VERSION: 5.0.2018 : JULY 2018 DOCUMENT NAVIGATION If viewing this document as a printed hard copy The Header color of each section defines the protocol type Introduction Blue – Adult Protocols Pink – Pediatric Purple – OB Emergencies Gray – Reference or Policy If viewing this document as portable document file (PDF with Adobe Reader) This document is hyperlinked for easy navigation in Adobe Reader. The colored boxes in each protocol tree are linked to the respective pages with further information on the specific procedure, medication, or protocol page. There is an active link when hovering over the text within the colored box and the cursor changes from a bar to a pointer finger. Left clicking will jump to the linked page containing further information. Right clicking and selecting “Previous View” will return you to the page you started at. This document is also bookmarked with respect to the individual sections. Use the book mark feature of Adobe Acrobat to display pre-designated bookmarks and click on each to jump between sections. PROTOCOL REVISION CHANGE LOG PROTOCOL VERSION CHANGE LOG Complete revision and reformatting of current 1.0.2017: January 2017 2014 Cleveland Clinic EMS Protocols and other DRAFT supportive documentation. Draft Revision Draft edits completed on content up to and 2.0.2017: January 2017 including Adult Medical Protocol section. DRAFT EDITS Completed Edits completed and reviewed by committee. All 3.0.2017: March 2017 sections compiled and combined into one (1) FINAL COPY PDF document. Hyperlinks to be completed. Finals last minute edits made. Protocol finalized 4.0.2017: April 2017 and approved. FINAL EDITION Signs and Symptoms of Stroke/CVA changed 5.0.2018 : July 2018 from less than 12 hours in duration to less than STROKE PROTOCOL EDIT 24 hours in duration. CLEVELAND CLINIC EMS MEDICAL CONTROL PROTOCOLS – INTRODUCTION - i - INTRODUCTION The Cleveland Clinic Physicians Advisory Board has developed the following EMS Medical Control Protocols and Procedures Manual to establish the minimum standard of care, which will be provided by all Emergency Medical Services organizations under their respective Medical Control authority. These protocols and procedures are to be used as guidelines for operation during EMS calls that require medical direction. They are also intended to be guidelines to ensure that personnel are trained in proper pre-hospital patient care. Procedures are not considered rigid rules, but rather established standards against which EMS practice can be measured. Treatment protocols are specific orders directing the actions pertaining to techniques and / or medications used by EMS personnel who are required to practice under direct supervision of a physician and under their respective EMS Medical Control authority of the Cleveland Clinic. Treatment protocols may and should be initiated without prior direct Medical Control contact, especially when the patient’s condition and / or situation is life threatening. As soon as the condition and / or situation permits, direct contact must be established with Medical Control for confirmation of medical care and further medical direction. Emergency Medical Services and their personnel who wish to operate under the Cleveland Clinic EMS Medical Control authority may do so only with the express written and signed authorization of their respective EMS Medical Director. Although not identical, these protocols and procedures are derived from the State of Ohio EMS guidelines. Please note that items in this manual are subject to continuous review for the sake of providing members with the most current emergency medical information. Updates to this material may be frequent to maintain a current standard of care to benefit both the patient and the provider of emergency medical care. The bottom of the page shows when the most current version was printed. Please replace older versions with newly updated material as soon as it is issued. Once updated, older versions are to be considered obsolete and thus, are to be discarded to help eliminate confusion. CLEVELAND CLINIC EMS MEDICAL CONTROL PROTOCOLS – INTRODUCTION - ii - ACKNOWLEDGEMENTS Appreciation is extended to all those who assisted in the development and revision of these protocols. All Signatures are on file with the Ohio Department of Public Safety-EMS Division. Ashtabula County Medical Center Imraan Hanniff, MD Medical Director Ryan Fertig, EMSI, EMTP EMS Coordinator Akron General Hospital Amy Raubenolt, MD Medical Director Kathy Cern, EMSI, EMTP EMS Coordinator Euclid Hospital Jason Watson, MD Medical Director Greg Ivanovics, EMSI, EMTP EMS Coordinator Hillcrest Hospital James Sauto, MD Medical Director Jonathan Keary, MD Medical Director Karen Shelby, EMSI, RN EMS Coordinator Bruce Shade, EMSI, EMTP EMS Coordinator Medina Hospital Chris Myers, MD Medical Director Rick Moskalski, EMSI, EMTP,CICP EMS Coordinator Marymount Hospital James Sauto, MD Medical Director Jeff Gembus, RN, EMSI, EMTP EMS Coordinator Brian Summers, EMSI, EMTP EMS Coordinator CLEVELAND CLINIC EMS MEDICAL CONTROL PROTOCOLS – INTRODUCTION - iii - ACKNOWLEDGEMENTS-Cont. South Pointe Hospital Jonathan Klein, MD Medical Director Dennis Linsky, EMSI, EMTP EMS Coordinator Brian Summers, EMSI, EMTP EMS Coordinator Fairview Hospital Joseph Lally, MD Medical Director Cheryl Behm, RN, EMSI EMS Coordinator Joe Gavlak EMSI, EMTP EMS Coordinator Cleveland Clinic Lakewood Joseph Lally, MD Medical Director Mary Sidell, RN, EMSI, EMTP EMS Coordinator Avon REJ Hospital Roy Seitz, MD Medical Director Greg Laborie, EMSI, EMTP EMS Coordinator Cleveland Clinic Twinsburg Jonathan Keary, MD Medical Director John Dunn, EMSI, EMTP EMS Coordinator Cleveland Clinic Brunswick Stephen Sayles, MD Medical Director Rick Moskalski, EMSI, EMTP EMS Coordinator CLEVELAND CLINIC EMS MEDICAL CONTROL PROTOCOLS – INTRODUCTION - iv - MEDICAL CONTROL PROTOCOLS AND PROCEDURES GUIDELINES 1. The patient history should NOT be obtained at the expense of the patient. Life-threatening problems detected during the primary assessment MUST be treated first. 2. Cardiac arrest due to trauma is not treated by medical cardiac arrest protocols. Trauma patients should be transported promptly with CPR, control of hemorrhage, Spinal motion restriction (SMR), and other indicated procedures attempted en route. 3. In patients with non-life-threatening emergencies who require IV’s, only two IV insertions should be attempted in the field; additional attempts must be made enroute. 4. In patients requiring IV’s, lab draw should be obtained if appropriate and applicable. 5. Patient transport, or other needed treatments, must not be delayed for multiple attempts at endotracheal intubation. 6. Verbally repeat all orders received before their initiation. 7. Any patient with a cardiac history, irregular pulse, unstable blood pressure, dyspnea, or chest pain MUST be placed on a cardiac monitor and a copy of the EKG (with 2 patient identifiers) MUST be attached to the EMS Run Sheet. 8. When transferring lower level prehospital care to a higher level of prehospital care, a thorough consult should be performed between caregivers describing initial patient presentation and care rendered to the point of transfer. 9. If the patient’s condition does not seem to fit a protocol or protocols, contact Medical Control for guidance. 10. All trauma patients with mechanisms or history for multiple system trauma will be transported as soon as possible. The scene time should be 10 minutes or less. 11. Medical patients will be transported in the most efficient manner possible considering the medical condition. Advanced life support therapy should be provided at the scene if it would positively impact patient care. Justification for scene times greater than 20 minutes should be documented. CLEVELAND CLINIC EMS MEDICAL CONTROL PROTOCOLS – INTRODUCTION - v - KEY TO ALGORITHMS All algorithms are color coded to denote procedures which may be performed by each level of EMS certification. To perform procedures color - coded RED, Medical Control MUST be contacted for permission. Higher levels of certification will perform lower level evaluations and procedures when interpreting the algorithms. The protocol format is for quick reference and does not detail patient assessment, interpretation or interventions. EMS personnel are accountable for all patient care and documentation to their level of training and lower. COLOR CODES BLACK Universal Patient Care Protocol YELLOW EMT – EMT Skill and Assessment Level Interventions GREEN EMT – Advanced EMT and Assessment Level Interventions BLUE Paramedic Skill and Assessment Level Interventions RED Medical Direction Contact / Authorization - Consult Required ALGORITHM LEGEND E EMT E A AEMT A P PARAMEDIC P M MEDICAL CONTROL M Stop – Do NOT Perform Intervention if Listed Criteria Present Caution – Reminder About Specific Intervention. Do NOT Perform Action Unless Listed Criteria Are Met and Understood. If Question(s), Contact Medical Control CLEVELAND CLINIC EMS MEDICAL CONTROL PROTOCOLS – INTRODUCTION - vi - UNIVERSAL MEDICAL CARE PROTOCOL E EMT E A AEMT A P PARAMEDIC P M MED M CONTROL SCENE SAFETY PATIENT ASSESSMENT Cardiac Arrest ? Adult Assessment Procedure Pediatric Assessment Procedure Cardiac Arrest Protocol AIRWAY Adult Airway Protocol Pediatric Airway Protocol Circulation Protocols Spinal Motion Restriction (SMR) Determine VITAL SIGNS Respirations Breathing Rate and Quality Heart Rate Blood Pressure SPO2 Consider Cardiac Monitor Appropriate Protocol Patient doesn’t fit any protocol?