EMERGENCY MEDICAL SERVICES PARAMEDIC UPDATE

MAY

2015

MATTHEW CONSTANTINE DIRECTOR

INTRODUCTIONS / WELCOME / ANNOUNCEMENTS

Ed Hill Director

Jana Richardson Senior EMS Coordinator

Survey and Quiz Information

• You should have received an email that included the lecture slides for this update class. Please be sure to follow along and take notes as you see fit as your quiz will not take place here today. You will be provided instruction for taking your quiz at the end of class today.

Paramedic Accreditation Test Results

Since January 1st

• 81 tests taken

• Average Score = 49.3/60

• Average Percentage = 82.2%

STEMI Run Review

CPAP 2014 REVIEW

CPAP CALLS

• Total = 204

• Within protocol = 123

• Outside protocol = 78

– Vital Signs = 60

– Documentation = 11

– Systolic B/P = 7

Trauma Policies

Trauma Policies

• Three separate policies:

– Trauma Center

– Pre-Hospital

– Receiving Hospital

• Now all three are combined into one policy

Criteria changed in step 3

• Items removed: – Major auto deformity >20 inches – Extrication time >20 minutes – Pedestrian thrown or run over

• Items Changed: – Auto-pedestrian/auto-bicycle injury with significant (>20 mph) impact – Auto-Pedestrian/bicyclist thrown, run over, or with significant impact

(>20 mph) – High-speed auto crash – High-speed auto crash (>40 mph) – Motorcycle Crash > 20 MPH or with separation of rider from bike – Motorcycle Crash > 20 MPH

Trauma Center

• Previously we have had only level II Trauma Center Designation

• We added Level III and IV Trauma center Designation

– Consistent with State regulations

– Currently no Level III or IV in Kern County

Trauma Center

• Basic requirements for Trauma Centers – Trauma Program medical director (Surgeon for Level II

and II) – Must be a Certified Emergency department basic or

comprehensive level (stand-by level IV) – Trauma Nurse Coordinator – Transfer agreements to higher level trauma center – Continuing education (Physicians, Nurses and EMS

personnel) – Base station and COR MED Channel and Phone

line(Level II and III Only) – MED 9 all levels (II, III and IV)

Level IV

• No surgical service required

• Services available:

– Radiological service

– Laboratory service

Level III

• Required to have surgeons promptly available:

– General Surgeon (Part of the initial Trauma team)

– Orthopedic Surgeon

• In addition to Level IV requirements:

– ICU care service

– Surgical service

– Rehabilitation service

Level II

• Required to have surgeons promptly available: – General Surgeon (Part of the initial Trauma team)

– Orthopedic Surgeon

– Obstetric/Gynecologic Surgeon

– Ophthalmologic Surgeon

– Oral, Maxillofacial, Head and neck surgeon

– Plastic Surgeon

– Reimplantation/microsurgery

– Urologic surgeon

Level II

• In addition to Level III requirements : – Physical Therapy service

– Respiratory care service

– Acute Hemodialysis service

– Occupational therapy service

– Speech therapy service

– Social service

– Acute spinal cord injury management capability

– Organ donation identification

Trauma QA/QI

Core Measures 37.4

0

5

10

15

20

25

30

35

40

2014 90th %

Ground On-Scene Time

25.1

0

5

10

15

20

25

30

2014 Mean

Ground On-Scene Time

Core Measure Kern County

31.2

0

5

10

15

20

25

30

35

2014 90th %

Ground On-Scene Time

20.5

0

5

10

15

20

25

2014 Mean

Ground On-Scene Time

On Scene Time

• If your on scene time is over 10 Minutes you must input a reason for delay.

• Reference form Trauma Policy- IX. Pre-Hospital Time Standards, D, 1 and 2 “D. On –scene time goal: 1. Maximum of ten (10) minutes from scene arrival to scene departure time, for patients that meet “Trauma Triage Criteria”. 2. If the on-scene time goal is not met, EMS field personnel are expected to document the reasons for delay on the patient care record (PCR).”

• If one of the reason listed does not fit your delay reason then input

other. • If other is documented as scene delay then you must document the

delay reason in detail in your narrative.

Direct to Trauma Center

89.36%

10.64%

Direct To TraumaCenter

Landing Zone andOther Hospital

Direct to Trauma Center

689

66 20

2014

Direct to Trauma Center from Scene

Trauma Center Landing Zone Other Hospital

Trauma Case Review

Protocol Format

Chris Niswonger

Protocol Format

• Possible change in format

• EMS Division wants your input

• Voice your opinions by taking a survey

• We will be conducting a focus group

• Survey link will be sent out to everyone

• https://www.surveymonkey.com/s/paramedicprotocol

Current Protocol

Option 2

Option 3

Option 4

Stroke System of Care

Chris Niswonger

Stroke System of Care

• As of January 1st the Stroke Center Policies were updated

• The new policy establishes levels of Stroke Centers (Comprehensive, Primary, Satellite)

• Currently we only have Primary Stroke centers (BMH, SJ, MSW, Mercy, BHH)

• Once Satellite Stroke Centers come online it will dramatically change the destination policy (Currently No Satellite Stroke Centers)

Stroke System of Care

• Therefore, the only time a patient should be transported to a non-stroke center is if they meet Thrombolytic Inclusion Criteria

What is the Thrombolytic Criteria?

Stroke QI Committee

• The new Stroke System of Care policy also established a Quality Improvement group made up of all the ambulance providers, all stroke centers, and all fire agencies.

• The group reviews data and recommends changes to the protocols.

EMS PCR Data EMS Times Average Mode

Dispatch to On-Scene 7.65 4.00

On Scene Time 14.67 13.00

Transport Time 20.48 29.00

Demographics Average Mode

Patient Age 65.41 72

Hospital Ground Transports

Bakersfield Heart Hospital 23

Bakersfield Memorial Hospital 93

Mercy Hospital 57

Mercy Southwest Hospital 50

San Joaquin Hospital 320

Antelope Valley Hospital 28

Ridgecrest Regional Hospital 20

Tehachapi Valley Healthcare District 2

Delano Regional Medical Center 7

Kern Medical Center 0

Kern Valley Hospital 5

Palmdale 3

Total 605

Transport Mode Transports

Code 3 Transport 336

Code 2 Transport 317

Begin Code 2-Upgraded Code 3 9

Begin Code 3-Downgraded Code 2 10

Calls By Provider Totals

Delano Ambulance 48

Edwards Air force Base 2

Hall Ambulance 536

Liberty Ambulance 91

EMS Data By Location

93306 North East Bakersfield 53

93307 South East Bakersfield 55

93308 Oildale 45

93309 99 to Gosford/Truxtun-White 92

93311 South West Bakersfield 22

93312 Northwest Bakersfield 30

93313 South 17

93314 Far West 13

93501 Mojave 4

93505 Cal City 14

93516 Boron 7

93518 Caliente 1

93523 Edwards 2

93527 Inyo Kern 3

93528 Johannesburg 1

93531 Keene 1

93534 Lancaster 1

93555 Ridgecrest 43

93560 Rosamond 6

93561 Tehachapi 21

93562 Trona 3

Calls By Location Total Calls

93203 Arvin 12

93215 Delano 41

93222 Pine Mountain Club 2

93224 Fellows/Taft 2

93225 Frazier Park 4

93238 Kernville 3

93240 Lake Isabella 23

93241 Lamont 7

93243 Lebec 1

93250 Mcfarland 8

93252 Maricopa 1

93255 Onyx/Isabella 2

93260 Posey 1

93263 Shafter 3

93268 Taft 10

93280 Wasco 15

93283 Weldon 1

93285 Wofford Heights 4

93301 Central Bakersfield 44

93304 South Central Bakersfield 38

93305 East Bakersfield 20

State Required Core Measures STR-2 Glucose

Preformed

Total

Stroke

Percentage State Average

2013

Glucose Testing for

Suspected Stroke

687 874 79% 87%

STR-3

Scene Time for Stroke

Patients

Average Mode 90th Percentile

On Scene Time 14.67 13.00 21.93 21.00

STR-5

Direct Transport to Stroke

Center

Numerator Denominat

or

Percentage

697 873 80% 69%

STR-4 New in 2015

Advance Hospital

Notification

STR-1 New in 2015

Documentation of Cincinnati Prehospital

Stroke Scale in the Field

Stroke Changes

• One of the first changes being made is extending the Last Known Well time from 3 hours to 4 hours.

• Therefore, the patient may be a candidate for Thrombolytic therapy up to 4 hours after onset and transport should be expedited.

Stroke

• TIME IS BRAIN

• Patient whose onset was 30 minutes ago does not mean they have 3.5 hours to get to the Hospital: TIME IS BRAIN

• Brain tissue is dying; Patients need to be rapidly transported to a Stroke Center

• We want to see on scene times similar to Trauma standards; less than 10 minutes & early activation of “Stroke Alerts” to hospitals

Stroke Center Presentation

Paramedic Protocol Changes

Dr. Kristopher Lyon

Narcotics

• Providers will only be required to carry 1 opiate and 1 benzo – Fentanyl & Versed

• Protocols have been adjusted to reflect only carrying 1 opiate and 1 benzo

• In many cases other medications have been left in the protocol – This is to ensure a smooth transition when shortages

come around; We will be able to switch medications out without changing protocols and without having to provide re-education on these meds.

Medication Tables & Reference Guide

• Both removed

Medications

• Moved

– Morphine- Level I

– Fentanyl- Level I

• Removed

– Ativan- Removed from protocol

– Verapamil- Removed from protocol

– ET Tube administration of any medication-Removed

Medications

• Changes

– Atrovent – May repeat dose of Atrovent every 20 minutes (No longer a single dose)

• Example: You start your Atrovent treatment at 1:00am; the treatment finishes at 1:20am; you may give another Atrovent treatment at 1:40am; 20 minutes from the time the treatment is completed

• Combine Atrovent with Albuterol when appropriate to do so

Medications

• Calcium Chloride

– Clarified

• “Best if administered through large bore catheter”

• Dextrose 50%

– Changed to Dextrose 10%

• 5ml/kg for Adults & Peds

Medications

• Epinephrine – Only time Epi will be given as an IV Bolus is in

cardiac arrest patients

– If you are giving Epi while progressing through any other protocol on a “live” patient it will be given IM or IV Drip (i.e. Anaphylaxis, Bradycardia, etc.)

• IV Drip will be given

•Adult Epi Drip 2-8 MCG/Min

•Ped Epi Drip 0.1-1 MCG/KG/Min

Procedure Changes

Airway Adjunct Devices • Devices used to assist in intubation may be used regardless if it

is deemed the patient has a difficult airway or not

• If you have the Bougie, Flexglide, or other device and have had the proper training on how to use them you may use them as a primary device

Procedures

• Removed

– Nasotracheal Intubation

• Changed

– Intraosseous Infusion • May be used as a primary

route in cardiac arrest

– Thoracic Decompression • Make sure you are using a

needle at least 3.25 inches for an adult patient

Protocol Changes

Asystole/PEA

• Atropine has been removed from the Aystole/PEA protocol

Tachycardia with a pulse

Chest Pain

• Contradiction for giving Nitro to a Chest Pain Patient has been added.

– ST Elevation in Leads II, III, or AVF

• Left Bundle Branch Block has been removed from the “STEMI Alert” criteria in multiple protocols

Chest Pain • Fentanyl has been added as an option for Chest

Pain patients • Morphine remains in the protocol to allow for

shortages of Fentanyl

Chest Pain

Premature Ventricular Contractions

• Protocol removed

– The protocol directed the use of Amiodarone or Lidocaine for treatment of runs of PVC’s

– “Runs” of PVC’s is really “Runs” of V-Tach

– Therefore “Runs” of V-Tach should be treated in the V-Tach protocol

– There was no need to have a PVC protocol if it did not direct the use of a medication

CVA Protocol

• Last known normal extended from 3 hours to 4 hours

Pediatric Tachycardia • Adenosine Removed for Pediatric wide

complex tachycardia

Altered Mental Status

• Clarification on Narcan Administration

Anaphylaxis • 1st Line: Epi 1:1000 IM

– Adult 0.3 MG IM (no longer a range)

– Peds 0.01 MG/KG

• 2nd Line: Benadryl – Adult 50-100 MG IM or 25-50 MG IVP

– Peds 12.5 MG IM

• If not resolved you can repeat IM dose of Epi

• If in severe distress you may start an Epi Drip – Adult 2-8 MCG/Min

– Peds 0.1-1 MCG/KG/Min

Pain Protocol

• Altered Mental Status moved from Caution to Contraindication

Respiratory Compromise-Adult & Peds

• Atrovent treatment may be repeated every 20 minutes to a max of 3 doses

Respiratory Compromise-Adult

• Morphine Removed

Seizure Activity

Head Trauma

• Versed - no longer used to facilitate intubation

Shock/Hypoperfusion

Destination Decision

• Clarification made

Spinal Motion Restriction

Pediatric QI Review

By Jana Richardson

Pediatrics: By the Numbers

• 2014 Population estimate: 874,589

• 2014 Children population: 256, 535: 29%

• Total persons under 5 (2014): 87,923

• Total run numbers in 2014: 97,971

• Total ped run numbers in 2014: 6,366 (6.5%)

Kern County Child Health

• 2011-2012 data: 10% of children 1-17 have been diagnosed with asthma at some point

– 15% California

• 10 out of every 10,000 children 0-17 were hospitalized due to asthma in 2012

– 7th statewide

Kern County Child Health

• Leading cause of hospitalizations for injury: Unintentional injuries

– 2012: 21 deaths

– 2012: 483 non-fatal injuries

– 2002-2012: 311 deaths (28.3 annual average)

– 2002-2012: 5,721 hospitalizations (520.1 annual average)

• Falls account for majority

Unintentional Injuries • Falls: 2012- 6,310 ER visits for falls

– 2002-2012: 1,635 admits (annual avg. 148.6)

• Burns: 2012- 46 hospitalized, 3 killed – 2002-2012: 294 admits, 9 deaths (annual avg. 26.7

and 0.8)

• MVA: 2012: 58 hospitalized, 11 killed – 2002-2012: 1,218 admits, 153 deaths (annual avg.

110.7 and 13.9)

• Traffic related: 2002-2012, 284 admits, 27 deaths (veh vs. ped)

• 2000-2010: 200 injured, 17 deaths (veh vs. bicyle or motorcycle)

Unintentional Injuries

• Drowning: 2012- 15 hospitalized, 3 killed

– 2002-2012: 114 hospitalized, 47 deaths (annual avg. 10.4 and 4.3)

• Child Death 2012: 148 total

– 33% MVA deaths children were unrestrained or improperly restrained

– Homicide victims: 4 from beating/blunt trauma; 2 from GSW.

ALS vs. BLS Procedures

30.60%

69.40%

Procedures

ALS

BLS

PED-1 Core Measure

• Total of pediatric patients with primary impression = respiratory distress (376)

• Total of pediatric patients with primary impression = respiratory distress that were given Ipratropium Bromide and/or Albuterol (171)

• Report percentage= 45.48%

2013 State Data

Pediatric Intubations

• Total procedures documented with intubation= 19

• Total successful within first two attempts= 12

• Success rate = 63.2%

• Remember: This is optional scope and must be reported to State after three years.

– Successes, improvements, complications, etc.

Pediatric Intubation Overview

• If possible, position the patient on the gurney at your waist level for optimal viewing of vocal cords.

• Do not hyperextend the neck. This collapses the tracheal rings. Proper positioning is key.

• Vocal cords are higher and more anterior than an adult.

• Use properly sized equipment. Best to use length-based tape.

Pediatric Intubation Overview

• Use a straight blade for children under 8.

• Be sure to secure the tube well.

• Proper depth is critical.

• Use adjuncts for proper placement in addition to lung sounds. End Title CO2 is best!

• Be on the lookout for complications!

– Increased intracranial pressure, damage to soft tissue, emesis and aspiration to name a few

Pediatric I.O.

• Total procedures documented with interosseous= 16

• Total successful within first two attempts= 14

• Success rate = 87.5%

I.O. Overview

• Complications: – Fractures with insertion, compartment syndrome,

cellulitis.

• Placement: Tibia has less overlying muscle. – Proximal tibia site. Palpate the tibial tuberosity.

Entry site ½ to 1 inch distal to the tibial tuberosity at the midline of the anterior tibia

• It is helpful to place the child supine with a rolled towel under the knee to create 45

I.O. Overview

• 90 insertion is easier: recommended 60 away from the joint.

• Avoid rocking the needle from side to side.

• No marrow aspirated? Infuse up to 5mL sterile saline. Should be easy with no edema of soft tissue.

• Monitor site continuously! Check for tension or edema.

Pediatric I.V.

• Total pediatric patients= 929

• Total procedures attempts documented with intravenous access= 1101

• Total successful attempts= 795

• Success rate = 72.2%

I.V. Overview

• Use child’s non-dominate hand.

• In the A/C, roll the forearm back and forth to distinguish the tendon from the soft vein. Vein will roll less and not follow arm movement.

• Place strong light under the hand or wrist to silhouette vessels.

• Place a 4x4 under the slipknot of the tourniquet to avoid pinching.

I.V. Overview

• Help make veins more prominent: – Gently tap the vein with a finger

– Keep extremity in dependent position

– Apply warm compress to enhance visibility

– Chubbier child: press the skin with an alcohol swab allows for a brief view of the vein. EMT may hold the swab in this location during venipuncture

– Older child: clench and unclench fist. Younger child: gently squeeze and release extremity proximal to tourniquet.

I.V. Overview

• Common mistakes to avoid

– Advancing needle too deeply and too quickly

– Withdrawing needle before catheter is threaded into the vein

– Selecting needle too large for child’s vein

– Not waiting long enough to see blood return in the hub of a small needle.

Pediatric Case Review

Survey / Quiz

Survey link will be sent to the email address you provided.

Survey

• You will receive this link, via email, to take your survey.

• Please be sure to complete each question in the survey.

• As soon as you submit your survey you will be sent to the login page for the quiz.

Quiz

• Once you are on the login page for “Class Marker” enter your username as follows;

– Your Pnumber, including the P, first name and last name, no spaces. The username is only 18 characters long so if you have a long name you will not have to enter your entire name.

– Example – P12345jefffariss

– Your password will be included in the email

CE Certificate

• Upon successful completion of the quiz, meaning passing with 80% or greater, you will be provided a CE Certificate that can be downloaded in PDF format.

• You have until Friday, June 5th to complete your survey and quiz. Failure to complete by June 5th will result in suspension of your local accreditation

PLEASE WATCH YOUR EMAIL FOR THE LINK TO THE SURVEY AND QUIZ

SEE YOU NEXT YEAR!

MATTHEW CONSTANTINE DIRECTOR