universal 7.1  Patient Care Reports (PCR) transporting EMS unit to gather all necessary information from the scene and ancillary personnel. Information given to the transporting EMS unit from other First Responder Agencies/Organization should be included in the report left with the receiving facility. Abbreviations To avoid confusion, certain abbreviations, acronyms, and symbols are no longer advocated for use in the health care setting. To ensure continued patient safety, the following abbreviations should not be used as outlined below. Item Prohibited Abbreviations Potential Problems Use Instead Mistaken for a “0” (zero), the 1. U or u (unit) Write “unit” number 4 (four), or “cc” Mistaken as IV (intravenous) or the 2. IU (International Unit) Write “International Unit” number 10 (ten) 3. Q.D., QD, or q.d., qd Mistaken for each other Write “daily” The period after the “Q” can be 4. Q.O.D., QOD, or q.o.d., qod mistaken for an “I” and the “O” can Write “every other day” be mistaken for an “I” Trailing zero Write “X mg” 5. Decimal point is missed (X.0) mg* (do not use a trailing zero) Lack of leading zero Write “0.X mg” 6. Decimal point missed (.X mg) (always use a leading zero) 7. MS Can mean morphine sulfate or Write “morphine sulfate” 8. MSO4 magnesium sulfate. Confused for one another Write “magnesium sulfate” 9. MgSO4 Glasgow Coma Scale Reference Adult Score Infant Eye Opening Response Spontaneous – Open with blinking 4 Spontaneous – Open with blinking To verbal stimuli, command, speech 3 To verbal stimuli, command, speech To pain only (not applied to face) 2 To pain only (not applied to face) No response 1 No response Verbal Response Oriented 5 Coos, babbles Confused conversation, but answers questions 4 Irritable cry, inconsolable Inappropriate words 3 Cries to pain Incomprehensible speech 2 Moans to pain No response 1 No response Motor Response Obeys commands 6 Normal movements Localizes pain 5 Withdraws to touch Withdraws to pain 4 Withdraws to pain Flexion 3 Flexion Extension 2 Extension Flaccid, no response 1 Flaccid, no response April 1, 2020 Universal 7.2  Medical Director Notification Any incident which has, or potentially has had, an adverse impact on patient care and/or the Medical City Plano EMS medical control system as a whole, should be reported to the EMS Medical Director. This should be completed as soon as practical after call completion. Notification of the EMS Medical Director Should Occur When: Observation of action and/or inaction of an EMS provider that could possibly lead to the injury or death of a patient. Performance/administration of any evaluations, interventions, procedures, medications, and/or therapies outside the scope of credentials and/or qualifications of an EMS provider. o This includes medication errors Missing controlled substances and/or evidence of controlled medications being tampered with or abused. Any attempt at a surgical airway (successful or not) Sudden and/or unanticipated cardiac arrest occurs after the use of: o An anti-arrhythmic or vasodilator in a previously hemodynamically-stable patient. o Physical, mechanical, or chemical restraint. o Sedation (midazolam, ketamine), o Analgesia (morphine, fentanyl). o Neuromuscular blockade o An electronic control device by law enforcement (e.g., Taser). January 1, 2017 Universal 8 Authority for Control of Medical Services at an Emergency Scene Pursuant to TEXAS MEDICAL BOARD RULES, in the Texas Administrative Code, Title 22, Part 9, Chapter 197: Rule 197.5. Authority for Control of Medical Services at the Scene of a Medical Emergency (a) Control at the scene of a medical emergency shall be the responsibility of the individual in attendance who is most appropriately trained and knowledgeable in providing pre-hospital emergency stabilization and transport. (b) The pre-hospital provider on the scene is responsible for management of the patient(s) and acts as the agent of the physician providing medical direction. (c) If the patient’s personal physician is present and assumes responsibility for the patient’s care, the pre-hospital provider should defer to the orders of said physician unless those order conflict with established protocols. The patient’s personal physician shall document in his or her orders in a manner acceptable to the EMS system. The physician providing on-line medical direction shall be notified of the participation of the patient’s personal physician. (d) If the medical orders of the patient’s personal physician conflict with system protocols, the personal physician shall be placed in communication with the physician providing on-line medical direction. If the personal physician and the on-line medical director cannot agree on treatment, the personal physician must either continue to provide direct patient care and accompany the patient to the hospital or must defer all remaining care to the on-line medical director. (e) The system’s medial director or on-line medical control shall assume responsibility for directing the activities of pre-hospital providers at any time the patient’s personal physician is not in attendance. (f) If an intervenor physician is present at the scene and has been satisfactorily identified as a licensed physician and has expressed his or her willingness to assume responsibility for care of the patient, the on-line physician should be contacted. Once the on-line physician is contacted, he or she is ultimately responsible for the care of the patient unless or until the on-line physician allows the intervenor physician to assume responsibility for the patient. (g) The on-line physician has the option of managing the case exclusively, working with the intervenor physician, or allowing the intervenor physician to assume complete responsibility for the patient. (h) If there is any disagreement between the intervenor physician and the on-line physician, the pre-hospital provider shall be responsible to the on-line physician and shall place the intervenor physician in contact with the on-line physician. (i) If the intervenor physician is authorized to assume responsibility, all orders to the pre-hospital provider by the intervenor physician shall also be repeated to medical control for recordkeeping purposes. (j) The intervenor physician must document his or her intervention in a manner acceptable to the local EMS. (k) The decision of the intervenor physician not to accompany the patient to the hospital shall be made with the approval of the on-line physician. (l) Nothing in this section implies that the pre-hospital provider can be required to deviate from standard protocols. January 1, 2017 Universal 9  Disaster Response Whether natural or manmade/terrorism related, a disaster is present when an incident overwhelms local, regional, or state response capabilities. Because a disaster can severely disrupt resources across multiple agencies/jurisdictions, agencies/providers under the Medical City Plano (MCP) EMS Medical Direction may be requested for immediate mutual aid assistance. Due to the urgency of care needed during disasters, MCP EMS Medical Direction providers; as part of an organized response by the State Operations Center (SOC), Texas Department of State Health Services (TDSHS), or agency-specific mutual aid agreements; are allowed to function under MCP Medical Direction and utilize MCP EMS Treatment Protocols outside of their primary service area, without first having to obtain written approval. It is important to note that all disaster response/relief/recovery operations in jurisdictions outside of your immediate area are being performed under the command/control of the respective public safety agency in that jurisdiction/region. It is therefore inappropriate to deploy local resources to another jurisdiction without those resources first being requested by/from either the State Operations Center (SOC) or Texas Department of State Health Services (DSHS), and/or previously established agency-specific mutual aid agreements. Disaster Response Mode A “Disaster Response Mode” may be declared by the EMS Medical Director when a local or regional situation prevents an agency from effectively transporting sick or injured patients to routine destinations. Examples of such events include, but are not limited to, hurricanes, tornadoes, fires, flooding, or large-scale man-made disasters. This mode may also be utilized for fire or EMS crews responding in support of statewide or interstate events at the request of appropriate Texas government authorities. A. In the event that disaster mode is declared, EMS crew members are authorized to do the following: 1. Treat and Release – Crews should treat the patient to the full extent of these protocols as per the capability of the apparatus assigned to the event. If transport is not feasible, then release them to the care of themselves or their family members. The patient’s information will then be placed in a log and the EMS Provider will follow up with the patient and offer transport once conditions warrant a safe transport. 2. Consult with a Supervisor for any life threatening or potentially life-threatening situations. B. These actions should ONLY be implemented during disaster declarations that include the services normal response area: 1. Determine if the patient has any complaints other than those symptoms typically felt prior to dialysis. These include mild shortness of breath, weight gain, back pain and/or fatigue. 2. If there are no other complaints aside from the usual symptoms, ask the patient if they would prefer to be transported to an outpatient dialysis center. Agencies are not required to transport the patient to their usual dialysis center if that facility is outside the normal response area for the agency or if that facility has been impacted by the declared disaster. 3. Screen for acute illness: hemodynamic instability, profound dyspnea, fever, or other concerning symptoms: i. If any of these acute illnesses are present, follow current treatment protocols and transport to an appropriate emergency department as indicated by your agency’s Transport Guidelines ii. If symptoms are absent or mild and consistent with the patient’s usual pre-dialysis symptoms AND the patient wishes to be transport to outpatient dialysis facility, contact MED-COM for assistance in determining availability of outpatient dialysis resources within your response area. 4. Patients meeting the criteria for transport to a dialysis center may be transported to such facilities with their consent and if such facilities are available. 5. If there is any concern regarding the appropriate destination for these patients, the OLMCP should be contacted via MED-COM. April 30, 2024 Universal 10  Use of Expired Medications and Supplies Due to the national problem with shortages of medications and/or disposable supplies used to treat EMS patients, Medical City Plano EMS has adopted the recommendations of the U.S. Food and Drug Administration. These recommendations allow for the utilization of expired medications and supplies listed in the protocols that are currently unavailable from the various pharmaceutical and supply manufacturers. These guidelines are in line with the Texas Department of State Health Services acknowledgments and apply to pharmaceutical items and disposable supplies listed within the Scope of Practice and “Drug References” section of the Medical City Plano EMS Protocols or on the department specific Minimum Equipment and Pharmaceuticals Lists. Medications or supplies on manufacturer backorder or not available from known suppliers will be considered for approval to use beyond the manufacturer’s current recommended expiration date. Medical City Plano EMS systems may use these medications or supplies up to one year beyond the original expiration date. Expired medications and supplies must be stored in reserve until Medical City Plano EMS systems have used all of their supply that has not passed the expiration date before placing expired items into EMS vehicles or drug boxes/bags. Medical City Plano EMS Systems will follow the availability with suppliers and will obtain unexpired items as soon as they are available. If unexpired items become available, then the use of expired items will cease, and the unexpired medications or supplies will be used. Each agency will maintain a current list of expired items in use by that agency and will place a copy of said list within all apparatus protocol books for that agency. January 11, 2023 Universal 11  Respiratory R.1 Difficulty Breathing/Respiratory Distress 04/30/2024 R.2 Airway Management Reference Guidelines 04/01/2020 R.3 Pharmacologically Assisted Intubation (PAI) 01/11/2023 R.4 Rapid Sequence Intubation (RSI) 04/30/2024 R.5 Advanced Airway Confirmation Protocol 01/01/2017 R.6 I-Gel Airway Reference 01/01/2017 R.7 King Airway Reference 01/01/2017 R.8 Positive End Expiratory Pressure (PEEP) 04/01/2020 R.9 End-Tidal CO2 Detection & Monitoring Reference 01/01/2017 R.10 Continuous Positive Airway Pressure (CPAP) 01/01/2017 R.11 Tracheostomy Tube and Stoma Management 01/01/2017  Difficulty Breathing/Respiratory Distress TREAT PATIENT PER UNIVERSAL PATIENT GUIDELINES – MEDICAL ADULT PEDIATRIC Allergic Reaction Allergic Reaction Treat in accordance with Allergic Reaction protocol Treat in accordance with Allergic Reaction protocol Asthma/Bronchoconstriction Asthma/Bronchoconstriction Albuterol 2.5 to 3 mg mixed with Ipratropium 0.5 mg** Albuterol 2.5 to 3 mg mixed with Ipratropium 0.5 mg** nebulized and repeat as needed nebulized and repeat as needed Dexamethasone 12 mg IV/IM/PO Dexamethasone 0.2 mg/kg IV/IM/PO (max 12mg) If no improvement or signs and symptoms of severe respiratory distress: If no improvement or signs and symptoms of severe respiratory distress: Apply CPAP Epinephrine 1 mg/ml (1:1000), Magnesium Sulfate 2 Grams IV/IO 0.01 mg/kg up to 0.5 mg IM Mix in NS up to 500 ml and infuse over 5 min. Repeat every 15 minutes if needed CHF Epinephrine 1 mg/ml (1:1000), (Pulmonary Edema) 0.5 mg IM For Pediatric patients presenting with CHF, contact Repeat every 15 minutes if needed OLMCP COPD Epiglottitis/Croup Albuterol 2.5 to 3 mg mixed with Ipratropium 0.5 mg** nebulized and repeat as needed Transport patient in upright position If no improvement or signs and symptoms of severe Establish IV only if doing so will not respiratory distress: aggravate patient’s condition. Consider: Epinephrine Apply CPAP 1 mg/mL (1:1,000), nebulize 3 mg (3 ml) Magnesium Sulfate 2 Grams IV/IO for suspected croup Mix in NS up to 500 ml and infuse over 5 min. May repeat once as needed Laryngoscopy and advanced airways are only CHF (Pulmonary Edema) indicated if positive pressure ventilation is ineffective Apply CPAP Tension Pneumothorax Perform Perform Needle Decompression for Tension Pneumothorax Perform rapidly deteriorating patient Needle Decompression for rapidly deteriorating patient April 30, 2024 Respiratory 1.1  Dyspnea/Respiratory Distress PEARLS: For respiratory distress secondary to airway burns, pre-emptive intubation may be necessary (Consult the PAI or RSI protocols) For patients with a tracheostomy or stoma, refer to “Tracheostomy and Stoma Management Reference” In the pediatric population, humidifying the nasal mucosa has been proven to improve their outcome. Consider utilizing nebulized saline instead of “blow by” oxygen or oxygen by mask in these patients. If the pediatric patient is exhibiting signs of obstruction due to visible and/or audible secretions, attempt to clear these with nasal, oral, or oropharyngeal suctioning. Hypoxia secondary to suctioning should be treated with positive pressure ventilation (PPV). Nebulized medications should be administered utilizing oxygen at 6-8 lpm to aerosolize the medication CPAP is the primary treatment for CHF, may be considered in asthma and COPD. **May utilize Duoneb® which contains both Albuterol and Ipratropium in a premixed solution. If giving Dexamethasone PO, consider mixing it with juice or another liquid if available to improve taste Respiratory Distress Refusal Guidelines: Patients who receive a nebulized treatment of Albuterol & Atrovent (Ipratroprium Bromide), or the combination product Duoneb®, may refuse ambulance transport offline ONLY if the following criteria are met. Otherwise, OLMCP consult for refusal is necessary. The patient must have a history of either asthma or COPD. If the symptoms are new in onset, transport or OLMCP consult is required. SpO2 on room air must be greater than 90% both pre and post treatment. Symptoms must be relieved by a single nebulizer treatment (including no audible wheezing). Initiating a second nebulizer treatment or the administration of additional medications (i.e. Epinephrine 1:1000) or other treatment modalities (i.e. CPAP) requires transport. Patient is alert, oriented x 4, and all other vital signs are compatible with the refusal guidelines found is SOG.1 Consent and Patient Refusal. Patient is without further medical complaints (chest pain, fever, etc.) Patient is able to speak in full sentences and is able to tolerate oral intake. If the patient is a minor, a responsible adult must be present to monitor patient and assist with re- contacting EMS if necessary. If the treating paramedic has any doubts or concerns about the patient meeting this criteria or the appropriateness of letting them refuse, contact the OLMCP. Respiratory 1.2 April 30, 2024  Airway Management Reference Guidelines TREAT PATIENT PER UNIVERSAL PATIENT GUIDELINES – MEDICAL - Utilize “head-tilt, chin-lift” or “jaw thrust” with in-line stabilization as appropriate to open the airway. “Head-tilt, chin-lift” is NOT to be used if there is a possible cervical spine injury. - Suction if blood, vomitus, or secretions are present - Supplemental oxygen via nasal cannula or non-rebreather mask as appropriate to relieve respiratory distress, titrating to a SpO2 reading of at least 94% - If respiratory distress is significant or effort is absent, ventilate with BVM (in sync with patient’s efforts if assisting) o Utilize an oropharyngeal or nasopharyngeal airway, as appropriate, to help maintain the airway during BVM ventilation o Consider advanced airway management for respiratory failure or airway protection. Consider factors such as altered mental status (GCS Score < 8), respiratory rate, spontaneous effort, pulse oximetry, and EtCO2 readings in making this complex clinical decision. o Utilize PAI or RSI Protocol as appropriate - For patients with suspected airway obstruction due to a foreign body: o If conscious and able to talk, transport carefully o If conscious but unable to talk, perform the abdominal thrusts until obstruction is resolved or patient becomes unconscious o If unconscious and unable to ventilate, perform chest compressions to expel foreign body. Continue cycles of chest compressions and ventilation attempts until obstruction is relieved. o Paramedics may attempt to visualize the obstruction with laryngoscope and utilize Magill Forceps to remove any obstructions seen. If unable to remove foreign body, but vocal cords are visualized, then intubate and ventilate the patient. - If the suspected cause of the airway obstruction is traumatic obstruction or edema: o If laryngoscopy possible, attempt oral intubation. Maximum of two attempts. o Utilize PAI or RSI Protocol as appropriate o If laryngoscopy not possible or unable to intubate after two attempts, then place a supraglottic airway. - For any cause of airway obstruction, if you have attempted the above techniques TWICE and still cannot ventilate the patient, consider surgical cricothyroidotomy as a last resort - The Bougie introducer must be utilized for any intubation attempt; video laryngoscopy, if available, may be used. - An endotracheal intubation attempt is defined as placing a laryngoscope in the oropharynx of a patient and attempting to pass an endotracheal tube. After two failed attempts to intubate, proceed to a supraglottic airway. - End-Tidal CO2 detection MUST be used to verify and monitor all advanced airway placements (to include supraglottic airways). Refer to Confirmation of Advanced Airways protocol. April 1, 2020 Respiratory 2.1  Airway Management Reference Guidelines - Utilize the LBRT as needed for airway management equipment guidance with pediatric patients - The sniffing position, also known as the head up/ear to sternal notch position, is the optimal position for basic and advanced airway management - In preparation for advanced airway management, simultaneously place a NRB mask and a nasal cannula on the patient. Both should be set at 15 lpm on the oxygen flow meter. Leave the nasal cannula in place during placement of either supraglottic or endotracheal tube advanced airways. April 1, 2020 Respiratory 2.2  Pharmacologically Assisted Intubation (PAI) TREAT PATIENT PER UNIVERSAL PATIENT GUIDELINES – MEDICAL ADULT PEDIATRIC Rapid Sedation Phase/Pre-Intubation Rapid Sedation Phase/Pre-Intubation Ketamine 2 mg/kg rapid IV/IO Ketamine 2 mg/kg rapid IV/IO And And Midazolam 5 mg slow IV/IO Midazolam 0.1 mg/kg (up to 5 mg) slow IV/IO Repeat once as needed to obtain advanced airway Repeat once as needed to obtain advanced airway Continuous Sedation/Post-Intubation Continuous Sedation/Post Intubation Ketamine 2 mg/kg rapid IV/IO Ketamine 2 mg/kg rapid IV/IO And And Midazolam 5 mg slow IV/IO Midazolam 0.1 mg/kg (up to 5 mg) slow IV/IO Repeat once as needed for continued sedation Repeat once as needed for continued sedation PEARLS: Consider Midazolam 5 mg (adult patient) or 0.1 mg/kg (pedi patient) if the patient exhibits signs/symptoms of dissociative or psychotropic side effects following Ketamine administration See Advanced Airway Confirmation Protocol and Airway Management Reference Guidelines Airway confirmation for all advanced airways will include continuous EtCO2 waveform monitoring. This includes supraglottic airways All patients with advanced airways shall receive the constant ongoing monitoring of their SpO2, BP, ECG, EtCO2, and respiratory status An intubation attempt should take no longer than 30 seconds and use of the bougie introducer is mandatory Use PAI with caution in obese patients. Oxygen levels in obese patients tend to rapidly decrease due to reduced functional reserve capacity, the weight of the viscera on the diaphragm, compliance changes, and/or the weight of the chest wall in respect to accessory muscle usage during labored respiration. Midazolam (Versed) should be withheld if the systolic blood pressure is less than 90 mmHg in adult patients or less than 70 + (2 x age in years) mmHg in pediatric patients January 11, 2023 Respiratory 3  Rapid Sequence Intubation (RSI) TREAT PATIENT PER UNIVERSAL PATIENT GUIDELINES – MEDICAL ADULT PEDIATRIC Rapid Sedation Phase Rapid Sedation Phase Ketamine 2 mg/kg IV/IO Ketamine 2 mg/kg IV/IO And And Midazolam 5 mg slow IV/IO Midazolam 0.1 mg/kg (up to 5 mg) slow IV/IO Neuromuscular Blockade Phase Neuromuscular Blockade Phase Rocuronium 100 mg IV/IO Rocuronium 1mg/kg (up to 36 mg) IV/IO Wait 1 minute before attempting intubation Wait 1 minute before attempting intubation Or Or Vecuronium 10mg IV/IO (One time dose only) Vecuronium 0.1 mg/kg IV/IO (One time dose only) Wait 1 minute before attempting intubation Wait 1 minute before attempting intubation Continuous Sedation/Post-Intubation Continuous Sedation/Post Intubation Ketamine 2 mg/kg rapid IV/IO Ketamine 2 mg/kg rapid IV/IO And And Midazolam 5 mg slow IV/IO Midazolam 0.1 mg/kg (up to 5 mg) slow IV/IO Repeat once as needed for continued sedation Repeat once as needed for continued sedation PEARLS See Advanced Airway Confirmation Protocol and Airway Management Reference Guidelines Airway confirmation for all advanced airways will include continuous EtCO2 waveform monitoring. All patients with advanced airways shall receive the constant ongoing monitoring of their SpO2, BP, ECG, EtCO2, and respiratory status An intubation attempt should take no longer than 30 seconds and use of the bougie introducer is mandatory Midazolam (Versed) should be withheld if the systolic blood pressure is less than 90 mmHg in adult patients or less than 70 + (2 x age in years) mmHg in pediatric patients If Rocuronium or Vecuronium are on national backorder and unavailable to the provider, the following dosing changes may be used and apply to both Adult and Pediatric patients: o Calculate Ketamine and Midazolam dosing as guided above o The Ketamine dose may be repeated up to three times, as needed, to obtain or maintain the advanced airway o The Midazolam dose may be repeated, as needed, up to a cumulative total of 20 mg administered o Should the provider feel that additional medication dosing is required, they should consult the OLMCP April 30, 2024 Respiratory 4  Advanced Airway Confirmation Protocol The following sequence is to be used to confirm correct advanced airway placement: 1. Visualization of endotracheal tube passage between the vocal cords: A. This is not applicable for supraglottic airways. B. This may or may not be applicable with utilization of the airway bougie. 2. Auscultation of the epigastrum and then the thorax: A. If epigastric sounds are heard, intubation should be reattempted. i. A supraglottic airway may be left in place if mild epigastric sounds are noted. The thorax should be auscultated and the presence of bilateral breath sounds should be easily noted. B. If no epigastric sounds, auscultate the thorax bilaterally. If breaths sounds are present on the right and absent on the left, this suggest a right main stem intubation. Withdraw the endotracheal 1cm and repeat breath sound auscultation. If necessary, the tube may be withdrawn an additional 1-2 cm. 3. Physiologic changes should be observed, these include: A. Equal rise and fall of the chest. B. Condensation in the endotracheal tube on exhalation. C. Improvement in the patient’s color and/or in the patients’ respiratory distress or failure. 4. Use end-tidal carbon dioxide detection (EtCO2): A. Use the monitor capnograph as the means of detecting