General Principles

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. Crews must continually assess for hazards and request additional resources as early as possible.
2. Proper personal protective equipment and body substance isolation must be utilized according to agency and industry standards.
3. A patient is any person who requests, appears to need, or is reasonably suspected of needing medical assessment or care, whether self-identified or identified by a third party. This includes a person who:
   • Requests medical attention or assistance
   • Appears in need of medical assessment or care
   • Is reasonably likely to have sustained injury or illness
   • Has 911 activated on their behalf by a bystander, family member, or caregiver
4. A patient encounter shall occur with each patient as defined above. All patients will have a completed chart with a minimum of two full sets of vital signs. Lift-assist or fall-assist patients meet the definition of a patient and require a full chart when refusing transport.
5. All patients in the care of EMS shall be advised of the need for 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. Please see Refusal Guidelines section for further specific requirements for refusals. 
6. An EMS patient care report will be generated at the conclusion of each patient encounter. No 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. If the initial treating paramedic on scene is not the lead transporting paramedic and care is transitioned upon arrival of the rescue, a second chart must be completed by a paramedic on the first arriving unit. This must include all vitals recorded prior to the arrival of the transporting unit, any interventions and a narrative summarizing all care that was completed prior to transfer of care. If the initial paramedic on scene is riding in as a third rider, they can write their own addendum to the narrative section of the transport chart instead of writing a second chart. Both paramedics will need to sign the patient’s chart.
8. Crews must be prepared to render immediate medical interventions, appropriate for the call level (e.g., defibrillation, airway management, sedation, etc.), upon initial patient contact. Lifesaving medications should be immediately available at the time of initial assessment.
9. 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 lead paramedic to determine the status of assessment and seamlessly assist in patient care. Role assignments fall to the lead treating paramedic.
10. Prior to the transfer of patient care between crews, the EMT/paramedic assuming care should receive a concise handoff report of all pertinent information including the patient’s initial presentation, all interventions that have been performed, and any changes in the patient’s condition. 
11. Nontransport personnel shall provide information pertinent to the patient’s identification, patient assessment and medical care to the transporting paramedic or other agency EMT/paramedic using the mini-SOAPP format when time allows:
    
    • Subjective– the patient’s chief complaint (in their own words) and history of present illness (including history of events surrounding call)

    • Objective – 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.)

    • Assessment – the initial EMT/paramedic's impression of the problem and/or working diagnosis. This can be the chief complaint, e.g. "chest pain"
    • Plan – which protocols and treatments were administered
    • Prehospital course – pertinent events that occur prior to transporting unit arrival, as well as the patient's response to treatments administered
12. Expanded SOAPP or narrative information will be provided to the receiving facility by the transporting paramedic. This verbal hand off should include the first responder information, however each unit that performed independent patient care shall complete a run report for every patient (as above).

13. For 911 responses where both EMTs and paramedics are present, the treating paramedic directs patient care. When patient volume exceeds the number of paramedics, EMTs may begin assessment and lifesaving interventions and must notify the on-scene paramedic as soon as feasible. 

14. The paramedic should decide immediately upon patient contact if advanced life support (ALS) measures will be needed. An EMT on scene with multiple patients should decide within 3 minutes after patient contact if advanced life support (ALS) measures will be needed and notify the lead paramedic on scene. The following patients require a full ALS assessment (this is not all inclusive):

    • moderate to high mechanism trauma
    • chest pain
    • shortness of breath
    • abdominal pain above the umbilicus
    • altered mental status
    • agitation
    • stroke symptoms or acute onset dizziness
    • any patient with abnormal vital signs

15. ALS assessment and initiation of resuscitation should be completed within 3 minutes after patient contact. Exceptions may include:

    •  Adult medical cardiac arrest (minimum of 20 minutes of on-scene resuscitation – compressions should be performed where the patient is found, they should not be moved from the site of collapse to the rescue during this time)
    • Extensive extrication
    • Atypical situations
    • Hazmat incidents
    All exceptions must be documented.
    
    

16. Patients should be en route to a receiving facility within 15 minutes of patient contact, except when working a medical code or in a peri-arrest* medical emergency. Any “alert” or trauma code (Trauma, STEMI, CPAP, Stroke, Sepsis) patients should be en route to a receiving facility within 10 minutes of patient contact.

17. 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. Document reasons for any deviation. Manual vitals should be obtained and recorded in cases of technology failure.

18. Upon identifying a cardiac arrest, notify dispatch with “patient contact—working code.”

19. Whenever possible, obtain verbal consent prior to initiating treatment; respect the patient's privacy and dignity.
20. Prior to the administration of any medication, assess for allergies. If uncertainty exists, contact Medical Control. Use two-person verification for all medication administration.
21. 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.
22. When caring for pediatric patients, use an age or weight-based system to determine medication dosages and equipment sizes.
23. For trauma triage, a pediatric patient is defined as ≤15 years of age or, if unknown, has the anatomical and physical characteristics of a person fifteen (15) years or younger.
24. Upon completion of a medical director approved training program, EMTs 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.
25. 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. Personnel must display continued competency in their field through annual assessment by the office of medical direction.
26. 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.
27. 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 the person or entity who received the transfer of care. A chart must be completed for these patients.
28. For all cases where patients require parenteral narcotics or sedative agents, continuous cardiac monitoring, oxygen saturation, and ETCO2 monitoring shall be performed and maintained for the duration of treatment/transport until transfer of care is completed.
29. Contact the Regional Poison Control Center (800-222-1222) for poisoning, hazardous exposures, overdoses, or envenomation. If RPCC recommendations fall outside protocol, obtain authorization from Medical Control before implementation.
30. When using supplemental oxygen in accordance with adult or pediatric treatment protocols, adhere to the following:
    • Noncritical patients without respiratory distress should receive the lowest concentration needed to maintain SpO₂ ≥94%
    • For patients with serious respiratory symptoms, persistent hypoxia, or where otherwise specified in protocol, use 100% supplemental oxygen via nonrebreather mask or BVM.

31. 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. Contact Osceola County Medical Control for further guidance if needed.

32. In cardiac arrest, attempt peripheral IV access twice; if unsuccessful, proceed to IO. For non-arrest patients, the most experienced provider should attempt IV access; consider IO for critical patients when IV access is unobtainable. All IV medications may be administered IO The preferred IO site in the adult patient is the humeral head.

33. Medications that can be administered intranasal include Naloxone, Midazolam and Fentanyl.

Contact Medical Control for Additional Orders if Needed

*Peri-arrest (principle #16): critically ill medical patients who are adequately resuscitated prior to transportation have better outcomes. Specifically for patients who can be resuscitated with the interventions we have available, patients should receive the initial treatments they need prior to moving them to the rescue whenever possible. Examples include anaphylaxis, severe asthma/COPD, CHF with pulmonary edema, hypoglycemia, septic shock. 

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 60 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.

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

• 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

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
• Intoxicated patients
• Seizures in a patient with no known seizure history
• Altered mental status or Glasgow score < 15
• 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. Encourage 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

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:

Osceola County, Florida
Office of the Medical Director

Thank you for your offer of assistance. Be advised these Emergency Medical technicians and Paramedics are operating under the authority of Florida Law and Osceola County Protocols developed by the Medical Director. No physician or any other person may intercede in patient care without the Medical Command physician on duty relinquishing responsibility for patient care/treatment via radio or telephone. If responsibility is given to a physician at the scene, that physician is responsible for any and all care given at the scene, and must accompany the patient(s) to the hospital. Furthermore, the physician accepting the above responsibilities must sign the patient’s prehospital medical record.

Thank You.

Contact Medical Control for Additional Orders if Needed

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 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 this case, the patient will be transported to the nearest hospital.

Contact Medical Control for Additional Orders if Needed

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

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

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

• 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

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

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

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, transport by ambulance should be recommended 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  
• Only a documented Power of Attorney may refuse transport on behalf of an incapacitated patient, if the POA demonstrates capacity
• Consider Medical Control contact in high risk refusal cases; provide an end-tidal CO2 along with other vital signs

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 clearly 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.

• Exceptions to this requirement are:
  • Bronchospasm resolved after one nebulizer treatment
  • Insulin induced hypoglycemia-resolved after glucose administration

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 and the patient has a known history 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%)
• The patient has access to additional bronchodilators and follow up care

Insulin induced hypoglycemia

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 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 > 60)
  • There is no indication of an intentional overdose or dosing error
  • There is no evidence of stroke, cardiac ischemia or infection
• 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 recommended, and subsequently refused
  • Document who witnessed the refusal and obtain their signature
  • 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

Refusal Guidelines

A refusal is valid only when the patient demonstrates decision-making capacity and makes a voluntary, informed choice after being clearly advised of the risks, benefits, and alternatives. Thorough, structured documentation—including a witness signature—protects the patient, the crew, and the integrity of the medical record.

Who May Serve as a Witness (in order of preference)

• Power of attorney or medical surrogate if patient currently has capacity to refuse on their own behalf
• Responsible, unbiased adult on scene (family member, caregiver, bystander).
• On-scene healthcare professional (e.g., clinic/ED staff during interfacility encounters).
• Law enforcement officer on scene.
• A second EMS crew member not leading the conversation.

Who Should Not Serve as a Witness

• Minors; individuals who are impaired, combative, or clearly biased/coercive; interpreters with conflicts of interest. Avoid using the person who is exerting pressure on the patient.

When the Witness Signature Is Required

• All refusals of assessment and/or transport.
• Refusal of transport to the most appropriate facility.
• High-risk refusals of medical intervention or treatment 

Consider engaging medical control for all high risk refusals including but not limited to: abnormal vital signs, suspected stroke/AMI/trauma, altered mental status, reported alcohol ingestion (but still demonstrating capacity without clinical signs of intoxication), language barriers, low health literacy, repeat 911 calls, and when leaving a minor or dependent adult in place with a guardian/caregiver.

Procedure (Field Use)

1. Assess capacity: Orientation, understanding, appreciation of consequences, ability to reason/communicate a consistent choice.
2. Deliver an informed-refusal discussion: Condition concern, recommended care/transport, specific risks of refusing (including death or disability when applicable), and alternatives (e.g., private transport, urgent care, follow-up).
3. Confirm teach-back: Ask the patient to repeat key risks/plan.
4. Complete the narrative: Document capacity, specific risks that were discussed with the patient, which alternatives you discussed, vitals, exam findings, and return precautions.
5. Obtain signatures:
   • Patient (or legal representative).
   • Witness (print name, role, contact if available).
   • Crew member completing the form.
6. Provide return precautions and instructions on when to call 911 or seek care immediately.
7. Offer re-evaluation if the patient’s condition changes prior to departure.

If a Witness Is Unavailable

• If truly no witness is available, document: “No witness available despite reasonable efforts,” who was present, why a witness could not be obtained, and consider two crew signatures.
• When doubt remains about capacity or safety, err on the side of medical control consultation and consider law-enforcement or clinician involvement as appropriate.

Documentation Checklist (things that should be documented in the narrative)

• ☐ Capacity assessed and meets criteria
• ☐ Risks, benefits, and alternatives explained in lay terms
• ☐ Patient teach-back documented
• ☐ Vital signs and pertinent exam recorded
• ☐ Return precautions and follow-up plan provided
• ☐ Patient (or representative) signature
• ☐ Witness signature with name/role
• ☐ Crew signature(s)
• ☐ Considered/consulted medical control for high-risk or uncertain capacity

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.