PURPOSE

The Regional Emergency Medical Advisory Committee (REMAC) of New York City Advanced Life Support (Paramedic) Protocols define the minimum standard of Advanced Life Support care provided to patients by Advanced Emergency Medical Technician-Paramedics (AEMT-Ps) in New York City. These protocols reflect both the curriculum and Advanced Emergency Medical Technician-Paramedic (AEMT-P) certification requirements of the New York State Department of Health Bureau of Emergency Medical Services and the Regional Emergency Medical Advisory Committee (REMAC) of New York City. They have been endorsed by the Regional Emergency Medical Services Council (REMSCO) of New York City.

These protocols are guidelines which should be used in conjunction with good clinical judgment.

SCOPE

These protocols apply to all Advanced Emergency Medical Technician-Paramedics (AEMT-Ps) who are certified by the New York State Department of Health and the Regional Emergency Medical Advisory Committee (REMAC) of New York City, including supervisory and administrative personnel, operating within the New York City region.

RESPONSIBILITIES

AEMT-Ps shall provide appropriate care in accordance with these Advanced Life Support (Paramedic) Protocols as indicated by the patient's complaint and/or condition without exceeding the limit of their training.

MEDICAL CONTROL AT THE SCENE

In accordance with Article 30 of the New York State Public Health Law, the Regional Emergency Medical Services Council (REMSCO) is responsible for the coordination of emergency medical services within the region. In accordance with Article 30 of the New York State Public Health Law, the Regional Emergency Medical Advisory Committee (REMAC) is responsible for the medical oversight of the emergency medical service system within the region. In accordance with

500 GENERAL OPERATING PROCEDURES (continued)

MEDICAL CONTROL AT THE SCENE (continued)

the Regional Protocol on Coordination of Prehospital Resources, the highest level prehospital provider from the ems agency which first arrives at the scene of a prehospital medical emergency is responsible for coordination of patient care resources at the scene. In accordance with the Regional Protocol on Coordination of Prehospital Resources, when a NYC "911" participating ems agency is not the first ems agency on the scene and is not acting in the role of the primary care provider, it shall act as an operational resource for information regarding hospital diversions, specialty referral center bed availability, and other specialized resources, as well as incident scene safety (e.g., environmental conditions, crowd/traffic control in the absence of NYPD, potentially dangerous patient or family member to self and/or others); the Fire Department, City of New York (FDNY) is responsible for coordination of patient care resources at the scene of Multiple Casualty Incidents (MCIs), unscheduled MEDEVAC transports, Hazardous Material (HAZMAT) situations which require decontamination, fires/crimes in progress or unusual public health or safety emergencies. At the point that FDNY assumes operational responsibility for coordination of prehospital resources, incident command procedures are in effect. (See Protocol #500-B.)

In all cases where EMTs are present at the scene of a medical emergency and AEMTs are not present, EMTs are responsible for medical control at the scene. EMTs shall also assume medical control at the scene if EMTs and Certified First Responders (CFRs) are present; CFRs shall assume medical control at the scene until the arrival of EMTs. AEMTs shall assume medical control at the scene if AEMTs and EMTs (and/or CFRs) are present. AEMT-Ps shall assume medical control at the scene if other level AEMTs are present.

On calls where AEMT-Ps encounter multiple patients requiring Advanced Life Support (Paramedic) treatment and the Transportation Decision requires the use of available Basic Life Support units, any Advanced Life Support (Paramedic) protocols initiated by the AEMT-Ps should continue enroute as long as an AEMT-P is attending the patient.

AEMTs may release patients not having received or not requiring Advanced Life Support care to Basic Life Support personnel for care and transportation to a medical facility. However, under no circumstances shall an AEMT or EMT transfer responsibility for patient care to a CFR once patient care has been initiated by an AEMT or EMT. This does not relieve CFRs of their patient care responsibilities.

1. PROVIDERS TRAINED IN DEFIBRILLATION MAY NOT ABDICATE RESPONSIBILITY FOR DEFIBRILLATION TO PROVIDERS NOT TRAINED IN DEFIBRILLATION.
   
   

500 GENERAL OPERATING PROCEDURES (continued)

MEDICAL CONTROL AT THE SCENE (continued)

AEMT/EMT/CFR medical control includes, but is not limited to, decisions involving patient care, movement, and transportation, in accordance with scope of practice, these protocols, and agency policy.

If a prehospital care provider receives an order from a public safety official that is detrimental to the patient's condition, contrary to good patient care, or in violation of these protocols or agency policy, the crew shall inform the official of such and continue providing appropriate care.

If the official persists, the crew shall request a prehospital care supervisor from the appropriate agency to respond to the scene.

Upon completion of the assignment, the crew shall prepare a written statement and forward it to the Regional Emergency Medical Advisory Committee via appropriate supervisory personnel.

In the event that a physician who appropriately identifies himself/herself appears at the scene and only wishes to intervene in Basic Life Support care, the EMTs/AEMTs will present the physician with a document outlining the agency's policy regarding "Non-Solicited Medical Intervention". The on-scene physician's requests concerning emergency care and movement of the patient should be followed provided they do not conflict with Basic Life Support Standing Orders, policies and procedures. The on-scene physician's name and address shall be noted in the comment section of the Prehospital Care Report (PCR). If any conflicts arise with the on-scene physician, the EMTs/AEMTs shall contact Medical Control and proceed as directed.

In the event that a physician who appropriately identifies himself/herself appears at the scene and also wishes to intervene in Advanced Life Support care, the AEMT-P will present the physician with a document outlining the agency's policy regarding "Non-Solicited Medical Intervention", and must contact Medical Control to approve the AEMT-P taking orders from the physician. If granted approval, the on-scene physician's requests concerning emergency care and movement of the patient should be followed provided they are confined to Advanced Life Support Standing Orders and Medical Control Options contained in the appropriate protocol. In such cases, the on-scene physician may not order Discretionary Decisions. The on-scene physician's name and address and Regional Emergency Medical Advisory Committee (REMAC) of New York City Medical Control number (if applicable) shall be noted in the comment section of the Prehospital Care Report (PCR). If any conflicts arise with the on-scene physician, the EMTs/AEMTs shall contact Medical Control and proceed as directed. If the AEMT-P is unable to establish contact with Medical Control, the AEMT-P, at his/her option, may follow directions from the on-scene physician within the context of the protocols.

500 GENERAL OPERATING PROCEDURES (continued)

MEDICAL CONTROL AT THE SCENE (continued)

In the event that any licensed health care professional other than a physician appears at the scene and wishes to direct AEMT-P care, the AEMT-P is to maintain responsibility for the care of the patient.

SCENE SAFETY

It is the responsibility of the EMTs/AEMTs to evaluate and judge the scene with regard to safety. Safety factors include, but are not limited to, environmental conditions, crowd/traffic control, potentially dangerous patient or family member to self and/or others, Hazardous Material (HAZMAT) situations, fires/crimes in progress, or unusual public health or safety emergencies. Such conditions may be a threat to the health or safety of EMTs/AEMTs, patients, and other persons at the scene. EMTs/AEMTs must use caution in situations that they are not trained or equipped to handle.

In accordance with the Regional Protocol on Coordination of Prehospital Resources, EMTs/AEMTs may use a NYC "911" system participating agency as an operational resource for incident scene safety (e.g., environmental conditions, crowd/traffic control in the absence of NYPD, potentially dangerous patient or family member to self and/or others); and must notify FDNY in situations involving Multiple Casualty Incidents (MCIs), unscheduled MEDEVAC transports, Hazardous Material (HAZMAT) situations which require decontamination, fires/crimes in progress, or unusual public health or safety emergencies. (See Protocol #500-B.)

INTERPRETATION OF PROTOCOLS

The following Advanced Life Support (Paramedic) Treatment Protocols are for the use of the AEMT-P in the field and the Medical Control physician. They have been developed to ensure high quality, standardized prehospital emergency medical care. The protocols are specific for Advanced Life Support (Paramedic) treatment. Patient assessment and Basic Life Support treatment have not been enumerated herein. However, they are the foundation upon which these protocols are based, and are always to be performed as necessary. All references to Basic Life Support procedures refer to the appropriate Regional Emergency Medical Advisory Committee (REMAC) of New York City Basic Life Support Treatment Protocols.

500 GENERAL OPERATING PROCEDURES (continued)

INTERPRETATION OF PROTOCOLS (continued)

Protocols 501 through 521 apply to adult patients 14 years of age and older. (For patients 14 years of age and older who weigh less than 40 kg, see the Pharmacology Table below for appropriate drug dosages.) Protocols 527 through 528 apply to all patients. Protocols 540 through 559 apply to pediatric patients 13 years of age or younger.

STANDING ORDERS

Standing Orders may be performed without contacting Medical Control. However, Medical Control may be used as a resource at any time prior to the implementation or completion of Standing Orders.

Unless specific conditions are outlined in a protocol, Endotracheal Intubation may be performed under Standing Orders whenever it is required for advanced airway management. Other methods of advanced airway management (e.g., Dual Lumen Esophageal/Tracheal Intubation) are permitted as an alternative to Endotracheal Intubation provided they have been approved by the Regional Emergency Medical Advisory Committee (REMAC) of New York City.

Blood Drawing may be performed under Standing Orders in conjunction with intravenous access.

MEDICAL CONTROL OPTIONS

Medical Control Options require contact with Medical Control prior to their implementation. Once Medical Control has been contacted, only those options listed in the particular protocol(s) being utilized may be considered.

DISCRETIONARY DECISIONS

These protocols should be considered as the "model" guidelines by which all patients should be treated. Since patients do not always fit into a rigid formula approach, situations may occur which do not fit these guidelines. For patients who do not fit into a rigid formula approach, or where there is no existing protocol and a clear need for Advanced Life Support exists, the term "Discretionary Decision" shall be utilized between the AEMT-P and the Medical Control physician. The AEMT-P shall initiate appropriate therapy (oxygen administration, cardiac

500 GENERAL OPERATING PROCEDURES (continued)

DISCRETIONARY DECISIONS (continued)

monitoring, intravenous infusion to keep the vein open, and/or transportation) and should contact Medical Control in order to differentiate the most emergent clinical problem and define the most suitable therapy. At that time, the Medical Control physician shall order the most appropriate treatment within the AEMT-P's scope of practice. AEMT-Ps should not exceed their level of training while carrying out a Discretionary Decision .

COMMUNICATIONS WITH MEDICAL CONTROL FACILITIES

Under no circumstances is an AEMT-P to operate at the scene for more than 20 minutes after making patient contact without attempting to contact Medical Control.

In the event of failure of voice contact with Medical Control, AEMTs will perform only those procedures which come under Standing Orders and will be required to transport the patient.

TRANSPORTATION DECISIONS

The term "Transportation Decision" appears throughout these protocols. This term encompasses all of the following Basic Life Support Transportation Procedures and Advanced Life Support Transportation Decisions:

• Manner of extrication, when required, and preparation of the patient for transport;
• Safe conveyance of the patient from the scene to the ambulance on appropriate equipment in an appropriate position;
• Transportation of the patient in a properly equipped ambulance in accordance with current staffing policies of the Regional Emergency Medical Advisory Committee (REMAC) of New York City;
• Timing of transport in consultation with Medical Control (e.g., before, during or after Medical Control Options and/or Discretionary Decisions);
• Designation of another unit to transport the patient (e.g., Basic Life Support unit, mortuary unit).
  
  

500 GENERAL OPERATING PROCEDURES (continued)

TRANSPORTATION DECISIONS (continued)

Once appropriate treatment has been initiated in accordance with these protocols, and the Transportation Decision has been made, EMTs/AEMTs should transport the patient as soon as possible to the nearest appropriate hospital:

Major Trauma

If the mechanism of illness/injury and/or historical/physical findings indicate major trauma, transport the patient to the nearest New York City 911 System Trauma Center (see Appendix F), unless one of the following conditions is met:

• The patient is in cardiac arrest;
• The patient has an unmanageable airway:
• An on-line medical control physician so directs.
  

1. PATIENTS IN CARDIAC ARREST OR WITH UNMANAGEABLE AIRWAYS MUST BE TAKEN TO THE NEAREST NEW YORK CITY 911 SYSTEM AMBULANCE DESTINATION EMERGENCY DEPARTMENT.

Major Burns

If the mechanism of illness/injury and/or historical/physical findings indicate major burns, transport the patient to the nearest New York City 911 System Burn Center (see Appendix G), unless one of the following conditions is met:

• The patient also has major trauma;
• The patient is in cardiac arrest;
• The patient has an unmanageable airway:
• An on-line medical control physician so directs.
  

1. PATIENTS WITH MAJOR BURNS AND MAJOR TRAUMA MUST BE TAKEN TO THE NEAREST NEW YORK CITY 911 SYSTEM TRAUMA CENTER.

PATIENTS IN CARDIAC ARREST OR WITH UNMANAGEABLE AIRWAYS MUST BE TAKEN TO THE NEAREST NEW YORK CITY 911 SYSTEM AMBULANCE DESTINATION EMERGENCY DEPARTMENT.

500 GENERAL OPERATING PROCEDURES (continued)

TRANSPORTATION DECISIONS (continued)

Specialty Care

If the mechanism of illness/injury and/or historical/physical findings indicate a need for another type of specialty care, transport the patient to the nearest New York City 911 System Specialty Referral Center (see Appendix H). These include:

• Hyperbaric Center;
• Replantation Centers;
• Spinal Cord Injury Centers;
• Venomous Bite Center.

Other Care

If the mechanism of illness/injury and/or historical/physical findings do NOT indicate major trauma or burns or a need for these other types of specialty care, transport the patient to the nearest New York City 911 System Ambulance Destination Emergency Department (see Appendix I), unless one of the following conditions is met:

• The patient remains stable or potentially unstable throughout transport, AND the patient requests treatment or receives regular medical/surgical care at an alternative destination, AND the additional transport time to the alternative destination is LESS THAN TEN MINUTES;

• The patient requires specialty care available at the alternative destination that is unavailable at the nearest New York City 911 System Specialty referral Center;
• An on-line medical control physician so directs.
  

1. PATIENTS WHO BECOME CRITICAL OR UNSTABLE MUST BE TRANSPORTED TO THE NEAREST NEW YORK CITY 911 SYSTEM AMBULANCE DESTINATION EMERGENCY DEPARTMENT.
   
   

500 GENERAL OPERATING PROCEDURES (continued)

ENDOTRACHEAL DRUG ADMINISTRATION

If no IV or Saline Lock is in place and the patient is intubated, Lidocaine, Epinephrine, Atropine, and Naloxone may be administered via the endotracheal route. In the adult patient, the dosage for these medications should be DOUBLED, and diluted to 10 ml total drug volume with Normal Saline (0.9 NS). The patient must be hyperventilated prior to drug administration. CPR must be halted while administering any drug via the endotracheal route. After administration the patient should be hyperventilated at the rate of 20-30 breaths/min for 2-3 minutes to facilitate absorption of drug from the lungs; CPR should also be resumed.

PHARMACOLOGY TABLE

The following are recommended doses for adult patients fourteen (14) years of age and older and under 40 kg in weight:

Atropine Sulfate	0.02 mg/kg (minimum dose 0.1 mg)
Epinephrine	0.01 mg/kg/dose
Furosemide (Lasix)	1.0 mg/kg/dose
Lidocaine (bolus)	1.5 mg/kg/dose
Lidocaine (infusion)	1.0-2.0 mg/min
Sodium Bicarbonate	1.0 mEq/kg/dose

1. THE DOSE OF EPINEPHRINE 1:1,000 SHOULD NOT EXCEED 0.3 MG, SUBCUTANEOUSLY.
   

DRUG ADVISORY GUIDELINES

• Aspirin should NOT be administered to patients with known hypersensitivity to aspirin. Gastrointestinal complaints are NOT a contraindication to aspirin administration.
  
  
  

500 GENERAL OPERATING PROCEDURES (continued)

DRUG ADVISORY GUIDELINES (continued)

• Diphenhydramine Hydrochloride has an atropine-like action and must be used with caution in patients with a history of increased intraocular pressure, hyperthyroidism, cardiovascular disease, and/or hypotension.

• Epinephrine must be used in a 1:1,000 solution instead of a 1:10,000 solution when doubling the initial dose or subsequent doses of standard dose Epinephrine for administration via the endotracheal route in patients 14 years of age or older, then diluted to 10 ml total fluid volume with Normal Saline (0.9 NS).

• Lidocaine must be used with caution in patients 70 years of age or older, and in patients with liver disease, congestive heart failure, and/or hypotension. The initial dose should not be reduced, but subsequent doses should be reduced to HALF the normal dose.

• Normal Saline (0.9 NS) may be used interchangeably with Ringer's Lactate (RL) for intravenous or intraosseous infusion.

• Verapamil and Diltiazem must be used with caution in patients with liver or kidney disease, congestive heart failure, atrioventricular conduction abnormalities, and/or hypotension. Medical Control should be alerted to these conditions, and the dose should be reduced to HALF the normal dose.
  

PEDIATRIC PROTOCOLS

The number of encounters with children are far fewer than with adults. These protocols therefore address situations where Advanced Life Support in the field can directly affect a child's survival.

Control of the airway and rapid transport are the underlying principles of the pediatric protocols and best serve the needs of the pediatric patient. Since intravenous or intraosseous access are more difficult in small children, these and other Advanced Life Support interventions are carried out enroute, or during a transport delay, except for special circumstances as clearly noted in the protocols.

1. AIRWAY and VENTILATION

Airway management by mouth-to-mouth-and-nose, mouth-to mask, or bag-valve-mask ventilation should be used in neonates, infants, and children as a first maneuver for providing assisted ventilation. The above will be referred to throughout the pediatric

500 GENERAL OPERATING PROCEDURES (continued)

PEDIATRIC PROTOCOLS (continued)

protocols as "Assisted Ventilation." Remember that the correct position to maintain the optimal airway is age-dependent. In pediatric patients with suspected trauma, the airway maneuver of choice is a modified jaw thrust combined with cervical spine stabilization.

Oxygen should always be provided at high concentration in the pediatric patient and should be humidified when feasible. There are NO CONTRAINDICATIONS to high concentration oxygen in the pre-hospital setting for the pediatric patient.

2. INTUBATION

When noted in the protocols, or when other maneuvers used to ventilate the pediatric patient are inadequate, Endotracheal Intubation should be attempted. Suspicion of croup/epiglottitis is a contraindication to attempted Endotracheal Intubation.

Children suspected of having croup/epiglottitis may rapidly close off their airways during attempts at Endotracheal Intubation. Children with suspected croup/epiglottitis should be rapidly evacuated to the nearest 911 Ambulance Destination emergency department for definitive airway management. Children in cardiac arrest with upper airway obstruction should have attempts at high pressure bag-valve-mask ventilation.

3. INTRAVENOUS (IV)/SALINE LOCK OR INTRAOSSEOUS ACCESS

IV/Saline Lock or IO access to be started only enroute or during transport delay. There should be only one attempt of each method in obtaining access to pediatric patients. IV access should always precede IO access. IO access should not to be used in patients greater than six (6) years of age.

4. NASOGASTRIC TUBE/OROGASTRIC TUBE

It may become necessary to pass a Nasogastric (NG) Tube or an Orogastric (OG) Tube in the neonate, infant, or child in order to successfully perform resuscitation. These patients may swallow air or have air forced into their stomach with CPR and Assisted Ventilation. The diaphragm may be forced upward, resulting in decreased tidal volume, if the stomach is not decompressed by an NG or OG tube.

5. PEDIATRIC DRUG DOSAGE AND FLUID ADMINISTRATION

For drug dosage and fluid administration, refer to both the Broselow Tape and the Pediatric Schedule in Appendix J.

500 GENERAL OPERATING PROCEDURES (continued)

PEDIATRIC PROTOCOLS (continued)

If no IV/Saline Lock, or IO is in place and the patient is intubated, Lidocaine, Epinephrine, Atropine, and Naloxone may be administered via the Endotracheal Tube. Initial drug dosage of these medications via the Endotracheal Tube is the SAME as the IV/Saline Lock or IO dose for all drugs but Epinephrine, which is TEN TIMES HIGHER than the initial IV/Saline Lock or IO dose except in Pediatric Anaphylactic Reaction (Protocol #555) where it remains the same as the initial IV/Saline Lock or IO dose; these medications should be diluted to 3-5 ml total drug volume with Normal Saline (0.9 NS), instilled through a catheter passed beyond the tip of the Endotracheal Tube, and followed by several positive pressure ventilations via a bag-valve device attached to the Endotracheal Tube.

Initial fluid administration should not exceed 20 ml/kg.

6. PEDIATRIC VALUES

The Pediatric Schedule in Appendix J provides average weight, respiratory rate, heart rate, and blood pressure for age as well as drug dosages. Patients who are hypotensive according to blood pressure should be examined for other signs of shock to support the diagnosis. Note that it may be technically difficult to obtain a blood pressure in a small or agitated child; in this case, clinical judgment should be used in assessing for hypovolemic shock, especially in a trauma patient.

500-A COORDINATION OF PREHOSPITAL RESOURCES

1. The purpose of this protocol is to set forth New York City Regional guidelines for the coordination of prehospital resources at the scene when multiple emergency medical service (ems) agencies are present. The protocol addresses who has the authority to determine:

• who will provide patient care;
• who will accompany the patient;
• which ambulance(s) will provide transport;
• the hospital destination(s); and
• the need for additional resources.

1. PARTICIPATION GUIDELINES

All providers must properly and reasonably identify themselves and their certification levels. The provider must provide his/her name, organization name, and provider number (shield or NYS DOH certification number). Written identification is preferable.

All providers present at an incident must function as part of a response by the ems agency with which they are affiliated and remain within their scope of training and practice.

The ems agency must be authorized to provide prehospital care within the New York City region and operate under regionally approved protocols specific to the agency's approved level(s) of care.

1. RESPONSIBILITY FOR PATIENT CARE

The highest level prehospital emergency medical provider from the ems agency that first establishes patient contact at the scene assumes the role of primary care provider. S/he retains responsibility for patient care, until relinquished to a prehospital emergency medical provider from another ems agency as determined by patient condition/medical necessity, mutual consent, operational necessity, or patient request.

If the primary care provider assumes control of the patient from a BLS level provider, the BLS provider should assist in the delivery of patient care as requested until such time as the primary ALS care provider determines that assistance is no longer required.

500-A COORDINATION OF PREHOSPITAL RESOURCES (continued)

In cardiac arrest situations, EMT-D or CFR-D units will be considered a higher level of patient care provider over units which are not equipped with defibrillators.

1. COORDINATION OF PREHOSPITAL RESOURCES

Decisions related to coordination of prehospital resources are the responsibility of the highest level prehospital provider from the ems agency whose unit first arrives at the scene.

Higher level prehospital providers may assume responsibility for coordination of prehospital resources if they assume responsibility for patient care.

Responsibility for coordination of prehospital resources may be relinquished to later arriving prehospital providers based on mutual consent.

When a NYC "911 System" participating ems agency is not the first ems agency on the scene and is not acting in the role of primary care provider, it shall act as an operational resource for:

• information regarding hospital diversions, specialty referral center bed availability and other specialized resources; and

• Incident scene safety (e.g., environmental conditions, crowd/traffic control in the absence of NYPD, potentially dangerous patient or family member to self and/or others).

FDNY shall be responsible for coordination of prehospital resources in situations involving:

• Multiple Casualty Incidents (MCIs);
• Unscheduled MEDEVAC transports;
• Hazardous Material (HAZMAT) situations which require decontamination;
• Fires/Crimes in progress; or
• Unusual public health or safety emergencies.

At the point that FDNY assumes operational responsibility for coordination of prehospital resources, incident command procedures are in effect, incorporating all participating ems agencies and resources into the response, as appropriate.

500-A COORDINATION OF PREHOSPITAL RESOURCES (continued)

1. MULTIPLE CASUALTY INCIDENTS (MCIs)

MCIs are generally defined as five (5) or more patients with the potential need for extraordinary resources. However, the criteria for the definition of MCIs are not primarily dependent upon the number of patients.

The Regional Emergency Medical Services Council of New York City and FDNY should include all ems agencies participating in MCIs into MCI planning, and should coordinate training in MCIs for all participating ems agencies.

1. PATIENT TRANSPORTATION

The primary care provider who is responsible for patient care will determine who accompanies the patient. In all practical circumstances the number of individuals in the patient compartment, excluding the patient, shall not exceed four (4). However, the primary care provider who is responsible for patient care makes the ultimate decision regarding who is in the patient compartment.

1. IMPLEMENTATION/EVALUATION

Each ems agency shall develop guidelines, policies and procedures to ensure the implementation of this protocol. Evaluation of the effectiveness of the protocol shall be ongoing as part of each ems agency's QA processes and integrated into system-wide QA activities pursuant to Article 30 of the New York State Public Health Law.