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<C)
• General Skillset– Automated defibrillation– Six medications– Intermediate airway (SGA)
Primary Care Paramedics
• Community college– Three years
• AEMCA (MOH<C)
• Ontario ACP (MOH<C)
• 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<C 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?