The URL can be used to link to this page

Item R08 R8 BOARD OF COUNTY COMMISSIONERS COUNTY of MONROE �� i Mayor Holly Merrill Raschein,District 5 The Florida Keys Mayor Pro Tern James K.Scholl,District 3 Craig Cates,District 1 Michelle Lincoln,District 2 ' David Rice,District 4 Board of County Commissioners Meeting July 17, 2024 Agenda Item Number: R8 2023-2637 BULK ITEM: No DEPARTMENT: Fire Rescue TIME APPROXIMATE: STAFF CONTACT: James K. Callahan N/A AGENDA ITEM WORDING: A public hearing to consider an application for issuance of a Class A Certificate of Public Convenience and Necessity to Southernmost Medical Transport, LLC for the operation of an ALS and BLS Transport Service in Monroe County, Florida, except for within the city limits of Marathon, for the period 07/18/2024 through 07/17/2026 for responding to requests for inter- facility transports. Southernmost Medical Transport is not permitted to perform 911 emergency response work in Monroe County. ITEM BACKGROUND: Southernmost Medical Transport, LLC has submitted an application for a Class A COPCN. Once approved, the Class A COPCN certificate will be for the period commencing on 07/18/2024 and ending on 07/17/2026. Monroe County Code Sections 11-171 et seq., requires the BOCC to hold a public hearing to consider the application for a new certificate. At the hearing, the Board may receive a report from the County Administrator or his designee, testimony from the applicant or any other interested party, and other relevant information. The Board will consider the public's convenience and necessity for the proposed service and whether the applicant has the ability to provide the necessary service(s). The Board shall then authorize the issuance of the certificate with such conditions as are in the public's interest or deny the application, setting forth the reason(s) for denial. Per County Ordinance, all existing COPCN holders were notified via email of the Public Hearing for the new COPCN. PREVIOUS RELEVANT BOCC ACTION: Agenda item was presented and discussed at the May 15th BOCC meeting. The BOCC requested that the item be heard again once Monroe County Fire Rescue confirmed that the application was complete and that there was a need for the transport services. INSURANCE REQUIRED: 5151 Yes CONTRACT/AGREEMENT CHANGES: N/A STAFF RECOMMENDATION: Monroe County Fire Rescue approves based upon the completeness of the application that was submitted and specified need of the designated transport area. The certification for actual operation of the medical transport service will ultimately be granted by the Department of Health based upon state requirements, including compliance and inspection. DOCUMENTATION: Notice of Public Hearing for Southernmost Medical Transport 07-17-24.pdf COPCN Certificate for Southernmost Expires 07.17.2026.pdf Southernmost Medical Transport Class A COPCN Application- 2nd Application Updated 06.20.2024.pdf City of Marathon - COPCN Letter dated 7-1-24 updated.pdf FINANCIAL IMPACT: Effective Date: 07/18/2024 Expiration Date: 07/17/2026 Total Dollar Value of Contract: N/A Total Cost to County: N/A Current Year Portion: N/A Budgeted: N/A Source of Funds: N/A CPI: N/A Indirect Costs: N/A Estimated Ongoing Costs Not Included in above dollar amounts: N/A Revenue Producing: N/A If yes, amount: N/A Grant: N/A County Match: N/A Insurance Required: Yes, as mandated by the State of Florida 5152 NOTICE OF PUBLIC HEARING NOTICE IS HEREBY GIVEN TO WHOM IT MAY CONCERN that on J u I y 17, 2024, at 9:00 A.M. or as soon thereafter as the matter may be heard, at the Marathon Government Center, 2798 Overseas Highway, Marathon, Florida, the Board of County Commissioners of Monroe County, Florida, intends to consider the following: ISSUANCE OF A CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY TO SOUTHERNMOST MEDICAL TRANSPORT FOR THE OPERATION OF A CLASS A ALS AND BLS AMBULANCE TRANSPORT SERVICE WITHIN MONROE COUNTY, FOR THE PERIOD JULY 18,2024 THROUGH JULY 17,2026. The public can participate in the July 17, 2024 meeting of the Board of County Commissioners of Monroe County, FL by attending in person or via Zoom. The Zoom link can be found in the agenda at llu�t l„/u.1o.i] l.)ec(..)unutyf u„ un2,c(.)un/citizetisl(l�e�„iul asll.!. ADA ASSISTANCE: If you are a person with a disability who needs special accommodations in order to participate in this proceeding,please contact the County Administrator's Office,by phoning(305)292- 4441, between the hours of 8:30a.m.-5:00p.m.,prior to the scheduled meeting; if you are hearing or voice-impaired, call "711': Live Closed-Captioning is available via our web portal @ EL.a,�"i��,for meetings of the Monroe County Board of County Commissioners. DATED at Key West,Florida, this 27'day of June, 2024. (SEAL) KEVIN MADOK, Clerk of the Circuit Court and Ex Officio Clerk of the Board of County Commissioners of Monroe County, Florida Publication dates: Keys Citizen: Thur., 06-27-24 Keys Weekly: Thur., 06-27-24 News Barometer: Fri., 06-28-24 5153 dq LO T- LO O p 14 N O O COO Co N U U O � -U p�j 40 O p�j O aj a N Z O O a � cd U � U � Co QL) `o '- � o o zt Co co U p co z y' U H -CO � N ° H cd Z N N O N —(� U Q U � W z U Z,o a o a) p a� ,V,, U w c0+-o OU r.3 U F� vi M U � Q —c� Cd rx a Z o ;� a o � UW C) o Cl) o o a � U Z04 aj p O O N N W N N U � QL) El ��• N Cl) of O O co U co U co u N r coO p N U � 00 ° ® CM U) x co f�W� 14 � o � UU o U Cd smM II ��IIIIIIIM'J)111�I�Nk;NMl�y ry� um Southernmost Medical Transport, LLC COPCN Application ^Ip` muu ouu uuu ICI 1 yp�,on�liip ��lVilll��l IlNwll�I. luomll` I, l0000lu�Im mll I S�olllm NIIIIIII I Mll IIII I p,at�` ��tl�io, I�� O�I� Di o,lq lolollll roe °�1�� . �luolll V lonoll III duo 1��.....p`I�. IIIIII��,,,,,III��,I�IIIP I11... IIIIG��rl,,,,III� IIIIII IIIII ll ��„Illll�hr Illlh �luo�� p,,,,,1lll� IIIIII �IIIV IIII ��,,,,,,,��,,1111111' ��ll„IIIIII��,,,,,,II� Illllllls��l�IIi IIIIV ��III,,, Ili°P ��pmmullp �M„null�� IUIIIIIINIVII 1q�,vnmVq. i��, �1loumlN`��Illuuool�0� ��1>IuuWN J, I f / d I r I I/(/ JI v r� f cl y rnryl ✓ ° i i IIIJI�i�aYlYlll, 'I',:� I YJII,:�S �I',II;�;;;n1Y'C r I5 Ir tJ1 tJ1 tJ1 Southernmost Medical Transport, LLC COPCN Application 8�'sdr�mJedw�r crp�wrca �. Table of Contents Tableof Contents........................................................................................................... 2 COPCNApplication................................................................................................................... 4 Appendix A:Southernmost Medical Transport, LLC Proof of Florida Incorporation ................... 9 Appendix B: Southernmost Medical Transport Schedule of Rates............................................. 10 Appendix C: Verification of Adequate Insurance Coverage........................................................ 11 Appendix D: Southernmost Medical Transport Ambulance Verification.................................... 12 Appendix E:Agreement with Medical Director......................................................................... 13 Appendix F: Medical Director—DEA License and ACLS/ PALS Certification Cards...................... 19 :7 Dr. Bruce Guerdan DEA License.............................................................................................. 19 Dr. Bruce Guerdan ACLS/PALS Certification Cards................................................................ 20 AppendixG: Standing Orders/Protocols................................................................................... 21 INTERFACILITY TRANSFER and TRAUMA PROTOCOL ................................................................. 21 Tableof Contents..................................................................................................................... 21 Appendix H: Compliance with Federal Law............................................................................... 100 FCCRequirements.................................................................................................................. 100 tJ1 t11 Southernmost Medical Transport, LLC COPCN Application pendixI: Compliance with Florida Law................................................................................. 101 AppendixJ: Compliance with Monroe County Code ................................................................. 104 Monroe County Business Tax Receipt.................................................................................... 104 Monroe County Fire Rescue Department Inspection............................................................. 105 MonroeCounty Audit............................................................................................................ 105 Appendix K: Compliance with the City of Key West .................................................................. 107 BusinessTax Receipt .............................................................................................................. 107 AppendixM: SMT Dispatch Process.......................................................................................... 108 <ll <11 4 ut Southernmost Medical Transport, LLC COPCN Application COPCNApplication - --------------------------------------------•- --...----- ...................................... MON -- ROE COUNTY,FLORIDA i APPLICA710N FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY(COI"CN) CLASS A EMERGENCY MEDICAL SERVICE [PRINT OR Ti'PE�i - ----------------- --------- -----------•--------•--•--•--- INITIAL APPLICATION-S95OM :0 RENE1WAL APPLICATIONS S475.00 .....:•••-•-........................ IE REiYEWWAL,PLEASE I.[S..lNIIihIBER t)E PREVIOUS CERTIFICATE:#,mm �' ------------------------------------------------------------ --------- 'Sa lluviritiii�sII FVI-e&W— kAff ty;L C NAME Q1E SLRVICffi ------------•----- : 6Q8 attttU$CO:Dt,ICisf,FL"�314f1:...................... ............ .. BUSINESS MAILING ADDPJFSS: � W�„„ :BUSINESS PHONE NUMBER 305-393-9275 EMERGENCY PHONE NUMBER 727-657-1668 -_ ..................... .. ..._ .. TYPE flF OVWNERSHIP(L.e'Sofe Proprietor,Partnership,Corporattoa,etc.) LIl C ---•---------_... ...............�................. DATE,,OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION:27riU112 c-------- :3. LIST ALL OFFICERS,DMEC ORS,AND SHAREHOLDERS(Use separate meet It accessary). ........•.........................................••----.......................................----•--•---•-••--•-----•----••-•-•--------------•-•-_: NA1VII PAGE:, .ADDRESS: TELE PHONE P , 10SITIONMTLE:Mmmm i Paula Turner:: i4Il i 727-687-1668 i Operating Manager . .... .... �W _ Janes Caton 434-962-I58. 9 Member M.Annabelle Boyal i :55 i 434-466-4727 Member ........................... ........ ............... . �. LEVELOF CARE TO BE PRGVtII1Edr: ;M BLS or[M ALS:.......-,- .................................................... aF ALS:i 01RANSPOItT or 0 NON TRANSPORT: .................................................. 5:_.._ DESCRDBE THE�f1NES(S)THAT YOUR SERVICE©ESIRES TO SERVE(Use.palate sheet.if necattry): ........... .............................. :Inter-facility transfers within Monroe County;no 911 response caffs will 6e performed.: :6. 14�D �_�Bt AA_I R :EI SAS_ _1E F l ?1IlfJ4.4a4t �------- ------ -------------I----fir.$------ ,....-., ;$'l'A�'141�iS•(Bie•� �atesliietClnec ••------------- .( aepa essary: BASE STATION 1608 Jamaica Dr Kew West,EL33040 S[DBSTAT[Ol+i ----- ------------------------ --- 1 J a 2 l 5 00 Southernmost IMedicall Transport, LL 11/11Ir�'f slit!'! I,ly COP COPCN Appllicaboin ,I IT � 30 M-937 " 2 39736 , �... , , u 003 3796 h n ilnl l»«IIeMdX IIYlIIIt Ii, VYd, e:t `^r^�r-r-r-�a-soxrrx >•r -xaaAn ixnr#'r� lrrarrV II r I Iw Qq ukYarru,Nu al rlll««,I,A,,iu 4rirarl, tru,a oulreo rz%V'uUrfrr wrutE;VE r,Grl'Cfl4rr«unrru„", mtthrr a,Y+uarrl µu«GrFr,,ia;» »�iJn�n wa'rmul�llrti',r vvCua,uu�upauoran�upwure�rroli�r«lafr»r�",iJ«_"«¢c�aruirrrr„+�«�I«a»I`uJdrurlriPbr»,11,'f�ui[ �u A,urua�rrrop„ Y;;,p�I�naravrr m:'t M1rarr aA »+,yI»r uu & Lam` p-NAMES AMADDRUM0 ( )U&CMUM WHO WHX ACT AS REFFMWra FM Y OU ICII Biff Lffy 19658 SeminOle St SummerlandKey, L 3 .. i John T ino; Box 787, Key Wcst PL 330_ 41 e Kelfty NormanPAtltrsen Avg,Key West,FL 33040 Sc tij!,MC,i utd,b,u,.19 r,«,I.ra�frll »r,ll»h.lo'm; ' It. ATTACK eA CDPT OFYOURJ lc' l' 1f�l A IllPC d'ri lfq'Au v»r1u«E I L 9f'OFALL STANDMG(TRIDKIRSAS C RII ICE BY O MEDICAL D . �NLrl4i@1, U. ATTACH A CKIWX OR MONRY ORDER IN THE APPROPRIATEAMOUNT, A PAYARLE IPA ; ?,IPr°a"hn�u�r�.uon��lr IMe w v DIE RRQtMWMlM poR UON OF AN EMZRGgNCyO' COUNTY AND T F PLoRmA. r,vuRTumTHAT ALL INFOMWrII THIS g IARA STANSBURY Notary Plublic•Stmt@ of Fiodda commission I HH 16:3921 p� my Comm,Upifes Auk r rSrarrSed t9rrru4s II Karf AS9l1, r 11rpt_ 11 l >I Y rl l,l.if,:(I, If bl,rl,J r.'I'"1 N, N„ r n'icy Ul Ul Southernmost Medical Transport, LLC uNN91 Hn IA 1I1� � a0 �u�ivi��i�a� �� t,� COPCN Application ..m........,., NAME t K yr E.gst; SOCIA#�LS E:C13Et&0 ; --i.CK1tT ICA1.�'iON# ;EXPIRATION E1AT�• i Carlos Barba PMD51511.3 1212024 Andy Harris e `�� PMD515372 12l2024 " „ , m .............M___---------— ---------- :." ,,_..a u,a- ,, • " • " ' r _____................................. _....:. ...._.. ...,, a m...... _.. , • 'I .,...................... ... _ ..._w ..__ ......... .., f'��sf'1"i�ii_ I 3I;is40 U1 O RN jqq Southernmost Medical Transport, LLC COPCN Application P-ERS-ONNE1,-EMMENCY MEDICALTECHNICIANS NAME EMT CERTIFICATION First.,Middk Last SOCIAL SECURI an, MSffi0N 0 EXPIRATION DATE �. E sera Steluly i ,. ,� i EMT563193 i Il2/2024 u y 5 y ....gym.. . .mn �...........�......,m....._.__ „iY.. tJ1 o Ill I��1111 S Ii�IW" lit Iw Southernmost Medical Transport, LLC � , a� ��r�� COPCN Application m STATE I't ,"It �,SOCIAL BECiI Y 0 RJDATE OF BIRTH DfaV6R LI Eggi! OF f$iUANCC LRFOtA'�'F4TI lYA•ILr AndyHnrne ,-., 02/23/76 .13620-a1U-76-063 0 FLt 02f2' , 03128197 46i-97-109-0 FL 03129132Yodis Fuentes-Flores ..... .........Mm :f - — u s I D01HZRlBYA=T,TO THk BEST OF MY KH6WL14PCr THAT ALLOFT9B AWV6IYAMED�IRIV6YS RLQ4JRt6M tbF' . ..• N�M6IC6 hI.L OFTttC •CHAPTM OLM F.&AHD CHAI"t'M&&R-"22 FACF02 AN2tFLA4CE DIHYERB.. ro/c� AV coma.[rprHAW i •39ii I �.Baptl�6tlrou�tllltflFA h6Fdfj�=: � �„• Rar Lace Auput Paw Provide the Following lure madolR Wse hate Sheet LC Nec ap .................. UCEINBSE 1YIL4 SPEG�B ::TAGNMBEW i i wof - :22: : �a��•- .�� ;gip: 2p23; U g ..... r PtRtitS stet 3G��AY!II}GllPL579394 I „mm.,,,,,,,, i T ........................................ .............. .................... ............ , tJ1 IV Southernmost Medical Transport LLC urr� � tniu'r,m�dPuAga COPCN Application Appendix A: Southernmost Medical Transport, LLC Proof of Florida Incorporation Detail i l �M1 1pnm i Wi�p�i i irri Florida Limited Liability Company SOUTHERNMOST MEDICAL TRANSPORT, LLC Filing.Information Document Number L22000420033 FEVEIN Number 93-4466178 Date Filed 09/27/2022 Effective Date 10/01/2022 State FL Status ACTIVE Last Event LC AMENDMENT Event Date Filed 01/03/2024 Event Effective Date 11/17/2023 Principal Address 1608 JAMAICA DR KEY WEST, FL 33040 Mailin ,,Address 1608 JAMAICA DR KEY WEST, FL 33040 Registered Agent_Name &Address TURNER, PAULA 1608 JAMAICA DR KEY WEST, FL 33040 tJ1 W w ,. R,a Southernmost Medical Transport, LLC uY�r �C �"Ua�,�w�� , ," COPCN Application ��P�m�a��f��um��xn. 11� 11111111 Appendix B: Southernmost Medical Transport Schedule of Rates BLS Transport Base Fees: • Basic Life Support $650 • Loaded Miles $12/mile AL5 Transport Fees: • Advanced Life Support (LEVEL 1) $800 • Advanced Life Support(LEVEL 2) $900 • Critical Care Transports (CCT) $1,000 • Loaded Miles $12/mile Non-Emergent Base Fees: • Wheelchair(WC) $45 • .Gurney/Stretcher(STR) $150 • Ambulatory (AMB) $45 • Baker Acts $45 • Loaded Miles $9.50/mile All fees billed are inclusive to include the correct licensed staff members, equipment, and supplies for each transport. All fees are in accordance with regulatory standards and found to be in line with today's market for service and in line with Medicare reimbursement fee schedules. I '1J,i'rlira'lu i ,i:r ilt ' ll.,li �rt,it tJ1 P Southernmost Medical Transport, LLC COPCN Application Appendix C. Verification of Adequate Insurance Coverage �._ CERTIPICATE OF INSURANCE r+ wwueW `xaw wcww�wwar ww¢wrurw u�,: ", mw., .-mr .� yarn..raxr�5a�tar;qw;�e�m�":,.w.,er"�"� '. w.nccc..romen V TM en t,wcmuwuicevwas v, ens, ,.,, n or u sro»r..nmm.r«arrrw 'Q w.lrw. ❑ � simwu u rwxu., ❑P4Iw ❑6+L. ❑a.rxrn 1p cem a C7 rmerrww� '.,. !p vea sawowawvsovs ❑e. .Howe R wa, I 4ynw. .. ._... ., �q%wJmwa�w luwroraw -ffjiwm�;mum d'rMWWAI rjrm nnmrr sumn r r ua�rcm ar-� ^' n. u§aC.i. _ ...:dM4',d`,Uw,e Rere4rk�Ck&i� rer ,rKxrmw.m..cnrentinoorvosrvu m�..rwo Southernmost Medical Transport. e G service mcpinsurance.Com 11:32AM(I hourago) {r Q E-t , CO RIQ. Paula, The Commercial Auto system automatically pulls the VIN number for the vehicle type. The Insurance Company is well aware that you are a medical transport company and the vehicle that we insure is in fact an ambulance being used for medical transport purposes. Please let me know if you have any additional questions or concerns. Regards, Michael MCP INSURANCE SERVICES 19 W Tarpon Ave Tarpon Springs,FL 34689 (727)942-8999 lJ 11, P,YI i l l y J;:{',,,k j a I I „i J 7 rc lI' ..r_/ S 3 14" INN Southernmost Medical Transport, LLC COPCN Application Appendix D: Southernmost Medical Transport Ambulance Verification The card below serves as evidence of SMT's Ambulance Conformance Certification. Om "MU � IM m � �� FRtonNersions,ln<. �� 12317echCourt atVVjWft Westminster,M6 Z1157 Ram Promaster 2M kr 3MLRVPGOPE579339 VW&TgeadW TAft 2M WALMUMM 3,30 j; 'Ih51de[t�+(rtlAedEafiYSfib�f/�k Yes "AaYst �tsd1+ � J�sr V30N-58Z7$ry....... i FS�Wm1r7iP�aiprJ�a �� w a,mm�n� ME=Mz' Al IM i i r IIIII � � M a" J,2 Ilii�Y%'I"IIIII f r`.tli ��fli �'i I If'� i,�Pl"I. ia.�, CI tJ1 Southernmost Medical Transport, LLC Itd�d��o�ff°rF�rF :P �C�IG> COPCN Application Appendix E: Agreement with Medical Director AGREEMENT BETWEEN Southernmost Medical Transport, LLC. AND Bruce Guerdan,M.D. For MEDICAL DIRECTOR SERVICES This Is an agreement between Southernmost Medical Transport,LLC.a limited liability company organized and existing under the laws of the State of Florida (hereinafter referred to as SMT) ' AND Bruce Guerdan,M.D.(hereinafter referred to as CONSULTANT)whose principal place of business is 1800Atlantic Blvd B117,Key West FL,33040. WHEREAS,SMT,is a provider of basic and advanced life support medical transport services,and Is required by Chapter 401,Florida Statutas,to contract with a licensed physician to serve as SMT's"MEDICAL DIRECTOR",and WHEREAS,the CONSULTANT provides Medical Director services and SMT desires to utilize the services of the CONSULTANT, NOW,THEREFORE,in consideration of the mutual terms and conditions, promises,covenants and payments set forth below,SMT and CONSULTANT agree as follows: ARTICLE 1 SCOPE OF SERVJCES 1.1 Under the direction of SMT Director of Operations as defined in Florida Administrative Code Chapter 64.1-1.004 for medical transport only,the CONSULTANT shall provide a qualified physician to serve as Medical Director for the 3Mrs Emergency Medical Transport Services Program as more particularly set forth herein: 1.1.1 ' Develop transport protocols that permit specified ALS and BLS procedures when communication cannot be established with a physician during medical transport when a delay In patient care and treatment would threaten the life or the health of the patient 1.1.2 Medical Director will be available:"offI to resolve administrative problems,system conflicts,and provide services in an emergency as that term is defined by Section 252.34(3), Florida Statutes. Such"off-line"services will be provided at a rate of$300.00 per hour or at a rate mutually agreed upon by the CONSULTANT and SMTs Chief of Operations. L1'n°fl'u,'iiD,t I Jai i�Jpujt I� ' fT�lliJr �.�I'1IP= 05 3 of_7':.,, tJ1 4 Southernmost Medical Transport, LLC COPCN Application use� a r� 1.1.3 Develop and implement a transport patient care quality assurance program to assess the medical performance of SMT's Paramedics,EMTs and Critical Care Nurses. Clerical and administrative support will be provided by SMT. 1:1.4 Audit the performance of SMTs personnel from time to time by use of a quality improvement program,to include but not limited to,a prompt review of transport reports,direct observation,and comparison of performance standards for drugs, equipment, protocols and procedures. 1.1.5 Provide a DEA registration for SMT in order to provide equipment, medications, including controlled substances to SMT, N needed. DEA registration shall Include the address at which controlled substances are stored. Prof of such registration shall be maintained on file with SMT and shall be readily available for Inspection. SMT will forward any and all renewal documents and correspondence received regarding the DEA to CONSULTANT to assure continuous registration and will pay for the cost of the DEA certificate or reimburse CONSULTANT for the cost of such registration. 1.1.6 Review SMT's security procedures for medications,fluids,and controlled substances to ensure they are In compliance with Chapters 499 and 893, Florida Statutes,and Chapter 64F-12,Florida Administrative Code. 1.1.7 Assist and coordinate,with the Chief of Operations,written operating procedures,creating,authorizing and ensuring adherence to rules and regulations regarding all aspects of the handling of medications,fluids, and controlled substances by SMT certified personnel in accordance with State and Federal regulations. 1.1.8 Notify the Department of Health in writing,when applicable,of each' substitution by the SMT of equipment or medication. 1.1.9 Review and approve training for EMT/Paramedic continuous education training and/or refresher courses for the purpose of EMT re-certification. 1.1.10 Assume responsibility for the use by an EMT/P of an automatic or semi- automatic defibrillator;the performance of esophageal intubatlon by an EMTIP;and the monitoring and maintenance of non-medicated We by and EMTIPm as well as the use of epinephrine for allergic reactions,when necessary. 1.1.11 Advise and implement a plan for prompt medical review of possible infectious exposures reported to the Chief of Operations and provide medical1bilow-up when indicated,in compliance with State and Federal requirements. Medical follow-up care to SMT employees will include a$3,000 retainer due May 1,2024,with deductions based on consultation hours billed at$300.00 per hour. ARTI L 2 COMPENSATION AND METHOD OF PAYMENT 2.1 SMT agrees to pay the CONSULTANT as full compensation for the services described in Article 1 an annual fee of$40,000.00 to be paid to the CONSULTANT in , ,75 to 00 Southernmost Medical Transport, LLC ��yi� �'` aurk�✓r�u :V COPCN Application twelve consecutive equal monthly Installments of$3,333.34. This fee includes all costs and expenses.of CONSULTANT. Services requested beyond the scope of this contract 'will be Invoiced separately as a rate of$300.00 per hour,subject to approval of SMT Chief of Operations. 2.2 SMT agrees to pay the CONSULTANT on the first day of each month for which the CONSULTANT'S service are rendered. ARTICLE 3 QEFINITIONS 3.1 "Department"means the Department of Health, Bureau of EMS 3.2 "Emergency Mad[cat Technician"or"EMT"means a person who Is certified by the Department to perform basic life support. 3.3 "Medical Director'means a physician who Is employed or contracted by CONTRACTOR who provides medical supervision,including appropriate quality assurance but not including administrative and managerial function,for daily operations and training. 3.4 "Paramedle means a person who is certified by the Department to perform basic and advanced life support. 3.5 "Physician"means practitioner who is licensed under the provisions of Chapter 458 and Chapter 469, Florida Statutes. 3.6 "Chief of Operations"means the highest ranking medical professional In charge of SMT's medical transport services. ARJICLE 4 CONSULTANT RESPONSIBILITIES 4.1 In accordance with Section 401.265, Florida Statutes,and Rule 64J-2.004, Florida Administrative Code,the Medical Director shall possess and maintain through the term of th Is Agreement a Florida license to practice medicine. 4.2 The Medical Director may designate an alternate Medical Director,when needed, who shall be available in the absence of the Medical Director. The Alternate Medical Director will have an understanding of ALS and BLS medical transports and report to the Director of Operations. 4.3 The CONSULTANT shall perform such other duties and responsibilities as now are imposed or may be imposed during the term of this Agreement by Florida Law, including but not limited to the applicable provisions of Chapters 252 and 401, Florida Statutes,and Rule 64J-1, Florida Administrative Code, as may be amended from time to time. I l i a I iS l n .l r l 71 1 i'u !T;1, , rli,Fi�l tJ1 W p AP Southernmost Medical Transport, LLC COPCN Application ARTICLE_5 SMT.REEPOt1SIBILITY 5.1 The SMT shall assist the CONSULTANT by placing at its disposal all available Information pertinent to the services to-be performed by the CONSULTANT, Including access to all EMTIP, EMT,and RN employment records and patient medical transport records. 5.2 SMT will provide CONSULTANT appropriate administrative support Including secretarial support services and other equipment as may be needed from time to time to provide oversight to EMTIP,EMT's and RN's. 5.3 SMT will comply with FL Chapter 64J-1 in all aspects related to the performance of medical transport operations. ARTICLE 6 TERM 6.1 This agreement shall commence on May 1,2024.The Medical Director role and salary commence on July 1,2024,and shall continue through June 30,2025,unless terminated earlier under Article 7. SMT shall have the option to renew this agreement for 4 additional 2-year terms subject to the same terms and conditions, by providing the CONSULTANT written notice to renew no less than 30 days prior to the expiration date. N this agreement is renewed under Article 6,the CONSULTANT shall be entitled to a fee Increase of five percent annually for each subsequent renewal. ARTICLE 7 I AT O 7.1 If through any cause,the CONSULTANT fails to fulfill Its obligation under this agreement,SMT shall have the right to terminate this agreement upon providing written 90-day notice to the CONSULTANT. 7.2 This agreement may be terminated by SMT without cause upon 90 days written notice to the CONSULTANT If SMT terminates without cause,the CONSULTANT shall be compensated for all services performed prior to the termination date,provided that all property belonging to SMT Is returned prior to release of final compensation to the CONSULTANT. 7.3 CONSULTANT may terminate the agreement,with or without cause upon providing written 90-day notice to SMT. If CONSULTANT terminates without cause. SMT shall compensate CONSULTANT for all services performed prior to termination date. ARTI LE 8 M "CFAN tJ1 O A1' R Southernmost Medical Transport, LLC lr',ss�abprrr �rrb; , COPCN Application 8.1 Ownership of Documents/Deliverables: Any files,documents,studies,transport report reviews,training curriculum,and other data prepared by the CONSULTANT (excluding standing medical orders, medical treatment protocols,infection control manuals), in connection with this agreement are and shall remain the property of CONSULTANT,and shall be delivered to the CONSULTANT, upon request, no later than 60 days after termination of this agreement. 8.2 Policy on Non-Discrimination: The CONSULTANT shall not discriminate against any employee or applicant for employment for work under this agreement because of race,color,religion,sex.Age, marital status or nation of origin, physical or mental disability. 8.3 Independent Contractor. The CONSULTANT is an independent contractor under this agreement. Services provided by the CONSULTANT shall be by employees/contractors of the CONSULTANT and subject to supervision by the CONSULTANT,not as officers,employees,or agents of SMT. Personnel pollcies,'tax responsibilities,social security and health insurance, employee benefits, purchasing policies and other similar administrative procedures applicable to service rendered under this agreement shall be those of the CONSULTANT. ARTICLE 9 INSURANCE 9.1 The SMT shall maintain In force and effect for the term;,of this agreement the insurance described below: 9.1.1 Professional and General Liability: SMT shall provlde professional liability insurance for the CONSULTANT and Medical Director during the tenn of this agreement. SMT shall be responsible for maintaining this professional liability insurance for a minimum of 3 years from the date of termination of this contract. 9.2 Consent to Jurisdiction: The parties Irrevocably submit to the jurisdiction of any Florida state or federal court in any action or proceeding arising out of or relating to the agreement,and unanimously agree that all claims in respect of such action or proceed€ng may be heard and determined In such court. Each party further agrees that venue of any action to enforce this agreement shall be in Monroe County,Florida. 9.3 Headings: Headings are for convenience of reference only and shall not be considered on any interpretation of this agreement. 9.4 Exhibits: Each Exhibit referred to in this agreement forms an essential part of this agreement. The Exhibits,if not physically attached,should be treated as part of this agreement,and are incorporated for reference. 9.5 Severability: If any provisions of this agreement or Its application to any person or situation shall to any extent be held invalid or unenforceable,the remainder of this agreement,and the application of such provision to persons or situations other that hill ^.riir 'I: f,l 1i !ill ri ii �n;:lh tJ1 i ro Southernmost Medical Transport, LLC COPCN Application those as to which It shall have been invalid or unenforceable shall not be affected,and shall continue in full force,and be enforced to the fullest extent permitted by law. IN WITNESS WHEREOF,the partles hereto have set their hands and seal the day and year first written above. BY Bruce Gu day,M.D. WITNESS: Southemmostdlcal Transport,LLC. BY: Chief OperaWns Officer: Paula,Turner WITNESS: tJ1 W Southernmost Medical Transport, LLC COPCN Application Appendix F: Medical Director — DEA License and ACLS/PALS Certification Cads Dr. Bruce Guerdan DEA License w ................. �. m„ ��,,,,,. ,,rri„----- DEA REGISTRATION THIS REGISTRATION FEE CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE NUMBER EXPIRES PAID UNITED STATES DEPARTMENT OF JUSTICE BG052(i939 rv,. 09-30-2024 $888 j DRUG ENFORCEMENT ADMINISTRATION WASHINGTON D-C,20537 SCHEDULES BUSINESS ACTIVITY ISSUE DATE .,,�..ma„�..�...__-___. 2,2N,3, PRACTITIONER- 09 13 2021 I 3N,4,S 111111- GUERDAN,ERUCE R 9AD I SectPon%304 and 1008(21 USC 824 and 958)of the Controlled GUE I Substances Act of 1970,as amended,provide that the Attorney 18GO ATLANTIC C I General may revoke or suspend a registration to manufacture, I distribute,dispense,import or export a controlled substance. KEY WEST, FL 39040 THIS CERTIFICATE IS NOT TRANSFERABLE ON CHANGE OF OWNERSHIP,CONTROL,LOCATION,OR BUSINESS ACTIVITY, wn AND IT IS NOT VALID AFTER THE EXPIRATION DATA;. CONTROLLED SUBSTANCE REGISTRATION CERTIFICATE UNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION WASHINGTON D.C.20537 DEAREGISTRATION THIS REGISTRATION rEE NUMBER EXPIRES PAID BG0526939 09-30-2024 $880 SCHWULES BUSINESSACTIVrTY, ISSUE DATE 3N 4 8 PRACTITIONER 09-13-2021 2 2N 5 W GUERDAN,SRUCf R MD Sections 304 and 1008(21 USC 824 and 958)of the 1800 ATLANTIC BLVD Controlled Substances Act of 1970, as amended, B117 KEY WEST, FL33044 provide that the Attorney General may revoke or suspend a registration to manufacture, distribute, odispense,import or export a controlled substance. ID ERTIFICATE IS NOT R TRANSFERABLE DATE. NGE OF OWNERSHIP,CONTROL,LOCATION,OR BUSINESS ACTIVITY, AM 1)8 1ai i,I ;< I "/ L1 tJ1 W Southernmost Medical Transport, LLC COPCN Application ruce Guerdan ACLS / PALS Certification Cards jr oVANCEo CARDIOVASCULAR ur-E SUPPOR I mMANCED CARDIOVASCULAR LfFE SUPPOR P ACLS T4 M NY[0-M-116� 90YRII2f"§AM 13 GYANCED cpn.,.hlm laxlww mcgnca!1 IwIGM:NECGR-l;WlC�n.nw.am PROWDER cmmcm suartFxa'iga p¢roamEr f, 6n.ce Guert4n aawta.a.at,...xmns v.Trk carte.A.Tw¢u,veA �„�„�,�r ... ...� carw.eamMane strove •crtaputtytr�mse 1he.Ucve mdn'TduNFru.vccrs.hFly compllwwf NrAM.iscai w..q.m.ydmrt TlCnyirtlryEllfa.! Cv'aw.—ftr Life aupp*MACL8I C-w in.mmd.nce wan aCLi seiwrq. Isiywonwtr crR lfdvanced CertiRe.tiort lmfitrlb's ouriiadumtdMAmericart lk.H ..4ELI Pkxm.wropydrrMMmn e.enpnslna Asswsrtiona:•gui4elMes .III'Ii1 MIOPaM-A-01— •Alr.a»mu.royz.r.�c. CRTIFICATTON CODE TI 02MMe M� wc o Esser bate: c�-n�xaz, Expiratbn bate: p1fi8.7026 �...�,i.��• ea�e,owr. .. ._. •�ooTm.naa,.eerl IPII II'NI'I IY�YI YWR.UC N)VA CIE INS,,n::i sI I IIIIoR iiir !)17�1PoAlllllllllllllllllllllllll ji j IPAiii S Ilhluumuo� MEDICALMNING DrueD fslaaeda&n Apr 9!26� Apr ea,W2G wKcW— ACL9 wetlI�ITralninq w®6326 nwmw cerurwm u.wq ew.m 9633 a69926 M73ve rj0` )J1 I .a} C1 I" e 31 J tJ1 P y" BOARD OF COUNTY COMMISSIONERS County of Monroe ''��`;�� Mayor Holly Merrill Raschein,District 5 The Florida Keys Mayor Pro Tem James K. Scholl,District 3 Craig Cates,District t Michelle Lincoln,District 2 David Rice,District 4 Monroe County Fire Rescue '; �� 490 63Td Street Ocean Marathon,FL 33050 Phone(305)289-6004 " MEMORANDUM TO: Nicole Lyons FROM: Cara Johnson SUBJECT: Check for Deposit- COPCN DATE: June 12, 2024 ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Attached please find Check= dated May 7, 2024 in the amount of$950.00 per check to be deposited in revenue account 141-342000-RC 00345. This check has been issued for the initial application of a Class A Certificate of Public Convenience for Southernmost Medical Transport. Thank you, ca4'z ;'6� Cara Johnson 5175 cfl ti LO ir 69 cc 028 I. lu 0 i CIXR 1 1 ti ti LO a I l l,! I n .a ilnu �i�, rn� June 20, 2024 o. To Whom It May Concern: " The attached Interfacility Transfer Protocols and Trauma Protocols, Appendix G of Southernmost Medical Transport's application for COPCN license, are approved by me, Dr. Bruce Guerdan. Should you require any further information, please contact me. Bruce Gu: , . , .... .,,, ......., _,.......... erdan, M.D., MPH 1800 Atlantic Ave B117, Key West, FL 33040 (724) 312-1251 keywestnightdoc@gmail.com u" �!PrY.�`�`,6�"k��`;��akPV1Yo�` �1�ii.ili,tl6"'i��N�'i��4��h,14�y�h�•�r 00 rv- k,�AAI n Southernmost Medical Transport, LLC I ,i�sb rJFfC�IIIE�r„C if(P d d�1!4In'k ' COPCN Application Appendix G: Standing OrderslProtocols INTERFA CILITY TRANSFER and TRAUMA PROTOCOL Table of Contents 1. Procedures and Policies a. Introduction b. Documentation c. Transport Crew Levels d. Contacting Medical Control by Paramedics/CCs e. Transferring Patients with Drugs and Devices f. Requesting Additional Personnel II. Drugs a. Cardiovascular Drugs a.i.Antiarrythmics a.ii.Beta-Blockers a.iii.Blood Pressure Lowering Agents a.iv.Calcium Channel Blockers a.vi.Heparin Drip a.vii.lnotropes a.viii.Nitroglycerine Drip a.ix.Thrombolytic Therapy b. Sedation and Paralytic Agents b.i.Benzodiazepine Drips b.ii.Moderate Sedation Agents �I ct, to Southernmost Medical Transport, LLC COPCN Application b.iii.Opioid Drugs/Drips b.iv.Pa ra lyti c Agents c. CNS Drugs c.i.Anticonvu Isants c.ii.Mannitol c.iii.Steroids d. Hyperalimentation/TPN, Insulin and Electrolytes d.i.Hyperalimentation/TPN d.ii.lnsulin d.iii.Potassium Chloride e. Obstetric Drugs e.i.Magnesium Sulfate e.ii.Oxytocin (Pitocin) f. Anti-Infective Therapy � f.i.Antibiotics and Antivirals f.ii.Antifungals g. Pain Control g.i.Opioid Drips g.ii.PCA (Patient Controlled Anesthesia) Pumps and Subcutaneous Pumps g.iii.Sprays and Gels h. Antidotes h.i.N-Acetyl Cysteine or NAC(Acetadote) h.ii.Cyanide Antidote Kit (Amyl Nitrate, Sodium Nitrate, Sodium Thiosulfate) h.iii.Thiamine h.iv.Bicarbonate Drip h.v.Pyridoxine (Vitamin 136) h.vi.Atropine/2-PAM i. GI Drugs i.i.Antiemetic Agents ct, 00 0 � rl„w Southernmost Medical Transport, LLC "° COPCN Application i.ii.Acid Reduction i.iii.Gl Bleed Related Medications III. Devices c.i.Temporary Cardiac Pacing c.ii.Thoracostomy Tubes (Chest Tubes) c.iii.Ventricular Assist Devices (VADs) c.iv.Tracheostomy Care c.v.BiPap Machines c.vi.lnvasive Cardiovascular Monitoring c.vii.Intracranial Pressure (ICP) Monitors c.viii.lnsulin Pumps c.ix.Central Vascular Access IV. Pediatric Transfer Protocols d.i.Antironvulsants d.ii.Continuous Albuterol Nebulization d.iii.Insulin Drip d.iv.IV Antibiotics V. Special Situations e.i.The Hospice Patient e.ii.The Pediatric Patient and Consent Issues e.iii.The Therapeutically Cooled Patient VI. Glossary and Abbreviations v, 00 0 � Southernmost Medical Transport, LLC COPCN Application 1. Procedures and Policies a. Introduction b. Documentation c. Transport Crew Levels d. Contacting Medical Control e. Transferring Patients with Drugs and Devices f. Requesting Additional Personnel v, 00 N Southernmost Medical Transport, LLC COPCN Application a. Introduction The decision to transfer a patient rests with the transferring physician (or other care provider, such as a physician assistant).This physician bears responsibility for the transfer decisions. It is the transferring physician who must: 1. Determine whether the benefits of transfer outweigh the risks. 2. Ensure that the patient is properly stabilized prior to departure. 3. Be responsible for complying with currently accepted community standards of practice regarding interfacility transfer. The Paramedics/CCs/RN's and Medical Control Physician (MC) assume responsibility for management of the patient, given the circumstances of the patient's condition, while en route between facilities. This protocol recognizes there will be situations where potentially unstable patients will require transfer to anotherfacility to obtain a higher level of care. b. Documentation It is the responsibility of the transferring hospital/physician to provide appropriate documentation which includes a transfer form or other documentation indicating compliance with current statutes or laws regarding patient transfers. Included should be identifying information (name, address, date of birth, etc.),treatments,'test results, preliminary diagnosis, reason for transfer, names of transferring/accepting physicians/institutions, pertinent medical records and orders. c. Transport Crew Level's The following is a description of which levels of care may transport what drugs and devices. EMT Saline lock Patients with PICA pumps with settings unchanged for > 6 hours Stable patient with no anticipation of further interventions en route EMT-P listed plus: All Intubated patients v, ao w �o Southernmost Medical Transport, LLC COPCN Application Listed plus: Arterial and Swann-Ganz lines- not to be RN: used for monitoring by paramedic The medical director of the transporting service shall insure that all transporting providers are credentialed and trained for interfacility transfer and may transport drugs in the so named categories at their discretion. d. Contacting Medical Control by Paramedics/CCs Medical Control MUST be contacted in the following circumstances: 1. Ongoing administration of blood products or resuscitative medications 2. Intubated patients 3. Patients with chest tubes 4. Patients with temporary pacemakers 5. Changes in symptoms/signs/conditions potentially indicating deterioration 6. Unstable vital signs 7. Medications not specifically listed in the protocol Patients with the first four listed items should be contacted before arrival, and preferably before the patient leaves the sending facility. Patients with the 5th and 6tn listed items should have MC called en route as these occur. Patients on medications not specifically listed in the protocol may be transported by EMT Ps or RN's ONLY.These medications will need to be reviewed by MC and must fall into a similar category as other drugs ALREADY LISTED in the protocol.A patient receiving a completely new category of drug may not be transported without further personnel trained in the use of that drug. Medical Control (MC) may be defined as either the transporting service agency Medical Director,the transferring or receiving MD and as a last resort the ED physician of the transferring or receiving hospital. The Medical Director of the transporting service may set additional standards regarding contacting MC. to 00 n Southernmost Medical Transport, LLC COPCN Application e. Transferring Patients with Drugs and Devices During interhospital transfer crew members shall follow all BLS/ALS algorithms and protocols via American Heart Association guidelines per crew members certifications in the event of patient status change with contact with MC. In addition, patients on medications and devices at pick up may only be transported if the respective drugs have been initiated at the transferring hospital by the transferring physician/care provider. At the discretion of MC, the drug rates/doses may be altered or discontinued depending on the patient's clinical condition. Where indicated, EMT- Ps and RN's may titrate a drug up or down once depending on parameters delineated in the specific protocol. The following precautions should be kept in mind by transferring providers: 1. All medications have potential to cause allergic reactions. 2. Some medications cause local irritation around the IV site. Several may even cause tissue necrosis if there is infiltration. If there is infiltration of any line,the IV should be immediately discontinued. 3. Many of the listed drugs are incompatible with other medications.Therefore, additional medication should be given through a separate IV line, or, if one is not established, the infusion should be stopped and the line flushed before administering a second medication.This should only be done under direct MC guidance. 4. Most require infusion pumps and/or cardiac monitoring. 5. MC should be contacted if there is any change in patient condition or if any medication needs to be emergently discontinued during transport. 6. If the need arises for emergency medications to be given, infusions may need to be discontinued; contact MC. 7. The MC physician may determine that the number or types of drugs/devices may require the presence of additional personnel (such as a second paramedic, nurse or physician). 8. Transfer of patients with ongoing infusion of medication outside the scope of practice and training of the transporting crew (either because of lack of credentialing or medication not listed in the protocol) can not be accomplished without additional personnel who possess a higher level of training. to 00 u, ,PIP ^ mWJ'k,, Southernmost Medical Transport, LLC COPCN Application f. Requesting Additional Personnel When the EMS provider anticipates that they will require more assistance to appropriately care for the patient during transfer, they shall request the transferring physician/health care provider to provide appropriately trained hospital staff to accompany the patient and assist. The EMS provider must contact MC for medical direction in all situations where they are not comfortable with the circumstances of the transfer.The transfer will not occur unless the EMS provider and MC are confident the personnel and equipment are appropriate for transfer. r v, 00 rn 1" Southernmost Medical Transport, LLC �� COPCN Application !I. Drugs a. Cardiovascular Drugs b. Sedation and Paralytic Agents c. CNS Drugs d. HAL/TPN, Insulin and Electrolytes e. Obstetric Drugs f. Anti-infective Therapy g. Pain Control h. Antidotes i. GI Drugs v, 00 4 Southernmost Medical Transport, LLC COPCN Application a. Cardiovascular Drugs If. Anti-arrythmic Drugs ii. Beta Blockers iii. Blood Pressure Lowering Drugs iv. Calcium Channel Blockers u Heparin Drip A Inotropes vii.Nitroglycerine Drip viii.Thromholytic Therapy v, 00 00 V�"I�Vilj nui9a Southernmost Medical Transport, LLC COPCN Application Cardiovascular Drugs a.i.Antiarrythmics . ...... Use: Treatment and cardioversion of Atrial Fibrillation or Atrial Flutter Treatment and prophylaxis of refractory Ventricular Tachycardia Adverse Effects: • Hypotension • QT prolongation • Torsades • Ventricula r Tachycardia AV Block Dosing: Amiodorone • Infuse: 300 mg IVP 1st dose; 150 mg IV 2nd dose Diltiazem(Car&, • Bolus: 0 0.25 mg/kg over 2 minutes (20 mg for average patient) o If needed may repeat bolus in 15 minutes @ 0.35 mg/kg (25 mg in the average patient) over 2—5 minutes • Infusion: o Dilute 125 mg (25ml) in 100 ml NS/D5W o Drip @5—15 mg/hour titrated to desired heart rate Mc • Bolus: 1-2 grams over 5 minutes • infusion Hours: 6-12 grams over 24s Proofenone.( ,mot) • Bolus: 2 mg/kg in 15-20 minutes; followed by • Infusion: 0.0067 -0.0078 mg/kg/minute ct, 00 to Southernmost Medical Transport, LLC rp COPCN Application Special Considerations: • Use infusion pump for drips • May not be compatible with heparin, lidocaine, amiodarone or bicarb Frequent BP checks for hypotension • Increased risk for ventricular dysrythmias if on certain antihistamines or anti- nausea medications Transport by EMT-Ps or RN's only Cardiovascular Drugs a.ii.Beta-Blockers Use: • Slow ventricular response in SVT,Atrial Fibrillation and Atrial • Flutter Slow sinus node rate Adverse Effects: • Hypotension, bradycardia • Hypoglycemia (diabetics on medications); usual signs and symptoms are masked • Bronchospasm Sinus node arrest Dosing: Atenolol (Tenormin' • Infuse: 5 mg over 5 minutes o May be repeated in 10 minutes Esmolol B,reviblo • Bolus: Bolus: 500 mcg/kg (0.5 mg/kg) over one minute • infusion: 50 mcg/kg/minute for 4 minute to to 0 Southernmost Medical Transport, LLC lutild�'v�('ilPdff'�»1V COPCN Application If inadequate response, repeat bolus and increase drip rate by 50 mcg/kg/minute up to 3 times (total dose of 2000 mcg bolus and in fusion @ 200 mcg/kg/minute) Drug comes in a 100 mg(10 mg/ml)vial or 2500 mg ampule into 250 ml (10 mg/ml) or 500 ml (5 mg/ml) NS or D5W Labetalol(Normodyne'I • Infusion: 2 mg/minute (concentration 1mg/ml; • 2ml/min) duration from 25 minutes to 2.5 hours Metoprolol(Lopressor) • Inject: 2.5 mg IV slow push over 2 minutes • May repeat does up to 5 times every 5 minutes for a total does of 15 mg Sotolol (Betaoace) • Bolus: 1-1.5 mg/kg;followed by • Infusion: 0.008 mg/kg/minute-8 mcg/kg/min Special Considerations: • Use infusion pump • Check BP frequently; monitor heart rate • Carefully monitor for hypotension, excessive bradycardia or new AV blocks • Patient with DIABETES may have symptoms of hypoglycemia masked;watch carefully for mental status changes. • Contact MC if develop adverse reaction. Cardiovascular Drugs a.iii.Blood Pressure Lowering Agents ------------ Uses: Short term parenteral treatment when oral treatment is not feasible Nitroprusside may be used in CHF to reduce both preload and afterload (reduces work of the heart) Adverse Effects: • Hypotension, bradycardia, dysrythmias Palpitations,flushing, angina ' Headache, restlessness, drowsiness, confusion or slurred speech ct, W Southernmost Medical Transport, LLC COPCN Application Dosing: H • 5-40 mg IV push over 1-2 minutes • Usually given as repeat bolus doses every 20-30 min desired • Rarely given as drip: 1-10 mg/hour Nicardioene Cardene • Dilute to: 0.1 mg/ml • Infusion: Start @ 50 ml/hr(5 mg/hr) • May increase rate by 2.5 mg/hr every 15 minutes until BP is reached for a maximum dose of 15 mg/hr Nitrorusside • Infusion: Continuous to maintain BP See dosage chart below; amount listed is in mL/hr Nitroprusside: • Small boluses or slight increases in infusion rate may produce profound hypotension • Solution must be wrapped in foil to protect it from light • Do not mix other medications in the same line Check BP and heart rate every 5 minutes • Hypotension can be alleviated by decreasing the infusion rate Nesiritide: • Caution in pregnant or lactating patients • Contact MC for worsening signs/symptoms, significant BP change or if BP<90 Blood Pressure Lowering Drugs should be transported by EMT-Ps or RN's only. ct, to N Ao IIhiIW Southernmost Medical Transport, LLC aJ;,t COPCN Application NITROFRUSSIDE DOSING CHART CONCENTRATION 200MCGIML 100MGf500ML 50MG1250ML Pat Wt MCWGIMINUTE in Kg 0.5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 35 5 11 21 32 42 53 63 74 84 95 105 116 128 137 147 158 40 6 12 24 36 48 60 72 84 96 108 120 132 144 156 168 180 45 7 14 27 41 54 68 81 95 108 122 135 149 162 176 189 203 50 8 15 30 45 60 75 90 105 120 135 150 165 100 195 210 225 55 8 17 33 50 66 83 99 116 132 149 165 182 198 215 231 248 60 9 18 36 54 72 90 108 126 144 162 180 198 216 234 252 270 65 10 20 39 59 78 98 117 137 156 176 195 215 234 254 273 293 70 11 21 42 53 84 106 126 147 168 139 210 231 252 273 294 315 75 11 23 45 68 90 113 135 158 190 203 225 248 270 293 315 338 80 12 24 48 72 96 120 144 168 192 216 240 264 288 315 336 360 85 13 26 51 77 102 128 153 179 204 230 255 281 306 332 357 383 90 14 27 54 81 108 135 162 189 216 243 270 297 324 351 378 405 95 14 29 57 86 114 143 171 200 228 257 285 314 342 371 399 428 100 15 30 60 90 120 150 180 210 240 270 300 330 360 390 420 450 105 16 32 63 95 156 158 189 221 252 284 315 347 378 410 441 473 110 17 33 65 99 132 168 198 231 264 297 330 363 396 429 462 495 115 17 35 69 104 138 173 207 242 276 311 345 380 414 449 483 518 120 18 36 72 108 144 180 216 252 288 324 360 396 432 468 504 540 Cardiovascular Drugs a.iv.Calcium Channel Blockers Uses: Ventricular Rate Control in A Fib,Atrial Flutter, MAT or SVT Adverse Effects: • May cause Atrial Flutter, AV Block, Bradycardia, Chest Pain, CHF, Ventricular Arrhythmias, nausea/vomiting, dyspnea or hypotension ct, to w Southernmost Medical Transport, LLC COPCN Application Dosing: Diltiazern Cardizern • Bolus: 0 0.25 mg/kg over 2 minutes (20 mg for average patient) o If needed may repeat bolus in 15 minutes @ 0.35 mg/kg (25 mg in the average patient) over 2—5 minutes • Infusion: o Dilute 125 mg (25rnl) in 100 ml NS/D5W o Drip @5—15 mg/hour titrated to desired heart rate Nica rd i pene(Cardene) • Dilute to: 0.1 mg/ml • Infusion: Start @ 50 ml/hr (5 mg/hr. May increase rate by 2.5 mg/hr every 15 minutes until BP is reached fora maximum dose of 15 mg/hr Special Considerations: • Carefully monitor for hypotension/excessive bradycardia/ new A/V block PVC's can occur with conversion to NSF: • Don't use in the presence of a WIDE COMPLEX TACHYCARDIA Nicardipene: • If hypotensive or tachycardic, discontinue drip. May resume when stable @ 3-5 mg/hr • Infusion site must be changed after 12 hours • Use with caution in patients with liver failure, since it is metabolized in the liver. • May be contraindicated in severe Aortic Stenosis as may decrease preload. Should not be infused in same IV with other drugs Cardiovascular Drugs a.vi.Heparin Drip Uses: Prevents blood clotting, espec ally in the following situations:Acute MI, Pulmonary Embolus, Deep Vein Thrombosis ct, co .p 7i' gym,„, � ri�. Southernmost Medical Transport, LLC COPCN Application Adverse Effects: • Hemorrhage from various sites including needle sticks, GI tract, CNS bleeds Dosing: • Bolus: 15-18mg/kg • Infusion: 800-1600 mg/hour Infusion rates may be outside this range and should not require adjustment during transport Special Considerations: • Use infusion pump • D/C immediately for onset of major bleeding or acute mental status change Contact MC for any bleeding such as IV sites or gums Cardiovascular Drugs a.vii.lnotropes Uses: • Short term intravenous treatment of patients with acute decompensated heart failure • Severe CHF/Cardiogenic Shock • 7o increase cardiac output by increasing myocardial contractility and stroke • Hemodynamically significant hypotension not resulting from hypovolemia Adverse Effects: • May develop hypokalernia resulting from increased cardiac output and/or diuresis May have tachycardia, ventricular dysrhythmias or ectopy, hypertension, angina or vomiting ischemic chest pain • Dobutamine may also cause hypotension • Dopamine may cause nervousness, headache, palpitations, dyspnea ct, to u, 01 i�i� 3�ww„ Southernmost Medical Transport, LLC COPCN Application Dobutamine: • 2.5—20 mcg/kg/min continuous infusion; • onset may be 10 minutes See dosing chart below for different concentration solutions DOBUTAMINE DOSING CHART CONCENTRATION 2MG/ML iG/50OML OR 100MG/501VIL 50gMG/250 ML PAT WTI I MCGIKG/M UTE INKG 1 21 ...31 4L .5 6 7 8 9 1O 17 12 13' 14 15' 16' 17 18 19 20 ' 25' 3QI 35 40 35 1 r 2 ' 4 5 6 7 31 8 9 11 �72 13-14 YS 16` 77 78 19 20.21 26 32 37 42 2.. 4 5; 6- 7 8 10 11 12 13, 14 16 17 1$ .19 20' 22 23 24;C454 : 42 48.. „45 1 3 4 5 7 8 9 11 12 14 15 16 16 19 20 22 23...24 26 27 4750 2 3 5 6 ..8 9 11 32' 14 15 171 18 20 21 23 24 26'..27. 29, 30p 53 60 55 23S 7j 8 10 12 13 15 17 18 20 27 23 29 2B 28 3031 33 S8 66 64 2' 4 5 7 9 17 13 14 16 1$ 20""-.22 23'-25 27' 29 37 32. 34'36 63 72 65 .. 2 4 6 8 1O 12 Y4 161$ 2q 2123. 25 27 29 31 33 35 37 39 68 78 70 2'.4 6. B 1 i 13 15'. 17 19 21 23 1 25 27 29 �32 34 36 38 40 42 . 74 54 75 2 5. 7 9 11 14 16,,..752q23 2S 27-'28 32 34m 36 38 41 .43 45 . 79 . .90 80..... 2 14 17 79 22 24 26 29 81��..34 36 361 47 „4 � 46 RB 60..... 72 84 96 65 3 5 _8 10 13 75 YS 20 23 26 28 31 33' 36 38 47 43 46 48 51'' 64 77 $9 1q2 mm ... .... . .... :, I^ . 90 3 5' 8 11 141 16 19 22 24 27 30 32 35 38 41 43 46 49 51 54 58 81 aS-108 95 3 6. .9 11 .14 17 20 23 ,26 z9 311 M 37 40 43 46 48 51 54 57 � _.... 7i 86 700 774 1q0 3 6 9 Y 2' 15 18 21 24 271 30 33 36 39'`42' 45 f 48 57 54 57 6Q 75 90 105 120 i05 3 6! 9 13 i6 1922 25 28' 32 35;38 41 ;44 47160 54 57 6tl 63 79 95'110' 726 11 Q 3 7 10 13 17 20 23 26 3D 33 36 40 43 46 50' 53 56 59 63-,66 83 99', 1 7 6 i 32 115wwwwww 3 7, 10 i4' Y7 21 24 28 39 35 38 49 45 48 52. 55 p59 62 66 69 86. 104 121 138 720 4,7 11 14 16 22 25 29 32 36 40 43 47 5Q 54 50 61 65 68 72 90 108 126 144 ml /hr or drops/miry, using minidrip tubing=60 drops 1 1111 tJ1 Southernmost Medical Transport, LLC ° d d COPCN Application DOUBLE CONCENTRATION DOBUTAMINE DOWNG CHART CONCENTRATION 4MG/ML 1000 M G1250 ML 500MG1125M L PAT WT MCGIKG/MINUTE IN KG 111 2 3 4115 6' 7 8 91 10 1111 12113114 14 15 161 -171 18 19 20 25 301 351 40 35 1 '1 2 21 3 3 4 4 5 5 6 6 7' 7 8 6 9 9 10 7i 13 16 18 2Y 40 1 1 2 2 3 4 4 5' S 6 7 7 e 8 9 10 10 11. 11'.. 12 1$ 18 2Y 24 45 1 1 , 2 3'' 3 4 5 5 6 7 7 8 9 9 10 11 17 12 13 74 17 20 24 M27W 50 1 2 2 3 4 5 5 6 7,M8 8 9 10 17 11 12 13 14 14 75 19 23 .,,,,2 11 6 1.�30�, 55 1 2 2 3' 4 5 6 7 7' 8' 9 10 11 12 32 13 14 15 16' 17 21 25 29 33 Bq 1 2 3 4' 4 5 61 7 8 9'' 10 11 12 #3 74 14 15 16 17 16 23 27 32 36 65 1 2 3 4 5 6 ....7 8 9 10. 11 12 13!14- 15' 16 17 1B 19 20 24 29, 34 39 70 1 2 3 4 5 6 7'. 8 9 7 Y 12 13 14 15'.. 16 }7 18 1 9 1"20 21 26 32 I 37 42 75 1 2, 3 6 6 7 5 9 10 11 _12 14 15 16 17 18 19 2021 23 28 34 39 45 80 —1 2'. 4 5 6 7 e .:10 11 12. 13, 14, 16-17' 18 19 20 22 23 24 30 3B; 42 48 95 1 3'. 4'. 5 6 8 9 10 17 13 14 #$ 17 18 19 20 22 23 24 ....25 32 90 1 Ij 3 4 5 7 B 9 it 72 14 151 16 18 19 20 22 23 24 26 27 341 41 47 54 95 7 3 4'' 6 7 9 1O Y1 13 14'I6 17' 19 20 21 23 24 26 27 29 361 43 50 57 100 2 3 5 to 8 9 111 12' 14 55!17 18' 20 21 23 24 26 27 29 30 38 45 53 60 105 2' 3. 5 is a 9 11 13 14 16� 17' 19 20 22: 24 25 27 28 30' 32 39 47 55 6a�, 110 2` 3 5• 8 70', 12 13 15 17 i8 2U' 21 23 25 26 28 3d 31 33 47 50 Be Be 715 2 3 S 7 9 10: Y2 14 16 17 t 9 21 22 24 26 28 29 31 33 35 43 521 60 89 120 2 m 4 5 7 9 YO 13 14 16 18'..... 63 72•. 20 20 23 25 27 29 31 j 32 34� 36 45 54 �� rnl/hr or drops/ruin. using minidrip tubing 60 drops/ml D,oamne: • 1-20 mcg/kg/min continuous infusion • Onset may be 10 minutes See dosing chart below for different concentration solutions ct, to 4 Southernmost Medical Transport, LLC COPCN Application Dopamine Dosing 4--hart Double Concentration 3.2 m&/ni 800 rng/250 ml vineg/ka/mirlute ............. ........ ......... ................... ......................... ....................................... .. ......... 1 2 3 4 5 10 15 20 35 1 7 10 13 —11111111111111 11" 1.. ......... ........- 40 1 2 2: 3 4i 15 45 1 -2 3 13; 17 9 1rz, 1 Ell) 55 1 -2 3 5 16 16 2-1 ............... .. .................................. ........................................-—----........— . 60 1 2 3 S fj 1 1 17 23 ...........-.. ..... Ptwt . �........................................................ ---------............. ....................... .......................... ............................ ............................. 75 11 Z 4 ...... 4 21 in Kg ------------ 28 80 2 3 85 2' ...................................... 3, 5 6 32 ..... ...... ................. ........... 90 ;2 3 51 �7 8, 17 4 5 8 ei 18 271 3f-- 100 —6- 8- ,,2"'"a...............................................3 0.............................. 110 2 4 5 9 1 T1 211 31 41 115 .......... -—----------------:4 9 11 -22 3-2-1 4- I.................................. .......... 1---,�CF-d 120 '9- -V .... ................ ........ .......... .................. ml/hir or cirops/rrairk- xxNixip,rninidrip tubing� 60 idrops/rni 3l3c3pnmhmd5 g:omxzblie)�Dosing Chart Dosing Chart Single Concentration 1.6 mg ml 800 mg/500 ml 400 mg/250 ml mcg/kg/minute Ta -1 15 2D 35 2 3 1 3 4 7'—iN 20 261 40 2 3 5 6 8 15 23 301 .............. 45 2 3 5 7 a 17 2634 50 2 4: 6 a 9 19 28 38 �1 6 8 10 21 31 41 551 2 Pt 51 7 9 if 23 34 45 www ..........--- ......................................................... ..................................—5 7 1 Q 121 24 37 49 I. ——-.............................................................. n 70 3 5 8 11 13 26 39 53 75 3 1 1 14 28 42 56 80, 3 6 9 ;- 3��—I 1 4 5 60 85 a 6 10 1 16 48 64 z! 9 3 Y 16 1�4 17 34, 51 68 9 r> 4 7 11 14 is 36, 53 71 106 4 L-1-1....... 5 19 38 56 75 105 4 a 12 16 20 3,9 5U 11 4 8 12 17 211 41 621 ,8 . .................. 4 ...................—17 8 ::M1 ........129 1G 9C]0 ..................... ni or drops/min. using minidrip tubing=60 drops/ml Dopamine(Single)Dosing Chart • Epinephrine: 1-10 mcg/min titrated to desired effect • Norepinephrine: 0.5-1.0 mcg/min • (Levophed):Titrated up to 30 mcg/minto desired hemodynarnic effect vl 00 ° Southernmost Medical Transport, LLC Silk r P d iIW rPr o ;P:r COPCN Application Special Considerations: • Monitor for cardiac dysrythmias; these may be caused by hypokalemia, preexisting arrhythmias, abnormal drug levels, catheter placement, etc. • Check blood pressure and heart rate frequently. Discontinue briefly if develop hypotension secondary to vasodilatation • EMT-Ps and RN's may titrate up/down one increment without calling MC • Contact MC for any adverse affects Cardiovascular Drugs a.viii.Nitroglycerine Drip Uses: • Acute Coronary Syndrome, CHF, Hypertension • Decreases preload, and to a lesser extent, afterload Adverse Effects: • Excessive hypotension which can provoke angina, headache, restlessness, • palpitations,tachycardia or dizziness Dosing: • Continuous infusion titrated to maintain therapeutic effect while avoiding hypotension. • Usual range 10-200 mcg/min. May be higher in treatment of pulmonary edema. Special Considerations: • Use Infusion pump Monitor heart rhythm • Check 8P and HR frequently(every 5 minutes); may decrease to every 10 minutes if at the same rate for>1 hour Do not mix other medications in the same line • Hypotension can be alleviated by decreasing the rate of infusion D/C infusion if BP systolic is<60mm Hg and contact MC Contact MC for worsening or persisting adverse signs/symptoms or for persisting BP<90 mmHg to to to �u Southernmost Medical Transport, LLC H COPCN Application NITROGLYCERIN DOSING CHART DOUBLE CONCENTRATION CONCENTRATION 200MCG/ML NITROGLYCERIN DOSING CHART 100 MG1500 ML CONCENTRATION 400MCG/ML 50 MG/250 ML 100 MG/250 ML PUMP PUMP PUMP PUMP MCGIMIN SETTING MCGIMIN SETTING MCGIMIN 5ETnNG MCGIMIN SETTING 10 3 160 48 10 2 160 24 20 6 170 51 20 3 170 26 30 9 180 54 30 5 180 27 40 12 190 57 40 6 190 29 50 15 200 60 50 8 200 30 60 18 210 63 60 9 210 32 70 21 220 66 70 11 220 33 80 24 230 69 80 12 230 35 90 27 240 72 90 14 240 36 100 30 250 75 100 15 250 38 120 36 260 78 120 18 260 39 130 39 270 81 130 20 270 41 140 42 280 84 140 21 280 42 150 45 150 23 ,r 12 tJ1 IV O O t� Southernmost Medical Transport, LLC F COPCN Application Cardiovascular Drugs a.ix.Thrombolytic Therapy Uses: • Dissolves clots in blood vessels • Generally used in the setting of Acute MI or CVA; occasionally used Pulmonary Embolus Adverse Effects: • Minor hemorrhages from IV sites and gums • Major hemorrhage from GI and intracranial or spinal sites • Reperfusion dysrhythmias often occur about 30-60 minutes after staring infusion Allergic reactions including anaphylaxis may occur with Streptokinase or APSAC Dosing: Stretokmase,APSAC or TPA:, • Dose to be determined by transferring physician (determined by patient weight and indication for therapy) Rate should not require adjusting en route Tenecteplase TAIK • weight-based one time dose, administered over 5 seconds Pt weight: o <60 kg Dose: 30 mg o >_60- <70 kg 35 mg o >_70-<80 40 mg o >_80-<90 45 mg o >_90 50 mg Occasionally used as continuous infusion for peripheral arterial thrombus 0.25-0.5 mg/hour up to 48 hours Special Considerations: • Use infusion pump • Monitor heart rhythm • Check BP and HR frequently • Do not mix with other medications in the same line ct, N 0 tea i C... �r�uuir Southernmost Medical Transport, LLC W-,flj�Tlfr�'�I�YP�%'i��lPd�1k�'m�,�✓ COPCN Application • D/C infusion immediately if there is cardiac arrest, major hemorrhage, anaphylaxis or change in mental status AND call MC.] l,rr to N 0 N IN N" P � Southernmost Medical Transport, LLC ,rN I COPCN Application b. Sedation and Paralytic Agents i. Benzodiozepine Drips ii. Moderate Sedation Agents iii. Opioid Drips iv. Paralytic Agents Only to be used by EMT-P or RN's v, N 0 w Southernmost Medical Transport, [[C [OPCNAppUcution Sedation and Paralytic Agents b^i.BeDZ0diaZepiD8Drips __.. Uses: Sedation for patients who are intubated (and often concurrently on a paralytic drip) May be used to treat Status Epi|epticus Adverse Effects: ° May be more prone to hypotension if used with an opioid drug Can cause paradoxical agitation, hypertension ortachycardia Dosing: ` ° Loading dose: 0.5-4.0 mg |V bolus; may be repeated in 10 min ° Infusion: O.O2'O.1nmg/kp/hour ° Loading dose: O.O1-O.1 mg/kg |Vbolus ° Infusion D.O2-0.1rng/ko/hour Special Considerations: ° Only tnbe used in intubated patients npuurTi„ 4� Southernmost Medical Transport, LLC COPCN Application Sedation and Paralytic Agents b.ii.Moderate Sedation Agents Uses: Sedation for patients who are intubated (and often concurrently on a paralytic drip). May also be used for refractory seizures or therapeutic coma Adverse Effects: • May be more prone to hypotension if used with an opioid drug Can cause paradoxical agitation, hypertension or tachycardia Dosing: Profol„. • Loading dose: 0.5-5 mg/kg • Maintenance infusion:2-10 mg/kg/hour Barbiturates:Pentobarbital is most commonly used • Loading dose: 10 mg/kg; infuse up to 25 mg/min Maintenance: 1-2 mg/kg/hour Ketamine • Loading dose: 1-5 mg/kg • Maintenance infusion:0.01-0.05 mg/kg/hour Special Considerations: • Only to be used in intubated patients ct, N 0 v, Southernmost Medical Transport, LLC COPCN Application Sedation and Paralytic Agents b.iii.Opioid Drugs/Drips Uses: Typically partof a sedation combination for patients who are intubated Occasionally for pain control Adverse Effects: • May cause hypotension, especially in volume depleted patients or those with right-sided heart failure Dosing: MpMhl ine,: • Loading dose: 2 mg increments given every 5-10 minutes until adequate pain control; typically max dose is 10 mg- may be higher in patients on chronic pain therapy • Infusion: 1-10 mg/hour Fentanyl; • Loading dose: 1-5 mcg/kg given IV push • Infusion: 1-5 mcg kg/hour Special Considerations: • Not advisable to give patients on narcotic drips Naloxone, as this may precipitate acute withdrawal • Antihistamines (both H1 and 1-12) may counteract hypotension; this is an MC contact drug. ct, N 0 rn Southernmost Medical Transport, LUC WrT COPCNApp|ication Sedation and Paralytic Agents b'iV.P@rGlVtjCJ\gentS Uses: ° Total muscular paralysis when patient movement may: 1. Compromise airway control (e.g. causing unwanted extubot|on) 2. Exacerbate a naa| or potential illness or injury(e.g. spinal cord injury from a spine fracture) ]. Endanger the patient, EMS care provider orothers Adverse Effects: ° Bronchospasm,flushing, hypotension and tachycardia have been rarely reported Dosing: ° Initial dose 1Onn0 |Vpush ~ Repeat dose of1Onng |V push every 2O-4D minutes as ~ Maintenance infusion may bean alternative: 1.1 mg/kg/min ° Loading dose 0.6mg/kg ° May rebn|us 0.2 mg/kg every 3O'45 minutes ° Maintenance infusion may bean a|ternutive:1.1-0.15 mg/kg/min Special Cmn»idmnations- ° Produces COMPLETE APNEA;therefore an intact airway(e.g. endotrachea| intubatinn) ~ Indications: adequate ventilation/oxygenation MUST 8E ESTABLISHED PRIOR TO ADMINISTRATION. Likewise, personnel and equipment with the ability to restore an airway, ventilation and oxygenation must be available during transport Note: Paralysis may alter the din|ca| exam. For example, motor seizure activity will not beseen, but the brain will continue to undergo seizure activity, and this must be treated! Also, conditions such as shock, hypoxia, pain, intracranial injury, hypoglycemia, etc. maybe the cause of this unvvanted, spontanebuspatiantnnnxemmn1inthefirstp|ace.Theyecomdltionsmnustbm addressed but may bemasked by the paralytic agent! 49 Southernmost Medical Transport, LLC ZW';1 COPCN Application c. CNS Drugs i. Anticonvulsonts ii. Mannitol iii. Steroids v, N 0 CO Southernmost Medical Transport, LLC COPCN Application CNS Drugs c.i.Anticonvulsants Uses: Prevention and treatment of seizures Adverse Effects: • If intravenous phenytoin is given too rapidly, may result in: o Cardiac dysrhythmias including ventricular fibrillation or asystole o Hypotension • Subcutaneous extravasation of intravenous phenytoin may cause tissue necrosis or pain at the IV site Dosing: Phenytoin • 100-1200mg IV piggy back in normal saline; • Rate not to exceed 50 mg/min Kgm,r ,AWet racetam': • Loading dose: 60mg/kglV over 10 min (not to exceed 4500mg max dose) • Then 20-30 mg/kg IV maintenance • 40-60 mg/kg • Rate up to 3 mg/kg/min Special Considerations: • Use infusion pump Monitor heart rhythm • Check BP frequently; vital sign monitor recommended D/C infusion and contact MC for any adverse effects j. v, N 0 co Southernmost Medical Transport, L[[ [DP[NApp|ioation [NS Drugs cji.MaDOitol Uses: Treatment nf increased intracrania| pressure or selected fluid overload Adverse Effects: ° Hypernatremku Volume Depletion Dosing: ° 2S—SO grams |V push or bolus infusion (in 50ccDSVV over %Ominutes) Special Considerations: ° Patients receiving mannho| should have a Foley to monitor fluid status CNS Drugs C.iii.St8rOids Uses: ° Spinal cord injury to decrease edema ° Cerebral edema due tn injury nrCNSmoayyor |esion Adverse Effects� ° GI Bleed ~ Electrolyte disturbance and hyperg|ycenmia Hypertension oar Acute [HF ° Agitation ° Corticosteroid hormonal suppression (hypoglycemia, hypotension, hypothermia) Higher risk for infection or masking symptoms ufinfection 52 pu �� Southernmost Medical Transport, LLC COPCN Application Dosing: Meth 1prednisolone iSolumedrolL • Initial bolus: 30 mg/kg over 15 minutes • Start infusion 45 minutes later: 5.4 mg/kg/hour for 23 hours Dexamethasone l;Decadronl: • 0.1-0.6 mg/kg day • May be given as IV drip of 2 mg/kg over 2 hours Special Considerations: • Contact MC for question of adverse effects s v, N Southernmost Medical Transport, LLC Nb COPCN Application d. Hyperalimentation/TPN, Insulin and Electrolytes i. Hyperalimentation/TPN ii. Insulin Drip iii. Potassium Chloride v, N N Nil Southernmost Medical Transport, Lh[ COPCNAppUcation HyperalimentotionITP/lill, Insulin Electrolyte solutions d.i.HVperGlinl�OtGtj�D/TP�� Uses: ° Intravenous nutrition Adverse Effects; ° Catheter related sepsis ° Air embolism if centra I venous IV tubing becomes disconnected Subcutaneous extravasation of solution can cause tissue necrosis Discontinuation of infusion may cause hypoQ|ycennia Dosage: ~ Continuous infusion usually through central venous catheter but occasionally through a peripheral |Vline. ° Rate should not require adjustment enroute. Special Considerations: ~ Use infusion pump. ° Do not administer any other medication through the same |Vline. ° Contact K4[for any adverse effects listed above ~ Consider use ofa cardiac monitor pu �� r�N�WAn��i wv Southernmost-Medical Transport, LLC ndr ° ;2ai COPCiV Application Nyperalimentation/TPN, Insulin, Electrolyte solutions d.ii.lnsulin Uses: • Lowers blood glucose • Used in diabetics especially with ketoacidosis or hyperosmolar nonketonic coma. Adverse Effects: • Hypoglycemia related (tachycardia, diaphoresis, mental status changes, and seizures) Dosage: • 5-15 units per hour but dosages outside this range may be used. Special Considerations: • Use infusion pump • Do not administer medications in the same IV line except D50. If symptoms of hypoglycemia develop: o turnoff infusion, o perform a D-Stick o administer 25 grams, (one AMP) D50) if glucose <80, o contact MC. • Monitor blood sugar every 30 minutes during transport • Cardiac monitoring required to N Southernmost Medical Transport, LLC COPCN Application Hyperalimentation/TPN, Insulin, Electrolyte solutions d.iii.Potassium Chloride Uses:. • Replacement therapy for hypokalemia Adverse Effects: • Cardiac dysrythmias (prolonged PR interval;wide QRS complex; depressed ST segment; tall, peaked T-waves; heart block; cardiac arrest) Subcutaneous extravasation of solution can cause tissue necrosis Dosage: • Usual range is up to 20 mEq/hr., continuous infusion. May be mixed with various IV solutions in various sized bags including"piggy back" solutions. Rate should not require adjustment en route. Special Considerations: • Monitor heart rhythm • Often causes burning during infusion; contact MC if this is problematic • Contact MC for changes in EKG configuration and/or dysrythmias ct, N ct, Southernmost Medical Transport, LLC �`�°°� ° COPCN Application e. Obstetric Drugs i. Magnesium Sulfate ii. Oxytocin v, N rn WI pl �IK Southernmost Medical Transport, LLC COPCN Application Obstetric Drugs e.i.Magnesium Sulfate Uses: • Treatment of pre-eclampsia and eclamptic seizures Premature rupture of membranes Adverse Effects: • Lethargy, nausea, vomiting, hypotonia, respiratory depression, dysrythmia Dosing: • Loading dose: 2-6 grams IV over 15 minutes (may give 2 grams over 5 min) • Followed by either: 0 5 grams IM in each buttock o Maintenance infusion: 1-2 grams/hr Special Considerations: • Monitor reflexes • For symptomatic toxicity: 10 mLs of 10%Calcium Chloride and contact MC may also request furosemide and/or NS bolus as MCO • In renal failure, patient may require emergency dialysis v, N Southernmost Medical Transport, [[[ COPCNAAp|ication Obstetric Drugs Uses: Stimulates post partum contraction of the uterus to control bleeding Adverse Effects: ~ Hypertension,tachycardia, dynrythnnian Dosing: ~ 10'4O units added to1O00rnL |V Fluid tn control hemorrhage ° Usual rate is 10'20mni|Uunit»/m)n Special Considerations: ~ Use infusion pump ~ Monitor heart rhythm ° Check 8P frequently; vital sign monitor recommended ° Contact M[for any adverse effects pu 00 , il'4a. ud�wwu d a,W Southernmost Medical Transport, LLC iP"ir ^p�(ry�Iry�� I`ryp p ry ryp ry COPCN Application f. Anti-Infective Therapy i. Antibiotics ii. Antifungals Y � 1. v, N co Southernmost Medical Transport, LLC COPCN Application Anti-infective Therapy f.i.Antibiotics and Antivirals Uses: Bacterial or Viral infections (treatment and prophylaxis) Adverse Effects: • Allergic signs and symptoms, including anaphylaxis Dosage: • Vary depending on the antibiotic • Generally given as a "piggyback" solution Rate should not require adjustment en route Special Consideration: • D/C infusions if there are any allergic signs or symptoms,then contact MC. Most Commonly used: • Acyclovir • Azithromycin • (Zithromax)Cefazolin • (Ancef)Ceftriaxone • (Rocephin)Gentamicin • Levofloxacin(Levaquin) • Metronidazole(Flagyl) • Piperacillin/Tazobactam(Zosyn) • Vancomycin ct, N N 0 Southernmost Medical Transport, LLC n ' COPCN Application ri Anti-infective Therapy f.ii.Antifungals ...... ........ Uses: • Fungal infections • Often in immune-compromised patients,those on chemotherapy or chronic antibiotics Adverse Effects: • Nausea or diarrhea • Amphotericin-fever, rigors, chills Dosing: Amhotercin 6 Azoles or"Funins": • Usually given as bolus dosing once daily to TID • May be given as continuous bladder irrigation: 50 mg/liter Over 24 hours @ 42 ml/hour Special Considerations: • Drug interactions may occur with statins, coumadin, antivirals, benzodiazepines, oral hypoglycemic drugs and transplant anti-rejections drugs • Side effects can be pre-treated with Acetaminophen or Diphenhydramine v, N N 04 Southernmost Medical Transport, LLC COPCN Application g. Pain Control i. Opioid Drips ii. PCA Pumps and Subcutaneous Pumps iii. Anesthetic Sprays or Topical Gels 4 V1 N N N W'/ PI 1!1y b UI Up, ,Q/'✓p I Southernmost Medical Transport, LLC pry 11' IPS COPCN Application Pain Control g.i.Opioid Drips Uses: Control of pain Adverse Effects: • May cause hypotension, especially in volume depleted patients or those with right-sided heart failure • Respiratory Depression Dosing: Morphine• • Loading dose: 2 mg increments given every 5-10 minutes until adequate pain control; typically max dose is 10 mg- may be higher patients on chronic pain therapy • Infusion: 1-10 mg/hour Fentanl: • Loading dose: 1-5 mcg/kg given IV push • Infusion: 1-5 mcg/kg/hour MydromorRhone(D laudidi: • Loading dose: 0.5-4 mg IV slow • Continuous infusion: 1-10 mg/hour Special Considerations: • Avoid Naloxone as this could precipitate acute withdrawal • Pump malfunction could precipitate withdrawal • Antihistamines (both H1 and 112) may counteract hypotension; this is an MC option to N N w IN Southernmost Medical Transport,LLLC COPCNApp|icatinn POinCOntro/ g.ii.PCA (Patient Controlled Anesthesia) Pumps and Subcutaneous Pumps Uses: ° Treatment for patients with palliative care or chronic pain conditions Often PO analgesia is not feasible Adverse Effects: ° Hypotension Respiratory depression ~ Catheter site infection orirritation Dosing: ° PCA(Patient Controlled Analgesia) Pumps ~ Morphine, Fmntony| and Hydronmorphmne are most commonly used. ° Pre-programmed settings for patient ~ Patient may require assistance tu "self-administer" medication Subcutaneous Catheter Pump most commonly'.y5go,', ° Up to 2 nnLs volume at a time regardless of concentration ° May also give |V fluids ata usual rate of1-10nmLs/hnur; MAX of25rnLs/hr Special Considerations: ° Encourage patient to use medication asneeded ~ Avoid Na|oxoneos this could precipitate acute withdrawal ° Pump malfunction could precipitate withdrawal ~ Subcutaneous catheter sites need tobe changed every 7day GG Southernmost Medical Transport, LLC COPCN Application Pain Control g.iii.Sprays and Gels Uses: Topical pain control- usually prior to a procedure Adverse Effects: • Allergy to medication • Depressed gag reflex if used orally Dosing: Sprays: • Usually 2-3 sprays to desired area Topical eels: • Enough to thinly cover area • Duration can be minutes to hours Special Considerations: • Some can induce Methemoglobinemia • Watch for hypoxia n] , iy,Ilhwn�,�waoouuub,wra,I, ) �; Southernmost Medical Transport, LLC ,0 �4r��7� $ NIk' COPCN Application h. Antidotes i. NAC ii. Sodium Thiosulfate iii. Thiamine iv. Bicarbonate Drip v. Pyridoxine A Atropine/2-PAM v, N N rn Southernmost Medical Transport, LLC fil COPCNApp|ication Antidotes h.i l Cysteine or NAC ( d ) Uses: Acetaminophen ovemdose'toxic quantities Adverse Effects: ° Anaphxlac1o|d type reactions (urUcaha,flushing, hypotensionand brondhospasno Dosing: ° Loading dose-. 1SO mg/kg over 15-2Uminutes ° Maintenance infusion: SU mg/kg over 4hm then 1OO mg/kg over 16hours Special Considerations: ° Ideal time of onset of treatment is within 8'10 hours nfingestion ~ Anaphx|actoid reactions may be treated with |Vdiphenhvdnannine ° Maintenance infusion must be doubled at the 4'hourperiod �� Southernmost Medical Transport, LLC COPCN Application Antidotes h.ii.Cyanide Antidote Kit (Amyl Nitrate, Sodium Nitrate, Sodium Thiosulfate) Uses: Cyanide poisoning Adverse Effects: • May cause methemoglobinemia Dosing: • Dosing as described in kit; weight based for children Special Considerations: • Not to be used with Carbon Monoxide poisoning v, N N 00 Southernmost Medical Transport, [LC COPCNAppUcatiun Antidotes h.iij.Thiar0iD8 Uses: \Nern|cke'sEncepha|opathy Adverse Effects: ° Possible anaphylactic reactions Dosing: ° 1OOnnQK/over 1S-3Ominutes Special Considerations: ° Glucose administration in nutritionally depleted patients should be accompanied by thiamine Antidotes h i\(BiCarbOOat8 Drip Uses: ° Tricyclic, aspirin or other acidotic overdoses ° Renal protection after |V contrast orwith severe muscle breakdown (rhabdonoyo|ysis) Adverse Effects: ° Sodium load Dosing: ~ Titrated1n urine pH >7by hospital staff Special Considerations: ° Usually will have Foley tocheck urine pH and output 7� Southernmost Medical Transport, LhC COP[NApp|ication ° Maybe associated with hvpoka|ann|a Antidotes h.V\PV[idqXiOe (VitanliD 136) woma: |son|odde (INH) Overdose Adverse Effects: ° GI upset ~ Headache ursleepiness ° Tingling or burning 0fhands/feet Dosing: ° S grams |V over 3—S minutes; repeat every 5~2O minutes until seizures resolve Special Considerations: ° often patient is in status epilepticus; seizures may respond to benzodiazepines Antidotes h.Vi.AtrOpiDe/2-PAM Uses: For SEVERE Cholinesterase inhibitor poisoning (e.Q. pesticides, nerve agent) Adverse Effects: ° Blurry vision, dry mouth Southernmost Medical Transport, LLC COPCN Application Dosing: Atropine,; • 2-4 mg given every 5 minutes until signs of atropinization (this may take 25-50 mg) 2-PAM i2„eayridinealdoxime • 1 gram slow IV injection; if muscle weakness persists, give 500 mg after 30 minutes Special Considerations: • 2-PAM should be given WITH Atropine to N w Sri Southernmost Medical Transport, LLC �r COPCN Application i. GI Drugs i. Antiemetrc Agents ii. Acid Reduction iii. GI Bleed Related Medications v, N w N 1Al2v Southernmost Medical Transport, LLC Ir y COPCN Application MM GI Drugs i.i.Antiemetic Agents .................. Uses: • For control of severe nausea and vomiting Adverse Reactions: • Drowsiness, dizziness, blurred vision, skin reactions, hypotension • Extrapyramidal symptoms (EPS)—motor restlessness, dystonic reactions, pseudo- parkinsonism,tardive dyskinesia with metaclopramide, prochlorperazine, or promethazine • Headache or dizziness may occur with ondansetron Dose: Metaclooramide, e ian) • 10 mg IV over 2 minutes • If needed, dose may be repeated once in 10 minutes Prochlorpigr%Zine (Com azine'i • 5 mg IV over 2 minutes • If needed, dose may be repeated once in 10 minutes hazine iPhener aanni • 25 mg IV over 2 minutes • If needed, dose may be repeated once in 10 minutes Qndansetron,(,Z qfran) • 4 mg slow IV over 2 minutes or IM • If needed, dose may be repeated once in 10 minutes Special Considerations: • Extra-pyramidal symptoms may be treated by administering Diphenhydramine (Benadryl) 50 mg IV over 2 minutes • Confirm with MD regarding IV administration of Promethazine due to "black box warning" to N w w Southernmost Medical Transport, LLC �f r� COPCN Application G!Drugs Lii.Acid Reduction Uses: • Decrease secretion of gastric acid or chronic reflux Patients with UGI Bleed Adverse Effects: • (all rare) • Occasional CNS symptoms — more so in the elderly Jaundice • GI upset Dosing: Pantoorazole[Protonix,. • Bolus: 80 mg over 5 minutes; • Infusion: 8 mg/hour Lanso,Prazole Prevacid, • Bolus: 30- 60 mg over 30 minutes • Infusion:6 mg/hour Ranitidirvne Zantac" • Bolus: 50 mg over 20-30 minutes • Infusion:150 mg over 24 hours Special Considerations: • May be used for antihistamine effects ct, N w .p Atr Southernmost Medical Transport, LLC i�� I�uiwimQ�o GuHrvAiV COPCN Application GI Drugs Liii.Gl Bleed Related Medications Uses: • Variceal Upper GI Bleed Adverse Effects: • Gall Bladder sludging or stones • Diarrhea and • GI Upset Hypoglycemia Dosing: Octreotide: • 50 mcg IV bolus,then 50 mcg/hour Special Considerations: • Alters the balance between insulin/gldcagon; could result in either hypoglycemia or hyperglycemia • Vasopressin is presently rarely used due to its potent vasoconstrictive and catecholamine inducing properties. ct, N w v, kA � Southernmost Medical Transport, LLC COPCN Application 111. Devices a. Temporary Cardiac Pacing b. Chest Tubes c. VA Ds d. Trachesotomy Care e. BiPap Machines f. Invasive Cardiovascular Monitoring g. 1CP Monitors h. Insulin Pumps i. Central Vascular Access v, N w rn E914 m,P Southernmost Medical Transport, LLC COPCN Application Devices c.i.Temporary Cardiac Pacing Uses: • To ensure adequate heart rate; Most common use is for symptomatic bradycardia or heart block Adverse Effects: • Problems related to transvenous/transthoracic insertion: pericardial tamponade, pneumothorax, myocardialperforation, air embolus sepsis and thrombophlebitis • Failure to pace due to: displacement of pacing electrode (most common complication)loose connection,faulty generator, myocardial ischemia • Failure to sense due to: patient's native beats not sensed by the pacemaker and the output pulse may occur after a spontaneous beat which may induce dysrhythmias • Catheter induced dysrhythmias Pacer Box Settings: • Rate control: usually between 60-100 beats/minute • Output(electric current used to stimulate myocardium): usually between 5-20 mAmps • sensitivity control: used to sense heart's native electric activity(QRS deflection) Special Considerations: • Monitor heart rhythm. A functioning pacemaker usually reveals a pacer spike followed the QRS by a bundle branch pattern on the monitor strip • Contact MC if develops a bradycardia with no pacer spikes or non capturing of consider initiating transthoracic pacing if patient is unstable v, N w 4 t Southernmost Medical Transport, LLC COPCN Application Devices c.ii.Thoracostomy Tubes (Chest Tubes) Uses: • To evacuate an abnormal collection of air (pneumothorax), blood (hemothorax) or fluid (pleural effusion)from the pleural space Complications: • Mechanical problems: tube dislodgement from the wall, air leaks from tubing, drainage site or skin site • Blocked drainage: kinked tube or clots • Bleeding: local incision hematoma, artery or vein laceration Visceral perforation • Re-expansion pulmonary edema Procedure: • Usually placed in the midaxillary line at the fifth-seventh intercostal space, or in the midclavicular line at the second intercostal space • Tube is sutured to the chest wall and Vaseline gauze and an adhesive bandage are placed over the site • The distal part of the chest tube is connected to a chest drainage system (under a water seal) which includes an air seal, a drainage reservoir and suction capability Special Considerations: • Avoid traction on the chest tube; this could dislodge the tube • The chest tube drainage system should remain below the chest level • Avoid kinking or clamping the drainage system • Contact MC if any of the above complications develop, or if the patient develops shortness of breath or change in vital signs v, N w 00 Southernmost Medical Transport, LLC COPCN Application Devices c.iii.Ventricular Assist Devices (VADs) Uses: • Implantable external heart pump used to treat patients with debilitating heart failure • May be used in patients who are not candidates for transplant as well as those transplant FAQs: • There are many types of VAD units; • some have pulses (usually pulse will not be in sync with the patient's rhythm) and some are continuous flow units resulting in no pulse Complications: • VAD Pump Failure: o Need to initiate hand pumping at a rate of 60-90 strokes/min; arrhythmia- appropriate may be a Bi-VAD with two pumps. a Disconnect power source first; prime pump with a purge valve before use • VAD Working- Blood Flow Low- ECG Abnormal: o Usually with a single VAD device; patient's function is influenced by may need to treat the rhythm if patient is symptomatic o LVAD (Left-sided VAD) patient may require large amounts of IV fluids RVAD (Right- sided VAD) patient should not get IV fluids • VAD Working- Blood Flow Low- ECG Normal: o Hypovolemia; could be internal bleeding. If symptomatic initiate therapy to treat cause of hypovolemia Procedures: • If need to transport a STABLE patient • Heart monitor: ECG may not match pulse Large bore IV should be star • Bring companion with patient if available who is able to hand pump the VAD • Bring backup equipment: Hand pumps, extra batteries, primary and backup available ct, N w to u i�ualim ;� Southernmost Medical Transport, LLC �w ,yy COPCN Application Special Considerations: • Need to ask patient. 1. Can I perform CPR on you? 2. IF not- is there a hand pump? 3. If the device slows down-will alarms go off for low flow state? 4. How can I speed up the device? S. Does patient need heparin if the device slows down? 6. Can patient be defibrillated while connected to the device? 7. If can be defibrillated, do I need to disconnect anything first? 8. Does the patient usually have a pulse with the device? 9. What are acceptable vital sign parameters? 10. Can patient be externally paced? Contact Patient's Cardiac Care Team ASAP for problems and prior to transfer Unstable VAD patients should be transferred with a higher level of care Devices c.iv.Tracheostomy Care Uses: • Inadequate airway Respiratory Insufficiency Excessive secretions • Need for prolonged mechanical ventilation Adverse Effects: • Dislodgement of tracheostomy tube Obstruction of tube or stoma • Malfunction of mechanical ventilator or loss of 02 supply Procedures: Suit o W • Sterile gloves v, N .p 0 Southernmost Medical Transport, LLC (0+PIIV'F �,V'"nC COPCN Application • Suction with 120-150mmHg (adults); 80-100mm Hg (pediatric) Hyperventilate with 100%02 • Suction up to 10 seconds (adult); up to 3-4 seconds (pediatric) If mucus plugs/thick secretions — may instill 3-5cc sterile saline Bronchodilator Administration: • Assemble nebulizer assembly as usual Attach trach collar to reservoir tubing • Connect to oxygen source at a flow rate sufficient to produce misting Fit trach collar over stoma and have patient breathe slowly and deeply Stoma Intubation: • Select largest tube able to fit in stoma without force; cuffed for adult,for pediatric Sterile gloves • Hyperventilate with 100%02 Suction, if necessary. • Pass the ET tube and inflate the cuff.The tube will protrude several • Hold the tube and watch for chest rise with ventilation; secure the tube. Auscultate the lung fields. Check for subcutaneous emphysema. • Allow no longer than 30 seconds for the procedure. Special Considerations: • Avoid oral intubation if possible DO NOT USE DEMAND VALVE WITH BVM! Devices c.v.BiPap Machines Uses: • Obstructive Apnea • Respiratory Insufficiency Adverse Effects: • Chance of Pneumothorax • Mechanical failure • Disconnected tubing i,ml VI N A Southernmost Medical Transport, LLC COPCN Application • Misfit of facial/nasal mask • Drying of mouth/nasal passages Special Considerations: • Usually will not involve intervention by EMS- should be pre-set • If fails, may need to switch to CPAP or supplemental 02; contact MC Devices c.vi.lnvasive Cardiovascular Monitoring For use by EMT-Ps and RN's only Uses: • Usually used to monitor Cardiac Output • Used in ICU setting with ICU monitors- not for EMS use Complications: Arterial Line Pressure Monitor; • Hematomas • Distal ischemia/thrombosis Disconnection and hemorrhage Inadvertent drug injection Swan-Ganz catheter: • Arrythmias • Knotting and displacement Cardiac Valve trauma Pulmonary Artery Rupture Balloon Rupture • Catheter thrombosis or embolism Monitor components: Arterial Line Pressure Monitor: • Arterial cannula • Monitoring line • Transducer Monitoring system to N N Apoxv, Southernmost Medical Transport, LLC COPCN Application Swan-Ganz catheter: • Balloon tipped catheter through central vein;floated through right side of heart into pulmonary artery • Monitoring line • Transducer Monitoring System Special Considerations: • Require prolonged pressure if lines are pulled out Devices c.vii.lntracranial Pressure (ICP) Monitors .... Uses: • Measurement of Intracranial Pressure in ICU setting • May also be used to relieve pressure as well Adverse Effects: • Infection at skin site into brain • Dislodgement of catheter Special Considerations: • if pulls out- apply sterile dressing; may have CSF leaking from site _y 5 ct, N .p w � rerumi(flmuujy � „ w Southernmost Medical Transport, LLC COPCN Application Devices c.viii.lnsulin Pumps Uses: Computerized device delivering a steady dose of insulin (basal rate)through a flexible subcutaneous catheter Adverse Effects: • Hypoglycemia can occur Dosing: • Patient has a pre-set basal rate and pre-programmed corrections Special Considerations: • If hypoglycemic treat as per protocol • If seemingly in DKA(Diabetic Ketoacidosis), make sure the pump is working or the catheter is intact ® SHOULD NOT REQUIRE ANY DIRECT INTERVENTION BY TRANSPORTING CREW UNLESS. PATIENT BECOMES HYPOGLYCEMIC; IN THAT SCENARIO,TURN OFF THE PUMP Devices c.ix.Central Vascular Access Uses: • Specialty vascular access in patient with problematic access or requiring frequent infusion of medication or parenteral nutrition Adverse Effects: • Line infection can cause bactermia/sepsis • Complications can be related to insertion of line such as pneumothorax, hematomas, vascular rupture ct, N .p .p Southernmost Medical Transport, LLC COPCN Application Different Types: Triple Lumen Central Venous Catheter; • Can be in Femoral, Internal Jugular or Subclavian location • Usually red hub is for blood draws- it is typically the most certain line of the three ports. Indweliin ,Catheter • External Access(Broviac,Hickman,Groshung)catheters: o Usually placed in Subciavian region o Usually contains heparin; draw 10 mL waste before infusions • Implanted ports (Port-a-cath, Bard Port): o Require Huber needle to access • Shiley: Usually used for dialysis o Usually contains heparin; draw 10 rnL waste before infusions,then flush saline if needed in emergency situations • Peripherally Inserted Central Catheter(PICC) line: o Location usually in the anti-cubital regions o Usually contains heparin; draw 10 mL waste before infusions Special Considerations: STERILE TECHNIQUE is imperative! Only to be accessed m emergency situations b„ EMT,mP's or RN's to N P to emu, Southernmost Medical Transport, LLC COPCN Application IV. Pediatric Transfer Protocols a. Anticonvulsonts b. Continuous Albuterol Nebulization c. Insulin Drip d. IV Antibiotics v, N .p rn Southernmost Medical Transport, LLC ro "° m COPCN Application Pediatric Transfers d.i.Anticonvulsants Uses: Prevention and treatment of seizures Adverse Effects: • Ventricular dysrhythmias or hypotension if phenytoin given too rapidly • Respiratory depression, especially with benzodiazepines or phenobarbital • Subcutaneous extravasation may cause tissue necrosis Dosing: Phenytoin; • 10-20 mg/kg; IV piggy back in NS • Rate not to exceed 50 mg/min Propofol: • Loading dose: 3 mg/kg • Maintenance infusion:50 mcg/kg/min • May increase up to 250 mcg/kg/min Special Considerations: • Monitor heart rhythm • Use infusion pump • Check BP frequently; vital sign monitor if available D/C Infusion and contact MC for adverse reactions ct, N .p 4 Southernmost Medical Transport, LLC COPCN Application Pediatric Transfers d.ii.Continuous Albuterol Nebulization Uses: Treatment of status asthmaticus Adverse Effects: • Tachycardia • Nervousness, headache, shakiness • Nausea/vomiting • Hypokalemia Dosing: • 0.5 mg/kg/hour or otherwise directed by MC Special Considerations: • Need to use a special large volume nebulizer designed for continuous administration • Cardiac monitor • Should have IV running concurrently Pediatric Transfers d.iii.insulin Drip Uses: Lower blood glucose and treat diabetic ketoacidosis Adverse Effects: • Hypoglycemia (tachycardia, diaphoresis, mental status change, seizure) Hypokalemia (occurs as acidosis improves) V1 N W p� ��uw�y Southernmost Medical Transport, LLC xaremimi 4hrca pv/ VWd.d COPCN Application Dosing: • 0.05-0.1 units/kg/hour; may be varied depending on glucose response by patient Special Considerations: • Glucose must be checked every hour • If hypoglycemia occurs, D/C insulin drip and administer D25 (2-4 mL/kg) Pediatric Transfers d.iv.IV Antibiotics Uses: Treat infections and prophylaxis Adverse Effects: • Allergic signs and symptoms, including anaphylaxis Dosing: • Varies depending on antibiotic and patient weight/size • Generally given as a piggyback infusion • Rate should not require change en route Special Considerations: • D/C infusion if allergic signs and symptoms • Contact MC to N co OF M � Southernmost Medical Transport, LLC COPCN Application V. Special Situations a. The Hospice Patient b. The Pediatric Patient and Consent Issues c. The Psychiatric Patient d. The Therapeutically Cooled Patient v, N v, 0 Southernmost Medical Transport, L[C COPCNAppUcation Special Situations e.i.The Hospice Patient Introduction The Hospice patient presents a unique situation in regards to care and transport.These patients have often been deemed to be in the terminal stages of a disease process, for which treatment is no longer effective in reversing or arresting the progress of the disease, Care becomes focused on patient and family comfort, which often flies in the face of usual resuscitative care. What might be considered as an unstable patient might well be in line with the course as planned by the patient's caregivers. Family members are often torn between sticking with the recognized treatment plan versus emotion as they see their loved one approach their end. It is important to keep in mind that these patients do not have a situation that can be fixed. It is often up to us to gently encourage the family to adhere to the goal of patient comfort. The Hospice patient truly has needs that are not those of the usual prehospital patient and special considerations need to be made in the response of the prehospital provider. Assessment The assessment of the Hospice patient requires a redefinition of what is considered an "unstable' vital sign requiring action.A terminal patient might have either lower or higher parameters in temperature, heart rate, respiratory rate orblood pressure.The AB['n might also be altered. This is not unexpected. An important part of the assessment is evaluation of the DNR status. IF the patient or family do not have a copy of the DNR or MOLST form, Hospice staff is often able to fax a copy, orat least confirm the existence of the DNR status ifnecessary. Treobnent in general,the only measures that should be implemented are oxygen or stretcher positioning. Narcotic administration might be in order; however, medical control should be contacted if there are questions regarding administration. Typically, Hospice patients should not receive on IV or be placed on a cardiac monitor, unless there has been direction by Hospice to do so. Their medications are usually given orally, transcutaneous|y (e.g. opioid drug patch) or subcutaneously per Hospice. AR � M,re Southernmost Medical Transport, LLC 11 COPCN Application PoWwxmM Morphine may be given as per ALS Pain Protocol if this has been approved in the patient's Hospice care plan. Medical Direction The Hospice patient is still under Medical Control by a Base Station medical physician. However, since these patients are in a situation that is more similar to an "Interfacility Transport", input may be made by the Hospice physician.The patient's plan of care may be confirmed with them. Transport If the decision is made for the patient to be transported to the Hospice Inpatient Unit either for an acute intervention or for an inpatient bed, then there are considerations to be made. The destination of the patient should be as directed by Hospice.This might include direct transport to an inpatient unit at a hospital, bypassing the Emergency Dept. The medications that the patient is on should accompany the patient to the Hospice Inpatient Unit. However, if the patient is being brought to.a Hospice Unit in a hospital, family members should bring the medications (a list is adequate). In keeping with the goal of patient comfort, lights and sirens should not be used during transport. If the patient expires in the ambulance anytime during transport,the patient should be taken to the previously instructed facility. DO NOT take the patient back home. Special Situations e.ii.The Pediatric Patient and Consent Issues 1. Introduction Transport and treatment of a pediatric patient is met with unique issues.The pediatric patient is unable to give consent/refusal as they are a minor. Usually, the patient's parent or guardian will be available to give consent. However,there are times when either the legal guardian is not available or does not have legal ability to consent. The following is a review of situations where consent might be given by someone other than the child's legal guardian. The Emancipated Minor ct, N ct, N v Southernmost Medical Transport, LLC COPCN Application a minor is considered emancipated if the following events have occurred: • He or she is married. • He or she is in the armed services. • He or she has established a home and is financially independent. • His or her parent has failed to fulfill parental support obligations and the minor seeks emancipation. The CPS patient Occasionally a child presents with a picture of abuse or negligence, and the suspected perpetrator is the legal guardian. Mandated reporters must make a report to New York State Child Protective Services (CPS).After a preliminary investigation, CPS might decide to take custody of the child. There should be documentation of the CPS custody with the patient's chart.This will allow care of the child to proceed. The Guardian is Unavailable In situations where a child's guardian is unable to be reached or are incapacitated, administrative consent might be obtained.This can be confirmed with the transferring facility. Special Situations e.iii.The Therapeutically Cooled Patient 1. Introduction There has been a recent resurgence of therapeutic cooling used in patient care scenarios. These require maintenance of specific hypothermic target temperature.The current two most likely indications are those of the post cardiac arrest patient, the stroke patient and the traumatic brain or spinal cord injury patient. The theory behind therapeutic hypothermia is to decrease circulation of ischemic and injury mediators. Further, metabolism is decreased thus preventing further inflammatory response. The balance that must be maintained is to provide adequate coling to achieve the above but to avoid acidosis and damage from the hypothermia itself. Patients must be intubated and paralyzed to prevent shivering. The hypothermia is achieved by surface and internal cooling. Surface cooling is achieved with ice (applied at head, neck, axillae and groin), cooling blankets and/or heat exchange ct, N ct, w Southernmost Medical Transport, LLC 10 �A ,' wa � COPCN Application surface cooling devices. Internal cooling is achieved either by cooled fluids or by endovascular heat exchange catheters.These usually involve a femoral line placement. Clinical Uses of Therapeutic Hypothermia The Post Cardiac Arrest Patient In 2005 the American Heart Association offered guidelines regarding the use of hypothermia in unconscious patients with return of spontaneous circulation after out- of-hospital cardiac arrest. It is recommended that these patients be cooled to 32- 34C for 12-24 hours.The cooling should occur within 6 hours post cardiac arrest.They should have a systolic blood pressure of>90mm Hg. The Acute Stroke Patient There is evidence that hypothermia reduces the volume of infarct and may preserve brain tissue. However, a large study has yet to be done showing clear benefit. The Traumatic Brain Inury(TBI)Patient Mild therapeutic hypothermia has been shown to be effective in TBI with high intracranial pressure. These patients have better outcomes with longer hypothermia (5 days). The Traumatic Spinal Cord Injury(SCI)Patient There have not been large scale reviews or studies to demonstrate benefit of hypothermia with SCI. However, case reports suggest that there may in fact be some advantage in using hypothermia to treat patients with SCI. Transporting the Therapeutically Cooled Patient These patients are often critical and may require additional personnel. Not only must the cooling apparatus be kept in attention, but the patient must be carefully watched with frequent vital signs (every 10-15 minutes during transport). Consideration should be given for backup cooling alternatives should there be device failure. ct, N ct, .p �uh u Southernmost Medical Transport, LLC rcnuwuu l lmuuu ma in)cC`tidrc COPCN Application Vl. Glossary and Abbreviations AILS Provider Includes EMT-1 and EMT-P (Advanced Life Support Provider) BiPAP Bi-phasic Positive Airway Pressure BP Blood Pressure BVM Bag-Valve Mask CHF Congestive Heart Failure CNS Central Nervous System COPD Chronic Obstructive Pulmonary Disease CPAP Continuous Positive Airway Pressure D/C Discontinue DKA Diabetic Ketoacidosis DNR Do Not Resuscitate EMT D(Emergency An individual trained to perform patient assessment, handle Medical Technician- emergencies using Basic Life Support equipment, perform CPR, Defibrillation) control hemorrhage, provide non-invasive shock treatment,fracture and spinal stabilization, manage environmental emergencies, emergency childbirth and use a defibrillator. EMT P(Emergency An individual trained to perform all EMT-I skills and utilization of Medical Technician- equipment. In addition, is able to perform under Advanced Cardiac Paramedic) Life Support (ACLS) and Advanced Trauma Life Support Standards (ATLS), is knowledgeable and competent in the'use of cardiac monitor/defibrillator, IV drugs and fluids.The EMT-P has reached the highest level of pre-hospital certification. EPS (Extrapyramidal Avariety of motor and sensory nervous system disorders related to Symptoms) medications or disease processes. ETA Estimated Time of Arrival ETtube Endotracheal tube FB Foreign Body 01 to N to to n qqA 'f� Southernmost Medical Transport, LLC uWapWW9Ntltl�'IIYNV COPCN Application GI Gastrointestinal H/O History of HR Heart R rate Huber needle A needle designed to access an indwelling vascular port. It has a ninety-degree bend. IM Intramuscular IV Intravenous JVD Jugular Venous Distention KVO Keep Vein Open; usually indicates an IV rate of 20-60mL/hour Large Bore 1V 14 or 16 gauge IV Loading dose Initial amount of medication required to establish a therapeutic effect LR Lactated Ringers Solution MC(Medical Control 1. A physician (Medical Director or designee) responsible for the care or Medical of a patient who is being served by an EMS provider. 2. (aka Medical Command) direction)The process of providing responsibility for the care of a patient who is being served by an EMS provider. MCO Medical Control Option Medical Director The physician who has authority and responsibility over all clinical and patient care aspects of the EMS provider.This includes responsibility for off-line MC Methemoglobinemia a condition where the hemoglobin is altered in a way which decreases its ability to carry and release oxygen to tissues milligram milligram MI Myocardial Infarction mL milliliter NS Normal Saline; usually refers to 0.9 normal saline OD Overdose to N to rn Ai 1 Southernmost Medical Transport, LLC COPCN Application Off-line Medical Provision of care in accordance with patient care protocols developed Control and promulgated by physicians.This also includes training,testing, certifications, continuing education, operational policy and procedures development and continuous quality improvement. On-line Medical Provision of care via direct voice communication with a physician Control PO Orally PRN Ass needed PVC Premature ventricular contraction Q Every SL Sublingual SQ Subcutaneous Standing Orders Treatment algorithms for the AILS provider to follow prior to contacting MC Status Epilepticus Ongoing seizure activity or a series of seizures with separation of less than or equal to one hour Syst Systolic TID Three times per day VS Vital signs ct, N ct, 4 Southernmost Medical Transport, LLC Ape COPCN Application Appendix H: Compliance with Federal Law FCC Requirements As described in our brief, per FCC Form 605 requirements (Federal Communications Commission Public Safety and Homeland Security Bureau Radio Station Authorization),SMT must submit its approved COPCN in order to obtain its FCC license(s). Excerpt of application- "ADVANCED/BASIC LIFE SUPPORT SERVICE LICENSE APPLICATION INSTRUCTIONS: The items listed below are required for a complete application. Please use this list of instructions to ensure the application is complete before mailing. A complete application will greatly reduce the processing time. Your application must be received in this office 30 days before you wish to start a new service or renew your current license. Type of Application:Mark all the appropriate lines. Number One:The name of the service that is placed on line 1 must be identical to the name listed on your Certificate of Public Convenience and Necessity (COPCN). All the rest of the lines need to be filled out appropriately. Include your internet e-mail address if you have one. The manager's name should be the person who would receive all correspondence from this office. Under the Type of Ownership, check ALL of the items that apply to your service." to fv to 00 11 m K '41,,1 if,puo)x'�,(' Southernmost Medical Transport, LLC tlnC Vg 1f d;a I�U�WJa COPCN Application Appendix I: Compliance with Florida Law As described in our brief,to obtain Advanced Life Support Service License from the State of Florida Department of Health Bureau of Emergency Medical Oversight (Chapter 401, 64J-1 FAC), the COPCN must be issued by the County prior to submitting this application. Below is SMT's Medical Director ALS DOH license, as per Florida DOH application requirements. �0� gNtlu mirs, uiwuunr Morin O V 14 m o, ff Wo � 1� fNo r l an t ��91r�4pw�I(fr' ��fr 6540 COLLEGE ROAD A LmJn W( P"A"O my T NMI,rtis l i/i i� ii IV / / d 107ifya NYi i�ly /J From Department of Health Form: dh-form-631, Number Seven, Item 1: "Attachment 1: A COPCN is required for each county in which you operate. If you change a county throughout the year, the changes must be submitted to the department pursuant to Chapter 401.25, F.S. See full application instructions below. ADVANCED/BASIC LIFE SUPPORT SERVICE LICENSE APPLICATION INSTRUCTIONS The items listed below are required for a complete application. Please use this list of instructions to ensure the application is complete before mailing. A complete application will greatly reduce the processing time. Your application must be received in this office 30 days before you wish to start a new service or renew your current license. Type of Application: Mark all the appropriate lines. v, N v, to Southernmost Medical Transport, LLC Hu :�. r , COPCN Application Number one: The name of the service that is placed on line 1 must be identical to the name listed on your Certificate of Public Convenience and Necessity (COPCN).All the rest of the lines need to be filled out appropriately. Include your internet e-mail address if you have one. The manager's name should be the person who would receive all correspondence from this office. Under the Type of Ownership, check ALL of the items that apply to your service. Number Two:All the blanks need to be filled in. If you have more than one medical director include the same information for each one on a separate sheet of paper. Number Three: Fill in as requested or if it does not apply put NIA. Number Four: List the address of your base station (headquarters) and all substations, including the substation identifier (e.g. station 2). Number Five: List all counties in which you have a COPCN, or mutual aid agreement. Number Six: List the type of communication between your vehicle and the hospital. Med 8 is required pursuant to the EMS communications plan established in Chapter 401 part 1, Florida Statutes. Number Seven: Attachment 1: A COPCN is required for each county in which you operate. If you change a county throughout the year, the changes must be submitted to the department pursuant to Chapter 401.25, F.S. Attachment 2: The permit application, DH Form 1510, needs to be filled out and signed. If you have a computer-generated list of vehicles, you may just put "see attached" on Form 1510, sign the form and attach your list. Permit applications must be received by the department 30 days prior to change, as required on DH Form 1510, which is incorporated in Chapter 64J-1.002(1), Florida Administrative Code. Attachment 3: Insurance verification: A copy of an insurance policy, a self-insurance policy or certificate of insurance is acceptable. Documentation must include a schedule of vehicles covered, if the policy is not blanket coverage or self-insurance. Limits of vehicle liability and property damage coverage and expiration date must be shown. Minimum limits — Bodily injury $100,0001$300,000 and property damage $50,000 for non-government owned services. Bodily injury and property damage for government services is $200,000 total. Attachment 4: Trauma Transport Protocols expire at the same time as your license. If there have been no changes, a signed statement from your medical director to that effect is acceptable. If they are uniform for the entire county a signed statement from your medical DH 631 04/09 1 Incorporated by reference 647-1.002,1~.A.c.director to that effect is acceptable. Otherwise, there are directions and forms included in this package. a.0 2 v, N rn 0 Southernmost Medical Transport, LLC ill' ip/rl Cr!N(`G;,mP 1aG'1�Jrfr l��y�' COPCN Application Attachment 5: A copy of a fully executed contract between a Florida licensed physician and the applicant or a letter of agreement signed by the physician and the other party must be included, Attachment 6: The medical director must be a Florida license physician.A copy of his/ her current license from the department must be included. Attachment 7: AILS providers must also include a copy of the U.S. Department of Justice, Drug Enforcement Administration Certificate issued to the physician or hospital pharmacy (if hospital based) listing the address at which the applicant stores controlled substances. v, N rn ,m,n Southernmost Medical Transport, LLC COPCN Application Appendix J: Compliance with Monroe County Code Monroe County Business Tax Receipt As described in our brief, in order to obtain a Monroe County Business Tax Receipt for our services, SMT must receive a State of Florida Department of Health (DOH)license in order to obtain the Monroe County Business Tax Receipt. As stated above, COPCN must be approved by Board prior to submitting final application to Florida DOH. Relevant excerpt from the application instructions: "ADVANCED/BASIC LIFE SUPPORT SERVICE LICENSE APPLICATION INSTRUCTIONS The items listed below are required for a complete application. Please use this list of instructions to ensure the application is complete before mailing. A complete application will greatly reduce the processing time. Your application must be received in this office 30 days before you wish to start a new service or renew your current license. Type of Application: Mark all the appropriate lines. Number One:The name of the service that is placed on line 1 must be identical to the name listed on your Certificate of Public Convenience and Necessity (COPCN). All the rest of the lines need to be filled out appropriately. Include your internet e-mail address if you have one. The manager's name should be the person who would receive all correspondence from this office. Under the Type of Ownership, check ALL of the items that apply to your service. v, N rn N Southernmost Medical Transport, LLC COPCN Application 7. Attach the following: Attachment#1 Certificate of Public Convenience and Necessity(for each county in which you operate). Attachment#2 Application for ambulance permit(s) DH Form 1510(multiple vehicle permit application). Attachment#3 Insurance verification-copy of insurance policy,certificate of insurance or certificate of self-insurance showing limits of auto liability coverage and expiration.date. Must also list schedule of vehicles covered if not blanket coverage or self insured. Attachment#4 Trauma Transport Protocols signed by the current Medical Director. Monroe County Fire Rescue Department Inspection The Monroe County Fire Rescue Department shall perform a life safety inspection of the business location placed on the application prior to the beginning of operations within Monroe County.As described in our brief, this inspection occurs after the Board approves the COPCN. Monroe County Audit An audit to be provided to the county administrator by an independent certified public accountant of the annual operating statistics and accounts and records of the service involved, said audit to be done annually to coincide with the end of the business year of the service.See email below, explaining that the audit is not required at this point(it occurs at the end of the first year of operations). i' to N w � Southernmost Medical Transport, LLC IV muwnullJ uumu®V JJyy COPCN Application Temborakf-Cheri-1.Txt.ofy.djjjIiCV" u9 > Fri,Dec 8,2023 at 2:07 PM To:Paula Turner Cc:Johnson-Cara Good afternoon Paula, Happy Friday! n o„ WO""" x v it 1'r,r�` INadlbi^)Nl iV V�� v Eft'Please email your completed application to us as soon as your Insurance is In order. We will also need you to either drop off the original notarized package or overnight it to us. With the upcoming holidays and out of office schedules,we are quk*ly corning up on the agenda cutoff for January. Once you submit your application and we've had a chance to review it to make sure everything Is In order and check the nempaper publication dates for the required public notice,I will advise as to whether your COPCN application Will be heard at the January or February BOCC. Thanks, Cheri Cheri Tamborski Executive Administrator Monroe County Fire Rescue 490 6P Street,Ocean,Suite 140 Marathon,FL 33050 305-289-6088(Office) tJt N d7 P Southernmost Medical Transport, LLC COPCN Application Appendix K: Compliance with the City of Key West Business Tax Receipt CITY OF KEY WEST, FLORIDA Business Tax Receipt This Document is a business tax receipt Holder must meet all City zoning and use provisions. P.O.Box 1409,Key West,Florida 33040(305)809-3955 Business Name SOUTHERNMOST MEDICAL TRANSPORT LLC Location Addr 1608 JAMAICA DR Lic NBRIClass LIC2024- TRANSPORTATION SERVICES 000286 Issued Date Expiration Date: TRANSPORTATION VEHICLE Comments: -EMERGENCY MEDICAL TRANSPORT Restrictions: MOBILE SERVICE SOUTHERNMOST MEDICAL This document must be prominently displayed. TRANSPORT LLC CIO PAULA TURNER SOUTHERNMOST MEDICAL 1608 JAMAICA DR TRANSPORT LLC KEY WEST,FL 33040 tJt IV to tJ1 Southernmost Medical Transport, LLC COPCN Application Appendix M. SMT Dispatch Process Southernmost Medical Transport takes pride regarding how we set up our new dispatch and communications process. Our objective is to ensure patient safety first and foremost, provide all necessary care using our trained local staff, and provide friendly and professional dispatch and call services. Board approval of the COPCN is required for us to receive our Federal Communications Commission private FCC frequencies. SMT has received its FRN##: 0034537969. SMT has also established our call numbers, number of portables (2) and number of mobiles (2). Upon Board approval of the COPCN, FCC will issue SMT the necessary frequency to support dispatching and communications. v, N rn rn CITY OF MARATHON, FLORIDA 9805 Overseas Highway, Marathon, Florida 33050 Phone: (305)743-0033 POO r VIA EMAIL AND U.S. MAIL July 1, 2024 Monroe County Board of County Commissioners 530 Whitehead Street Key West, Florida 33040 RE: July 17, 2024; PEAK Item 2023-2637 (Item Title: "A public hearing to consider an application for issuance of a Class A Certificate of COPCN to Southernmost Medical Transport, LLC. for the operation of an ALS and BLS Transport Service in Monroe County, Florida, except for within the city limits of Marathon, for the period 07/18/2024 through 07/17/2026 for responding to requests for inter-facility transport. Southernmost Medical Transport is not permitted to perform 911 emergency response work in Monroe County." I am writing on behalf of the City of Marathon regarding Southernmost Medical Transport LLC and their COPCN application which will be a topic at the July 17, 2024, County Commission meeting. The agenda item regards an application for issuance of a Class A Certificate of Public Convenience and Necessity (COPCN)for Southernmost Medical Transport LLC. This application proposes such services within the City of Marathon. Section 11-173(d)(2) of the Monroe County Code, which addresses such matters, provides in relevant part: "The board will consider the public's convenience and the necessity for the service in the zone or area requested and whether the applicant has the ability to provide the necessary service. The board will consider recommendations from municipalities within the applicant's requested service zone or area." The City has reviewed the application and recommends that the Commission the application based on the first two criteria listed in Section 11-173(d)(2): the public's convenience and necessity for the service in the zone or area requested. 1. The Public's Convenience Granting this application does not make things more convenient for the public. To the contrary, there is the potential for the public's convenience to be negatively impacted. 5267 CITY OF MARATHON, FLORIDA 9805 Overseas Highway, Marathon, Florida 33050 Phone: (305)743-0033 POO r In the past when other companies were granted the ability to provide services to our City they would cause our fire department to scale down in size, only to have to expand when they were unable to provide the service for multiple reasons, including but not limited to: personnel, cost of running the service in the Keys, etc. Our Fire Chief has been with the city for over 13 years and has seen this happen twice. Our Fire Chief is responsible for providing the citizens and visitors of Marathon with the highest level of medical care from home to hospital, hospital to hospital, and scene to Trauma Star if required. Because the City provides all the above services, our Fire Chief can ensure that our equipment, personnel, and system meet these high standards and provide the required services to anyone who needs it. I. Necessity for the Service There is no need for these additional companies, as the current providers in Monroe County are more than adequate for the number of emergencies that we have. Our Fire Chief has spoken to Fishermen's Hospital and asked if they requested additional services. They responded that they had not. We did not ask or require any additional assistance for our services. Thus, we do not know of any reason why there is the need for additional services. Based upon the above, it is the City of Marathon's recommendation, in accordance with Section 11-173(d)(2) of the Monroe County Code, that the COPCN application for Southernmost Medical Transport LLC only be approved provided the COPCN excludes the city limits of Marathon in the description for the service area. Respectfully, Steve Williams City Attorney Copy: Marathon City Council George Garrett, City Manager John Johnson, Fire Chief Kevin Wilson, Acting Monroe County Administrator Bob Shillinger, Monroe County Attorney James Callahan, Monroe County Fire Chief/Emergency Services Division Director 5268 CITY OF MARATHON, FLORIDA 9805 Overseas Highway, Marathon, Florida 33050 Phone: (305)743-0033 POO r 5269