Regulation & Administration - Province of Manitoba...VERSION Z01 Code of Ethics 2017 -04 -10 Z02...

A00.4 Regulation & Administration

All patient care duties and functions must be performed in accordance with the EMS Protocols and Procedures as published by the Minister.

VERSION Z01 Code of Ethics 2017-04-10 Z02 Minimum Requirements for Practice 2017-02-14 Z03 Medical Functions; Delegations of Reserved Acts revised 2018-10-10 Z04.1 Medical Director Requirements & Responsibilities revised 2018-10-16 Z04.2 Service Operator Requirements & Responsibilities revised 2018-10-16 Z04.3 Technician Requirements & Responsibilities revised 2018-10-16 Z04.4 Specialty Course Requirements for Delegations NEW 2018-10-16 Z05.1 Delegated Acts – Procedures revised 2018-10-09 Z05.2 Delegated Acts – Medications revised 2018-10-09 Z06 Reporting Delegations revised 2017-06-19 Z07 Documentation Requirements 2017-04-10 Z08 Refusal of Care see Treatment Guideline G15 Pending Approval Z09.1 Emergency Vehicle Operations 2016-05-20 Z09.2 Operation of Ambulance by Fire Fighter see Treatment Guideline G24 Pending Approval Z10 Medical First Response 2017-04-10 Z11 Physical Restraint 2017-04-10 Z12 Other Professionals at Scene see Treatment Guideline G23 Pending Approval Z13 Orders from Non-EMS Physicians 2015-11-25 Z14 Infection Prevention & Control Post Exposure Care 2017-04-10 Z15 Controlled Substances 2015-09-22 Z16 Legislation revised 2017-11-15 Z19.2 Cross References: Treatment Guidelines to Care Maps 2017-04-10 Z20 Homebirths & Midwives 2016-07-04 Z21 Physician Accompaniment on IFT 2015-06-03

A00.4 EMS Branch / Office of the Medical Director

2018-11-19 Regulation & Administration

EMS personnel:

The Code of Ethics defines standards of conduct for Manitoba pre-hospital practitioners. It is the overall goal to ensure all licensed practitioners provide competent, safe and ethical pre-hospital care, emergent or non emergent, ensuring that practices are consistent with provincial legislation and standards of care.

Responsibility to the Patient and Others

The licensed practitioner must:

• Provide the most effective, efficient, and safe patient care as is reasonably possible within the level of his / her competencies and seek consultation with other health care professionals when necessary

• Only initiate care, conduct procedures, or intervene in situations involving a patient where those procedures are explicitly intended for the benefit or well being of the patient

• Practice in accordance with the EMS Protocols and Procedures as published by the Office of the Medical Director and the Manitoba Health, Seniors and Active Living, Emergency Medical Services Branch

• Provide high quality patient care, including physical comfort and emotional support, to the extent that the licensed practitioner is reasonably able to do

• Once accepting responsibility for a patient or initiating the provision of patient care, continue provision of care until it is no longer required or until another appropriately qualified heath care professional accepts responsibility of care

• Treat individuals with dignity and respect

• Advocate in the best interest of the person

• Practice clinical and professional judgment to ensure informed consent and informed refusal of care

• Respect and maintain appropriate relationship boundaries

• Communicate clearly and respectfully

• Recognize the rights of the person

• Protect and maintain patient privacy and confidentiality in accordance with the requirements of federal and provincial legislation

• Demonstrate patience, compassion and courtesy

• Work collaboratively with others

Z01 Office of the Medical Director / Emergency Medical Services Branch

2017-04-10 Code of Ethics

Z01 Code of Ethics Page 1

Responsibility to the Profession


• Practice in accordance with the Emergency Medical Response and Stretcher Transportation Act and land, air or stretcher regulation

• Honour the profession by ensuring that his / her conduct reflects positively on the integrity of the profession

• Demonstrate leadership

• Share professional knowledge, participate in mentorship, and be willing to learn and accept new knowledge shared by others

• Actively participate in the quality assurance system

• Foster respectful, professional, and positive work and learning environments

• Report any unsafe practice, professional incompetence, unprofessional conduct, and any participation in, or conviction of a criminal activity to the appropriate authorities

• Recognize professional limitations

Responsibility to Self


• Understand the importance of personal safety and that practitioners are not obligated to place him / her in harm’s way beyond what a reasonable licensed practitioner would do

• Comply with health and workplace safety policies, procedures and legislation

• Comply with emergency medical response and transport vehicle operation policies, procedures and legislation

• Maintain professional accountability, integrity, good character and reputation

• Demonstrate accountability for actions in practice

• Maintain and improve professional competencies by actively engaging in the Manitoba Continuing Competency for Paramedics Program (MCCPP) and other opportunities for lifelong learning

• Maintain impartiality and recognize conflicts of interest

• Understand the Office of Medical Director’s, structure, roles, responsibilities, and direction, as well as its authority for delegating permissions to paramedics

Z01 Code of Ethics Page 2

Prehospital care in Manitoba is governed by The Emergency Medical Response and Stretcher Transportation Act and the related Regulations. Patient care must be provided in accordance

with procedures and functions as set out in the “Emergency Medical Services (EMS) Protocols and Procedures” published by the Minister.

All Manitoba EMS personnel licence holders must hold the necessary education, training and experience, and be able to demonstrate the knowledge and psychomotor skills to safely and appropriately:

• Recognize a known or potential health crisis • Evaluate a patient’s clinical condition, by collecting and analyzing pertinent information • Manage a patient’s health crisis to maintain or improve the patient’s condition • Transport a patient and transfer their care to the next appropriate health care provider • Document and report pertinent information related to a patient’s health crisis and their clinical

condition

In order to accomplish these goals, all emergency prehospital personnel must at minimum be competent to:

• Provide scene assessment and management • Appropriate use of personnel protective equipment (PPE) • Conduct a primary patient survey • Perform a secondary patient survey, appropriate to the nature of the patient’s health crisis • Provide basic CPR, including the use of an automated external defibrillator (AED) • Maintain a patent airway using basic airway techniques • Support adequate breathing and gas exchange • Recognize and manage internal and external hemorrhage • Apply immobilization techniques for known or suspected fractures • Apply initial treatment to wounds and environmental injuries • Manage multiple or mass casualties • Use protocols or procedures appropriate to level of training and licensure to

o Assess and manage an acute or chronic medical disorder o Assess and manage a traumatic or environmental injury o Assess and manage emergency childbirth and newborn care o Assess and manage an acute mental health crisis or chronic mental health disorder

• Provide psychological support measures to a patient undergoing a health crisis • Conduct lifting and moving techniques to ensure patient and provider safety • Perform patient extrication, packaging and transport procedures • Complete a patient care record in the appropriate format • Use and maintain required equipment and supplies, including appropriate cleaning and

disinfection

Z02 Emergency Medical Services Branch/Office of the Medical Director

2017-02-14 Minimum Requirements for Practice

Z02 Minimum Requirements Page 1

Z03 Delegation Page 1

Z03: Medical Functions: Delegation of Reserved Acts

Version: 2018-10-10

Start: 2018-12-01

End: **

** With the establishment of the Paramedic Act and self-regulation, the Provincial Medical Director (PMD) will no longer define the professional scope of practice of registered EMS providers.

Prehospital clinical care and patient transport in Manitoba is currently governed by the Emergency Medical Response and Stretcher Transportation Act and its regulations. The Land Emergency Medical Response System Regulation authorizes the provincial medical director (PMD) to establish protocols and procedures for clinical care including establishing standardized scopes of practice for paramedics and emergency medical responders (EMR).

RESERVED ACT:

Any medical function performed by an EMS provider, such as administering oxygen or establishing an intravenous line, is a reserved act as defined by the Regulated Health Professions Act (RHPA). The RHPA mandates that no person shall perform any of the twenty-one reserved acts unless authorized to do so by a profession-specific act (e.g. physicians and the Medical Act) or exempted by another act (e.g. layperson rescuers and the Defibrillation Public Access Act). A reserved act that is authorized to a regulated profession is often referred to as being within that profession’s “scope of practice” or “in scope”.

DELEGATION:

Although EMS providers do not currently have their own act allowing their own scope of practice, the RHPA does allow a medical director to delegate the authority to perform certain reserved acts to a paramedic or EMR. This has traditionally been called “transfers of function”, however it is more accurate to refer to these as “delegated acts”. EMS providers in Manitoba have what is known as a “delegated scope of practice”.

Medical directors must delegate reserved acts by the process established by the PMD and the EMS Branch, as defined in Z04.1 LOCAL MEDICAL DIRECTOR REQUIREMENTS AND RESPONSIBILITIES. The provider receiving the delegations and the licensed service operator they work for share in the responsibility for the provision of safe clinical care, as described in Z04.2 SERVICE OPERATOR REQUIREMENTS AND RESPONSIBILITIES and Z04.3 TECHNICIAN / ATTENDANT REQUIREMENTS AND RESPONSIBILITIES.

The delegation of the reserved acts is a privilege and not a right of licensing or employment. In the interest of patient or public safety, delegations can be suspended or removed at any time with reasonable cause.

REQUIREMENTS TO PERFORM MEDICAL FUNCTIONS:

EMS providers must meet the following requirements to perform any medical function. A provider must: • Hold the appropriate level of licensure from the EMS Branch • Be employed by a Manitoba-licensed service • Have the appropriate delegation • Satisfy the requirements and responsibilities listed in Z04.3, including all obligations regarding self-

assessment, maintenance of competency and self-reporting • Complete the additional training courses as listed in Z04.4 ADDITIONAL COURSES REQUIRED FOR

DELEGATION OF RESERVED ACTS.


CORE MEDICAL FUNCTIONS:

Upon satisfying the licensing requirements of the EMS Branch, the core medical functions will be authorized by standing delegations from the PMD. These represent the minimum scope of practice for EMS personnel providing clinical care to Manitobans and all licensed services are responsible to ensure this minimum level of care.

Core medical functions are identified by the letter “A” in Z05.1 DELEGATED ACTS – PROCEDURES and Z05.2 DELEGATED ACTS – MEDICATIONS.

SPECIALIZED MEDICAL FUNCTIONS:

Additional reserved acts may be delegated based upon the needs of the service and the provider’s education, training, experience and ability. Specialized functions require formal delegation from the local medical director (LMD) in accordance with the requirements as described in Z04.1. Some delegations require an initial assessment of competency and regular demonstrations of ongoing proficiency.

Specialized medical functions are identified by the letter “D” in Z05.1 DELEGATED ACTS – PROCEDURES and Z05.2 DELEGATED ACTS – MEDICATIONS.

SCOPE OF PRACTICE VERSUS SCOPE OF WORK:

“Scope of practice” (also known as professional scope of practice) refers to what a paramedic or EMR is lawfully able to perform. “Scope of work” (also known as occupational scope of practice) describes the medical functions that a service operator and its clinical oversight have determined are required and allowed while employed with the service. The scope of work can be smaller than the scope of practice, but it can never exceed the latter.

Appendix A illustrates the relationship between scope of practice and scope of work.

DELEGATIONS AND LICENSE LEVEL:

• Satisfying licensing requirements at the EMR level, individuals are authorized to perform the core medical functions from the Basic Care group. Additional specialized medical functions may be available.

• Satisfying licensing requirements at the primary care paramedic (PCP) level, individuals are authorized to perform the core medical functions from the Primary Care group. Additional specialized medical functions may be available.

o PCPs may be eligible for additional specialized medical functions from the Intermediate Care group. These individuals must hold all the basic and primary care functions; have acceptable education, training and experience; and demonstrate competency.

• Satisfying licensing requirements at the advanced care paramedic (ACP) level, individuals are authorized to perform the core medical functions from the Advanced Care group. Additional specialized medical functions may be available with formal delegation.

o ACPs with appropriate education and training, as approved by the EMS Branch and PMD, may be eligible for additional specialized medical functions from the Critical Care group.


Appendix A: The relationship between scope of work, scope of practice and license level.

License Level (MHSAL)

Scope of Practice (OMD)

Scope of Work (Service)

Emergency Medical Responder Basic Care Delegations EMR

Primary Care Paramedic Primary Care Delegations PCP

Intermediate Care Delegations ICP

Advanced Care Paramedic Advanced Care Delegations

ACP Critical Care Delegations

Example #1: Wil is licensed as a PCP. He is employed by a licensed EMS service as a PCP where he performs all of the primary care delegations (his scope of work equals his scope of practice). Occasionally, he works as an EMR for a medical first response service where he is limited to performing the basic care delegations (his scope of work is within his scope of practice).

Example #2: Tony and Susan trained together and are both licensed as ACPs. Tony is hired by a licensed service as an ICP where he can perform the all of the intermediate care delegations (his scope of work is within his scope of practice). Susan is employed by a larger service as an ACP where she can perform all of the advanced care delegations (her scope of work equals her scope of practice).

Example #3: The service Susan works for decides to switch from endotracheal intubation to using Combitubes for advanced airway management, now her scope of work has changed but her scope of practice has remained the same.

Z04.1 Delegation - LMD Page 1

Z04.1: REQUIREMENTS & RESPONSIBILITIES FOR DELEGATION OF

MEDICAL FUNCTIONS – LOCAL MEDICAL DIRECTOR

Version: 2018-10-16

Start: 2018-12-01

End: **

The Land Emergency Medical Response System Regulation requires that clinical care be provided in accordance with protocols and procedures as established by the provincial medical director, and that EMS personnel perform their patient care duties and functions in accordance with the EMS Protocols and Procedures published by the minister in

2015, as amended from time to time.

For all personnel employed by the service, the local medical director (LMD), in collaboration with the licence holder, must:

1. Ensure that each recipient holds a valid Manitoba personnel licence and is compliant with the Manitoba Continuing Competence Program for Paramedics (MCCPP).

2. Evaluate the needs of the service’s patient population to determine the appropriateness of any medical functions provided by the service.

3. Weigh the complexity and risk(s) of the reserved act, along with the skill level and practice experience, in determining their suitability of each recipient for the delegation of any specialized medical function(s).

4. Ensure that each recipient has satisfactory and sufficient education, training and clinical experience, and has received sufficient training and practice to receive the delegation of any specialized medical function(s).

5. Ensure that there are satisfactory processes for assessing initial proficiency and confirm that each recipient demonstrates competency prior to receiving the delegation of any specialized medical function(s).

6. Ensure that there are adequate processes for promoting and sustaining ongoing proficiency of all core and specialized medical functions.

7. Review each recipient’s continuing proficiency in all core and specialized medical function(s) as required and notify the Provincial Medical Director (PMD) and the Emergency Medical Services Branch (EMSB) in an approved form.

8. Ensure that all core and specialized medical functions are performed in accordance with the procedures and protocols established by the PMD.

9. Be available for clinical supervision of any core and specialized medical function(s) including on-line and in real-time as required. Ensure that an appropriate physician is available to provide medical oversight including clinical supervision of any core and specialized medical function(s) when the medical director is unavailable.

10. Ensure that there are satisfactory quality assurance (QA) processes for monitoring the ongoing proficiency of all core and specialized medical functions.

11. Ensure that any and all deficiencies in the performance of any core and specialized medical function(s) identified in QA processes are immediately and appropriately addressed.

12. Revoke the delegation of any specialized medical function(s) if deficiencies cannot be immediately and appropriately corrected and there is a risk to public safety.

13. Suspend the delegation of any core medical function(s) if deficiencies cannot be immediately and appropriately corrected and there is a risk to public safety. Note that the final decision on

Z04.1 Delegation - LMD Page 2

revocation of the standing delegation of any core medical function(s) will be made by the PMD after appropriate investigation.

14. Notify the PMD and the EMSB of the delegation of any specialized medical function(s) within 5 business days in an approved format.

15. Notify the PMD and the EMSB immediately if any delegation(s) is/are removed.

16. Report any significant adverse occurrence during the conduct of any core or specialized medical function(s) to the PMD and the EMSB as soon as possible, and in accordance with Critical Incident and Disclosure Reporting guidelines of Manitoba Health Seniors and Active Living.

Z04.2 Delegation - Licence Holder Page 1

Z04.2: REQUIREMENTS & RESPONSIBILITIES FOR DELEGATION OF MEDICAL FUNCTIONS – LICENSE HOLDER

Version: 2018-10-16

Start: 2018-12-01

End: **

The Land Emergency Medical Response System Regulation requires that clinical care be provided in accordance with protocols and procedures as established by the provincial medical director, and that EMS personnel perform their patient care duties and functions in accordance with the EMS Protocols and Procedures published by the minister in

2015, as amended from time to time.

The license holder must support and assist the local medical director (LMD) to:

1. Ensure that each recipient holds a valid Manitoba personnel licence and is compliant with the Manitoba Continuing Competence Program for Paramedics (MCCPP).

2. Evaluate the needs of the service’s patient population to determine the appropriateness of any medical functions provided by the service.

3. Ensure that each recipient has satisfactory and sufficient education, training and clinical experience, and has received sufficient training and practice to receive the delegation of any specialized medical function(s).

4. Ensure that there are satisfactory processes for assessing initial proficiency and confirm that each recipient demonstrates competency prior to receiving the delegation of any specialized medical function(s).

5. Ensure that there are adequate processes for promoting and sustaining ongoing proficiency of all core and specialized medical functions.

6. Ensure that all core and specialized medical functions are performed in accordance with the procedures and protocols established by the Provincial Medical Director (PMD).

7. Ensure that there are satisfactory quality assurance (QA) processes for monitoring the ongoing proficiency of all core and specialized medical functions.

8. Ensure that any and all deficiencies in the performance of any core and specialized medical function(s) identified in QA processes are immediately and appropriately addressed.

9. Notify the PMD and the Emergency Medical Services Branch (EMSB) of the delegation of any specialized medical function(s) within 5 business days in an approved format.

10. Notify the PMD and the EMSB immediately if any delegation(s) is/are removed.

11. Report any significant adverse occurrence during the conduct of any core or specialized medical function(s) to the PMD and the EMSB as soon as possible, and in accordance with Critical Incident and Disclosure Reporting guidelines of Manitoba Health Seniors and Active Living.

12. Notify the PMD and EMSB immediately if the agreement between the licence holder and medical director is terminated.

Z04.3 Delegation - Personnel Page 1

Z04.3 REQUIREMENTS & RESPONSIBILITIES FOR DELEGATION OF MEDICAL FUNCTIONS – PERSONNEL

Version: 2018-10-16

Start: 2018-12-01

End: **

The Land Emergency Medical Response System Regulation requires that clinical care be provided in accordance with protocols and procedures as established by the provincial medical director, and that EMS Personnel perform their patient care duties and functions in accordance with the Emergency Medical Services (EMS) Protocols and Procedures

published by the minister in 2015, as amended from time to time.

Each person must:

1. Maintain a valid Manitoba personnel licence and remain compliant with the Manitoba Continuing Competence Program for Paramedics (MCCPP).

2. Have satisfactory education and training, and maintain sufficient clinical experience relevant to the delegated medical function(s).

3. Maintain satisfactory knowledge and appropriate psychomotor skills for the safe performance of all delegated medical functions.

4. Maintain the physical ability to perform the delegated medical functions in a safe and satisfactory manner. Immediately inform the medical director and license holder if unable to perform any medical functions in a safe and satisfactory manner due to illness, injury, impairment or other change in physical ability.

5. Perform all delegated medical functions in accordance with procedures and protocols as established by the PMD.

6. Perform all patient care duties and functions in accordance with the EMS Protocols and Procedures.

7. Document any medical functions performed in the patient care record (PCR) in accordance with the EMS Protocols and Procedures as published by the Minister.

8. Document any significant adverse occurrence during the conduct of any core or specialized medical function(s) performed in the PCR and convey that information to the health care provider who will be accepting that patient’s care.

9. Report any significant adverse occurrence during the conduct of any core or specialized medical function(s) to the PMD and the Emergency Medical Services Branch (EMSB) as soon as possible, and in accordance with Critical Incident and Disclosure Reporting guidelines of Manitoba Health Seniors and Active Living.

Z04.4.1 Course Requirements Page 1

Z04.4: SPECIALTY COURSE REQUIREMENTS FOR DELEGATION BasicPrimary

Intermediate

Advanced

Critical All ages Version date: 2018-10-12

Start: 2018-12-01

EMS personnel must maintain satisfactory knowledge and appropriate psychomotor skills for the safe performance of all delegated medical functions (as per Z04.3 Technician / Attendant Responsibilities and Requirements).

CARDIOPULMONARY RESUSCITATION (CPR):

• To receive and maintain standing delegation of the core medical functions, providers must successfully complete an accepted CPR course, and demonstrate ongoing proficiency by successfully completing a refresher course each year. The following courses are acceptable. o Heart and Stroke Foundation Basic Life Support (HSF-BLS) provider and annual renewal course o Canadian Red Cross Level HCP CPR/AED course (must recertify annually) o St. John Ambulance CPR Level “C” & AED (must recertify annually)

ADVANCED CARDIAC LIFE SUPPORT (ACLS):

• To receive and maintain formal delegation of the specialized medical functions at the intermediate, advanced or critical care levels, providers must successfully complete the HSF ACLS provider course, and demonstrate ongoing proficiency by successfully completing the renewal course every two years.

• Successful completion of the HSF ACLS for Experienced Providers (ACLS-EP) course every two years is an acceptable alternative to the ACLS renewal course.

• The HSF regards American Heart Association (AHA) resuscitation / emergency cardiac care training courses as equivalent to the HSF Resuscitation Program courses.

Z05.1 Procedures Page 1

Z05.1 Medical Functions: Delegation of Reserved Acts

Version date: 2018-10-09

Start date: 2018-12-01

End date: **

** Under current regulation, the Office of the Medical Director defines the professional scope of practice of licensed EMS providers. When the College of Paramedics of Manitoba General Regulations are proclaimed, the professional scope of practice will be established by the college.

MEDICAL FUNCTIONS License level

A - Core medical functions / standing delegation from PMD

EMR

(tab

le A

)

PCP

(tab

le B

)

ACP

(tab

le C

)

D - Specialized medical functions / require formal delegation from local medical director

E - Exempted medical functions / require approval by PMD

N - Not available at that license level

BASIC CARE PROCEDURES (all providers)

Airway & breathing management with basic devices A A A Clinical assessment A A A Defibrillation without rhythm interpretation (AED) A A A Determination of obvious death & stillbirth A A A Discontinuing after unsuccessful basic resuscitation D D A Emergency reduction of fracture with vascular compromise A A A Eye irrigation A A A Glucometry D A A Maintenance of established devices - level 1 (table D) D A A Management of prehospital delivery & obstetrical emergencies A A A Medication administration - level 1 (table E) A A A Medication administration - level 2 (table E) D A A Newborn resuscitation - basic A A A Pelvic binding D A A Physical restraint D D A Pulse oximetry D A A Spinal motion restriction A A A Splinting A A A Suctioning of the oropharynx A A A Tourniquet application A A A Wound care (without repair) A A A

PRIMARY CARE PROCEDURES (PCP license & above)

Blind insertion airway device (BIAD) N D A Continuous positive airway pressure (CPAP) ventilation N D A


Cardiac monitoring with rhythm interpretation N A A Electrocardiogram (12 /15 lead ECG) acquisition N D A End-tidal CO2 detection and capnometry N D A Forceps removal of supraglottic foreign body N D A Maintenance of established devices - level 2 (table D) N A A Medication administration - level 3 (table E) N A A Medication administration - level 4 (table E) N D A Peripheral vein cannulation N D A Removal of foreign body from the skin N D A Removal of superficial foreign body from the eye N D A Valsalva maneuver N D A

INTERMEDIATE CARE PROCEDURES (PCP license & above; additional approval required)

Clinical assessment for treat & release N D A Cardioversion – adult N D A Cardioversion – infant, child & adolescent N D D Carotid Sinus Massage N D A Defibrillation with rhythm interpretation (manual) N D A Discontinuing after unsuccessful advanced resuscitation - adult N D A Discontinuing after unsuccessful advanced resuscitation - infant, child & adolescent N D D Electrocardiogram (12 / 15 lead) interpretation N D A Intraosseous device insertion N D A Maintenance of established devices - level 3 (table D) N D A Needle decompression during cardiac arrest N D A Newborn resuscitation - advanced N D A Suctioning beyond the oropharynx N D A

Transcutaneous pacing - adult N D A Transcutaneous pacing - infant, child & adolescent N D D Venous blood sample acquisition N D A Wound repair N D D

ADVANCED CARE PROCEDURES (ACP license & above)

Arterial blood sample acquisition N N D

Bi-level positive airway pressure (BiPAP) ventilation N N D Blood product administration N N D

Endotracheal intubation without paralytics N N D

Forceps removal of tracheal foreign body N N D

Gastric tube insertion N N D

Interpretation of basic test results N N D

Maintenance of established device - level 4 (table D) N N D

Medication administration - level 5 (table E) N N D Needle decompression for suspected tension pneumothorax N N D

Needle (percutaneous) cricothyroidotomy N N D


Reduction of specific joint dislocation N N D Temperature probe insertion N N D Urinary catheterization N N D

CRITICAL CARE PROCEDURES (ACP license & above; additional approval required)

Arterial cannulation for monitoring N N E Balloon insertion for esophageal bleed N N E

Central vein cannulation N N E

Chest tube or percutaneous catheter insertion N N E

Endotracheal intubation with paralytics N N E

Escharotomy N N E

Mechanical ventilation N N E

Open (surgical) cricothyroidotomy N N E Umbilical vein cannulation N N E

TABLE A - EMERGENCY MEDICAL RESPONDER

CORE MEDICAL FUNCTIONS

• Airway & breathing management with basic devices • Clinical assessment • Defibrillation without rhythm interpretation (AED) • Determination of obvious death & stillbirth • Emergency reduction of fracture with vascular compromise • Eye irrigation • Management of prehospital delivery & obstetrical emergencies • Medication administration (level 1) • Newborn resuscitation - basic • Spinal motion restriction • Splinting • Suctioning of the oropharynx • Tourniquet application • Wound care (without repair)

SPECIALIZED MEDICAL FUNCTIONS

• Discontinuing after unsuccessful basic resuscitation • Glucometry • Maintenance of established devices - level 1 • Medication administration - level 2 • Pelvic binding • Physical restraint • Pulse oximetry


TABLE B - PRIMARY CARE PARAMEDIC


• Airway & breathing management with basic devices • Clinical assessment • Cardiac monitoring with rhythm interpretation • Defibrillation without rhythm interpretation (AED) • Determination of obvious death & stillbirth • Emergency reduction of fracture with vascular compromise • Eye irrigation • Glucometry • Maintenance of established devices - levels 1 & 2 • Management of prehospital delivery & obstetrical emergencies • Medication administration - levels 1, 2 & 3 • Newborn resuscitation - basic • Pelvic binding • Pulse oximetry • Spinal motion restriction • Splinting • Suctioning of the oropharynx • Tourniquet application • Wound care (without repair)

SPECIALIZED MEDICAL FUNCTIONS - PRIMARY

• Blind insertion airway devices (BIAD) • Continuous positive airway pressure (CPAP) ventilation • Discontinuing after unsuccessful basic resuscitation • Electrocardiogram (12/15 lead) acquisition • End-tidal CO2 detection & capnometry • Forceps removal of supraglottic foreign body • Medication administration - level 4 • Peripheral vein cannulation • Physical restraint • Removal of foreign body from the skin • Removal of superficial foreign body from the eye surface • Valsalva maneuver

SPECIALIZED MEDICAL FUNCTIONS- INTERMEDIATE

• Clinical assessment for treat & release • Cardioversion - adult • Cardioversion - infant, child & adolescent • Carotid sinus massage • Defibrillation with rhythm interpretation (manual) • Discontinuing after unsuccessful advanced resuscitation - adult • Discontinuing after unsuccessful advanced resuscitation - infant, child & adolescent • Electrocardiogram (12 /15 lead) interpretation • Intraosseous (IO) device insertion


• Maintenance of established devices - level 3 • Needle decompression during cardiac arrest • Newborn resuscitation - advanced • Suctioning beyond the oropharynx • Transcutaneous pacing - adult • Transcutaneous pacing - infant, child & adolescent • Venous blood sample acquisition • Wound repair

TABLE C - ADVANCED CARE PARAMEDIC


• Airway & breathing management with basic devices • Blind insertion airway devices (BIAD) • Clinical assessment • Cardiac monitoring with rhythm interpretation • Cardioversion - adult • Carotid sinus massage • Continuous positive airway pressure (CPAP) ventilation • Defibrillation without rhythm interpretation (AED) • Defibrillation with rhythm interpretation (manual) • Determination of obvious death & stillbirth • Discontinuing after unsuccessful advanced resuscitation - adult • Discontinuing after unsuccessful basic resuscitation • Electrocardiogram (12/ 15 lead) acquisition • Electrocardiogram (12/15 lead) interpretation • Emergency reduction of fracture with vascular compromise • End-tidal CO2 detection & capnometry • Eye irrigation • Forceps removal of supraglottic foreign body • Glucometry • Intraosseous (IO) device insertion • Maintenance of established devices - levels 1, 2, 3 & 4 • Management of prehospital delivery & obstetrical emergencies • Medication administration - levels 1, 2, 3 & 4 • Needle decompression during cardiac arrest • Newborn resuscitation - advanced • Pelvic binding • Peripheral vein cannulation • Physical restraint • Pulse oximetry • Removal of foreign body from the skin • Removal of superficial foreign body from the eye surface • Spinal motion restriction • Splinting • Suctioning beyond the oropharynx • Suctioning of the oropharynx


• Tourniquet application • Transcutaneous pacing - adult • Valsalva maneuver • Venous blood sample acquisition • Wound care (without repair)

SPECIALIZED MEDICAL FUNCTIONS - ADVANCED

• Arterial blood sample acquisition • Bi-level positive airway pressure (BiPAP) ventilation • Blood product administration • Cardioversion - infant, child & adolescent • Clinical assessment for treat & release • Discontinuing after unsuccessful advanced resuscitation - infant, child & adolescent • Endotracheal intubation without paralytics • Forceps removal of tracheal foreign body • Gastric tube insertion • Interpretation of basic test results • Maintenance of established devices - level 4 • Medication administration - level 5 • Needle decompression for suspected tension pneumothorax • Needle (percutaneous) cricothyroidotomy • Reduction of specific joint dislocation • Temperature probe insertion • Transcutaneous pacing - infant, child & adolescent • Urinary catheterization • Wound repair

SPECIALIZED MEDICAL FUNCTIONS - CRITICAL

• Arterial cannulation for monitoring • Balloon insertion for esophageal bleed • Central vein cannulation • Chest tube or percutaneous catheter insertion • Endotracheal intubation with paralytics • Escharotomy • Mechanical ventilation • Open (surgical) cricothyroidotomy • Umbilical vein catheterization


TABLE D - MAINTENANCE OF ESTABLISHED DEVICES

LEVEL 1: • Continuous peritoneal dialysis - managed by patient or their caregiver • Infusion pump - running fluid only without added medication • Nasogastric or orogastric tube - draining by gravity • Peripheral venous catheter - running fluid only without added medication • Peripherally inserted central catheter (PICC) - capped (not running) • Urinary (Foley, suprapubic or Kelly irrigation) catheter - draining

LEVEL 2: • Central venous catheter - capped (not running) • Chest tube or intrapleural catheter - with Heimlich valve and/or draining by gravity • Esophageal or rectal temperature probe • Infusion pump - running with medication not requiring dosage titration or adjustment • Nasogastric or orogastric tube - draining by suction • Paracentesis (intraperitoneal) catheter - draining by gravity • Peripherally inserted central catheter (PICC) - running • Intraosseous (IO) device / catheter – running

LEVEL 3: • Central venous catheter - running with medication not requiring dosage titration or adjustment • Chest tube or intrapleural catheter - draining by suction • Continuous peritoneal dialysis - requiring assistance from health care provider • Infusion pump - running with potential for medication titration or dosage adjustment

LEVEL 4: • Arterial catheter for monitoring • Central venous catheter - pressure monitoring • Central venous catheter - running with potential for medication titration or dosage adjustment • Transvenous pacing catheter & pacemaker


TABLE E - MEDICATION ADMINISTRATION

LEVEL 1: • Administration into mouth (oral) • Application to inside of cheek (buccal) or under tongue (sublingual) • Inhalation with metered dose inhaler (MDI) • Intramuscular with autoinjector

LEVEL 2: • Administration into feeding tube • Application to nasal mucosa (intranasal) • Inhalation with nebulizer

LEVEL 3: • Application to surface of eye (ophthalmic) or skin (dermal) • Insertion into rectum (infants & children only) • Intramuscular or subcutaneous injection

LEVEL 4: • Intraosseous or intravenous injection • Injection into an established peripherally inserted central catheter (PICC) or subcutanous reservoir (eg. Port-a-cath)

LEVEL 5: • Instillation into endotracheal tube during cardiac arrest • Injection into an established central venous catheter, dialysis catheter or fistula during cardiac arrest

Z05.2 Medications Page 1

Z05.2: Delegated Medical Acts - Medications

Version date: 2018-10-09

Start date: 2018-12-01

End date: **

** Under current regulation, the Office of the Medical Director defines the professional scope of practice of licensed EMS providers. When the College of Paramedics of Manitoba General Regulations are proclaimed, the professional scope of practice will be established by the college.

MEDICAL FUNCTIONS License level

A - Core medical functions / standing delegation from Provincial Medical Director (PMD)

EMR

(tab

le A

)

PCP

(tab

le B

)

ACP

(tab

le C

)

D - Specialized medical functions /require formal delegation from local medical director

E - Exempted medical functions / require approval by PMD

N - Not available at that license level

BASIC CARE MEDICATIONS (all providers)

Acetylsalicylic acid A A A Bronchodilators - metered dose inhaler A A A Bronchodilators - nebulizer D A A Epinephrine for anaphylaxis - autoinjector A A A Glucose A A A Glucagon - intranasal D A A Naloxone - intranasal D A A Nitroglycerin - sublingual D A A Oxygen A A A Simple analgesics & antipyretics D A A

PRIMARY CARE MEDICATIONS (PCP license & above)

Benzodiazepines - oral & intranasal N D A Dextrose N A A Antihistamines & antipruritics N A A Antinauseants & antiemetics N A A Epinephrine for anaphylaxis - intramuscular N A A Fentanyl - intranasal N D A Glucagon N A A Intravenous crystalloid solutions N D A Local anesthetics - ophthalmic N D A Naloxone N A A Nitroglycerin - dermal N A A Nitrous oxide N A A Olanzapine for amphetamine delirium N D A


Oxytocin N D A Ticagrelor N D A

INTERMEDIATE CARE MEDICATIONS (PCP license & above; additional approval required)

Adenosine N D A Atropine for unstable bradycardia N D A Benzodiazepines N D A Enoxaparin for acute coronary syndrome N D A Furosemide N D A Haloperidol N D A Hydrocortisone N D A Ketamine for analgesia N D A Ketorolac N D A Local anesthetics for wound repair N D A Magnesium sulfate for eclampsia N D A Medications for cardiac arrest (epinephrine; amiodarone; magnesium) N D A Medications for hyperkalemia (calcium; bicarbonate; insulin & dextrose) N D A Opioids N D A Sodium bicarbonate for cyclic antidepressant overdose N D A Tranexamic acid N D A

ADVANCED CARE MEDICATIONS (ACP license & above)

Adrenergics for unstable bradycardia N N D Antibiotics N N A Anticoagulants & antiplatelets N N A Anticonvulsants N N A Antidotes & neutralizers for overdose / poisoning N N D Antidysrrhythmics N N A Antihypertensives N N A Antipsychotics N N A Beta blockers N N A Calcium channel blockers N N A Corticosteroids N N A Diuretics N N A Electrolytes for replacement (potassium; magnesium; calcium) N N A Epinephrine for anaphylaxis - intravenous; intraosseous N N D Flumazenil N N D Immunizations N N D Insulin N N A Ketamine for sedation / anesthesia N N D Propofol N N D Sodium bicarbonate N N A Vasodilators N N D


Vasopressors & inotropes N N D Volume expanders N N A

CRITICAL CARE MEDICATIONS (ACP license & above; additional approval required)

Anticholinesterases N N E Fibrinolytics N N E Paralytics N N E

TABLE A - EMERGENCY MEDICAL RESPONDER

CORE MEDICATIONS

• Acetylsalicylic acid • Bronchodilator - metered dose inhaler • Epinephrine for anaphylaxis - autoinjector • Glucose • Oxygen

SPECIALIZED MEDICATIONS

• Bronchodilators - nebulizer • Glucagon - intranasal • Naloxone - intranasal • Nitroglycerin - sublingual • Simple analgesic & antipyretics

TABLE B - PRIMARY CARE PARAMEDIC

CORE MEDICATIONS

• Acetylsalicylic acid • Antihistamines & antipruritics • Antinauseants & antiemetics • Bronchodilators • Dextrose • Epinephrine for anaphylaxis - autoinjector & intramuscular • Glucagon • Glucose • Naloxone • Nitroglycerin - sublingual & dermal • Nitrous oxide • Oxygen • Simple analgesics & antipyretics

SPECIALIZED MEDICATIONS - PRIMARY

• Benzodiazepines - oral & intranasal • Fentanyl - intranasal


• Intravenous crystalloid solutions • Local anesthetics - ophthalmic • Olanzapine for amphetamine delirium • Oxytocin • Ticagrelor

SPECIALIZED MEDICATIONS - INTERMEDIATE

• Adenosine • Atropine for unstable bradycardia • Benzodiazepines • Enoxaparin for acute coronary syndrome • Furosemide • Haloperidol • Hydrocortisone • Ketamine for analgesia • Ketorolac • Local anesthetics for wound repair • Magnesium sulfate for eclampsia • Medications for cardiac arrest (epinephrine; amiodarone; magnesium sulfate) • Medications for hyperkalemia (calcium; sodium bicarbonate; insulin & dextrose) • Opioids • Sodium bicarbonate for cyclic antidepressant overdose • Tranexamic acid

TABLE C - ADVANCED CARE PARAMEDIC

CORE MEDICATIONS - ADVANCED

• Acetylsalicylic acid • Adenosine • Antibiotics • Anticoagulants & antiplatelets • Anticonvulsants • Antidysrrhythmics • Antihistamines & antipruritics • Antihypertensives • Antinauseants & antiemetics • Antipsychotics • Atropine for unstable bradycardia • Benzodiazepines • Beta blockers • Bronchodilators • Calcium channel blockers • Corticosteroids • Dextrose • Diuretics • Electrolytes for replacement (potassium; magnesium; calcium) • Epinephrine for anaphylaxis - autoinjector & intramuscular


• Glucose • Glucagon • Insulin • Intravenous crystalloid solutions • Ketamine for analgesia • Ketorolac • Local anesthetics • Magnesium sulfate for eclampsia • Medications for cardiac arrest (epinephrine; amiodarone; magnesium sulfate) • Medications for hyperkalemia (calcium; sodium bicarbonate; insulin & dextrose) • Naloxone • Nitroglycerin - sublingual & dermal • Nitrous oxide • Opioids • Oxygen • Oxytocin • Simple analgesics & antipyretics • Sodium bicarbonate • Tranexamic acid • Volume expanders

SPECIALIZED MEDICATIONS - ADVANCED

• Adrenergics for unstable bradycardia • Antidotes & neutralizers for overdose / poisoning • Epinephrine for anaphylaxis - intravenous& intraosseous • Flumazenil • Immunizations • Ketamine for sedation / anesthesia • Propofol • Vasodilators • Vasopressors & inotropes

SPECIALIZED MEDICATIONS - CRITICAL

• Anticholinesterases • Fibrinolytics • Paralytics

Z06 Reporting Specialized Delegations Page 1

Z06: Reporting Specialized Delegations

Version: 2017-06-19

Start: 2017-06-19

End:

The Land Emergency Medical Response System Regulation identifies the reporting requirements for delegations by the service and their medical director.

Reporting will take place electronically on a Specialized Delegation Reporting spreadsheet provided by the Office of the Medical Director (OMD).

The spreadsheet will include the following columns:

• Date of revision • Personnel name • Personnel licence number • Level of licensure • Licence expiry date • Service affiliation • Delegated specialized functions per individual

Medical Director and Service Operator Responsibilities

As part of the initial or renewal application for a service licence, medical directors and service operators must attest that they will abide by the processes and standards supporting the delegation of reserved acts as set by the Minister and published in Z04.1 Medical Director Requirements & Responsibilities/Z04.2 Service Operator Requirements & Responsibilities.

As part of initial or renewal application for a service licence, or when there is a change in an employee’s status, service operators must submit a list of specialized medical functions for employees via the electronic format provided by OMD. This form is to be updated and provided to OMD within five (5) working days of a change in an employee’s status of specialized medical functions.

Licensed Personnel Responsibilities

As part of the initial and renewal personnel licence application, personnel must attest that he or she will abide by the processes and standards supporting the delegation of reserved acts as set by the Minister and published in Z04.3 Technician Requirements & Responsibilities.

Every patient encounter requires a patient care record (PCR), even if there was no treatment given or transport rendered. The following is the minimum information required on all PCR’s:

1. Chief complaint & relevant secondary complaints.

2. Any and all information obtained from dispatch report, scene & bystander observations, and history taking, (including collateral history) relevant to the patient’s presenting condition(s); supporting any diagnosis, diagnoses or differential diagnosis; and providing indication for any clinical procedure being performed or medication being administered.

3. Full head-to-toe or focused physical examination (as indicated) relevant to the patient’s presenting

condition(s); supporting any diagnosis, diagnoses or differential diagnosis; and providing indication for any clinical procedure being performed or medication being administered.

4. At least one complete set of vital signs, including GCS and oxygen saturation and glucometry measurements (with appropriate delegations).

5. Clinical reassessments at appropriate intervals as indicated by the patient’s clinical condition, including before and after any clinical procedure or medication administration.

6. Repeat vital signs (full or partial set as indicated) at appropriate intervals as indicated by the patient’s condition.

7. For any and all procedures performed: a. Indications & absence of contraindications b. How the procedure was performed including methods of verifying successful completion (eg.

verification of correct ETI placement) c. Outcome of the procedure, including any recognized complications

8. For any and all medications administered;

a. Indications & absence of contraindications b. Medication name, dose, route and time of administration c. Outcome of the administration, including any recognized adverse effects

9. Use of any operational procedures such as destination policies (eg. Acute Stroke Bypass).

10. Refusal of care rationale.

11. Discharge in the field rationale.

Z07 EMS Branch/ Office of the Medical Director

2017-04-10 Documentation Requirements

Z07 Documentation Requirements Page 1

12. Any possible reportable event, including but not limited to: a. Clinical occurrence & critical incidents b. Workplace health & safety incidents c. Communicable disease or HAZMAT exposures d. Potential child or elder abuse / neglect e. Use of physical / mechanical restraint

13. Other relevant information as required by specific care maps (eg. evidence of open fractures)

14. Any consultation with on-call supervisor or on-line clinical support.

15. Documentation of any orders from non-EMS affiliated physicians including name.

16. Documentation of care provided by non-EMS personnel.

17. Signature and licence number of all EMS personnel involved in the patient’s care.

Z07 Documentation Requirements Page 2

Manitoba Health EMERGENCY TREATMENT GUIDELINES GENERAL

GENERAL - Refusal of Care August 2003 Page G14-1

G14 REFUSAL of CARE The non-transport of patients because of refusal of care is a common occurrence in prehospital care. The EMS personnel must attempt to obtain as thorough a history and patient assessment as possible so that the patient who refuses medical evaluation and treatment has an opportunity to make an informed decision on refusing care. Careful documentation is required whenever care is refused. GENERAL • while patients have the right to refuse medical evaluation and treatment, it is incumbent on the EMS personnel

to first attempt to ensure the following • the patient must be oriented to person, place, and time • there are no signs of significant impairment due to alcohol, drugs, or mental or organic illness • vital signs are normal • patient must have a reasonable understanding of the provisional diagnosis and the risks of refusing

treatment • EMS personnel must take care to ensure that the instructions given to the patient and the family member or

friend present who is willing to assume responsibility for the patient's care are clearly understood. • this information must include

• a reasonable plan of action should the patient’s condition deteriorate and

• how to activate the EMS system if the patient wishes to seek medical evaluation and transport • the patient should be encouraged to seek medical follow-up

→ the following information must be documented on the patient care report

• date, time, and location where patient found • presenting complaint • history and physical examination, including vital signs • mental status examination

• alert and orientated to person, place, time and events • patient not under influence of alcohol, drugs, other substances, or injuries that may impair ability to make

decisions • patient is clearly not a risk to self or others • reason(s) for refusal • consequences of refusal of care reviewed with the patient • information on how to contact EMS if patient changes mind about seeking medical care and transport • other advice given to the patient • identification of police on scene (if applicable) • name of family member or other adult present as witnesses

• record name of person(s) present with patient at disposition → a copy of the refusal of care form must be completed and attached to the patient care report



• if the patient does not meet the above criteria and subsequent to the EMS personnel’s evaluation and assessment of the patient that, in the EMS personnel's judgement, the patient should receive medical assessment, then the following actions should be considered • responsible family members or friends who are present should be enlisted to encourage the patient to

accept transportation • if this fails, the Regional EMS Medical Director or physician designate should be contacted to discuss the

situation • if required, direct communication between the physician and the patient could be conducted to ensure

the patient clearly understands the consequences of their decision to refuse care and to assist in convincing the patient to accept transport for medical assessment

• if these measures fail and the EMS personnel have concerns about the patient's capacity to decide and ability

to make an informed decision to refuse care and transport, the police should be contacted for assistance • if a decision is made that a patient requires medical assessment and is unable to make an informed

decision, and the patient must be transported against their wishes • police must make this decision based on consultation with the on scene EMS personnel and the

Regional EMS Medical Director or their physician designate • if a patient is identified as requiring transport to a health care facility and all attempts to persuade the

patient are unsuccessful, then a decision must be made whether to restrain the patient during transport • EMS personnel should request that the police restrain the patient

→ restraining a patient is not an EMS function → procedure for managing a restrained patient

• explain restraining actions to the patient, family, and others at the scene • use all reasonable precautions to safeguard the welfare of the patient and others

• ensure the patient is not injured in the restraining process or by the restraints • ensure the airway is maintained • position the patient in the recovery position, if possible • document the indication(s) for restraint and action(s) taken • record examinations at regular, frequent intervals while the patient is restrained • police assisting in patient restraint must accompany the patient in the ambulance in case the

restraints need to be removed

→ a number of patients must be transported even if they meet all the criteria for discharge in the field, including: • patients who are a danger to themselves or others

• the decision to transport is done in consultation with the police • victims of child abuse if there is the potential for further abuse • patients who are critically ill or injured

• an exception to this may be a critically ill patient who has a Health Care Directive • EMS personnel should refer to the Appendices – Health Care Directives Act or Medicolegal

Guideline for further information.

• in all but the most minor situations, the patient should be encouraged to accept transportation for medical evaluation

• if there are any doubts regarding transportation, then EMS personnel should err on the side of caution and

safety and undertake transport of the patient, if possible

• patients who are not transported should always be advised to seek further medical attention as indicated by their circumstances or to call for EMS if they wish transportation at a later time



• if the patient initially refuses transport but later changes their mind and requests transport the EMS personnel cannot refuse to transport the patient

• EMS personnel must not attempt to dissuade the patient from transport

• whenever possible, EMS personnel should attempt to obtain a signature from the patient, the patient's care

giver, the patient's proxy or responsible family member confirming refusal of care NOTE → all patients who refuse care must sign a completed refusal of care form

• EMS personnel must recognize that the form does not absolve them of the EMS system of medicolegal responsibility

• a person is determined to have the capacity to make health care decisions if he or she is able to understand

the information that is relevant to making a decision and is able to appreciate the reasonably foreseeable consequences of a decision or lack of a decision

• EMS personnel should follow the information laid out in a Health Care Directive or information that is provided

by the patient's proxy regarding instructions contained within the patient's Health Care Directive. There is no onus on the EMS personnel to inquire whether a Health Care Directive exists or whether the Directive has been revoked.

• obtaining the reason for refusal may be useful for the EMS personnel in order to persuade the patient to be

transported • EMS personnel may be required to use creativity and compromise to persuade patients to cooperate with

further evaluation, management, and transportation • there may be reluctance on the part of EMS personnel to contact the police to assist in the transport of a

patient • the risk of legal action against EMS personnel for unlawful confinement or battery must be balanced

against the risk of malpractice and the fundamental needs of a patient who is unable to make an informed decision

• despite all efforts to remain at a safe distance or to avoid becoming involved in a violent situation, there may be

times when EMS personnel find themselves confronted by a violent non-competent patient while attending the patient • if necessary EMS personnel should leave the scene until the police arrive • if they cannot leave the scene then protective actions should be taken • to protect themselves, the patient's family, friends, and the patient from harm it may be necessary for the

EMS personnel to temporarily physically restrain the patient • though restraint of a non-competent patient is normally a police function, the police may be delayed or

not immediately available to undertake the immediate restraint of the suddenly violent patient • EMS personnel should use only the minimum amount of physical restraint required to prevent injury to all

involved



NOTES :

To promote and sustain a safe driving culture and to promote safety for all persons and property in EMS, all EMS personnel must comply with the various Federal, Provincial, Municipal, and local laws, regulations, and Regional Health Authority policies affecting the operation of an ambulance or a designated emergency medical services (EMS) vehicle.

General

In order to operate a vehicle registered as an ambulance or designated emergency medical services (EMS) vehicle the operator must:

• be a minimum of 18 years of age • possess a current valid Manitoba Class 4 driver’s license • possess a current and valid EMS personnel license under the provisions of the Manitoba Emergency

Medical Response and Stretcher Transport Act and Regulation • ensure awareness and compliance with Provincial EMS policies • be familiar with the operation of all EMS voice communication devices and ensure compliance with

Provincial law and EMS service licence holder policies regarding voice communications • ensure familiarity and compliance with the Manitoba Highway Traffic Act at all times • be in compliance with all Provincial and Service policies, standards protocols, procedures and legislation

Operation of an ambulance vehicle or dedicated emergency response vehicle

Section 106 of the Manitoba Highway Traffic Act permits the driver of an emergency vehicle certain privileges. The Act does not excuse the driver from exercising due care, caution, consideration and common sense when operating the emergency vehicle. The operators of EMS vehicles bear the sole responsibility for driving safely, with due regard and could be held liable if deemed responsible for an accident or injury.

Starting in 2014, the Provincial ambulance fleet vehicles are equipped with an ambulance vehicle monitoring system. The ambulance vehicle monitoring system is capable of tracking, recording and reporting ambulance driving operations.

Starting in 2015, the Provincial fleet ambulances will be equipped with an audible notification system. The audible notification system will provide reminders to ambulance operators when speeds or driver handling of the ambulance vehicle are outside of pre determined acceptable ranges.

When transporting a patient the ambulance operator must adjust the speed and handling of the vehicle so as to provide as smooth a transport as possible; this not only minimizes any detrimental effects of the transport but will provide a safe environment for the treating EMS personnel to attend to the patient. The safe transport, arrival and patient welfare shall always have priority while en route to a dispatched call or to a receiving facility.

Responsibilities of ambulance crew - vehicle operator

• emergency services vehicles must be operated within the limits of his or her own vehicle operators licensure, road conditions, mechanical limitations of the vehicle, and environmental conditions

• emergency services vehicles must be operated using defensive driving techniques focusing on due care caution, common sense and consideration of other drivers, pedestrians, passengers and patients

• the vehicle operator is the "final authority" as to whether a particular response or transport can be safely carried out and should refuse any requests or orders to initiate a trip that he/she feels is unsafe

Z09.1 Emergency Medical Services Branch

2016-05-20 Emergency Vehicle Operation

Z09.1 Emergency Vehicle Operation Page 1

• speed must be adjusted / reduced according to road, traffic, weather, and patient condition • EMS personnel must operate the vehicles in a careful and controlled manner; excessive speed, rapid

accelerations, heavy or hard braking, decelerating, and radical maneuvering of the vehicle are not acceptable practice

• EMS personnel may drive in an emergency mode only when: o dispatched as such to an emergent priority primary call or interfacility transfer o the patient’s condition requires emergent transport (i.e. lights and siren)

• when operating the vehicle in non-emergency mode EMS personnel must: o operate within posted speed limits o respect all traffic control signs and signals

• EMS personnel and all passengers, when an ambulance is in motion, must be secured by a seatbelt. In certain circumstances it may be necessary for EMS personnel to remove their seatbelt to provide patient care, in these situations they must perform only the interventions or care requiring EMS personnel to leave their seat and immediately return to a seat belted position

• use of a communications device while operating a vehicle is restricted to essential communication with either dispatch, the receiving facility, on-line medical control , or other required and approved EMS communication:

o all forms of approved EMS communication should be kept to a minimum o use of mobile cellular, or personal electronic devices is restricted to voice communication for

EMS operational purposes only o refer to section 215 of the Highway Traffic Act for additional information

• never operate an ambulance or other vehicle: o while under the influence of alcohol or while taking drugs or medications, either prescription or

non-prescription, that preclude the operation of machinery, could affect motor skills, could impair judgment or could cause endangerment to any other person in any way

o while at risk for impaired judgment or reflexes due to illness, injury or fatigue

Responsibilities of ambulance crew - patient attendant

• the ambulance crew member responsible for patient care must at all times remain with the patient in the patient care compartment of an ambulance vehicle during transport

Responsibilities of EMS service licence holder

• service license holders must have written policy and procedures which describes the authorized practices for operating an ambulance or EMS response vehicle by their employees or designates

o written policies must include but are not limited to the employer and vehicle operators’ roles and responsibilities included in this Standard (Z09.1) and the Highway Traffic Act

Smoking

Smoking or use of “E” cigarettes or similar products is not permitted in any ambulances or designated emergency medical services vehicles.

Z09.1 Emergency Vehicle Operation Page 2

Emergency Medical Services Emergency Treatment Guidelines

GENERAL: Operation of Ambulance by Fire Fighter

approved September 2006 revised October 2008 G24-1

Within their respective operating mandates, there is a need for cooperation between EMS personnel and fire fighters when responding to emergency situations. Background Existing legislation (The Emergency Medical Response and Stretcher Transportation Act and Regulations under the Act) provides the basis for the standards for operation of land ambulances. Pursuant to subsection 16(2) of the Act, the Minister of Health is empowered to exempt any person from the operation of any provision under Part I where it is considered to be in the public interest to do so and substitute another provision therefore. Discussion It is recognized that there may be extenuating circumstances where both of the emergency medical response personnel licensed under The Emergency Medical Response and Stretcher Transportation Act staffing an ambulance are required to actively provide emergency medical response services in response to an urgent and serious threat to the life and limb of a patient or patients. In these rare circumstances, EMS personnel may need the assistance of fire fighters to drive the ambulance to properly carry out their functions in the best interests of their patients. Requirement A. This Emergency Treatment Guideline is in effect only when a related Ministerial Order pursuant to

subsection 16(2) of the Act is in effect. B. Any license holder that permits licensed EMS personnel to request the assistance of a fire fighter to operate

an ambulance will have a policy and procedure that limits the permission to the following: 1. Both of the emergency medical response personnel licensed under The Emergency Medical Response

and Stretcher Transportation Act staffing an ambulance are required to actively provide emergency medical response services in response to an urgent and serious threat to the life and / or limb of a patient or patients, and

2. Additional emergency medical response personnel licensed under the Act to act as an ambulance operator a. are not available at the scene, and, b. in the opinion of the emergency medical response personnel staffing the ambulance, cannot be

dispatched to arrive at the scene in the time necessary to appropriately address the threat to the life and / or limb of the patient(s), and

C. Where access to supervision is available, the senior EMS person or the EMS person who is currently attending and has responsibility for the patient will obtain the permission of an on-line supervisor or manager who is delegated the authority to provide permission to the EMS personnel.

D. EMS personnel will ensure that the individual that is enlisted to drive the ambulance is properly licensed under The Highway Traffic Act.

E. The license holder will submit a critical occurrence report in accordance with the Manitoba Health and Healthy Living critical occurrence policy.

GENERAL: Operation of Ambulance by Fire Fighter

approved September 2006 revised October 2008 G24-2

Related Discussion 1. EMS personnel may request individuals, who are not licensed as EMS personnel, to assist them at the

scene, in the back of the ambulance, or drive the ambulance in a manner consistent with the capabilities and competence of that person. The purpose of this assistance is to enable the EMS personnel to carry out their responsibility to provide required emergency medical treatment. At all times, the EMS personnel maintain responsibility for the assessment, treatment and outcome of the patient and are responsible for directing and supervising the assistance that is provided by that person and for adjusting care when required. The EMS personnel will have responsibility to ensure that a person providing such assistance is following their direction. EMS personnel will respect the position of the individual who may refuse to assist EMS personnel. The EMS personnel will ensure that documentation reflects the assistance provided by the unlicensed person. There are no reporting requirements if the fire fighter does not drive the ambulance.

2. Official response personnel such as fire fighters may be requested by EMS personnel to move the ambulance at the scene. On this basis, the individual moving an ambulance at the scene for purposes of scene management is practical and reasonable. It is assumed that the individual is duly qualified under the Highway Traffic Act to operate an ambulance. There are no reporting requirements in this instance.

Medical First Response (MFR) refers to the provision of EMS services by agencies operating non-patient-transporting units to provide medical care at an incident scene, either before the arrival of a transporting ambulance, or by providing assistance to an ambulance-based EMS crew while on scene.

Agencies which may provide MFR include (but are not limited to): • Fire departments operating as part of an integrated fire-paramedic service • Independently-operating fire departments • Regionally/municipally employed and operated MFR services • Community-based volunteer MFR services

Operational Requirements for MFR Agencies MFR is a component of an EMS system. In order to provide MFR, an agency must be licensed and meet the following operational requirements:

• MFR agencies must have a written agreement with the regional health authority (RHA) within which the agency operates. A copy of the agreement must be forwarded to the Emergency Medical Services Branch.

• All staff providing MFR must hold a current Manitoba EMS provider licence. The minimal licence level for providing MFR is Technician (formerly EMR).

• MFR agencies must operate under medical direction. Furthermore, each MFR agency will be subject to the same quality assurance processes and practices as a patient-transporting ambulance service.

• MFR agencies will respond to medical incidents only when dispatched by a licensed dispatch centre.

Role of MFR Agencies The roles and responsibilities of MFR agencies are as follows:

• To provide primary EMS response, assessment and treatment to urgent situations where MFR may be able to arrive prior to an ambulance. MFR will be primarily dispatched to high-priority calls (Priority 1, 2 or 3) as defined by the dispatch centre in accordance with Medical Priority Dispatch System (MPDS) protocols.

• MFR may be dispatched to selected lower-priority calls in accordance with dispatch centre protocols. • To provide ambulance-based EMS crews with assistance in the performance of medical procedures (e.g.

CPR) while on scene. • To provide ambulance-base EMS crews with assistance with ancillary tasks (e.g. lifting patients). • Ambulance-based EMS crews may encounter situations in which they believe that MFR may be required

for assistance. In these circumstances ambulance crews may request MFR dispatch through the dispatch centre.

• MFR may, in selected circumstances, be dispatched to an incident without an ambulance also being dispatched. This decision is solely made by the dispatch center as per established protocols.

Scope of Practice As EMS providers, scope of practice will be defined as follows:

• MFR personnel scope of practice is defined within the EMS Protocols and Procedures. • MFR personnel may receive delegated medical acts authorized by the medical director of their

respective service/region in accordance with each individual’s licensing level.

Z10 Emergency Medical Services Branch

2017-04-10 Medical First Response

Z10 Medical First Response Page 1

Z11 Physical Restraint Page 1

1. All licensed EMS services in Manitoba must establish physical restraint protocols and procedures:

a. Licensed EMS services must establish protocols and procedures that comply with their regional protocols and procedures on physical and / or mechanical restraint.

b. Licensed EMS services not affiliated with RHAs, such as basic air ambulances, must establish

protocols and procedures that are in accordance with accepted best practice.

2. In the event that any aspect of a regional procedure cannot be applied in the EMS environment, reasonable alternatives may be established in accordance with accepted best practice.

3. All EMS services must ensure that all personnel are compliant with the regional or service protocols and procedures by ensuring appropriate education and training, in-servicing and resources.

4. All EMS services must ensure that all applications of physical and / or mechanical restraint undergo quality assurance auditing.

5. Physical and mechanical restraint use must be documented on the patient care report (PCR).

Z11 Office of the Medical Director

2017-04-10 Physical/Mechanical Restraint

Emergency Medical Services

Emergency Treatment Guidelines

GENERAL: Other Medical Professional on Scene

approved June 2006 revised October 2008

G23-1

It is well recognized that physicians, nurses, and other health care professionals who are at the scene of an EMS response may feel obliged to render patient care. Despite their willingness to assist, they may be unfamiliar with prehospital care and the protocols and procedures associated with this care. EMS personnel must consider the relative merits and difficulties associated with assistance from medical professionals at the scene. EMS personnel must recognize that although other medical professionals have knowledge and skills that may be valuable in providing care, EMS personnel are trained to provide care in the out-of-hospital environment. It is for this reason that EMS personnel must direct activities at the scene. The other medical professionals may assist EMS personnel and act as a resource, but EMS personnel must provide scene direction and coordination of patient care activities.

GENERAL

EMS personnel have a duty to respond to an emergency, conduct an assessment, and initiate treatment of the patient to the extent possible

a physician or other medical professional who voluntarily offers or renders medical assistance at an emergency scene is generally considered a “Good Samaritan”

if the physician or other medical professional initiates treatment he/she is responsible for the care provided until a transfer of care to appropriate EMS personnel takes place

good patient care should be the focus of any interaction between EMS personnel and physician or other medical professionals

every situation involving a physician or other medical professional will be different, depending on the situation, the patient’s condition, and the physician or other medical professional

in all cases, the physician or medical professional must present EMS personnel with valid identification confirming the individual is appropriately licensed to provide care in Manitoba

INTERACTIONS with PHYSICIANS

if a physician at the scene appropriately* identifies him/herself and wishes to intervene in patient care, EMS

personnel will present the physician with the Non-EMS System Medical Interveners information

the on-scene physician’s requests concerning emergency care and movement of the patient should be followed provided they do not conflict with established guidelines and protocols

if the requests are inconsistent with established guidelines and protocols, the physician should be made aware of this fact

online medical control should be contacted, if available

the on-scene physician’s name, address, telephone number, and other pertinent contact information must be noted in the patient care report

*ideally, appropriate identification is any document that confirms the physician is registered with The College of Physicians and Surgeons of Manitoba

registered physicians have wallet cards documenting their status

if the physician at the scene is unable to provide identification, or is licensed in a jurisdiction other than Manitoba, and the physician (in the judgment of the EMS crew on the scene) appears knowledgeable and willing to provide help, the EMS crew may permit the physician to provide assistance

the ability of a physician to provide potentially life-saving care should not be impeded due to issues of identification and jurisdiction



G23-2

time permitting, in the event identification cannot be confirmed, online medical control should be contacted (if available)

proceed as directed by the online medical control physician

INTERACTIONS with MIDWIVES

refer to the section on EMS Personnel and Midwives in Treatment Guideline M10 – Obstetrical Emergencies

INTERACTIONS with OTHER HEALTH CARE PROFESSIONALS (not including midwives)

if a non-physician health care professional at the scene appropriately* identifies him/herself and wishes to

intervene in patient care, EMS personnel will present the non-physician with the Non-EMS System Medical

Interveners information

non-physician health care professionals have no authority to direct EMS personnel

non-physician health care professionals may possess certain skills EMS personnel do not possess

EMS personnel may request the non-physician health care professional to utilize their skills in the interest of optimal patient care

the on-scene health care professional may be permitted to provide care

any care provided must be within their scope of practice and does not conflict with established EMS guidelines and protocols

if the care is inconsistent with established guidelines and protocols, the health care professional should be made aware of this fact

EMS personnel should maintain patient care and no longer permit the heath care professional to be involved in patient care

online medical control should be contacted, if available

the health care professional’s name, address, telephone number, and other pertinent contact information must be noted in the patient care report

*appropriate identification is limited to any document that confirms the health care provider is registered with the provincial registration authority

registered individuals should have and carry wallet cards documenting their status

in the event identification cannot be confirmed, online medical control should be contacted (if available)

proceed as directed by the online medical control physician

NOTE

EMS personnel

provide care under the auspices of the Regional Health Authority and its Medical Director

can only carry out medical acts as designated by a physician licensed in Manitoba, and only if the acts are within the EMS personnel’s scope of practice

cannot accept direction from non-physician health care providers

this fact should not prevent EMS personnel from utilizing other health care professionals should the need arise and the skills of these professionals be required

under no circumstances should another health care professional be permitted to carry out any intervention that contravenes an established EMS policy, protocol, or guideline unless there is a valid, justified, and medically sound reason to do so

in these exceptional circumstances, advice from physician online medical control should be sought



G23-3

Non-EMS System Medical Interveners Thank you for your assistance. Please be advised that EMS personnel are providing care under the auspices of the Regional Health Authority and its Medical Director, in accordance with policies, procedures, and protocols established by the Emergency Services Branch, Manitoba Health. All procedures permitted and drugs carried are restricted by established protocols. If you are currently providing care to the patient, you will be asked to relinquish care to the EMS personnel. Please do not intervene in the care of this patient unless:

you are requested to do so by the EMS personnel and

capable of assisting or delivering more extensive emergency medical care at the scene. EMS personnel acknowledge your abilities. Under certain circumstances, EMS personnel may request your assistance for particular aspects of care.

If you choose not to relinquish care of the patient, you must be a licensed medical practitioner, continue your patient management, and accept responsibility for the care you provide. The EMS personnel will assist you to

the extent that their protocols and scope of practice permit, but any care provided to the patient will be your

responsibility. The EMS personnel will not assist you in specific deviations from their protocols or permit non-authorized procedures or use or drugs. If you continue to provide patient care, you are required to accompany the patient to the hospital. This is required in order to maintain continuity of care and permit transfer care to the physician at the receiving hospital.

Thank you for offering your assistance during this emergency.

Z13 Non-EMS Physicians Page 1

EMS-affiliated physicians include licensed service local medical directors, the Provincial Medical Director and Associate Medical Directors, and physicians who are members of an established mechanism to provide clinical support (on-line medical control) to EMS personnel.

1. Under most circumstances clinical procedures and medication administration must be in accordance with EMS Protocols & Procedures (Emergency Treatment Guidelines).

2. In exceptional circumstances, licensed technicians in consultation with their EMS on-call supervisor may receive order(s) for medications and procedures from a non-EMS affiliated physician (or an appropriate designate for that physician) provided that all of the following are met.

a. The patient’s clinical condition or the situation is time-sensitive and there is not sufficient time for consultation with an EMS-affiliated physician, and

b. The order is for a procedure or medication that falls within the accepted scope of practice for the technician at their licence level as defined by Z05.1 Delegated Acts – Procedures and Z05.2 Delegated Acts – Medications, and

c. The physician providing the order(s) has sole or shared responsibility for the care of that patient:

i. The physician is directly involved in the patient’s care at a referring facility or is part of the treatment team at the referring facility, or

ii. The physician has accepted and/or will be receiving care of the patient in a receiving facility or is part of the treatment team at the receiving facility, or

iii. The physician has a pre-existing clinical relationship with that patient, such as a primary care physician, and knowledge of the current clinical situation.

3. Except as in item 4 below, all orders must be in written format and appended to the EMS Patient

Care Report (PCR). The orders must include: a. patient’s identifying data b. date and time c. indications for all medications d. parameters for any medication requiring titration e. physician’s signature and printed name

4. While in transit to or from a health care facility, the attendant technician may accept an order by

radio or telephone. The service Medical Director or designate must ensure that a written order (in a format as described in 3 above) is subsequently obtained and attached to the patient’s facility record or PCR.

Z13 Emergency Medical Services Branch/Office of the Medical Director

2015-11-25 Orders from Non-EMS Affiliated Physicians

All MHHLS licensed EMS service, including land and air medical response and stretcher transportation services, must:

1. Establish infection prevention and control (IP&C) protocols and procedures and ensure that all EMS personnel are compliant with the established IP&C protocols and procedures.

a. Regional EMS services must establish protocols and procedures that comply with their regional IP&C protocols and procedures.

b. EMS services not affiliated with an RHA and providing service solely or predominantly within one

RHA, such as non-devolved land medical response services, are required to establish protocols and procedures that comply with the IP&C protocols and procedures of that Region.

c. EMS services not affiliated with an RHA and providing care across Regional boundaries, such as air medical response services, are required to establish protocols and procedures that comply with MHHLS “Routine Practices and Additional Precautions - Preventing the Transmission of Infections in Health Care”.

2. Establish post-exposure (PE) protocols and procedures for EMS personnel and Ensure that EMS personnel are compliant with the established PE protocols and procedures.

a. Regional EMS services must establish protocols and procedures that comply with their regional

PE protocols and procedures.

b. EMS services not affiliated with an RHA and providing service solely or predominantly within one RHA are required to establish protocols and procedures that comply with the PE protocols and procedures of that Region.

c. EMS services not affiliated with an RHA and providing care across Regional boundaries are required to establish protocols and procedures that comply with MHHLS “Integrated Post Exposure Protocol for HIV, HBV and HCV: Guidelines for Managing Exposures to Blood and Body Fluids”.

Web links: • Routine Practices and Additional Precautions: Preventing the Transmission of Infections in

Health Care: http://www.gov.mb.ca/health/publichealth/cdc/docs/ipc/rpap.pdf

• Integrated Post Exposure Protocol for HIV, HBV and HCV: Guidelines for Managing Exposures to Blood and Body Fluids: http:// www.gov.mb.ca/health/publichealth/cdc/protocol/hiv_postexp.pdf


2017-04-10 Infection Prevention & Control / Post Exposure Care

Z14 Infection Control and Communicable Diseases Page 1

http://www.gov.mb.ca/health/publichealth/cdc/protocol/hiv_postexp.pdf

Z15 Controlled Substances Page 1

Some delegated advanced skills carried out by EMS personnel involve the use of controlled substances. Use and storage of these substances in health care settings are monitored closely according to federal and provincial regulations.

EMS services must operate according to their respective regions controlled substances policies, which must be consistent with established provincial and federal legislation.

EMS services not-affiliated with a region must have policies which are consistent with established provincial and federal legislation.


2015-09-22 Controlled Substances

Z16 Legislation Page 1

Z16: LEGISLATION

Version: 2018-10-10

Start: 2018-12-01

End: **

All MHHLS licensed EMS services, including land and air medical response and stretcher transportation services, must ensure that all EMS personnel are familiar with the most current versions and adhere to the following laws of Manitoba, and their associated regulations:

• The Emergency Medical Response and Stretcher Transportation Act • The Personal Health Information Act • The Heath Care Directives Act • The Mental Health Act • The Child and Family Services Act • The Highway Traffic Act • The Public Health Act • The Midwifery Act • The Protection for Person's in Care Act • The Vulnerable Persons Living with Mental Disability Act • The Manitoba Evidence Act • Freedom of Information and Protection of Privacy Act • The Fatality Inquiries Act • The Evidence Act • The Regulated Health Professions Act • The Vulnerable Persons Living with Mental Disability Act • Controlled Drugs and Substances Act

EMS personnel should also be familiar with the following:

• The Apology Act • The Defibrillator Public Access Act • The Good Samaritan Protection Act • Pharmacy Act

http://web2.gov.mb.ca/laws/statutes/ccsm/v090e.php

Old version 2015 New Version

G1 Code of Ethics Z01 Code of Ethics PDF

G2 Scope and Function

Z02 Minimum Requirements for Practice PDF Z03 Delegation of Reserved Acts PDF Z04.1 Medical Director Requirements & Responsibilities PDF Z04.2 Service Operator Requirements & Responsibilities PDF Z04.3 Technician Requirements & Responsibilities PDF Z05.1 Delegated Acts – Procedures PDF Z05.2 Delegated Acts – Medications PDF

G3 Scene Assessment A01 Medical Assessment PDF A02 Trauma Assessment PDF

G4 Triage A03 Multiple Casualty Incident PDF

G5 Primary Survey A01 Medical Assessment PDF A02 Trauma Assessment PDF

G6 Shock

C07A Hypotension & Shock – Adult PDF C07B Hypotension & Shock – Adolescent PDF C07C Hypotension & Shock – Child PDF C07C Hypotension & Shock – Infant PDF

G7 Load and Go A04 Transport PDF

G8 Secondary Survey A01 Medical Assessment PDF A02 Trauma Assessment PDF

G9 Unconscious Patient

E05A Coma & Decreased LOC – Adult PDF E05B Coma & Decreased LOC – Adolescent PDF E05C Coma & Decreased LOC – Child PDF

G10A Obstructed Airway Adult & Child B02Airway Obstruction PDF G10B Obstructed Airway Infant B02Airway Obstruction PDF

G11 Airway Management B01 Airway & Breathing Management – All ages PDF P02 Basic Airway Adjuncts PDF

G12 Dyspnea and Respiratory Distress

E06A Dyspnea & Respiratory Distress – Adult PDF E06B Dyspnea & Respiratory Distress – Adolescent PDF E06C Dyspnea & Respiratory Distress – Child PDF E06D Dyspnea & Respiratory Distress – Infant PDF

G13 Cardiopulmonary Resuscitation C01 Basic Resuscitation PDF

G14 Refusal of Care Z08 Refusal of Care

G15 Determination of Death P13.1 Determination of Obvious Death PDF P13.2 Determination of Still Birth PDF

G16 Emergency Vehicle Operations Z09.1 Emergency Vehicle Operations PDF G17 Medical First Response Z10 Medical First Response PDF G19 Infectious and Communicable Diseases Z14 Infectious Prevention & Control PDF G20 Controlled Substances Z15 Controlled Substances PDF G21 Response to an Expected Death at Home Refer to Health Care Directives Act G22 Automated External Defibrillation C01 Basic Resuscitation PDF G23 Other Professional at Scene Z12 Other Professionals at Scene G24 Operation of Ambulance by Fire Fighter Z09.2 Operation of Ambulance by Fire Fighter M1 Chest Pain E04A Acute Coronary Syndrome PDF M2 Congestive Heart Failure E19A Cardiogenic Pulmonary Edema – Adult PDF

Office of the Medical Director

2017-04-07 Z19.2 Cross Reference to Patient Care Maps & Clinical Care

Procedures

M4 Chronic Respiratory Diseases B01 Airway & Breathing Management – All ages PDF E06A Dyspnea & Respiratory Distress - Adult PDF

M5 Cerebrovascular Accident E15.1A Stroke PDF

M5B Acute Stroke Management

E15.2A Stroke Bypass for Primary Response PDF E15.3 Stroke IFT referred PDF E15.4 Stroke IFT non-referred PDF A06.2 Pre-arrival Notification - Stroke PDF

M6 Seizures

E14.1A Seizures – Adult PDF E14.1B Seizures – Adolescent PDF E14.1C Seizures – Child PDF E14.1D Seizures – Infant PDF E14.2C Febrile – Child PDF E14.2D Febrile – Infant PDF

M7 Diabetic Emergencies

E10A Hypoglycemia & Diabetic Emergencies - Adult PDF E10B Hypoglycemia & Diabetic Emergencies – Adolescent PDF E10C Hypoglycemia & Diabetic Emergencies – Child PDF

M8 Anaphylaxis

E03A Anaphylaxis – Adult PDF E03B Anaphylaxis – Adolescent PDF E03C Anaphylaxis – Child PDF

M9 Abdominal Pain

E01A Abdominal Pain – Adult PDF E01B Abdominal Pain – Adolescent PDF E01C Abdominal Pain – Child PDF

M10 Obstetrical Emergencies

D01 Newborn Care & Resuscitation PDF D02 Prehospital Delivery PDF D03.1 Prolapsed Umbilical Cord PDF D03.2 Breech PDF D03.3 Multiple Gestations PDF D03.4 Shoulder Dystocia PDF D04 Maternal Hemmorhage PDF D05 Preeclampsia & Eclampsia PDF

M11 Poisoning

E12A Overdose & Poisoning – Adult PDF E12B Overdose & Poisoning – Adolescent PDF E12C Overdose & Poisoning – Child PDF

M12 Drug and Alcohol Abuse

E12A Overdose & Poisoning – Adult PDF E12B Overdose & Poisoning – Adolescent PDF E12C Overdose & Poisoning – Child PDF E20A Alcohol & Drug Withdrawal – Adult E20B Alcohol & Drug Withdrawal - Adolescent

M13 Mental Health Emergencies E02A Agitation & Behavioural Emergencies – Adult PDF E02B Agitation & Behavioural Emergencies – Adolescent PDF

M14 Obstetrical Triage pending

T1 Soft Tissue Injuries and Wounds F07 Amputations & Lacerations PDF F09 Impaled Object pending

T2 External and Internal Bleeding F02 Exsanguinating External Hemorrhage PDF T3 Amputations F07 Amputations & Lacerations PDF

T4 Fractures and Dislocations

F06 Fractures & Dislocations PDF P23.1 Basic fracture Management P23.2 Emergency Reduction fractures/dislocations

T5 Central Nervous System Injuries F04 Spinal Motion Restriction PDF F05 Head Injury pending

T6 Eye, Ear, Nose, and Throat Injuries F08 Eye Trauma & Other Emergencies pending P20 Eye irrigation

T7 Chest Injuries pending

T8 Abdominal Injuries

E01A Abdominal Pain – Adult PDF E01B Abdominal Pain – Adolescent PDF E01C Abdominal Pain – Child PDF

T9 Genital Injuries pending T10 Burns F03 Burns PDF T11 Sexual Assault pending T12 Trauma Triage pending E1 Cold Related F10 Frostbite & Hypothermia

E2 Heat Related

E07A Fever & Hyperthermia - Adult PDF E07B Fever & Hyperthermia - Adolescent PDF E07C Fever & Hyperthermia - Child PDF E07D Fever & Hyperthermia - Infant PDF

E3 Near Drowning

E06A Dyspnea & Respiratory Distress – Adult PDF E06B Dyspnea & Respiratory Distress – Adolescent PDF E06C Dyspnea & Respiratory Distress – Child PDF E06D Dyspnea & Respiratory Distress – Infant PDF

A1 EMS Drug Formulary Medication Documents

A2 Routes for Drug Administration

P21.1 Medication Administration – Level 1 PDF P21.2 Medication Administration – Level 2 PDF P21.3 Medication Administration – Level 3 PDF P21.4 Medication Administration – Level 4 PDF P21.5 Medication Administration – Level 5 PDF

A3 Splinting and Immobilization

F04 Spinal Motion Restriction PDF F06 Fractures and Dislocations PDF P23.1 Basic Fracture Management P23.2 Emergency Reduction

A4 Glasgow Coma Scale N/A A5 APGAR Scoring Scale N/A A6 Normal Vital Signs H01 Pediatric Vital Signs PDF A7 Age-appropriate Weights N/A A8 Fleetnet Radio Identification Numbers N/A A9 Priority for Patient Transport A04 Transport PDF A10 Personal Health Information Act Refer to applicable legislation A11 Health Care Directives Act Refer to applicable legislation A14 Medical Abbreviations N/A A15 Metric Conversion N/A A16 Process for Revision of Treatment Guidelines N/A

A17 Tubes Maintenance

P19.1 Maintenance of Established Devices – Level 1 PDF P19.2 Maintenance of Established Devices – Level 2 PDF P19.3 Maintenance of Established Devices – Level 3 PDF P19.4 Maintenance of Established Devices – Level 4 PDF

A18 End of Life Directive Refer to applicable legislation A19 Pulse Oximetry P18 Pulse Oximetry PDF Other patient care maps E 17A Undifferentiated Symptoms

E 17A Undifferentiated Symptoms G01.1 Preparation for Ground Transport G01.2 Preparation for Air Transport P15 Foreign Body Removal from Skin Documentation requirements

Acetaminophen M02 Analegisics / Antipyretic PDF Airway Obstruction with Foreign Body P01.1 Forceps Removal of Supraglottic FB PDF

P01.2 Forceps Removal of Tracheal FB PDF Anaphylaxis M05.1 Epinephrine for Anaphylaxis PDF Antiemetic M04 Antiemetics PDF Acetylsalicylic Acid (ASA) for Suspected Acute MI M37.1 Antiplatelet: Acetylsalicylic – ASA PDF Bradycardia (Unstable) C05.A,B,C,D Bradycardia – All ages PDF Bronchospasm M15 Bronchodilators PDF Cardiac Arrest - Asystole C02 Advanced Resuscitation PDF

M05.2 Epinephrine CPA PDF Cardiac Arrest - Discontinuing Resuscitation at scene P13.3A Discontinuing Resuscitation for Refractory

Asystole PDF Cardiac Arrest – Dialysis Patient C02 Advanced Resuscitation PDF

M10 Hyperkalemia Therapy PDF Cardiac Arrest - Hypothermia C02 Advanced Resuscitation PDF

M05.2 Epinephrine CPA PDF Cardiac Arrest – Pulseless Electrical Activity C02 Advanced Resuscitation PDF

M05.2 Epinephrine CPA PDF Cardiac Arrest – Trauma C04 Trauma PDF

M05.2 Epinephrine CPA PDF Cardiac Arrest – Trauma Discontinuation Resuscitation Trauma P13.3A Discontinuing Resuscitation for Refractory

Asystole PDF Cardiac Arrest - Ventricular Fibrillation / Pulseless VTach C02 Advanced Resuscitation PDF

M05.2 Epinephrine CPA PDF M14 Amiodarone CPA PDF M24.1 Magnesium Sulfate for CPA PDF

C-spine Clearance F04 Spinal Motion Restriction PDF Double Lumen Airway Using Esophageal Tracheal Combitube P03 Blind Insertion Airway Devices PDF Drug Infusion Maintenance P07 Maintenance of Established Infusion PDF End Tidal Co2 Detection P11 Continuous Waveform Capnometry Hypoglycemia E10 Hypoglycemia PDF

M06.1 Glucose PDF M06.2 Dextrose PDF M06.3 Glucagon PDF

Infusion Pump Maintenance P19 Device Maintenance PDF Intraosseous Cannulation and Infusion P08 Intraosseous PDF Intravenous Cannulation and Infusion P09 IV Cannulation PDF

M30 Intravenous fluid PDF Midazolam Administration M07 Midazolam PDF Morphine Administration E08 General Pain Management PDF

M03 Opioid Analgesics PDF Nitroglycerine for Ischemic Chest Pain E04 Acute Coronary Syndrome PDF

M21A Nitroglycerine PDF Nitrous Oxide – Oxygen Administration Pending Suspected Opioid Overdose Management using Naloxone E12 Overdose and poisoning PDF

M11 Naloxone PDF Obstretrical Triage Pending Oxytocin for Postpartum Hemorrhage D04 Maternal Hemorrhage PDF

M16 Oxytocin PDF Pulmonary Edema E06 Dyspnea & Respiratory Distress PDF

M15 Bronchodilators PDF M21A Nitroglycerine PDF M09A Furosemide PDF P22.1A CPAP ventilation PDF

Seizure Management E14.2 Seizures all ages PDF M7 Midazolam PDF M36 Propofol

Tachycardia - unstable C06 Tachycardia (unstable) all ages PDF M01 Adenosine PDF P12 Defibrillation, Cardioversion, Pacing PDF

Taser Dart removal P15 Foreign Body Removal from Skin Tension Pneumothorax P17A Needle thoracostomy PDF Tracheal Intubation P04A,B,C,D Tracheal Intubation all ages PDF Twelve lead 12/15 Lead ECG P14.1 ECG Acquisition PDF

P14.2 ECG Interpretation PDF

Z20 Home Births Page 1

Midwives operate in Manitoba under the Midwifery Act and Regulation to the Midwifery and Consequential Amendments Act.

EMS personnel may be called to a home birth or health care facility where a midwife is in attendance:

when attending a home birth with a midwife present, EMS personnel should obtain the midwife's name and the midwife’s assistant’s name, and record them on the patient care report

Each region may have additional policies in place for the interaction between midwives and other health care providers:

EMS personnel should be current on local policies relating to working with midwives

In planning a home delivery attended by a midwife, the College of Midwives of Manitoba recommends that the midwife involved use their "Standard for Planned Out of Hospital Births" protocol.

the midwife is responsible for planning for the home birth and this planning must include: o identifying the distance to a health care facility capable of performing operative obstetrics o access to telephones and other communication resources o weather conditions o availability of emergency support systems o psycho-social support factors

the midwife must also ensure that a back-up plan is in place in the event of an emergency. The back-up plan must include: o presence of an adequately trained second birth attendant is present at each home birth o making prior contact with:

local emergency medical service

nearest hospital or health care facility capable of dealing with an obstetrical emergency o ensuring satisfactory transport service for mothers and infants can be initiated within 30 minutes o ensure a satisfactory means of communication is available

The College of Midwives of Manitoba recommends that the midwife should pre-register the home birth with Emergency Medical Services if:

the birth is to occur in a location at a distance of at least thirty minutes journey from a hospital with surgical facilities, using a method of transportation ordinarily used for health care purposes in the area

the mother lives in a location with difficult or obscure access

The College of Midwives of Manitoba recommends that the midwife:

provide written notification of a planned home birth to the appropriate ambulance dispatch office when the mother has reached 37 weeks gestation

provide written registration of a planned home birth to the appropriate ambulance dispatch office within 48 hours scheduled date of the birth

In most instances, the midwife will take the lead role in delivering the baby:

EMS personnel will be called to transport the mother and baby to an appropriate health care facility should the need arise

If there are complications associated with the delivery, the midwife may request EMS personnel to assist with the delivery and transport the mother and baby to a health care facility.

EMS personnel should assist the midwife within the limits of their occupational competencies, level of training, and protocols

EMS personnel are responsible for providing emergency care for the mother and baby when the care required is beyond the scope of practice of the midwife, this includes but is not limited to: o seizures o cardiac arrest o trauma o shock

Under normal circumstances, the midwife must arrange for a second birth attendant to assist in the home delivery.

Z20 EMS Branch / Office of the Medical Director

2015-04-23 Home Births & Midwives

Z20 Home Births Page 2

EMS personnel are responsible to assume care of either the mother or newborn if a second birth attendant is not present or the condition of either mother or baby is compromised:

if the patient's condition requires interventions outside the scope of practice of the midwife but within the practice for the EMS personnel, EMS personnel should initiate treatment as per the Patient Care Map o EMS personnel should assist the midwife to care for the patient(s) within the EMS personnel’s scope of

practice

If transport is required for either or both the mother and baby:

the appropriate personnel should accompany the most critical patient in the ambulance

the midwife may elect to accompany the most critical patient and assist with treatment en route

if one patient is transported without the midwife in attendance, the EMS personnel should treat as per the appropriate Patient Care Map

If EMS personnel are confronted with a situation where roles and responsibilities are unclear, EMS personnel may avail themselves to physician on-line medical control (if available).

Z21 Physicians & IFT Page 1

Physicians are ultimately responsible to ensure that patients are as stable as possible and remain so during interfacility transfer (IFT). If there is any concern about a patient deteriorating en route and the management of that patient may require medical level intervention, the physician must accompany the patient or ensure that reasonable mechanisms are in place to support that patient. In many circumstances however patients can be safely transported and managed by non-physician health care providers. Physicians do not routinely have to accompany patients on IFT carried by EMS providers if both of the following conditions are met:

1. The care required or potentially required by the patient while en route is within the accepted scope of practice of the EMS personnel.

a. “Accepted scope of practice” means in accordance with the procedures and functions as approved by the Minister and as set out in the Manitoba Emergency Treatment Guidelines (Z05.1 and Z05.2).

i. The scope of practice for EMS personnel licensed as “Technician”, “Technician-Paramedic”, or “Technician-Advanced Paramedic” is established by MHHLS EMS Branch directive.

ii. The scope of practice for aeromedical attendants licensed as “Technician-Advanced Paramedic” is established by MHHLS EMS Branch directive.

iii. The scope of practice for aeromedical attendants licensed as “Registered Nurse” is established by the College of Registered Nurses of Manitoba (CRNM).

2. The patient’s condition is stable at the time of dispatch or the condition is time sensitive. a. “Stable” means an absence of any and all critical conditions or issue(s).

i. “Critical conditions or an issue” means actual or potential conditions involving, but not limited to, the airway, ventilatory system and/or circulatory system affecting safe patient transport.

1. “Actual” means as currently known or suspected. 2. “Potential” means reasonably foreseeable.

b. In some exceptional circumstances a condition may be time sensitive. If in the opinion of the referring, receiving or most responsible physician the time to definitive specialty care is judged to be clinically more important than physician accompaniment and there would be no additional benefit to physician presence, the condition of patient stability need not be met.

In all circumstances where the physician does not accompany the transporting EMS staff, the management of any critical condition(s) or issue(s) should be accomplished in the safest manner possible, within the accepted scope of practice of the EMS staff. The referring, receiving or most responsible physician must remain readily available to provide direct on-line control to the EMS crew and/or clinical support to local health care provider(s). The OMD supports the right of EMS providers to restrict patient care to their accepted scope of practice. EMS personnel can contact on-line medical support or the EMS supervisor on duty for assistance if required.

Z21 Operations EMS Branch / Office of the Medical Director

2015-06-03 Physician on Interfacility Patient Transfer All ages

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