Condell Medical Center EMS System

1. ECRN Packet 2006:SOP UpdatesDisaster CommunicationPatients With Special Challenges and Interventions for Patients with Chronic Care Needs Condell Medical Center EMS System Revised by: Sharon Hopkins, RN, BSN EMS Educator

2. Objectives Upon successful completion of this module, the ECRN should be able to: • identify key changes in the Region IX & X SOP’s • state the components of disaster communication • discuss the uniqueness when caring for patients with special challenges • identify the differences between hospitalization and homecare • review acute interventions necessary at home for the chronic care patient • identify components of a valid DNR form

3. Region X SOP UpdateHighlightsEffective March 1, 2007

4. SOP Update • Many updates are in keeping with revised AHA guidelines • Synopsis in notebook by EMS radio • All ECRN’s to read the document and sign off in the notebook • EMS providers were updated during February in-station CE

5. What’s New With The SOP’s? • AHA changes • CPR 1 and 2 person adult 30:2 • CPR 1 person infant and child 30:2 • CPR 2 person infant and child 15:2 • Switch compressors every 2 minutes , you’ll be tired • Once intubated, breaths are 1 every 6-8 seconds for all persons, compressor does not pause • Immediately after a shock, resume CPR • check rhythm only after 2 minutes of CPR • check pulse after 2 minutes of CPR only if you see a rhythm that should have a pulse

6. SOP’s and Antidysrhythmics • Any SOP that had listed Lidocaine now also includes Amiodarone in adult and pediatric SOP’s • It is EMS choice for which antidysrhythmic to use • ED should continue with same drug choice • heart more irritable when mixing antidysrhythmic drugs

7. Revised SOP’s • Table of Contents • organized into sections and each section alphabetized • Pediatric patient • Per EMSC guidelines, a pediatric patient is someone under the age of 16 (15 or less) • medications are calculated on weight • pediatric medication dose is maximized at the adult dosage (ie: cap off the dose at the adult dosage even if the child’s weight indicates more to be given)

8. Revised SOP’s • Conscious sedation • initial dose of Versed 5 mg, repeated every 1 minute at 2mg until sedation achieved • may continue Versed 1 mg every 5 minutes after intubation to keep patient sedated • Asystole - no longer recommend TCP attempt • Bradycardia • all Atropine dosages at 0.5 mg (“when they’re alive give them 0.5”) with a maximum still of 3mg

9. Revised SOP’s • Acute Coronary Syndrome • if patient reliable and took ASA in last 24 hours EMS will hold the dose and document • if pain unchanged after 2 doses of NTG will advance to Morphine (NTG continues only on Medical Control order) • Ventricular Fibrillation/Pulseless VT • shocks are delivered singularly & at highest watt setting • EMS choice of antidysrhythmic - (use only 1) • Amiodarone 300mg; in 5 minutes 150 mg • Lidocaine 1.5 mg/kg; in 5 minutes 0.75 mg/kg

10. Revised SOP’s • Ventricular Tachycardia with Pulse • EMS choice for Amiodarone or Lidocaine • Amiodarone to be diluted in 100 ml D5W and run IVPB over 10 minutes for adult • Acute Abdominal/Flank Pain • Pain control must be ordered by Medical Control • Be an advocate for the patient for pain control • Severe Respiratory Febrile Illness • New; heightens awareness of infection control • If patient needs a mask, use surgical mask • N95 (orange duck bill) only for medical team use

11. Revised SOP’s • Adult and Pediatric Heat Emergencies • Clarifies that heat stroke (the worst) can present hot & dry or hot & moist • Moist skin if exerting self before the collapse • marathoner • construction worker • Pediatric Bradycardia • Epinephrine is first drug of choice • EMS must contact Medical Control for Atropine order • appropriate for AV block or increased vagal tone

12. Revised SOP’s • Pediatric Allergic Reaction/Anaphylaxis • Benadryl 1 mg/kg added to the SOP’s • 25 mg maximum for stable allergic reactions with hives, itching and rash • 50 mg maximum for stable patient with airway involvement • 50 mg maximum for patient with anaphylaxis • Suspected Elder Abuse • effective 1-1-07 added self-neglect to behaviors that can be reported to the hot line

13. ECRN Responsibilities • Answer radio promptly • Identify that appropriate interventions/SOP’s are being followed based on report received • ECRN cannot order what is not already stated in protocol • to give an additional order, the ECRN must obtain the order from the ED MD • Document clearly and fully on the EMS radio log - it is a legal document

14. Highlights of Changes to Region 9 NWC EMSS SOP’s Member Fire Departments transporting to Condell: Buffalo Grove Lincolnshire/Riverwoods Long Grove Lake Zurich

15. NWC EMSS SOP’s • Full SOP in notebook above radio marked “NWC SOP” • ECRN & ED MD responsible to know the NWC SOP for those respective transporting departments • Each ECRN & ED MD responsible to: • review changes • review 55 question self-assessment tool • sign off that information was reviewed

16. Region X - CMC <16 years old (15 and younger) Region 9 - NWC <13 years old (12 and younger) Pediatric Ages

17. Region X - CMC ETT Combitube Region 9 - NWC ETT King LTS-D airway Advanced Airway Tools

18. Reinforcement of AHA Changes • Ventilations • With BVM: 1 breath every 5-6 seconds (10-12 breaths/minute) • With BVM to ETT: 1 breath every 6-8 seconds (8-10 breaths/minute) • Obstructed airway, unconscious person • Reposition head once & reattempt ventilation • If unsuccessful, begin CPR • look in mouth when opening airway to ventilate • Compressions • Minimize interruptions to <10 seconds • Switch compressors at end of every 2 minute cycle

19. Defibrillation • 360 joules if monophasic device; if biphasic device joules are manufacturer dependent • IV access • IO route via EZ IO drill for adult and pediatric patients if unable to establish a peripheral IV

20. Region X - CMC Lidocaine if head injury Benzocaine to eliminate gag reflex Morphine for pain Versed for sedation Versed for post-sedation continued sedation Region 9 NWC EMSS Lidocaine if head injury Benzocaine to eliminate gag reflex Morphine for pain Versed & Etomidate for sedation Versed for post-sedation continued sedation Conscious Sedation vs Drug Assisted Intubation

21. Region X - CMC Stable - Benadryl Stable with airway involvement Epi 1:1000 Benadryl Albuterol if wheezing Anaphylaxis Epinephrine 1:1000 Benadryl Albuterol if wheezing Region 9 NWC EMSS Mild - Benadryl Moderate Epinephrine 1:1000 Benadryl Albuterol & Atrovent if wheezing Severe Epinephrine 1:10,000 Dopamine if B/P <90 Glucagon possibly Benadryl Albuterol & Atrovent if wheezing Allergic Rx/Anaphylaxis

22. Region X - CMC Albuterol nebulizer Call Medical Control to consider use of CPAP for COPD Region 9 NWC EMSS Albuterol & Atrovent Severe distress: Epinephrine 1;1000 Albuterol & Atrovent Magnesium if distress persists Asthma/COPD

23. Region X - CMC 12 lead faxed to receiving hospital Aspirin NTG 2 doses Morphine if pain persists NTG taken with Viagra, Levitra, or Cialis can lead to untreatable hypotension Region 9 NWC EMSS 12 lead faxed to receiving hospital Aspirin NTG 3 doses Morphine if pain persists NTG taken with Viagra, Levitra, or Cialis can lead to untreatable hypotension Acute Coronary Syndrome

24. Region X - CMC Narrow QRS Atropine Wide QRS TCP Atropine if TCP ineffective Valium for comfort during TCP use Region 9 NWC EMSS TCP if clinical deterioration Versed and Morphine for comfort during TCP use If TCP ineffective or delayed, give Atropine Glucagon if beta or calcium blockers (stimulates release of catecholamines) Bradycardia

25. Region X - CMC Vasopressor used: Epinephrine 1:10,000 every 3-5 minutes Region 9 NWC EMSS Vasopressor used: Epinephrine 1:10,000 every 3-5 minutes or Vasopressin one time in place of 1st or 2nd dose Epinephrine Ventricular Fibrillation & Pulseless Ventricular Tachycardia

26. Region X - CMC Vasopressor used: Epinephrine 1:10,000 every 3-5 minutes Region 9 NWC EMSS Vasopressor used: Epinephrine 1:10,000 every 3-5 minutes or Vasopressin one time in place of 1st or 2nd dose Epinephrine Asystole/PEA

27. Region X - CMC NTG - 3 doses max Consider CPAP Lasix Morphine If wheezing, Albuterol Region 9 NWC EMSS CPAP Aspirin NTG - no dose limit Morphine Heart Failure/Pulmonary Edema

28. Region X - CMC Lasix NTG only on Medical Control order Valium if seizures Region 9 NWC EMSS Morphine NTG Versed if seizures Hypertension

29. Region X - CMC Valium IVP, IM, or rectally Region 9 NWC EMSS Versed IVP or intranasally (IN) via MAD device (“mucosal atomization device”). Dose different - not in ED or EMS pyxis for patient safety reasons! Seizures

30. Region X - CMC To control seizure activity: •Valium Region 9 NWC EMSS To control seizure activity: Magnesium For persistent seizures: Versed Pre-eclampsia

31. Disaster Communication Steps

32. Disaster Communication • Everyone’s responsibility to know their duties • Internal plan • Local plan • State wide plan • Federal plan • Resource manuals • Which ones are in your ED? • Where they are kept? • What do they contain? • How do you use them?

33. Types of Disaster Plans • Multiple Victim & Mass Casualty Plan • local plan with local resources • Emergency Medical Disaster Plan • State response plan with POD hospital • National Disaster Medical System NDMS • large scale national response utilized

34. Multiple Victim & Mass Casualty Plan • When the local event occurs, the Resource Hospital (CMC) for that department acts as the communication link to Receiving Hospitals Condell departments included are: • Countryside Libertyville • Grayslake  Round Lake • Mundelein Wauconda • Lake Forest Fire Lake Bluff, Knollwood • Murphy Ambulance

35. Multiple Victim & Mass Casualty Plan • Patients are being transported now • Transport from the scene may have already started with the most critical patients before official notification has even taken place • Resource hospital (CMC) will also be a receiving hospital • Need good coordination from the scene to the Resource Hospital (CMC) to best distribute the patient load to appropriate receiving hospitals

36. Emergency Medical Disaster Plan - State Plan • Statewide disaster plan for when a local area has exhausted their resources (ie: tornado) • Local POD hospital (ie: Highland Park Hospital for Region X) is the lead hospital in that Region (communication & coordination) PODCMCAssociate Hosp (LFH) • Resource Hospital (CMC) contacts their Associate Hospital (LFH) and conveys information back to the POD

37. State Plan - Phase I • Purpose • to determine resource availability within the region • No personnel or equipment is mobilized yet, this is a “heads-up” alert phase • Resource Hospital (CMC) to contact Associate Hospital (LFH) to obtain Phase I information (ie: resources) • Phase I form completed by CMC with CMC and LFH information combined and faxed to POD (HPH) within 1 hour

38. State Plan - Phase II • When notified by the POD (HPH), Resource Hospital (CMC) contacts Associate Hospital (LFH) for Phase II information • Phase II form completed by CMC with CMC and LFH information combined and faxed to POD (HPH) within 1 hour • The POD (HPH) passes on regional resource information to the State

39. Phase I & Phase II Paperwork • Forms in small red notebook by EMS radio marked “Disaster Worksheets - State Plan” • Instructions printed on the forms • State Disaster Plan could go on for days • Typically, early days are fact finding and gathering of information on availability of local resources • Typically may not see patient activity for days

40. National Disaster Medical System NDMS • Federal response for a major disaster (ie: Katrina) • FEMA coordinating activities • Utilize POD system for hospital communications • Most likely will not see patient activity for days • Early days spent gathering information regarding local resources

41. Special Challenges andChronic Care

42. Patients With Hearing Impairment • Deafness – partial or complete inability to hear • Conductive problem due to: • infection • injury • earwax • Sensorineural deafness due to: • congenital problem, birth injury • disease, tumor, viral infection • medication-induced • aging • prolonged exposure to loud noise

43. Patients With Hearing Impairment • Recognizing patients with hearing loss • Hearing aids • Poor diction • Inability to respond to verbal communication in the absence of direct eye contact • Speaks with different syntax (speech pattern) • Use of sign language

44. Patients With Hearing Impairment • Assessment/management accommodations • Provide pen/paper • Do not shout or exaggerate lip movement • Speak softly into their ear canal • Use pictures or demonstrate procedures • Consider use of interpreter services as needed (ie: discussion medical issues, consents)

45. Patients With Visual Impairment • Etiologies • Injury • Disease • Degeneration of eyeball, optic nerve or nerve pathways • Congenital • Infection (C.M.V.)

46. Patients with Visual Impairment • Central vs peripheral loss • Patients with central loss of vision are usually aware of the condition • Patients with peripheral loss are more difficult to identify until it is well advanced Central loss Peripheral loss

47. Patients With Visual Impairment • Assessment/management accommodations • Retrieve visual aids/glasses • Explain/demonstrate all procedures • Allow guide dog to accompany patient • EMS to notify hospital of patient’s special needs • Carefully lead patient when ambulatory • patient holds your arm • call out obstructions, steps and turns ahead oftime

48. Etiologies of Speech Impairment • Language disorders • Stroke •Hearing loss • Head injury •Lack of stimulation • Brain tumor •Emotional disturbance • Delayed development • Articulation disorder • Damage to nerve pathways passing from brain to muscles in larynx, mouth, or lips • Delayed development from hearing problems; slow maturation of nervous system • Speech can be slurred, indistinct, slow, nasal

49. Etiologies of Speech Impairment • Voice production disorders • Disorder affecting closure of vocal cords • Hormonal or psychiatric disturbances • Severe hearing loss • Hoarseness, harshness, inappropriate pitch, abnormal nasal resonance • Fluency Disorders • Not well understood • Marked by repetition of single sounds or whole words • Stuttering

50. Recognizing Patients With Speech Impairment • Reluctance to verbally communicate • Inaudible or nondiscernable speech pattern • Language disorders (aphasia) • Limitations in speaking, listening, reading & writing • Slowness to understand speech • Slow growth in vocabulary/sentence structure • Common causes: blows to head, GSW, other traumatic brain injury, tumors