Orientation for Base Hospital Physicians

1. Orientation for Base Hospital Physicians Version 2013

3. RPPEO (Program Overview)

4. RPPEO • Hosted by TOH • Partnership with HDH • One of seven in Ontario • Coordination provided by a provincial MAC

5. RPPEO Mandate • Medical direction • Certification • Continuing education • Quality management • Consultation and advice

6. Medical Leadership • Medical Director • Dr. Justin Maloney • Associate Medical Directors • Dr. Richard Dionne • Dr. Andrew Reed • Dr. Christian Vaillancourt

7. RPPEO – Facts and Figures • 1,200 paramedics • 9 EMS services • 100,000 + calls for service • 100 paramedic students • 4 community colleges

8. Paramedic Scope of Practice

9. Currents Scopes of Practice • EMAs (2%) • PCPs (73%) • ACPs (25%) • CCPs

10. Primary Care Paramedics • Community college • Two years • AEMCA (MOH&LTC) • General Skillset • Automated defibrillation • Six medications • Intermediate airway (SGA)

11. Advanced Care Paramedics • Community college • Three years • AEMCA (MOH&LTC) • Ontario ACP (MOH&LTC) • General Skillset • Manual defibrillation • 22 medications • Advanced airway

12. Drugs (Mandatory)

13. Controlled Acts and Procedures (Mandatory)

14. Drugs (Auxiliary)

15. Controlled Acts and Procedures (Auxiliary) Some PCPs in Ontario are authorized to administer dextrose and GravolTM under the PCP Autonomous IV Program

16. Patching

17. Why Paramedics Patch • Patient care consultation • Additional orders • Patient updates • Cease resuscitation orders

18. Goals of a Patch • Provide concise but detailed information to BHP • Adopt a systematic approach • Obtain physician guidance and direction

19. Patch Form

20. Step 1 – Patch Initiation • Answer phone • Confirm paramedic copies transmission • Start with: “Hello, this is BHP number __, can you hear me? Your patch number is __, go ahead.”

21. Step 2 – Verbal Report • Do not interrupt patch • Complete patch form while receiving information • Wait for paramedic to complete patch before asking questions

22. Step 3 – Request for Orders, Advice and/or Authority • Paramedic should ask for orders, advice, or authority to proceed • Ask for clarification if necessary

23. Step 4 – Physician Direction • Provide clear direction consistent with paramedic’s scope of practice • Scope of practice cards available in ER

24. Step 5 – Confirm Order(s) • Have paramedic repeat orders • Last chance to say yes or no • If concerned about patch, write ‘Review Patch’ on patch sheet

25. Step 6 – Request Destination • If transport is being initiated, determine patient’s destination

26. Step 7 – File Patch Form • Deposit completed patch form in BH drop box in ER • Patch forms will be paired with ACR submitted by paramedic • Audio account of patch is not a substitute for the patch form

27. Remember Patches are recorded by the Central Ambulance Communications Centers and may be used as a matter of record for investigations, coroner’s inquests, and/or litigation.

28. How Paramedics Can Ensure an Effective Patch • Proper identification • Brief and concise • Sequential • Order(s) requested is (are) within scope of practice • Orders are repeated • Care and documentation reflect BHP’s orders

29. How BHPs Can Ensure an Effective Patch • Proper identification • No interruptions • All relevant information obtained and documented • Orders consistent with paramedic’s scope of practice • Orders repeated by paramedic • Patch form completed

30. Termination of Resuscitation

31. TOR vs. Pronouncement of Death Termination of Resusciation Pronouncement of Death 

32. Provincial DNR • Obvious signs of death - No vital signs and: • Grossly charred body • Open head or torso wounds with gross outpouring of cranial or visceral contents • Gross rigor mortis • MOH&LTC DNR form

33. TOR - General Principles • The TOR decision always rests with the BHP • If in doubt, ask for more info and/or order transport with ongoing care • Never speak to body disposition

34. TOR – Patch Required The RPPEO still allows a small number of PCPs to call the BHP for a TOR order for medical cardiac arrests of presumed cardiac origin. These are medics in the Cornwall and Prescott-Russell EMS services that were trained under the TORIT study.

35. “ALS termination of resuscitation” rule was established to consider terminating resuscitative efforts prior to ambulance transport if all of the following criteria are met: Arrest not witnessed No bystander CPR was provided No ROSC after complete ALS care in the field No shocks were delivered

36. Blunt Trauma TOR Protocol

37. Penetrating trauma Literature… J Trauma. 2007 Jul; 63(1): 113-20. • Regression analysis identified prehospital procedures are a sole predictor of mortality. • Patient is 2.63 times more likely to die • Conclusion • Performance of prehospital procedures in critical, penetrating trauma has a negative impact on survival… • Paramedics should adhere to a minimal “scoop & run” approach to transportation in this setting…

38. Resuscitative Thoracotomy Literature…J Trauma. 2011 Feb; 70(2): 334-9. Considered futile when: • Prehospital CPR exceeds 10 min. after blunt trauma & no response… • Prehospital CPR exceeds 15 min. after penetrating trauma & no response… • Asystole is the presenting rhythm and no pericardial tamponade…

39. Resuscitative Thoracotomy When should I consider resuscitative thoracotomy? • Patients with penetratingthoracic injury arriving with PEA may be a candidate • When a surgeon with appropriate skills is present (trauma center) • ED thoracotomynot indicated in blunt trauma with PEA

40. Penetrating Trauma TOR Protocol

41. Questions?