Transcript EMS seminar #2

EMS seminar #2
Joseph Ip BSc (Hon), MSc, MD
VGH Emergency
May 28, 2002
Dispatch
 Introduction
 911 dispatch
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MPDS
Trauma 99 protocol
CCB
Primary and secondary redirections
 Transfer fleet dispatch
 Provincial Airevac dispatch
Components in EMD
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Systematized, scripted formal caller interrogation
process (key questions)
Systematized, scripted post-dispatch and pre-arrival
instructions (PAIs)
Clinical/ situational problem descriptors and
associated codes that match the dispatcher’s
evaluation of the injury or illness and severity with
vehicle response mode and configuration (dispatch
priorities including determinants and response)
Support and definitional reference information
Roles of EMD
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Interrogator
Vehicle allocation
Pre-arrival instructions
Radio dispatcher
Triager
Logistics coordinator
Resource provider
Vertical Dispatch
 refers to one individual handling all functions
for each call
Horizontal Dispatch
 refers to one individual handling all functions
for each call
Considerations in planning dispatch
response
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Response configuration
Response mode
Referral to alternate care and evaluation
methodologies
Economics of response
Politics of response
Personnel satisfaction and crew burnout
Responder and public safety secondary to
emergency response modes
Prioritization risk management and legal concerns
Tiered Response
 means sending different response
configuration in different response mode
according to the presenting complaint
PAI vs Telephone Aid
 Prearrival instruction (PAI)
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telephone-rendered, medically approved,
written instructions given by trained EMDs to
callers to aid victim and control the situation
before prehospital personnel arrive.
 Telephone aid
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ad lib advice provided by dispatchers based
on their own experience and training in a
procedure or treatment but not following a
written PAI protocol.
Quality Management Program for EMD
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Selection
Orientation
Initial training
Certification
Continuing dispatch education
Medical oversight
Data gathering
Performance evaluation or case review and feedback
Recertification
Risk management
Medical Priority Dispatch System
(MPDS)
Introduction:
 Developed in Salt Lake City
 Used to standardize dispatch
 Step by step instructions for dispatchers
 Standardized entry and exit processes
 6 dispatch patterns (A, B, C, D, E, )
MPDS
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Medical incident protocols (AP, Allergies/
envenominations, back pain, CP, Sz, diabetic
problems, headache, heart problems/ AICD, hot/
cold exposure, OD, psychiatric problem, sick
person, stroke, interfacility/ palliative care)
Traumatic incident protocol (animal bite, assault,
burns, eye problem, falls, hemorrhage, industrial
accident, penetrating trauma, MVA, traumatic
injuries)
Time-life incident protocol (breathing problem, CO
poisoning, Cardiac arrest, choking, drowning,
electrocution, pregnancy, childbirth, miscarriage,
fainting, man down)
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AP
Allergies/ Envenomations
Animal bites/ attacks
Assault/ SA
Back pain (non-traumatic or nonrecent)
Breathing problems
Burns (scalds)/ Explosion
CO poisoning/ inhalation/ HAZMAT
Cardiorespiratory arrest/ death
CP
Choking
Convulsions/ seizures
Diabetic Electrocution/ problems
Drowning (near)/ diving/ scuba
accident
Lightning
Eye problems/ injuries
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Falls
Headache
Heart problems/ A.I.C.D
Heat/ Cold exposure
Hemorrhage/ Laceration
Industrial/ Machinery Accidents
Overdose/ Poisoning
Pregnancy/ Childbirth/
miscarriage
Pyschiatric/ abnormal behaviour/
suicide attempt
Sick person
Stab/ GSW/ penetrating trauma
Stroke (CVA)
Traffic/ Transportation accident
Traumatic injuries
Unconscious/ Fainting (Near)
Unknown problem (man down)
Transfer/ Interfacility/ Palliative
care
Response Mode in MPDS
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ECHO – closest ambulance (hot)
Delta – Closest BLS and ALS (hot)
Charlie – ALS (cold)
Bravo – Closest BLS (hot/cold)
Alpha – BLS (cold)
Omega – referral or alternate care
Trauma 99 Protocol
Essence of Trauma 99:
 No
matter how seriously-injured or
unstable these trauma patients are, they
must be transported to a trauma receiving
hospital, bypassing the closest hospital,
provided they are 20 minutes or less
transport time from a trauma receiving
hospital.
Trauma 99 protocol:
 In the Lower Mainland, four trauma receiving
hospitals, plus a special role for St. Paul's
Hospital.
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1. Vancouver Hospital and Health Sciences Centre
(VHHSC)
2. Lions Gate Hospital
3. Royal Columbian Hospital
4. BC Children's Hospital
5. St. Paul's Hospital - penetrating, non-neuro;
VHHSC backup.
VHHSC
 catchment area bounded:
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north by the boundary with St.Paul's,
east by Boundary Road
south to include Richmond, Delta, Ladner and
Tsawwassen.
 Blunt trauma in the urban core (St. Paul’s
catchment) goes to VHHSC.
Lions Gate
 catchment area
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entire North Shore from Horseshoe Bay to Deep
Cove
Royal Columbian
 The dividing line between the Royal Columbian
catchment area and VHHSC is west of No. 8 Road in
Richmond and then along an imaginary line to the
Highway 99 interchange with Highway 10.
 catchment area
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Port Moody, Port Coquitlam and Coquitlam
extends east to 203rd Avenue in Maple Ridge. South
of the Fraser River the catchment area extends from
Fort Langley, through Langley, Surrey, and north of
White Rock
St. Paul’s Hospital
 receives penetrating, non-neuro trauma
 acts as back up for VHHSC for blunt trauma, when
VHHSC is on Trauma Bypass
 catchment area boundary
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4th Avenue, from Burrard west to UBC
Terminal Avenue, from Main Street across the
Grandview Viaduct to Clark Drive
along 1st Avenue east to Boundary Road.
 Any penetrating trauma occurring north of the
"boundary" would fall in St. Paul's catchment area
Trauma Center Criteria - Physiological and
Anatomical:
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GCS less than or equal to 13
respiratory rates less than 10 or greater than 30
BP less than 90
penetrating injury to chest, neck, head. abdomen,
groin or proximal extremity (above knee or elbow)
 two or more proximal long bone fractures, i.e.
humerus and /or femur
 flail chest
 Major amputation of extremity
mechanism criteria :
 severe deceleration injury
 falls greater than 20 feet
 high speed MVI
 roll-over
 ejection of patient from vehicle
 pedestrian hit at 20 mph (30 kph) or more
 bicycle, motorcycle accident at 20 mph (30 kph) or
more
Examples:
 Example 1 - Parts of Maple Ridge are more than 20
minutes from the Royal Columbia Hospital, so major
trauma patients from that area should be transported
to Maple Ridge Hospital.
 Example 2 - Major trauma patients in Richmond are
usually less than 20 minutes Code 3 from VHHSC, so
these major trauma cases must be transported
directly to VHHSC, bypassing Richmond General
Hospital.
Triaging Pediatric Trauma patients:
 All paediatric trauma patients must be
transported to paediatric trauma receiving
hospitals regardless of their physical
findings provided you are within the 15
minutes transport time limit.
Pediatric Trauma Centers
 three paediatric trauma-receiving hospitals in the
GVRD:
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l. BC Children's
2. Royal Columbian
3. Lions Gate.
 VHHSC (and St. Paul's for penetrating only) are
secondary paediatric trauma receiving hospitals (
used when can't get to BCCH within 15 minutes)
Triaging Pregnant patients:
 Trauma center if following mechanisms regarless
of vital signs:
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Severe deceleration injury.
falls greater than 20 feet
high speed MVI
roll-over
ejection of patient from vehicle
pedestrian hit at 20 mph (30 kph) or more
bicycle, motorcycle incident at 20 mph (30 kph) or
more
Physiological and anatomical criteria – Pregnant
patients
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BP less than 90
GCS less than or equal to 13
respiratory rates less than 10 or greater than 30
penetrating injury to chest, neck, head. abdomen, groin or
proximal extremity (above knee or elbow)
two or more proximal long bone fractures, i.e. humerus and
/or femur
flail chest
major amputation of extremity, i.e. proximal to knee or
elbow
abdominal pain
vaginal bleeding
Critical Burn Criteria
 Burns associated with significant fractures or other major
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injury
Facial or airway burns with or without inhalation injury
2° burn to more than 20% of total body surface area (child
or adult)
3° burns to more than 10% of total body surface area in an
adult
2% of total body surface area for a child
Any 3° burns involving the eyes, neck, hands, feet or groin
Any high-voltage electrical burns regardless of size
Triaging Burn patients:
 All patients who do not meet the triage criteria for a critical burn
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should be transported to the closest hospital
All patients (adults and children) with a critical burn injury who are
within 20 minutes Code 3 transport time of VHHSC should be
transported there.
Children less than 14 years suspected to have inhalation injury only,
should be transported to BCCH if it can be reached within 15
minutes.
If greater than 20 minutes from VHHSC, but within 20 minutes of a
closer trauma hospital, go to the closest trauma hospital.
If greater than 20 minutes to VHHSC, go to the nearest trauma
hospital.
Critical Care Bypass
Definition of CCB
 Very vague
 “the hospital cannot admit even one more critically
ill patient without compromising the care of patients
already in the Department” (CMAJ; Feb 19, 2002;166(4))
BCAS expectation:
 CCB reflects temporary inability to provide
immediate resuscitation
 Used by hospital only as a last resort and in
extreme cicumstances
 Not invoked by hospital because stretchers are full
or department is busy
 Time limit = 20-30min
New proposed consensus – Vancouver Coastal Regional
workgroup
 2 active simultaneous resuscitations
 CCB will not apply to followings:
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CPR in progress
Unrelieved airway obstruction
Trauma
Closest hospital is > than 20 minutes from scene
Redirect Consideration (CMAJ; Feb 19, 2002;166(4)) :
 A request that the ambulance dispatch centre
send all but critically ill patients to another hospital
 Resources of the ED are being stretched, but
another critically ill patient could be accomodated
if necessary
 This is a way for the ED to buy time so it does not
have to go on CCB
Criteria for the proposed redirect policy:
 All acute care beds are full and all internal
contingency plans have been exhausted
 All stretchers are full and 90% of staffed acute
stretchers are full of admitted patients
OR
 Total census in the ED is equal to 150% of staffed
acute stretchers and 75% of ED stretchers are full
of admitted patients
Secondary Diversion:
 Occurs after assessment at originating hospital
and acceptance of responsibility for the patient by
the originating hospital
 Paramedics may not assume responsibility for
care that they are not qualified to maintain
 Must be a hospital to accept responsibility for the
patient (w/i 20 minutes of ambulance arrival)
Transfer Fleet Dispatch
Transfer Fleet:
 Seperated from 911 dispatch
 CAD operated
 Advanced bookings
 Separate fleet
 Emergency fleet may be borrowed under special
circumstances
 Mainly interfacility transfer
Airevac Dispatch
Aircraft selection:
 Fixed wing aircraft are the aircraft of choice in most
airevacuations, except:
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at night in areas where the airport is daylight use only, and;
when the patient's condition meets specified medical
indicators and the location meets specified operational
indicators.
 At least one medical and one operational indicator must
be met before helicopters can be confirmed as the aircraft
of choice.
 Helicopters may be preferable for:
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rapid access to seriously ill or injured patients at an incident
scene or in a hospital, or;
short distances.
Why fixed wing over helicopters?
 in most cases faster;
 less expensive;
 more conducive to patient care because they:
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are pressurized, and;
have more room for patient care.
Operational Indicators for Helicopter Inter-Hospital
Transfers:
 When patient transport by road ambulance would be
greater than one hour but by helicopter would be less
than one hour (include crew response and patient out of
hospital times).
 If helicopter transport is longer than one hour, fixed
wing transport is indicated unless:
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there is no fixed wing access, or;
the combined time for ground and fixed wing transport is
greater than helicopter transport time.
Medical Indicators for Helicopter Inter-Hospital Transfers of
Patients:
 requiring urgent or advanced airway management; in acute
respiratory distress (respirations less than 10 or greater than
30), and/or with oxygen saturation less than 90%;
 with active uncontrollable bleeding;
 who are haemodynamically unstable (BP less than 90, with
previously normal BP), and/or displaying clinical evidence of
shock, and/or requiring vasopressor intervention;
 who are unconscious (GCS less than 9), and/or patients who are
being transferred for emergency neurosurgical consultation
 for whom, in the best judgement of the referring physician and/or
transport advisor, additional transfer time could represent a
threat to life or limb.
Airevac Dispatch Considerations:
 The EMD will select the type of aircraft and the crew by
considering the following factors:
a) patient diagnosis and condition;
b) altitude required en route;
c) weather conditions;
d) airport capability;
e) grounding times;
f) availability of hospital-based helipads;
g) EMA level of crew members required;
h) crew members available, and;
i) cost.
BCAS Area of Jurisdiction
 BCAS operations extend beyond the boundaries of the
provincial border when community hospitals outside of
British Columbia are considered to be the closest
appropriate higher level of care. The following are the only
communities included in this policy:
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Banff, Blairmore, Calgary, Edmonton, Grand Prairie, Jasper,
Lethbridge, and Medicine Hat in Alberta;
Fort Liard in the Northwest Territories, and;
Watson Lake and Whitehorse in the Yukon Territories.
 Communities outside of British Columbia other than these
listed above are considered to be out-of-province.
Indicators for helicopter scene response (Stage 1-Scramble):
• severe deceleration injury;
• fall greater than 20 feet;
• high speed MVA;
• ejection of patient from vehicle;
• patient trapped;
• pedestrian struck at greater than 30 km/h;
• motorcycle accident at greater than 30 km/h;
• severe burns, including high voltage, and/or;
• multiple patient incident.
AND
 it is anticipated that the patient will not arrive at the nearest
hospital within one hour of receiving the call.
Indicators for helicopter scene response (Stage 2-Launch):
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GCS of 9 or less;
respiratory rate of less than 10 or greater than 30;
systolic BP less than 90 and/or clinical signs of shock;
penetrating injury to chest, neck, head, abdomen, groin, or proximal extremity;
two or more proximal bone fractures;
major amputation of extremities;
second degree burns to more than 20% BSA (Body Surface Area);
third degree burns to more than 10% BSA (2% in paediatric patients);
any high voltage electrical burns;
any facial or airway burns with inhalation injury;
any third degree burns involving eyes, neck, hands, feet or groin;
only method of accessing ill or injured patients (refer to medical/rescue
protocol), and/or;
 multi-patients at regional/provincial discretion.
AND
 it is anticipated that the patient will not arrive at the nearest hospital
within one hour of receiving the call.
Helicopter Landing:
 usually land at an airport and the patient is then
transferred by road ambulance to the
hospital/medical facility because:
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have the appropriate facilities such as night landing
lights and space;
will cause less noise for people in adjacent buildings
and fewer traffic hazards (unlike metropolitan
landing sites), and;
are generally safer (e.g. no overhanging wires or
obstructions).
Landings at helipads in metropolitan areas will be
restricted to:
a) neonatal and paediatric transports;
b) adult patients who meet the inter-hospital
transfer medical indicators
c) the pick-up of a specialized care team and/or
equipment needed to respond urgently to an
extraordinary emergency.
Landing at VGH, BCCH, & Canada Place
 only receive patients who, in the opinion of the receiving
medical personnel, are at substantial risk of dying or
suffering irreversible damage or injury, including:
a) patients in acute respiratory distress;
b) patients with active uncontrolled bleeding;
c) patients who are haemodynamically unstable;
d) patients who are unconscious;
e) patients for whom, in the best judgement of the transferring
physician or transport advisor, additional transfer time could
present a threat to life or limb;
f) patients with a severed spinal cord.