*

Largest US Bioterror Attack

Rajneeshee1984 - The DallesContaminated salad bars Salmonella enterica Typhimurium751 affected/45 hospitalized

Török, JAMA 1997;278(5)

Health ofEMS Protocols

Oregon EMS EMS medical directionSystems of careAdequacy of EMS protocolsNext steps

Paul S. Rostykus, MD, MPH• Family Medicine - 4 years

OR, AK, AZ, WV, Nepal, CO

• Emergency Medicine – 25 yearsSouthern Oregon

• EMS medical director – 25 years

• State EMS Committee

• NAEMSPRural Committee chairProgram Committee chair

Medical Marijuana

Oregon Health Authority- Public Health - Oct 1, 2013Oregon Health Authority- Public Health - Oct 1, 2013thority- Public He - Oct 1, 20egon Health A

0.0

2.0

4.0

6.0

8.0

Multnomah (Portland)

Lane (Eugene) Jackson

(Medford) Josephine (Grants Pass)

Oregon Medical Marijuana Cards# cards per capita (%) Population (100,000)

Medical Marijuana& Oregon EMS

Oregon Medical Marijuana Program (OMMP)

OMMP 56% of EMS & Trauma $ $1,025,000/year

Oregon Health Authority- Public Health - Oct 1, 2013

EMS & Medical Marijuana

EMS(Emergency Medical Services)

• 911 dispatched – 24/7/365First responding – usually fire departmentTransporting - ambulance

• Aeromedical transport• Inter-facility transport• Event EMS, S&R, Industrial EMS• Mobile Integrated Health (MIH)

If you’ve seen one EMS system…..….then you’ve seen one EMS system.

EMS in Oregon

OHA - EMS & Trauma – January 30, 2015OHA - EMS & Trauma – April11, 2017*

36# Counties# EMS Providers# Non-transporting Agencies# Ambulance Agencies# EMS Medical Directors

EMS in Oregon

OHA - EMS & Trauma – January 30, 2015OHA - EMS & Trauma – June 2017*

3612,779*

# Counties# EMS Providers# Non-transporting Agencies# Ambulance Agencies# EMS Medical Directors

EMS in Oregon

OHA - EMS & Trauma – January 30, 2015OHA - EMS & Trauma – June 2017*

3612,779*

380*

# Counties# EMS Providers# Non-transporting Agencies# Ambulance Agencies# EMS Medical Directors

EMS in Oregon

OHA - EMS & Trauma – January 30, 2015OHA - EMS & Trauma – June 2017*

3612,779*

380*137*141

# Counties# EMS Providers# Non-transporting Agencies# Ambulance Agencies# EMS Medical Directors

EMS Provider Levels

Fire Department Calls

Fire20%

EMS

ASA map

EMS Medical Directors

Oregon EMS Rules• Oregon Medical Board (OMB) – OAR 847

EMS provider Supervising PhysicianEMS Scope of Practice – maximum = ceilingEMS Advisory Committee – recommends changes

• EMS & Trauma Office – OAR 333Public Health h h –– Oregon Health Authorityg

EMS Provider licensure & y

relicensureEducation standardsEMS Provider disciplineAmbulance licensure Medical DirectorTrauma care

Supervising Physician

OAR 847 (OMB)

EMS Provider

Medical DirectorOAR 333(OHA)

Ambulance Service

Oregon Military

Department,Office of

Emergency Management

911PSAP

Medical DirectorOAR 333(OHA)

EMS Education

Non-transporting

EMS Agency

Supervising Physician QualificationsOAR 847-035-0020

Oregon licensed MD or DO in current practiceResident of or actively working in EMS areaKnowledgeable of EMS skills, ORS & OAR< 1 year, complete one of:

3 years as EMS medical directoryNAEMSP medical director course (1 or 3 day)EMS fellowshippEMS subspecialt

pltalty y y certificationp yy

Ongoing education every 2 yearsAttend 1 Oregon EMS Forumgg8 hours EMS CMEEMS S S subspecialty y y maintenance of certification (MOC)

Supervising Physician DutiesOAR 847-035-0025

Written standing orders (protocols)EMS currently licensed and in good standingRegular review of practice

Direct observation – “ride alongs”Indirect observation

Prehospital emergency care report review;pp g y pPrehospital communications tapes review;ppDemonstration of technical skills;

Case reviews & Continuing education2 hours contact with EMS providers/year

EMS Scope of PracticeOAR 847

✓EMS Provider must have:Supervising PhysicianWritten standing orders

✓Not exceed Scope of Practice✓Provide Pre-hospital Care✓Honor POLST

Oregon Medical Board EMS Scope of Practice - OAR 847

Supervising PhysicianWritten Standing Orders (Protocols)

EMS Provider Practice

EMS protocols vary• Pediatric seizure treatment

• Pelvic fracture binding

• Naloxone administration for opioid OD

• Statewide protocols

• CBG in seizure patients

• Hypoglycemia treatment

• Time-dependent emergencies?

Systems of CareTime-dependent emergencies

Trauma – Oregon law & ruleTrauma center & surgeon

STEMI (ST elevation Myocardial Infarction)Cath lab for stent

StrokeCT, TPA or catheter procedure

OHCA (Out of Hospital Cardiac Arrest)ROSC Cooling & more

Sepsis?

Trauma Areas& Hospitals

Josephine County 1,640 sq milesJackson County 2,802 sq milesSiskiyou County 6,347 sq miles

Acute STEMI PCI Coverage Approximately= 5,000 sq miles

30 STEMI ProgramsEach covering 5-25 sq. mi.

DisclosureThis project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H54RH00049, Rural Hospital Flexibility Program.This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

*

Rural vs Non-rural Counties

No protocols received 1 EMS agency 2-5 EMS agencies 6-10 EMS agencies

OHCA

Stroke

STEMI

Volume 132, Number 18, Suppl 2, November 3, 2015ISSN 0009-7322http://circ.ahajournals.org

2015 AMERICAN HEART ASSOCIATION GUIDELINES UPDATE FOR CARDIOPULMONARY RESUSCITATION AND EMERGENCY CARDIOVASCULAR CARE

Part 1: Executive Summary

Part 2: Evidence Evaluation and Management of Conflicts of Interest

Part 3: Ethical Issues

Part 4: Systems of Care and Continuous Quality Improvement

Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality

Part 6: Alternative Techniques and Ancillary Devices for Cardiopulmonary Resuscitation

Part 7: Adult Advanced Cardiovascular Life Support

Part 8: Post–Cardiac Arrest Care

Part 9: Acute Coronary Syndromes

Part 10: Special Circumstances of Resuscitation

Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality

Part 12: Pediatric Advanced Life Support

Part 13: Neonatal Resuscitation

Part 14: Education

2015 AMERICAN HEART ASSOCIATION AND AMERICAN RED CROSS GUIDELINES UPDATE FOR FIRST AID

Part 15: First Aid

SUPPLEMENT TO

by guest on March 29, 2017

http://circ.ahajournals.org/D

ownloaded from

Next steps?

EMS medical director supportEMS medical director course

Twice yearly EMS ForumStatewide protocols?

294 PREHOSPITAL EMERGENCY CARE APRIL/JUNE 2015 VOLUME 19 / NUMBER 2

FIGURE 1. States with mandatory or model statewide ALS protocols as of October 1, 2013. Types of protocols used by each state are indicatedby colors (see key). For states that are white on the map, no statewide protocols or model guidelines exist.

with mandatory C). Seventeen states had model proto-cols at the BLS or ALS levels (Figures 1 and 2).

Al t h lf f t t (24/50) t d h i l l

tion protocols for patients with STEMI, stroke, cardiacarrest, or burns (Table 3).cols at the BLS or ALS levels (Figures 1 and 2). arrest, or burns (Table 3).

Kupas DF, Schenk E, Sholl JM, Kamin R. Characteristics of statewide protocols for emergency medical services in the United States. Prehosp Emerg Care. 2015;19(2):292-301

ALS protocolsMandatory A – required useMandatory B – required use, may alter protocolMandatory C - required use, may use own protocolsModel Guidelines – statewide protocols may be used

Take homeAmbulance protocols vary

What is optimal care?

Improve EMS care

Rural EMS medical directors

Office of Rural Health

Funded this study

$ for twice yearly EMS Forum