1.0 - Routine Patient Care
Respond to scene in a safe manner:
- Review dispatch information
- Use lights and sirens and/or pre-emptive devices when responding as appropriate per emergency medical dispatch information and local guidelines.
Scene arrival and size-up:
- Utilize Body Substance Isolation, as appropriate.
- Scene safety, bystander safety.
- Environmental hazards assessment.
- Number of patients.
- Determine need for additional resources.
- Utilize Mass Casualty Incident (MCI) and/or Incident Command System (ICS) procedures as necessary.
- Determine mechanism of injury/illness.
Patient Approach:
The presumption is that patients requesting EMS services should not walk to the stretcher or ambulance, but should be moved using safe and proper lifts and devices. Specifically the condition of patients with cardiac, respiratory, or neurological conditions, and of patients with unstable vital signs, can be worsened by exertion, so patient effort in moving to the stretcher and ambulance should be minimized. Unique circumstances and deviations from these principles must be clearly described in the Patient Care Report (PCR) and the service must have an internal performance improvement (PI) mechanism to review each case.
- DO NOT allow sick or injured patients to walk or otherwise exert themselves. Use safe and proper lifts and carries and appropriate devices to extricate patients to the ambulance stretcher.
Begin assessment and care at the side of the patient; avoid delay.
Bring all necessary equipment to the patient in order to function at your level of certification and up to the level of the ambulance service license.
Activate air-medical transport early and if applicable to do so.
Determine if a valid MOLST order or Comfort Care/DNR Verification form is in place, and act accordingly.
Initial request for ALS should take place immediately after recognizing severity of symptoms.
Note that there is no such regulatory concept as a “lift-assist call.” Under 105 CMR 170.345 of the EMS System regulations, each EMS call – including but not limited to those cases in which no treatment is provided, the patient refuses treatment and there is no transport – a patient care report (PCR) must be documented. When EMS is dispatched to a patient who is requesting a “lift assist,” EMS must complete and document an appropriate patient assessment on a PCR. If the patient is not transported, then an informed refusal must be documented, in accordance with Protocol 7.5, and included in the PCR.
Assessment and Treatment Priorities:
Determine unresponsiveness, absence of breathing and pulselessness; Initiate high quality CPR with minimal interruptions in chest compressions for patients found to be in cardiac arrest and in the absence of a MOLST/CC/DNR. Determine patient’s hemodynamic stability, symptoms, level of consciousness, ABCs, vital signs.
Maintain an open airway and assist ventilations as needed.
Apply the cardiac monitor and obtain a 12-lead ECG tracing as soon as possible when clinically appropriate and within your scope of practice.
Administer supplemental oxygen using the appropriate delivery device, if indicated.
Within your scope of practice, obtain peripheral access via intravenous (IV) or intraosseous (IO) on all patients exhibiting signs and symptoms consistent with shock or who are hemodynamically compromised, or have the potential to become compromised. For pediatric patients, administer a 20mL/kg fluid bolus if applicable.
When obtaining IO access in patients able to perceive pain, in adults, administer Lidocaine 40mg over two minutes, followed by a 10mL fluid bolus over five seconds. In pediatrics, 1mg/kg to a maximum of 20mg.
Patients who may be in need of medications for conditions such as but not limited to nausea or pain should also have IV access established if possible to do so. In a critical patient with no other vascular access, if trained to do so and with concurrent on-line medical control order, Paramedics may access a Peripherally Inserted Central Catheter (PICC) line (not any other central access) in order to administer medications.
Consider the use of advanced airway interventions as appropriate and if trained to do so.
Ventilation rates are to be titrated to goal ETCO2 recommendations.
Use quantitative, recordable waveform capnography for all patients with advanced airway interventions and consider its use with all respiratory compromised conditions.
The capnography waveform must be recorded on all intubated patients and clinically significant data attached to the patient care report for the receiving facility. In patients who are not in cardiac arrest, all efforts should be made to avoid end-tidal carbon dioxide levels that have been shown to be detrimental and to ensure quality ventilation and oxygenation. In general this means that capno-ETCO2 values should be kept between 35-40 mm Hg in these patients; specific exceptions should be discussed with online medical control.
At a minimum, monitor and document vital signs every 15 minutes on stable patients and every 5 minutes for patients with critical conditions.
Obtain a thorough assessment (O-P-Q-R-S-T) related to the event.
Obtain a complete medical history (S-A-M-P-L-E).
Obtain venous blood samples according to the receiving hospital policies.
Obtain additional field diagnostic testing when clinically indicated, and if available; (not limited to) blood glucose, pulse oximetry, temperature, carbon monoxide, stroke scale.
Administer medications in accordance with the specific patient condition and scope of practice.
Contact on-line Medical Control for all procedures outside the provisions of standing orders, which may include repeat doses of medications within the standing orders.
Follow service or regional policies for all radio or communication failures.
If indicated, contact the receiving hospital to provide a clear and concise report on the patient’s condition, all interventions, findings, and estimated time of arrival to the receiving department.
Continually reassess all patients, especially after any interventions and/or medication administration.
If no palpable, distal pulse is present following suspected extremity fracture, position injured extremity in correct anatomic position, and apply gentle traction along the axis of the extremity distal to the injury until the distal pulse is palpable and immobilize in place. Note: This does not apply to dislocations.
EMS crews should not begin or administer interventions that would require medical assessment if a patient is being brought to an environment where formal medical assessment will not be provided; for example, giving IV narcotics to a patient who is about to be left at home.
Ambulance Stretcher Operations:
Operate the ambulance stretcher in accordance with your service training and manufacturer’s specifications at all times.
When moving a patient on the ambulance stretcher, adjust the height of the ambulance stretcher from the “load position” to a safe position for travel.
All EMTs moving the patient must keep both hands on the ambulance cot when elevated or in motion. Properly secure all patients using the required straps, including the over-the-shoulder harness, hip and leg restraining straps.
If patient care requires the removal of any of the restraining straps, re-secure them as soon as practical to do so.
Pediatric patients are to be transported in a properly secured child transport device/seat if spinal injury is not suspected. (See 7.4 Pediatric Transport for more).
Patient care reports and data collection:
The EMS System regulations require an accurate, concise and properly documented patient care report to be completed at the time of the call or as soon as practicable afterwards for all patient encounters. Pertinent data must be left at the receiving hospital at the time of transport. The regulations also require that patient care reports include the minimum required data elements, as defined by the administrative requirement (A/R 5-403).
Note that EMS personnel dispatched to an EMS call in a certified ambulance vehicle of any class (Class I through V) must always complete an appropriately documented patient care report. This is required under 105 CMR 170.345 of the EMS System regulations. See last bullet under Patient Approach, above.
Clinically relevant data must be conveyed to a nurse, physician assistant or physician before leaving the receiving facility.
The patient care report(s) must include clinically relevant ECG tracings, 12-lead tracings and waveform capnography tracings when obtained.
Additional data elements may be collected at the request of your Affiliate Hospital Medical Director. This data may pertain to, but is not limited to; trauma, cardiac arrest, stroke and infectious disease processes.
Medication use and storage:
Medications may be administered in divided doses up to the maximum noted in protocol.
The medication lists are to be considered a reference list only and may contain information and uses not intended for prehospital administration.
Inclusion of this information does not imply approval of and use of that medication unless specifically stated in the applicable protocol.
Securely maintain and store all medications and fluids at the appropriate temperatures as designated by manufacturer’s recommendations and in accordance with all Drug Control Program regulations.
Pharmaceutical shortages and supply chain issues have become more frequent. The Department will issue Advisories addressing these shortages and outlining alternative therapies when needed.
All EMTs and service providers must adhere to all advisories, memos and administrative requirements issued by the Department regardless of the topic.
Medications administered by nasal atomizer (IN) should be with no more than 1mL of volume per nare. If additional medication must be administered, wait one minute before repeating IN.
Avoid hyperoxygenation, oxygen administration should be titrated to patient condition, and administered with evidence of hypoxemia, dyspnea, or an SpO2 <94%, especially in the presence of a suspected CVA/TIA or ACS.
IV pumps are the preferred method of administering vasoactive medications. Norepinephrine must be administered via pump, Dopamine may be used until pump available. Those providers with the equipment and training may begin using pumps immediately.
Exception principle of the protocols:
The Statewide Treatment Protocols represent the best efforts of the EMS physicians to prehospital providers of the Commonwealth and reflect the current state of out-of-hospital emergency medical care, and as such should serve as the basis for such treatment.
On occasion, good medical practice and the needs of patient care may require deviations from these protocols, as no protocol can anticipate every clinical situation. In those circumstances, EMS personnel deviating from the protocols should only take such actions as allowed by their training and only in conjunction with their on-line medical control physician.
Any such deviations must be reviewed by the appropriate local medical director, but for regulatory purposes are considered to be appropriate actions, and therefore within the scope of the protocols, unless determined otherwise on Department review by the State EMS Medical Director.
Transport decision
Transport to the nearest appropriate treatment facility as defined in EMS regulations. In rare circumstances, delayed transport may occur when necessary treatment cannot be performed during transport.
Request and use available advanced life support (ALS) – paramedic resources in accordance with these protocols, initiate transport as soon as possible, with or without ALS.
EMS personnel shall make decisions about the destination hospital in accordance with the EMS System regulations and Department-approved point-of-entry (POE) plans.
There are currently Department-approved condition-specific POE plans for trauma, stroke and STEMI, as well as a POE for a patient’s other condition or need, not covered in the specific POE plans.
Department-approved regional POE plans for trauma; stroke and STEMI identify specific hospitals to be used. The EMT must be aware of all these POE plans affecting his/her service when choosing the appropriate hospital destination.
EMS personnel may call medical control if they have a question about POE.
Notify receiving facility as early as possible.
Use of lights and sirens should be justified by the need for immediate medical intervention that is beyond the capabilities of the ambulance crew using available supplies and equipment.
Continuous quality improvement (CQI)
The Department’s Hospital Licensure regulations for medical control service (105 CMR 130.1501-1504.) require that hospital physicians providing medical direction must be knowledgeable in the communication system and its usage and must know the Statewide Treatment Protocols for each level of EMT.
Medical directors for ambulance services must take an active role in reviewing clinical performance and competency of its EMTs at all levels in the delivery of patient care and in overseeing and conducting the ambulance service’s CQI process.
Ambulance services with their medical directors must develop and implement a comprehensive and dynamic quality assurance program in accordance with the ambulance service’s affiliation agreement.
An ambulance service and medical director that uses certain optional diagnostic and treatment modalities must do so in accordance with Section 6: Medical Director Options and its program specific CQI requirements. The affiliate medical director is responsible for overseeing of such programs and ensuring the ambulance service meets the CQI requirements and the Department’s data reporting requirements.
Advanced airway confirmation:
Advanced EMT and Paramedic treatment protocols require that EMTs provide advanced airway management when clinically indicated. Specific training and airway adjuncts are necessary and require training in accordance with scope of practice and service specific devices.
Endotracheal tube insertion and supraglottic airway devices such as the King LT are commonly used in patients that require advanced airway management. Airway devices must be secured, with depth noted as appropriate.
All EMT-Paramedics must be able to insert NGT / OGT for those unconscious post-intubation patients who need gastric decompression.
The standard of care requires specific methods of verification to be used including capnography and at least two of the following;- auscultation, colorimetric readings, visualization of the chords, the presence of condensation, and other clinical signs that the advanced airway is positioned correctly.
All patients with an advanced airway in place must have recordable waveform capnography documented.
Documentation on the patient care report must include at least three evidence based methods of verification of tube placement (one being capnography) and must include at least three separate times in which verification was completed, including verification of tube placement at the time of arrival at the receiving department and staff.
For patients under 12 years old, the airway is in most cases best managed with a BVM or SGA. In some cases, intubation may be preferred. This is at the discretion of the treating paramedic.