What equipment is mandatory to be brought in with the transport team when at a receiving facility
1. Monitor
2. Response bag
What equipment is mandatory to be brought in with the transport team when at a sending facility
1. O2 bag
2. CCT bag
3. Response bag
4. Pump
5. Monitor
According to REACH definitions, what age range are the following:
Neo
Infant
Ped
Adult
Neo - birth to 28 days
Infant - 29 days to first birthday
Peds - 1 year to 15th birthday
Adult - 15 years of age to death
Per REACH protocol, name the drugs that may be given intranasally
1. Narcan
2. Fentanyl
3. Ativan
4. Versed
5. Ketamine
Name the two primary medications specific to the Acute Aortic Disease protocol that are utilized for control of heart rate and blood pressure
1. Esmolol
2. Nitroprusside
Per REACH protocol, what is the DO NOT MISS associated with the Severe Anaphylaxis protocol
Utilize Epinephrine IM (or IV, IO without a palpable pulse) and via continuous infusion for refractory hypotension
According to REACH protocol, we must re-zero an art line every _____ feet of cabin altitude change
every 2000 feet of cabin altitude change
If a patient has an art line, per REACH protocol this is optional to transduce and monitor during transport
T/F
FALSE
MUST be transduced in transport- even if waveform is dampened
State the 8 patient rights per REACH standards
Right -
- Patient/person
- Medication
- Dose
- Time
- Route
- Documentation
- Reason
- Response
In order to continue IV medication being infused at sending facility, what must we obtain?
1. a physician's order to continue the medication
or
2. obtain a copy of the original physicians's order
What must BOTH crew members do PRIOR to continuation of a medicated infusion?
All sending hospital infusions and medications are to be double checked and verified by both crew members prior to continuation of medication
Must complete the Medication Timeout prior to administration of the infusion
When calculating medication doses and rates, per REACH protocol, to what decimal point do we round up to?
Round Up to the nearest tenth decimal point
It is the responsibility of the medical crew to obtain physician orders for procedures and or chemical administration when these are not established by REACH policy/protocol
Name 2 methods to obtain and document a physician order
1. When receiving a physician order, the order must be written on a hospital issued order form. Have it signed by the physician who rendered the order.
2. When not practical to have the ordering physician sign the sheet, note it as a verbal or phone order and include appropriate documentation in the ePCR
Perform and record neurologic exams at least every 15 minutes. The neuro exam should include at least:
- All pain must be assessed and documented for all patients
- Document which pain scale is used for the non-verbal patient
According to REACH protocol, IV access utilizing the External Jugular vein is not allowed.
True or False?
False
When transporting to a Neonatal ICU or a Pediatric ICU what must the Medical Crew do prior to departing the referring facility?
the Medical Crew must contact the receiving physician and discuss plan of care prior to departing the referring facility. When practical, contact the receiving physician within 10 minutes of making patient contact
True or False
You have been dispatched to an interfacility transfer, your patient has a life threatening injury, because this is life threatening it is OK to initiate transfer before the regional trauma center has accepted the patient. The sending physician reassures you the trauma center will receive the patient because they are great friends and they will always accept his patients.
FALSE
This is a violation of EMTALA
Your adult patient (85kg) has an allergy to Zofran, she is nauseated.
Per REACH protocol, what drug is your option? and what are the routes of administration and the dose per route?
Benadryl
25 mg IV/IO
50 mg deep IM
There are many medical/surgical/traumatic conditions affected by changes in atmospheric pressure.
Per REACH protocol, name the 5 conditions that would limit your altitude to 8000 MSL?
- Abscesses
- Dental work
- Diseases of the middle ear
- Emphysematous bullae
- Pneumothorax or recent chest tube removal
Name the Parkland formula
4ml/kg/%BSA (max 80%)
1/2 total amount in 1st 8 hours
1/4 total amount in 2nd 8 hours
1/4 total amount in 3rd 8 hours
Per REACH protocol, is it necessary to add maintenance IV fluids to the Parkland formula?
YES
Name the Rule of Nines for an adult patient
Head 9%
Chest 18%
Back 18%
Arms 9% each
Legs 18% each
Genital 1%
Name the Rule of Nines for a pediatric patient
Head 18%
Chest 18%
Back 18%
Arms 9% each
Legs 14% each
Name the DO NOT MISS criteria for the Bubble CPAP protocol
Must have spontaneous respiratory effort present
For neonates and infants weighing <10 kg
Crew must have stron sense that intubation will not be required
Bubble CPAP, describe how to select the appropriate size of RAM cannula
Prongs to occlude no more than 60-80% of the nare opening
Expect a leak with the cannula - designed to work this way
DO NOT attempt to completely seal nares
GCS - Describe the 4 points of the Eye opening response
4 Spontaneous (already open)
3 To Speech
2 To pain
1 None
GSC - Describe the 5 points of the Verbal response
5 Oriented
4 Confused
3 Inappropriate
2 Incomprehensible sounds
1 None
GCS - Describe the 6 points of Best Motor Response
6 Obeys command
5 Localized
4 Withdraws
3 Flexor response (decorticate)
2 Extensor response (decerebrate)
1 None
What are the documentation requirements of the Pressure Easy device?
A. Document Pressure Easy device indicator in "safe zone" and provide rationale if outside "save zone"
B. Document rationale if Pressure Easy device is NOT utilized in presence of cuffed ETT
Hypoglycemic Emergencies
What glucose concentration is used to treat all hypoglycemic patients
D10W
Hypoglycemic Emergencies
Name the Abnormal glucose levels for:
- Adult
- Pediatric
- Neonate
Adult <70 mg/dl
Pediatric <60 mg/dl
Neonate <50 mg/dl
How soon should you assess blood glucose while caring for a child less than 1 yr of age
Within the first 30 minutes
When transporting a patient with a neurological emergent condition, how often must you document the neuro checks
every 15 minutes
Intracranial Hemorrhage or Brain Circulation Vascular Occlusion - Per REACH protocol, what are the two acceptable medications to be considered for anti-hypertensive therapy?
Nicardipine
Labetelol
Pulmonary Edema
DO NOT MISS points
NTG is the first line treatment
Consider CPAP/BIPAP prior to advanced airway management
What is the process for an "auto-launch" request?
The term "auto-launch" is subject to interpretation
1. According to flightguard an auto-launch is any time a crew is launched without a receiving facility, in which case crew goes to bedside and assists with patient care until a receiving bed is found
2. Auto-launch on scene call will come from an outside source, at which time crew chief will notify FG of destination/manifest/planned receiving if known. PIC will always check weather, do Baldwin and report this information to FG as with other scheduled flights prior to liftoff
Esmolol for Aortic Disease
Initial dose?
Increase how often?
Dosing Regimen?
Initiate IV infusion at 50 mcg/kg/min
Increase rate of infusion q 5 min
50 mcg/kg/min
100 mcg/kg/min
200 mcg/kg/min
300 mcg/kg/min
Esmolol for aortic Disease
What is MAP goal?
What is HR goal?
MAP goal 60-80 mmHg
HR goal 60-80
Acute Aortic Disease
Assessment
Obtain and document bilateral blood pressure
Treat the higher pressure
Titrate all medications to the MAP goal of 60-80 mmHg
C-MAC Video Laryngoscope
Use on all first intubation attempts
Do not forget to push record
What is the REACH mission statement
To provide customer oriented high quality air medical transport services in a safe and efficient manner. In every situation to do what is right for the patient
Describe the components of the Uniform Policy
REACH flight suit
REACH name tag
T-shirt, white or black, crew or turtle neck
Boots, black leather or fire resistance material with steel or carbon safety toe
Underclothing - natural fibers only
Optional - Jacket - black leather, cotton, or Nomex with natural fiber liner
Vest/radio pouch, black, fire resistant recommended
Hat - REACH issued hat, branding must match that of the employees flight suit
Under-helmet scull cap: natural fiber, solid color white or black
Duty Day
Red Hour
1st hour of shift
On-coming Flight team will present in full uniform at the start of the Red Hour
Off going crew will transfer the assigned controlled substance supply to the on-coming medical crew
Hand off assigned radios and phones
Report any significant info from prior duty shift that may have an immediate impact on operation for the on-coming team
Oxygen status aircraft/portable
Know equipment or supply deficiencies
Any required follow up
Any know customer relations events scheduled
Fatigue mitigation
Required rest prior to shift
Medical crew will have at least ten hours of rest before standing duty on an assigned shift
Fatigue stand-down
1. Team member who identifies that they are fatigued to the point of no longer being able to safelyperform their assigned duties will immediately self-report to the other team members.
2. The PIC will make immediate contact with Flight Guard to advise the unit service status has changedsecondary to a fatigue stand-down.
3. The fatigued Flight Team member(s) will immediately retreat to the private crew rest area for twohours. During this two hour period, the fatigued Flight Team member(s) will not be disturbed except inthe case of an emergency.
4. Flight Guard will notify the AOC that the unit’s service status has changed to out of service secondaryto a fatigue stand-down. The unit may remain available for “team flights only” dependent on thenumber of Medical Crew members requiring the fatigue stand-down and the mission profile of theeffected base.
5. Flight Guard will automatically return the unit to in-service status at the end of the two-hour period.
6. A Flight Team member who requires more than two hours rest during a fatigue stand-down willcontact the AOC via Flight Guard.
7. A Flight Team member who identifies that they will require a fatigue stand-down while away from thebase (e.g. after the completion of a transport but still at the receiving facility) will immediately contactthe AOC via Flight Guard to discuss their ability to safely return to the base. If the Flight Team is notable to safely return secondary to fatigue, the AOC will provide assistance and resources as needed.If the Flight Team is capable of safely returning, the two hour stand down period will not begin untilthe Flight Team has arrived at the base. The PIC will re-contact Flight Guard on arrival at the base totrigger the beginning of the stand-down period.
8. A Flight Team member that requests a fatigue stand-down within the last two hours of their assignedduty shift will be required to rest at the base even if the two hour rest period crosses over their end ofshift time.
9. A fatigue stand-down request made after being assigned to a transport request will require a postshiftdebrief with the AOC and/or the Flight Team’s Program Manager
Non-Patient Based Flight Operations
Search Request
1. The Flight Team may be used to assist in the search of a potentially lost or injured individual onlyafter confirmation that all local or regional search-capable assets have been utilized.
2. The Flight Team will not assist in the recovery of a deceased individual.
3. The unit status will remain in-service during the search activity.
4. Search activity lasting longer than 30 minutes of flight time will require the Flight Team to consult withthe AOC for continued operations.
The Flight Team will target the following on-scene time requirements:
Scene call: 10 minutes from landing to take off at scene landing zone
Inter-facility transport total bedside time:
i. General medical or traumatic injury: 20 minutes
ii. Aortic emergency: 15 minutes
iii. STEMI or stroke: 15 minutes
1.2.8 Availability, Post-Transport
An encumbered aircraft will be returned to in-service and available status immediately uponlanding at the receiving facility helipad.
If the aircraft is unable to land directly at the receivingfacility, the aircraft will be returned to available status when the PIC contacts Flight Guard andplaces the aircraft in-service.
The Medical Crew member designated to sit on the left side of the aircraft will utilize helmet mountedNight Vision Goggles during all phases of night-time flight operations to include:
a. En-route to a scene or referring facility.
b. En-route from a scene or referring facility to a receiving facility (when authorized by thespecific airframe NVG STC).
c. En-route back to base from any location.
The following manufacturerrecommended aircraft litter-base weight limits should be considered when deciding if a patient can besafely transported in a specific airframe:
a. Agusta 109: 350lb/159Kg
b. Agusta 109 Power: 375lb/170kg
c. Agusta 119: 375lb/170kg
d. Bell 407: 450lb/204Kg
e. Beechcraft 200 King Air: 450lb/204Kg
f. Eurocopter AS350: 400lb/181Kg
g. Eurocopter 135/G: 350lb/159Kg
h. Pilatus PC-12 (tail number N271SM): 375lb/170kg
i. Pilatus PC-12 (tail numbers N273SM and N275SM): 560lb/254kg
There are many times during the course of a flight wherein the Flight Team should observe sterile cockpitcommunications. Sterile cockpit is defined as refraining from all unnecessary communication includingunnecessary radio traffic. Listed below are general rules when all crewmembers should observe sterilecockpit rules:
Fixed-Wing Applications
a. Take-off and landing phases of flight.
b. During IFR operations
.c. When operating within Class B, C or D airspace.
2. Rotor-Wing Applications
a. Take-off and landing phases of flight.
b. During landing zone reconnaissance operations.
c. During IFR operations.
d. When operating within Class B, C or D airspace.
Clinical Quality Improvement
3.1.4.1
Peer Review
The Primary Contact is responsible for assuring the completion of the daily CQI process
1. The Medical Crew will perform peer review CQI on any and all outstanding base specific Patient CareRecords.
2. Verification of peer review CQI completion will require both of the on-duty Medical Crew member’snames and credentials entered in the CQI section.
Scheduled Shift Call-Off (<24 hours’ notice):
A Medical Crew member calling off for a shift scheduled within the next 24 hours will make directcontact with the on-duty Primary Contact at the effected base and notify them of their inability to workas scheduled.
a. If within reason a reasonable hour to do so, the on-duty Flight Team will contact all availablelocal off-duty staff to communicate the immediate staffing need and attempt to find coverage.
b. If unsuccessful in finding coverage, the Primary Contact will notify the AOC via Flight Guard.
c. The AOC will use ePro to immediately page out the open shift to all available regional staff.
d. If the call-out takes place before 17:00 hours, the AOC will contact the effected ProgramManager to assist with a staffing plan.
e. If the call-out takes place after 17:00 hours, the AOC will review the Medical Crew on-callstatus for the effected shift and consider the overall regional staffing picture.
f. If unsuccessful in finding coverage, the AOC will activate, if available and qualified, the oncallMedical Crew member for that base/region.
g. On-call Medical Crew members may be requested to work at bases or regions other thanwhere they are assigned as a full time employee. As such, on-call Medical Crew membersare strongly encouraged to have their flight helmet and uniform with them when standing anon-call shift.
h. Medical Crew members scheduled to be on-duty the day of a call-off may be requested tomove to a base other than where they are assigned as a full time employee. The AOC willattempt to minimize such movement but all Medical Crew members should understand theoperational necessity surrounding service-wide staffing needs.
i. The AOC will update ePro as needed.
j. If unable to staff the unit, the AOC will email the effected Program Manager and Director ofProgram Operations of the changed status.
Controlled Substance Inventory count,
When to perform
Controlled medications will be inventoried by ALL medical crew members presentat the base at least once daily and anytime there is a change in personnel. This willoccur each time there is a change in medical crew regardless of the frequency perday.
At the beginning of each shift or change of personnel, all off‐going medical crewmembers and all on‐coming medical crew members are to verify the types andamounts of controlled substances in stock.
Controlled Substance Inventory count
What does it include
This daily inventory of all controlled substances shall includeverification of expiration dates on each container, both in thenarcotic pouch AND the narcotic safe.
Handling of packaging MUST be conducted during the daily inventoryof controlled substances to ensure ALL original packaging is intactand has not been tampered with.
Controlled Substance Inventory Count
What is documented
All entries from the day prior shall also be audited to confirm ALLrequired data has been entered (date, CAD number, name,given/wasted amounts, both signatures present, etc). If ANYinformation is missing during the audit, the off‐going crew may notleave the base until the information has been completed.
Controlled Substance Inventory count
The total counts of the pouch and the stock inventory will then be entered on thecontrolled substance inventory log and will be signed immediately by off‐goingcrewmember who was controlling the pouch and the on‐coming crewmemberwho will be receiving the pouch.
Key points
i. Signatures must be legible and include the signee’s type of licensure.
ii. Entries shall be made in blue or black ink only.
iii. Errors shall be corrected by drawing a single line through the incorrect wording. The writing underneath the line must be readable and the error must be initialed adjacent to the correction by the crew member.
iv. The use of correction fluid or erasure material is not permitted.
v. Controlled substance may never be brought onto foreign soil, doing so is against Federal law and is prohibited.
Controlled Drug Waste Procedures
Unused or broken vials
a. All wasting of unused controlled substances or broken vials must bewitnessed by two medical crew members and entered on the narcotic log.
b. Wasting of medications must be completed in accordance with theMedication Management policy.
i. To render injectable controlled drugs unusable the medicationshould be withdrawn from the vial and disposed of in the sharpscontainer by “squirting” the drug into the receptacle.
ii. Do not put medications into the water system or garbage.
Controlled Drug Waste Procedures
Expired
All expired controlled substance wastes must be completed in the presence of the Program Manager or Regional Clinical Manager.
In the event expired controlled substances are discovered in the supply(pouch or safe), the PM must be notified and the expired substances secured in the safe in such a way as to prevent their use.
Controlled Drug Waste Procedures
Full vial wastes
In the event a full vial of medication is wasted, a Controlled Substance Waste form must be completed and scanned and emailed to the Clinical Compliance Coordinator within 24 hours of the waste. The original form will be sent via inter office mail to the Program Manager. This shall include full container waste of expired controlled substances
The Clinical Compliance Coordinator will forward the form to the Medical Director and Director of Clinical Services.
Examples of full vial waste include:
i. Broken vial
ii. Open, unused vial
iii. Full dose of medication drawn up and not administered.
Controlled Drug Waste Procedures
Reporting of Discrepancies
a. Any incident involving an unresolved discrepancy in the narcotic count,including loss of controlled substances, controlled substances removed from custody of the on‐duty crew member or any errors/omissions in the narcotic log will be immediately reported to the Administrator on call(AOC). The AOC will ensure that the Director of Clinical Services and Chief Medical Officer are notified within 24 hours of the event.
b. A company incident report will be completed and submitted via the company reporting system and an internal investigation will be initiated.
c. Loss of controlled substances or unresolved discrepancies will be reported by the Director of Clinical Services or designee to all appropriate regulatory agencies.
d. All efforts to resolve discrepancies should be exhausted before the off going crew will be relieved from duty by the AOC or Program Manager
Controlled Drug Waste Procedures
Record Keeping
All controlled drug use must be documented on the REACH Patient Care Record.
Each base will maintain a separate controlled substance log.
The Program Manager (PM) or designee will monitor controlled substance policy compliance through log audits and will ensure that all completed controlled substance logs are scanned and emailed to the Clinical Compliance Coordinator on the first business day following the end of the month.ii. These logs will be audited monthly by the Clinical Compliance Coordinator and the Chief Medical Officer or designee.
The Clinical Compliance Coordinator will maintain electronic copies of all Controlled Substance Inventory logs for a minimum of three years.
Controlled Drug Crew Responsibilities
It is the responsibility of each REACH Medical Crew member acting in the capacity of providing ALS services for the company to have all solutions, medications, and other ALS adjuncts within their respective scope of practices at their availability. This includes medications controlled by the D.E.A. and Section 1100 of the California Health and Safety Code
