01. 2021 USAF EMS Protocols (11 Apr 21).pdf

Version 1 – 01 April 2021

Air Force Emergency Medical Services

Protocols

“The Star of Life was designed by Leo R. Schwartz, who was Chief of the EMS Branch of the National Highway Traffic Safety Administration. In 1973, the American Red Cross complained to the NHTSA that the use of the common Omaha Orange Cross on a square background of reflectorized white closely resembled the Red Cross symbol. Once the NHTSA investigated and agreed with the complaint, the new Blue Star of Life (displayed above) was born.

This new symbol was designed using the Medical Identification Symbol as a guide. The Star of Life was registered as a certification mark with the Commissioner of Patents and Trademarks on February 1, 1977.

The center of the star consists of the snake and staff. The staff is named Asclepius, who according to Greek mythology, was the son of Apollo.

Theory states Asclepius learned the art of healing from the centaur Cheron. Asclepius was usually shown in a standing position with a long cloak and holding a staff with a serpent coiled around it. This is why the staff is the long-standing symbol representing medicine. In the Physicians and Military Medical Corp, the Caduceus is used. The Caduceus is a winged staff with two serpents intertwined around it.

The six points of the Star of Life Symbol are meant to represent the true meaning of the EMS System. These include Detection, Reporting, Response, On Scene Care, Care in Transit, and Transfer to Definitive Care.

The use of the Star of Life Symbol is regulated and monitored by the NHTSA” http://www.globalemergencyvehicles.com/blog/history-of-the-star-of-life/ http://www.globalemergencyvehicles.com/blog/history-of-the-star-of-life/

DEPARTMENT OF THE AIR FORCE

HEADQUARTERS UNITED STATES AIR FORCE

WASHINGTON DC

16 March 2021

MEMORANDUM FOR PREHOSPITAL RESPONSE PERSONNEL

FROM: AFMRA/SG1E

7700 Arlington Blvd Falls Church, VA 22042-5157

SUBJECT: USAF Approved Emergency Medical Services (EMS) Protocols

1. This policy letter supersedes previous directives regarding the same subject. Attached are the approved 2021 EMS Protocols. These protocols direct the provision of care in the prehospital environment and while en-route to a military treatment facility or civilian emergency department. These protocols must be used by 4N0X1X, 3E7X1 and civilian personnel (GS/contractors) providing prehospital care under the direction of USAF EMS medical control, unless a waiver has been approved during the previous calendar year.

2. Protocols are based on the 2009 National EMS Education Standards and the 2019 National EMS Scope of Practice Model. Additionally, the Air Force State Office of EMS included CFETP and TCCC skills. Resources employed in the creation of the protocols included: American Academy of Orthopaedic Surgeons, Emergency Care and Transportation of the Sick and Injured (12th Edition) as well as American Red Cross Emergency Cardiovascular Care guidelines and the National Association of Emergency Medical Technicians’ TCCC-AC and TCCC-MP standards. Protocols must be implemented within 60 days of receipt of this memorandum.

3. Deviations from these protocols that are outside the established scope of practice of the 4N0X1X CFETP must be approved in advance and require a waiver of the provisions of AFI 44-119, Medical Quality Operations, paragraph

7.28.2. and AFI 44-102, Medical Care Management, paragraph 2.20.4. Units with approved scope of practice waivers will be trained IAW standards set forth by the MTF/F&ES EMS Medical Director.

4. Air Force uniformed personnel, civil service employees and personal services contractors are protected from personal liability so long as they are acting within the scope of their official duties and the Federal Tort Claims Act (Title 28, U.S.C., Section 1346(b), 2671-2680). Please contact your regional Medical Law Consultant if you have questions regarding personal liability under the FTCA.

5. This is an AF/SG1E and AF Civil Engineer Center (AFCEC), Fire and Emergency Services (F&ES) Division coordinated letter. If you require additional information, please contact the AFMS EMS Program at:

usaf.jbsa.afmoa.mbx.ems-program-manager@mail.mil or the F&ES EMS Program at: frederic.terryn.1@us.af.mil

CHARLES M. MORRIS, CMSgt, USAF 3E7 Career Field Manager

TALIAH M. WILKERSON, CMSgt, USAF 4N Career Field Manager

Attachment:

2021 USAF EMS Protocols

Authors and Advisors for the 2021 USAF EMS Protocols

Matthew J. Streitz, Lt Col, USAF, MD, MC Emergency Medicine Consultant to the Surgeon General

Erica M. Simon, Maj, USAF, DO, MC Medical Director, USAF State Office of EMS

Britton S. Adams, SMSgt, USAF, IDMT / NRP Director, USAF State Office of EMS

Ashley L. Jackson, MSgt , USAF, NRP Manager, USAF EMS and TCCC Program

Alysha D. Waite, TSgt, USAF, NRP NCOIC, USAF EMS and TCCC Program

Mr. Fred Terryn, USAF, GS-13, NREMT Manager, F&ES EMS Program

Mr. John D. Hearn, USAF, GS-11, NREMT Assistant Manager, F&ES EMS Program

Medical-Legal Consultant Robert E. Vorhees II, Lt Col, USAF

Legal Advisor to the Air Force Surgeon General

EMS Consultants Edward H. Crowe, MSgt, USAF, IDMT / NRP Angela G. Belk, TSgt, USAF, NRP

Timothy A. Reynolds, NJ-03, USAF, NRP Matthew S. Giambelluca, GS-11, USAF, NRP

F&ES Consultants Javie Blanco, GS-13

NRAEMT

Andrew Lambert, GS-11

NREMT

Daniel Gallegos, GS-10

NRAEMT

Jason Rose, GS-9

NREMT

Doug Hicks, GS-8

NREMT

John Rice, GS-8

NRP

Brian Schultz, GS-8

NRP

Robert Conklin, GS-7

NRP

Emergency Medicine Consultants

Alex P. Keller, Lt Col, USAF, MC, SFS Commander, Special Warfare Operational Medical Sq

Nicholas M. Studer, USA, MD, FS, NRP Staff Physician / Disaster Medicine Fellow

Trauma Consultants James B. Sampson, Col, USAF, MD, MC SG Consultant, Chief of Surgical Services

Brian J. Gavitt, Lt Col, USAF, MD, MC SG Consultant, Trauma/Surgical Critical Care

Caitlin M. Howard, MAJ, USA, MD Trauma, Burn and Rehabilitative Medicine Program

Pediatric & Neonatal Consultants

Renee I. Matos, Lt Col, USAF, MD, MC SG Consultant, Critical Care Pediatrics

Thomas J.Lee Jr., Lt Col, USAF, MD, MC Staff Physician, Pediatric Critical Care

Matthew A Borgman, LTC, USA, MD Katie Neumayer, MAJ, USA, MD

Chief Editors Maj Simon, SMSgt Adams, SMSgt Valerie Lee, MSgt Jackson and TSgt

Waite

Obstetrics Consultants Larissa F. Weir, Lt Col, USAF, MD, MC

SG Consultant, Maternal Child Dalia J. Wenckus, Lt Col, USAF, MD, MC

SG Consultant, OB/Gyn Maternal-Fetal Medicine

Toxicology Consultant Joseph K. Maddry, Lt Col, USAF, MD, MC

Deputy Commander, US Army Institute of Surgical Research

Flight and Operational Medicine Consultant Kristy L Raso, SMSgt, USAF

Aeromedical Evacuation Technician Consultants Thomas F. Ward, SMSgt, USAF, IDMT / NRP Erik W. Rodriguez, MSgt, USAF, IDMT / NRP

Installation Contributors / Reviewers

Air Force District of Washington MSgt Lauren Everett, NRP MSgt Sophia Parrish, NREMT SSgt Gina Harkness, NRP

Aviano AB MSgt Jennifer Canales, NREMT MSgt Kenneth Gasilos, NRP MSgt Dominique Brigman, NREMT

TSgt William Knowles, NREMT TSgt Kimberly Weaver, IDMT TSgt Ryan Tegtmeier, NRP

SSgt Megan McCarthy, NREMT

Eglin AFB Maj Scott Schott, EMP Mr. Christopher McMillian, NRP TSgt Pablo Pinon Gonzalez, NRP

Joint Base McGuire-Lakehurst-Dix Maj Abigail Capps, MD (Peds) TSgt Delfin Padilla, NREMT TSgt Kevin Marcelino, NREMT

SrA Zachary Yap, NREMT SrA Krystianna Der, NREMT

Lackland AFB Mrs. Wanda Jackson, NRP TSgt Timothy Johansen NRP SSgt Adam Tellez, NRP

2021 Protocol Test Development MSgt Lawrence Whitmore, IDMT / NRP MSgt Christeana Schwartz, NREMT MSgt Venus Bock, IDMT

TSgt Pablo Pinon Gonzalez, NRP TSgt Kayla Techur, NRP SSgt Jessica Opsal, NREMT

Air Force Medical Readiness Agency Approval Col Artemio Chapa (AFMRA/SG3) Col Jennifer Hatzfeld (AFMRA/SGN) Col Kyle Hudson (AFMRA/SGH)

CMSgt Taliah Wilkerson (AFMS 4N Career Field Manager) CMSgt Noe Chavez (AFMRA/SG3 Superintendent)

Table of Contents

(2021 V1: 01 April 2021)

Administrative Information Page Date Approved Philosophy of Protocols i 01 Apr 2021 Expectations of Protocols i 01 Apr 2021 Use of Protocols i-iii 01 Apr 2021 Medication Administration in the Prehospital Environment iii 01 Apr 2021 Procedures in the Prehospital Environment iii 01 Apr 2021 Communication iv 01 Apr 2021 On-Scene Personnel iv 01 Apr 2021 USAF EMS Protocol Scope of Practice Additions iv-v 01 Apr 2021 Addition of Tactical Combat Casualty Care to USAF EMS Protocols v 01 Apr 2021 Universal Precautions v 01 Apr 2021 Exposure to Blood (or other body fluids) or Needle Sticks v 01 Apr 2021

General Protocols Page Date Approved Trauma Center / Air Ambulance Criteria A - 1 01 Apr 2021 Care of Minors (Implied Consent, Abuse/Neglect, Sexual Assault) A - 2 01 Apr 2021 Care of Adults (Implied Consent, Abuse/Neglect, Domestic Violence, Sexual Assault) A - 3 01 Apr 2021 Patient Refusal / Active Duty Considerations A - 4 01 Apr 2021 Combative Patients / Security Forces or Law Enforcement Transport A - 5 01 Apr 2021 Field Termination / Non-Initiation of CPR A - 6 01 Apr 2021 Local Hospital / EMS / Air Ambulance Contacts (Locally Developed) A - 7 01 Apr 2021

Adult Medical Protocols Page Date Approved General Patient Care / Patient Monitoring & Vascular Access B - 1 01 Apr 2021 Airway Management (Adult) B - 2 01 Apr 2021 Nausea & Vomiting B - 3 01 Apr 2021 Pain Management B - 4 01 Apr 2021 Cardiac Arrest B - 5 01 Apr 2021 Return of Spontaneous Circulation (ROSC) / Post-Arrest Care B - 6 01 Apr 2021 Bradycardia B - 7 01 Apr 2021 Tachycardia, Narrow Complex B - 8 01 Apr 2021 Tachycardia, Wide Complex B - 9 01 Apr 2021 Chest Pain (Cardiac) B - 10 01 Apr 2021 Difficulty Breathing - Asthma / COPD B - 11 01 Apr 2021 Difficulty Breathing - Congestive Heart Failure / Pulmonary Edema B - 12 01 Apr 2021 Stroke / CVA B - 13 01 Apr 2021 Airborne Illness (COVID-19 / Influenza) B - 14 01 Apr 2021 Abdominal Pain B - 15 01 Apr 2021 Altered Mental Status B - 16 01 Apr 2021

(2021 V1: 01 April 2021)

Anaphylaxis / Allergic Reaction B - 17 01 Apr 2021 Behavioral Emergencies / Restraints B - 18 01 Apr 2021 Bites and Envenomation B - 19 01 Apr 2021 Diabetic Emergencies B - 20 01 Apr 2021 Hypertension (Non-Pregnancy, see D - 2, Seizures (Pregnancy)) B - 21 01 Apr 2021 Hyperthermia / Heat Exposure B - 22 01 Apr 2021 Hypothermia / Cold Exposure B - 23 01 Apr 2021 Overdose / Toxic Ingestion B - 24 01 Apr 2021 Renal Failure / Dialysis B - 25 01 Apr 2021 Submersion Injuries / Drowning B - 26 01 Apr 2021 Sepsis / Septic Shock B - 27 01 Apr 2021 Seizures, Non-Pregnant B - 28 01 Apr 2021 Shock / Hypotension B - 29 01 Apr 2021 Syncope B - 30 01 Apr 2021

Adult Trauma Protocols Page Date Approved Trauma, General C - 1 01 Apr 2021 Burns C - 2 01 Apr 2021 Crush Injuries C - 3 01 Apr 2021 Epistaxis C - 4 01 Apr 2021 Eye Injuries C - 5 01 Apr 2021 Head / Facial Injuries C - 6 01 Apr 2021 Spinal Motion Restriction C - 7 01 Apr 2021

Obstetrics / Gynecology & Neonatal Protocols Page Date Approved Vaginal Bleeding D - 1 01 Apr 2021 Seizures (Pregnancy) D - 2 01 Apr 2021 Childbirth / Labor D - 3 01 Apr 2021 Newborn Care D - 4 01 Apr 2021 Neonatal Resuscitation D - 5 01 Apr 2021

Pediatric Medical Protocols Page Date Approved General Patient Care / Patient Monitoring & Vascular Access E - 1 01 Apr 2021 Airway Management E - 2 01 Apr 2021 Nausea / Vomiting & Abdominal Pain E - 3 01 Apr 2021 Pain Management E - 4 01 Apr 2021 Cardiac Arrest E - 5 01 Apr 2021 Return of Spontaneous Circulation (ROSC) / Post-Arrest Care E - 6 01 Apr 2021 Bradycardia E - 7 01 Apr 2021 Tachycardia, Narrow Complex E - 8 01 Apr 2021 Tachycardia, Wide Complex E - 9 01 Apr 2021 Altered Mental Status E - 10 01 Apr 2021 Anaphylaxis / Allergic Reaction E - 11 01 Apr 2021

(2021 V1: 01 April 2021)

Asthma / COPD E - 12 01 Apr 2021 Croup / Epiglottitis / Bronchiolitis E - 13 01 Apr 2021 Diabetic Emergencies E - 14 01 Apr 2021 Overdose / Poisoning / Substance Abuse E - 15 01 Apr 2021 Sepsis / Septic Shock E - 16 01 Apr 2021 Seizures & Post-seizure Management E - 17 01 Apr 2021 Shock (non-Trauma) / Hypotension E - 18 01 Apr 2021 *Bites and Envenomation (see Adult) B - 19 01 Apr 2021 *Carbon Monoxide Poisoning / Smoke Inhalation / Cyanide G - 1c 01 Apr 2021 *Airborne Illness (COVID-19 / Influenza) (see Adult) B - 14 01 Apr 2021 *Hyperthermia / Heat Exposure (see Adult) B - 22 01 Apr 2021 *Hypothermia / Cold Exposure (see Adult) B - 23 01 Apr 2021 *Submersion Injuries / Drowning (see Adult) B - 26 01 Apr 2021

Pediatric Trauma Protocols Page Date Approved Trauma, General F - 1 01 Apr 2021 Burns F - 2 01 Apr 2021 Head / Facial Injuries F – 3 01 Apr 2021 *Epistaxis (see Adult) C - 4 01 Apr 2021 *Eye Injuries (see Adult) C - 5 01 Apr 2021 *Spinal Motion Restriction (see Adult) C - 7 01 Apr 2021

Specialty Protocols Page Date Approved

Operational Protocols

Altitude Illness (In-Flight, Mountaineering, High Altitude Ops) G - 1a 01 Apr 2021 Protocol Number Not Used G - 1b Carbon Monoxide Poisoning / Smoke Inhalation / Cyanide G - 1c 01 Apr 2021 Decompression Sickness (DCS) - Aviator’s Mask G - 1d 01 Apr 2021 SCUBA / Dive Injuries G - 1e 01 Apr 2021

Base Response / Range Support

Mass Casualty Incidents G - 2a 01 Apr 2021 Triage - SALT (Adults ONLY) G - 2b 01 Apr 2021 Triage - START / JumpSTART G - 2c 01 Apr 2021 Helicopter Landing Zone (HLZ) Operations G - 2d 01 Apr 2021 Firefighter / Scene Rehab G - 2e 01 Apr 2021 Decon - Hydrazine / POL Exposure & OC/OS Spray G - 2f 01 Apr 2021

Chemical, Biological, Radiation, Nuclear

(CBRNE)

Organophosphate Poisoning / Nerve Agent Exposure G - 3a 01 Apr 2021 Blood Agent TBD Blister Agents TBD Radiation Injury TBD Laser Injuries TBD i

Philosophy of Protocols

Prehospital medical protocols are established to ensure the safe, efficient, and effective provision of patient care. All United States Air Force (USAF) Emergency Medical Services (EMS) providers will utilize these protocols to guide their clinical decision making and delivery of prehospital care. Safety should be the final determinant for all decisions.

EMS providers will deliver care according to protocols ONLY if trained in the task.

The goals of EMS providers are to:

• Do no harm.

• Improve patient outcomes while alleviating pain and suffering.

• Provide quality pre-hospital care; the direct result of comprehensive education, thorough patient assessment, sound clinical judgment, and continuous quality improvement.

• Maintain clinical competency and meet care delivery standards; vital components in providing quality pre-hospital emergency medical care to the patients who rely on our services.

Air Force EMS embraces two fundamental concepts in establishing a standard of care:

1) The emergent patient benefits from immediate medical interventions, and timely definitive treatment.

2) Early and aggressive treatment modalities will be updated continually based upon published prehospital data (evidence-based medicine).

Our role as EMS professionals is to act as the eyes, ears, and hands of the physician. This task requires a commitment to continuous education and dedication to integration with the total prehospital/hospital care team.

Expectations of EMS Personnel

Ongoing review of protocols is mandatory as evaluations, treatments, and procedures will be updated as prehospital data allows. It is expected that all EMS providers maintain a functional knowledge of the contents contained herein.

Use of Protocols

• The Table of Contents will include the most recent date of protocol revision.

• Protocols utilize National Registry of Emergency Medical Technicians (NREMT) / Air Force (AF) State certification levels to identify appropriate treatments and procedures.

• All skill levels begin care at Skill Level 1 and progress to the current level of the EMS provider.

If ever in doubt, EMS providers should immediately contact On-Line Medical Direction (OLMD) to discuss patient care; this may be their Military Treatment Facility (MTF) EMS Medical Director or the attending physician at the receiving facility. If an EMS provider is unable to make contact with OLMD, the provider will continue contact efforts while providing care in accordance with (IAW) relevant protocols, within his/her scope of practice.

ii

S L

S L

S L

S L

● Skill Level 1 – Emergency Medical Responder (EMR) (All certifications start here)

● Skill Level 2 – Nationally Registered Emergency Medical Technician (NREMT)

● Skill Level 3 – 4N0 & Advanced Emergency Medical Technician (AEMT)

● Skill Level 4 – Nationally Registered Paramedic (NRP)

• Each protocol has specific “Patient History”, “Signs and Symptoms”, and a “Differential Diagnosis” to assist the EMS providers in the clinical decision making process.

- OPQRST (Onset, Provocation, Quality, Radiation, Severity, Time)

- SAMPLE (Signs/Symptoms, Allergies, Medications, Past Medical History, Last Oral Intake, Events Preceeding)

• Medications are bold and blue. Drip calculations are provided in relevant protocols.

• Procedures are bolded.

• Red, BOLDED text indicates important information (allergies, interactions, specific medication information, etc.)

• Items with a “*” should reference Additional Considerations.

• The Additional Considerations section provides pertinent content regarding the protocol.

Some protocols have reversible causes of cardiac arrest (H’s & T’s). Although traditionally used in advanced cardiac care, all skill levels have “H’s & T’s” that can be treated within their scope.

Adult and Pediatric Protocols: Pediatric protocols should be used until the patient is > 45kg or displaying signs of puberty; thereafter adult protocols should be used.

MTFs have transitioned from American Heart Association (AHA) to American Red Cross (ARC) life support courses. Current contracts require the continued instruction of AHA through 2023. In order to prevent confusion, the cardiac arrest algorithms detalied within are a hybrid of the organization-specific algorithms, the combination of which meets ARC and AHA intents. CPR compression rates, defibrillation (joules) and medication dosing standards are and IAW ARC and AHA guidelines. To ensure care standardization, members are required to utilize the cardiac algorithms contained herein.

Protocols are color-coded by group for ease of reference. General Patient Care is listed first, followed by cardiac-arrest, and other cardiac/respiratory protocols. Individual protocols follow and are in alphabetical order.

The bottom of each protocol details the approval date. Individual protocols may be updated as evidence-based data arises. The table of contents will reflect the publication date of the most recently approved version which will be utilized for the provision of prehospital care.

Infusion Pumps should be utilized for all vasopressor and/or anti-dysrhythmic infusions. In the absence of an infusion pump, micro-drip tubing will be utilized for adults; a 60gtt Buretrol must be used for pediatric patients.

iii

General Protocols – A Series Adult Medical Protocols – B Series Adult Trauma Protocols – C Series Obstetrics / Gynecology & Neonatal Protocols – D Series Pediatric Medical Protocols – E Series Pediatric Trauma Protocols – F Series Specialty Protocols – G Series

Protocols may address the use of equipment not currently possessed by an EMS agency. All ambulance transport agencies operating under an AF Medical Director must possess the mandatory equipment and supplies outlined in the Minimum Ambulance Stock List located on the EMS Kx page. Equipment and supplies on Fire & Emergency Services (FES) response vehicles are limited to those detailed on the O&M funded stock list in AFMAN 41-209. Items not included on the O&M funded stock list may be purchased by F&ES units at their discretion, but they are not required, even if the protocol references the procedure (i.e. cardiac monitors).

If units possess the capability to transmit 12-Lead EKGs, they should be sent to the receiving facility (if equipped to receive them). If not, they should be printed and delivered to receiving facility staff. MTFs should coordinate with their local information technology department for mobile Wi-Fi capabilities.

Medication Administration in the Prehospital Environment

Following completion of the USAF Medication Administration Course and 7-Level “Intravenous Medication” task detailed in the Career Field Education and Training Plan (CFETP), 5-level 4N0X1 Emergency Medical Technicians (EMTs) / NRPs assigned to or participating in prehospital response are authorized to administer intravenous medications according to protocol.

FES EMTs and AEMTs will be trained/validated by their MTF EMS Medical Director regarding the utilization of medications in the AF EMS Protocols.

Procedures in the Prehospital Environment

EMS personnel must be credentialed by the local Medical Director. Credentialing: Local Medical Directors ensure that assigned EMS personnel possess the cognitive, affective, and psychomotor skills to deliver prehospital care IAW USAF EMS Protocols. The credentialing process should include: initial training, performance of supervisory ride-alongs, the development of continuing education and simulation curriculums, and documentation of training and credentialing in electronic training records.

A list of medications that are required to be carried based on skill level is located on the Kx at https://kx.health.mil/kj/kx9/usafems/Pages/home.aspx . Optional medications may be carried with local EMS Medical Director approval. MTFs should create a local authorized drug list (ADL) that includes the mandatory medications as well as any optional medications approved for use by the local EMS Medical Director.

https://kx.health.mil/kj/kx9/usafems/Pages/home.aspx iv

Communication

When communicating with OLMD or a receiving facility, the following format should be utilized for:

Critical Patients

• Unit Call Sign (and estimated time-of-arrival if receiving facility)

• Patient's age, sex and mental status

• Mechanism of Injury/Illness

• Injuries/Illness

• Signs and Symptoms

• Treatment

• Most recent vital signs Follow local/state receiving facilities’ protocols for trauma, sepsis, STEMI (heart alert), and stroke notifications.

Non-Critical Patients

• Unit Call Sign (and estimated time-of-arrival if receiving facility)

• Patient's age, sex, and mental status

• Chief complaint

• Pertinent previous medical history

• Vital signs

• Pertinent physical assessment findings

• Treatments administered and patient's response Follow local/state receiving facilities protocols for trauma, sepsis, STEMI (heart alert), and stroke notifications.

On-Scene Personnel

EMS personnel will not accept orders from an on-scene physician without the approval of OLMD.

If a controversy arises with an on-scene physician, contact OLMD for a direct discussion with the on-scene provider.

USAF EMS Protocol Scope of Practice Additions

The following scope of practice additions are not required to be implemented, but are highly recommended and authorized for use following skills verification by the local Medical Director. Approval for the performance of each skill must be documented in the member’s training record.

Skill Level 1 – EMR and above Nasopharyngeal Airway (NPA) Insertion High-Flow Nasal Cannula Blood Glucose Testing Oral Glucose Administration Temperature Measurement (oral and tympanic) Co Oximetry (SpCO) Monitoring HEPA Filter for Bag-Valve Mask (BVM)

Skill Level 2 – NREMT and above Supraglottic Airway Insertion (SGA) Capnometry Continuous Positive Airway Pressure (CPAP) Positive End Expiratory Pressure (PEEP) Valves w/BVMs Medication Administration: Albuterol, Ipratropium Bromide, CBRN related medications, Oxymetazoline 12-Lead Acquisition / Cardiac Monitoring Junctional Tourniquets

Skill Level 3 – 4N0X1 & AEMT Medical and above

In-Line Suction (SGA tube) Blood/Fluid Warmer Medication Administration: Pain Management Meds, v

Epinephrine 1:10,000, Dexamethasone, Ertapenem, Hypertonic Saline, Nifedipine, Oxytocin, Tetracaine Infusion Pump

Skill Level 3 – F&ES AEMT specific requirements

New addition to AF EMS Protocols. FES units desiring their personnel to perform care at this level must have approval of the FES EMS Program Manager. Additionally, the AEMT scope must the outlined in an installation memorandum of understanding between the EMS Medical Director, MTF Commander, and FES Fire Chief. Personnel must be NREMT-AEMT certified and credentialed by the EMS Medical Director on the use of Skill Level 3 protocols.

Addition of Tactical Combat Casualty Care (TCCC) Concepts to USAF EMS Protocols

TCCC is not only utilized in a “Tactical Combat” environment. TCCC is evidence-based, directed trauma care which reduces patient mortality. Select TCCC skills/concepts have been added to trauma protocols.

Universal Precautions

Medical history and examination cannot reliably identify patients with communicable diseases. Blood and bodily-fluid precautions will be used for all patients. EMS personnel will routinely utilize barrier precautions to prevent skin and mucous-membrane exposure. Gloves will be worn when the possibility of contacting blood /bodily fluids, mucous membranes, and open wounds exists. Gloves will be worn when handling materials soiled with blood and/or bodily fluids and for performing procedures with needles (to include Epi-Pen administration). Gloves will be changed after each patient contact.

Masks and protective eyewear (or face shields) will be worn during all procedures which expose EMS personnel to blood/bodily fluids. N95 masks will be worn for all patients with known or suspected airborne illnesses (i.e. meningitis, influenza, SARS, COVID-19, TB).

Although communicable diseases are very rarely transmitted through saliva, mouthpieces and ventilation devices should be available for use in areas in which the need for resuscitation may arise.

Wash hands/skin surfaces immediately and thoroughly if contaminated with blood/bodily fluids. To prevent needle stick injuries, do not recap, bend or break needles. Dispose of sharps in puncture-resistant containers. In the case of a needle-stick injury, EMS personnel will immediately follow local policies for exposure to blood/bodily fluid.

The EMS professional who has exudative lesions or weeping dermatitis should seek evaluation by his/her primary care physician and refrain from all direct patient care and from handling patient-care equipment until the condition is evaluated IAW Occupational Safety and Health Administration guidelines.

Exposure to Blood/Body Fluids or Needle Sticks

Immediately report the event to the receiving facility on arrival. Additionally, the member should follow local guidance and procedures as implemented by the MTF and Public Health.

Created by SMSgt Valerie Lee

ABBREVIATIONS AND ACRONYMS

AAA – Abdominal Aortic Aneurysm AC – Antecubital AChEI – Acetylcholinesterase Inhibitor ACLS – Advanced Cardiac Life Support ACS – Acute Coronary Syndrome AED – Automated External Defibrillator AEIOU-TIPS – Acidosis/Alkalosis/Alcohol, Epilepsy/Endocrine/Electrolytes, Infection, Overdose/Organophosphates, Uremia, Trauma/Tremor, Insulin/Intracranial Pressure, Psychosis/Poisoning, Stroke/Shock/Seizure AD – Advanced Directive ADL – Authorized Drug List AF – Air Force AFI – Air Force Instruction AFCEC – Air Force Civil Engineer Center AFMRA – Air Force Medical Readiness Agency AFMS – Air Force Medical Services AGE – Arterial Gas Embolism AHA – American Heart Association AKA – Above the Knee Amputation ALS – Advanced Life Support AMA – Against Medical Advice AMS – Acute Mountain Sickness AMS – Altered Mental Status APGAR – Appearance, Pulse, Grimace, Activity, Respiration ARC – American Red Cross ARDS – Acute Respiratory Distress Syndrome ASAP – As Soon As Possible ATNAA – Antidote Treatment Nerve Agent Antidote AV – Atrioventricular AVPU – Alert, Responsive to Verbal Stimuli, Responsive to Painful Stimuli, Unresponsive BEE- Bioenvironmental Engineering BG – Blood Glucose BGL – Blood Glucose Level BLS – Basic Life Support BP – Blood Pressure BRUE – Brief Resolved Unexplained Event BSI – Body Substance Isolation BURP – Backwards, Upwards, Rightward Pressure (change in condition, decreased SpO2/vent alarms) BVM – Bag Valve Mask CANA – Convulsant Antidote for Nerve Agent CBRN(E) – Chemical, Biological, Radiological, Nuclear (High Yield Explosive) CCP – Casualty Collection Point CDC – Center for Disease Control CEW – Conductive Electrical Weapon CFETP – Career Field Education and Training Plan CHAPS – Chest Pain, Altered Mental Status, Signs/Symptoms of Shock, Hypotension, Pulmonary Edema CHF – Congestive Heart Failure cmH2O – centimeters of water

CNS – Central Nervous System CO – Carbon Monoxide COPD – Chronic Obstructive Pulmonary Disease CoTCCC – Committee on Tactical Causality Combat Care COVID-19 – Coronavirus Disease 2019 CP – Chest Pain CPAP – Continuous Positive Airway Pressure CPR – Cardiopulmonary Resuscitation CPSS – Cincinnati Pre-Hospital Stroke Scale CSF – Cerebral Spinal Fluid CSM – Circulation, Sensory, Motor CS Spray – 2-chlorobenzalmalononitrile (tear gas) CVA – Cerebrovascular Accident DBP – Diastolic Blood Pressure DCS – Decompression Sickness DHP – Defense Health Program DKA – Diabetic Ketoacidosis dL – deciliter DM – Diabetes Mellitus DNI – Do Not Intubate DNR – Do Not Resuscitate DO – Doctor of Osteopathic Medicine DOPE – Dislodgement, Obstruction, Pneumothorax, Equipment (vocal cord view) DUMBBELS – Diarrhea, Urination, Myosis, Bradycardia, Bronchorrhea, Emesis, Lacrimation, Salivation DVPRS – Defense and Veterans Pain Rating Scale ECP – Entry Control Point EKG – Electrocardiogram EMR – Emergency Medical Responder EMS – Emergency Medical Services EOD – Explosive Ordnance Disposal EPU – Emergency Power Unit EtCO2 – End Tidal CO2 ETI – Endotracheal Intubation ETT – Endotracheal Tube F&ES also known as FES – Fire and Emergency Services FLACC – Face, Legs, Activity, Cry, Consolability FTCA – Federal Tort Claims Act GCS – Glasgow Coma Scale GEMS – Ground Emergency Medical Service GI – Gastrointestinal GPS – Global Positioning System GS – General Schedule (predominant pay scale for federal employees) gtt – guttae (Latin for “drop”) HACE – High Altitude Cerebral Edema HAPE – High Altitude Pulmonary Edema HAZMAT – Hazardous Material HDL – Hyperlipidemia HEPA – High Efficiency Particulate Air HEMS – Helicopter Emergency Medical Service HFNC – High Flow Nasal Cannula HLZ – Helicopter Landing Zone

HPMK – Hypothermia Prevention and Management Kit HR – Heart Rate hr - hour H’s & T’s – Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia, Tension Pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary), Thrombosis (coronary) HTN - Hypertension IAW – In Accordance With IC – Incident Commander ICH – Intracerebral Brain Hemorrhage ICP – Intracranial Pressure ICS – Intercostal Space IDMT – Independent Duty Medical Technician IED – Improvised Explosive Device ILCOR – International Liaison Committee on Resuscitation IM – Intramuscular IN – Intranasal IO – Intraosseous ISR – Institute for Surgical Research IU – International Unit IV – Intravenous JVD – Jugular Vein Distention Kg – Kilogram Kx – Knowledge Exchange LBBB – Left Bundle Branch Block L - Litter LE – Law Enforcement LEMON – Look, Evaluate (3-3-2), Mallampati, Obstruction/Obesity, Neck Rigidity (Difficult Laryngoscopy) LLL – Left Lower Lobe LMA – Laryngeal Mask Airway LMP – Last Menstrual Period LOC – Level of Consciousness LPM – Liters Per Minute LR – Lactated Ringers LBS – Long Spine Board LSI – Life Saving Intervention LUQ- Left Upper Quadrant LVH – Left Ventricular Hypertrophy LVO – Large Vessel Occlusion LZ – Landing Zone MACE – Military Acute Concussion Evaluation MAP – Mean Arterial Pressure MARCH - PAWS – Massive Hemorrhage, Airway/AVPU, Respiration, Circulation, Hypothermia/Head – Pain, Antibiotics, Wounds, Splints MC – Medical Corps mcg – microgram MCI – Mass Casualty Incident MD – Doctor of Medicine MDI – Metered-dose Inhaler MEB – Medical Evaluation Board MERS – Middle East Respiratory Syndrome mg – milligram MI – Myocardial Infarction MIST – Mechanism of Injury/Illness, Injuries/Illness, Signs & Symptoms, Treatment mL – milliliter mmHG – Millimeters of Mercury MOANS – Mask Seal, Obesity/Obstruction, Age > 55, No Teeth, Sleep Apnea/Stiff Lungs (difficult BVM seal) MODS- Multi-organ Dysfunction Syndrome MOI – Mechanism Of Injury mph – miles per hour MTF – Military Treatment Facility MVC – Motor Vehicle Collision NC – Nasal Cannula NDC – Needle Decompression NHTSA – National Highway Traffic Safety Administration NIBP – Non-Invasive Blood Pressure NICU – Neonatal Intensive Care Unit NPA – Nasopharyngeal Airway NRAEMT – Nationally Registered Advanced Emergency Medical Technician NRB – Non-rebreather Mask NREMT – Nationally Registered Emergency Medical Technician NRP – Nationally Registered Paramedic NRS _ Numeric Rating Scale NS – Normal Saline NTG – Nitroglycerine N/V – Nausea/Vomiting OB/Gyn – Obstetrics and Gynecology OC Spray – Oleoresin Capsicum (Pepper Spray) OD – Overdose ODT – Oral Disintegrating Tablet OG – Orogastric OLMD – On-Line Medical Direction OPA – Oral Pharyngeal Airway OPQRST – Onset, Provocation, Quality, Radiation, Severity, Time OSHA – Occupational Safety and Health Administration OSI – Office of Special Investigations OTFC – Oral Transmucosal Fentanyl Citrate PACE Plan – Primary, Alternate, Contingency, Emergency (for HLZ operations) PALS – Pediatric Advanced Life Support PCI – Percutaneous Coronary Intervention PCR – Patient Care Report PE – Pulmonary Embolism PEA – Pulseless Electrical Activity PEEP – Positive End-Expiratory Pressure PMHx – Past Medical History PO – per os (Latin for “by mouth”) (oral administration) POL – Petroleum, Oil and Lubricants PPE – Personal Protective Equipment PPM CO – Parts per Million Carbon Monoxide measurement PRN – Pro re nata (Latin for “when necessary”) and/or As needed RLL – Right Lower Lobe

RLQ – Right Lower Quadrant RODS – Restricted Mouth Opening, Obstruction, Disrupted/Distorted Airway, Still Lung/Cervical Spine (difficult extraglottic device) ROSC – Return of Spontaneous Circulation RR – Respiratory Rate RUQ – Right Upper Quadrant SAMPLE – Symptoms, Allergies, Medications, Previous medical history, Last meal, Events preceding SARS – Severe Acute Respiratory Syndrome SBP – Systolic Blood Pressure SCBA/SAR – Self-contained Breathing Apparatus/Supplied Air Respirator SCUBA – Self-Contained Underwater Breathing Apparatus SDS – Safety Data Sheet SFS – Security Forces Squadron SG – Surgeon General SGA – Supraglottic Airway SHORT – Surgery/scars (other obstruction), Hematoma (infection/abscess/mass), Obesity, Radiation distortion (deformity), Tumor (difficult crichothyroidotomy) SI/HI – Suicidal Ideations/Homicidal Ideations SIRS – Systemic Inflammatory Response Syndrome SJA – Staff Judge Advocate SL – Skill Level SLUDGE – Salivation, Lacrimation, Urination Defecation, GI Upset, Emesis SMR – Spinal Motion Restriction SOB – Shortness of Breath SpCO – Carbon Monoxide measurement SpHb – Hemoglobin Measurement SpO2 – Pulse Oximetry (Oxygen) S&S (S/Sx) – Signs and symptoms STEMI – ST-Elevation Myocardial Infarction SVT – Supraventricular Tachycardia Sx – Symptoms TB – Tuberculosis TBI – Traumatic Brain Injury TBSA – Total Body Surface Area TCA – Tricyclic Antidepressant TCCC – Tactical Casualty Combat Care TCCC-AC – Tactical Casualty Combat Care – All Combatants TCCC-MP – Tactical Casualty Combat Care – Medical Provider TIA – Transient Ischemic Attack TKO – To Keep Open (Keep Vein Open) TQ – Tourniquet Triage - Salt – Sort, Assess, Life-saving Interventions, Treatment/Transport Triage - START – Simple Triage and Rapid Transport Triage – JumpSTART – Simple Triage and Rapid Transport (used for pediatric mass casualty incident) TXA – Tranexamic Acid USAF – United States Air Force VAN Stroke Exam – Vision, Aphasia, Neglect VBIED – Vehicle Borne Improvised Explosive Device VS – Vital Signs WPW – Wolff-Parkinson-White q – quaque (Latin for “every”)

Trauma Center / Air Ambulance Criteria

V1 For use AFTER 31 March 2021

General Protocols A - 1

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*Both CDC Trauma Center Criteria and HEMS guidance is subject to change

Use the below algorithm to determine Trauma Center Criteria* https://www.cdc.gov/mmwr/pdf/rr/rr6101.pdf https://www.cdc.gov/mmwr/pdf/rr/rr6101.pdf

General Protocols A - 1

Use the below algorithm to determine Ground EMS (GEMS) vs Helicopter EMS (HEMS) https://www.ems.gov/ficems/june2012/Draft%20Manuscript%20for%20HEMS%20Evidence-based%20Guideline.pdf

Prehospital providers must utilize clinical judgement, anticipated transport length, incorporate logistical considerations to determine whether primary air transport is appropriate.

Installations should develop local guidance for “Early Launch” and “Auto-Launch” criteria if the flight distance is greater than 10 minutes and/or 29 miles or if a critical patient is greater than 20 miles from a specialty hospital http://aams.org/wp-content/uploads/2014/01/EarlyActivationFINAL.pdf.pdf

● Helicopter Landing Zones (HLZ), see G - 2d, Helicopter Landing Zone (HLZ) Operations:

- Installations should have Primary, Alternate, Contingency and Emergency HLZs established and/or pre-determined helicopter landing zones (HLZ) for rotary aircraft, especially if unable to make contact with the aircraft. Communication should be relayed through dispatch or a cell phone patch.

- Ambulances or fire apparatus should be equipped with GPS to provide alternate HLZ coordinates if needed.

● Literature support for primary air transport of non-trauma patients from the scene is limited. Contact OLMD to determine whether primary air transport is appropriate in this patient population:

Patient Diagnoses for Medical Launch Consideration:

● Acute coronary syndrome with the need for interventional therapy (e.g. cardiac catheterization, intra-aortic balloon pump)

● Cardiogenic shock (especially in the presence of a ventricular assist device or an intra-aortic balloon pump) http://aams.org/wp-content/uploads/2014/01/EarlyActivationFINAL.pdf.pdf

● Cardiac tamponade with impending hemodynamic compromise

● Mechanical cardiac disease (e.g. valve failure, ventricular wall rupture)

Critically Ill Medical/Surgical Patients:

● Post cardiac/respiratory arrest

● Requirement for IV vasoactive medications or mechanical ventilation

● Risk for airway deterioration (e.g. angioedema, epiglottitis)

● Severe poisoning/overdose requiring specialized toxicology services

● Urgent need for hyperbaric oxygen therapy (e.g. vascular gas embolism, carbon monoxide toxicity)

● Requirement for emergent dialysis

● Gastrointestinal hemorrhage with hemodynamic instability

● Surgical emergencies: aortic dissection or aneurysm, extremity ischemia, etc.

Special Populations:

Neonatal, pediatric, obstetric, and neurologic patients should be transported to receiving facilities capable of providing appropriate evaluation and treatment (e.g. transport of neurologic patients to stroke centers, etc.).

Systems Considerations:

● In regions in which air ambulance crews represent the only asset capable of treating/transporting critically ill/injured patients, Installation leadership should partner with the local Medical Director and the air transportation asset to determine local policies for air ambulance dispatch and transport.

● Air medical dispatch may be appropriate in miscellaneous settings including: transplant (e.g. organ salvage or organ recipient requires air transport to the transplant center to maintain viability of time-critical transplant), Search and Rescue operations, and field training exercises.

Reference the National Association of EMS Physicians Guidelines for Air Medical Dispatch Position Paper:

https://aams.org/wp-content/uploads/2014/01/GuidelinesAirMedDispatch.pdf.pdf

Trauma Center Criteria Sasser SM, Hunt RC, Faul M, Sugerman D, Pearson WS, Dulski T, Wald MM, Jurkovich GJ, Newgard CD, Lerner EB, Cooper A. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011. Morbidity and Mortality Weekly Report: Recommendations and Reports. 2012 Jan 13;61(1):1-20.

https://aams.org/wp-content/uploads/2014/01/GuidelinesAirMedDispatch.pdf.pdf

This Page Not Used

Care of Minors Consent & Implied Consent / Abuse & Neglect / Sexual Assault

V1 For use AFTER

31 March 2021

General Protocols A - 2

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Clinical Practice Guidelines S L

S L

S L

S L

● E - 1, General Patient Care / Consult OLMD as needed

● Provide life-saving interventions for all patients IAW certification level and applicable protocol

● Contact Security Forces (SFS) as needed

● If suspected abuse (or known assault), ensure SFS is on-scene prior to arrival of EMS / F&ES personnel Note: A legal guardian is defined by installation, county, state, or federal law; agencies must be familiar with local guidance

Additional Considerations

Consent & Implied Consent

● Care of Minors: Generally, a minor is any patient under the age of 18; individual states dictate legal age

● Parent/Guardian Consent (in person or over the phone): Consent must be given by a legal guardian for the evaluation, treatment, and transport of a non-emancipated minor who requires care for a non-life-threatening condition. If unable to reach Parent(s)/Guardian(s) or Parent(s)/Guardian(s) refuse evaluation/transport: Contact OLMD for further guidance and intervention.

● Parent/Guardian Consent may not be required for minors who present with complaints related to pregnancy, sexually transmitted infections, mental health, and/or substance abuse; MTFs should develop local guidance IAW state requirements with the advice of the installation SJA.

● Parent/Guardian Consent is not required for emancipated minors. The definition of an emancipated minor varies by state. EMS/F&ES personnel should be aware of geographic state law. Emancipated minors commonly include:

● Individuals < 18 years of age serving in the military.

● Persons who are financially self-supporting and living independently of guardians.

● Persons who have been declared emancipated by a court of law.

● Emancipated minors: Patient MUST be able to show proof of legal emancipation. If a patient poses a risk to self or others (self-harm, suicide attempt, etc.), contact OLMD to discuss SFS involvement and transport. If the patient appears to be under the influence of a known/unknown substance, but is able to demonstrate capacity, every effort should be made to provide care. If the patient refuses, contact OLMD; see A - 4, Patient Refusal.

● Implied Consent: Applies to scenarios in which consent is not expressly given by a legal guardian, but in which a reasonable person would expect it to be given. If a patient is suffering from a life-threatening condition and does not possess the capacity to provide consent, consent is implied.

A - 2

Abuse & Neglect (MANDATORY REPORTING to Child Protective Services)

● Child Abuse and/or Neglect is the physical or mental injury, sexual abuse, negligent treatment, and/or maltreatment of a child under the age 18 by a person who is responsible for the child’s welfare. The recognition and reporting of abuse/neglect is critical to ensuring child safety and reducing the risk for future abuse.

● Suspected Abuse and/or Neglect: Suspect that the patient may be a victim of abuse if the injury or illness is not consistent with the reported history or physical exam:

- Assess for/document psychological characteristics of abuse (excessive passivity, complaint/fearful behavior, excessive aggression, violent tendencies, excessive crying, etc.).

- Assess for/document physical signs of abuse (unexplained bruises, abrasions, bite marks, cigarette burns, etc.)

- Assess for/document signs of neglect (inappropriate levels of clothing, inadequate hygiene, absence of an attentive caregiver, or malnutrition).

● Contact OLMD for immediate reporting of suspected abuse and/or neglect IAW installation policy.. This is a legal requirement. In discussion with OLMD, contact installation SFS to obtain protective custody, provide care IAW specific protocol and certification level, and transport the patient.

Sexual Assault (MANDATORY REPORTING to Child Protective Services)

● Assess for/document signs of sexual abuse (pain, itching, bleeding, bruising in the genital area; inappropriate dress, multiple layers in a hot environment; reports of recurrent urinary tract infections).

● If sexual assault is suspected, contact OLMD for immediate reporting (to Family Advocacy, Child Protective Services, and SFS). This is a legal requirement for all first responders. In discussion with OLMD, contact installation SFS to obtain protective custody, provide care IAW specific protocol and certification level.

● When providing care: address only life threats to avoid destruction of evidence. If applicable: clothing should be placed in paper bags. If the patient is unable to wait until arrival at the hospital to utilize the restroom, or they vomit enroute, attempt to collect all bodily fluids for evidence processing.

● SFS or OSI (or other LE) should secure the scene and evidence IAW their local policies.

● Transport the patient to a facility capable of performing pediatric sexual assault examinations.

Care of Adults Consent & Implied Consent / Abuse & Neglect / Sexual Assault

V1 For use AFTER 31 March 2021

General Protocols A - 3

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Clinical Practice Guidelines S L

S L

S L

S L

● B - 1, General Patient Care / Consult OLMD as needed

● Provide life-saving interventions for all patients IAW certification level and applicable protocol

● Contact Security Forces (SFS) as needed

● If suspected abuse (or known assault), ensure SFS is on-scene prior to arrival of EMS / F&ES personnel Note: A legal guardian is defined by installation, county, state, or federal law; agencies must be familiar with local guidance

Additional Considerations

Consent & Implied Consent

● Consent: Consent must be given for evaluation, treatment, and transport of a patient with a non-life-threatening condition.

● Patients must demonstrate capacity in order to provide consent: Alert and oriented, GCS 15, possesses the ability to understand his/her condition and associated outcomes, and is able to verbalize an understanding of the risk(s)/benefit(s) of evaluation and treatment. If a patient poses a risk to self or others (self-harm, suicide attempt, etc.), contact OLMD to discuss SFS involvement and transport. If the patient appears to be under the influence of a known/unknown substance, but is able to demonstrate capacity, every effort should be made to provide care. If the patient refuses, contact OLMD; see A - 4, Patient Refusal.

● Implied Consent: Applies to scenarios in which consent is not expressly given, but in which a reasonable person would expect it to be given. If a patient is suffering from a life-threatening condition and does not possess the capacity to provide consent, consent is implied.

● Legal Incompetence: A court of law may identify an individual as “Legally Incompetent,” or lacking capacity. In this scenario, the court will have appointed a legal guardian or power of attorney for medical decision-making.

This appointed individual must consent to patient evaluation and treatment, unless the patient presents with a life-threatening condition as above (Implied Consent).

Elder/Incompetent Patient Abuse & Neglect

● Abuse and/or Neglect: EMS/F&ES personnel should be aware of geographic state law. Abuse may be physical, emotional, sexual, or financial.

● Suspected Abuse and/or Neglect: Suspect that the patient may be a victim of abuse if the injury or illness is not consistent with the reported history or physical exam:

- Assess for/document psychological characteristics of abuse (excessive passivity, complaint/fearful behavior, excessive aggression, violent tendencies, excessive crying, etc.).

- Assess for/document physical signs of abuse (unexplained bruises, abrasions, bite marks, cigarette burns, etc.)

- Assess for/document signs of neglect (inappropriate levels of clothing, inadequate hygiene, absence of an attentive caregiver, or malnutrition).

● Contact OLMD for immediate reporting of suspected abuse and/or neglect (to Family Advocacy, Adult

Protective Services, and SFS). This is a legal requirement. In discussion with OLMD, contact installation SFS to obtain protective custody, provide care IAW specific protocol and certification level, and transport the patient.

A - 3

Domestic Violence

● Known or Suspected Domestic Violence: EMS/F&ES personnel should be aware of geographic state law as reporting requirements vary. The vast majority of states require reporting for firearm injuries, rape, torture, and stabbings.

● Always ensure scene safety. Contact SFS as needed.

Sexual Assault

● Assess for/document signs of sexual abuse (pain, itching, bleeding, bruising in the genital area; reports of recurrent urinary tract infections).

● If sexual assault is reported, when providing care: address only life threats to avoid destruction of evidence. If applicable: clothing should be placed in paper bags. If the patient is unable to wait until arrival at the hospital to utilize the restroom, or they vomit enroute, attempt to collect all bodily fluids for evidence processing.

● SFS or OSI (or other LE) should secure the scene and evidence IAW their local policies.

● Transport the patient to a facility capable of performing a sexual assault examination.

● Contact of law enforcement is at the discretion of the patient. The Patient Advocate who has been assigned by the Sexual Assault Response Coordinator will counsel the patient regarding reporting options.

Patient Refusal / AMA & Active Duty Considerations

V1 For use AFTER 31 March 2021

General Protocols A - 4

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Clinical Practice Guidelines S L

S L

S L

S L

● B - 1, General Patient Care / Consult OLMD as needed

● Provide life-saving interventions for all patients IAW certification level and applicable protocol

● See A - 2, Care of Minors or A - 3, Care of Adults to determine if refusal is appropriate

Additional Considerations

● Adults & Emancipated Minors - If patients are alert and oriented with a GCS of 15 and able to demonstrate capacity a refusal may be accomplished.

- Capacity: The ability to understand the benefits and risks of obtaining treatment for a particular condition.