Section 1

Question 1

1.01 Routine Patient Care (Up to Transport)

Answer 1

1. Respond to the scene in a safe manner:
   * Use information available from the dispatcher, consider scene safety and
   pre-arrival assessment and treatment of
   the patient.
   * Request appropriate additional resources, including advanced life support (ALS) response / intercept if available.
   * Use of emergency warning devices and siren should be used with discretion and only as appropriate for the nature of the response and given information.
2. Approach the scene cautiously and assess scene safety:
   * If a hazard is identified, request appropriate assistance and maintain scene safety through appropriate measures including the use of personal protective equipment (PPE) as indicated. If the scene is unsafe, stage until hazards / threats are mitigated.
   * Utilize standard precautions for all patient contacts. Standard precautions include, depending on the anticipated degree or exposure, the use of gloves, gowns, mask, and eye protection or a face shield. Hand hygiene should be performed before and after each patient contact. Institute transmission based precautions as indicated in Table 1 below.
   * Bring all necessary equipment to the patient.
3. Utilize the Multiple Patient Incident (Mass Casualty Incident) Protocol if indicated based the number of patients and/or need for resources.
4. Determine if the patient(s) meet pediatric or adult criteria by age. A pediatric patient is defined as a patient less than 16 years of age. For patients ≤ 36 kg/80 lbs., utilize a pediatric dosing device (BroselowTM, Handtevy or other). If the BroselowTM Pediatric Emergency Resuscitation Tape is utilized, patients measuring beyond the length of the tape should receive weight based medication dosing until the age of 16 years old or their total body weight is ≥50kg. Some special needs patients may require continued use of pediatric protocols regardless of age.
5. For trauma patients, evaluate mechanism of injury (MOI) and employ spinal movement restriction precautions (SMRPs) if indicated following the Spinal Movement Restriction Precautions Protocol.
6. Obtain and document the patient’s chief complaint (CC), history of the present illness (HPI), past medical history (PMH), current medications (including over-the-counter medications) and allergies to medications.
7. Perform a primary assessment and obtain vital signs. Vital signs at a minimum shall include blood pressure (BP), palpated pulse, respiratory rate, and oxygen saturation as measured by oximeter (SpO2). Temperature (oral, rectal, axillary, or esophageal probe) should be obtained and documented when available and in all critically ill or injured pediatric patients.
8. Perform a secondary assessment (the secondary assessment may consist of a focused examination for isolated injuries).
9. Treat life-threatening conditions in the order in which they are identified. Manage as indicated per age appropriate protocol(s).
10. All patients shall have their level of pain assessed utilizing an age appropriate pain scale (see age appropriate Patient Comfort Protocol). This assessment shall be documented on the Patient Care Report.
11. Pain, nausea and vomiting should be managed following age appropriate
    Patient Comfort Protocols.
12. Some patients who are beyond the pediatric age limit with chronic medical conditions may request or require transportation to a Pediatric Specialty Care Facility.

Question 2

1.01 Routine Patient Care (During Transport)

Answer 2

22. During transportation:
    * Stretcher patients shall be secured in an appropriate restraint system providing both transverse and longitudinal protection. Straps are required at the patient’s knees, hips, and over the shoulders.
    * Ambulance cots shall be positioned at the lowest possible position during transportation and movement of the patient.
    * Seated patients shall be restrained with a lap and chest safety belt restraining system.
    * Pediatric patients of appropriate age, height or weight shall be transported utilizing a restraint system (child safety seat) compliant with Federal Motor Vehicle Safety Standards (FMVSS). The car safety seat shall be properly affixed to a stretcher with the head section elevated or to a vehicle seat, unless the patient requires immobilization of the spinal column, pelvis, or lower extremities; or the patient requires resuscitation or management of a critical problem.
    * All heavy items and equipment (e.g. cardiac monitors, oxygen cylinders) in the patient care compartment of the ambulance shall be secured following the manufactures specifications.
    * Use of emergency warning devices and siren are to be restricted to use only while transporting patients with acute life threatening conditions requiring time sensitive interventions.
23. The following may be used as a reference for pediatric age appropriate systolic blood pressure:
    Neonate >60 mmHg
    Infant to 1 year >70 mmHg
    1-10 years >70 + (2 x age in years)
    >10 years >90 mmHg
24. A face to face verbal report (hand-off) detailing the patient’s chief complaint, abnormal assessment findings, EMS interventions, and the patient’s response to treatment shall be given to a licensed health care provider at the receiving facility.
25. All care shall be documented in accordance with the Documentation Protocol on an ePCR.
26. Direct patient care provided by a non-transporting R.I. licensed ambulance (i.e. fire suppression unit, ALS intercept, etc.) must be documented by the completion of an ePCR by the licensed EMS providers staffing the unit and providing care. This may result in the generation of two ePCRs within one service for the same patient/incident.

Question 3

1.04 Biological Death

Answer 3

Recognition:
* Adult patient without vital signs and with at least one of the following: rigor mortis (rigid stiffness of the body), fixed lividity, obvious injury incompatible with life (e.g. decapitation, transection) or obvious changes of decomposition (i.e. bloating, skin slippage, extensive green or black skin discoloration).
* Pediatric patient without vital signs and with at least one of the following: obvious injury incompatible with life (e.g. decapitation) or obvious changes of decomposition (i.e. bloating, skin slippage, extensive green or black skin discoloration).

• Patients not meeting the above criteria must receive resuscitative care following the age appropriate Cardiac Arrest Protocol unless the patient or the patient’s qualified health care decision maker pursuant to Rhode Island Code of Regulations, 216-RICR-20-15-4 has completed Medical Orders for Life Sustaining Treatment (MOLST) or the patient has Comfort One status. Manage patients with MOLST or Comfort One status per the MOLST/Comfort One Protocol.
• By recognizing the evidence of lifelessness (as above, in recognition), EMS practitioners have made the determination of death. The determination of death by EMS practitioners does not constitute pronouncement or certification of death, which are the responsibility of a physician or licensed independent practitioner (nurse practitioner [advanced practice RN] or a physician assistant (PA) who at the time is practicing in a physician supervised role).
• Once a determination of death has been made, responsibility for the patient lies with local or state law enforcement. Law enforcement is responsible for contacting the Medical Examiner’s Office. The body should not be removed from the scene and the scene should be disturbed as little as possible.
• EMS documentation must include the specific criteria on which the determination of death was made.
• Follow Deceased Persons Protocol.

PEARLS:
* Fixed lividity (purple/blue discoloration in gravitationally dependent parts of the body), does not change appearance with palpation.
* Cyanosis and skin changes associated with hypoperfusion should not be confused with fixed lividity.