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Multnomah County and AMR
Clackamas County, Oregon
Emergency Medical Services
Patient Treatment
Protocols
Effective: February 1, 2008
CONTENTS
Table of Contents
Preface Section 00.000

Advance Directives and Do Not Attempt Resuscitation Orders .00.020 Medical Control for Drugs and Procedures .00.040 Treatment . Section 10.000

Anaphylaxis and Allergic Reaction .10.030 Psychiatric and Behavior Disorders .10.150 Drugs . Section 20.000

Drugs . Section 20.000

Methylprednisolone (Solu-Medrol®) .20.180 Xylocaine, Viscous (Lidocaine®, topical) .20.300 Procedures . Section 30.000

Automatic Implantable Cardio-Defibrillator (AICD) Deactivation .30.020 Management of Intravenous Lines and IV Solutions .30.090 Procedures . Section 30.000

Control and Monitoring of Intravenous Solutions .30.100 Refusal and Informed Consent Flow Chart Tension Pneumothorax Decompression .30.170 Communications . Section 40.000

BOEC EMS Dispatch (Multnomah County) .40.010 Medical Resource Hospital, Receiving Hospitals and the Operations . Section 50.000

Guidelines for Assisting Grieving People .50.050 Operations . Section 50.000

Task Card - Medical Branch Director Scene Checklist Task Card - Treatment Group Supervisor Task Card - Medical Staging Area Manager Task Card - Transportation Group Supervisor Transportation and Patient Destination .50.140 Trauma Protocol ATAB 1 . Section 60.000

Recommended Air Ambulance Response Zones .60.060 Special Operations Treatment . Section 70.000

Abbreviations, Symbols and Special Notes
Abbreviations, Symbols and Special Notes
Stars (*)
The protocols identify levels of care based on certification levels.
All levels of out-of-hospital providers are able to provide this level of EMT-B through EMT-P are able to provide this level of care EMT-I through EMT-P are able to provide this level of care Three stars *** EMT-P is able to provide this level of care Brackets [***]
A. If not preceded by any stars, provide care at the level of certification.
[***] Be prepared to support ventilation and oxygenation through BVM or ET intubation and manual ventilation.
B. If preceded by any star, the minimum level of certification is identified, and care
by a higher level of certification is indicated.
*[**] Apply AED [or cardiac monitor], if available, and use the following
C. The use of brackets may also be used to indicate limitation of a particular level of
***[**] If IV is immediately established, administer atropine [0.5 mg]
to1.0 mg IV and repeat every 3 to 5 minutes (to a maximum of. . .
Special Notes
EMT Intermediates must complete one of the following to administer medications in list 1: 1. Complete the bridge class approved by the Oregon Department of Human Services
2. Complete the full EMT Intermediate course which included the medications on list
1 and become certified with the State of Oregon as an EMT Intermediate.
Advanced Directives and Do Not Attempt Resuscitation Orders
Advance Directives and
Do Not Attempt Resuscitation Orders

Purpose:
This EMS system believes in respect for patient autonomy. The patient with decision-making capacity has the right to accept or refuse medical intervention. This includes the right to specify, in advance, patient preferences when the person is no longer able to communicate wishes.
Procedure:
The EMS system shall honor POLST forms, Advance Directives and other Do Not Attempt Resuscitation (DNAR) orders that the EMT sees in writing under the following circumstances: A. Do Not Attempt Resuscitation: In the pulseless and apneic patient who does not
meet the criteria of the Death in the Field protocol, but is suspected to be a
candidate for withholding resuscitation, BLS protocols will be followed until one 1. The EMT sees a written DNAR, which should be honored, and resuscitation
2. The patient’s physician is contacted and directs the EMTs not to continue
3. The EMTs see a valid Advance Directive or Directive to Physician which directs
4. The patient’s attorney-in-fact (PAHC or DPAHC) directs the EMTs not to
5. OLMC directs the EMTs not to continue resuscitation.
6. If a person, who is terminally ill, appears to have ingested medication under the
provisions of the Oregon Death with Dignity Act (see section F below).
B. Advance Directives: DNAR orders only apply if the patient is in cardiopulmonary
arrest. If the patient’s PAHC, DPAHC, Directive to Physicians, or other Advance Directive is available to convey the patient’s wishes, and the EMTs have seen a copy of the document, the EMTs must honor the treatment preferences as expressed.
C. Physician Orders for Life-Sustaining Treatment: If a POLST form is available, and it

clearly expresses the patient’s wishes and is signed by a physician, nurse practitioner or physician’s assistant, EMTs shall honor the patient’s treatment care preferences as documented in the EMS section of the POLST. [Cite: OAR 847-035-030 (7)] D. If there are questions regarding the validity, or enforceability, of the health care
instruction, begin BLS treatment and contact OLMC.
Preface revised 12/04/07 00.020 - Page 1 Advanced Directives and Do Not Attempt Resuscitation Orders
E. It is always appropriate to provide comfort measures as indicated.
F. Oregon Death with Dignity Act: If a person who is terminally ill appears to have
ingested medication under the provisions of the Oregon Death with Dignity Act, the 1. Provide comfort care, as indicated.
2. Determine who called 9-1-1 and why (i.e., to control symptoms or because the
person no longer wishes to end their life with the medication).
3. Establish the presence of DNAR orders and/or documentation that this was an
action under the provisions of the Death with Dignity Act.
4. Contact OLMC.
5. Withhold resuscitation, if:
a. DNAR orders are present, and
b. There is evidence that this is within the provisions of the Death with Dignity
c. OLMC agrees.
Definitions:
A. Do Not Attempt Resuscitation Order (DNAR): An order written by a physician
stating that in the event of cardiopulmonary arrest, cardiopulmonary resuscitation
will not be administered. DNAR orders apply only if the patient is pulseless and B. Health Care Instruction: A document executed by a person to indicate the person’s
instructions regarding health care decisions.
C. Advance Directive: A document that contains a health care instruction or a power of

D. Living Will: A document that may confirm an Advance Directive or Directive to
Physician informing her/him that if the patient has a terminal illness and death is imminent, the patient would not wish to be placed on artificial life support that will only prolong the process of dying. In general, the traditional Living Will
document alone is not helpful in the out-of-hospital setting because of its
multiple restrictions and lack of clarity on when it should take effect.
E. Attorney in Fact: An adult appointed to make health care decisions for a person.
F. Power of Attorney for Health Care (PAHC): Power of attorney document
that authorizes an attorney-in-fact to make health care decisions for a person when the Preface revised 12/04/07 Advanced Directives and Do Not Attempt Resuscitation Orders
G. Physician Orders for Life-Sustaining Treatment (POLST): The POLST is a

voluntary form, which was developed to document and communicate patient treat ment preferences across treatment settings. 1. It includes a section for documentation of DNAR orders and a section communicating patient preferences for EMS care. 2. While these forms are most often used to limit care, they may also indicate that the patient wants everything medically appropriate done. 3. Read the form carefully!
4. When signed by a physician (MD or DO), nurse practitioner or physician’s assistant, the POLST is a medical order and EMTs are directed to honor it in their Scope of Preface revised 12/04/07 Death in the Field
Death in the Field
Procedure:
A. Determining death in the field (DIF) without initiating resuscitative efforts

should be considered under the following conditions:
1. Patient qualifies as a Do Not Resuscitate (DNR) or Do Not attempt
Resuscitation (DNAR) patient (See Advance Directives and Do Not
Attempt Resuscitation Orders protocol).
2. A pulseless, apneic patient in a Mass Casualty Incident or Multiple Patient Scene

where the resources of the system are required for the stabilization of living 3. Decapitation.
4. Rigor Mortis in a warm environment.
5. Decomposition.
6. Skin discoloration in dependent body parts (dependent lividity).
NOTE:
If a bystander, family or first responder has started BLS these conditions may still be used to determine DIF without OLMC consultation.
B. Medical Cardiac Arrest:
1. Patients with persistent/refractory Ventricular Fibrillation should be transported,

except when Advance Directives, DNAR orders, or other withholding resuscitative efforts apply. If in doubt, contact OLMC.
2. Patients with Pulseless Electrical Activity (PEA) who have not responded to

Advanced Cardiac Life Support for PEA may be determined to be dead in the field (if End Tidal CO <20) after consultation with OLMC.
3. When a patient’s cardiac rhythm deteriorates to asystole or an agonal rhythm despite

appropriate cardiac resuscitative measures (including establishing an effective airway, administering epinephrine and/or vasopressin and 3 mg atropine, adequate CPR and checking the rhythm in at least 3 leads at full amplitude) the PIC may determine 4. If the patient’s ECG strip shows asystole or agonal rhythm upon initial monitoring

(and after confirming in six leads) and if the patient, in the Paramedic’s best judgment, is not a candidate for resuscitation efforts, the PIC may: a. Determine DIF, notify the Medical Examiner and law enforcement; OR
b.
Begin BLS procedures, and contact OLMC with available patient history,

current condition, and with a request to discontinue BLS resuscitation.
Preface revised 10/05 Death in the Field
C. Traumatic Cardiac Arrest:
Traumatic cardiac arrest is a difficult situation with no easy answers. Response time, mechanism of injury, safety, and proximity to hospital care are all factors that merit At a trauma scene the EMT should consider the circumstances surrounding the incident, including the possibility that a medical event (cardiac dysrhythmia, seizure, hypoglycemia) preceded the accident. When a medical event is suspected, treat as a 1. A victim of trauma should be determined to be dead at the scene if:
a. The patient is a victim of trauma (blunt or penetrating) and has no vital signs/

signs of life (pulseless, apneic, fixed pupils) when the EMT arrives at the scene.
b. If opening the airway does not restore vital signs/signs of life, the patient
should NOT be transported unless there are extenuating circumstances. 2. Cardiac monitor may be beneficial in determining death in the field:
a. A narrow complex rhythm (QRS less than 0.12) may suggest profound
hypovolemia, which may respond to fluid resuscitation, b. Ventricular fibrillation should raise the index of suspicion for a medical event,
c. Asystole, or an agonal rhythm, is not compatible with life.
3. In instances prior to transport where the patient declines to the point that no vital

signs (i.e., no pulse or respiration) are present, the cardiac rhythm should be reassessed. A viable rhythm (narrow complex with QRS <0.12), especially in patients with penetrating trauma may reflect hypovolemia or obstructive shock (tamponade, tension pneumothorax) and aggressive care should be continued.
Documentation:
A. All patient care provided should be documented with procedure and time.
B. When a cardiac monitor is used, the patient’s rhythm should be recorded and attached

C. All conversations with attending physicians or OLMC should be fully documented
with physician’s name, times, and instructions.
D. If resuscitation of a person found in asystole is not attempted based on paramedic
judgment, the reason resuscitation was not attempted must be clearly documented on Preface revised 10/05 Death in the Field
A. ORS allows a lay person, EMT, or Paramedic to determine “Death in the Field.”
B. The EMT is encouraged to use OLMC if any doubt exists about the resuscitation potential of the patient.
C. A person who was pulseless or apneic, or has received CPR, and has been resuscitated, is not precluded

from becoming a candidate for solid organ donation (i.e., kidney, heart, liver, etc.). D. ETCO2 may be a useful adjunct with regard to the decision to terminate resuscitation with PEA. An

ETCO2 of 10 or less in patients in PEA after 20 minutes of ACLS resuscitation does not correlate with E. The probability of survival from trauma arrest is low, but not completely zero.
Preface revised 10/05 Medical Control for Drugs and Procedures
Medical Control for Drugs and Procedures
If a patient receives a procedure or medication; is conscious (or regains consciousness); and refuses trans-
port, every effort shall be made to encourage transport of the patient. If the patient persists in refusing
transport, see the Non-Transport procedure.
These protocols contain Category A and B drugs and procedures. Before using any Category B drug or
procedure you must contact OLMC. If the EMT is unable to contact OLMC, Category B drugs or proce-
dures should be administered as indicated in the protocol. If a Category B drug or procedure is used without
OLMC contact, a written report must be sent to the Medical Director or Physician Supervisor. Contin-
ued attempts must be made to reach OLMC en route.
Category A:
Drug or procedure will be used at the EMT’s discretion in accordance with the standing orders.
*** Calcium Gluconate (Cardiac Arrest & Hyperkalemia) ** Dextrose 50%, IV *** Droperidol (Inapsine®) * Epinephrine *** Etomidate (Amidate) Advanced airway training required ** Glucagon Glucose, Oral ** Fentanyl (Sublimaze) ** Furosemide (Lasix®) *** Hydroxocobalamin (Cyanokit®) ** IV Solutions ** Ipratropium (Atrovent®) ** Lidocaine (Xylocaine®) *** Magnesium Sulfate: In cardiac arrest *** Methylprednisolone (Solu-Medrol): In resp. distress *** Midazolam (Versed® ** Morphine Revised 11/29/07 00.040 - Page 1 Medical Control for Drugs and Procedures
Category A:
Procedures:

* Use of the Combi-tube *** Chemical Patient Restraint * End-Tidal CO2 Monitoring *** Endotracheal Intubation ** Intraosseous Infusion * King LT-D/LTS-D Airway Device *** NeedleCricothyrotomy *** Quick-Trach® (type device) *** Paralytic Intubation: Advanced Airway Training Required Physical Patient Restraint Self-Care Instructions Pelvic Wrap *** Synchronous Cardioversion a. Unstable V-Tachycardia, OR b. SVT, unstable patient with BP less than 90 mm/Hg Taser barb removal *** Tension Pneumothorax Decompression *** Transcutaneous Pacing Category B:
Drug or procedure, not included in Category A, shall be initiated by request from EMT to OLMC. Confirmation of dosage or procedure will be obtained directly from a Physician on Duty at OLMC.
Procedures:
*** Magnesium Sulfate (OB/GYN and asthma) *** Sodium Bicarbonate (Cyclic antidepressant Revised 11/29/07 00.040 - Page 2 Medical Control for Drugs and Procedures
Required Multnomah County Medications
Activated Charcoal, 50 Gm -- 2 (1)
Lidocaine
Earliest Expiration Date:________________  2%, 100 mg/10 cc -- 6 (3)
Adenosine, 6 mg, 12 mg
Earliest Expiration Date:________________ Earliest Expiration Date:________________  2%, Viscous Jelly -- 2
Earliest Expiration Date:________________
Albuterol, 2.5 mg/3 cc --5 (2)
Earliest Expiration Date:________________
Magnesium 10%, 2 Gm/20 cc, -- 4 (2)
Earliest Expiration Date:________________
Amiodarone, 150 mg/3ml --6 (4)

Earliest Expiration Date:________________  Methylprednisolone, 125 mg/2 ml -- 4 (2)

Earliest Expiration Date:________________  Aspirin, 81 mg tablets -- 1 btl. (8 tabs)
Earliest Expiration Date:________________
 *Midazolam, 10 mg/2cc -- 4 (1) * 11-1-99
Earliest Expiration Date:________________
Atropine, 1 mg/10 cc-- 6 (3)
Earliest Expiration Date:________________
Naloxone, 2 mg/2 cc -- 9 (3)
Earliest Expiration Date:________________
Calcium Gluconate, 4 (2)

Earliest Expiration Date:________________  Nitroglycerin
Spray, 0.4 mg -- 2 (1)
Dextrose
Earliest Expiration Date:________________  50%, 50 cc -- 4 (2)
Tablets, 0.4 mg -- 2 (1)
Earliest Expiration Date:________________ Earliest Expiration Date:________________  Oral, 30 Gm --2 (1)
Earliest Expiration Date:________________
Ondansetron, 4 mg/2 ml -- 2 (1)

Earliest Expiration Date:________________  Diphenhydramine, 50 mg/1 cc -- 2 (1)
Earliest Expiration Date:________________
Sodium Bicarb, 50 mEq/50cc -- 3 (2)
Earliest Expiration Date:________________
Epinephrine:
1:1,000, 30 cc -- 2 (1)
Succinylcholine, 500 mg; -- 2 (1)
Earliest Expiration Date:________________ Earliest Expiration Date:________________  1:1,000, 1 mg/1 cc -- 2 (1)
[9-1-1 Responding Units Only]
Earliest Expiration Date:________________  Vasopressin, 20 U/cc - 4 (2)
1:10,000, 1 mg/10 cc -- 10 (4)
Vecuronium, 10 mg- powder; -- 2
Earliest Expiration Date:________________ Earliest Expiration Date:________________  Etomidate (Amidate), 40 mg (2 mg/ml) 4 (2)
[9-1-1 Responding Units Only]
 *Fentanyl (Sublimaze), 100 mcg/2ml 10 (5)
* must be locked and counted at each shift
Furosemide, 40 mg/4 cc -- 4 (2)
Earliest Expiration Date:________________  Glucagon, 1 mg/1 cc -- 2 (1)
Earliest Expiration Date:________________
Droperidol, 2.5 mg/1 cc -- 4 (2)
Earliest Expiration Date:________________
Dopamine, 400 mg/10 cc -- 2 (1)
Earliest Expiration Date:________________
Ipatropium, 500mcg/2.5cc -- 5 (2)
Earliest Expiration Date:________________
Preface Revised 1/04

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