General Principles

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General Principles of Medical Care

The following measures shall be applied to promote prompt and efficient emergency medical care to all patients:

1. The safety of EMS personnel is paramount. Each scene must be evaluated for hazards upon arrival, and throughout patient care. Assess the need for additional resources as soon as possible after arrival.
2. Proper personal protective equipment and body substance isolation must be utilized according to agency and industry standards.
3. A patient shall be considered any person who meets ANY of the following: 
   • Requesting medical attention or medical assistance of any kind
   • In obvious need of medical attention or medical assistance
   • Likely to have sustained an injury from an incident or accident
   • A caretaker/family member requests medical attention or assistance on their behalf
4. A patient encounter shall occur with each patient as defined above. If the person does not meet the above criteria, you must follow agency documentation guidelines, which may include a Public Assist report. 
5. All patients in the care of EMS shall be offered transport by ambulance to the nearest appropriate hospital or other protocol based destination. In the event a patient refuses transport, a properly executed refusal process must be completed.
6. An EMS patient care report will be generated at the conclusion of each patient encounter. A complete copy, or the approved abbreviated report, must be left with the receiving facility at the time of transport. No copies or patient information will be given to anyone other than those covered by Florida Statute, and other applicable laws, without written permission from the patient or their surrogate.
7. Crews must be prepared for immediate medical interventions, appropriate for the call level (e.g., defibrillation, airway management, etc.), upon initial patient contact.
8. Upon arrival at a scene where patient care is being rendered by an initial EMS responding crew, all subsequent arriving EMS crews should immediately engage the on scene crew. The goal is to determine the status of assessment and seamlessly assist in patient care.
9. Prior to the transfer of patient care between crews, the EMT/paramedic rendering initial care should directly interface with the EMT/paramedic assuming care, to ensure all pertinent information is conveyed.
10. For all 911 calls where EMT’s and paramedics are in attendance, patient care decisions shall be performed by the paramedic.
11. The paramedic should decide within 3 minutes after patient contact if advanced life support (ALS) measures will be needed. Perform a more comprehensive exam after the patient has been stabilized.
12. Generally, initial assessment and therapy should be completed within 10 minutes after patient contact. Exceptions may include:
    1. Adult medical cardiac arrest (20 mins of on scene resuscitation)
    2. Extensive extrication
    3. Atypical situations
    4. Hazmat incidents
13. Patients should be enroute to a receiving facility within 15 minutes, except when working a medical code. Any “alert” or trauma code (Trauma, STEMI, CPAP, Stroke, Sepsis) patients should be enroute to a receiving facility within 10 minutes. 
14. All Medical Reports shall contain two complete sets of vital signs.  ALS Patients' complete vital signs should be reassessed at a minimum of every 5 minutes and BLS Patients every 10 minutes, as well as before and after every treatment/medication administration.  Any deviation from these norms shall be explained in the narrative of the report. 
15. For all patients in cardiac arrest, call into your dispatcher the “patient contact/working code” at the time of initial patient contact.
16. Whenever possible, obtain verbal consent prior to initiating treatment; respect the patient's privacy and dignity.
17. Prior to the administration of any medication, assess for allergies. If any questions arise in reference to medication allergies, contact Medical Control prior to giving any medication.
18. Nontransport agency personnel shall provide information pertinent to the patient’s identification, patient assessment and medical care to the transporting agency personnel at the time patient care responsibilities are turned over. The mini-SOAPP format may be used when time allows:
    1. Subjective - document the patient’s chief complaint (in their own words) and history of present illness (including history of events surrounding call)
    2. Objective- document vital signs, (normal and abnormal), pertinent physical findings (e.g. document normal or abnormal heart and lung exam if chest pain, normal or abnormal abdominal exam if abdominal pain, normal or abnormal neurologic exam if neurologic complaint etc.)
    3. Assessment – document the EMT/paramedic's impression of the problem and/or working diagnosis. This can be the chief complaint, e.g. "chest pain"
    4. Plan – document which protocols and treatments were administered
    5. Prehospital course – document pertinent events that occur prior to ED arrival, as well as the patient's response to treatments administered
19. Expanded SOAPP or narrative information will be provided to the receiving facility by the transporting agency. This more detailed note will include the first responder information, and shall be documented on a run report for every patient.
20. The agency or authority having jurisdiction of the EMS incident location (when on scene) is responsible for scene safety, scene command and control, as well as resource management decisions.
21. When caring for pediatric patients, use a age/weight based system to determine medication dosages and equipment sizes.
22. For trauma situations, a pediatric patient is known to be 15 years of age or younger or if age not known, has the anatomical and physical characteristics of a person fifteen (15) years or younger.
23. Following training and successful competency assessment by their respective agencies, EMT’s are authorized to apply pulse oximetry and capnography monitoring devices, perform blood glucose evaluations, perform bag-valve-mask ventilation, perform supraglottic airway insertion/ventilation, and perform bag-valve ventilation of paramedic inserted endotracheal tubes.
24. To perform as an EMT/Paramedic, personnel must be knowledgeable and proficient in the scope of practice described and taught with education based upon the National EMS Education Standards, and maintain active State certificates.
25. Perform all procedures as per the Osceola County EMS System Procedures section of the protocol. If a procedure that is not addressed in this section is deemed necessary, contact Medical Control.
26. When transferring care of a patient to another entity (i.e.; hospital, air transport, other fire/EMS agency), notify dispatch “transfer patient” to document the time the transfer occurred as well as person who received the transfer of care.
27. For all cases where patients require parenteral narcotics or sedative agents, continuous cardiac monitoring, oxygen saturation and ETCO2 monitoring shall be performed.
28. The Regional Poison Control Center (800-222-1222) should be contacted when handling calls involving poisonous/hazardous material exposures, overdoses or suspected envenomation. In the event that the RPCC gives recommendations or orders that are not contained within these protocols, EMS providers shall contact Medical Control for authorization to carry out the RPCC’s instructions.
29. When using supplemental oxygen in accordance with adult or pediatric treatment protocols adhere to the following:
    1. In patients who are noncritical, and have no evidence of respiratory distress use only the concentration of oxygen needed to achieve oxygen saturations over 94%. In most cases this can be accomplished using a nasal cannula.
    2. For patients with serious respiratory symptoms, persistent hypoxia, or where otherwise specified in protocol, use 100% supplemental oxygen via nonrebreather mask or BVM.
30. In cases of out of county, mutual aid response, Osceola County Emergency Medical Services (OCEMS) agencies are directed to utilize these Protocols in conducting patient care.
31. Attempt peripheral IV, if unobtainable proceed to adult intraosseous access.  All medications listed for IV use can be given IO.
32. Medications that can be administered intranasal include Glucagon, Naloxone, Midazolam and Fentanyl.

Contact Medical Control for Additional Orders if Needed

Unstable Patients

The following applies throughout the protocol when an unstable patient is referenced.

All patients whose condition is judged to be unstable will be transported to the closest appropriate receiving facility.

Unstable Patients are:

• Those in cardiac arrest
• Those requiring immediate airway intervention with an unstable airway
• OB patients with an abnormal delivery presentation
• When the following conditions are persistent after initial management:

• Systolic Blood Pressure less than 90 mmHg (hypotension)
• Heart Rate greater than 120 bpm with alteration of mental status or hypotension
• Heart Rate less than 50 bpm with alteration of mental status or hypotension
• Blood Glucose less than 50 mg/dL with alteration of mental status or hypotension
• Acutely altered mental status
• Persistent seizures
• Respiratory distress or failure

       Unstable Airway

• Inability to maintain adequate SpO₂ after two failed intubation attempts
• Unable to successfully oxygenate/ventilate via supraglottic device
• Unable to maintain SpO₂ > 88% with airway adjuncts (NPA, OPA) and BVM techniques by the most experienced provider on scene 
• Advanced airway immediately required to prevent death

If several hospitals are within the same approximate distance from the scene, allow the patient and/or patient’s family to select the receiving facility of their choice

Medical Transport Destination

All patients should be transported to the hospital of their choice (when operationally feasible) unless the patient is unstable(as defined in protocol) or the patient has one of the following conditions below.

• For transport destination of Cardiac Arrest-Post Resuscitation, VAD, SEPSIS, STROKE, STEMI ALERT, TRAUMA, or OB (>20 week) patients, refer to appropriate protocol for transport destination 
• Patients in cardiac arrest or with an unstable airway will be transported to the closest facility. 

If patient’s selected hospital is outside of the agency’s coverage area, notify the field supervisor of the request and destination  

Contact Medical Control for Additional Orders if Needed

Suspected Child/Elder Abuse

• Assess the scene closely, make mental notes, and document thoroughly.
• Upon arrival at the Emergency Department (ED), a verbal report summarizing your findings should be given to the responsible medical personnel. Complete any appropriate paperwork in compliance with organizational and administrative procedures.
• Do NOT delay transport to obtain information.
• Do NOT make accusatory, confrontational, angry, or threatening statements to any parties present

Reporting information to the Abuse Hotline:

• Lieutenant or Paramedic should report information to the Department of Children and Families (DCF) directly, as well as to the hospital staff.
• If we can report exactly what we saw at the home, DCF and the hospital can be more accurate in their reports and serve the patient better.
• For any non-transported patient, if you have concerns about the possible abuse, it will need to be reported to the appropriate local or state agency (Department of Children and Families or LEA)
  • Battalion Chief or supervisor should also be notified.

Florida Department of Children and Families (DCF) Abuse Website:

https://www.myflfamilies.com/services/abuse/abuse-hotline

Free Standing Emergency Rooms

Freestanding ED’s are licensed emergency departments that accept patients as an extension to an affiliated hospital.  Although freestanding emergency departments must follow the same regulatory requirements as an emergency department on the main hospital premises, there are some patients that may be better served with transport directly to the appropriate facility.  The following patients should not be transported to a freestanding emergency department unless in cardiac arrest or with an unstable airway:

• Any alert defined within the Osceola EMS Protocols (STEMI, Stroke, Sepsis, Trauma, Safety, Cardiac, CPAP, Hazmat, ROSC)

• Pregnant women at or greater than 20 weeks
• LVAD patients
• Baker acts
• Violent patients
• Altered mental status or Glasgow score <15 (except if obvious intoxciation)
• Concern for pulseless/ischemic extremity
• Peds < 18 years old with unstable vital signs and/or requiring oxygen

*Paramedic discretion can be used in deciding between a freestanding emergency department and a hospital, except for the conditions specified above.   Also consider transport to main hospital if it’s likely the patient will require admission.  

*Unstable airway:

• Inability to maintain adequate SpO2 after 2 failed intubation attempts
• unable to successfully oxygenate/ventilate via supraglottic device
• unable to maintain SpO2 >88% with airway adjuncts (NPA, OPA) and BVM techniques by the most experienced provider on scene 
• advanced airway immediately required to prevent death

Contact Medical control for additional orders if needed

Physician/Nurse on Scene

Occasions will arise when a physician on the scene will attempt to direct or assist prehospital care.

The physician must be willing to accept the following conditions:

• Provide documentation of her/his status as a physician (copy of medical license)
• Assume responsibility for outcomes related to his/her oversight of patient care
• Agree to accompany the patient during transport if accompaniment is deemed necessary
• The Medical Control physician must relinquish the responsibility of patient care to the physician on scene for the scene physician to take control
• All interactions with physicians on the scene must be well documented in the Patient Care Report, including the physicians name and contact information

Orders provided by the physician should be followed as long as they do not, in the judgment of the paramedic, endanger patient well being. The paramedic may request the physician to attend the patient during transport if the suggested treatment varies significantly from standing orders.

If the physician’s care is judged by the paramedic to be potentially harmful:

• Politely voice his or her concerns and immediately contact Medical Control
• If the conflict remains unresolved, follow the directives of the Medical Control Physician
• If the physician on scene continues to carry out the intervention in question, offer no assistance and enlist aid from law enforcement

Licensed Nurses present at an emergency scene who wish to participate in administering care must function in accordance with Florida law (F.S. 401 and F.S. Chapter 464)

"Orange Card" to be given to physician on scene offering assistance:

Contact Medical Control for Additional Orders if Needed

Patient Care During Transport

The following situations require a second attendant providing care during transport:

• Medical or trauma cardiac arrest or post-resuscitation care
• Patients requiring active airway assistance (e.g. endotracheal tube, supraglottic airway, CPAP or BVM)
• Imminent and/or post delivery of a fetus
• Unstable patients
• Physically/Chemically restrained patients
• In custody of law enforcement except for those who are being transported from Osceola County Corrections when accompanied by a corrections officer
• A 2nd attendant is not required if there will be an unacceptable delay in transport.  Reason for unacceptable delay shall be documented in the run report. 
• For scenarios not covered in the instances listed above:

  • Situations where the patient’s clinical condition does not meet the two attendant criteria listed above,
       and a second attendant is deemed necessary, the lead paramedic shall obtain approval for the second
       attendant from the on-duty Battalion Chief prior to transport.

  • Document in the patient care report the reason and justification that required two attendants during transport.

Note: A student is not defined as a crewmember.

Contact Medical Control for Additional Orders if Needed

Interfacility Transport

Interfacility transport requires unique skills and capabilities, both in clinical care and operational coordination. Adhere to the following standards for all interfacility transports:

• Notify Medical Control as soon as possible on any request for Interfacility Transport
• Interfacility transport decisions (including staffing, equipment and transport destination) should be made based on the patient’s medical needs
• Coordination between hospitals and interfacility transport agencies is essential, before transports are initiated, to ensure that patient care requirements do not exceed the capabilities of the patient attendant
• When a hospital is requesting interfacility transport please contact communications.
• If EMS crew members are not capable of managing devices or medications that must be continued during transport, an adequately trained care provider (critical care paramedic or RN) from the transferring facility, must accompany the patient during transport. Re-contact Medical Control.

Emergency Interfacility Transports:

This form of transport should be utilized for the immediate transfer of patients requiring emergency care not available at the sending facility, where time to definitive care is critical.

·       The patient will be transported to the facility at which a physician has accepted the patient unless:

•  Operationally unfeasible
• There is no accepting physician
• During transport, the patient experiences unforeseen life threatening events requiring immediate intervention (i.e. cardiac arrest, unstable airway)

*in which case, the patient will be transported to the nearest hospital

Contact Medical Control for Additional Orders if Needed

Transfer of Care at Hospitals

Once on hospital property, the receiving facility assumes responsibility for all further medical care delivered to EMS transported patients. OCEMS personnel are not authorized to follow prehospital protocols after arrival at an ED.

Exceptions to this should occur only in the following circumstances:

• Life threatening situations such as cardiac arrest, airway emergencies or imminent delivery of a fetus
• Continuation of treatments started prior to arrival (e.g. nebulizers, CPAP, IV fluids)
• When specifically instructed to continue care by the ED physician, document the physician’s name and time verbal order was given.

To assure all pertinent information is conveyed to the hospital staff, crews should interface with the charge nurse within 2 minutes of arrival to give a verbal report. Transporting personnel shall provide the receiving facility with any available patient identification, as well as all pertinent incident and patient care information at the time of transfer. In addition to the EMS run report, turn over all prehospital 12 lead ECGs to the ED staff.  Furthermore, EMS personnel should document the name of the person receiving the patient. 

Contact Medical Control for Additional Orders if Needed

Delayed Offload Procedures

Excessive ED volumes may result in a delay in the physical transfer of a patient onto a hospital stretcher. When this occurs, crews shall continue to monitor patients while awaiting bed assignment. In the interest of patient and public safety, the monitoring period should not exceed 20 minutes.

• EMS agency supervisor contact should occur notifying them of the extended delayed scenario
• Immediately alert the ED staff if a change occurs in a patient’s condition that requires urgent attention
• Document the event well for quality review purposes
• Document the patient condition (including pain level when appropriate) at time of transfer
• Document the name of the ED staff-member who was given final report, and the time report was given
• Continue to monitor patient’s vitals for changes in condition

Contact Medical Control for Additional Orders if Needed

Radio Report Format

For all EMS transported patients radio contact should be made with the receiving center at least 5 minutes prior to arrival if possible, to provide general patient information and estimated time of arrival. For unstable patients or patients meeting ALERT criteria, notify the receiving facility as soon as possible. Communications may notify the receiving facility at the direction of on scene crews.

• Select the appropriate receiving facility talk-group on the 800 Mhz radio
• All receiving facilities in Osceola and Orange County have an individual talk-group.
• Listen before transmitting to determine if the talk-group is in use.

Begin each transmission with the following:

• Agency name and unit number
• Paramedic / EMT name or ID number
• Triage category and triage level
• Estimated time of arrival
• After the receiving facility acknowledges the initial information, give a concise report, including repeat triage category/level, age and gender, chief complaint, vital signs, Glasgow Coma Score, treatment provided or under way, and any anticipated delay in transport (e.g. extrication)

Contact Medical Control for Additional Orders if Needed

Triage Categories

• Trauma
  • Indicates a trauma patient
• Medical
  • Indicates a medical patient
• Red
  • High acuity, but does not meet ALERT criteria (this does not apply to trauma)
• Yellow
  • Serious, but not critical
• Green
  • Low acuity of illness (minimal radio report)
• Trauma Alert
  • Meets Trauma Alert criteria
• STEMI Alert
  • Meets STEMI Alert Criteria
• Stroke Alert
  • Meets Stroke Alert Criteria
• HAZMAT Alert
  • ​Suspected Hazardous Material exposure
• CPAP Alert
  • Indicates patient on CPAP
• Cardiac Arrest
  • Cardiopulmonary arrest
• Cardiac Alert
  • Unstable cardiac patients that are not STEMI alert
• Sepsis Alert
  • Meets sepsis alert criteria
• Safety Alert
  • Patient potentially violent/combative

Contact Medical Control for Additional Orders if Needed

Contacting Medical Control

The Medical Directors channel shall be utilized for any additional orders that may be needed to meet the patient’s needs during on-scene care or transport.  To contact the Medical Director:

• Contact dispatch and request that they hail the Medical Director and have him/her come up on the Medical Directors channel or on cellular phone (via phone call to dispatch so the call may be recorded).
• If unable to reach the Medical Director, medical orders can be requested from the receiving emergency department.
  • If unable to contact Medical Director, send notification in writing to company officer to be forwarded up the chain of command.

Contact Medical Control for Additional Orders if Needed

Police Custody/Patient Care Standards

When called to a scene to assess a person in police custody perform all assessments and treatment consistent with the standards set for the typical, non-detained patient. EMS personnel are not equipped to perform formal medical clearance for patients in police custody prior to jail transport.

• After assessing the patient, and treating any obvious conditions, transport to the ED should be offered in a manner consistent with the OCEMS General Guidelines A patient care report will be generated for all such encounters. 
• If the detained patient refuses transport, execute a standard refusal process as detailed in protocol
• Advise the Law Enforcement Officer (LEO) of the patient’s decision, and if all criteria are met, release the patient to the LEO
• If the patient does not meet refusal criteria, advise the LEO that transport is indicated and coordinate a safe transport of the detained patient.
• If the LEO requests EMS transport in a scenario where the patient has refused, comply with the LEO’s request and transport the patient to the nearest appropriate ED
• If a patient is in the custody of Law Enforcement, the LEO shall accompany that patient to the receiving facility
• Per the Osceola County EMS System Medical Director, paramedics are not authorized to conduct blood draws for Law Enforcement in the field. If the subject is determined to be in need of medical attention and/or treatment, then transport shall be provided in accordance with the appropriate protocol. If the subject has no medical issue, advise Law enforcement to transport the subject to the Emergency Department where blood draws will be performed in a controlled environment. If any further issues, contact Medical Control. 
• In scenarios where a LEO is unwilling to allow transport of a detained patient after EMS personnel have determined transport is indicated (i.e. requested transport, obvious medical necessity or not a candidate for refusal) adhere to the following:
  • Assure that the LEO understands transport is indicated and that medical clearance prior to incarceration is not a process performed by EMS
  • Contact on duty Battalion Chief and advise of the situation
  • Contact Medical Control for further input and assistance as needed
  • If unable to resolve the issue, defer to the officer’s legal authority to retain custody of the patient
  • Document the interaction well, including the law enforcement agency and officer involved

Contact Medical Control for Additional Orders if Needed

Refusal of Medical Care

General Guidelines for Patient Refusal of Treatment and/or Transport

• A patient shall be considered any person who is:
  • Requesting (or has had a request made on their behalf) medical attention or medical assistance of any kind
  • In obvious need of medical attention or medical assistance
  • Likely to have sustained an injury from an incident or accident
• All patients shall be assessed and offered transport by ambulance to the nearest appropriate hospital, regardless of the nature of the complaint
• In the event a patient, or their custodian, refuses transport to the hospital, a properly executed refusal process/checklist must be completed
• To provide "informed refusal of medical care" a person must be one of the following:
  • ≥ 18 years of age
  • A court emancipated minor
  • A legally married person of any age
  • An unwed pregnant female < 18 y/o, when the medical issue relates to her pregnancy
  • A parent (of any age) on behalf of their child when the refusal of care does not put the child at risk
  • Other relatives who may refuse care on behalf of a minor when parent unavailable:
  • Step-parent
  • Grandparent
  • Adult sibling
  • Adult aunt or uncle 
• Consider Medical Control contact in cases when the parent cannot be contacted
  • Assure patients understand the risks of refusal, which may include death or disability or injury to self or others
• Only a documented Power of Attorney may refuse transport on behalf of an incapacitated patient, if the POA demonstrates capacity
• In the event a patient who has capacity refuses to sign, this must be documented in the PCR and witnessed by law enforcement or field supervision
• Consider Medical Control contact in high risk refusal cases; provide an end-tidal CO2 along with other vital signs
• High risk refusals include
  • Patients > 65 years old or < 2 years old
  • Chest pain
  • Respiratory distress
  • Altered mental status (patients who have received Naloxone cannot refuse care)

Assessing Decision Making Capacity

Decision making capacity is a clinical judgment that must be made, and documented, on every refusal. Many conditions can alter decision making capacity, including intoxication, poisoning, closed head injuries, stroke and psychiatric disease. When conducting the assessment, take the patient's normal baseline into account. The goal is to be reasonably certain the patient can make an informed decision at the time they refuse EMS care or transport.

• In addition to vital signs, all of the following must be assessed and documented:
• Orientation: All patients undergoing the refusal process must be awake, alert and oriented to time, person, place and situation. Even if the patient is at their baseline, failure at this step necessitates transport, or involvement of a surrogate.
• Gait and/or Coordination: Staggering gait, or inability to stand and ambulate may indicate an impairment that alters decision making capacity.
• Speech Pattern: Slurred, incoherent or otherwise inappropriate speech patterns may indicate an impairment that alters decision making capacity.
• Insight & Judgment: Determine if the patient expresses good insight into the nature of their condition, and conveys a reasonable plan to deal with their condition.
• Evidence of Psychiatric Decompensation: Determine if the patient is experiencing suicidal or homicidal thoughts. Assess for hallucinations or other forms of delusional behavior. Assess speech for signs of thought disorder.

Medical Incapacitation

When it is determined that a patient's decision making capacity is impaired the patient shall be deemed medically incapacitated and should be transported to the hospital for further assessment and treatment.

• When a patient is deemed medically incapacitated, paramedics are authorized to transport against the patient's will, using no unreasonable force
• Contact Medical Control if questions about medical incapacitation arise
• Refer to Florida Statute 401.445 for more details

Pediatric Refusals

The following scenarios require Medical Control contact prior to completing the refusal process:

• Refusals involving patients less than 12 months old
• Pediatric refusals where significant vital sign abnormalities are present
• In the event a parent or custodian refuses medical care for a minor when there is reasonable concern that the decision poses a threat to the well being of the minor:
  • Contact Medical Control for physician input
  • Enlist the aid of law enforcement personnel for patient and crew safety
  • If an immediately life threatening condition exists, transport the patient to the nearest appropriate emergency department

Refusal of Transport After ALS Initiated

Contact Medical Control for refusal situations that arise after advanced life support has been initiated.

• Exception to this requirement are:
  • Bronchospasm resolved after nebulizer treatment (see page 1-13)
  • Insulin induced hypoglycemia-resolved after glucose administration (see page 1-13)

Bronchospasm Resolved After Nebulizer Treatment

After treatment of bronchospasm, and return to an asymptomatic state, some patients will refuse transport to the hospital. The following items should be accounted for and included in the assessment and documentation:

• The presentation is consistent with a mild exacerbation of asthma
• No severe dyspnea at onset
• Not initially hypoxic (oxygen saturation < 90%)
• No pain, fever or hemoptysis
• Significant improvement after a single nebulizer treatment, with complete resolution of symptoms
• Vital signs within normal limits after treatment given (BP, pulse, respiratory rate, end tidal carbon dioxide, pulse oximetry > 96%)

This protocol applies only to adult Insulin dependent diabetic patients who are refusing hospital transport after the resolution of insulin-induced hypoglycemia by the administration of oral glucose, Glucagon IM/IN or IV/IO Dextrose. After treatment with any of the above meds and return to an asymptomatic state, some patients will refuse transport to the hospital. The following items should be accounted for and included in the assessment and documentation:

• The patient is on Insulin only (does not take oral diabetes medication)
• The presentation is consistent with hypoglycemia:
  • Rapid improvement, and complete resolution of symptoms, after administration of above meds
  • Vital signs within normal limits after glucose given (BP, pulse, respiratory rate, end tidal carbon dioxide, oxygenation, and blood sugar > 70)
  • There is no indication of an intentional overdose or dosing error 
• Concerning both situations noted above, the following patient safety measures shall be considered:
  • A family member or caregiver should be available to stay with the patient and assist if a relapse occurs
  • There is nutrition available for the patient
  • Assure the patient understands transport has been offered, and subsequently refused
  • Inform the patient to follow-up with their physician as soon as possible and to recontact 911 if symptoms re-occur
• If the above items are accounted for, a properly executed refusal can be accepted from the patient or custodian without contacting Medical Control

Refusal of Medical Care/Transport Checklist

 Patient/Custodian is awake, alert and oriented to person, place, time and events

 Patient/Custodian is not exhibiting signs or symptoms of a medical condition that may impair their capacity to make an informed decision:

• Does not appear intoxicated, or under the influence of any substance that would impair their ability to make an informed decision

 Gait and coordination are apparently normal, or at baseline

 Speech is clear and appropriate, or at baseline

 Expresses good insight into the nature of their condition, and has a plan to deal with the Problem

 Patient is not exhibiting evidence of a psychiatric decompensation:

• No suicidal or homicidal thoughts or actions
• No delusions, hallucinations, or bizarre behavior

 Patient/Custodian has been advised of the risks of refusing transport to the hospital or specific treatments offered (including permanent disability, injury to self/others and death when appropriate)

 Patient/Custodian understands and accepts the risks of refusal

 Patient/Custodian understands to re-contact 911 should he/she change their mind and desire transportation to the hospital

 Patient/Custodian has been advised to contact their primary care physician, or otherwise seek medical attention, as soon as possible

If indicated in the protocol, Medical Control contact was made

Patient gives reason for refusing transport (document in narrative)

Patient Name (Print): ______________________________________________________

Patient Signature: _________________________________________________________

If patient is a minor, obtain the following:

Parent or Custodian Name (print): ___________________________________________

Parent or Custodian Signature: ________________

Contact Medical Control for Additional Orders if Needed

General Approach to Pit Crew for Critical Care

Approach: Utilize the ABCDE method as a checklist and a means to assign roles during critical care calls.

Purpose: Allows for cognitive offloading and the ability to multi-task to ensure high quality care for complex and critical calls.

*For calls where there is only 1 paramedic, the team leader (paramedic) may need to assign specific tasks under each category to the EMT(s) rather than assign the entire category, as some tasks within the category may not be within the EMT scope of practice. However, many times more than one paramedic will be dispatched to a critical call, therefore you can assign the entire category to those individuals that are paramedics.

Procedure:

1. Team leader verbalizes the category and the associated tasks for the specific call. At that time, the team leader will also delegate the tasks to the individuals on scene.
2. Crew should be addressing the category verbalized and reporting back as needed. Team leader advises of the intervention.
3. Team leader will continue with assessment and move on to the next category, as long as preceding categories have been addressed or are being addressed simultaneously.

Category	Tasks	Role
A - Airway	activate airway assistance (BVM, Supraglottic or ETT) if GCS <8, refractory hypoxia or other indication c-collar	Paramedic
B - Breathing	monitor O2 monitor respirations monitor Capnography O2 supplementation as needed BVM(OPA/NPA) as needed Pre-oxygenate (NRB, CPAP, BVM) in preparation for intubation Set up apneic oxygenation for intubation	EMT can be assigned all tasks in this category (EMT to alert paramedic of abnormalities)
C - Circulatory	Monitor BP frequently IV/IO Fluids meds EKG	Paramedic
D - Diagnostic & Destination	Check Glucose Review specific protocol Recommended meds based on protocol Review if any specific destination requirements	EMT can be assigned all tasks in this category (open protocol book/app & call out to team leader)
E - Exposure	Look for hives DCAP BTLS Decon as needed	Paramedic

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