Altered Mental Status Protocol A5

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					                                Altered Mental Status Protocol

                                                    A5
Created: 31 July 2004

Revised: 15 November 2009



This protocol outlines the procedure for patients with an altered mental status (AMS) or lowered level of
consciousness. Special attention should be paid to an AMS patient’s airway and respirations; ALS should
be contacted immediately if there is any compromise or impending compromise of airway, breathing, or
circulation.



    1. Assess the patient according to initial assessment and medical or trauma assessment protocols.



    2. Ensure a patent airway. Initiate oxygen therapy according to oxygen administration protocol.
       Assist with ventilations by bag valve mask if respiratory effort is inadequate.



    3. Be prepared to suction airway throughout patient encounter.



    4. Assess for trauma to head, neck, or spine with significant mechanism of injury. If present,
       consider spinal immobilization according to spinal immobilization protocol. Document a
       Glasgow Coma Scale (GCS) score if patient has suffered traumatic head injury.



    5. Obtain patient history according to SAMPLE & OPQRST algorithms to the fullest extent possible
       given the patient’s mental status, and inspect patient for medical tags.



    6. Obtain a blood glucose level.



    7. If that patient’s blood glucose level is below 60 mg/dL, and the patient is able to follow
       instruction and able to swallow:

        a. Administer 25g oral glucose
       b. Initiate transport immediately



   8. If a blood glucose level is unable to be obtained in a patient with AMS and a history of diabetes
      mellitus:

       a. Administer 25g oral glucose if the patient is able to follow instruction and able to swallow

       b. Initiate transport immediately



   9. Continually reassess the patient and evaluate for improvement



   10. Transport immediately.




Approved by Medical Director                             Date
                        Cardiac Arrest (Non-Traumatic) Protocol

                                                   A7
Created: 31 July 2004

Revised: 20 October 2009



This protocol outlines treatment for patients in non-traumatic cardiac arrest. ALS should be dispatched
immediately in all cases.



    1. Follow initial assessment and medical assessment protocols for general guidelines on patient care.



    2. Open airway and check breathing for five to ten seconds. If respirations are inadequate of absent,
       deliver two rescue breaths.



    3. Determine circulatory status. If pulse is inadequate or absent, being CPR.



    4. Determine whether the arrest was witnessed.

        a) if witnessed  apply AED and analyze as soon as available.

        b) if unwitnessed with call-to-arrival interval greater than 4 to 5 minutes  perform five cycles of
        CPR (lasting approximately two minutes) and then apply the AED.



    5. Attach AED and analyze rhythm. Defibrillate if indicated.



    6. Perform one shock on scene, if indicated, before transport.



    7. If AED indicates "no shock advised," check for pulse and respirations. If absent, continue to
       perform CPR and transport immediately. Initiate basic airway procedures to include OPA or
       NPA. Ventilate via BVM.
   8. Notify receiving facility as soon as possible.



   9. Transport immediately.




Approved by Medical Director                           Date
                                  Trauma Assessment Protocol

                                                     B1
Created: 31 July 2004

Revised: 15 November 2009



This protocol outlines the basic assessment for a patient with known or suspected traumatic injuries.
Providers should complete all basic information and use advanced assessment skills as appropriate.



    1. Complete a scene size-up and determine if the scene is safe to approach. If the scene becomes
       unsafe at any time, withdraw.



    2. Determine and evaluate the mechanism of injury.



    3. Determine the number of patients and initiate MCI plan as appropriate.



    4. Complete initial assessment according to initial assessment protocol, with attention to airway,
       breathing, and circulation.



    5. Consider the need for spinal stabilization.



    6. Determine the patient’s level of consciousness by use of the AVPU scale

        a. A – Alert

        b. V – Responsive to verbal stimuli

        c. P – Responsive to painful stimuli

        d. U – Unresponsive



    7. In the case of traumatic injury to the head, neck, or spine, document the patient’s score on the
         Glasgow Coma Scale (GCS) according to the following criteria:
    a. Eye Opening

            4 – Spontaneous

            3 – To voice

            2 – To painful stimuli

            1 – None

    b. Verbal Response

            5 – Oriented

            4 – Confused

            3 – Inappropriate Words

            2 – Incomprehensible Words

            1 – None

    c. Motor Response

            6 – Obeys command

            5 –Localizes Pain

            4 – Withdraw from painful stimuli

            3 – Flexion in response to painful stimuli

            2 – Extenstion in response to painful stimuli

            1 – None



8. Assess vital signs



9. Identify patient priority and need for ALS care. Dispatch ALS, if necessary.



10. Complete an appropriate secondary physical exam (see below):

    a. Rapid Trauma Exam: for patients with multi-system trauma or single-system trauma with a
    high index of suspicion for serious MOI.
       b. Focused Physical Exam: for patients with isolated injuries resulting from low index of
       suspicion for serious MOI who have no critical criteria according to dispatching ALS protocols.



   11. Treat all life threatening injuries as found.



   12. Complete history of event and past medical history using SAMPLE & OPQRST.



   13. Treat all non-life threatening injuries as time allows.



   14. Transport immediately.




Approved by Medical Director                              Date
                                  Bleeding Control Protocol

                                              B3

Revised: 30 December 2009
Created: 8 August 2004

This protocol outlines the sequence of treatments to control bleeding wounds.

   1. Assess the patient according to Initial Assessment and Trauma Assessment protocols. If
       warranted by patient condition, immediately dispatch a DC Fire & EMS Advanced Life
       Support unit to the scene.

   2. Monitor and maintain a patent airway. Ensure adequate respirations, including
      supplementary oxygen therapy if indicated; assist respirations via BVM if indicated.

   3. Evaluate for and attempt control of any major bleeding immediately. Use the following
      steps to control major bleeding:
          a. Apply direct pressure
          b. Elevate wound above the level of the heart, if feasible
          c. Apply tourniquet 2 inches above the wound and tighten until bleeding stops. Mark
              the time of application around or on the tourniquet.

   4. If a puncture wound is found in the chest, stomach or on the back, take the following
      steps:
           a. Immediately apply direct pressure and cover wound with a gloved hand
           b. Place occlusive dressing over wound
           c. Tape on three sides
           d. Evaluate for lung sounds around the site of the wound in the case of chest, upper
              back or upper abdominal wounds

   5. If not already started, provide oxygen via non-rebreather mask or BVM as indicated.

   6. Evaluate all minor wounds after ensuring ABC's, completing assessment and treating all
      life-threatening emergencies.

   7. Bandage all wounds using proper BLS technique.




Approved by Medical Director                                              Date
                                                 Burns Protocol

                                                         B4
     Created: 30 July 2004

     Revised: 2 November 2009



     This protocol outlines treatment for patients with burns. Take special consideration of scene safety and
     transport decisions when dealing with burn patients.



         1. Follow initial assessment and trauma assessment protocols for general patient care guidelines.



         2. Call ALS for the following significant burn injuries:

             a) Partial thickness on greater than 10% of body surface
             b) Full thickness on greater than 2% of body surface
             c) Inhalation Injury
             d) Significant burns to face, hands, feet, or perineum
             e) Any other burn injury with compromise or impending compromise of airway, breathing, and
                circulation


         3. Pay close attention to airway and breathing considerations. Always be aware of possible
            compromise to airway and breathing caused by burns to the airway.



         4. Provide oxygen via NRB at 15 lpm. Assist respirations with BVM as necessary.



         5. Determine cause of burn:
             f) If thermal burn:
a.   Remove involved clothing which is not adhering to the patient.
b.   Remove jewelry and other constricting items.
c.   Apply dry sterile burn dressings to the affected areas.
             g) If chemical burn:
                     a. Remove clothing which is not adhering to the patient.
               b. Remove jewelry and other constricting items.


               c. Remove the chemical in a manner appropriate to the substance:


                         i.     If the substance is a dry powder, brush it off.


                        ii.      If the substance is an alkali or acid, irrigate the area with water or saline
                           for at least 10-15 minutes or until the patient’s pain is relieved.


               d. If the chemical is in the eye, remove any dry material and irrigate the eye with sterile
                  water throughout the period of prehospital care.


               e. Apply dry sterile dressings to the affected areas. Cool water or saline is of value to
                  reduce pain and the burning process if applied within 15 minutes of the burn. This
                  should not be applied to more than 10 percent of the body surface area at one time.
       h) If electrical burn:
               a. Monitor vitals and be prepared to use AED.
               b. Remove the clothing which is not adhering to the patient and any other constricting
                  items such as jewelry.
               c. Examine patient for both entrance and exit wounds.
               d. Apply only dry sterile burn dressings to the affected areas. Do not apply water or
                  saline to electrical burns.


   6. Determine the degree and extent of burns using the "rule of nines" when appropriate. Document
      findings in PCR.



   7. Keep the patient warm and guard against hypothermia.



   8. For significant burn injuries, contact Medical Control for decision regarding transport to trauma
      center or designated burn center.




Approved by Medical Director                              Date
          Helmet Removal Procedure for Spinal Immobilization
                                B11

Created: 13 December 2009

In traumatic injuries Wwhen rescuers need to take spinal precautions in traumatic injuries,
rescuers may remove the helmet if when it is compromising head stabilization or blocking access
to the patient’s airway. The type and position of the helmet dictate whether removal is
necessary.

As in all traumatic injuries, rRescuers should ascertain circulation, motor, and sensory status in
each extremity prior and after the immobilization, and as well as a detailed assessment of any
other injuries during the secondary survey.

For Non-Football Helmets:
Rescuers must remove a bicycle or motorcycle helmet prior to spinal immobilization to prevent
placing the neck in flexion.
       1. One rescuer should manually stabilize the head and neck (including the helmet) while
           a second rescuer removes any facemasks, chinstraps, or visors.
       2. The first rescuer should transfer manual spinal stabilization to the second rescuer,
           who will hold the sides of the head underneath the helmet and support. The second
           rescuer will support the head with pressure to the mandible and occipital region.
       3. The first rescuer should remove the helmet by spreading the sides and angling the
           helmet upwards. The second rescuer should prepare to increase support to the head
           once the helmet is no longer providing a base.
       4. The first rescuer should retake support for the head behind the head of the patient and
           maintain inline spinal stabilization.
       5. Rescuers should immediately apply the cervical collar and padding and maintain
           proper spinal stabilization..

For Football Helmets:
When worn in conjunction with properly fitted shoulder pads, fFootball helmets, when worn in
conjunction with properly fitted shoulder pads, will naturally keep maintain the cervical spine in
the neutral position. Therefore, the rescuers should only attempt to remove a football helmet if
the injury has dislodged the device and or the helmet impedes access to the patient’s airway.
If the removal of the helmet is not indicated and the patient’s spine must be immobilized,
rescuers should use rolled towels, blankets, and trauma pads and other devices to stabilize the
crevices between the head, neck, and shoulders. The facemask should be removed in this
situation.

Removal of the facemask
Rescuers should remove      Tthe facemask should be removed any timewhen they are
immobilizing the player is being immobilized and leaving the helmet and shoulder pads are
being left on the player. The athletic trainers carry the necessary tools to cut the facemask.
When removing the facemask on a football helmet, rescuers can minimize movement to the
cervical spine by cutting all four of the loops that secure the mask to the helmet and lifting the
mask off the patient rather than cutting two loops and laterally rotating the mask laterally. If
removal of the helmet is indicated, removing the facemask is not required.Removal of the helmet
will release the facemask as well, so rescuers do not need to remove the facemask first in this
scenario.

Removal of the football helmet
      1. One rescuer should manually stabilize the head and neck (including the helmet),
          while a second rescuer removes the facemask, ear pads, and chin straps. When
          removing the facemask on a football helmet, rescuers can minimize movement to the
          cervical spine by cutting all four of the loops that secure the mask to the helmet rather
          than cutting two loops and laterally rotating the mask. Rescuers should also deflate
          any internal air padding with assistance from athletic training staff.
      2. The first rescuer should transfer manual spinal stabilization to the second rescuer,
          who will hold the sides of the head underneath the helmet and place his or her
          forearms on the patient’s chest.

Removal of the shoulder pads
   Rescuers should remove the shoulder pads if they will be removing helmet will be removed
   for spinal immobilization, if multiple injuries require full access to the shoulder, or if the
   shoulder pads do not fit well and will cause further damage to the patient.
       1. Rescuers should first remove the jersey by cutting it along the midline and at the
           sleeves.
       2. Rescuers should then Ccut the straps that attach the shoulder pads to the torso and
           arms, and then cut the seam located above the sternum.
       23. Loosen and remove any accessories, such as neck rolls or collars, if not already
           completed during the helmet removal.
       34. Place additional lift support staff with hands underneath the sides of the patient,
           especially under the posterior thoracic region. All staff should lift the patient
           simultaneously.
       45. While the second rescuer holds the patient’s head from the thoracic region, the first
           rescuer should remove the helmet by applying slight traction upwards. Rescuers
           should not excessively spread apart the sides of the ear holes, as this maneuver
           functions tightens helmet pressure on the forehead. However, the sides of the
           helmet will have to be spread slightly to remove the helmet. As soon as the
           helmet has been removed, pull the shoulder pads apart and over the head until they
           are clear of the body.
       56. Slide a long spine board underneath the patient’s spine from the feet of the patient
           towards the head while the patient is being supported by the staff. Lower the patient
           onto the board..
       67. Apply a cervical collar and secure the patient to the spine board.




Approved by Medical Director                                Date
                               Behavioral Emergencies Protocol

                                                    E1
Created: 4 August 2004

Revised: 20 October 2009



This protocol outlines special considerations and procedures to be followed when a patient presents with
behavioral abnormalities and/or psychiatric problems. Management of such patients presents a serious
risk to emergency response personnel. All personnel should take extra precautions to ensure their own
safety.



    1. Continuously observe for indicators of dangerous behavior and for potentially dangerous
       situations.



    2. Summon DPS to on-campus scenes and MPD to off-campus scenes immediately.



    3. Assess the patient for signs of potentially dangerous or harmful actions:

            a. Verbal abuse of emergency personnel or others

            b. Violent actions against emergency personnel or others

            c. Planned or actual suicide attempts

            d. Threats against self or others

            e. Presence of weapons or materials that could potentially be used as weapons



    4. Assess the patient for any underlying traumatic or medical problems.



    5. Special Considerations:

            f.   Take all threats seriously
           g. Make every effort to keep at least one route of escape for providers from the patient. Do
              not allow the patient to corner or isolate individuals or keep providers away from exits
              and/or other emergency personnel

           h. Keep a safe distance from all potential weapons

           i.   Do not argue with patient

           j.   Remain calm, objective and accepting

           k. Make slow and deliberate movements; avoid sudden movements.



   6. Transport the patient with a DPS or MPD officer in the back of the ambulance. If the patient
      exhibits signs of agitation or violent behavior, request that law enforcement restrain the patient
      with handcuffs or whatever means deemed necessary per their discretion.




Approved by Medical Director                             Date
                              Do Not Resuscitate (DNR) Protocol
                                             E5

Revised: 28 December 2009
Created: 5 July 2006

This protocol is designed to address situations in which a patient or authorized decision-
maker/surrogate verbally declines resuscitative efforts, or when a "Do Not Resuscitate,"
“Comfort Care Order,” or similar written documentation (of any form) is provided to GERMS
personnel on the scene. A “Comfort Care Order” is a specific type of Do Not Resuscitate order
recognized by the government of the District of Columbia. The Emergency Medical Services
Non-Resuscitation Procedures Law of 2001 (D.C. Law 13-224) permits a patient to request a
written order from his or her physician that instructs healthcare providers to withhold
resuscitation efforts.

Resuscitative efforts include artificial ventilation and CPR.

   1. Upon arrival on scene, all patients should be evaluated per applicable GERMS protocols
      and a DC Fire & EMS Advanced Life Support unit should be dispatched if warranted by
      the patient’s condition.
   2. If the patient is alert and conversant and wishes to refuse treatment or transport, follow
      the Refusal of Service protocol.

   Comfort Care Orders
   3. The patient may possess a Comfort Care Order, which is a sequentially numbered form
      on security paper, as well as a metal Comfort Care Bracelet from his or her physician.
      The Comfort Care form must be filled out entirely with the signature and date from the
      patient (if not incapacitated) and the patient’s physician. The bracelet cannot be
      defaced, torn, or removed from the patient. Any of these activities would void the
      bracelet’s authority. If there is a reason to question whether the comfort care bracelet or
      necklace is intact or has been defaced, EMS personnel shall resuscitate. In addition, the
      patient or authorized decision-maker/surrogate would hold the ultimate authority to
      request GERMS personnel to withhold resuscitative efforts. An on-scene request from
      the patient or surrogate would override any previous order.
   4. Upon presentation of a Comfort Care Order (a form or bracelet), rescuers should initiate
      resuscitative efforts until the order can be validated.
   5. Ensure that the current emergency is related to the underlying terminal medical condition.
          a. Ex. Patient has a Comfort Care Order for cancer, but is choking on food. In this
              case the order does not apply.
   6. Provide non-resuscitative interventions as needed. These include, but are not limited to,
      clearing the airway, suctioning, oxygen administration through a non-rebreather mask,
      pain medication, and bleeding control.
   7. If not already completed, Ddispatch a DC Fire Advanced Life Support paramedic to the
      scene, and contact Medical Control immediately for confirmation of the order.
   8. Upon receiving approval from Medical Control, rescuers may cease further resuscitative
      efforts. Wait on-scene for the paramedic to arrive for further documentation.
   Do Not Resuscitate (DNR) Orders
   3. The patient may possess a do not resuscitate order, which must be completely filled out
      with the signature and date from the patient (if not incapacitated) and the patient’s
      physician. The bracelet cannot be defaced, torn, or removed from the patient. Any
      of these activities would void the bracelet’s request. If there is a reason to question
      whether the comfort care bracelet or necklace is intact or has been defaced, EMS
      personnel shall resuscitate.        In addition, the patient or authorized decision-
      maker/surrogate would hold the ultimate authority to request GERMS personnel to
      withhold resuscitative efforts. An on-scene request from the patient or surrogate would
      override any previous order.
   4. Upon presentation of a DNR, rescuers should initiate resuscitative efforts until the order
      can be validated.
   5. Ensure that the current emergency is related to the underlying terminal medical condition.
          a. Ex. Patient has a DNR for cancer, but is choking on food. In this case, the order
              does not apply.
   6. Provide interventions as needed. The DNR should have specific instructions pertaining
      to the types of permitted interventions.
   7. If not already completed, dDispatch a DC Fire Advanced Life Support paramedic to the
      scene, and contact Medical Control immediately for confirmation of the order.
   8. Upon receiving approval from Medical Control, rescuers may cease further efforts. Wait
      on-scene for the paramedic to arrive for further documentation.

Crews should notify the Duty Officer during or immediately after the call for further
documentation and obtain signatures from all appropriate medical authorities on scene.
                                          Aspirin Protocol
                                                 F6

Created: 13 December 2009

Aspirin (acetylsalicylic acid) has an anti-platelet effect that may reduce future heart attacks when given
immediately following the onset of cardiac symptoms. Aspirin should be given in conjunction with high
oxygen therapy and rapid transport. The crew should request DC FEMS Advanced Life Support and
provide advanced notification to the receiving facility for all patients with chest pain that is cardiac in
etiology.

    1. Uses: Aspirin is given per oral after receiving authorization from medical control

    2. Indications:
           a. Chest pain or discomfort indicative of a myocardial infarction or cardiac ischemia
           b. Medical control authorization

    3. Contraindications:
          a. Known hypersensitivity or allergy
          b. Arterial bleeding
          c. Patient taken aspirin within previous 24 hours

    4. Dosage:
          a. 324 mg / 4-81 mg baby aspirin, chewable

    5. Administration:
          a. Ensure that the patient meets criteria and obtain permission from Medical Control
          b. Instruct the patient to chew and swallow 4-81 mg baby aspirin tablets
          c. Record the time and dosage of administration

    6. Reassessment:
           d. Continuously assess the patient, paying particular attention to airway, breathing and
               circulation
           e. Assess for effectiveness, including improving chest discomfort
           f. Watch for side effects, including (but not limited to): gastritis, nausea, vomiting




Approved by Medical Director                              Date
                                  Advanced Life Support (ALS) Protocol

                                                    H4



Revised: 30 December 2009

Created: 29 January 1997



Advanced Life Support (ALS) should be dispatched for all unstable or potentially unstable patients.
Additionally, an ALS unit should be requested whenever it is believed that the patient may substantially
benefit from care at a level greater than the capabilities of BLS. EMS should always err on the side of
caution and dispatch ALS when they feel it is necessary, or may become necessary during the course of
assessment or transport.



1. If GERMS decides to request ALS, a member of the crew should contact the DC Fire EMS Liaison
   Officer (ELO) via cell phone or any other available mechanism at 202-373-3805. If this method is
   unsuccessful, GERMS should contact DC Fire Unified Communications at 202-673-3262. As an
   alternative, GERMS may contact the DPS dispatcher to make the request.


2. GERMS should ask for an estimated time of arrival of an ALS unit. If the ETA is deemed longer than
   the transport time to the receiving facility, GERMS should immediately initiate transport and request
   that ALS intercept en route.


3. If the patient is deemed to be unstable or potentially unstable, GERMS should contact Medical
   Control to report an incoming patient. Such contact should be made as soon as feasible following
   ALS dispatch.


4. If GERMS requests ALS, the crew may begin transport before ALS arrives. GERMS should notify the
   DC Fire EMS Liaison and request that ALS intercept en route. In the event that GERMS reaches the
   receiving facility prior to intercept with ALS, the DC Fire EMS Liaison should be contacted to cancel
   the ALS request.


5. Should any unit other than GERMS transport the patient, the GERMS crew must complete a full run
   report, including clear documentation of the number of the unit which transported the patient and
   the receiving facility.
6. If any unit other than GERMS transports the patient, the GERMS Duty Crew may send a GERMS EMT
   with the patient at the discretion of the crew officer and the transporting unit.


7. If other emergency units aside from GERMS (i.e. Engines, Rescue units, ALS of BLS units, Metropolitan
   Police) respond, their unit number(s) should be logged on the run report if at all possible.




The following is a sampling of conditions (although not inclusive) which would classify a patient as
unstable or potentially unstable:




        A. Any life threatening condition in the initial assessment, including (but not limited to):
           1. Occluded, compromised, or potentially compromised airway
           2. Inadequate or absent spontaneous breathing or ventilation
           3. Major bleeding
           4. Cardiac arrest
           5. Unstable vital signs
           6. Glasgow Coma Scale (GCS) less than or equal to 8
        B. The following conditions also classify a patient as unstable or potentially unstable (but not
           limited to these):
           General Conditions:

            1. Post cardiac arrest
            2. Chest pain
            3. Hypertension with BP systolic greater than 200, or diastolic greater than 100
            4. Hypotension with BP systolic less than 90
            Traumatic Conditions:

            5.    Unstable chest injuries (i.e. pneumothorax, flail chest)
            6.    Penetrating wounds to head, neck, chest, abdomen, pelvis, or groin
            7.    Major amputations or avulsions
            8.    Impaled objects
            9.    Two or more suspected proximal long bone fractures
            10.   Nervous system injury or trauma associated with posturing, lateralizing signs, paralysis,
                  or alteration of mental status
            11.   Burn victims deemed significant according to the Burn Protocol
            12.   Patients involved in motor vehicle collisions with an estimated impact speed greater
                  than 30 mph
            13.   Pedestrians/bicyclists/others hit by vehicles traveling at a speed greater than 10 mph
            14.   Patients thrown from moving vehicles
            15.   Patients involved in a “roll-over” motor vehicle collision
            16.   Passenger compartment intrusion greater than 15 inches
17. Death of another person in the same vehicle in a motor vehicle collision
18. Patients falling from heights estimated to be greater than 10 feet or more than 3 times
    the patient’s height
Obstetric/Gynecologic Conditions:

19. Pregnant or potentially pregnant patients with any of the following:
        a. Seizure(s)
        b. Continuous vaginal bleeding
        c. Signs of imminent delivery
        d. Delivery on scene
Other:

20. Any patient who does not clearly fit the above criteria, but is clinically assessed as being
    unstable or potentially unstable
                                     Mass Casualty Protocol

                                                H10

Revised: 30 December 2009
Created: 29 January 1997


Any medical emergency with less than 9 patients, which overwhelms the resources of a GERMS
crew, is deemed a Multiple Casualty Incident. Any incident with more than 9 patients is deemed
a Mass Casualty Incident and must be declared to the DC Fire & EMS Department by contacting
the EMS Liaison Officer and to the DC Hospital Emergency Notification Center at (877) 323-
4262.

Adequate numbers of personnel is often the greatest resource during an MCI. The following
protocol will facilitate the most efficient use of personnel and provide the most effective patient
care. Remember that the principal in MCI management remains doing the greatest good for the
greatest many.

   1. When the GERMS crew arrives on scene, the following procedures should be followed:

           a. Survey and evaluate the scene
           b. Request additional help from DC Fire & EMS as well as available GERMS
              personnel (based on the estimated number of patients determined in the scene
              size-up)
           c. Establish a treatment sector and a transport sector
           d. Initiate triage procedures using the START and JumpSTART triage algorithms
              outlined below.

   2. Triaging procedures are the responsibility of the highest ranking member of the duty
      crew, who will serve as the Incident Commander until a GERMS Crew Chief or DC Fire
      & EMS Chief assumes the role of Incident Commander. The Incident Commander
      assigns care of the patients, updates/changes the treatment priority of patients, and
      coordinates patient transport. The Incident Commander should perform the initial triage
      assessment, though the task may be divided among members of the duty crew at the
      discretion of the Incident Commander. During the initial phase of triage, providers
      should spend no more than 30 seconds with each patient.

   3. START Triage should be used for all adult patients, as follows:
        a. Walking wounded should be encouraged to congregate in a designated location
               under their own power and triaged in the GREEN (minor) category.
       b. Patients with no respiratory effort should be triaged in the BLACK (deceased)
          category following an attempt to open the airway.
       c. Patients with difficulty in respirations, perfusion or mental status as specified
          below should be triaged in the RED (immediate) category:
               i. Respirations >30/min
               ii. Perfusion – No radial pulse or capillary refill times >2 seconds
             iii. Mental Status – Unable to follow simple commands
       d. All patients who cannot walk, have respiratory effort, and do not meet criteria for
          the RED category should be triaged to the YELLOW (delayed) category.




4. JumpSTART Triage should be used for all pediatric patients (≤14 years old)

       a. Walking wounded should be encouraged to congregate in a designated location
          under their own power and triaged in the GREEN (minor) category.
b. Patients with no respiratory effort or peripheral pulse should be triaged in the
   BLACK (deceased) category.

c. Patients with difficulty in respirations, perfusion or mental status as specified
   below should be triaged in the RED (immediate) category.

        i. Respirations >45/min or <15/min

       ii. Perfusion – No peripheral pulse or capillary refill times >2 seconds

      iii. Mental Status – unresponsive or responsive to painful stimulus

d. Patients with a peripheral pulse but without respiratory effort should receive 5
   ventilations then categorized as RED (immediate) if respiratory effort resumes or
   BLACK (deceased) if apnea continues.

e. All patients who cannot walk, have respiratory effort, and do not meet criteria for
   the RED category should be triaged to the YELLOW (delayed) category.
   5. After the initial triage is complete, the first triage officer should then designate a
      treatment sector a safe distance from the incident, and clearly marked (preferably with
      signs that match the patient's triage designations). The triage officer should also mark a
      transport sector which allows for easy ambulance access to the treatment sector.

   6. The Incident Commander should then direct arriving EMS personnel to patients
      according to triage designation. The Incident Commander must ensure that the arriving
      crews complete the following:

           a. Move patients to the treatment sector in order of their priority (Red followed by
              Yellow followed by Green)

           b. Patients should be immobilized, if necessary, before being moved.

           c. Patients should be placed in rows according to their triage category. The treatment
              sector itself should be divided into three areas: Red, Yellow and Green.

           d. As soon as the number of personnel permits, the Incident Commander should
              assign a Treatment Officer to each of the three treatment areas (Red, Yellow and
              Green). Each Treatment Officer is then responsible for the ongoing triage and
              reassessment of each patient in his/her treatment sector.

   7. Until all patients are moved to the appropriate treatment sectors and placed under the care
      of the Treatment Officer, the Incident Commander and available EMS personnel must
      continually reassess patients. Remember that triage is ongoing process and that a
      patient's triage category may change as his/her condition deteriorates or improves.

   8. As units arrive that are able to transport patients, patients should be transported in order of
      their triage category.

   9. If the number of personnel permits, the first triage officer may find it necessary to appoint a
      transportation sector officer to direct ambulances and crews to the treatment sector.

   10. While transporting a patient, the driver or crew officer should notify the hospital (if it has not
       already been notified by the first triage officer) of the number of patients being transported,
       the nature of their injuries, and the estimated time to ED arrival.

Special Considerations:
    Remember that the initial time spent to properly organize an MCI will payoff in terms of
        more effective patient care.
    Adequate numbers of trained personnel remains the best resource in an MCI. Be cautious
        of personnel fatigue. It is better to request too much assistance up front, than to find that
        you do not have enough personnel during an MCI.
    Triage is a continuous process. Many patients' triage categories will change as their
        condition improves or deteriorates.
    The ultimate goal in an MCI is to transport each patient to definitive care as efficiently as
     possible.



Approved by Medical Director                                               Date
                                   Protocol Violations Protocol

                                                 H13

Revised: 30 December 2009
Created: 01 March 2004


This protocol is designed to address the proper procedure to follow when there has been a
violation of protocol by any GERMS member.

In the event of any act or failure to act (in practice or in judgment) involving patient care that is
not consistent with protocol, the crew officer must perform the following (in order):

   8. Notify Medical Control as soon as the violation is discovered, if it is discovered prior to
      arriving at Georgetown University Hospital (or other receiving facility).

   9. Monitor the patient’s condition closely for any changes during transport. Complete
      transfer of patient care and explain the protocol violation to the charge nurse and/or the
      attending physician.

   10. Before returning to service, the crew must immediately notify the Duty Officer and write
       an incident report. The crew must also meet with the Duty Officer to discuss the
       circumstances surrounding the incident. The Duty Officer should take any necessary
       actions before putting the crew back in service, including consultation with Medical
       Control and/or the GERMS Medical Director.

   11. After meeting with the crew and taking any necessary immediate action, at the discretion
       of the Duty Officer, he or she may write a separate incident report including, but not
       limited to: a statement of the circumstances surrounding the incident, a general time line
       of the incident, and an outline of any actions taken.

   12. The incident report(s) must immediately be forwarded to the GERMS Medical Director
       for review.

These steps must be followed regardless of whether or not the protocol error resulted in any
change of the patient's status or condition.

If any crew members disagree as to whether or not a violation occurred, the Duty Officer should
be called and consulted prior to formally reporting an incident. The Duty Officer will make the
final determination after consulting with online Medical Control, and/or the GERMS Medical
Director, as needed.




Approved by Medical Director                                                   Date
                                 BLS Transfer of Care Protocol

                                                H15

Revised: 30 December 2009
Created: 26 February 2007

In most situations, it is not necessary for the GERMS duty crew to transfer care to or from other
BLS-level providers. However, there may be some unusual instances that warrant this procedure.
This protocol outlines the protocol to be followed when this occurs.:

If transferring care to the GERMS duty crew:
     13. Establish the identity of the BLS providers and confirm that they wish to transfer full care
         and transport of the patient to the GERMS duty crew. Record the names of all providers
         and the unit number from which care originated.

   14. Obtain all the necessary information about the patient from the BLS providers on-scene
       (including any assessments and/or interventions already performed) and assume care of
       the patient. Treat the patient according to GERMS protocols and document the transfer
       of care in the patient care report.

As soon as possible upon transfer of patient care to ED staff, the GERMS crew must contact the
Duty Officer to inform him or her of the transfer of care. An incident report must be filed
afterwards.If transferring care to another BLS ambulance:
    1. Establish the identity of the BLS providers and confirm that they are able to accept care
       of the patient from the GERMS duty crew. If the GERMS duty crew is a transporting
       crew, the other BLS providers must have an ambulance on-scene before the transfer can
       occur.

   2. Contact the Duty Officer immediately to inform him or her of the situation and request
      permission to allow the transfer of care.

   3. Once approved by the Duty Officer, provide all the necessary information about the
      patient to the BLS providers on-scene (including any assessments and/or interventions
      already performed).

   4. Record the names of all providers and the unit number in the patient care report, and
      provide a copy of the patient care report to the BLS providers, if possible. An incident
      report must be filed afterwards.




Approved by Medical Director                                                 Date