2.11 Attachment 15 NAVAVSCOLSCOMINST 6710.1 (Series) EMERGENCY RESPONSE MEDICAL CARE AND STANDARDIZATION PROGRAM FOR HRT COURSES.pdf

DEPARTMENT OF THE NAVY

COMMANDING OFFICER

NAVAL AVIATION SCHOOLS COMMAND

181 CHAMBERS AVE SUITE C

PENSACOLA, FLORIDA 32508-5221

NAVAVSCOLSCOMINST 6710.ID

XT Os 2018

NAVAV S COLS COM INSTRUCTION 6710.ID

From: Commanding Officer, Naval Aviation Schools Command

Subj: EMERGENCY RESPONSE MEDICAL CARE AND STANDARDIZATION

PROGRAM FOR HIGH RISK TRAINING COURSES

Ref: (a) (b) (c) (d) (e) (f) (g) (h) (i) (j)

Enel: {1} (2) (3) (4) (5) (6)

(7)

C 8)

NAVEDTRA 135C

NAVAVSCOLSCOMINST 1610.IIS

NAVAVSCOLSCOMINST 5100.ID (CH-3)

Emergency Response Course

NAVSCHOOLSCOMINST 5100.2A (CH-1)

NASPNCLAINST 2400.2B

NASPNCLAINST 10550.IL

CNRGC 5100.lA

OPNAVINST 1500.75D

NETCINST 1500.13B (CH-2)

In-Service Training Checklist Manual of Emergency Treatment Protocols Medical Equipment Inventory Oxygen Delivery Systems Medical Equipment Inspection Checklist Command Medical Standardization Program Manager (CMSPM) Designation Letter Division Training Medical Representative {DTMR) Designation Letter Emergency Medical Responder (EMR) Designation Letter

1. Purpose. To establish policies and procedures to ensure aPProPriate and effective response to medical emergencies during training evolutions conducted within Naval Aviation Schools Command (NASC).

2. Cancellation. NAVAVSCOLSCOM Instruction 6710.1C

3. Scope. This instruction applies to all NASC training courses and the response to medical emergencies in both the training and non-training environments. The Command Medical Director (CMD), Command Medical Standardization Program Manager (CMSPM), Command Training Safety Administrator

(CTSA), Department Heads, Division Officers, Training Chief Petty Officers (TCPO), Division Training Medical Representative (DTMR), and High-Risk Training (HRT) Instructors assigned as Emergency Medical Responder (EMR), or any staff member responding to a medical emergency, shall ensure proper medical standards are provided and that pertinent protocols, training medical equipment, and personnel qualifications are maintained and enforced. All High Risk Training evolutions shall have an EMR present in the building. More Medical Staff may be required for additional training. If High Risk Training events leave the building, i.e. Physical Training <PT) run, an EMR shall be present.

4. Discussion. Safe training of our students is an ALL HANDS responsibility that requires constant involvement and participation. Working knowledge of the references and other guidance is a fundamental requirement of all personnel involved in student training, especially first line supervisors and instructors. References noted in this instruction, related instructions, instructor qualification programs, and department specific curricula, contain guidance necessary to conduct safe training. Additionally, this instruction exists to identify the required standard medical equipment and staff medical qualifications needed to safely conduct training and effectively respond to a medical emergency.

Outlying Training Sites. All training sites located outside of the Pensacola area, but falling under the purview of NASC shall maintain the Emergency Response and Medical Care Standardization Program in accordance with this instruction.

Site-specific variations and/or deviations from this instruction will be handled on a case-by-case basis. It is the responsibility of the DTMR to liaison with the CMSPM, via the CTSA, on all matters pertaining to this instruction.

6. Personnel Training.

a* Personnel Job Qualification Requirements (JQR). In addition to requirements listed in references (a) and (b), all EMR's are required to complete a certified Emergency Medical Responder (EMR) or an Emergency Medical Technician (EMT) course, and maintain certification throughout their tour at NASC. Upon certification, all members shall complete the Emergency Medical Responder JQR before being designated as an EMR.

NAVAVSCOLSCOMINST 6710.ID

N7

(1) The EMR course ensures a solid baseline of medical response knowledge that is essential in the High-Risk training environment. It allows for instructor diversity in scheduling and increases safety awareness during day-to-day training events.

(2) All training certificates/certifications, to include CPR for the Professional Rescuer, and Oxygen Administration shall be kept current. An EMR qualification shall be suspended if any certificates/certifications are not current and that the individual shall not be reinstated until all certificates/ certifications are current.

(3) Training certificates/ certifications shall be maintained in the instructor's individual training jacket and recorded into the Enterprise Safety Application Management System (ESAMS). It is the instructor's responsibility to maintain currency of this certification.

b. In-Service Training. In-Service Training shall be conducted per enclosure (1). Training shall be held monthly, quarterly, and annually based on training topic and division requirements. It is the responsibility of the TCPO and DTMR, to ensure training is completed in accordance with this instruction. The completed training shall be maintained in the instructor's individual training jacket, under in-service training and recorded into ESAMS per reference (c).

c. Subject Matter Experts (SME). It is highly recommended that department senior leadership continue the practice of certifying exceptional instructors as EMT's through the Naval EMT program (if available). The utilization of the EMT-B, higher qualified personnel, as training coordinators, facilitators, and oversight as SME's is an invaluable tool toward quality medical training of NASC EMRs. To the max extent possible, command SMEs should be assigned and consulted when considering the Command Medical Standardization Program Manager position.

7. EMR/EMT-B Protocols.

a. It is the responsibility of every EMR to have a thorough knowledge of, and maintain compliance with, all American Red Cross standards and protocols per reference (d). Any protocols above and beyond these establish standards and protocols shall be approved by the medical director and placed in enclosure (2)

b. All standards and protocols shall be developed in conjunction with reference (e) Emergency Action Plans (EAP).

This will ensure consistency and proper treatment of patients during an emergency, and maintain oversight from the NASC Medical Director. Additionally, this plan ensures current medical qualifications of all EMRs, augments the in-service training requirements for all EMRs, and protects the medical provider from legal repercussions. Deviation from these protocols may result in revocation of medical certification, EMR designation, and/or instructor qualification. The CMSPM may review and submit protocol revisions through the CMD as needed to support training objectives.

8. EMR Designation. Any staff member who has completed a local EMR JQR and has been designated by the Commanding Officer (or their designee) as an EMR, can fill the position as an EMR during training.

Communications. If radios are used as communication for any HRT evolution, the EMR shall use appropriate radio frequencies and radio etiquette as listed in references (f) and (g).

Unauthorized radio frequencies and/or transmitters are strictly prohibited. It is the responsibility of the EMR to maintain constant radio communications with the training team(s) in order to ensure adequate response time during an emergency.

Communications shall be conducted within the guidelines of the department EAP and this instruction.

10• Emergency Response Vehicles. All emergencies shall be transported by an ambulance. All non-urgent medical care can be transported by a military duty vehicle. If a military duty vehicle is going to be used for non-urgent medical care transport, the EMR and primary Instructor are responsible to ensure an appropriate vehicle is available for this purpose.

11‘ Personal Protective Equipment (PPE) and staff health. In accordance with references (c), (h), and (i) all personnel, when involved in direct patient contact, have a potential risk of exposure to blood and/or bodily fluids in the training environment and shall use approved PPE supplied in all standardized training medical bags/cases. Instructors and EMRs may maintain their own PPE, however, the CMSPM must approve it prior to use. Use of PPE not authorized by the CMSPM is strictly prohibited.

12. Standardized Medical Equipment.

a. Equipment Inventory. In order to ensure continuity of medical response equipment, a standard medical inventory list and medical equipment configuration has been established. All medical supplies/equipment shall be maintained in accordance with enclosures (3), (4), and (5). It is the intent of this guidance to maintain a minimum inventory of medical supplies to ensure safe and adequate response to training medical emergencies, as well as enabling cross-utilization of medical equipment by all training divisions if necessary. Therefore, the minimum equipment level and bag configuration shall not be modified without the prior approval of the CMSPM. Though the equipment inventory list is a minimum, with the approval of the CMSPM, individual training divisions may supplement the inventory with additional non-consumable items as needed to support specific training needs. Only those items listed in enclosure (5) are authorized for use as supplemental equipment.

All supplemental consumable items shall be maintained in the medical bag's accessory outside pocket only. Due to varying purchase costs, the ordering of supplemental equipment should be limited to only those items absolutely necessary to facilitate training requirements.

b. Standard Medical Bag. The standardized medical bag inventory and layout shall be maintained per enclosure (3). At a minimum, one standard medical bag shall be present at all aquatic and physical training evolutions. Supplemental equipment may be included with prior CMSPM approval only. The purchase, use, distribution, holding, and/or storage of medications or medical items of any kind not listed in the standard medical inventory list are strictly prohibited. All non-expendable equipment shall be inventoried/tracked in ESAMS using E-Tracker.

c. Automated External Defibrillator (AED). The standard AED plays an essential role in the ''Chain of Survival", thus they are considered crucial and mandatory pieces of medical equipment and shall be maintained per this instruction. All AED's shall be inventoried and tracked in ESAMS, using E-tracker and an annual report shall be sent to the base fire department.

The use of an AED for other than that which is prescribed by current American Red Cross (ARC) standards, command course curriculum, or other governing instructions is strictly prohibited. To reinforce the requirements of, and in addition to, the requirements listed in paragraph 10.f. AED's shall be maintained in the following locations:

(1) Water Survival (Building 3828).

(a) Two in the pool area. One centrally located on the wall in the shallow end pool deck and the other AED centrally located on the wall in the deep end pool deck.

(b) One centrally located in a designated position on the gymnasium side of the building adjacent to Kane Field.

(c) One portable AED shall be readily available to the EMR for all PT sessions on Kane Field.

3828.

(d) One centrally located on the 2nd deck of building

(2) Building 3860.

(a) A minimum of one AED shall be centrally located in Room 129, N7 Remote Training Office.

(3) Aviation Enlisted Aircrew Training School, Naval Military Training, Aircrew & Rescue Swimmer Barracks (Building 623 & 626).

(a) A minimum of one AED for each Quarter Deck in building 626 and building 623.

(b) A minimum of one AED outside of the medical office in Building 623.

(c) A minimum of one AED centrally located on the 2nd deck in both buildings 626 and 623.

(d) One portable AED shall be readily available to the EMR for Aircrew PT sessions.

(4) NASC Main (Building 633)

(a) A minimum of one AED located on the main Quarterdeck, 1st deck.

(b) A minimum of one AED located on the 2nd deck outside room 216 and one on the 2nd deck of Aviation Preflight Indoctrination (API) outside the API conference room, down the hallway from room 256.

(c) One portable AED shall be readily available to the EMR for all RSSI PT sessions. This AED can be found in the Aircrew Search and Rescue Course Manager's Office (building 633 room 143).

(5) Aviation Rescue Swimmer's School (Building 4142 Rescue Swimmer School Instructor Course.

and

(a) One AED shall be centrally located in a designated position on the pool deck.

(b) One portable AED shall be readily available to the EMR for all Aviation Rescue Swimmer's School (ARSS) PT sessions.

(6) Remote Swimming Sites. All remote swimming sites shall have one AED present for all high risk training.

d. Spinal Immobilization. All emergency spinal immobilization boards and specialized spine boards utilized specifically for water removal during aquatic training shall be maintained per this instruction. The use of all spinal immobilization/water extrication equipment shall be governed by current ARC standards. A minimum of one spinal immobilization board and one water extrication board shall be maintained for each pool in which aquatic high risk training is conducted. In the case where a pool is separated into individual tanks by a catwalk or fixed stationary object these minimum requirements apply to each individual training tank. All spinal immobilization/water extrication equipment shall be inventoried and tracked on ESAMS using E-Tracker.

e* Oxygen Delivery Systems. Per references (f), (g), (h), and (i), due to the extreme conditions and high-risk training performed, medical oxygen is required for all aquatic and physical training conducted at NASC. Specific guidance, regarding maintenance, configuration, inventory, purchase, and inspection of oxygen delivery systems can be found in enclosures (3), (4) and (5). Both oxygen bottle and regulator shall be inventoried and tracked on ESAMS using E-Tracker.

f* Minimum Equipment Requirements. The minimum equipment requirements shall be maintained per reference (f) and this instruction, as well as divisional curriculum requirements, and shall not be altered without the authorization of the CMSPM.

g- Supply Ordering. For supply purchasing, refer to enclosure (3). In the event a purchase item becomes unavailable, it is the responsibility of the division/department supply personnel, in coordination with the DTMR, to advise the CMSPM to ensure that the item is replaced by one of equivalency.

The CMSPM will act as the liaison with NASC supply department as needed.

h. Equipment Inspection. All medical equipment shall be inspected in accordance with enclosure (5) prior to conducting any High Risk Training event. This requirement can be extended to a weekly check for nonexpendable items provided bag/case has tamper seal on it. All Medical equipment, including medical bag/case, shall be inventoried after each use. Medical equipment shall be placed on pool decks, placed in the medical duty vehicle and/or hand-carried during PT events. All medical equipment shall be utilized per individual department's EAP and this instruction. It is the responsibility of all EMRs and HRT instructors to be familiar with departmental EAPs in order to ensure knowledge of medical equipment staging areas, and proper cross-utilization of medical equipment during training events.

Use of medical equipment beyond items listed in enclosure (3) is not authorized.

13. Non-urgent Medical Supplies. Non-urgent medical supply inventories (e.g., insect repellents and sting kits, ammonia inhalants, etc.) are authorized for use by staff Hospital Corpsman assigned to NASC only. These supplies shall be maintained in a locked storage locker at all times.

14. Emergency Action Plan Activation/Patient Declination. When it is deemed necessary to activate the EAP due to a medical emergency involving an active duty member and an ambulance is summoned to the incident site, that active duty member shall be evaluated and cleared to return to training by a physician. The active duty member can refuse to be transported by ambulance, but all activations of the EAP require the active duty member to be evaluated by a physician, before he/she can return to training. This is an order to comply and the service member does not have the right or ability to decline care if their condition is serious enough to warrant EAP activation. Staff shall brief ambulance crews that local branch health clinics are not authorized or equipped to accept a patient following EAP activation.

15. Medical Tracking. It is the responsibility of the training site to gather as much information as possible and communicate this information to the schoolhouse/command where the student is assigned. The schoolhouse shall maintain a tracking log to ensure the most current medical status of the injured student is tracked.

16. Responsibilities. Using this instruction, appropriate scope of patient care, and Operational Risk Management, all personnel listed below shall ensure safe training conditions are provided during all training events conducted at NASC.

a. Command Medical Director (CMD): The senior flight surgeon shall act as the CMD. Their duties shall include the following:

(1) Be designated in writing by the Commanding Officer or his designee.

(2) Oversee all aspects of the Emergency Response and Medical Care Standardization Program including medical equipment, training, standards of care, protocols, and command developed policies and procedures as they pertain to this program.

(3) Utilize the Command Medical Standardization Program Manager as the primary resource for management of all program aspects including, but not limited to: maintenance and/or development of above mentioned equipment and administration, scheduling and tracking of command sponsored medical training, inspection and ordering of equipment, and tracking of instructor medical qualifications.

b. Command Medical Standardization Program Manager shall:

(1) Be designated in writing by the Commanding Officer or his designee, see enclosure (6).

(2) Be a senior command Hospital Corpsman, or an E-6 and above, or a GS-7 and above. CMSPM shall be a certified EMT-B or EMR, with no less than six months on board the command, and they should have at least 12 months to projected rotation date (PRD), It is highly recommended that this individual be an EMT-B or higher.

(3) Manage all aspects of the Emergency Response and Medical Care Standardization Program as listed above.

(4) Act as liaison with Medical Director.

(5) Coordinate with all department/division medical representatives to ensure medical program standards are maintained and functional.

(6) Coordinate inspections of medical equipment.

(7) Monitor all contracts/agreements with outside agencies to ensure equipment upkeep and maintenance.

(8) Act as Approving Authority regarding use of medical equipment not listed in this instruction.

(9) Manage in-service training per this instruction and coordinate special training sessions as required.

(10) Update directives. Standard Operating Procedures, Emergency Action Plans, medical inventories, training criteria, and protocols as required.

(11) Notify Command Medical Director of a training medical emergency as required.

(12) Perform an annual review of Department Emergency Treatment Protocols. Submit protocol revisions through the Medical Director as required to support training objectives.

required.

13) Evaluate and track department EAP drills as

(14) Manage all medical equipment placed in E-Tracker.

(15) CMSPM (When on scene) will maintain patient control and ensure continuity of care until relieved by proper authority.

c. Command Training Safety Officer shall:

(1) Assist as needed, and coordinate with Command Medical Standardization Program Manager to ensure program standards are maintained per this instruction.

(2) Maintain enforcement of all staff medical training requirements and inspect departments as needed.

(3) Ensure department heads maintain an effective Emergency Response and Medical Care Standardization Program in accordance with command directives.

(4) Ensure Schoolhouse Directors and department heads hold required in-service training in accordance with this instruction and record training in ESAMS.

(5) Maintain copies of monthly medical equipment inspection reports for a minimum of two years.

d. Schoolhouse Directors and Department Heads shall:

(1) Maintain an effective Emergency Response and Medical Care Standardization Program in accordance with command directives.

(2) Allocate funds required to maintain medical equipment to the standards set forth by this instruction with the understanding that a certain level of surplus consumable items may be required in order to maintain such standards.

e.

shall:

Division Officers and Training Chief Petty Officers

(1) Ensure all HRT Instructors maintain medical qualifications in accordance with this instruction.

(2) Ensure the appropriate management of medical supplies to support safe training.

C3) Ensure all EMRs conduct initial and in-service training as set forth by respective JQRs and this instruction.

(4) Ensure division medical representatives maintain program standards in accordance with this instruction.

(5) Ensure the coordination of medical coverage prior to each training event.

f. Division Training Medical Representatives shall:

(1) Be designated in writing by the Schoolhouse Director, department head or his designee, see enclosure (7).

(2) Be a department Hospital Corpsman or an EMR who is E-5/GS-5 or above. Military personnel shall have no less than one year before their PRD.

(3) Ensure appropriate levels of medical supplies are maintained to support safe training environment.

(4) Coordinate with division training personnel and EMTs to conduct specific monthly, quarterly, and annual in-service training requirements for all division EMRs in accordance with this instruction.

(5) Coordinate special in-service training as needed to correct immediate training deficiencies.

(6) Coordinate inspections of medical equipment with CMSPM to ensure equipment standards.

(7) Ensure medical equipment oversight upkeep includes, but is not limited to: visual and scheduled equipment inspections, oxygen cylinder maintenance, replacement of consumable and non-consumable medical items through appropriate supply channels, and maintenance of medical supply surplus.

(8) Ensure a copy of all medical supply requisitions are received by the CMSPM within 15 days of the date requisition was generated.

(9) Notify CMSPM of a training medical emergency as soon as practical.

(10) Coordinate with division training representative to ensure completed medical training is documented in instructor's individual training jacket and logged into ESAMS.

(11) Enforce radio etiquette requirements in accordance with references (c) and (d).

(12) Maintain medical tracking log.

g. EMR Shall:

(1) Be designated in writing by the Schoolhouse Director or department head in accordance with enclosure (8).

Designation letter shall be filed in the instructor's training jacket.

(2) Coordinate with primary instructors from all divisions conducting training to consolidate medical coverage and medical response vehicle coverage, if possible.

(3) Ensure appropriate medical response vehicle (duty vehicle, utility vehicle (UTV), etc..) is available as required.

(4) Ensure approved radio equipment is maintained on an appropriate frequency throughout the duration of the training evolution and that radio is tested prior to start of training.

(5) Maintain radio etiquette in accordance with references (c) and (d).

(6) Ensure medical equipment is visually inspected, in good working order, and maintained either in the immediate training area or in the medical response vehicle.

(7) Maintain currency of medical certification regardless of training level.

(8) Have a thorough knowledge of, and maintain strict compliance with, all Emergency Treatment Protocols.

(9) Ensure proper PPE is accessible at all times.

(10) Maintain appropriate additional medical equipment based on the scope of the training event, e.g.. Open Water Lab.

(11) Notify division training medical representatives of a training medical emergency as soon as practical.

(12) Respond to all medical emergencies in accordance with command and departmental directives. Emergency Action Plans, ARC guidelines, and this instruction.

(13) Ensure all medical reports and injury reports are completely filled out.

h. Non-assigned staff personnel responding to any medical emergency shall adhere to the guidelines listed in this instruction.

V. W. GARS

Distribution:

NAVAVSCOLSCOMINST 5215.4K

List I (A-B)

IN-SERVICE TRAINING CHECKLIST

**Training modules shall be conducted per reference (b).

Required in-service training

1. Quarterly Training

a. Emergency Plan Walk Through: conduct in accordance with reference (c),(i)and (j).

b. Conduct two lessons from the recommended training list below.

(1) Semi Annual Training

(a) Spinal Injury Management: Must include back boarding.

Training.

(b) CPR Training: Must be "Hands-on" Annual

(c) Emergency Plan Drill conducted in accordance with reference (c), (i)and (j).

(d) Bloodborne Pathogens training.

2. Recommended training (Modules/Lessons can be found in the Emergency Response Manual).

a. Recognition drills to identify items maintained in the standard medical bag.

b. Patient Assessment Module including: trauma and medical.

c. Airway Management including: "Breathing Emergencies' and "Breathing Devices."

d. Oxygen therapy equipment recognition and maintenance

e. Preparatory Module including: "Lifting and Moving.

Enclosure 1

f. Circulation Module including:

Emergencies''.

NAVAVSCOLSCOMINST 6710.ID

N7

CPR and "Cardiac

g. Illness and Injury Module including: "Bleeding and Shock, Specific Injuries, Muscle and Bone Injuries, and Head, Neck, and Back Injuries".

h. Preparatory Module including: "The First Responder, Well-Being of the First Responder, Preventing Disease Transmission, Legal and Ethical Issues, and Human Body Systems'

i. Illness and Injury Module including: "Medical and Behavioral Emergencies, and Poisoning".

j. Review Emergency Medical Protocols, (Enclosure (2)).

Enclosure 1

NAVAL AVIATION SCHOOLS COMMAND

Naval Air Station Pensacola, Florida

Medical Standardization Program

MANUAL

of

EMERGENCY TREATMENT

PROTOCOLS

Submitted By:

HMl (NAC/FMF/AW) Douglas C. Johnson

Mr. John C. Prince Medical Standardization Program Developers

Approved By:

LT TODD A. NANNI

Naval Aviation Schools Command, Flight Surgeon Implemented: September 2018

Enclosure 2

TABLE OP CONTENTS

FRONT MATTER

TABLE OF CONTENTS

References

PREFACE

GENERAL GUIDELINES - INTERPRETATION OF PROTOCOLS

GENERAL PROTOCOLS

BODY SUBSTANCE ISOLATION

COMMUNICATIONS

CRITICAL INCIDENT STRESS DEBRIEFING

GENERAL GUIDELINES FOR ALL PATIENTS

GUIDELINES FOR DOCUMENTING PATIENT CARE

PATIENT CARE FLOW CHART

MEDICAL/TRAUMA EMERGENCY PROTOCOLS

UNCONSCIOUS PATIENT

CHEST PAIN

RESPIRATORY DISTRESS

DROWNING, NEAR DROWNING, AND SHALLOW WATER BLACKOUT

HEAT INJURY

COLD INJURY

MAJOR TRAUMA, FRACTURE/BLEEDING

PROCEDURES

AUTOMATED EXTERNAL DEFIBRILLATOR

HEAT EMERGENCY FLOWCHART

OXYGEN THERAPY

WATER ASPIRATION - LARYNGOSPASM FLOWCHART

Enclosure (2

Reference

1. Brady Emergency Care Manual

2. ARC Emergency Response Manual

PREFACE

1. INTRODUCTION. NASC emergency treatment protocols are standardized with local Emergency Medical Systems (EMS) in order to provide initial emergency care to NASC students, staff, and visitors until those patients can be transported to the most appropriate medical facility. NASC protocols recognize the publication of American Heart Association (AHA) and American Red Cross (ARC) standards, as well as those standards maintained by the local area EMS. Notable content includes recognition of First Responder and Emergency Medical Technicians (EMT) Basic Life Support level standards of care, integrated Automatic External Defibrillation (AED) deployment, and incorporation of AED actions into the cardiac arrest management. These protocols include both algorithmic and narrative elements and are not intended to be a manual on the treatment of all medical emergencies or necessarily an instruction manual, but instead, a set of specific guidelines used in the treatment of general medical emergencies. The protocols include instructions for certain procedures characteristic to field treatment and especially those instances where special care must be exercised.

In no way are these protocols meant to interfere with specific policies or procedures that have been established regarding both the "risk7' and/or "non-risk" training environment.

2. PURPOSE. The following information is provided to serve as a quick reference of medically correct standing orders and/or emergency treatment protocols. The intent of the emergency treatment protocol is not to substitute physician direction, but rather to provide rapid guidance concerning pre-hospital emergency care when either physician contact cannot be established or when any delay in patient care would have potential life or limb threatening consequences.

NASC instructors certified at the level of ARC-Emergency Responder (First Responder), EMT-Basic, or higher are responsible for the content of these protocols and have the added responsibility for maintaining proficiency in these skills.

3. ACTION. The local Medical Director is encouraged to review and approve and/or revise emergency treatment protocols according to the command's mission.

a. For the purpose of command-wide continuity, personnel are not authorized to perform medical treatments above their respective level of care.

b. These protocols should be reviewed with a permanent change of Medical Director or as needed as changes arise in medical treatments or procedures.

c. A copy of these protocols shall be reviewed and adhered to by all medically trained personnel. A copy of these protocols shall be maintained by division level medical representatives and readily accessible by division personnel.

Medical Director: LT Todd Nanni, Flight Surgeon for NASC has authorized these Emergency Treatment Protocols.

T. A. NANNI, FS

NASC EMS MEDICAL DIRECTOR

Enclosure (2)

GENERAL GUIDELINES - INTERPRETATION OF PROTOCOLS

1. The NASC Medical Treatment Protocols have been developed for First Responders and Emergency Medical Technicians operating during training hours to ensure the delivery of high quality standardized emergency medical care.

2. All protocols must be explicitly followed. Protocols should not be exceeded nor is the management of the patient to be altered without the instructions of the NASC EMS Medical Director.

3. The medical provider should generally be able to decide within a reasonable period of time after reaching the patient if Advanced Life Support measures will be needed. In an unstable patient or potentially unstable patient scenario, stabilizing therapy such as oxygen administration should be started almost simultaneously with the initial assessment,

4. Generally, the initial assessment and initial therapy should be completed as quickly as possible after reaching the patient.

Except for problems with extrication, the patient should be transferred to advanced care within 10 minutes of incident, or as quickly as possible.

5. Initial assessment and emergency treatment of a patient must be carried out simultaneously. Common sense should be exercised in those cases where the time required rendering appropriate treatment is much greater than the time required to transport the patient to a receiving facility. Always keep treatment priorities in mind in order to achieve a successful result.

Activate EMS as required.

6. If the Emergency Action Plan is activated and EMS is required, the Commanding Officer has mandated that the patient must be transported to the appropriate Emergency Medical Facility and report to NASC Medical as a follow on. It is the responsibility of the responding EMR to submit a brief statement to the Command Medical Standardization Program Manager and Senior Flight Surgeon before the end of the business day.

7. Respect the patient's right to privacy and dignity.

Courtesy, concern, and common sense will assure the patient that they are receiving the best possible care.

8. The management of situations and conditions not covered by the written protocols in this manual must be under the direct orders of the Medical Director.

9. Accurate documentation on the Personnel Accident and Injury Notification (PAIN) report is a necessity. This must include a description of the chief complaint, brief history, vital signs (at least two sets), mental status and emergency management.

The narrative on the report must be complete and follow the PAIN report note format. When protocols are exceeded, the name and signature of the Command Medical Standardization Program Manager and the Medical Director must be obtained.

10. Patients exhibiting the signs and symptoms of severe hypoxia require aggressive airway management. Insertion of airway management devices such as oral adjuncts may be used in conjunction with the Bag-Valve-Mask.

11. At times, NASC medical providers may respond to or happen upon pre-hospital emergency scenes in areas other than their area of responsibility, including disaster aid responses, vehicle collisions, etc. Naval Aviation Schools Command medical providers are authorized by the Medical Director to perform within the scope of the Naval Aviation Schools Command Medical Treatment Protocols under these circumstances. In the event a Naval Aviation Schools Command medical provider does render assistance outside of the training element, the medical provider is required to notify the Command Medical Standardization Program Manager and the Medical Director of the incident by the following workday.

12. If anyone, regardless of medical credentials obstructs the care or causes unnecessary delay in transport of patient to definitive medical treatment facility, the senior instructor/SMT present should;

a. Communicate the situation to the participating hospital.

b. Request law enforcement or appropriate military authorities' involvement if necessary to ensure that the team's members can continue to provide patient care according to system protocol.

c. Behavior of the on-scene health care professional should be documented on the ambulance report.

13. Certain situations may require instructors/Search and Rescue medical technicians (SMTs) to use physical restraints.

This is utilized ONLY WHEN NECESSARY and in those situations where the patient is exhibiting behavior that the instructors/SMTs believe presents a danger to the patient, staff and/or other. This procedure applies to patients being treated under implied consent. USE OF LAW ENFORCEMENT OR MILITARY

ASSISTANCE WHEN AVAILABLE IS HIGHLY ENCOURAGED.

14. DETERMINATION OF DEATH:

a. Obvious Death Criteria: A patient may be determined obviously dead by SMTs if, IN ADDITION to the absence of respiration, cardiac activity and neurological reflexes (e.g., pupillary, corneal responses); one or more of the following physical or circumstantial conditions exists:

(1) (2) (3) (4) (5)

Decapitation Massive crush injury to the head, neck or trunk

Rigor Mortis

Post-Mortem Lividity Traumatic Cardiac Arrest: No pulse, no spontaneous respirations, no response to aggressive stimulation and pupils are fixed and dilated.

NOTE: The unit's flight surgeon recognizes that SMTs have the discretion to initiate resuscitation in cases where the patient is obviously dead but a concern for unit/team morale exists.

However, the SMT may decide to cease CPR once in route and or out of sight of the concerned unit/team. Additionally, given this situation, the SMT may preform CPR as long as:

(a) (b) (c)

The patient is not decapitated.

No obvious signs of rigor mortis.

Doing so does not put the SMT or team in danger.

BODY SUBSTANCE ISOLATION

1. PROCEDURE: The risk of exposure to body fluids and blood borne pathogens requires that health care providers consider all patients as potential carriers of infectious disease. It is imperative that providers adhere rigorously to infection control precautions to minimize that risk of exposure to blood and other body fluids.

a. PROTECTIVE BARRIER PRECAUTIONS:

(1) Gloves shall be worn.

(a) Whenever handling patient.

(b) During use or disposal of soiled equipment.

(c) Change gloves for each new patient.

(2) Meticulous hand washing with antibacterial soap.

(a) Between patient contacts.

(b) Immediately after removal of gloves.

(c) After final disposition of patient, prior to continuation of training.

(3) Mask, shall be present and used.

(a) When exposure to body fluids is possible.

(b) Used when inserting an airway adjunct.

b. CLEANING AND DISPOSAL OF CONTAMINATED EQUIPMENT:

(1) Wear gloves while cleaning equipment.

(2) Thoroughly disinfect all re-usable equipment.

(a) Wash with soap and water.

(b) Cleanse with appropriate disinfecting agent.

(c) Dry thoroughly before returning to storage.

8 Enclosure (2

(3) All soiled clothing, dressings, and other non sharps material must be placed in appropriate (red) "Bio-Hazard" designated garbage bag, and handled per OSHA guidelines.

c. DISPOSAL OF SHARPS (IF APPLICABLE):

(1) Do not recap, bend, or cut contaminated needles.

(2) Do not remove needles from disposable syringes.

(3) Dispose of used needles and syringes in puncture resistant container.

(4) The location of disposal container should be as close as possible to patient treatment area.

COMMUNICATIONS

1. PROCEDURE: Communications between pre-hospital personnel, base stations, and the supporting hospitals are a vital part of patient care. Communications should follow the general outline below.

NOTE: IF ACTING IN THE CAPACITY OF EMR, DOCUMENT THE FOLLOWING

INFORMATION FOR TURN OVER WITH EMS:

a. Patient age and sex.

b. Chief complaint or problem.

c. Level of consciousness {Glasgow Coma Scale, if appropriate, and vital signs.

d. Brief pertinent history as needed to clarify problem such as mechanism of injury.

e. Physical assessment.

f. Treatment given and patient/s response.

NOTE: IF CONDUCTING ENROUTE PATIENT CARE, UTILIZE THE FOLLOWING

ADDITIONAL INFORMATION:

g. Specific questions and/or additional orders.

h. Estimated time of arrival.

10 Enclosure {2

CRITICAL INCIDENT STRESS DEBRIEFING (CISD)

1. PROCEDURE; Stress is an inherent aspect of emergency medicine. Only in recent years has stress been recognized as a legitimate hazard of emergency work. Pre-hospital personnel must learn to manage stress, as well as the conditions that cause it. Dealing with stress in a positive manner promotes emotional and physical healing and prevents burnout. This stands true for the High-Risk Training environment as well. All personnel must be capable of identifying stressors in both themselves and co-workers and utilizing techniques to alleviate negative stress,

2. TYPES OF STRESS: A stress reaction has both physical and psychological components. There are three types of stress reactions that can occur: acute, delayed, and cumulative stress,

a. Acute Stress Reaction usually occurs after a catastrophic event (Critical incident). The reaction has a powerful emotional impact on the rescuer.

b. Delayed Stress Reaction, also called "post-traumatic stress disorder," occurs days, weeks, months, or even years after a critical incident.

c. Cumulative Stress Reaction, or "burnout," unlike the other types of stress, does not result from a single incident.

Instead, it stems from recurring minor stressors, both work and non-work related.

3. MANAGING JOB STRESS: You must learn to manage stress in both the pre-hospital and High-Risk Training environments. You must recognize the early warning signs of anxiety. Remember that some stress is valuable. It protects an individual and improves performance. Therefore, you need to discover your own optimal stress level and attempt to maintain it. Some events may be more stressful than others, so it is important to remember that we are all susceptible and that identifying and coping with stress is a normal part of the healing process. Never be afraid to seek additional help, if necessary, request a Critical Incident Stress Debriefing (CISD) session. Often, an informal session with a trained peer on scene may be all that is required.

11 Enclosure (2

GENERAL GUIDELINES FOR ALL PATIENTS

1. PROCEDURE:

a. Initiate American Red Cross Emergency Response PRIMARY Survey:

(1) Check the scene for safety and form an initial impression of the patient's condition. If you see severe bleeding, use any available resources to control the bleeding including applying DIRECT PRESSURE and/or using a TOURNIQUET if you are trained.

(2) Check for the patient's responsiveness. If no response, call EMS and activate the EAP. If face-down, roll the patient onto his or her back while supporting the head, neck and back.

(3) Open the airway and check for breathing and a pulse. For a breathing emergency (e.g., drowning, hypoxia), give 2 ventilations prior to (4)

(4) If the patient is not breathing but has a pulse, give 1 ventilation every 5-6 seconds (Adult). If the patient is not breathing and has no pulse, begin CPR starting with Compressions.

b. Initiate Emergency Response SECONDARY SURVEY:

(1) Perform a brief head-to-toe assessment. Obtain and record vital signs including pulse, B/P, respiration, skin color, skin temperature, and capillary refill.

(2) Obtain brief history from patient, family, and bystanders.

c. TREATMENT / RESUSCITATION:

(1) Treat all problems in order of priority and according to Emergency Treatment Protocols.

(2) Reassure the patient and keep him/her informed of treatment.

d. TRANSPORT: All patients should be evaluated, appropriate treatment performed, and prepared for transportation as quickly

12 Enclosure (2) as possible. Scene time for all trauma patients should be ten minutes or less, unless extrication procedures prolong transfer of patient.

13 Enclosure (2

GUIDELINES FOR DOCUMENTING PATIENT CARE

1. PROCEDURE: All patient contacts shall be documented on the Emergency Action Plan (EAP). The written report is the medical-legal document of the assessment and management of the patient.

The importance of completeness and accuracy of the report cannot be over emphasized. The comments section of the EAP Form will be completed using the following:

a. CHIEF COMPLAINT: Document the reason for the medical response.

b. SUBJECTIVE: History, Symptoms described by the patient, circumstances of illness, mechanism of injury, etc. Include brief past medical history if appropriate, current medications, allergies.

c. OBJECTIVE: Findings and physical examination. Vital signs are charted in the physiological status or flow chart sections.

d. ASSESSMENT: Summarized, synthesized statement of patient's problem(s). The assessment serves as the basis for treatment.

e. THERAPY/TREATMENT: All procedures, oxygen therapy, etc.

conducted. Document all actions required to manage the patient's problems.

(1) If orders from Medical Director are received via radio, document completely all instructions given and document the name of the physician giving the order(s). Read back confirmation is required.

(2) Document patient refusal of therapy if it occurs.

(3) Document rationale for any deviation from written protocols.

(4) Document equipment left at scene, receiving Medical Treatment Facility (MTF), or transported with patient.

(5) Document the NAME of accepting higher medical authority, with who the patient was turned over to (i-e. EMT or Physician).

14 Enclosure 12

PATIENT CARE FLOWCHART

IS PATIENT RESPONSIVE?

YES

Stop training!

Activate EMS / EAP Perform Primary Assessment Care Protocol #1 Unconscious Pt.

Meet EMS, assist in transport

NO

Perform Primary Assessment Perform Secondary assessment

IS EMS TRANSPORT NEEDED?

YES

Self or Instructor 1st Aid Document on EAP timeline, Submit PAIN

CHIT

Follow Up with NASC Medical

• Document Event, fill out PAIN Chit

• Notify Chain of Command

• Report event to NASC Medical

Officer

Stop training Activate EMS/EAP Utilize Protocols #2. Chest Pain #3. Trouble Breathing #4. Near Drowning #5. Heat Injury #6. Cold Injury #7. Major Trauma {Fractures/Bleeding) Document PAIN Chit and follow up report to NASC Medical Officer

15 Enclosure (2

UNCONSCIOUS PATIENT

1. POSSIBLE CAUSES:

- Alcohol Intoxication

- Dysrhythmia

- Shock

- Drug Overdose

- Respiratory Failure

- Trauma

- Meningitis

- Seizures (postictal)

- Diabetes

- Cardio Vascular

Accident (CVA)

- Heat Stroke

2. INITIAL ASSESSMENT:

Pay special attention to:

a. Routine patient assessment:

(1) Airway, Breathing, Circulation (ABC)

(2) Vital signs

(a) Evidence of trauma

(b) History

(c) Breath odor: Alcohol (ETOH), acetone, etc.

(d) Skin Turgor

(e) Level of Consciousness (LOG), attempt to arouse

b. Cervical spine protection.

c. Airway management per protocol with special attention to preventing aspiration. Airway maintenance to include: 100% oxygen via Non-Rebreather (NRB) mask, assisted ventilations via Bag Valve Mask (BVM), and use of airway adjunct as required.

d. Frequent recheck of vital signs, LOC, and neurological status.

e. Call EMS.

16 Enclosure (2

CHEST PAIN

1. POSSIBLE CAUSES:

Cardiac Ischemia Pulmonary Edema Pulmonary Emboli Abdominal Pain

2. SIGNS & SYMPTOMS:

Pericarditis Trauma Chest Wall Pain Stress, Emotional Upset, Phobia

a. May be multiple depending on pathologic cause.

b. Cardiac related symptoms: Pain may be crushing, substernal, neck/jaw and/or left arm and/or back pain, nausea/ vomiting, diaphoresis, Shortness of Breath (SOB), or rales.

3. INITIAL ASSESSMENT:

Pay special attention to:

a. General guidelines

b. Mental status

c. Blood pressure

d. Breath sounds (rales, rhonchi)

e. Skin (color, cool, clammy)

f. History of cardiac problems

4. PATIENT MANAGEMENT:

a. Establish Airway, Breathing, Circulation (ABC), administer 100% oxygen via Non-Rebreather (NRB) mask. Be prepared to assist ventilations with oral airway and Bag Valve Mask (BVM) as required.

b. Place patient in position of comfort or supine if hypotensive. Minimize patient exertion.

c. Call EMS and monitor.

d. Treat for shock as required and monitor.

17 Enclosure (2)

RESPIRATORY DISTRESS

POSSIBLE CAUSES:

Asthma Pulmonary Edema

- Airway Obstruction Allergic Reaction

SIGNS & SYMPTOMS

Traumatic injury to neck/chest Congestive Heart Failure (CHF) Bronchospasm/Laryngospasm Cardiac abnormalities

a. Increasing Shortness of Breath (SOB)

b. Labored respirations with use of accessory muscles

c. Altered Level of Consciousness (LOC)

d. Respiratory arrest

e. Dysrhythmias (determined by altered or absent pulse via palpation or auscultation)

f. Hypoxia

3. INITIAL ASSESSMENT:

Pay special attention to:

a. Rapid patient assessment

(1) Vital signs

(2) Level of Consciousness (LOC)

(3) Breath sounds

(4) Retraction of intercostal muscles

4. PATIENT MANAGEMENT

a. Establish and maintain airway.

b. Administer 100% oxygen via Non-Rebreather (NRB) mask or Bag Valve Mask (BVM) as appropriate for level of distress.

c. When possible, place patient in position of comfort.

18 Enclosure (2

d. Be prepared to begin rescue breathing/CPR as required.

e. Dysrhythmias, utilize an Automated External Defibrillator (AED) in preparation for Cardiac progression.

19 Enclosure (2)

1.

DROWNING, NEAR DROWNING, AND SHALLOW WATER BLACKOUT

DEFINITIONS:

a. Drowning - death within 24 hours of asphyxia due to a submersion injury,

b. Near drowning - when recovery occurs following asphyxia due to a submersion injury.

c. Shallow Water Blackout (SWB) — loss of consciousness due to hyperventilation and overexertion prior to submerging. A submersion injury can result.

2. POSSIBLE CAUSES:

a. Drowning or Near-Drowning: Asphyxia due to submersion in water or other fluid media.

b. Shallow Water Blackout (SWB): Hyperventilation prior to submersion in water or other fluid media.

3. INITIAL ASSESSMENT

a. Airway, Breathing, Circulation (ABC)

b. Pulse, and blood pressure

c. Skin, color, temperature

d. Auscultate lung sounds

4. PATIENT MANAGEMENT

a. If poolside, activate alarm, follow Emergency Action Plan.

b. Airway, Breathing, Circulation (ABC) and establish airway, use jaw thrust for possible cervical injury. Be prepared to begin CPR procedures.

c. Protect C-spine if head, neck, or back injury suspected.

d. Remove foreign matter if obstructing airway.

e. Oral pharyngeal airway and ventilate with 100% oxygen via Bag Valve Mask (BVM).

20 Enclosure (2

f. Call EMS.

g. Provide blankets if cold water submersion Hypothermia Protocol) see

NOTE:

All victims of SWB or near-drowning should be evaluated by a physician. Patients who go on to develop delayed symptoms (secondary drowning) display signs of respiratory distress usually within the first four hours.

SAFETY NOTE:

Remove patient from water and dry chest before applying Automated External Defibrillator (AED), Document if patient was in contaminated water.

21 Enclosure (2

HEAT INJURY

1. POSSIBLE CAUSES:

a. Exposure to extreme temperature conditions

b. Over-exertion (i.e.: indoor or outdoor labor, sports, or physical training)

c. Improper Acclimatization

d. Improper Hydration

e. Exacerbated by age or alcohol intake or drugs

2. SIGNS & SYMPTOMS: Varies according to type

a. HEAT CRAMPS

(1) Muscle cramps {common to abdomen and legs)

(2) General malaise

b. HEAT EXHAUSTION

(1) Moist, cool, clammy skin (may be pale / ashen)

(2) Weakness, dizziness, and headache

(3) Nausea/vomiting

(4) Fainting

(5) Normal or subnormal temperature

(6) Dilated pupils

c. HEAT STROKE - "MEDICAL EMERGENCY"

{1} Temperature above 103.0 degrees F.

(2) Extreme fatigue

(3) Unconsciousness

(4) Pinpoint pupils

22 Enclosure (2)

(5) Hot, dry skin (may be bright red / flushed)

3. INITIAL ASSESSMENT:

Pay special attention to:

a. Routine patient assessment

b. Body temperature

c. Skin condition

d. Vital signs

e. Level of Consciousness (LOG)

4. PATIENT MANAGEMENT:

NOTE:

In all cases, move patient to cool environment out of sun.

Patient's condition may worsen rapidly. COOL THE PATIENT DOWN!

a* HEAT CRAMPS: Give oral fluids (Gatorade) and monitor.

b. HEAT EXHAUSTION:

(1) Administer 100% oxygen via Non-Rebreather (NRB) mask.

(2) Treat for shock.

(3) Call EMS.

c. HEAT STROKE:

(1) Airway, Breathing, Circulation (ABC)

(2) Administer 100% oxygen via Non-rebreather (NRB) mask

(3) Apply cold packs (if available) to back of neck, armpits, chest, groin, and back of knees.

(4)…