County of Kern. Emergency Medical Services. ALS BOAT MEDIC PROGRAM May 13, 2013

County of Kern Emergency Medical Services ALS BOAT MEDIC PROGRAM May 13, 2013 Ross Elliott Director Robert Barnes, M.D. Medical Director

Table of Contents I. GENERAL PROVISIONS:... 1 II. ALS BOAT MEDIC SCOPE OF PRACTICE:... 1 III. ALS BOAT MEDIC PROVIDER:... 2 IV. ALS BOAT MEDIC QUALIFICATIONS, CERTIFICATION & TRAINING:... 3 V. ALS BOAT MEDIC PLANNING & DEPLOYMENT:... 3 VI. ALS BOAT MEDIC SCENE OPERATIONS:... 3 VII. EMS RESOURCE USE:... 4 VIII. DOCUMENTATION & QUALITY ASSURANCE:... 5 IX. REQUIRED ALS BOAT MEDIC EQUIPMENT & SUPPLIES:... 5 Appendix A. Required ALS supplies and equipment.... 6 Revision Listing: 09/2012- Create draft policy 05/09/2013- EMCAB Approval Kern County Emergency Medical Services Division

I. GENERAL PROVISIONS: A. The Advanced Life Support Boat Medic Program (Program) is an optional prehospital advanced life support program administered by the Kern County EMS Division (Division) through authorized Kern County Paramedic Providers (Provider). The program functions as an extension to state and county Paramedic rules, regulations, policies, procedures, protocols and operates under medical control and authority of the Division Medical Director. B. The primary purpose of the Program is to provide expedient ALS response and care to EMS incidents that may occur on bodies of water within Kern County prior to ALS ground transport. The Program is to be provided by an authorized ALS Boat Medic Provider where the area or access to the patient can only be made by water proving a delay in patient care by conventional ALS ambulance or ALS First Responder to an incident within the area. The Program is a specialty program authorized through the Division and shall be used as an adjunct to the basic EMS system operations. C. The Program entails the use of specially equipped and trained Paramedic(s) with State licensure and local accreditation, employed by a Provider that is authorized by the Division to operate the Program. D. The ALS Boat Medic Provider shall be responsible to provide a vessel, supplies, and equipment in accordance with these policies that are mechanically sound, properly configured and safe to operate within the ALS Boat Medic role. Vessels may be rented, borrowed, or used in conjunction with law enforcement operations provided the vessel meets the above requirements. The Program shall only be operated in accordance with these policies by a two member team; including one member at EMT or Paramedic level with required courses outlined ALS Boat Medic training section of this policy; and one member at Paramedic level with required courses outlined in ALS Boat Medic training section of this policy and advanced life support supplies and equipment. E. Use of the Program shall not be construed, interpreted or allowed to replace or modify in any way ALS ground transportation resources maintained by a Provider. F. Use of the Program shall not in any way affect, change or modify Provider ambulance response time standard performance requirements as specified in Ordinance Code 8.12. Regulations and Policies. G. ALS Boat Medic Policies and Procedures may be revised or discontinued as necessary by the Division. II. ALS BOAT MEDIC SCOPE OF PRACTICE: A. The ALS Boat Medic Paramedic is authorized to provide prehospital Advanced Life Support (ALS) within the scope of practice allowed by the State of California and the Division according to these policies and procedures. B. The ALS Boat Medic Paramedic is authorized to provide prehospital ALS skills and procedures according to Paramedic treatment protocols authorized by the Division Medical Director. This authorization shall be commensurate with the ALS Boat Medic ALS supplies and equipment inventory specified in these policies and specially refined for ALS Boat Medic function. C. The ALS Boat Medic Paramedic is authorized to provide patient transport across water to a ground transport ambulance. The transportation of patients across water shall only be initiated on a vessel that is configured to provide such transportation safely. D. The ALS Boat Medic Paramedic shall comply with all Division Paramedic rules, regulations, policies, procedures and protocols at all times. E. The ALS Boat Medic Paramedic shall coordinate appropriate notification, response, communications and use of local EMS resources when requesting ambulance back up response to the incident. Such coordination shall Kern County Emergency Medical Services Division Page 1

include, but not be limited to, identifying the appropriate entrance for responding resources, coordinating rendezvous locations for patient hand-off, and identifying appropriate response mode for requested resources. III. ALS BOAT MEDIC PROVIDER: A. Valid Division authorization as an ALS Boat Medic Provider shall be required for a Provider to operate the Program. B. ALS Boat Medic Provider authorization shall immediately be terminated if the Provider is unable to provide personnel meeting the requirements of these policies or the program is terminated. C. A Provider wishing to be authorized as an ALS Boat Medic Provider shall submit a written application to the Division. The written application shall include a thorough description of proposed program, ALS Boat Medic personnel qualifications and training, and a written commitment to comply with ALS Boat Medic policies and procedures. D. The ALS Boat Medic Provider shall develop a plan which defines ALS Boat Medic staffing, deployment, hours of coverage, communications, area resources, incident reporting, and procedures for requesting additional resources. All assigned Boat Medic personnel shall be provided a briefing in the plan prior to each deployment. The plan shall be submitted to the Division along with the application for approval. Any changes in the plan shall be submitted in writing to the Division. E. To be eligible for ALS Boat Medic Provider authorization all of the following minimum requirements shall be met: 1. Be an existing Paramedic Provider authorized by the Division; 2. Have and maintain an ALS Boat Medic training program as outlined in section IV which complies with the provisions of these policies and procedures; 3. Have and maintain at least one (1) vessel appropriately configured for patient transport, supplied and equipped in the ALS role as specified by these policies, to be deployed in a two (2) person ALS Boat Medic team; a. If ALS Boat Medic Provider will be using a vessel belonging to another agency, the Provider shall have a written agreement with the other agency to allow ALS Boat Medic team to operate from their vessel. b. The vessel deployed as an ALS Boat Medic shall be inspected prior to the first use by the United States Coast Guard. 4. All ALS Boat Medic programs shall comply with Division Quality Improvement processes and remain consistent with Title 22, Division 9, Chapter 12 of the California Code of Regulations. 5. If the Boat Medic program will be operating on a County owned vessel, the following additional requirements shall be met: a. A feasibility and risk assessment shall be conducted by either Risk Management or a third party consultant. b. An agreement between the Boat Medic Provider and the County shall be crafted to provide optimal protection to the County in both terms of indemnification and insurance coverage. F. An authorized ALS Boat Medic Provider shall ensure the Program is continually operated according to these policies and procedures. The Division may terminate ALS Boat Medic Provider authorization for noncompliance to these policies and procedures. Kern County Emergency Medical Services Division Page 2

IV. ALS BOAT MEDIC QUALIFICATIONS, CERTIFICATION & TRAINING: A. A minimum of one (1) member of the ALS Boat Medic team shall have and maintain active Kern County Paramedic accreditation. The other member of the ALS Boat Medic team may be an EMT or Paramedic with active Kern County accreditation. B. Members of the ALS Boat Medic team shall receive a minimum of two (2) hours training in ALS Boat Medic policies and procedures, ALS Boat Medic scope of practice, communications systems, Scene Control Policy, and EMS resource use before being authorized to operate in an ALS Boat Medic capacity. The ALS Boat Medic Provider may provide the training. C. Members of the ALS Boat Medic team shall complete a boat safety training class approved by the State of California through the Department of Boating and Waterways. Such classes may be taken online or self-study type of classes. Members must possess a valid certificate of completion of the Boat Safety Class prior to deployment on an ALS Boat Medic team. D. Members of the ALS Boat Medic team shall complete a water rescue training course. Members shall complete training equivalent to life guard training. Such training shall include, but not be limited to, self-rescue, and water cervical spine immobilization procedures. E. The ALS Boat Medic Provider shall maintain records of all personnel that have completed all required ALS Boat Medic training courses, which shall be forwarded to the Division prior to deployment of the ALS Boat Medic team. All records pertaining to the ALS Boat Medic program shall be made available to the Division upon request. F. The ALS Boat Medic Provider or the Division may withdraw ALS Boat Medic authorization at any time for non-compliance with policies and procedures. The ALS Boat Medic Provider or the Division may also establish re-authorization training requirements (similar to reaccreditation) or mandatory ALS Boat Medic education sessions. V. ALS BOAT MEDIC PLANNING & DEPLOYMENT: A. The ALS Boat Medic Provider shall ensure appropriate deployment and use of the Program. The ALS Boat Medic program shall only be deployed in a manner consistent with the pre-approved deployment and operations plan submitted per Section III.D. B. The ALS Boat Medic boat shall only be deployed in a two member team configuration; including one member at EMT or Paramedic level with required ALS Boat Medic training and one member at Paramedic level with required ALS Boat Medic training with advanced life support supplies and equipment as specified within these policies. C. Non-emergent activity, movement and positioning of an ALS Boat Medic team shall be at the discretion of the ALS Boat Medic provider. D. The Program shall only be provided by the ALS Boat Medic Provider where areas or access to a patient can only be made by watercraft and would significantly delay the response or patient contact time of a conventional ground ambulance. E. ALS Boat Medic team members, who are not also law enforcement officers, are prohibited from engaging the public, or cause reasoning for the public to view team members as law enforcement personnel when operating on a law enforcement vessel. VI. ALS BOAT MEDIC SCENE OPERATIONS: A. ALS Capacity (meaning the ALS Boat Medic team is the first ALS level personnel arriving at the scene, and has the capability of providing patient transport across water): Kern County Emergency Medical Services Division Page 3

1. The ALS Boat Medic Paramedic is expected to assume patient health care authority until a ground transport paramedic arrives. If the ALS Boat Medic team is not operating in conjunction with law enforcement and is the first unit arriving at the scene of an emergency incident involving a multiagency response, the ALS Boat Medic would assume incident commander responsibility until a public safety agency arrives. In medium scale or complex incidents requiring a dedicated person(s) for Medical Group Supervisor for medical group operations, resource use, communications and transportation coordination, patient health care authority shall be delegated to another qualified person at the scene. Refer to the Scene Control Policy for further information. Nothing in this section is intended to supersede the Scene Control Policy. 2. The ALS Boat Medic Paramedic is expected to establish medical control, complete scene and patient assessment and initiate BLS/ALS patient treatment intervention according to Kern County Paramedic Policies and Procedures and Kern County Paramedic Treatment Protocols as the patient condition necessitates. The ALS Boat Medic Paramedic is expected to initially bring necessary medical equipment and supplies to the patient for appropriate overall patient care. B. Patient hand-off procedures: 1. The ALS Boat Medic Paramedic provides patient care and necessary transport of a patient from a body of water to the shore and maintains patient health care authority until a ground transport ambulance arrives and the ALS Boat Medic transfers patient care responsibility to the ALS ambulance Paramedic. The normal focus of the ALS Boat Medic program is to provide immediate care and watercraft transport of an otherwise inaccessible patient to the shore until an ALS ambulance arrives, transfer of patient care responsibility occurs, and the ALS Boat Medic team rapidly becomes available for additional responses or use. 2. The ALS Boat Medic team shall ensure the safety of all EMS personnel responding to the scene for patient transport. It is recommended that ground transport personnel not be allowed to receive patient care responsibility, or provide interventions until the patient is completely off the boat or pier and on the shore. 3. If a BLS ambulance arrives at scene and ALS patient care procedures are indicated, initiated or carried out, the ALS Boat Medic Paramedic must bring necessary equipment and supplies from the boat to manage the patient and attend the patient during transport to an ALS ambulance or the hospital. 4. During a multi-casualty or mass casualty incident, the ALS Boat Medic Paramedic may use a BLS ambulance for patient transport when ALS procedures have been initiated, if an ALS ambulance is not reasonably available, or the patient(s) require rapid transport and the situation mandates that the ALS Boat Medic Paramedic remain at scene to administer ALS level care to additional patients. C. ALS Boat Medic Safety Procedures 1. ALS Boat Medic team shall be required to have in their possession a United States Coast Guard (USCG) approved life jacket at all times while onboard a vessel and on duty. See section IX.C. for required specifications of approved life jackets. ALS Boat Medic team shall be responsible to provide for their safety. 2. All patients and family members shall be required to wear a USCG approved life jacket while on board the ALS Boat Medic vessel or during transport of a patient to an awaiting ground ambulance. Such safety measures are not intended to restrict access to or treatment of a patient, however safety must be a priority. Paramedic judgment shall be used for patients requiring cervical spinal immobilization as to not manipulate the spine or cause further injury to the patient from application of a life jacket. 3. When transferring a patient from a vessel onto the ALS Boat Medic vessel, patients must be properly equipped with a USCG approved life jacket. VII. EMS RESOURCE USE: Kern County Emergency Medical Services Division Page 4

A. The ALS Boat Medic team shall be responsible for prudent notification, response and efficient use of all EMS resources in conjunction with the Scene Control Policy. During Med-Alert operations, the ALS Boat Medic team shall coordinate incident communications and resource use through the Medical Group Leader. B. The ALS Boat Medic team shall notify their dispatch center of the appropriate entry point for responding resources and specific instructions to access the rendezvous point for transfer of patient care. VIII. DOCUMENTATION & QUALITY ASSURANCE: A. The ALS Boat Medic Paramedic shall complete an electronic Patient Care Record (epcr) for every prehospital patient contact by the ALS Boat Medic program, in accordance with Division Patient Care Record Policies and Procedures. The epcr completed by the ALS Boat Medic shall be submitted in to the Division according to standard procedure. Submission of an epcr is mandatory regardless of the number of patient contacts per year. B. The ALS Boat Medic provider shall provide ALS Boat Medic pre-event plans, incident reports, related data or ALS Boat Medic program evaluations to the Division upon request. C. The Division shall be notified in advance of any anticipated changes in function of the ALS Boat Medic program and shall monitor the program for operational and medical quality assurance. D. The ALS Boat Medic Provider shall participate in the EMS system-wide quality improvement program, as it is expanded and further developed as requested by the Division. IX. REQUIRED ALS BOAT MEDIC EQUIPMENT & SUPPLIES: A. The ALS Boat Medic Paramedic and ALS Boat Medic Provider shall be responsible to maintain a complete inventory of required ALS Boat Medic equipment and supplies as specified in these policies. B. The ALS Boat Medic vessel must be equipped with at a minimum an ambulance identification sign, one steady red warning lamp, and siren or a law enforcement vessel. C. The ALS Boat Medic Paramedic and ALS Boat Medic Provider shall be responsible for the care and maintenance of all ALS Boat Medic inventory. ALS Boat Medic inventory shall also be subject to inspection by the Division. D. The ALS Boat Medic team shall have a USCG life jacket of type I, II, III or V. Accommodations shall also be made for additional life jackets to be made available for all patients and family members that may be transported by the ALS Boat Medic team. The vessel must also be equipped with a USCG Type IV throwable device. E. The ALS Boat Medic team shall have all of the ALS supplies and equipment listed in Appendix A. Kern County Emergency Medical Services Division Page 5

Appendix A. Required ALS supplies and equipment. 1. Required ALS Boat Medic Medical Supplies and Equipment Inventory - Expendable: a. Medication Inventory: 1. Adenosine (Adenocard) ------------------------------------------------------------- 24.0 mg 2. Albuterol Sulfate (pre-dilute 2.5 mg per 3 ml solution) ----------------------- 5.0 mg 3. Amiodarone --------------------------------------------------------------------------- 450 mg 4. Ammonia Inhalants------------------------------------------------------------------- 2 amps 5. Aspirin (150 to 325 mg. tablets-chewable preferred) --------------------------- 4 tablets 6. Atropine Sulfate ---------------------------------------------------------------------- 3.0 mg 7. Dextrose 50% (prefilled) ------------------------------------------------------------ 50.0 gm 8. Diphenhydramine (Benadryl) ------------------------------------------------------- 100.0 mg 9. Dopamine ------------------------------------------------------------------------------ 400.0 mg 10. Epinephrine, 1:10,000 --------------------------------------------------------------- 3.0 mg 11. Epinephrine, 1:1,000 ----------------------------------------------------------------- 2.0 mg 12. Furosemide (Lasix) ------------------------------------------------------------------- 100.0 mg 13. Glucagon ------------------------------------------------------------------------------- 1.0 mg 14. Lidocaine, 1% or 2% (IVP) --------------------------------------------------------- 200.0 mg 15. Magnesium Sulfate -------------------------------------------------------------------- 4.0 gm 16. Naloxone (Narcan) -------------------------------------------------------------------- 4.0 mg 17. Nitroglycerine Tablets Gr 1/150 or Metered Dose Aerosol Units (0.4 mg)- 1.2 mg 18. Sodium Bicarbonate ------------------------------------------------------------------ 50.0 meq 19. Verapamil------------------------------------------------------------------------------- 20.0 mg b. Narcotics Inventory: 1. Diazepam ------------------------------------------------------------------------------ 20.0 mg 2. Midazolam ---------------------------------------------------------------------------- 8.0 mg 3. Morphine ------------------------------------------------------------------------------ 20.0 mg c. Intravenous Access - Solutions & Accessories: 1. Alcohol Preps --------------------------------------------------------------------------- 10 2. Betadine Preps ------------------------------------------------------------------------- 5 3. IV Catheters (14,16,18,20,22,24 ga) ----------------------------------------------- 2 each 4. IV Tubing (Microdrip, 60 gtts/ml) ------------------------------------------------- 2 5. IV Tubing (10 gtts/ml - or (1) 10 gtts/ml and (1) 15/20 gtts/ml) -------------- 2 6. Hypodermic Needles (18 or 20 ga) ------------------------------------------------ 5 7. Lancets (for BG analysis) ------------------------------------------------------------ 5 8. Mucosal Atomization Device (MAD) ---------------------------------------------- 1 9. Normal Saline 0.9% (1000 ml bags) ------------------------------------------------ 2 liters 10. Normal Saline 0.9% for Injection - Single Dose Vials -------------------------- 20 ml total 11. Saline Locks ------------------------------------------------------------------------------ 2 12. Syringes (1,3,10,20 cc) ----------------------------------------------------------------- 1 each 13. Tourniquets (1"X 5" Penrose or =) ------------------------------------------------- 2 14. D5W or Normal Saline (50 or 100ml) ---------------------------------------------- 1 15. Intraosseous Needle (EMS Approved Only) Adult/Ped------------------------- 1 each d. Airway Maintenance: 1. Cricothyrotomy Unit (EMS Dept. Approved Unit Only) ----------------- 1 sterile 2. Endotracheal Tubes (2.5,3,4,4.5 mm) ------------------------------------------- 1 each 3. Endotracheal Tubes (5,6,6.5,7,8 mm)(with cuff) ----------------------------- 1 each 4. ET Intubation Tube Stylets (adult/pediatric) ---------------------------------- 1 each 5. Commercial ET tube holder ------------------------------------------------------ 1 6. Lubricant, water soluble (K-Y) -------------------------------------------------- 5 ml Kern County Emergency Medical Services Division Page 6

7. Oral Airways - Must meet CHP, HPH 82.4 recommendations, Page 4-2 1 set 8. Oxygen Mask - Adult & Pediatric ----------------------------------------------- 1 each 9. Oxygen Nasal Cannula ------------------------------------------------------------- 1 each 10. Oxygen Mask Adult Non-Rebreather ---------------------------------------- 1 each 11. Scalpel - # 11 Blade ----------------------------------------------------------------- 1 each 12. Thoracic Decompression Unit (EMS Dept. approved unit only) -------- 1 set 13. Bite Stick ------------------------------------------------------------------------------ 1 14. King Airway (size 3, 4, 5) ---------------------------------------------------------- 1 each 15. Secondary ET Conformation Device -------------------------------------------- 1 16. Nebulizer Set -------------------------------------------------------------------------- 1 17. Suction Catheter (10,18 fr) --------------------------------------------------------- 1 each 18. Suction Catheter (rigid) ------------------------------------------------------------- 1 19. Suction tubing ------------------------------------------------------------------------- 1 20. Ventilation Bag-valve unit with oxygen port and reservoir or demand valve bag attachment (Adult, Pediatric and Infant) ------------------------- 1 each 21. Ventilation Bag Mask - Semi-open, valveless, transparent (infant, pediatric and adult) ----------------------------------------------------------------- 1 each e. Bandages and Dressings: 1. Band-aids (1"X 3") -------------------------------------------------------------------- 5 2. Dressing, 3" Kling/Kerlix ------------------------------------------------------------ 2 sterile 3. Dressing, 4"X 4" ----------------------------------------------------------------------- 2 tubs 4. Dressing, 8 x 10 ---------------------------------------------------------------------- 2 sterile 5. Tape, 1" Plastic or Silk---------------------------------------------------------------- 2 rolls 6. Tape, 2 Cloth -------------------------------------------------------------------------- 1 roll 7. Triangle Bandage ---------------------------------------------------------------------- 1 8. Vaseline Gauze ------------------------------------------------------------------------- 1 sterile f. Miscellaneous Supplies: 1. Cervical Collars, Solid Plastic Construction (infant, child, adult-adjustable or =) ---------------------------------------------------------------- 1 each 2. Cervical Spine immobilization pads/device/blocks----------------------------- 1 3. Cold Packs (single use disposable) ------------------------------------------------ 2 4. Dextrose Sticks/Chemstrips or Blood Glucose Analysis Device------------- 6 Strips 5. ECG Electrodes, Adult -------------------------------------------------------------- 6 sets 6. ECG Electrodes, Pediatric ---------------------------------------------------------- 3 sets 7. Electrode Jell --------------------------------------------------------------------------- 1 bottle 8. Gloves, multi-size, non-permeable and non-sterile (box with minimum of 6 individual gloves) ---------------------------------------------------------------- 1 box 9. Shield, transparent or goggles for Eye Protection------------------------------ 1 10. Splint, Cardboard (arm, wrist, leg) or equivalent------------------------------ 1 each 11. Surgical Mask -------------------------------------------------------------------------- 1 12. Burn Pack or Burn care supplies -------------------------------------------------- 1 13. EKG paper, extra---------------------------------------------------------------------- 1 roll 14. Multifunction pacing/defib pads (adult/pediatric) ----------------------------- 1 each 15. Cleaning solution, 10% bleach or agent for infection control --------------- 1 16. Non permable plastic bags for medical waste, red ----------------------------- 5 17. Triage tags (EMS Approved) ------------------------------------------------------- 10 18. DOT Emergency response guidebook Hazardous Materials----------------- 1 19. OB Kit ------------------------------------------------------------------------------------ 1 2. Required ALS Boat Medic Medical Supplies and Equipment Inventory - Non-Expendable: a. Airway Maintenance: Kern County Emergency Medical Services Division Page 7

1. Laryngoscope Blades: Straight sizes - 0,1,2,3; Curved sizes - 2,3) ---------- 1 each 2. Laryngoscope Handle ------------------------------------------------------------------ 1 3. Magill Forceps --------------------------------------------------------------------------- 1 4. Oxygen Tank - Portable with regulator, liter flow control (500 psi) --------- 1 tank 5. Portable Suction Unit, CHP, HPH 82.4 recommendations, Page: 4-3 ------- 1 unit 6. Laryngoscope batteries, extra -------------------------------------------------------- 1 set 7. Laryngoscope bulbs, extra ------------------------------------------------------------ 1 each type b. Cardiac and Communications: 1. Defibrillation Paddles or pads (adult and ped) ----------------------------------- 1 set each 2. Biomedical Radio (portable) with voice access to Med Channels 1-7, 9 with Required PL codes of the Kern County Medical Radio System---------------- 1 unit 3. Defibrillator with patient cable and capable of synchronization --------------- 1 set 4. Replacement EKG cables and lead wires ------------------------------------------- 1 set c. Miscellaneous Medical Supplies and Equipment: 1. Blood Pressure Cuff with Gauge Infant, Child, Obese, Adult ----------- 1 each 2. Puncture Proof Sharps Container ----------------------------------------------- 1 3. Scissors and Portable Light ------------------------------------------------------- 1 each 4. Stethoscope --------------------------------------------------------------------------- 1 5. Pediatric dosage chart and/or Kern County Paramedic Treatment Protocols ---------------------------------------------------------------------------- 1 6. Pediatric length based resuscitation tape ------------------------------------- 1 7. Thermometer, oral (EMS Approved) ----------------------------------------- 1 8. Backboard, long with straps ---------------------------------------------------- 1 9. Femur skeletal traction device -------------------------------------------------- 1 Kern County Emergency Medical Services Division Page 8