Orientation for Base Hospital PhysiciansVersion 2013

RPPEO(Program Overview)

• Hosted by TOH

• Partnership with HDH

• One of seven in Ontario

• Coordination provided by a provincial MAC

RPPEO

• Medical direction

• Certification

• Continuing education

• Quality management

• Consultation and advice

RPPEO Mandate

• Medical Director– Dr. Justin Maloney

• Associate Medical Directors– Dr. Richard Dionne– Dr. Andrew Reed– Dr. Christian Vaillancourt

Medical Leadership

• 1,200 paramedics

• 9 EMS services

• 100,000 + calls for service

• 100 paramedic students

• 4 community colleges

RPPEO – Facts and Figures

ParamedicScope of Practice

• EMAs (2%)

• PCPs (73%)

• ACPs (25%)

• CCPs

Currents Scopes of Practice

• Community college– Two years

• AEMCA (MOH&LTC)

• General Skillset– Automated defibrillation– Six medications– Intermediate airway (SGA)

Primary Care Paramedics

• Community college– Three years

• AEMCA (MOH&LTC)

• Ontario ACP (MOH&LTC)

• General Skillset– Manual defibrillation– 22 medications– Advanced airway

Advanced Care Paramedics

Drugs (Mandatory)

Drug PCP ACP

Adenosine X

ASA X X

Atropine X

Dextrose X

Diazepam X

Dimenhydrinate X

Diphenhydramine X

Dopamine X

Epinephrine X X

Fentanyl X

Drug PCP ACP

Glucagon X X

Oral Glucose X X

Lidocaine X

Midazolam X

Morphine X

Naloxone X

Nitroglycerin X X

Salbutamol X X

Sodium Bicarb X

Xylometazoline X

Controlled Acts and Procedures (Mandatory)

Controlled Act / Procedure PCP ACPCardioversion XDefibrillation, Semi-Automatic X XDefibrillation, Manual XGlucometry X XIntraosseous Cannulation, Pediatric XIntravenous Cannulation XIntubation, Nasotracheal XIntubation, Orotracheal XNeedle Thoracostomy XTranscutaneous Pacing X

Drugs (Auxiliary)

Controlled Act / Procedure PCP ACPAnaesthetic Eye Drops (CEMD) X XAmiodarone XAtropine (CEMD) X XCalcium Gluconate (CEMD) X XDiazepam (CEMD) X XFurosemide XHydroxocobolamin (CEMD) XObidoxime or Pralidoxime (CEMD) X XSodium Thiosulfate (CEMD) X

Controlled Acts and Procedures (Auxiliary)

Controlled Act / Procedure PCP ACP12-Lead ECG / STEMI Recognition X XCPAP X XDart Probe Removal (TaserTM) X XIntraosseous Cannulation, Adult XIntravenous Cannulation X *Supraglottic Airway Insertion X X

Some PCPs in Ontario are authorized to administer dextrose and GravolTM under the PCP Autonomous IV Program

Patching

• Patient care consultation

• Additional orders

• Patient updates

• Cease resuscitation orders

Why Paramedics Patch

Goals of a Patch

• Provide concise but detailed information to BHP

• Adopt a systematic approach

• Obtain physician guidance and direction

Patch Form

• Answer phone

• Confirm paramedic copies transmission

• Start with: “Hello, this is BHP number __, can you hear me? Your patch number is __, go ahead.”

Step 1 – Patch Initiation

Step 2 – Verbal Report

• Do not interrupt patch

• Complete patch form while receiving information

• Wait for paramedic to complete patch before asking questions

Step 3 – Request for Orders, Advice and/or Authority

• Paramedic should ask for orders, advice, or authority to proceed

• Ask for clarification if necessary

Step 4 – Physician Direction

• Provide clear direction consistent with paramedic’s scope of practice

• Scope of practice cards available in ER

Step 5 – Confirm Order(s)

• Have paramedic repeat orders

• Last chance to say yes or no

• If concerned about patch, write ‘Review Patch’ on patch sheet

Step 6 – Request Destination

• If transport is being initiated, determine patient’s destination

Step 7 – File Patch Form

• Deposit completed patch form in BH drop box in ER

• Patch forms will be paired with ACR submitted by paramedic

• Audio account of patch is not a substitute for the patch form

Patches are recorded by

the Central Ambulance

Communications Centers

and may be used as a matter

of record for investigations,

coroner’s inquests, and/or

litigation.

Remember

How Paramedics Can Ensure an Effective Patch

• Proper identification

• Brief and concise

• Sequential

• Order(s) requested is (are) within scope of practice

• Orders are repeated

• Care and documentation reflect BHP’s orders

How BHPs Can Ensure an Effective Patch

• Proper identification• No interruptions• All relevant information

obtained and documented• Orders consistent with

paramedic’s scope of practice

• Orders repeated by paramedic

• Patch form completed

Termination ofResuscitation

TOR vs. Pronouncement of Death

Terminationof

Resusciation

Pronouncementof

Death

• Obvious signs of death - No vital signs and:– Grossly charred body– Open head or torso

wounds with gross outpouring of cranial or visceral contents

– Gross rigor mortis

• MOH&LTC DNR form

Provincial DNR

• The TOR decision always rests with the BHP

• If in doubt, ask for more info and/or order transport with ongoing care

• Never speak to body disposition

TOR - General Principles

TOR – Patch Required

Reason PCP ACPDNR, Verbal X XDNR, Written X XUnsuccessful Resuscitation Attempt XTrauma, Blunt X XTrauma, Penetrating X XTORIT X

The RPPEO still allows a small number of PCPs to call the BHP for a TOR order for medical cardiac arrests of presumed cardiac origin.

These are medics in the Cornwall and Prescott-Russell EMS services that were trained under the TORIT study.

• Arrest not witnessed• No bystander CPR

was provided• No ROSC after

complete ALS care in the field

• No shocks were delivered

“ALS termination of resuscitation” rule was established to consider terminating resuscitative efforts prior to ambulance transport if all of the following criteria are met:

Blunt Trauma TOR Protocol

Penetrating trauma

Literature… J Trauma. 2007 Jul; 63(1): 113-20.

• Regression analysis identified prehospital procedures are a sole predictor of mortality.

• Patient is 2.63 times more likely to die

Conclusion

• Performance of prehospital procedures in critical, penetrating trauma has a negative impact on survival…

• Paramedics should adhere to a minimal “scoop & run” approach to transportation in this setting…

Resuscitative Thoracotomy

Literature… J Trauma. 2011 Feb; 70(2): 334-9.

Considered futile when:

• Prehospital CPR exceeds 10 min. after blunt trauma & no response…

• Prehospital CPR exceeds 15 min. after penetrating trauma & no response…

• Asystole is the presenting rhythm and no pericardial tamponade…

Resuscitative Thoracotomy

● Patients with penetrating thoracic injury arriving with PEA may be a candidate

● When a surgeon with appropriate skills is present (trauma center)

● ED thoracotomy not indicated in blunt trauma with PEA

When should I consider resuscitative thoracotomy?

Penetrating Trauma TOR Protocol

Questions?