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 wishes to intervene in patient care, the physician will be presented with a document outlining the agency's policy regarding "Non-Solicited Medical Intervention". The physician's requests concerning emergency care and movement of the patient should be followed provided they do not conflict with standard policies and procedures. The physician's name and address shall be noted in the comment section of the Prehospital Care Report (PCR). If any conflicts arise, the CFRs shall contact Medical Control and proceed as directed.

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SCENE SAFETY

It is the responsibility of the CFRs to evaluate and judge the scene with regard to safety. Safety factors include, but are not limited to, environmental conditions, the emotional state of a patient or family members, and the contact with potentially hazardous materials and/or spreading of contaminants or disease. Such conditions may be a threat to the health or safety of CFRs , patients, and other persons at the scene. CFRs must also use caution in situations that they are not trained or equipped to handle.

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CARDIOPULMONARY RESUSCITATION

Basic Cardiac Life Support in adults, children, infants, and newborns should conform to the current guidelines recommended by the American Heart Association and the American Red Cross. The following guidelines apply to the initiation and termination of CPR:

CPR should be initiated on all patients who are not breathing (apneic) and pulseless unless one of the following conditions exist:

• Extreme dependent lividity;
• Rigor mortis;
• Tissue decomposition;
• Obvious mortal injury; or
• A valid Do Not Resuscitate order is present. (See Appendix C.)

NOTE:

CPR IS NECESSARY IN NEWBORNS, INFANTS, AND CHILDREN UNDER NINE (9) YEARS OF AGE WITH EXTREMELY SLOW HEART RATES AND POOR VITAL ORGAN PERFUSION TO ENSURE ADEQUATE CIRCULATION TO THE HEART, LUNGS, AND BRAIN.

CPR should be continued until one of the following occurs:

• Spontaneous circulation has been restored;
• Resuscitative efforts have been transferred to providers of equal or higher level of

training;

• A qualified, licensed physician assumes responsibility for the outcome of the patient;
• The crew is exhausted to the point of not being able to continue resuscitative efforts.

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AIRWAY MANAGEMENT

All patients require continuous monitoring of their airways to ensure airway patency. Wherever the term "Monitor airway" is used throughout these protocols, the following elements must be considered:

• Position of the patient's head;
• Need for airway adjuncts;
• Need for oropharyngeal suctioning; and
• Need for Advanced Life Support airway management techniques.

OXYGEN ADMINISTRATION

NOTE:

DO NOT USE A DEMAND VALVE RESUSCITATOR DUE TO THE POSSIBILITY OF CAUSING SEVERE, LIFE-THREATENING COMPLICATIONS.

Adult patients who require supplemental oxygen should receive high concentration oxygen via a non- rebreathing mask set at 10 to 15 liters per minute. The reservoir bag must remain at least one-third full following inspiration. If a mask is not tolerated by the patient, a nasal cannula set at 6 liters per minute should be used and such use properly documented.

Patients who are chronically maintained on oxygen and do not require high concentration oxygen shall be administered oxygen at their prescribed rate of flow.

NOTE:

THERE IS NO REASON TO WITHHOLD HIGH CONCENTRATION OXYGEN WHEN REQUIRED IN ADULT PATIENTS.

Adult patients breathing at a rate less than 12 or greater than 28 times per minute and/or exhibiting signs of hypoxia may require assisted ventilations. This shall be done with one of the following methods:

• Pocket mask with supplemental oxygen flow set at 10-15 liters/minute;
• Bag-Valve-Mask and reservoir with flow set at 10-15 liters/minute;
• Mouth-to-mouth (at provider option, only when adjuncts are not available).

Pediatric patients who require supplemental oxygen should receive high concentration oxygen via the mask that best fits around the mouth and nose, preferably a non-rebreathing mask. Humidified oxygen is preferred. If a mask is not tolerated, then "blow by" oxygen is acceptable.

NOTE:

HIGH CONCENTRATION OXYGEN SHOULD ALWAYS BE USED IN PEDIATRIC PATIENTS.

Pediatric patients exhibiting signs of respiratory failure require assisted ventilations via a mask which completely covers the mouth and nose but not the eyes. This shall be done utilizing one of the following methods:

• Pocket mask with supplemental oxygen flow set at 10-15 liters/minute;
• Bag-Valve-Mask and reservoir with flow set at 10-15 liters/minute;

Mouth-to-mouth or mouth-to-mouth and nose (at provider option, only when adjuncts are not available).

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DEFINITION OF COMPENSATED SHOCK

Any adult patient having a systolic blood pressure ABOVE 90 mm Hg AND exhibiting signs of inadequate perfusion, which may include:

• Altered mental status (e.g., agitation, confusion);
• Increased Pulse Rate (Tachycardia);
• Pale Skin (Pallor);
• Cool, Clammy Skin (Diaphoresis);
• Pale conjunctiva;
• Delayed capillary refill.

Any pediatric patient with signs of inadequate peripheral (distal) perfusion, which may include:

• Altered mental status (e.g., agitation, confusion);
• Increased Pulse Rate (Tachycardia);
• Pale Skin (Pallor);
• Cool, cyanotic lower extremities;
• "Blotchy" Skin;
• Delayed capillary refill;
• Weak or absent peripheral (distal) pulses (radial, tibial, pedal).

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DEFINITION OF DECOMPENSATED SHOCK

Any adult patient having a systolic blood pressure BELOW 90 mm Hg AND exhibiting signs of inadequate perfusion, which may include:

• Altered mental status (e.g., lethargy, coma);
• Increased Pulse Rate (Tachycardia);
• Pale Skin (Pallor);
• Cool, Clammy Skin (Diaphoresis);
• Pale conjunctiva;
• Delayed capillary refill.

Any pediatric patient having a systolic blood pressure below 70 mm/Hg OR the following signs of inadequate central (proximal) perfusion:

• Altered mental status (e.g., lethargy, coma);
• Extensive cyanosis of all extremities;
• Weak or impalpable central (proximal) pulses (femoral, brachial, carotid).

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CONTROL OF EXTERNAL BLEEDING

Whenever the term "Control external bleeding" is used throughout these protocols, the following elements must be considered:

• Application of direct pressure with a sterile dressing.
• Elevation of the injured part above the level of the heart.
• Application of a pressure dressing.

Only when these measures fail should the following elements be considered:

• Application of pressure to proper arterial pressure point.
• Application of a tourniquet (only as a last resort).

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MEDICATION ADMINISTRATION

CFRs may allow a patient to self-administer the patient's own medication as prescribed by the patient's physician.

REQUESTING ADDITIONAL ASSISTANCE

When CFRs respond to an assignment where the patient's condition requires further treatment and/or transport, CFRs should request additional assistance as soon as possible.

INITIATING TRANSPORT

When CFRs are on the scene of an assignment and requesting advanced life support, other medical assistance, or ambulance transport, patient transport procedures should begin in accordance with their level of training. Ambulance transport should begin once an appropriate transport vehicle from the designated transporting agency is available.

SUSPECTED CHILD/SPOUSE/ELDER ABUSE

Whenever child, spouse, or elder abuse is suspected, visually assess the scene for evidence of possible abuse, and record all appropriate information on the Prehospital Care Report (PCR). The transporting ambulance unit will make a verbal report summarizing the above to the responsible medical personnel upon arrival at the Emergency Department. The transporting ambulance unit will complete any appropriate paperwork in compliance with organizational and administrative procedures, e.g., Report of Suspected Child Abuse or Maltreatment (NYS-DSS-2221-A).

PEDIATRIC PATIENTS

Any patient under 14 years of age shall be considered a pediatric patient, and the appropriate protocols shall be used. To further define pediatric patients, the following age separations shall be used:

• Premature - birth prior to the eighth month of gestation;
• Newborn - immediately following birth;
• Infant - from birth to 1 year;
• Child - from 1 year to under 14 years of age.

Avoid agitating pediatric patients. Conducting an assessment or treatment procedure which is not tolerated by the patient may provoke or increase respiratory distress.

Obtaining a blood pressure is not necessary when it agitates the patient or delays transport.

Every attempt should be made to keep pediatric patients warm during transport.

If an appropriate pediatric protocol does not exist, follow the adult protocol that would be indicated.

NOTE:

USE INFANT OR CHILD TECHNIQUES AND RATES FOR CPR AND ASSISTED VENTILATIONS IN PEDIATRIC PATIENTS UNDER 9 YEARS OF AGE. DO NOT USE THE SEMI-AUTOMATIC DEFIBRILLATOR OR THE ABDOMINAL SECTION OF THE MAST FOR PEDIATRIC PATIENTS UNDER 9 YEARS OF AGE.

MINORS

A person under the age of 18 is a minor. Any minor with a life-threatening condition should be treated and transported as soon as possible . A minor may request or refuse treatment without parental consent under the Laws of Emancipation if the minor:

• Is a mother;
• Is married;
• Has left home and is self-supporting; or
• Is enlisted in the Armed Forces.

A minor may request treatment without parental consent under the Laws of Emancipation if the minor is requesting treatment for a sexually transmitted disease, drug abuse, or child abuse.

Minors are considered emancipated only during the period when they can be placed into one of the above categories.

NOTE:

PATIENTS CATEGORIZED AS MINORS WHO ARE 14 YEARS OF AGE OR OLDER SHALL BE TREATED UNDER THE ADULT PROTOCOLS.

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