(gr, BLANKET CONTRACT The City 0" sea?le Blanket Contract Date Change Order PURCHASING SERVICES 700 SIhAvenue? Suite #4112 0000002687 04/13/2016 #2 PO Box 94687 Seattle, WA 98124-4687 Payment Terms Freight Terms Prepaid Allowed: FOB: Destination Buyer: FAX: Phone: Sara utt 206?233?51 55 206-684-0456 Vendor 0000162852 American Medical Response Ambulance Service, Inc. 13075 Gateway Drive, Suite 100 Tukwila, WA 98168 Ship To: Seattle Fire Department 301 2"d Avenue South Seattle, WA 98104-2618 Contact: Kristen Moody Phone 206-605-3331 E-mail: Bill To: Same as Ship to American Medical Response Ambulance Service, Inc. was awarded a contract for providing BLS Ambulance Services to the City of Seattle, as a result of and per the Contract for Basic Life Support Ambulance Services entered into between the City of Seattle and AMR on 06/01/2011, in receipt. Original contract term: 06/01/2011 through 05/31/2016. Change Order #1 issued 04/04/2013 to increase prices, per attachment in receipt. Change Order #2 Term: 06/01/2016 through 05/31/2018 issued to extend. Change Order #2 per voicemail messages left on 03/30/2016 and 04/06/2016, C. Atwood/K. Moody. In all other respects, this contract remains unchanged. Authorized Signature/Date ,7 xC/g BLANKET CONTRACT The City of Seattle PURCHASING SERVICES 700 5th Avenue, Suite #4112 PO Box 94687 Seattle, WA 98124-4687 Blanket Contract # Date 0000002687 Payment Terms 04/04/13 Change Order #1 Freight Terms N/A Prepaid & Allowed: FOB: Destination Buyer: FAX: Phone: Sharon Rothwell 206-233-5155 206-684-8310 Vendor #: 0000162852 American Medical Response Ambulance Service, Inc. 13075 Gateway Drive, Suite 100 Tukwila, WA 98168 Contact: Rodney Chandler Phone #: 206-605-3331 Fax #: 206-444-4589 E-mail: Rod.chandler@amr.net Ship To: Seattle Fire Department 301 2nd Avenue South Seattle, WA 98104-2618 Bill To: Same as Ship to American Medical Response Ambulance Service, Inc. is awarded a contract for providing BLS Ambulance Services to the City of Seattle, as a result of RFP-SFD-2687 conducted by the City. The term of the Contract is five (5) years with one, two (2) year extension. See attached contract. Original contract term: 6/1/11 – 5/31/16 Change Order #1: 4/4/13, Price increase per attachment #2. Authorized Signature/Date BLANKET CONTRACT The City 01' Seattle Blanket Contract Date Change Order PURCHASING SERVICES NIA 7'00 Aven ue, Suite #41 12 000000263? 6? PO Box 9468? Seattlel Payment TEFITIS FrEIght Terms Prepaid 8: Allowed: FOB: Destination Buyer: FAX: Phone: Sharon Rothwell 206-233-5155 206634-8310 Vendor 0000162852 Ship To: American Medical Response Ambulance SEWICB. lnG- Seattle Fire Department 1307'5 Gateway Drive, Sunte 100 301 2nd Avenue south Tukw?a, WA 98158 Seattle, WA 93104-2618 Contact: Rodney Chandler am To, Phone #2 206-605-3331 E-mail: Rod.chandler@amr: net American Medical Response Ambulance Service, Inc. is awarded a contract for providing BLS Ambulance Services to the City of Seattle, as a result of conducted by the City. The term of the Contract is five (5) years with one, two (2) year extension. See attached contract. Original contract term: 6l1l'11 - 5131116 gait Authorized Signaturel'Date 573?)? City of Seattle CONTRACT FOR BASIC LIFE SUPPORT AMBULANCE SERVICES This Contract is made effective June 1, 2011, and entered into by and between the City of Seattle (?Seattle?), a Washington municipal corporation; and American Medical Response Ambulance Service Inc. (?Contractor?), a corporation of the State of Delaware, and authorized to do business in the State of Washington. Contractor Business American Medical Response Ambulance Service Inc. Name of Rodney Chandler, General Manager Representative Contractor Address 13075 Gateway Drive, Suite 100 Tukwila, WA 98168 Contractor Phone (206) 605-3331 Contractor Fax (206) 444-4539 Contractor E-mail Rod.chandler@amr.net WHEREAS, the purpose of this contract is to provide the City of Seattle with Basic Life Support Ambulance Services; and WHEREAS, Contractor was selected as a result of a Request for Proposal process initiated December 8, 2011 as required by Seattle Municipal Code (SMC) 2060.106; NOW, THEREFORE, in consideration of the terms, conditions, covenants, and performance of the scope of work contained herein, as attached and made a part hereof, Seattle and Contractor mutually agree as follows: Term: The term of this agreement shall be ?ve (5) years from the effective date. The term may be extended at the option of the City for an additional two (2) years. Such extensions shall be automatic, and shall go into effect without written confirmation, unless the City provides advanced notice of the intention not to renew. The Contractor may also provide notice not to extend, but must provide such notice at least one (1) year prior to the otherwise automatic renewal date. Scope of Work Summary: The Contractor shall provide Basic Life Support emergency ambulance services 24 hours per day, 365 days per year within the corporate limits of The City of Seattle in response to requests from the Seattle Fire Department SFD is the ?rst responder for all 9-1-1 EMS calls, performs triage and interrogation of all patients, and 1of37 provides the transport services for ALS Medical Emergencies within The City of Seattle. The Contractor shall transport patients as directed by SFD. Contractor will operate as the primary emergency ambulance service within the Seattle service area. SFD may refer patient transfers to other ambulance companies for a variety of reasons including but not limited to: where the patient has requested transfer by another ambulance company; where the Contractor has failed to respond to a SFD request for transfer; and in times of major emergencies or disasters. 1.0 Definitions: De?nitions in WAC 246-976-010 and RCW18.73.030 as now or hereafter amended apply to this Agreement. In addition, unless the context plainly requires a different meaning, the following words and phrases used in this Agreement mean: ?At Scene Time? means the point in time when the ambulance unit is physically stopped or staged at the correct scene. In situations where the unit has been directed to respond to a location other than the scene, staging areas for hazardous materialslviolent crime incidents, or non-secured scenes, ?at scene time? shall be the point in time the ambulance unit reports it has arrived at the designated staging location. In instances when an ambulance unit fails to report when it has arrived ?at scene," ?at scene time" shall mean the point in time of the first communication or status transmission from a mobile data terminals verifiany transmitted from the scene by that ambulance unit. ?City? means the City of Seattle, Washington. ?Contractor? means [American Medical Response Ambulance Service Inc]. ?Critical care transport" or means the inter?facility transport of a patient whose condition requires ALS services. ?Patch-Through" calis are those 9-1-1 calls sent directly from SF dispatch or Seattle Police Department units in the ?eld to the Contractor?s dispatcher without SFD responding to the scene with initial rapid response. ?Request Received" means the point in time when the incident address is confirmed by the Contractor?s dispatcher. ?Response Time? means the time interval from the time when the Contractor?s data records system electronically time stamps the call requesting service to the time an ambulance unit arrives at the scene of the incident. "Unit Hours? means amount of time calculated in hours that a fully staffed and equipped apparatus is available for service. 2of 2. Patient Care Performance 2.1 Standards: The Contractor shall continuously meet or exceed the patient care performance standards set forth in State law, Seattle and King County Patient Care Protocols for Basic Life Support, and SFD Operating Guideline 5001: Aid and Medic Response (Appendices A 8: D) as well as any revisions. Additionally the Contractor shall have its own medical direction and performance review programs. 2.2 Transport Protocols: 2.2.1 SFD will provide the rapid initial response to all requests for emergency medical assistance within the City. Except in limited circumstances, the Contractor shall not provide rapid initial response or ALS to medical emergencies within the City. 2.2.2 When the Contractor arrives at an incident scene in response to a SFD request, the Contractor?s personnel shall report to the ranking SFD of?cial or his or her designee in charge of the emergency who shall, when appropriate, designate the mode of transponation and the hospital to be utilized. Patients in a life-threatening or potentially life-threatening condition shall be transported to area hospitals as directed by SFD. 2.2.3 The Contractor shall immediately request an SFD response if the Contractor receives a request for assistance from a citizen for any medical emergency. 2.2.4 Critical Care Transport (CCT) of patients. The Contractor will record and routinely review with SFD all direct requests from medical providers to transport critical but stable patients between medical facilities for the purpose of assessing which were subsequently picked up by SFD. The Contractor shall refer to SFD all requests for inter?hospital transportation involving critically ill but unstable patients that it cannot adequately handle medically. 2.2.5 In the event the Contractor?s dispatcher determines a SFD rapid initial response is required, the call will be immediater patched back to SFD. 2.2.6 In the event the Contractor?s unit arrives on-scene and determines that an ALS reSponse is required, the Contractor shall immediately notify SFD. 2.2.7 Due to the nature of BLS transport within the City of Seattle EMS system, all transports to area hospitals from the scene of an incident shall be non-priority (Code Yellow - without lights and sirens) unless the patient?s condition is actively deteriorating in which case, SFD dispatch should be immediately notified. If transport subsequently becomes priority (Code Red with lights and sirens) the incident should be reported in the next performance report for an exception from liquidated damages. 2.2.8 In the event that a BLS transport being handled by the Contractor becomes an emergency requiring the services of an ALS technician, the Contractor shall immediately request the services of SFD. 2.3 Patient Care Performance Standards Monitoring: 30f 3? The Contractor shall ensure its personnel complete documents related to responses and patient care, including, but not limited to, Pre-hospital Care Reports (PCRs), Against Medical Advice AMA Summary Audits, and ambulance response failurerr unusual occurrence forms and other forms needed for providing such patient care. Such documents shall be made available to the City upon request. The City reserves the right to require the use of certain forms or to approve the content of any Contractor forms. if, in the City?s judgment. the Contractor forms are not adequate to provide the information needed for quality patient care, The Contractor shall provide to SFD by the 10th day of each calendar month a report summarizing its patient care performance during the preceding month. The Contractor and SFD shall meet to discuss matters of concern and to review adherence to patient care performance standards and transport protocols. The purpose of these meetings will be to maintain open and proactive communications, resolve problems, and to provide a forum to confer about patient care performance on the part of the Contractor or SFD. 3. Response Time Performance 3.1 Requirements: In order to reliably track and report on response time performance, the Contractor is required to have a Computer Aided Dispatch (CAD) system that has the features and capacity as detailed in Appendix F. The Contractor shall meet or exceed the response time standards set forth in subsection 3.2, 3.3 and 3.4 below and as summarized in Appendix E. Standards are to be met both Citywide and within each of the five tire battalions which are displayed in Appendix B, Battalion Map. . Response times shall be measured in minutes and seconds, and shall be timed? stamped by the Contractor's computer aided dispatch (CAD) system. Liquidated damages for exceeding the response time standard will be assessed as provided in Section 11 (Finance). Recognizing that operations are impacted by weather and other occurrences of nature as well as the state of regional and national disasters, SFD has established three operational levels with different standards for response time andror liquidated damages. Regardless of operational level, Code Red will mean responses made with both lights and sirens in operation while Code Yellow means without either lights or siren in operation. 3.2 Level 1 Level 1 is de?ned as that time during which there is no extraordinary weather or heightened circumstances due to manmade threat or natural disasters either locally or nationally. Level 1 Operation needs no special declaration. It is the baseline which may be changed by SFD to Level 2 or Level 3. 3.2.1?Code Red" Response Performance Standard. The Contractor shall respond to ninety-two percent of all ?Code Red? requests within each of the ?ve fire battalions which have not been exempted from such time performance standards within 9:59 minutes and an overall response time performance of ninety-four percent on a city wide basis. Liquidated damages for late arrival on scene will be assessed per 401? 3? minute for up to ?ve minutes after which liquidated damages for a failed response will be assessed 3.2.2 ?Code Yellow? Response Performance Standard The Contractor shall respond to ninety?two percent of all "Code Yellow" requests within each of the ?ve ?re battalions which have not been exempted from such time performance standards within 14:59 minutes and an overall response time performance of ninety-four percent on a city wide basis. Liquidated damages for late arrival on scene will be assessed per minute for up to five minutes after which liquidated damages for a failed response will be assessed. 3.2.3 "Patch-Through? Calls Response Performance Standard - The Contractor shall respond to ninety-two percent of all ?Patch-Through? requests within each of the ?ve fire battalions which have not been exempted from such time performance standards within 14:59 minutes and an overall response time performance of ninety- four percent on a city wide basis. Liq uidated damages for late arrival on scene will be assessed per minute for up to ?ve minutes after which liquidated damages for a failed response will be assessed. 3.3 Level 2 Level 2 includes times of severe weather, other natural conditions or circumstance that impede routine delivery of service that are beyond the control of the Contractor and are typically affecting the entire City. The Fire Chief shall determine when Level 2 Operations commence and when Level 2 Operations return to Level 1 Operations. 3.3.1 ?Code Red? Response Performance Standard The Contractor shall respond to ninety?two percent of all ?Code Red" requests within each of the ?ve ?re battalions which have not been exempted from such time performance standards within 14:59 minutes and an overall response time performance of ninety-four percent on a city wide basis. Liquidated damages for late arrival on scene will be assessed per minute for up to five minutes at which time the request is considered non?responsive and liquidated damages for a failed response will be assessed. 3.3.2 ?Code Yellow? Response Performance Standard. The Contractor shall respond to ninety-two percent of all "Code Yellow? requests within each of the ?ve ?re battalions which have not been exempted from such time performance standards within 19:59 .and an overall response time performance of ninety-four percent on a city wide basis Liquidated damages for late arrival on scene will be assessed per minute for up to five minutes at which time the request is considered non-responsive and liquidated damages for a failed response will be assessed. 3.3.3 ?Patch-Through? Response Performance Standard - The Contractor shall respond to ninety two percent all patch-through requests within each of the five ?re battalions which have not been exempted from such time performance standards within 19:59 minutes, and an overall response time performance of ninety-four percent on a city wide basis Liquidated damages for late arrival on scene will be assessed per minute for up to ?ve minutes at which time the 50f 3? request is considered non-responsive and liquidated damages for a failed response will be assessed. 3.4 Level 3 Level 3 includes times of signi?cant service deterioration within the city because the Contractor has re?deployed local resources elsewhere and thus degraded the minimum coverage plan that was approved by the City. The Contractor shall notify SFD of any occurrences where local assets are dispatched outside of the City. Response time requirements remain the same as for Level however, because the Contractor has opted to remove from service resources to fulfill the performance standards in this contract, the SFD will need to deploy its own resources to provide BLS transport and to subsequently charge the Contractor for this additional expense to the city. 3.5 Performance Incentive: For any calendar month, SFD will waive liquidated damages for late arrivals that are not considered failed responses, if the following conditions are met: a The Contractor meets or exceeds the response time standards for ninety ?ve percent of requests which have not been exempted from such time performance standards Citywide and The Contractor meets or exceeds ninety two percent requests which have not been exempted from such time performance standards within each of the ?ve ?re battalions. 3.6 Response Time Performance Monitoring: Performance reports created by the Contractor are to be based on veri?able data from its CAD system. The Contractor shall provide to SFD by the 10th day of each calendar month a draft report detailing its response time performance citywide and within each of the ?ve fire battalions during the previous month. Along with this report, the Contractor is to submit any requests for exemptions from the imposition of liquidated damages. The Contractor shall document each instance wherein a response was in excess of the response performance standard and for which a liquidated damage exemption is being sought and shall detail the reasons for such an exemption request based on the guidelines for exemptions in Section 11 (Finance). SFD will respond to requests for exemption within five business days of receipt of the exemption request. The Contractor shall submit the ?nal report or request further review of denied exemptions within 5 business days of receipt of the SFD response. Failure by the Contractor to meet submission dates will result in automatic waiver of exemption requests. Quality Improvement Program: The Contractor shall take all steps necessary to eliminate causes of poor response time performance and upon request shatl provide the City with a summary of such corrective actions. In addition to the Quality Improvement reviews described in Patient Care Performance (Section the reporting in Response Time Performance (Section 3 above) and its program for Quality Improvement for Dispatch Sofa? Communications (Section 5.3 below),the Contractor shall develop and maintain a Quality Improvement Program that includes, at a minimum: 3.7.1Review of incident reports with SFD and other governmental agencies to evaluate Contractor?s performance; 3.7.2Establishment of a Quality Improvement peer review committee designed to review documentation and performance of pre-hospital care personnel 3.7.3 Observation and evaluation of EMTs in the ?eld, including patient assessment, diagnosis, protocol selection and compliance, and procedural competency. 3.8 Inquiries and Complaints: The Contractor shall provide prompt written responses and follow-up to inquiries and compiaints within 15 business days. Such responses shall be subject to the limitations imposed by patient con?dentiality restrictions. Contractor shall, on a basis, submit to SFD a list of all complaints received and their respective dispositions. Copies of such complaints will be made available to the City upon request. Any complaint received by the City shall be forwarded to the Contractor for action and the Contractor shall forward the disposition of the complaint to the City within ?fteen business days of receipt. 3.9 Electronic Patient Care Reporting AMR uses an application to collect patient information. AMR will provide access to Seattle Fire Medical personnel and others, as appropriate. The key goals are: a Seattle Fire can do Quality Assurance on AMR performance 0 Additional medical information can be used by Seattle Fire Medical Services 4. Factors of Production All equipment, supplies, facilities, locally assigned personnel, and other production factors utilized by the Contractor in performing the services under the Agreement resulting from this solicitation, whether furnished by the City or not, shall be devoted to the services under the Agreement. 4.1 Initial Coverage Plan: During the ?rst three (3) months of operations, the Contractor shall adhere to the initial coverage plans submitted in its proposal or a modi?cation of that plan which is approved by the City. Thereafter, in the Contractor's discretion, the plan of coverage may be altered by the Contractor to produce the required response time performance with the greatest possible ef?ciency. 4.2 System Status Management PlanIUnit Hour Utilization: The Contractor is encouraged to be innovative in developing and implementing sophisticated techniques for maximizing unit hour utilization. The Contractor shall submit to the City for review, its system status management plan detailing its TofS?r deployment methods and unit levels to provide coverage within the Seattle service area. 4.3 Dispatch and Communications 30f 3? 4.3.1 City Provided Radio Frequency: The City shall provide radio frequency for use between the SFD and the Contractor. The City will provide the primary SFD -to - Contractor communication system channel for Contractor's use including authorization to use a designated channel of the SeattlefKing County 800 radio and repeater system. 4.3.2 Furnishing of Dispatcthommunication Equipment and Personnel: The Contractor shall furnish, operate, maintain. and replace or upgrade all dispatch and communication equipment. radios, telephone equipment, computer aided dispatch system equipment, including hardware and software supporting the interface and security technology, communication infrastructure enhancements (such as CAD upgrades, mobile data terminals, automatic vehicle locators, etc.) and all other equipment and software necessary for the provision of emergency and non-emergency BLS services. All personnel employed as dispatchers shall be trained in an appropriate manner. 4.3.3 Computer Aided Dispatching: The Contractor shall provide a CAD system to record dispatch information for all requests for services and install and maintain an interface to the SFD CAD system as described in Appendix E. This system must meet the following requirements: 4.3.3.1 Allow SFD Dispatchers to electronically transmit 9-1-1 call and incident information from the SFD CAD system directly to the Contractor's CAD system. 4.3.3.2 Transmit the real time status and location (gee-coordinates) for all Contractor ambulances that serve the City. 4.3.3.3 Record the SFD incident number for every ambulance dispatched to an SFD incident and includes the SFD incident number and other unique key data with the status and location information. 4.3.3.4 Record all patch through calls and report on response time by Contractor and other factors reported for non-patch through cails. 4.3.3.5 The Contractor will provide all networking, firewall and other communications equipment necessary to support the interface and will provide all network connections whether leased from a commercial carrier or otherwise. 4.3.3.6 The Contractor will provide the technology described herein to ensure 99.99% availability of the network connecting the two CAD systems and 99.99% availability of the technology maintained at the Contactor?s premise. 4.3.3.7 Operation and availability of the interface will not excuse the Contractor from meeting the performance and other standards described in this solicitation. Additional details for the interface and other technical requirements are contained in Appendix E. 4.3.4 CAD Interfacer?lnformation Provide real-time dispatch information from Seattle Fire to AMR on medical incidents. This allows AMR to pre-stage their ambulances in order to respond to medical transport requests. The key goals are: - Improve transparency between the agencies Provide information sharing to bene?t both organizations - Increase efficiencies in requesting and obtaining transport services 5. Dispatch and Communications The Contractor shall record and maintain for a minimum of 365 days by tape or other voice recording media all radio and telephone communications with and between personsfagencies requesting ambulance service, its units, personnel, and the Contractor's EMS Communications Center, including time track. Such recordings and records shall be made available to the City upon request. 5.1 Emergency Alerting Devices: The Contractor shall equip each ambulance unit with emergency alerting devices and installed radio communications equipment capable of notifying ambulance personnel of response needs. In addition, each ambulance unit shall contain at least one portable two?way radio to provide the driver or attendant with alerting and two-way communications capabilities when away from the ambulance unit. 5.2 Cooperation in Upgrading City?s System: The Contractor shall cooperate with the City during its planning and implementation of upgrades and enhancements to the City's dispatch and communications system- 5.3 Quality Improvement Program for Dispatch and Communications: The Contractor shall develop and maintain an internal Quality Improvement (Ql) program for its dispatch/communications center, which shall, at a minimum, include a mechanism for the identi?cation and resolution of problems or potential problems related to dispatch and communications; and a center Ql committee that meets regularly to consider the following issues: receipt of call, compliance with prescribed call triage guidelines, appropriate dispatch procedures, unit coverage and unit utilization, system status management plan including posting locations, all call response time elements, and crewidispatch rapport. The Contractor shall meet with personnel from the SFD Alarm Center to discuss quality improvement issues related to the dispatching and the dispatch personnel located at the SFD Alarm Center. 6. Ambulance Vehicles The Contractor shall furnish, operate, maintain and replace as necessary any and all 9033? ambulance vehicles, equipment and supplies. 6.1 Vehicle Specifications: vehicles shall be of a Type I, II, or and shall meet or exceed the higher of the current Federal 622 standards and applicable State of Washington requirements. Vehicles must be of a condition and mileage consistent with section 6.4 below to be able to ful?ll the BLS patient care and transport requirements of the contract. Replacement vehicles shall meet the then current Federal standards at the time of the vehicle being piaced into service, except where such standards con?ict with State of Washington standards, in which case the higher standards shall prevail. 6.2 Vehicle Report: The Contractor shall maintain and provide to the City a complete listing of all vehicles including reserve vehicles used in the performance of the Contract, including their license and vehicle identi?cation numbers, and the name and address of the lien holder, if any. Changes in the lien holder, as well as the transfer of ownership, purchase, or sale of vehicles used under the contract shall be reported to the City within ten (10) calendar days of such occurrences. 6.3 Minimum Inventory of Vehicles: The Contractor shall furnish a suf?cient number of ambulances equipped for emergency and non-emergency BLS ambulance services to maintain a surplus of ambulances in excess of peak hour coverage requirements in the City. The Contractor shall maintain a minimum vehicle inventory and on-board equipment equal to 125% of peak ambulance coverage. 64 Vehicle Replacement Program: The Contractor shall develop and implement a vehicle replacement program that incorporates provisions to rotate older vehicles out of front line service. Gasoline powered units shall be replaced with units that comply with 6.1 prior to 125,000 miles and diesel powered units shall be replaced prior to 225,000 miles with vehicles in compliance with 6.1. 6.5 Vehicle Equipment and Supplies: Each ambulance unit shall, at all times, maintain an equipment and supply inventory suf?cient to meet Seattle and King County Patient Care Protocols for Basic Life Support. (Appendix A and D) 6.6. Ambulance Unit Maintenance: All vehicles, equipment and supplies shall be maintained in a clean, sanitary, and safe mechanical condition at all times. The Contractor shall provide a vehicle maintenance program that is designed and conducted to achieve high standards of reliability appropriate to a modern emergency and non-emergency BLS ambulance service by utilizing appropriately trained personnel knowledgeable in the maintenance and repair of ambulances, developing and implementing standardized maintenance practices, and incorporating an automated maintenance program record keeping system. Vehicle Markings and Advertising Restrictions: All advertising and markings on ambulance units shall emphasize the emergency telephone number. The advertising of other telephone numbers for any type of emergency service is not permitted. 10 0137 6.8 Disaster Response Vehicle: The Contractor shall provide an equipped Disaster Response Vehicle. This vehicle will be kept in good working condition and will be available for emergency response to the scene. The vehicle should not be operated as an ambulance unit for day?to-day operations, but may be used as a supervisor vehicle. This vehicle may carry personnel and equipment to the disaster site. This vehicle may not be included in the SFD deployment plan and is not used for day to day operations. It is stationed at the Seattle Operation location, and the unit is continually in ?ready? mode. It is capable of operating as a mobile command post the unit is equipped with all required patient care and communications equipment including medical supplies, necessary tracking supplies, maps radios, and cellular telephones. The following is a list of equipment included in the vehicle: - 20 extra backboards and straps Three cases of cervical collars 20 head immobilization sets One case of splints for legs and arms Oxygen equipment Bandaging material First aid supplies Blankets Personal protective equipment 69 Bariatric Response Unit: The Contractor shall provide a Bariatric Response Unit that meets the standards identified in 6.1 above and is suitable fortransporting patients identified to be of greater weight than is suitable for the normal fleet of ambulances. The Bariatric Response unit is a Type 3 bariatric unit designed to transport patients weighing anywhere from300 to 1600 pounds, the bariatric unit will be fitted with a power-winch system and a specially designed stretcher that can be pulled of lowered down sturdy metal ramps. It is outfitted to include the identical equipment and supply configurations as the remainder of the fleet. 6.10 Vehicle Collision Reporting: The Contractor shall report all vehicle collisions involving Contractor's vehicles. 7. Contractor?s Personnel 7.1 Staf?ng: Each ambulance unit responding to requests for BLS service shall have at least two personnel who are certi?ed and accredited as Basic Life Support Emergency Medical Technicians, as de?ned in RCW18.73 and WAC 246-976 as now or hereafter amended. 7.2 Driver Training and Area Knowledge: Prior to driving any ambulance pursuant to this Agreement, the Contractor?s ambulance operators must successfully complete an Emergency Vehicle Operator's Course approved by the City. Additionally each driver shall have knowledge of the geographic area of the City of Seattle and the ability to read maps prior to driving any ambulance units. 11of3? 7.3 Safety Program: The Contractor shall take actions necessary to minimize the risk of disease or injury to all employees, and provide a safety and risk program that instructs all employees in safety practices and prepares them to avoid risks. The Contractor shall establish a safety committee that is representative of all departments of the Contractor's local operation, with the exception of strictly administrative ones, that meets on a regular basis to review and make recommendations regarding the Contractor's operations as it applies to issues of risk and safety. The SFD shall be invited to participate in all safety committee meetings. 7.4 Work SchedulesNVorking Conditions: The Contractor shall utilize reasonable work schedules and shift assignments that provide adequate working conditions. The primary concern is patient care, and the Contractor shall utilize management principles that ensure that field personnel working extended shifts, part-time jobs, voluntary overtime, or mandatory overtime, are not exhausted to an extent that may impairjudgment or motor skills. Because of the wide variety of management practices utilized throughout the industry, no specific requirements or restrictions regarding work schedules and working conditions shall apply. The City reserves the right to view schedules prior to implementation and to review them at any time. If events warrant such action, the City may require revision of the established work schedule to address rest periods for extended shifts and standards limiting the use of back-to-back shifts and mandatory overtime, as deemed necessary to protect patients from the possibility of error caused by exhaustion of ?eld personnel. 7.5 Compensation and Fringe Benefits: The Contractor shall provide its employees with compensation and fringe bene?ts to promote a professional and motivated work force. The combined compensation and fringe benefit program for field personnel, on- site management, and EMS dispatch personnel should provide a financial bene?t to those personnel that is, at least, substantiaily equivalent to the average rate of compensation for similar private sector ?eld personnel in similar sized and cost-of?living areas of the United States. These speci?c wage or salary packages should be structured so that the overall combination of wages, bene?ts, shift schedules, working conditions, and factors related to job satisfaction will work to reduce employee turnover. Other employee incentives such as retirement savings programs are encouraged. 7.6 New Employee Recruitment, Screening, and Orientation Program: The Contractor shall operate an aggressive, stringent, and comprehensive program of initial and ongoing personnel recruitment, screening, and orientation designed to attract, select, and thoroughly orient, prior to ?eld or EMS dispatch placement, individuals who are among the industry's most qualified candidates for EMS employment. It is important to stress that the recruitment, selection and retention of high quality on- site management personnel are paramount to the success of this program. Therefore, Contractor is highly encouraged to select such personnel carefully. 12 of 37 The Contractor will provide a reasonable opportunity for the work force of the previous provider to seek employment opportunities with the Contractor. 7.7 Employee Training and Orientation of City's EMS System: The Contractor shall coordinate with SFD to provide supervisory, ?eld, and dispatch personnel assigned to the City with an orientation on the City's EMS System prior to ?eld assignment. This program shall be subject to the review and approval of the SFD. Additionally, the Contractor shall grant SFD access to information regarding the Contractor's personnel, equipment and operation to assure compliance with contract terms for these areas. 7.8 Character and Competence of Personnel: The Contractor shall ensure that its personnel conduct themselves in a professional and courteous manner. The Contractor's personnel shall be competent, holders of required permits or certificates in their respective trades or professions and shall undergo background checks and drug testing as a condition of employment. The City may demand the removal of any employee or subcontractor of the Contractor for misconduct or incompetent or negligent performance. Such persons shall not be allowed to perform services on this contract with the City without the written consent of the City. 8. Additional Contactor Responsibilities 3.1 Outside Work. The Contractor may do other work within the City limits scheduled transports, non-ambulance medical transportation, special event standby coverage, HMOI?Government contract work, etc.), provided the outside work does not negatively affect the Contractor's peak load capacity, disaster readiness, and overall efficiency, and does not detract from the Contractor's contractual obligations to the City. Requests for service andior contractual obligations outside of the city in other regions which would draw down the Contractor?s resources below 125% of peak coverage will be subject to approval by SFD. 8.2 Major Emergency and Disaster Response within the City of Seattle Limits. The Contractor acknowledges that the City is entering into an Agreement with the Contractor for the benefit of the public. The Contractor shall consider the City as its ?rst priority and shall make its best effort to provide BLS services to the City in a timely manner. The Contractor shall develop a plan for the immediate recall of personnel to staff units during multi-casualty situations; times of peak overload, or major emergency and disaster situations. This plan shall include the ability of the Contractor to aiert off- duty personnel. The Contractor shall participate in training programs and exercises designed to upgrade, evaluate, and maintain readiness of the City?s EMS system's disaster and multi-casualty response system. 8.3 Public Information and Education: The Contractor shall participate in Seattle and regional EMS system public education and information programs including press relations, explanations regarding rates, regulations and system operations, increasing 13of3T public awareness and knowledge of the EMS system, injurylmortality preventionfreduction, and general health and safety promotion. 8.4 Integration of Services: Contractor shall integrate its services with the services of other EMS System participants including first responder agencies, public safety agencies, hospitals, other health professionals, and neighboring ambulance provider agencies. In addition to the other provisions set forth in this RFP, Contractor shall be an active participant in the Regional EMS System. 8.5 Mutual Aid Agreements. The Contractor may enter into and use mutual aid agreements with other private ambulance providers to augment the Contractor?s services during peak load periods Seafair) or during major emergency and disaster responses. Prior to execution of such mutual aid agreements, the Contractor shall submit the agreement to SFD for review and approval. 9. Local Administrative Office The Contractor shall maintain an administrative office within twenty miles of SFD Headquarters, 301 AVE S, Seattle, WA 98104. 10. Inspections At any time during normal business hours, and as often as may reasonably be deemed necessary, the City representatives and the EMS Medical Director(s), may observe the Contractor's operations. Additionally, the Contractor shall make available for their examination and audit, all contracts, invoices, materials, payrolls, inventory records, records of personnel (with the exception of con?dential personnel records), daily logs, conditions of employment, all operational and procedure policy manuals, excerpts or transcripts from such records, all relevant ?scal records and other data related to all matters covered by this contract. City representatives and the EMS Medical Director(s), may, at any time, and without notification, directly observe Contractor's operation of its EMS Communications Center, maintenance facility, or any ambulance post location, and a City representative and the EMS Medical Director(s), may, at any time, ride as a third person on any of the Contractor's ambulance units, provided however, that in exercising this right to inspection and observation, such representatives shall conduct themselves in a professional and courteous manner. shall not interfere in any way with Contractor's employees in the performance of their duties, and shall, at all times, be respectful of Contractor's employerlemployee relationship. The City?s right to observe and inspect Contractor's business office operations or records shall be restricted to normal business hours, and reasonable noti?cation shall be given by Contractor in advance of any such visit. The Contractor will cooperate with and respond to the Seattle Fire Department, the EMS Medical Director and the City on all matters related to the provision of emergency and non-emergency BLS ambulance services. 1414.31E 37 11. Finance 11.1 Billing, Collections and Reporting: The Contractor shall be responsible for all billing and collection functions related to BLS transport services The Contractor shall perform all such billing and collection functions in a professional and courteous manner and in accordance with applicable federal, state and local laws, regulations, procedures and policies including, without limitation, collection and credit reporting laws. The Contractor will not attempt to collect fees at the scene, in route, or upon delivery of the patient to a health facility for services rendered. The Contractor shall maintain billing and accounts receivable information. The Contractor shall provide, within ninety (90) days after the end of each of the Contractor's ?scal years, data that clearly identify collection rates and compliance with rate structure, and the preliminary balance sheet and income statement for its operations within the City. The City shall have the right to examinefaudit ?nancial records at any reasonable time. The City will maintain con?dentiality of submitted ?nancial records and statements, subject to the requirements of law. 11.2 Contractor Payments to the City 11.2.1 Payment: The Contractor shall make an annual payment of $509,000 payable in equal payments of $42,417 to the City to cover the City?s costs of administering the Agreement and providing resources to support BLS transport. Such costs include and are not limited to: 11.2.1.1 The costs associated with the dispatch of and communication with EMS providers, including the Contractor?s use of the City?s radio frequency and the City?s equipment, hardware, software, and maintenance to support such frequency; 11.2.1.2 The City?s incremental cost associated with monitoring Contractor?s compliance with the Agreement; and, 11.2.1.3 The City?s incremental cost associated with medical control and quality assurance. 11.2.1.4 This payment amount shall be adjusted annually for inflation by the Seattle, Tacoma, and Bremerton CPI. 11.2.2 One Time Payment: Immediately upon execution of the Agreement, the Contractor shall pay to the City of Seattle a total of $300,000 toward the City?s acquisition of an emergency response vehicle to be utilized in support of this agreement and for hardware and software to upgrade and support dispatch, Computer Assisted Dispatch (CAD) and other technology to support BLS patient care over the life of the contract. 15 of3? 11.3 Compensation and Rates 11.3.1 Compensation: The Contractor?s sole ?nancial compensation for services rendered under the Agreement shall be the rates billed and collected from patients and responsible third parties. The City, local tax support, or subsidy shall not fund any services provided by Contractor. 11.3.2 Rates: The rates shall be all inclusive and shall be the sole compensation for services rendered under the Agreement. There shall be no additional charges to the patients or third parties for disposal supplies). The City, local tax support, or subsidy shall not fund any services provided by the vendor. The rates are based on the contract in the RFP. The rates shall remain ?rm and ?xed for the ?rst year of the Agreement. Thereafter, the contractor may request annual adjustments based on the CPI. BLS - Non-Emergency Base Rate per Transport: $580.00 Mileage Rate per mile $17.68 BLS - Emergency Base Rate per Transport: $729.00 Mileage Rate per mile $17.68 Except as required by law, the Contractor shall charge customers resulting from the scope of this Agreement the rates not to exceed those proposed on the Fee PrOposal Form. Except as required by law or as approved by the City, the Contractor shall charge all customers for BLS transports resulting outside the scope of this Agreement and occurring within the City limits rates no less than the rates proposed on the Fee Proposal Form. This restriction does not apply to any other contracts. 11.4 Liquidated Damages This Agreement provides for the payment by the Contractor of liquidated damages in certain circumstances of nonperformance, breach and default. Each party agrees that the damaged party's actual damages in each such circumstance would be dif?cult or impossible to ascertain and that the liquidated damages provided for herein with respect to each such circumstance are intended to place the damaged party in the same economic position as it would have been in had the circumstance not occurred. Nothing in this Section shall be construed to limit any remedies, including termination, provided for herein with respect to any nonperformance, breach or default by the Contractor. The Contractor shall pay liquidated damages to the City for failure to meet patient care standards and response time standards described in Section 2 which details performance standards for the three operational levels. Every call that does not adhere to the performance standards shall ?rst be classified as an alleged performance failure. Each alleged performance failure shall be investigated by the Contractor and evaluated by the City. The City shall determine whether there were appropriate or acceptable extenuating circumstances that caused or signi?cantly contributed to the performance failure. The Contractor shall pay liquidated damages to the City for all performance 16 of3? failures that are determined to be the fault of the Contractor and not the result of an extenuating circumstance. All payments for liquidated damages shall be payable to ?The City of Seattle.? 1?of37 11.4.1 For each Level 1 Operations code yellow request (including patch throughs) that exceeds 14:59 minutes, the Contractor shall be assessed liquidated damages at a rate of sixty dollars per minute or fraction thereof for each minute late up to ?ve minutes. For any response greater than 5 minutes late, the Contractor shall be deemed to have failed to respond to the request and a total of six hundred dollars ($600) in liquidated damages will be assessed for a failed response. 11.4.2 For each Level 1 Operations code red request that exceeds 9:59 minutes, the Contractor shall be assessed liquidated damages at a rate of sixty dollars per minute or fraction thereof for each minute late up to ?ve minutes. For any response greater than 5 minutes late, the Contractor shall be deemed to have failed to respond to the request and a total of six hundred dollars ($600) in liquidated damages will be assessed for a failed response. 11.4.3 For each Level 2 Operations code yellow request (including patch throughs) that exceeds 19:59 minutes the Contractor shall be assessed liquidated damages at a rate of sixty dollars per minute or fraction thereof for each minute up to ?ve minutes. For any response greater than 5 minutes late, the Contractor shall be deemed to have failed to respond to the request and a total of six hundred dollars ($600) in liquidated damages will be assessed for a failed response. 11.4.4 For each Level 2 Operation code red request that exceeds 14:59 minutes, the Contractor shall be assessed liquidated damages at a rate of sixty dollars per minute or fraction thereof for each minute up to five minutes. For any response greater than 5 minutes late, the Contractor shall be deemed to have failed to respond to the request and a total of six hundred dollars ($600) in liquidated damages will be assessed for a failed response. 11.4.5 For each Level 3 Operations code yellow request (including patch throughs) that exceeds 14:59 minutes, the Contractor shall be assessed liquidated damages at a rate of sixty dollars per minute or fraction thereof for each minute late up to ?ve minutes. For any response greater than 5 minutes late, the Contractor shall be deemed to have failed to respond to the request and a total of six hundred dollars ($600) in liquidated damages will be assessed for a failed response. 11.4.6 For each Level 3 Operations code red request that exceeds 9:59 minutes, the Contractor shall be assessed liquidated damages at a rate of sixty dollars per minute or fraction thereof for each minute late up to ?ve minutes. For any response greater than 5 minutes late, the Contractor shall be deemed to have failed to respond to the request and a total of six hundred dollars ($600) in liquidated damages will be assessed for a failed response. 11.4.? For Level 3 Operations, the contractor will be invoiced for additional actual costs incurred by the City for use of its personnel and vehicles to ?ll the coverage gap created by the Contractor removing resources that were needed to fulfill the terms of this agreement. 11.4.8 For Dropping Below 125% of Peak Coverage during Level One and Two Operations: For any day that the Contractor fails to have adequate vehicle inventory to cover 125% of peak coverage, the Contractor shall be assessed liquidated damages at a rate of ?ve thousand dollars ($5,000) per day. These liquidated damages would not apply during level 3 operations when other remedies as detailed in section 11.5 below are in force. 11.4.9 Liquidated Damages for Failure to Properly Eq uiplStaff Unit: Any deployed unit failing to meet the minimum required equipment, supplies and staffing shall be assessed liquidated damages as a missed call at a rate of $600. Such units must be immediately removed from service until the de?ciency is COrrected. 11.4.10 Liquidated Damages for Failure to Furnish Required Documentation: in the event Contractor fails to furnish required information, reports, or documentation, the City shall notify the Contractor of such failure. If the Contractor does not furnish the information, report, or document within the time period speci?ed, the City may, at its option, impose liquidated damages of sixty dollars ($60.00) per day for each item of such information, report, or document until the requested item is provided. Such liquidated damages shall not be applied in cases where the cause of such reporting de?ciency was beyond the Contractor's reasonable control. 11.4.11 Liquidated Damages for Mechanical Failure: If an ambulance experiences a mechanical failure (breakdown) while transporting a patient to a hospital, liquidated damages of six hundred Dollars ($600) will be assessed for each occurrence. 11.4.12 Liquidated Damages for Failure of Crew to Report: Liquidated damages of six hundred dollars ($600) will be assessed for failure of the ambulance crew to report its on-scene arrival to the dispatch center. 11.4.13 Liquidated damages of six hundred dollars ($600) will be assessed for each incident where the City determines that the crew, dispatchers, or management personnel of the Contractor reported a false on-scene arrival time. 11.4.14 Liquidated Damages for not transporting code yellow (without lights and sirens) as required by subsection 2.2.7 will be assessed at one hundred dollars ($100) per incident. 11.5 Level 3 Remedies Consistent with section 3.4, Level 3 Operations: Failure of the Contractor to notify the City of its intent to so deploy such resources is grounds for termination of this contract. 13of37 To avoid these system wide impacts on public safety created by the contractor removing local resources, the Seattle Fire Department would need to put on duty more of its units and personnel to provide BLS transport capability lost due to the Contractor?s action. The Contractor shall be responsible for all costs associated with deployment of additional units due to the need to operate at Level 3. Responsibility for these costs is in addition to the liquidated damages imposed for the contractor to meet performance requirements by the Contractor?s units detailed in Section 11.4.5 and Section 11.4.6. 12. Liquidated Damages Exemptions The Contractor may apply for and the City may grant exemptions to liquidated damages resulting from situations beyond the Contractor's control that cause unavoidable delay or no response. SFD shall examine each request for exemption and shall take into consideration the Contractor?s system status management plan, staf?ng levels, dispatch times, in-service times, traf?c, street blockages, and other in?uencing factors. If SFD determines the circumstances warrant, SFD shall grant an exemption to liquidated damages resulting from the response time performance standards. To be eligible for such an exemption, the Contractor shall apply for the exemption in accord with the terms of section 3.6. 12.1 Concurrent Responses: In the event three or more units are simultaneously committed to one incident and two or more additional units are concurrently responding to at least two other separate incidents, SFD may grant an exemption for each unit starting with the third incident. 12.2 Declared disaster: In the event an emergency is officially declared SFD may grant exemption to liquidated damages resulting from response time performance standards for all units during the declared emergency. 12.3 Multiple Unit Response: In the event two or more units are simultaneously committed to one incident, the ?rst arriving unit shall be held to the response time standard. SFD may grant an exemption for each unit starting with the second unit provided the units arrive at the scene within 19:59 minutes. 12.4 Response Location Errors: In the event SFD provides an inaccurate address, or if the location does not exist, SFD shall grant a response time exemption. 12.5 Response Location Change: In the event SFD changes the incident location and the change delays the unit?s response time because the unit must reroute farther than one city block to respond to the call, SFD may grant an exemption. 12.6 Canceled Request: In the event a request is canceled prior to or at the unit?s arrival on scene for reasons other than exceeding the maximum response time standard, SFD may grant an exemption. 12.? Response Delayed by Accident: In the event the unit is involved in an accident and cannot continue to respond to the call, SFD will grant an exemption provided the 19 of37 accident is not the fault of the ambulance unit. 12.6 Reducedepgraded Response: In the event SFD reduces the priority of the response from a Code Red to a Code Yellow or upgrades the response from a Code Yellow to a Code Red, the response shall be considered a Code Yellow response. 13. Invoicing and Payment of Liquidated Damages No more frequently than and at least quarterly, the City shall invoice Contractor for any liquidated damages assessed during the prior period. The Contractor shall pay the liquidated damages within 30 days of receipt of invoice. 13.1 Appeal of Liquidated Damages Assessment During Level One and Two Operations: In instances when the City?s Contract Administrator, at the request of the Contractor, has reviewed the circumstances for imposing liquidated damages, and determined that the grounds are suf?cient to justify the imposition of the liquidated damages, the Contract Administrator shall report the Contractor's appeal and the reasons for denial to the Seattle Fire Chief. The Contractor shall have the right to appeal such ruling to the Seattle Fire Chief within 2 weeks. The determination of the Fire Chief shall be ?nal. 13.2 Liquidated Damages Adjustment. Liquidated damages may be adjusted annually by the City in an amount not to exceed the rate of inflation for the period since the last adjustment. 14. Breach of Agreement- The City considers any breach of the Agreement a serious situation and will seek remedies commensurate with the severity and magnitude of the event. Remedies could include but are not limited to corrective measures, liquidated damages, probation or suspension, or termination of the Agreement. It is the intent and desire of the City to maintain a good working relationship with the Contractor while at the same time ensuring service to the community. 15. Aggregated Failure. Without limiting the breadth of Section 14, if in any contract year the Contractor maintains a response time performance level at less than 90% compliance in any four (4) months or two (2) consecutive months, the City shall have the right to terminate the Agreement. 16.0 Taxes, Fees and Licenses 16.1 Taxes, Fees and Licenses: The Contractor shall pay, before delinquency, all taxes, levies, and assessments arising from its activities and undertakings under this Agreement; taxes levied on its property, equipment and improvements; and taxes on the Contractor's interest in this Agreement. 16.2 Licenses and Similar Authorizations: The Contractor, at no expense to the City, shall secure and maintain in full force and effect during the term of this Agreement all 20 of 3? required licenses, permits, and similar legal authorizations, and comply with all requirements thereof. 17.0 Contract Notices, Deliverable Materials and Invoices Delivery The City of Seattle agent for Contract changes shall be the City of Seattle Buyer named below, hereinafter referred to as ?Buyer.? Contract notices such as change requests, shall be delivered to the Buyer at the following addresses (or such other address as either party may designate in writing): If delivered by the U.S. Postal Service, it must be addressed to: Sharon Rothwell City of Seattle Purchasing and Contracting Services PO Box 94687 Seattle, WA 98124-4687 If delivered by other than the U.S. Postal Service, it must be addressed to: Sharon Rothwell City of Seattle Purchasing and Contracting Services Seattle Municipal Tower r00 5th Ave, #4112 Seattle, WA 98104-5042 Phone: 206-684-8310 Fax: 206-233-5155 E-Mail: Sharon.rothweli@seattle.qov Project work and communications shall be delivered to the SF BLS Transport Contract Administrator: City of Seattle, Seattle Fire Department Attention: Asst Ch Hepburn Address: Seattle Fire Department 301 Second Avenue South Seattle. WA 98026 Phone: (206)-386-1404 18.0 Representations Contractor represents and warrants that it has the requisite training, skill and experience necessary to perform all its obligations under this Agreement and is appropriater accredited and licensed by all applicable agencies and governmental entities. 19-0 Inspection. The BLS Ambulance service at all times, shall be Subject to inspection by and approval of the City, but the making (or failure or delay in making) such inspection or approval shall not relieve Contractor of responsibility for performance of the Work in accordance with this Contract, notwithstanding Seattle?s knowledge of defective or non-complying performance, its substantiality or the ease of its discovery. Contractor shall provide 21 of 3? suf?cient, safe, and proper facilities and equipment for such inspection and free access to such facilities. 20.0 Performance. Acceptance by Seattle of unsatisfactory performance with or without objection or reservation shall not waive the right to claim damage for breach, nor terminate the Agreement, nor constitute a waiver of requirements for satisfactory performance of any obligation to be performed by Contractor. 21.0 Af?rmative Efforts for Utilization of Women and Minority Subcontracting and Employment, Non discrimination in providing services a. Employment Actions: Contractor shall not discriminate against any employee or applicant for employment because of race, religion, creed, age, color, sex, marital status, sexual orientation, gender identity, political ideology, ancestry. national origin, or the presence of any sensory, mental or physical handicap, unless based upon a bona ?de occupational qualification- Contractor shall take af?rmative action to ensure that applicants are employed, and that employees are treated during employment, without regard to their creed, religion, race, age, color, sex, national origin, marital status, political ideology, ancestry, sexual orientation, gender identity, or the presence of any sensory, mental or physical handicap. Such action shall include, but not be limited to employment, upgrading, promotion, demotion, or transfer; recruitment or recruitment advertising, layoff or termination, rates of pay, or other forms of compensation and selection for training. b. In accordance with Seattle Municipal Code Chapter 20.42, Contractor shall actively solicit the employment and subcontracting of women and minority group members when necessary and commercially useful for purposes of ful?lling the scope of work required for this Contract. Contractors shall actively solicit subcontracting proposals from subcontractors as needed to perform the work of this contract, from quali?ed, available and capable women and minority businesses. Contractors shall consider the grant of subcontracts to women and minority companies on the basis of Substantially equal proposes in the light most favorable to women and minority businesses. At the request of Seattle, Contractor shall furnish evidence of the Contractor?s compliance with these requirements. c. If upon investigation, the Director of Executive Administration finds probable 22 of cause to believe that the Contractor has failed to comply with the requirements of this Section, the Contractor shall noti?ed in writing. The Director of Executive Administration shall give Contractor an opportunity to be heard, after ten calendar days? notice. If, after the Contractor?s opportunity to be heard, the Director of Executive Administration still ?nds probable cause, sihe may suspend the Contract andlor withhold any funds due or to become due to the Contractor, pending compliance by the Contractor with the requirements of this Section. d. Any violation of the mandatory requirements of this Section, or a violation of Seattle Municipal Code Chapter 14.04 (Fair Employment Practices), Chapter 14.10 (Fair Contracting Practices), Chapter 20.45 (City Contracts - Non? Discrimination in Bene?ts), or other local, state, or federal non-discrimination laws, shall be a material of contract for which the Contractor may be subject to damages and sanctions provided for by the Contract and by applicable law. In the event the Contractor is in violation of this Section shall be subject to debarment from City contracting activities in accordance with Seattle Municipal Code Section 20.70 (Debarment). 22.0 Equal Employment Opportunity. All Contractors must comply with federal Executive Order 11246, ?Equal Empioyment Opportunity,? as amended by Executive Order 11375, ?Amending Executive Order 11246 Relating to Equal Employment Opportunity," and as supplemented by regulations at 41 CFR part 60, ?Office of Federal Contract Compliance Programs, Equal Employment Opportunity, Department of Labor. 23.0 Civil Rights Act Title VI. The Contractor must comply with the provisions of the Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq). The law provides that no person in the United States shall, on the grounds of race, color or national origin, be denied the bene?ts of, be excluded from participation in, or be subjected to, discrimination under any program or activity receiving federal financial assistance. 24.0 Publicity. No news release, advertisement, promotional material, tour, or demonstration related to Seattle?s use of the Contractor?s services performed pursuant to this Agreement shall be produced, distributed, or take place, without the prior, specific written approval of the City?s Project Manager or hisiher designee. 25.0 Proprietary and Confidential Information 25.1 Contractor understands that any records (including but not limited to its proposal submittals, this Agreement, and any other contract materials) it submits to the City, or that are used by the City even if the Contractor possesses the records, are public records under Washington State law, RCW Chapter 42.56. Public records must be disclosed upon request unless a statute exempts them from disclosure. The Contractor also understands that even if part of a record is exempt from disclosure, the rest of that record generally must be disclosed. 25.2 If the City receives a public disclosure request made pursuant to RCW Chapter 42.56, the City will not assert an exemption from disclosure on behalf of the Contractor. For materials that the Contractor has properly marked, the City will notify the Contractor of the request and postpone disclosure for ten business days to allow the Contractor the opportunity to file a lawsuit seeking an injunction to prevent the release of documents pursuant to RCW 42.56.540. Any noti?cation is provided as a courtesy and 23 of 3? is not an obligation on behalf of the City. Unless the Contractor obtains and serves an injunction upon the City before the close of business on the tenth business day after the date of the noti?cation, the City may release the documents. It is the Contractor?s discretionary decision whether to ?le the lawsuit. 25.3 In order to request that material not be disclosed until receipt of notification of a public disclosure request, you must identify the specific materials and citations very clearly on the City Contractor Questionnaire that you believe are exempt from disclosure. The City will not withhold material for noti?cation if the Contractor simply marked confidential on the document header, footer, stamped on all pages, or offered a generic statement that the entire document is protected. Only material speci?cally listed and properly cited on the Contractor Questionnaire will be temporarily withheld until the City provides notification of a public disclosure request. 254 If the Contractor does not obtain and serve an injunction upon the City within 10 business days of the date of the City?s noti?cation of the request, the Contractor is deemed to have authorized releasing the record. 25.5 If the Contractor does not submit a request within the Vendor Questionnaire. the Contractor is deemed to have authorized releasing any and all information submitted to the City. 25.6 Notwithstanding the above, the Contractor must not take any action that would affect the City?s ability to use goods and services provided under this Agreement or the Contractor's obligations under this Agreement. 25.7 The Contractor will fully cooperate with the City in identifying and assembling records in the event of any public disclosure request. 26.0 General Legal Requirements A. General Requirement: Contractor, at no expense to Seattle, shall comply with all applicable laws of the United States and the State of Washington; the Charter and ordinances of Seattle; and rules, regulations, orders, and directives of their administrative agencies and the of?cers thereof. Without limiting the generality of this paragraph, the Contractor shall speci?cally comply with the following requirements of this section. B. Licenses and Similar Authorizations: Contractor, at no expense to Seattle, shall secure and maintain in full force and effect during the term of this Agreement all required licenses, permits, and similar legal authorizations, and comply with all requirements thereof. C. Taxes: The Contractor shall pay, before delinquency, all taxes, import duties, levies, and assessments arising from its activities and undertakings under this Agreement; taxes levied on its property, equipment and improvements; and taxes on the Contractor's interest in this Agreement. 24 of 37 27.0 American with Disabilities Act Contractor shall comply with all applicable provisions of the Americans with Disabilities Act of 1990 (ADA) in performing its obligations under this Agreement. In particular, if the Contractor is providing services, programs or activities to Seattle employees or members of the public as part of this Agreement, the Contractor shall not deny participation or the bene?ts of such services, programs, or activities, to people with disabilities on the basis of such disability. Failure to compty with the provisions of the ADA shall be a material breach of, and grounds for the immediate termination of, this Agreement. 28.0 OSHAIWISHA. Contractor agrees to comply with conditions of the Federal Occupational Safety and Health Acts of 1970 (OSHA), as may be amended, and, if it has a workplace within the State of Washington, the Washington Industrial Safety and Health Act of 1973 (WISHA), as may be amended, and the standards and regulations issued there under and certi?es that all items furnished and purchased under this order will conform to and comply with said standards and regulations. Contractor further agrees to indemnify and hold harmless the City from all damages assessed against the City as a result of Contractor's failure to comply with the acts and standards there under and for the failure of the items furnished under this order to so comply. 29.0 Contract Work Hours and Safety Standards. For all contracts that employ mechanics or laborers, the Contractor and all subs shall comply with Sections 102 and 107 of the Contract Work Hours and Safety Standards Act (40 U.S.C. 327-333), as supplemented by Department of Labor regulations (29 CFR part 5). Under Section 102 of the Act, each Contractor shall be required to compute the wages of every mechanic and laborer on the basis of a standard work week of 40 hours. Work in excess of the standard work week is permissible provide that the worker is compensated at a rate of not less than 1 3/2 times the basic rate of pay for all hours worked in excess of 40 hours in the work week. Section 107 of the Act is applicable to construction work and provides that no laborer or mechanic shall be required to work in surroundings or under working conditions which are unsanitary, hazardous or dangerous. These requirements do not apply to the purchases of supplies or materials or articles ordinarily available on the open market, or contracts for transportation or transmission of intelligence. 30.0 Indemni?cation To the extent permitted by law, the Contractor shall protect, defend, indemnify and hold the City harmless from and against all claims, demands, damages, costs, actions and causes of actions, liabilities, ?nes, penalties, judgments. expenses and attorney fees, resulting from the injury or death of any person or the damage to or destruction of preperty, or the infringement of any patent, copyright, or trademark, or trade secret arising out of the work performed or goods provided under this Agreement, or the Contractor's violation of any an, ordinance or regulation, contract provision or term, or condition of regulatory authorization or permit, except for damages resulting from the sole negligence of the City. As to the City of Seattle, the Contractor waives any 25 of immunity it may have under RCW Title 51 or any other Worker?s Compensation statute. The parties acknowledge that this waiver has been negotiated by them, and that the contract price reflects this negotiation. 31.0 Insurance Contractor shall maintain at its own expense at all times during the term of this Agreement the following insurance, as well as any other additional coverage requirements issued by the City. 31.1. Minimum Coverage and Limits of Liability. Contractor shall at all times during the term of this Agreement maintain continuously, at its own expense, minimum insurance coverage and limits of liability as speci?ed below: A. Commercial General Liability (CGL) insurance, including: - PremisesJOperations - Productstompleted Operations PersonalfAdvertising Injury - Contractual - Independent Contractors Stop GapIEmployers Liability With minimum limits of liability of $1,000,000 each occurrence combined single limit bodily injury and property damage except: $1,000,000 PersonalfAdvertising Injury $2,000,000 Produdstompleted Operations Aggregate $2,000,000 General Aggregate $1,000,000 Each accidentfdiseaseiemployee Stop GapIEmployer?s Liability B. Automobile Liability insurance, including coverage for owned, non- owned, leased or hired vehicles with a minimum limit of liability of $1,000,000 CSL. C. UmbrellaiExcess Liability insurance as may be required to demonstrate minimum CGL and Automobile Liability total limits requirement of $5,000,000, which may be satisfied with primary limits or any combination of primary andfor UmbrellaIExcess limits. D. Medical Errors 8: Omissions insurance with a minimum limit of liability of $1,000,000 each claim. E. Worker?s Compensation covering industrial injury to Contractor?s employees in accordance with the provisions of Title 51 of the Revised Code of Washington. 31.2. City as Additional Insured. The City of Seattle shall be included as an additional insured under CGL and Automobile Liability insurance for primary and non-contributory limits of liability. 26 of 3? 31.3 No Limitation of Liability. The limits of liability specified herein in subparagraph 1.A., 1.3. and 1.C.are minimum limits of liability only and shall not be deemed to limit the liability of Contractor or any Contractor insurer except as respects the stated limit of liability of each policy. Where required to be an additional insured, the City of Seattle shall be so for the full limits of liability maintained by Contractor, whether such limits are primary. excess, contingent or otherwise. 31.4. Minimum Security Requirement. All insurers must be rated A- VII or higher in the current AM. Best's Key Rating Guide and licensed to do business in the State of Washington unless coverage is issued as surplus lines by a Washington Surplus lines broker. 31.5. Self-Insurance. Any self-insured retention not fronted by an insurer must be disclosed. Any defense costs or claim payments falling within a self-insured retention shall be the responsibility of Contractor. 31.6. Evidence of Coverage. Prior to performance of any scope of work under paragraph Contractor shall provide certi?cation of insurance acceptable to the City evidencing the minimum coverage?s and limits of liability and other requirements specified herein. Such certi?cation must include a copy of the policy provision documenting that the City of Seattle is an additional insured for commercial general liability insurance on a primary and non-contributory basis. 32.0 Audit. Upon request, Contractor shall permit Seattle, and any other governmental agency involved in the funding of the Work (?Agency?), to inspect and audit all pertinent books and records of Contractor, any subcontractor, or any other person or entity that performed work in connection with or related to the work or services performed, at any and all times deemed necessary by Seattle or Agency, including up to six years after the ?nal payment or release of withheld amounts has been made under this Agreement. Such inspection and audit shall occur in King County, Washington or other such reasonable location as Seattle or Agency selects. The Contractor shall supply Seattle with, or shall permit Seattle to make, a copy of any books and records and any portion thereof. The Contractor shall ensure that such inspection, audit and copying right of Seattle and Agency is a condition of any subcontract, agreement or other arrangement under which any other person or entity is permitted to perform work under this Agreement. 33.0 Contractual Relationship The relationship of Contractor to Seattle by reason of this Agreement shall be that of an independent contractor. This Agreement does not authorize Contractor to act as the agent or legal representative of Seattle for any purpose whatsoever. Contractor is not granted any express or implied right or authority to assume or create any obligation or responsibility on behalf of or in the name of Seattle or to bind Seattle in any manner or thing whatsoever. 2? of 3? 34.0 Assignment and Subcontractin Contractor shall not assign or subcontract any of its obligations under this Agreement without Seattle's written consent, which may be granted or withheld in Seattle?s sole discretion. Any subcontract made by Contractor shall incorporate by reference all the terms of this Contract except for Equal Benefit provisions. Contractor shall ensure that all subcontractors comply with the obligations and requirements of the subcontract, except for Equal Bene?t provisions. Seattle?s consent to any assignment or subcontract shall not release the Contractor from liability under this Agreement, or from any obligation to be performed under this Agreement, whether occurring before or after such consent, assignment, or subcontract. 35.0 Transition Plan: In recognition of the potential adverse impact on the public?s health and safety resulting from even a temporary cessation of the provision of ambulance services as set forth in this Agreement, the parties re00gnize the need for there to be an orderly transition in ambulance operations at the end of the term of this Agreement or extensions thereof. Six months prior to the expiration of the term of the Agreement or any extension thereof, the Contractor shall present a transition plan to the City for approval. Such plan shall fully address the transfer of ambulance operations to the subsequent ambulance service provider or the City as the case may be. At a minimum, the transition plan shall address the following issues and meet the following minimum requirements: A. The Contractor shall continue to meet all its obligations under this Agreement, including speci?cally, the response time standards. The transition plan shall specifically address the steps that the Contractor will take to ensure full compliance with the performance requirements of the Agreement. B. Unless requested by the City, the transition plan shall be based on the same operation plan that the Contractor has utilized successfully to date during the term of the Agreement. C. Employment. The transfer plan shall address the Company?s plans to relocate, layoff, terminate, etc. its then current work force. Recognizing that some of the Contractor?s employees may seek other employment as a result of the upcoming transition, the transition plan shall address how the Contractor intends to maintainlretain qualified personnel to meet its performance obligations under the Agreement. D. Records. The transition plan shall provide for an orderly transfer of all records, data, ?les or other information, regardless of source, kept by the Contractor arising out of this Agreement to the subsequent service provider or the City. No records, data, or information, regardless of source, shall be erased, discarded, removed from the premises or modified without the specific written approval of the City. Any information, spreadsheets, or data 23 of 37 sets which may be required by this Agreement, whether in hard copy, tape or other electronic media, shall become the property of the City at the conclusion of the Agreement. Any loss or damage to such records, materials or information, for any reason, shall be replaced Irecreated by the City and the cost for such restoration shall be paid by the Contractor. This requirement shall not include materials proprietary to the Contractor except those items necessary to satisfy reporting and other requirements of this Agreement. E. The transition plan shall address the Contractor?s plan, if any, to "wind down" its operations in anticipation of the transfer of its operations to a subsequent service provider or the City as the case may be; provided that, in no event shall the Contractor be relieved from full compliance with the performance requirements of the Agreement. The transition plan shall address the Contractor?s plans, if any: to begin to reduce inventory; and to terminate, assign or sublease existing equipment, vehicle, service and facility leases, contracts, and subcontracts. F. Vehicles: To the extent the Contractor expects to transfer vehicles, equipment andlor facilities to a subsequent service provider or the City, the transition plan shall address the schedule(s) for such transfers and the transfer of all relevant records related thereto. Such records shall include but not be limited to leases, contracts, maintenance records, operating manuals, warranties, ?nancing documents, and any other d00uments or records related to the vehicles, equipment andfor facilities to be transferred. The City shall have thirty (30) days to accept or reject the transition plan. In the event that the City rejects the transition plan, the City shall advise the Contractor of the changes to the transition plan that must be made by the Contractor to meet the requirements of this Subsection. The Contractor shall make the necessary changes to the transition plan within thirty (30) days. If the Contractor cannot or will not make the necessary changes, the City may make the changes, and the cost of the City in performing this work shall be the responsibility of the Contractor. Both parties shall operate in accordance with the approved transition plan for the remainder of the term of the Agreement. Any approved changes to the transition plan shall be documented in writing signed by both parties. 36.0 Federal Debarment for Primes and all Subcontractors. Contractor shall immediately notify the City of any suspension or debarment or other action that excludes the Contractor and any subcontractor from participation in Federal contracting. Contractor shall verify all subcontractors that are intended andlor used by the Contractor for performance of City work are in good standing and are not debarred, suspended or otherwise ineligible by the Federal Government. Debarment shall be verified at The Contractor shall keep proof of such verification within the Contractor records. 29 of 3? 3?.0 Supervision and Coordination. Contractor shall: Competently and ef?ciently, supervise and direct the implementation and completion of all contract requirements specified herein. - Designate to Seattle, a representative(s) with the authority to legally commit Contractor?s ?rm. All communications given or received from the Contractor's representative shall be binding on the Contractor. 0 Promote and offer to Purchasers only those materials, equipment andfor services as stated herein and allowed for by contractual requirements. Violation of this condition will be grounds for contract termination. 38.0 Involvement of Former City Employees Contractor shall notify Seattle in writing of any person who is expected to perform any of the Work and who, during the twelve (12) months immediately prior to the expected commencement date of such work or subcontract, was a City officer or employee. Contractor shall ensure that no Work or matter related to the Work is performed by any person (employee, subcontractor, or otherwise) who was a City of?cer or employee within the past twelve (12) months; and as such was of?cially involved in, participated in, or acted upon any matter related to the Work, or is otherwise prohibited from such performance by SMC 4.16.075. 39.0 Anti-Trust Overcharges. Seattle maintains that, in actual practice, overcharges resulting from antitrust violations are borne by the purchaser. Therefore the Contractor hereby assigns to Seattle any and all claims for such overcharges except overcharges which result from antitrust violations commencing after the price is established under this contract and which are not passed on to Seattle under an escalation clause. 40.0 No Conflict of Interest. Contractor confirms that Contractor does not have a business interest or a ciose family relationship with any City officer or employee who was, is, or will be involved in the Contractor selection, negotiation, drafting, signing, administration, or evaluating the Contractor's performance. 41.0 No Gifts or Gratuities. Contractor shall not directly or indirectly offer anything of value (such as retainers, loans, entertainment, favors, gifts, tickets, trips, favors, bonuses, donations, special discounts, work or meats) to any City employee, volunteer or of?cial, that is intended, or may appear to a reasonable person to be intended, to obtain or give special consideration to the Contractor. Promotional items worth less than $25 may be distributed by the contractor to City employees if the Contractor uses the items as routine and standard promotions for business. Any violation of this provision may result in termination of this Contract. Nothing in this Contract prohibits donations to campaigns for election to City office, so long as the donation is disclosed as required by the election campaign disclosure laws of the City and of the State. 30 of 37 42.0 Current and Former City Employees, Of?cers, and Volunteers. Throughout the life of the contract, Contractor shall provide written notice to City Purchasing and the City Project Manager of any current or former City employees, officials or volunteers that are working or assisting on solicitation of City business or on completion of the awarded contract. The Contractor must be aware of the City Ethics Code, Seattle Municipal Code 4.16 and advise Contractor workers as applicable. 43.0 Intellectual Property Rights. 43.1 Patents: Contractor hereby assigns to Seattle all rights in any invention, improvement, or discovery, together with all related information, including but not limited to, designs, speci?cations, data, patent rights and findings developed in connection with the performance of this Agreement or any subcontract hereunder. Notwithstanding the above, the Contractor does not convey to Seattle, nor does Seattle obtain, any right to any document or material utilized by Contractor that was created or produced separate from this Contract or was preexisting material (not already owned by Seattle), provided that the Contractor has clearly identified in writing such material as preexisting prior to commencement of the Work. To the extent that preexisting materials are incorporated into the Work, the Contractor grants Seattle an irrevocable, non?exclusive, fully paid, royalty-free right andfor license to use, execute, reproduce, display, and transfer the preexisting material, but only as an inseparable part of the Work- 43.2 Copyrights: For materials and documents prepared by Contractor in connectiOn with the Work, Contractor shall retain the copyright (including the right of reuse) whether or not the Work is completed. Contractor grants to Seattle a non-exclusive, irrevocable, unlimited, royalty-free license to use every document and all other materials prepared by the Contractor for Seattle under this Contract. If requested by Seattle, a copy of all drawing, prints, plans, ?eld notes, reports, documents, ?les, input materials, output materials, the media upon which they are located (including cards, tapes, discs and other storage facilities), software programs or packages (including source code or codes, object codes, upgrades, revisions, modi?cations, and any related materials) andlor any other related documents or materials which are developed solely for, and paid for by, Seattle in connection with the performance of the Work, shall be delivered to Seattle. Seattle may make and retain copies of such documents for its information and reference in connection with their use on the project. The Contractor does not represent or warrant that such documents are suitable for reuse by Seattle, or others, on extensions of the project, or on any other project. Contractor represents and warrants that it has all necessary legal authority to make the assignments and grant the licenses required by this Section. 44.0 Key Persons. Contractor shall not transfer or reassign any individual designated in this Agreement as essential to the Work, without the express written consent of Seattle, which consent shall not be unreasonably withheld. If, during the term of this Agreement, any such individual leaves the Contractor?s employment, the Contractor shall present to Seattle 31 of 3? one or more individual(s) with greater or equal quali?cations as a replacement, subject to Seattle's approval, which shall not be unreasonably withheld. Seattle?s approval or disapproval shall not be construed to release the Contractor from its obligations under this Agreement. 45.0 Disputes. The parties shall endeavor to resolve any dispute or misunderstanding that may arise under this Agreement concerning Contractor?s performance, if mutually agreed to be appropriate, through negotiations between the Contractor?s Project Manager and Seattle?s Project Manager, or if mutually agreed, referred to the City?s named representative and the Contractor?s senior executive(s). Either party may decline or discontinue such discussions and may then pursue other means to resolve such disputes including termination as allowed for within the contract, or may by mutual agreement pursue other dispute alternatives such as alternate dispute resolution processes. Nothing in this dispute process shall in any way mitigate the rights, if any, of either party to terminate the contract for cause or convenience. Notwithstanding the above, if Seattle believes in good faith that some portion of Work has not been completed satisfactorily, Seattle may require Contractor to correct such work prior to Seattle payment. In such event, Seattle will provide to Contractor an explanation of the concern and the remedy that Seattle expects. Seattle may withhold from any payment that is otherwise due, an amount that Seattle in good faith finds to be under dispute, or if the Contractor does not provide a sufficient remedy. Seattle may retain the amount equal to the cost to Seattle for otherwise correcting or remedying the work not properly completed. 46.0 Termination A. For Cause: Seattle may terminate this Agreement if the Contractor is in material breach of any of the terms of this Agreement, and such breach has not been corrected to Seattle?s reasonable satisfaction in a timely manner. B. For City?s Convenience: Seattle may terminate this Agreement at any time, without cause and for any reason including Seattle?s convenience, upon written notice to the Contractor. C. Nonappropriation of Funds: Seattle may terminate this Agreement at any time without notice due to nonappropriation of funds, whether such funds are local, state or federal grants, and no such notice shall be required notwithstanding any notice requirements that may be agreed upon for other causes of termination. D. Acts of Insolvency: Seattle may terminate this Agreement by written notice to Contractor if the Contractor becomes insolvent, makes a general assignment for the bene?t of creditors, suffers or permits the appointment of a receiver for its business or assets, becomes subject to any proceeding under any bankruptcy or insolvency law whether domestic or foreign, or is wound up or liquidated, voluntarily or otherwise. 32 of 3? E. Termination for Gratuities: Seattle may terminate this Agreement by written notice to Contractor if Seattle ?nds that the Contractor either is in violation of the Gifts and Gratuities section 41. F. Notice: Seattle is not required to provide advance notice of termination. Notwithstanding, the Buyer may issue a termination notice with an effective date later than the termination notice itself. In such case, the Contractor shall continue to provide products and services as required by the Buyer until the effective date provided in the termination notice. G. Actions upon Termination: In the event of termination not the fault of the Contractor, Contractor shall be paid for the services properly performed prior to the effective termination date that has been specified by the Buyer, together with any reimbursable expenses then clue, but in no event shall such compensation exceed the maximum compensation to be paid under the Agreement. Contractor agrees that this payment shall fully and adequately compensate Contractor and all subcontractors for all profits, costs, expenses. losses, liabilities, damages, taxes, and charges of any kind whatsoever (whether foreseen or unforeseen) attributable to the termination of this Agreement. Upon termination for any reason, Contractor shall provide Seattle with the most current design documents, contract documents, writings and other product it has completed to the date of termination, along with copies of all project-related correspondence and similar items. Seattle shall have the same rights to use these materials as if termination had not occurred. 47.0 Force Majeure Suspension and Termination. This section applies in the event that either party is unable to perform the obligations of this Agreement because of a Force Majeure event as de?ned herein, to the extent that the Agreement obligations must be suspended in full. A Force Majeure event is an event that prohibits performance and is beyond the control of the party. Such events may include natural or man-made disasters, or an action or decree of a superior governmental body, which prevents performance. Force Majeure under this Section shall only apply in the event that performance is rendered not possible by either party or its agents Should either party suffer from a Force Majeure event and is unable to provide performance, such party shall give notice to the other party as soon as practical and shall do everything possible to resume performance. Upon receipt of such notice, the party shall be excused from such performance as is affected by the Force Majeure Event for the period of such Event. If such Event affects the delivery date or warranty provisions of this Agreement, such date or warranty period shall automatically be extended for a period equal to the duration of such Event. 33 of 37 48.0 City Debarment In accordance with SMC Ch. 20.70, the Director of Executive Administration or designee may debar a Contractor from entering into a contract with the City or from acting as a subcontractor on any contract with the City for up to ?ve years after determining that any of the following reasons exist: a. Contractor has received overall performance evaluations of deficient, inadequate, or substandard performance on three or more City contracts. b. Contractor failed to comply with City ordinances or contract terms, including but not limited to, ordinance or contract terms relating to small business utilization, discrimination, prevailing wage requirements, equal bene?ts, or apprentice utilization. c. Contractor abandoned. surrendered, or failed to complete or to perform work on or in connection with a City contract. d. Contractor failed to comply with contract provisions, including but not limited to quality of workmanship, timeliness of performance, and safety standards. e. Contractor submitted false or intentionally misleading documents, reports, invoices, or other statements to the City in connection with a contract. f. Contractor colluded with another contractor to restrain competition. 9. Contractor committed fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a contract for the City or any other government entity. h. Contractor failed to cooperate in a City debarment investigation. i. Contractor failed to comply with SMC 14.04, SMC Ch. 14.10, SMC Ch. 20.42, or SMC Ch. 20.45, or other local, State, or federal non-discrimination laws. The Director may issue an Order of Debarment following the procedures speci?ed in SMC 2070050. The rights and remedies of the City under these provisions are in addition to any other rights and remedies provided by law or under the Contract. 49.0 Environmental Speci?cation Paper and Paper Product Requirements: To promote and encourage environmentally sustainable practices for companies doing business with the City, the City requests contractors under City contract use environmentally preferable products in production of City work products. - The City desires the use of 100% PCF (post consumer recycled content, chlorine-free) Grays Harbor paper or equivalent to encourage environmentally preferable practices for City business. Such paper is available at City contract prices from Complete Office at 206-628-0059 or Keeney?s Office Supplies. Note - Keeney?s is a Women Owned Firm and may be noted on your Outreach Plan. I The City prohibits plastic or vinyl binders. The City prefers 100% recycled stock Binders. ?Rebinders? are a product that fit this requirement and are available at City contract prices from Complete Office at 206-628-0059 or Keeney?s Of?ce 340f 3? Supplies at 425-285-0541. Please do not use binders or plastic folders, unless essential. Note - Keeney?s is a Women Owned Firm and may be noted on your Outreach Plan. - Contractors are to duplex all materials that are prepared for the City under this Agreement, whether such materials are printed or copied, except when impracticable to do so due to the nature of the product being produced. This directive is executed under the Mayor's Executive Order, issued February 13, 2005. 50.0 Workers Right to Know. "Right to Know" legislation required the Department of Labor and Industries to establish a program to make employers and employees more aware of the hazardous substances in their work environment. WAC 296-800-180 requires among other things that all manufacturersldistributors of hazardous substances include completed Material Safety Data Sheets (MSDS) for each hazardous material with each delivery. Additionally, each container of hazardous material must be appropriately labeled with: the identity of the hazardous material, appropriate hazardous warnings, and the Name and Address of the chemical manufacturer, importer or other responsible party. Labor and Industries may levy appropriate ?nes against employers for noncompliance and agencies may withhold payment pending receipt of a legible copy of the MSDS. OSHA Form 20 is not acceptable in lieu of this requirement unless it is modi?ed to include appropriate information relative to "carcinogenic ingredients: and ?routes of entry? of the product(s) in question. 52. Miscellaneous Provisions. A. Amendments: No modi?cation of this Agreement shall be effective unless in writing and signed by an authorized representative of the City, except as otherwise authorized herein. The City shall issue change notices to Contractor, and such notices shall take effect under the signature of the City unless written objection of the notice is received by the Contractor upon Contractor receipt of the change notice. B. Conflict: In the event of conflict between contract documents and applicable laws, codes, ordinances or regulations, the most stringent or legally binding requirement shall govern and be considered a part of this Agreement to afford Seattle the maximum bene?ts. C. Liens, Claims and Encumbrances: All materials, equipment, or services shall be free of all liens, claims or encumbrances of any kind and if Seattle requests a formal release of same shall be delivered to Seattle. D. Binding Contract: This Agreement shall not be binding until signed by both parties. The provisions, covenants and conditions in this Agreement shall bind the parties, their legal heirs, representatives, successors, and assigns. 35 of 3? a?of3? Applicable LawNenue: This Agreement shall be construed and interpreted in accordance with the laws of the State of Washington. The venue of any action brought hereunder shall be in the Superior Court for King County, Washington Remedies Cumulative: Rights under this Agreement are cumulative and nonexclusive of any other remedy at law or in equity. . Captions: All titles, including sections or subsections, are for convenience only and do not define or limit the contents. Severability: Any term or provision of this Agreement found to be prohibited by law shall be ineffective to the extent of such prohibition without invalidating the remainder of the Agreement. Waiver: No covenant, term, or the breach thereof shall be deemed waived, except by written consent of the party against whom the waiver is claimed, and any waiver of the breach of any covenant, term or condition shall not be deemed to be a waiver of any preceding or succeeding breach of the same or any other covenant, term or condition. Neither the acceptance by Seattle of any performance by the Contractor after the time the same shall have become due nor payment to the Contractor for any portion of the Work shall constitute a waiver by Seattle of the breach or default of any covenant, term or condition unless othenrvise this is expressly agreed to by Seattle, in writing. The City?s failure to insist on performance of any of the terms or conditions herein or to exercise any right or privilege or the City?s waiver of any breach hereunder shall not thereafter waive any other term, condition, or privilege, whether of the same or similar type. Entire Contract: This document, along with any attachments and work orders, constitutes the entire agreement between the parties with respect to the Work. No verbal agreement or conversation between any officer, agent, associate or employee of Seattle and any of?cer, agency, employee or associate of the Contractor prior to the execution of this Contract shall affect or modify any of the terms or obligations contained in this Agreement. Negotiated Contract: The parties acknowledge that this is a negotiated Agreement, that they have had the opportunity to have this Agreement reviewed by respective legal counsel, and those terms and conditions are not construed against any party on the basis of such party's draftsmanship thereof. . No personal liability: No officer, agent or authorized employee of the City shall be personally responsible for any liability arising under this Agreement, whether expressed or implied, nor for any statement or representation made herein or in any connection with this Contract. IN WITNESS WHEREOF, in consideration of the terms, conditions, and covenants contained herein, or attached and incorporated and made a part hereof, the parties have executed this Agreement by having their authorized representatives affix their signatures below. (Contractor) City of Seattle f. it.? I In ?3.5 l. 1 BY 5" 35?5" I1f Signature Date Signature Date 7 . . Ema) g4," (Printed Name) NANCY LOCKE, Purchasing and - Contracting Director er?? L2 Title Appendices: Appendix A Seattle King County Protocols Appendix Battalion Map Appendix Historical Call Data Appendix SFD Aid and Medic Response Operating Guidelines Appendix CAD Interface and AVLIGPS Connection Requirements Appendix Summary of Response Time Standards and Liquidated Damages 3? of 3? TABLE OF CONTENTS 5 TABLE OF CONTENTS Conditions Abdominal Altered Level of Consciousness Asthma Behavioral . Chest Cold-Related Congestive Heart . Eve Injuries Head and Orthopedic Pediatric Fever and Seizures Sepsis Soft Tissue . FAST Procedures 3. Policies Advance Life Support Criteriaww Airway Management . Gropharvngeal Airway . Suctioning TABLE or CONTENTS Bag-Valve Bleeding Cardiac . ROC Phone Code ACS (Acute Coronary ..62 Code OVA {Cerebral Vascular Accident) - CPR For Adults - CPR For Children 8: Infants - CPR for Newborns T2 Dressing and Bandaging - Amputation ECG Monitoring End of Life Issues Epinephrine Epistaxis Excited FAST Exam Gluoometry Group Health Consuit Option Helicopter 8? Medication Administration I Activated - Inhalers I . Oral Glucose Multi?Casualty Incident 92 Field Triage 96 MCI Organization Chart 95 Transportation 93 Transporting 94 93 Triage 93 TAB LE OF CONTENTS Neurological .. 98 - AVPU - Glasgow Coma Scale Noxious Oxygen . . .. . . 105 .. 105 Patient .. - . ..1oa .. 109 - Shock Position Patient Personal Protective Equipment (PPE) and Postural Vital Evaluations .. Pulse Reportable SICKINOT SICK Spinal Immobilization . 130 Taser Dart Removal and Care .. 135 Teeth . Transport ant-1 Final Disposition . Appendix Normal Vital Signs By Telephone Temperature .. Index 93 99 100 101 10? 112 114 115 118 120 122 123 133 135 H.138 142 143 144 1,143 ACKNOWLEDGEMENTS Thanks to all of the EMS providers for their help in the development of these protocols. Speoid thanks to Betty Hurlado for formatting and production. Thanks to Jonathan Larsen, Norm Nedelt, and Jim tie for their meticulous review of the protocols, and to the training of?cers of Seattle and King County tire departments for their helpful comments. INTRODUCTION These patient care protocols are intended to help you in your job. Additional information and documents are on the EMS training site at: emsoniine. net. These protocols de?ne best practices for EMT care in Seattle 3. King County. it is important to realize that adherence to theae protocols provides quality care to patients and protects you and your department. You have a very challenging job - but a very rewarding one. There can be nothing more satisfying than providing hetp to the iititmindedr sympathy to the distressed. retief to the arctiotisr comfort to the frightened. and most importantly therapy and aid to the sick and injured. Your skills and training literally bring life back from the brink of death. We applaud the ?ne jot:- you do. it W5 We? Mickey lsenberg, D. Michael K. Copass. MD King County Medical Medical Director Program Director Medic One Seattle Fire Department Mid-tale Ptorde. MPH Tracey White Training Manager Emergency Medical Services interim Division Director Emergency Medical Services ACKNOWLEDGEMENTS ABDOMINAL COMPLAINTS ALS Indicators Signs and of shock which include: . Poor skin signs {pate sweaty) - Sustained tachycardia {see page 54} - Hypotension (systolic BP less than 90 mmHg} with an appropriate clinical setting Unstable vital signs Positive postural changes (see page 116) Evidence of ongoing bleeding Severe unremitting pain 3L3 Indicators Stable cardiac and respiratory functions Stable vital signs BLS Care Request paramedics if indicated. Provide supplemental oxygen andlor ventilatory assistance as necessary. Position of comfort (Shock Position if hypotensive). Prepare to suction patient if vomiting. estimate volume and describe character {color and consistency} of vomitus. Reassure patient. Monitor vital signs every ?ve minutes. ALTE RED LOC ALS Indicators Decreased LDC . Respiratory distress or airway compromise Signs and of shock which include: . Poor skin signs (pale. sweaty) . Sustained tachycardia (see page 54) . Hypotension (systolic BP less than 90 mmI-lg) with an appropriate clinical setting Unstable vital signs Multiple seizures {status seizures) Single seizure longer than ?ve (5) minutes or with more than 15 minutes postictal with no improvement in LDC Cyancsis Hypoglycemia with decreased LDC Seizure in pregnant female Seizure with severe headache Seizure associated with trauma Drug or alcohol related seizures BLS Indicators Adequate respirations Transient including seizure with stable vital signs First time or typical seizure pattern for the patient with stable vital signs ALTERED LOG (CONTJ BLS Gare Provide supplemental oxygen andfor ventilatory assistance as necessary. Protect patient from injury, remove objects from mouth and upper airwraiyir do not restrain patient during seizure, remove hazardous obi-acts near patient. Position patient in position of comfort if alert and airway is secure; it not, then use recovery position. Perform blood glucornetry. Loosen restrictive clothing. Retain relevant drug containers and notes for transport with patient. ANAPHYLAXIS ALS indicators Respiratory distress Signs and of shock wl'lich include: . Poor skin signs (pale. sweaty) . Sustained tachycardia (see page 54) - Hypotension [systolic BP less than 90 mmH} with an appropriate clinical setting Unstable vital signs Use of EpiPen (see page T9) BLS Indicators Bite or sting with local reaction or usual reaction to medication or food Stable vital signs No anaphylaxis BLS Care EpiPen for anaphvlaxis (see page Oxygen as needed. Reassure patient. Remove stinger by scraping away from puncture site. Any patient who receives an EpiPen {pre or post EMS arrival) should be transported {mode of transport depends on clinical ?ndings and and evaluated in a hospital. ASTHMA ALS Indicators Decreased LOG Extreme anxiety:r and agitation Ashen color, oyanosis Failure to respond to repeated inhalers History of previous intubation Respiratory distress?unable to speak normally Lahored respirations regardless of rate when found with other indicators Audible wheezing not improved with inhalers Sustained tachycardia (see page 54). BLS Indicators Responds to self-administered metered- dose inhaler Normal vital signs Able to speak normally BLS Care Assist patient with his or her medications. Provide supplemental oxygen andior ventilatory assistance as necessary. Reassure patient and urge calmness. Obtain oximetry reading {see page 118). Monitor vital signs every ?ve to ten minutes. 10 BEHAVO RIAL ALB Indicators Decreased LOG Abnormal behavior with unstable vitals Abnormal behavior with serious oo-morbidity drug or alcohol OD) BLS Indicators Abnormal behavior with stable vital signs BLS Gare Secure safety of personnel and patient. Provide support, reassurance to patient. Provide supplemental oxygen andror ventilatorv assistance as necessary. Wound or trauma care if indicated. Call police if necessary {if patient refuses transport but EMTs feel patient needs further evaluation). Use restraints wi'len warranted (see page 109). Monitor patient behavior and physiotogioal changes. do not leave patient alone or unobserved. Incapacitated or impaired patients or patients with mental or behavioral problems should be evaluated in local hospital emergency departments. 11 BURNS ALS Indicators Possible involvement including singed facial hain soot in mouthinose or hoarseness Eiurns with associated injuries: electrical sheds fracture, or respiratory problems Second or third degree burns to faceihead Second or third degree bums severing greater than 20% of the body Severe pain (request ALB for pain control} BLS indicatom All other burns BLS Care First degree burn - Cool. moist pads Second degree burn . Cover with dry dressing (commercial burn sheets are acceptable} . DO NOT apply ointment or creams Always be alert to possible airway involvement. 12 CHEST DISCOMFORT ALS Indicators Chest pain or discomfort of suspected myocardial ischemia (angina or Ml} (See Code ACS page 62) Altered LOG Use of nitroglycerin Unstable vital signs Signs and of shock which include: a Poor skin signs (pale. sweaty} - Sustained tachycardia (see page 54} . Hypotension (systolic BP less than 90 mmHg} with an appropriate clinical setting Discomfort, pain, or unusual sensations between the navel and the jaw if the patient is 40 years old or older auditor has a history of heart problems BLS Indicators Apparent non-cardiac or minor traumatic chest pain if patient is less than 40 years old and no cardiac history and stable vital signs and no associated Stablei'normal vital signs 13 CHEST BLS Care Request paramedics if indicated. Provide supplemental oxygen andior ventilatory assistance as necessary. Assist patient with nitroglycerin if indicated (see page 89). Provide aspirin if indicated (see Code ACS page 62}. Position of comfort. Reassure patient. Monitor vital signs sliver}.r 5 minutes. Monitor ECG if authorized. record strip. Special Instructions For Chest Pain Patients with possible cardiac chest pain require ALS evaluation Maintain high index of suspicion that atypical chest pain mayr be cardiac in origin Elderly patients1 women, and diabetics may present with atypical ?ndings such as fatigue, weakness, shortness of breath. or syncope See Code ACS page 62 14 COLD-RELATED Indicators Decreasedfaltered LDC Temperature less than 95' oral or tympanic Cessation of shivers in a cold patient Signi?cant co-mcrbidities eldedy, illness. circumstances, trauma, alcohol. drugs] Cardiac arrest Hypotension {systolic BP less than 90 mmHg) with an appropriate clinical setting BLS Indicators Cold exposure. temperature greater than normal vital signs and no abnormal LDC Frostbite with tamperature greater than normal vital signs and no abnormal LOG BLS Care {Hypothermia} Remove patient from the cold environment and protect the patient from further heat loss. Provide supplemental oxygen andfor ventilatory assistance as necessary. Provide high flow oxygen via NRB or bag- valve mask (see page 58). 15 COLD-RELATED (Gout) Remove wet clothing. Position of comfort. lfdecreased LOG, place in recovery position. Wann the patient. Warm the aid unit. Monitor patient's vital signs. use ECG monitor if authorized. repeat temperature measurements. BLS Care [Hypothennlc Cardiac Arrest Or Profound Bradycardla] If no puise is detected after one minute, begin CPR and apply AED. If breathing, assume there is cerebral perfusion. Therefore. CPR. If AED states ?Shock Indicated", follow cardiac arrest protocol. If pulse is present, withhold CPR regardless of rate or BF. BLS Care (Frostbite) Protect coldsinjured part from further injury. Remove any constricting or wet clothing or shoes and replace with a dry buiky dressing. Splint the affected extremity and do not let the patient walk on or use it. 16 COLD RELATED {001112) Remove constricting jewelry rings, watohbands). Do not rub or massage injured tissue. Transport to an emergency room. Do not rewarm frozen tissue unless transport time will exceed two hours and it is oertain that the thawed tissue will not refreeze. Obtain medical direction prior to initiating rewarming. Rewarming should be done with - water. Do not use dry heat: it heats unevenly and may burn frozen tissue. Stop rewanning when the tissue turns red-purple and beoomes pliable. 1T GONG ESTIVE HEART FAILURE Congestive heart failure (CHF) can range ?rm the very mild to very severe {pulmonary edema} Usually patients with oongestive heart failure oall EMS for worsening shortness of breath andror worsening fatigue. ALS Indicators Decreased LOG Signs and of shock WhiCh include: - Poor skin signs (pale, sweaty} . Sustained tachycardia (see page 54} - Hypotension (systolic BP less than 90 mmHg) with an appropriate clinical setting Extreme anxiety and agitation Unable to lie ?at Ashen color. oyanosis Respiratory distress?unable to speak normally Respirations greaterthan 30 per minute Labored respirations regardless of rate BLS Indicators Normal vital signs without respiratory distress Able to speak normally BLS Care Provide supplemental oxygen andfor assist ventilation with a BVM as necessary. 18 CONGESTIVE HEART FAILURE (CONTJ Position patient upright with legs dangling (dependent) unless hypotensive. If hypotenslve, place patient In supine position. Reassure patient and urge calmness. Obtain omimetryr reading (see page 113}. Monitor vital signs everyr 5 to1D minutes depending on patient's condition. 19 ALS Indicators Altered LOG Absent or depressed gag reflex, as indicated by inability to swallow Patient unable to protect aimay Unstable vital signs Rapid respiration Signs and of shock which include: . Poor skin signs {pale, sweaty) - Sustained tachycardia (see page 54] . Hypotension (systolic BP less than 90 mmHg} with an appropriate clinical setting Failure to respond to oral glucose unit with continued glucose <60 despite repeated treatment. Suspected diabetic ketoacidosis (glucometry reading a40!] or "high" with associated Seizures BLS Indicatols Normal or mild reduction in LOG Gag reflex intact. as indicated by swallowing Patient can protect airway Non?nal vital signs of hypoglycemia relieved by oral glucose with normal vital signs 20 DIABETIC (CONTJ BLS Care Request paramedics if blood glucometry {see page 83). Provide supplemental oxygen andior yentilatory assistance as necessary. If hypoglycemic and patient is able to swallow. position upright and give oral glucose. If hypoglycemic, and patient is unable to swallow. position on side. give oxygen, ventilation and await paramedics. Maintain normal body temperature. Monitor vital signs in response to sugar. Diabetic patients with of should be evaluated in an emergency room. Transport decision based on clinical presentation. if in doubt whether are due to hypoglycemia and swaii?o wing ability is intact, position upright and give orai giucose. Special Instructions For Diabetic Patients Patients with hypoglycemia who have responded to oral glucose may be left at scene [see page 84). These patients must have a repeat glucose level of so mgidl or higher documented and after-care instructions must be left with the patient. 21 DIABETIC loom.) Distinguishing from hypoglycemia can be dif?cult without a blood glucose. Recent medical history can help. History Suggesting Hypoglycemia Insuf?cient food intake Excessive insulin dosage Normal to excessive activity level Rapid onset Absent thirst Intense hunger Headache May have seizures History Suggestion Recent infection Polyphagia (excessive food intake} Polydipsia (intense thirst) Polyuria {excessive frequency and amount of urine) Vomiting, abdominal pain ?Flu-like" nausea Insuf?cient insulin dosage Gradual onset Normal activity level 22 Signs and of Diabetic Coma with Ketoaoldosls) Altered LOC {restless to coma) Warm and dry skin Hypotension (systolic BP less than 90 mmHg} with an appropriate clinical setting Sustained tachycardia Reduced circulation in extremities Vomiting Sweet, fruity breath Kussmaul breathing (deep, rapid) High blood glucose . Greater than 200 [mild Greater than 300 mgde (moderate . Greater than 400 mgidl (severe Signs and of Hypoglycemia Hypoglycemia may be due to excessive insulin or decreased food intake, or increased activity. Irritability. confusion, seizures or some Pale, moist skin Non'nal or rapid pulse Low blood glucose {usually less than 60 with gluccmetry 23 BROWNING ALS Indicators Any underwater rescue Altered LOC Respiratonr distress Labored breathing Hypotension {systolic BP less than 90 mmHg) with an appropriate ciinicat setting Temperature less than Signi?cant too-morbidity injury. intoxication} Cardiac or respiratory arrest BLS Indicators Water-related accident including aspiration of water. injury in diving or swimming, with normal CNS function and vital signs BLS Care Request paramedics if indicated. Remove the victim from the water, do not become a victim. Neutral in-line cervical stabilization during removal from water with a badtboard if spine injury is suspected or patient is unresponsive. 24 BROWNING If there is no suspected spinal consider recovery position. Provide supplemental oxygen andior yentilatory assistance as necessary. Prepare suction, expect vomiting. Follow resuscitation protocols if cardiac or pulmonary arrest. Warm aid unit. Monitor vital signs. All Immersion incidents should be transported to the hospital for further evaluation. Care For Scuba Diving Accidents Request paramedics High ?ow oxygen by NRM andior BVM as necessary Position patient ?at {supine} or on side to avoid cerebral edema 25 EYE INJURIES ALB Indicators Major mechanism of injury Penetrating injuries to BLS Indicators Minor mechanism of injury Eyelid laceration with intact vision Ultraviolet burns BLS Care Request paramedics if indicated. Stabilize an impaled object in place and bandage both eyes. Flush chemical burns to the eyes for 15 minutes with normal saline or water if saline is not available. Ultraviolet burns to the eyes: treat with cool compresses over closed eyes. GYM ECOLOGIC ALB Indicators Decreasedr?altered LDC vaotension (systolic BP less than 90 mmHg] with an appropriate clinical setting Sustained tachycardia {see page 54} Moderate to severe hypertension systolic or greater} in a pregnant woman with neurologic Seizures Severe unremitting pelvic pain Excessive vaginal bleeding Possible ectopic pregnancy BLS Indicate?: Limited vaginal bleeding with stable vitals Pelvic pain or discomfort with stable vitals BLS Care Request paramedics if indicated Protect patient?s dignity. Offer reassurance and emotional support. Monitor vital signs. Direct pressure over lacerations. Provide supplemental oxygen. Obtain focused history. Allow patient to choose position of comfort. 27 HEAD AND NECK ALS Indicators Compromised airway Abnormal respiratory patterns Major mechanism of injury Glasgow Coma Scale of 12 or less Decreased LOC. unstable vital signs Paresis {partial or complete paralysis) andior paresthesia {abnormal sensation. tingling) Evidence of injury to brain or spinai cord Signi?cant alcohol or drug use BLS Indicators Minor mechanism of infury Intact airway, stable vital signs No evidence of injury to brain or spinal cord No signi?cant drug or alcohci use BLS Care Request paramedics if indicated. Ensure a patent airway. Provide supplemental oxygen andror ventilatory assistance as necessary. Provide neutral. in-line cervical stabilization with proper sized cervical collar and padding. 28 HEAD AND Necx loom.) Secure to backboard. Bandage as necessary. Monitor vital signs and neurologic status. Special Instructions For Suspected Cervical Injury Suspected cervical injury with non-alignment One attempt to realign neck to the neutral, in-line position unless new pain, additional numbness, tingling or weakness. additional compromise of airway or ventilation or resistance encountered. Apply cervical collar and backboard (see page 123). If unable to realign then secure in the original position. Helmet Removal As long as the airway is not affected and remains patent AND the c-spine can be secured in a neutral, in-line position. leave football and helmets on. Pad the backboardl?torso to maintain neutral alignment. All other non-?tted helmets may be removed as soon as possible bicycle helmets, skateboard helmets, rollerblade helmets). If helmet needs to be removed, two EMTs should stabilize head and neck. remove chinstrap, remove helmet wl'iile stabilizing head. and apply cervical collar. Secure the patient to a backboard [see page 128}. 29 EAT-RELATED ALS indicators Decreasedraltered LOC Hot dry skin in the presence of elevated temperature Sustained tachycardia (see page 54) Hypotension (systolic blood pressure less than 90 mmHg} Positive postural changes BLS Indicators Heat related cramps Minor to moderate heat-related complaint with stable vital signs BLS Care Request paramedics if indicated. Remove patient from the hot environment and place patient in a cool environment {back of air-conditioned transpart vehicle or aid unit with air conditioner running on high}. Reassure and cool patient. Provide supplemental oxygen andior ventilatory assistance as necessary Loosen or remove clothing. Apply cool packs to neck, groin and armpits for the heat-stroke patient. HEAT-RELATED (CONTJ KeEp skin wet by applying cool water with sponge or wet towels. Fan aggressively. Place patient in Shook position. If patient is responsive and not nauseated, have patient drink water. Ifthe patient is vomiting plaoe in recovery position. Monitor palient's Vital signs and temperature (oral or tympanio}. 31 ALB Indicators Imminent birth Decreaeedi'altered LOC of motherinewborn baby Abnormal blood pressure (less than Qt] systolic or greater than 140 mran systolic] with neurologic Complications with this pregnancy such as: . Placenta previa . Abruptio placenta - Diabetes Excessive vaginal bleeding Suspected ectopic pregnancy Any abdominal trauma to mother during third trimester Trauma with signi?cant MOI Known or anticipate delivery of twins or more Breech or limb presentation Prolapsed cord Shoulder dystocia Uncontrolled postpartum hemorrhage Seizures Dispatch to birthing centerimidwife 32 OssTETntc (sown) BLS Indicators Eady pregnancy. pain or bleeding with stable vital signs Childbirth has occurred and there are no complications and mother and baby stable BLS Care Request paramedics if indicated. Protect patient's dignity. Offer reassurance and emotional support. Monitor vital signs. Provide supplemental oxygen andior ventilatory assistance as necessary. Nothing by mouth. Allow patient to choose position of comfort. Supine hypotension may occur if patient is ?at on back. Piece patient onto ie?? side to reir?eve pressure on the vene cave and piece between knees for comfort. Imminent Delivery Instructions Prepare delivery area {out of public view). Position mother in semi-reclining position. Provide supplemental oxygen andior ventilatory assistance as necessary. Encourage mother to breathe deeply between contractions and push with contractions. 33 OBSTETRIC (coat) Prepare OB equipment and don sterile gloves, gowns. and protection. As baby crowns, support head with gentte preasure to avoid explosive birth. It membrane is still intaotr rupture with your ?ngers to allow amniotic ?uid to leak out. If cord is around the baby?s neck. gently slip it over the head. mm It the cord is too tight to slip over the head, apply umbilical cord clamps and out. As soon as baby's head emerges. suction the mouth and nose with bulb syringe. Allow the mother to push and support the head as it rotates. Caution: Babies are slippery as they exit the birth canai; be carefui and aiert. After delivery. place two clamps on the cord two inches apart and six inches away from the baby. Cut the cord between the clamps. Suction baby again. Dry and inspect the cord for bleeding. Wrap baby in warm blanket. Place baby on its side to facilitate drainage. Inform the mother of the baby's gender. Note the time of birth, APGAR score of baby and gender. 35 APGAR SCORING Score at 1 and 5 minutes after birth. Clinical Sign 0 points 1 point 2 points A Appearance Blue. pale Body pink, extremities blue Completety pink Pulse Absent Less than 100iminute More than 100iminute Grimace No response Grimaces to stimulation Cries (00111.) A i?tctivityr Limp Some ?exion of extremities Active motion Respiratory Absent Slow. in'eguiar Effort respirations (CONTJ Post Delivery Instructions Observe perineum for bleeding. NonnaHy there should be a mat! to moderate amount of bloody matertat that wit! ooze from the vagina. Apply oxygen to the mother as indicated via nasal cannula or nonrebreather mask to mother. Do not pull on the umbilical cord. The placenta should be delivered spontaneoust within 20 minutes. If delivered. wrap the placenta in the bag supplied in the OB Kit and send with the mother and baby' to the hospital. Massage the uterus with moderate ?rmness on the lower abdomen to stimulate uterine contraction. Monitor 1trital signs of both mother and infant. Maintain boot!?r temperature of both patients. BLS transport of mother and baby to hospital. it no ALS indicators. ORTHOPAEDIC ALB indicators Decreasedfaitered LOC Signs or of shock Excessive uncontrolled bleeding Pelvic fracture. bilateral femur fracture. or mum-system injurvifractures Femur fracture with excessive swelling Open fractures except for hands and feet High index of suspicion based on mechanism of injury Contact paramedic for severe pain (patient needs pain control) BLS Indicators Single extremityI fracture with stable vital signs Singie joint injurjlr with stable vital signs BLS Care Request paramedics if indicated. Protect cervical spine if indicated. Reassure and maintain normal bodj.r temperature Apva direct pressure and sterile dressing over major bleeding. - 37 ORTHOPAEDIC (CONTJ Provide supplemental oxygen andlor ventilatorv assistance as necessary. Nothing by mouth. support injured part (see page 130). Allow patient to choose position of comfort. Check and record distal circulation, motor, and sensor).I {nerve function) before and after splinting. Immobilize and splint if indicated. Apva coldlice pack to injured part (for closed tissue injury only). Elevate fractured limb. Prepare patient for transport (backboard). Monitor patient's vital signs everv 5 to 1D minutea Realignment of Long Bone Fractures Attempt to realign (open or closed) long bones that are angulated in the middle 1l3 then splint. Long-bone fractures, which occur in the proximal or distal that may or may not involve a Joint, may be realigned if compromise of distal circulation or nerve function is detected and de?nitive care is delayed. 38 ORTHOPAEDIC Realignment may sometimes be necessary to facilitate packaging for transport. Check and document OMS before and after splinting andlor realignment. Pelvic Fractures (see page 131) Multiple Extremity Fractures These patients should be secured to a backboard which will serve as a general body splint for several sites. Rapid packaging and transport of the unstable patient or patient with mul?pie fractures takes priority over de?nitive splinting at the scene. Falls In Elderly Patients In addition to consideration of orthopaedic injuries consider head trauma and possible CNS bleeding (especially if they are on oournadin}. Elderly patients on ooumadin with head injury or suspected head injury MUST be evaluated in an emergency department. 39 FEDS FEVER AND INFECTION ALS Indicators Decreased LOO Respiratory distress Seizure . Respiratory distress or airway compromise . Recurrent seizure - Prolonged, depressed LDC I High index of suspicion for sepsis or meningitis BLS Indicators Febrile seizure {generalized toniciclonio? see page 41) Feverl?infection with low index of suspicion 3L3 Care Use Pediatric Assessment Triangle. (Page 126, 127) Request paramedics if indicated. Provide supplemental oxygen andior ventilatory assistance as necessary. Monitor vital signs. Position of comfort. For seizures. place child on side to protect airway. FEDS FEVER AND INFECTION (CONTJ May assist caregiver with medication to reduce temperature Tylenoi [acetaminophen]. not aspirin]. If febrile, attempt to reduce patient?s temperature with cool towels. Remove clothes. Cover loosely with one layer. Do not allow to chill. Special Instructions for Febrile Seizures Patient with a historllr of a previous febrile seizure. who is now neurologically intact with stable vital signs. and a competent caregiver requests home care, mayr be left at home with a suggestion to follow-up with a physician. First time febrile seizures must be evaluated in an emergency department Febnte seizures are anvays generalized tonicfcionic in nature. Any rope! seizure is n_ot a febrile seizure unfit prove-n othemrise. 41 RESPIRATORY ALE Indicators Decreased LOC Extreme anxiety and agitation Tripod position Respiratory distress?unable to speak normally Respirations greater than 30 per minute Ashen color, cyanosis, retractions Failure to respond to usual treatments Labored respirations regardless of rate when found with other inditors Audible wheezing, rales when found with other indicators Use of EpiPen injector Sustained tachycardia {see page 54) 3L3 Indicators Respiratory complaints due to common causes such as a cold, flu. bronchitis Respiratory complaints of a chronic but stable nature Respiratory complaints with normal vital signs and adequate oxygenation with treatment Patent airway 42 RESPIRATORY 3L3 Care Provide supplemental oxygen andi'or ventilatory assistance as necessary. Obtain moimetrjgir reading (see page 113}. Reassure patient and urge calmness. Assist patient with his or her medications. Administer EpiPen if indicated for anaphylaxis (see page 79). Monitor vital signs every 5 to 10 minutes depending on patient's condition. 43 SEIZURES ALS Indicators Multiple seizures (status seizures} Single seizure longer than ?ve minutes or more than 15 minutes postiotal with no improvement in LOG Seizure due to hypoglycemia Seizure due to hypoxia Seizure following head trauma Drug or alcohol associated seizures BLB Indicators History of seizure. and seizure is similar to prior episodes and patient is awake BLS Care Seizures that East more than 5 minutes require paramedic care. After patient awakens. perform exam to determine if anyr injuries occurred or if any neurologio abnormalities exist. During seizure, position the patient on hislr her side. During and after seizure, provide oxygen. Perform blood gluoometry. Obtain oxirnetry reading after seizure. SEPSIS Sepsis is severe infection with many it is common and requires early identi?cation and aggressive resuscitation. Sepsis patients have veg: high mortality. Sepsis is more common in the elderly. EMT's should have a high index of suspicion for sepsis in pa_ tients that are infirm and are residents of long term care facilities. should be alert for the following signs and I Hot to the touch? Assume fever indicating infection. . Skin rash . Cough with thick sputum . Abnormal breath sounds . Headache . Abdominal pain. . Muscle aches. . Diarrhea Signs of sepsis should be suspected if 2 or more of the following signs are present: . Hot to the touch33- Systolic If the HR 3* SBP, consider volume depletion and measure orthostatic vital signs. See indications for postural vital signs per patient care protocols 45 (CONTJ and treat patients appropriately. ALS Indicators Request Paramedics for all "Sick" patients. Decreased LOG Airway problems Respiratory distress Respirations greater than 30 per minute Signs and of shock which in- clude: Poor skin signs (pale. sweaty} Sustained tachycardia {see page 54) Hypotension BF 90 or positive postural vital signs {20 point drop in SBP or 20 beats per minute increase in with appropriate clinical setting. {see page 116) BLS indicators "Not Sick" patients. Conscious and alert Stable airway Stable vital signs No orthostatic changes in vital signs BLS Care Use PPE Maintain airway. provide supplemental oxy- gen as necessary Monitor vital signs Place patient in position of comfort Notify transport agency and or receiving hospital of possible sepsis patient Document ?ndings of infection and possible sepsis on 4S SOFT TISSUE ALS Indicators Signi?cant head injury Signs and of shock which include: . Poor skin signs (pale, sweaty] . Sustained tachycardia (see page 54} . Hypotension {systolic BP less than 90 mmHg] with an appropriate clinical setting Soft tissue injuries that might compromise the airway Excessive uncontrolled bleeding Altered LDC High index of suspicion based on mechanism of iniury BLS Indicators Conscious and alert Stable vital signs Soft tissue iniuries limited to the super?cial layer of the skin (epidermis and dermis) Single digit amputations {see page 7'5} - Soft tissue injuries. with bleeding oontrotled by direct pressure andr?or elevation 47? SOFT TISSUE BLS Care for OPEN Soft Tissue Iniuries Request ALS if indicated. Provide supplemental oxygen andfor ventilatory assistance as necessary. Maintain an open airway. Ensure adequate breathing. Control bleeding. Maintain nom'Ial ood'glr temperature. Monitor vital signs. Cervical spine protection. if indicated. Special Instructions for OPEN Soft Tlssue Injuries Control bleeding with direct pressure on the area or upon pressure points. Use pressure dressings or pressure device (like a SP cuff) for severe. uncontrolled bleeding. Amputation (see page 75) Removal of Foreign Objects Large, easin removed debris. such as glass. splinters, or gravel must be removed before bandaging. 48 SOFT (CONTJ Large. deeply imbedded fragments or projectiles must be secured in place by the bandage. Decontamination Remove wet chemicals acid) by repeated flushing with water. Remove substances by ?rst brushing the area and then by ?ushing with water. Burns Easily removed debris should be taken off the burned area, then cover the area with dry. sterile dressings. Remove rings for hand burns. 453 ALS Indicators Unconsciousness Decreased LOC Severe hypertension (biood pressure greater than 200 systolic or 110 diastolic with neurologic signs) Hypotension and severe bradyoardia Seizures Severe headacheivomiting Uncontrolled airway and respiratory problems Progression of stroke BLS Indicators Vital signs and condition stable Stroke history Stroke signs Aimray secure BLs Care Call paramedics if indicated. Determine time onset of stroke if possible Position patient in upright position, Open and manage airway. 50 STROKE (Gown) Deliver oxygen andior ventilatory assistance as necessary. Maintain normal body temperature. Protect paralyzed limbs. Monitor vital signs. Perform FAST exam. Perform blood glucometry. STROKE PLAN Revascularization by clot dissolving medication should be initiated within several hours of a stroke. (See Code OVA page 66} If a stroke is of recent onset, very short scene times and transport times are critical. Notify receiving hospital as soon as possible and attempt to precisely document the time of onset of In general, arrival at hospital within several hours of onset of is critical as it will allow the ED to determine possible eligibility for thrombolylic or other therapy. 51 FAST EXAM The FAST exam is used in the ?eld to detect stroke. An abnormal ?nding strongly indicates a stroke. Face Ask the patient to show teeth or smite Normal: Both sides of the face move equatly. Abnormal: One side of the face does not move as well as the other or not at all, Arm Ask the patient to dose eyes and extend both arms straight out, paints up, for 10 seconds Normal: Both arms move the same, or both arms do not move at all. Abnormal: One arm drifts down compared to the other. Speech Ask the patient to say "The sky is Dive in Seattie" Normat: The patient says correct words with no slurring of words Abnormal: The patient slurs words. says the wrong words. or is unable to speak Time Determine the time of onset of or when the patient was last seen normal. 52 ADVANCE LIFE suepoe'r The following list is offered as a summary guide and is not comprehensive. Nor does it take into account your IDS or the MOI Abdominal Pain I Disoomfort or pain or unusual sensations between the navel and jaw if the patient is or to 4D yic andi?or has cardiac history - Severe unremitting abdominal pain Breathing I Respirations >30 min I Failure to respond to repeated inhalers I Asthma attack with history of previous tntubation I Audible wheezing not improved with inhaler I Abnormal respiratory patterns I Respiratory related with patient in the tripod position Burns I Burns with possible airway involvement I Burns with associated injuries: electrical shock. fracture, airway I or degree burns to facefhead I or degree burns of body Cardiac I Suspected ABS [see page 62) OVA I Progression of stroke Diabetic I Diabetic that is unable to swallow I Diabetic with rapid respirations I Diabetic that fails to respond to oral glucose I Suspected ketoacidosis 53 ADVANCE LIFE 5UPPORT INDICATORS Hypothermia I Temperature <95 degrees oral or tympanic I Hypothermia with signi?cant co-rnorbidity elderly, illness, circumstances, trauma, alcohol. drugsHypoglycemia with decreased LOG . Abnormal behavior with unstable vitals I Abnormal behavior associated with possible drug or alcohol overdose Pulsel? BP I Hypotension (systolic <90 with appropriate clinical settings) I Signs of shock: pulse generally minute. BP <90 I Positive posturals (decrease in systolic BP >20 or increase in pulse >20) I Sustained tachycardia {generally 3120! minute in appropriate clinical setting) I Systolic >200 or diastolic 3110 with associated I Pregnancy with systolic <90 or >140 I Hypotension and severe bradycardia GBIGYN I Female with severe unremitting pelvic pain I Excessive 1irauginal bleeding I Possible ectopic pregnancy I Dispatched to birthing centerimidwife I Pregnancy complications: placenta previa, abruptic placenta. diabetes, multiple birth. breech or limb presentation, prolapsed cord, shoulder dystocia. uncontrolled pastpartum hemorrhage I imminent birth ADVANCE LIFE SUPPORT INDICATORS Other Pregnancy 3'd trimester with abdominal trauma Pregnancy with signi?cant MOI. Use of epipen Suspected meningitis Sepals Decreased LOG Respiratory distress Respirations greater or RR a 3d per minute Signs and of shear Seizure Multiple seizures Single seizure 3'5 minutes or 315 minutes postictal with no LDC improvement Pregnant female Severe headache Associated with trauma Associated with or alcohol AssoCiated with hypoglycemia Trauma Falls >2 times the body height Thrown feet Penetrating injury to the head, eyes or box Pelvic fx. bilateral femur fit. or multisystem fx Femur with excessive swelling Open fx except hands and feet Severe pain Any underwater rescue Forests and or paresthesia due to trauma 55 AIRWAY MANAGEMENT ORGPHARYHGEAL An oropharyngeal airway rests in the patient's oropharynx, lifting the tongue away from the back of the throat preventing it from occluding the airway. The OP aimay is used only on unconscious patients and generally those without respirations. Do not use this device if a patient gags when inserted. Use of an airway on a patient with a gag reflex may cause retohlng. vomiting, or spasm of the vocal cords. To size an oropharyngeal airway: Choose correct size by measuring from the corner of the mouth to the ear lobe or from the chin to the angle of the jaw. In infants and children, insert the airway tip down or sideways along with a tongue blade. Rotate down when you are halfway in the mouth or approaching the curve on the tongue. An oropharangeal (DP) airway is not necessary if ventilation via am is easily accomplished. 56 AIRWAY MANAGEMENT SUCTIONING The Yankauer auction tip is preferred for most suctioning. If the holes on the Yankauer get plugged repeatedly, remove the tip and use larger bore tubing. To auction with a Yankauer tip: Measure the same as for an oropharyngeal away?approximately from the corner of the mouth to the ear lobe. Do not suction white inserting; suction only after the Yankauer (or similar device) is in place and as you withdraw. Suction for no more than 15 seconds at a time. in rare cases, copious vomiting that threatens the airway may require a ionger period of auctioning. nygenate the patient well before and after auctioning. 57 BAG-VALVE MASK Successful ventilation with a BVM requires a good seal between the mask and the patients face and maintaining an open sinnay. Correct ventilation generates only modest chest n'se. To properly place a BVM: Choose approoriate size for the patient. Plaoe the apex of the mask on the bridge of the nose (between the eyebrows). Settle the base of the mask between the lower lip and the prominenoe of the chin. TECHNIQUE Knee! with a knee on each side of the patients head. Hold the mask ?rmly in position by placing the heel of the hand on top of the mask, extending the ?ngers and thumb forward forming a and grasping the lowerjaw with the middle two or three ?ngers. Squeeze the bag to ventilate. If necessary, a seoond EMT may be needed to secure seal and assist with bagging. Each ventilation should take one second and achieve chest n'se. 58 BLEEDING CONTROL To stop external bleeding: Apply direct pressure on the open wound with sterile gauze or clean material. Apply additional pressure if bleeding continues. A pressure dressing can be used to apply direct pressure. if blood soaks through the dressings, add new dressings? do not remove the old dressings If not oontraindioated by the injury. elevate the bleeding extremity above the level of the heart. If bleeding is uncontrolled by direct pressure and elevation. apply pressure at the appropriate pressure point. Hold pressure only as long as necessary to control bleeding. Reappiy pressure it bleeding recurs. If pressure is held for along period of time. tissue damage can result. A ?pressure device" may be used for control of severe. uncontrolled bleeding when all other methods of bleeding control have failed. When necessary. an oversized blood pressure cuff may be used. Inflate it no more than is necessary to stop bleeding. Once stopped. you may need to immobilize the extremity and apply cold packs. 59 60 protocol applies only to Gunny agencies. Aims ll cardiac anesL begin CPR [while attaching de?brillator} to Coil Honine Include a1 least so meal compressions When de?brilalor is ready. slop after every cardiac event: dies: compressions and Immediately clear me patient and analyze Ihe 1-800-607-2926 Subsequ CPR intervais should begin and end with 30 west Provide your name. agmcy. compressions and each hlenral should he approudmaiely 2 minutes. company. dale. lime. medic Exception: Wl'nm the patient goes into VF Maire monitored or enamel! lo unit. pa?em age and gender. an AED. In Ihis situation a de?hl'ilalory shod: may be and your call back number. immedlately . i Ir Shack Indicated Ho Shook Indicated SINGLE Sm- Immediatst begin CPR The" Immedlamb' CPR Farrah-n 2 mlnulee of unlnlerruplsd CPR Ps?onn 2 mmu?lea ofurlnterruplead CPR no no. my man for In?. chug; Do not delay for pulse check or poet-enact; analysle i i After 2 minutes o1 CPR. Analyze Do not check pain before analyzing - if .L shook Indium: or Deliver SINGLE Shook. "0 SHOCK Indicated Then immediater CPR Check Pulse Perform 2 mimlsas sf minierrupled CPR 1' 365685 ?lmy. breath-no. and blood ll pressure "at my or Nit-mack "1 If no pulse. perl'onn 2 minutes of unintsnupied CPR CARDIAC ARREST 61 After 2 m'nutes of CPR, P-natyze Do not otreok pulse before She-ctr Indicated or 1il'Tt No Shook Indicated Shock. Check Pulse Then immediately begin CPR If pulse. assess airway. breathing. and bland pressure Perfomt 2 minutes otunintermpted CPR lfno pulse. perform 2 minutes at uninterrupted CPR Do not delay CPR lor pulse check or pest-shock analysis iv Aitor 2 minutes at Analyze Do not check prise before analyzing NOTES: 2 minutes In this protocol refers to 2 minutes or longer depending Wilton 3D compressions are complete, A Shosicable is de?ned as VF or moonsciousrputseless VT. B. Periods oi CPR should not be interrupted except in cases 0! need to manage airway (emesis. etc.) C, For manual departments. meet: pulse only if organized Start CPR it no pulse or seystole mytl'l'n. B. Any patient found momscious. with a systolic BP eon should have CPR iritiatod. It a pulse Is detected dutng resuscitation out systole blood pressure 60. resume CPR. If at anytime 3 mneeurlivs 'no shocks? are advised, continue CPR un'??mut interruption u?i?l medics entire. Count out loud for sheet compressions. Cardiac arrest pmtomts may change. Always 'I?otloimI current agency protocols. CARDIAC ARREST (count tour-:5 CODE ACS (ACUTE Concerns? Acute coronary (ABS) requires rapid assessment by Elu'lTs and paramedics and expedited transport to a oath-ready hospital. This policy applies to all patients presenting with possible ACS and who are initially evaluated by EMTs. Evaluation for ABS 1. Patient exhibits any of the following signs or a. Uncomfortable pressure. fullness. squeezing or pain in the center of the chest that lasts more than a few minutes. or goes away and comes back. b. Pain that spreads to the shoulders. neck. or arms. c. Chest discomfort with lightheadedness. fainting, sweating, nausea. or shortness of breath. .OR. 2. Patient exhibits any of the tw_o following signs or when ACS is suspected: a. Atypical chest pain. stomach. or abdominal pain. This may include discomfort that can be localized to a point. that is ?sharp? in nature. that is reproducible by palpitation. or that is in B2 CODE Acs (Acme CORONARY the ?wrong? location (such as the upper abdomen}. b. Unexplained nausea (without vomiting) or lightheadedness (not vertigo) without chest pain. c. Shortness Of breath and dif?ctu breathing (without chest pain). d. Unexplained anxiety. weakness. or fatigue. e. Palpitations. cold sweat. or paleness. Administer Aspirin (currently not authorized 1. for EMTs) Administer one 325 mg aspirin tablet (or four 81 mg baby aspirins) for patients with ACS. Patients may chew or swallow (with a small amount Of water} the aspirin{s). DO not use enteric coated aspin'n. Be sure that the patient is alert and responsive and meets indications and has no contraindications. Contraindications For Use 1. 2. Patient is allergic to aspirin. If they have taken 325 mg aspirin within ISO minutes for this event1 do not administer additional aspirin. Blood pressure a180b110. Active or suspected GI bleeding. 63 CODE ACS CORONARY Addl?onal Procedures 1. If the patient has hisi'her own nitroglycerin and meets the criteria for administration. do not delay assisting with nitroglycerin administration. . Request paramedics if not already dispatched. . Record your actions, including the dosage and the time of administration. . Record the time of onset of The time of onset should be the time that began which prompted the patient to call 91 1. NOTES 65 CODE OVA (CEREBRAL VASCULAR Selected patients with EVA {cerebral vascular can bene?t from rapid thrombolytic therapy designed to dissolve the clot causing the EVA. For thrombolytic therapy to be effective, it generally should be given within 4.5 hours of the onset of the stroke. Since the hospital requires one hour for evaluation and CT this means that onset to arrival at hospital should generally be <35 hours. Most hospitals in King County are now designated as stroke centers and are equipped and staffed to rapidly make the diagnosis and treat acute OVA. The following policy is designed to assist EMTs in their evaluation of possible stroke patients. The policy stresses the need for rapid evaluation and rapid transport. For the stable patient not requiring paramedic evaluation. the EMTs should expedite transport to the hospital. Expedite does not mandate code red but rather requires rapid decision making, patient loading into the aid vehicle, and noti?cation of hospital while enroute. CODE OVA (CONTJ VASCULAR You must include the following information in 1. your narrative: Face: Is it symmetrical? YES or NO Arm: Symmetrical strengthSpeech: Is it slurred or abnormal? YES or NO Time: What time was the patient last known to be normal? Is the patient on Coumadin (Warfarin)? Glucometry. Glucose should be over 60. Severe hypoglycemia can present like a stroke. Glasgow Coma Scale Score (see page 99) Time of hospital noti?cation Time you left the scene enroute to hospital A short telephone report to the hospital should include items 1? 4 above. 67 58 Initial Evaluation Rapid evaluation. treatment. noti?cation. 8: transport is very important when OVA is suspected. I OVA FAST exam - Face: asymmetry? a Arm: drift? I Speech: abnormal? . Time: onset of {yes to any of the ?rst three is a possible stoke} Measure glucose Calculate GCS Unstable 0! critical ms 4' Paramedic Evaluation Evaluate tor OVA Suspected OVA Not suspected CVA Treat as needed VASCULAR CODE OVA team.) 59 Determine Time of Onset If please onset is unclear, determine when patient was last seen to be normal. It is also useful to determine recent surgery. trauma, or active bleeding. Is patient on Coumadin? *Thte time is only a guide. In general, patients whose onset to ED arrived in <35 hours may be eligible for Therapy. Ra id Notify receiving hospital of time of onset. complications. ETA. Consider code red iftransport time 15 minutes. Thera? Provide low ?ow oxygen. Place patient in 10-15 degree incline. DetermineTlme of Onset 3.5 hours' 3.5 ham Treat as needed Rapid Vascuun CODE cw. loom.) CPR FOR ADULTS MANEUVER ADULT Adolescent and older HCP Health Care Provider Head tilt-chin lift (HCP: AIRWAY trauma. use jaw thrust} BREATHS: 2 breaths at 1 secondr'breath Initial {chest rise] Rescue breathing 10 to 12 without chest oom- breath every 5 to 6 seconds} pressions [chest rise} Rescue breaths for El to breathsr'minute CPR with advanoed breath every 6 to Elma? seconds) Foreign-body Responsive: Abdominal ?imsy obstruction thrusts Unresponslve: CPR wilh aimay cheek CIRCULATION: Carotid Pulse check for 5 10 (can use femoral in child) seconds Compression Center of cheat. between landmarks Compression method 2 Hands (Push hard at 100! minute. Allow complete recoil} Compression depth -1 1/2 to 2 inches Compression rate - 100Iminute Comprossion? 3?:2 ventilation ratio or 2 rescuers) DEFIB: AED Use adult pads only. 7?0 CPR FOR CHILDREN AND INFANTS CHHD 1 yearto ad?lescent year-:5. :11 age] Head tilt?chin lift {suspected trauma. use jaw thrust) INFANT Under 1 year of age 2 e?ective breaths at 1 {chest rise) 12 to 20 breath every 3 to 5 seconds) {chest rise! to 10 breath every 6 to seoonds) Responsive: Abdominal thrusts Unresponslve: CPR with check Responsive: Back slaps and chest thrusts Unrosponslve: CPR with airway check between nipples Carotid Braohial (can use femoral in child] Center of chest. Just below nipple line 2 Hands DR Heel of 1 Hand 1 rescuer: 2 ?ngers HGP: 2 rescuers: two thumb-encircling hands technique (prefened} ~16 to the depth of the chest ~1??l'minme 30:2 (single rescuer} HOP: 15:2 {2 rescuers) Not performed on children less than 3 years. 71 FOR Neweosn maneuver HCP Health Care Provider AIRWAY Head tiltlohin lift (Minimal. onlyr as needed] {Suction only as needed] BREATHE. 2 effective breaths at 1 Initial secondmreath {obtain chest rise] Rescue breathing 40-60 breaths-minutes without chest breath every 1 to 1.25 compression seconds} CIRCULATION Check pulse at umbilical cord stub or over the heart Compression land- Just below the nipple line merits Compression Method 2 rescuers perform skill: (allow full recoil] "two month-encircling hands? technique Compression Depth 113 depth of the chest Compression Rate 120 per minute Compression! 3:1 (2 rescuer) Ventilation Ratio and Deliver 9i] compressions and SD ventsiminute DEFIB: AED Not performed on children less than 3 years 172 NOTES 73 DRESSING AND BANDAGING If a patient's condition and time permits, perform dressing and bandaging as follows: Maintain bodv substance isolation by wearing appropriate personal protective equipment. Control bleeding with direct pressure or pressure points. Use a pressure device or pressure dressing for severe, uncontrolled bleeding. Do not remove the dressing once applied. It bleeding continues, put new dressings over the blood-soaked ones. Secure the dressing with a bandage that is snug but does not impair circulation. Large. easily removed debris. such as glass. splinters, or gravel can be removed before bandaging. Secure large. deeply imbedded fragments or projectiles in place with the bandage. If possible, leave patient?s ?ngers or toes exposed. Check circulation by feeling for a distal pulse or checking capillary re?ll. Elevate or immobilize the injured extremity. if possible. Cover eviscerated abdominal contents with a large multi?trauma dressing soaked with 7?4 DRESSING AND BANDAGING sterile saline [or clean water if saline unavailable}. Then apply an occlusive dressing, if available, to retain heat and moisture. Secure with tape. AMPUTATION Wrap amputated parts in sterile dressings. Place amputated part in a watertight container and then in a second container. Place the container on ice. Do not submerge the amputated part in water or place directly on ice. Rapid transpo? of the patient and the severed part is critical to the success of re-implantation. If transport of a patient is delayed. consider sending the amputated part ahead to be surgically preparedcool a severed part. Ice and chemical cold packs are acceptable. BURNS For burned areas, easily removed debris should be taken off the burn. Cover the area with sterile dressings. Remove wet chemicals. such as acid. with repeated flushing. Remove dry substance by ?rst brushing the area and then flushing. 75 ECG MONITORING The indications for ECG monitoring include: chest pain, congestive heart failure. syncope or hypotension. For BLS providers to perform ECG monitoring the following criteria must be met: An approved course in ECG monitoring techniques and recognition. Speci?c de?brillationimonitoring equipment, which will provide hard copy ECG strips for use by paramedics and others. Medical Program Director approval for addition of ECG monitoring to EMT care plans. EPISTAXIS Stop a non-traumatic, "everyday" nosebleed by asking the patient to sit. leaning forward. This prevents blood from being swatlowed or aspirated into the lung. Apply direct pressure by pinching iust below the bridge of the nose. Apply pressure for 10 to 15 minutes. Additionally, you can apply a cold pack to the bridge of the nose. 'r'6 END OF LIFE ISSUES EMTs have the responsibility to determine a patient's resuscitation wishes. and honor them if possible. Resuscitation efforts may be withheld or stopped in ANY of the following: . Injuries incompatible with life - Liyidity. rigor mortis . A Do Not Attempt Resuscitation (DNAR) directive. This directive may be in the POLST (Physician Orders For Life- Sustaining Treatment) format. This is based on patient's wishes. "Compelling reasons? to withhold resuscitation can be invoked wt'len written information is not available, yet the situation suggests that the resuscitation effort will be futile, inappropriate, and inhumane. A resuscitation effort may be withheld when the following two conditions are BOTH met: . End stage of a terminal illness - Family indicates that the patient would not wish to have a resuscitation effort If a resuscitation effort has been initiated and the EMT is provided with a DNAR directive or compelling reasons that such an effort should be withheld, the resuscitation should be stopped. 7'7 Eric LIFE Issues loom.) Documentation is important. (in the Incident Report Form, describe the patient's medical history, preaence of a DNAR directive if any. or verbal request to withhold resuscitation efforts. ?Do not attempt resuscitation? does not mean "do not care." A dying patient for whom no resuscitation effort is indicated can still be provided with supportive care. which may include the following: Clear the airway (including stoma) of secretions with suction device. Provide oxygen using a cannula or non-recreather. Control any bleeding. Provide emotional support to patient and family. Contact the patient?s private physician. Contact hospice if involved. Paramedics should be called if additional judgment or support is needed. I When in doubt, Initiate resuscitation. 'r'B EPINEPHRINE Indications For Use EMTs may drainer epinephrine via an EpiPen in?ector for ANY case of suspected snaphyiaxis {respiratory distress endior hypotension must be present). Seattle EMTs I Patient (anyr age) has a history of same and a prescription for epinephrine - Patient is less than 18 years of age with no prescription. but permission is obtained from parent or legal guardian. This mayr be written, oral or implied. King County EMTs There are no requirements for: I Age . Having a prescription - Writtenioral permission (beyond standard consent) If there is doubt about the need for EpiPen. consult with local paramedic or local control doctor. Dosages Adult and children equal to or over 30 kg or 66 lbs: use EpiPen (0.3 mg) . Child under 30 kg or 66 lbs: use EpiPen Jr. (0.15 mg) T9 EPINEPHRINE (CONTJ Iniection Procedure Con?rm that patient is experiencing anaphylaxis and meets above criteria. 1. Check medication date and that the EpiPen dose matches to patient's size. 2. Remove clothing and prop area of thigh with alcohol pad. 3. Remove safety cap and locate injection site on lateral thigh. 4. Place black tip of injector against thigh and push hard until injector activates. 5. Hold in place for 10 seconds. Note and document time of injection. 6. Remove injector, place in sharps container and massage site for 10 seconds. 7. Reassure patient and monitor for responseiside effects to injection. 8. Continue to provide oxygen. Ventilate if necessary. 9. Monitor and document vitals every 5 minutes. 10. Update incoming medics on patient status and response to injection. Any patient who receives an EpiF'en (pre or post EMS arrival) should be transported {mode of transport depends on clinical ?ndings and and evaluated in a hospital. EXCITED DELIRIUM De?nition: A state of extreme mental and physiological excitement. characterized by extreme agitation, hyperthennia. hostility, exceptional strength and endurance without apparent fatigue. This condition is usually associated with illicit stimulant drug use and is associated with in-custody deaths. ALS indicators: - Extreme agitation. disorientation . Hyperthem'lia. diaphoresis. seeking water . Stripping off of clothing. or no clothing I Shouting. or keening (making animal noises}. unintelligible speech . Eyes wide open. lid li? . Paranoia. hallucinations . Panic . Violence toward others . Unexpected physical strength and stamina . lnsensitiyity to pain . Violence or attraction to glass. re?ection or lights BLS indicators: No BLS indicators if Excited Delirium is suspected. ALS must evaluate these patients. 51 EXCITED DELIRIUM BLS Care: . Secure safety of personnel. assure scene safety before proceeding . Request Police if not already on scene - Restrain patient as necessary. See use of Restraints page 109. . Provide supplemental oxygen and or yentilatory assistance as necessary. . Wound or trauma care as necessary a Package patient for ALS transport . Be vigilant for changes in patient LDC, and I Patients can decompensate quickly, without warning and may suffer cardiac arrest . CPR as per protocol 32 GLUCOMETRY Gluoometry is an approved protocol but optional by individual departments. Indications For Use . Anytime an EMT encounters a patient with an altered level of consciousness. This mayr include patients with the following: - Unconsciousness - Suspected diabetic-related problem - Signs and of stroke - Suspicion of drug or alcohol intoxication . Any time EMTs feel that the blood sugar level may assist patient care. Contraindications Children less than 5 years of age. Use and application Perform the testing procedure as outlined in the instructions {or your speci?c device. All reading should be recorded on the incident response form. - Under no circumstances should the presence of a blood glucose monitor detract from basic patient care. 33 GLUCOMETRY loom.) Perform blood glucose evaluation after the A303 and initial assessment have been completed. ?its is Heated with are! glucose you mustpetfonn a second giucose tat-st check Patients on oral hypoglycemic agents who are initially found to be hypoglycemic should be strongly advised to seek further evaluation by a physician due to the high likelihood of repeated hypoglycemia secondary to long medication halfvlite. Patients on insulin may be safely left at home when ALL THREE of the following conditions are met: 1. Patient is able to eat and drink nonnallyt 2. Patient responds completely as evidence by BOTH: a Blood glucose TEECHES greater than 50 mgl?dl, AND - Patient is conscious and alert with - appropriate behavior. 3. A responsible person can remain with the pa?ent These patients must receive a?encai'e instructions if they are not being transported to the hospitat. You must documentpre and post treatment glucose and that after-care instructions were given to patient. 1?lf glucometry is available GROUP HEALTH CONSULT OPTION EMTs and paramedics are authorized to consult with Group Health (GH) Gin-Scene Physician Support (DPS) for non-critical Group Health patients Speci?cally OPS is intended for Group Health patients who are stable and do not require immediate paramedic transport. OPS does not replace paramedic contact with medical control doctors for protocol plans care or other required contact. The UPS program is designed to give EMTs and paramedics in King County telephone access to a consulting GH physician who has immediate access to the patient?s full medical record. The physician can assist in determining the most appropriate care, most appropriate destination, and most appropriate transportation, In addition the physician can arrange a variety of care options including a short-notice appointment ot GH clinics, arrangements for medications to be ?lled at OH pharmacy. emergency oxygen re?lls. and visiting nurse services. When consultation is provided by the GH physician he or she assumes medical responsibility for the decisions made. The GH consulting physician may be reached 244'? at 16006516684. 85 GROUP HEALTH CONSULT OPTION (CONE) Identify yourself as a King County paramedic and provide the following informationYour name. agency;r Patient name, age, gender, regular doctor, and GH number {if known} Provide the CC and medical history Describe the current clinical situation including vital signs and relevant ?ndings Describe Mat you have done so far Describe what you think is an appropriate plan of care Document on the MIRF that consultation was made with the Group Health DPS and what decisions made. 36 HELICOPTER PROCEDURES I The following are guidelines for the use of medical helicopters. in King County. Airlift Northwest is the primary medical helicopter. The use of medical helicopters may be considered when estimated ground transport times are likely to be excessive, due to traf?c, distance. Use of medical helicopters may be considered for any critical ill of injured patient requiring care at a facility outside of the local area when transport times are likely to be excessive. A medic unit must be dispatched anytime a medical helicopter is being considered. It is suggested that consultation with the responding medic unit take place prior to requesting a medical helicopter. Requests for helicopters are made through dispatch. Normally, there should only be one patient per helicopter. If two patients need to be flown, request a second helicopter. 87 MEDICATION ADMINISTRATION Follow departmental protocol regarding the administration of medication ASSISTING WITH ADMINISTRATION OF PRESCRIBED MEDICATION Initiate assessment and treatment of the patient as indicated by the signs and Verify the following when possible: - medication has been prescribed by a physician for the patient - medication inside the container is the one indicated on the prescription label . medication has not passed the expiration date on the prescription label Determine the last time the patient self-administered the medication and the number of macs taken. if in doubt, contact a medical control doctor, patient's personal physician, or paramedic for medical direction. Administer the medication as direded. Document the administration of the medication by recording the drug, dose, method, time and name of physician ordering the assistance with medication. After ?ve minutes, reassess and document the patients vital signs and any changes. 33 MEorcanON {coat} ACTIVATED CHARCOAL Only administer activated charcoal after conferring with the medical oontrol doctor or paramedic. In addition. feel free to oonsult with Poison Control at 1-800-222-1222. Recommended dosage is 1 grami'kg. INHALERS Patients with chronic respiratory diseases such as asthma and COPD will often have presoiiptions for bronchodilator. antioholinergio, andior steroid inhalers. The EMT may locate the inhaler and hand it to the patient. The patient should be able to self-administer the medication. EMTs are authorized to assist in one treatment only. If the patient has already used the medication in excess of the prescription, do not assist in additional treatment. If the patient is unable to self-administer the medication, you should focus on airway management and oxygenation. This would qualify as an ALS indicator. HITROGLYCERIN The patient should not have taken Viagra or Levitra within the past 24 hours or Ciafis within the past 48 hours. The patient may he assisted in taking prescribed nitroglycerin or nitro) ifthe pain is the same type of pain for which he or 59 Maorcn'rrorr ADHINIETRATION (connl she normally takes nitroglycerin typical angina] and systolic BP greater than 10o mmHg. The EMT may locate the nitro (pill or spray}, open the container. and offer it to the patient. Do not administer the drug into the patient's mouth. If in doubt, consult with the medical control doctor or paramedic before assisting with nitro. The following conditions must be met before assisting with nitro: Complaint of pain similar to that normally experienced as angina or cardiac pain Blood pressure greater than 100 systolic Patient takes no more than three doses total (5 minutes apart) Prescription expiration date should not have passed Patient should be siding or lying down before assisting with nitro Must be the patient's prescribed nitroglycerin ORAL GLUCOSE Prompt recognition and treatment of hypoglycemia is an important EMT skill. Indications for oral glucose: Suspected hypoglycemia in a diabetic (con?rm through blood glucometry when available} MEDICATION {coat} Patient is awake and able to swallow Contraindications for oral glucose: Unoonsciousness Patient is unable to swallow Procedure Help the patient sip or chew any sugar containing substance such as honey, orange juice, candy, or granulated sugar or place a head of the commercial sugar preparation under the patient's tongue. Monitor patient's response to the sugar. Repeat blood glucometry (when available). If the patient is left at home, you must leave aftercare instructions. 91 MU LTI-CAS UliliLT'lIr INCIDENT Medical Group Supervisor The MGS manages all teams within the Medical Group including triage, treatment, transportation, and morgue. Major Responsibilities of the M63: Assign triage. treatment. and transportation team leaders. The MGS may initiate speci?c tasks: . Notify Hospital Control of the if no transportation of?cer. - Consider initiating the call-up of off-shift personnel and the activation of Special Assignment Units through the IMS. . Request additional supplies and equipment through the lC. - Maintain records. Medical Positions within the MCI Plan IMS de?nes the chain of command ted by an Incident Commander (IC). who is in charge of the overall operation. The chain of command is "who reports to mom." The Medical team leaders include: Triage Team Leader Treatment Team Leader Transportation Team Leader Morgue Team Leader 92 MULTI-CASUALTY INCIDENT (CONTJ THE TRIAGE TEAM Major Responsibilities: Obtaining the initial patient oount for the Performing the initial triage of all patients and applying tape. Con?rming patient count and triage colors. Numbering the patients. Directing the work of litter-bearers. TREATMENT TEAM LEADER Major Set up treatment areas: rad, yellow. green, black. Assign leaders to each. Assure that all patients are taped, numbered. and tagged. Direct and supervise treatment area. Assure that proper treatment and decon is given. Prioritize patients for transportation. TRANSPORTATION TEAM LEADER Major Set up ambulance staging area. Designate a Transport Staging Manager. 93 MULTI-CASUALTY INCIDENT (CONE) Maintain medical communications. Document patient destination and number. Communication with Hospital Control should be brief but should include: Patient number Patient Triage status (red, yellow, green} Primary injury Treatment provided Any special information (pediatric, pregnant, eta} Confirm hospital destination Primary Hospital Control is Harboryiew Medical Center: 206-744-3074 Call and ask for the "Charge Nurse.? In the event that HMC is unavailable, the secondary Hospital Control is Overlake: 425-455-6941 TRANSPORNNG PATIENTS In order for patients to be transported. they must have: Number Triage color Hospital destination Transport vehicle 95 Incident Commander I Safeti I I PIO Liaison I I I I Logistics I I Planning I Extrication Rescue! IMedicaIGroupI I Haz-Mar I Patient Numbering (Funnel Paint it Required) Green Hos - ital Controi I I Finance I I Triage I ITreatmentI King Camry Fm Chub mu 24102 MCI ORGANIZATION CHART Med?nanism of Incident {Assess for Injury:r Potential} Demttan?ninatian (Haz Mat) Level of Consciousness {Is the patient awake?} Hazardous Materials Involved? If yes. then patients must be before any medical care! White Triage tape "Decontaminatedi?CIean" Yas AIRWA "Can you walk? Come over here!? No Open Aim-day! Breathing? FIELD TRIAGE ALGORITHM 9? Bmathing E?ori? BREA THING Distress? I Assess Circulation: Signs of BLACK iCmisider Resourceslj King County Chiefs 953mm 200.2 FIELD TRIAGE ALGORITHM AVPU Alert The patient's open spontaneously as you approach. The patient is aware and responsive to the environment. The patient appropriately follows commands. Verbal stimulus response The patient?s eyes do not open spontaneously. The patient's eyes open to verbal command and the patient is able to respond in some meaningful way when asked. Painful stimulus response The patient does not respond to your questions but moves or cries out when a painful (noxious) stimulus is applied: earlobe pinch or pressure behind earlobe. Unresponsive the patient does not respond to stimulus. NEUROLOGICAL Assessmeur GLASGOW COHA SCALE The Glasgow Coma Scale (GUS) is a means of measuring and monitoring tevel of consciousness by calculating a score based on the best eye, verbal, and mo- tor response. The lowest score possible is 3, the highest is 15. The (308 is part of Code OVA (see page 66}. Eyre Response Best Verbal Response Best Motor Response Spontaneously opens 4 Oriented and talking 5 Chess oommands 6 Opens to voice 3 Disoriented and confused 4 Locales pain 5 Opens to pain 2 Inappropriate words 3 Withdraws from pain 4 No response 1 Incomprehensihle 2 Flexes to pain 3 No response 1 Extends to pain 2 No response 1 NEUROLOGICAL ASSESSMENT NOXIOUS STIMULI Indications Any patient with decreased LDC. The only approved methods of delivering noxious stimuli: - Firm eanobe pressure (Figure 1} - Firm pressure behind earlobe (Figure 2) Apply ?rm pressure to the earlobe for up to ?ve seconds in order to assess a response to painful stimulation. This stimulation may be applied once or twice for no longer than 15 seconds during the initial evaluation and infrequently thereafter. if monitoring of the level of consciousness is necessary Prolonged appr'r'catron of str'm ulr', excessive applications, memrcar stimuli, sterner rubs or eyeball pressure are not indicated nor approved by the Medical Program Director: 100 OXYGEN DELIVERY The amount of oxygen given and the method of administration depend on many factors including a patient?s medical history and the type of problem. Flow Volume Device Low flow 2 - 4 Nasal cannula literalr minute High ?ow 10 - 15 Nonrebreathing liters! mask minute High ?ow 15+ Bag-valve mask with liters;Ir with reservoir ventilation minute CONSCIOUS PATIENT WITHOUT RESPIRATORY DISTRESS Begin with 2 liters per minute via nasal cannula as history is obtained. If no contraindications. you may increase to 4 liters per minute. Some patients may not require oxygen at all a Iaoerated ?nger), but it is always best to provide oxygen when in doubt. CONSCIOUS PATIENT WITH RESPIRATORY DISTRESS Increase oxygen delivery according to the patient's condition moving from nasal cannula to nonrebreathing mask. Use respiratory rate. 101 OXYGEN DELIVERY loom.) effort, exchange. ease of speaking, skin signs. and level of consciousness as a guide. When using a nonrebreathing mask, remember to use a liter ?ow that is high enough to keep the bag in?ated at least 1:3 full with the patient?s deepest inspiration. CONSCIOUS PATIENT WITH SEVERE RESPIRATORY DISTRESS Patients in severe respiratory distress may need assistance to breathe, as provided by a BVM with high flow oxygen. These patients mayr present with inability to speak, extreme exhaustion, minimal air movement, cyanosis, agitation, sleepiness, ora decreasing LDC. Examples include patients with chest or throat injury. ainivay obstruction, CHF, COPD, asthma, and near drowning. To assist respirations in a conscious patient, ?rst explain the treatment to the patient then gently place the mask over the patient's nose and mouth and begin ventilaticns. Observe chest and abdomen and time the assisted breaths to coincide with the patients or coach the patient to breathe with bag compressions. UNCONSCIOUS PATIENT SUFFICIENT RESPIRATORY EFFORT Oxygen delivery may range from low-?ow with a nasal nnula to high-flow with a nonrebreathing mask. Patient's level of 102 OXYGEN DELIVERY consciousness and vital signs (especially respiratory rate and effort). color, and nature of illness should determine oxygen flow level. Continually evaluate respiratory rate and effort and do not hesitate to assist respirations if necessary. UNCONSGIOUS PATIENT IWITH INSUFFICIENT OR NO RESPIRATORY EFFORT Ventilate patient or assist ventilations with a BUM and high flow oxygen. if the patient resists the attempts to ventilate, try to time breaths with the patients by compressing the bag as the patient inhales. SPECIAL NOTE: COPD bronchitis, asthma} The physiology of a person with COPD differs from that of a healthy person in that the primary stimulus to breathe comes from a decrease of oxygen in the blood rather than an increase in carbon dioxide. Providing the COPD patient with high concentrations of oxygen could theoretically depress their respiratory drive. Therefore, it is advisable to provide COPD patients with lower levels of oxygen initially, as long as they are not in Severe respiratory distress. Two liters per minute by nasal cannula is usually suf?cient in 103 Oxvsen DELIVERY (CONTJ this situation. If a patient with COPD presents in respiratory distress and does not improve with low levels of oxygen. increase oxygen up to four liters per minute. NOTE: With a COPD patient. King County have the option of using a nonrebreather if nasal cannula at four liter per minute is inadequate. A COPE) patient whose respiratory drive is diminished due to extrassive oxygen may present with increasing lethargy, confusion, and decreasing respiratory rate and effort. If this occurs. be prepared to assist ventilations. If a GOPD patient becomes unresponsive andror stops breathing, ventilate via BVM with a high ?ow oxygen. Over ventilation may worsen 'air trapping? and could cause pneumothorax. SPECIAL NOTE: Infant And Young Child For an infant or young child with mild to moderate respiratory distress oonsider the ?blow-by" technique. Hold the end of a supply tube or a nonrebreather mask approximately two inches away from the patient's face. Another method to supply ?blow-by" is with a paper cup. This can be done by pushing a supply tube through the bottom of the cup. Set the ?ow rate to 4-6 liters per minute. 104 POSITIONING The treatment plan for every patient should include consideration for patient positioning. Proper positioning can reduce pain. improve physiological function, and improve the patient's sense of well-being. There are three positions to consider: Recovery Semi-reclining Shock position RECOVERY POSITION This position is used for non-traumatic patients who are unresponsive but breathing. It protects the ainuvay from vomit and secretions. (Figure 3. page 107) The following steps are recommended: Kneel beside the patient and straighten the legs. Place the patient's arm that is nearest to you at a right angle to body. elbow bent. palm up. Place the other arm across the chest:r abdomen (Figure 1, page 106). if the patient is smatt, being this arm farther across so that the hack of the hand can be held against the patient?s nearest cheek. 105 PATIENT POSITIONING Grasp the patient?e far-side thigh above the knee; pull the thigh up towards the patient'e body (Figure Figure 1 Place your other hand on the patient'e far-aide ehouider and roll the patient toward you (Figure 2). Begin moving the patient?s uppen?noet hand toward the patients nearest cheek. Figure 2 106 PATIENT POSITIONING (CONTJ Adjust the leg you are holding until both the hip and knee are bent at right angles. Tilt the patient's head back and place the uppermost hand under the patient?s cheek. Use this hand to maintain head tilt (Figure 3). Use chin lift if necessary. Figure 3 I Monitor respirations closely. In suspected spinal cord traumaiinjury ?rst immobilize the patient with the appropriate size o?oollar and backboard. It the patient is unconscious, monitor and protest the airway, if necessary, turn patient and backboard 90 degrees to facilitate drainage. SEMI-RECLINIMG in the semi-reclining position (Figure 4} a patient is usually sitting at a forty-five degree angle. A gentle knee bend adds comfort and helps to maintain the upright position. Additional pillows behind the head and knees may improve comfort. Patients with mild to moderate respiratory may bene?t from this position. 107 PATIENT POSITIONING (Gout) Figure 4 SHOCK POSITION in this position the feet are elevated up to twelve inches and the patient is supine {Figure 5). The use of this position will increase venous return to the heart resulting in increased blood pressure. Figure 5 108 PATIENT RESTRAINT If the reason for use of a device is to prairent movement and it is done without the consent of the patient. it is a restraint. Generally, restraints are used in the prehospital environment whenever dangerous behavior {especially danger to self or others) is encountered. The provider has a clear duty to exercise increased vigilance for the safety of the patient. because the patient is unable to self protect while restrained. Likewise, the safety of the responders should be ensured. PROCESS OF RESTRAINT Safety and the prevention of injuries are the major concerns in the process of restraint application. it is imperative to maximize the patient's self-control before deciding to apply restraints. Self-control. The ?rst step is to encourage the patient to exercise all the self-?control he or she possesses. A statement such as know you don't want to hurt yourself or anyone else. I want you to try to stay in control. I know you can do it" is an example. Offer to help. Anxiety can interfere with concentration and an offer of assistance should reduce anxiety. A statement such as want to assure you that we will help you. We will not let you hurt yourself or someone else" is an example of an offer to help. 109 (count Be ready and able to overpower patient Never attempt physical restraint without the resources needed to safely overpower a patient. Physical restraint This is the time when most injuries tend to occur. Plan the actions so that each provider involved cleariy understands his or her role. Typically. one person is assigned to each limb. One provider should communicate with the patient continuously. Once a decision is made to restrain, act quickly. Use onty the force necessary for restraint. Depending on local requirements, it may be helpful to have the police present during restraint. EMTs should be aware of their own personal safety. TYPES OF RESTRAINTS The kinds of restraints used in the prehospital environment vary tremendously. Handcuff and cable ties should only be applied and removed by law enforcement personnel. Once a patient is restrained, he or she should be carefully monitored to avoid airway obstruction. An NRM with appropriate oxygen flow may he applied to protect the EMS personnel from spit. Alternatively a ?spit sock" may be used. 11E:l PATIENT RESTRAIHT DOCUMENTATION It is important to document the behavior that made restraints necessary as well as the restraint technique used. The documentation must re?ect continual concern for the patient?e safety and well-being as well as descriptions of the patients ongoing mental status and behavior. Do not remove restraints until directed by the hospital emergency department personnel. 111 PERSONAL PROTECTIVE EQUIPMENT (PPE) INFECTIOUS DISEASE PREVENTION Hendweshmg is the most e?bctiue way to pm vent tranemr?ssion of infectious disease Wash Hands . After patient contact . Before eating. drinking smoking or handling food . Before a. after using the bathroom . After cleaning or checking equipment PERSONAL PROTECTIVE EQUIPMENT Gtoves and protection must be worn for every patient. FULL PPE for possible infectious contacts Dunning Sequence (MEGGJ - Maek* Protection Gown Gloves . Mask patient fitpossibte) (removal) Sequence Gloves Gown Hand cleaner .- Protection Mask Hand cleaner . Handle ae contaminated waste - Decon Protection *Fit tested 112 PERSONAL PROTECTIVE EQUIPMENT (PPE) learn.) INFECTIOUS DISEASE Febrile Respiratory Illness - Dispatchers will notify units of - Infectious or locations . Dispatch info or fever w! cough or illness or possible infectious disease Full PPE .- Mask". Protection. Gowns, Gloves - Mask patient (ifpossible) - Limit patient contacts After Patient Contact . Remove PPE {approved sequence) . Dispose of PPE as contaminated waste . On scene decon - protection equipment w! gennicidal cleaner - MM - Elie Fmtectic'ni equipment and apparatus At station . Decon affected equipment contacts (kits, BPi?steth, radios. clipboards. etc.) - Wash hands before leaving apparatus ?con *Fit tested 113 PHYSICAL AsusE AND NEGLECT CHILDREN AND VULNERABLE ADULTS Child Abuse Signs and of suspected abuse and neglect include: . Multiple bruises in various stages of healing - . Bilateralisvmmetrical injuries andior bruises - Injury inconsistent With mechanism described . Repeated calls to the same patient or address . New suspicious injuries . Parents, guardian or caregiver inappropriater concerned . Con?icting stories I Fear on the part of the patient to discuss the incident . Lack of proper supervision of the patient I Malnourished appearance . Unsafe living environment . Untreated chronic illness Vulnerable Adults De?ned as adults age 60 and older who cannot care for themselves and adults age 18 and older who, have a legal guardian, are developmentally delayed. live in a DSHS licensed facility, receive in home care 114 Aeuse AND NEGLEGT or CHILDREN AND VULHERABLE ADULTS services, or have personal care aide who is paid for their services. Signs of abuse and neglect include: . Unexplained injuries or behavior . Reports of physical, mental, or sexual abuse - Reports of being abandoned or deserted without basic necessities .- Failing to provide basic life necessities. not taking action to prevent harm or pain . Failure to provide safe living conditions . Untreated injuries or health problems . Intentionally taking advantage of a vulnerable adult either financially, or personally I Undue in?uence or coercion By Washington state law, Fire Fighters. Paramedics. and are n'randatorgir reporters. REPORT OF VULNERABLE ADULTS TD DSHS: 1 666-353-4276 (1 -865-ENDHARM) Involve local Police in all suspicious cases. Call 91 1. 115 POSTURAL VITAL SIGNS Indications For Measurement Of Posturals Acute volume loss [such as suspected GI bleeding or internal hemorrhage) Generalized weakness Complaint ofdizziness. lightheadedness. or fainting Prolonged vomiting or diarrhea Contraindications hypotension while supine (systolic blood pressure less than Qt] mmHg} Third trimester bleeding Trauma patients Patient with suspected cardiac chest pain To Check For Postural Vital Signs Obtain blood pressure and heart rate after two minutes in supine position. Then bring patient to seating position. Next. stand patient upright slowly (caution: lay down patient if he or she becomes dizzy or lightheaded when seated or standing). After patient stands for one minute obtain blood pressure and heart rate. if fainting or light headedness deyeiops return patient to supine position. POSTURAL VITAL SIGNS Positive findings Increase in pulse of Z?fminuta or more or a 20 or more drop in systolic BP from supine to standing with associated Dizzy, iightheaded. or fainting while sitting or standing A positive postural is an ALB indicator in an appropriate clinical setting EVALUATIONS Assisting Police Police may call EMS for assistance in determining whether a patient is stable enough to go to jail. Your evaluation must be based on SicldNot Sick and MOI and IDS. You must document vital signs. 11? PULSE OXIMETRY Pulse oximetry is an approved protocol but optional by individual departments. Indications For Use Pulse oximetry may be used anytime oxygen administered to a patient based upon complaint or condition. This may inciude: . Shortness of breath - Chest pain a Altered level of consciousness (LOG) . Pregnancyiactiye labor . Chest trauma . Any time the EMT believes the oxygen saturation level needs to be assessed Contraindications .- Patients less then 5 years of age. Use and Administration Place the probe on a clean digit. This should be accomplished simultaneousiy with the initial administration of oxygen allowing for a ?room air? estimate. Under no circumstances should oxygen administration be delayed to obtain an oxlmetry reading. 118 PULSE OXIMETRY NOTE Pulse oxirneiry is inaccurate in the following clinical silualjons: Cardiac arrest Shock . Hypothermia a Carbon monoxide poisoning . Jaundioe - Presence of nail polish Decisions about patient care should be based on a patient's complaint and presentation and should not be based solely on a pulse oximeter reading. Pulse 0): device should NOT be used to acquire distal pulse readings. This should always be done by palpating the radial pulse. Under no circumstances should the presence of a pulse oximeter detract from patient care. 119 REPORTABLE EXPOSURES Bloodhorne Exposure This is an exposure or potential exposure to Blgog?mg Pathogens such as Hepatitis B. Hepatitis C, HIV or other pathogens that my be transmitted through contaminated bodllI ?uids or tissues. Examples include: blood. bioody body' ?uids including semen. vaginal secretions. cerebrospinal ?uid, synovial, pleural, pericardial, and amniotic ?uids. An exposure onlg occurs it: - There is a needle stick or outwith a possiblyr contaminated needle or object. - There is contact with non-intact skin tag. skin that is cut, chapped. abraded, or af?icted with dermatitis.) - There is ?uid oontact with your mucous membranes such as eyes, nose. mouth. Steps to take following exposure: a Initiate self-care which includes washing the site thorougth with soap and water. Flush mucous membranes with water only. - Immediately report exposure to immediate supervisor and exposure control of?cer for risk assessment and folIOw-up. Follow individual department's exposure oontrot policy. {see aiso PPE page 112). For all other exposures follow your department?s infectioniexposure control policy. 120 NOTES 121 SICK The SICK approach to rapid patient assessment has become a mainstay in determining the physiologic status of a patient in Seattler?King County. Whether it is medical or trauma, adult or pediatric. SICK is the tool of choice for rapid patient assessment and appropriate patient care. This revised edition of the Patient Care Protocols incorporates the SICKINOT SICK approach which leads to the early recognition of critical (Sick) and non-critical (Not Sick) patients and, ultimately, rapid and appropriate patient care. The clinical indicators used in the adult NOT approach provide clarity and offer clear and CONCISE indicators for determining a patient's physiologic stability. Often. these indicators are observable from across the room without even touching the patient. Additional considerations that need to be incorporated into your SICK decision- process include: mechanism of injury nature of illness and index of suspicion (IDS). These CONSIDERATIONS will help you in determining SICK and may alone determine into which category the patient is placed. NOTE - MOI - Mechanism of Injury . NOI - Nature . 103 - Index of Suspicion 122 SICKINOT SICK (CONTJ Adult SIC-K Clinical Indicators: . Chief complaint and MOIINOHIOS . Respirations . Pulse {circulation} .- Mental status . Skin signs (color, moisture, temperature} . Body positionrobvious trauma The pediatric SICK approach uses an innovative triad of indicators collectiver called the ?pediatric assessment triangle.? The triangle de?nes key indicators of physiologic stability. allowing the EMS provider to make an accurate and timely decision on the status of a pediatric patient. First. determine the chief complaint and consider MOI, NOI, IDS Then assess the elements of the Pediatric Assessment Triangle: Appearance Work of Breathing Circulation Alertness Re?ections Color Color Nasal ?aring TeMperature Distrac?blity Body position Capillary re?ll time Consolahilitv Abdomen sounds Pulse Eve contact Motor activity 123 SICKINOT SICK Medical Rapid Patient Assessment Conslderattons: ESP, scene size?up, family member, additiond staf?ng Chief Complaintr'NOI' Respiratiens Pulse Ilental Status Skin SignsiColor Body Position [Primary Assessment) The {Elinicat Picture SIC-K DECIDE HOT SICK 1' Short report to Lowi'lb'loder?e Flow 02 emu-m; threatening conditions "ms as "as immediately History Taking 100% nonrebreather I Baseline Vitals mask or EIVM I Rapid medical survey I SAMPLE history History Taking - Baseline 1tritsls - Rapid medical sumy '4 - MPLE history Secondary assessment *lndudes a complete Appropriate Position Of ?W's Short Report Rap?: 1? 0 ?mm Appropriate Treatment Secondary Assessment 3153? a complete sat Appropriate Transport Reassessment Reassessment - 124 SICKINOT SICK Trauma Rapid Patient Assessment Considerations: BSI. aeene size-up. family member. additional staf?ng Chief Complai Respiratims Pulse Mental Status Skin SignsiCplar Obvious Trauma (Fri mary Assasament} The Clinical Picture 1' DECIDE H- ~015ch 3'70? 1? LewModerate Flow 02 Spinal stabilization un'ts Care for an}:r obvious or additional inju ties as Rapid anncatien 02 mn- headed Treat any Iiie- rebreather threatening conditions mask or BVM Hittite,?f Taking immediate? . Baseline Vitals I Rapid medical survey History Taking . SAMPLE Nata? - Baseline Vitals a Rapid trauma auniregiI - SAMPLE ?story 4 Secondary assessment ?Inpludea a complete 1' set of vital: immobilize spine Shun to incurring Rapid TransponJ'ALS-I unite Appropriate Treatment tr Seconds: Assassment Includes eat Awmpnate Transport of vital: Reassessment Reassessment oi injury 125 SICKINOT SICK Medical Rapid Pedatr're Patient Assessment Pedlatrtc Triangle (Prirnergur Assessment} Conslderetlons: Scene size-u Famin member Additional staffing CiroulationlSI-zln Color DECIDE wore-ch LowlModerete Flow 02 Short report to Incoming units Treat any life- tnreatening conditions imirlediateh,r 100% 02 nonrebreather mask or BUM History Taking Baseline Vitals I Rapid medcalsurvey I SAMPLE history Appropriate Position Rapid TransponthS Secondary:I Assessment *lnoiudes a complete set of Vitals Reassessment (Keep Wann] - Nature oi 1llness Request ALSY Short Report to inooming units 126 Care for any obvious conditions as needed Historyr Taking - Baseline uitals - Rapid medieatsurvey . SAMPLE history I Secondary assessment Includes a oomplete set at uttals Appropriate Treatment Appropriate Transport Reassessment SICK Trauma Rapid Pediatric Patient a ASEBSSITIGN Considerations: Scene sizeuleOP Forcible entry Faminr member 9% Additional staf?ng Circulationr'SItin Color 1' 4? DECIDE NOT Short report to incoming Rapid extrication?Iv 100% D2 non- Traat any life- rabrsathsr In rsatsning conditions mask or BUM immediater History Taking I Baseline Vitals I Rapid trauma survey I SAMPLE historyl i Immobilize spine Rapid Secondary Assessment Includes a complete set of Reassessment {Keep Wan'n) 'MOi?Medlanism of Injury I..- Realms! ALS. Short Report to Inoom?ng units 127 Lowaoderan Flow 02 Spinai stabilization Care for strutr obvious or additions injuries as needed History Taking I Baseline Vitals I Rapid l'l'ledl'BaI-SHW I SAMPLE history i Seocurrolariir assessment Includes a complete set of vitds i Appropriate Treatment Appropriate Transport Reassessment {Keep Wan?) SPINAL The following summary of spinal immobilization assumes that the A305 and a distal circulation. motor. and sensory (OMS) exam have been assessed before and after spiinting and treated accordingly. Certain parts of this procedure may need to be modi?ed in a critically injured patient whose airway, breathing, or simulation problems need to be treated immediately. This summary also assumes that a patient is sitting upright in a car. The procedure will need to be modi?ed if a patient is found in a different position or situation. - Stabilize head in neutral, in-line position. {Do not release stabilization until the patient is completely secured to a long backboard, as described below. or until another EMT takes over. There should be no pulling or traction taken.) . Measure and apply. propeny-sized cervical collar. - Apply extrication device. using a short backboard. long board, or other device. The technique used will depend on the equipment available and the patient's condition. . Extricate, maintain spinal alignment with head and neck stabilization in a neutral. in-line position. 123 SPINAL IHMDBILIZATION teem.) . Place patient on a long backboard and immobilize chest by crisscrossing over shoulders. across chest to the hips. . Assess ventilation after tightening straps to ensure that respiratory effort is not impaired. - lmmobilize the pelvis by crisscrossing or by strapping straight across. Use caution with peivic or abdominal injuries . Put one strap across the thighs above the knees and one strap across the lower extremities. An additional strap mailr be placed across the feet. . Stabilize the patient?s head using a commercial immobilization device. rolled towels. or blankets. Secure patient's head to the backboard with two-inch adhesive tape across forehead. - Check CMS before and after immobilization. . Continue to monitor airway, breathing, simulation. vital signs. and level of consciousness. 129 SPLINTING Appropriate splinting can reduce or minimize dislocation. motion. hemorrhage. swelling. and pain. GENERAL PRINCIPLES The following general principles apply to splinting: Remove or out away clothing. Dress and bandage signi?cant wounds. using a sterile dressing. Check OMS distal to injury before and alter splinting. lmmobilize joints above and below injured bones. For joint injuries. leave in place and immobilize the bone above and below the joint It may be necessary on a mid-shaft (center 1i3) fracture to realign angulated injuries. Pad Splints well. Elevate extremity a?er splinting, if possible. Monitor CMS a?er splinting. GUIDELINES FOR SPECIFIC INJURIES Realignment of Long Bone Fractures Attempt to realign (open or closed) long bones that are angulated in the middle 113 then splint. 130 SPLINTING loom.) Long-bone fractures, which occur in the proximal or distal 113, that may or ma 5! not involve a Mini, may be realigned if compromise of distal simulation or nerve function is detected and de?nitive care is delayed. Realignment may sometimes be necessary to facilitate packaging for transport. Check and document CMS before and after splinting andror realignment. Splint dislocations or otherjoint injuries in the position found. Exception: Loss of a distal pulse and neurological function and de?nitive care is delayed. In that case, attempt to straighten into anatomical position until the pulse returns, excessive pain is felt, or resistance is encountered. Support with blanket, pillow. or mil-padded splint. Elevate the limb. Pack the injured area in ice or use an ice pack. Pelvic Fractures lmmobilization of these fractures can be accomplished by use of a bed sheet, disposable blanket, or a commercial device. Fold sheet into to 14" width. 131 (comm Flaoe beneath patient; twist then wrap ends around patient. crossing over pelvic area. Tie sheet with square knot to apply moderate side-to?side and front to back pressure. Secure the ends to the backboard. TRACHOH SPLINTING A lower extremity traction splint stabilizes fractures of the femur. This reduces motion. hemorrhage. swelling, and pain. Traction splints are indicated in midshaft femoral fractures without involvement of the hip ioint. knee, or lower leg. General Guidelines For Applying A Traction Splint At least Mo EMTs are required to apply a traction splint. Remove or cutaway clothing. Dress and bandage signi?cant wounds using a sterile dressing. Manually immobilize the injured extremity prior to dressingfbandaging. Check distal OMS before and after manipulation. Objectives: I Determine SICWNOT SICK . Control Bleeding - Property measure splint I Apply traction . Apply splint . Reassess CMS and vital signs 132 TASER DART REHDVAL AND CARE The TASER dart usually penetrates the skin only a few millimeters. EMTs can safely remove a dart simply by pulling it out. The only exception is involvement of the eye. face. neck, breast or groin. In this case. leave the dart in place and transport the patient to the hospital for dart removal. Consider scene safety and measures to protect yourself and other rescuers from a potentially violent patient in situations when a TASER gun has been used. You do not need to transport a person to the hospital based solely on TASER dart exposure. If a patient has no need for further medical evaluation. you can leave him or her in police custody. This skill may be performed by EMTs and ALS providers. (Depending on local protocol.) ALS Indicators . Compromise in A305 BLS Indicators - Taser dart imbedded in skin BLS Care . Assure the scene is safe . Wear PPE including gloves and protection?consider mask and gown if blood is present . Remove TASER cartridge from gun or cut wires before removing darts 133 TASER DART REMOVAL Ann CARE (com-J - Dispose of darts in sharps container or TASER cartridge . Police must be in custody of patient - Restrain if needed Removal Procedure . DO NOT REMOVE darts if: Patient is not under control - Eye, face, neck, breast or groin are involved?patient must be transported to hospital for dart removal in this case - Grasp ?rmly with one hand and pull to remove, one dart at a time . Reassess patient - Consider medical or behavioral problems as the original cause of violent behavior - Drugl'alcohol intoxication Behavioral problems - Trauma. etc. . Bandage wounds as appropriate . Document situation and patient contact thoroughly Patient Disposition Release to law enforcement if indicated . Transport with law enforcement support if: - Eye, face-1 neck, breast or groin are involved - ALS indicated - Law enforoement of?cer requires medical evaluation. Police protocol may require transport. This may be by PD or ambulance. 134 TASER DART REMOVAL AND CARE {coma} . Follow Patient Care Guidelines regarding restraint of aggressive or violent patients Bum Hazard When a TASER is used in the presence of pepper sprayr propellantI there is a burn hazard. Electrical arcing fnom Imperfect {but effective) dart contact can ignite the propellant. The resulting combustion mayr not be visible, but can lead to complaints of heat and burning. If a patient complains of heat or burning. evaluate for possible minor burns. . TEETH Place avuleedidielodged toothfteeth in milk or patient saliva and transport. 135 TRANSPORT AND Transport Options In deciding what is best for the patient. you have several transport options: .- Paramedic Transport . All ?Sick? patients and all patients with unstable vital signs should be transported by medic unit (when available}. If no medic unit is available, begin transport and rendezvous. All patients transported by paramedics must go to a hospital. . BLS Transport (via private ambulance or ?re department BLS unit}. Stable patients who require medical attention or oxygen during transport may' be transported with a BLS vehicle. In deciding whether to call for private ambulance or transport via fire department BLS unit, departmental policies should be followed. Before requesting a private ambutance, always inferm the patient that you would like to cat:F for a private ambutanoe, and that the ambutance company Witt charge a fee for transportation and service. When requesting an ambulance for BLS transport, the defautt mode in King County for ambulance travel to the scene is non- emergency response unless specific written protocols or contracts require code-red response. 136 TRANSPORT AND DESTINATION (CONTJ . Private Vehicle Transport . Patients with minor alterations in vital signs and stable conditions not requiring oxygen may be advised that travel to the hospital or clinic via private vehicle is safe. Obviously the patient should not be the driver. . Taxi Transport . Some departments utilize a taxi voucher program for patients who travel to a clinic. urgent care clinic, free-standing emergency department, hospital based emergency department. These patients must meet the following criteria: 1. Paramedic care is NOT required 2. Patient is ambulatory 3. Patient has a non-urgent condition (clinically stable} including low index of suspicion for: Cardiac problem Stroke Abdominal aortic aneurysm GI bleed problems Major mechanism of injury sense 4. Patient must not have Need for a backboard Uncontrolled bleeding Uncontrolled pain Need for oxygen {except patient self administered oxygen) 13':Ir TRANSPORT AND 5. 6. The EMT considers a taxi to be an appropriate and safe method of transportation for the particular clinical problem. Patient should be masked if there are respiratory Final Disposition Options In deciding what is best for the patient you have four disposition options: 1. Leave at Scene - Generally, patients with normal vital signs and minor injuries or illness may be left at the scene. Always caution the patient to seek medical care (or call 911) if the condition should worsen. 2. Urgent Care Clinic I Selected patients may be transported to a clinic or urgent care clinic by ?re department EMTs if they meet the following criteria: A. Paramedic care is NOT required B. Patient is ambulatory C. Patient has a non-urgent condition (clinically stable) including a. Low index of s?uspicion for: . Cardiac problem I Shake - Abdominal aortic aneurysm - GI bleed problems b. Lowr index of suspicion for major mechanism of injury 138 TRANSPORT AND DESTINAHON (CONTJ D. Patient must not have 8. Need for a backboard b. Uncontrolled bleeding c. Uncontrolled pain d. Need for high ?ow oxygen For guidance regarding transport decisions EMTs may consult with paramedics or with emergency department personnel at the medical control hospital. The EMT must notify the destination facility of the clinical problem and the facility must agree to accept the patient. 3. Free-standing Emergency Department Selected patients may be transported to a free-standing emergency department by EMTs if they meet the following criteria: . Paramedic care is NOT required . Patient has a non-urgent condition {clinically stable} including: A. Low index of suspicion for cardiac. stroke, abdominal aortic aneurysm. or GI bleed problems B. Low index of suspicion for major mechanism of injury C. Patient is willing to be transported to the free-standing emergency department. transport decisions guidance EMTs may consult with paramedics or with emergency department personnel at the medical control hospital. If a free-standing 139 TRANSPORT AND (CONTJ emergency department destination is selected, that facility must be noti?ed prior to transport and agree to accept the patient. . Hospital Emergency Department - Transferring Patients At Rendezvous Site Patients {particularly patients in less populated parts of King County) who are evaluated by EMTs and are in need of paramedic level care. may require transfer of care at a rendezvous site. This should be accomplished in the following fashion: A. The ?rst arriving EMT team will decide whether paramedic care is required according to EMT protocols. In some instances the dispatch center will have already dispatched paramedics to begin travel toward a rendezvous point. B. If the EMT team determines paramedic care is not warranted then they will cancel the paramedics according to protocols. If continued paramedic care is warranted then the EMTs will contact their dispatch center to request a paramedic rendezvous and a suggested site. Upon meeting at the rendezvous site the paramedics will decide if the patient 14D TRANSPORT AND DESHNATIDN (CONTJ should be transferred to the paramedic vehicle further evaluation and treatment. The paramedics may, depending on the clinical situation. decide to assess the patient in the EMT vehicle. The paramedics will decide on the most suitable mode of transport to the hospital. .141 AVPU CHF OMS CNS COPD DNAR FBAO IDS LDC MDI MGB MOI NOI RM NTG OPA OPQ RST POLST SAMPLE ABBREVIATIONS Alert, Verbal, Pain, Unresponsive Congestive Heart Failure Circulation. Motori Sensory Central Nervous System Chronic Obstructed Pulmonary Disease Do Not Attempt Resuscitation Endotracheal Tube Foreign Body Airway Obstruction Index Of Suspicion Level Of Consciousness Metered-Dose Inhaler Medical Group Supervisor Mechanism CH Injury Nature Of Illness Nonrebreathing Mask Nitroglycerin Oropharyngeal Airway Onset, Provocation. Ouality1 Radiation, Severity, Time Physician Orders for Life Sustaining Treatment Allergies, Medication, Past history, Last oral intake (mealL Events leading up to complaint 142 143 Age Respi- Pulse Systolic rations (heats! Blood {breath minute} Pressure 104 40 minute) Degrees mamas 1?33 39 4 Newbornmonth 166 935 37 Infantmonth to 160 1 year 94- 34.4 Toddlo: 24 to4? ooto15o oota1oo 92 33.3 Temperature 1 to 3 years 90 - 32.2 Preschool29.4 3 to 5 years 30 25.? School age110 1'5 23.3 NORMAL VITAL SIGNS BY AGE 6 to 12 years FD 21 1 AdolescentOver18 1210 20 5010100 90to14l] years 144 Organization Address Telephone Betlevue Fire Department 45011031 Avenue NE Belletrue. WA 93601 (425) 452-6392 {Phone} King Gaunt?r Medic One ?064 South 220'" Street #9 Kent, WA 98032 (206) zaeesso (Phone) Redmond Fire Department 3450 -161$tAvenue NE Redmond. WA 98052 (425) 553-2200 (Phone) Seet?e Fire Department Medic One 325 Ninth Avenue Seattle. WA 98104 (206) 336-1433 (Phone) Shoreline Fire Department 17525 Aurora Avenue N. Sharenne, WA 98133 [206) 533-6500 (Phone) Vaehen Island Fire a. Reswe 10020 SW Bank Road Vashon. WA EWING-1150 (206) 453-24115 (Phone) ALB PROVIDERS 145 Organization Address Telephone Tri-Mecl Ambulance 18821 E. Valley Highway Kent, WA 93032 [205} 243-5522 {Phone} American Medical Response 13075 Gateway Drive SE Suite 100 Tukwila. WA 93168 [205) 444-4440 {Main}- (205} 523-1 111 {Dispath or 1 eon-54247111 Kc Sheriffs Of?ce Search 81 Rescue 7'300 Pen'meter Road 3.. Room 143 Seattle, WA 98103-3349 (205) 295-5553 {Phone} RuralrMetro Ambulance 6405 - 213?" Street SW Mt. Lake Terrace. WA 98043 (425) 572-1 111 {Phone} 1-300-935-9993 Crisis Clinic of King County 205-451-3222 {205} 451-3353 {Fax} Mental hea?h resouroe agency for oonoemed arente. relatives. etc. Domestic Violence Hotlines - King County - Washington State - National (255) 2055555 1-555-552-5025 1-505-255-7233 RE3OURGE8 AMBULANCE mo 146 Agency Phone Number Reason to Ce? King County 24 hour Crisis Line (206} 461-3222 1-366-42?-4?47 Emotionalr Physical or Drug Abuse. Suicide King County EMS Division (205} 295-4693 Administration of EMS servioes Language Bank American Red Cross (206} 323-2345 Foreign language translation Medical Examiner - King County 1206} 731-3232 Report expected natural death: request death Investigation National Suicide Prevention Lite~ line 1 Suicide, emotional famin Sexual Assault - King County Resource Center - 24 hr Resource Line {425} 226-5062 1-333-993-5423 Support for rape Seattle Mental Health {203} 302-23130 All mental health services including 24hr Crisis Response Service Washington Poison Center 1 ~300-222-1222 Ingestion of substances COMMUNITY Resounoes DISPATCH CENTERS Airport Communication Center SeaTao International Airport Phone: (255} 4.335229 FAX: (205) 439-5157 Noroom Communications Center Phone: (425} 577-5555 FAX: (425) 577-5529 Enumolaw Police Department Phone: (350} 525-3505 FAX: (350) 52541134 Seattle Fire Department Dispatch Phone: (205} 355-1493 FAX: {255) 554-7275 Communications Center Phone: {253) 352-21 21 FAX: {253] 3?2-1 506 147 14B Hospital City Telephone Door Code Auburn Regional Medical Center Auburn 253-333-2561 Children?s Hospltal Seattle 205-987-2222 Enumclaw Regional Hospital Enumclaw 360-802-3203 Evergreen Hospital Kirkland 425899-171 1 Good Samaritan Hospital Puyallup Group Health - Central Seattle 206-326-3223 Group Health - Eastside Redmond 425-50241 2O Harbonriew Medical Center Seattle 206-744-3074 Highline Community Hospital Burien 206-431-5316 Highline Comm. Hospital - Riverton Tukwila Mary Bridge Children's Hospital Tacoma 253-403-1418 Monroe Valley Hospital Monroe 360-?94?1 402 Northwest Hospital Seattle 206-3684 765 Overlalce Hospital Beltevue 425688-51 GO EMERGENCY DEPARTMENTS 149 Providence Hospital Colby Everett 42 5261-3000 Providence Hospital Paci?c Everett 42 5-253-7555 Snoqualrnie Valley Hospital Snoqualmie 42 5-331-2323 St. Clare Hospital Lakewood 253-539-3300 St. Francis Hospital Federal Way St. Joseph Medical Center Tacoma 253-426-6963 Stevens Hospital Ed monds 425-640-4632 Swedish Hospital - Ballard Seattle 206-331-6341 Swedish Hospital - Central Seat?e Swedish Hospital - Providence Seattle 206620-21 1 1 Tacoma General Hospital Tacoma 253-403-1050 UW Medical Center Seattle 205-593-40-[10 VA Puget Sound Health Center Seattle 206-?62-1010 Valley Medical Center Renttin Virginia Mason Hospital Seattle 206-533-6433 EHERGENCY DEPARTMENTS INDEX A ACS .1 62 AED Protocols .. 65 ALS Criteria .. 53 Abdominal 53 Breathing .i 53 Burns .. 53 EVA .. 53 Cardiac .. 53 53 Hypothermia .7 53 L00 .. 54 GBIGYN 54 Seizure .. 55 Sepsis 55 Trauma .. 55 Other .. 55 APGAR Scoring .. 35 AVPU .r 93 Abbreviations .. 142 Abdominal Complaints .. 6 Abuse 5 Neglect 4.114 Activated Charcoal .. 39 Airway 56 Orophoryngeal Aimay .. 56 Suctioning .. 57 Airway Obstruction .. T0 Altered Level of Consciousness r. 7 Amputation .. 1'5 150 INDEX Anaphyiaxis 9. 43. 1'9. BU Aspirin .. 14. 41. 63 Asthma .. 10 Bag-Valve Mask (BUM) 58 Behavioral Emergencies 11 Bleeding Control 59 Bloodborne Exposure .. 120 Bradycardia (Hypothermia) .. 16. 50. 54 Bradycardia {Profound} .. 16 Breathing .. 53. 101, 104 Burns ..12.49.53.135 Chemical .. 75 Ultraviolet .. 26 13 Cardiac Arrest ..15.16.BO.119 Cervical Injury .. 24. 28. 29. 37. 46. 12B Charcoal (Activated) 89 Chest Discomfort .. 13. 62 Child Abuse 8: Neglect .. 114 Childbirth. Delivery .. 32 Post Delivery .. 36 Cold-Related .. 15 Congestive Heart Failure .. 15. T5, 142 CPR .. Adult .. 70 Child and Infant .. T1 Newboms .. T2 CVA .. 66 151 INDEX Decontamination .. 49. 96 De?brillation .. 76 Delivery (Childbirth) .. 32 Post Delivery (Childbirth) .. 36 Destination Options .. 133 Diabetic .. 14, 2t]. 53. 33. 90 Diabetic Coma .. 20. 23 Do Not Attempt Resuscitation .. 7'7. 142 Dressing and Bandsging .. 12. 1B, 59. T4 24. 102 ECG Monitoring 3?6 Elderly Abuse Neglect 114 End of Life Issues W. 142 Epinephrine El. 42, 55, T9 EpiFen 9. 42. 55, T9 Epistaxis (Nosebleed) 1'6 Exposure 120 Extremity 37, 55, 132 Long 3B. 130 Injuries 26, 55, 133 FAST Exam .. 52 Febrile Seizures .. 4D Fever and Infection (Pediatric) .. 40 Foreign Objects {Soft Tissue) .. 43 Foreign Objects (Aimay Obstruction} .. 7o. 142 152 INDEX Fractures .. 33 Extremity .. 37. 1'4, 1391 132 Femur .. 55. 132 Long Bone .. 36. 1311 Multiple I. 39 Pelvic: .. 37, 39, 55.129, 131 Frostbite .1 15. 1 6 Bleeding 53,115 Glasgow Coma Scale Glucometry .. 83 Group Health Consult 55 Gynecologic .. 27 Head and Neck ..28 Heat Related .. 30 Helicopter Procedures .. 57 Helmet Removal {Diabetic Coma} .120. 23 Hypoglycemia .. 20. 44. 54, 66. 84. Hypotension (Shock) .. 54 Hypothermia ..15, 53 :03 (Index of Suspicion} .4 122. 142 Inhaler .. 89 Insulin 83 LOG 54. 142 Long Bone Fractures ..33, 130 153 INDEX MOE [Mechanism Medication 38 55 Multi-Casuattv Incident 92 Field Triage Algorithm .. 96 Medical Group Supervisor .. 92 Organization Chart .. 95 Transportation Team .. 93 Transporting 94 Treatment Team .. 93 Triage 93 NOI [Nature 122. 142 Neurological Assessment .. 933 Glasgow Coma Scale 99 Nitroglyoerin ?39. 142 Normal Vital Signs by Age .. 143 Nose Bleed (Epistaxis) .. 76 Noxious Stimuli .. 1 no 0 Obstetric Delivery instructions .. 33 Obstetrics 32 Open Soft Tissue Iniuries ..47 Oral Glucose .. 20. 53. 34, 90 Oropharyngeal Aimay 53 Orthopedic Iniuries 7, 3? Oxygen Patient Positioning 105 154 INDEX Semi-Reclining {Semi-Fowler?s) .. Shock .. 1GB Pediatric Fever and Infection Pelvic 3Q, 55, 129,131 Personal Protective Equipment (PPE) 1 12 Handmashing 112 Infectious Physical Abuse and POLST (Physician Orders For Ltfe~Sustainlng Treatment) 142 Post Delivery Instructions 32 Delivery Instructions 36 Postural Vital Signs .. 116 Profound Bradycardia 16 117 PulserBP .154 Pulse Recovery Position ..105 Reportable Exposures Restraint of Patients 109 3 Scene Size Scuba Diving Accidents 25 55 Semi-Reclining 155 INDEX Sepsis ..45. 55 Shock Position TUB SICKINOT SICK ..122 Soft Tissue . . 4? Open . . 4a Spinal Immobilization 128 Splintan Stings and Bites (Anaphytaxisi A. 9 Suctionan Sustained .. 54 Syrup of Ipeoao .. 39 Taser Dart Removal and Care ..133 Teeth .. 135 Temperature Conversions ..143 Traction {splinting 132 Transport and Destination 136 Transport Options 136 Disposition 133 Transferring Patients At Rendezrrous 140 55 Yankauer Tip .. 57 156 1Miles LEEHD Mill-d bran. FI- DlplBattallan 2 Bamllon 4 Milan 5 Battalion a same" 7 FIRE smuous ARTERIAL ?Emwmm'm no lmuwmw?, Iwwmw_ .. EMERGENCY RESPONSE TOTALS 2005-2009 Total Seattle Fire Department Responses - 2005 to 2009 2005 2006 2007 2008' 2009 41,848 43,476 43,448 44,598 44,373 3.81% +3.89% 0% +2.65% 20,010 20,330 20,330 19,829 18,866 +23% +15% 0% 61,858 63,306 63,773 64,427 63,239 +3.45% +3.15% 0% l15,260' 16,717 15,292 14,340 14,551 +2.19% -8.82% -2.96 4.9% 80,523 79,070 79267 77,790 0% BLS Basic Life Support ALS Advanced Life Support CUIDELINE 5001 SEATTLE FIRE DEPARTMENT AID AND MEDIC RESPONSES I If 12mg - I .153}: ~Training Guide #1443 Form 2048 Instructions STAFFING - EMS REPORTS Rev Him/es Aid Units are normally staffed by detailingtheir respective station per- sonnel. The member in charge usually sits in the right side seat and is responsible for final decisions regarding emergency responses and patient treatment. A Report iq'reqirirerl for all EMS incidents vvhich receive an incident number, except for incidents that are cleared with a "Code Green" or "No Patient? disposition. The following are criteria for a "No Patient? disposition: - There was no person found at the scene after looking for a patient andfor asking any bystander to assist in identifying the patient or ask- ing the PAC for any additional information. No one at the scene appeared to need medical assistance. No one said or indicated that they needed medical assistance. Company Offioers will verify that a Form 203 is filled out as required for EMS incidents, including when medical assistance is needed but refused. These reports are required to document the med icai treatment provided by EMS responders and support our ongoing evaluation of EMS prac- tices. To assist with the task, a tool is available on the Department's InWeb site that will print out a list of all EMS runs for a particular Company, or all companies assigned to a Station. The information is updated by CAD each morning at UFUU hrs. 5001-1 GUIDELINES SEATTLE FIRE DEPARTMENT EQUIPMENT OPERFLTING Guroturvt 5001 All Aid and Medic units should be inventoried at the beginning of every shift. if units leave equipment with a patient-transported by a Medic Unit, the Medic Unit will be contacted to ensure the equip- replaced as soon as possible. However, Aid Unit personnel should be aestatthmadi'?'oa??om?ra?s not replace items left one Medic Unit. Equipment that is not immediately returned should be noted in the Watch Desk Journal and the Form 9. The nota- tion should include the items missing, the incident number, and the Medic Unit involved. Each Company, Aid, and Medic Unit has been issued backboards assigned as part of their inventory. Replacement boards will come from the on-scene Aid or Medic Unit, if possible. If none are available, replacement boards can be obtained from hospital emergency rooms, or requisitioned from Medic One. A double-wide backboard is?located in each fire station housing a ladder company. The backboards are 32? .72" and resemble the wood back? boards currently in service throughout the Department. Company Capu tains are responsible for the proper storage of the backboard within their respective stations. When the need for a double?wide backboard arises, on-scene personnel must prompt me 'Fire Alarm Center to dispatch an Operations company with one of the backboards. Each board has an approximate weight limit of .700 pounds. The eleven backboards com? prise the Department's current inventory, and arrangements must be made to recover-them, as soon as possible, after each use. When an Enginei'tadder Company and Aid Unit are dispatched to an incident, me Engineftadder Company shouid be the first to return to service. When relieved by the Medic Unit, Aid Unils and Enginei?Ladder Companies should be put in service unless their assistance is critical to the immediate care of the patient. Medic units will be placed in service if the Paramedic in charge has determined that the patient does not require the services of a Medic Unit. During such an event, the patient will be left in the care?of the Aid or EngineiIr Ladder Company crew at the scene. REvil?l-l?l??lrl?g. OPERATING CUIDELINE son?: SEATTLE FIRE DEPARTMENT NON-EMERGENCY OPERATIONS Aid Units may be used when there is insufficient staf?ng to accomplish inspections, deiiveries, or transportation. Units should keep the PAC advised when traveling out of their vicinity and of any possible delay in responding. Medic Units need not accompany the base company on non-emer- gency activities and should not be used for inspections or deliveries. Medic units must stay in the area of their assigned station whenever pos- sible. PARAMEDICS WORKING IN THE COMPANY A Paramedic is a member certified by the University of Washington School of Medicines Paramedic Training Program. in doubie houses Aid and Medic Units will be the responsibility of the Ladder Company Officer. Medical Services Officers are responsible for Medic 1 and Medic 10. MINORS When a person of minor age is being treated it is not necessary to await parentai consent prior to treatment or transportation. If a minor patient refuses first-a id treatment, ire department personnel are authorized to take whatever actionsare necessary to initiate first-aid treatment and transportation. INTOXICATED PERSONS An intoxicated person is one whose mental or physical functioning is substantialiy impaired because of the use of alcohol. . An Incapacitated person is an intoxicated person who, as a result of alcohol consumption, has impaired judgement so they are incapable of making rational decisions with respect to their needs for treatment and constitutes a danger to themselves, to others, or to property. While public intoxication does not constitute a criminai offense in the . State of Washington, the Uniform Alcoholism Act does provide that per.? sons who appear to be incapacitated by alcohol will be taken into pro- tective custody and taken to an approved facility for treatment. Protective custody provisions apply only in the case of one who is inca- Rtv. nouns spoil-'3 Flat DEPARTMENT TRAUMA 5001?4 DRUG ABUSERS OPERATING - 5001 pacitatedas a result of the consumption of alcohol. The Central Alcohol Agency has been set up to coordinate the handling of intoxicated persons. Many high mortality illnesses are frequently found in the chronic alco- holic; the patient should always be examined for any iniury or acute ill- ness. Patients should be screened for transport, dependent on the be determined whether the person is intoxicated to the point of being inca? pacitated as opposed to simply being intoxicated. The guidelines of the incapacitated or intoxi- cated persons are: - intoxicated, not incapacitated: A person who appears to be intoxi? cated in a public place may be assisted home or to an approved treat? ment facility with their consent. In other words, participation must be voluntary Intoxicated, incapacitated, and conscious: Place in protective custody and transport via the Detoxi?cation Van (also known as gency Service Patrol by Private Ambulance, or Seattle Police 0 intoxicated, incapacitated, and unconscious: Transport via private ambulance or call a Medic Unit if the patient's condition warrants it The police should take an intoxicated person, who has threatened, protective Custody. The response district for the Emergency Service Patrol is from South Spokane Street North to Roy Street and from the waterfront East to and including Broadway, 24 hours a day, days a week. Members of this department should not institute search for illegal or contraband materials. However, every effort should be made to deter- mine the type of drug involved when it could alter the patient?s treat- ment. It is important to remember that Harborview Medical Centm is a Level 1 Trauma Center and the only hospital that staffs their operating rooms at all times. Trauma patients with a Glasgow Coma Scale score of less than .13, hypotension, femur fracture, open or multiple fractures or a dynamic mechanism of injury will be triaged to Harborview Medical Center, including pediatric and obstetric patients. Rev. 114?21109 GUIDELINE 5001 REQUESTS FOR MEDICAL INFORMATION SEATTLE FIRE DEPARTMENT Requests for copies of medical incident reports will be directed to the Finance Director, Seattle Fire Department, 301 Second Avenue South, Seattle, Washington 93104-2630. AID UNrr AS TRANSPORTATION I. REV. 11:21!th vacy is our top priority. In that-spirit, the following information may be released regarding patient care: Number of patients Gender of patients . Condition of patients. This could include a brief, general description of injuries, burns to the hands, respiratory difficulty, etc. Information that may be released regarding patient care: - Name of patient Personal infmmation about patient, home telephone number, family information, etc. Personal health history of patient, heart disease, other illnesses, etc. Patient's medical records ma},r not be released without specific, writ ten permission from the patient Generally, an Aid Unit should not be used as an ambulance to transport patients if in the opinion of the Aid or Medic Unit crew, no emergency exists. However, at the discretion of the person in charge, the Aid or Medic Unit may transport if special circumstances'exist. Aid and Medic Units should use the teiephone, whenever possible, to relay information regarding patient status and assistance required to the hospital Emergency rooms. This information should inciude: - Patient description - Vitals status Patient signs and Paramedic Unit personnel, if the unit is going to be delayed excessively, may make the decision whether or not the on-scene Aid Unit wiil trans- port the patient to the hospital or a rendezvous location with the Medic Unit. - .5001SEATTLE FIRE AMBULANCE REQUESTS - TIME or ARRIVAL ORAL GLUCOSE ADMINISTRATION sum -.6 OPERATING - 5001 The primary method for making ambulance requests is via radio, using Zonei Channel 9. Requests can also be made via telephone by contacting . Attempts should be made to use phones other than department cellular phones for telephone requests. in the event, the above methods for. ordering an ambulance are unsuc- cessful, a request for an ambulance may be made via radio on the assigned channel, through the Fire Alarm Center. 'When requesting an ambulance directly, provide the ambulance dis- patcher with the following information: - address/location of the patient brief summary of the patient?s condition - requested destination of patient The ambulance dispatcher should advise the requesting unit of the ori- gin of the responding units. Requests for ?estimated time of arrival" should not be made until 15 minutes have elapsed from the initial call for an ambulance. After a total of 20 minutes have elapsed from the initial call, the (Jo?scene Aid or Medic Unit should provide transportation. if an Aid or Medic Unit is not on scene, the officer may request an Aid Unit. Oral glucose is a commercially available gel that dissolves when placed in the mouth. Dne toothpaste type tube equals one dose. The gel acts to increase blood glucose levels and should be given to any patient with a decreased level of consciousness who has diabetes that is controlled by medication. The only contra indications to glucose are an inability to swallow or unconsciousness since aspiration can occur. Refer to Training Guide #144 2 for more information and Standing Orders regarding the administration of oral glucose. REV. 'l 1f21f09 OPERATING CUIDELINE - 5001 -. LANGUAGE LINE SERVICE REV. TUEUDQ SEATTLE FIRE DEPARTMENT Anaphylaxis may result from bites or stings, ingestion of certain foods, or from medications. True anaphylaxis produces life threatening reactions in the airway, lungs, bleed vessels and heart characterized by respiratory distress and circulatory collapse that can lead to death. The two key categories of signs and that specifically indicate anaphyiaxis are respiratory compromise and shock. Epinephrine may be administered in accordance with the current Medi- cal Directors standing orders when true anaphylaxis is indicated. The adult and child size auto injectors are distributed annually to Oper? ations Division from Support Services Division. When and Epi-Pen is administered, a replacement Epi-Pen will be provided to the apparatus from the on-scene Medic Unit. If the Epi-Pen on an apparatus is past the expiration date, contact the Services Warehouse immediately at (206] 3364 530 for a replacement. Refer to Training Guide 14-11 for Standing Orders and more informa- tion regarding Epinephrine Administration. Airlift Northwest is a commercial helicopter ambulance service, opera- tional 24 hours a day. The helicopter can be in the air in six minutes with its own medical team. Aid and Medic units will notbe put out of service to transfer patients from the Harborview Medical Center helicopter pad to the emergency room until the helicopter has been sighted. Upon viSual contact of the helicopter, me Aid or Medic Unit will put themselves out of service to make the transport. To communicate-with non-English speaking citizens, Language Line Ser- vices have been available to the Department for translations since 1999. tit-Language Line identification card must be-kept in the cab of each responding apparatus as part of the inventory. A small ?how to use" card must be kept in all .First Aid Kits. The Language ID Card lists the languages most frequently encountered in North America grouped by the geographical region where they are commonly spoken. To use the Language ID Card efficientiy, locate the geographical region where you believe the non-English speaker may be from. an 1i SEATTLE FIRE DEPARTME N0 CPR GUIDELINES CUIDELINE - 50m - Show the person the languages iisted for that region. The message underneath each language says; ?Point to your language. An inter- preter will be called." Refer to your Quick Reference Guide to access an interpreter through Language Line Services. In most cases, an interpreter is avail- able within seconds. language; a'representa'tive - you. Dial the emergency number 14300-523-1?36 Provide to the Answer Point our Client 943025 and your unit 1D - Wait for the Answer Point to bring the Interpreter in on a conference call. . - Brief the interpreter on the purpose of the call. Listing of languages within this card does not guarantee availability of interpreters in these languages. Language Line Services interprets from English into more than 140 languages, only the most requested lan- guages are listed here. A demonstration phone line is available at 1-300?821-0301 so that members may familiarize themselves in the use of this service. This number is also iisted on the back of the. small "how to use? card. In the Washington CPR Program, emergency medical person- nel honor speciaily designed and printed directives and bracelets. This program applies to persons 18 years of age or oider who have decided they do not want CPR performed in the event they suffer a cardiac or respiratory arrest. The directive must be signed by the indi- vidual?s doctor. The original CPR directive or bracelet must be seen by the EMS provider. The original directive should be located at the patient?s bedside, on the back of the door to the patient?s room, or- on the refrigerator. If the patient is being transported, the original directive should accompany the patient. The bracelet is a white water?resistant iD bracelet uniquely designed with the Department of Health logo imprinted on the band. This brace- let is comsidered an extension of the original signed directive and can be. honored in the absence of the _original signed directive. The bracelet should be worn on the wrist or ankle. If extremities are not suitable then a sealed and closed bracelet shouid be placed on a necklace or neck- chain, and worn by the patient. REV. 5001 SEATTLE DEPARTMENT RESPONSE PROTOCOLS Responding personnel should perform routine patient assessment and respscitation or interventions until they confirm the CPR status in one of the foiiowing ways: i the bracelet is intact and not defaced 1. Ibc?t?a begin resuscitation if, in your medical judgement, the patiEnt has attempted suicide or is a victim of a homicide. After con?rming that the patient has a valid CPR directive, per- sonnei should stop all resuscitation efferts except: open the airway use suction to clear the airway provide oxygen by nasal cannuia control any bieeding - make the patient comfortable - provide emotional supportfor the family (once a death occurs, lire family and relatives become your patients) The patients wishes in regard to resuscitation should always be respected._5ometimes, however, the famiiy may vigorousiy and persis- located. In such circumstances attempt to convince the family to honor the patient's decision to withhold CPR. However, if the family persists, initiate resuscitation efferls and consult the Medic One doctor. NEWBORN INFANT DROP OFFS State law mandates that within ?2 hours of birth, newborns may be dropped off at a hospital ER or a staffed fire station without risk of pros~ ecotion under the state's Child Abandonment Laws. Newborn infants will be accepted at fire stations in conjunction with state law. Members should make every effort to protect the anonymity of the par- ent. The parentfs dropping off the infant should be encouraged to pro vide an anonymous medical history of the parentfnewborn, date and time of birth, if tobacco, drugs or alcohol were used during pregnancy, and if there was exposure to other diseases. Members may not detain the parent transferring the infant in an attempt to gain information. WHEN AN INFANT - Request a medic response for evaluation of the infant and mother ?5 DRUPPED OFF Obtain as much information asthe parent is willing to give Transport to the hospital, preferably Children?s Hospital. Transport should be done via SFD medic or aid unit to ensure proper transfer of information at the hospital. . Notify Child Protective Services (CPS) REV. ii?if?g I I LP 500 DOWNLOAD SEATTLE FIRE DEPARTMENT OPERATING GUIDEUNE 5001 - Request that the Fat: notify the Shift Commander and the PIO Instructions fordownloading patientsum mariasimm the are posted near the station computer. The instruction sheet is entitled ?Instructions for Downloading LPSDO Resuscitations". In the even that the sheet islost, the information is also available on the drive at Additional assistance can be obtained by contacting the EMS Coordina? tor or the onuduty M50. - TRANSPORTATION AND TREATMENT OF SUSPECTED STROKE PATIENTS FAC GUIDELINES RESPDN DING - COMPANY GUIDELINES ENT EVAL UATION 5001?10 Ail suspected stroke patients will be screened for inclusion as candidates for Thrombolysis. in order to be effective, the medication must be administered within three hours of the onset Hospital evalu- candidate for thrombolytic therapy, the patient should reach the hos pi? ml within approximately two hours. Patients exhibiting 'stroke wili be evaluated using the attached guideline for therapy approved by the SFD Medical Director. TAC Dispatchers will follow Dispatch protocol #33, which includes the question: Has the patient had (IVA {or less than two hours? If the answer is yes, the Dispatcher will include the statement in the response information, which will be communicated to responding com- panics. Once on scene, EMT's will attempt to determine or confirm the approx- innate onset time of the if iess than two hours, expedite transport to Hospital Emergency Depart- ment. This may be by Ambuiance, Aid Car, or Medic Unit. If less than Lwo hours onset, and the patient is transported by Ambu- lance or Aid Car, SFD wili contact the receiving Emergency Department using the phone numbers on the back of the F208. Ask for the Charge or Triage Nurse, and notify them that you are sending a patient with Less Than Two Hours." Give them an expected arrival time and patient information. Evaluate patienls per current EMT training to identify CVA including new: . 11(21109 Appendix E: Appendix E: CAD Interface and AVUGPS Connection Requirements. Interface Regyirements. A. Contractor Responsibility for Working with TriTech Software Systems The Contractor shall implement an interface between its CAD system and Seattle Fire Department?s TriTech system. It is the sole responsibility of the Contractor to contact TriTech Software Systems to determine the scope of work, requirements, technical speci?cations, cost and anything else necessary from TriTech Software Systems to meet the CAD interface terms described in this Appendix. TriTech Software Systems contact information is as follows: Kenneth Schulte Customer Account Manager TriTech Software Systems 9860 Mesa Rim Road San Diego, California 92121 Corporate Phone: 858-799?7900 Direct Phone: 720-379?3900 B. Contractor Responsibility for Costs The Contractor will pay all costs associated with implementing the interface including: 1. Any payments to TriTech for goods and services to implement the interface 2. Any servers or other computers and network equipment needed to implement the interface - 3. Any City labor costs for installation, testing, or con?guration of any software, hardware or network components needed for the interface. C. Security . The interface must operate through a firewall or comparable security ?rmware that is provided by the contractor that meets the City?s specifications and operational requirements. The City will identify the security product that the successful proposer must procure prior to executing the Agreement. D. Network Availability Requirement The Contractor shall install and maintain a network connection to support the interface that is available 99.99% of time, including any time required for network maintenance. This requirement applies to the network connection from the Contractor?s CAD system up to the City ?rewall. E. Interface Functional Requirements The interface must transmit dispatch, ambulance status, and location information from the Contractor?s CAD system to the SFD system in real-time i. whenever an ambulance is dispatched, while the ambulance is traveling to respond to the dispatch and whenever the status of the ambulance changes. For purposes of this Page 1 of 3 Appendix E: paragraph the phrase ?status of the ambulance changes? includes all of the status data and status events described in 3a and 3.b, below. 2. The delay between transmission of data from the Contractor's CAD system and receipt of the transaction data by the City's system must not exceed 5 seconds. 3. The information transmitted must include the following: a. Disbatch information: I Unique alphanumeric code associated with the ambulance (minimum of 4 alphanumeric characters to a maximum of 1D alphanumeric characters.) . - Fire Department incident number - 11 alphanumeric characters maximum b. Status information: I Unique alphanumeric code associated with the ambulance status that must reflect, at a minimum. the following status: DiSpatcher dispatches the ambulance Ambulance starts to respond Ambulance arrives at the scene Ambulance starts to transport the patient Ambulance arrives at transport destination Ambulance leaves the transport destination Ambulance is available to be dispatched Ambulance is out of service and not available for dispatching (eg. - Unique Alpha or numeric code indicating the destination. The codes must, at a minimum, include the following destinations: 00000000 Ballard Swedish Hospital MorguefMedical Examiner Children?s Hospital Jail Group Health Central Medical CliniciPrivate Doctor Harborview All Other Hospitals Northwest Hospital Other Providence Hospital Home Valley Medical Center Swedish Cherry Hill Hospital University Hospital Evergreen Hospital Swedish Hospital Overlake Hospital Virginia Mason Highline Hospital Veterans Hospital - Separate dateltime stamps (in the format) for the following statuses: Page 2 of 3 Appendix E: DiSpatcher diSpatches the ambulance Ambulance starts to respond Ambulance arrives on scene Ambulance starts to transport the patient Ambulance arrives at the transport destination Ambulance leaves the transport destination Ambulance is available to be dispatched Ambulance is out of service and not available for dispatching 00000000 I XY coordinate of the ambulance at the time the status information is recorded in the proposer?s CAD system (in wgsB4 format, units decimal degrees). c. Location Information Besides the XY coordinates at the time the status information is recorded, the proposer must transmit all XY coordinates of ambulances dispatched from the time of dispatch to the time arrived on scene, from the time the ambulance starts the transport to the time the ambulance arrives at the transport destination. The XY coordinates must be in WGSB4 format, units decimal degrees. Page 3 of3 RFP-SFD-ZBBT Appendix Appendix F: Summary of response time standards and penalties (liquidated damages) Operations Code Response time to Per minute Total Requested scene (minutes: penalty 1-5 penalty Laval to Scene Seconds) minutes After 5 late minutes late 1 Red 9:59 $60 $600 Yellow 14:59 $60 $600 Patch Thru 14:59 $60 $600 2 Red 14:59 $60 $600 Yellow 19:59 $60 $600 Patch Thru 19:59 $60 $600 3 Red 9:59 $60 $600 Yellow 14:59 $60 $600 Patch Thru 14:59 $60 $600