General Principles of Medical Care

General Principles of Medical Care

The following measures shall be applied to promote prompt and efficient emergency medical care to all patients:

  1. The safety of EMS personnel is paramount. Each scene must be evaluated for hazards upon arrival, and throughout patient care. Assess the need for additional resources as soon as possible after arrival.
  2. Proper personal protective equipment and body substance isolation must be utilized according to agency and industry standards.
  3. A patient shall be considered any person who is requesting and/or in need of medical attention or medical assistance of any kind.
  4. A patient encounter shall be considered any event when signs and symptoms, or a patient complaint, results in evaluation or treatment.
  5. All patients in the care of EMS shall be offered transport by ambulance to the nearest appropriate hospital or other protocol based destination. In the event a patient refuses transport, a properly executed refusal process must be completed.
  6. An EMS patient care report will be generated at the conclusion of each patient encounter. A complete copy, or the approved abbreviated report, must be left with the receiving facility at the time of transport. No copies or patient information will be given to anyone other than those covered by Florida Statute, and other applicable laws, without written permission from the patient or their surrogate.
  7. Crews must be prepared for immediate medical interventions, appropriate for the call level (e.g., defibrillation, airway management, etc.), upon initial patient contact.
  8. Upon arrival at a scene where patient care is being rendered by an initial EMS responding crew, all subsequent arriving EMS crews should immediately engage the on scene crew. The goal is to determine the status of assessment and seamlessly assist in patient care.
  9. Prior to the transfer of patient care between crews, the EMT/paramedic rendering initial care should directly interface with the EMT/paramedic assuming care, to ensure all pertinent information is conveyed.
  10. For all 911 calls where EMT’s and paramedics are in attendance, patient care decisions shall be performed by the paramedic.
  11. The paramedic should decide within 3 minutes after patient contact if advanced life support (ALS) measures will be needed. Perform a more comprehensive exam after the patient has been stabilized.
  12. Generally, initial assessment and therapy should be completed within 10 minutes after patient contact. Except for extensive extrication, or atypical situations, trauma patients should be en route to a receiving facility within minutes; medical patients should be en route to the receiving facility within 20 minutes.
  13. For all patients in cardiac arrest, call into your dispatcher the “patient contact time” at the time of initial patient contact, and “first shock time” at the time of initial defibrillation.
  14. Whenever possible, obtain verbal consent prior to initiating treatment; respect the patient's privacy and dignity.
  15. Prior to the administration of any medication, assess for allergies. If any questions arise in reference to medication allergies, contact Medical Control prior to giving any medication.
  16. Nontransport agency personnel shall provide information pertinent to the patient’s identification, patient assessment and medical care to the transporting agency personnel at the time patient care responsibilities are turned over. The mini-SOAPP format is preferred when time allows:
    • Subjective – document the patient’s chief complaint (in their own words) and history of present illness (including history of events surrounding call)
    • Objective – document vital signs, (normal and abnormal), pertinent physical findings (e.g. document normal or abnormal heart and lung exam if chest pain, normal or abnormal abdominal exam if abdominal pain, normal or abnormal neurologic exam if neurologic complaint etc.)
    • Assessment – document the EMT/paramedic's impression of the problem and/or working diagnosis. This can be the chief complaint, e.g. "chest pain"
    • Plan – document which protocols and treatments were administered
    • Prehospital course – document pertinent events that occur prior to ED arrival, as well as the patient's response to treatments administered
  17. Expanded SOAPP information will be provided to the receiving facility by the transporting agency. This more detailed note will include the first responder information, and shall be documented on a run report for every patient.
  18. The agency or authority having jurisdiction of the EMS incident location (when on scene) is responsible for scene safety, scene command and control, as well as resource management decisions. Patient care and patient movement decisions shall be made in coordination with the scene supervisor or incident commander.
  19. When caring for pediatric patients, use a weight or length based system to determine medication dosages and equipment sizes.
  20. For trauma situations, a pediatric patient has the anatomical and physical characteristics of a person fifteen (15) years or younger.
  21. Following training and successful competency assessment by their respective agencies, EMT’s are authorized to apply pulse oximetry and capnography monitoring devices, perform blood glucose evaluations, perform bag-valve-mask ventilation, perform Laryngeal Tube Airway (LTA) insertion and ventilation, and perform bag-valve ventilation of paramedic inserted endotracheal tubes.
  22. To perform as an EMT/Paramedic, personnel must be knowledgeable and proficient in the scope of practice described and taught in the Department of Transportation National Standardized Curriculum, and maintain active State certificates.
  23. Perform all procedures as per the Orange County EMS System Procedures Manual. If a procedure that is not addressed in this manual is deemed necessary, contact Medical Control or the receiving hospital physician for orders prior to proceeding.
  24. If Medical Control gives orders to perform a procedure that is not covered in the Orange County EMS System Procedures Manual, but is within the scope of practice of an EMT/Paramedic, perform the procedure in accordance with standards set for the level of certification.
  25. For all cases where patients require parenteral narcotics or sedative agents, continuous cardiac, oxygen saturation and ETCO2 monitoring shall be performed.
  26. The Regional Poison Control Center (800-222-1222) should be contacted when handling calls involving poisonous/hazardous material exposures, overdoses or suspected envenomations. In the event that the RPCC gives recommendations or orders that are not contained within these protocols, EMS providers are authorized to carry out the RPCC’s instructions.
  27. When using supplemental oxygen in accordance with adult or pediatric treatment protocols adhere to the following:
    • In patients who are noncritical, and have no evidence of respiratory distress use only the concentration of oxygen needed to achieve oxygen saturations over 95%. In most cases this can be accomplished using a nasal cannula.
    • For patients with serious respiratory symptoms, persistent hypoxia, or where otherwise specified in protocol, use 100% supplemental oxygen via nonrebreather mask or BVM.
  28. Monitor/Defibrillators used under the scope of these protocols must be able to provide:
    • Escalating energy, biphasic defibrillation (includes AED's)
    • Continuous ECG waveform and ETCO2 waveform simultaneously on the screen

Medical Transport Destination

All patients should be transported to the emergency department of their choice (when operationally feasible) unless the patient is unstable.

  • Unstable patients:
    • All patients whose condition is judged to be unstable will be transported to the closest appropriate receiving facility (see exceptions below)
    • If several emergency departments are within the same approximate distance from the scene, allow the patient, and/or patient’s family, to select the receiving facility of their choice
  • For transport destination of Cardiac Arrest-Post Resuscitation, SEPSIS, STROKE, STEMI ALERT, TRAUMA, LVAD or OB (>20 week) patients, refer to appropriate protocol

Physician/Nurse on Scene

Occasions will arise when a physician on the scene will attempt to direct or assist prehospital care.

The physician must be willing to accept the following conditions:

  • Provide documentation of her/his status as a physician (copy of medical license)
  • Assume responsibility for outcomes related to his/her oversight of patient care
  • Agree to accompany the patient during transport if accompaniment is deemed necessary
  • The Medical Control physician must relinquish the responsibility of patient care to the physician on scene for the scene physician to take control
  • All interactions with physicians on the scene must be well documented in the Patient Care Report, including the physicians name and contact information

Orders provided by the physician should be followed unless, in the judgment of the paramedic, they endanger the patient. The paramedic may request the physician to attend the patient during transport if the suggested treatment varies significantly from standing orders.

If the physician’s care is judged by the paramedic to be potentially harmful:

  • Politely voice his or her concerns and immediately contact Medical Control
  • If the conflict remains unresolved, follow the directives of the Medical Control Physician
  • If the physician on scene continues to carry out the intervention in question, offer no assistance and enlist aid from law enforcement

Licensed Nurses present at an emergency scene who wish to participate in administering care must function in accordance with Florida law (F.S. 401 and F.S. Chapter 464)

"Green Card" to be
given to physician
on scene offering

Patient Care During Transport

The following situations shall require more than one attendant in the back of the ALS unit:

  • Medical or trauma cardiac arrest or post-resuscitation care
  • Patients requiring active airway assistance (e.g. endotracheal tube, LTA, or BVM)
  • Imminent delivery of a fetus
  • For scenarios not covered above:
    • If either the nontransporting or the transporting agency request a 2nd attendant in the back of the ALS transporting unit, a 2nd attendant should accompany the patient
    • A 2nd attendant is not required if there will be an unacceptable delay in transport
    • A paramedic student or EMT can assist in attending ALS patients, but shall only be counted as the “second attendant” when determined appropriate by the primary paramedic attendant

Interfacility Transport

Interfacility transport requires unique skills and capabilities, both in clinical care and operational coordination. Adhere to the following standards for all interfacility transports:

  • Interfacility transport decisions (including staffing, equipment and transport destination) should be made based on the patient’s medical needs
  • Coordination between hospitals and interfacility transport agencies is essential, before transports are initiated, to ensure that patient care requirements do not exceed the capabilities of the patient attendant
  • If EMS crew members are not capable of managing devices or medications that must be continued during transport, an adequately trained care provider from the transferring facility must accompany the patient during transport

Radio Report Format

For all EMS transported patients radio contact should be made with the receiving center at least 5 minutes prior to arrival to provide general patient information and estimated time of arrival.

  • Select the appropriate receiving facility talk-group on the 800 Mhz radio
    • All receiving facilities in Orange County have an individual talk-group
  • Listen before transmitting to determine if the talk-group is in use; the system does not allow for two radios to transmit on the same talk-group at the same time
  • Begin each transmission with the following:
    • Agency name and unit number
    • Paramedic / EMT Orange County number
    • Triage category and triage level (e.g. trauma red, STEMI alert, cardiac arrest)
    • Estimated time of arrival
  • After the receiving facility acknowledges the initial information, give a concise report, including repeat triage category/level, age and gender, chief complaint, vital signs, Glasgow Coma Score, treatment provided or under way, and any anticipated delay in transport (e.g. extrication)

Medical Control Base Station

Using the Medical Control talk-group, raise On-line Medical Control (OLMC) for any additional orders needed to meet the patient’s needs during on-scene care or transport. If any problems arise in raising OLMC:

  • Hail Med-Com on the same channel; Med-Com will then contact the OLMC by phone (407) 296-1150 and advise that a unit is awaiting medical orders
  • If still unable to reach the OLMC, medical orders can be requested from the receiving emergency department
    • When preferred, medical orders can be obtained from the receiving ED
    • This should not occur if contact has been made with the OLMC and orders given

Any concerns or issues involving the OLMC should be forwarded to the Office of the Medical Director for review as soon as possible.

Triage Categories

Category Definition
Trauma Indicates a trauma patient
Medical Indicates a medical patient
Red High acuity, but does not meet ALERT criteria
Yellow Serious, but not critical
Green Low acuity of illness
Trauma Alert Meets Trauma Alert criteria
STEMI Alert Meets STEMI Alert criteria
Stroke Alert Meets Stroke Alert criteria
Sepsis Alert Meets Sepsis Alert criteria
HAZMAT Alert Suspected Hazardous Material exposure
Code Cardiopulmonary arrest

Authorized Pharmaceuticals

  • Adenosine
  • Albuterol
  • Amiodarone
  • Aspirin
  • Atropine Sulfate
  • Calcium Chloride
  • Dextrose
  • Diazepam
  • Diltiazem
  • Diphenhydramine
  • Dopamine
  • Epinephrine 1:1000
  • Epinephrine 1:10,000
  • Fentanyl
  • Glucagon
  • Glucose
  • Hydroxocobalamin (Cyanokit)
  • Ipratropium Bromide
  • Magnesium Sulfate
  • Methylprednisolone
  • Midazolam
  • Naloxone
  • Nitroglycerin
  • Ondansetron
  • Oxygen
  • Sodium Bicarbonate
  • Thiamine
  • Ziprasidone

Unless otherwise specified in protocol, give individual IV medication doses over 1-2 minutes. When treating cardiac arrest patients medications can be given more rapidly.

Transfer of Care at Hospitals

Once on hospital property, the receiving facility assumes responsibility for all further medical care delivered to EMS transported patients. OCEMS personnel are not authorized to follow prehospital protocols after arrival at an ED, and OCEMS Medical Control should not be contacted for orders.

Exceptions to this should occur only in the following circumstances:

  • Life threatening situations such as cardiac arrest, airway emergencies or imminent delivery of a fetus
  • Continuation of treatments started prior to arrival (e.g. nebulizers, CPAP, IV fluids)
  • When specifically instructed to continue care by the ED physician (when possible, document the physician’s name and time verbal order was given)

To assure all pertinent information is conveyed to the hospital staff, crews should interface with the charge nurse within 2 minutes of arrival to give a verbal report. Transporting personnel shall provide the receiving facility with any available patient identification, as well as all pertinent incident and patient care information at the time of transfer. In addition to the abbreviated report required by the Florida Administrative Code, turn over all prehospital 12 lead ECGs to the ED staff.

Important Considerations:

  • If offload cannot be completed in a timely manner refer to Delayed Offload Procedure (Orange County EMS Procedure Manual)
  • EMS agency supervisor contact should occur before making a final decision to leave a patient during an extended delayed offload scenario
  • The method of physical transfer should be safe, and not require the discontinuation medically indicated immobilization procedures
  • Document the event well for quality review purposes
  • Document the patient condition (including pain level when appropriate) at time of transfer
  • Document the name of the ED staff-member who was given final report, and the time report was given