A. Protocols

ObjectivesFirst Responder Continuing Education Program

Mecklenburg EMS Agency

IntroductionThe Objectives listed in this document outline the core competencies for all first responders affiliated with the Mecklenburg EMS Agency. The purpose of the First Responder Continuing Education Program is to describe and discuss the core content in detail using the objectives herein as the basis for instruction. At the conclusion of any continuing education course, the student will possess the knowledge and skills necessary to perform quality patient care in accordance with the First Responder Protocols adopted by the Mecklenburg EMS Agency.

Program ValidationQuality improvement processes will be conducted throughout the Program to ensure the quality of instructors, content, and adherence to the protocols and objectives. Review processes may include site visits to audit classes, student feedback (verbal or written), or focus group or committee consultation.

The Mecklenburg EMS Agency Medical Director has the authority to administer any form of test to ensure that all objectives outlined in this document have been met by each first responder personnel matriculating in the Continuing Education Program. A minimum score of 80% will always be required unless otherwise stated. Those failing to achieve this score will have the opportunity to take a second test. Failure to achieve this score on the second attempt may result in local certification revocation by the Medical Director. All tests will be administered by Mecklenburg EMS Agency Clinical Affairs personnel or designee.

Continuing Education Objectives1.2 DefinitionsA. Protocols

1. Definitions of terms and the understanding that the physiologic parameters listed in the Protocols are guidelines.

2. Multiple components that define “hemodynamically unstable.”3. Age difference between an adult and pediatric patient, and the reasons for this designated

age.4. All components of determining a patient’s competency to make informed health care

decisions.5. Definition of “patient” and determination of when a “patient encounter” has occurred.

B. General1. Definitions of common medical terms (eg. proximal, distal, superior, inferior, medial,

lateral).

2.1 Scene Response, Patient Categorization, and Hospital TransportationA. Protocols

1. The importance and components of the Medical Priority Dispatch System.a. The reasons why and methods used for call prioritization.

2. How calls are categorized, response configuration, and response mode for each.3. How patients are categorized and response mode for each.

a. Examples of Priority-1, 2, and 3 medical and trauma patients.4. How patients will be transported in the ambulance.

a. Position.

b. Restraint systems.5. How pediatric patients will be transported in the ambulance.

a. Parameters for using infant car seats.b. Location for securing car seats in the ambulance.c. Spinal immobilization techniques for infant and pediatric patients.

2.2 Mass Casualty Incident ResponseA. Protocols

1. Definition of a mass casualty incident response.2. Information required for a quick “Medical Command.” scene size-up. 3. Responsibilities of Medical Command.4. Roles and responsibilities of each of the following:

a. Triage Officerb. Treatment Officerc. Transportation Officerd. Staging Officere. Logistics Officerf. Operations Officerg. Safety Officer h. Public Information Officer

5. Patient identification procedures.6. All aspects and differences between the METTAG numbering system and the S.T.A.R.T

System of Triage. 7. Definition and color-coding for different triage areas based on priority assigned.8. Limited medical procedures performed during triage. 9. Documentation issues for a mass casualty incident.

2.3 Medical Incident Command and Scene Control, Transfer of Care, and Documentation

A. Protocols1. Performance objectives, roles, responsibilities, and differences when initial scene arrival

is by first responders prior to Medic, and by Medic prior to first responders.a. Roles and responsibilities of first responders when assuming the role of Medical

Incident Command. i. Initial assessment for priority. ii. Treatment algorithms. iii. Formal transferring of care.

b. Roles and responsibilities of first responders when Medic assumes the role of Medical Incident Command.i. Assisting with equipment, supplies, medication preparation, and

procedures as directed by the paramedic. ii. Cardiac monitor performance. iii. Endotracheal intubation equipment and supplies.iv. Hemorrhage control.v. Spinal and fracture immobilization.vi. Vital signs.vii. Glucometer.

2. Documentation policies.

B. General1. Importance of designating one individual as the “lead” technician for scene orchestration.2. Definition of official “transfer of care.”3. Importance of aggressiveness on the scene and early decision-making when critical

patients are encountered.a. Immediate assessment and patient preparation as critical actions for possible acute

myocardial infarctions, strokes, and priority trauma patients.

2.4 Medic CommunicationsA. Protocols

1. Indications or situations for communication between the on-scene first-responder and responding Medic personnel.

2. Minimum verbal information relayed to the Medic crew.3. Presenting a patient using the standard S.O.A.P. format.

2.5 Determination of DeathA. Protocols

1. Situations in which life support measures may be withheld by first responders in the prehospital setting. a. Injuries considered incompatible with life.b. Obvious signs of death that are incompatible with life.

i. Definition of post-mortem lividity.ii. Definition of rigor mortis.

2. Indications when life support measures may be terminated after being initiated by first responders or other medical personnel.

3. Role of authorized police officers in declaring a patient dead.4. Conditions and circumstances where the paramedic is authorized to pronounce an adult

patient dead if the resuscitative efforts are unsuccessful. a. Exceptions for patients where pulmonary embolism is suspected.b. Exceptions for pediatric patients.

2.6 “Do Not Resuscitate” OrdersA. Protocols

1. Indications for withholding resuscitation.a. State DNR form.b. Attending physician is present on the scene.c. Written DNR orders on a medical chart.d. DNR for a minor.

2 Appropriate care when special situations arise.a. No DNR, but relatives or friends request that resuscitation be performed.b. Doubt exists about a DNR order.c. Expired DNR.d. A valid DNR is presented after resuscitation is initiated.e. Situations involving pregnancy.f. Documentation.

2.7 Air Medical ServicesA. Protocols

1. Indications for requesting the helicopter in Mecklenburg County.2. Personnel permitted to request the helicopter.3. Personnel permitted to cancel the helicopter.4. Personnel responsible for landing zone designation, preparation, and notification.5. Criteria and dimensions for an appropriate landing zone.6. Appropriate patient preparation for helicopter transport.

B. General1. Additional skills or procedures that the Flight Service may bring to the patient.2. Role of the Flight Crew as being “facilitory.”3. Situations where it is appropriateness for the flight crew to accompany Medic personnel

in the ambulance rather than the helicopter (eg. patient already prepared in the back of the ambulance for ground transport and an emergent airway is required).

2.8 Patient-Initiated Refusal of Treatment or TransportA. Protocols

1. First responder personnel WILL NEVER refuse treatment or transport NOR SUGGEST alternative transportation or follow-up options to any patient at any time. Presumptive diagnoses or other expressed medical opinions that might suggest a minor clinical condition and/or influence a patient from not being transported by EMS is strictly forbidden.

2. Components of Competency for medical decision-making.3. Procedure to be followed when a patient refuses care.

a. Blood glucoseb. Pulse oximetry c. 12-lead ECG

4. Communication procedures when a language barrier exists.5. Documentation for patients who refuse care.6. Use of law enforcement officers on the scene.7. Options for patients continuing to refuse care.8. Competency as it relates to alcohol consumption and other conditions such as suicide.9. Definition and clinical presentation of ALTE and appropriate disposition of such infants.

B. General1. Suicide attempts are not considered competent acts. These patients may refuse care but

may not refuse transport.2. Documentation should be more detailed when a patient refuses care or transportation.3. If doubt exists about a patient refusing care, the Medic response should not be cancelled

because Medical Control may be contacted for assistance.

2.9 On-Scene PhysicianA. Protocols

1.1 Procedure for incidents where an on-scene physician has an established doctor-patient relationship.a. When orders are given within the scope of first responder practice.b. When orders are given outside the scope of first responder practice.c. Documentation.

2.1 Procedure for incidents where an on-physician does not have an established doctor-patient relationship.

a. When orders are given within the scope of first responder practice.b. When orders are given outside the scope of first responder practice.c. Documentation.

3. Role of medical control. B. General

1. Importance of treating physicians and nurses at a scene with mutual professionalism and respect as a healthcare colleague.

2.10 DocumentationA. Protocols

1. Importance of completing Patient Care Reports.2. Definition of primary retrocode.3. Minimum documented information required for each encounter.

a. Issue of obtaining and documenting a complete set of vital signs on all patient encounters.

b. Vital signs rule for Priority-1 patients.4. All therapeutic procedures and interventions, along with the responses to each will be

recorded. 5. Documentation policy for patients that refuse treatment and/or transportation.

2.11 Medical Incident Review ProcessA. Protocols

1. Purpose of the review process.2. Definition and differences between presumptive and definitive category assignments and

examples of each.3. Actions taken for each presumptive category.4. Purpose and composition of the Incident Review Committee.

meeting, although a formal meeting may be conducted at any time during the case review.

5. Remediation and appeal processes.

2.12 Prehospital Social ServicesA. Protocols

1. Definition, including age range, for geriatric (elder) abuse.2. Characteristics and warning signs for geriatric (elder) abuse.3. Issues of reporting and contact information.4. Definition for spousal abuse.5. Characteristics and warning signs for spousal abuse.6. Protocol for addressing spousal abuse.7. Definition, including age range for abusers, for pediatric (child and

infant) abuse.8. Characteristics and warning signs for pediatric (child and infant) abuse.9. Issues of reporting and contact information.10. Definition of infant abandonment.11. Protocol for addressing infant abandonment.

of Social Services at 704-366-CARE to report the suspicion.

2.13 Crime ScenesA. Protocols

1. Protocol for entering and functioning in a crime scene.2. How to address hangings.3. Protocol issues involved with sexual assault.4. The North Carolina State Law that authorizes police officers to prohibit prehospital

personnel from entering a crime scene.a. Protocol and documentation when not authorized to enter a scene when you feel

you should.

3.1.3 Medical MonitoringA. Protocols

1. Factors and characteristics involved in selecting the most appropriate site for medical monitoring.

2. Equipment and supplies that must be readily available.3. Role of and guidelines for rehydration.4. Guidelines for rest.5. Vital sign monitoring during rehabilitation and parameters for health concerns.6. Clinical characteristics for both psychological and physiological stress.7. Working fires:

a. Standard rotation parameters.b. Complaints related to heat illness.c. Basic Medical Care Protocold. Indications and contraindications for soaking any burned area with water or saline.

e. Differences between heat exhaustion and heat stroke.8. Hazardous Materials

a. Differences between level A, B, and C personal protective equipment.b. Protocol for decontamination of patients. c. Signs and symptoms of acute chemical exposure. d. Basic Medical Care Protocol.e. Methods for hazardous materials toxicity.f. Protocol for oxygen and limitations of pulse oximetry.g. Number for contacting The Carolinas Poison Center.h. Toxic manifestations of CO poisoning.i. Toxic manifestations of chemical nerve agents, organophosphates, and

carbamates toxicity, and differences between vapor and liquid exposure.j. Toxic manifestations of vesicant poisoning.k. Toxic manifestations of pulmonary agent poisoning.l. Toxic manifestations of cyanide poisoning.m. Toxic manifestations of riot control agent poisoning.

9. Police Operations. a. Types and risks of personal protective gear for police officers.b. Basic Medical Care Protocol.

10. Diving Operations.

a. Types of incidents associated with diving operations.

b. Water temperature where hypothermia can ensue.c. Clinical manifestations of hypothermia.d. Clinical manifestations of diving injuries.e. Basic Medical Care Protocol.f. Clinical conditional associated with hypothermic patients.g. Primary treatment requitred for hypothermic patients.

B. General1. Physiological parameters and responses when personnel are exposed to thermal or other

work environments.2. Basic principals and purposes of rehabilitation.3. Medic resources available for rehabilitation when major fires or other large-scale

operations are taking place.4. Cardiac arrest as the leading cause of death in firefighters on the fire ground. a. Importance of risk factors.

b. Importance of hydration regardless of subjective feelings of well-being.

3.2.1 Abdominal PainA. Protocols

1. Indications for categorizing as “abdominal pain.”2. Various presentations and associated symptoms.3. Common physical signs associated with abdominal pain.4. Basic Medical Care Protocol.5. Special attention to elderly patients with abdominal pain.6. Relationship of abdominal pain to a cardiac etiology.7. Relationship of abdominal pain and syncope in a female to ectopic pregnancy.8. Critical characteristics associated with vomiting in children.

B. General1. Basic anatomy of abdominal organs and structures.2. Pathophysiology and clinical signs and symptoms of some common abdominal illnesses.

a. Cholecystitis.b. Hepatitis.c. Pancreatitis.d. Bowel obstruction.e. Cystitis.f. Kidney stone.

3. Other:a. If pulsating masses are palpated and an abdominal aneurysm is suspected, limit

additional exams.b. Abdominal pain in the elderly should be considered critical until proven

otherwise.c. Life-threatening clinical conditions where abdominal pain is the presenting

symptom.d. Bilious or projectile vomiting at any age group is a serious condition.

3.2.2 Anaphylaxis and Allergic ReactionsA. Protocols

1. Definition and types of allergens.2. Common manifestations (subjective and objective) and associated symptoms of an

allergic reaction.

3. Differences in allergic and anaphylactic reactions.4. Basic Medical Care Protocol.5. Indications for using the EpiPen Auto-Injector.6. Documentation of assessment and reassessment when EpiPen is used.7. Types of medications that may affect allergic reaction physical signs.

B. General1. Pathophysiology and clinical signs and symptoms of allergic and anaphylactic reactions.

a. End-organ results from histamine (eg. bronchoconstriction, vasodilation, increase in vascular permeability).

2. Other:a. Effects of epinephrine.b. Importance of vital sign assessment pre and post-treatment.

3.2.3 Animal BitesA. Protocols

1. Association of animal bites to allergic or anaphylactic reactions.2. Types of tissue injury.3. Basic Medical Care Protocol.4. Important information for documentation.5. Protocol for applying dressings and bandages prior to Medic arrival. 6. Special considerations for human, dog, and cat bites.7. Protocol for snakebite wound management.

B. General1. Bites on hands are especially important because of potential infections and disability.2. Common areas to search for human bites or where human teeth have penetrated the skin

during fights (eg. Boxer’s fracture over 4th metacarpal).

3.2.4 Assault-Sexual AssaultA. Protocols

1. Common complaints or injuries associated with assaults.2. Basic Medical Care Protocol.3. Important documentation information about the description and circumstances surrounding

the event.4. Protocol for applying dressings and bandages prior to Medic arrival.

B. General1. Issue of not changing clothes or showering after sexual assaults.

3.2.5 Back PainA. Protocols

1. Indications for categorizing as “back pain.”2. Various presentations and associated symptoms.3. Common physical signs associated with abdominal pain.4. Basic Medical Care Protocol.5. Special attention to elderly patients with back pain.6. Relationship of back pain to abdominal aortic aneurysms, aortic dissection, and cholecystitis.7. Relationship of back pain in a diabetic patient to a cardiac etiology.

8. Critical characteristic associated with vomiting in children.9. Presentation of sciatica.

B. General1. Anatomy of the spinal column.2. Pathophysiology and clinical signs and symptoms of some common non-traumatic back

illnesses.

3. Other:a. Neurologic deficits or incontinence as indicators of severe disease.b. Consider waiting on Medic arrival prior to moving a severe back pain patient,

because analgesia may be indicated.

3.2.6 Respiratory DistressA. Protocols

1. Indications for categorizing as “respiratory distress.”2. Risk factors for pulmonary embolism.3. Various lung sounds heard on exam and the clinical correlations of each.4. Basic Medical Care Protocol.5. Indications, contraindications and Medic Assist protocol for inhaler or nebulizer

administration.6. Indications (and no contraindications) for administering supplemental oxygen.7. Issue of airway obstruction in infants and children.8. Recognition and patient care considerations for epiglottitis.

B. General1. Anatomy and physiology of the respiratory system.2. Pathophysiology and clinical signs and symptoms of some common respiratory illnesses.3. Other:

a. Description of COPD, including the differences between asthma, emphysema, and chronic bronchitis.

3.2.7 BurnsA. Protocol

1. Various types of burns and associated injuries that can be encountered.2. Difference between superficial, partial thickness, and full thickness involvement.3. Importance of noting soot around the mouth and nose or singed scalp, facial hair, or nasal

hair.4. Basic Medical Care Protocol.5. Indications and contraindications for soaking any burned area with water or saline. 6. Clinical manifestations or other toxic gases.7. Signs of significant thermal exposure.8. Protocol for applying dressings and bandages prior to Medic arrival. 9. Protocol for spinal immobilization.

B. General1. Calculation of % body surface area in adults and pediatrics.

3.2.8 Carbon Monoxide / Hazardous Materials ExposureA. Protocol

1. Various types of exposure and the body systems that may be involved.

2. Basic Medical Care Protocol.3. Indications for CPAP.4. Protocol for oxygen use for all patients with potential exposures.5. Number for contacting The Carolinas Poison Center.6. Protocol for applying dressings and bandages prior to Medic arrival. 7. Protocol for spinal immobilization.8. Toxic manifestations of CO poisoning.

9. Toxic manifestations of chemical nerve agents, organophosphates, and carbamates toxicity:

and differences between vapor and liquid exposure.10. Toxic manifestations of vesicant poisoning.11. Toxic manifestations of pulmonary agent poisoning.12. Toxic manifestations of cyanide poisoning.13. Toxic manifestations of riot control agent poisoning.

B. General1. Limitations of pulse oximetry in toxic gas inhalation.2. Pathophysiology and clinical signs and symptoms of some common inhalational injuries.

3.2.9 Cardiac ArrestA. Protocol

1. Etiology from either a medical or traumatic event.2. Risk factors for cardiac disease and pulmonary embolism. 3. Clinical signs of cardiac arrest.4. Basic Medical Care Protocol.5. Indications and contraindications for using the automatic external defibrillator.6. Important information for documentation.7. Protocol for performing CPR during the time period when the defibrillator is being set up. 8. Typical etiology and treatments for pediatric cardiac arrest.

B. General1. Pathophysiology and clinical signs and symptoms of cardiac arrest.2. Purpose and mechanism of action of defibrillation.3. Common ACLS medications.

3.2.10 Chest PainA. Protocol

1. Etiology may be medical or trauma.2. Differences between cardiac and non-cardiac pain presentation and associated symptoms.3. Risk factors for cardiac disease and pulmonary embolism.4. Common physical signs associated with cardiac chest pain. 5. Basic Medical Care Protocol.6. Indications, contraindications and Medic Assist protocol for nitroglycerine

administration.7. Important historical information for documentation.8. Issue of chest pain associated with recent crack use.

B. General1. Anatomy and physiology of the cardiovascular system.2. Pathophysiology and clinical signs and symptoms of some common chest illnesses.

a. Cardiac chest pain. b. Pulmonary embolism.c. Pneumonia.d. Pleurisy.e. Musculoskeletal pain.

3.2.11 ChokingA. Protocol

1. Complaints and associated symptoms commonly seen in patients who are or have been choking.

2. Basic Medical Care Protocol.3. Issues associated with infants experiencing apnea or cyanosis during a choking episode,

or apparent life-threatening event (ALTE).B. General

1. Issue of transporting all choking patients.

3.2.12 SeizuresA. Protocol

1. Difference between generalized and partial seizures.2. Precipitating symptoms or factors that may precede a seizure.3. Past medical, surgical, or social history that may precipitate a seizure episode.4. Basic Medical Care Protocol.5. Indications, contraindications and Medic Assist protocol for oral glucose administration.

B. Seizures1. Anatomy and physiology of the neurological system.2. Etiology and pathophysiology of seizures.

a. Metabolic.b. Drug or alcohol induced.c. Structural.d. Trauma.

3. Clinical signs and symptoms of seizures.a. Partial.b. Complex.

4. Medications used to control seizures.

3.13 Diabetic ProblemsA. Protocol

1. Various etiologies of hyperglycemia and hypoglycemia.2. Differences in clinical manifestations between hyperglycemia and hypoglycemia.3. Basic Medical Care Protocol.4. Indications, contraindications and Medic Assist protocol for oral glucose administration.5. Issue of similar presentation of alcohol intoxication abnormal blood sugar.

B. General1. Anatomy and physiology of the endocrine system.

2. Pathophysiology and clinical signs and symptoms of hyperglycemia and hypoglycemia.3. Medications used to control diabetes and hypoglycemia.

3.2.14 Near Drowning / Diving AccidentA. Protocol

1. Issue of precipitating symptoms or factors that may have preceded the incident.2. Basic Medical Care Protocol.3. Protocol for spinal immobilization.4. Definition of “dry-drowning.”5. Importance of rewarming techniques, especially in children. 6. Issue of transporting all near-drowning patients.

B. General1. Pathophysiology of drowning.2. Common injuries associated with diving accidents.

3.2.15 ElectrocutionA. Protocol

1. Issue of precipitating symptoms or factors that may have preceded the incident.2. The multiple complaints and injuries that may result from an electrical injury.3. Basic Medical Care Protocol.4. Protocol for lightning strikes.5. Difference between entrance and exit wounds and the management of each.6. Protocol for spinal immobilization.

B. General1. Differences between AC and DC current.2. Pathophysiology and clinical signs and symptoms of electrocution.

a. Fatal.b. Non-fatal.

3. Common injuries associated with electrical injuries.a. Burns.b. Other traumatic injuries.

3.2.16 Eye Problems / InjuriesA. Protocol

1. Different types of eye injuries or complaints.2. Significance of blood or pus in the anterior chamber.3. Clinical manifestations of ocular trauma.4. Basic Medical Care Protocol.5. Indications for flushing eyes.6. Differences between painful and painless visual loss.7. Protocol for applying dressings and bandages prior to Medic arrival. 8. Protocol for spinal immobilization.

B. General1. Clinical signs and symptoms of different eye problems or injuries.

a. Conjunctivitis.b. Corneal abrasion.c. Glaucoma.d. Retinal tear.

3.2.17 Falls / Back InjuriesA. Protocol

1. Indications for categorizing as “falls back injuries.”2. Basic Medical Care Protocol.3. Clinical conditions that may have precipitated the fall.4. Common injuries based on area of body that sustains initial impact.5. Protocol for spinal immobilization.6. Protocol for applying dressings and bandages prior to Medic arrival.

B. General1. Anatomy of the axial and appendicular skeleton, including the spinal column.2. Pathophysiology and clinical signs and symptoms of spinal cord injury.

a. Dermatomal patterns.b. Neurological complaints.

3. Common injuries associated with falls.

3.2.18 HeadacheA. Protocol

1. Significant associated symptoms.2. Basic Medical Care Protocol.3. Characteristics and differences between migraine headaches and those that may be of a

severe nature (stroke or bleed).B. General

1. Clinical signs and symptoms of different types of headaches.a. Migraine.b. Tension.c. Cluster.

3.2.19 Heart ProblemsA. Protocol

1. Common complaints and associated symptoms.2. Medical and social risk factors for heart disease.3. Clinical manifestations of congestive heart failure.4. Basic Medical Care Protocol.5. Indications for CPAP.4. Indications, contraindications and Medic Assist protocol for nitroglycerine

administration.7. Important historical information for documentation.8. Issue of hypoxia as a common etiology for symptomatic bradycardia in children.

B. General1. Anatomy and physiology of the cardiovascular system.2. Pathophysiology and clinical signs and symptoms of some common cardiac illnesses.

a. Cardiac chest pain. b. Supraventricular tachycardia.c. Ventricular tachycardia.d. Bradycardia and heart blocks.e. Congestive heart failure.

3.2.20 Heat / Cold ExposureA. Protocol

1. Common etiologies for environmental emergencies.2. Common complaints for environmental emergencies.3. Skin and cardiovascular signs seen with environmental emergencies.4. Basic Medical Care Protocol.5. Indications, contraindications and Medic Assist protocol for oral glucose administration.6. Important documentation information as to the incident conditions.7. Differences between heat exhaustion and heat stroke.8. Issue regarding how hypothermic patients must be handled with extreme caution. 9. Importance of rewarming techniques, especially in children.

B. General1. Pathophysiology and clinical signs and symptoms of temperature extreme illnesses.

a. Hyperthermia.b. Hypothermia.

2. Risk of environmental illnesses in the elderly and in pediatrics.

3.2.21 HemorrhageA. Protocol

1. Indications for categorizing as “hemorrhage.”2. Medical and social risk factors for hemorrhage.3. Basic Medical Care Protocol.4. Protocol for controlling epistaxis.5. Protocol for avulsed primary and secondary teeth.

B. General1. Pathophysiology, clinical signs and symptoms, and clinical significance of some common

hemorrhagic illnesses. a. Upper and lower gastrointestinal bleeding. b. Vaginal bleedingc. Epistaxis.

3.2.22 Industrial AccidentA. Protocol

1. Various injuries associated with accidents.2. Basic Medical Care Protocol.3. The objective for total scene time associated with critically injured patients and strategies

for quickly preparing a patient for transport.4. Issue of pain medications being provided prior to extrication procedures for patients with

isolated extremity injuries still trapped in machinery.5. Protocol for spinal immobilization.6. Protocol for controlling hemorrhage and applying dressings and bandages prior to Medic

arrival.

3.2.23 OverdoseA. Protocol

1. Various psychiatric complaints that may be seen.2. Significant clinical manifestations of overdose patients.3. Basic Medical Care Protocol.4. Indications, contraindications and Medic Assist protocol for oral glucose administration.

5. Number for contacting The Carolinas Poison Center.6. Indications for administering Ipecac in the field.

B. General1. Drugs of abuse.

a. Categories (eg. hallucinogens, opioids, stimulants, depressants, sedative-hypnotics).

b. Types or examples.c. Clinical signs and symptoms.d. Clinical significance.

2. Clinical manifestations of alcohol poisoning.a. Ethyl alcohol.b. Isopropyl alcohol.c. Methylene glycol.

3.2.24 Pregnancy / ChildbirthA. Protocol

1. Various complaints and other associated gynecological conditions or symptoms.2. Basic Medical Care Protocol.3. APGAR scoring.4. Protocol for problems associated with umbilical cord and breech presentations.5. Indications and rate for ventilating a newborn.6. Definition and clinical manifestations of toxemia.

B. General1. Anatomy and physiology of the gynecological system.2. Pathophysiology and clinical signs and symptoms of some common pregnancy-related

conditions.a. Early contractions.b. Vaginal bleeding or discharge.c. Ectopic pregnancy.d. Preeclampsia and eclampsia.e. Placenta previa and accretia.

3. Clinical significance of some common pregnancy-related conditions. a. Abdominal pain.b. Vaginal bleeding.c. Water broken.d. Contractions.

4. Common complications associated with pregnancy and childbirth.

3.2.25 Psychiatric / SuicideA. Protocol

1. Various complaints and other associated psychological conditions or symptoms.2. Clinical manifestations seen with psychiatric patients.3. Basic Medical Care Protocol.4. Indications, contraindications and Medic Assist protocol for oral glucose administration.5. Protocol for restraint use and other techniques used for actively psychiatric or aggressive

patients.6. Other etiologies that may mimic behavioral disorders.7. Protocol for spinal immobilization.8. Protocol for applying dressings and bandages prior to Medic arrival.

B. General1. Clinical signs and symptoms of some common psychiatric conditions.

a. Manic-depression.b. Schizophrenia.c. Depression.d. Delusional.e. Dementia.

3.2.26 Sick PersonA. Protocol

1. Indications for categorizing as “sick person.”2. Clinical manifestations seen with general sick patients.3. Basic Medical Care Protocol.4. Indications, contraindications and Medic Assist protocol for oral glucose administration.5. Importance of fevers and altered mental status.6. Definition of clinical significance of an ALTE.

3.2.27 Stab WoundA. Protocol

1. Clinical manifestations seen with stab wounds or hemorrhagic shock.2. Basic Medical Care Protocol.3. The objective for total scene time associated with critically injured patients and strategies

for quickly preparing a patient for transport.4. Protocol for controlling hemorrhage and applying dressings and bandages prior to Medic

arrival.

3.2.28 StrokeA. Protocol

1. Indications for categorizing as “stroke.”2. Clinical manifestations seen with stroke patients.3. Basic Medical Care Protocol.4. Indications, contraindications and Medic Assist protocol for oral glucose administration.5. Documentation of symptom onset and importance of time.6. Differences between ischemic and hemorrhagic, and the prognosis of each.

B. General1. Anatomy and physiology of the central nervous system.2. Pathophysiology and clinical signs and symptoms of stroke conditions.3. Familiarization with the LA Stroke Scale.

3.2.29 Traffic AccidentA. Protocol

1. Importance of incident information, including mechanism of injury.2. Basic Medical Care Protocol.3. Protocol for spinal immobilization.

4. Protocol for controlling hemorrhage and applying dressings and bandages prior to Medic arrival.

5. The objective for total scene time associated with critically injured patients and strategies for quickly preparing a patient for transport.

6. Issue of considering a medical etiology for motor vehicle crashes associated with minimal damage and resulting in a critical patient condition and the importance of quickly applying the AED.

B. General1. Common crash mechanisms and associated or expected injuries.

3.2.30 Traumatic InjuryA. Protocol

1. Indications for categorizing as “traumatic injury.”2. Clinical manifestations seen with traumatic injuries.3. Basic Medical Care Protocol.4. Issue of expediting the scene time for patients with significant injuries so that they may

arrive at the hospital for definitive care within 30 minutes from the time of injury. 5. Issue of pain medications being provided prior to extrication procedures for patients with

isolated extremity injuries still trapped in machinery.6. Protocol for spinal immobilization.7. Protocol for controlling hemorrhage and applying dressings and bandages prior to Medic

arrival.

3.2.31 UnconsciousA. Protocol

1. Medical and social risk factors for unconsciousness..2. Basic Medical Care Protocol.3. Indications, contraindications and Medic Assist protocol for oral glucose administration.4. Issue of relationship with alcohol intoxication.

3.2.32 Unknown ProblemA. Protocol

1. Indications for categorizing as “unknown problem.”2. Basic Medical Care Protocol.3. Indications, contraindications and Medic Assist protocol for oral glucose administration.4. Importance of fevers and altered mental status.5. Issue of relationship with alcohol intoxication.

3.2.47 Gunshot WoundA. Protocol

1. Clinical manifestations seen with gunshot wounds or hemorrhagic shock.2. Basic Medical Care Protocol.3. The objective for total scene time associated with critically injured patients and strategies

for quickly preparing a patient for transport.4. Protocol for controlling hemorrhage and applying dressings and bandages prior to Medic

arrival.

3.2.49 Traffic Accident – Pedestrian StruckA. Protocol

1. Importance of incident information, including mechanism of injury.2. Basic Medical Care Protocol.3. Protocol for spinal immobilization.4. Protocol for controlling hemorrhage and applying dressings and bandages prior to Medic

arrival. 5. The objective for total scene time associated with critically injured patients and strategies

for quickly preparing a patient for transport.B. General

1. Common crash mechanisms and associated or expected injuries.

4.1 Bag-Valve Mask Ventilation1. Indications and contraindications for using a bag-valve mask device.2. Assembly of bag-valve mask device and oxygen source.3. Review protocol for assessing the patient who may need assisted ventilations.4. Performing ventilations with a bag-valve mask device.

a. 1-person technique (with and without spinal immobilization)b. 2-person technique (with and without spinal immobilization)

5. Side effects or complications that may result from ventilations.6. Role of end-tidal CO2 (capnometry) for regulating the ventilation rate.

a. Appropriate quantitative range.b. Appropriate adjustment in rate if the level falls.c. Appropriate adjustment in rate if the level rises.d. Issues associated with cardiac arrest.

4.2 Endotracheal Intubation Assist1. Monitoring devices, equipment, and supplies required.

a. Appropriate preparation and assembly of each.2. Indications and contraindications for endotracheal intubation.3. Procedure for assisting with the procedure.

a. Attaching all monitoring devices.i. Cardiac monitor.ii. Pulse oximeter.iii. End-tidal capnometer.

4. Role of end-tidal CO2 (capnometry) for regulating the ventilation rate. a. Appropriate quantitative range.b. Appropriate adjustment in rate if the level falls.c. Appropriate adjustment in rate if the level rises.d. Issues associated with cardiac arrest.

. e. Use of the colorimetric qualitative device (Easy Cap).5. Protocol for moving an intubated patient. 6. Protocol for moving the intubated patient. 7. Issues associated with the intubated pediatric patient.

4.3 Automatic External Defibrillation1. Mechanism of action of the AED.2. Indications and contraindications for using the AED.3. Procedure for applying and operating the AED.

a. Recognition of all promptsb. Batteries.c. PC data cards.d. Troubleshooting.e. Limitations.

i. Temperature.ii. Portable radios.

4.4 Oral Glucose Administration1. Indications and contraindications for administering oral glucose.2. Complications or side effects associated with administering oral glucose.

4.5 Sublingual Nitroglycerine Administration1. Mechanism of action.2. Indications and contraindications for assisting a patient administer their nitroglycerine.3. Procedure for assisting a patient in taking their nitroglycerine.

a. Blood pressure parameters for assisting with nitroglycerine administration.4. Common side effects after nitroglycerine administration.

4.6 Metered-Dose Inhaler Administration1. Mechanism of action.2. Indications and contraindications for assisting a patient with their inhaler.3. Procedure for assisting a patient in using their inhaler.4. Common side effects after using an inhaler.

4.7 Nebulization Therapy1. Mechanism of action.2. Indications and contraindications for assisting a patient with their nebulizer.3. Procedure for assisting a patient in using their nebulizer.4. Differences in a hand-held and mask nebulizer.5. Common side effects after using an inhaler.6. Supplies used and assembly of hand-held nebulizer.7. Supplies used and assembly of mask nebulizer.4. Common side effects after using a nebulizer.

4.8 Intramuscular Epinephrine Administration1. Dose and concentration of epinephrine contained in the syringe.2. Mechanism of action and clinical effects of epinephrine3. Indications and contraindications for administering epinephrine.4. Procedure for administering epinephrine using the autoinjector.5. Common side effects after using an epinephrine autoinjector.

4.9 Intravenous Access Assist1. Equipment and supplies required for assembling an intravenous fluid set.2. Procedure for assisting a Medic personnel with setting up an intravenous line. 3. Common complications associated with intravenous therapy. 4. Importance of sterile technique.

4.10 Ancillary ProceduresSuction1. Indications for suctioning an airway.2. Equipment required and procedure for suctioning an airway. 3. Importance of preoxygenation. 4. Common side effects associated with suctioning.

Cardiopulmonary Resuscitation1. Procedure for performing adult and pediatric cardiopulmonary resuscitation.2. Establish apnea and pulselessness.3. Common side effects associated with cardiopulmonary resuscitation. 12-Lead Electrocardiogram1. Indications for obtaining a 12-lead electrocardiogram.2. Equipment required for obtaining a 12-lead electrocardiogram.3. Procedure for obtaining a 12-lead electrocardiogram.

a. Location for applying chest and limb electrodes.

Wound CareAbrasions and lacerations1. Wound care procedure for abrasions and lacerations.2. Issue concerning dressings and bandages being applied after the paramedic has had the

opportunity to examine the wound. 3. Protocol for amputations.Burns1. Protocol for burn care.2. Indications and contraindications for cooling a burned area and time required for cooling.

Fracture Immobilization1. Indications for fracture immobilization.2. Procedure for fracture immobilization.

a. Importance of fracture recognition and neurovascular status assessment and reassessment.3. Complications associated with fracture immobilization.

Spinal Immobilization1. Indications and contraindications for spinal immobilization.

a. Four specific indications for spinal immobilization.2. Procedure for spinal immobilization.3. Issue of providing manual in-line stabilization with or without a cervical collar until Medic

arrival, with full immobilization prior to paramedic evaluation performed if the patient is critically injured.

Restraints1. Indications for restraint use.2. Procedure for restraint use.

a. Issues associated with authorized restraints. 3. Complications associated with improper restraint use.

5.1 First Responder Medication Formulary 1. Generic and trade names for all oral, inhalational, and intramuscular medications used by first

responders.

5.2 Medic Medication Formulary1. Generic and trade names for all oral, topical, inhalational, subcutaneous, intramuscular, and

intravenous medications used by Medic personnel.

5.3 First Responder Medication Dose, Route of Administration, and Indications1. Dose, route of administration, and indications for oral glucose 2. Dose, route of administration, and indications for intramuscular epinephrine 1:1000 by autoinjector.

5.4 Medic Medication Dose, Route of Administration, and Indications1

1. Indications for all oral, topical, inhalational, subcutaneous, intramuscular, and intravenous medications used by Medic personnel.

1

Protocol 5.4 Medic Medication Indications, Route of Administration, and IndicationsHistorical Data Original: 12/02NCCEP Medication ListApproved ________12/02