SO WE TREATED HIM OUTSIDE OUR SCOPE OF PRACTICE, WHO’S GOING TO KNOW?

California• Skills, procedures and administration of

medications allowed by California regulations

Local (Must be approved by the state)• Skills procedures or administration of

medications approved for EMTs by the Los Angeles County EMS Agency Medical Director

The Los Angeles County EMT Scope of Practice was developed to:• Address special needs of patients prior to

the arrival of an ALS Unit and during interfacility transport

• Expedite care of patients in acute distress

Protocols allowing for utilization of BLS procedures and the EMT Local Scope of Practice prior to ALS arrival• EMTs may assist patients with certain medications

prior to the arrival of an ALS Unit.• An ALS Unit must be enroute or the patient must

be transported immediately to the nearest emergency department appropriate for the needs of the patient if ALS response is not available or is delayed.

A health care facility that is staffed, equipped, and prepared to administer emergency and/or definitive care appropriate for the needs of the patient.

Facilities EMTs should consider are:• Most Accessible Receiving (MAR)• Closest Emergency Department Approved For

Pediatrics (EDAP)• Closest Perinatal Center• Closest Trauma Center

Assisting patients with administration of physician prescribed emergency medications

Transporting patients with various tubes and indwelling vascular access lines

Transporting patients with certain medication additives in intravenous solutions

Transporting patients with specific patient operated medication pumps

The EMT must be:• Currently certified as an EMT in California

and working in Los Angeles County• Trained and tested in the knowledge and

performance of procedures and skills included in the local scope of practice All EMTs must be trained and tested in the LA

County Scope of Practice by December 31, 2013

Oral Glucose preparations Oxygen

Actions • Immediate source of glucose

Indications • Conscious diabetic patient with s/s of

hypoglycemia Signs and Symptoms of hypoglycemia

• Cool, moist skin, bizarre or combative behavior, anxiety, restlessness, appearance of intoxication

• May also have signs similar to a stroke(slurred speech and staggering gait, or weakness on one side)

Contraindications• Unresponsive patients• Patients unable to swallow or have a

diminished gag reflex• Patients complaining of nausea

Adverse Effects • Gastrointestinal: vomiting aspiration,

Respiratory: obstructed airway

Administration:• Solution 75-100g (10g/oz) PO, sipped slowly.• Paste/Gel 1 tube of paste/gel swallowed or 1

inch placed between cheek and gum. Pediatric

• Solution 1g/kg PO, sipped slowly• Paste/Gel Not recommended for prehospital

use Onset: Within 20 minutes Duration: Depends on the degree and

cause of hypoglycemia

Precautions• Patients must be able to hold the bottle and

drink without assistance or • Patients must be able to swallow if

administering paste/gel Risk of airway obstruction, vomiting, and/or

aspiration if patient is unable to swallow or has a diminished gag reflex.

Note:• The entire amount does not need to be

administered if the patient's condition improves.

Normal metabolic function requires oxygen

Do not withhold oxygen from patients in respiratory distress. • Oxygen may decrease the respiratory drive

in patients with COPD (CO2 retaining) Observe for any changes in respiratory and

mental status and be ready to assist ventilations if necessary.

Delivery Adjuncts Allowed in Los Angeles• Nasal Cannula (Do not give more than 6/l)• Face Mask• Bag-valve-mask with O2 reservoir• Endotracheal Tube (ALS)• King Tube (ALS)

Ventilate advanced airway adjuncts• Endotracheal tube• Esophageal-tracheal airway device• Perilaryngeal airway device (King LTS-D)• Tracheostomy tube or stoma

Suction a tracheostomy tube or stoma

ET Tube

Esophageal-tracheal tube (combi-tube)• Not currently used in LA

County

Perilaryngeal airway (King Tube)

Tracheostomy tube or Stoma

Avoid excessive ventilation and limit tidal volume to achieve chest rise

Problems due to excessive ventilation• Impedes venous return leading to decreased

cardiac output, cerebral blood flow, and coronary perfusion by increasing intrathoracic pressure

• Causes air trapping and barotrauma in patients with small airway obstruction

• Increases the risk of regurgitation and aspiration

Each breath should be given over 1 second

Each breath should make the chest rise• When you see the chest rise-stop squeezing

Avoid delivering too many breaths or breaths that are too forceful• Hyperventilation is now considered harmful

Without CPR (Respiratory Arrest Only)• 10-12 breaths per minute (once every 5-6

seconds) for adults• 12-20 breaths per minute (approx once

every 3-5 seconds) for infant or child With CPR

• After advanced airway, 8-10 breaths per minute (once every 6-8 seconds)—Do not pause compressions when giving the breath Both adult and child

Seven pigs Ventilated correctly

Seven pigs Hyperventilated

Survival: 1/7 (14%) Survival: 6/7 (86%*)

Report immediately if chest rise is not observed

Assess breath sounds after moving the patient

Report immediately if compliance is decreasing (it becomes harder to bag)

Ensure that the bag is attached to supplemental O2

Connect BVM to the tracheostomy tube• Sometimes air may escape through the nose

and mouth leading to inadequate ventilation Seal mouth and nose with one hand to prevent air

escape If unable to ventilate the tube

• Suction • If suctioning doesn’t help, attempt to ventilate

through the mouth and nose while sealing the stoma

Total laryngectomy• No airflow from the mouth and nose

Partial laryngectomy• May still have some airflow from the mouth

and nose

Suction to clear stoma of any foreign matter

Keep patient’s head straight and shoulders slightly elevated• No need to perform head-tilt, chin-lift

Use a child or infant mast, that fits securely over the stoma and can be sealed against the neck

continued

Squeeze bag and watch for adequate chest rise and fall• If the chest does not rise, suspect a partial

laryngectomy For partial laryngectomy

• Pinch nose with fingers while using the palm to seal the mouth

EMTs are required to suction:• Tracheostomy tubes• Stomas

INDICATIONS: To maintain a patent airway in patients with a tracheostomy tube or stoma.• Rattling mucus sound from tracheostomy

(noisy respirations)• Bubbles of mucus in trachea• Coughing up secretions• Patient requests to be suctioned• Respiratory distress due to airway

obstruction.

COMPLICATIONS• Hypoxia• Bronchospasm• Cardiac dysrhythmias• Hypotension• Tracheal trauma• Infection/sepsis• Cardiac arrest

Nasogastric (NG) tube Gastrostomy tube Saline/Heparin lock Foley Catheter Tracheostomy tube Ventricular assist device Surgical drains Medical Patches

Excluded are thoracostomy (chest) tubes

Nasogastric (NG) tube• Clamp tubing• Secure the tube and avoid tension or kinks

in the tubing Gastrostomy tube (GT)

• Clamp tubing• Secure the tube and avoid tension or kinks

in the tubing

Heparin/saline locks• Monitor for dislodgement and bleeding• Ensure locks are taped securely prior to

transport Foley catheter

• Keep bag below level of the bladder• Secure the tube and avoid tension or kinks

in the tubing• Empty the drainage bag prior to transport

Document the amount emptied

Tracheostomy tube• Monitor for secretions - if necessary, suction• Monitor for adequate air exchange - place in

position to facilitate air exchange (semi or high Fowlers.)

• Ensure that an obturator or new trach tube accompanies the patient - needed in case of dislodgement.

• Check to see that the trach ties are secure, have hospital personnel/caregiver adjust if necessary

Tracheostomy tube• If secretions are present, suction patient

Ventricular Assist Devices• VAD’s are implanted devices that is a pump

that may partially or completely replace the function of the heart

All VAD patients have a VAD team member who is available 24 hours a day.• The contact number is listed on a sticker on

the patient’s controller

Ventricular Assist Devices: Assessment and Treatment• Depending on the device, a pulse or BP may

not be obtainable Use other means to assess the patient.

• These patients are on anticoagulants and are prone to bleeding.

• If patient is in cardiac arrest: DO NOT start compressions, it may dislodge the VAD Call the VAD team member for further instructions

Ventricular Assist Devices• Take ALL equipment to the hospital.

The patient’s family receive training in the specific VAD that the patient may have and are good resources which should be utilized if possible. Take them in the ambulance when ever you can

Surgical Drains• Drains pus, blood & other fluids• Use clean technique around drain to

prevent introducing bacteria• Ensure drain apparatus is secured to

prevent accidental dislodgement of drain• Keep gravity drains at the appropriate level

for proper functioning

Common Surgical Drains• Jackson-Pratt drains -- clear plastic bulb that

creates suction when emptied of fluid and air. Used in abdominal, breast, mastectomy and thoracic surgery.

continued

Common Surgical Drains• Hemovac – wound suction device that

provides negative suction pressure when compressed.

continued

Common Surgical Drains• Penrose drain -- soft rubber tube which is

placed in a wound to prevent the build-up of fluid.

continued

Common Surgical Drains• Negative pressure wound therapy

Also called “topical negative pressure, subatmospheric pressure dressings or vacuum sealing technique”.

Is an enclosed foam dressing and suction device used to promote healing in acute or chronic wounds and burns

A vacuum source is used to create subatmospheric pressure in the wound.

Medication Patches• Prevent touching the adhesive surface or

getting the medication on your hands Medication can be absorbed if you come into

contact with it• Place a loose patch in a plastic closed

container and transport with the patient All patches contain residual medication that

could harm unprotected individuals

Allow patient to self-administer prescribed medications in the presence of BLS providers

Assist patient in taking prescribed medications if patient has difficulty with self-administration

Administer prescribed medication to the patient if patient is physically incapable of administering the medication

Medication is for emergency treatment

Medication is prescribed by a physician

Medication is prescribed for the patient

Meets indication for administration No contraindications are present

EMTs may only assist with physician prescribed emergency

medications for the relief of acute symptoms or a current emergency condition

Administration of these medications is for emergency supportive therapy only and not a substitute for immediate medical care

If medication assistance is rendered, an ALS unit must be enroute or the patient must be transported immediately to the most appropriate receiving facility

Verify the patient’s prescription (prescribed for the patient)

Check name of medication Check dose and route of medication Check the expiration date Check integrity of container Check the condition of the

medication; clarity of solution, impurities, or intact tablet

Repeat initial assessment Repeat vital signs Assess response to medication Assess for adverse/side effects

EMT’s may assist with include but are not limited to:• Nitroglycerin tablets or spray

Up to 3 doses if blood pressure is maintained at 100mmHg(includes any patient self-administered doses)

• Bronchodilator Inhaler or nebulizer (one dose) If patient is alert enough to use inhaler

• Epinephrine Auto-Injector as prescribed for s/s of severe allergic reactions or asthma (one dose)

Trade Names: Nitrolingual Spray, Nitrobid, Nitrostat, ect

Classification: • Vasodilator

Actions• Dilates blood vessels and coronary arteries• Decreases the workload of the heart

Indications • Chest pain

Contraindications • Blood pressure below 100 systolic• Patient has taken 3 doses prior to the arrival

of EMTs• Sexually enhancing/erectile dysfunction

drugs taken within 48 hours

Adverse effects• Cardiovascular: hypotension, bradycardia,

reflex tachycardia, rebound hypertension • Neurological: headache dizziness/faintness,

confusion, blurred vision• Gastrointestinal : nausea/vomiting• General: flushed skin, dry mouth, sublingual

burning

Administration • EMTs are not authorized to carry NTG, but

may assist patients with their own physician prescribed medication.

• Tablet 1 tablet (1/150gr or 0.4mg) SL• Spray 1 spray (0.4mg) SL or TM

(transmucosal) Do Not Shake container – shaking alters the dose

Onset • 1-3 minutes

Directions for Administering Nitroglycerin Tablets• Place or have patient place tablet under

tongue• Instruct patient not to swallow, but to allow

tablet to dissolve under tongue.• Retake blood pressure and pulse after 5

minutes. If hypotension develops, place patient in shock position.

Directions for Administering Nitroglycerin Aerosol• DO NOT shake container.• Administer or have patient spray on or

under the tongue.• Retake blood pressure and pulse after 5

minutes. If hypotension develops, place patient in shock position.

Trade Names: Proventil, Ventolin, Bronchometer, Bronkosol, Alupent, Metaprel

Actions • Dilates bronchioles• Reduces airway resistance

Indications • Bronchospasm caused by:

Acute asthma · Near drowning · COPD · Drug overdose · Bronchitis · Pulmonary edema · Toxic gas inhalation

• Crush syndrome, · Suspected hyperkalemia, · Crush force > 4 hours

Contraindications• Maximum prescribed inhalation dose

already taken by patient• Inhaler not prescribed for patient

Adverse Effects: • Cardiovascular: tachycardia, hypertension• Neurological: ,headache, tremors,

nervousness, dizziness• Respiratory: cough, wheezing

Administration• EMTs may only add a unit dose to the

nebulizer when assisting the patient with preparing a nebulizer May NOT draw up medication from a multi-dose

vial to add to the nebulizer

Administration: • 1 spray inhaled using the metered dose

inhaler with or without a spacer device. May repeat 1 spray in 3-5 minutes one time.

• Pediatric < 12 years Not recommended for prehospital

use > 12 years Same as adult

Onset• Within 5 minutes

Precautions: • Hypoxic patients may experience

dysrhythmias. Monitor pulse periodically for irregularity.

• Administer supplemental O2 before and after treatment to decrease hypoxemia.

Shake container vigorously several times. Instruct patient to:

• Exhale deeply and place lips around mouthpiece.• Take a slow, deep breath and depress the

medication canister while patient inhales.• Remove mouthpiece and hold breath for as long

as possible.• Exhale slowly through pursed lips.

Replace O2 and reevaluate breath sounds. Repeat procedure one time if needed.

Shake container vigorously several times. Remove cap from spacer and attach spacer to inhaler. Instruct patient to:

• Exhale deeply and place lips around mouthpiece.• Depress the medication canister to fill the spacer chamber.• Take several slow, deep breaths to inhale medication in

spacer. (Whistling sound may be present if patient inhales too rapidly.)

• Remove mouthpiece and hold breath for as long as possible.• Exhale slowly through pursed lips.

Replace O2 and reevaluate breath sounds. Repeat procedure one time if needed.

EPIPEN AUTO-INJECTOR

Trade Name: Adrenalin Actions

• Dilates bronchioles and constricts blood vessels Indications:

• Severe asthma• Signs and symptoms of anaphylaxis (severe

allergic reaction) Flushed skin, tachycardia, thready or unobtainable

pulse, hypotension, wheezing, stridor, dyspnea, itching, rash or hives and generalized edema

Contraindications: • Patient unconscious

Adverse effects• Cardiovascular: tachycardia, hypertension,

chest pain, ventricular fibrillation • Neurological: seizures, cerebral

hemorrhage, headache, Tremors, dizziness• Gastrointestinal: anxiety, nausea/vomiting

Administration• EMTs are not authorized to carry, but may

assist patients with their own prescribed device.

• EpiPen Auto-Injector (0.3mg) IM in the upper-outer thigh. No repeat.

• Pediatric: EpiPen Jr. Auto-Injector (0.15mg) IM in the upper-outer thigh. No repeat.

Onset: 5-10 minutes

Precautions• DO NOT INJECT INTO BUTTOCKS, HANDS,

FEET, OR ADMINISTER INTRAVENOUSLY. Injection into buttocks, hands or feet may result

in loss of blood flow to the affected area and tissue necrosis.

Result in delayed absorption Intravenous injection may result in an acute

myocardial infarction or cerebral hemorrhage.

Precautions• Outdated Epipen may be chemically altered

and may lose its potency or result in muscle damage.

Note• The EpiPen contains 2ml (2mg) of

epinephrine. The Auto-Injector delivers 0.3ml (0.3mg); approximately 1.7ml remains in the pen after activation.

Pull off gray safety cap. Cleanse site with alcohol swab.** Place black tip on the upper-outer

thigh, at right angle to the leg. Press hard into thigh until Auto-

Injector activates and hold in place for several seconds.

Massage the injection site for 10 seconds with alcohol swab.

Glucose Solutions Normal Saline Lactated Ringer’s Solution

In Los Angeles County, ONLY these solutions may be transported by

EMTs; all other solutions require ALS transport.

IV solutions must be either TKO or at a preset rate

EMTs may re-adjust rates in case the IV flow changes from preset rate.

If signs of infiltration occur during transport, the infusion should be turned off

EMTs are NOT allowed to discontinue IV catheters.

Flow rate may either slow significantly or stop

IV site becomes cool and hard to the touch

IV site or extremity may become pale & swollen

Patient may complain of pain, tenderness, burning or irritation at the IV site

There may be noted fluid leakage around the site

Pre-Existing Vascular Access Device Peripheral Inserted Central Catheter

(PICC) lines

Excluded are central venous catheter (CVP)

monitoring devices, arterial lines and Swan

Ganz catheters

Is inserted into a central vein for long term IV therapy and/or hemodialysis• Use clean technique around the catheter to

prevent infection of site• Ensure that device is secured to prevent

accidental dislodgement• Common pre-existing access devices:

Hickman catheter Broviac catheter Groshong catheter

Used for administration of chemotherapy or other medications, withdrawal of blood for analysis and some types are used mainly for dialysis

Similar to a Hickman and used for the same purpose, but has a smaller lumen and is used for children

Similar to a Hickman and Broviac catheter.

It has a three-way valve which opens outward during infusion, and opens inward during blood aspiration.

When not being accessed, the valve remains closed.

Long catheter inserted in a peripheral vein and advanced through increasingly larger veins, toward the heart until the tip rests in the superior vena cava.

Used for long term infusion (up to 6 months) to infuse chemotherapy, medications, blood products, fluids and IV nutrition.

Use clean technique around the catheter to prevent infection of site

Ensure that PICC line is secured to prevent accidental dislodgement

Central Venous Pressure (CVP) monitoring device• CVP manometer must be disconnected prior

to transport. The manometer may be dislodged or connections loosened during transport resulting in bleeding and possible air emboli.

• Removing the CVP manometer converts the IV line to an indwelling vascular access line.

Continued

Arterial lines and Swan Ganz catheters• These are placed in patients who are

medically unstable and require close monitoring. These patients require a nurse transport team.

Chest tubes• Chest tubes whether to suction or clamped may pull

out or develop clots which may result in a tension pneumothorax or hemothorax. Therefore, this transport is an ALS transport.

Folic acid - 1mg/1000ml Multivitamins - 1 vial/1000ml Magnesium Sulfate-2 gms/1000ml

and only in conjunction with multivitamins

Thiamine - 100mg/1000ml

These additives are nutritional supplements used to correct vitamin and mineral deficiencies

Several of these additives may be mixed in one IV bag; check bag for additives and appropriate concentrations for each additive.

Potassium chloride - 20mEq/1000ml Total Parenteral Nutrition (TPN)

These additives/solutions may not be transported without an infusion pump and specific precautions followed.• All rates must be preset by hospital/home

health personnel whether the pump is supplied by BLS provider, hospital, or from home.

• If the pump is supplied by the hospital or from home, the hospital/home health personnel must instruct EMTs in the operation of the pump in case of infiltration or fluid overload.

Any prescribed medication with an automated or patient operated pump

Any prescribed pain medication via a patient controlled analgesia (PCA) pump

Most common• Insulin• Meperidine HCL (Demerol)• Morphine Sulfate

Pumps may be either implanted or external.

PCA pumps must be on a locked setting and may only be activated by the patient or caregiver.

EMTs are NOT allowed to activate or adjust rates for these IV delivery systems.

Pregnant or nursing mothers should defer patient care to partner

Protective clothing should be worn when caring for patient• Exposure to chemotherapeutic agents places

the provider at risk for developing cancer, genetic damage and may cause birth defects

• Protective clothing consist of: latex or nitrile gloves that are at least 0.007 inch thick and gown; lint-free, low permeability fabric, closed front, long sleeves and tight-fitting cuffs

Exposure places the provider at risk for developing cancer, genetic damage, and may cause birth defects. • Pregnant or nursing mothers should defer

patient care to partner. Protective clothing should be worn

when caring for patient• Latex or nitrile gloves that are at least 0.007

inch thick and gown; lint-free, low permeability fabric, closed front, long sleeves and tight-fitting cuffs

Immediate first aid treatment is required for exposure• Contact with some chemotherapeutic

agents may cause irritation, burning and tissue destruction.

• Skin -- wash immediately with soap and water

• Eyes-- flush with normal saline solution for 5 minutes ***All exposures must be reported and

evaluated by a physician***

Chemotherapy Spill on Hand

All soiled linens, dressings and absorbent padding must be disposed of separately and not placed in regular waste containers• Chemotherapeutic agents are excreted in

body fluids.

Use either the Los Angeles County EMS Report form to document medications administered by the patient or the EMT, IV solution with medication additives, and if on an infusion pump.

Document in the Comments Section of the form, including vital signs that are pertinent for medication administration.

DO NOT document in the Drugs/EKG section.

Patient Problem (indication) Vital Signs Name of the medication, dose,

concentration and route of administration and describe the injection site.• Document if patient self-administered the

medication or if the patient required assistance with the medication.

Patient’s response to the medication

Type of IV solution infusing Medication and concentration of

additive Flow rate of solution Complications and treatment, if

pertinent

Type of infusion pump Medication and concentration of

medication Preset flow rate Complications and treatment, if

pertinent