*
Largest US Bioterror Attack
Rajneeshee1984 - The DallesContaminated salad bars Salmonella enterica Typhimurium751 affected/45 hospitalized
Török, JAMA 1997;278(5)
Health ofEMS Protocols
Oregon EMS EMS medical directionSystems of careAdequacy of EMS protocolsNext steps
Paul S. Rostykus, MD, MPH• Family Medicine - 4 years
OR, AK, AZ, WV, Nepal, CO
• Emergency Medicine – 25 yearsSouthern Oregon
• EMS medical director – 25 years
• State EMS Committee
• NAEMSPRural Committee chairProgram Committee chair
Medical Marijuana
Oregon Health Authority- Public Health - Oct 1, 2013Oregon Health Authority- Public Health - Oct 1, 2013thority- Public He - Oct 1, 20egon Health A
0.0
2.0
4.0
6.0
8.0
Multnomah (Portland)
Lane (Eugene) Jackson
(Medford) Josephine (Grants Pass)
Oregon Medical Marijuana Cards# cards per capita (%) Population (100,000)
Medical Marijuana& Oregon EMS
Oregon Medical Marijuana Program (OMMP)
OMMP 56% of EMS & Trauma $ $1,025,000/year
Oregon Health Authority- Public Health - Oct 1, 2013
EMS & Medical Marijuana
EMS(Emergency Medical Services)
• 911 dispatched – 24/7/365First responding – usually fire departmentTransporting - ambulance
• Aeromedical transport• Inter-facility transport• Event EMS, S&R, Industrial EMS• Mobile Integrated Health (MIH)
If you’ve seen one EMS system…..….then you’ve seen one EMS system.
EMS in Oregon
OHA - EMS & Trauma – January 30, 2015OHA - EMS & Trauma – April11, 2017*
36# Counties# EMS Providers# Non-transporting Agencies# Ambulance Agencies# EMS Medical Directors
EMS in Oregon
OHA - EMS & Trauma – January 30, 2015OHA - EMS & Trauma – June 2017*
3612,779*
# Counties# EMS Providers# Non-transporting Agencies# Ambulance Agencies# EMS Medical Directors
EMS in Oregon
OHA - EMS & Trauma – January 30, 2015OHA - EMS & Trauma – June 2017*
3612,779*
380*
# Counties# EMS Providers# Non-transporting Agencies# Ambulance Agencies# EMS Medical Directors
EMS in Oregon
OHA - EMS & Trauma – January 30, 2015OHA - EMS & Trauma – June 2017*
3612,779*
380*137*141
# Counties# EMS Providers# Non-transporting Agencies# Ambulance Agencies# EMS Medical Directors
EMS Provider Levels
Fire Department Calls
Fire20%
EMS
ASA map
EMS Medical Directors
Oregon EMS Rules• Oregon Medical Board (OMB) – OAR 847
EMS provider Supervising PhysicianEMS Scope of Practice – maximum = ceilingEMS Advisory Committee – recommends changes
• EMS & Trauma Office – OAR 333Public Health h h –– Oregon Health Authorityg
EMS Provider licensure & y
relicensureEducation standardsEMS Provider disciplineAmbulance licensure Medical DirectorTrauma care
Supervising Physician
OAR 847 (OMB)
EMS Provider
Medical DirectorOAR 333(OHA)
Ambulance Service
Oregon Military
Department,Office of
Emergency Management
911PSAP
Medical DirectorOAR 333(OHA)
EMS Education
Non-transporting
EMS Agency
Supervising Physician QualificationsOAR 847-035-0020
Oregon licensed MD or DO in current practiceResident of or actively working in EMS areaKnowledgeable of EMS skills, ORS & OAR< 1 year, complete one of:
3 years as EMS medical directoryNAEMSP medical director course (1 or 3 day)EMS fellowshippEMS subspecialt
pltalty y y certificationp yy
Ongoing education every 2 yearsAttend 1 Oregon EMS Forumgg8 hours EMS CMEEMS S S subspecialty y y maintenance of certification (MOC)
Supervising Physician DutiesOAR 847-035-0025
Written standing orders (protocols)EMS currently licensed and in good standingRegular review of practice
Direct observation – “ride alongs”Indirect observation
Prehospital emergency care report review;pp g y pPrehospital communications tapes review;ppDemonstration of technical skills;
Case reviews & Continuing education2 hours contact with EMS providers/year
EMS Scope of PracticeOAR 847
✓EMS Provider must have:Supervising PhysicianWritten standing orders
✓Not exceed Scope of Practice✓Provide Pre-hospital Care✓Honor POLST
Oregon Medical Board EMS Scope of Practice - OAR 847
Supervising PhysicianWritten Standing Orders (Protocols)
EMS Provider Practice
EMS protocols vary• Pediatric seizure treatment
• Pelvic fracture binding
• Naloxone administration for opioid OD
• Statewide protocols
• CBG in seizure patients
• Hypoglycemia treatment
• Time-dependent emergencies?
Systems of CareTime-dependent emergencies
Trauma – Oregon law & ruleTrauma center & surgeon
STEMI (ST elevation Myocardial Infarction)Cath lab for stent
StrokeCT, TPA or catheter procedure
OHCA (Out of Hospital Cardiac Arrest)ROSC Cooling & more
Sepsis?
Trauma Areas& Hospitals
Josephine County 1,640 sq milesJackson County 2,802 sq milesSiskiyou County 6,347 sq miles
Acute STEMI PCI Coverage Approximately= 5,000 sq miles
30 STEMI ProgramsEach covering 5-25 sq. mi.
DisclosureThis project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H54RH00049, Rural Hospital Flexibility Program.This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.
*
Rural vs Non-rural Counties
No protocols received 1 EMS agency 2-5 EMS agencies 6-10 EMS agencies
OHCA
Stroke
STEMI
Volume 132, Number 18, Suppl 2, November 3, 2015ISSN 0009-7322http://circ.ahajournals.org
2015 AMERICAN HEART ASSOCIATION GUIDELINES UPDATE FOR CARDIOPULMONARY RESUSCITATION AND EMERGENCY CARDIOVASCULAR CARE
Part 1: Executive Summary
Part 2: Evidence Evaluation and Management of Conflicts of Interest
Part 3: Ethical Issues
Part 4: Systems of Care and Continuous Quality Improvement
Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality
Part 6: Alternative Techniques and Ancillary Devices for Cardiopulmonary Resuscitation
Part 7: Adult Advanced Cardiovascular Life Support
Part 8: Post–Cardiac Arrest Care
Part 9: Acute Coronary Syndromes
Part 10: Special Circumstances of Resuscitation
Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality
Part 12: Pediatric Advanced Life Support
Part 13: Neonatal Resuscitation
Part 14: Education
2015 AMERICAN HEART ASSOCIATION AND AMERICAN RED CROSS GUIDELINES UPDATE FOR FIRST AID
Part 15: First Aid
SUPPLEMENT TO
by guest on March 29, 2017
http://circ.ahajournals.org/D
ownloaded from
Next steps?
EMS medical director supportEMS medical director course
Twice yearly EMS ForumStatewide protocols?
294 PREHOSPITAL EMERGENCY CARE APRIL/JUNE 2015 VOLUME 19 / NUMBER 2
FIGURE 1. States with mandatory or model statewide ALS protocols as of October 1, 2013. Types of protocols used by each state are indicatedby colors (see key). For states that are white on the map, no statewide protocols or model guidelines exist.
with mandatory C). Seventeen states had model proto-cols at the BLS or ALS levels (Figures 1 and 2).
Al t h lf f t t (24/50) t d h i l l
tion protocols for patients with STEMI, stroke, cardiacarrest, or burns (Table 3).cols at the BLS or ALS levels (Figures 1 and 2). arrest, or burns (Table 3).
Kupas DF, Schenk E, Sholl JM, Kamin R. Characteristics of statewide protocols for emergency medical services in the United States. Prehosp Emerg Care. 2015;19(2):292-301
ALS protocolsMandatory A – required useMandatory B – required use, may alter protocolMandatory C - required use, may use own protocolsModel Guidelines – statewide protocols may be used
Take homeAmbulance protocols vary
What is optimal care?
Improve EMS care
Rural EMS medical directors
Office of Rural Health
Funded this study
$ for twice yearly EMS Forum