EMS seminar 2 Joseph Ip BSc Hon MSc

EMS seminar #2 Joseph Ip BSc (Hon), MSc, MD VGH Emergency May 28, 2002

Dispatch n Introduction n 911 dispatch n MPDS n Trauma 99 protocol n CCB n Primary and secondary redirections n Transfer fleet dispatch n Provincial Airevac dispatch

Components in EMD n n 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 n n n n Interrogator Vehicle allocation Pre-arrival instructions Radio dispatcher Triager Logistics coordinator Resource provider

Vertical Dispatch n refers to one individual handling all functions for each call

Horizontal Dispatch n refers to one individual handling all functions for each call

Considerations in planning dispatch response n n n n 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 n means sending different response configuration in different response mode according to the presenting complaint

PAI vs Telephone Aid n Prearrival instruction (PAI) n telephone-rendered, medically approved, written instructions given by trained EMDs to callers to aid victim and control the situation before prehospital personnel arrive. n Telephone aid n 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 n n n n n 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: n Developed in Salt Lake City n Used to standardize dispatch n Step by step instructions for dispatchers n Standardized entry and exit processes n 6 dispatch patterns (A, B, C, D, E, )

MPDS n n n 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)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 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 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 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 n n n 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: n 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: n In the Lower Mainland, four trauma receiving hospitals, plus a special role for St. Paul's Hospital. 1. Vancouver Hospital and Health Sciences Centre (VHHSC) n 2. Lions Gate Hospital n 3. Royal Columbian Hospital n 4. BC Children's Hospital n 5. St. Paul's Hospital - penetrating, non-neuro; VHHSC backup. n

VHHSC n catchment area bounded: n north by the boundary with St. Paul's, n east by Boundary Road n south to include Richmond, Delta, Ladner and Tsawwassen. n Blunt trauma in the urban core (St. Paul’s catchment) goes to VHHSC.

Lions Gate n catchment area n entire North Shore from Horseshoe Bay to Deep Cove

Royal Columbian n 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. n catchment area n n Port Moody, Port Coquitlam and Coquitlam extends east to 203 rd 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 n receives penetrating, non-neuro trauma n acts as back up for VHHSC for blunt trauma, when VHHSC is on Trauma Bypass n catchment area boundary n n n 4 th Avenue, from Burrard west to UBC Terminal Avenue, from Main Street across the Grandview Viaduct to Clark Drive along 1 st Avenue east to Boundary Road. n Any penetrating trauma occurring north of the "boundary" would fall in St. Paul's catchment area

Trauma Center Criteria - Physiological and Anatomical: 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) n two or more proximal long bone fractures, i. e. humerus and /or femur n flail chest n Major amputation of extremity n n

mechanism criteria : n severe deceleration injury n falls greater than 20 feet n high speed MVI n roll-over n ejection of patient from vehicle n pedestrian hit at 20 mph (30 kph) or more n bicycle, motorcycle accident at 20 mph (30 kph) or more

Examples: n 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. n 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: n 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 n three paediatric trauma-receiving hospitals in the GVRD: l. BC Children's n 2. Royal Columbian n 3. Lions Gate. n n 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: n Trauma center if following mechanisms regarless of vital signs: Severe deceleration injury. n falls greater than 20 feet n high speed MVI n roll-over n ejection of patient from vehicle n pedestrian hit at 20 mph (30 kph) or more n bicycle, motorcycle incident at 20 mph (30 kph) or more n

Physiological and anatomical criteria – Pregnant patients n n n n n 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

$Critical Burn Criteria n Burns associated with significant fractures or other major n n$

Critical Burn Criteria n Burns associated with significant fractures or other major n n n 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: n All patients who do not meet the triage criteria for a critical burn n n 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 n Very vague n “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: n CCB reflects temporary inability to provide immediate resuscitation n Used by hospital only as a last resort and in extreme cicumstances n Not invoked by hospital because stretchers are full or department is busy n Time limit = 20 -30 min

New proposed consensus – Vancouver Coastal Regional workgroup n 2 active simultaneous resuscitations n CCB will not apply to followings: n CPR in progress n Unrelieved airway obstruction n Trauma n Closest hospital is > than 20 minutes from scene

Redirect Consideration (CMAJ; Feb 19, 2002; 166(4)) : n A request that the ambulance dispatch centre send all but critically ill patients to another hospital n Resources of the ED are being stretched, but another critically ill patient could be accomodated if necessary n 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: n All acute care beds are full and all internal contingency plans have been exhausted n All stretchers are full and 90% of staffed acute stretchers are full of admitted patients OR n 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: n Occurs after assessment at originating hospital and acceptance of responsibility for the patient by the originating hospital n Paramedics may not assume responsibility for care that they are not qualified to maintain n Must be a hospital to accept responsibility for the patient (w/i 20 minutes of ambulance arrival)

Transfer Fleet Dispatch

Transfer Fleet: n Seperated from 911 dispatch n CAD operated n Advanced bookings n Separate fleet n Emergency fleet may be borrowed under special circumstances n Mainly interfacility transfer

Airevac Dispatch

Aircraft selection: n Fixed wing aircraft are the aircraft of choice in most airevacuations, except: n n 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. n At least one medical and one operational indicator must be met before helicopters can be confirmed as the aircraft of choice. n Helicopters may be preferable for: n n rapid access to seriously ill or injured patients at an incident scene or in a hospital, or; short distances.

Why fixed wing over helicopters? n in most cases faster; n less expensive; n more conducive to patient care because they: n are pressurized, and; n have more room for patient care.

Operational Indicators for Helicopter Inter-Hospital Transfers: n 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). n If helicopter transport is longer than one hour, fixed wing transport is indicated unless: n n 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: n 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%; n with active uncontrollable bleeding; n who are haemodynamically unstable (BP less than 90, with previously normal BP), and/or displaying clinical evidence of shock, and/or requiring vasopressor intervention; n who are unconscious (GCS less than 9), and/or patients who are being transferred for emergency neurosurgical consultation n 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: n 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 n 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: n n n 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. n 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 n 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): 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; n multi-patients at regional/provincial discretion. AND n it is anticipated that the patient will not arrive at the nearest hospital within one hour of receiving the call. n n n

Helicopter Landing: n usually land at an airport and the patient is then transferred by road ambulance to the hospital/medical facility because: have the appropriate facilities such as night landing lights and space; n will cause less noise for people in adjacent buildings and fewer traffic hazards (unlike metropolitan landing sites), and; n are generally safer (e. g. no overhanging wires or obstructions). n

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 n 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.