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R-06-11-09-11B1 - 11/9/2006RESOLUTION NO. R -06-11-09-11B1 WHEREAS, the City of Round Rock wishes to obtain a First Responder Organization License for Round Rock Fire Department; and WHEREAS, one of the requirements for a First Responder Organization License as set forth in the Texas Administrative Code, Title 25, § 157.14 is that a First Responder Organization must enter into a written affiliation agreement with the primary licensed EMS provider in the service area; and WHEREAS, Williamson County Emergency Medical Services is the primary licensed EMS provider in the City of Round Rock service area; and WHEREAS, an affiliation agreement has been negotiated between the City of Round Rock and Williamson County Emergency Medical Services; which the City Council wishes to approve, Now Therefore BE IT RESOLVED BY THE COUNCIL OF THE CITY OF ROUND ROCK, TEXAS, That the Mayor is hereby authorized and directed to execute on behalf of the City an affiliation agreement between Williamson County Emergency Medical Services and the City of Round Rock, a copy of same being attached hereto as Exhibit "A" and incorporated herein for all purposes. The City Council hereby finds and declares that written notice of the date, hour, place and subject of the meeting at which this Resolution was adopted was posted and that such meeting was open to the public as required by law at all times during which this Resolution and the subject matter hereof were discussed, considered and formally acted upon, all as required by the Open Meetings Act, Chapter 551, Texas Government Code, as amended. 0:\wdox\RESOLUTI\R61109B1.WPD/rmc RESOLVED this 9th day of November 2006. EST: .antzkvk L, Mayor City of Round Rock, Texas CHRISTINE R. MARTINEZ, City Secret 2 Williamson County Emergency Medical Services To Respect, Care and Serve This Agreement is entered into between Williamson County EMS ("EMS"), an EMS provider currently licensed by the Department of State Health Services (DSHS), the medical director for EMS, Dr. Stephen Benold, M.D. ("EMS Medical Director") and the Round Rock Fire Department ("FRO"), a first responder organization registered by the DSHS. The parties agree that this Agreement is intended to be pursuant to the provisions set forth in 25 Texas Administrative Code §157.14(c). This Agreement shall become effective upon the final signature of the parties and shall remain in effect until January 31, 2008. EMS ambulances will, when resources are available, respond to all calls and transport patients from within the Williamson County geographical area served by the FRO. FRO will, when resources are available, respond to all life threatening EMS medical assist calls within the geographical area served by the FRO. Patient treatment, protocols and medical equipment used by either the FRO or EMS will be done according to the standards defined in the EMS Scope of Care and approved by the EMS Medical Director, a copy of which is attached hereto as Exhibit A and incorporated herein for all purposes ("EMS Scope of Care"). Response Code Policy The FRO shall follow the response code policy established by the Round Rock Fire Department, a copy of which is attached hereto as Exhibit B and incorporated herein for all purposes ("FRO Response Policy"). Assessment of Care 1. FRO First to Arrive Upon arriving at a call, the FRO shall proceed to assess the patient's medical condition and begin on -scene patient care until EMS arrives in accordance with the standards set forth in the EMS Scope of Care. 2. EMS First to Arrive EMS shall proceed to assess the patient's medical condition and begin on -scene patient care in accordance with the standards set forth in the EMS Scope of Care. FRO shall provide assistance when needed and requested. Chain of Command On -scene chain of command will follow the National Incident Management System (NIMS) with, generally, the FRO providing the Incident Commander and EMS providing the EMS Sector Commander. Should the FRO provide the EMS Sector Commander, EMS shall provide assistance when needed and requested. Law Enforcement personnel may assume the Incident Commander role in the case of a crime scene. EXHIBIT P.O. Box 873 303 Martin Luther King Street Georgetown, Texas 78627 Main: (512) 943-1264 Fax: (512) 943-1269 www.wilco.org Ambulance Cancellation 1. The FRO will not cancel a responding EMS ambulance prior to its arrival on -scene. The FRO may advise EMS through its dispatch that there is no obvious injury or illness and the patient expresses he or she does not want EMS (e.g. did not call EMS and does not want them) or that the situation found does not require an emergency response by EMS. It shall be EMS' sole decision whether to continue to respond and to determine the appropriate level of response. Should EMS decide not to respond, EMS shall request the FRO to obtain a written refusal of medical care on a form approved by EMS Medical Director. Once an EMS unit arrives or medical care has been initiated by EMS, all decisions concerning patient transport and/or patient refusal of transport will be done by EMS only. Transport Decisions Transport and destination of transport decisions will be determined according to the standards defined in the current EMS Scope of Care. Air medical transport resources may be requested and cancelled as deemed appropriate by the responding FRO or EMS unit as outlined in the EMS Scope of Care. FRO will not accompany the patient to the transport destination unless requested by EMS or for education purposes and approved by EMS. EMS shall be in charge of patient treatment during transport. Should EMS request the FRO to accompany the patient, EMS shall ensure that the FRO is returned to their station. Where the FRO has accompanied for education purposes, EMS shall make every attempt to return the FRO to their station, although there may be delays. Patient Care Reports The FRO shall report all responses in accordance with procedures established by law or policies and procedures adopted by their Department. Patient Confidentiality The FRO will develop and comply with a patient confidentiality policy designed to secure all patient records and information at all times and that is in accordance with all laws. The FRO will also ensure the Organization and its members comply with the requirements of the Health Insurance Portability and Accountability Act (HIPAA). The FRO's patient confidentiality policy must also address a patient record release procedure. System Credentials and Quality Improvement • The FRO system -credentialed responders must be authorized by the department to fully participate in the Quality Improvement process as required by the Medical Director. This process includes participation in in-person call reviews, documentation reviews and continuing education. At a minimum, the FRO will meet all continuing education requirements outlined in the Competency Based Training program. Responders must fully participate to retain system credentialing. The FRO shall ensure all system -credentialed responders maintain current certification or licensure at the appropriate level (at or above the system credentialing level) and shall report to the Medical Director any disciplinary actions imposed on a credentialed responder if the disciplinary action is associated with the provision of medical care and negatively affects the credentialed responders' certification or licensure. The Williamson County EMS System Page 2 of 4 July 11, 2006 FRO Identification The FRO and EMS shall agree on the following: • response availability days of the week & times of the day • FRO's identification tag must meet the following requirements: o Must have responder's photo o Must have a credentialing date that coincides with the FRO's registration date o Indicates the responder's name, agency and state certification level o Indicates the responder's system credentialing level using the following color code. The color code is prominently placed on the ID tag as a border or background. • Red Border — responder credentialing at Paramedic level ■ Blue/Red Border —responders credentialing at the Advanced Provider level ■ Blue Border —responder credentialing at the EMT level • Green Border —responder credentialing at ECA level ■ Black Border — responder credentialing at FR CPR/AED level • No color Border — trained or untrained personnel who are not credentialed to provide any patient care • All responder's identification tags must be prominently displayed when interacting with the patient and when patient care is being rendered, except when wearing appropriate safety gear. Other Requirements In addition to the above, the FRO will also: • ensure a copy of the current FRO registration is located on all apparatus/vehicles responding to medical incidents. Copies of EMS Scope of Care and approved Medical Equipment list shall be located at either the FRO's administrative offices or also provided on the apparatus/vehicles responding to medical incidents. Supplies and Equipment EMS will not be responsible for supplying, maintaining, or retrieving FRO equipment or supplies, except that EMS will replace supplies used by the FRO, on a one for one basis provided the FRO does not bill the patient for these same items. Responsibility and Liability The FRO assumes any and all associated liability, if any, related to patient care rendered by FRO personnel. EMS shall not be responsible for care rendered, training, accidents, injuries, exposures or any liability involving FRO personnel, equipment, supplies or vehicles. EMS assumes any and all associated liability, if any, related to patient care rendered by EMS personnel. The FRO shall not be responsible for care rendered, training, accidents, injuries, exposures or any liability involving EMS personnel, equipment, supplies or vehicles. Party Disputes and Termination In the event any discrepancies arise between EMS and FRO personnel relating to patient care or transport, the respective Department Chiefs/Directors shall be advised. A meeting will be The Williamson County EMS System Page 3 of 4 July 11, 2006 arranged for all personnel involved with the Medical Director (clinical issues) and/or the EMS Director of Operations (operational issues). This will be done to prevent any problems from creating animosity between departments, thus adversely affecting patient care. Any party may cancel this Agreement upon sixty (60) days written notice. The Round Rock Fire Department will function under the following EMS Scope of Care (please check one). g4ersion A (all medications carried by first out response apparatus or responders) 0 Version B (no medications other than oxygen are carried by any apparatus or responders) City of Round Rock: Nyle Maxwell Mayor (print name) (signature) Williamson County EMS: Jeff Haves (title) (date) Director of Operations (print name) Williamson County EMS: Stephen Benold, M.D. (signature) (title) (date) Medical Director (print name) (signature) (title) (date) WILLIAMSON COUNTY SCOPE OF CARE INTRODUCTION CREDENTIAL LEVEL: ALL BLS RESPONDERS VERSION A EFFECTIVE APRIL 10, 2006 THROUGH JANUARY 31, 2008 The Williamson County EMS System Page 1 Scope of Care Intro To Respect, Care & Serve TABLE OF CONTENTS - BLS VER. A TOPIC PAGE NO. INTRODUCTION SECTION 1 SCOPE OF CARE PURPOSE 4 SCOPE OF CARE CONCEPT 5 WCEMS MEDICAL DIRECTOR 6 PERSONNEL COVERED 7 DO NOT RESUSCITATE 8 ON-LINE MEDICAL CONTROL 9 ADULT & PEDIATRIC DEFINITIONS 10 CANCELLATION OF RESPONDING UNITS 11 REFUSAL OF TRANSPORT OR TREATMENT 12 GENERAL USE OF THE SCOPE OF CARE DOCUMENT 13 BLS SCOPE OF CARE SECTION 15 ADVANCED BLS SKILLS 16 AIRWAY & VENTILATORY MANAGEMENT 17 ASSESSMENT 18 BLOOD GLUCOSE MANAGEMENT 19 CIRCULATORY SUPPORT 20 COMBATIVE PATIENT MANAGEMENT 21 NAUSEA & EMESIS MANAGEMENT 22 PAIN MANAGEMENT 23 SPECIFIC MEDICAL INTERVENTIONS 24 • ACUTE CORONARY SYNDROMES 24 • ALTERED MENTATION 24 • ALLERGIC REACTION / ANAPHYLAXIS 24 • BRADYCARDIA 24 • CONVULSIONS 25 • CPR - CARDIAC ARREST MEDICAL, ALL RHYTHMS 25 • CROUP / EPIGLOTTITIS 26 • HEAT EXHAUSTION 26 • HYPERTHERMIA 26 • HYPOTHERMIA 26 • INGESTION POISONING 26 • OBSTETRICAL EMERGENCIES 27 • ORGANOPHOSPHATE POISONING 27 • PULMONARY EDEMA- CARDIOGENIC 27 • REACTIVE AIRWAY DISEASE 27 TRANSPORT 28 • TRAUMA TRANSPORT 28 • HELICOPTER TRANSPORT 28 The Williamson County EMS System Page 2 Scope of Care Intro To Respect, Care & Serve TABLE OF CONTENTS - BLS VER. A (CONTINUED) TOPIC PAGE NO. TRAUMA MANAGEMENT, SPECIFIC INTERVENTIONS 29 • ABUSE - SUSPECTED 29 • BURNS 29 • CARDIAC ARREST - MULTI -SYSTEM TRAUMA 29 • CONDUCTED ENERGY WEAPONS (TASER®) 29 • CRYOTHERAPY 30 • CRUSH INJURY 30 • DEATH - OBVIOUS 30 • ELEVATION 30 • FACIAL TRAUMA AND EYE INJURIES 30 • HEAD INJURY WITH RESPIRATORY FAILURE/ARREST 31 • MUSCULOSKELETAL MOTION RESTRICTION (SPLINTING) 31 • SNAKEBITE 31 • SPINAL MOTION RESTRICTION 32 • WOUND CARE 33 REQUIRED EQUIPMENT LIST - BLS VER. A The Williamson County EMS System Page 3 Scope of Care Intro To Respect, Care & Serve SCOPE OF CARE PURPOSE The Williamson County Emergency Medical Services Scope of Care is designed to clearly define the scope of care expected by and for all persons within Williamson County. This scope of care is founded in excellence, diligently maintained, continuously reevaluated and enhanced. The Scope of Care is based on the most current, nationally accepted standards for out of hospital emergency medical care. To the extent possible, the therapies identified in this Scope of Care are based on valid, current clinical research and/or WCEMS clinical data. Successful implementation of this Scope of Care requires providers dedicated to quality patient care, appropriate medical equipment, administrative facilitation, continuing education, public support and medical direction. The Scope of Care defines the expected therapies for specific patients. The Scope of Care pre- defines the limits of practice for a provider under the authorization of the Medical Director. Any practice outside of these limits requires authorization at the time of performance by a licensed physician or the responder's designated Medical Control. The Williamson County EMS System Page 4 Scope of Care Intro To Respect, Care & Serve Scope of care defines what diagnostic tools and interventions providers may utilize. The Scope of Care defines the therapies identified as appropriate for specific patients. Discretion may be used to omit specific therapies if deemed inappropriate for a specific patient. Therapies beyond those listed in the Scope of Care require approval of other medical direction. The scope of care varies with 1) certification level, 2) credentialing status, and 3) departmental approval by the WCEMS Medical Director. Any reference to paramedic includes both certified and licensed paramedics (WCEMS Paramedics and First Responder Paramedics). Coordination of patient care under this scope of care must follow a specific medical chain of command. All on -scene credentialed providers are encouraged to actively participate in patient care. Final decisions regarding patient care are made as follows: First Responders without On -Scene System -Credentialed Paramedics(P) One person must be assigned to lead the patient care. All on -scene credentialed responders are expected to be actively involved in the care of the patient. Questions arising regarding medical decisions will ultimately be resolved by the first responder with the highest credentialing level until the credentialed Paramedic (P) arrives on scene. System -Credentialed Paramedics(P) On -Scene One person must be assigned to lead the patient care. Both Credentialed Paramedics (P) will both be actively involved in the care of the patient. Questions arising regarding medical decisions will ultimately be resolved by the Credentialed Paramedic (P) leading the patient care once he/she is on scene. Conflicts regarding treatment modalities should not be discussed in front of patients. If a conflict arises which might endanger the patient, the providers should discreetly discuss concerns to ensure patient safety. When disagreement exists, the above described process for resolution must be followed. Discussion among the providers involved regarding the conflict should occur after patient care is complete. Any concerns unresolved by discussion should be submitted in writing to the Medical Director within three business days for evaluation and resolution. If an in person discussion is required, the Clinical Practices Division will schedule a meeting with all involved providers. The first responder organization may include their chain of command in the conflict resolution, but this should not delay evaluation and resolution by the Medical Director. The Williamson County EMS System Page 5 Scope of Care Intro To Respect, Care & Serve s Medical direction for the Williamson County EMS System is provided by Stephen Benold, M.D.. His medical direction is provided through this scope of care, educational oversight, quality assurance, quality improvement, administrative cooperation and regular interaction with the care providers. It is recognized that his knowledge, dedication and license make it possible for the EMS system to function. By State of Texas Department of State Health Service Regulation and the Texas Medical Practice Act, all emergency medical care is performed under the auspices of the Medical Director. All privileges and rights are granted with the requirement of maintaining all State, National and System Standards, Certifications and Licenses, as appropriate. The Medical Director, or in his absence his appointed physician designee, has the authority at any time to limit, suspend or revoke System Credential to Practice. Stephen Benold, M.D. — Medical Director The Williamson County Emergency Medical Services System Valid from April 10, 2006 through January 31, 2008 The Williamson County EMS System Page 6 Scope of Care Intro To Respect, Care & Serve This scope of care is for use by Medical Director credentialed providers. These providers are allowed to practice under his license according to the Delegated Practice Act. This scope of care applies to the credentialing level of the on -scene provider. This authorization to practice applies while the provider is functioning as a responder with a Williamson County Registered First Responder Organization or Williamson County EMS. Personnel may not operate beyond his/her credentialing level regardless of his/her personal state certification level. Any WCEMS personnel responding with a first responder or fire agency must operate under that agency's policies unless requested to provide advanced life support (ALS) by an on -scene WCEMS paramedic. Any WCEMS paramedic, not responding for another agency, may operate under this scope of care while off-duty in the state of Texas. Any advanced procedures shall be performed only at the request of the on scene EMS agency. Williamson County First Responders may practice under the BLS Williamson County Scope of Care when responding as a responder for their first responder organization. Non -credentialed providers may be utilized under the guidance of Williamson County credentialed providers. Williamson County credentialed providers include the following: • Paramedics (P) — Providers meeting all credentialing requirements for the Paramedic level; May utilize all therapies included in the Scope of Care • First Responder Paramedic (FRP) — Providers who respond as part of a Williamson County registered first responder organization who have met all credentialing requirements for the First Responder Paramedic level; May utilize all therapies included in the Scope of Care identified by the FRP, FRAP, EMT -B, ECA, FR notations. • First Responder Advanced Provider (FRAP) — Providers who respond as part of a Williamson County registered first responder organization who have met all credentialing requirements for the First Responder Advanced Provider level; May utilize all therapies included in the Scope of Care identified by the FRAP, EMT -B, ECA, FR notations. • First Responder EMT -B (EMT -B) — Providers certified at the EMT, EMT -1 or EMT -P level AND meeting all credentialing requirements for the first responder BLS level; May utilize all therapies delegated to the EMT, ECA and FR credentialing levels • First Responder ECA (ECA) — Providers certified at the ECA level AND meeting all credentialing requirements for the first responder BLS level; May utilize all therapies delegated to the ECA or FR credentialing levels • First Responders that are CPR/AED trained (FR) — Providers who are not certified at any EMS level but who meet all credentialing requirements for the first responder level; May utilize all therapies delegated to the FR credentialing level The Williamson County EMS System Page 7 To Respect, Care & Serve Scope of Care Intro A DNR order will be honored for any patient presenting the Department of State Health Services (DSHS, formerly TDH) form that is complete or approved identification device. A photocopy or fax copy of a Texas DNR may be honored. A device without a DNR form will be honored only if it is an official Texas device. As well, an original and complete DNR form from any state will be honored, with or without a bracelet, necklace or other device. A device from another state cannot be honored without the original and complete DNR form from that state. A verbal order from the patient's personal physician on -scene will also be honored. Other documents, such as an advanced directive or living will, should be honored. However, only a valid DNR legally applies to pre -hospital providers. If the form is valid and the patient is eligible (e.g. cardiac or respiratory arrest without any exclusions listed below), Do Not: • begin CPR • transcutaneous cardiac pacing • defibrillation • advanced airway management • artificial ventilation DNR orders will NOT BE honored if there is any suspicion of suicide, homicide or other unnatural death, or if the patient is pregnant. It is always acceptable to contact medical control in the event the scene situation is unclear, or if conflict arises. Document the form or device number on the patient care record. The Williamson County EMS System Page 8 Scope of Care Intro To Respect, Care & Serve The complexity of medicine and the nature of EMS guarantee patient conditions that cannot be completely addressed by this scope of care. Therefore, authorization of on-line medical control may be obtained to implement the needed interventions. In those situations, contacting on-line medical control for direction is appropriate and encouraged. The on-line medical control for first response agencies is the responding Paramedic unit, unless a licensed physician is on -scene. On-line medical control for WCEMS Paramedics includes: • the patient's physician, • the emergency department's receiving physician, • the base hospital emergency department's physician, or • a licensed physician on -scene Interventions preceded by "SUGGEST" indicate the need to contact on-line medical control and receive authorization before proceeding with the intervention. Physician assistance on -scene (e.g. not the patient's physician) can be an asset; however, certain procedures must be followed for the safety of the patient. Appropriate identification should be requested if the physician is unknown to the providers. The on -scene physician must assume responsibility for the patient, accompany the patient to the hospital and sign the patient care documentation. The physician name, address, and contact number should be documented with the signature. If the on -scene physician refuses, this scope of care will be followed and the physician's name should be documented if possible. Base Hospital Region .' Hospital North Region Georgetown Hospital South Region Round Rock Medical Center East Region Johns Community Hospital West Region Round Rock Medical Center or Georgetown Hospital The Williamson County EMS System Page 9 Scope of Care Intro To Respect, Care & Serve ADULT & PEDIATRIC DEFINITIONS For this scope of care, adult and pediatric patients are defined as: Neonatal — birth to one month Infant - one month to one year of age Child - one year to onset of puberty (approximately 12-14 years of age) Adult — age greater than onset of puberty The Williamson County EMS System Page 10 Scope of Care Intro To Respect, Care & Serve Once EMS registered first responders and EMS ambulance units are dispatched, cancellation of units will occur only as follows: • First Responders o May be cancelled by any on -scene provider credentialed at the EMT -B level or greater following an initial patient/scene assessment • EMS Ambulances o May be cancelled by any on -scene provider credentialed at the EMT -B level or greater if • Authorized by the provider's organization, and • No patient exists or no obvious injury/illness exists, and • Patient does not want EMS or ambulance transport o May be cancelled by any on -scene provider credentialed at the FRP level or greater if: • Authorized by the provider's organization, and • Patient refuses transport or treatment, and • Patient does not want EMS or ambulance transport, and • Provider completes an approved patient care report for refusal of transport/treatment o May be cancelled by • On scene Law Enforcement • Communications (Dispatch) Center if Caller requests cancellation or new information indicates EMS not needed (e.g. patient left scene) • EMS Helicopters o May be cancelled by any on -scene provider credentialed at the EMT -B level or greater following an initial patient/scene assessment o May be cancelled by responding WCEMS Paramedic Unit The Williamson County EMS System Page 11 Scope of Care Intro To Respect, Care & Serve All patients will be offered treatment and transport. Williamson County EMS does not deny treatment or transport to any patient. Patients, who in the judgment of the paramedic crew should be evaluated by a physician, may occasionally refuse transport (against medical advice refusal — AMA refusal). In these cases, every effort must be made to obtain consent for transport. If the patient continues to refuse transport, the paramedic must: • Contact the patient's primary care physician if applicable • Contact on-line medical control at the region's base hospital When contact is made with either of the above physicians, the assessment findings and concerns should be quickly and clearly communicated. The Paramedic should speak to the physician concerning the need for EMS transport. This serves as a medical consult in an effort to identify any additional measures that might be used to obtain patient consent for transport/treatment. or If the patient or responsible party continues to refuse EMS transport, the paramedic must document the following: • Name of physician contacted and direction provided • Evaluation of the patient's capacity to refuse transport • Efforts to offer treatment and transportation • Other methods used to encourage EMS transport • Consequences of transport refusal were explained to the patient &/or family • Consequences of transport refusal were understood by the patient &/or family • Patient was advised EMS will return if patient later desires transport Any patient 17 years of age or younger may not consent to or refuse treatment, unless they meet the legal qualifications of an emancipated minor. All such consent to or refusal of treatment must be obtained from a parent, legal guardian (including law enforcement) or other adult family member. In the absence of such consent to or refusal of treatment, the patient should be treated under implied consent. The Williamson County EMS System Page 12 To Respect, Care & Serve Scope of Care Intro GENERAL USE OF THE SCOPE OF CARE DOCUMENT This Document applies to all responders while functioning as an emergency responder within one of the Williamson County Registered First Responder Organizations or the Williamson County EMS department. Every Scope of Care item (protocol) listed in this document outlines the preferred interventions to be performed by System Credentialed Responders. These interventions are listed in the preferred order of use. In some cases, the interventions are intended to be performed simultaneously. In other cases, one intervention must be completed before proceeding to the next. Each intervention is available at the responder's discretion unless noted otherwise. When the responder omits a listed intervention for which he/she is authorized to perform, the patient care record must reflect the rationale for the omission. Along the same line, the responder must document all requests for and authorizations for interventions not contained in this Scope of Care document as well as all SUGGEST interventions. Each intervention is accompanied by a notation designating the credentialing levels authorized to perform the intervention. The notations used are: All Responders, FR, ECA, EMT -B, FRAP, FRP, and P. Any intervention that is not accompanied by one of these notations is assumed to be authorized for all levels of responders. Each Responder Credentialing Level will be provided with the Scope of Care document containing the interventions for his/her level only. The document will not discuss interventions which are outside the scope or authorization for a specific responder credentialing level. The Williamson County EMS System Page 13 Scope of Care Intro To Respect, Care & Serve THIS PAGE INTENTIONALLY LEFT BLANK The Williamson County EMS System Page 14 To Respect, Care & Serve Scope of Care Intro BLS SCOPE OF CARE Credential Level: BLS Version A (FR, ECA, EMT -B) The Williamson County EMS System Page 15 BLS Version A Scope of Care To Respect, Care & Serve PHARMACEUTICAL INTERVENTIONS Medication usage will be done only according to the specific trauma or specific medical intervention protocols. • Prior to medication administration, all patients should be asked about allergies. • All medications should be checked for name, concentration, expiration date, discoloration, particulate matter and other signs of contamination. • It is critical that a patient only be given the indicated drug at the appropriate dosage, route, rate and interval. The following pharmaceutical interventions are approved for use: ECA, EMT -B • Glucose Gel • Oxygen EMT -B • Albuterol, nebulized • ASA, oral • Charcoal (Activated), oral • Epi -pen / Epi -pen Jr. Autoinjector • NTG, Sublingual These medications may be used as listed in the specific trauma and specific medicine intervention sections of this document. No Responder may utilize an intervention, pharmaceutical or medical device: • For which he/she is not trained, or • Which is beyond the scope of his/her WCEMS Medical Director recognized training, or • Which is not authorized by the WCEMS System Medical Director (not a part of the responder's credentialing level) The Williamson County EMS System Page 16 BLS Version A Scope of Care To Respect, Care & Serve 1 BLS (All Responders) Airway management will be based on rapid, accurate assessment of the patient, with interventions beginning as soon as the need is identified. (Refer to the Procedures section for detailed airway assessment and management) Initial airway management will always begin with any of the following basic life support measures as indicated by patient presentation and based on available equipment: • Head tilt/chin lift (if no C-spine precautions indicated or unable to use jaw thrust) • Jaw thrust (if C-spine precautions indicated) • Suction — oral pharyngeal and nare(s) • Oral pharyngeal airway (OPA) insertion • Nasal pharyngeal airway (NPA) insertion The following oxygenation and ventilation procedures may be utilized as indicated by patient presentation and based on available equipment: • Non-rebreather attached to 02 at >10 LPM (ECA, EMT -B) • Nasal cannula attached to 02 at 1-6 LPM (ECA, EMT -B) • Bag valve mask without oxygen (authorized responders may add oxygen) • Bag valve mask attached to 02 at 15-25 LPM (ECA, EMT -B) • Nebulizer attached to 02 at 6-10 LPM (EMT -B) The following assessment aids may also be used in addition to clinical signs: • Pulse oximetry (if equipment available) The following procedures may be used to assist ALS personnel if requested: • Cricoid pressure • Backward, Upward, Right Pressure (BURP) Ongoing assessments are needed to assure continued efficacy of the interventions. The Williamson County EMS System Page 17 BLS Version A Scope of Care To Respect, Care & Serve BLS (All Responders) All patients will be assessed initially, with continuous reassessments done until the patient is transferred to more definitive care. (The minimum standard for the assessment, which may be modified based on individual circumstances, is outlined in the Procedures reference section). When scene circumstances do not allow the responders to meet the following requirements, the PCR must document reasons for the omissions. • Vital Signs will be obtained and recorded as follows for all patients who are treated or transported (not required for patients who are not treated or not assessed): o approximately every 15 minutes during patient contact o after each medication or advanced therapy o approximately every 5 minutes during patient contact with a critically ill or injured patient • At a minimum, two (2) sets of Vital Signs will be obtained and will include: pulse rate, respiration rate, and blood pressure (auscultated or palpated) • As time permits and patient presentation suggests, vital signs should also include oxygen saturation, blood glucose level, and temperature. o Oxygen saturation is obtained in all patients with evidence of or a complaint of respiratory difficulty o Blood glucose level is obtained in all patients with altered mental status and when abnormal glucose level is suspected. The Williamson County EMS System Page 18 BLS Version A Scope of Care To Respect, Care & Serve BLS (ECA, EMT -B) A conscious, hypoglycemic patient or adult patient with a blood glucose level Tess than 90 mg/dl may be treated with 15-25 gm oral glucose gel as needed, ONLY if the patient has the ability to swallow and maintain his/her own airway without assistance The Williamson County EMS System Page 19 BLS Version A Scope of Care To Respect, Care & Serve Circulatory support will be based on a rapid, accurate assessment of the patient, with interventions beginning when the need is identified. BLS (All Responders) The following circulatory support interventions may be utilized to establish/maintain a patient's hemodynamic stability: • Positioning (as appropriate) o Trendelenburg position o Supine o Lateral recumbent, preferably left side (for non -trauma patients) o Tilting backboard for pregnant or obese patients, preferably left side • Adequate warmth based on patient comfort • CPR (Current American Heart Association or equivalent guidelines) • Defibrillation/AED for cardiac arrest patients only, when available The BLS responder may obtain a blood sample for glucose check. However, BLS responders are not authorized to collect or transfer blood (syringe and/or blood tube methods). The following procedures may be used to assist ALS personnel if requested and trained to do so: • Setup saline lock for IV/IO application • Setup IV/IO fluid bag(s) for infusion with / without extension set as specified • Setup IV/IO medication bag(s) for infusion (lidocaine, dopamine, magnesium) on micro tubing with / without extension set as specified. • Do not perform IV/IO venipuncture • Do not connect IV/IO medication bag or tubing to the patient's IV/IO • Do not draw up or measure medications, adjust IV/IO flow rate or adjust dosing Ongoing assessments are needed to assure continued efficacy of the interventions. The Williamson County EMS System Page 20 BLS Version A Scope of Care To Respect, Care & Serve At times it may be necessary to restrain combative patients in order to prevent them from further injuring themselves, bystanders or providers. The first step must be to identify the patient who poses a significant threat to himself/herself or others. BLS (All Responders) The following procedures MUST be followed when restraining combative patients: • Maintain a professional demeanor at all times. • If possible, request that a Law Enforcement Officer initiate the restraint • Check for and, if possible, provide treatment for underlying causes of combativeness including: o hypoglycemia o hypoxia o closed head injury o substance abuse • The preferred method of soft physical restraint by EMS involves use of triangular bandages. Handcuffs should only be used when the Law Enforcement Officer deems necessary. o The officer must remain with the patient at all times. o Do not allow patient's weight to rest on the handcuffs unless they are double locked o Confer with the LE officer to change to soft restraints (e.g. triangular bandages) o All restraints must be able to be removed quickly • Combative patients being transported MUST be restrained in the Supine position o The preferred position is with legs and arms extended. o If necessary to achieve initial restraint, the prone or semi-prone position may be used ONLY until control of the patient is established. o The prone or semi-prone position WILL NOT be used for an extended period of time or anytime during transport o No patient will be transported in the hogtied position. • Administer oxygen by non-rebreather mask to ALL patients restrained due to combativeness, delirium, or extreme excited state. o No other devices will be used to cover the patient's mouth • Monitor the oxygen saturation on all restrained patients The Williamson County EMS System Page 21 BLS Version A Scope of Care To Respect, Care & Serve NAUSEA & EMESIS MANAGEMENT BLS (ECA, EMT -B) High flow oxygen administration can be helpful in combating nausea on the BLS level. The Williamson County EMS System Page 22 To Respect, Care & Serve BLS Version A Scope of Care 1 Every reasonable effort should be made to control pain for the patient after life threatening injuries or illnesses are treated BLS (All Responders) The primary methods available for trauma include gentle patient packaging, careful movement, motion restriction, oxygen therapy and cryotherapy. These methods should be utilized at all times (if appropriate). The Williamson County EMS System Page 23 BLS Version A Scope of Care To Respect, Care 8 Serve ACUTE CORONARY SYNDROME (ADULT CARDIAC ISCHEMIA WITH / WITHOUT CHEST PAIN) BLS • Oxygen to maintain oxygen saturation greater than 90% (if no pulse ox available, use NRB mask) (ECA, EMT -B) • ASA 324 mg chew and swallow (EMT -B) • NTG tablet/spray, may repeat every 5 minutes to a total of 3 doses if: (EMT -B) o SBP>_ 90 mmHg and o No severe bradycardia or tachycardia, and o No erectile dysfunction medication use within 48 hours ALTERED MENTATION (ALL. RESPONDERS) • Assess for cause and treat per trauma or medical protocol ALLERGIC REACTION / ANAPHYLAXIS BLS (EMT -BI If a systemic reaction with signs/symptoms of hypotension, severe dyspnea or airway obstruction is present: • Epi Auto -injection pen if patient > 70 lbs (32 kg) o PEDI: Epi pediatric Auto -injection pen if pt 33 lbs -70 lbs (15 kg -32 kg) • Albuterol 1 unit dose nebulized if wheezing is present BRADYCARDIA (WITH SIGNS OF POOR PERFUSION) • PEDI (with a pulse causing cardiorespiratory compromise) BLS (ECA, EMT -B) o Oxygen by NRB mask or ventilate with Bag Mask • Continue if HR < 100 o If HR < 60 with continued poor perfusion, perform CPR The Williamson County EMS System Page 24 BLS Version A Scope of Care To Respect, Care & Serve CONVULSIONS BLS (ECA, EMT -8) • Protect patient from injury • Oxygen NRB mask or ventilate with Bag mask • Remove clothing to cool patient if febrile convulsions suspected CPR - CARDIAC ARREST MEDICAL (ALL ARREST RHYTHMS) BLS (All Responders) • Open airway and assess breathing • If not breathing give two breaths that make chest rise (no more than 2 attempts for adults) • Check pulse for up to 10 seconds. If no pulse, begin chest compressions o Adult 1- or 2 -rescuer use ratio of 30 compressions to 2 breaths o Infant & Child ■ 1 -rescuer use ratio of 30 compressions to 2 breaths • 2 -rescuer use ratio of 15 compressions to 2 breaths o Push Hard, Push Fast (100/min) and Allow complete chest recoil o Rotate person performing chest compressions every 2 minutes • If arrest witnessed by responder, apply AED or Defibrillator immediately and prepare to deliver a defibrillatory shock o If not witnessed by responder but two minutes of EFFECTIVE CPR provided prior to arrival of responder, may apply AED or Defibrillator • Perform CPR for approximately 2 minutes (5 cycles) before applying AED • AED (child > 1 year of age), if available o Follow AED prompts o Use Pediatric pads or child system if < 8 years of age ■ Use Adult pads if pediatric pads are not available • Continue until Paramedics take over patient care or patient begins to move o Adult - ventilate at 10-12 breaths per minute (one every 5 to 6 seconds) o Infant/Child — ventilate at 12-20 breaths per minute (one every 3 to 5 seconds) The Williamson County EMS System Page 25 BLS Version A Scope of Care To Respect, Care & Serve CROUP / EPIGLOTTITIS BLS (All Responders) • Interventions ONLY as tolerated • If altered LOC or central cyanosis, positive pressure ventilation with BVM using 2 person technique (override pop-off valve if pediatric patient) HEAT EXHAUSTION BLS (All Responders) • Water or 50% diluted sport drinks by mouth if no LOC change or nausea (if available) HYPERTHERMIA BLS (All Responders) • Cool patient rapidly if indicated HYPOTHERMIA BLS (ECA, EMT -B) • Handle patient gently • Remove wet clothing • Oral glucose gel (not injectable glucose), 15-25 gm if able to control airway INGESTION POISONING BLS (All Responders) • Contact Poison Control Center (PCC) 1-800-222-1222. PCC insists on one point of contact only. The individual who makes the original contact must inform PCC when a new provider takes over, in order to assure continuation of care • Charcoal (Activated) if requested by PCC and no forceful administration required up to 1 gm/kg by mouth to maximum of: (EMT -B) o Adult: 100 gm o Child: 50 gm o Infant: consult medical control The Williamson County EMS System Page 26 BLS Version A Scope of Care To Respect, Care & Serve OBSTETRICAL EMERGENCIES Abruptio Placenta & Placenta Previa BLS (EMT -B) • Treat for shock Postpartum Hemorrhage BLS (EMT -B) • Massage upper abdomen over uterus (fundal massage) • Have baby breast-feed if possible Prolapsed Umbilical Cord BLS (EMT -B) • Place the mother in the supine knee -chest position as tolerated • Provide oxygen by non-rebreather mask • Place a gloved hand into vagina and gently lift infant's head to relieve pressure on umbilical cord ORGANOPHOSPHATE POISONING (Pesticides — signs/symptoms: increased salivation, urination, defecation, gastric distress, emesis and tear production) BLS (All Responders) • Protect responders • Decontaminate patient PULMONARY EDEMA - CARDIOGENIC BLS (All Responders) • Place patient upright if possible or semi -fowlers • Positive Pressure Ventilation with BVM • SUGGEST Albuterol 1 unit dose by nebulizer (EMT -B) REACTIVE AIRWAY DISEASE BLS (EMT -B) • Albuterol 1 unit dose by nebulizer in the presence of wheezing The Williamson County EMS System Page 27 BLS Version A Scope of Care To Respect, Care & Serve TRAUMA TRANSPORT (ALL RESPONDERS) Definitive treatment of any critical trauma is only possible in the hospital environment. In recognition of this fact, transport is the most important intervention, after the ABCs are managed. For critical trauma patients: • Interventions done on -scene should focus on preparing the patient for transport. • Advanced procedures should be done enroute to the hospital unless delays which cannot be controlled are present There are two primary sources of transport, although others may be used if needed and available due to catastrophic conditions: Ground Transport and Helicopter Transport HELICOPTER TRANSPORT (ALL RESPONDERS) For any patient, air transport may be considered. The following guide the use of helicopter transport: • Reduction in transport time to a trauma center compared to ground transport for a seriously injured trauma patient • The patient meets criteria for transport to the closest trauma center and whose condition will likely need immediate intervention not available in the pre -hospital setting • The patient meets criteria for transport to the closest trauma center and whose condition is stable provided the patient's condition requires the shortest out of hospital time possible • When air transport is considered, the helicopter should be requested immediately based on initial call information • Air transport should be cancelled immediately during patient contact once patient assessment findings do not indicate its need • Air transport may be cancelled by an on -scene EMT -B, FRAP, FRP or Paramedic assuming medical command • Air transport should never delay patient arrival at the hospital; The transport provider should rarely wait at the scene for a helicopter when the critical trauma patient is ready for ground transport MAST helicopter may be requested, if no commercial service is available, with approval of the on -duty EMS Shift Commander. The Williamson County EMS System Page 28 BLS Version A Scope of Care To Respect, Care & Serve TRAUMA MANAGEMENT, SPECIFIC INTERVENTIONS ABUSE — SUSPECTED (ALL RESPONDERS) • Treat traumatic injuries as described previously • Report privately to next care provider responsible for patient • Report to Protective Services at (800) 252-5400 unless confident another agency is reporting. Failure to report is a misdemeanor BURNS (Au. RESPONDERS) • Do not remove clothing from burn area if embedded • Moist sterile dressing(s) if < 10% body surface area involved • Dry sterile dressing(s) if >_ 10% body surface area involved • Maintain body temperature (blankets, heaters, etc.) • Albuterol 0.083% unit dose by nebulizer if wheezing or evidence of reactive airway present (EMT -B) CARDIAC ARREST — MULTI -SYSTEM TRAUMA BLS (All Responders) • Establish pulselessness and apnea • Perform CPR for approximately 2 minutes unless multiple patient triage • AED (if equipment available) (Responder authorized to use device) • Continue CPR CONDUCTED ENERGY WEAPONS (TASER®) (ALL RESPONDERS) • Do not remove probes unless necessary for patient care o Secure the wires and probes to the patient's body or clothing using tape • Transport patient to the closest appropriate hospital for continued assessment and treatment as needed o Law enforcement policy may dictate that patient be transported if conducted energy weapon was used. WCEMS will honor this policy if patient is in custody of the law enforcement agency. The Williamson County EMS System Page 29 To Respect, Care & Serve BLS Version A Scope of Care TRAUMA MANAGEMENT, SPECIFIC INTERVENTIONS - CONT. CRYOTHERAPY (ALL RESPONDERS) Cold pack(s) may be applied over an isolated injured area. • Do not apply cold packs or ice directly on the skin's surface. • Limit Cryotherapy to 20 minutes per hour. • Reassess patient for hypothermia. Discontinue cryotherapy if hypothermia is suspected. CRUSH INJURY BLS (All Responders) • Coordinate patient care with extrication team leader • Provide supplemental oxygen by non-rebreather mask (if no increased risk of fire/explosion) • Maintain normal body temperature (prevent hypothermia) • Maintain supine position if tolerated by patient DEATH — OBVIOUS (EMT -B) (Decapitation, Decomposition, Rigor Mortis, Livor Mortis, Hemisection, Injuries incompatible with life, Mass Casualty Incident) • Do not initiate CPR • Contact law enforcement for JP ELEVATION (ALL RESPONDERS) Injured extremities (except in poisonous bites) should be elevated above the level of the heart if there is no risk of further injury. If elevating the extremity compromises spinal alignment in the spinal motion restricted patient, then do not elevate. FACIAL TRAUMA AND EYE INJURIES (ALL RESPONDERS) • Eye dressings should be bilateral • Hard cover protection should be used if available The Williamson County EMS System Page 30 BLS Version A Scope of Care To Respect, Care & Serve TRAUMA MANAGEMENT, SPECIFIC INTERVENTIONS—<CONT. HEAD INJURY WITH RESPIRATORY FAILURE/ARREST (Au. RESPONDERS) • If severe injury is suspected based upon altered mental status and/or other findings, Ventilate with BVM if possible o Adult —10-12 breaths per minute o Child and Infant — 12-20 breaths per minute MUSCULOSKELETAL MOTION RESTRICTION (SPLINTING) (ECA, EMT -B) All skeletal instability will be splinted as soon as possible, but only after the ABC interventions are complete • Distal circulation, motor function and sensation should be checked prior to splinting, after splinting, during reassessment and after moving the patient (such as to the stretcher, to the unit, etc.). . To achieve and maintain musculoskeletal motion restriction any of the following may be utilized as appropriate for the patient condition and situation: • Patient's body (i.e. tying the legs together on a backboard where the non -injured leg is secured to the backboard) • Padded Board splints • Pillow splints (i.e. In isolated ankle, foot or hand injuries • Preformed or vacuum splints • Traction splints — Traction used in closed or open midshaft femur fractures (provided the bone end is not protruding from the open wound) • Scoop (when spinal injury is not suspected) SNAKE BITE BLS (All Responders) • Extremity at or below level of heart • Motion restrict extremity with splint; Limit all patient activity • ID snake if possible • Coral snakes only - Apply mild pressure by wrapping elastic bandages (gauze) over the bite and the entire arm or leg. o Check distal pulses every 5 minutes The Williamson County EMS System Page 31 BLS Version A Scope of Care To Respect, Care & Serve TRAUMA MANAGEMENT, SPECIFIC INTERVENTIONS - CONT. SPINAL MOTION RESTRICTION (ALL RESPONDERS) Spinal motion restriction is necessary in any patient with the potential for spinal compromise. The need for spinal motion restriction is based on mechanism of injury and patient presentation. • Cervical motion restriction should be achieved manually immediately upon patient contact, if mechanism of injury and patient presentation indicate the necessity. • Manual cervical motion restriction should be maintained until mechanical spinal motion restriction is completed. Minimal spinal motion restriction will be achieved utilizing the following: • Long Backboard o C-collar — properly sized and placed o Cervical Immobilization Device (CID) —after patient is secured to backboard o Padding — As needed to restrict motion and provide patient comfort o Straps — preferred arrangement includes two over the shoulder crossed at the chest; two crossed at the hips; one across the thigh; and one across the tib-fib Other considerations for spinal motion restriction: • Do not secure the head of the patient prior to completely securing the torso. • Athletic Helmet and Shoulder Pads — Helmet and shoulder pads should not be removed from the injured athlete unless airway compromise is caused. If one of the two pieces of equipment is removed, then the other piece must also be removed. • Helmets without shoulder pads — Helmets used without shoulder pads should be removed. When available, the following spinal motion restriction devices may be utilized with discretion: • KED — (Kendrick Extrication Device) • Pediatric Devices o Infant and child safety seats may be utilized for patient packaging if the device has no visible damage and there is minimal concern for potential spinal injury. o Removal of a pediatric patient from such a device into a pediatric unit, KED or long backboard is always appropriate if the provider feels the risk in moving the patient is outweighed by the potential inability of the safety seat to restrict spinal motion The Williamson County EMS System Page 32 To Respect, Care & Serve BLS Version A Scope of Care TRAUMA MANAGEMENT, SPECIFIC INTERVENTIONS - CONT. WOUND CARE (ALL RESPONDERS) • Control severe hemorrhage • Wound cleansing with normal saline may be performed at the responder's discretion only if hemorrhage is minor or controlled (clean water is acceptable if normal saline is not available) o Irrigation — Rinse out major contaminants • Bandaging — Completely cover wounded area with sterile dressing and cover the dressing with an appropriate bandage The Williamson County EMS System Page 33 BLS Version A Scope of Care To Respect, Care & Serve Equipment & Supply Inventory The equipment and supplies listed on the following pages are authorized for use on all in-service Williamson County EMS First Responder Units and Vehicles. Stepheh Benold, M.D. — Medical Director Williamson County Emergency Medical Services Effective April 10, 2006 through January 31, 2008 The Williamson County EMS System To Respect, Care & Serve Equipment & Supply Inventory 1 Williamson County First Responder Organization Minimum Equipment and Supply Inventory The following is the minimum list of medications, supplies and specialized equipment, which are carried by Williamson County First Responder Organizations. Items that are carried on an apparatus can also be carried in a personal vehicle used to respond to an emergency incident. The medications on the above list may be supplied in concentrations or amounts other than those listed. Regardless of the particular manner in which medications are supplied, equivalent total amounts must be present It is the patient care provider's responsibility to be certain that correct dosages are administered to patients. Unless specified otherwise, generics and brand name products are considered interchangeable. All medications must be maintained at the manufactures recommended tempature range at all time. BVM, Adult BVM, Child 1 1 BVM, Infant 1 1 KY Jelly (Lubricant) 1 1 Nasal Cannula, Adult 1 1 Nebulizer Mask, Adult 1 1 Nebulizer Mask, Pedi 1 1 Non -Rebreather, Adult Non -Rebreather, Pedi 1 1 1 1 NPA, 20f 1 1 NPA, 24f 1 1 NPA, 28f NPA, 32f 1 1 1 1 OPA, 100mm OPA, 40mm 1 1 1 1 OPA, 60mm OPA, 80mm 1 1 1 1 Suction Device - Portable 1 1 fid'd• 1 Alcohol Prep Pads Lancets, springy loaded 2 2 2 AED 1 Adult AED Pads 2 BP Cuff, Adult BP Cuff, Child 1 1 BP Cuff, Infant 1 1 Glucometer 1 1 1 Glucometer Strips 1 bottle OB Kit 1 Penlights Pulse Ox Probe, Adult (Optional) 1 1 Pulse Ox Probe, Pedi ( Non -disposable) (Optional) 1 Pulse Oximeter (Optional) 1 Scissors Stethoscope 1 1 1 1 1 of 2 BLS Inventory - Version A Effective 02/01/04 Albuterol 0.083% solution 1 unit dose 1 unit dose Aspirin - 81 mg tablets 1 bottle 1 bottle Charcoal, Activated - 50 grams / 240 ml 100 GM 100 GM EpiPen, Adult 1 1 EpiPen, Jr 1 1 Glucose Gel - 15 - 25 grams 2 tubes 2 tubes Nitroglycerine spray / tabs - 0.4 mg / dose 1 bottle 1 bottle Oxygen (Portable) with regulator 1 1 The medications on the above list may be supplied in concentrations or amounts other than those listed. Regardless of the particular manner in which medications are supplied, equivalent total amounts must be present It is the patient care provider's responsibility to be certain that correct dosages are administered to patients. Unless specified otherwise, generics and brand name products are considered interchangeable. All medications must be maintained at the manufactures recommended tempature range at all time. BVM, Adult BVM, Child 1 1 BVM, Infant 1 1 KY Jelly (Lubricant) 1 1 Nasal Cannula, Adult 1 1 Nebulizer Mask, Adult 1 1 Nebulizer Mask, Pedi 1 1 Non -Rebreather, Adult Non -Rebreather, Pedi 1 1 1 1 NPA, 20f 1 1 NPA, 24f 1 1 NPA, 28f NPA, 32f 1 1 1 1 OPA, 100mm OPA, 40mm 1 1 1 1 OPA, 60mm OPA, 80mm 1 1 1 1 Suction Device - Portable 1 1 fid'd• 1 Alcohol Prep Pads Lancets, springy loaded 2 2 2 AED 1 Adult AED Pads 2 BP Cuff, Adult BP Cuff, Child 1 1 BP Cuff, Infant 1 1 Glucometer 1 1 1 Glucometer Strips 1 bottle OB Kit 1 Penlights Pulse Ox Probe, Adult (Optional) 1 1 Pulse Ox Probe, Pedi ( Non -disposable) (Optional) 1 Pulse Oximeter (Optional) 1 Scissors Stethoscope 1 1 1 1 1 of 2 BLS Inventory - Version A Effective 02/01/04 S.lint, 12-18" Cold Packs Williamson County First Responder Organization Minimum Equipment and Supply Inventory H1RoOkiar0`;a Backboard Stra . s, Dis. osable C -Collar, Pedi - Adult Sizes Head Blocks, Dis.. able Lon. Back Boards 4x4 Sterile or Non-sterile . auze Bandaids 1" Conformin. Banda.e, 4" Sterile S.lint, 30-42" Sterile Irri.ation Ta. - , 2" Trauma Pad, 10"X30" Trian.ular Banda .es Blankets, Dis•osable Biohazard ba.s Sco.e of Care en Wrench Face Mask, N95 medium & la .e Gloves L, Non -Latex Gloves M, Non -Latex Gloves S, Non -Latex Gloves XL, Non -Latex Gloves XXL, Non -Latex Pm if needed Hand Sanitizer Protective Glasses pates. us=Pri" 1 1 each size 1 1 ssonat V bkJe-' 10 5 1 3 2 2 2 1 roll 1 4 2 1 1 1 Appropriate size per responder 1 unit 1 .•rres .•nder 10 5 1 3 1 4 1 1 1 Appropriate size per responder 1 unit 1 .-rres.. der It is understood that first responders may arrive on the scene of a call without all of the required equipment. However, the expectation is that the required equipment will arrive on the scene during patient care with the appropriate vehicle. The goal of Williamson County First Responders and EMS is to provide expeditious patient care regardless of the constraints of equipment location. 2 of 2 BLS Inventory - Version A Effective 02/01/04 Title: Three Tier Response Policy Number: 205.18 Effective: July 21, 2006 Replaces: n/a Purpose: To establish a policy for interpreting various tiers of emergency response, understanding that all calls to the 911 center do not generate a wide scale emergency response. Scope: Includes all Round Rock Fire Department Suppression Personnel. Policy: To create specific operation guidelines for emergency responses. Definitions: This policy has the definitions described within the procedure Procedure Hot Response (Single or Multiple Unit Response) A hot response is a response by all responding units assigned to a call for those incidents that involve immediate and / or potential life threatening situations, where a delay in response may cause further harm to human life. This type of response requires: 1. All responding units will utilize all emergency warning devices (audible/visual) at all times. 2. Drivers will operate with due regard for the safety of all persons; maintain control of the vehicle at all times; obey all applicable motor vehicle laws for emergency vehicle operation set fourth by Texas Transportation Code, in addition to departmental and city policy. 3. All medical calls will be classified as a hot response, unless otherwise directed by the dispatch center, shift commander or company officer. Round Rock Fire Department Standard Operating Procedure Three Tier Response Policy 205.18 Effective: July 21, 2006 Page 2 of 5 Warm Response (Multiple Unit Response Only) A warm response is for incidents that could pose an immediate and / or potential life threatening situation. This type of response requires the first assigned unit to respond in the following manner: 1. Utilize all emergency warning devices (audible/visual) at all times. 2. Drivers will operate with due regard for the safety of all persons; maintain control of vehicle at all times; obey all applicable motor vehicle laws for emergency vehicle operation set fourth by Texas Transportation Code, in addition to departmental and city policy. 3. All other dispatched units shall respond cold (non -emergency) — during this response, audible/visual are not utilized unless the first assigned unit, shift commander or dispatcher receives further information that upgrades the response. All other dispatched units arriving on scene will assume level 1 staging and await instructions from the incident commander. Cold Response (Single or Multiple Unit Response) A cold response is a non emergency response, not requiring the use of audible/visual warning devices. This type of response requires that all assigned units respond in the following manner: 1. All dispatched units will respond non emergency for the duration of the response, unless other side directed by the first arriving unit, shift commander and or dispatcher. 2. Drivers will operate with due regard for the safety of all persons, maintain control of the vehicle at all times; obey all applicable motor vehicle laws for emergency vehicle operation set fourth by the Texas Transportation Code, in addition to departmental and city policy. 3. Later arriving units will assume level 1 staging and await instructions from the incident commander. Round Rock Fire Department Standard Operating Procedure Three Tier Response Policy 205.18 Effective: July 21, 2006 Page 3 of 5 Medical Call Response Medical calls will be responded to HOT or Cold depending on the information obtained from the caller and the status of available medic units. To further clarify, please use the information below in making your response decision. Keep in mind to always trust your gut instinct and if a call turns priority we can upgrade and most likely be around the corner. 1. Your station is assigned a medic unit and they are in house and can be notified prior to being dispatched by Williamson County. 2. You are aware of the location of the medic unit responding and discuss by Nextel or radio transmission the medic unit time of arrival. 3. Information obtained from the caller that indicates non priority. Fire Alarm Response Daytime All fire alarms received in the daytime (0700 hrs-1700 hrs) by the dispatch center will initiate a cold response by a single company. It is always appropriate to check by the incident location, even if the proper code has been approved by the alarm company. Fire Alarm Response Night All fire alarms received after normal business hours (1700 hrs — 0700 Hrs) by the dispatch center will initiate a warm response. If contact is made at the incident location, the response can be scaled back. It is always appropriate to check by the incident location, even if the proper code has been approved by the alarm company. * * *Fire Officers are to utilize this matrix as a guideline in making the appropriate response decision. The goal is to reduce response, when information is obtained that is considered non-priority. Fire Officers do have discretionary authority and may use it at the appropriate time. Round Rock Fire Department Standard Operating Procedure Three Tier Response Policy 205.18 Effective: July 21, 2006 Page 4 of 5 Authority From and after their effective date, procedures issued by the Round Rock Fire Department shall be in full force and effect and shall set forth all of the rights and duties of the employees of the Round Rock Fire Department with respect to the subject matter thereof, and shall replace any and all previous procedures or understanding, whether written or oral, relating thereto. Larry Hodge Fire Chief Round Rock Fire Department Standard Operating Procedure Three Tier Response Policy — 205.18 Effective: July 21, 2006 Page 5 of 5 ***Fire Officers are to use this matrix as a guideline in making the appropriate response decision. The goal is to reduce Response, when information is obtained that is considered non priority. Please use your discretion.*** HOT RESPONSE WARM RESPONSE COLD RESPONSE ACCIDENT MAJOR X ACCIDENT MINOR X ACCIDENT PIN IN X BOMB THREAT X CARBON MONOXIDE X DUMPSTER FIRE AWAY FROM STRUCTURE X DUMPSTER FIRE NEAR STRUCTURE X FIRE ALARM DAY X X FIRE ALARM NIGHT X FIRE OTHER X FIRE STRUCTURE X FIRE VEHICLE X FLUID SPILL X NATURAL GAS INSIDE X NATURAL GAS OUTSIDE X GRASS FIRE X HAZ MAT X LINE DOWN X X MEDICAL ASSIST X X ODOR INV INSIDE X ODOR INV OUTSIDE X FIRE ORDINANCE VIOLATION X PUBLIC SERVICE FD X SMOKE INV INSIDE X SMOKE INV OUTSIDE X SUBJECT DOWN X SUICIDE THREAT X VEHICLE UNLOCK W/CHILD X X HELICOPTER LANDING X ASSIST W/ EVACUATION X ASSIST W/ SEJSPICIOUS PACKAGE X HI LIFE WATER FLOW X WATER FLOW ALARM X CONTROLLED BURN X CONFINED FIRE MANHOLE X CHEMICAL ODOR INSIDE STRUCTURE X UNKNOWN MATERIAL X COMMERCIAL/INDUSTRIAL FIR}'. X APARTMENT FIRE X ***Fire Officers are to use this matrix as a guideline in making the appropriate response decision. The goal is to reduce Response, when information is obtained that is considered non priority. Please use your discretion.*** DATE: November 2, 2006 SUBJECT: City Council Meeting - November 9, 2006 ITEM: 11.B.1. Consider a resolution authorizing the Mayor to execute an affiliation agreement between Williamson County Emergency Medical Services (EMS) and the Round Rock Fire Department. Department: Fire Department Staff Person: Larry Hodge, Fire Chief Justification: Under provisions set forth in 25 Texas Administrative Code §157.14, a First Responder Organization: (1) Routinely responds to emergency situations, (2) utilizes employees, and/or members who are emergency medical service (EMS) certified by the Texas Department of State Health Services (department), (3) provide on -scene patient care, and (4) does not transport patients. Any organization which meet these descriptions, as does the Round Rock Fire Department, must comply with the requirements outlined in 25 Texas Administrative Code §157.14 including submission of an application for a license. One requirement as set outlined in 25 Texas Administrative Code §157.14 requires that a "written affiliation agreement with the primary licensed EMS provider..."(§157.14 (b)(1)(E)) be submitted with the First Responder Organization application for license. Funding: Cost: $70.00 Source of funds: General Funds Outside Resources: N/A Background Information: The previous license and agreement expired January 31, 2006. The agreement has been negotiated and has taken time to fully materialize. The current agreement and license application will expire January 31, 2008. Public Comment: N/A EXECUTED DOCUMENT FOLLOWS Williamson County Emergency Medical Services To Respect, Care and Serve This Agreement is entered into between Williamson County EMS ("EMS"), an EMS provider currently licensed by the Department of State Health Services (DSHS), the medical director for EMS. Dr. Stephen Benold, M.D. ("EMS Medical Director") and the Round Rock Fire Department ("FRO"), a first responder organization registered by the DSHS. The parties agree that this Agreement is intended to be pursuant to the provisions set forth in 25 Texas Administrative Code §157.14(c). This Agreement shall become effective upon the final signature of the parties and shall remain in effect until January 31, 2008. EMS ambulances will; when resources are available, respond to all calls and transport patients from within the Williamson County geographical area served by the FRO. FRO will, when resources are available, respond to all life threatening EMS medical assist calls within the geographical area served by the FRO. Patient treatment, protocols and medical equipment used by either the FRO or EMS will be done according to the standards defined in the EMS Scope of Care and approved by the EMS Medical Director, a copy of which is attached hereto as Exhibit A and incorporated herein for all purposes ("EMS Scope of Care"). Response Code Policy The FRO shall follow the response code policy established by the Round Rock Fire Department, a copy of which is attached hereto as Exhibit B and incorporated herein for all purposes ("FRO Response Policy"). Acsessrnent of Care 1. FRO First to Arrive Upon arriving at a call, the FRO shall proceed to assess the patient's medical condition and begin on -scene patient care until EMS arrives in accordance with the standards set forth in the EMS Scope of Care. 2. EMS First to Arrive EMS shall proceed to assess the patient's medical condition and begin on -scene patient care in accordance with the standards set forth in the EMS Scope of Care. FRO shall provide assistance when needed and requested. Chain of Command Or -scene chain of command will follow the National incident Management System (NIMS) with, cenerally, the FRO providing the incident Commander and EMS providing the EMS Sector Commander. Should the FRO provide the EMS Sector Commander, EMS shall provide assistance when needed and requested. Law Enforcement personnel may assume the Incident Commander role in the case of a crime scene. R -010 -/I -Dc? 1181 P.O. Box 873 303 Martin Luther King Street Georgetown, Texas 78627 Main: (512) 943-1264 Fax: (512) 943-1269 www.wilco.org Ambulance Cancellation 1. The FRO will not cancel a responding EMS ambulance prior to its arrival on -scene. The FRO may advise EMS through its dispatch that there is no obvious injury or illness and the patient expresses he or she does not want EMS (e.g. did not call EMS and does not want them) or that the situation found does not require an emergency response by EMS. It shall be EMS' sole decision whether to continue to respond and to determine the appropriate level of response. Should EMS decide not to respond, EMS shall request the FRO to obtain a written refusal of medical care on a form approved by EMS Medical Director. Once an EMS unit arrives or medical care has been initiated by EMS, all decisions concerning patient transport and/or patient refusal of transport will be done by EMS only. Transport Decisions Transport and destination of transport decisions will be determined according to the standards defined in the current EMS Scope of Care. Air medical transport resources may be requested and cancelled as deemed appropriate by the responding FRO or EMS unit as outlined in the EMS Scope of Care. FRO will not accompany the patient to the transport destination unless requested by EMS or for education purposes and approved by EMS. EMS shall be in charge of patient treatment during transport. Should EMS request the FRO to accompany the patient, EMS shall ensure that the FRO is returned to their station. Where the FRO has accompanied for education purposes, EMS shall make every attempt to return the FRO to their station, although there may be delays. Patient Care Reports The FRO shall report all responses in accordance with procedures established by law or policies and procedures adopted by their Department. Patient Confidentiality The FRO will develop and comply with a patient confidentiality policy designed to secure all patient records and information at all times and that is in accordance with all laws. The FRO will also ensure the Organization and its members comply with the requirements of the Health Insurance Portability and Accountability Act (HIPAA). The FRO's patient confidentiality policy must also address a patient record release procedure. System Credentials and Quality Improvement ■ The FRO system -credentialed responders must be authorized by the department to fully participate in the Quality Improvement process as required by the Medical Director. This process includes participation in in-person call reviews, documentation reviews and continuing education. At a minimum, the FRO will meet all continuing education requirements outlined in the Competency Based Training program. Responders must fully participate to retain system credentialing. The FRO shall ensure all system -credentialed responders maintain current certification or licensure at the appropriate level (at or above the system credentialing level) and shall report to the Medical Director any disciplinary actions imposed on a credentialed responder if the disciplinary action is associated with the provision of medical care and negatively affects the credentialed responders' certification or licensure. The Williamson County EMS System Page 2 of 4 July 11, 2006 FRO Identification The FRO and EMS shall agree on the following: • response availability days of the week & times of the day • FRO's identification tag must meet the following requirements: o Must have responder's photo o Must have a credentialing date that coincides with the FRO's registration date o Indicates the responder's name, agency and state certification level o Indicates the responder's system credentialing level using the following color code. The color code is prominently placed on the ID tag as a border or background. • Red Border — responder credentialing at Paramedic level • Blue/Red Border —responders credentialing at the Advanced Provider level • Blue Border —responder credentialing at the EMT level • Green Border —responder credentialing at ECA level • Black Border — responder credentialing at FR CPR/AED level • No color Border — trained or untrained personnel who are not credentialed to provide any patient care • All responder's identification tags must be prominently displayed when interacting with the patient and when patient care is being rendered, except when wearing appropriate safety gear. Other Requirements In addition to the above, the FRO will also: • ensure a copy of the current FRO registration is located on all apparatus/vehicles responding to medical incidents. Copies of EMS Scope of Care and approved Medical Equipment list shall be located at either the FRO's administrative offices or also provided on the apparatus/vehicles responding to medical incidents. Supplies and Equipment EMS will not be responsible for supplying, maintaining, or retrieving FRO equipment or supplies, except that EMS will replace supplies used by the FRO, on a one for one basis provided the FRO does not bill the patient for these same items. Responsibility and Liability The FRO assumes any and all associated liability, if any, related to patient care rendered by FRO personnel. EMS shall not be responsible for care rendered, training, accidents, injuries, exposures or any liability involving FRO personnel, equipment, supplies or vehicles. EMS assumes any and all associated liability, if any, related to patient care rendered by EMS personnel. The FRO shall not be responsible for care rendered, training, accidents, injuries, exposures or any liability involving EMS personnel, equipment, supplies or vehicles. Party Disputes and Termination In the event any discrepancies arise between EMS and FRO personnel relating to patient care or transport, the respective Department Chiefs/Directors shall be advised. A meeting will be The Williamson County EMS System Page 3 of 4 July 11, 2006 arranged for all personnel involved with the Medical Director (clinical issues) and/or the EMS Director of Operations (operational issues). This will be done to prevent any problems from creating animosity between departments, thus adversely affecting patient care. Any party may cancel this Agreement upon sixty (60) days written notice. The Round Rock Fire Department will function under the following EMS Scope of Care (please check one). errsion A (all medications carried by first out response apparatus or responders) 0 Version B (no medications other than oxygen are carried by any apparatus or responders) City of Round R Nyle Maxwell (print name) (signature) Williamson County EMS: Jeff Haves (print name) Williamson County E Stephen Benold, M. D: (print name) (signature) Manor I) '0C1`040 (title) (date) (date) 06 Medical Director (//4/06 (title) (date) Director of Operations (title) WILLIAMSON COUNTY SCOPE OF CARE INTRODUCTION CREDENTIAL LEVEL: ALL BLS RESPONDERS VERSION A EFFECTIVE APRIL 10, 2006 THROUGH JANUARY 31, 2008 The Williamson County EMS System Page 1 To Respect, Care & Serve Scope of Care Intro TABLE OF CONTENTS - BLS VER. A TOPIC INTRODUCTION SECTION PAGE NO. 1 SCOPE OF CARE PURPOSE 4 SCOPE OF CARE CONCEPT 5 WCEMS MEDICAL DIRECTOR 6 PERSONNEL COVERED 7 DO NOT RESUSCITATE 8 ON-LINE MEDICAL CONTROL 9 ADULT & PEDIATRIC DEFINITIONS 10 CANCELLATION OF RESPONDING UNITS 11 REFUSAL OF TRANSPORT OR TREATMENT 12 GENERAL USE OF THE SCOPE OF CARE DOCUMENT 13 BLS SCOPE OF CARE SECTION 15 ADVANCED BLS SKILLS 16 AIRWAY & VENTILATORY MANAGEMENT 17 ASSESSMENT 18 BLOOD GLUCOSE MANAGEMENT 19 20 21 22 23 24 ACUTE CORONARY SYNDROMES 24 ALTERED MENTATION 24 ALLERGIC REACTION / ANAPHYLAXIS 24 BRADYCARDIA 24 CONVULSIONS 25 CPR - CARDIAC ARREST MEDICAL, ALL RHYTHMS 25 CROUP / EPIGLOTTITIS 26 HEAT EXHAUSTION 26 HYPERTHERMIA 26 HYPOTHERMIA 26 INGESTION POISONING 26 OBSTETRICAL EMERGENCIES 27 ORGANOPHOSPHATE POISONING 27 PULMONARY EDEMA- CARDIOGENIC 27 REACTIVE AIRWAY DISEASE 27 TRANSPORT 28 • TRAUMA TRANSPORT 28 • HELICOPTER TRANSPORT 28 CIRCULATORY SUPPORT COMBATIVE PATIENT MANAGEMENT NAUSEA & EMESIS MANAGEMENT PAIN MANAGEMENT SPECIFIC MEDICAL INTERVENTIONS • • • • • • • • • • • • • • • The Williamson County EMS System Page 2 Scope of Care Intro To Respect, Care & Serve TABLE OF CONTENTS - BLS VER. A (CONTINUED TOPIC PAGE NO. TRAUMA MANAGEMENT, SPECIFIC INTERVENTIONS 29 • ABUSE - SUSPECTED 29 • BURNS 29 • CARDIAC ARREST - MULTI -SYSTEM TRAUMA 29 • CONDUCTED ENERGY WEAPONS (TASER®) 29 • CRYOTHERAPY 30 • CRUSH INJURY 30 • DEATH - OBVIOUS 30 • ELEVATION 30 • FACIAL TRAUMA AND EYE INJURIES 30 • HEAD INJURY WITH RESPIRATORY FAILURE/ARREST 31 • MUSCULOSKELETAL MOTION RESTRICTION (SPLINTING) 31 • SNAKEBITE 31 • SPINAL MOTION RESTRICTION 32 • WOUND CARE 33 REQUIRED EQUIPMENT LIST - BLS VER. A The Williamson County EMS System Page 3 To Respect, Care & Serve Scope of Care Intro The Williamson County Emergency Medical Services Scope of Care is designed to clearly define the scope of care expected by and for all persons within Williamson County. This scope of care is founded in excellence, diligently maintained, continuously reevaluated and enhanced. The Scope of Care is based on the most current, nationally accepted standards for out of hospital emergency medical care. To the extent possible, the therapies identified in this Scope of Care are based on valid, current clinical research and/or WCEMS clinical data. Successful implementation of this Scope of Care requires providers dedicated to quality patient care, appropriate medical equipment, administrative facilitation, continuing education, public support and medical direction. The Scope of Care defines the expected therapies for specific patients. The Scope of Care pre- defines the limits of practice for a provider under the authorization of the Medical Director. Any practice outside of these limits requires authorization at the time of performance by a licensed physician or the responder's designated Medical Control. The Williamson County EMS System Page 4 Scope of Care Intro To Respect, Care & Serve Scope of care defines what diagnostic tools and interventions providers may utilize. The Scope of Care defines the therapies identified as appropriate for specific patients. Discretion may be used to omit specific therapies if deemed inappropriate for a specific patient. Therapies beyond those listed in the Scope of Care require approval of other medical direction. The scope of care varies with 1) certification level, 2) credentialing status, and 3) departmental approval by the WCEMS Medical Director. Any reference to paramedic includes both certified and licensed paramedics (WCEMS Paramedics and First Responder Paramedics). Coordination of patient care under this scope of care must follow a specific medical chain of command. All on -scene credentialed providers are encouraged to actively participate in patient care. Final decisions regarding patient care are made as follows: First Responders without On -Scene System -Credentialed Paramedics(P) One person must be assigned to lead the patient care. All on -scene credentialed responders are expected to be actively involved in the care of the patient. Questions arising regarding medical decisions will ultimately be resolved by the first responder with the highest credentialing level until the credentialed Paramedic (P) arrives on scene. System -Credentialed Paramedics(P) On -Scene One person must be assigned to lead the patient care. Both Credentialed Paramedics (P) will both be actively involved in the care of the patient. Questions arising regarding medical decisions will ultimately be resolved by the Credentialed Paramedic (P) leading the patient care once he/she is on scene. Conflicts regarding treatment modalities should not be discussed in front of patients. If a conflict arises which might endanger the patient, the providers should discreetly discuss concerns to ensure patient safety. When disagreement exists, the above described process for resolution must be followed. Discussion among the providers involved regarding the conflict should occur after patient care is complete. Any concerns unresolved by discussion should be submitted in writing to the Medical Director within three business days for evaluation and resolution. If an in person discussion is required, the Clinical Practices Division will schedule a meeting with all involved providers. The first responder organization may include their chain of command in the conflict resolution, but this should not delay evaluation and resolution by the Medical Director. The Williamson County EMS System Page 5 To Respect, Care & Serve Scope of Care Intro WILLIAMSON COUNTY EMS MEDICAL DIRECTOR Medical direction for the Williamson County EMS System is provided by Stephen Benold, M.D.. His medical direction is provided through this scope of care, educational oversight, quality assurance, quality improvement, administrative cooperation and regular interaction with the care providers. It is recognized that his knowledge, dedication and license make it possible for the EMS system to function. By State of Texas Department of State Health Service Regulation and the Texas Medical Practice Act, all emergency medical care is performed under the auspices of the Medical Director. All privileges and rights are granted with the requirement of maintaining all State, National and System Standards, Certifications and Licenses, as appropriate. The Medical Director, or in his absence his appointed physician designee, has the authority at any time to limit, suspend or revoke System Credential to Practice. Stephen Benold, M.D. — Medical Director The Williamson County Emergency Medical Services System Valid from April 10, 2006 through January 31, 2008 The Williamson County EMS System Page 6 Scope of Care Intro To Respect, Care & Serve This scope of care is for use by Medical Director credentialed providers. These providers are allowed to practice under his license according to the Delegated Practice Act. This scope of care applies to the credentialing level of the on -scene provider. This authorization to practice applies while the provider is functioning as a responder with a Williamson County Registered First Responder Organization or Williamson County EMS. Personnel may not operate beyond his/her credentialing level regardless of his/her personal state certification level. Any WCEMS personnel responding with a first responder or fire agency must operate under that agency's policies unless requested to provide advanced life support (ALS) by an on -scene WCEMS paramedic. Any WCEMS paramedic, not responding for another agency, may operate under this scope of care while off-duty in the state of Texas. Any advanced procedures shall be performed only at the request of the on scene EMS agency. Williamson County First Responders may practice under the BLS Williamson County Scope of Care when responding as a responder for their first responder organization. Non -credentialed providers may be utilized under the guidance of Williamson County credentialed providers. Williamson County credentialed providers include the following: • Paramedics (P) — Providers meeting all credentialing requirements for the Paramedic level; May utilize all therapies included in the Scope of Care • First Responder Paramedic (FRP) — Providers who respond as part of a Williamson County registered first responder organization who have met all credentialing requirements for the First Responder Paramedic level; May utilize all therapies included in the Scope of Care identified by the FRP, FRAP, EMT -B, ECA, FR notations. • First Responder Advanced Provider (FRAP) — Providers who respond as part of a Williamson County registered first responder organization who have met all credentialing requirements for the First Responder Advanced Provider level; May utilize all therapies included in the Scope of Care identified by the FRAP, EMT -B, ECA, FR notations. • First Responder EMT -B (EMT -B) — Providers certified at the EMT, EMT -1 or EMT -P level AND meeting all credentialing requirements for the first responder BLS level; May utilize all therapies delegated to the EMT, ECA and FR credentialing levels • First Responder ECA (ECA) — Providers certified at the ECA level AND meeting all credentialing requirements for the first responder BLS level; May utilize all therapies delegated to the ECA or FR credentialing levels • First Responders that are CPR/AED trained (FR) — Providers who are not certified at any EMS level but who meet all credentialing requirements for the first responder level; May utilize all therapies delegated to the FR credentialing level The Williamson County EMS System Page 7 Scope of Care Intro To Respect, Care & Serve A DNR order will be honored for any patient presenting the Department of State Health Services (DSHS, formerly TDH) form that is complete or approved identification device. A photocopy or fax copy of a Texas DNR may be honored. A device without a DNR form will be honored only if it is an official Texas device. As well, an original and complete DNR form from any state will be honored, with or without a bracelet, necklace or other device. A device from another state cannot be honored without the original and complete DNR form from that state. A verbal order from the patient's personal physician on -scene will also be honored. Other documents, such as an advanced directive or living will, should be honored. However, only a valid DNR legally applies to pre -hospital providers. If the form is valid and the patient is eligible (e.g. cardiac or respiratory arrest without any exclusions listed below), Do Not: • begin CPR • transcutaneous cardiac pacing • defibrillation • advanced airway management • artificial ventilation DNR orders will NOT BE honored if there is any suspicion of suicide, homicide or other unnatural death, or if the patient is pregnant. It is always acceptable to contact medical control in the event the scene situation is unclear, or if conflict arises. Document the form or device number on the patient care record. The Williamson County EMS System Page 8 Scope of Care Intro To Respect, Care & Serve The complexity of medicine and the nature of EMS guarantee patient conditions that cannot be completely addressed by this scope of care. Therefore, authorization of on-line medical control may be obtained to implement the needed interventions. In those situations, contacting on-line medical control for direction is appropriate and encouraged. The on-line medical control for first response agencies is the responding Paramedic unit, unless a licensed physician is on -scene. On-line medical control for WCEMS Paramedics includes: • the patient's physician, • the emergency department's receiving physician, • the base hospital emergency department's physician, or • a licensed physician on -scene Interventions preceded by "SUGGEST" indicate the need to contact on-line medical control and receive authorization before proceeding with the intervention. Physician assistance on -scene (e.g. not the patient's physician) can be an asset; however, certain procedures must be followed for the safety of the patient. Appropriate identification should be requested if the physician is unknown to the providers. The on -scene physician must assume responsibility for the patient, accompany the patient to the hospital and sign the patient care documentation. The physician name, address, and contact number should be documented with the signature. If the on -scene physician refuses, this scope of care will be followed and the physician's name should be documented if possible. Base Hospital Region Hospital North Region Georgetown Hospital South Region Round Rock Medical Center East Region Johns Community Hospital West Region Round Rock Medical Center or Georgetown Hospital The Williamson County EMS System Page 9 Scope of Care Intro To Respect, Care & Serve For this scope of care, adult and pediatric patients are defined as: Neonatal — birth to one month Infant - one month to one year of age Child - one year to onset of puberty (approximately 12-14 years of age) Adult — age greater than onset of puberty The Williamson County EMS System Page 10 To Respect, Care & Serve Scope of Care Intro Once EMS registered first responders and EMS ambulance units are dispatched, cancellation of units will occur only as follows: • First Responders o May be cancelled by any on -scene provider credentialed at the EMT -B level or greater following an initial patient/scene assessment • EMS Ambulances o May be cancelled by any on -scene provider credentialed at the EMT -B level or greater if • Authorized by the provider's organization, and • No patient exists or no obvious injury/illness exists, and • Patient does not want EMS or ambulance transport o May be cancelled by any on -scene provider credentialed at the FRP level or greater if: • Authorized by the provider's organization, and • Patient refuses transport or treatment, and • Patient does not want EMS or ambulance transport, and • Provider completes an approved patient care report for refusal of transport/treatment o May be cancelled by • On scene Law Enforcement • Communications (Dispatch) Center if Caller requests cancellation or new information indicates EMS not needed (e.g. patient left scene) • EMS Helicopters o May be cancelled by any on -scene provider credentialed at the EMT -B level or greater following an initial patient/scene assessment o May be cancelled by responding WCEMS Paramedic Unit The Williamson County EMS System Page 11 To Respect, Care & Serve Scope of Care Intro REFUSAL OF TRANSPORT OR TREATMENT All patients will be offered treatment and transport. Williamson County EMS does not deny treatment or transport to any patient. Patients, who in the judgment of the paramedic crew should be evaluated by a physician, may occasionally refuse transport (against medical advice refusal — AMA refusal). In these cases, every effort must be made to obtain consent for transport. If the patient continues to refuse transport, the paramedic must: • Contact the patient's primary care physician if applicable or • Contact on-line medical control at the region's base hospital When contact is made with either of the above physicians, the assessment findings and concerns should be quickly and clearly communicated. The Paramedic should speak to the physician concerning the need for EMS transport. This serves as a medical consult in an effort to identify any additional measures that might be used to obtain patient consent for transport/treatment. If the patient or responsible party continues to refuse EMS transport, the paramedic must document the following: • Name of physician contacted and direction provided • Evaluation of the patient's capacity to refuse transport • Efforts to offer treatment and transportation • Other methods used to encourage EMS transport • Consequences of transport refusal were explained to the patient &/or family • Consequences of transport refusal were understood by the patient &/or family • Patient was advised EMS will return if patient later desires transport Any patient 17 years of age or younger may not consent to or refuse treatment, unless they meet the legal qualifications of an emancipated minor. All such consent to or refusal of treatment must be obtained from a parent, legal guardian (including law enforcement) or other adult family member. In the absence of such consent to or refusal of treatment, the patient should be treated under implied consent. The Williamson County EMS System Page 12 Scope of Care Intro To Respect, Care & Serve This Document applies to all responders while functioning as an emergency responder within one of the Williamson County Registered First Responder Organizations or the Williamson County EMS department. Every Scope of Care item (protocol) listed in this document outlines the preferred interventions to be performed by System Credentialed Responders. These interventions are listed in the preferred order of use. In some cases, the interventions are intended to be performed simultaneously. In other cases, one intervention must be completed before proceeding to the next. Each intervention is available at the responder's discretion unless noted otherwise. When the responder omits a listed intervention for which he/she is authorized to perform, the patient care record must reflect the rationale for the omission. Along the same line, the responder must document all requests for and authorizations for interventions not contained in this Scope of Care document as well as all SUGGEST interventions. Each intervention is accompanied by a notation designating the credentialing levels authorized to perform the intervention. The notations used are: All Responders, FR, ECA, EMT -B, FRAP, FRP, and P. Any intervention that is not accompanied by one of these notations is assumed to be authorized for all levels of responders. Each Responder Credentialing Level will be provided with the Scope of Care document containing the interventions for his/her level only. The document will not discuss interventions which are outside the scope or authorization for a specific responder credentialing level. The Williamson County EMS System Page 13 Scope of Care Intro To Respect, Care & Serve THIS PAGE INTENTIONALLY LEFT BLANK The Williamson County EMS System Page 14 Scope of Care Intro To Respect, Care & Serve BLS SCOPE OF CARE Credential Level: BLS Version A (FR, ECA, EMT -B) The Williamson County EMS System Page 15 To Respect, Care & Serve BLS Version A Scope of Care PHARMACEUTICAL INTERVENTIONS Medication usage will be done only according to the specific trauma or specific medical intervention protocols. • Prior to medication administration, all patients should be asked about allergies. • All medications should be checked for name, concentration, expiration date, discoloration, particulate matter and other signs of contamination. • It is critical that a patient only be given the indicated drug at the appropriate dosage, route, rate and interval. The following pharmaceutical interventions are approved for use: ECA, EMT -B • Glucose Gel • Oxygen EMT -B • Albuterol, nebulized • ASA, oral • Charcoal (Activated), oral • Epi -pen / Epi -pen Jr. Autoinjector • NTG, Sublingual These medications may be used as listed in the specific trauma and specific medicine intervention sections of this document. No Responder may utilize an intervention, pharmaceutical or medical device: • For which he/she is not trained, or • Which is beyond the scope of his/her WCEMS Medical Director recognized training, or • Which is not authorized by the WCEMS System Medical Director (not a part of the responder's credentialing level) The Williamson County EMS System Page 16 BLS Version A Scope of Care To Respect, Care & Serve 1 BLS (All Responders) Airway management will be based on rapid, accurate assessment of the patient, with interventions beginning as soon as the need is identified. (Refer to the Procedures section for detailed airway assessment and management) Initial airway management will always begin with any of the following basic life support measures as indicated by patient presentation and based on available equipment: • Head tilt/chin lift (if no C-spine precautions indicated or unable to use jaw thrust) • Jaw thrust (if C-spine precautions indicated) • Suction — oral pharyngeal and nare(s) • Oral pharyngeal airway (OPA) insertion • Nasal pharyngeal airway (NPA) insertion The following oxygenation and ventilation procedures may be utilized as indicated by patient presentation and based on available equipment: • Non-rebreather attached to 02 at >10 LPM (ECA, EMT -B) • Nasal cannula attached to 02 at 1-6 LPM (ECA, EMT -B) • Bag valve mask without oxygen (authorized responders may add oxygen) • Bag valve mask attached to 02 at 15-25 LPM (ECA, EMT -B) • Nebulizer attached to 02 at 6-10 LPM (EMT -B) The following assessment aids may also be used in addition to clinical signs: • Pulse oximetry (if equipment available) The following procedures may be used to assist ALS personnel if requested: • Cricoid pressure • Backward, Upward, Right Pressure (BURP) Ongoing assessments are needed to assure continued efficacy of the interventions. The Williamson County EMS System Page 17 To Respect, Care & Serve BLS Version A Scope of Care BLS (All Responders) All patients will be assessed initially, with continuous reassessments done until the patient is transferred to more definitive care. (The minimum standard for the assessment, which may be modified based on individual circumstances, is outlined in the Procedures reference section). When scene circumstances do not allow the responders to meet the following requirements, the PCR must document reasons for the omissions. • Vital Signs will be obtained and recorded as follows for all patients who are treated or transported (not required for patients who are not treated or not assessed): o approximately every 15 minutes during patient contact o after each medication or advanced therapy o approximately every 5 minutes during patient contact with a critically ill or injured patient • At a minimum, two (2) sets of Vital Signs will be obtained and will include: pulse rate, respiration rate, and blood pressure (auscultated or palpated) • As time permits and patient presentation suggests, vital signs should also include oxygen saturation, blood glucose level, and temperature. o Oxygen saturation is obtained in all patients with evidence of or a complaint of respiratory difficulty o Blood glucose level is obtained in all patients with altered mental status and when abnormal glucose level is suspected. The Williamson County EMS System Page 18 To Respect, Care & Serve BLS Version A Scope of Care BLOOD GLUCOSE MANAGEMENT BLS (ECA, EMT -B) A conscious, hypoglycemic patient or adult patient with a blood glucose level Tess than 90 mg/di may be treated with 15-25 gm oral glucose gel as needed, ONLY if the patient has the ability to swallow and maintain his/her own airway without assistance The Williamson County EMS System Page 19 BLS Version A Scope of Care To Respect, Care 8 Serve Circulatory support will be based on a rapid, accurate assessment of the patient, with interventions beginning when the need is identified. BLS (All Responders) The following circulatory support interventions may be utilized to establish/maintain a patient's hemodynamic stability: • Positioning (as appropriate) o Trendelenburg position o Supine o Lateral recumbent, preferably left side (for non -trauma patients) o Tilting backboard for pregnant or obese patients, preferably left side • Adequate warmth based on patient comfort • CPR (Current American Heart Association or equivalent guidelines) • Defibrillation/AED for cardiac arrest patients only, when available The BLS responder may obtain a blood sample for glucose check. However, BLS responders are not authorized to collect or transfer blood (syringe and/or blood tube methods). The following procedures may be used to assist ALS personnel if requested and trained to do so: • Setup saline lock for IV/IO application • Setup IV/IO fluid bag(s) for infusion with / without extension set as specified • Setup IV/IO medication bag(s) for infusion (lidocaine, dopamine, magnesium) on micro tubing with / without extension set as specified. • Do not perform IV/IO venipuncture • Do not connect IV/IO medication bag or tubing to the patient's IV/IO • Do not draw up or measure medications, adjust IV/IO flow rate or adjust dosing Ongoing assessments are needed to assure continued efficacy of the interventions. The Williamson County EMS System Page 20 BLS Version A Scope of Care To Respect, Care & Serve COMBATIVE PATIENT MANAGEMENT At times it may be necessary to restrain combative patients in order to prevent them from further injuring themselves, bystanders or providers. The first step must be to identify the patient who poses a significant threat to himself/herself or others. BLS (All Responders) The following procedures MUST be followed when restraining combative patients: • Maintain a professional demeanor at all times. • If possible, request that a Law Enforcement Officer initiate the restraint • Check for and, if possible, provide treatment for underlying causes of combativeness including: o hypoglycemia o hypoxia o closed head injury o substance abuse • The preferred method of soft physical restraint by EMS involves use of triangular bandages. Handcuffs should only be used when the Law Enforcement Officer deems necessary. o The officer must remain with the patient at all times. o Do not allow patient's weight to rest on the handcuffs unless they are double locked o Confer with the LE officer to change to soft restraints (e.g. triangular bandages) o All restraints must be able to be removed quickly • Combative patients being transported MUST be restrained in the Supine position o The preferred position is with legs and arms extended. o If necessary to achieve initial restraint, the prone or semi-prone position may be used ONLY until control of the patient is established. o The prone or semi-prone position WILL NOT be used for an extended period of time or anytime during transport o No patient will be transported in the hogtied position. • Administer oxygen by non-rebreather mask to ALL patients restrained due to combativeness, delirium, or extreme excited state. o No other devices will be used to cover the patient's mouth • Monitor the oxygen saturation on all restrained patients The Williamson County EMS System Page 21 BLS Version A Scope of Care To Respect, Care & Serve BLS (ECA, EMT -B) High flow oxygen administration can be helpful in combating nausea on the BLS level. The Williamson County EMS System Page 22 BLS Version A Scope of Care To Respect, Care & Serve Every reasonable effort should be made to control pain for the patient after life threatening injuries or illnesses are treated BLS (All Responders) The primary methods available for trauma include gentle patient packaging, careful movement, motion restriction, oxygen therapy and cryotherapy. These methods should be utilized at all times (if appropriate). The Williamson County EMS System Page 23 To Respect, Care & Serve BLS Version A Scope of Care ACUTE CORONARY SYNDROME (ADULT CARDIAC ISCHEMIA WITH / WITHOUT CHEST PAIN) BLS • Oxygen to maintain oxygen saturation greater than 90% (if no pulse ox available, use NRB mask) (ECA, EMT -B) • ASA 324 mg chew and swallow (EMT -B) • NTG tablet/spray, may repeat every 5 minutes to a total of 3 doses if: (EMT -B) o SBP >_ 90 mmHg and o No severe bradycardia or tachycardia, and o No erectile dysfunction medication use within 48 hours ALTERED MENTATION (ALL RESPONDERS) • Assess for cause and treat per trauma or medical protocol ALLERGIC REACTION / ANAPHYLAXIS BLS (EMT -B1 If a systemic reaction with signs/symptoms of hypotension, severe dyspnea or airway obstruction is present: • Epi Auto -injection pen if patient > 70 lbs (32 kg) o PEDI: Epi pediatric Auto -injection pen if pt 33 lbs -70 lbs (15 kg -32 kg) • Albuterol 1 unit dose nebulized if wheezing is present BRADYCARDIA (WITH SIGNS OF POOR PERFUSION) • PEDI (with a pulse causing cardiorespiratory compromise) BLS (ECA, EMT -B) o Oxygen by NRB mask or ventilate with Bag Mask • Continue if HR < 100 o If HR < 60 with continued poor perfusion, perform CPR The Williamson County EMS System Page 24 BLS Version A Scope of Care To Respect, Care & Serve CONVULSIONS BLS (ECA, EMT -B) • Protect patient from injury • Oxygen NRB mask or ventilate with Bag mask • Remove clothing to cool patient if febrile convulsions suspected CPR - CARDIAC ARREST MEDICAL (ALL ARREST RHYTHMS) BLS (All Responders) • Open airway and assess breathing • If not breathing give two breaths that make chest rise (no more than 2 attempts for adults) • Check pulse for up to 10 seconds. If no pulse, begin chest compressions o Adult 1- or 2 -rescuer use ratio of 30 compressions to 2 breaths o Infant & Child • 1 -rescuer use ratio of 30 compressions to 2 breaths • 2 -rescuer use ratio of 15 compressions to 2 breaths o Push Hard, Push Fast (100/min) and Allow complete chest recoil o Rotate person performing chest compressions every 2 minutes • If arrest witnessed by responder, apply AED or Defibrillator immediately and prepare to deliver a defibrillatory shock o If not witnessed by responder but two minutes of EFFECTIVE CPR provided prior to arrival of responder, may apply AED or Defibrillator • Perform CPR for approximately 2 minutes (5 cycles) before applying AED • AED (child > 1 year of age), if available o Follow AED prompts o Use Pediatric pads or child system if < 8 years of age • Use Adult pads if pediatric pads are not available • Continue until Paramedics take over patient care or patient begins to move o Adult - ventilate at 10-12 breaths per minute (one every 5 to 6 seconds) o Infant/Child — ventilate at 12-20 breaths per minute (one every 3 to 5 seconds) The Williamson County EMS System Page 25 BLS Version A Scope of Care To Respect, Care & Serve CROUP / EPIGLOTTITIS BLS (All Responders) • Interventions ONLY as tolerated • If altered LOC or central cyanosis, positive pressure ventilation with BVM using 2 person technique (override pop-off valve if pediatric patient) HEAT EXHAUSTION BLS (All Responders) • Water or 50% diluted sport drinks by mouth if no LOC change or nausea (if available) HYPERTHERMIA BLS (All Responders) • Cool patient rapidly if indicated HYPOTHERMIA BLS (ECA, EMT -B) • Handle patient gently • Remove wet clothing • Oral glucose gel (not injectable glucose), 15-25 gm if able to control airway INGESTION POISONING BLS (All Responders) • Contact Poison Control Center (PCC) 1-800-222-1222. PCC insists on one point of contact only. The individual who makes the original contact must inform PCC when a new provider takes over, in order to assure continuation of care • Charcoal (Activated) if requested by PCC and no forceful administration required up to 1 gm/kg by mouth to maximum of: (EMT -B) o Adult: 100 gm o Child: 50 gm o Infant: consult medical control The Williamson County EMS System Page 26 BLS Version A Scope of Care To Respect, Care & Serve SPECIFIC MEDICAL INTERVENTIONS - CONT. OBSTETRICAL EMERGENCIES Abruptio Placenta & Placenta Previa BLS (EMT -B) • Treat for shock Postpartum Hemorrhage BLS (EMT -B) • Massage upper abdomen over uterus (fundal massage) • Have baby breast-feed if possible Prolapsed Umbilical Cord BLS (EMT -B) • Place the mother in the supine knee -chest position as tolerated • Provide oxygen by non-rebreather mask • Place a gloved hand into vagina and gently lift infant's head to relieve pressure on umbilical cord ORGANOPHOSPHATE POISONING (Pesticides — signs/symptoms: increased salivation, urination, defecation, gastric distress, emesis and tear production) BLS (All Responders) • Protect responders • Decontaminate patient PULMONARY EDEMA - CARDIOGENIC BLS (All Responders) • Place patient upright if possible or semi -fowlers • Positive Pressure Ventilation with BVM • SUGGEST Albuterol 1 unit dose by nebulizer (EMT -B) REACTIVE AIRWAY DISEASE BLS (EMT -B) • Albuterol 1 unit dose by nebulizer in the presence of wheezing The Williamson County EMS System Page 27 BLS Version A Scope of Care To Respect, Care & Serve TRAUMA TRANSPORT (ALL RESPONDERS) Definitive treatment of any critical trauma is only possible in the hospital environment. In recognition of this fact, transport is the most important intervention, after the ABCs are managed. For critical trauma patients: • Interventions done on -scene should focus on preparing the patient for transport. • Advanced procedures should be done enroute to the hospital unless delays which cannot be controlled are present There are two primary sources of transport, although others may be used if needed and available due to catastrophic conditions: Ground Transport and Helicopter Transport HELICOPTER TRANSPORT (ALL RESPONDERS) For any patient, air transport may be considered. The following guide the use of helicopter transport: • Reduction in transport time to a trauma center compared to ground transport for a seriously injured trauma patient • The patient meets criteria for transport to the closest trauma center and whose condition will likely need immediate intervention not available in the pre -hospital setting • The patient meets criteria for transport to the closest trauma center and whose condition is stable provided the patient's condition requires the shortest out of hospital time possible • When air transport is considered, the helicopter should be requested immediately based on initial call information • Air transport should be cancelled immediately during patient contact once patient assessment findings do not indicate its need • Air transport may be cancelled by an on -scene EMT -B, FRAP, FRP or Paramedic assuming medical command • Air transport should never delay patient arrival at the hospital; The transport provider should rarely wait at the scene for a helicopter when the critical trauma patient is ready for ground transport MAST helicopter may be requested, if no commercial service is available, with approval of the on -duty EMS Shift Commander. The Williamson County EMS System Page 28 BLS Version A Scope of Care To Respect, Care & Serve TRAUMA MANAGEMENT, SPECIFIC INTERVENTIONS ABUSE — SUSPECTED (ALL RESPONDERS) • Treat traumatic injuries as described previously • Report privately to next care provider responsible for patient • Report to Protective Services at (800) 252-5400 unless confident another agency is reporting. Failure to report is a misdemeanor BURNS (ALL RESPONDERS) • Do not remove clothing from burn area if embedded • Moist sterile dressing(s) if < 10% body surface area involved • Dry sterile dressing(s) if >_ 10% body surface area involved • Maintain body temperature (blankets, heaters, etc.) • Albuterol 0.083% unit dose by nebulizer if wheezing or evidence of reactive airway present (EMT -B) CARDIAC ARREST — MULTI -SYSTEM TRAUMA BLS (All Responders) • Establish pulselessness and apnea • Perform CPR for approximately 2 minutes unless multiple patient triage • AED (if equipment available) (Responder authorized to use device) • Continue CPR CONDUCTED ENERGY WEAPONS (TASER®) (ALL RESPONDERS) • Do not remove probes unless necessary for patient care o Secure the wires and probes to the patient's body or clothing using tape • Transport patient to the closest appropriate hospital for continued assessment and treatment as needed o Law enforcement policy may dictate that patient be transported if conducted energy weapon was used. WCEMS will honor this policy if patient is in custody of the law enforcement agency. The Williamson County EMS System Page 29 BLS Version A Scope of Care To Respect, Care & Serve TRAUMA MANAGEMENT, SPECIFIC INTERVENTIONS CONT. CRYOTHERAPY (ALL RESPONDERS) Cold pack(s) may be applied over an isolated injured area. • Do not apply cold packs or ice directly on the skin's surface. • Limit Cryotherapy to 20 minutes per hour. • Reassess patient for hypothermia. Discontinue cryotherapy if hypothermia is suspected. CRUSH INJURY BLS (All Responders) • Coordinate patient care with extrication team leader • Provide supplemental oxygen by non-rebreather mask (if no increased risk of fire/explosion) • Maintain normal body temperature (prevent hypothermia) • Maintain supine position if tolerated by patient DEATH — OBVIOUS (EMT -B) (Decapitation, Decomposition, Rigor Mortis, Livor Mortis, Hemisection, Injuries incompatible with life, Mass Casualty Incident) • Do not initiate CPR • Contact law enforcement for JP ELEVATION (ALL RESPONDERS) Injured extremities (except in poisonous bites) should be elevated above the level of the heart if there is no risk of further injury. If elevating the extremity compromises spinal alignment in the spinal motion restricted patient, then do not elevate. FACIAL TRAUMA AND EYE INJURIES (ALL RESPONDERS) • Eye dressings should be bilateral • Hard cover protection should be used if available The Williamson County EMS System Page 30 To Respect, Care & Serve BLS Version A Scope of Care TRAUMA MANAGEMENT, SPECIFIC INTERVENTIONS CONT. HEAD INJURY WITH RESPIRATORY FAILURE/ARREST (Au. RESPONDERS) • If severe injury is suspected based upon altered mental status and/or other findings, Ventilate with BVM if possible o Adult —10-12 breaths per minute o Child and Infant —12-20 breaths per minute MUSCULOSKELETAL MOTION RESTRICTION (SPLINTING) (ECA, EMT -B) All skeletal instability will be splinted as soon as possible, but only after the ABC interventions are complete • Distal circulation, motor function and sensation should be checked prior to splinting, after splinting, during reassessment and after moving the patient (such as to the stretcher, to the unit, etc.). . To achieve and maintain musculoskeletal motion restriction any of the following may be utilized as appropriate for the patient condition and situation: • Patient's body (i.e. tying the legs together on a backboard where the non -injured leg is secured to the backboard) • Padded Board splints • Pillow splints (i.e. In isolated ankle, foot or hand injuries • Preformed or vacuum splints • Traction splints — Traction used in closed or open midshaft femur fractures (provided the bone end is not protruding from the open wound) • Scoop (when spinal injury is not suspected) SNAKE BITE BLS (All Responders) • Extremity at or below level of heart • Motion restrict extremity with splint; Limit all patient activity • ID snake if possible • Coral snakes only - Apply mild pressure by wrapping elastic bandages (gauze) over the bite and the entire arm or leg. o Check distal pulses every 5 minutes The Williamson County EMS System Page 31 BLS Version A Scope of Care To Respect, Care & Serve TRAUMA MANAGEMENT, SPECIFIC INTERVENTIONS - CONT. SPINAL MOTION RESTRICTION (ALL RESPONDERS) Spinal motion restriction is necessary in any patient with the potential for spinal compromise. The need for spinal motion restriction is based on mechanism of injury and patient presentation. • Cervical motion restriction should be achieved manually immediately upon patient contact, if mechanism of injury and patient presentation indicate the necessity. • Manual cervical motion restriction should be maintained until mechanical spinal motion restriction is completed. Minimal spinal motion restriction will be achieved utilizing the following: • Long Backboard o C-collar — properly sized and placed o Cervical Immobilization Device (CID) —after patient is secured to backboard o Padding — As needed to restrict motion and provide patient comfort o Straps — preferred arrangement includes two over the shoulder crossed at the chest; two crossed at the hips; one across the thigh; and one across the tib-fib Other considerations for spinal motion restriction: • Do not secure the head of the patient prior to completely securing the torso. • Athletic Helmet and Shoulder Pads — Helmet and shoulder pads should not be removed from the injured athlete unless airway compromise is caused. If one of the two pieces of equipment is removed, then the other piece must also be removed. • Helmets without shoulder pads — Helmets used without shoulder pads should be removed. When available, the following spinal motion restriction devices may be utilized with discretion: • KED — (Kendrick Extrication Device) • Pediatric Devices o Infant and child safety seats may be utilized for patient packaging if the device has no visible damage and there is minimal concern for potential spinal injury. o Removal of a pediatric patient from such a device into a pediatric unit, KED or long backboard is always appropriate if the provider feels the risk in moving the patient is outweighed by the potential inability of the safety seat to restrict spinal motion The Williamson County EMS System Page 32 BLS Version A Scope of Care To Respect, Care & Serve TRAUMA MANAGEMENT, SPECIFIC INTERVENTIONS - CONT. WOUND CARE (ALL RESPONDERS) • Control severe hemorrhage • Wound cleansing with normal saline may be performed at the responder's discretion only if hemorrhage is minor or controlled (clean water is acceptable if normal saline is not available) o Irrigation — Rinse out major contaminants • Bandaging — Completely cover wounded area with sterile dressing and cover the dressing with an appropriate bandage The Williamson County EMS System Page 33 BLS Version A Scope of Care To Respect, Care & Serve Equipment & Supply Inventory The equipment and supplies listed on the following pages are authorized for use on all in-service Williamson County EMS First Responder Units and Vehicles. F.4kiJ,A) Stephen Benold, M.D. — Medical Director Williamson County Emergency Medical Services Effective April 10, 2006 through January 31, 2008 The Williamson County EMS System To Respect, Care & Serve Equipment & Supply Inventory Williamson County First Responder Organization Minimum Equipment and Supply Inventory The following is the minimum list of medications, supplies and specialized equipment, which are carried by Williamson County First Responder Organizations. Items that are carried on an apparatus can also be carried in a personal vehicle used to respond to an emergency incident. Effective 02/01/04 1 of 2 BLS Inventory - Version A '4,1' Pastat"uPtiarl+ xs %il lte Albuterol - 0.083% solution 1 unit dose 1 unit dose Aspirin - 81 mg tablets 1 bottle 1 bottle Charcoal, Activated - 50 grams / 240 ml 100 GM 100 GM EpiPen, Adult 1 1 EpiPen, Jr 1 1 Glucose Gel - 15 - 25 grams 2 tubes 2 tubes Nitroglycerine spray / tabs - 0.4 mg / dose 1 bottle 1 bottle Oxygen (Portable) with regulator 1 1 The medications on the above list may be supplied in concentrations or amounts other than those listed. Regardless of the particular manner in which medications are supplied, equivalent total amounts must be present It is the patient care providers responsibility to be certain that correct dosages are administered to patients. Unless specified otherwise, generics and brand name products are considered interchangeable. All medications must be maintained at the manufactures recommended tempature range at all time. � ,:`�, _,,,�i�rt�i`:Manageretertt ,,,- � ;, e "'.. _._.'�• BVM, Adult 1 1 BVM, Child 1 1 BVM, Infant 1 1 KY Jelly (Lubricant) 1 1 Nasal Cannula, Adult 1 1 Nebulizer Mask, Adult 1 1 Nebulizer Mask, Pedi 1 1 Non -Rebreather, Adult 1 1 Non -Rebreather, Pedi 1 1 NPA, 20f 1 1 NPA, 24f 1 1 NPA, 28f 1 1 NPA, 32f 1 1 OPA, 100mm 1 1 OPA, 40mm 1 1 OPA, 60mm 1 1 OPA, 80mm 1 1 Suction Device - Portable 1 Me „ _...._ - `nom Alcohol Prep Pads 2 2 Lancets, spnnq loaded 2 AED 1 Adult AED Pads 2 UtU{KNlli it. BP Cuff, Adult 1 1 BP Cuff, Child 1 1 BP Cuff, Infant 1 1 Glucometer 1 Glucometer Strips 1 bottle OB Kit 1 Penlights 1 1 Pulse Ox Probe, Adult (Optional) 1 Pulse Ox Probe, Pedi ( Non -disposable) (Optional) 1 Pulse Oximeter (Optional) 1 Scissors 1 1 Stethoscope 1 1 Effective 02/01/04 1 of 2 BLS Inventory - Version A Williamson County First Responder Organization Minimum Equipment and Supply Inventory Sir VI' sfioit'ReatnCtron , , ►pparaWs- Pnmaty ' r,ROOPerionat Vetiiete - ;7 Backboard Straps, Disposable 1 C -Collar, Pedi - Adult Sizes 1 each size Head Blocks, Disposable 1 Long Back Boards 1 ktS{itttitin9 fir. 4x4 Sterile or Non-sterile gauze 10 10 Bandaids 1" 5 5 Cold Packs 1 1 Conforming Bandage, 4" Sterile 3 3 Splint, 12-1& 2 Splint, 30-42" 2 Sterile Irrigation 2 Tape, 2" 1 rot Trauma Pad, 10"X30" 1 1 Tnanwlar Bandages 4 4 Blankets, Disposable • 2 Biohazard bags 1 1 Scope of Care 1 1 Oxygen Wrench 1 1 Face Mask, N95 (medium & large) Appropriate size per responder Appropriate size per responder Gloves L, Non -Latex Gloves M, Non -Latex Gloves S, Non -Latex Gloves XL, Non -Latex Gloves XXL, Non -Latex (Pm if needed) Hand Sanitizer 1 unit 1 unit Protective Glasses 1 per responder 1 per responder It is understood that first responders may arrive on the scene of a call without all of the required equipment. However, the expectation is that the required equipment will arrive on the scene during patient care with the appropriate vehicle. The goal of Williamson County First Responders and EMS is to provide expeditious patient care regardless of the constraints of equipment location. Effective 02/01/04 2 of 2 BLS Inventory - Version A Title: Three Tier Response Policy Number: 205.18 Effective: July 21, 2006 Replaces: n/a Purpose: To establish a policy for interpreting various tiers of emergency response, understanding that all calls to the 911 center do not generate a wide scale emergency response. Scope: Includes all Round Rock Fire Department Suppression Personnel. Policy: To create specific operation guidelines for emergency responses. Definitions: This policy has the definitions described within the procedure Procedure Hot Response (Single or Multiple Unit Response) A hot response is a response by all responding units assigned to a call for those incidents that involve immediate and / or potential life threatening situations, where a delay in response may cause further harm to human life. This type of response requires: 1. All responding units will utilize all emergency warning devices (audible/visual) at all times. 2. Drivers will operate with due regard for the safety of all persons; maintain control of the vehicle at all times; obey all applicable motor vehicle laws for emergency vehicle operation set fourth by Texas Transportation Code, in addition to departmental and city policy. 3. All medical calls will be classified as a hot response, unless otherwise directed by the dispatch center, shift commander or company officer. Eldl 4• d�T l� Round Rock Fire Department Standard Operating Procedure Three Tier Response Policy 205.18 Effective: July 21, 2006 Page 2 of 5 Warm Response (Multiple Unit Response Onlv) A warm response is for incidents that could pose an immediate and / or potential life threatening situation. This type of response requires the first assigned unit to respond in the following manner: 1. Utilize all emergency warning devices (audible/visual) at all times. 2. Drivers will operate with due regard for the safety of all persons; maintain control of vehicle at all times; obey all applicable motor vehicle laws for emergency vehicle operation set fourth by Texas Transportation Code, in addition to departmental and city policy. 3. All other dispatched units shall respond cold (non -emergency) — during this response, audible/visual are not utilized unless the first assigned unit, shift commander or dispatcher receives further information that upgrades the response. All other dispatched units arriving on scene will assume level 1 staging and await instructions from the incident commander. Cold Response (Single or Multiple Unit Response) A cold response is a non emergency response, not requiring the use of audible/visual warning devices. This type of response requires that all assigned units respond in the following manner: 1. All dispatched units will respond non emergency for the duration of the response, unless other side directed by the first arriving unit, shift commander and or dispatcher. 2. Drivers will operate with due regard for the safety of all persons, maintain control of the vehicle at all times; obey all applicable motor vehicle laws for emergency vehicle operation set fourth by the Texas Transportation Code, in addition to departmental and city policy. 3. Later arriving units will assume level 1 staging and await instructions from the incident commander. Round Rock Fire Department Standard Operating Procedure Three Tier Response Policy 205.18 Effective: July 21, 2006 Page 3 of 5 Medical Call Response Medical calls will be responded to HOT or Cold depending on the information obtained from the caller and the status of available medic units. To further clarify, please use the information below in making your response decision. Keep in mind to always trust your gut instinct and if a call turns priority we can upgrade and most likely be around the corner. 1. Your station is assigned a medic unit and they are in house and can be notified prior to being dispatched by Williamson County. 2. You are aware of the location of the medic unit responding and discuss by Nextel or radio transmission the medic unit time of arrival. 3. Information obtained from the caller that indicates non priority. Fire Alarm Response Daytime All fire alarms received in the daytime (0700 hrs-1700 hrs) by the dispatch center will initiate a cold response by a single company. It is always appropriate to check by the incident location, even if the proper code has been approved by the alarm company. Fire Alarm Response Night All fire alarms received after normal business hours (1700 hrs — 0700 Hrs) by the dispatch center will initiate a warm response. If contact is made at the incident location, the response can be scaled back. It is always appropriate to check by the incident location, even if the proper code has been approved by the alarm company. ***Fire Officers are to utilize this matrix as a guideline in making the appropriate response decision. The goal is to reduce response, when information is obtained that is considered non-priority. Fire Officers do have discretionary authority and may use it at the appropriate time. * * * Round Rock Fire Department Standard Operating Procedure Three Tier Response Policy 205.18 Effective: July 21, 2006 Page 4 of 5 Authority From and after their effective date, procedures issued by the Round Rock Fire Department shall be in full force and effect and shall set forth all of the rights and duties of the employees of the Round Rock Fire Department with respect to the subject matter thereof, and shall replace any and all previous procedures or understanding, whether written or oral, relating thereto. Larry Hodge Fire Chief Round Rock Fire Department Standard Operating Procedure Three Tier Response Policy — 205.18 Effective: July 21, 2006 Pa 5 of 5 ***Fire Officers are to use this matrix as a guideline in making the appropriate response decision. The goal is to reduce Response, when information is obtained that is considered non priority. Please use your discretion.*** HOT RESPONSE )sil COLD RESPONSE ACCIDENT MAJOR X ACCIDENT MINOR X ACCIDENT PIN IN X BOMB THREAT X CARBON MONOXIDE X DUMPSTER FIRE AWAY FROM STRUCTURE X 1)1 Air., i l k !IRI. AIAR S1121('T11RI X FIRE ALARM DAY X X FIRE ALARM NIGHT X FIRE OTHER X FIRE STRUCTURE X FIRE VEHICLE X FLUID SPILL X NATURAL GAS INSIDE X NATURAL GAS OUTSIDE X GRASS FIRE X HAZ MAT X LINE DOWN X X MEDICAL ASSIST X X ODOR INV INSIDE X ODOR INV OUTSIDE X FIRE ORDINANCE VIOLATION X PUBLIC SERVICE FD X SMOKE INV INSIDE X SMOKE INV OUTSIDE X SUBJECT DOWN X SUICIDE THREAT X VEHICLE UNLOCK W/CHILD X X II! 11(( I'lI R I _A\DI\(i X \SSI'! \\ I V:1t. 1 ,A"l I0\ X \SSIS 1 \V ' SI' ,I'll 1()U 1'1(k:A(i l X 111 LIII[ \\ \ IRIIOW X \\ 11 R 11 (A\ :AI \10.1 X (0\ I ROLI.I:1) 111,R\ X 1 (1\1:1\11) 1 1RI: M\NI101 1 X (III\11( \I ODOR INS11)I' SIRI (11 RI X I \K\OW\ \1A 11 RI:A1 X ( ()\1\1I R(l.A1 iti01 RI \I 11121_ X AI, :\R I \1I \1 1 IR!. X ***Fire Officers are to use this matrix as a guideline in making the appropriate response decision. The goal is to reduce Response, when information is obtained that is considered non priority. Please use your discretion.***