EMS Governance
Describe the difference between single-tier vs. multi-tiered EMS systems.
Single-tier
Every response by same level of personnel and equipment regardless of call type
Multi-tier
Combination of ALS and BLS
volume of a gas is inversely proportional to pressure
What is Boyle's Law
OHCA TOR; AHA Guidelines recommend all EMS providers DO NOT INITIATE resuscitation of any patient in the following scenarios.
2015 AHA guidelines recommend all EMS providers DO NOT initiate resuscitation of any patient in the following scenarios:
Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril
Overt clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, decomposition)
A valid advanced directive, a Physician Orders for Life-Sustaining Treatment (POLST) form indicating that resuscitation is not desired, or a valid Do Not Attempt Resuscitation (DNAR) order
List 2 early causes of death from crush injury.
Third spacing of fluid
Dysrhythmia from severe metabolic acidosis
Hyperkalemia
What is the fee for 911 transport fee for those with MSP?
$80
Define direct medical control.
Concurrent direction to EMTs providing patient care (i.e. radio, telephone)
Centralized system = a selected hospital is designated lead facility
Decentralized system = each hospital functions as base hospital
Volume of a gas is proportional to temperature
What is Charle's Law?
List the 3 criteria for BLS termination of resuscitation in adult out-of-hospital cardiac arrest.
BLS Termination of Resuscitation for Adult OHCA
Arrest not witnessed by EMS personnel AND
No shock delivered AND
No pre-hospital ROSC
Describe the three distinct phases of tactical combat care.
Care under fire = Hot Zone
Direct exposure to hostile fire
Mitigation of threat (suppressive fire), rescue position if possible, tourniquet use, evacuation to safer zone or phase of care
Tactical field care = Warm Zone
Under threat of injury but not direct hostile fire
Airway establishment, breathing (tension and open PTX), replacement of tourniquets with direct pressure bandages or advanced hemostatic agents, fluid therapy (IV/IO access), prevent hypothermia, analgesia
Casualty evacuation care = Cold Zone
Safe zone with NO threat of injury
Care begins to approximate civilian medical care advanced life support
What was the "bottom line" of the 2004 NEJM OPALS study, Stiell et al.?
Bottom Line: Addition of an advanced life support algorithm to BLS management did not increase the survival to hospital discharge for patients with OHCA.
Describe the role of an EMS medical director.
2. Interact with all aspects of the system.
3. Remove provider from practice if medical care or behaviour is substandard.
Total barometric pressure is equal to sum of partial pressures of gases in mixture
What is Dalton's Law?
List the 4 criteria for ALS termination of resuscitation in adult out-of-hospital cardiac arrest.
ALS Termination of Resuscitation for OHCA
Arrest not witnessed by EMS personnel AND
No bystander CPR AND
No shock delivered AND
No pre-hospital ROSC
List 4 delayed causes of death from crush syndrome.
Renal failure
ARDS
Sepsis
Ischemic organ injury
DIC
Electrolyte disturbances
Describe the process of Refusal of Transport.
Assess capacity 🡪 informed decision must be made by patient
Consent elements:
consent must be voluntary
Patient/SDM must have capacity
Patient/SDM must be properly informed
Informed consent: understand material risks and benefits of having treatment and not having treatment; understand alternatives
List 4 examples of indirect medical control.
Indirect medical control:
Medical accountability for patient care activities
Protocol development
Personnel education
Prospective and retrospective patient care reviews
Quality improvement processes
List 6 potential injuries that can occur during transport as a result of Boyle's Law.
Potential Injuries on Descent (volume contraction)
Barotitis, Barosinusitis, toothache
Potential Injuries on Ascent (volume expansion)
Conversion of simple PTX to tension PTX
Rupture of hollow viscus from expansion of intestinal gas
Increased pressure in medical equipment with closed air spaces (IV tubing, air splints, ventilators, ETT/LMA cuffs)
List 5 indications for air medical transport.
Distance too great
Time critical condition, ASAP transport
Time critical condition, requiring treatment not available at referring hospital
Delay with ground transport likely to worsen clinical condition
Requires critical care not available with ground transport
Patient in area not accessible by ground
Local ground units are not available for long-distance transport
Ground transport would leave the local area without adequate EMS coverage
Requesting physician best judgment for transport is by AMT
List important items in the management of crush syndrome.
Early aggressive therapy (hydration) prior to extrication
Continuous monitoring during extrication
Fluid resuscitation (can require up to 12 L/day to sustain forced diuresis of 8 L/day to prevent renal complications)
Treatment of hyperkalemia (insulin/glucose, beta-agonist, ion-exchange resins, dialysis)
IV Calcium ONLY for arrhythmias that do not respond to other measures or documented severe hypocalcemia
Risk formation of calcium phosphate calcifications crush syndrome associated with hyperphosphatemia
? Alkalinization of urine
List 6 medications that BLS paramedics can administer to patients.
Oxygen
ASA
Nitro
Ventolin
Glucagon
Epi (IM)
Narcan
List 8 essential components of an EMS System.
Manpower
Transportation
Communications
Training
Facilities
Critical Care
Access to Care
Transfer of Care
Define Henry's Law.
Mass of gas absorbed by liquid is proportional to partial pressure of gas above the liquid
List the advantages and disadvantages of rotor-wing transport.
ADVANTAGES
- Faster than ground (120-180mph)
- Avoid traffic/ground obstacles
- Ability to land in otherwise inaccessible locations
- Landing zone requirements do not require an airport
DISADVANTAGES
- Noise, vibration
- Turbulence
- Cramped quarters
- Weight limitations
- Weather restrictions
- Limited range (150-200miles)
List 7 clinical problems that occur with much higher frequency in the urban search and rescue environment.
Crush syndrome
Compartment syndrome
Particulate inhalation
HAZMAT exposures
Blast injuries
Hypothermia
List 6 components of an EMS COMMUNICATION system.
1. Public information regarding access to care
2. Call triage system
3. Education
4. Dispatch support to bystanders for resuscitation
5. Prehospital notification
6. QI