Transcript EMS Seminar #1

EMS Seminar #1 – Introduction,
Training, Medical Oversight
Joseph Ip BSc (Hon), MSc, MD, FRCPC
Attending Emergency Physician, Royal Columbian Hospital, Vancouver, BC
Local Medical Consultant, Standard of Care Committee, Region 2W, British Columbia
Ambulance Services
PART I - Introduction

History of BCAS
 Health Emergency Act
 Organization of BCAS
 Regionalization of BCAS
 Review of 2001 call volumes
History of BCAS

Prior to 1974, multiple providers
– Private companies
– Municipal
– Volunteer

1974, Foulkes Royal Commission Report:
– recommended “… that the fractionated ambulance services
provided by private companies, volunteer agencies and
municipal fire departments be amalgamated under one
jurisdiction”.
– BCAS took over private and volunteer operators while 40
municipal fire department were permitted to continue
providing pre-hospital emergency medical services under
agreements with BCAS

1974 – 1980
– Establishment of standards of training and care
– Elimination of cross boundary disputes

1986 - “the Review of Pre-Hospital Care in
British Columbia” by Cain
– regarded BCAS as the most appropriate agency to
provide ambulance services in the Province

1990, BCAS was providing direct service in all
but 7 communities
 Today only Kitimat continue to provide EMS
directly
Health Emergency Act (HEA)

proclaimed in 1974
 replaced the Ambulance Service Act of 1973
 established the Emergency Health Services
Commission (EHSC)
 HEA provided the EHSC with the legislated
mandate to ensure provision of high quality and
consistent levels of pre-hospital emergency
health care services throughout the province
Power and authority of commission

Provide emergency health services in British Columbia
 Establish, equip and operate emergency health centres
and stations in areas of British Columbia that the
commission considers advisable
 Assist hospitals, other health institutions and agencies,
municipalities and other organizations, and persons,
– to provide emergency health services
– to train personnel to provide services
– to enter into agreements or arrangements for that purpose
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Establish or improve communication systems for
emergency health services in British Columbia
Make available the services of medically trained persons
on a continuous, continual or temporary basis to those
residents of British Columbia who are not, in the opinion
of the Commission, adequately served with existing
health services
Recruit and train emergency medical assistants
Provide ambulance services in British Columbia to be
known as the British Columbia Ambulance Service
Perform any other function related to emergency health
services as the Lieutenant Governor in Council may
order.
Practise of medicine by emergency medical assistant

Nothing in this Act authorizes a person to
practise medicine without being registered under
the Medical Practitioners Act; but if the
unavailability of a medical practitioner is likely
to result in a person's death or deterioration of
health, an available emergency medical assistant
may perform emergency procedures that he or
she has been trained for and considers necessary
to preserve the person's life or health until the
services of a medical practitioner are available.
Licence required

A person must not assume or use the title
"emergency medical assistant" or otherwise
represent himself or herself to be an
emergency medical assistant unless the
person is the holder of a valid and
subsisting licence under this Act.
Emergency Medical Assistants Licensing Board

(1) The Emergency Medical Assistants Licensing
Board is continued.
 (2) The board is composed of 3 members, one of
whom must be an emergency medical assistant
selected in the prescribed manner and another of
whom must be a medical practitioner, appointed
by the Lieutenant Governor in Council.
 (3) The Lieutenant Governor in Council may
– (a) establish the remuneration and other terms and
conditions of appointments under subsection (2), and
– (b) designate a member of the board as its chair.

(4) A member of the board is entitled to necessary and
reasonable travelling and living expenses incurred while
exercising powers or performing duties on behalf of the
board.
 (5) Subject to this Act and the regulations, the board has
the power and authority to do the following:
– (a) examine, register and license emergency medical
assistants;
– (b) set terms and conditions for a licence under this section;
– (c) investigate complaints;
– (d) delegate to one or more persons the power and authority to
act under one or more of the provisions of paragraphs (a), (b)
and (c).
HEA – EMA regulation
BCAS Management Team
BCAS functions
Pre-hospital emergency care - 911 calls
 Inter-facility transports
 Stand-by at public events (450 standby
locations in 2000-2001; 50% film industry)
 Disaster Readiness

Regionalization of BCAS

198 ambulance stations in 163 communities
across the province
 ground ambulances dispatch centres are located
in Victoria, Vancouver and Kamloops
 air ambulance services dispatch centre in Victoria
Employee composition:

3300 paramedics
– 2100 part time
– 1200 full time

Average age of paramedic is 48yo
 By 2005, 161 full time staff will be eligible for
retirement
– 37/161 are ALS attendants
Air Ambulance Program
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budget is $22.5 million
Approximately $16 million for aircraft
charters, fuel and associated costs.
remainder for wages and benefits, training,
equipment and contracts with physician
advisors.
60 flight paramedics positions based in
Victoria, Vancouver, Kelowna and Prince
George.
4 Management positions
2000-2001 Ground Ambulance Statistics
Call Volume breakdown by
stations
Fees For Ambulance Service In British Columbia
(Effective April 1, 1998 - Subject to Change)
B.C.
1 Residents/Beneficia
. ries:
Ground or Air Ambulance Service $54 for the first 40 km, plus 50
cents for each additional km to a maximum of $274.
2 Non-Residents/
. Non-Beneficiaries:
Ground Service
Air Service
--Helicopter
Fixed Wing
3 Response Fee:
.
$50
When an ambulance is called to a residence, a
care facility or patient's place of employment,
and transportation is not required or is refused,
a response fee will be charged.
4 Employer Related
. Cases:
Same as #2
above
Employers are responsible for arranging
transportation of injured workers from a work
site to seek medical attention and are
responsible for the fee.
$396
$2,400 per hour
$6 per statute mile
Financial Challenges

2001-2002
– $180.668 million
– Expenditures $7.4 million over budget

2002-2003 to 2004-2005
– Reduced $2.2 million
– $178.5 million/ year frozen
– $31 million gap for 2002-2003
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$12.3 million for collective agreement
$12.5 million for anticipated increase in demand
70% wages & benefits; 10% contracted air ambulance
cost; 10% repair, maintenance, medical supplies, fuel;
4.5 % training; 5% for amortization costs of fixed assets
PART II - Training

P1 training curriculum & protocols
 EMA II training curriculum & protocols
 EMA III/ ALS training curriculum & protocols
 CME program
Primary Care Paramedics

Prerequisites:
– Age > 19
– Grade 12 or higher education
– OFA Level III
– Class 1, 2, or 4 driver’s license
– BLS Level C CPR

5 weeks independent study & 13 weeks
classroom/ clinical/ preceptorship
EMA II course

Prerequisites:
– EMA I license
– BCAS employee

6 months long
 Evaluation: 3 exams, ambulance and in-hospital
clinical components, Level II/ III driving, EMA
lifting, automobile extrication, sidehill evacuation
 Recertification course 70 hours long (1 written
exam and 4 call stimulations; q5 years)
EMA 2 Training Requirements

Course length: 240 hours.
 Course content:
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(a) anatomy, physiology, pathology and pharmacology, as they relate to injuries or medical
conditions;
(b) knowledge of, and practical experience in, basic rescue and extrication of sick or injured
patients;
(c) general study of, and practical experience in, ambulance work including care of the
elderly, extended transfer, psychology of intervention (abusive or hostile individuals), care of
the dead, infection control, medical-legal aspects of ambulance work and coordination with
other emergency services;
(d) filing standardized reports, in a form fixed by the commission, with the receiving
hospital and the commission;
(e) knowledge of, and practical experience in, the use of automatic external defibrillators;
(f) understanding and management of land, sea and air patient transport as appropriate to the
EMA's scope of practice;
(g) a minimum of 10 hours of theoretical and practical training in a format determined by the
board with respect to intravenous procedures including the following:
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(i) performing a critical examination of patients suffering from traumatic injuries and making a
reasonable diagnosis;
(ii) beginning an intravenous infusion;
(iii) a minimum of 25 supervised intravenous starts in a hospital approved by the board for that
purpose, and
(iv) intravenously administering nutrient and electrolyte solutions as required by the clinical
situation.
EMA III/ ALS course

Prerequisites
– EMA II license
– BCAS employee (min 3 yrs experience)
– Demonstrated exceptional related abilities

Length: 12 months
 Evaluation:4 exams, patient assessment/ treatment
plans, ambulance practicum
 Recertification 70 hours long (1 MC exam, 4 case
scenario simulations; q 5 years)
EMA 3 (ALS) — Advanced Life Support Training Requirements
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1 Length of training course: 56 weeks.
2 Course content:
– (a) recognition and interpretation of cardiac dysrhythmias and understanding the
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principles of therapy for life threatening cardiac situations;
(b) recognition of various forms of acute respiratory failure and understanding the
therapy for life threatening respiratory disorders;
(c) treating those situations outlined in paragraphs (a) and (b) by appropriate
techniques including the administration of the appropriate drugs designated by the
local medical coordinator;
(d) operation of a D.C. defibrillator under appropriate life threatening conditions;
(e) receiving directions on administering drugs from a medical practitioner;
(f) treatment of other life threatening disorders as directed by a medical
practitioner with due attention to current medical standards and patient safety;
(g) understanding and management of land, sea and air patient transport as
appropriate to the EMA's scope of practice.
ITT course

Prerequisites:
– EMA II license
– BCAS employee

Length: 18 months
 Evaluation: BCLS CPR, PALS, NRP, 4
exams, ambulance internship
 License valid for 5 years
EMA 3 (ITT) — Infant Transport Team Training Requirements
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1 Length of training course: 18 months.
2 Course content:
– (a) recognition of normal and abnormal obstetrical, neonatal and pediatric care;
– (b) collection of patient history and performance of a physical assessment on both
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normal and abnormal infants, children and high risk obstetrical patients;
(c) interpretation and effective communication of the information in paragraphs (a)
and (b) to medical and nursing staff in the appropriate unit;
(d) sensitive and appropriate communication of the patient's problems to immediate
family;
(e) initiation of stabilization or emergency treatment prior to and during
transportation of an infant, child or high risk obstetrical patient both with and
without the assistance or direction of other health care professionals;
(f) safe operation of all equipment required to support the patient being transported;
(g) understanding and management of land, sea and air patient transport as
appropriate to the EMA's scope of practice.
Airevac
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Prerequisites
– ALS
– BCAS employee (3 yr seniority min)

2 weeks & 120 days practicum
 Evaluation: patient assessment/ treatment
plans; ambulance practicum; 4 exams (o, w,
cs)
CME

Annually in order to be eligible for renewal of
license every five years
 2 days long
 6 components:
– Preworkshop preparation (web-based; log 3 cases from
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past year)
Workshop 1 – review of core skills
Workshop Block II – reflective call review
Workshop Block III- segmented call review
Workshop Block IV Interactive lecture
Post workshop Continuing Professional Education Paln
P1 protocols
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AED
Discontinuation of
resuscitation*
Chest pain
COPD/ asthma
Trauma protocols
Anaphylaxis*
ALOC (NYD & OD)*
Diabetic emergencies*
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Medications
– Nitroglycerin
– Entonox
– Ventolin
– SC epi*
– SC narcan*
– SC glucagon
– po glucose gel*
EMA II

Patient Care Skills
– Cardiac protocols
– Respiratory protocols
– Trauma protocols
 Entonox
 hypovolemia
– Medical protocols
 Unconsciousness NYD
 ? Narcotic OD
 Diabetic
 anaphylaxis
– Treatments
 Wound care
 Spinal
 Fracture
 Burn
 Hypothermia
– Procedures
 IV
 Sager splint
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Drugs
– Chlorpheniramine
– IV Dextrose
– Epinephrine
– Narcan
– Thiamine
– Ventolin
ALS - Protocols
– Cardiac protocols
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VF, puleless VT
Asystole
PEA
Unstable VT, stable VT
Hypothermia cardiac
arrest
Post arrest bradycardia
Ventricular irritability
CP
Symptomatic
bradycardia
Narrow complex
tachycardia
Cardiogenic shock
– Respiratory protocols
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SOB
CHF/ pulmonary edema
– Trauma protocols
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Hypovolemia
Major burn
– Medical protocols
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Anaphylaxis
ALOC/ poisoning
Diabetic
Hypothermia
seizures
– Cardioversion
– EJV cannulation
– External pacing
– Needle
cricothyrostomy
– Needle thoracocentesis
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Drugs
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Atrovent
Benadryl
Calcium
D50W
Gravol
Lidocaine
Lasix
Midazolam
Morphine
Nitro paste
Nitroglycerin
Procainamide
Adenosine
epinephrine
PART III – Medical Oversight
EMS Medical Oversight

The responsibility and requisite authority to
oversee the clinical management of patients
provided by prehospital system and
providers
 Bear legal responsibility of medical acts of
providers
Desirable qualification

Board certified in EM
 Active clinical practice in EM
 EMS fellowship
Direct Medical Oversight
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Physician makes contemporaneous decisions on
patient care
Decisions rendered in the form of consultation or
medical orders to EMS providers
May be online, base station, on site
Through radio, telephone, or on scene physician
Ability to order or withhold interventions
Examples of Direct Medical
Oversight
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Medical orders
Refusal of medical aid
Transportation destinations
Medevac authorizations
Hospital diversion requests
Triage out of system
Pronouncement of death
Quality assurance mechanism management
Patient discharge with community follow up
Types of direct medical oversight

Physician on scene
 Physician with mobile radios
 EPs in ED
 EM residents in ED
 Physician surrogates (nurse, senior
paramedics)
Indications for Direct Medical
Oversight
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Critical medical cases (e.g. CHF, OD, Respiratory
distress, hypotension of uncertain etiology, AMI)
Management outside of protocols
Transmission of information for specific decisions
Pronouncement of death
Patient refusal
Physician on scene
Triage decisions
Indications of Scene Supervision
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Multiple casualty
incidents
Major vehicle collisions
with entrapment
Specialized rescue
Airplane crash
Hazardous materials
incidents
Weapons of mass effect
incidents
Tactical hostage
situations
Major fire
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Structural collapse with
entrapment
Anticipated difficult
airways
Difficult deliveries
Need for field amputation
Field termination of
resuscitative efforts
Mass gathering events
Major political or media
events
Unusal medical situation
Indirect Medical Oversight
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Medical oversight activities that are
performed prospective, concurrent,
retrospective, to prehospital care of the
patient
 Protocols, policy, QA/QI, education,
operations, communications, system design,
disaster management, public health
BCAS medical direction

Medical Advisory Committee
 Provincial Medical Director
 Regional Medical Directors
 Medical Director – Licensing Branch
 Medical Directors – Regional Standard of
Care Committees
 Local Medical Consultants – at each
receiving hospital
Principles in protocol
development
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Medically appropriate
 Can be implemented in the field
 Cost effective
Factors to consider when
developing medical protocols
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Need
 Evidence based medicine
 Financial and administrative impact
 Educational requirement
 Performance measure indicator
 Agreement among all stakeholders
Practice management issues in protocol development
 Definition of patient vs non-patient
 Definition of a minor
 Transport vs non transport criteria
 Refusal of care process and requirement
 Termination of field resuscitation
 Assessment of patient competency
 On scene physician authority
 Transport destination determination
 Hospital diversion issues
 Credentiating and decreditiating requirements for
providers
 Patient record documentation requirements
 Mass casualty management
Patient Care issues in protocol
development
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Communication issues
 Clinical practice in the field
 Criteria for determination of death
 Criteria for performing clinical procedures
and interventions