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Emergency Medical Dispatcher National Certification Course

Revised January 2024

3535 Peachtree Rd, N.E. · Suite 520‐417 · Atlanta, GA 30326-3287 Telephone: 855-532-7691FAX: 855-833-3984 · Email: admin@NECI911.com

2|Page Disclaimer & Copyright This publication is designed to provide accurate and authoritative information regarding the subject matter covered with the understanding of the user that the authors or publishers are not engaged in rendering legal advice or services. No part of this publication can be reproduced, distributed, or stored in a database or retrieval system. Brief quotations are allowable under the United States Copyright Act of 1976, and Violators will be prosecuted on criminal charges and for civil damages as fully as the law allows. Certain federal, state, or local regulations may restrict or require modification of the recommendations contained in this document. Therefore, this document should be one of many sources of information used. NECI customers should contact legal counsel to ensure conformity with criteria or standards that various local, state, or federal regulatory agencies promulgated. Using this document, the user agrees that NECI will have no liability for any consequential, incidental, special, or punitive damages arising from using the document.

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Introduction1 The content of this course is based on national EMS education standards by the National Highway Traffic and Safety Administration (NHTSA). NHTSA allowed significant flexibility to adapt to local needs and develop creative Emergency Medical Dispatcher (EMD) instructional programs. This training program applies voluntary practice standards developed by the American Society for Testing and Materials (ASTM), the National Association of Emergency Medical Services Physicians (NAEMSP), and the American Heart Association (AHA). Emergency services providers use these national uniform standards to develop or select an emergency medical dispatch program that includes proper training of EMDs who will use “medically approved” protocols. Medically-approved means “by a physician involved in all aspects of the local patient care system, including the local EMD agency.” Emergency medical services (EMS) are a medical care system in which physicians delegate responsibilities to non-physician providers, including first responders, Emergency Medical Technicians (EMT), Paramedics, Aero-medics, and Emergency Medical Dispatchers (EMD). First responders manage patient care during the pre-hospital phase of a medical emergency outside the traditional confines of the office or hospital.

1 National Highway Traffic Safety Administration (NHTSA) and the Health Resources and Services Administration (HRSA) (1996): The EMS Agenda for the Future.

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COURSE PURPOSE The primary purpose of this course is to certify EMD candidates to the national standards of the Emergency Medical Services (EMS) profession. Once certified, the EMDs’ agency is responsible for meeting state and local standards. This course trains and certifies EMD candidates to use “any set of emergency medical protocols” that have been reviewed, adapted, and “approved for local use by a state or local medical director.” This includes protocols that private companies have copyrighted.

COURSE OBJECTIVES The objectives of this course are to ensure the EMD candidate can implement the knowledge and techniques learned during this course to an observable and measurable standard. To become certified as an EMD, the EMD candidate will be able to accomplish the course objectives below upon completing this course. 1. The EMD candidate shall demonstrate the knowledge necessary to serve as an EMD by achieving 75% or higher on a Final Written Exam, 2. The questions on the Final Written Exam are taken from the Unit Learning Objectives at the beginning of each Unit, 3. The EMD candidate shall demonstrate a mastery of skills to properly handle EMD calls according to national standards of the EMS profession by achieving a score of 90% on a practical skills test administered by the course administrator and 4. The course administrator will administer a series of pre-scripted role-play scenarios for the practical skills test at the end of the course.

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Unit One: The Emergency Medical Dispatch Profession

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UNIT PURPOSE The purpose of this unit is to provide the EMD candidate with the historical development of the Emergency Medical Services System (EMSS) and how Emergency Medical Dispatching (EMD) became a subsection of the EMSS.

UNIT LEARNING OBJECTIVES Upon completion of this unit: 1. The EMD candidate will be able to explain the origins of EMD, 2. The EMD candidate will be able to explain Highway Safety Standard 11, 3. The EMD candidate will be able to define EMD Protocols and their purpose and 4. The EMD candidate will be able to explain the requirements for Medical Oversight of the EMD Program.

7|Page The EMD candidate will be able to explain the history of EMD.

THE ORIGINS OF EMERGENCY MEDICAL DISPATCHING In 1966, a White Paper titled “Accidental Death and Disability: The Neglected Disease of Modern Society “was released. As a result, in September 1966, the 89th Congress created the United States Department of Transportation (USDOT) to implement highway safety programs and safety standards. One of the first assignments for the newly appointed USDOT Director was establishing 18 new safety standards outlined by the newly enacted National Traffic and Motor Vehicle Safety Act (The Act) by July 1967. One of the new standards, Highway Safety Standard 11, was directed at the pre-hospital care providers, including the EMD.

HIGHWAY SAFETY STANDARD 11. The Highway Safety Program Guideline Standard No. 11, Section 3 states, among other things, “Each State should ensure that its EMS system has trained persons to perform the required tasks. These personnel include first responders (e.g., police and fire), pre-hospital providers (e.g., emergency medical technicians (EMT) and paramedics), communications specialists (EMD), physicians, nurses, hospital administrators, and planners.” This federal standard included the call-takers and the dispatchers by specifically naming them as “Communications Specialists.” Communications Specialists were included on the team of pre-hospital care providers. Since the 9-1-1 system was not implemented until 1968, Standard 11 could not name them as “9-1-1 Dispatchers.” In 1969, the Highway Safety Bureau (HSB), later to become the National Highway Traffic Safety Administration (NHTSA), came into existence, and the development of the first curriculum to standardize ambulance attendant training (EMT-Ambulance) was one of its primary goals.

8|Page In 1970, NHTSA released the first national training program for Communication Specialists and made major revisions, including a new EMD manual for the EMD candidate, instructor, and manager. Police and fire departments used their personnel to staff the emergency phones, including emergency medical calls. Sometimes, the “sick, lame, and lazy” were assigned to “the radio room.” It was quickly realized that firemen and policemen might be very good at helping patients in the field as first

responders.

However,

they

typically

needed

training

providing.

“over-the-phone instructions” to the caller and a patient they cannot see. They often reverted to free-lancing and ignoring the protocol cards. The solution to this problem became apparent: civilians who were highly trained in emergency communications and the use of physician-approved medical protocols were better at providing over-the-phone instructions to the caller.

EMD PROTOCOLS AND THEIR PURPOSE. Just as other professions that deal with peoples’ lives utilize protocols, such as airline pilots, protocols were needed to standardize the method by which the call-taker and dispatchers allocate response mode and configuration and provide over-the-phone instructions to the caller. Civilians were often trained as EMD call-takers and dispatchers using medically approved EMD protocols. Slowly, the firemen and policemen returned to the field. Many were trained as EMTs and Paramedics using their new skills as First Responders.

MEDICAL OVERSIGHT OF THE EMD PROGRAM. Good medical care requires a systematic approach to quality controls. Much more is involved in medical oversight than simply having a medical director. Quality assurance (QA) for EMD calls occur at the inhouse level. The EMD program’s QA unit should review EMD reports and recordings of EMD calls to compare EMD performance against medical standards of practice. The QA staff should review EMD calls by listening to live calls and recordings of recent EMD calls and reviewing Computer-aided.

9|Page Dispatch (CAD) reports to identify deviations from standard medical practice. When trends and patterns are identified as not conforming to defined policy or procedure, Quality Improvement (QI) recommendations can be made for system adjustment. Quality assurance exists to identify deviations from standard medical practice and provide input for employee performance evaluation outlining positive reinforcement when medical policies, procedures, protocols, and practices are carried out appropriately. Given the size and complexity of the supervisory and administrative tasks required for a well-functioning EMD (QA/QI) program, it is unreasonable to expect a single individual to accomplish both. To meet both goals, the responsible person at each level must have sufficient emergency medical dispatch knowledge and authority to carry out this responsibility effectively.

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UNIT TWO: ROLES AND RESPONSIBILITIES OF THE EMD

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UNIT PURPOSE The purpose of this unit is to provide the EMD with an understanding of the roles and responsibilities of the EMD. This unit also dispels several myths about the EMD while pointing out their positive characteristics. Unit Learning Objectives Upon completion of this unit: 1. The EMD candidate will be able to explain common attributes of the EMD, 2. The EMD candidate will be able to explain common myths and truths about EMD and the EMD, 3. The EMD candidate will be able to define the roles of the EMD, CTO, and QA Officer, 4. The EMD candidate will be able to identify the members of Tier 1 – Tier 4 in the EMS Tiered Response System, 5. The EMD candidate will be able to identify each step in the EMD 4-step goal system for emergency medical calls, 6. The EMD candidate will be able to identify the four primary personnel in the agency-level EMD program and 7. The EMD candidate will be able to explain the three response modes.

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COMMON ATTRIBUTES OF THE EMD There must be more than knowing an EMD's responsibilities to succeed in emergency medical dispatching. Certain attributes and behaviors of the EMD separate the successful EMD from the rest. The successful EMD possesses the following attributes: 1. The EMD is helpful and compassionate, 2. The EMD gathers pertinent information from callers, 3. The EMD determines the precise location of the medical emergency, 4. The EMD determines the specific nature of the medical emergency, 5. The EMD assists EMS field personnel en route and on the scene, 6. The EMD reacts passively to hostile callers, 7. The EMD remains calm, and 8. The EMD maintains confidentiality.

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COMMON MYTHS AND TRUTHS ABOUT THE EMD PROGRAM MYTH 1: Callers are too upset to provide Experience indicates that using the question accurate and useful responses to the EMD.

sequences provided by the EMD protocols will allow you to elicit information necessary for effective dispatch.

MYTH 2: Callers could not provide the EMD The EMD protocols are designed to elicit with the information necessary to dispatch

information

needed

for

the

appropriate

emergency medical resources effectively.

response.

MYTH 3: The medical expertise required for

The EMD is trained with specific EMD

effective emergency medical dispatch is protocols to make response decisions based on unimportant. Therefore, non‐EMD personnel

pre-approved response configurations.

can effectively dispatch EMS resources.

MYTH 4: All EMS calls must be assigned an In most cases, this is unnecessary. Most calls “emergency response” with lights and sirens.

are not life-threatening. Using an all‐out response can be dangerous for responders and bystanders. Leave it to the responders to determine if they want to use lights or sirens.

MYTH 5: The EMD needs to be more busy The EMD is trained to use the EMD protocols, dispatching to worry about asking all those

which contain medically approved questions

questions or providing sufficient instructions

designed to get pertinent information.

in their protocol cards.

MYTH 6: Medical instructions to callers The local medical authority has approved the cannot help patients and could be dangerous.

EMD protocols used by the EMD.

MYTH 7: Using EMD protocols increases the Experience has shown that the time required to time and resources required to process a call.

process a call increases very little in systems using EMD protocols compared to systems that

14 | P a g e do not use them. In some cases, the response time even decreases.

MYTH 8: An EMD must be certified in CPR Although and as a CPR Instructor.

the

ASTM

Standards

F1258-

95(2022) Standard Practice for Emergency Medical

Dispatch,

94(2016) Standard Instructor

ASTM F1552-

Practice

Qualification

for

and

Training

Certification

Eligibility of Emergency Medical Dispatchers, and ASTM F1560-00(2022) Standard Practice for Emergency Medical Dispatch Management do not require the EMD to be a certified CPR Instructor or have a current CPR certification to practice EMD, some state boards do require it. The agency may have CPR requirements because you work in an environment where you cannot see the patient. It is vital to tell a caller how to do CPR via telephone using the instructions approved by EMD protocols. Being trained in CPR is a definite advantage. MYTH 9: An EMD must have “advanced” Because the EMD operates in a blind medical knowledge.

environment, having “advanced” medical knowledge, such as EMT or paramedic certification, is not required5. The basic medical information presented in this curriculum provides sufficient medical knowledge for the EMD to operate effectively.

MYTH 10: An EMD should relay confidential The EMD should NEVER relay confidential information to responding personnel.

information to responders, including HIV status.

15 | P a g e MYTH 11: An EMD should fear being sued If the EMD follows the procedures outlined in for giving medical instructions.

the EMD training program in which they were EMD certified, follow agency policy and procedures, and use the EMD protocols as trained, they have met the standard of care.

MYTH 12: An EMD should fear telling The callers fear that “help isn’t coming.” callers that an ambulance is coming.

Telling a caller that an ambulance is on the way (if one has already been dispatched, is responding, or is en route) helps callers relax, making it easier for you to enlist their help in providing medical assistance to the patient.

EMS SUB-SPECIALTIES: Emergency Medical Technician (EMT) Other ALS levels include EMT‐D (for Defibrillator) and EMT‐I (for Intermediate). These individuals are trained in defibrillation, breathing support methods (like endotracheal intubation), and establishing intravenous lines to deliver fluids. ALS personnel trained at the paramedic level can perform all the same functions as the basic life support personnel. Additionally, the paramedics have specialized training in advanced cardiac life support and EKG interpretations and are certified to establish intravenous lines. They can also administer specific cardiac medication along with many other therapeutic medicines under the direction of medical control. The paramedics are trained in advanced techniques such as endotracheal intubation and intracardiac injection, which allows them to inject adrenalin directly into the heart. An EMT, paramedic, or nurse cannot work as an EMD! Emergency Medical Dispatcher (EMD) Where does the EMD fit into the scheme of the EMS? The answer to this question varies by local. Each system may differ greatly from the EMD in the adjacent county, city, or suburb. The EMD is responsible for fully understanding the EMS system within which they work. The EMD is the vital link between the caller and the medically trained person who will provide hands-on assistance at the emergency scene. The first link to getting help in a medical emergency is often a telephone

16 | P a g e call to the EMD. The EMD plays an important role by mobilizing the emergency response and determining whether a call is a minor medical emergency or requires advanced life support resources. The EMD is a member of the local EMS system and, therefore, carries responsibilities in addition to those in emergency communications, and the U.S. Department of Transportation authorizes the EMD to wear the Star of Life shoulder patch, collar, or lapel pins other EMS personnel wear.2

2 DOTHS 808 721 Rev. June 1995. chrome-

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THE ROLE OF EMD IN EMERGENCY MEDICAL SERVICES (EMS) The EMD must be certified through an EMD certification program officially recognized by the medical physician with regulatory responsibility and authority over the jurisdiction within which the EMD is an employee. EMD certification follows the employee to other agencies with an EMD program. However, a few states require an EMD to complete an EMD program developed by that state. ●

EMD is a specialty in public safety communications and emergency medical services.

●

The EMD is the principal link between the public requesting emergency medical assistance and an EMS response.

●

The EMD plays a key role in the ability of the EMS to respond to a perceived medical emergency.

●

The EMD can accurately interrogate the caller and gain pertinent information.

●

The EMD can dispatch the appropriate responders.

●

The EMD can provide pertinent information to responders while en route and

●

The EMD can instruct patients via the Emergency Medical Protocols.

THE ROLES OF THE CTO AND QA OFFICER IN THE EMD PROGRAM. The roles of the EMD Team members in the call center, whether a 9-1-1 center or a private EMD center, differ, and no one person should be assigned the task of several positions. A classification system has been developed to meet national standards adopted by agencies concerned about risk management and being the best.3 This classification system provides a pathway for the EMD to advance. With experience and further training, the EMD can progress through the higher positions within the EMS system, contingent upon agency policies. Smaller agencies may need more personnel for multiple positions, resulting in a training officer serving in multiple positions.

3 Preparedness and Education Optimizing Emergency Response Status: FINAL Date: August 10, 2023, FINAL

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EMD COMMUNICATIONS TRAINING OFFICER (CTO) The EMD CTO Officer provides valuable on-the-job (OJT) training. The CTO should have completed the EMD Certification program and become certified through a CTO program recognized by the state agency with regulatory responsibility and authority over the jurisdiction within which the person is an employee.

QUALITY ASSURANCE (QA) OFFICER The QA Officer will have completed the EMD Certification program recognized by the state agency with regulatory responsibility and authority over the jurisdiction within which the person is an employee.

THE TIERED RESPONSE CLASSIFICATION SYSTEM EMS has a tiered response classification system. There are as many EMS system configurations as places with EMS systems. These systems are usually broken down into layers or “tiers.” Each tier has a different response mode based on local EMS system design. In general, there are four tier types. Not all EMS systems have these tiers. Tier 1 ‐ First Responders (law enforcement and fire services) are used to respond immediately to events that are determined to be highly urgent. These personnel are trained in basic life support, including airway maintenance, shock, and bleeding control. Due to the availability and proximity of these units, they can provide a quick response and early assistance to the patient while the ambulance is en route to the scene. They can provide immediate treatment and patient stabilization. Some are CPR-certified. Tier 2 ‐ Basic Life Support (BLS) EMS units are usually transport ambulances staffed by emergency medical technicians (EMTs). In many states, the EMT has at least 110 hours of training in patient assessment and treatment of fractures, lacerations, and other minor injuries. The EMTs are also CPR-certified and can provide appropriate care to patients. EMTs provide treatment and transportation of sick and injured patients in cases requiring more advanced treatments and interventions. They may also assist or back up the more advanced ALS responders. Tier 3 ‐ paramedics usually staff Advanced Life Support (ALS) units with at least 600 hours of experience and advanced training in the care and treatment of the sick and injured. There are several levels of ALS. Currently, paramedics are at the highest level. All levels of advanced life‐ support function under medical control and have a physician medical advisor responsible for the medical content of the program.

19 | P a g e Tier 4 ‐ Air Ambulance/Aeromedical Services are usually hospital‐based ALS helicopter services staffed by paramedics and nurses. These resources are used in the most severe cases where transport time to the hospital may be the determining factor in patient survival. They are also utilized in remote areas where EMS ground transportation units have difficult access. The EMS program at the agency level includes Physician Medical Control, EMD Quality Assurance (QA), the CTOs, and the Emergency Medical Dispatcher (EMD).

EMD CERTIFICATION REQUIREMENTS4 Successful emergency medical dispatching (EMD) requires complex skills and knowledge. These skills and the knowledge required to develop them are used daily to save lives nationwide. The emergency medical dispatching functions have become so specialized that only an individual with dispatch‐specific medical training can perform such required tasks. Contrary to some beliefs, training as an emergency medical technician (EMT), paramedic, nurse, physician, or basic communications officer does not prepare a person to function as an EMD. EMD certification is an advanced public safety training primarily emphasizing dispatching emergency medical calls. It involves the combination of basic 9‐1‐1 skills and medical knowledge. EMDs who work in a 9-1-1 agency are expected, but not required, to have been previously trained and experienced in handling 9‐1‐1 calls through an agency-recognized basic 9-1-1 certification program. Exceptions include EMDs who work for an EMD-only communications center, i.e., ambulance companies and secondary PSAPs.

4 ASTM-F1258 › Standard Practice for Emergency Medical Dispatch. https://www.document-

center.com/standards/show/ASTM-F1258.

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RESPONSE MODES The first link to getting help in a medical emergency is often a telephone call to the EMD. The EMD plays an important role by mobilizing the emergency response and determining whether a call is a minor injury requiring no response, a non-life-threatening medical emergency, or a life-threatening medical emergency that requires advanced life support resources. Response modes vary from place to place. They fit into three categories: 1. Emergency Response: This is “only” when a caller reports a life-threatening situation. a. EMS Vehicle Response: Both lights and sirens safely violate normal traffic laws. 2. Non‐emergency Response: This is the appropriate response when a caller fails to report any life‐threatening situations, but medical attention is required to assess the situation further. a. EMS Vehicle Response: No lights or sirens, and all traffic regulatory devices followed. 3. Non-response: This is the “most appropriate” response when a caller fails to report a lifethreatening situation, and there is no need for medical attention to assess the situation further. a. EMS Vehicle Response: None. Someone at the scene should transport minor injuries, sprains, etc. unless their agency’s medical control authorizes a vehicle response.

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LIGHTS AND SIREN The National Association of EMS Physicians and the then National Association of State EMS Directors5 created a position statement on emergency medical vehicle use of lights and sirens in 19946. This document updates and replaces this previous statement and is now a joint position statement with the Academy of International Mobile Healthcare Integration, American Ambulance Association, American College of Emergency Physicians, Center for Patient Safety, International Academies of Emergency Dispatch, International Association of EMS Chiefs, International Association of Fire Chiefs, National Association of EMS Physicians, National Association of Emergency Medical Technicians, National Association of State EMS Officials, National EMS Management Association, National EMS Quality Alliance, National Volunteer Fire Council and Paramedic Chiefs of Canada. In 2009, there were 1,579 ambulance crash injuries (2), and most EMS vehicle crashes occur when driving with lights and sirens (lights and siren) (3). When compared with other similar-sized vehicles, ambulance crashes are more often at intersections, more often at traffic signals, and more often with multiple injuries, including 84% involving three or more people (4). From 1996 to 2012, there were 137 civilian fatalities, 228 civilian injuries resulting from fire service vehicle incidents, 64 civilian fatalities, and 217 civilian injuries resulting from ambulance incidents. According to the U.S. Fire Administration (USFA), 179 firefighters died from vehicle crashes from 2004 to 2013 (5). The National EMS Memorial Service reports that approximately 97 EMS practitioners were killed in ambulance collisions from 1993 to 2010 in the United States (6). Traffic-related fatality rates for law enforcement officers, firefighters, and EMS practitioners are estimated to be 2.5 to 4.8 times higher than the national average among all occupations (7). In a recent survey of 675 EMS practitioners, 7.7% reported being involved in an EMS vehicle crash, with 100% occurring in clear weather and while using lights and sirens. 80% reported a broadside strike as the type of MVC (8). Additionally, one survey found estimates of approximately four “wake effect” collisions (defined as collisions caused by, but not involving, the lights and siren operating an emergency vehicle) for every crash involving an emergency vehicle (9). For EMS, using lights and sirens improves patient outcomes by decreasing the time to care at the scene or arrival at a hospital for additional care. However, only a small percentage of medical emergencies have 5 Douglas F. Kupas, Matt Zavadsky, Brooke Burton, Shawn Baird, Jeff J. Clawson, Chip Decker, Peter Dworsky,

Bruce Evans, Dave Finger, Jeffrey M. Goodloe, Brian LaCroix, Gary G. Ludwig, Michael McEvoy, David K. Tan, Kyle L. Thornton, Kevin Smith, Bryan R. Wilson. 6 Use warning lights and sirens in emergency medical vehicle response and patient transport. Prehosp and Disaster Med. 1994;9(2):133-136.

22 | P a g e better outcomes from light and siren use. Over a dozen studies show that the average time saved with lights and siren response or transport ranges from 42 seconds to 3.8 minutes. Alternatively, lights and siren response increase the chance of an EMS vehicle crash by 50% and almost triples the chance of a crash during patient transport (11). Emergency vehicle crashes cause delays to care and injuries to patients, EMS practitioners, and the public. These crashes also increase emergency vehicle resource use through the need for additional vehicle responses, have long-lasting effects on an emergency organization's reputation, and increase emergency service personnel stress and anxiety. Despite these alarming statistics, lights and sirens continue to be used in 74% of EMS responses and 21.6% of EMS transports, with a wide variation in lights and siren use among agencies and census districts in the United States (10). Although lights and siren responses are currently common to medical calls, few (6.9%) of these result in a potentially lifesaving intervention by emergency practitioners (12). Some agencies have used an evidencebased or quality improvement approach to reduce their use of lights and sirens during responses to medical calls to 20-33%, without any discernable harmful effect on patient outcomes. Additionally, many EMS agencies transport very few patients to the hospital with lights and sirens. Emergency medical dispatch (EMD) protocols have been proven to categorize requests safely and effectively for medical response by call types and level of medical understanding and urgency. Emergency response agencies have successfully used these EMD categorizations to prioritize the calls that justify a lights and siren response. Physician medical oversight, formal quality improvement programs, and collaboration with responding emergency services agencies to understand outcomes are essential to effective, safe, consistent, and high-quality EMD. The sponsoring organizations of this statement believe that the following principles should guide lights and siren use during emergency vehicle response to medical calls and initiatives to decrease the use of lights and sirens when appropriate safely: 1. The primary mission of the EMS system is to provide out-of-hospital health care, saving lives and improving patient outcomes, when possible, while promoting safety and health in communities. In selected time-sensitive medical conditions, the difference in response time with lights and sirens may improve patient outcomes. 2. EMS vehicle operations using lights and sirens pose a significant risk to EMS practitioners and the public. Therefore, during emergency response or transport of patients by EMS, lights and sirens should only be used when the time saved by lights and siren operations is considered clinically

23 | P a g e important to a patient’s outcome. They should not be used when returning to the station or posting on stand-by assignments. 3. Communication centers should use EMD programs developed, maintained, and approved by national standard-setting organizations with structured call triage and call categorization to identify subsets of calls based on response resources needed and the medical urgency of the call. Active physician medical oversight is critical in developing response configurations and modes for these EMD protocols. These programs should be closely monitored by a formal quality assurance (QA) program for accurate use and response outcomes, with such QA programs being in collaboration with the EMS agency physician medical director. 4. Responding emergency agencies should use response-based EMD categories and other local policies to identify further and operationalize the situations where lights and siren response or transport is clinically justified. Response agencies should use these dispatch categories to prioritize expected lights and siren response modes. The EMS agency physician medical director and QA programs must be engaged in developing these agency operational policies/guidelines. 5. Emergency response agency leadership, including physician medical oversight and QA personnel, should monitor the use rates, appropriateness, EMD protocol compliance, and medical outcomes related to lights and siren use during response and patient transport. 6. Emergency response assignments based on approved protocols should be developed at the local/department/agency level. A thorough community risk assessment, including risk reduction analysis, should be conducted and used with local physician medical oversight to develop and establish safe response policies. 7. All emergency vehicle operators should complete a robust initial emergency vehicle driver training program, and all operators should have required regular continuing education on emergency vehicle driving and appropriate lights and siren use. 8. Municipal government leaders should know the increased risk of crashes associated with lights and siren response to the public, emergency responders, and patients. Service agreements with emergency medical response agencies can mitigate this risk by using tiered response time expectations based on EMD categorization of calls. Rather than time, quality care metrics should drive these contract agreements. 9. Emergency vehicle crashes and near misses should trigger clinical and operational QA reviews. States and provinces should monitor and report on emergency medical vehicle crashes to better understand the use and risks of these warning devices.

24 | P a g e 10. EMS and fire agency leaders should work to understand public perceptions and expectations regarding lights and siren use. These leaders should work toward improving public education about the risks of lights and siren use to create safer expectations for the public and government officials. In most settings, lights and siren response or transport saves less than a few minutes during an emergency medical response, and there are few time-sensitive medical emergencies where an immediate intervention or treatment in those minutes is lifesaving. These time-sensitive emergencies can usually be identified through high-quality dispatcher call prioritization using approved EMD protocols. For many medical calls, a prompt response by EMS practitioners without lights and sirens provides high-quality patient care without the risk of lights and siren-related crashes. EMS care is part of the much broader spectrum of acute health care, and efficiencies in the emergency department, operative, and hospital phases of care can compensate for any minutes lost with non-light and siren response or transport.

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SPONSORING ORGANIZATIONS AND REPRESENTATIVES: •

Academy of International Mobile Healthcare Integration American Ambulance Association

•

American College of Emergency Physicians Center for Patient Safety

•

International Academies of Emergency Dispatch International Association of EMS Chiefs International Association of Fire Chiefs

•

National Association of EMS Physicians

•

National Association of Emergency Medical Technicians National Association of State EMS Officials

•

National EMS Management Association National EMS Quality Alliance

•

National Volunteer Fire Council

REFERENCES: Grant CC, Merrifield B. Analysis of ambulance crash data. The Fire Protection Research Foundation. 2011. Quincy, MA. Kahn CA, Pirallo RG, Kuhn EM. Characteristics of fatal ambulance crashes in the United States: an 11-year retrospective analysis. Prehosp Emerg Care. 2001;5(3):261-269. Ray AF, Kupas DF. Comparison of crashes involving ambulances with those of similar-sized vehicles. Prehosp Emerg Care. 2005;9(4):412-415. U.S. Fire Administration. Firefighter fatalities in the United States in 2013. 2014. Emmitsburg, MD. Maguire BJ. Transportation-related injuries and fatalities among emergency medical technicians and paramedics. Prehosp Disaster Med. 2011;26(5): 346-352. Ann Emerg Med, 2002;40: 625-632. Drucker C, Gerberich SG, Manser MP, Alexander BH, Church TR, Ryan AD, Becic E. Factors associated with civilian drivers involved in crashes with emergency vehicles. Accident Analysis & Prevention. 2013; 55:116-23. Clawson JJ, Martin RL, Cady GA, Maio RF. The wake effect: emergency vehicle-related collisions. Prehosp Disaster Med. 1997; 12 (4):274-277. Kupas DF. Lights and sirens used by emergency medical services: Above all, do not harm. National Highway

Traffic

Safety

Administration.

2017.

Available

online

https://www.ems.gov/pdf/Lights_and_Sirens_Use_by_EMS_May_2017.pdf

26 | P a g e Watanabe BL, Patterson GS, Kempema JM, Magailanes O, Brown LH. Are warning lights and sirens associated with an increased risk of ambulance crashes? A contemporary analysis using national EMS information system (NEMSIS) data. Ann Emerg Med. 2019;74(1):101-109. Jarvis JL, Hamilton V, Taigman M, Brown LH. Using red lights and sirens for emergency ambulance response: How often are potentially life-saving interventions performed? Prehosp Emerg Care. 2021; 25(4): 549-555.

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UNIT THREE: LIABILITY AND LEGAL ISSUES FOR THE EMD

28 | P a g e Unit Purpose The EMD deals with life-and-death situations daily. The last thing they should have to deal with is legal issues. They must first learn the most common legal terms and concepts to deal with legal concerns. This unit ensures the EMD understands legal concepts, terms, and specific issues related to 9-1-1 and EMD. The overall goal is to train the EMD in the laws that govern their conduct and the potential consequences for neglecting to meet certain standards of conduct. The various laws that affect the EMD will be reviewed in this unit. The definitions of legal terms and issues should provide a comprehensive understanding of the terms and laws related to 9‐1‐1 and EMD. This section on liability, legal issues, and the law is designed to provide accurate and authoritative information regarding the subject matter covered. It is provided with the understanding of the user that the author or publisher is not engaged in rendering legal advice or services. By using this document, the user, user agency, or company agrees that NECI will have no liability for any consequential, incidental, special, or punitive damages arising from this document. Certain federal, state, or local regulations may restrict or require modification of the recommendations contained in this document. EMD candidate Performance Objectives By the end of this unit, the EMD candidate will be able to demonstrate the ability to: 1. Explain the term “A legal Duty of Care.” 2. Provide the legal definition of standard of care” and how it is determined. 3. Provide the legal definition of liability. 4. Explain the difference between liability and negligence. 5. Provide the legal definition of negligence. 6. Provide the legal definition of gross negligence, and 7. Explain the components of negligence.

ELEMENTS OF A CIVIL LAWSUIT Elements of a case are the parts of a legal claim or cause of action that a plaintiff must prove to win a lawsuit. Each legal claim consists of “elements” the plaintiff must prove to prevail. The plaintiff can

29 | P a g e prevail in a civil case only if each element of the legal claim is proved by a “preponderance of the evidence.” For example, here are the elements of a “negligence” claim: 1. The existence of a legal duty that the defendant owed to the plaintiff. 2. The defendant's breach of that duty 3. The plaintiff's sufferance of an injury, and 4. Proof that the defendant's breach caused the injury (typically defined through proximate cause). When a plaintiff brings a civil lawsuit against a defendant, they file a court document called a “complaint” that identifies the cause(s) of action and alleges the specific acts of the defendant that violated the law. In a negligence claim, the plaintiff would allege that the defendant had a duty and breached it, that their breach was the proximate cause of the plaintiff’s injuries, and that damages were sustained.

LEGAL DUTY OF CARE7 Generally, members of society have entered a social contract that includes a duty not to cause harm to others. When considering legal duty as an element of negligence, there is a duty to act reasonably. When a jury is asked to determine if a defendant’s actions were reasonable, the standard is what a reasonable person would have done in the defendant’s situation. The following is a non-exhaustive list of ways to determine if the defendant owed a duty of care to the plaintiff: 1. The defendant created risk, which resulted in the plaintiff’s harm. 2. Voluntary undertaking: The defendant volunteered to protect the plaintiff from harm, possibly preventing others from protecting the plaintiff and 3. Knowledge: the defendant knows or should know that their conduct will harm the plaintiff. A legal duty is an obligation created by law or contract. A legal duty requires people to conform their actions to a particular standard. And it also carries with it a recognition that the law will enforce this duty to the benefit of other individuals to whom this duty is owed. Put another way, the existence of a legal duty depends on whether the interest that a defendant has allegedly invaded is entitled to legal protection. For example, in tort law, a landowner may have a legal duty to protect invitees from hazards on their property, like an open pit.

7Four https://www.law.cornell.edu/wex/legal_duty

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BREACH OF DUTY OF CARE EXAMPLE 1: Excusable Tardiness This section relates to discharge for misconduct concerning one's most recent work due to single or repeated instances of delay in reporting to work. 1. Employee's Duty to Employer: The employee's obligation to arrive at work on time is an implied obligation that the employer does not have to set forth at the time of hire. 2. Tardiness as a Breach of the Employee's Duty: Tardiness breaches the standard of punctual behavior, which the employer has the right to expect. 3. Tardiness is misconduct if it results in a substantial breach and disregard of the duty owed to the employer and shows a willful or wanton disregard of and injures or tends to injure the employer's interests, such as any of the following circumstances: a. Repeated inexcusable tardiness to work despite a recent warning that inexcusable delay may result in discharge. b. An instance of inexcusable tardiness considered in conjunction with violations of other employer standards and prior reprimands or warnings for those violations. c. A single instance of inexcusable tardiness which causes reasonably foreseeable substantial injury to the employer's interests. The following circumstances do not establish a willful or wanton disregard of the employer's interests and are not misconduct: 1. Occasional or isolated lapses of tardiness without previous reprimands or warnings, except as provided by subdivision (c) of this regulation. 2. Compelling reasons for delay regardless of the number of prior instances of tardiness, reprimands, or warnings. 3. Occasional or isolated lapses of tardiness without previous reprimands or warnings. 4. Compelling reasons for delay regardless of the number of prior instances of tardiness, reprimands, or warnings. EXAMPLE 2: Back Pain/Numbness in Legs A caller reports to the EMD that his brother has sharp back pain and requests an ambulance. The EMD, using the All-callers Card to determine the correct Chief Complaint Card or Scripted Protocol, tells the caller to stay on the line while she dispatches an emergency ambulance. She tells him she is right back to

31 | P a g e give him instructions on what to do until the ambulance arrives. The caller stays on the line, and the EMD provides the following information to the responding emergency ambulance. “Medic One, respond to 123 Main Street for back pain on a white male, age 35, with no cardiac history.” The EMD selects the Chief Complaint Card, “Back Pain.” In response to the Key Questions on the Back Pain Chief Complaint Card, the EMD determines the following: 1. He was not doing anything strenuous and had no back injury or pain history. 2. He just went numb from the waist down and cannot stand up and 3. He is breathing normally, has no history of cardiac problems, and is fully alert. The EMD then provided the following Pre-arrival Instructions to the caller regarding the “Back Pain.” Chief Complaint Card: The caller then disconnected. Twelve minutes later, the ambulance arrived. The patient told the paramedics that his back still hurt very badly, and he could not feel his legs. The paramedics asked if he was having any difficulty breathing, chest pains, or a history of cardiac problems. He answered “Negative” to all questions. The paramedics connected the patient to an EKG in his house. The EKG was reading Normal Sinus Rhythm (NSR), a normal reading. The patient was transferred to the ambulance and again connected to an EKG to be monitored en route to the hospital. The EKG was still reading NSR.

32 | P a g e The patient was transferred to the emergency room triage staff in the emergency room. After the vitals were recorded, the patient was placed in the waiting room, where he remained for two- and one-half hours. He was then admitted to a hospital room. Three hours later, he went into cardiac arrest. After resuscitation attempts, CPR, defibrillation, and cardiac stimulation medications, he was pronounced dead. The autopsy indicated the cause of death was an aneurysm. Specifically, “aortic dissection” occurs with a “tear” or disruption within the degenerated medial layer of the aorta and involves bleeding within and along the aortic wall. An aortic dissection develops from a tear in the innermost layer of the aortic wall, known as the intima. Blood starts to flow through the tear, causing it to separate from the aortic wall’s middle layer, called the media. Aortic dissections can form anywhere along the length of the aorta, but they’re more likely to occur in the part of the aorta that crosses the chest. An aortic dissection can reduce blood flow to major organs, causing severe symptoms. An aortic dissection is a life-threatening medical emergency.8 During their cardiac system training, paramedics learn to recognize the symptoms of an aneurysm since it cannot be seen without imaging. Since the paramedics were not told by the EMD either verbally or via computer, the caller had advised her of the sudden and acute back pain and numbness from the waist down (precise symptoms of an aneurysm), they were not prepared for an immediate trip to the hospital for emergency surgery. They would have known that emergency surgery might be needed and taken more hasty actions to get to the ER rather than waste time at the patients’ home with an EKG. According to their training, they knew, “Acute dissection involving the ascending thoracic aorta typically requires urgent surgical repair.9 They would have notified the ER while en route that there was a possibility of an aneurysm and provided the patients’ symptoms. The ER staff would have most likely taken the patient for a quick MRI, which most likely would have revealed the aortic dissection, and directly for emergency surgery. The family sued the 9-1-1 agency, the ambulance company, the county, and the EMD. The attorney for the plaintiff subpoenaed the audio recordings and written transcripts of the EMD call, audio recordings of the EMD dispatching the ambulance, and the radio traffic between the ambulance and the emergency room. The attorney also subpoenaed the personnel file of the EMD, which must include the following records:

8 Aortic Dissection vs. Aneurysm: What’s the Difference? https://www.healthline.com/health/aortic-

dissection-vs-aneurysm. 9 National Library of Medicine, Aneurysm or Dissection of the Aorta and Peripheral Arteries, 2010, https://www.ncbi.nlm.nih.gov/books/NBK209982/#:~:text=Develop%20the%20definitions%20for%20ane urysm,rest%20of%20the%20arterial%20wall. NECI© 1987-2024

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Employment application

●

All training records, and

●

All personnel performance reviews.

In addition, the law firm for the plaintiff subpoenaed the Basic 9-1-1 training manual, EMD training manual, agency policies and procedures manual, and EMD Policies and Procedures manual. Depositions were scheduled for the EMD, EMD Shift Supervisor, EMD Training Officer, EMD QA/QI Officer, and the 9-1-1 Director. Did the EMD meet the Elements of Negligence on the next page? 1. The existence of a legal duty that the defendant owed to the plaintiff 2. The defendant's breach of that duty 3. The plaintiff's suffering from an injury 4. Proof that the defendant's breach caused the injury typically defined through proximate cause) and 5. Proof of financial, material, or human limb or life losses. (1) Did the EMD owe a legal duty to meet a certain patient care standard? (2) If so, did the EMD breach that duty? (3) Did the patient suffer an injury or harm? (4) Was the breach of duty the proximate cause of the injury or harm? (5) Were there any financial, material, human limb, or life losses?

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STANDARD OF CARE10 Standard of care is essential in determining whether a person was negligent and potentially liable for a tort (Breach of Contract). If a person breaches the standard that applies to them and their actions cause harm to another person, they will be liable for negligence. The standard of care usually revolves around the reasonable person standard: whether someone acted with care as the average person would have in those circumstances. In some circumstances, the concept applies very easily. For example, a reasonable person would not drive after taking medication that causes hallucinations for half the people who take the medication. If a person were to drive under those circumstances, they would have breached the standard of care. In other cases, the situations are harder to determine. If a person is taking medication that causes hallucinations for 1 in 1,000 people, the reasonable person arguably may or may not drive under those circumstances. In most cases, the standard of care is just that of a reasonable person, but in some cases, a different standard will apply. Children receive a lower standard of care than adults based on how a reasonable child of the same age would act. Higher or broader standards of care apply to professionals and people of authority. For example, a doctor will be evaluated under the reasonable standard of a doctor for their medical work. This differentiation is necessary because a doctor or lawyer would get away with many things if held to the standards of an average person. A “Breach of Duty” is “a failure to meet a standard of care.” What is the standard of care for the EMD? 1) The EMD must follow the agency policies and procedures, which include: a) The EMD must answer all calls using the All-callers Card. b) The EMD must select the appropriate Chief Complaint or Scripted Protocol Card c) The EMD must recognize when they have selected the wrong Chief Complaint or Scripted Protocol Card. When so: i)

The EMD must re-select the appropriate Chief Complaint or Scripted Protocol Card.

10 https://www.law.cornell.edu/wex/standard_of_care.

35 | P a g e ii) The EMD must ask the Key Questions in the order they appear on the Chief Complaint or Scripted Protocol Card d) The EMD must dispatch or effect the appropriate response mode and configuration to the exact location of the medical emergency. e) The EMD must provide Pre-arrival Instructions to the caller and f) The EMD must remain on the line with the caller until medical assistance arrives in all lifethreatening emergencies. 1. Did the EMD have a lawful duty to protect the patient from harm? a. Yes, by being a government employee, it advertises, “Call 9-1-1 when you have a medical emergency.” This becomes a legal duty (contract with the public) to prevent harm to the caller. 2. Did the EMD breach that duty to protect? a. Yes! The EMD failed to advise the responding paramedics of the exact symptoms reported by the caller. Also, the EMD only remained on the line with the caller when medical assistance arrived. 3. Did the patient suffer an injury? a. Yes, a loss of life! 4. Is there proof that the EMD's breach of duty caused the injury through proximate cause? a. Yes. The audio recording of the 9-1-1, written transcripts of the 9-1-1 call, EMD protocol cards instructing the EMD to remain on the line in life-threatening emergencies, and the agency policies and procedures that instruct the EMD to remain on the line. 5. Is there proof of financial, material, human limb, or life losses? a. Yes. i. Life - Autopsy Report ii. Financial – Medical costs iii. The Value per Statistical Life (VSL)11

LIABILITY Liability is a legally enforceable claim on the assets of a business or property of an individual. In business, liability results from a breach of duty or obligation by act or failure to act. Liability and the EMD

11 https://www.federalregister.gov/documents/2023/03/24/2023-06081/notice-of-availability-proposed-

draft-guidance-for-estimating-value-per-statistical-life.

36 | P a g e An EMD can be personally responsible for the losses caused to others if it can be proven that their actions (or inactions) were inconsistent with agency policies and procedures or statutory laws.12 Vicarious Liability13 Vicarious liability is the liability that a supervisory party (such as an employer) bears for the actionable conduct of a subordinate or associate (such as an employee) based on the relationship between the two parties. Another term for vicarious liability is Respondent Superior.14

NEGLIGENCE15 Negligence is a failure to behave with the level of care that someone of ordinary prudence would have exercised under the same circumstances. Primary factors to consider in ascertaining whether the person's conduct lacks reasonable care are the foreseeable likelihood that the person's conduct will result in harm, the foreseeable severity of any harm that may ensue, and the burden of precautions to eliminate or reduce the risk.

LIABILITY VERSUS NEGLIGENCE Most people need clarification on liability with negligence because the terms are often misunderstood and misused. For example, when someone says, “I don’t want to be liable,” they probably mean, “I don’t want to be negligent.” No one should fear the liability inherent to working in public safety. Laws regulating liability and negligence as guiding principles of professional conduct should be readily accepted. The EMD needs to understand the standard of care they have a liability (duty) to meet. Negligence is the failure to behave with the level of care that a reasonable person would have exercised under the same circumstances. Either a person’s actions or omissions of actions can be found negligent. The omission of actions is considered negligent only when the person must act (e.g., a duty to help someone because of one’s previous conduct).

12 Legal Information Institute, University of Cornell School of Law,

https://www.law.cornell.edu/wex/liability. 13 https://www.law.cornell.edu/wex/vicarious_liability. 14 https://www.law.cornell.edu/wex/respondeat_superior. 15 https://www.law.cornell.edu/wex/negligence.

37 | P a g e Negligence is a foundational concept of tort law. Some primary factors to consider in ascertaining whether a person’s conduct lacks reasonable care are the foreseeable likelihood that the conduct would result in harm, the foreseeable severity of the harm, and the burden of precautions necessary to eliminate or reduce the risk of harm. The following elements may typically be required to prove negligence: 1. Proof of a legal duty that the defendant owed the plaintiff. 2. Proof the defendant breached that duty. 3. Proof that the defendant’s actions are the proximate cause of harm to the plaintiff, and Proof of the defendant’s actions of financial, material, or human limb of life losses to the plaintiff.

GROSS NEGLIGENCE Gross negligence is a lack of care that demonstrates reckless disregard for the safety or lives of others, which is so great that it appears to be a conscious violation of other people's rights to safety. Gross negligence is a heightened degree representing an extreme departure from the ordinary standard of care. Falling between intent to do wrongful harm and ordinary negligence, gross negligence is defined as willful, wanton, and reckless conduct affecting the life or property of another. Gross negligence is considered more harmful than ordinary negligence because it implies a thoughtless disregard of the consequences and the failure to use even slight care to avoid harming the life or property of another. As such, someone who is found liable for gross negligence can be responsible for higher damages than ordinary negligence.

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UNIT FOUR: ANATOMY AND PHYSIOLOGY

39 | P a g e Unit Purpose The purpose of this Unit is to provide the EMD with the knowledge of the anatomy of the human body, its seven systems, and their functions. EMD answers calls for many traumatic emergencies as a regular part of the job. Therefore, they must have some basic knowledge of human anatomy. This unit will assist the EMD in understanding what the caller is describing and make it easier for them to match the appropriate response to what might be happening to the victim. It will also allow them to communicate more effectively within the EMS system. This unit on human anatomy provides the EMD with that basic medical knowledge. They will learn about the major systems of the body, as well as learn what kills patients. Also included in this unit is basic information regarding shock, bleeding, and respiratory distress. Unit Learning Objectives Upon completion of this unit, the EMD will be able to: 1. Describe the major systems of the body. 2. Describe what kills patients? 3. Define shock. 4. Describe methods for dealing with bleeding and shock, and 5. Describe the levels of consciousness and their symptoms.

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Human Body Organ Systems16 The human body is made up of 11 organ systems that work with one another (interdependently). These systems include the integumentary system, skeletal system, muscular system, lymphatic system, respiratory system, digestive system, nervous system, endocrine system, cardiovascular system, urinary system, and reproductive system. 1. The integumentary system– (skin, hair, nails) Forms the external body covering and protects deeper tissues from injury. It houses cutaneous receptors, sweat glands, and oil glands and synthesizes vitamin D. 2. Skeletal system– (bones, joints) Supports and protects the body’s organs. Provides a framework for muscle use (movement). Bones also store minerals and create blood cells. 3. Muscular system– (skeletal muscles) Maintains posture and moves (locomotion). Produces heat. 4. Lymphatic system– (red bone marrow, thymus, lymphatic vessels, thoracic duct, spleen, lymph nodes) Houses white blood cells (lymphocytes) in immunity. Returns leaked fluid from blood vessels to the blood and dispose of debris within the lymphatic stream. 5. Respiratory system– (nasal cavity, pharynx, larynx, trachea, bronchus, lung) Removes carbon dioxide and continually supplies blood with oxygen. Gaseous exchanges occur in the respiratory system (lungs). 16 https://anatomyandphysiologyi.com/author/acroagogue.

41 | P a g e 6. Digestive system– (oral cavity, esophagus, liver, stomach, small intestine, large intestine, rectum, anus) Breaks down food to be absorbed and eliminates indigestible waste. 7. Nervous system– (brain, spinal cord, nerves) Control system of the body, responds to internal and external changes, and activates muscles and glands. 8. Endocrine system– (pineal gland, pituitary gland, thyroid gland, thymus, adrenal gland, pancreas, ovary, testis) Glands from the endocrine system secrete hormones that regulate many processes like growth, metabolism, and reproduction. 9. Cardiovascular system– (heart, blood vessels) The heart pumps blood, and blood vessels transport it. Blood carries oxygen, carbon dioxide, nutrients, waste, and more throughout the body. 10. The urinary system (kidneys, ureter, urinary bladder, urethra) eliminates nitrogenous wastes from the body. Regulates acid-base, electrolyte, and water balance of blood. 11. Reproductive systems a. MALE (prostate gland, penis, testis, scrotum, ductus deferens) i. The main function of the reproductive system is to produce offspring. The male testes produce sex hormones and sperm. Male ducts and glands help deliver sperm. b. FEMALE (Mammary glands, ovary, uterus, vagina, uterine tube) i. Ovaries produce female sex hormones and eggs. Other female reproductive structures serve as sites of fertilization and development. For instance, the mammary glands produce milk for the newborn.

42 | P a g e For this course, the following seven systems will be taught: 1. Nervous system 2. Circulatory system 3. Respiratory system 4. Digestive system 5. Musculoskeletal system 6. Genitourinary system, and 7. Skin.

43 | P a g e The Nervous System

The nervous system is the part of your body that controls all your body functions and allows for interaction with the outside world through sensation. This system comprises the brain, spine, spinal column, and nerves. The nervous system is made of three smaller subsystems: 1. Central nervous system 2. Peripheral nervous system, and 3. Autonomic nervous system Central Nervous System. Brain The brain is the control center of the body. Nothing in the body happens without first being told to do so by the brain. It receives input from the nerves in your body and directs all your functions. The brain is also responsible for reason and thought. Spinal Cord The spinal cord acts as an electric cable throughout your body. It carries messages from all parts of your body to the brain. It also carries messages from the brain to the parts of your body.

44 | P a g e Peripheral Nervous System The motor nerves are responsible for controlling movement. They tell muscles in your body to contract (flex) or relax, causing movement. Sensory Nerves Sensory nerves send messages to the brain (and get messages from the brain) about the world around you. They recognize feelings of hot, cold, light, pain, smell, taste, motion, and balance. Autonomic Nervous System Like the peripheral nervous system, the autonomic nervous system also comprises motor nerves. It transports messages from the brain to the body using the motor nerves like the peripheral nervous system. It provides automatic and unconscious monitoring and regulation of internal body functions. Its functions include heartbeat, the force of the heart's contractions, blood vessel diameter, bronchial diameter, pupil dilation, and contraction in response to light levels.

45 | P a g e The Circulatory System The circulatory system carries blood to and from all parts of the body.

Blood Blood is made of plasma (the fluid that carries carbon dioxide, nutrients, hormones, and water), red blood cells, white blood cells, and platelets. Red blood cells carry oxygen to the cells and carbon dioxide away from the body (oxygen sticks to a substance known as hemoglobin). White blood cells fight diseases, and platelets are used to create clots. The blood carries: 1. Nutrients and oxygen (O2) to the cells of the body, and 2. Carbon dioxide (CO2) and other waste products from the cells for removal from the body.

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Circulatory System The circulatory system is made up of the following: Heart The heart is a four-chamber pump located below and to the left of the breastbone (sternum). It pumps blood through a series of one‐way valves through arteries, capillaries, and veins. Arteries Arteries carry oxygenated blood (blood carrying oxygen to cells) away from the heart to the body and have thick walls that expand and shrink as blood goes through them. They get smaller the further they are from the heart. Most arteries are protected from damage by being buried deep within the muscles or being protected by bones. If cut, arteries bleed bright red blood that comes out in spurts.

47 | P a g e Veins Veins carry blood toward the heart and get larger as you get closer to the heart. Veins do not expand or contract like arteries. If cut, they, too, can bleed a lot. A normal adult has approximately 5‐6 liters of blood. Simple cuts should clot within six to 10 minutes. Capillaries Capillaries are thin-walled vessels between arteries and veins throughout the body. They carry oxygenated blood from the arteries to the cells of the body. Also, they exchange oxygenated blood for carbon dioxide and other waste products the cells make. The waste products and blood are then taken to the veins and returned to the heart. If cut, they ooze.

48 | P a g e The Respiratory System

If breathing stops, the person will die. The respiratory system: 1. Makes us breathe. 2. Takes in the oxygen. 3. Is responsible for carrying out waste products like excess water and carbon dioxide, and 4. Helps maintain your body temperature. Respiration (breathing) is an automatic function controlled by respiratory centers in the brain that are sensitive to the level of carbon dioxide in your blood. Carbon dioxide levels are constantly monitored by carbon dioxide and oxygen sensors in your carotid arteries (on the sides of your neck). You will breathe faster when oxygen levels are too low, or carbon dioxide levels get too high.

49 | P a g e Breathing Complications

Airway obstructions can occur at any point in the respiratory system. It is important to note that obstructions do not just occur in the throat. Agonal respirations are: 1. Breaths that occur after cardiac arrest 2. Ineffective in gathering oxygen for the body and 3. Frequently described as weak, heavy, gasping, snoring, gurgling, or moaning. The rates at which these respirations occur are usually referred to as weak or heavy, occasional, or occasionally. The caller will not identify cardiac arrest to you because the patient shows these respirations. In some cases, you can identify these respirations by listening. You may hear the patient's breathing in the background (when the caller is near the patient). The respiratory system is made up of the following parts:

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1. Pharynx ‐ A two‐channeled organ through which air enters and exits the body. It includes the nasal (in the nose) and oral pharynx (in the mouth). Air can travel in or out through either one of these. 2. Epiglottis ‐ A leaf-shaped organ hanging over the larynx's opening. When you swallow, it covers the larynx, ensuring food goes down the esophagus instead of to the lungs. 3. Larynx - the narrowest part of the respiratory system. Also, called the voice box, it is called this because the vocal cords are found here. If anything gets past your epiglottis and touches them, they will clamp down to protect your lungs. 4. Trachea ‐ A round air passage (tube) approximately four inches long, through which air passes in and out. It is held open by a series of cartilage rings. 5. Bronchi ‐ Two passages, each passage going to a lung. 6. Lungs ‐ Where the actual exchange of oxygen and carbon dioxide takes place. Normal humans have two lungs, with the right lung divided into three lobes and the left divided into two lobes. 7. Bronchioles ‐ Small air tubes found in the lungs' body. They are simply bronchi that are broken down into smaller branches. 8. Alveoli - Small microscopic thin-walled air sacs. The oxygen exchange occurs across the membranes between the alveoli and the capillaries.

51 | P a g e 9. Diaphragm ‐ Used to expand or contract your lungs during inhalation. The diaphragm is the major muscle for breathing. Intercostal muscles are located between the ribs and help you breathe and 10. Pleura ‐ Two thin membranes covering the surfaces of the lung. They lubricate the lung, allowing it to expand easily during inhalation and contraction.

52 | P a g e 11. The Digestive System

The digestive system is responsible for the following functions: 1. Swallowing food 2. Digesting food and liquids 3. Providing cells with fuel, and 4. Eliminating body wastes. The digestive system is made of the following components:

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1. Mouth ‐ Used to chew (masticate) food, moisten food with saliva, and start swallowing. Saliva is produced in your salivary glands at about 1.5 liters per day. Chemicals in your saliva start digestion by beginning to break down food. 2. Throat ‐ Consists of the pharynx used to transport food and air. When this is blocked, it is called an airway obstruction. 3. Esophagus ‐ It is ten inches long; it forces food down toward the stomach by constant, rhythmic contractions, which begin at the top and go to the bottom. 4. Stomach ‐ Receives and stores food. It helps push food down toward the bowels. The stomach makes 1.5 liters of pepsin per day. Pepsin is used to break down proteins. Digestion in the stomach usually lasts one to three hours.

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5. Liver ‐ Changes sugars, fatty acids, and amino acids into simpler products for the body. It also neutralizes the harmful products that are produced by digestion. Sugars that are used immediately by the body are stored there. The liver also produces products that help your platelets clot and make products that improve your body's ability to fight diseases.

6. Gall bladder ‐ Produces and stores bile (2‐3 oz). Bile is used to digest fats in your food. 7. Pancreas ‐ Regulates the sugar level in the blood and makes juices and enzymes that digest fats, starches, and proteins. It has two main functions: producing the enzymes that digest fats, starches, and proteins and producing insulin, which regulates sugar levels in the bloodstream. 8. Spleen ‐ Produces and destroys blood cells. Its most important role is fighting infection by acting as a filter to eliminate bacteria from the bloodstream. If destroyed, part of its function can be taken over by the bones and marrow in your body.

9. Appendix ‐ It is thought to play a part in children's immune responses. It is about three to four inches long and has no other known purpose.

55 | P a g e 10. Small intestine ‐ Receives liquids made by your pancreas, liver, and gallbladder. These are used to digest food further. The small intestine is approximately twenty feet long and is made of the following parts: o

Duodenum

Jejunum

Ilium

11. Large intestine ‐ It is five feet long. The main purpose is to absorb liquid from digested food as it passes through. It absorbs 5‐10% of the moisture residing in the products of digestion. The large intestine extends from the ileum to the rectum and consists of the following parts: 1. Cecum 2. Ascending colon 3. Transverse colon 4. Descending colon 5. Sigmoid colon 6. Rectum ‐ a large, hollow organ that stores feces until expelled. 7. Anal canal ‐ The anal canal is two inches long; it controls the escape of liquids, gasses, and solids produced by digestion through contraction of the sphincter muscle, and 8. Anus (opening).

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The musculoskeletal system comprises the head, vertebral column, chest, upper extremities, pelvis, and lower extremities. Other parts include the three types of muscles, tendons, and ligaments. Tendons and ligaments are connective tissues: Tendons connect your muscles to your bones, and ligaments connect your bones to other bones. 1. It is a system of bones, muscles, and connecting tissues. 2. Gives support for the body and provides movement through the actions of muscles and joints. 3. Protects vital organs like your lungs and heart, and 4. Stores minerals your body needs. Muscles: 1. Are attached to bones. 2. Allow you to move through their contracting and relaxing actions. 3. Help us breathe (diaphragm) 4. Help circulate blood (the heart is a muscle) and 5. Aid in digestion (the stomach).

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The three types of muscles include: 1. Voluntary muscles, which are consciously controlled (like when you are walking) 2. Involuntary muscles, which are unconsciously controlled (like blood vessels, diaphragm) and 3. Cardiac muscles, which are the muscles that make the heart pump.

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The head is composed of four bone groups: 1. Skull (includes the cranium and base) 2. Face 3. Maxillary (upper jaw), and 4. Mandible (lower jaw).

60 | P a g e The Thorax is comprised of the following bones: 1. Vertebral Column (Spinal column) 2. Chest 3. Ribs 4. Sternum (breastbone) 5. Xiphoid process (Cartilage at the lower tip of the sternum) 6. Shoulder girdle 7. Clavicle (collarbone) 8. Scapula (shoulder blade) 9. Shoulder joint, and 10. Arm. Upper Extremity: 1. Humerus (upper arm) 2. Forearm 3. Radius 4. Ulna 5. Hand 6. Carpals 7. Metacarpals, and 8. Phalanges (Fingers). Pelvis: 1. Ilium, 2. Pubic symphysis, and 3. Iliac crest.

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62 | P a g e

Lower Extremity: 1. Upper leg a. Femur (thigh bone) b. Knee joint c. Patella (kneecap) 2. Lower leg a. Tibia b. Fibula 3. Foot a. Tarsal b. Metatarsal c. Phalanges - The seven bones found in each foot's toes. Each toe has three phalanges (the distal, middle, and proximal); the big toe only has two and d. Metacarpal bones - The seven bones found in each hand's toes. Each finger has three phalanges (the distal, middle, and proximal); the thumb only has two.

63 | P a g e The Genitourinary System

The genitourinary system has two primary functions: 1. Reproductive System, and 2. Liquid Waste Removal.

64 | P a g e Female Reproductive System

1. Fallopian Tubes ‐ Carry eggs from the ovaries to the uterus. 2. Ovaries ‐ Produces female hormones, matures, stores, and releases eggs. 3. Uterus ‐ Where the fetus (fertilized egg) develops and where menstruation (periods) occurs, and 4. Vagina ‐ The birth canal through which babies are born.

65 | P a g e Male Genitourinary System

Reproductive System 1. Prostate ‐ Surrounds the urethra and produces the fluid that makes up most of the bulk of semen. 2. Testes ‐ Produces sperm and male hormones. 3. Scrotum ‐ Surrounds and protects the testes, and 4. Penis ‐ Contains the urethra and through which semen and urine pass.

66 | P a g e Urinary System Male and Female

1. Kidneys ‐ Filters waste from your bloodstream and make urine. 2. Ureters ‐ Tubes that connect kidneys to the urinary bladder and through which urine flows to the bladder. 3. Urinary Bladder ‐ The reservoir for urine, and 4. Urethra ‐ The urine tube passes through on the way out of the bladder and body.

67 | P a g e The Skin

The skin has many functions in addition to being the outer covering of the body: 1. Is the largest organ of the body? 2. Serves as a protective barrier against microorganisms. 3. Protects the soft tissues and organs below it from injuries. 4. Insulates against heat and cold. 5. Helps remove wastes from the body through sweat.

68 | P a g e

6. Protects against the sun's rays through pigmentation. 7. Helps convert some of the sun's energy into Vitamin D and 8. Enables the body to sense pain, heat, cold, and pressure. The skin consists of the following two major components: 1. Epidermis: The thin outer layer of skin. It comprises various cell types, and its thickness varies across different body areas (thickest in the hands and feet). The outer layer of the epidermis is constantly being shed. Its cells are nonliving and require no blood for nourishment. If the epidermis remains intact, no microorganism can enter the body through the skin. 2. Dermis: The inner layer of skin. It is the thickest layer of the skin. The dermis is made up of connective tissue that contains nerves, sweat glands, and blood vessels. Sensations like heat, cold, touch, etc., are felt through the nerves found here. The body's reaction to heat and cold causes the expansion and contraction of the blood vessels found in the dermis. Because of the expansion and contraction of the blood vessels in the dermis, blood flows through the vessels. This expansion and contraction results in the loss or conservation of body heat.

69 | P a g e What Kills Patients?

Traumatic causes of death include: 1. Severe blood loss 2. Airway obstructions that prevent breathing 3. Shock 4. Brain/spinal cord damage, and 5. Cardiac Arrest

70 | P a g e The most common non-traumatic cause of death is cardiac arrest.

Many traumatic emergencies get worse as time passes, while medical emergencies tend to get better over time. Three problems can worsen the medical situation over time: 1. Severe blood loss 2. Breathing obstructions, and 3. Cardiac arrest.

71 | P a g e Pre-arrival Duties

The EMD can affect the following three situations most by using medically approved pre‐arrival instructions. 1. Consciousness 2. Shock, and 3. Respiratory Distress Consciousness. Consciousness is very hard to determine without seeing the patient. You must rely on the protocols and callers' information to get this information. The protocols are designed to help you do this. Not all sick people appear sick. At the same time, patients in shock or respiratory distress will look sick. When field personnel get to the patient, they see a pale, sweaty, weak, and nauseous. People immediately know they have a sick person on their hands. It is up to the EMD to recognize truly sick people based on the information you get from callers.

72 | P a g e Levels of Consciousness

There are four levels of consciousness that you need to learn. They are taught in order of severity, with an alert being the highest level and unresponsive being the lowest and most serious. 1. Alert ‐ the patient is awake and aware of their surroundings. This is the highest level of consciousness. If a patient is determined to be alert, then there is less cause for concern. 2. Verbal ‐ the second highest level of consciousness. These patients are only awake when you talk to or yell at them (verbal stimulus). They tend to fall asleep unless you constantly talk to them. 3. Pain ‐ the second lowest level of consciousness. A person in this state can only be awakened with noxious (ammonia) stimuli. They require noxious stimulants to stay awake and 4. Unresponsive ‐ the lowest and most dangerous level of consciousness. Any stimulus cannot arouse patients in this state.

73 | P a g e Determining Consciousness

How can you determine consciousness? EMD protocols will help you determine a patient's level of consciousness. You can determine consciousness by asking the caller three questions: 1. Is the patient awake? 2. Have you tried to wake them up? 3. Can they talk to you? Don’t worry about using consciousness categories with the responders. For example, if the caller says that the patient is talking gibberish and can only stay awake when they yell at them, tell the responding personnel that. You need to recognize the level of consciousness and dispatch accordingly. The EMD is trying to determine whether a patient is conscious or is in an altered state of consciousness. The priority is airway maintenance. It is not so important to determine why the patient is unconscious; all that matters is that the patient is unconscious. If the patient is unconscious, turn them on their side and monitor their breathing.

74 | P a g e Shock Shock is a major killer of patients. It can rapidly appear without symptoms. For this reason, shock is often called the silent killer. Shock is defined as "inadequate tissue perfusion." This means there is a lack of circulation throughout the body, but most importantly to the major organs (heart, lungs, brain, kidneys, etc.).

Signs and Symptoms of Shock Signs of Shock: How the patient looks How the patient looks as described by the caller when based on their observation: 1. Pale, cool and moist skin 2. Shallow and rapid breathing 3. Lackluster eyes and dilated pupils (pupils appear larger than they should), and 4. Decreasing levels of consciousness leading to unconsciousness.

75 | P a g e Symptoms of Shock: How the patient feels 1. A feeling of "impending doom." Death is imminent or going to happen soon. 2. Weakness 3. Nausea 4. Thirst 5. Dizziness, and 6. Restlessness/anxiety. Types of Shock

76 | P a g e 6. Psychogenic, and 7. Septic.

1. Anaphylactic Shock Anaphylaxis is a severe, potentially life-threatening allergic reaction. It can occur within seconds or minutes of exposure to something you are allergic to, such as a peanut or the venom from a bee sting. The flood of chemicals released by the immune system during anaphylaxis can cause someone to go into shock, the blood pressure drops suddenly, and the airway narrows, blocking normal breathing. Signs and symptoms of anaphylaxis include: 1. Rapid, weak pulse 2. Skin rash and hives covering large parts of the body. 3. Nausea and vomiting 4. Difficulty breathing 5. Swelling of the face and tongue 6. Tightness in the chest, and 7. Itching/burning skin.

77 | P a g e Common triggers of anaphylaxis include certain foods, some medications, insect venom, and latex. Anaphylaxis requires an immediate trip to the emergency department and an injection of epinephrine. If anaphylaxis is not treated right away, it can lead to unconsciousness or even death. 2. Cardiogenic Shock occurs when the heart can no longer develop enough pressure to circulate blood properly. 3. Hemorrhagic Shock occurs when the body loses substantial amounts of blood through internal or external bleeding. It also occurs with Hypovolemic shock.

78 | P a g e 4. Hypovolemic Shock occurs when the body loses a large amount of body fluid through vomiting or diarrhea. 5. Neurogenic Shock ‐ It usually occurs with spinal cord damage. Blood vessels that are normally tightened (constricted) begin to relax, and blood pressure rapidly drops. Blood begins to pool below the level of the spinal cord injury. 6. Psychogenic Shock ‐ (Fainting or vaso‐vagal reaction) It occurs when blood vessels suddenly dilate (expand or relax) due to some shock to the system, like extreme fear or minor injury. Blood flow to the brain is temporarily interrupted, and the person faints. 7. Septic Shock ‐ It is caused by severe infections, including toxic substances from the infection that causes blood vessels to dilate and plasma to be lost through vessel walls. Typical Pre‐arrival Instructions for Shock

Based on the caller’s responses to your questions on the All‐Callers Card and the Key Questions on the Chief Complaint Cards, you can determine if the victim is in shock and has an altered level of consciousness. Always follow the instructions on the EMD protocol card for difficulty breathing. Typical pre‐arrival instructions for shock include the following: 1. Do not give them anything to eat or drink.

79 | P a g e 2. Make sure the patient's airway is clear so they can breathe. 3. Control bleeding (if external) using direct pressure. 4. Calm and reassure the patient. 5. Lay the patients on their side (preferably left side) or allow them to remain in the most comfortable position unless they are trauma patients. 6. Do not move trauma patients and 7. Keep the patient warm and prevent the loss of body heat by covering the patient. Respiratory Distress

Callers often say that a person is "having difficulty breathing." It is up to the EMD to determine if the caller is describing respiratory distress or breathing difficulty. It is hard to tell if a patient is suffering from respiratory distress or has a breathing problem without understanding the difference. Each can occur from various sources, including benign (not dangerous) sources like allergies or colds. Because of the difficulty in distinguishing true respiratory distress from breathing difficulty, these calls can be among the most challenging presented to the EMD. Listed below are the primary differences: 1. Breathing Difficulty - Breathing problems are present “with other” medical complaints. For example, most people have breathing difficulty when vomiting. This does not constitute distress. NECI© 1987-2024

80 | P a g e 2. Respiratory Distress patients in true respiratory distress are very sick people. These patients look, act, and sound sick, usually being able to speak only short phrases (or 1 2- to 2-word sentences) if they must speak. Callers may describe their breathing as very noisy or very quiet. 3. Patients in true respiratory distress are putting all their efforts and energy into trying to breathe or getting where they think there might be more air. They look as if they were (and still are) working hard. 4. Patients in respiratory distress appear sweaty (diaphoretic), pale, and sometimes blue (cyanosis). In cases of true respiratory distress, the patient rapidly runs out of oxygen (losing the ability to keep breathing often due to fatigue or airway obstruction). 5. Choking is also a form of respiratory distress. Persons with obstructed airways will demonstrate classic choking symptoms. The caller will immediately recognize these as such unless the caller was not present when the victim choked and found the victim in a collapsed state.

Signs and Symptoms of Respiratory Distress Classic choking symptoms: 1. Clutching or grasping at the throat 2. Anxious or restless 3. Ashen or bluish color 4. Rapid breathing

81 | P a g e 5. Noisy respiration 6. Labored appearance: The patient appears to be working hard and 7. Profuse sweating Always follow the instructions on the EMD protocol card for difficulty breathing. Bleeding Bleeding has a set of unique problems and may elicit strong emotional responses. Severe bleeding must be treated immediately. The body attempts to stop bleeding using the process of clotting. Blood platelets break down and block the hole through which the blood escapes. When severe bleeding, such as a cut artery, clotting cannot happen fast enough or completely enough to fill the hole, resulting in shock and then death. Control of Bleeding

Always follow the instructions on the EMD protocol card to control bleeding. When instructing a caller to use direct pressure, tell them to put firm direct pressure on the wound. Firm, direct pressure will stop even arterial bleeds. Most bleeding can be controlled with firm, direct pressure. The caller (or a bystander) should be directed to use a universal bandage or clean gauze pad and press down directly on the open wound. In most situations, callers will not have these. So, they must be told to use the cleanest cloth available.

82 | P a g e Instruct callers not to remove soaked bandages (dressing) because this will open the clot forming in the wound. If they need to replace the bandage because it is soaked, place another on top and continue the pressure. If the bleeding has stopped, they can tie the dressing in place with a bandage. Elevate bleeding extremities. This method is good for extremities because it gets the bleeding limb higher than the heart, thereby slowing blood flow through the force of gravity. In internal bleeding, you need to recognize it due to shock issues. There's only a little you can do about it. Tourniquets can cause much damage by stopping blood flow completely through an extremity. This causes nerve and cell damage that is frequently permanent and can even be the cause of an amputation. Never instruct callers to apply a tourniquet! If a caller says a tourniquet has already been applied, leave it on!

83 | P a g e

UNIT FIVE: EMD PROTOCOLS

84 | P a g e Unit Purpose The purpose of this unit is to provide the EMD with the information necessary to understand the EMD protocol systems and the opportunity to demonstrate the ability to utilize them properly. Unit Learning Objectives Upon completion of this unit, you should be able to demonstrate the ability to utilize properly: 1. The All‐Callers Card, 2. Chief Complaint Cards, and 3. Scripted Protocols.

85 | P a g e

EMD PROTOCOL CARDS

There are three types of EMD Protocol Cards: 1. All‐Callers Card 2. Chief Complaint Cards, and 3. Scripted Protocol Cards. Regardless of which call type the EMD encounters, every call begins with the All-callers Card. All‐Callers Card The EMD uses the "All Callers" protocol card to extract information from callers, including: 1. Obtain and verify the location of the medical emergency. 2. Obtain and verify the telephone number of the caller. 3. Determine if there is a medical emergency. 4. Classify the emergency. 5. Determine the patient’s level of consciousness, and 6. Determine the patient’s level of breathing.

86 | P a g e Before selecting the Chief Complaint Card or Scripted Protocol Card, the EMD will dispatch the appropriate response mode (emergency or non-emergency) and response configuration (fire, police, and EMS) pre-approved by the agency for the specific call type. The EMD can upgrade the response mode and configuration as the situation changes as the agency approves. For example, predetermined criteria for a response might need to be established during the Allcallers Card questioning. However, during the questioning in the Key Questions section of a Chief Complaint Card, the EMD determines that criteria are now sufficient for a response. At this point, the EMD will immediately dispatch the appropriate response pre-approved by the agency.

87 | P a g e

SAMPLE ALL-CALLERS CARD

Where is your emergency?

Does it compare to ALI screen?

Ask caller to repeat address i nformation.

Ask if this is a single family residence, multi family residence, or a business?

Is the address in your jurisdiction?

Ask what number they are calling from?

Tran sfer to other PSAP

Single family Ask location in house? Multi family Ask for floor and Apt ?

Medical

What is the emergency?

Fire Select the appropriate Fire Protocol

Police Select the appropriate Police Protocol

Business Ask for floor or room ? es

Are they BR EATHING?

Not Life Threatening Refer to appropriate Chief Complaint Car d

Go to appropriate age Card

Are they CONSCIOUS?

Life Threatening

Go to

Card

Go to appro priate Card

88 | P a g e

CHIEF COMPLAINT CARD The Chief Complaint Card is used to extract information from the caller to provide additional information to the field responders and provide pre-arrival instructions to the caller to assist the patient. Chief Compliant Cards are used only after the all‐callers card except when going directly to a Scripted Protocol is more appropriate. The information in the chief complaint types discussed during this training represents most emergency medical conditions likely to be reported by callers. The Chief Complaint Cards are divided into two sections: 1. Key Questions: The Key Questions section aims to gather specific information not received or asked for on the All‐Callers Card. This section lists important questions the local medical authority has determined should be asked of the caller: a. Extract specific information about the patient's condition. b. Extract ongoing clarification of the nature and severity of the medical emergency. c. Identify conditions that require pre‐arrival instructions. d. Determine Scene safety requirements for responders and bystanders and e. Determine other resources to notify. 2. Pre‐arrival Instructions: The purpose of the pre‐arrival instructions section is to provide medically approved pre‐scripted instructions to the caller. Pre-arrival instructions shall be read to the caller verbatim unless the agency has pre-approved discretionary deviations in writing.

89 | P a g e

RESPONSE MODE AND CONFIGURATION Should the EMD send an emergency (lights and siren) or non-emergency (no lights or siren) response? If so, should they also dispatch law enforcement and fire services, and how many? The factors used to determine response levels are different. For example, a gunshot wound would justify an emergency response even though there may be no signs of an altered level of consciousness, difficulty breathing, and minimal bleeding. Response to Trauma Calls 1. Mechanism of the injury: a. gunshot, b. stabbings, and c. falls. 2. Location of the injury defines “where” on the body of the victim, including these descriptive terms: a. Central b. Peripheral c. Torso, and d. Upper or lower extremities. Significant priority symptoms include: 1. Altered levels of consciousness indicative of the onset of shock 2. Head injury 3. Underlying medical problem 4. Severe hemorrhage, and 5. Breathing problems associated with injuries to the central core. Studies have shown that there are primary determining factors when selecting the appropriate response. In addition to affecting the appropriate response mode and configuration, the Scripted Protocol Card provides a flowchart for the EMD to follow to determine more specific information about the victim's condition. Scripted Medical Protocols The scripted medical protocol provides medically approved step-by-step instructions for the EMD to read to callers. The scripted instructions shall be read to the caller “verbatim unless discretionary deviations have been pre-approved in writing by the agency.” Pre-arrival instructions provide the caller with lifesaving NECI© 1987-2024

90 | P a g e treatments for the victim before dispatched responders arrive. Examples of the scripted medical protocol are: 1. CPR 2. Adult 3. Child 4. Infant 5. Childbirth 6. Normal 7. Emergency 8. Airway Management 9. Adult 10. Child, and 11. Infant

91 | P a g e

SAMPLE SCRIPTED PROTOCOL CARD

92 | P a g e Traumatic Incident Types Trauma is defined as "some physical injury caused by accident or violence." Although the call begins with the All‐Callers Card and progresses to the Chief Complaint Card, proper response and pre-arrival instructions in these cases rely on your ability to gather information regarding: 1. Mechanism of injury 2. Location on the body of the patient, and 3. Identification of priority-type symptoms. Trauma denotes a situation where a patient has sustained an injury by accident or violence. The chief complaint will usually be reported by the caller in the form of a verb (he was hit, shot, cut, etc.) or by describing the mechanism of injury (an auto-pedestrian accident, he fell off the roof, etc.).

PRE‐ARRIVAL INSTRUCTIONS Once you have dispatched the appropriate field units, return to the caller and begin the Pre‐arrival Instructions required for the situation at hand. Pre‐arrival instructions vary widely based on the situation and complaint type reported. They often include the same instructions as the individual chief complaints, especially regarding airway control. However, traumatic incident protocols include more specific injuryrelated instructions. These directions protect the patient from further injury from a well-meaning but untrained bystander who attempts to help. Pre‐arrival instructions for bleeding due to a minor cut would be treated differently than bleeding due to a gunshot wound. Pre‐arrival instructions are intended to: 1. Ensure the safety of the responders, caller, patients, and bystanders. 2. Control external bleeding 3. Ensure the patient’s airway is clear. 4. Advise the caller when it may be best to do nothing. 5. Advise the caller to direct responding units to the patient. 6. Keeping the patient comfortable until field responders arrive 7. Gather patient medications before the arrival of field responders and 8. Update the responders with all situational changes.

93 | P a g e

94 | P a g e

95 | P a g e

96 | P a g e

Where is your emergency?

Does it compare to ALI screen?

Ask caller to repeat address i nformation.

Ask if this is a single family residence, multi family residence, or a business?

Is the address in your jurisdiction?

Ask what number they are calling from?

Tran sfer to other PSAP

Single family Ask location in house? Multi family Ask for floor and Apt ?

Medical

What is the emergency?

Fire Select the appropriate Fire Protocol

Police Select the appropriate Police Protocol

Business Ask for floor or room ? es

Are they BR EATHING?

Not Life Threatening Refer to appropriate Chief Complaint Car d

Go to appropriate age Card

Are they CONSCIOUS?

Life Threatening

Go to

Card

Go to appro priate Card

97 | P a g e

98 | P a g e

Is the a sailant still pres ent? es

Has the patient been raped? es

Remain calm, help is on the w ay. Leave, o nly if it safe to do so. Describe the assailant. If you can leave, call me back to tell me where you are, so I can help.

The patient shoul d not bathe, urinate or douche.

Is the abuse child, elderly, or spousal?

Do not move or touc h anything. Do not disturb items used as weapons.

Go to

Card

Any serious injuries/bleeding?

Stay on the line until EMS and PD arrive.

99 | P a g e

Is the patient having associated chest, abdom inal, or jaw pain? es Go to

Card

Was this caused by an injury?

Do NOT move the patient unless in immediate da nger.

Allow the patient to aassume a positio n of ccomfort.

Are ther e any signs of sh ock? (i.e., pale, cool, moist skin)

Stay on the line until EMS arrives.

Do Not give the patient anything to eat or drink. Maintain airway, breathing, and keep patient warm. Elevate feet and legs. Stay on the line until EMS arrives.

100 | P a g e

What was the type of bite or sting?

Insect

Animal (domestic/Wild)

Human

Snake

Keep patient still Is there any severe bleeding? es

Go to

Do Not apply tourniquets.

Are there signs of shock? (i.e., pale, cool, moist skin)

Card.

Is there any nausea or vomiting?

If patient is having an allergic reaction to the bite, administer an EpiPen injection, if available.

101 | P a g e

What caused the bleeding?

Do not remove the object. Bandage around the object to secure it in place.

No Animal

Animal

What part of the body was bitten?

Is the blood

Oozing

Is it a nosebleed?

Pinch the patient s nostrils closed have the patient lean forward until the bleeding stops.

Is the animal contained? Where is the animal?

Is there anything stuck in the wound?

Spurting

Apply a clean cloth to the area and keep the patient comfortable. If it keeps bleeding, you re probably not pressing hard enough. Remember, keep firm, steady pressure on the wound.

ALL BLEEDING Do not give the patient anything to eat or drink. Maintain

C Spine if trauma related.

Maintain airway, breathing Nausea/Vomiting

Apply direct pressure by putting the cleanest cloth available directly on the wound apply pressure with your hand. Do not remo e the cloth to see if the leedin has stopped. If it keeps bleeding, you re probably not pressing hard enough. Remember, keep firm, steady pressure on the wound.

Does the patient have any amputated part(s)? es

keep warm.

Turn patient on their side.

Do not remove the cloth. If it keeps bleeding, you re probably not pressing hard enough. Remember, keep firm, steady pressure on the wound. Stay on the line until EMS arrives.

102 | P a g e

Can the patient speak in full sentences? Place patient in a position of comfort until EMS arrives.

Are breathing sounds like snoring or gasping? No

Do not give t e patient anythi ng to eat or drink. Go to appropriate age Card Stay on the line until EMS arrives or call back if anything chan ges.

103 | P a g e

Is the baby breathing? No

Carefully, turn the baby on its back, while supporting its head and neck, keeping the body very straight.

Carefully turn the baby onto its side, while you support the head and neck. Position the baby s arm underneath it so it is in front of the bab y s body.

Carefully move the baby to a hard surface. Open the baby s airway by gently tilting the head back and lifting the chin.

Do not give the baby an ything to eat or drink. Do you see anything inside the mout h?

Place your mouth over the baby s mouth and nose.

Give 2 Breaths (1 second each breath) This should e a normal reath for you not lar e, hard or fast.

Attempt to remove the object if you can. (NO BLIND FINGER SWEEP)

Does the bab y s chest rise and fall? es

Could you remove the object? No

Stay on the line until EMS arrives or call back if anything changes.

Continue process until help arrives.

Go to appropriate age Card

104 | P a g e

Does the patient have any breathing problems? es

Remove patient from burn source IF SAFE to do so.

What caused the burn?

Fire/Heat Go to appropriate age Card

Cool the burn with COOL water.

Chemical

Dry

Electrical

Wet

Cover with sheet.

Cover with dry dressing. Prepare for CPR

Brush off Dry chemicals with protective mask, cloth, and gloves. Flush with large amounts of water.

Remove clothing. Flush with large amounts of water.

Do not give the patient anything to eat or drink.

Stay on the line until EMS arrives or call back if anything changes.

105 | P a g e

Is the patient having any difficulty in breathing? es

Position the patient in a position of comfort. If unconscious, perform chin lift. If breathing stops: Go to

Are there any nausea or vomiting?

Card es

Do NOT move the patient unless in immediate danger. Do Not give the patient anything to eat or drink. Stay on the line until EMS arrives.

Are there any signs of shock? (i.e., pale, cool, moist skin)

Do Not give the patient anything to eat or drink. Mai ntain airway, bre athing, and keep patient warm. Elevate feet and legs. Stay on the line until

106 | P a g e

Does the patient have any breathing problems? Go to BREATHING card. No

Is the Patient over age 16 with no reported stroke symptoms?

Does anyone there have anyAspirin? No

Is there someone else there thatcan retrieve the aspirin? Additional questions to ask:

Is the pain locatedon the right, left, upper, or lower chestof the patient? Is the patient pale? Is the patient sweaty?

Is the patient allergic to aspirin? es

Does the patient have a history of heart trouble? What was the patientdoing when the chest painstarted? Is there an automatic defibrillator nearby? (If es Have someone retrieve it.)

Has the patient vomited blood or coffee ground material in the last 24 hours? es

Has the patient passed bloody orblack stools in the last 24hours? es

107 | P a g e

Place the patient in a position of comfort.

Initial questio ns to ask: How many months pregnant is the patient?

Does the patient feel the urge to push? es

Has the patient had a baby before?

Have the patient take deep breaths with the contractions; blowing each breath out.

Stay on the line until EMS arrives or call back if anything changes.

If so: how many? Has the water broken? Is the patient having contractions? If so: when do they begin and end?

Have the patient lie on her back, with her back propped up. Remove all clothing below the waist. Bend knees up her buttocks.

place clean sheets/towels under

Gently dry the baby. The baby should begin to look pink.

Keep th e baby below the level of the mother s abdomen. Keep th e baby and the mother calm. Do Not cut or pull on the umbilical cord. If the afterbirth delivers, wrap it in a towel and save. Stay on the line until EMS arrives.

If you see the baby s hand, arm , foot, or umbilical cord deliver first Go to Card Can you see the baby s head beginningg to deliver?

Have more clean towels available.

Wrap the baby in a clean towel or blanket.

Keep the patient calm.

es Place your hand against the baby s head and apply gentle pressure. As the baby begins to deli ver, support the head with your hand. If you see the umbilical cord around the n eck immediately attempt to loosen it by inserting one finger between the cord and the neck. Gently cl ean the baby s mouth and nose with one finger.

No Gently clean the baby s mouth and nose with one finger.

Snap the bottom of the baby s feet with your finger and/or rub its back with a towel.

Is the baby breathing?

Hold onto the baby as the shoulders and body are delivered. es es

Is the bab y breathing?

No Go to

Ca rd

108 | P a g e

Gently dry the baby. The baby should begin to look pink.

If the baby s hand, arm,foot, or the umbilical cord deliver first Inform the responding unitsimmediately

Wrap the baby in a clean towel or blanket.

If there is a sudden, large gush of blood from the birth canal (before the baby s head begins todeliver) Inform the respondingunits immediately

Keep the baby below the level of the mother sabdomen. Keep the baby and the mother calm.

Keep the patient calm. Do not allow the patient to push even if she feels the urge to.

If the baby delivers Is it breathing?

Place at least two pillows under the patient s buttocks andhave her lie back. Instruct the patient to pant through the contractions DO NOT PUSH

Keep thepatient as comfortable aspossible.

Do Not cut or pull on the umbilical cord. If the afterbirth delivers, wrap it in a towel and save. Stay on the line until EMS arrives

Gently clean the baby s mouth andnose with one finger. Snap the bottom of the baby s feet with your finger and/orrub it s back with a towel.

Is the baby breathing?

Is she bleeding? Is there any afterbirthor placenta? If so, tryto wrap that in a towel for the doctor. Watch her and be sure she is alright.

Go to

Card

Wrap the patient ina blanket. If anything changes, tell me immediately.

109 | P a g e

Gently dry the baby. The baby should begin to look pink.

If the baby s hand, arm,foot, or the umbilical cord deliver first Inform the responding unitsimmediately

Wrap the baby in a clean towel or blanket.

If there is a sudden, large gush of blood from the birth canal (before the baby s head begins todeliver) Inform the respondingunits immediately

Keep the baby below the level of the mother sabdomen. Keep the baby and the mother calm.

Keep the patient calm. Do not allow the patient to push even if she feels the urge to.

If the baby delivers Is it breathing?

Place at least two pillows under the patient s buttocks andhave her lie back. Instruct the patient to pant through the contractions DO NOT PUSH

Keep thepatient as comfortable aspossible.

Do Not cut or pull on the umbilical cord. If the afterbirth delivers, wrap it in a towel and save. Stay on the line until EMS arrives

Gently clean the baby s mouth andnose with one finger. Snap the bottom of the baby s feet with your finger and/orrub it s back with a towel.

Is the baby breathing?

Is she bleeding? Is there any afterbirthor placenta? If so, tryto wrap that in a towel for the doctor. Watch her and be sure she is alright.

Go to

Card

Wrap the patient ina blanket. If anything changes, tell me immediately.

110 | P a g e

Is the patient conscious? es

Go to

Card

Stand behind the patient / Wrap your arms aroun d the patient s waist. Make a fist wit h one hand. Place the thumb side of your fist against the patient s abdomen in the middle, slightly above the naval and well below the breast bone. Grasp with the other hand and press your fist into the patient s abdomen with a quick and forceful upward thrust. Repeat thrusts until object is removed or patient becomes unresponsive. Stay on the line until EMS arrives.

Wrap arms around chest. Place han ds against breast bone and perform thrusts.

111 | P a g e

Is the patient conscious? es

Go to

Card

Stand behind the patient / Wrap your arms aroun dthe patient s waist. Make a fist wit h one hand. Place the thumb side of your fist against the patient s abdomen in the middle, slightly above the naval and well below the breast bone. Grasp with the other hand and press your fist into the patient s abdomen with a quick and forceful upward thrust.

Repeat thrusts until object is removed or patient becomes unresponsive. Stay on the line until EMS arrives.

112 | P a g e

Is the patient conscious? es

Go to

Card

Kneel or sit with the infant in your lap. Hold the infant s head face dow n, lower than the chest. Deliver 5, quick, back slaps. Turn the infant over, cradling th em in your arms Deliver 5, quick, downward chest thrusts, at a rate of 1 per second.

Repeat 5 back slaps and 5 chest thrusts until object is removed or infant becomes unresponsive. Stay on the line until EMS arrives.

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114 | P a g e

115 | P a g e

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117 | P a g e

118 | P a g e

119 | P a g e

Is the patient alert?

Additional Questions?

Do Not give the patient anything to eat or drink.

Check for medical alert tag/card/bracelet. Is the patient having difficultyin breathing? No

Are there any signs of shock? (i.e., pale, cool,moist skin)

Maintain Airway Positionof comfort,tilt head back if unconscious.

No Do Not give the patient anything to eat or drink.

Maintain airway, breathing, and keep patient warm.

Stay on the line until EMS arrives.

Go to

Card if breathing stops.

Is there any nausea or vomiting?

Elevate feet and legs. Stay on the line until

Do NOT move the patient unless in immediate danger. Do Not give the patient anything to eat or drink. Stay on the line until EMS arrives.

120 | P a g e

Is the patient out of the water? es

No Remo ve the patient from the water if you can reach them safely.

Go to

Card

Is th e victim breathing?

Be cognizant of neck injuries associated with diving injuries.

SCUBA Diving Place victim on left side. Keep head lower than feet. Notify responding units Decompression Chamber might be needed.

Turn the patient on their side. Do Not give the patient a nything to eat or drink. Maintain airway, breathing, and keep patient warm. Stay on the line until

121 | P a g e

Is the patient free from t he current? No

Is the patient breathing?

Do not touch the patient. Do not touch the wire(s).

Stay in vehicles. (If applicable) Shut off power, if you can do so safely.

Go to

Card

Go to Card See Electrical Burn

122 | P a g e

Does the patient have chemicalsin eye(s)? es

No Is there an object sticking in the eye(s)?

Flush with water for 10 minutes from nose to ear.

Did the patient receive a blunt injury to the eye(s)? es

Do not remove the object stabilize in place. Cover both eyes.

Have the patient lay down remain quiet. Cover both eyes.

Stay on the line until EMS arrives.

Did the patient get cut on the eye(s)? es

Do not put pressure on the eye(s. Do not try to mov e the eye(s). Cover both eyes.

123 | P a g e

Is the patient breathin g?

Go to

Card

PROBLEMS ASSOCIATED WITH FALLS May have been caused by medical pr blem How far was the fall? Cervical spine injury Hip fractu res

Elderly

Head Injuries Notify responding units. aw lift to open airway

How far was the fall?

Do NOT move the patient im mediate danger.

unless in

Notify responding units.

Do NOT give the patient anything to eat or drink. Sta y on the line until EMS arrives.

124 | P a g e

Is the patient having difficulty breathing? es

Go to

Card COMMON S MPTOMS Is the patient having any nausea or vomiting?

Sudden

severe pain

Speech problems Turn patient on their si de.

Notify responding units.

Was the onset sudden?

Notify responding units.

Does the patient have a history of migraines? No

Do Not give the patient anything to eat or drink. n Maintain airway, breathing, and keep patient e warm. Gather/List all patient me dications. Stay on t he line until

125 | P a g e

Is the patient h aving difficulty breathing? es Go to

Card

Is the patient experiencing c hest pain? es Go to

Notify responding units.

C ard

HEART PROBLEMS is a complaint that represents a diagnosis rather than a chief complaint . Patient may have implanted pacemaker, etc. that have malfunctioned; may not be associated with classic c ardiac symptoms.

Does the patient have a hist ory of heart problems?

Notify responding units.

Are there associated symptoms?

Do Not give the patient anything to eat or drink. n Maintain airway, breathing, and keep patient e warm. Gather/List all patient me dications. Stay on t he line until

126 | P a g e

Is the patient breathing?

Go to

Card

Is the skin Hot or Dry? Remove from heat. es

Remove clothing.

Rapid aggressive cooling(i.e., air conditioning,fans, cold wet sheets) Is this a Cold Exposure?

Remove from cold. Remove wet clothing.

Turn the patient on their side. Maintain airway, breathing.

Wrap in dry blankets.

Is there nausea or vomiting?

Stay on the line until EMS arrives. Maintain airway, breathing. Stay on the line until EMS arrives.

127 | P a g e

Is the patient out of dan ger? es

Turn machinery OFF , if safe to do so.

Do not attempt to rescue unless the area is safe to do so

Is the patient trapped or caught in machinery?

Notify responding units. No

Do Not try to remove the patient from the machinery.

What happened?

Electrocuted

Fall

Bleeding

Go to

Go to Card

Card

Chemical

Go to

Burn

Sick

Go to Card

Card

128 | P a g e

129 | P a g e

130 | P a g e

Is the patient breathing?

What type of poisoning?

Go to

Surface Contact

Inhaled

Swallowed

Remove clothing, flushwith water until medical units arrive (unless the poison/chemicalis water reactive)

Remove patient to freshair.

Contact Poison Controlimmediately.

Protectyourself rom poison.

Atte pt to identify the substance swallowed.

Card

Is there any ausea or vomiting?

What was taken the amount.

Turn the patient o their side.

Notifyresponding units.

Is the patient having a seizure?

Go to

Is this a possi le suicide attempt?

Stay on the line until EMS arrives.

Card Go to

Card

131 | P a g e

Describe the location of the patient s pain.

Chest Pain

Go to

Abdo minal Pain

Back Pain

Card Go to

or Card

Do NOT move v the patient unless in immediate danger.

Extremity Pain

Go to Card

Do Not give the patient anything to eat or drink. Stay on the line until EMS arrives.

132 | P a g e

Is the patient violent? No

Protect yo urself and the patient.

Don t turn your back on the patient.

Look for possible h ad injury, medical problems, drugs / alcohol use, etc

If the patient is not violent to you , then don t leave them alone. Are the re weapons present?

Do not try to restrain.

Leave the area if possible Notify responding units.

Any suicide attempt or threat?

Go to

Card

Stay on the line until EMS arrives.

133 | P a g e

Has the seizure stopped? es

Is the patient breathing?

Do not restrain the patient. e Move furniture or dangerous objects out of the patient s way.

No Do not put anything in he patient s mouth. Turn the patient on their side when the seizure stops. Go to appropriate

Card

No Is the patient injured?

Go to appropriate Card

Iss the patient breathing?

Stay on the line until EMS arrives.

134 | P a g e

Does the patient have or complain of

Not Breathing

Go to

Card

Unknown

Go to

Go to Card

Do OT move the patient danger. Do

Bleeding

unless in immediate

ot give the patient anything to eat or drink.

Gather list of all pati ent medications. Stay on the line until EMS arrives.

Heart Problems

Card

Go to

Chest Pain

Go to Card

Card

A sick person is a patient who has no specific Chief complaint. This card is primar ly used when a second party call er reports a diagnosis . This card assists the EMD with finding the specific Chief complaint. The initial caller diagnosis could be old and unrelated to the current proble m.

135 | P a g e

Is the sus ect still at the scene? es

Is the patient in a safe area?

Do Not approach.

Is the patient breathing?

N No

Go to

Card

Stay in a safe area. Notify responding units.

Stay on the line u ntil EMS and PD arrive. Was the patient stabbed or shot?

Does the suspect still have the weapon?

Go to

Card

Is the patient bleeding badly? Do Not give the patient anything to eat or drink. No

Stay on the line until EM S and PD arrive.

Is the patient showing signs of shock? (i.e., pale, cool,moist skin)

Maintain airway, breathing, and keep patient warm. Elevate feet and legs. es

Stay on the line until EMS and P D arrive.

136 | P a g e

Partial or complete paralysis on each side. Decreased levels of consciousness.

Is the patient breathing?

Difficulty Speaking.

Seizure.

Go to

card.

Difficulty swallowing or breathing. Loss of facial tone.

Is there any paralysis?

Headache. No

Do Not give the patient anything to eat or drink

Position the patient on the paralyzed side. Attempt to communicate. Patient may understand, but is unable to answer.

Can the patient talk clearly? No

Look for signs of understanding (i.e., glances, nodding, motion, etc.). Stay on the line until EMS arrives.

137 | P a g e

Is this a suicide about an

or is this a witness calling suicide?

Threat

Attempt

ou can ask the following blocks of questions to keep the caller on the line until responding officersarrive.

ou have reached the right number, I m glad you called.

Where is the person who attempted suicide?

Is anyone attemptinglife saving measures? Why do you want to kill yourself?

Have you really thought this out?

Has anything just happened in your life?

How long have you been planning this?

Have you been ill late y?

When are you planning to do this?

What are you feeling right now? Have you taken any d rugs or alcohol?

How did they commi (or attempt) suicide?

No Go to

Where are you planning to do this?

If it was a gun do NOT touch or allow anyone to touch the gun.

What method do you plan to use?

Where is the location of the gun

Be a caring listener.

card.

If it is safe to do so, ha ve someone meet the officers outside.

Stay on the line until EMS arrives.

Support their feelings Do not discount them.

138 | P a g e

How many people are injured?

Gather these questions

Is there anyone trapped?

How many vehiclesare involv ed? Is the roadway blocked?

How did this happen? How many? Do not attempt to move patients unless they are in danger, and unless you can get to them safely.

Is anyone bleeding severely? es

Go to

Card

Are there any signs of shock? (i.e., pale, cool,moist skin) es

Do Not give the p atient anything to eat or drink. Maintain airway, breathing, and keep patient warm. Elevate feet and legs.

Does the patient have any broken bones present?

Stay on the line until EMS arrives.

Do not move, stabilize in place.

139 | P a g e

Is the patient breathing? es

Go to

Card

Does the patient have severe bleeding? es

No Are there any signs of shock? (i.e., pale, cool,moist skin)

Go to

Do Not give the patient anything to eat or drink.

Card No

Maintain airway, breathing, and keep patient warm. a Elevate feet and legs. Is the patient having any nausea or vomiting? es

Turn the patient on their side.

Does the patient have any broken bones present?

Stabilize head and neck. Stay on the line until EMS arrives.

Do not move, stabilize in place.

140 | P a g e

PRACTICAL EXERCISES EMD PRE-SCRIPTED ROLE-PLAY SCENARIOS

141 | P a g e Abdominal Pain CALLER STATEMENT: I need an ambulance; my stomach hurts. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: She is complaining of abdominal pain, which she has had for three days. She is conscious and breathing with no other complaints and is not pregnant - but has been going to the bathroom frequently for the past three days. LOCATION OF EMERGENCY: 123 Main St AGE OF PATIENT: 28 CALLER'S ADDRESS: Same CALLBACK NUMBER: 123-4567 MEDICAL HISTORY: Stomach virus past three days

142 | P a g e Allergic Reaction CALLER STATEMENT: A bee stung my son. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: A bee has just stung The caller's son. The boy is having trouble breathing, and the caller cannot find the boy's allergic reaction kit. LOCATION OF EMERGENCY: 123 Main St AGE OF PATIENT: 6 CALLER'S ADDRESS: Same CALLBACK NUMBER: 123-4567 MEDICAL HISTORY: Allergic to bee stings

143 | P a g e Animal Bite CALLER STATEMENT: The girl across the street was bitten by a dog. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: A girl has just been bitten by a dog in the face. The patient is lying down in the yard. LOCATION OF EMERGENCY: 123 Main St AGE OF PATIENT: 10 CALLER'S ADDRESS: 2513 Stone Mountain Street CALLBACK NUMBER: 123-4567 MEDICAL HISTORY: Unknown

144 | P a g e Assault/Rape CALLER STATEMENT: I just got raped. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: The caller has been raped and beaten. She calls from a pay phone approximately 1/4 mile from where the incident occurred. LOCATION OF EMERGENCY: At the corner of Sanford Avenue and 3rd Street, "City Park" AGE OF PATIENT: 23 CALLBACK NUMBER: Unknown, at phone booth without a number. CALLER PHONE NUMBER: 1234567 MEDICAL HISTORY: None

145 | P a g e Back Pain CALLER STATEMENT: My husband can't get out of bed. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: Her husband can't get out of bed. He tried and had too much pain. He is in no distress when he does not move. Yesterday, he was replacing tiles on the roof all day. LOCATION OF EMERGENCY: 316 Redmon Lane AGE OF PATIENT: 68 CALLER'S ADDRESS: Same CALLBACK NUMBER: 123-4567 MEDICAL HISTORY: None

146 | P a g e Bleeding CALLER STATEMENT: My grandma is sick, send an ambulance! Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: The caller is 12 years old and is at his grandmother's house. She is a 65-year-old female and is vomiting dark-colored blood into the garbage can. She is very weak, pale, and too weak to come to the phone. The only history the caller knows is that she has heart problems. LOCATION OF EMERGENCY: 872 Deer Run Avenue. AGE OF PATIENT: 65 CALLER'S ADDRESS: Same CALLBACK NUMBER: 231-4157 MEDICAL HISTORY: Previous heart attack two years ago

147 | P a g e Bleeding CALLER STATEMENT: Some lady cut her foot badly. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: The caller heard a neighbor scream. He went next door, where he found her on the ground screaming. She had cut her foot very badly with the lawn mower. Although her toes are badly cut, the bleeding is oozing rather than spurting. LOCATION OF EMERGENCY: 123 Main St AGE OF PATIENT: 40s CALLER'S ADDRESS: 125 Main St CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: Unknown

148 | P a g e Breathing Problems CALLER STATEMENT: Please help me...uh. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: The caller is having an asthma attack and is out of her medication. No one is around, and he is new to the area. LOCATION OF EMERGENCY: 48963 Mills Drive AGE OF PATIENT: 28 CALLER'S ADDRESS: Same CALLBACK NUMBER: 322-5732 MEDICAL HISTORY: Asthma

149 | P a g e Burns CALLER STATEMENT: I need an ambulance, quick! Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: The babysitter is the calling. The patient is a four-year-old male who pulled a cord hanging over the kitchen counter, which was attached to the coffee maker. The pot was full of hot coffee and spilled all over the child, who was screaming next to the caller. LOCATION OF EMERGENCY: 6321 Jefferson Street AGE OF PATIENT: 4 CALLER'S ADDRESS: Same CALLBACK NUMBER: 456-7899 MEDICAL HISTORY: None

150 | P a g e Carbon Monoxide/Inhalation/HAZMAT CALLER STATEMENT: A truck hit a tree! Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: A pickup truck without markings has hit a tree and has a middle-aged man unconscious outside the truck by the bed of the truck on his back, not moving. There are three large barrels in the back of the truck's bed with white powder spilled in the truck's bed with one barrel broken and in the road with white powder spilled. The caller tried to go and help the unconscious driver but became dizzy and out of breath. LOCATION OF EMERGENCY: At the intersection of Roosevelt Boulevard and San Jose Lane. CALLBACK: Not available AGE OF PATIENT: Middle-aged CALLER'S ADDRESS: Same MEDICAL HISTORY: Unknown

151 | P a g e Cardiac Arrest CALLER STATEMENT: Can you tell me how to do CPR? Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: The caller, age 14, couldn't wake her grandfather. The patient is very blue. The caller wants to know how to do CPR. She is alone. LOCATION OF EMERGENCY: 7148 Lynx Court CALLBACK NUMBER: 436-5936 AGE OF PATIENT: 76 CALLER'S ADDRESS: Same MEDICAL HISTORY: Bypass Surgery

152 | P a g e Chest Pain CALLER STATEMENT: I'm having some crushing chest pains. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: The caller had just finished waxing his car when he suddenly started having chest pains. LOCATION OF EMERGENCY: 123 Main St AGE OF PATIENT: 48 CALLER'S ADDRESS: Same CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: None

153 | P a g e Choking CALLER STATEMENT: I need the paramedics; somebody's choking. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: The caller is at a backyard cookout. Someone there is choking on food. LOCATION OF EMERGENCY: 1123 Nancy Creek Drive AGE OF PATIENT: About 30 CALLER'S ADDRESS: Same CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: Unknown

154 | P a g e Convulsions/Seizures CALLER STATEMENT: Somebody is having a seizure. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: The caller just witnessed someone who fell and started jerking all over. LOCATION OF EMERGENCY: 1333 South Main St at the 7-11 Store AGE OF PATIENT: Teenager CALLER'S ADDRESS: Same CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: Unknown

155 | P a g e Diabetic CALLER STATEMENT: My wife is unconscious. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: The caller’s wife was mowing grass when becoming dizzy. Came inside and collapsed. LOCATION OF EMERGENCY: 1567 S.W. 7th Street AGE OF PATIENT: 62 CALLER'S ADDRESS: Same CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: Diabetes

156 | P a g e Eye Injury CALLER STATEMENT: Some guy got some chemicals in his eyes. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: While working in an industrial shop, the victim tore open a bag of dry powder when some of the contents got in his eyes. LOCATION OF EMERGENCY: Grinnell Industrial Maintenance, 1234 S. Broad St AGE OF PATIENT: 40s CALLER'S ADDRESS: Same CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: Unknown

157 | P a g e Falls CALLER STATEMENT: My husband fell; I need an ambulance. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: While cleaning leaves from the gutter, the victim fell from a ladder approximately 15 feet. He is lying in a puddle of water. He is conscious and says he can't move his legs. LOCATION OF EMERGENCY: 1412 Jackson Ave. A GE OF PATIENT: 64 CALLER'S ADDRESS: Same CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: Heart Condition

158 | P a g e Headache CALLER STATEMENT: I'm having terrible headaches. This is the worst one I've ever had. I can't stand it. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: The caller has been having headaches since yesterday. LOCATION OF EMERGENCY: 1098 Country Court AGE OF PATIENT: 48 CALLER'S ADDRESS: Same CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: Migraines

159 | P a g e Heat/Cold/Exposure CALLER STATEMENT: Some kid had a heat stroke; we need an ambulance. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: While playing soccer, a 12-year-old boy came to the sidelines. He is groggy. His face is bright red, and he is sweating profusely. The temperature is 98. LOCATION OF EMERGENCY: Sweetwater Middle School on Cruse Road. AGE OF PATIENT: 12 CALLER'S ADDRESS: At the soccer field behind the school on a cellular phone. CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: Unknown

160 | P a g e Overdose/Ingestion/Poisoning CALLER STATEMENT: My daughter is unconscious. I think she has overdosed on drugs. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: The caller came home from work and found the daughter unconscious on her bed. She is breathing very slowly. LOCATION OF EMERGENCY: 8734 Meadowcreek Dr. AGE OF PATIENT: 16 CALLER'S ADDRESS: Same CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: Drug abuse

161 | P a g e Unconscious/Fainting CALLER STATEMENT: My husband is unconscious. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: The caller came home from work and found their husband unconscious on the floor. He is breathing and is drooling. LOCATION OF EMERGENCY: 28394 S.W. 164th Ave. AGE OF PATIENT: 66 CALLER'S ADDRESS: Same CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: High Blood Pressure

162 | P a g e CPR – Adult (Over 8 Years) CALLER STATEMENT: My husband is unconscious. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: The caller came home from work and found their husband unconscious on the floor. He is not breathing. His face is a bluish color. LOCATION OF EMERGENCY: 2839 Club Drive AGE OF PATIENT: 66 CALLER'S ADDRESS: Same CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: None

163 | P a g e CPR – Child (1-8 Years) CALLER STATEMENT: My daughter is unconscious. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: The caller came home from work and found her daughter unconscious on the bed. She is not breathing. There is an empty medicine container and a glass of water on the nightstand beside her. LOCATION OF EMERGENCY: 28394 S.W. 164th Ave. AGE OF PATIENT: 16 CALLER'S ADDRESS: Same CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: Drug abuse, depression

164 | P a g e CPR – Infant (0 - 12 months) CALLER STATEMENT: My baby is unconscious. Any Information elow should e pro ided “only” when requested y the 9-1-1 call-taker. BACKGROUND INFORMATION: The caller found the baby unconscious in a crib. He is not breathing. LOCATION OF EMERGENCY: 283 Krome Avenue AGE OF PATIENT: 3 months CALLER'S ADDRESS: Same CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: None

165 | P a g e Airway – Adult (Over 8 Years) CALLER STATEMENT: My husband is unconscious. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: The caller is at a backyard cookout. Her husband is choking on some food. LOCATION OF EMERGENCY: 8394 S.W. 14th Ave. AGE OF PATIENT: 36 CALLER'S ADDRESS: Same CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: None

166 | P a g e Airway – Child (1 - 8 Years) CALLER STATEMENT: My child is unconscious. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: The victim has a balloon stuck in the throat and can't breathe. LOCATION OF EMERGENCY: 2456 West Hamby, Apartment #4 AGE OF PATIENT: 6 CALLER'S ADDRESS: Same CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: None

167 | P a g e Airway – Infant (0-12 months) CALLER STATEMENT: My baby is choking; please help me. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: Baby is choking on a piece of hard candy that is lodged in the throat. The baby is turning blue. LOCATION OF EMERGENCY: 13 Burnham Circle AGE OF PATIENT: 6 months CALLER'S ADDRESS: Same CALLBACK NUMBER: 236-4657 MEDICAL HISTORY None

168 | P a g e Childbirth – non-life-threatening CALLER STATEMENT: My wife's water broke. I think she is about to have her baby right here. Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: Her water has broken. This is their third child, and there are no complications during the first two. Baby's head is slightly showing. LOCATION OF EMERGENCY: 28394 S.W. 164th Ave. AGE OF PATIENT: 36 CALLER'S ADDRESS: Same CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: None

169 | P a g e Childbirth – Life-threatening Emergency CALLER STATEMENT: My wife is about to have her baby. A leg is coming out! Any Information below should be provided “only” when requested by the 9-1-1 call-taker. BACKGROUND INFORMATION: Her water has broken. This is their third child, and there are no complications during the first two. When asked if the top of the baby's head is showing, he sees what looks like the baby's leg. LOCATION OF EMERGENCY: 28394 S.W. 164th Ave. AGE OF PATIENT: 26 CALLER'S ADDRESS: Same CALLBACK NUMBER: 236-4657 MEDICAL HISTORY: None

170 | P a g e

APPENDICES

171 | P a g e

APPENDIX A HIGHWAY SAFETY PROGRAM GUIDELINE NO. 11 EMERGENCY MEDICAL SERVICES Each State, in cooperation with its political subdivisions, should ensure that persons incurring traffic injuries (or other trauma) receive prompt emergency medical care under the range of emergency conditions encountered. Each system component should be equally committed to its role and, ultimately, to the patient's care. At a minimum, the EMS program should comprise the components detailed in this chapter. I.

REGULATION AND POLICY

Each State should embody comprehensive enabling legislation, regulations, and operational policies and procedures to provide an effective emergency medical and trauma care system. This legal framework should: A.

Establish the program and designate a lead agency.

Outline the lead agency's basic responsibilities, including licensure and certification.

Require comprehensive planning and coordination.

Designate EMS and trauma system funding sources.

Require data collection and evaluation.

Provide authority to establish minimum standards and identify penalties for noncompliance; and

Provide for an injury/trauma prevention and public education program.

All these components, discussed in different sections of this guideline, are critical to the effectiveness of legislation that is the legal foundation for a statewide EMS system.

172 | P a g e

II.

RESOURCE MANAGEMENT

Each State should establish a central lead agency at the State level to identify, categorize, and coordinate resources necessary for overall system implementation and operation. The lead agency should: A.

Maintain a coordinated response and ensure that resources are used appropriately throughout the State.

Provide equal access to basic emergency care for all victims of medical or traumatic emergencies.

Provide adequate triage and transport of all victims by appropriately certified personnel (at a minimum, trained to the emergency medical technician [EMT] basic level) in properly licensed, equipped, and maintained ambulances.

Provide transport to a facility that is appropriately equipped, staffed, and ready to administer to the needs of the patient (section 4: Transportation) and

Appoint an advisory council to provide a forum for cooperative action and maximum use of resources.

III.

HUMAN RESOURCES AND TRAINING

Each State should ensure that its EMS system has essential trained persons to perform required tasks. This personnel includes first responders (e.g., police and fire), prehospital providers (e.g., emergency medical technicians and paramedics), communications specialists, physicians, nurses, hospital administrators, and planners. Each State should provide a comprehensive statewide plan for stable and consistent EMS training programs with effective local and regional support. The State agency should: A.

Ensure sufficient availability of adequately trained EMS personnel.

Establish EMT-Basic as the state minimum level of training for all transporting EMS personnel.

173 | P a g e C.

Routinely monitor training programs to ensure uniformity and quality control.

Use standardized curricula throughout the State.

Ensure availability of continuing education programs.

Require instructors to meet State requirements.

Develop and enforce certification criteria for first responders and prehospital providers and

Require EMS operating organizations to collect data to evaluate emergency care regarding the frequency, category, and severity of conditions treated and the appropriateness of care provided.

IV.

TRANSPORTATION

Each State should require safe, reliable ambulance transportation, critical to an effective EMS system. States should: A.

Develop statewide transportation plans, including the identification of specific service areas.

Implement regulations that provide for the systematic delivery of patients to appropriate facilities.

Develop routine, standardized methods for inspecting and licensing all emergency medical transport vehicles.

Establish a minimum number of providers at the desired level of certification on each response.

Coordinate all emergency transports within the EMS system, including public, private, or specialty (air and ground) transport and

Develop regulations to ensure ambulance drivers are properly trained and licensed.

174 | P a g e V.

FACILITIES

The seriously injured patient must be delivered promptly to the closest appropriate facility. Each State should ensure that: A.

Both stabilization and definitive care needs of the patient are considered.

The determination is free of non-medical considerations, and the capabilities of the facilities are clearly understood by prehospital personnel.

Hospital resource capabilities are known in advance so that appropriate primary and secondary transport decisions can be made, and

Agreements are made between facilities to ensure that patients receive treatment at the closest, most appropriate facility, including facilities in other states or counties.

VI.

COMMUNICATIONS

An effective communications system is essential to EMS operations and provides how emergency resources can be accessed, mobilized, managed, and coordinated. Each State should require a communication system to: A.

Begin with the universal system access number 911.

Strive for quick implementation of enhanced 911 services, which make possible, among other features, the automatic identification of the caller's physical location.

Provide for prioritized dispatch (dispatch-to-ambulance, ambulance-to-ambulance, ambulance-to-hospital, and hospital-to-hospital communication).

Ensure that the receiving facility is ready and able to accept the patient and

Provide dispatcher training and certification standards.

Each State should develop a statewide communications plan that defines State government roles in EMS system communications.

175 | P a g e VII.

TRAUMA SYSTEMS

Each State should maintain a fully functional trauma system to provide high-quality, effective patient care. States should implement legislation requiring the development of a trauma system, including: A.

Trauma center designation, using American College of Surgeons Committee on Trauma guidelines as a minimum.

VIII.

Triage and transfer standards for trauma patients.

Data collection and trauma registry definitions for quality assurance.

Mandatory autopsies to determine preventable deaths and

Systems management and quality assurance.

PUBLIC INFORMATION AND EDUCATION

Public awareness and education about the EMS system are essential to a high-quality system. Each State should implement a public information and education (PI&E) plan to address: A.

The components and capabilities of an EMS system.

The public's role in the system.

The public's ability to access the system.

What to do in an emergency (e.g., bystander care training).

Education on prevention issues (e.g., alcohol or other drugs, occupant protection, speeding, motorcycle and bicycle safety).

The EMS providers' role in injury prevention and control and

The need for dedicated staff and resources for PI&E programming.

176 | P a g e IX.

MEDICAL DIRECTION

Physician involvement in all aspects of the patient care system is critical for effective EMS operations. EMS is a medical care system in which physicians delegate responsibilities to non-physician providers who manage patient care outside the traditional confines of the office or hospital. States should require physicians to be involved in all aspects of the patient care system, including:

Planning and protocols.

On-line and off-line medical direction and consultation; and

Audit and evaluation of patient care.

EVALUATION

Each state should implement a comprehensive evaluation program to effectively assess and improve a statewide EMS system. EMS system managers should: A.

Evaluate the effectiveness of services provided to victims of medical or trauma-related emergencies.

Define the impact of patient care on the system.

Evaluate resource utilization, scope of service, patient outcome, and effectiveness of operational policies, procedures, and protocols.

Develop a data-gathering mechanism that provides for the linkage of data from different data sources using common data elements and

Evaluate process and impact measures on injury prevention and public information and education programs.