Lisbon Fire Department Standard Operating Guidelines and Policies

INTERACTION/CONTACT WITH MEDICAL CONTROL

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  The off-line medical control physician will be the authority for Emergency Medical Technicians’ operations and medical care in the service to which they are licensed.
  
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  All Emergency Medical Technicians must be approved by the off-line medical control physician
  
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  The on-line medical control physician will provide direction for patient care during and medical emergency event.
  
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  Contact will be made with the on-line medical control physician for direction in patient care as required by the policies and protocols of the EMS department.
  
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  EMTs will, at no time, perform duties/procedures beyond the scope of their practice or outside the guidelines/standards of care of their EMS department off-line medical control physician.
  
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  The off-line medical director will determine under what circumstances orders may be accepted from on-scene physicians. Circumstances to be addressed include:
  

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  On-scene physician who is the patient’s personal physician:
  

EMTs may take orders from on-scene physicians if:

The orders are within the scope of practice

The EMT knows the orders are within the guidelines/standard of care for the working assessment for that patient

The EMT should contact the on-line medical control physician if there are any questions or concerns.

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  On-scene physician who is unknown to the patient or EMTs
  

The EMT should contact the on-line medical control physician before accepting any orders from an individual on the scene who states he/she is a physician but who is unknown to the EMT or the patient/family.

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  Telephone orders from a physician who is not the on-scene nor off-scene medical control
  

EMTs will not take telephone orders from any individual other than the on-line medical control physician. Any other individual/physician should be directed to call on-line medical control and his/her orders should be evaluated and relayed through standard on-line practices at the discretion of the on-line physician.

GUIDELINE/STANDARD OF CARE

The following content will be considered the Guideline for Care for the patient who is seen and evaluated by the Advanced Life Support (ALS) team and will be turned over to a Basic Life Support (BLS) team for transport: (Note: For the purpose of this guideline, ALS will mean paramedic, intermediate and/or IV technician.)

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  Assure scene safety and observe universal precautions. (see guideline #107).
  
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  Perform and document the history and physical assessment to determine that a life-threatening or potentially life-threatening condition is not present (see guideline #103, 1001).
  
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  Complete documentation on the patient care report. All data that supports the decision to transport the patient in the BLS mode and the agreement by BLS to accept responsibility for the patient must appear on all copies. A copy of the patient care report and a copy of the ECG (if applicable) must be given to the transporting unit. (see guideline #102)
  
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  A minimum of two (2) sets of vital signs including level of consciousness must be recorded, one of which must have been obtained by the ALS team no more than 5 minutes prior to their departure.
  
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  The decision to transport the patient by the BLS team must be unanimous among the ALS team members.
  
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  At the point of transfer of care from the ALS to the BLS team, the team leader of the ALS team will communicate directly with the BLS team, informing them of the physical condition of the patient, the working assessment by the ALS team and a formal statement that, in the judgment of the ALS team, the patient’s condition can be safely managed by the EMT during transport. (e.g. “Our working assessment is…… Vital signs have been stable over 15 minutes. We do not feel the patient requires ALS intervention at this time and can be safely transport by you. Do you have any questions or concerns about the patient?”)
  
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  The BLS team must formally accept/agree to assume responsibility for the care and transport of the patient. If the BLS crew on the scene does not accept that responsibility, the patient will be transported by the ALS team without further discussion.
  
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  The Medical Control physician should be contacted if there are any concerns regarding transportation of a patient. If the dispatch information indicated an ALS response (chest pain, unresponsive, etc., all new ALS services are required to contact medical control prior to releasing a patient to a BLS unit. The medical director may waive this requirement when evidence based on annual QA of this topic supports a sound practice pattern and good medical decision-making.
  
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  The time of transfer of care to the BLS unit or to another ALS unit will be documented (e.g. “1624 hours: responsibility for medical care transferred from ALS [or BLS] unit X to BLS [or ALS] unit XX”).
  
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  Patients who have received ALS treatment by the ALS team or by other medical professionals must be transported by the ALS team. ALS treatment includes but is not limited to establishing or attempting to establish an IV, administration of medications and any advanced airway placement.
  
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  If an ALS provider is on the scene prior to the arrival of the BLS unit, the ALS provider will perform duties allowed by their scope of practice and department operational guidelines. If the call is BLS in nature, the ALS provider will return to previous duties when BLS personnel arrive on scene and assume care. If, after assessment of the patient it is determined that ALS care is needed, the ALS provider will continue to provide the care and activate the proper departmental operational guidelines.
  

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  Patient who may not be turned down from an ALS to a BLS unit include, but are not limited to:
  
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    Individuals who have fallen a distance of 15 or more vertical feet
    
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    Individuals in whom there is a high degree of suspicion of spinal cord injury
    
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    Individuals involved in trauma which required prolonged or complicated extrication
    
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    Individuals with a complaint that includes chest pain or probable/possible cardiac origin or difficulty breathing
    
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    Tricyclic overdoses
    
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    Penetrating injuries of the head, neck, torso or groin
    
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    Diabetics with blood glucose levels greater than 400 mg%
    
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    Patient with medical or traumatic conditions which could potentially benefit from ALS monitoring or care.
    

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  Document any reasons for deviations from the above Guideline/Standard of Care.
  

GUIDELINE/STANDARD OF CARE

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  Observe universal precautions (see guideline #107).
  
• Assure patent airway. (see guideline # 101,201).
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  Allow the patient to assume the position of comfort.
  
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  Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate for the condition of the patient if appropriate.
  
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  Complete the history and focused physical assessment (see guideline # 103, 1001)
  
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  Any “discomfort” including pain, muscle spasm, dyspnea or anxiety should be addressed.
  
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  An age-appropriate pain scale (number scale, smiley face, etc.) should be used.
  
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  Consider prompt treatment of pain rated at a 4 or above. Clinical judgment regarding patient’s level of distress, apparent injury and reported pain scale number must be used before categorizing and treating patient as Mild, Moderate or Severe pain.
  
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  The goal is to reduce pain or discomfort while monitoring hemodynamic and respiratory side effects.
  
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  The intravenous route is preferred. IM or subcutaneous routes may have delayed peak effect.
  
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  Intravenous medications for pain should be given over 2 to 3 minutes.
  
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  Vital signs must be monitored within 5 minutes prior to and after each dose.
  
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  Airway and ventilation equipment should be immediately accessible.
  
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  Naloxone (Narcan) should be immediately available. (see drug profile # 014)
  
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  Recognize contraindications and limitations of all medications available.
  
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  Short acting narcotics are preferred over long acting narcotics in the prehospital setting.
  
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  Conditions for which analgesia is frequently needed include:
  

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  Ischemic chest pain
  
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  Left congestive heart failure
  
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  Kidney stones
  
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  Cancer pain
  
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  Extremity trauma
  
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  Burns (without inhalation injuries)
  
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  Back pain, spasms
  
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  Abdominal pain not associated with pregnancy
  

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  Medical control should be contacted for pain associated with other conditions than those listed above.
  

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  Contraindications to prehospital analgesia include:
  

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  Known allergy to medication
  
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  Pregnancy (relative contraindication)
  
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  Imminent obstetrical delivery
  
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  Respiratory distress with fatigue
  
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  Signs of elevated intracranial pressure
  
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  Intake of other central nervous system depressant(s)
  
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  Hypotension/hypoperfusion
  
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  Hypoventilation
  
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  Altered mental status
  
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  Acute bronchospasm
  
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  Major trauma and the presence of shock
  

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  Pediatric patients who weigh more than 50 kg usually need adult doses. All pediatric maximum doses are the adult equivalent.
  
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  Reassess and document the patient’s respiratory and cardiovascular systems frequently.
  
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  Complete a patient care report (see guideline #102) documenting all pertinent information received, procedures ordered/completed, results of interventions and changes in the patient’s condition.
  
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  Transport to the closest, most appropriate hospital.
  
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  Document reasons for any deviation from the preceding Guideline/Standard of care.
  

The following content will be considered the Guideline/Standard of care for the patient in need of:

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  Observe universal precautions (see guideline #107).
  
• Assure patent airway. (see guideline # 101,201).
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  Allow the patient to assume the position of comfort.
  
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  Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate for the condition of the patient if appropriate.
  
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  Complete the history and focused physical assessment (see guideline # 103, 1001)
  
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  Sedation may be indicated for:
  

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  Premedication prior to cardioversion (Example: the patient is about to undergo synchronized cardioversion with symptomatic supraventricular tachycardia who has failed treatment with adenosine and is in danger of hemodynamic decompensation. The patient has no contraindication (see below) to sedation.)
  
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  Premedication prior to intubation (Example: Sedation to facilitate intubation in a conscious patient with progressive respiratory failure requiring immediate intubation.)
  

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  Contraindications to sedation:
  

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  Known allergy to the medication
  
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  Hypotension/hypoperfusion
  
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  Major trauma with impending shock
  

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  Pediatric patients who weight more than 50 kg usually need adult doses. All pediatric maximum doses are the adult equivalent.
  

MEDICATION

PATIENT

USUAL INITIAL DOSE

	Diazepam (Valium)	Adult	2-5 mg	Consider repeating if need greater effect
		Pediatric	0.05 mg/kg	Consider repeating if need greater effect

	Midazolam (Versed)	Adult	2-5 mg 0.05-0.1 mg/kg for intubation	Consider repeating sedation dose if need greater effect
		Pediatric	0.05 mg/kg	Consider repeating if need greater effect

	Lorazepam (Ativan)	Adult	0.5-2 mg	Consider repeating if need greater effect
		Pediatric	0.05 mg/kg	Consider repeating if need greater effect

	Etomidate (Amidate)	Adult	0.2-0.3 mg/kg IV bolus	Consider repeating if need greater effect
		Pediatric	Not recommended

	Propofol (Diprivan)	Adult	5 micrograms/kg/min for 5 minutes until peak effect reached	Interfacility services only
		Pediatric	Not recommended

END

The following content will be considered the Guideline/Standard of care for the patient in need of:

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  Selecting a transport destination should be based on the following factors:
  

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  The presence of a medical condition where the loss of life or limb is imminent (ie.. inability to effectively ventilate a failed airway)
  
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  Patient hospital preference
  
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  Proximity to hospitals
  
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  Specialty medical care available (ie.. Trauma care based on trauma level designation, Stroke center, Advanced cardiac care – cardiac cath lab, Burn management, Neonatal intensive care, Pediatric intensive care, Hyperbaric therapy)
  
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  Current available bed status at hospital or emergency department (diversionary status)
  
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  Available resources at area hospitals affected by other transports from current emergency or mass casualty
  
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  Local rules or policies limiting destination choices
  
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  Current level of service (scope of practice) on scene or available
  

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  Patient preference is typically the leading factor in determining a hospital destination for patients in Waukesha County. EMTs should assist patients in making this decision based on consideration of the above factors.
  

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  An emergency department should not be bypassed if an EMT is unable to affectively ventilate a patient or if a patient has a critically low blood pressure that is not responding to all available treatments.
  

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  Additional options include ALS intercept before approaching the closest hospital or utilizing aeromedical services.
  

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  An emergency department should not be bypassed if an EMT is concerned that a patient’s condition will significantly worsen during the delay caused by driving to the alternate facility.
  

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  Exceptions:
  

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  Upon occasion, patients, or their legal representatives, will insist on being transported to a facility that is not the closest most appropriate facility when in the opinion of the EMT, the closest most appropriate facility is medically indicated. Under such circumstances, it is advisable to discuss the situation with medical control and have the patient or their legal representative sign an appropriate waver indicating their desire to deviate from the medical plan of care proposed.
  

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  Contact on-line medical control with any questions.
  

The following content will be considered the Guideline/Standard of care for the patient in need of:

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  Objective:
  
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    To transport patients to the most accessible medical facility which is staffed, equipped, and prepared to administer emergency care appropriate to the needs of the patient.
    
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    To have a mechanism where hospitals can have ambulance patients diverted away from their emergency departments when it has been determined that the hospital is not staffed, equipped, and/or prepared to provide emergency care for additional patients.
    
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    Provide a means of communicating hospital status and capabilities to EMS providers.
    

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  Eligibility:
  
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    A condition exists where the emergency department is unable to safely care for additional patients and the hospital has already implemented its own internal procedures for activating backup staff and resources.
    
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    A condition exists where the hospital inpatient status or ICU is full (and the hospital has already implemented its own internal procedures for expanding capacity) – preventing additional admissions to the hospital through the emergency department or direct admissions from ambulance services
    

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  Notification:
  
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    Emergency Departments changing status should contact area dispatch centers by phone as well as update WITRAC.
    
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    “WITRAC” internet posting is the location for official hospital status posting
    

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  Hospital Status will be listed as one of the following in WITRAC:
  
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    Open : Open to all patients
    
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    Divert : Not accepting patients
    
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      Comments (qualifiers are not limited to)
      
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        Open to OB
        
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        Open to Trauma
        
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        Open to ECG confirmed AMI (Acute Myocardial Infarction)
        
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        Open to Burn
        
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        Open to TPA candidate CVA (Cerebral Vascular Accident)
        
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        Diverting Psychiatric only
        
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    If the Emergency Department (ED) is completely closed due to plant failure (ie, power, fire, etc.. .) The Emergency Department can accept no patients under any circumstances. This will be listed in the comments section of WITRAC and the status will be set at Divert. Hospitals closed for this reason can not be “forced open”.
    

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  Diversion Reason (hospitals will choose a reason) and list in WITRAC:
  
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    Diagnostic services unavailable (CT scanner down, Cath Lab down, etc..)
    
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    No ED Beds / ED at capacity
    
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    No Inpatient Beds : Critical Care (the hospital has no critical care beds)
    
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    No Inpatient Beds : Telemetry/Floor (the hospital has no general medical beds)
    
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    No Inpatient Beds : Other (explain)
    
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    Physical Plant Problems : (ie. Power outage)
    

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  Forced Open : Hospital can be forced open once all Waukesha County Emergency Departments are diverted
  
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    Control of “forced open” status is linked to communication and cooperation between hospital administrators
    
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    Once 2 Waukesha County Hospitals have diverted, hospital administrators from each hospital will immediately review area resources and discuss options to open facilities.
    
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    If all hospitals in Waukesha County are diverting, all hospitals will be opened using the above process.
    

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  Procedure:
  
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    When a hospital is diverting patients, ambulances transporting the type of patient being diverted, will bypass that hospital and transport to an “open” facility.
    
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    If in a EMTs judgment, the patient has not been stabilized to the extent that the extra transport time would be life or limb threatening, they should transport to the diverting hospital (override diversion). The EMT must also consider the delay that may occur once the patient has arrived at an already overwhelmed facility.
    
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      Some possible examples (not limited to) :
      
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        PNB
        
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        Failed airway
        
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        Symptomatic hypotension resistant to pre-hospital treatment (BPs < 90mmHg & symptomatic)
        
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        Severe trauma where the diverting hospital is the preferred and proper facility based on area trauma triage criteria.
        
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        Status Epilepticus (continuous seizure activity lasting longer then 30 min. resistant to treatment)
        
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        Pregnant patients in active labor
        
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        Cerebral Vascular Accident who is a TPA candidate
        
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        EKG documented Acute Myocardial Infarction
        
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    All cases where hospital diversion has been overridden will be reviewed by the service medical director for quality assurance.
    
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    A hospital may not change their status while in the midst of receiving an ambulance radio report. “In-Route” diversions are not acceptable.
    
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    If a patient demands transport to a diverting facility, the patient may still be transported to that facility however the EMT must explain to the patient all of the possible delays and dangers associated with entering an overwhelmed emergency department and discourage this destination choice. The EMT should document this carefully. EMTs must understand that they could incur liability regarding their destination choice if a patient is released to a knowingly overwhelmed facility unless they stay in attendance with the patient until an equal or greater level of care can be provided at that facility.
    
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    A diverting hospital may not refuse a patient who has presented to them.
    
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    In cases of Mass Casualty incidents, each hospital should be in communication with incident command on scene to give active capacity updates allowing fluid transport decisions. These communications may supersede the above process.
    
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    Field triage must be considered where incidents involve multiple victims. Avoid overwhelming any one facility and transport the most appropriate patient to the closest most appropriate hospital.
    
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    The above policy may not apply to direct admission patients if the admission has been arranged before the diversion status. Agencies transporting direct admission patients should clarify the destination if needed before starting the transfer.
    

GUIDELINE/STANDARD OF CARE

The following content will be considered the Guideline/Standard of care for

SPECIAL OPERATIONS

Care in a Tactical/Disaster Environment
Purpose

The purpose of this guideline is to outline care that should be rendered while involved in a tactical environment. Keeping in mind “tactical” may mean involvement with Law Enforcement, but could also reflect care in an austere/disaster type situation. The basis of this guideline is in-line with the tenants of TCCC (tactical combat casualty care) as outlined in the 6^th edition of PHTLS. The three phases of care are as follows:

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  Care Under Fire: where the hostile act or disaster is still in progress,
  
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  Tactical Field Care: care rendered while the hostile act or disaster is in a lull, but keep in mind this is dynamic and may revert back to care under fire.
  
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  Tactical Evacuation: this is care rendered while transporting the injured to definitive care. The expectation is that a higher level of care is given in this phase and may include ALS providers.
  

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  Care Under Fire: (EMT, AEMT, I and P) Safety of the EMS provider is paramount, if gunfire is being exchanged, seek cover and do not attempt medical intervention unless escorted by armed law enforcement personnel. Equipment should be kept to a minimum as to ensure rapid movement and extrication of the patient from the point of wounding.
  
  1. 
     Address massive extremity hemorrhage with the use of an approved commercial tourniquet. (See guideline 5013) Apply as high on the extremity as possible and tighten till bleeding stops. For hemorrhages not amenable to a tourniquet the wound should be packed with an approved Hemostatic agent, direct pressure should be applied over the Hemostatic agent for 2-5 minutes. (See guideline 5014) Bleeding control should be confirmed before applying a pressure dressing over the wound. Frequent re-assessment should be done to check for re-bleeding.
     
  2. 
     Penetrating Torso Trauma should rapidly be addressed. Shortness of Breath in the presence of penetrating trauma is the indication for immediate chest needle decompression (per guideline # 2015 with the addition of using a 3.25 inch 14 gauge needle). If your scope of practice allows for needle decompression, remember to apply a full occlusive dressing(s) to entrance and exit wounds. If your scope of practice does not allow for needle decompression, apply an occlusive dressing that is not taped on all sides. Check patient for improvement of respiratory effort. EMT and AEMT should apply and occlusive dressing that allows the wound to vent one-way (Asherman Chest Seal®, Bolin Chest Seal®) or apply a 3-sided occlusive dressing that may be “burped” to relieve any tension. Immediate ALS intervention is needed to facilitate a chest needle decompression.
     
  3. 
     Airway compromise: Any patient found with airway compromise should be placed in position that best maintains airway i.e. sitting and leaning forward to allow secretions to drain. Insert Nasal Pharyngeal Airway (per guideline #2007) if likelihood of patient becoming unconscious. To decrease equipment load, use 28fr nasopharyngeal airway as standard size.
     

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  Tactical Field Care: (EMT, AEMT, I and P) Keeping in mind this phase may be dynamic, the environment in which the EMS provider is working must constantly be reassessed for unstable changes and safety concerns.
  
  1. 
     Wounds that have been addressed with tourniquets should be reassessed and if bleeding continues a 2^nd tourniquet should be applied 2-3 inches above the point of wounding. Once applied and bleeding controlled, the 1^st tourniquet can be slowly removed. If Hemostatic agent was used, continue to reassess the wound, re-apply additional pressure dressing and direct pressure.
     
  2. 
     If airway compromise continues, consider definitive airway per scope of practice (i.e. Non-Visualized Airway (per guideline #2008) or Endotracheal Intubation (per guideline #2009). Assist ventilations as needed and continue to reassess. With massive facial injury and associated airway insult, consider Surgical Airway (per guideline # 2016).
     
  3. 
     If penetrating torso injury and shortness of breath was addressed with occlusive dressing(s) and chest needle decompression, reassess breathing. If patient’s respiratory effort does not improve, consider 2^nd needle decompression right next to the first needle insertion.
     
  4. 
     Initiate at least one large bore IV 18-16 gauge (per guideline #3002) and infuse boluses of 250-500cc of 0.9% NS not to exceed 2000 ml if possible. Attempt to keep systolic BP around 90mmHg. (Key Point…Bleeding must be identified and stopped. Over hydration of IV fluids reduces the remaining blood volume’s ability to carry O2 and clot).
     
  5. 
     Prevent heat loss. Cover patient even in warmer months to help prevent complications associated with clotting abnormalities.
     
  6. 
     Address pain control with short-acting narcotics (drug profile # 035, guideline 112)
     

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  Tactical Evacuation: (EMT, AEMT, I and P) This Phase of TCCC is much like mainstream EMS transportation. The expectation is that an ambulance would be able to provide oxygen, cardiac monitoring, pulse oximetry, vital signs, and protection from the elements (i.e. warmth and light.)
  
  1. 
     Constantly monitor for bleeding. Ensure tourniquet is tight and has not become loose during patient movement (there should be an absence of distal pulse in the extremity that has a tourniquet applied). Bandage all wounds as appropriate.
     
  2. 
     Monitor Vital Signs, frequently assess for oxygenation and perfusion.
     
  3. 
     Provide psychological support for the patient
     
  4. 
     Complete documentation of events and rational for use of Tourniquets and Hemostatics MUST be explicitly detailed.
     
  5. 
     Patient must be transported to appropriate medical center. Consider use of Aero- Medical Services, but DO NOT delay transport.
     
  6. 
     Contact medical control from scene to ensure early notification and appropriate trauma activations.
     

The following content will be considered the Guideline/Standard of care for

•    Identify patients for whom safe use of emergency lights and siren during transport can potentially reduce patient morbidity and mortality.

•    Eliminate unnecessary use of emergency lights and siren during transport to improve patient comfort, reduce anxiety, and enhance safety for the patient, the team and the community.
 

PROCEDURE

1. Lights and Siren transport does not necessitate exceeding posted speed limits or violating other traffic laws.

2. Road type, traffic conditions, and weather conditions all must be considered when using lights and siren. (For example, when driving on a highway, it may be safer to drive with the flow of traffic at normal highway speeds without lights and siren, instead of stimulating possibly erratic lane changes by using lights and siren.)

3. When using lights and siren extreme caution must be taken when approaching an intersection even if a priority light control system is being used. It is recommended that the ambulance come to a complete stop before proceeding through an intersection when there is a possibility that cross traffic may have the right-of-way (ie. “Stop” sign, “yield” sign, yellow traffic light, red traffic light, uncontrolled intersection, or round-about).

4. When using lights and siren

a. Never pass another vehicle while in a “no passing zone” unless the vehicle moves to the right shoulder and comes to a complete stop.

b. Come to a complete stop 100 feet from the front or rear of a school bus displaying flashing red lights and/or a “stop” sign.

c. Never force the right of way or assume the right of way. Emergency vehicles only have the right of way when the other vehicle yields to you.

d. Never tailgate another vehicle, even if they have not moved to the right shoulder of the road and come to a complete stop.

5. At the discretion of the ambulance crew, driving with lights and siren may be considered if the following clinical conditions or circumstances exist:

 Inability to establish an adequate airway or ventilation

 Severe respiratory distress or respiratory injury not responsive to available field treatment.

 Acute coronary syndrome with one or more of the following:

ST elevation in 2 or more contiguous leads, acute congestive heart failure (CHF), hypotension, bradycardia, wide complex tachycardia, or other signs of impending deterioration.

• 
  Cardiac dysrhythmia accompanied by signs of potential or actual instability (hypotension, acute CHF, altered level of consciousness, syncope, angina, resuscitated cardiac arrest) which is unresponsive to available field treatment.
  

  Shock, unresponsive to available treatment

b.      Severe trauma including (but not limited to):

          Penetrating wounds to head, neck, and torso.

          Two or more proximal long bone fractures.

          Major amputations (proximal to wrist or ankle)

          Neurovascular compromise of an extremity

          Multi-system trauma

 Status epilepticus

 Substantial or rapidly deteriorating level of consciousness

 For a suspected Stroke where a significant reduction of time to receive thrombolytic therapy can be achieved and the patient meets treatment inclusion criteria.

d.      Obstetrical emergencies including (but not limited to):

 Labor complications that threaten survival of the mother or fetus

Such as : (Prolapsed cord, breech presentation, arrested delivery {inability to complete delivery of a baby that is partially born}, or suspected ruptured ectopic pregnancy.

6.      For any transport, where reducing time to definitive care is clinically indicated, consider options other than emergent driving.  In these cases, an alternative mode of transportation or higher level of care (such as ALS intercept, air-medical, or critical care transfer) should be considered, if available, appropriate, and if it will not delay the arrival of the patient. 

7.      Critical-care level inter-facility patient transports should not automatically be handled as lights and siren events.  Clinical judgment and the patient criteria listed above should be applied on transfers to determine the level of urgency and transport mode.

8.      When a physician or nurse attempts to order lights and siren transport for a patient, when it is believed by the crew to be contraindicated , attempt to resolve the issue with the ordering physician/nurse. If necessary, contact medical control to assist in resolving the issue.

9.      Transport with lights and siren should be avoided in the following circumstances:

a.      Patients who present with a written and valid “Do Not Resuscitate” (DNR or DNAR) order, confirmed by the patient’s wishes and/or medical authority orders to withhold treatment.

b.      Inter-facility transfers when the patient is being transported to a lower level of care. 

c.      Transport of human organs, blood, or organ transplant teams.  The possible exception would be a long distance inter-city transport of an organ or organ recipient, where the time frame for successful reimplantation is in jeopardy, and use of lights and siren would save a significant amount of time.      

d.      Transport of an unsalvageable patient (including cardio-pulmonary arrests) even if treatment procedures are continued en route.

e.   Situations where the crew is requested to respond to another call while currently transporting a patient who does not warrant emergent transport.

10. For any lights and siren transport, specifically document in the narrative the patient's condition, case circumstances, and the rationale for choosing emergent transport.
REFERENCE:
Use of Warning Lights and Siren in Emergency Medical Vehicle Response and Patient Transport (http://www.naemsp.org/documents/usewarnlightssirens.pdf)