EMS Protocols 2024 PDF

Revision Date: September 27, 2023 v5 Table of Contents Revision Date: August 1, 2020 General Protocols - Section 1 Refusal of Care & Transport 1.1 BHAP & CISM Activation Process 1.2...

Revision Date: September 27, 2023 v5 Table of Contents Revision Date: August 1, 2020 General Protocols - Section 1 Refusal of Care & Transport 1.1 BHAP & CISM Activation Process 1.2 Do Not Resuscitate Order 1.3 Determination of Death 1.4 Crime Scene Considerations 1.5 Helicopter Safety 1.6 Mass Casualty Incident 1.7 Standing Orders - Section 2 General Information 2.1 Patient Assessment 2.2 Ventilatory Assistance 2.3 Transport Destinations 2.4 Helicopter Transport Criteria 2.5 Table of Contents Table of Contents Revision Date: August 1, 2020 ALS Medical Emergencies - Section 3 Acute Adrenal Insufficiency 3.1 Allergic Reaction 3.2 Diabetic Emergencies 3.3 Dystonic Reaction 3.4 Fluid Resuscitation/Dehydration 3.5 Hyperkalemia 3.6 Nausea/Vomiting 3.7 Respiratory Distress 3.8 Seizure 3.9 Sepsis 3.10 Stroke 3.11 Table of Contents Table of Contents Revision Date: August 1, 2020 Cardiac Emergencies - Section 4 Atrial Fibrillation & Atrial Flutter 4.1 Bradycardia 4.2 Cardiogenic Shock 4.3 Chest Pain 4.4 STEMI Alert 4.5 CHF (Pulmonary Edema) 4.6 Supraventricular Tachycardia 4.7 Wide Complex Tachycardia (WCT) 4.8 Regular Really (WCT) 4.9 Polymorphic V-tach/Torsades Left 4.10 Ventricular Assist Device 4.11 Cardiac Arrest - Section 5 Standing Orders 5.1 Adult Cardiac Arrest 5.2 Adult Post Resuscitation 5.3 Pediatric Cardiac Arrest 5.4 Pediatric Post Resuscitation 5.5 Special Considerations 5.6 Table of Contents Table of Contents Revision Date: August 1, 2020 Overdose Emergencies - Section 6 Standing Orders 6.1 Beta Blockers 6.2 Calcium Channel Blockers 6.3 Cocaine 6.4 Narcotics 6.5 Tricyclic Antidepressants 6.6 Chemical Control - Section 7 Chemical Restraint 7.1 Pain Management 7.2 Delayed Sequence Intubation 7.3 Environmental Emergencies - Section 8 Decompression Sickness 8.1 Non-Fatal Drowning 8.2 Heat Emergencies 8.3 Carbon Monoxide Exposure 8.4 Cyanide Exposure 8.5 Organophosphate Poisoning 8.6 Table of Contents Table of Contents Revision Date: August 1, 2020 Trauma - Section 9 Standing Orders 9.1 Eye Emergencies 9.2 Bites & Stings 9.3 Pelvis & Closed Fractures 9.4 Open Fractures 9.5 Bleeding Control 9.6 Blood Transfusion— Whole 9.7 Blood Head Injuries 9.8 Chest Trauma 9.9 Crush Injury 9.10 Hemmorhagic Shock 9.11 Neurogenic Shock 9.12 Trauma in Pregnancy 9.13 Trauma Arrest Standing Orders 9.14 Burn Injuries 9.15 START Triage (Adult) 9.16 JumpSTART Triage (Pediatric) 9.17 Trauma Alert Criteria (Adult) 9.18 Trauma Alert Criteria (Pediatric) 9.19 Tranexamic Acid (TXA) 9.20 Table of Contents Table of Contents Revision Date: August 1, 2020 Obstetrical - Section 10 Standing Orders 10.1 1st & 2nd Trimester Complications 10.2 3rd Trimester Complications 10.3 Pre-Eclampsia/Eclampsia 10.4 Meconium Staining 10.5 Normal Delivery 10.6 Delivery Complications 10.7 Table of Contents  Editors & Contributors Revision Date: August 1, 2020 FIRE CHIEF Chief Michael McNally DIVISION CHIEF OF EMERGENCY MEDICAL SERVICES Chief Juan Cardona MEDICAL DIRECTORS Dr. Peter Antevy, MD, Medical Director Dr. Kenneth Scheppke, MD, Associate Medical Director Dr. Paul Pepe, MD, Associate Medical Director EDITORS Dr. Peter Antevy, MD, Medical Director EMS Division Chief Juan Cardona Assistant EMS Chief John Whalen Lieutenant Lazaro Ojeda Lieutenant Karl Kellenberger Lieutenant Kevin O’Connell Lieutenant Caroline Quevillon Lieutenant Johana Cinque Lieutenant Janet Neita CONTRIBUTORS Data Analyst Sharon Maraj SPECIAL RECOGNITION: A special thank you to Dr. Ken Scheppke and staff of Palm Beach County Fire Rescue for permission to utilize their protocol template. BACK TO TABLE OF CONTENTS Editors & Contributors  Medical Directors Revision Date: August 1, 2020 The following Emergency Medical Services Protocols are the Official Advanced and Basic Life Support Protocols for Coral Springs Parkland Fire Department and are approved for such use by Paramedics and EMTs of the department to care for the sick and injured. Only those Paramedics and EMTs approved by the Medical Director shall be authorized to utilize these protocols. Peter M. Antevy, MD Medical Director Kenneth A. Scheppke, MD Associate Medical Director Paul E. Pepe, MD Associate Medical Director BACK TO TABLE OF CONTENTS Medical Directors  BACK TO MAIN Medical Emergencies TABLE OF CONTENTS Standing Orders - Section 1  1.1 Refusal of Care & Transport Revision Date: December 20, 2021 I. Purpose: Any and all individuals who are involved as patients or potential patients should receive proper evaluation, treatment, and transportation to the appropriate medical facility. There may be times when this policy may not be carried out due to a refusal of care. The refusal of care procedure should be utilized in situations in which a patient refuses evaluation, treatment, and/or transportation by prehospital personnel. Persons should be assessed for competency to make decisions affecting their medical care. II. Definitions: A. Person can refuse medical care and/or transport based on the following guidelines: 1. Competent Adult Patient - defined by the ability to understand the risks and lack of potential benefits of his/her actions by refusing medical care and/or transportation 2. Adult - eighteen (18) years of age or older, including: a. A competent emancipated minor b. A self-sufficient minor c. A married minor d. A minor in the military 3. A legal representative for the patient (parent, guardian, health care surrogate) B. Patients not able to refuse care: A person may be considered incompetent to refuse medical care and/or transportation if the severity of his/her medical condition prevents the patient from making an informed, rational decision regarding medical care. Therefore, the individual may not refuse medical care and/or transportation based on the following guidelines: (Incapacitated persons law—401.445) 1. Altered level of consciousness 2. Suicide (attempt or verbal threat) 3. Severely altered vital signs 4. Mental retardation and/or deficiency 5. Not clinically sober (slurred speech, difficulty with balance or coordination) 6. Younger than eighteen (18) years of age (except those persons outlined above) C. Refusals of care or transport for minors in the absence of parent or guardian: 1. If the parent or legal guardian whose child(ren) have traumatic injuries (e.g., due to an MVA, sports injury, etc.) and are unable to make it to the scene within a reasonable amount of time, the parent or guardian may request by phone that their child not be transported to the hospital. 2. If there is an adult present and willing to sign the patient refusal form, accepting responsibility on behalf of the parent and the parent verbally consents to granting that responsibility to such adult, as well as leaving their child(ren) in the care of that adult. It is then acceptable to have the child stay on scene. 3. These interactions should be well documented in the electronic patient care report (ePCR). 4. If there is no authorized adult to sign, the minor must be transported to the appropriate hospital. BACK TO MAIN TABLE OF CONTENTS 1.1 Refusal of Care & Transport BACK TO SECTION 1  1.1 Refusal of Care & Transport Revision Date: December 20, 2021 D. Refusal of transport or transport destination: 1. Patients who refuse to be transported to the closest appropriate facility and are adamant about being transported to a different facility should be considered to be refusing transport. The supervising officer should be contacted for further consultation on the transport destination according to operational availability. 2. When a patient refuses to be transported to any facility, Medical Direction should be considered for further consultation, when such refusal represents a significant risk to the patient or the EMS system/agency. E. Implied consent 1. If a person is determined to be incompetent, he or she may be treated and transported under the principle of “implied consent” and/or as an incapacitated person. 2. If the patient is transported and/or treated on the basis of implied consent, field personnel should use reasonable measures to ensure safe transport to the closest appropriate facility. F. Medical Direction: The physician at the destination facility or the agency’s Medical Director. G. High Risk Refusals: Contact with Medical Direction should be considered for consultation under the following high risk circumstances: 1. A patient who is under 18 years of age 2. A patient whose refusal of care represents a significant risk to the patient or EMS system/agency 3. A patient who is not his/her own legal guardian 4. A patient who refuses transport after administration of any IV medication (exception: Diabetic patient, see below) 5. Persons in custody of a LEO no longer have the legal right to refuse transport but CAN refuse treatment by EMS unless it is deemed life threatening. a. In EVERY case where EMS is requested by PD to evaluate a person in custody, whether for evaluation or treatment the patient WILL be transported to a proper medical facility and be accompanied by LEO. 6. If any questions on the assessment of competency or refusal of care occur, contact Medical Direction for further guidance. 7. Diabetics: Patients with diabetes who received treatment may sign a Patient Refusal Form provided all of the following conditions are met: a. The patient is lucid and can understand the risk/benefits of refusal b. The patient has blood glucose levels that have returned to acceptable levels c. Has immediate access to food d. The patient otherwise meets the criteria to refuse as outlined in this protocol 8. If refusal of care or transport of a minor is in question based on paramedic judgement, contact Medical Direction immediately BACK TO MAIN 1.1 Refusal of Care & Transport BACK TO SECTION 1 TABLE OF CONTENTS  1.1 Refusal of Care & Transport Revision Date: December 20, 2021 H. Multiple patients: The procedure does not allow for more than one refusal on a single EMS Run Report. However, individuals who refuse ALL assistance, including proper evaluation, can be combined on a single report (e.g., all parties deny injury). Once an examination is begun on an individual, a separate EMS Run Report must be filled out to record the examination. Also, any later refusal of care requires following the complete protocol outlined below. The use of multiple refusals of care is primarily designed for incidents that have numerous participants (potential patients) where it becomes evident that some participants are not injured at all or refuse to be examined when approached by EMS personnel. a. Use Sections A, B & C to determine if patient can refuse care or transport b. Document all names, addresses, and witnesses III. Refusal Procedure: All measures should be taken to convince the patient to consent, including enlisting the help of family or friends. 1. Single patient a. Determine that the individual is involved in the incident. b. Determine that the individual is refusing to allow the proper evaluation, or necessary treatment, or necessary transport to the appropriate medical facility. c. Determine the mental status and extent and history of injury, mechanism, or illness. i. Ensure that the patient is conscious, alert, and oriented and understands (mental reasoning) his/her condition (patient GCS = 15). ii. Unless the patient specifically refuses, do a complete physical assessment. d. Inform the patient and/or responsible party (parent or guardian) of the risk/benefits of the decision to refuse treatment and/or transport to a definitive-care facility (loss of life or limb, irreversible sequelae), and ensure that the patient and/or responsible party fully understands the explanation. 2. If the patient continues to refuse, the patient and/or responsible party may then sign a “Refusal of Care” form. Ensure that the following information is provided to the patient: a. The release is against medical advice. b. The release applies to this instance only. c. EMS should be requested again if necessary or desired. 3. After the “Refusal of Care” form is signed, it must be witnessed (including legibly printed name, contact information, and signature of witness). 4. If the patient or responsible party will not sign the release, then document this refusal on the EMS Run Report. If available, witness signatures should be obtained. 5. Where possible, patients should be left in the care of family, friends, or responsible parties. 6. Carefully document the assessment and vital signs, including all issues and circumstances indicated. BACK TO MAIN 1.1 Refusal of Care & Transport BACK TO SECTION 1 TABLE OF CONTENTS  1.2 BHAP & CISM Activation Process Revision Date: December 20, 2021 INFORMATION Behavioral Health Access Program (BHAP) is a multicomponent program for firefighter mental health/wellness and crisis intervention. BHAP is becoming a world standard of care for first responders and is recognized by the following: National fallen firefighter's foundation National Fire Protection Association (NFPA) Fire Service Joint Labor Management Wellness-Fitness Initiative International Association of Firefighters (IAFF) International Association of Fire Chiefs (IAFC) The Fire Chief’s Association of Broward County (FCABC) has developed a Health and Safety committee which has embraced the BHAP model. The Health and Safety committee is designed to bring workers and management together to promote safety and health in the workplace in compliance with FL Statute 633.522 BHAP BENEFITS: Reduction in symptoms of PTS Reduced worker’s comp claims Quicker return to normal productive functioning Reduced absenteeism Increased job satisfaction Reduced Errors Enhanced group cohesion Increased personal confidence Extended longevity Types of incidents for BHAP response are called Debilitating Critical Incidents (DCI). Examples are: Serious injury or death of a member of the department Pediatric injury or death Large Scale/Long Term Event with or without loss of life (natural disaster, ASHER event, etc.) Multiple youth fatalities or violence to a minor Events with severe operational challenges Line-of-duty death or line-of-duty injury Officer involved in a shooting Off-duty death, suicide, homicide, or injury Events with multiple or mass casualties Events when the victim(s) is (are) known Events with excessive media interest Serious injury or death of a civilian resulting from fire department operations (e.g., vehicle accidents or structure fires) Any incident that could perceivably cause emotional impact Police officer or firefighter in an accident at or above Level 1 Trauma BACK TO MAIN TABLE OF CONTENTS 1.2 BHAP & CISM Activation Process BACK TO SECTION 1  1.2 BHAP & CISM Activation Process Revision Date: December 20, 2021 BHAP SERVICES CISM Family Support Peer Support Effective Insurance Coverage Chaplaincy Trained Clinician Response Team (CRT) Retiree Support Programs Evaluated Recovery Centers Culturally Competent Employee Assistance Programs CRITICAL INCIDENT STRESS MANAGEMENT (CISM) CISM is the Mitchell Model ICSF trained Team. Below are the components if this model: Small group defusing: 1. Recommended within the first 12 hours after a critical incident. 2. Best delivered as soon as possible after a critical incident occurs 3. Homogenous groups. 4. Assessment and education with possible referral and follow up. Small group debriefing: 1. 12-72 hours post-critical incident occurs. 2. Prior to demobilization from extended deployment or upon return from extended deployment 3. Events of significant personal loss (expanded-phrase defusing within 12 hours) Crisis Management briefing: 1. Appropriate for large incidents, incidents with high media involvement, respite/rehab centers and demobilization. 2. Best for large groups or mixed groups. 3. Primary focus on assessment and information. Florida Statute 401.30(4) (e) protects the discussions held during a CISM intervention as being “confidential and privileged communication under section 90.503.” Therefore, all information shared during any part of a CISM intervention is held in the strictest of confidence. BACK TO MAIN TABLE OF CONTENTS 1.2 BHAP & CISM Activation Process BACK TO SECTION 1  1.2 BHAP & CISM Activation Process Revision Date: December 20, 2021 PEER SUPPORT Provides confidential emotional/mental wellness support and trained empathetic/active listening for first responders and their families Facilitates early education, intervention, and diffusing of behavioral/mental health problems to prevent or cope with personal crisis Determines a member’s immediate needs with the ability to recommend appropriate resources Fosters development of dual certified Peer/CISM members to participate in the peer role of CISM Recommends organizational mental health needs of fire departments CHAPLAIN Pastoral/Spiritual Crisis Intervention Grief Counseling Privileged Confidentiality with immunity from court testimony CLINICIAN RESPONSE TEAM (CRT) Trained in first responder specific culture and treatment Offer assessment, evaluation, educational services, treatment, referral, follow-up, and crisis intervention EVALUATED RECOVERY CENTERS Evaluated by various BHAP professionals Fixed facilities that provide first responder specific treatment programs for substance abuse, PTSD, and other co-occurring behavioral health issues Must meet strict criteria developed by BHAP professionals FAMILY SUPPORT: Family caregivers (Spouses, Life partners, Parents, and Children) are in an ideal position to be attuned to and provide support toward identifying need for professional care for their loved ones. Educational programs may be designed to enhance the caregiver’s knowledge of Stress injuries/mental health related issues specific to the first responder and develop strategies to manage conflict, prevent relapse, and promote recovery for themselves and their loved ones. RETIREE SUPPORT PROGRAMS: Mental wellness programs should be extended to include retirees who may continue to suffer from job related stress and could benefit from positive BHAP programs. The retiree demographic can be a higher risk of depression, substance abuse, and suicidal ideation due to a multitude of factors including but not limited to: loss of sense of purpose, decreased activity and involvement in fire department related functions/ Operations, and perceived low levels of connectivity with others within the fire service community. Your retiree demographic can be an invaluable asset in areas such as peer support and other areas as pertaining to resiliency and mental wellness within your department. BACK TO MAIN TABLE OF CONTENTS 1.2 BHAP & CISM Activation Process BACK TO SECTION 1  1.2 BHAP & CISM Activation Process Revision Date: December 20, 2021 EFFECTIVE INSURANCE COVERAGE: Effective insurance policies for first responders should be inclusive of first responder specific providers as well as provide the highest level of service while limiting any potential impedances to accessing clearly identified first responder specific resources. These programs should seek out and provide a current and detailed list of culturally aware providers that have tangible and validated experience working with first responders as well as fixed facilities that have first responder specific programs. CULTURALLY COMPETENT EMPLOYEE ASSISTANCE PROGRAMS: Employee Assistance Programs should be available to first responders and their families through a process that includes program managers knowledgeable in first responders mental health professional and effective treatment options specific to the unique first responder culture and community. Resource portal for up to date BHAP providers: www.coralspringsstrong.org “The use of one intervention does not preclude the use of others for the same critical incident.” BACK TO MAIN TABLE OF CONTENTS 1.2 BHAP & CISM Activation Process BACK TO SECTION 1  1.2 BHAP & CISM Activation Process Revision Date: December 20, 2021 ACTIVATION OF CISM The Officer initiating the CISM request will notify their Safety and Health Chief who will assist with the activation. The requesting agency may call any of the 3 Broward Regional Communications Centers and ask for the Duty Officer to initiate a BHAP Team response. Broward Regional Communications Center Numbers: North – (954) 476-4720 Central – (954) 476-4730 South – (954) 476-4740 When activating the CISM, the duty officer will provide the following info: 1. Agency name 2. Type of incident 3. Number of members involved 4. Call-back contact name and number The BHAP Team Coordinator receives the information and informs the BHAP Clinical Director of the incident. BHAP Team Coordinator contacts the incident contact person, receives details of the incident, and advises the contact person of the appropriate type and timing of response. The type of response is dictated by: How early the BHAP is activated The nature of the incident BHAP Team Coordinator begins assembling a response team. BHAP response team members assemble for a briefing with the BHAP Team Coordinator and then meet with the contact person or designee All personnel receiving support shall be off-duty or out of service Intervention is done in a secure location without written, audio, or video recording After the intervention, the responding BHAP team gathers for a team debriefing ACTIVATION ADDITIONAL BHAP RESOURCES For activation for additional resources, contact the Safety and Health Chief. The most updated Coral Springs BHAP resources can be found: www.coralspringsstrong.org. This includes: Peer Support, Clinician Response Team, Chaplaincy, Retiree Support Programs, Effective Insurance Coverage, Family Support, CCEAP, Evaluated Recovery Centers EAP may also be contacted @ 800-554-6931 BACK TO MAIN TABLE OF CONTENTS 1.2 BHAP & CISM Activation Process BACK TO SECTION 1  1.3 Do Not Resuscitate Order Revision Date: April 28, 2022 I. Purpose: All patients found in cardiac arrest will receive cardiopulmonary resuscitation unless an exception is met as outlined in the following: II. ADVANCED DIRECTIVES/DO NOT RESUSCITATE ORDERS (DNRO) 1. Legislative authority Under Florida Administrative Code (FAC) 64J-2.018. Do Not Resuscitate Order (DNRO) Form and Patient Identification Device. The Florida DNRO form is the only form approved in the State of Florida. If there is a DNRO/POLST/MOST/MOLST form from another State presented by the patient or family, contact Medical Control as soon as possible for direction. 2. EMS shall withhold or withdraw cardiopulmonary resuscitation: a. Upon the presentation of an original or completed copy of DH Form 1896, Florida Do Not Resuscitate Order Form, December 2004, which is incorporated by reference and available from DOH at no cost, or, any previous edition of DH Form 1896; or 1.IV.2.1.2 b. Upon the presentation or observation, on the patient, of a Do Not Resuscitate Order patient identification device. Upon the presentation of a patient identification device 3. The Do Not Resuscitate Order Form shall be printed on yellow paper and have the words “DO NOT RESUSCITATE ORDER” printed in black and displayed across the top of the form. DH Form 1896 may be duplicated, provided that the content of the form is unaltered, the reproduction is of good quality, and it is duplicated on yellow paper. The shade of yellow does not have to be an exact duplicate. 4. Patient identification device is a miniature version of DH Form 1896 and is incorporated by reference as part of the DNRO form. Use of the patient identification device is voluntary and is intended to provide a convenient and portable DNRO which travels with the patient. a. The device is perforated so that it can be separated from the DNRO form. It can also be hole- punched, attached to a chain in some fashion and visibly displayed on the patient. In order to protect this device from hazardous conditions, it shall be laminated after completing it. Failure to laminate the device shall not be grounds for not honoring a patient’s DNRO order, if the device is otherwise properly completed. 5. The DNRO form and patient identification device must be signed by the patient’s physician. In addition, the patient, or if the patent is incapable of providing informed consent, the patient’s healthcare surrogate or proxy as defined in Section 765.101, F.S., or court appointed guardian or person acting pursuant to a durable power of attorney established pursuant to Section 709.08, F.S., must sign the form and the patient identification device in order for them to be valid. The form does not need to be notarized, once signed the form does not expire. BACK TO MAIN 1.3 Do Not Resuscitate Order BACK TO SECTION 1 TABLE OF CONTENTS  1.3 Do Not Resuscitate Order Revision Date: April 28, 2022 6. EMS shall verify the identity of the patient who is the subject of the DNRO form or patient identification device. Verification shall be obtained from the patient’s driver’s license, or photo identification or from a witness in the presence of the patient. If a witness is used to identify the patient, this fact shall be documented in the EMS Run Report, which must include the following information: a. The full name of the witness b. The address and telephone number of the witness c. The relationship of the witness to the patient 7. During each transport, the EMS provider shall ensure that a copy of the DNRO form or the patient identification device accompanies the live patient. The EMS provider shall provide comforting, pain-relieving and any other medically indicated care, short of respiratory or cardiac resuscitation. 8. A DNRO may be revoked at any time by the patient, if signed by the patient, or the patient’s health care surrogate, or proxy or court appointed guardian or person acting pursuant to a durable power of attorney established pursuant to Section 709.08, F.S. Pursuant to Section 765.104, F.S., the revocation may be in writing, by physical destruction, by failure to present it, or by orally expressing a contrary intent. 9. Oral orders from non physician staff members or telephoned requests from an absent physician do not adequately assure EMS that the proper decision-making process has been followed and are NOT acceptable. 10. In the near future Florida will be adopting POLST (Physician Orders for Life Sustaining Treatment Paradigm) The National POLST Paradigm is an approach to end-of-life planning that emphasizes patients’ wishes about the care they receive. The POLST Paradigm is an approach to end-of-life planning emphasizing: (i) advance care planning conversations between patients, health care professionals and loved ones; (ii) shared decision-making between a patient and his/her health care professional about the care the patient would like to receive at the end of his/her life; and (iii) ensuring patient wishes are honored. As a result of these conversations, patient wishes may be documented in a POLST form, which translates the shared decisions into actionable medical orders. a. The POLST form assures patients that health care professionals will provide only the care that patients themselves wish to receive, and decreases the frequency of medical errors. POLST is not for everyone. Only patients with serious illness or frailty should have a POLST form. For these patients, their current health status indicates the need for standing medical orders. For healthy patients, an Advance Directive is an appropriate tool for making future end-of-life care wishes known to loved ones. b. Several States use the POLST program and there several other forms used by these States, Medical Orders for Life Sustaining Treatment (MOLST), Medical Orders for Scope of Treatment (MOST) and the Physician Orders for Scope of Treatment (POST) form. Specific Authority 381.0011, 401.45(3) FS. Law Implemented 381.0205, 401.45, 765.401 FS. History–New 11-30-93, Amended 3-19-95, 1-26-97, Formerly 10D-66.325, Amended 2-20-00, 11-3-02, 6-9-05, Formerly 64E-2.031.5. BACK TO MAIN 1.3 Do Not Resuscitate Order BACK TO SECTION 1 TABLE OF CONTENTS  1.4 Determination of Death Revision Date: December 20, 2021 I. Purpose: The EMT or paramedic may determine that the adult or pediatric patient is dead/non-salvageable and decide not to resuscitate the patient under the following guidelines: a. At least 1 of the following conditions is present: 1. Lividity 2. Rigor mortis 3. Tissue decomposition 4. A valid DNRO is presented or discovered OR b. If all of the following are present: 1. Suspected down time > 30 minutes 2. Asystole 3. Pupils fixed and dilated 4. Apneic 5. Without hypothermic mechanism for arrest c. Patients with suspected hypothermia, barbiturate overdose, or electrocution require full ALS resuscitation unless they have injuries incompatible with life or tissue decomposition. d. EMS personnel may contact medical direction for a “determination of death” whenever support in the field is desired. Clearly state the purpose for the contact as part of the initial hailing. e. Resuscitation on a TRAUMA victim should NOT be attempted if patient has ALL 3 of the following presumptive signs of death present: 1. Apneic 2. Asystole 3. Fixed and dilated pupils OR 4. If the following conclusive sign is present: a. Injuries incompatible with life (e.g., decapitation, massive crush injury, incineration, etc.) 5. Prolonged extrication time (more than 15 minutes) where no resuscitative measures can be initiated prior to extrication. 6. SPECIAL CONSIDERATIONS IN PATIENTS with PENETRATING or BLUNT CHEST TRAUMA: a. Bilateral needle decompression may be performed in an attempt to achieve ROSC b. Resuscitation efforts DO NOT need to be started if the patient did not regain pulses immediately following the bilateral needle decompression f. If there is any concern regarding leaving the patient at the scene, begin resuscitation and transport g. Consideration should be given for the possibility of organ harvest; however, this should not be the sole reason for resuscitation. h. The local law enforcement agency that has jurisdiction will be responsible for the body once death has been determined. The body is to be left at the scene until a disposition has been made by the Medical Examiner’s Office or the local jurisdiction. BACK TO MAIN 1.4 Determination of Death BACK TO SECTION 1 TABLE OF CONTENTS  1.5 Crime Scene Considerations Revision Date: December 20, 2021 This SOG is issued by the Fire Chief’s Association of Broward County, FCABC—SOG 301. Date: May 31, 2019 I. Purpose/Intent: This procedure will be used when law enforcement personnel advise EMS that they are responding to a crime scene or EMS determines that a crime scene may exist. This below information is to ensure the protection of patient welfare as well as to ensure the ability to conduct an effective and thorough investigation. II. Response/on-scene situations: a. Only those units assigned will respond to the call. b. When approaching a potential crime scene that is being protected by law enforcement personnel, EMS may request entry into the area to determine the life status of the individual. c. If law enforcement personnel refuse access to the crime scene, do not become confrontational. Notify the EMS Agency Supervisor and complete an incident report as required. d. When personnel are allowed access into the scene, the minimum number of required EMS personnel should enter to minimize disturbance of the crime scene. e. Do not attempt resuscitation if the patient has no pulse, has no spontaneous respiration, and meets criteria outlined the protocol, DETERMINATION OF DEATH f. If treatment and/or resuscitation are warranted, follow the appropriate protocol. g. When on scene: 1. Keep your medical equipment close to the victim. 2. Stay close to the body. 3. Keep your hands out of any blood that has pooled. 4. Do not wander around the scene. 5. Minimize destruction of the patient’s clothing. If the patient’s clothing has a puncture, do not use the hole in the clothing to start cutting. Begin cutting at another part of the garment. Removed clothing should be left with the patient or turned over to law enforcement personnel. 6. Do NOT go through the victim’s personal effects, clean the body, or cover the body with a sheet or other material (if expired). a. Do NOT move, take, or handle any object at the scene or litter the crime scene with medical equipment, dressings, bandages, or other supplies. b. If resuscitation efforts are deemed necessary, transfer the victim from the scene to the vehicle expeditiously and stabilize the victim in the vehicle, when possible. c. If the patient relates any information relating to the crime while in transit to the medical facility, inform law enforcement personnel at once. BACK TO MAIN BACK TO SECTION 1 TABLE OF CONTENTS 1.5 Crime Scene Determination  1.6 Helicopter Safety Revision Date: December 20, 2021 I. Communication Procedures: The standard dispatch for an Air Rescue assignment should be one (1) engine company and one (1) rescue. The need for additional units should be dictated by the incident circumstances. It should be kept in mind that the unit assigned as the heli-spot (HS) group may need all of its personnel to properly secure the HS site. This may create the need for additional units to address patient care needs. Dispatchers should not take it upon themselves to modify this assignment, nor should they suggest modification of the assignment. As with any Fire Department assignment, the only personnel who can modify the assignment are Uniformed Fire Department Officers. II. Air Rescue Capabilities: The following represents incident that may necessitate Air Rescue response: 1. Level 1 trauma patient with a ground transport time of greater than twenty (20) minutes to an appropriate trauma facility. 2. Level 2 trauma patient with a ground transport time of greater than thirty (30) minutes to an appropriate trauma facility. 3. The patient is located in an area inaccessible by ground. 4. Extrication of a trauma patient is anticipated to exceed fifteen (15) minutes. 5. Severe cardiac crisis, severe pulmonary crisis, stroke, drowning, or life threatening pediatric illness with a transport time of greater than twenty (20) minutes to an appropriate medical facility. 6. Dive emergencies. 7. Inter-facility patient transfers that are time-critical. 8. Search and rescue of lost or missing people in the Intracoastal Waterway, ocean, lakes, canals, the Florida Everglades, or other large wilderness areas. 9. Aerial coverage for an overhead vantage point on brush fires, large industrial or commercial fires. III. Transport Guidelines: A. If it is determined that Air Rescue response may be necessary, the request should be made as soon as possible through Dispatch. B. All personnel who request Air Rescue for patient transport shall take the following safety considerations into account: 1. Weather Conditions – The helicopter is unable to fly in lightning, strong winds, heavy rain and fog. 2. Location of powerlines. 3. Trees, signs, posts, debris or other obstacles in the landing zone (LZ). 4. Civilians and other pedestrian and/or vehicular traffic in the area. 5. Consider wet down of the area if the landing zone site is significantly dusty and/or dry. C. If it is determined that Air Rescue may be utilized for transport, a tactical channel must be assigned for communications. BACK TO MAIN TABLE OF CONTENTS 1.6 Helicopter Safety BACK TO SECTION 1  1.6 Helicopter Safety Revision Date: December 20, 2021 D. On scene personnel must communicate the following information to Air Rescue as quickly as possible: 1. Patient status. 2. Patient weight. 3. Airway compromise and/or the need for rapid sequence intubation. 4. If the patient is combative, suicidal or is a prisoner. E. On scene personnel must secure a MedCom channel and supply an initial telemetry report to the receiving facility. E. Landing zone considerations should begin as soon as the request for Air Rescue is made. 1. Landing zones require a one hundred (100) feet by one hundred (100) feet area free from any potential safety hazards listed above. 2. Incident Command shall communicate the intended landing zone area to the Air Rescue flight medics. Flight medics will relay the information to the pilot and the pilot will confirm or deny the landing zone once arrival overhead. 3. Every landing zone must have a designated marshaller present at all times during helicopter landing, patient loading, and take off to ensure that no bystanders approach the aircraft. The designated marshaller cannot leave their post until the helicopter departs the scene. 4. On the helicopter’s final approach to the landing zone, the radio air traffic must remain clear and only emergency traffic shall be communicated. Ground crews should announce “Abort. Abort. Abort” over the radio if a hazard is identified. Once the helicopter has landed safely on the ground, normal radio traffic can resume. 5. It is not necessary to have a hose line pulled and charged. In the event of a catastrophic event involving the helicopter, tactics and strategy will be left up to the Incident Commander. G. Patient Preparation and Transport 1. When preparing a patient for transport by Air Rescue, the patient shall be secured to a long spine board using the cross-strap method. Personnel shall ensure that the patient’s feet and lower legs are strapped and are firmly in place. 2. Personnel shall inform the patient that they are about to be loaded aboard a helicopter and that noise, heat and wind levels will be high. 3. Upon Air Rescue’s arrival on scene, personnel shall not approach the aircraft. The patient must be kept inside of the rescue unit until flight medics meet with the crew for a briefing on the patient’s status and prior treatment. 4. Prior to approaching the helicopter, personnel shall remove all sheets and blankets from the patient and stretcher. High winds from the helicopter rotor may cause these items to become airborne hazards. IV poles should also be lowered as they may cause an additional hazard. BACK TO MAIN BACK TO SECTION 1 TABLE OF CONTENTS 1.6 Helicopter Safety  1.6 Helicopter Safety Revision Date: December 20, 2021 5. When patient preparation is complete, a minimum of three (3) personnel, including the flight medic, will be utilized to move the patient to the helicopter. The flight medic will be at the left foot of the patient. No person may approach the helicopter without being accompanied by a flight crew member. a. All personnel directly involved with loading or offloading the patient should have proper head and eye protection in place. 6. Following patient loading, all ground personnel shall immediately leave the landing zone area together as a unit, following the same route used when approaching the helicopter. 7. Upon the helicopter’s arrival at the designated receiving hospital’s helipad, all hospital staff must remain clear of the landing area until directed to approach by the flight crew. 8. The patient shall be offloaded from the helicopter with assistance from hospital staff and at the direction of the flight crew. VII. Inter-Facility Transfers In some cases, a fire department may be requested to assist with a Landing Zone for an inter-facility patient transfer from one hospital to another. When a request for an inter-facility patient transfer is made by the hospital , the fire agency will operate as detailed in Section F under Transport Guidelines. The flight medics of the aircraft may also need assistance in commuting from the LZ to the transferring hospital. BACK TO MAIN TABLE OF CONTENTS 1.6 Helicopter Safety BACK TO SECTION 1  1.7 Mass Casualty Incident Revision Date: December 20, 2021 This SOG is issued by the Fire Chief’s Association of Broward County, FCABC—SOG 203. Date: May 31, 2019 I. Purpose: To efficiently triage, treat, and transport victims of mass/multiple-casualty incidents (MCIs). The following protocol is applicable to all multiple-victim situations. This protocol is intended for the everyday MCI when the number of injured exceeds the capabilities of the first-arriving unit as well as for large-scale MCIs. II. Definitions a. Active Assailant(s) (AA) – An individual or individuals actively engaged in killing or attempting to kill people in a confined and populated area with means other than the use of firearms. b. Active Shooter – An individual or individuals actively engaged in harming, or attempting to kill people in a populated area with the use of firearm(s). c. Active Shooter Hostile Event Response (ASHER) – An incident where one or more individuals are or have been actively engaged in harming, killing, or attempting to kill people in a populated area by means such as firearms, explosives, toxic substances, vehicles, edged weapons, fire or a combination thereof. d. Ballistic Protection Equipment (BPE) – An item(s) of personal protective equipment (PPE) intended to protect the wearer from threats that could include ballistic threats, stabbing, fragmentation, or blunt force trauma. Minimally consists of ballistic vest, helmet and/or shield. e. Casualty Collection Point (CCP) – A temporary location used for gathering, triage, medical stabilization, and subsequent evacuation of nearby casualties. Where vehicular access might be limited and is usually occurring in the warm zone. Casualties can be transferred to an ambulance exchange point/loading zone from these locations. f. Complex Coordinated Attack – Frequently this is done using multiple asymmetric attack modes, such as firearms, explosives, fire and smoke as weapon and/or vehicle assaults. It will also often involve coordinated and concurrent attacks on multiple locations which will usually require multiple attackers. g. Concealment – The protection from observation. Anything that prevents direct observation from the threat that might or might not provide protection from the threat. h. Contact Team/Law Enforcement Entry Team – A team of law enforcement officers tasked with locating the suspect(s) and neutralizing the threat. i. Cover – The protection from firearms or other hostile weapons. j. Extraction Team/Litter Bearers – Personnel used to move the injured/uninjured to an area of safety. k. Force Protection (FP): Is preventive measures taken to mitigate hostile actions in specific areas or against a specific population, those protected by FP can include civilians and unarmed responders. l. Improvised Explosive Device (IED) – Per the Department of Defense (DOD), it is a device placed or fabricated in an improvised manner incorporating destructive, lethal, noxious, pyrotechnic, or incendiary chemicals and designed to destroy, incapacitate, harass or distract. An IED may be made with military or nonmilitary components. BACK TO MAIN BACK TO SECTION 1 TABLE OF CONTENTS 1.7 Mass Casualty Incident  1.7 Mass Casualty Incident Revision Date: December 20, 2021 This SOG is issued by the Fire Chief’s Association of Broward County, FCABC—SOG 203. Date: May 31, 2019 m. Rescue Task Force (RTF) – A combination of fire and/or EMS personnel and law enforcement who provide force protection. The RTF could provide the following tasks: threat based care, triage, and extracting victims to a casualty collection point or other designated location. The law enforcement officers (LEO) are assigned as force protection for this team, and should not separate from the fire and/or EMS personnel. There could be instances where the warm zone suddenly becomes a hot zone and the LEO must immediately respond to that threat to ensure the safety of the team. Based on the scene, number of victims, and available emergency personnel, there could be more than one RTF assigned. RTFs can operate in the warm zone. Once triage and treatment is complete, the RTF can assist with victim movement. The RTF could also have tactical objectives such as breaching, utility control, managing building systems, and fire control. These teams treat, stabilize, and remove the injured in a rapid manner, while wearing Ballistic Protective Equipment (BPE) and under the protection of law enforcement officers. n. THREAT – Acronym from the Hartford Consensus highlighting the importance of initial actions to control hemorrhaging. T – Threat suppression H – Hemorrhage Control RE – Rapid Extrication to safety A – Assessment by medical providers T – Transport to definitive care o. Unified Command (UC) – An authority structure in which the role of the incident commander is shared by individuals from all responding organizations responsible for the incident, operating together to develop a single incident action plan. During an ASHER incident, Unified Command generally consists of law enforcement, fire and EMS representatives at a minimum. p. Zones as they relate to Active Shooter Hostile Events: The areas at ASHER incidents within an established perimeter that are designated based upon safety and the degree of hazard. Hot Zone – Area that has not been cleared by law enforcement personnel, an area where there is known hazard or direct and immediate threat. Rescue Task Force’s (RTF’s) should NOT be deployed in this area. Warm Zone – An area where there is the potential for a hazard or an indirect threat to life. Where the perpetrator is not believed to be and is available for entry by a trained RTF to treat victims and extract them to the CCP. Cold Zone – Areas where there is little or no threat due to geographic distance from the threat or the area has been secured by law enforcement (i.e., the area where fire/EMS may stage to triage, treat, and transport victims once removed from the warm zone). BACK TO MAIN 1.7 Mass Casualty Incident BACK TO SECTION 1 TABLE OF CONTENTS  1.7 Mass Casualty Incident Revision Date: December 20, 2021 This SOG is issued by the Fire Chief’s Association of Broward County, FCABC—SOG 203. Date: May 31, 2019 III. Procedure: A. The officer of the first-arriving unit will establish Command and: 1. Perform a size-up, estimating the number of victims. 2. Request a Level 1, 2, 3, 4, or 5 response, and request additional units and/or specialized equipment as needed. If the incident is an active shooter/hostile event with unknown victims, request a MCI level 2 response until a count can be determined and then upgrade or downgrade as needed. 3. Identify a staging area. 4. If it is an active shooter/assailant incident or any tactical environment MCI, establish a Unified Command (UC) with Law Enforcement (LE). Consider establishing Liaisons for FD and LE, the Liaisons can interact with each other allowing the transfer of info between agencies. Law Enforcement will make entry with their contact team and provide feedback to the UC. The decision may be made to establish a Rescue Task Force (team of LE May 31, 2019 304-3 officers providing forced protection for rescue personnel). The Rescue Task Force will initiate triage and provide immediate lifesaving treatment (i.e. hemorrhage control). 5. If the area is deemed safe to enter, direct the remaining crew members and any additional arriving personnel to initiate triage. 6. Triage will be performed in accordance with START or JumpSTART. Prioritize victims utilizing color coded ribbons: : Immediate care : Delayed care : Ambulatory (minor) : Deceased (non-salvageable) 7. Locate and direct the “walking wounded” to one location away from the incident, if possible. These victims need to be assessed as soon as possible. Assign someone to keep the walking wounded together. 8. Active shooter/hostile event considerations: Be on high alert for suspicious individuals, packages, vehicles or potential IEDs. Integrated active shooter/assailant response should include the critical actions contained in the acronym THREAT. Threat suppression Hemorrhage control Rapid Extrication to safety Assessment by medical providers Transport to definitive care BACK TO MAIN 1.7 Mass Casualty Incident BACK TO SECTION 1 TABLE OF CONTENTS  1.7 Mass Casualty Incident Revision Date: December 20, 2021 This SOG is issued by the Fire Chief’s Association of Broward County, FCABC—SOG 203. Date: May 31, 2019 B. As additional units arrive, Command will designate the following officers: 1. Triage (Initially the responsibility of the first-arriving officer). 2. Treatment. 3. Transport. 4. Staging. C. Additional branches/sections may be required depending on the complexity of the incident. These officers may include, but are not limited to: 1. Medical Branch 2. Landing Zone/Heli-spot 3. Extrication 4. Hazardous Materials (hazmat) 5. Rehabilitation 6. Safety 7. Public Information Officer (PIO) 8. Medical Intelligence - to assist with suspected or known WMD (weapons of mass destruction) events for decontamination, antidotes, and treatment D. MCI: predetermined response plan 1. Considerations: a. An MCI shall be classified by different levels depending on the number of victims. The number of victims will be based on the initial size-up, prior to triage. b. Levels of response will augment the units already on the scene, and units enroute will be included in the assignment. The exception would be in conjunction with a Fire Alarm assignment i.e., a fire with multiple victims may be a Second Alarm with an MCI Level 3 response; this will be two separate assignments. c. Command can downgrade or upgrade the assignments at any time. d. All units will respond to the staging area emergency response unless otherwise directed by Command. e. When announcing an MCI, specify the general category (e.g., trauma, hazardous materials, smoke inhalation). f. Any victim meeting trauma transport criteria must be reported to a state-approved trauma center for determination as to transport destination. Trauma transport criteria will be determined during the secondary triage in the treatment phase. When the trauma center(s) are overwhelmed they will notify MedCom of the need for units to transport to other trauma centers or non-trauma centers. g. Consider the use of air transport for patients with special needs, mass-transit resources for multiple “walking wounded” patients, and private BLS transport units. BACK TO MAIN TABLE OF CONTENTS 1.7 Mass Casualty Incident BACK TO SECTION 1  1.7 Mass Casualty Incident Revision Date: December 20, 2021 This SOG is issued by the Fire Chief’s Association of Broward County, FCABC—SOG 203. Date: May 31, 2019 h. Consider the use of mobile command vehicles, medical supply trailers, and communication trailers as needed. i. Upon notification of an MCI, Medical Control (Medcom/MRCC) will gather information about each hospital’s capability and relay this information to the Transport Officer or Medical Communication Officer. j. On a large-scale incident, consider sending a Hospital Coordinator to each hospital to assist with communications. k. Request law enforcement to set up a safety parameter. PRE—DETERMINED RESPONSE PLAN MCI Level 1 (5-10 victims) 4 ALS Transport Units 2 Suppression Units 1 Shift Supervisor 1 EMS Supervisor Note - The two hospitals and trauma center closest to the incident will be notified by Medical Control (Medcom or local communications center). MCI Level 2 (11-20 victims) (any active assailant incident until an accurate victim count can be made) 6 ALS Transport Units 3 Suppression Units 2 Shift Supervisors 2 EMS Shift Supervisors Note - The three hospitals and two trauma centers closest to the incident will be notified by Medical Control (Medcom or local communications center). MCI Level 3 (21-100 victims) 8 ALS Transport Units 4 Suppression Units 3 Shift Supervisors 3 EMS Shift Supervisors Command Vehicle MCI Trailer Operations Chief Note – The four hospitals and three trauma centers closest to the incident will be notified by Medical Control (Medcom or local communications center). The Warning Point will notify the Emergency Management Agency. BACK TO MAIN 1.7 Mass Casualty Incident BACK TO SECTION 1 TABLE OF CONTENTS  1.7 Mass Casualty Incident Revision Date: December 20, 2021 MCI Level 4 (101-1000 victims) 5 MCI Task Forces (25 units) 2 ALS Transport Strike Teams (10 units) 1 Suppression Unit Strike Team (5 units) 2 BLS Transport Strike Teams (10 units) 2 Mass Transit Buses 2 MCI Trailers Command Vehicle Communications Trailer 5 Shift Supervisors 3 EMS Shift Supervisors,1 EMS Chief Operations Chief Note - The 10 hospitals and 5 trauma centers closest to the incident will be notified by Medical Control. The Warning Point will notify the Emergency Management Agency. In an ongoing, long-term MCI, the Metropolitan Medical Response System (MMRS) and the State Medical Assistance Response Team (SMRT), Medical Reserve Corp (MRC), Florida Advanced Surgical Team (FAST) Disaster Medical Assistance Team (DMAT) may be notified. MCI Level 5 (more than 1000 victims) 10 MCI Task Forces (50 units) 4 ALS Transport Strike Teams (20 units) 2 Suppression Unit Strike Teams (10 units) 4 BLS Transport Strike Teams (20 units) 4 Mass Transit Buses 2 Command Vehicles 4 Supply Trailers Communications Trailer 10 Shift Supervisors 6 EMS Shift Supervisors 2 EMS Chiefs 2 Operations Chiefs Note -The 20 hospitals and 10 trauma centers closest to the incident will be notified by Medical Control. The Warning Point will notify the Emergency Management Agency. In an ongoing, long-term MCI, the MMRS, DMAT, SMRT, MRC, FAST and the International Medical and Surgical Response Team (IMSURT) may be notified. Strike Team: Five of the same type of units, including common communications and leader. Task Force: Five different types of units, including common communications and leader. MCI Task Force: May be two ALS Transport Units, two BLS Transport Units, and one Suppression Unit, including common communications and leader. BACK TO MAIN BACK TO SECTION 1 TABLE OF CONTENTS 1.7 Mass Casualty Incident  1.7 Mass Casualty Incident Revision Date: December 20, 2021 OFFICER RESPONSIBILITIES A. Command 1. Established by the first arriving officer. Radio designation “Command.” 2. Follow Field Operation Guide (FOG) #1. 3. If ASHE get briefing from LE, establish a Unified Command and co-locate with LE. Consider establishing Liaisons for FD and LE, the Liaisons can interact with each other allowing the transfer of info between agencies. 4. Remain in a safe, fixed, and visible location, uphill and upwind of the incident. 5. Determine the MCI Level (1, 2, 3, 4, or 5). If unknown victims in an ASHE initiate a MCI level 2 until a count can be determined. 6. Designate a staging area. 7. Assign personnel to perform the functions of Triage, Rescue Task Force (if needed), Treatment, Transport, and Staging. 8. Advise the Communications Center of the number of victims and their categories once triage is complete. 9. During large-scale or complex MCIs (e.g., a fire with multiple victims/tactical environment incident), designate a Medical Branch to reduce the span of control. 10. Ensure proper security of the incident site, treatment area, and loading area; also provide for traffic control and access for emergency vehicles, including law enforcement. 11. If the incident is due to a known or suspected weapon of mass destruction (WMD event), refer to WMD FOG #8 and designate a Medical Intelligence Officer to assist with decontamination, antidotes, and treatment of victims. 12. If ASHE incident refer to FOG #9 B. Medical Branch. 1. Radio designation “Medical.” Follow FOG #2. 2. Assure Triage, Treatment, and Transport has been established. If established by Command, Triage, Rescue Task Force, Treatment, and Transport will now report to the Medical Branch. 3. Work with Command, and direct and/or supervise on-scene personnel from agencies such as the Medical Examiner’s Office, Red Cross, private ambulance companies, and hospital volunteers. 4. Ensure notification of Medical Control (Medcom/MRCC). 5. If the incident is due to a known or suspected WMD, refer to WMD FOG #8 and designate a Medical Intelligence Officer to assist with decontamination, antidotes, and treatment of victims. 6. If active assailant/ tactical environment refer to FOG #9 7. Ensure proper security of incident site, treatment area, and loading area; also provide for traffic control and access for emergency vehicles, including law enforcement. BACK TO MAIN TABLE OF CONTENTS 1.7 Mass Casualty Incident BACK TO SECTION 1  1.7 Mass Casualty Incident Revision Date: December 20, 2021 C. Triage Officer 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. D. Treatment Officer 1. 2. 3. 4. a. b. c. d. 5. 6. 7. 8. 9. 10. 11. Provide periodic status reports to Command/Medical Branch. BACK TO MAIN BACK TO SECTION 1 TABLE OF CONTENTS 1.7 Mass Casualty Incident  1.7 Mass Casualty Incident Revision Date: December 20, 2021 E. Transport Officer Reports to Command or the Medical Branch. Supervises the Medical Communication Coordinator and Documentation Aide(s). The Transport Officer is responsible for the coordination of victims and maintenance of records relating to victim identification, injuries, mode of transportation, and destination. 1. Radio designation “Transport”, follow FOG #5. 2. Assign a Documentation Aide with a radio to assist with paperwork and communications. 3. Assign a Medical Communication Coordinator to establish continuous contact with Medical Control (Medcom or MRCC). 4. Establish a victim loading area. Advise Staging of the location and direction of travel. Consider requesting law enforcement assistance for ensuring the security of the loading area. 5. Arrange for the transport of victims from the treatment area. Maintain a Hospital Transportation Log #5B. Keep a piece of the triage tag for future documentation. 6. Communicate with the Landing Zone (LZ)/Heli-spot Officer and relay the number of victims to be transported by air. Air-transported victims should be assigned to distant hospitals, unless the victims’ needs dictate otherwise (e.g., trauma center, burn unit). F. Medical Communications Coordinator Reports to the Transport Officer and is responsible for maintaining communication with Medical Control to assure proper victim transport information and destination. 1. Radio designation “Communication.” Follow FOG #5A. 2. Establish communication with Medical Control (Medcom or MRCC1). Advise Medical Control of the overall situation (e.g., smoke inhalation, trauma, burns, hazardous materials exposure) and the number and categories of victims. Medical Control will survey area hospitals to determine their capabilities and capacities and then relay this information to the field. Document this information on the Hospital Capability Worksheet #5C and maintain this document for the duration of the incident. 3. When units are prepared to transport, advise Medical Control and supply of the following information: a. The unit transporting b. The number of victims to be transported c. Their priority: Red, Yellow, or Green d. Any victims with special needs (e.g., cardiac, burn, trauma) 4. The Medical Communication Coordinator, in conjunction with Medical Control, will determine the most appropriate facility. Ground-transported victims should be assigned to hospitals on a rotating basis. 5. Once Medical Control receives the information from the Medical Communication Coordinator, Medical Control will notify the appropriate hospital. Transporting units will not contact the individual hospital on their own, unless there is a need for medical direction/care outside of protocols. 1 Medical Resource Coordination Center (MRCC): The MRCC’s prime function is to maintain status information—that is, the number of victims and the hospital readiness status to accept victims, to coordinate transportation, and to direct patients to the appropriate hospital during a disaster or other situation characterized by a high demand for medical resources BACK TO MAIN TABLE OF CONTENTS 1.7 Mass Casualty Incident BACK TO SECTION 1  1.7 Mass Casualty Incident Revision Date: December 20, 2021 G. Medical Supply Coordinator Reports to the Medical Branch and is responsible for acquiring and maintaining control of all medical equipment and supplies. 1. Radio designation “Supply”, follow FOG #6. 2. Assure necessary equipment is available on the transporting vehicle. 3. Provide an inventory of medical supplies at the staging area for use on scene. 4. Assure support vehicles are requested. (Broward County has four MCI supply trailers and Region 7 has three large MCI supply trailers available for use during a large-scale MCI.) H. Staging Officer Reports to Command and is responsible for managing all activities within the staging area. 1. Radio designation “Staging”, follow FOG #7. 2. Establish the location of a staging area and notify the Communication Center to direct any incoming units. 3. Maintain a Unit Staging Log #7A. 4. Ensure that all personnel stay with their vehicles unless otherwise directed by Command. If personnel are directed to assist in another function, ensure that the keys stay with each vehicle. 5. Coordinate with the Transport Officer the designation of a location for victim loading and the best route to the area. 6. Maintain a reserve of at least two transport vehicles. When the reserve is depleted, request additional units through Command. DOCUMENTATION A. The Incident Commander will, at the completion of the incident, coordinate the gathering of all pertinent documentation. B. A Post-Incident Analysis (PIA) will be completed. BACK TO MAIN TABLE OF CONTENTS 1.7 Mass Casualty Incident BACK TO SECTION 1  1.7 Mass Casualty Incident Revision Date: December 20, 2021 MCI Kits For Responder Vehicles A. 2. 3. 4. One (1) pediatric face mask 5. Colored ribbons (Red, Yellow, Green & Black) either rolls or ribbons. 6. Trauma Tourniquets (2) 7. Hemostatic Dressing (2) 8. Chest Decompression Needles(2) 9. Chest Seals (2) B. Fifty (50) triage tags—Disaster Management Systems (DMS) All Risk Triage tags C. Pencils/grease pencils and pens D. Additional tourniquets, hemostatic dressing, chest seals & chest decompression needles (10) E. The following MCI FOGs, logs, and associated paperwork for each officer: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. A. 1. 2. 3. 4. 5. 6. 7. 8. B. C. D. E. F. BACK TO MAIN BACK TO SECTION 1 TABLE OF CONTENTS 1.7 Mass Casualty Incident  1.7 Mass Casualty Incident Revision Date: December 20, 2021 A. 1. 2. 3. 4. 5. 1. 2. 3. START (modified 9/2015) Move the walking wounded GREEN No Respiration after head tilt BLACK Control Severe Bleeding Respirations over 30/min or Respiratory Distress RED Perfusion (No radial pulse) RED Mental Status (unable to follow commands) RED Stable RPM/Walking GREEN Stable RPM/Non-ambulatory YELLOW Conduct Secondary Triage in the Treatment Phase BACK TO MAIN 1.7 Mass Casualty Incident BACK TO SECTION 1 TABLE OF CONTENTS  1.7 Mass Casualty Incident Revision Date: December 20, 2021 Physiological differences in children necessitate adaptation of the standard START triage method in children 8 years of age or younger, or in those victims with the anatomical or physiological features of a child in the age group. The same parameters (RPM) are utilized, with the adaptations indicated here. JumpSTART (modified 9/2015) Move the walking wounded (access as soon as possible) GREEN No Respiration after head tilt/No peripheral pulse BLACK Respirations 45/min or 15/min (Work of Breathing) RED  No resp. w/ pulse, give 5 ventilations via barrier — respirations resume RED  No spontaneous respirations BLACK Control Severe Bleeding Perfusion (No radial pulse) RED Mental Status (AVPU) Alert/Verbal YELLOW  Pain/Unresponsive RED  Stable RPM/Walking GREEN  Stable RPM/Non-ambulatory YELLOW Conduct Secondary Triage in the Treatment Phase Note -Infants who are developmentally unable to walk should be triaged using the JumpSTART algorithm either during initial triage or in the Green area if carried out by a non-rescuer. During triage, if the infant does not fulfill the criteria of a Red victim and has no other outward signs of significant injury; he/she may be triaged as a Green victim. Note -The START Triage system was developed by Newport Beach Fire Rescue and Hoag Hospital. The JumpSTART Triage system was developed by Dr. Lou Romig. BACK TO MAIN BACK TO SECTION 1 TABLE OF CONTENTS 1.7 Mass Casualty Incident  1.7 Mass Casualty Incident Revision Date: December 20, 2021 Complex MCI Command Structure Active Assailant/Tactical Environment MCI Command Structure BACK TO MAIN 1.7 Mass Casualty Incident BACK TO SECTION 1 TABLE OF CONTENTS  BACK TO MAIN Medical Emergencies TABLE OF CONTENTS Standing Orders - Section 2  2.1 General Information Revision Date: February 13, 2024 INFORMATION These EMS protocols have been developed for use of the City of Coral Springs and Parkland Fire Department. It is recognized that the EMS protocols cannot address every possible scenario and may require therapy not otherwise specified. Therefore, all frontline, personnel are given the authority to deviate from the ALS protocols as needed. Clear documentation of the deviation is required. Good judgment and the patient’s best interest must always be considered. The EMS provider may consult medical direction at any time if he/she deems necessary. The following will be general information that may apply to most patients. This information is for both adult and pediatric patients. BACK TO TABLE OF CONTENTS 2.1 General Information BACK TO SECTION 2  2.1 General Information Revision Date: February 13, 2024 MEDICATION ADMINISTRATION & MEDICATION ROUTES ADULT & PEDIATRIC Prior to administering any medication, inquire about medication allergies or adverse reactions to medications. A true allergy to a medication causes a rash, SOB, swelling of the tongue, face and/or throat Follow the 6 Rights of drug administration: Person Time Drug Route Dose Documentation INTRAOSSEOUS SITES (EZ-IO) An IO should be placed for patients with emergency medical conditions that require urgent vascular access in whom an IV is not immediately obtainable or is deemed to have insufficient access Adult: Proximal Humerus (only if the surgical neck can be palpated) Distal Femur Proximal Tibia Pediatric: Proximal Humerus (only if the surgical neck can be palpated) Distal Femur Proximal Tibia IM INJECTIONS All IM injections shall be administered in the lateral thigh, medication can be delivered through clothing. Adults: 21-23 gauge 1.5 inch needle 4mL maximum per site Pediatric: 23 gauge 1 inch needle 1mL maximum per site If > 1mL needs to be administered, split the dose between both thighs MUCOSAL ATOMIZATION DEVICE (MAD) The following medications can be administered via the MAD. Versed Fentanyl Glucagon Ketamine Desired dose: 0.3mL - 0.5mL per nostril, Max 1mL per nostril Narcan BACK TO TABLE OF CONTENTS 2.1 General Information BACK TO SECTION 2  2.1 General Information Revision Date: February 13, 2024 PEDIATRIC Patients who have not reached puberty are considered pediatric patients and shall be treated under the pediatric guideline section of these protocols Patients who have reached puberty shall be treated as an adult IO is the preferred method of vascular access during pediatric cardiac arrest PUBERTY Female puberty is defined as breast development. Male puberty is defined as underarm, chest or facial hair. THE HANDTEVY SYSTEM The Handtevy system shall be utilized in the resuscitation and treatment of all pediatric patients. The child’s age should be used as the primary reference point for determining the appropriate patient care. If the child appears shorter or taller than stated age or if the age is unknown use the Handtevy system length based tape Refer to the Handtevy system for the following: Medication Dosages/Infusions Equipment Electrical Therapy Vital Signs PEDIATRIC AGE CLASSIFICATIONS Neonates: Birth to 1 month Infants: 1 month to 1 year Children: 1 year to puberty PEDIATRIC TRANSPORT DECISIONS Trauma patient—15 years of age or younger Medical patient—17 years of age or younger BACK TO TABLE OF CONTENTS 2.1 General Information BACK TO SECTION 2  2.2 Patient Assessment Revision Date: July 5, 2022 ADULT & PEDIATRIC MENTAL STATUS (AVPU) Alert: to person, place, time, and event (AAOX4) Patient with AMS consider possible causes: Verbal: responds only to verbal stimuli AEIOU-TIP Pain: responds only to painful stimuli Alcohol Unresponsive Epilepsy (Seizures) Insulin (Hyper-/Hypoglycemia) MENTAL STATUS (GCS) Overdose/Oxygenation Uremia (Kidney Failure) Trauma Infection (Sepsis) Psychiatric AIRWAY / BREATHING Assess Airway, if breathing is present without compromise, continue assessment If spontaneous breathing is present with compromise or patient is not breathing provide ventilatory support. Refer to Ventilatory Assistance Protocol CIRCULATION ADULT & PEDIATRIC Assess pulse (carotid, brachial or radial pulse) Assess capillary refill Assess skin (color, condition and temperature) Refer to the “Cardiac Arrest” algorithm for all patients found pulseless Refer to the “Bradycardia” protocol for pediatric patients found bradycardic with signs of poor perfusion and AMS BACK TO MAIN TABLE OF CONTENTS 2.2 Patient Assessment BACK TO SECTION 2  2.2 Patient Assessment Revision Date: July 5, 2022 PHYSICAL ASSESSMENT All patients shall receive a physical exam Physical exams include primary and secondary assessments When injuries or abnormalities are found, focused exam shall be conducted and refer to specific protocol VITAL SIGNS: All patients shall receive a minimum of 2 sets of vitals if time allows. Patients being cared for over an extended period of time should also have the appropriate number of vital sign assessments Pulse (rate, rhythm and quality) Respirations (rate and quality) Skin (color, temp, condition) Monitor Temperature Lung Sounds Pulse Oximetry Blood Pressure (capillary refill) Pupillary response EtCO2 Blood Glucose Level (BGL) Unstable patients shall receive vitals every 5 minutes Unstable can be defined as hypotension, chest pain, AMS and/or SOB. A manual blood pressure shall be taken to confirm any abnormal or significant changes of an automatic blood pressure cuff reading Blood pressure shall be checked before and after administration of a drug Hypotension for adults is defined as Systolic BP < 90 mm Hg ETC O2 - Monitoring Shall be utilized for the following patients: Patients requiring ventilatory support (e.g., BVM, ET tube, SGA, CPAP) Patients in respiratory distress Patients with Altered Mental Status Patients who have been sedated Patients who have received pain medication Seizure patients Suspected Sepsis Cardiac arrest GLUCOSE A BGL shall be documented for the following patients: History of diabetes Altered mental status General weakness Seizure Syncope/lightheadedness Dizziness Poisoning Stroke Cardiac arrest BACK TO MAIN TABLE OF CONTENTS 2.2 Patient Assessment BACK TO SECTION 2  2.2 Patient Assessment Revision Date: July 5, 2022 ECG MONITORING All ALS patients shall be continuously monitored in Lead II 12 lead ECG shall be performed on the following patients: Chest/arm/neck/jaw/upper back/shoulder/epigastric pain or discomfort Palpitations Syncope, lightheadedness, general weakness, or fatigue CHF, SOB, hypertension or hypotension Unexplained diaphoresis or nausea Any heart rate less than 50 or greater than 150 12 lead ECGs shall be repeated every 10 minutes and upon ROSC When transporting, leave cables connected until patient is turned over to the Emergency Department (ED) staff PATIENT HISTORY Obtain the following information: CHIEF COMPLAINT: Why did the person call 911? S.A.M.P.L.E. HISTORY (S.A.M.P.L.E) SIGNS & SYMPTOMS ALLERGIES MEDICATIONS: Prescribed, over the counter, or not prescribed to patient PAST MEDICAL HISTORY (patient’s and immediate family’s) LAST ORAL INTAKE EVENTS PRECEDING HISTORY OF THE PRESENT ILLNESS (O.P.Q.R.S.T.A) ONSET: Did the symptoms appear gradually or suddenly? PALLIATIVE: What makes the symptoms better? PROVOKE: What makes the symptoms worse? PREVIOUS: Previous similar episodes? QUALITY: (What kind of pain?) pressure, squeezing, aching, dull, etc. RADIATION: Does the pain or discomfort radiate? Where? SEVERITY OF PAIN: 1-10 scale (utilize “Faces” pain scale for pediatrics) TIME: What time did the symptoms begin? ASSOCIATED: What are the associated signs & symptoms? BACK TO MAIN TABLE OF CONTENTS 2.2 Patient Assessment BACK TO SECTION 2  2.3 Ventilatory Assistance Revision Date: February 13, 2024 INFORMATION If spontaneous breathing is present with compromise or not breathing maintain airway patency: ADULT & PEDIATRIC AIRWAY POSITIONING: Medical patient: Position patient with external auditory meatus (a.k.a. “The Earhole”) on the same external plane as the sternal notch Trauma patient with suspected spinal cord injury: Modified jaw thrust VENTILATORY SUPPORT Assist ventilations with a bag-valve mask (BVM) attached to supplemental oxygen at 15-25 lpm Suction as needed Apply and monitor pulse oximeter / ETCO2 VENTILATORY RATES ADULT PEDIATRIC Patients with a pulse 1 breath / 6 seconds 1 breath / 3 seconds Patients without a pulse 1 breath / 10 seconds 1 breath / 6 seconds Maintain EtCO2 between 35-45 mm Hg and SpO2 > 94% while continuously Patients with ICP/ Herniation monitoring BP If air exchange is inadequate and there is suspicion of foreign body airway obstruction (FBAO) follow FBAO protocol. If unconscious, insert OPA, NPA as needed. Consider supraglottic airway (SGA) device or ETT NASOPHARYNGEAL AIRWAY (NPA): Semi-conscious patients with an intact gag reflex shall insert NPA, unless contraindicated OROPHARYNGEAL AIRWAY (OPA): Unresponsive patients without a gag reflex shall insert OPA, unless contraindicated If unable to successfully place ETT , SGA or ventilate with BVM /NPA/OPA Perform cricothyrotomy Needle cricothyrotomy : age 12 years or younger Surgical cricothyrotomy: age 13 years or older ATTENTION In certain patients, excessive ventilation rates may be harmful. Overzealous positive pressure ventilation can impair venous return, cardiac output and cerebral perfusion Ultimately the patients SpO2 and EtCO2 should determine the ventilation rate for the patient (ideally EtCO2 should be 35-45 mm Hg). BACK TO TABLE OF CONTENTS 2.3 Ventilatory Assistance BACK TO SECTION 2  2.3 Ventilatory Assistance Revision Date: February 13, 2024 OXYGEN ADMINISTRATION DO NOT withhold Oxygen if the patient is dyspneic or hypoxic SpO2: Maintain SpO2 of 94% for all patients Exception: Maintain SpO2 of 90% for COPD & Asthma The following patients regardless of SpO2 shall receive 15 LPM via NRB: All 3rd trimester pregnancy trauma patients All head injury patients Decompression sickness Carbon Monoxide exposure Cyanide exposure WARNING DO NOT ATTEMPT TO AGGRESIVELY NORMALIZE CAPNOMETRY/ETCO2 READINGS IN THE FOLLOWING PATIENTS: Cardiac arrest pre/post ROSC Bronchospasm (i.e., asthma, COPD) High EtCO2 levels are acceptable and even desired in these patients FOREIGN BODY AIRWAY OBSTRUCTION: Apply abdominal thrusts on a conscious patient until unresponsive Unresponsive patient receives chest compressions INFANTS: Apply chest compressions and back blows If unable to relieve the FBAO, visualize it with a laryngoscope and extract the foreign body with Magill forceps If unable to extract FBAO or adequately ventilate, perform a surgical cricothyroidotomy (age > 13 y/o) or needle cricothyroidotomy on Pediatrics (age < 12 y/o) If air exchange is adequate with a partial airway obstruction, DO NOT interfere, instead encourage the patient to cough up the obstruction Attention IF SPONTANEOUS BREATHING IS NOT PRESENT AFTER REMOVAL OF FBAO; THERE IS FAILURE TO VENTILATE; FAILURE TO MAINTAIN AIRWAY PATENCY OR RAPID DETERIORATION OF CLINICAL PRESENTATION REFER TO: DELAYED SEQUENCE INTUBATION PROTOCOL BACK TO TABLE OF CONTENTS 2.3 Ventilatory Assistance BACK TO SECTION 2  2.4 Transport Destinations Revision Date: February 13, 2024 INFORMATION: Every effort shall be made to encode patient in