FREDERICKSBURG EMS Air Medical Transport APP

FREDERICKSBURG EMS
APP
1
Air Medical
Transport
Basic Considerations Indications:
 Would the amount of time needed to transport a patient by ground
transportation to an appropriate medical facility pose a threat to the
patient's survival and/or recovery?
 Would weather, road conditions, or other factors affecting the use of
ground transportation seriously delay the patient's access to tertiary
medical care?
 Does the available ground ambulance have the clinical skills, equipment or
extra personnel to care for the patient during transport from the scene?
 If the seriously injured patient is trapped, would the extrication time allow
for the helicopter to arrive at the scene and speed delivery of the patient to
a trauma receiving facility?
Indications for Requesting Air Medical:
 Patient injury evaluation by the first-arriving Paramedic meets criteria for
Trauma Criteria Red / Blue (APP 21)
 The scene of injury is more than 30 minutes lights-and-siren driving time to
the trauma center destination (distance, traffic, and weather conditions
considered)
 Patient extrication, vital on-scene care, and ground transport time is
estimated to be greater than the time span from requesting Aeromedical
service to Aeromedical patient arrival at the trauma center
 A Mass-Casualty Incident (MCI) in which awaiting sufficient numbers of
ground transport units for critical patient(s) would result in a transport time
delay that exceeds the time span from request of Aeromedical service to
Aeromedical patient arrival at the designated trauma center. In this
situation Aeromedical Unit should transport to a distant tertiary care center
if all possible to allow local resources to be used by ground units
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
1
Air Medical
Transport
Considerations:
 Dispatch will activate the next Air Medical service in rotation unless:
o Specifically requested by a patient (memberships) all efforts will be
made to accommodate the patient unless waiting jeopardizes the
patient’s health
o Specialty capabilities (rescue, equipment, weight capability)
o Requesting aircraft from out of the normal service area
 Patients that are contaminated by hazardous materials
o Air Medical Provider will be notified of contamination
o Proper DECON should be done prior to loading the patient onto any
aircraft
 Patients exhibiting signs of erratic or violent behavior
o Refer to Combative & Violent Patients (Medical 5)
o Notify Air Medical Provider as soon as possible
Helicopter safety and landing zones:
 When a helicopter has been requested, indicate a safe landing zone by
taking into account, crowds, trees and overhead hazards
 Never approach a helicopter until instructed by the flight crew to do so
 If the rotors are turning, never approach a helicopter from the rear or from
above
Landing Zone (LZ) Requirements:
During normal daylight hours the LZ should be at least 60 x 60 feet. Additionally,
it should be marked with one traffic cone at each corner and one traffic cone on
the upwind side
During nighttime hours the LZ should be at least 100 x 100 feet with lighted cones
at each corner and one lighted cone on the upwind side
Additionally, all emergency vehicles should turn off all emergency lights,
especially strobe lights
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
2
Airway Classifications
Mallampati Score System should be used to assess patient’s airway prior to
intubation. Class of airway should be documented in all patient care records
where advanced airway procedures have been performed
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
2
Airway Classifications
Blank
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
3
APGAR Score Chart
TEST
0 Points
1 Point
Tone)
Absent
Arms & Legs
extended
Pulse (Heart Rate)
Grimace (Response
Absent
Below 100 bpm
Stimulation or Reflex
Irritablity)
No Response
Facial Grimace
Sneeze, cough, pulls
away
Blue-gray,
pale all over
Pink body & blue
extremities
Normal over entire
body – Completely
Pink
Absent
Slow, irregular
Good, crying
Activity (Muscle
Appearance (Skin
Color)
Respiration
(Breathing)
2 Points
Active movement
with flexed arms &
legs
Above 100 bpm
Score of 7-10 is usually associated with coughing and crying within seconds of
delivery. Newborns with this score typically do not require and further
resuscitation
Score of 4-6 the newborn is moderately depressed. Will typically appear pale or
cyanotic and have respiratory complications and flaccid muscle tone. These
newborns will require some type of resuscitative efforts
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
3
APGAR Score Chart
Blank
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
4
Burns:
Rule of Nine Charts
Detailed calculation reference for pediatrics > 1 year of age: For every year over one,
add 0.5% to each leg and subtract 1% for the head
Age
Head
Each Leg
Age
Head
Each Leg
2
3
4
5
17%
16%
15%
14%
14.5%
15%
15.5%
16%
6
7
8
9
13%
12%
11%
10%
16.5%
17%
17.5%
18%
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
4
Burns:
Rule of Nine Charts
Blank
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
5
Child / Elder / Domestic Abuse
It is the responsibility of all EMS personal to be on the watch for suspected
abuse of children, the elderly and domestic partners for physical, sexual
emotional / psychological abuse and be observant to the signs of possible
neglect self-neglect and abandonment.
General Information State law requires all professionals to report suspected
cases of abuse (Texas Family Code § 261.101). Therefore, all employees are
required to report actual and suspected cases of abuse. However, it is not the
responsibility of Fredericksburg EMS crews to confront and attempt to remediate
abusive situations. When abuse is suspected, provide all assessment and
treatment as indicated. Attempt to persuade the patient to be transported to the
hospital regardless of the severity of the injuries.
Transport Situations – Upon arrival at the emergency room, privately and
discreetly advise the nurse and/or physician of your suspicions.
Non-transport Situations – If transport is refused, leave the scene and request to
meet with law enforcement at a nearby location. When law enforcement arrives,
advise them of your suspicions. In either situation Child Protective Services or
Adult Protective Services should be contacted by the Fredericksburg EMS crew
responding to the call and or witnessing the event.
Documentation In all cases, medics should include a detailed assessment of the
actual or suspected abuse situation in the patient’s report. The assessment should
describe the patient’s condition, emotional state, and the surrounding
environment. Also, employees should include details in the patient’s report
concerning the circumstances that created their suspicions of abuse and the
employees’ actions. The appropriate agency should be contacted within 24 hours
after the employee witnesses the actual or suspected abuse.
Child and Elderly Abuse should be reported to Adult Protective Services (AS) or
Child Protective Services (CPS): 1-800-252-5400 or https://www.txabusehotline.org
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
5
Child / Elder / Domestic Abuse
 Assess the scene for safety
 Call for law enforcement support, stage if necessary until law
enforcement secures the scene
 ABC’s maintained and support
 Treat injuries per protocol
 Talk to patient alone in a safe, private environment. Use direct simple
questions such as: Who caused these injuries? Are you in a
relationship with someone who hurts or threatens you? 6. Look for
history of domestic violence, behavioral and physical clues
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
6
Communicable Diseases
Type and Use of Personal Protective Equipment (PPE)
 Gloves - For any patient contact, and when cleaning/disinfecting
contaminated equipment. Puncture resistant gloves will be worn in
situations where sharp or rough edges are likely to be encountered, i.e.,
auto extrication
 Face Mask & Eye Protection - Facial protection will be used in any situation
where splash contact with the face is possible. This protection may be
afforded by using both a face mask and eye protection, or by using a fullface shield. When treating a patient with a suspected or known airborne
transmissible disease, particulate facemasks should be used. For respiratory
illnesses (TB, SARS) it is beneficial to mask the patient
 Coverall/fluid resistant gowns - Designed to protect clothing from
splashes, gowns may interfere with, or present a hazard to, the member in
some circumstances. The decision to use gowns to protect clothing will be
left to the member. Structural firefighting gear also protects clothing from
splashes and is preferable in fire, rescue, or vehicle extrication activities
 Shoe/Head Coverings - Fluid barrier protection will be used if suspected
contamination is possible
General Precautions against disease:
 If it's wet, it's infectious - use gloves
 If it could splash onto your face, use eye shields and mask or full face shield
 If it's airborne, mask yourself or patient
 If it can splash on your clothes, use a gown or structural firefighting gear
 If it could splash on your head or feet, use appropriate barrier protection
Post Exposure Management:
 Provide first aid
 Secure area to prevent further contamination. (Stop bleeding with direct
pressure)
 Remove contaminated clothing and flush
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
6
Communicable Diseases

Wash the contaminated area well with soap and water, or waterless hand
cleanser, and apply and antiseptic
 If the eyes, nose, or mouth are involved, flush them well with large
amounts of water





Notification and relief of duty. The worker's supervisor should be immediately
notified if a worker experiences an exposure involving potentially infectious
source material. The supervisor should determine if the worker needs to be
relieved of duty
Report the Exposure. The worker or immediate supervisor should promptly
complete an Exposure Report appropriate for the agency, and submit it to the
designated Infection Control Officer
A HCMH "Report of Injury" form will be filled out and taken with you at the
emergency room at the hospital
Follow the regional exposer plan, Regional Blood or Body Fluids Exposure
Process for EMS or other Public Safety Personnel (attached) www.strac.org
Seek Medical Attention, Counseling, Consent and Testing per established
policies and procedures
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
7
Crime Scene
When pre-hospital personnel encounter a dead person or if they enter a scene
where a crime is suspected or being considered, the following guidelines should
be strictly adhered to:
 If dispatched to a potentially unsafe scene where staging is necessary units
should respond in the non-emergency mode until the scene is secured by
law enforcement
 Establish scene safety. Make sure law enforcement is enroute if not
already present. Do not enter an unsafe scene until it is safely secured. It
may be necessary to stage in an area close to the scene. When staging
responders should not be visible from the location of the incident
 Be careful not to touch any surroundings unless it is absolutely necessary.
Do not leave any items at the scene. If anything at the scene is moved
(including patient), law enforcement must be advised
 Limit access of the immediate scene to essential personnel only. Entry and
exit routes should remain the same. When establishing if a patient is still
alive (especially at a homicide scene), it is often best if only one
crewmember enters the immediate patient area initially
 Any suicide note should not be handled
 If a viable patient is encountered, proceed with proper resuscitation and/or
protocols as needed. The following situations and responses may indicate
resuscitation:
o Hangings- leave all knots intact, including the knot that the rope is
suspended from and the knot making the noose. Cut the rope in an
area halfway between the noose and the suspension point in the
rope
o Weapons- EMS personnel should not move any weapons. If possible,
this should be left to law enforcement. If necessary for scene safety
and law enforcement is not on scene the weapon should be removed
to a safe place, away from the patient and bystanders. Weapons
should not be tampered with, opened, or unloaded by responders at
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
7
Crime Scene
any time. When treating a patient that has sustained a penetrating
wound and the clothes need to be removed, do not cut through knife
or bullet holes (may affect subsequent evidence analysis)
o Sexual assault- it is important that victims of sexual assault be moved
quickly to a safe environment. It is vital that the patient not shower
or wash any part of their body or clothing, change clothing, or use
the bathroom
 Bodies of patients determined to be dead at the scene are not to be moved
until authorized to do so by the Justice of the Peace/ME. This may require
in some instances that the ambulance remain on scene until released by
the Justice of the Peace/ME
 Document well. Document surrounding’s, patient condition, patient
injuries, interventions, transported to which facility, or time pronounced,
any objects that needed to be moved in order to work on the patient, if the
body had to be moved, etc
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
8
Do Not Resuscitate (DNR)
Orders
An Out of Hospital – Do Not Resuscitate (OOH-DNR) order allows a patient with a
terminal condition to direct health care professionals in the out-of-hospital
setting to withhold or withdraw specific life-sustaining treatments in the event of
respiratory or cardiac arrest. A terminal condition is defined as a condition that is
incurable or irreversible and that would produce death without the application of
life-sustaining procedures
 When responding to a call for assistance, personnel shall honor an OOHDNR in accordance with statewide protocols
 Identify the DNR order. The original OOH-DNR or copy must be present and
appear valid or the patient must be wearing the approved device
 Approved devices include:
o White vinyl, hospital-style, Texas Out-Of-Hospital Do-Not-Resuscitate
bracelet with the patient’s name, physician’s name and the patient ID
number entered on the back side of the bracelet
o Stainless steel Texas OOH-DNR bracelet with the patient’s name,
physician’s name and the patient ID number engraved on the
backside of the bracelet
o Stainless steel Texas OOH-DNR necklace with the patient’s name,
physician’s name and the patient ID number engraved on the
backside of the necklace
o All other DNR orders not on an approved State of Texas OOH-DNR
form or device can not be honored by pre-hospital professionals in
Texas. If presented with one immediately begin/continue
resuscitative efforts while a crew member contacts OLMC for
permission to honor DNR
 Resuscitation efforts shall be withdrawn or withheld in the pulseless and
apneic patient if the above criteria have been met. Resuscitation efforts
would include the following:
o CPR
o Defibrillation
o Cardiac resuscitation medications
o Advanced airway management
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
8
Do Not Resuscitate (DNR)
Orders
o Artificial ventilation
o Transcutaneous cardiac pacing
 Patient care documentation must include:
o Detailed physical assessment of the patient
o Confirmation that OOH-DNR order was presented and what format
was accepted
o Any problems encountered accepting the DNR order
o Name of the patient’s attending physician with the address and
phone number
o Name, address and phone number of witnesses used for patient
identification
o Name, address and phone number of hospice agency, if any
 The OOH-DNR may be revoked by the:
o Patient or someone with the patient and at the patient’s discretion
destroys the form and removes any ID devices
o Person executing order or someone in this person’s presence and at
the patient’s discretion destroys form and removes any ID devices
o Patient communicating his/her intent to revoke
o Person executing order orally states his/her intent to revoke
 THE OOH-DNR ORDER IS AUTOMATICALLY REVOKED IN CASE OF:
o Known pregnancy of the patient
o Suspected criminal activity involving the patient
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
8
Do Not Resuscitate (DNR)
Orders
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
8
Do Not Resuscitate (DNR)
Orders
Blank
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
9
Dead On Scene Criteria
Obvious Death:
Patients must meet one or more of the following criteria if resuscitation efforts
are to be withheld or stopped if initiated by bystanders prior to EMS arrival. If
there is ample evidence (as qualified by the following criteria) that a patient will
not survive a resuscitation effort, there is no ethical reason to initiate or continue
resuscitation in the field
Signs of Obvious Death include one or more of the following:
 Decomposition
 Dependent lividity
 Decapitation
 Rigor Mortis (normo-thermic patients)
 Total Body Surface burns
 Obvious Mortal Wounds WITH NO spontaneous pulse and
respiration
 Valid State of Texas OOH DNR
Once it is decided that the patient is an Obvious Death, the body should be
covered from public view and the family notified of the patient’s condition if on
scene. Until the scene is cleared by law enforcement, every effort should be used
to limit access to the scene
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
9
Dead On Scene Criteria
Blank
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
10
Field Termination
Encountering patients at or near their time of death is often one of the most
complex and difficult responses that pre-hospital providers can make. Often, onscene family members, bystanders, or other concerned individuals compound the
decision-making process because of the normal emotions encountered when
human beings die. Additionally, there is a need to make rapid decisions during
these encounters, as any hopes of resuscitation must include rapid and
appropriate interventions
As a result, in any situation, if it is not absolutely clear to the arriving care
providers that the patient meets the criteria for obvious death (see below),
resuscitation will be started and followed with appropriate measures until such
time as the resuscitation team decides that efforts to cease the resuscitation
should be made
Patients in the State of Texas have the individual right, if they are sound in mind,
to refuse any attempts at EMS care up to and including CPR. Currently, the only
way for a patient to refuse CPR however, is through complete and thorough
documentation on a State of Texas Out of Hospital Do Not Resuscitate (OOHDNR)
form (APP 8). Evidence of this is proven by the presence of an OOHDNR form
(original or copy) properly completed and signed and/or a DNR bracelet or a DNR
necklace properly engraved and worn by the patient. Even though the patient
may have requested no CPR, it may still be appropriate to provide supportive and
comfort care such as IV, oxygen, and appropriate medications (rhythm treatment,
pain relief, etc)
Termination of Resuscitation:
Any pulseless and apneic patient, in whom it is not immediately apparent meets
the criteria for Obvious Death, should receive aggressive and appropriate
resuscitative measures without delay as prescribed in this medical protocol. All
patient’s, regardless of personal opinions of the validity of the resuscitation, will
receive the highest level of care and treatment until it is determined, through
consult with the on duty physician or the Medical Director, that resuscitation
measures should be stopped
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
10
Field Termination
While performing resuscitative measures, any or all of the following indications
may be used to cease resuscitative measures after consult with the on duty
physician or the Medical Director:
 The cardiac arrest is not related to a reversible factor (i.e.
hypothermia; respiratory issues; drug overdoses; etc)
 Obvious Death criteria become apparent while performing
resuscitation
 The patient has not regained spontaneous circulation after
appropriate advanced life support measures are taken including but
not limited to intubation, IV/IO access, cardiac drug administration
(multiple rounds), and/or pacing
 The patient’s rhythm has declined during resuscitation to asystole or
PEA (pulseless electrical activity) in multiple leads
 The patient’s ETCO2 readings, with appropriate ventilation, is < 10
mm/Hg
 The resuscitative effort with appropriate interventions (CPR,
Intubation, IV access) has been on-going for greater than 25 minutes
with no return of sustained spontaneous circulation
If your patient meets any of these criteria, and you believe it is appropriate to
stop resuscitation measures, the following procedure will be used:
 A discreet conversation will be had with all First Responders involved in the
resuscitation to review the measures that have been taken and to poll
them regarding their impressions regarding stopping the resuscitation. If
there is not a unanimous consensus, the resuscitation must be continued
 Any family on scene should be consulted to explain what has been done
and that it is apparent nothing else can be done so that they will be
informed that EMS is about to stop the procedures they are doing
 Medical Counsel from the on duty ED Physician or department’s Medical
Director will be contacted. All information regarding the scene shall be
relayed to the physician and permission shall be requested to stop
resuscitation. The physician’s name should be gleaned and documented as
well as a time of death
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
10
Field Termination
 The care providers should be instructed to stop their procedures on the
authority of Dr. __________ of Hill Country Medical Hospital ED or Medical
Director. All procedures should be immediately stopped and all
interventions left in place including but not limited to ET tube, IV, EKG pads,
patient therapy pads (Combi-pads), and the patient should not be moved
 The family should be notified of the decision of physician and consoled for
their loss. Family members could desire to see their loved one and this
should only be done, if possible, with the permission of law enforcement
 Care must be taken to meet the needs of the family. Contacting family,
neighbors, clergy, etc may be necessary to meet these needs
 If not on scene, law enforcement should be notified
 EMS and/or First Responders should remain on scene until relieved by the
appropriate agency having jurisdiction. This may be law enforcement or
the Justice of the Peace
Careful documentation must be done on these calls including factors such as
patient location upon arrival, any extenuating circumstances, history obtained by
bystanders and/or family as well as all care provided and the physician directing
the stopping of resuscitation
Traumatic Arrests:
At a trauma scene, careful consideration should be taken as to the cause of the
cardiac arrest. This includes the possibility that a medical event (MI, CVA, seizure,
etc) preceded the trauma event. Survival from a traumatic cardiac arrest is
extremely rare and several factors in your initial assessment can help determine if
resuscitation is warranted
 If a medical event is suspected, treat as a normal medical cardiac arrest
 If the victim is a trauma patient, they should be considered Obviously Dead
if the following is found:
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
10
Field Termination
o The patient is without vital signs, is a victim of blunt or penetrating
injury, showing other signs of obvious death AND
o The patient presents in asystole or an agonal rhythm
o Regardless of the severity of the injury if the patient has a pulse,
immediately transport to a trauma center
 If the victim presents in ventricular fibrillation, the likelihood of a medical
event precipitating the traumatic event is more likely. Treat as per Medical
Cardiac Arrest protocols
 If the patient is found with a narrow complex QRS in PEA, this may suggest
profound hypovolemia, which could respond to aggressive fluid
resuscitation. Rapid extrication and transport is appropriate.
 If the patient is entrapped and extrication will be prolonged, and while in
progress the patient declines to asystole with a loss of vital signs, Medical
Counsel from the on duty ED Physician should be contacted to determine if
resuscitation can be terminated. The procedures outlined above should be
followed for ceasing resuscitation
Other Considerations:
Calls involving deaths will often invoke all types of issues including social,
psychological, emotional, moral, religious, and a host of others. Some additional
things to keep in mind when responding to these calls include:
 Families of patient’s with valid OOHDNR may change their mind
when EMS arrives on scene and request resuscitation to begin.
These issues are often very complex and go beyond the actual end of
life event you have responded to. Using your best judgment, it is
often best to begin resuscitation unless the Obvious Death criteria
are met. If no response to resuscitation is realized, then this protocol
can still be used to terminate the resuscitation efforts. Constant and
vigilant communication must be maintained with the family
throughout this process
 Often times cardiac arrests occur in public places. When you arrive
on scene and resuscitation is warranted, it is not appropriate to
terminate these efforts while in a public place. This will require
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
10
Field Termination
transport to the hospital even though there is no response to
resuscitation efforts. Your judgment and Medical Counsel will be
vital in this decision making process
 Pediatric patients in cardiac arrest pose their own sets of difficulties.
From emotional issues for family as well as rescuers, it may not be
appropriate to terminate resuscitation in the field on these patients.
Evaluating the emotional and psychological needs of the family as
well as the healthcare team must be done prior to making a decision
regarding the efficacy of ceasing resuscitation or transporting the
patient to the hospital
Additional considerations will always arise in these instances. Medical Counsel
from the on duty ED Physician is an invaluable asset and should be used at any
time to help work through and overcome all issues that arise during a cardiac
arrest. Never hesitate to seek Medical Counsel from the on duty ED Physician at
any time for any reason
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
10
Field Termination
Blank
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
11
Glasgow Coma Score /
Revised Trauma Score
Adults / Children
Best Eye Opening
Spontaneous
To Voice
To Pain
No response
Best Motor Response
Obeys Command
Localizes Pain
Withdraws from pain
Flexion (Decorticate)
Extension (Decerebrate)
No Response
Best Verbal Response
Oriented
Confused
Inappropriate
Incomprehensive
No Response
Infants
Best Eye Opening
Spontaneous
To Voice
To Pain
No Response
Best Motor Response
Normal movement
Withdraws to touch
Withdraws from pain
Abnormal flexion
Abnormal extension
No response
Best Verbal Response
Coos and Babbles
Irritable cries
Cries to pain
Moans to pain
No response
4
3
2
1
6
5
4
3
2
1
5
4
3
2
1
Glasgow Coma Scale
Best Eye Opening (Score)
1-4
Best Motor Response (Score)
1-6
+ Best Verbal Response (Score) 1-5
Total Glasgow Coma Score
3-15
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
4
3
2
1
6
5
4
3
2
1
5
4
3
2
1
FREDERICKSBURG EMS
APP
11
Glasgow Coma Score /
Revised Trauma Score
Adult Revised Trauma Score
Pediatric Revised Trauma Score
GCS
13-15
9-12
6-8
4-5
<4
Trauma Points
4
3
2
1
0
Respiratory
Rate
10-29
>30
6-9
1-5
0
Trauma Points
Airway
4
3
2
1
0
CNS
Systolic BP
>90
76-89
50-75
1-49
0
Trauma Points
4
3
2
1
0
+2
+1
-1
Weight
>20KG
10-20KG
<10KG
Systolic BP
Wounds
Revised Trauma Score- Adult
Converted GCS
Component
Fractures
Maintainable
Requires
w/out
Normal
invasive
invasive
procedures
procedure
Responds to
Alert, no
verbal or
history of
Unresponsive
painful
LOC
stimuli
Carotid or
Pulse at
femoral
No palpable
wrist
pulse
pulse <50
>90mmHg palpable 50mmHg
90 mmHg
Major or
None
Minor
Penetrating
Open or
Closed
None
Multiple
Fractures
Fractures
0-4
Respiratory Rate (Score) 0-4
+Systolic BP (Score)
0-4
Total Revised Trauma Score
0-12
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
12
Heart Alert
Regional
Patient’s meeting the Heart Alert Criteria should be considered for Air Medical
Transport or Medical Bypass to a Designated Heart Center in San Antonio. Refer
to Hospital Bypass Procedures (APP 5), and reference the Regional Hospital
Selection Guide for the most appropriate destination for the patient’s condition
Patients in which suspected STEMI should be suspected:
 Patients with chest or upper abdominal discomfort suggestive of
Acute Coronary Syndrome.
 New onset of cardiac dysrhythmia
 Syncope or near syncope
 Unexplained acute weakness with or without diaphoresis
 Acute onset of dyspnea suggestive of CHF (hypertension,
hypotension, diaphoresis, “wet” breath sounds, etc)
 Other signs or symptoms of acute coronary syndrome
 12-lead ECG with any of the following:
o ST Elevation of 1mm or more in 2 or more contiguous leads
o A monitor interpretation of “***ACUTE MI SUSPECTED***”
 Diabetic, elderly, female patients with atypical MI presentations
When you encounter a patient that meets one or more of the above
criteria, the following shall be done immediately:
1. Place patient on oxygen to titrate to an SpO2 > 94%
2. Obtain a 12-lead ECG (goal of <5 minutes of arrival on scene)
a. 12-lead should only be delayed for life-saving treatment
3. If signs and symptoms and 12-lead signifies a “Heart Alert” patient
then:
a. Consider Air Medical Transport or Medical Bypass if
appropriate
b. Transmit 12-lead to appropriate Hill Country Memorial
Hospital or approved Primary PCI Center
c. If 12-lead cannot be transmitted receiving facility should be
contacted to be advised of incoming Heart Alert
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
12
Heart Alert
Regional
4.
5.
6.
7.
8.
d. As soon as possible, after 12-lead transmission is complete, PCI
Center should be notified via phone that you have a “Heart
Alert”
Continue with patient treatment per Chest Pain Protocol (Medical
4). Do not delay transport but treatment and transport shall be done
simultaneously. Treatment should not be delayed to move the
patient to the ambulance. Movement to the unit should be done
during appropriate times (i.e. in between NTG doses, etc) so that
algorhythm is followed appropriately but transport or treatment is
not delayed
Patient should be left on all interventions and monitoring devices at
all times. This includes oxygen, ECG, SPO2, ETCO2, NIBP, etc.
Anytime a patient is disconnected from any treatment or monitoring,
this shall be documented as to the length and reasons for this
disconnect. As soon as the patient is reconnected to the EKG a repeat
12-Lead should be done to re-establish ST segment monitoring
“Heart Alert” patients, or suspected MI/ACS patients who do not
meet “Heart Alert” criteria, WILL NOT be allowed to walk for any
reason. These patients shall be moved by care-givers on the scene
via cross-chest carry, stair chair, and stretcher to avoid any
unnecessary exertion or increases in myocardial oxygen demand
Any interventions or changes in patient condition shall warrant a
repeat 12-lead ECG. These include pain relief, pain increases,
significant vital sign changes, and changes in LOC or overall patient
condition
“Heart Alert” patients shall be transported without delay in the nonemergency mode. Sirens have a profound psychological effect on
patients that increases anxiety and potentially increases myocardial
oxygen demand. If an Emergency Transport mode is necessary,
appropriate steps should be taken to properly explain to the patient
why (dense traffic, unstable rhythm, inability to relieve pain with or
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
12
Heart Alert
Regional
without worsening 12-lead, etc) and mild sedation may be warranted
9. Upon arrival at PCI Center, thorough and concise report shall be
given to ED physician along with initial 12-lead and any follow-up 12leads. Patient will be placed on hospital stretcher unless specifically
instructed to move directly to the cath lab. If this occurs, the patient
shall be moved to the cath lab and report given
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
13
Hospital Bypass Procedures
Regional
Pre-Hospital Trauma Triage and Bypass Algorithm:
Hospital bypass is defined as transporting the patient to the nearest hospital that
has the appropriate level of care for the patient’s suspected severity of injury. The
goal of the TSA-P regional trauma system plan is to deliver the right patient to the
right facility in the right amount of time. To accomplish this, a “Bypass” of the
nearest facility in favor of transport to a facility with the appropriate resources
may be required. Bypass reduces the amount of time from injury to definitive care
at a Level I Trauma Center by eliminating inter-hospital transfer issues.
The STRAC supports the Bypass of “nearest” hospital in favor of a Level I Trauma
Center for those patients who are deemed to have severe injury or the potential
for same. There are, however, special circumstances where Bypass may not be
the optimal choice, such as areas where on-scene advanced life support is not
available and the patient requires ALS procedures.
When a patient is without pulse or breath at the scene, and CPR is initiated,
transport to the nearest acute care facility is again the most prudent action.
The STRAC recommends the use of the Prehospital Trauma Triage and Bypass
Algorithm developed for TSA-P and based on materials published by the American
College of Surgeons and approved by the Texas Department of Health. Emergency
care providers at the scene should utilize the Triage Algorithm, in conjunction
with on-line medical control to evaluate the level of care required by the injured
person and to determine the patient’s initial transport destination. If on-line
medical control is not available, then the agency’s Standard Operating Procedures
(SOPs) and/or protocols should reflect decision-making based on the Triage
Algorithm.
The purpose of the Hospital Bypass Guideline is to assist field personnel with
selection of the appropriate destination (see next page)
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
13
Hospital Bypass Procedures
Regional
Pre-Hospital Trauma Triage and Bypass Algorithm Southwest Texas Regional
Advisory Council Trauma Service Area-P
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
13
Hospital Bypass Procedures
Regional
Definitions for Trauma Triage and Bypass Guidelines for TSA-P
In February, 2003, the STRAC formally adopted the Red/Blue triage criteria to
help EMS agencies identify Trauma Alert patients
 ADULT (APP 21)
 PEDI (APP 22)
Multi-System Trauma with Unstable Vital Signs:
Hemodynamic compromise, respiratory compromise and/or altered mentation
that results in a Revised Trauma Score (RTS) < 12
Major Anatomical Injury
 Penetrating injury of the head, neck torso, or groin
 Combination of burns > 20% or involving the face, airway, hands, feet or
genitalia
 Amputation above the wrist or ankle
 Paralysis
 Flail Chest
 Two or more obvious long bone fractures
 Open or suspected depressed skull fractures
 Unstable pelvis or suspected pelvic fracture
Significant Mechanism of Injury:
 Ejection from vehicle
 Death of occupant in same vehicle
 Extrication time > than 20 minutes with injury
 Fall > than 20 feet
 Unrestrained passenger in vehicle rollover
 Pedestrian, motorcyclist or pedalcyclists thrown or run over
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
13
Hospital Bypass Procedures
Regional
Blank
“When in doubt, do something in favor of your patient.” Jay Cloud
July, 2014
APPENDIX C. HOSPITAL SELECTION GUIDE
a) Field paramedics and Dispatch shall NOT divert patients from an appropriately selected hospital without the approval of Medical Control; patients with an altered level of consciousness shall not
be taken to a hospital with a non-functioning CT Scanner.
b) "Trauma Alert" (Priority 1 or 2) Adult patients are transported to the nearest Level 1 Hospital (SAMMC, UH); Pediatric "Trauma Alert" patients may ONLY be taken to University Hospital.
"Trauma Alert" burn patients - All Adult Burn Trauma Alert (R-8) patients are transported to SAMMC, all Pediatric Burn Trauma Alert (R-7) patients fo to Univierstiy Hospital. Transports are done as
rapidly as is safely possible.
c) Sexual assault patients 17 years or older who are assessed as Priority 2 or 3 patients (Non Trauma Alert) shall be transported to Methodist Specialty and Transplant Hospital; patients not yet 17 years
of age shall be transported to Children's Hospital of San Antonio.
d) Free standing ED's accept Priority 3 patients. See STRAC guidelines for further guidance.
e) For suspected CO poisoning, Full = multi-patient chamber with CO testing available, Partial = CO testing capabilities but does not have multi-patient chamber, None = does not have CO testing
capabilities.
f) For other catagories of care use the following grid:
Adult
Christus
Methodist
Baptist
Baptist Medical Center
North Central Baptist
Baptist Children's Hospital
Mission Trails Baptist
Northeast Baptist
St. Luke's Baptist
P-1
Medical
Yes
P-2
Trauma Medical
Yes
Yes
Post ROSC
Heart Alert
Stroke Alert Obstetrics
Hypothermia
Yes
Yes
Yes
-Yes
Yes
Yes
-Yes
Yes
Yes
-Yes
Yes
Yes
--Yes
Yes
Yes
-Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Methodist
Methodist Children's
Yes
--
Yes
--
Yes
--
Yes
--
Yes
Yes
Metropolitan Methodist
Methodist Specialty and Transport
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
-Yes
Yes
-Yes
Yes
Yes
Yes
Yes
Yes
--
Methodist Stone Oak
Northeast Methodist
Methodist TexSan Hospital
Children's Hospital of San Antonio
Christus Santa Rosa Medical Center
Christus Santa Rosa Westover Hills
San Antonio Military Medical Center *
Nix Medical Center
Southwest General
University Hospital
South Texas Veteran's Health Care Center **
Yes
-Yes
Yes
-Yes
Yes
-Yes
Yes
1
-Yes
Yes
1
-Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
--Yes
--
--
Yes
--
--
Yes
Yes
2
Yes
CO
Poisoning
Partial
Bariatric
CT
lbs / in
600 / 26
Pediatric
(Not yet 17 years of age)
P-1
Medical
4
--
P-2
Trauma Medical
Yes
Yes
4
Yes
--Yes
Partial
Partial
Partial
Partial
450 / 26
450 / 26
450 / 26
400 / 26
---
-Yes
Yes
Yes
-Yes
Yes
Yes
Yes
Partial
450 / 26
4
4
--
Yes
Yes
-Yes
-Yes
-Yes
-Yes
4
4
Yes
--
FULL
FULL
660 / 30
660 / 30
-Partial
---
450 / 28
650 / 27
450 / 28
660 / 28
4
-Yes
Yes
Yes
-Yes
--
--4
-4
--
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
--
--
--
425 / 27
4
Yes
Yes
Yes
Partial
660 / 28
Yes
Yes
Yes
Yes
2
1
Yes
--
2
---Yes
Yes 2
--
-Yes
Partial
--
Yes
-Yes
Yes
-FULL
-Partial
--
--
4
-Yes
450 / 23
4
--
Yes
Yes
450 / 28
4
--
Yes
Yes
660 / 30
450 / 28
350 / 27
650 / 32
4
--4
-Yes
-Yes
Yes
Yes
Yes
Yes
Yes
Yes
--
--
--
3
--
4
*SAMMC - Accepts only military beneficiaries (exception: Trauma Alert ); ** VA Beneficiaries only; 1 - Go to Methodist; 2 - Accept Pediatric Strokes; 3 - CT Scan at UHS;
4 - Except for P1 Override / Patient Extremus
FREDERICKSBURG EMS
APP
14
Trauma Centers
SAMMC
SAMMC Burn Cen.
University Hosp.
Hospital EMS Report Line
Regional
210.916.3010
210.916.2876
210.615.0159
Zone 1 – Medical Center
Zone 3 – North SA
Audie Murphy VA
Methodist Main
Meth. Children’s
Meth. Specialty
St. Luke’s Baptist
Santa Rosa Med.
Methodist Texsan
University Hosp.
SAMMC
North Cent. Baptist
Baptist Children’s
Northeast Baptist
Northeast Meth.
Meth. Stone Oak
210.617.5219
210.575.4773
210.575.7170
210.615.0967
210.615.1504
210.705.6810
210.732.52.76
210.615.0159
210.916.3010
210.496.2989
210.496.0589
210.654.1217
210.757.5081
210.447.6770
Zone 2 – Downtown
Zone 4 – South SA
Baptist Med. Center 210.222.9784
Metropolitan Meth. 210.757.2178
Nix Medical Center 210.223.3606
Mission Trail Baptist 210.359.8613
Southwest General 210.921.3400
CSR Westover Hills
210.521.9260
East Region
Memorial Hosp – Gonzales 830.672.2226
Guadalupe Reg. – Seguin
830.401.7333
Santa Rose – New Braunfels 830.629.2411
Otto Kaiser – Kennedy
830.583.4576
So. Tx. Reg. Med. Ctr. – Jourdanton 830.769.5203
Connally Memorial – Floresville
830.393.7155
West Region
Community General – Dilley
Dimmit Regional – Carrizo Springs
Frio Regional – Pearsall
Fort Duncan – Eagle Pass
830.965.2003
830.876.2424
830.334.3617
830.872.2941
Hill Country Mem. – Fredericksburg
Medina Regional – Hondo
Uvalde Memorial – Uvalde
Val Verde Reg. Med. – Del Rio
“When in doubt, do something in favor of your patient.” Jay Cloud
830.997.1375
830.741.6295
830.278.3392
830.703.1702
FREDERICKSBURG EMS
APP
15
Infant Abandonment
“Baby Moses Law”
Introduction:
Of the over 100 babies that are abandoned each year in Texas, about 16 will be
found dead. An unknown number of babies are never found. There is a solution. A
Texas Law provides a responsible alternative to mothers who might otherwise
abandon, harm, or murder a newborn child. This law is nicknamed “The Baby
Moses Law” from the ancient story of the baby Moses who was abandoned, but
was saved and grew to become an important person. This bill was authored by
Geanie Morrison, who is a State of Texas Representative for the Austin/Victoria
area, which was put into law on September 1, 1999.
Under the Texas State Law 262.301, Texas fire stations, EMS stations and
hospitals are “designated emergency infant care providers” for these abandoned
babies. In addition, Texas State law 262.306 says, “Each designated emergency
infant care provider shall post in a conspicuous location a notice stating that the
provider is a designated emergency infant care provider location and will accept
possession of a child.”
This policy is to be enforced with regard to Texas Family Code Chapter 262 Subchapter D, concluding that Fredericksburg EMS & Fire Station is considered a safe
baby drop site.
Your responsibilities:
 Accept an infant who appears to be less than 60 days old and who appears
not to be injured
 Ask the parent for all pertinent medical information including name (first
name, last name if possible) & date of birth.
 Assess the infant for any injury or illness
 Follow the Chain of Command and notify on-duty officer
 Notify EMS Director
 Notify Law Enforcement
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
15
Infant Abandonment
“Baby Moses Law”
 Contact CPS between call 1-800-252-5400
 Transport to Hill Country Memorial for further assessment
If the infant appears to be injured or older than 60 days old:
 Always accept infant/child
 Follow the above guide lines
 Always use prudent judgment for your safety and the infant’s safety
 You may attempt to gather identifying information, such as vehicle
description, license plate, description of parent, direction of travel, etc.
In the case of an Administrative Staff member receiving a child, handle it as a
walk-in patient and immediately notify on-duty officer and appropriate med crew
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
16
Mass Casualty / Mass Care
A mass casualty incident (MCI) is any event where the available resources are
insufficient to manage the number of casualties or the nature of the emergency.
Any event that overwhelms existing manpower, facilities, equipment, and the
capabilities of a responding agency or institution is considered a mass casualty
incident.
Examples of this include:
1. Highway accident
2. Airplane crashes
3. Major fires/ explosions
4. School bus accidents
5. Train derailments
6. Building collapses
7. Hazardous material releases
8. Environmentalearthquakes, floods,
tornadoes, hurricanes,
blizzards, ice storms
9. Terrorism
A major incident for one community (or agency) may be routine for another.
This is quite evident in comparing the response capabilities of a rural vs. an
urban community. General characteristics of a major incident include:
 Local pre-hospital care response system is taxed and overloaded
 More patients exist than can be handled by the responding units
 Mutual aid required from outside agencies
EMS Response:
1. First Response - In the event of an incoming call to dispatch of a mass
casualty incident (disaster), an EMS and a fire unit will be sent
immediately to the scene. The first unit on scene will assume command
of the incident, give a scene size-up and direct the initiation of triage.
Based upon the scope of the incident and/or initial triage numbers,
additional recourses will be requested. As personnel arrive on scene
medical and transport leader assignments will be made and patient
removal and transport will begin as soon as triage is complete
2. Additional Recourses - For additional medical resources contact dispatch
and have them contact mutual-aid partners and for additional / specialty
resources contact MEDCOM 210.233.8515 to request the following:
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
16
Mass Casualty / Mass Care
a. Ambulance Strike Teams
b. AMBUSs (MPV 801 Schertz EMS, MPV 802 San Antonio Fire, MPV 701
Austin/Travis Co. EMS)
c. Air Medical units
d. Command / Communication Trailer
e. Mass Casualty Trailer(s)
f. Mobile Medical Unit (field hospital)
Consider contacting the school district transportation department for use of school
buses for low acuity
3. Extrication & Decontamination - No personnel shall enter a contaminated
area until it is secured by firefighting personnel. Extrication will proceed
under the direction of the senior medical member first on the scene, who
will set priorities for extrication and direct two essential medical
therapies: (1) Airway Management and (2) Control Hemorrhage. To
minimize personnel needs the technician shall encourage “self-care”
whenever possible. Patient’s with uncontrolled hemorrhage will be
extricated first, followed by patients with breathing difficulties. Pulseless
patients and apneic will be extricated last. If the mechanism of injury
suggest fractures, spine boards will be used as litters for extrication. Most
extrication functions will be conducted by regular firefighting personnel
working with the technicians. Operationally, the firefighting will be
responsible to their chain of command. Medically, they will be responsible
to the officer on scene or senior crewmember
4. Medical Treatment and Staging Area -
a. Patients shall be brought from the disaster site to a triage officer,
who will designate that the patient be taken to 1 of 4 areas:
1. CRITICAL patient treatment area
2. STABLE patient treatment area
3. MINOR treatment area
4. MORGUE (command of the morgue belongs to the
Justice of the Peace or Law Enforcement)
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
16
Mass Casualty / Mass Care
b. These areas, except the morgue shall be in a safe place, protected
from inclement weather, and far enough from the disaster scene to
avoid interfering with the extrication and transportation functions.
The paramedic will be the triage officer unless he is replaced by a
triage team from a hospital; at that time, the paramedic will continue
to assist and advise the triage team.
c. Each treatment area will have a designated paramedic officer, who
will control the movement of patients out of his area, monitor supply
requirements and assure that as many patients as possible are being
treated. When patients are ready for transportation, they will be
brought to the attention of the transportation and supply officer
(preferably a paramedic), who will call in ambulances for loading,
from the staging area. The transportation and supply officer will
designate the appropriate hospital and see that a report is given by
the communication officer (paramedic). The communications officer
will call in the report and keep accurate record of patients and
vehicles en route. If additional supplies are needed, they will be
brought in by ambulances from the staging area; they will be brought
from hospitals by returning ambulances. The transportation and
supply officer will restock the supplies in the treatment areas, or will
supervise such activities.
d. Transportation priority will be:
i. CRITICAL
ii. STABLE
iii. MINOR
iv. DEAD
e. Identification - No patient will be allowed to leave the scene
without first being identified, if possible
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
16
Mass Casualty / Mass Care
Blank
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
17
Minors / Underage Patient Care
& Transport
Patient Transport:
Note: Texas State Laws requires all children to be properly restrained when riding
in a vehicle. An ill or injured child must be restrained in a manner that minimizes
injury in an ambulance crash. The method of restraint will be determined by
various circumstances including the child’s medical condition and weight.

Convertible car seat with two points of belt attachment to the cot
(front and back) is considered a best practice for pediatric patients
who can tolerate a semi-upright position
o Position safety seat on cot facing foot-end with backrest
fully elevated
o Consider removing mattress
o Secure safety seat with 2 pairs of belts at both forward
and rear points of seat.
o Place shoulder straps of the harness through slots just
below child’s shoulders and fasten snugly to child
o Follow manufacturer’s guidelines regarding child’s
weight
Note: Non-convertible safety seats cannot be secured safely to cot. If child’s
personal safety seat is not a convertible seat, it cannot be used on the cot

Car bed with both a front and rear belt path (example: Cosco Dream
Ride SE)
o Position car bed so child lies perpendicular to cot,
keeping child’s head toward center of patient
compartment
o Fully raise backrest and anchor car bed to cot with 2
belts, utilizing 4 loop straps supplied with car bed
o Used for infants who cannot tolerate a semi-upright
position or who must lie flat
o Only appropriate for infants from 5 – 20 lbs

Restraint device with 5-point harness
o Attach securely to cot utilizing upper back strap behind
cot and lower straps around cot’s frame
o 5-point harness must rest snugly against child
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
17
Minors / Underage Patient Care
& Transport

o Head portion of cot may be adjusted to any angle for
comfort of child
o Pedi-Mate fits children weighing 10 – 40 lbs
Belting child directly to cot in manner to prevent ramping or sliding in
a crash
o Loop narrow belts over each shoulder and under arms,
attaching to a non-sliding cot member
o Use soft, sliding, or breakaway connector to hold
shoulder straps together on chest
o Anchor belt to non-sliding cot member and route over
thighs, not around waist
Non-Patient Transport:
There is no place in the patient compartment that is recommended for child
passengers. Best practice is to transport well children in a vehicle other than the
ambulance, whenever possible, for safety.
If no other vehicle is available and circumstances dictate that the ambulance must
transport a well child, he/she may be transported in the passenger seat of the
driver’s compartment if they are large enough (according to manufacturer’s
guidelines) to ride forward-facing in a child safety seat or booster seat. If the air
bag can be deactivated, an infant, restrained in a rear-facing infant seat, may be
placed in the passenger seat of the driver’s compartment.
Use of Patient’s Child Passenger Safety Seat After Involvement in Motor
Vehihicle Crash
The patient’s convertible safety seat may be used to transport the child to the
hospital after involvement in a minor crash if ALL of the following apply:
 Visual inspection, including under movable seat padding, does not reveal
cracks or deformation
 Vehicle in which safety seat was installed was capable of being driven from
the scene of the crash
 Vehicle door nearest the child safety seat was undamaged
The air bags (if any) did not deploy
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
18
Non-Fredericksburg EMS
Personnel On Scene
General Information:
This policy establishes the guidelines for EMS personnel and identifies the limits
that trained/civilian bystanders may assist during an emergency response.
Certified/Licensed Individuals Wishing to Assist:
Individuals who possess valid EMS certification and/or other healthcare license but
are NOT employed by the City of Fredericksburg EMS, may be allowed to assist
Fredericksburg EMS personnel in rendering patient care under the following
conditions:
 The individual may only participate in patient care under the direct
supervision of Fredericksburg EMS personnel
 Individuals who possess advanced certification should NOT be permitted to
administer invasive treatment UNLESS the Medical Director or Supervisor
specifically approves such treatment. Such treatment should only be
approved during Mass Casualty Incidents (MCI’s) when local EMS resources
are strained
Non-Certified Bystanders:
The use of non-certified bystanders in an emergency situation is not
recommended and should be reserved for instances when their assistance could
make a crucial difference in the outcome of the situation. Common situations in
which a non-certified bystander might assist include but not limited to the
following: CPR, manual C-spine stabilization, and hemorrhage control, etc. It is
appropriate to provide PPE to bystanders offering assistance in patient care
activities. Thorough documentation indicating the justification for such assistance
should be documented in the patient care report.
Fire Department/First Responder Personnel:
Fire department personnel are responsible for all fire suppression, hazard control
and heavy extrication.
In all rescue and extrication operations, the role of Fredericksburg EMS personnel
is to direct patient care and advise rescue teams on phases of the operation
which might compromise the patient's condition. Unless specifically trained to do
so, EMS personnel should not direct the technical aspects of patient rescue.
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
18
Non-Fredericksburg EMS
Personnel On Scene
First responder personnel should be utilized in a manner that allows them to
practice their assessment and treatment skills.
Law Enforcement:
Law Enforcement is responsible for traffic control, control of disruptive
bystanders and scene security. Law Enforcement personnel with specialized
training in First Response/AED may be utilized in a manner that maximizes their
training and best assists in the positive outcome of the emergency.
On Scene Physician:
Texas State Board of Medical Examiners Rule 197.5 addresses “On Scene
Physician intervention” and shall govern situations involving an on scene
physician who offers assistance in treating patients.
All physicians who are present at the scene of an emergency and who offer
assistance should be treated with professional courtesy. Any physician who offers
assistance will be required to provide proof of identity and credentials before
being allowed to provide patient care on the scene. Below is a summary of the
Rules governing Physician on Scene guidelines.
Patient’s Doctor on Scene:
 When a patient's private physician is on the scene of an incident and has
provided the appropriate credentials, EMS personnel should comply with
his/her directions concerning treatment of the patient to the extent that
those orders are consistent with established protocols. On-line medical
control should be notified of all on scene physician contacts wishing to
assist.
 When a physician elects to accompany his/her patient to the hospital, EMS
personnel should respect the physician's wishes in the management of the
patient during the entire course of patient care
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
18
Non-Fredericksburg EMS
Personnel On Scene
 When the physician requests that the patient be transported immediately,
EMS personnel should honor the physician’s requests with all reasonable
haste after obtaining the patient’s consent
 It is not appropriate to re-evaluate a patient after the patient has been
thoroughly evaluated by a physician and the physician has made an
adequate report concerning the patient’s condition to the responding crew
prior to transporting the patient. Additional information concerning the
patient should be obtained from the physician, his/her representative or
the patient, if necessary
 If Fredericksburg EMS employees believe that the physician has not
properly evaluated the patient, they should perform an assessment of the
patient, provide all immediately necessary treatment, and move the patient
to the ambulance for further assessment and treatment
 The patient’s physician may write orders beyond the Fredericksburg EMS
Medical Protocols. Employees shall attempt to carry out the physician’s
orders if the orders do not extend beyond the employees’ training,
certification, or capabilities and the employees are in direct contact with
the patient.
Disagreements with Physician(s) on scene:
 An employee who disagrees with a patient’s physician concerning the
management of the patient, or who disagrees with the physician’s
judgment concerning the use of the EMS system, should NOT express
his/her disagreement to the physician; rather, the employee should discuss
the matter with the on-duty Supervisor
 Advise the physician that all Fredericksburg EMS personnel function under
written standing orders and/or on-line medical direction that have been
established by the department’s Medical Director
 Advise the physician that he/she may continue to offer assistance by
providing advice to on-scene EMS personnel or assisting with patient care
under the direction of Fredericksburg EMS current Medical Protocols
 If the physician insists on providing direction outside established guidelines,
he or she should take complete responsibility for the care of the patient,
Continued
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
18
Non-Fredericksburg EMS
Personnel On Scene
including accompanying the patient to the hospital. Crews shall document
all activities during transport
 If the physician assumes responsibility for the care of the patient, EMS
personnel should comply with his/her directions as long as those orders are
consistent with established standing orders
 If the orders proposed by the intervening physician are not consistent with
standing orders, EMS personnel shall respectfully decline to participate in
that specific care. In this event, employees shall immediately contact an
their supervisor and or the EMS Director
 EMS personnel should document all events and interaction between an
intervening physician and the crew, including direction given and care
provided
Once direct contact with a physician ends, EMS personnel shall give a progress
report to the receiving Emergency Department and supervisor by radio or
telephone. The supervisor may then give additional orders or change previous
orders if necessary, depending on the patient's condition.
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
19
Patient Priority Status
Patient status updates allow for the prioritization of the patient's clinical status.
When crews update the patient status it signifies that the crew has recognized the
urgency of their patient. Additionally, it allows the other EMS crew, First
Responders as well as, the receiving facilities to react accordingly.
Priority 1 (Critical)
 Critically ill or injured patient (immediately life-threatening illness or injury)
needing immediate intervention
 Examples might include:
o Cardiac arrest or post cardiac arrest
o Head injury with GCS < 8 c)
o Penetrating trauma to head, neck, chest, or abdomen
Priority 2 (Urgent)
 Potentially life-threatening illness or injury
 Examples might include:
o GCS 8 -12
o Altered level of consciousness
o Status epilepticus
o Unresponsive patient
o Unstable vital signs and/or clinical signs of shock
Priority 3 (Stable)
 A Non-urgent condition which may require medical attention, but not
immediate treatment
 Examples might include:
o GCS 15
o Stable vital signs
o Minor Injuries
o "Hemodynamically stable chest pain with no evidence of ischemia"
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
19
Patient Priority Status
Blank
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
20
Refusal of Treatment
When a patient refuses treatment and / or transport by a Fredericksburg EMS unit
for any reasons the following steps should be taken.
Assess the physical and psychological status of the patient to the best of your
ability as the patient permits. This should include a complete set of vital signs
(whenever the patient allows the attendant to obtain the Vital Signs). Problems
occur when a person who has refused treatment and/or transport, later suffers
harmful consequences after the EMS service leaves. Some of the significant legal
questions that arise are:
 Can it be determined what information the patient was given to make the
decision to refuse treatment and/or transport?
 Did the patient have the capacity to make an informed decision?
 Did they fully understand the risks that they were taking by refusing
treatment or transport?
 What options were given to the patient if they changed their mind? If
deemed an emergent situation, explain to the patient the necessity of
seeking further medical help by being transported to a local facility
 When possible, have your partner, a family member or a law enforcement
official explain the same concerns to the patient
 If all reasonable options have been exercised, try again to convince the
patient of the need for further care
 If the patient still refuses to be transported, have them sign a Patient
Refusal Form. Refusals will be completed on ePCR with a detailed
description of the incident and the Patient Refusal with the signature will
be attached
Documentation should include the following:
 Oriented to person, place, and situation?
 Altered level of consciousness?
 Possible head injury?
 Alcohol or drug ingestion by exam of history?
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
20
Refusal of Treatment
 Complete description of illness/injury
 Advised to seek medical attention
 If parent/guardian was on scene and or contracted via telephone
All patients should be advised of the following:
 Medical treatment/evaluation needed
 Ambulance transport needed
 Further harm could result without medical treatment/evaluation
 Transport by means other than ambulance could be hazardous in light of
patient’s present illness/injury
If the patient will not sign the back of the run form document the refusal and get
substantiating witness signature, preferably law enforcement if possible.
Regarding Witnesses
 EMS personnel may sign as witnesses on a refusal form
 On any unusual or questionable refusal, law enforcement, fire department
personnel or credible bystander should sign as a witness
 It should be made clear that the cosigner is witnessing only the refusal and
not making a comment on any medical situation
EMS / Fire Station Walk-In Patient(s)
 EMS Station Walk-In patient(s) shall receive treatment, transport and/or
follow this document
 Crew member(s) encountering any patient at the station will complete a
run form with the proper signature(s)
 Should a minor request aid without the presents of his/her parent
(guardian), an attempt should be made to obtain permission for
treatment/transport, if they’re not available treat and transport
 A parent (guardian) signature is required on the run form when not
treating/transporting
 Should the minor refuse treatment/transport and the parent (guardian) not
be available, contact law enforcement officials
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
21
Taser Removal &
Treatment
EMS Procedures:
 Scene safety
 Before approaching the patient who has been subdued with the Taser
device, inform the officer of your intentions and verify that the probe wires
have been removed from the hand held unit
 Remember that the patient was at one time uncooperative. Use caution
when dealing with these patients
Assessment and Treatment
 When assessing a patient that has been subdued with the Taser device:
o Identify the location of the probes on the patient’s body.
o If the probes are located in one of the following areas, DO NOT
remove them but transport patient to the ED to have probes
removed by the physician:
 Face
 Neck
 Groin
 Any probe not removable by the technique below
 Obtain from the police officers and document the condition of the patient
since being Tased (level of consciousness, any complaints, activity, etc.)
 Assess vital signs and EKG rhythm. If patient is greater than 35 years old,
perform a 12-lead
 Determine from the patient and document:
o Chief complaint
o Date of last tetanus shot
o Any cardiac history
o Any seizure history
o Intake of any intoxicants or mind-altering substances
 All complaints and assessment findings should be treated as per protocol
Continued
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
21
Taser Removal &
Treatment
Removal of Taser Probe(s)
If, when you arrive on scene, the Taser probe(s) is/are still embedded in the
patient’s skin somewhere other than the areas listed above for ED removal,
use the following techniques to remove them:







Verify that the probes are disconnected from the hand-held unit
Place one hand flat on the patient’s skin with the probe between the
fingers to stabilize the skin and the imbedded probe
With your second hand, firmly grasp the probe, and with one firm, fluid
motion, pull the probe straight out of the skin
Repeat this with the second probe
Probes should be placed into device cartridge and place cartridge into a
Sharp’s Shuttle. The Sharp’s Shuttle should be given to the police officer
in charge of the patient
Clean puncture sites with alcohol and bandage as appropriate
If last tetanus shot was longer than 5 years, patient should be
encouraged to obtain one
Patients with priority medical complaints either before or after being Tased,
should be evaluated in an ED. If patient has a medical complaint and wishes to
refuse transport, PD and Medical Control should be consulted. The patient
and police officer should be instructed to alert EMS or transport the patient to
an ED if abnormal signs or symptoms develop.
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
22
Trauma Alert Criteria - Adult
RED / BLUE
(Adult patient > 16 years of age)
1 RED or 2 BLUE Criteria = TRAUMA ALERT
Choose all that apply
ONE OR MORE RED CRITERIA
TWO OR MORE BLUE CRITERIA
R1
GCS < 13 due to trauma
B1
R2
ACTIVE airway assistance required (i.e.,
more than supplemental O2 without
airway adjunct)
B2
B3
R3
No radial pulse AND heart rate > 120
R4
BP < 90 systolic
R5
Pelvic fracture or flail chest
R6
Acute Paralysis, loss of sensation, or
suspected spinal cord injury
R7
Amputation proximal to wrist or ankle
R8
> 15 % BSA 2nd/3rd degree burns
R9
Penetrating injury to head (or
depressed skull fracture), neck, torso,
extremities proximal to elbow or knee,
excluding superficial wounds
R10 Crushed, degloved, mangled, or
pulseless injured Extremity
R11 Two or more long bone fractures (on
different extremities)
B4
B5
B6
B7
B8
B9
B10
B11
B12
B13
Reliable loss of consciousness > 5
minutes
Sustained respiratory rate > 30 or 10
Sustained heart rate > 120 (with radial
pulse) and BP >90 systolic
Best Motor Response = 5
Pregnancy > 20 weeks
Fracture to humerus or femur due to
Motor Vehicle Crash
Fall from > 20 feet
Age > 55
Ejection from vehicle (excludes open
vehicles)
Driver with deformed steering wheel
or intrusion > 12 inches to occupant or
18 inches at any site
Death in the same vehicle
Auto vs Pedestrian / bicyclist /
motorcyclist thrown, run over, or with
significant (>20 mph) impact
Patient on anticoagulation with a
suspected T.B.I.
Paramedic intuition may serve as a Red / Blue Criteria override
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
22
Trauma Alert Criteria - Adult
RED / BLUE
Blank
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
23
Trauma Alert Criteria - Pedi
RED / BLUE
(Pedi patient < 16 years of age)
1 RED or 2 BLUE Criteria = TRAUMA ALERT
Choose all that apply
ONE OR MORE RED CRITERIA
R1
Patient not “awake and appropriate”
R2
ACTIVE airway assistance required (i.e.,
more than supplemental O2 without
airway adjunct)
Weak carotid/femoral pulse or Absent
distal pulses
Degloving injury, major flap avulsion
Acute Paralysis, loss of sensation, or
suspected spinal cord injury
Amputation proximal to wrist or ankle
> 10 % BSA 2nd /3rd degree burns
R3
R4
R5
R6
R7
Penetrating injury to head (or
depressed skull fracture), neck, torso,
extremities proximal to elbow or knee,
excluding superficial wounds
R9 Crushed, mangled, or pulseless injured
extremity
R10 Two or more long bone fractures (on
different extremities)
R11 Any open long bone fracture
R12 Pelvic fracture or flail chest
TWO OR MORE BLUE CRITERIA
B1
B2
B3
B4
B5
B6
B7
R8
B8
B9
Reliable history of any loss of
consciousness and or Amnesia
Weight < 10 Kg (< 22 lbs.) or RED or
PURPLE Broselow Tape Zone
Single closed long bone fracture site
Ejection from vehicle (excludes open
vehicles)
Death in the same vehicle
Fracture to humerus or femur due to
Motor Vehicle Crash
Auto vs Pedestrian / bicyclist /
motorcyclist thrown, run over, or with
significant (>20 mph) impact
Pregnancy > 20 weeks
Intrusion > 12 inches to occupant or 18
inches at any site
Paramedic intuition may serve as a Red / Blue Criteria override
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
23
Trauma Alert Criteria - Pedi
RED / BLUE
Blank
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
24
TXA Checklist
TXA Checklist
Administration of TXA is indicated if all of the following
criteria are present
Age > 16 years
Evidence of blunt or penetrating traumatic injury
(MVC with ejection, MVC rollover, fall > 20ft, auto vs. pedestrian, penetrating
injuries to the head, neck, torso, etc)
Evidence or concern for severe internal or external bleeding
(bleeding requiring a tourniquet, unstable pelvic fracture, two or more proximal
long bone fractures, flail chest, etc)
Sustained Systolic BP <90mmHg (or <100mmHg for 55 years or older)
Sustained Heart Rate > 100 bpm
Time since initial injury is known to be < 3 hours
To administer TXA mix 1gm in 100ml of N/S, infuse at 100gtts/min
over 10 minutes. (If given IVP may cause hypotension)Use dedicated
IV or IO line when possible. DO NOT administer in the same line as
blood products, factor VIIa or Penicillin)
Mark the main IV line that the TXA was administered through with
TXA and time administered
“When in doubt, do something in favor of your patient.” Jay Cloud
FREDERICKSBURG EMS
APP
24
TXA Checklist
Blank
“When in doubt, do something in favor of your patient.” Jay Cloud