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Procedures – AIRWAY MANAGEMENT: 12.2 BAG-VALVE-MASK VENTILATION a) PURPOSE...

Procedures – AIRWAY MANAGEMENT: 12.2 BAG-VALVE-MASK VENTILATION a) PURPOSE (1) Bag-valve-mask (BVM) ventilation is the technique of providing rescue breathing for patients with inadequate respiratory effort or cardiac arrest. Patients in respiratory failure may respond to BVM ventilation and not require endotracheal intubation. (2) A BVM may also be used to administer inhaled medications for patients with severe respiratory failure. b) INDICATIONS (1) Inadequate respiratory rate (a) Adult less than 8 Procedures: Airway Management – Bag-Valve-Mask Ventilation 12.2 (b) Adolescent (13–18 years of age) less than 12 (c) Child (1–12 years of age) less than 16 (d) Infant/Toddler (less than 1 year of age) less than 20 (2) Inadequate respiratory effort (a) Absent or diminished breath sounds (b) Paradoxical breathing (chest and abdomen moving in opposite directions) (c) Cyanosis or oxygen saturation less than 90% on 100% oxygen by nonrebreather with the exception of patients with chronic hypoxemia (3) Symptomatic Bradycardia (a) Adult/Adolescent Heart rate less than 60 (greater than 13 years of age) (b) Child (1–12 years of age) Heart rate less than 80 (c) Infant (less than 1 year of age) Heart rate less than 100 (4) Cardiac arrest (5) Altered mental status Glasgow Coma Scale of 8 or less c) CONTRAINDICATIONS None d) POTENTIAL ADVERSE EFFECTS / COMPLICATIONS (1) Gastric distension (2) Vomiting (3) Increased intracranial pressure as a result of increased vagal stimulation if mask applied over the patient’s eyes e) PRECAUTIONS (1) Have suction available since vomiting may occur. (2) Use an appropriate size airway adjunct with BVM. Release Date July 1, 2023 1077250 of 2175 www.miemss.org Back to Contents  Procedures – AIRWAY MANAGEMENT: BAG-VALVE-MASK VENTILATION (continued) 12.2 (3) Use an appropriate size mask to avoid pressure over the eyes (pediatric patient), which may cause vagal stimulation. (4) For single clinician BVM use the “E-C clamp” technique to achieve an adequate seal and avoid pressure on the soft tissues of the face or neck: Place the third, fourth, and fifth fingers along the jaw to provide a chin lift (forming an E); use the thumb and index finger to hold the mask on the child’s face (forming a C). (5) If the patient does not have adequate chest rise and breath sounds with BVM, con- sider the following interventions: (a) Use 2-hand jaw lift and oral airway to relieve tongue obstruction. (b) Use a larger bag to increase the volume of air delivered into the patient. (c) Evaluate and treat the patient for gastric distension. Procedures: Airway Management – Bag-Valve-Mask Ventilation 12.2 Clinicians may manually decompress the stomach and/or open an existing gastric tube or button and/or place NG or OG tube. f) SUGGESTED SIZES FOR RESUSCITATION MASKS Age Mask Size Premature infants Neonatal Newborn to 1 year Infant 1–4 years Toddler 5–12 years Pediatric Greater than 13 years of age Small adult Adult Adult g) SUGGESTED SIZES FOR RESUSCITATION BAGS Age Bag Size Infant to less than 1 year of age Infant (450–500 mL) Child 1-12 years Pediatric (750 mL) Adolescent/Adult Adult (1,000–1,200 mL) www.miemss.org 1078251 of 2175 Release Date July 1, 2023 Back to Contents  Procedures – ELECTRICAL THERAPY: 12.14 AUTOMATED EXTERNAL DEFIBRILLATION (AED) a) INDICATIONS Sudden cardiac arrest (patients with no pulse and not breathing). Neonate (1 hour to 28 days of life) Manual defibrillator preferred. (If unavailable, to less than 1 year of age an AED with pediatric capability is preferred over an adult AED.) 1 year of age to 8 years of age AED with pediatric capability, using the pediat- ric capability, is preferred over an adult AED. Procedures: Electrical Therapy – Automated External Defibrillation (AED) 12.14 Child 8 years of age or greater Adult AED b) CONTRAINDICATIONS Patient exhibiting signs of life Newly born patients (up to one hour after birth) USE OF THE AED IN THE MANUAL MODE IS RESERVED FOR ALS. c) POTENTIAL ADVERSE EFFECTS/COMPLICATIONS (1) Burns to skin (2) Deactivation of patient’s implanted pacemaker (3) Injury to patient, self, and/or bystanders d) PRECAUTIONS (1) Make sure the patient and the environment are dry. (2) Avoid placing pads over cardiac pacemakers/defibrillators or nitroglycerin patches. (3) DO NOT touch the patient while the AED is analyzing the patient or discharging energy. (4) ENSURE that no one is touching the patient when the shock button is pushed. (5) Never defibrillate while moving the patient or when in a moving ambulance. e) PROCEDURE (1) Initiate analysis of rhythm. (2) If shock is indicated: (a) Ensure all individuals are clear of the patient. (b) Initiate shock to the patient. (c) Immediately perform 5 cycles of CPR between shocks, then initiate analysis of rhythm. (d) If patient remains pulseless, continue this cycle of CPR and shocks until the AED prompt states “no shock advised,” or ROSC is achieved or ALS arrives or the patient is transported or the Termination of Resuscitation protocol is initiated. (3) If shock is not indicated and the patient remains in cardiac arrest: (a) Perform 5 cycles of CPR. (b) Initiate analysis of rhythm. (c) If shock is indicated, see “If shock is indicated” section above. Release Date July 1, 2023 1079270 of 2175 www.miemss.org Back to Contents  Procedures – GO-TEAM ACTIVATION 12.18 a) PURPOSE The University of Maryland Medical System, R Adams Cowley Shock Trauma Cen- ter (STC) maintains a deployable advanced surgical team (Go-Team) that includes an attending physician with surgical skills and an anesthetist capable of assisting EMS clinicians with the care of seriously injured patients when extrication times are anticipat- ed to be more than 1 hour. On-scene incident commanders may request the Go-Team by contacting SYSCOM. b) INDICATIONS The on-scene incident commander may contact SYSCOM and request the Go-Team for seriously injured patients with potentially life or limb threatening injuries when ex- trication times are anticipated to be more than 1 hour and who may require advanced resuscitative or surgical services that are beyond the scope of prehospital emergency services. Examples include: (1) During a prolonged extrication, assist rescue personnel with planning the type and Procedures: Go-Team Activation 12.18 pace of the rescue by assessing the extent of injury and determine potential conse- quences that delays in time to definitive care might have on patient outcome. (2) A patient trapped in heavy machinery requiring anesthesia/pain management to perform extrication (3) A patient surviving a building collapse requiring an amputation to enable extrication (4) A patient with a prolonged extrication requiring advanced fluid resuscitation includ- ing the administration of blood products (5) Insertion of chest tubes or gastric and urinary catheters during the course of pro- longed extrication c) PROCEDURE (1) On-scene incident commander will request the Go-Team by contacting SYSCOM. SYSCOM will coordinate the Go-Team’s transport to and from the scene with Maryland Express Care. (2) If the Go-Team is dispatched by air, then SYSCOM will notify the Go-Team when the aircraft is landing on the STC helipad. If the Go-Team is dispatched by land, then Maryland Express Care will coordinate the Team’s response. (3) Prior to the Go-Team’s departure to the scene, SYSCOM will notify the on-scene in- cident commander for the Go-Team’s ETA and reconfirm the need for the Go-Team. (4) If the Go-Team is dispatched, the EMS medical commander will contact them using the “Trauma Line” (or other radio) to update them about the circumstances of the entrapment and the patient’s condition. (5) When the Go-Team arrives on the scene, they are to report to the on-scene incident commander and operate within the Incident Command System. (6) Once the patient is extricated, the EMS system will transport the patient to the appropriate facility under established EMS guidelines with consultation by the Go- Team physician. (7) The Go-Team will document the care they provide and file a patient care report with the State EMS Medical Director at MIEMSS. www.miemss.org 1080277 of 2175 Release Date July 1, 2023 Back to Contents  Procedures – HIGH PERFORMANCE CPR 12.20 a) PURPOSE To improve survival of sudden out-of-hospital cardiac arrest patients in Maryland. High Performance Cardio-Pulmonary Resuscitation (HPCPR) employed with Code Resource Management (CRM) is a proven concept based on a team approach that ensures ef- fective and efficient use of EMS resources. This systematic change in treatment and management of cardiac arrest patients has demonstrated effectiveness in Maryland, and provides an example for systems embarking on measuring and improving care that is based upon proven research and practices. b) INDICATIONS Patients in cardiac arrest who are greater than 24 hours old. c) CONTRAINDICATIONS (1) Patients meeting the criteria for Pronouncement of Death in the Field protocol (2) Patients who are less than 24 hours old Procedures: High Performance CPR 12.20 d) POTENTIAL ADVERSE EFFECTS/COMPLICATIONS None e) PRECAUTIONS None f) IMPORTANT ROLE OF DISPATCHER TELEPHONE CPR (T-CPR) (1) Immediate recognition of unresponsiveness, activation of EMS system response via 9-1-1, and initiation of CPR by the lay rescuer is essential to maximize survival. (2) In an unresponsive patient, rapid recognition of agonal (gasping) respirations, or no respirations should prompt dispatcher-directed compressions to the caller (Dispatch-directed T-CPR). (3) Dispatch-directed T-CPR delivers CPR prior to EMS system arrival and presents a patient more responsive to EMS interventions, thus providing the ability to improve survival. g) PROCEDURE FOR HIGH PERFORMANCE CPR (1) The first clinician at the patient’s side will assess and initiate compressions. (2) Effective Compressions - Manual chest compressions should be initiated im- mediately upon identification of cardiac arrest, as long as the scene is safe. When compressions are done manually, compressors should be rotated every 2 minutes in order to maintain high-quality compressions. Ideally, one compressor is on each side of the patient’s chest: one person compressing the chest and the other person ready to start. Chest compressions will be performed at a depth of at least 2 inches allowing for complete recoil of the chest after each compression. For patients less than one year of age, compressions will be performed at a depth of 1½ inches. For patients greater than one year old up to age 13, compressions will be at a depth of 2 inches. (3) Compressions should be accomplished with equal time given for the down and up motion and achieve a rate of 100–120 per minute. www.miemss.org 1081279 of 2175 Release Date July 1, 2023 Back to Contents  Procedures – 12.20 HIGH PERFORMANCE CPR (continued) (4) Continuous Compressions - Chest compressions will be performed at a rate of 100–120 per minute and will NOT be interrupted during the two-minute cycle for any reason. Other treatments such as ventilations, IV access, or intubation attempts will be done while compressions are ongoing. After completion of a two-minute cycle, a brief pause to assess pulses and/or defibrillate will be limited to less than 10 sec- onds. (5) Defibrillation – placement of the defibrillator pads will not interrupt chest compres- sions (a) Automatic External Defibrillation The AED will be powered on as soon as the cardiac arrest is confirmed. Do not interrupt chest compressions to remove clothing or place defibrillation pads. If the AED charges after analyzing, chest compressions will be performed while the device charges, then the patient will be “cleared” and defibrillated. Com- pressors will hover over the patient with hands ready during defibrillation so compressions can start immediately after a shock. Another two-minute cycle of compressions will be immediately performed. Pulse checks will not occur after a Procedures: High Performance CPR 12.20 shock, but only after the AED prompts “no shock advised.” If no pulse is palpat- ed, or if unsure, immediately perform another two minutes of CPR. (b) Cardiac Monitor/Defibrillator When a manual defibrillator is in use, it will be charged to the appropriate energy level as the end of the compression cycle nears (approximately 1 minute and 45 seconds into a two-minute cycle). At the end of the two-minute cycle, the pa- tient will be cleared, the rhythm will then be interpreted rapidly, and the patient will either be defibrillated or the defibrillator energy charge will be cancelled. This sequence must be performed within 10 seconds. During this sequence, the compressors will hover over the patient with hands ready. If a shock is delivered, the compressor will immediately resume CPR. Rhythm interpretation will not occur after a shock, but only occur after the two-minute cycle of CPR is per- formed. If a shock is not indicated, check for a pulse. If patient remains pulse- less, immediately resume HPCPR. (6) Ventilations - Ventilations will be performed without stopping chest compressions. Ventilations are important but can impede the cardiac output from compressions. Thus, rescuers should not provide too many breaths or use excessive force. One ventilation will be given every 10th compression during recoil (upstroke). Once an ad- vanced airway is in place, ventilations will be interposed asynchronously with unin- terrupted compressions (for adults and children over 13 years of age: one ventilation every six seconds; for neonates until the 13th birthday: one ventilation every three seconds). Ventilation volume should be low volume (approximately 500 cc), best ap- proximated by a three finger or end of bag squeeze. High performance continuous compressions remain the priority. Ensure ventilations are adequate with bag-valve- mask attached to 100% oxygen. Clinicians will not interrupt compressions to obtain an advanced airway. For children up to age 13, maintain a ratio of 2 ventilations every 30th compression for single rescuer CPR or 2 ventilations every 15th compression for two or more res- cuer CPR (one ventilation on the recoil of the 14th compression and one ventilation on the recoil of the 15th compression). Release Date July 1, 2023 1082280 of 2175 www.miemss.org Back to Contents  Procedures – HIGH PERFORMANCE CPR (continued) 12.20 Rescuers Should Rescuers Should Not Perform chest compressions at a rate of 100-120/min Compress at a rate slower than 100/min or faster than 120/min Compress to a depth of at least 2 inches (5 cm) Compress to a depth of less than 2 inches (5 cm) or greater than 2.4 inches (6 cm) Allow full recoil after each compression Lean on the chest between compressions Minimize pauses in compressions Interrupt compressions for greater than 10 seconds Ventilate adequately (1 breath every 10th compression during Provide excessive ventilation (ie, too many breaths or breaths recoil) with excessive force) (7) Advanced Life Support - ALS clinicians will address defibrillation, IV/IO access, medication administration, and advanced airway placement, as indicated within Procedures: High Performance CPR 12.20 these protocols; however, the placement of an advanced airway is no longer an early focus of cardiac arrest management and will not interrupt chest compressions. Nasal capnography may be utilized to optimize CPR performance and evaluation of ROSC, with use of bag-valve-mask ventilation. (8) Return of Spontaneous Circulation (ROSC) – Refer to ROSC protocol. (9) Quality Improvement/Performance Metrics – Time to CPR, time to defibrillation, and quality of CPR are all factors that have been shown to have a positive impact on survival. One metric that field crews can use to evaluate performance is CPR Frac- tion. (a) CPR Fraction – The time CPR is being performed divided by the total time of the cardiac arrest. This fraction is typically reported as a percentage. (i) A target goal for crews, that has been associated with improvements in sur- vival, is a CPR fraction of equal to or greater than 80%. (ii) Minimizing pre-shock pauses (e.g., charging defibrillator while clinicians per- forming chest compressions) (iii) Feedback is best provided in real time or as close to the provision of care as possible. (b) CPR compression rates should be between 100 and 120 per minute. (c) Compression pauses should always be less than 10 seconds. h) PROCEDURE: CODE RESOURCE MANAGEMENT (CRM) Crews should coordinate their duties keeping the call priorities in mind. Intervention priorities are (in order of highest to lowest): www.miemss.org 1083281 of 2175 Release Date July 1, 2023 Back to Contents  Procedures – 12.20 HIGH PERFORMANCE CPR (continued) The number of personnel on a given incident and the qualifications of those personnel can vary; however, the priorities remain the same. Appropriate crew roles are outlined below: 2 clinician crew: Clinician 1 – Chest compressions Clinician 2 – Ventilate, attach/operate AED/defibrillator, assume crew leader responsibilities (clinicians rotate positions every two minutes) Roles remain the same even if clinicians are ALS equipped 3 clinician crew: Clinician 1 – Chest compressions Clinician 2 – Ventilate Clinician 3 – Crew Leader, attach/operate AED/defibrillator (Clinicians 1 and 2 rotate every two minutes) Roles remain the same even if clinicians are ALS equipped Procedures: High Performance CPR 12.20 4 clinician crew: Clinician 1 – Chest compressions Clinician 2 – Ventilate Clinician 3 – Attach/operate AED/defibrillator Clinician 4 – Crew leader (Clinicians 1, 2, and 3 rotate every two minutes) ** Once first two roles have begun treatment, ALS clinicians will establish IV/IO and administer medications. Greater than 4 clinicians - Utilize the same initial assignments as the four clinician crew. The crew leader will assign additional roles such as informing the family of patient status, gathering patient information, and documenting the medical interventions performed on the call. If resources allow, rotate additional clinicians to do chest compressions to achieve optimal performance. Crew leader - The crew leader will keep time, record interventions performed during the arrest, give compression feedback and ensure rotation of personnel doing compressions every two minutes. Verbal announcements of time should occur at one minute, 30 seconds before reassessment, 15 seconds left, and countdown to reassessment at 10 seconds. Release Date July 1, 2023 1084282 of 2175 www.miemss.org Back to Contents  Procedures – HIGH PERFORMANCE CPR (continued) 12.20 PEDIATRIC HIGH PERFORMANCE CPR (HPCPR) Assess Patient (less than 10 seconds) Remain on Scene Begin HPCPR Unresponsive Not Breathing No pulse Clinician # 1 Start Chest Compressions (100-120/min) Ventilations 2 Breaths: 30 Compressions Call for AED/Defibrillator Procedures: High Performance CPR 12.20 Clinician #2 2 minute cycles Attach AED/Defibrillator Assume Ventilation Role - 2 Breaths: 15 compressions Place Airway Adjunct Suction Continue HPCPR for 2-minute Clinician #3 or More cycle – less than10 second pause BLS – HPCPR Coach for coordinated activities BLS – Family Support Check pulse ALS – Establish IO Check rhythm (AED) ALS – Administer medication Shock if indicated ALS – Establish ALS airway Change compressors Pediatric HPCPR Team Member Initial Roles Essentials of High Performance CPR for Pediatrics Clinician #1: 1. Ensure proper chest compression rate Chest compressions at 100-120 per minute 100-120/min Call for AED 2. Ensure proper compression depth Less than 1 year – 1 ½ inches (4 cm) Clinician #2: Greater than or equal to 1 year – 2 inches (5 cm) Ventilate at 2 breaths:15 compressions 3. Minimize interruptions (less than 10 second pause) Attach AED 4. Ensure full chest recoil 5. Coordinate 2 minute cycles Clinician #3 or MORE: 6. Rotate Compressor Assume timekeeper role Assume AED role IO Access Medications * Once an advanced airway is in place, one ventilation Establish ALS Airway every three seconds interposed asynchronously Family Support www.miemss.org 1085283 of 2175 Release Date July 1, 2023 Back to Contents  Procedures – MEDEVAC UTILIZATION 12.23 a) PURPOSE Summarize Medevac Utilization Protocol indications, contraindications, principles for consideration of medevac request, medevac request process, standardized medevac request dataset, optimal landing zone setup, and safety recommendations when inter- acting with helicopters b) INDICATIONS FOR “MEDEVAC REQUEST” The following indications must meet the specific criteria of the indicated protocol(s) (1) Trauma Category Alpha, Bravo, Charlie*, Delta* (2) Specialty Category (a) Burn (b) Hand* (c) Eye (d) Head (e) Spinal (3) Medical Category (a) Stroke Procedures: Medevac Utilization 12.23 (b) STEMI (c) Hyperbaric (CO, Toxic Inhalation, or SCUBA) (4) Consult-Approved Critical/Unstable (Time-critical illness or disease requiring specialized care) * All of the above requests containing an asterisk (*) (adult or pediatric) require accep- tance at the Trauma/Medical/Specialty Center for medevac authorization before SYSCOM can dispatch the helicopter. c) PRINCIPLES FOR CONSIDERATION OF MEDEVAC TRANSPORT MEETING ABOVE INDICATIONS: (1) Priority 1 Patients (critically ill or injured person requiring immediate attention: unsta- ble patients with life-threatening injury or illness) (a) Consider air transportation if the patient will ARRIVE at the appropriate receiv- ing facility more quickly than could be accomplished by ground transportation. (b) The clinician should consider all of the following: (i) Time for helicopter response (ii) Patient turnover (loading time) (iii) Flight time to appropriate facility (iv) Weather conditions (2) Priority 2 Patients (less serious condition yet potentially life-threatening injury or illness, requiring emergency medical attention but not immediately endangering the patient’s life) Consider medevac transport if drive time is greater than 30 minutes. Special Consideration: Consider medevac transport if ground transport greater than 60 minutes to a trau- ma or specialty center would deplete limited EMS resources in the community. www.miemss.org 1086289 of 2175 Release Date July 1, 2023 Back to Contents  Procedures – 12.23 MEDEVAC UTILIZATION (continued) d) CONTRAINDICATION FOR MEDEVAC REQUEST EMS/DNR-B or MOLST B patients are not candidates for field medevac transport. ALL REQUESTS FOR SCENE HELICOPTER TRANSPORTS SHALL BE MADE THROUGH SYSCOM. e) FORMAL REQUEST PROCESS The Systems Communications Center (SYSCOM) at MIEMSS serves as the com- munications center for the dispatching and management of Maryland’s public safety helicopter resources. This mission is accomplished through the partnership between jurisdictional 9-1-1 call-centers and SYSCOM operations at MIEMSS. All helicopter re- quests must be routed through SYSCOM. The Medevac Request Data form is designed to provide a consistent standard by which SYSCOM receives “request” information. Considering the variety in the types of requests received by SYSCOM (e.g., medevac, search-and-rescue, law enforcement tracking) the information requested will vary, de- pending on the nature of the request. The county communications centers and the EMS Procedures: Medevac Utilization 12.23 clinicians that make the request should be familiar with the Medevac Data Request form to provide essential data to SYSCOM for prompt dispatch of the requested helicopter support. EMS clinician and 9-1-1 center medevac request process: (1) Decision made to request medevac based on indication and principles above (if 9-1-1 center has enough information from phone interrogation of call, and trauma indications meet Trauma Decision Tree Category Alpha or Bravo, the 9-1-1 cen- ter operator does not have to wait for EMS clinician to arrive on scene to make medevac request). (2) If indicated, consult with trauma/specialty center for physician authorization to use medevac for transport and acceptance of the patient. (3) Essential information gathered to complete the Medevac Data Request form (most of this is handled by 9-1-1 center). (4) Contact SYSCOM for formal medevac request. (5) Select and secure landing zone following optimal landing zone setup and safety tips. Release Date July 1, 2023 1087290 of 2175 www.miemss.org Back to Contents  Procedures – MEDEVAC UTILIZATION (continued) 12.23 Medevac Data Request Form Maryland Helicopter Dispatch Request 1 Identify Call Origin & Operator ID 2 Identify Request Type: Medevac, Search & Rescue, Airborne Law Enforcement 3 Jurisdictional Incident Number & 9-1-1 Dispatch Time Medevac Dispatch 1 Incident Type 2 Incident Location: Community & Site 3 Landing Zone 4 ADC Map Page/Grid OR Lat/Lon 5 Primary Condition 6 Severity, Category & Priority 7 Adult or Pediatric or Estimated Age? Procedures: Medevac Utilization 12.23 8 Multiple Patients? 9 ALS Unit & LZ Contact Info 10 Additional Relevant Information Search & Rescue Dispatch 1 Incident Type 2 Incident Location: Community & Site 3 ADC Map Grid OR Lat/Lon Info for LZ 4 Primary Target Description 5 Time Last Observed 6 Ground Contact Unit 7 Additional Relevant Information Airborne Law Enforcement Dispatch 1 Incident Type 2 Incident Location: Community & Site 3 ADC Map Grid OR Lat/Lon Info for LZ 4 Primary Target 5 Time Last Observed 6 Ground Contact Unit 7 Additional Relevant Information www.miemss.org 1088291 of 2175 Release Date July 1, 2023 Back to Contents  Procedures – 12.23 MEDEVAC UTILIZATION (continued) f) HELICOPTER SAFETY (1) OPTIMAL LANDING ZONE (LZ) SETUP (a) 150 x 150-foot area close to the incident scene and free from obstructions is the minimum required, with a 175 x 175-foot area preferred. (In mass casualty incident, identify a large enough area to land multiple large helicopters.) (b) The landing zone should be a flat surface that is firm, free of overhead obstructions, and free of any debris that can blow up into the rotor system. The maximum allowable slope is 10 degrees. (c) Obstacles such as wires, poles, signs, etc. can be difficult to see from the air- craft. If wires are present at or near the scene, this information must be relayed to the flight crew prior to landing. (d) Advise the flight crew on overhead radio contact if there are any obstructions in the area, obstructions at the edge of the LZ, or any obstructions in-line with the Procedures: Medevac Utilization 12.23 departure or approach path. (e) The landing zone will not be located near fixed objects that may be susceptible to wind damage or unsecured objects (e.g., patio furniture, small boats) that may become airborne as the AW-139 aircraft produces a significant amount of main and tail rotor wash. (f) If the roadway is too narrow, or numerous trees or other obstacles are present, another area must be selected as an alternate LZ and checked for ob- stacles and other unsafe conditions. After the LZ Officer has evaluated all areas, the best unobstructed landing site must be secured and the flight crew advised of any unsafe conditions they may encounter during the landing. NOTE: In determining landing zones, be aware that helicopter take-offs and landings can be done in a vertical manner; however, these landings limit the pilot’s visibility of the LZ. Increased power requirements on the helicopter may eliminate land-back areas should an engine malfunction occur, making the approach slower and causing extended periods of rotor wash. (2) ADDITIONAL LANDING ZONE TIPS (a) The LZ Officer should walk the area on both sides of the LZ and check for haz- ards. During night operations, walk the LZ with a flashlight that is directed up and down to detect wires in and around the LZ. (b) 45-Degree Test—The LZ Officer should stand in the middle of the LZ with one arm extended at a 45-degree angle in front of him/her. Any objects at or above this line are obstacles and need to be reported to the incoming aircraft. This test is done for the full 360 degrees. (c) Do not recommend landing zones that contain loose material such as gravel. The rotor wash will cause stones or gravel to become airborne, striking person- nel and/or damaging vehicles. (d) When a roadway is to be used as an LZ, all traffic must be stopped in both di- rections of the roadway, even on multi-lane highways or interstates. Release Date July 1, 2023 1089292 of 2175 www.miemss.org Back to Contents  Procedures – MEDEVAC UTILIZATION (continued) 12.23 (e) The LZ Officer will ensure that enough personnel is available to prevent any breach of LZ security by pedestrians while the helicopter is approaching, on the ground, or while departing. Failure to do so may cause injuries and/or delay patient transport. (f) Do not allow traffic to use the roadway until after the aircraft has departed. Traf- fic will be stopped at least 200 feet in both directions from the landing zone. (g) Do not use flares or cones to mark the landing zone: they will become airborne during the landing. (Weighted cones/lights that are designed for aircraft operations are generally acceptable.) (h) The flightcrew is the final authority when selecting an LZ. On some occasions, the flightcrew may not choose to utilize the ground personnel’s suggested LZ and choose an alternate LZ. This decision is usually based on information that is unknown to the ground personnel (e.g., wind, aircraft performance limitations). (3) APPROACHING THE AIRCRAFT Personnel should only approach MSP aircraft under the following conditions: Procedures: Medevac Utilization 12.23 AW-139 (a) Hearing and eye protection shall be utilized at all times when approaching the aircraft. (b) Only when accompanied by an MSP flight crew member to the aircraft Response personnel are usually limited to four when loading patients. The crew will provide additional guidance prior to these personnel approaching the air- craft. (c) In an emergency situation when it becomes necessary to render assistance or rescue occupants of the helicopter. In such cases: DO NOT APPROACH THE AIRCRAFT UNLESS THE MAIN ROTOR HAS STOPPED! (d) Only approach the aircraft from the Safe Zone (see diagram). (i) Never approach the aircraft from the rear areas due to the hazards existing from the tail rotor. REMAIN CLEAR OF THE REAR AND TAIL ROTOR AT ALL TIMES! www.miemss.org 1090293 of 2175 Release Date July 1, 2023 Back to Contents  Procedures – 12.23 MEDEVAC UTILIZATION (continued) (ii) If it becomes necessary to go from one side of the aircraft to the other, this will be done by walking around the front of the aircraft; however, do not walk under the rotor blades. (iii) Personnel shall not wear hats and loose clothing when approaching the air- craft. Do not lift anything above shoulder height (e.g., IV bags). (e) If the aircraft has landed on a slope or hill, care must be taken when approaching the aircraft from the downhill side. Uphill side approaches should be avoided, as the main rotor blade is spinning and is lower to the ground on one side of the aircraft. The Trooper/Flight Paramedic will provide additional guidance in this situation. (f) Never bring the patient to the aircraft prior to advising the Trooper/Flight Para- medic of the patient’s information. Very high noise levels found in the general proximity of the aircraft make communication and patient turnover impossible. (g) If debris gets in the eyes and it impairs the vision, do not continue to approach or egress from the aircraft. Personnel will immediately “take a knee,” and the Trooper/Flight Paramedic will provide assistance. Procedures: Medevac Utilization 12.23 (4) MISCELLANEOUS SAFETY TIPS (a) Aircraft Doors Personnel should not attempt to open or close any aircraft doors. If a person is in the aircraft, they should remain inside until the flight crew member opens the door, thus preventing damage to the door and greatly reducing the risk of an aircraft door opening inadvertently in flight. (b) Vehicles (i) No vehicles or personnel shall be permitted within 200 feet of the aircraft. (ii) Do not direct spotlights onto the landing area or at the aircraft, but keep vehicle’s emergency lights displayed until the aircraft is overhead. Once the LZ has been confirmed and verified by the flight crew, vehicle lighting can be reduced to running lights or parking lights for night vision purposes. Release Date July 1, 2023 1091294 of 2175 www.miemss.org Back to Contents  Procedures – 12.24 PATIENT-INITIATED REFUSAL OF EMS a) Initiate General Patient Care. For the purposes of this protocol, a patient is defined as any person encountered by in-service rescue or emergency medical personnel with an actual or potential injury or medical problem. (The term “patient,” in this protocol only, refers both to patients and to persons who are potential patients. This protocol is not intended to determine the legal status of any person, the establishment of a clinician-patient relationship, or a legal standard of care.) – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –– – – – A minor patient is defined as a patient who has not reached their 18th birthday and is not (1) Married, OR (2) Parent of a child, OR (3) Requesting: (a) Treatment for drug abuse or for alcoholism, (b) Treatment for Sexual Transmitted Infection (STI) or for contraception, Procedures: Patient-Initiated Refusal of EMS 12.24 (c) Treatment of injuries from alleged rape or sexual offense, OR (4) Living separate and apart from the minor’s parent, parents, or guardian, wheth- er with or without consent of the minor’s parent, parents, or guardian, and is not self-supporting, regardless of the source of the minor’s income. An authorized decision maker for minor patients is defined as an adult who identifies themselves as the parent or guardian, or has written authorization for medical decision making or states that they have written authorization for medical decision making. Clini- cians may request the parent or guardian to present identification and will document the name of the individual who identifies themselves as the decision maker. IN CASES OF ALLEGED RAPE OR SEXUAL OFFENSE, LAW ENFORCEMENT OR SOCIAL SERVICES SHALL BE NOTIFIED. b) These persons may have requested an EMS response or may have had an EMS re- sponse requested for them. Because of the hidden nature of some illnesses or injuries, an assessment must be offered and performed, to the extent permitted, on all patients. For patients initially refusing care, attempt to ask them, “Would you allow us to check you out and evaluate whether you are OK?” ––––––––––––––––––––––––––––––––––––––––––– IF THE AUTHORIZED DECISION MAKER REFUSES TO PERMIT THE EMS CLINICIAN TO EXAMINE A MINOR PATIENT TO DETERMINE THE SEVERITY OF THE ILLNESS OR INJU- RY, THEN CONSIDER CONTACTING LAW ENFORCEMENT FOR ASSISTANCE. CONSID- ER CONSULTATION WITH PEDIATRIC BASE STATION. c) Each patient’s assessment shall include: (1) Visual assessment - injuries, responsiveness, level of consciousness, orientation, respiratory distress, gait, skin color, diaphoresis (2) Primary survey - airway, breathing, circulation, and disability (3) Vital signs - pulse, blood pressure, respiratory rate and effort, pulse oximeter when available Release Date July 1, 2023 1092296 of 2175 www.miemss.org Back to Contents  Procedures – PATIENT-INITIATED REFUSAL OF EMS (continued) 12.24 (4) Secondary survey - directed by the chief complaint (a) Medical calls - exam of lungs, heart, abdomen, and extremities. Blood glucose testing for patients with Diabetes Mellitus. Neurological exam for altered con- sciousness, syncope, or possible stroke. (b) Trauma calls - for patients meeting criteria in the Maryland Medical Protocols Trauma Decision Tree recommending transport to a Trauma Center: exam of neck and spine, neurological exam, palpation and auscultation of affected body regions (chest, abdomen, pelvis, extremities). (5) Capability to make medical decisions (complete questions 1 through 4 on the Pa- tient-Initiated Refusal of EMS form): (a) Disorientation to person, place, time, situation (b) Evidence of altered level of consciousness resulting from head trauma, medical illness, intoxication, or other cause (c) Evidence of impaired judgment from alcohol or drug ingestion (d) Language communication barriers were removed by assuring “language line” Procedures: Patient-Initiated Refusal of EMS 12.24 translation when indicated (e) The patient understands the nature of the illness d) Following the assessment, complete items 5 through 9 on the Patient-Initiated Refusal of EMS Form, noting the presence of conditions that may place the patient at higher risk of hidden illness/injury or of worse potential outcome. Management (1) Patients at the scene of an emergency who meet criteria to allow self-determination shall be allowed to make decisions regarding their medical care, including refusal of evaluation, treatment, or transport. These criteria include: (a) Medical capacity to make decisions - the ability to understand and discuss and understanding of the nature and consequences of the medical care decision (b) Adult (18 years of age or greater) (c) Those patients who have not reached their 18th birthday and are: (i) Married, OR (ii) Parent of a child, OR (iii) Requesting: a. Treatment for drug abuse or for alcoholism, b. Treatment for STI or for contraception, c. Treatment of injuries from alleged rape or sexual offense, OR (iv) Living separate and apart from the minor’s parent, parents, or guardian, whether with or without consent of the minor’s parent, parents, or guardian, and is self-supporting, regardless of the source of the minor’s income. (d) A patient who has been evaluated by EMS clinicians as having ‘no’ answers to questions 1, 2, 3a, 3b, and 4 on the Patient-Initiated Refusal of EMS form shall be considered to be medically capable to make decisions regarding their own care. www.miemss.org 1093297 of 2175 Release Date July 1, 2023 Back to Contents  Procedures – 12.24 PATIENT-INITIATED REFUSAL OF EMS (continued) (e) Patients with ‘no’ answers to questions 1, 2, 3a, 3b, and 4 on the Patient-Initiat- ed Refusal of EMS form but one or more ‘yes’ answers to questions 5 through 8 (medical conditions) have a higher risk of medical illness. The EMS clinician should consider consulting medical direction if the patient does not wish trans- port. The purpose of the consultation is to obtain a “second opinion” with the goal of helping the patient realize the seriousness of their condition and accept transportation. (f) If the EMS clinician is unsure whether the patient has adequate ability to make medical decisions, they should seek medical consultation. (g) At any time the EMS clinician identifies patient conditions that indicate that the patient should be transported to a hospital, and the patient is refusing transport, then the clinician should seek medical consultation. (2) Any person at the scene of an emergency requesting an EMS response, or for whom an EMS response was requested, and who is evaluated to have any one of Procedures: Patient-Initiated Refusal of EMS 12.24 the following conditions, shall be considered incapable of making medical decisions regarding care and shall be transported, with law enforcement involvement, to the closest appropriate medical facility for further evaluation: (a) Continued altered mental status from any cause including altered vital signs, in- fluence of drugs and/or alcohol, metabolic causes (CNS or hypoglycemia), head trauma, or dementia (b) Attempted suicide, danger to self or others, or verbalizing suicidal intent (c) Acting in an irrational manner, to the extent that a reasonable person would be- lieve that the medical capacity to make decisions is impaired (d) Judgment impaired by severe illness or injury to the extent that a reasonable and medically capable person would seek further medical care (e) On an Emergency Petition (3) Further care should be provided according to Maryland Medical Protocols, Agitation protocol or other protocol sections as appropriate, based on patient’s condition. e) Base Station Hospital Physician Consultation Patient refusals are one of the highest risk encounters in clinical EMS. Careful assessment, patient counseling, and appropriate base hospital physician consultation can decrease non-transport of high-risk refusals. Patients who meet any of the following criteria require Base Station hospital physician consultation: (1) The clinician is unsure if the patient is medically capable of refusing transport. (2) The clinician disagrees with the patient’s decision to refuse transport due to un- stable vital signs, clinical factors uncovered by the assessment, or the clinician’s judgment that the patient may have a poor outcome if not transported. (3) The patient was involved in any mechanism included in the Trauma Decision Tree of the Maryland Medical Protocols that would recommend transportation to a Trauma Center. Release Date July 1, 2023 1094298 of 2175 www.miemss.org Back to Contents  Procedures – PATIENT-INITIATED REFUSAL OF EMS (continued) 12.24 (4) Minor patients: No parent, guardian, or authorized decision maker is available or the clinician disagrees with decision made by the parent, guardian, or authorized decision maker. For patients with significant past medical history, consider consultation with the specialty center that follows the patient if possible. Patients who do not meet the criteria above but have one or more positive answers to questions 6 through 10 on the Patient-Initiated Refusal of EMS form may have a higher risk of illness. In these situations, clinicians shall consult with the Base Station hospital physician. f) Documentation (1) Complete Section One of the Patient-Initiated Refusal of EMS form, documenting the patient’s medical decision-making capability and any “At-Risk” criteria. (2) Complete Section Two, which documents clinician assessment and actions. Procedures: Patient-Initiated Refusal of EMS 12.24 (3) Following patient counseling and Base Station hospital consultation, when indicat- ed, complete Section Three: Initial Disposition, Interventions, and Final Disposition. (4) Document your assessment, the care provided, elements of the refusal, medical de- cision-making capability, and “At-Risk” criteria in the eMEDS® report. Request that the patient and a witness sign the eMEDS® report to indicate refusal of treatment and/or transport. (5) If the patient/authorized decision maker refuses to sign the refusal statement: (a) Contact a supervisor. (b) Explain the need for a signature and again attempt to have the patient sign the refusal statement. (c) If not already done, have a witness sign the refusal statement. (d) Transmit the patient’s unwillingness to sign the refusal statement on a recorded channel and document all steps taken to convince patient to sign. www.miemss.org 1095299 of 2175 Release Date July 1, 2023 Back to Contents  Procedures – 12.24 PATIENT-INITIATED REFUSAL OF EMS (continued) Section One: When encountering a patient who is attempting to refuse EMS treatment or transport, assess their condition and record whether the patient screening reveals any lack of medical decision-making capability (1, 2, 3a, 3b, and 4) or high risk criteria (5–8): 1. Disoriented to: Person? yes no Place? yes no Time? yes no Situation? yes no 2. Altered level of consciousness? yes no 3. Alcohol or drug ingestion by history or exam with: a. Slurred speech? yes no b. Unsteady gait? yes no 4. Patient does not understand the nature of illness and Procedures: Patient-Initiated Refusal of EMS 12.24 potential for bad outcome? yes no 4A. Judgment impaired by severe illness or injury? yes no If yes, transport 5. Abnormal vital signs For Adults Pulse greater than 120 or less than 60? yes no Systolic BP less than 90? yes no Respirations greater than 30 or less than 10? yes no For minor/pediatric patients Age inappropriate HR or yes no Age inappropriate RR or yes no Age inappropriate BP yes no 6. Serious chief complaint (chest pain, SOB, syncope) yes no 7. Head Injury with history of loss of consciousness? yes no 8. Significant MOI or high suspicion of injury yes no 9. For minor/pediatric patients: ALTE, significant past medical history, or suspected intentional injury yes no If yes, consult 10. Clinician impression is that the patient requires hospital evaluation yes no Section Two: For clinicians: Following your evaluation, document information and care below: 1. Did you perform an assessment (including exam) on this patient? yes no If yes to #1, skip to #3 2. If unable to examine, did you attempt vital signs? yes no 3. Did you attempt to convince the patient or guardian to accept transport? yes no 4. Did you contact medical direction for patient still refusing service? yes no Release Date July 1, 2023 1096300 of 2175 www.miemss.org Back to Contents  Procedures – PATIENT-INITIATED REFUSAL OF EMS (continued) 12.24 Patient Refusal of EMS I, ________________________, have been offered the following by ___________________ (EMS Operational Program) but refuse (check all that apply): Examination Treatment Transport Patient Name: _____________________________ Phone: ________________ Patient Address: __________________________________________________ Signature: ________________________________Witness: ________________ Patient Parent Guardian Authorized Decision Maker (ADM) If you experience new symptoms or return of symptoms after this encounter, we recommend that you seek medical attention promptly. Section Three: (CHECK ALL THAT APPLY) Procedures: Patient-Initiated Refusal of EMS 12.24 Initial Disposition: Patient refused exam Patient refused treatment Patient refused transport Patient accepted exam Patient accepted treatment Patient accepted transport ADM refused exam ADM refused treatment ADM refused transport Patient refused transport to the closest appropriate facility (per protocol) Interventions: Attempt to convince patient Attempt to convince family member/ADM Contact Medical Direction (Facility: ___________________________________) Contact Law Enforcement None of the above available Final Disposition: Patient refused exam Patient refused treatment Patient refused transport Patient accepted exam Patient accepted treatment Patient accepted transport ADM refused exam ADM refused treatment ADM refused transport Patient refused transport to the closest appropriate facility (per protocol) Section Four: (MUST COMPLETE) Provide in the patient’s own words why they refused the above care/service: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Jurisdiction ______________________ Incident: ______________________ Date: __________ Unit #: _________________________ Clinician Name/EID: _______________Time: __________ www.miemss.org 1097301 of 2175 Release Date July 1, 2023 Back to Contents  Procedures – PHYSICAL RESTRAINTS 12.26 a) PURPOSE To prevent harm to patient or others b) INDICATIONS (1) Patient physical restraints should be utilized only when necessary and only in sit- uations where the patient is exhibiting behavior that the EMS clinician believes will present a danger to the patient or others. (2) The procedure does apply to patients treated under implied consent. c) PROCEDURE (1) The physical restraint procedure applies to patients greater than 1 year of age. (a) Ensure that the scene is safe. (b) Ensure sufficient personnel are present to control the patient while restraining. Use police assistance when available. (c) Position the patient for safe transport: (i) Place patient face up or on their side, if at all possible. (ii) Secure extremities: Procedures: Physical Restraints 12.26 ADULT: For adults, use 4-point restraints (ideally with one arm up and the opposite arm down) or use a sheet to carefully wrap the patient before ap- plying a Reeves™-type stretcher. PEDIATRIC: For patients less than 13 years of age, use 3-point restraints (two arms, one leg) or use a sheet to carefully wrap the patient before applying a Reeves™-type stretcher. (iii) If police have handcuffed the patient, reposition the patient in face-up posi- tion with hands anterior and secured to the stretcher (jointly with police). (iv) If necessary, utilize cervical-spine precautions to control violent head or body movements. (v) Place padding under patient’s head. Pad any other area needed to prevent the patient from further harming himself or herself or restricting circulation. (vi) Secure the patient onto the stretcher for transport, using additional straps if necessary. Be prepared at all times to logroll, suction, and maintain airway, especially in the event of vomiting. (d) Monitor airway status continuously, utilize pulse oximetry, vital signs, and re- assess pulse/capillary refill, motor, and sensory status distal to the restraints. Document findings every 15 minutes, along with reason for restraint. (e) Assess for traumatic or medical causes for the patient’s agitation. Refer to Agitation protocol. (f) For interfacility transfers, obtain a written physician’s order for use of restraints. d) PHYSICAL RESTRAINT GUIDELINES: (1) Use the minimum restraint necessary to accomplish necessary patient care and ensure safe transportation; soft restraints may be sufficient in some cases. If law en- forcement or additional personnel are needed, call for assistance prior to attempting restraint procedures. Do not endanger yourself or your crew. www.miemss.org 1098303 of 2175 Release Date July 1, 2023 Back to Contents  Procedures – 12.26 PHYSICAL RESTRAINTS (continued) (2) Avoid placing restraints in such a way as to preclude evaluation of the patient’s medical status (airway, breathing, and circulation). Consider whether placement of restraints will interfere with necessary patient-care activities or will cause further harm. (i) Patient positioning should be modified when restraining patients with limit- ed mobility, previous injury, or preexisting conditions (e.g., osteoporosis or contracture) to maintain extremities in a neutral position. (3) Patients shall not be restrained in a prone, hobbled, or “hog-tied” position. (4) Once restraints have been placed, do not remove them until you arrive at the hos- pital unless there is a complication from their use. If possible, take extra personnel during transport to hospital to deal with potential complications. Procedures: Physical Restraints 12.26 Release Date July 1, 2023 1099304 of 2175 www.miemss.org Back to Contents  Procedures – MULTIPLE CASUALTY INCIDENT/UNUSUAL EVENT 12.28 A Multi-Casualty Incident (MCI) or Unusual Event is any event where the number of injured persons exceeds the normal capabilities of the EMS Operational Program in whose juris- diction the event takes place. Due to the size of the incident, the responding EMS Opera- tional Program may require additional resources and/or must distribute patients to multiple hospitals. Local EMS Operational programs should have a plan or operational procedures that ad- dress response to multiple patient incidents or unusual events. This protocol does not supersede those plans. There are some general practices and procedures that must be followed to ensure the EMS system can be prepared to respond appropriately to support a local response. Procedures: Multiple Casualty Incident/Unusual Event 12.28 ALERT: THIS PROTOCOL IS SIMPLY A LIST OF REQUIRED TASKS IN THE EVENT OF AN UNUSUAL EVENT. IT IS NOT ALL-INCLUSIVE. ALL CLINICIANS ARE ENCOURAGED TO REVIEW LOCAL EMERGENCY RESPONSE PLANS, THE MARYLAND TRIAGE SYSTEM TRAINING PROGRAM, START/JUMPSTART, AND NIMS PRACTICES AND PROCEDURES ON AT LEAST AN ANNUAL BASIS. Procedure a) Assess scene and recognize that the incident is an MCI or Unusual Event. The definition of MCI or Unusual Event for the purposes of this protocol is an incident that causes more than 5 patient encounters or that involves unusual circumstances that suggest it could place an extraordinary strain on EMS or health care resources. The following events are examples of an MCI or Unusual Event. (1) More than five patients from one or related incidents (2) Multi-patient events that require specialized rescue (3) Three or more immediate (Priority 1) patients (4) Multiple pediatric patients requiring specialty resources (5) More than one burn patient meeting burn center referral criteria (6) Use of more than two medevac helicopters (7) Use of Medical Ambulance Bus (MAB) (8) Multiple patients with unusual signs and symptoms (9) Unresolved WMD related activity that could result in multiple patients (active shooter, bomb threat, intentional WMD agent release, etc.) (10) Decontamination of more than 5 patients resulting in at least one transport (11) Unresolved hazardous material incident that has the potential to affect multiple patients (12) Evacuation of a licensed health care facility or housing complex for individuals requiring special assistance b) Notify EMRC or the Regional EMRC as soon as the incident is recognized to be an MCI or Unusual Event. Use the specific terms “MCI” or ”Unusual Event” when communi- cating with EMRC to be clear this protocol is being enacted. This should be done as early in the incident as possible when there is a strong suspicion that such an event has occurred so that EMRC may begin to notify hospitals and response partners of the www.miemss.org 1100307 of 2175 Release Date July 1, 2023 Back to Contents  Procedures – 12.28 MULTIPLE CASUALTY INCIDENT/UNUSUAL EVENT (continued) incident. Responding units can request their dispatchers notify EMRC before the scene is fully assessed if there is reasonable information to suggest that the incident meets the criteria above. As soon as available, the following information should be relayed to EMRC. (1) Type and general description of the incident (2) General location or address of the incident (3) Age range of patients (4) Estimated number of patients by priority (5) Approximate number of patients involved (6) Any hazardous agents involved c) Initiate the incident command structure according to local SOPs and/or the National Incident Management System. Update EMRC with more details about the incident as Procedures: Multiple Casualty Incident/Unusual Event 12.28 they become available. d) Consider utilization of the MCI Communications protocol. e) Triage patients using the START / JumpSTART methods. (1) Identify the patient’s triage category by utilizing the appropriately colored triage ribbon and securely attach a MIEMSS-approved Triage Tag. f) Do not delay transport of patients for extensive patient care procedures. Provide only the care required to sustain life and limb during transport to the hospital. g) Track the care, movement, and disposition of EVERY patient utilizing the locally ap- proved triage/treatment/transport logs. Patient information should be written on the triage tag. h) Consider the need for and request specialty resources through the local dispatch center and/or emergency management as per local procedures. These may include, (1) Mass Casualty Support Units (MCSU) – (Medical Supply Caches) (2) Medical Ambulance Buses (3) CHEMPACK (Organophosphate antidotes - contact EMRC) (4) Ambulance Strike Teams or EMS Taskforces (5) Shock Trauma Go-Team