Pediatric emergency medicine trisk 1153

FIGURE 134.2 Sample offline patient care guideline (From Utah Department of Health, Bureau of EMS.) 9-1-1 calls are answered at a public safety answering point (PSAP) There, Emergency Medical Dispatchers are specially trained in emergency medical dispatch (EMD) to prioritize calls, determine the appropriate level of response (EMR, BLS, or ALS), give callers prearrival instructions, and stay on the line with the caller to provide support Formal EMD systems exist in guide card and electronic formats Using structured, protocol-driven caller interrogation, dispatchers follow scripted medical protocols based upon the chief complaint The goal of standardized dispatch is to send “the right resource in the right mode at the right time.” EMS systems vary in the configuration of personnel into units or teams Some systems have EMT-only units, while other systems may have EMTs partnered with paramedics in all units In a tiered system , there is a set of criteria that determine whether an ALS or BLS response is indicated and dispatched, based on the scripted caller interrogation For example, a call for an isolated minor foot injury would receive a BLS unit, while a call for a seizure would receive an ALS ambulance In a nontiered system , the highest level of provider is dispatched to all calls Based on local policies, other resources such as police and fire units may be dispatched along with EMS It should be a goal in every community to have reliable medical advice available for the 9-1-1 caller while awaiting EMS response The importance of EMD has been underscored by increased recognition and research For instance, dispatcher-assisted CPR increases rates of bystander CPR, and bystander CPR has been associated with improved morbidity and mortality outcomes of out-of-hospital cardiac arrest More information can be found at http://www.emergencydispatch.org/Science/ EQUIPMENT AND MODES OF TRANSPORT EMS transports occur by ground ambulance and by air ambulance, in both rotor-wing and fixed-wing aircraft Both modes of transport are used for scene and interfacility transports The mode of transportation is determined by personnel at the scene or at the transferring healthcare facility, by 9-1-1 dispatch personnel, or in mass casualty events, by the incident commander Guidelines for use of air versus ground ambulance have been published, including an evidence-based guideline for the use of air transport for trauma patients Air transport is covered more specifically in Chapter 11 Interfacility Transport and Stabilization In 1969 and 1973, the National Academy of Science and the DOT published documents that generally defined the purpose of an ambulance and its contents A list of both adult and pediatric equipment for ground ambulances has been published collectively by the AAP, the American College of Emergency Physicians (ACEP), American College of Surgeons Committee on Trauma (ACS-COT), the EMSC Program, the Emergency Nurses Association (ENA), the National Association of EMS Physicians (NAEMSP), and the National Association of State EMS Officials (NASEMSO), and was most recently revised in 2013 This list is commonly used to establish the minimum standard requirements for EMS programs ( Table 134.3 ) The consensus document is undergoing revision, with anticipated publication in 2020 There are typically two classes of ambulance service in the United States—each is primarily dedicated either to ALS or BLS service BLS units are equipped to conform to the previously mentioned list ( Table 134.3 ) Included are ventilation and noninvasive airway equipment, an automated external defibrillator (AED), immobilization devices, bandages, two-way communication equipment, obstetric kits, a length-based resuscitation tape or similar guidance material, and other miscellaneous items In addition to the equipment contained in the BLS list, ALS units carry intubation and vascular access equipment, a portable monitor/defibrillator, and a variety of medications Because of the limited space on an ambulance, most EMS crews will not have all of the mechanical or pharmacologic options available in a hospital Examples are a paramedic crew that carries morphine but not fentanyl for analgesia, or normal saline and not lactated Ringer solution for fluid resuscitation An example of a state-approved list of medications for ALS ambulances is provided in Table 134.4 More technically sophisticated equipment and medications can often be added if required, as long as its use is established and monitored by the medical director for the EMS service COMMUNICATION Equipment It is imperative for EMS personnel to have a means of communication from the scene and while in transit, in order to fulfill the requirement for online medical direction This may require redundant systems, including but not limited to radio transmission, wireless cellular transmission, satellite telephones, and Wi-Fi or WiMAX mesh networks In addition, base station hospitals must ensure redundant incoming communication lines and must have a plan for communication failure, such as forwarding calls to the next closest base hospital Many base hospitals are equipped to receive paper transmissions from EMS vehicles, such as prehospital 12-lead electrocardiograms (ECGs) EMS Reports to Hospital Personnel Once the child is en route to the receiving hospital, either medical control or the EMS unit itself should notify the receiving hospital of the transport, even if online medical direction is not being requested Based on the nature of the child’s illness or injury, the facility then can begin to assemble personnel and equipment for prompt treatment This is especially important for hospitals where some resources may not be immediately accessible and, in cases of trauma or serious illness, when a specific resuscitation team can be assembled to meet the EMS personnel in the treatment room On arrival, essential information concerning the child’s condition and the field treatment is transferred by verbal report to the accepting care team ED staff receiving patients from ambulance crews will naturally be focused on their own initial assessment of the patient, which may distract them from listening carefully to the ambulance crew’s handover Any information that was not handed over verbally, not recorded on the patient report form, or not retained by ED staff may be irretrievable after the ambulance crew leave There is significant variation in sign out practice, and current processes have been criticized as being highly variable, unstructured, and potentially unreliable Several standardized approaches to sign outs have been defined, including IMISTAMBO: Identification of the patient Mechanism of trauma or Medical complaint Injuries or Information relative to the complaint Signs (vital signs and GCS) Treatment and trends/response to treatment Allergies Medications Background history Other To aid in family reunification, it is important for the transition of care from EMS providers to include information about the condition and destination of family members It is also important for providers to report pieces of information or visual clues to potential nonaccidental trauma or neglect that may be noted at the scene Each encounter between EMS and the hospital should be considered as a potential learning and teaching experience, and deficits noted as a stepping stone for future improvement Providing patient follow-up, where allowable, is another way of including the EMTs in the care continuum TABLE 134.3 EQUIPMENT FOR AMBULANCES (2014 CHANGES ARE UNDERLINED) ... and its contents A list of both adult and pediatric equipment for ground ambulances has been published collectively by the AAP, the American College of Emergency Physicians (ACEP), American College... mortality outcomes of out-of-hospital cardiac arrest More information can be found at http://www.emergencydispatch.org/Science/ EQUIPMENT AND MODES OF TRANSPORT EMS transports occur by ground... Physicians (ACEP), American College of Surgeons Committee on Trauma (ACS-COT), the EMSC Program, the Emergency Nurses Association (ENA), the National Association of EMS Physicians (NAEMSP), and the