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EMS Medical Oversight

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					The EMS System:
 An Introduction



Division of Prehospital Medicine
      Office of Prehospital Care
University of Rochester Medical Center
     Monroe-Livingston System
Overview
 Certification-- Required by NYS
 Review of System Structure
  – State Oversight
  – Regional Oversight
  – Medical Director Oversight
 Medical-legal concerns in medical control
 Hospital destinations
 Review of important protocols
 About the paperwork
 Exam (at noon)
                          2
Legal Statutes
                        FEDERAL STATUTE 93-154
                                   1973
Provided For Development Of Comprehensive Emergency Medical Services


                NEW YORK STATE PUBLIC HEALTH LAW
                                ARTICLE 30
                              1974, Rev. 1998
            Provides "Structure" & Dedicated Funding to EMS


             STATE EMERGENCY MEDICAL SERVICES CODE
                               PART 800
                               Rev. 1998
                  Governs How EMS Functions in NYS



                                    3
State EMS Structure
                     NYS DEPARTMENT OF HEALTH
                              Department Commissioner
                               Director, Bureau of EMS




NYS EMERGENCY ADVISORY                            NYS EMS COUNCIL
      CMTE (SEMAC)                                    (SEMSCO)
Member from Each Regional “REMAC”
                                              Member from Each Regional Council
 Provide Continuity, Standard of Care,
                                             Develop & Standardize EMS Within NYS
           & Input to DOH




                                         4
Regional EMS Structure
     Delegated Authority and Budget from NYS DOH



  MONROE-LIVINGSTON              MONROE-LIVINGSTON
   PROGRAM AGENCY               REGIONAL EMS COUNCIL
                                      (MLREMS)
  Office of Prehospital Care
Supports Regional EMS System   Coordinate EMS Services Within Region


                                 REGIONAL EMERGENCY
                                  MEDICAL ADVISORY
                                  COMMITTEE (REMAC)
                                         Medical Oversight
    TRAINING

                                 REMAC SUBCOMMITTEES
                                 (Protocol, RSI, SCT, QA, ALS)
                                  5
Regional EMS Medical Director
 Responsibilities
  – Serve as patient advocate
  – Set and ensure compliance with patient care
    standards
  – Develop and implement EMS protocols &
    standing orders
  – Ensure appropriate initial qualifications
  – Ensure appropriate ongoing qualifications


                        6
Regional EMS Medical Director
 Responsibilities
  – Develop and Implement QI
     •   Legal considerations
     •   Audits
     •   Trending
     •   Remediation
  – Promote EMS Research




                                7
Regional EMS Medical Director
 Responsibilities
  – Maintain liaison with medical community
  – Interact with federal, state, and local EMS
    authorities
  – Arrange for coordination of Specialized
    Medical Activity
  – Promulgate Public Education




                         8
Agency Medical Director
 Essential Qualifications
  – License to practice medicine
  – Familiarity with design of EMS systems
  – Experience in prehospital emergency care
  – Experience or training in medical direction
  – Active participation in management of acutely
    ill or injured



                        9
Medical-Legal Concerns
 Claims against EMS:
  – 1 per 24,000 – 27,371 patient encounter
  – 1 per 19,995 patient transport
  – 37% MVC, 36% pt handling, 12% clinical
 Good Samaritan Laws
 Negligence vs Gross Negligence
  – Willful and wanton misconduct
  – Reckless disregard of the consequences

                       10
Medical Legal Concerns
 Medical Direction Liability
  – Authorizes or Demands function above level
  – Willfully/Wantonly disregards protocols
  – Willfully/Wantonly disregards laws
  – Issues order clearly harmful, reckless, or
    negligent




                       11
Medical Legal Concerns
 High Risk Areas
  – Interfacility transports
      • Sending facility responsibility
      • COBRA/EMTALA
      • Adequate staffing




                            12
Medical Legal Concerns
 HIPAA
  – Medical command
       • Implied consent
       • Not a pre-existing relationship
  –   EMS report
  –   PCR- part of medical record
  –   QA reports- protected
  –   Complaints
  –   EMS follow up- ok for educational purposes


                             13
AED
 Public Access Defibrillation
 First responder
 EMT
 Paramedic




                     14
Medical Direction
 Indirect Medical Control (off-line)
   – Protocols/standing orders
   – Education
   – QA/QI
   – Systems supervision
   – Certification
   – Responsibility of regional medical director



                         15
Medical Direction
 Direct Medical Command (on-line)
  – Real-time communication between prehospital
    provider and medical control physician
  – Locally can only be provided by:
     • REMAC certified physicians
     • Course completion certificate




                          16
Appropriate Destinations
 Burn Center
  – URMC/Strong Memorial Hospital
 Cardiac Centers
  – Rochester General Hospital
  – Unity/Park Ridge Hospital
  – URMC/Strong Memorial Hospital
  – STEMI/cath lab notifications- computer



                       17
Appropriate Destinations
 Psychiatric Centers
   – Rochester General Hospital
   – Unity/Park Ridge Hospital
   – Unity/St. Mary’s Hospital
   – URMC/Strong Memorial Hospital

  – Medical Clearance
     • Can occur at any hospital
  – Medical Command Considerations

                           18
Appropriate Destinations
 Stroke Centers
   – Highland Hospital
   – Lakeside Hospital
   – Rochester General Hospital
   – Unity/Park Ridge Hospital
   – URMC/Strong Memorial Hospital




                     19
Appropriate Destinations
 Major Trauma
  – URMC/Strong Memorial Hospital
     • only trauma center in region
        – adult
        – pediatric
  – Time/Distance Factors– bypass others
     • Special Situations- the ONLY exceptions
        – Airway
        – Trauma/Arrest




                           20
Appropriate Destinations
 Trauma triage guidelines
  – Physiologic Criteria
  – Anatomic Criteria
  – Mechanism of Injury
  – Special Patient Characteristics
 EMS providers may call medical command
  for clarifications


                         21
EMS Certification Levels
 NYS
  – Paramedic (EMT-P)
  – Critical care (level 3)
  – Intermediate
  – Basic
 National Registry
  – Paramedic (NREMTP), Intermediate, Basic
 Other
  – Critical Care paramedic (CCEMTP or MICP)

                      22
Protocols
 Patient care practice guidelines
 Often include standing orders based on
  prehospital conditions
    i.e. ASA and nitroglycerin for chest pain
 Most allow certain procedures to be done
  and medications to be given before contact
  with Medical Control


                        23
Protocols
 Treatment                Communication
 Procedures               Special Policies
 Destination
 Transport mode
  – ALS vs. BLS
  – Air vs. Ground




                     24
Protocols
 Protocols developed by (REMAC) Protocol
  Subcommittee
 Approved by REMAC
 Approved by State Emergency Medical
  Advisory Council (SEMAC)




                   25
                                            7
 Protocols
 Protocols can be found:
  1. In the binder located by the Medical
     Command telephone
  2. www.mlrems.org


 As part of this self study, you are expected
    to read and understand all of the protocols



                        26
Protocols that frequently need
medical control input
 Apparent Life Threatening Event (ALTE)
 Behavioral Emergencies
 Chest Pain
 Pain Management
 Pulmonary Edema/CHF
 Rapid Sequence Intubation (RSI)
 Respiratory Distress/Bronchospasm


                    27
2.6 Apparent Life Threatening Event
(ALTE)
Criteria: An episode in a child <2 yrs which is frightening to
  the observer and is characterized by one or more of the
  following:
       • Apnea (central or obstructive)
       • Skin color change (cyanosis, erythema, pallor, plethora
       • Marked change in muscle tone
       • Choking or gagging not associated with feeding or foreign
         body aspiration
       • Seizure-like activity
 EMS required to call medical control if parents or
  caregivers refuse transport

                                28
2.7 Behavioral Emergencies
 Criteria
  – Potentially violent behavior
  – Regardless of underlying diagnosis
  – Continues to resist against restraints
  – Or unable to restrain
 Medical Control: Haloperidol 2-5 mg IV/IM
 Medical control authorization
  – Diazepam 5mg IV/IM OR Midazolam 2.5mg IV/IM.
    Repeat doses per medical control.
 MHA vs EMS restraint


                        29
2.9 Chest Pain/Threatened AMI
 ASA 324 mg PO
 NTG q5 min
   – BLS if SBP >120 mmHg
       • If patient has their own, max 3 doses
   – ALS - if SBP >90 mmHG HR>50<130
       • CC - max 3 doses, additional per Medical Control
       • P - max 6 doses, additional per Medical Control
 Right sided MI
   – SBP <90 mmHG, fluid challenge (500ml NS)
   – If signs/symptoms of shock – with Medical Control:
       • Dopamine 5-10mcg/kg/min, titrate to keep SBP >90 mmHg
 Morphine 5 mg if SBP >90 mmHg and inadequate
  response to NTG – Absolute on-line only


                                    30
2.23 Pain Management
Criteria
   – Pain >4/10 due to burns, amputation, or isolated extremity
     fracture/dislocation without evidence of head injury on standing
     order
   – Others as ordered by Medical Control
ALS- Morphine IM or slow IV/IO
   – Adult 5 mg (SBP >100mmHg)
   – Pediatric 0.1 mg/kg max 5 mg
Medical control required for additional doses
   – Adult 0.1 mg/kg every 10 minutes (with SBP >100, RR >8)
   – Pediatric 0.1 mg/kg (max 5 mg/dose) every 10 minutes
   – [EMS has narcan]


                                 31
2.25 Pulmonary Edema/CHF
 SBP > 90mmHg – NTG q3-5
 CPAP, if available
 Consider Intubation (RSI?):
   – Respiratory failure
   – Altered mental status
   – Inadequate ventilations
 Medical Control
   – Lasix 1mg/kg (max 100mg) with medical control
   – Dopamine 5-10 mcg/kg/min to keep SBP >90 mmHg
   – [note– no morphine]


                         32
2.26 Rapid Sequence Intubation
(RSI)
 Structure of program
   – On-line only, strict oversight, limited group
   – Dual paramedic requirement
   – No facilitated intubation
 Indications
   –   Control of airway in patients with potential or actual airway compromise
   –   Patient with decreased LOC (GCS 8 or less)
   –   Combativeness that threatens airway or spinal cord stability
   –   Smoke inhalation with tracheal/airway compromise
   –   Facilitation of therapeutic ventilations
 Contraindications
   –   Patient <16yrs or <40kg
   –   Obvious facial, neck and/or spinal deformity
   –   Full or significant partial thickness burns >48 hrs
   –   Degenerative neurological diseases
   –   End-Stage renal disease requiring dialysis (relative)


                                                33
RSI, continued
 Induction
   – Etomidate 0.3mg/kg IV/IO push


 Paralysis
   – Succinylcholine 1.5mg/kg IV/IO push
   – If not paralyzed after 3 min, repeat
     Succinylcholine at 0.5mg/kg



                        34
RSI, continued
 Post Intubation Management
   – Maintain Sedation
     • Etomidate 0.3mg/kg IV/IO push, no repeat OR
     • Midazolam 2.5mg IV/IO (repeat with Med control)
  – Maintain Analgesia –
     Use with caution if SBP <90mmHg
         – Morphine 5 mg slow IV/IO (repeat with Med control)
  – Maintain Paralysis
      May be used in conjunction with sedation and analgesia
        – Vecuronium 0.1mg/kg IV (Med control required)



                               35
2.28 Respiratory Distress
    /Bronchospasm
 Albuterol
  - BLS can assist if age 1-65 AND
      patient has their own     OR
      previously diagnosed asthma & agency trained
  - 5mg (2.5mg Peds) Nebulized
  - Contact Medical Control if pt has:
      CHF                 Angina
      Dysrhythmia         Previous AMI


                       36
Respiratory Distress, continued
 ALS Albuterol 5 mg (2.5 mg peds)
  CC-repeat x1, additional per medical control
  P - Max 30 mg/hr
 Albuterol may be given with 0.5 mg Ipratroprium
 Consider CPAP
 Medical control
   – EPI 1:1000 0.3 mg IM (0.01 mg/kg peds)
   – Mag Sulfate 2 gm (50 mg/kg peds max 2 gm) in 100 ml over 10
     minutes – contraindicated with suspected renal failure
   – Intubation if AMS, sats <90 with O2, persistent cyanosis
   – Repeat EPI 1:1000 0.3 mg (0.01 mg/kg peds) IM x2 q 15



                               37
Special Situations
 On Scene Medical Personnel
 Do Not Resuscitate
 Termination of Resuscitation
 Obvious Death




                       38
1.2 On-Scene Medical Personnel
 If personal MD on scene
   – Must write and sign for all orders for EMS provider on PCR
   – If MD refuses to sign, medical control must be called
 Bystander MD on scene
   – Can only assume responsibility after approval from medical
     control
   – Must write and sign for all orders for EMS provider on PCR
   – Accompany the patient to the hospital
 RN, PA, LPN, etc on scene
   – May assist with care under direction of EMT, cannot assume
     responsibility for patient




                                39
1.3 Do Not Resuscitate Orders
    (DNR)
 Conscious alert patients- their wishes are
  followed according to standard consent
 Unconscious patients
  – No DNR – begin standard treatment
  – Valid DNR - check pulse
     • If pulse present – provide comfort measures (O2,
       suctioning, and transport as requested by patient,
       family, family MD).
     • If no pulse present – call local police
     • Valid: NYS EMS DNR, MOLST, NH record
                           40
1.4 Termination of Resuscitation
 Criteria (must meet ALL)
  – 18 yrs old or older
  – Non-traumatic, non hypothermic
  – Cardiac arrest protocols for >25 min
      • ETT or advanced alternate airway, IV/IO, CPR, meds
   – No return of perfusing rhythm during the 25 minutes
   – Asystole in 3 leads, ventricular standstill or pulseless
     idioventricular rhythm with rate <10
   – Patient not in a public place
   – Appropriate emotional support to family etc is available
     if needed


                              41
Termination, continued
 Transport & code is required if:
  – Patient does not meet ALL criteria
  – If family or patient’s physician (if contacted)
    disagree with termination
  – Patient has already been moved to an
    ambulance




                         42
1.5 Obvious Death
 Criteria
  – Body decomposition
  – Rigor mortis with warm air temperature
  – Dependent lividity
  – Injury not compatible with life
     • Decapitation
     • Burned beyond recognition
     • Massive open or penetrating trauma to the head or
       chest with obvious organ destruction


                          43
Obvious Death
 All cases of hypothermia should receive full
  resuscitative efforts
 If bystander or first responder CPR or AED prior
  to EMS arrival and any of the obvious death
  criteria are met, providers must call medical
  control prior to stopping resuscitative efforts
 If patient was submerged for >1 hour in any water
  temperature medical control must be contacted
  prior to following obvious death protocol


                         44
MOLST
 Medical Orders for Life-Sustaining
  Treatment
 Approved as Pilot Project for Monroe
  County
 Standard Form vs MOLST
 Improved Compliance
 Easier Understanding
 Portable

                     45
Medical Command Sheet
 Documentation
  – Required by State
  – Legal Document
  – Voice Recording Back-up
  – QA




                      46
Medical Control Sheet
 Medic Unit              Meds Prior
 Time/Date               Meds Ordered
 Age
 Chief Complaint         Controlled substances


 Vital Signs             Print Name
 BG                      Signature
 Lung Sounds


                    47
Controlled Substances
 Record Keeping and Documentation
  – MD Name & Signature
  – Date, Time, Run ID
  – Patient Name
  – ALS Agency Name, AEMT Number & Name
  – PR Complaint & Presenting Problem
  – Controlled Substance
  – Dosage & Administration
  – Receiving Hospital
                   48
Medical Control Phone
 Identify yourself
 Caller should give you a brief description of
   – What their name is, and their level
   – Why they are calling (notification, orders, advice)
   – Pertinent History
   – Vital Signs
   – ETA
 Give orders, allow caller to repeat orders back.
 You may be asked to spell your last name for
  documentation on the PCR

                             49
Next Steps
 Review the protocols and other documents
 Take the Post-Test
 Send it to OPC
 If you pass, you will receive a certificate
 Call OPC at 463-2900 for questions


 Only certified medical control physicians, R2 and
  higher, may give medical control advice.
   – NO EXCEPTIONS

                          50

				
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