orientation for base hospital physicians
DESCRIPTION
Orientation for Base Hospital Physicians. Version 2013. RPPEO (Program Overview). RPPEO. Hosted by TOH Partnership with HDH One of seven in Ontario Coordination provided by a provincial MAC. RPPEO Mandate. Medical direction Certification Continuing education Quality management - PowerPoint PPT PresentationTRANSCRIPT
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Orientation for Base Hospital PhysiciansVersion 2013
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RPPEO(Program Overview)
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• Hosted by TOH
• Partnership with HDH
• One of seven in Ontario
• Coordination provided by a provincial MAC
RPPEO
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• Medical direction
• Certification
• Continuing education
• Quality management
• Consultation and advice
RPPEO Mandate
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• Medical Director– Dr. Justin Maloney
• Associate Medical Directors– Dr. Richard Dionne– Dr. Andrew Reed– Dr. Christian Vaillancourt
Medical Leadership
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• 1,200 paramedics
• 9 EMS services
• 100,000 + calls for service
• 100 paramedic students
• 4 community colleges
RPPEO – Facts and Figures
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ParamedicScope of Practice
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• EMAs (2%)
• PCPs (73%)
• ACPs (25%)
• CCPs
Currents Scopes of Practice
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• Community college– Two years
• AEMCA (MOH<C)
• General Skillset– Automated defibrillation– Six medications– Intermediate airway (SGA)
Primary Care Paramedics
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• Community college– Three years
• AEMCA (MOH<C)
• Ontario ACP (MOH<C)
• General Skillset– Manual defibrillation– 22 medications– Advanced airway
Advanced Care Paramedics
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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
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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
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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
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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
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Patching
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• Patient care consultation
• Additional orders
• Patient updates
• Cease resuscitation orders
Why Paramedics Patch
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Goals of a Patch
• Provide concise but detailed information to BHP
• Adopt a systematic approach
• Obtain physician guidance and direction
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Patch Form
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• 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
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Step 2 – Verbal Report
• Do not interrupt patch
• Complete patch form while receiving information
• Wait for paramedic to complete patch before asking questions
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Step 3 – Request for Orders, Advice and/or Authority
• Paramedic should ask for orders, advice, or authority to proceed
• Ask for clarification if necessary
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Step 4 – Physician Direction
• Provide clear direction consistent with paramedic’s scope of practice
• Scope of practice cards available in ER
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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
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Step 6 – Request Destination
• If transport is being initiated, determine patient’s destination
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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
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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
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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
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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
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Termination ofResuscitation
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TOR vs. Pronouncement of Death
Terminationof
Resusciation
Pronouncementof
Death
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• 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
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• 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
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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.
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• 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:
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Blunt Trauma TOR Protocol
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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…
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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…
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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?
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Penetrating Trauma TOR Protocol
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Questions?