The URL can be used to link to this page

Home My WebLink AboutItem C27 C27 BOARD OF COUNTY COMMISSIONERS COUNTY of MONROE Mayor James K.Scholl,District 3 The Florida Keys Mayor Pro Tern Michelle Lincoln,District 2 Craig Cates,District 1 David Rice,District 4 Holly Merrill Raschein,District 5 Board of County Commissioners Meeting February 19, 2025 Agenda Item Number: C27 2023-3625 BULK ITEM: Yes DEPARTMENT: Fire Rescue TIME APPROXIMATE: STAFF CONTACT: R.L. Colina N/A AGENDA ITEM WORDING: Approval for renewal of a Class A Certificate of Public Convenience and Necessity (COPCN) to E Care Ambulance Inc. The renewal COPCN is for the operation of an ALS Transport Service in Monroe County, Florida, excluding the City of Marathon, for the period March 18, 2023 through March 17, 2025 for responding to requests for inter-facility transports only. E Care Ambulance Inc. is not authorized to perform 911 scene response work within Monroe County. ITEM BACKGROUND: The existing Class A COPCN certificate for E Care Ambulance Inc. will be expiring on March 17, 2025. In view of the foregoing, E Care Ambulance Inc. is applying to renew this Class A COPCN for the period March 18, 2025 through March 17, 2027. PREVIOUS RELEVANT BOCC ACTION: On March 15, 2023, the BOCC approved an application for a new Class A COPCN to E Care Ambulance Inc. for the operation of an ALS transport ambulance service for the period March 18, 2023 through March 17, 2025. On March 17, 2021, the BOCC approved an application for a new Class A COPCN to E Care Ambulance Inc. for the operation of an ALS transport ambulance service for the period March 18, 2021 through March 17, 2023. INSURANCE REQUIRED: Yes CONTRACT/AGREEMENT CHANGES: 1250 None STAFF RECOMMENDATION: Approve DOCUMENTATION: COPCN ApplicationClassA 2025 Received 01.30.2025 V2—Redacted PEAK Version.pdf E-Care—COPCN—Renewal_Expires_03.17.2027(LegaI Stamped).pdf 2025 02 C01 GL MED exp 4.16.25 ALIT' exp 10.12.25 signed.pdf FINANCIAL IMPACT: N/A 1251 MONROE COUNTY, FLORIDA APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) CLASS A EMERGENCY MEDICAL SERVICE (PRINT OR TYPE) ❑ INITIAL APPLICATION-$950.00 ■❑ RENEWAL APPLICATION-$475.00 IF RENEWAL,PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE: # 23-01 1. NAME OF SERVICE E Care Ambulance Inc. BUSINESS MAILING ADDRESS 91551 Overseas Hwy Tavernier FL 33070 BUSINESS PHONE NUMBER 800 863 7023 EMERGENCY PHONE NUMBER 8008637023 2. TYPE OF OWNERSHIP (i.e.,Sole Proprietor,Partnership,Corporation,etc.) Corporation DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION 05/05/2020 3. LIST ALL OFFICERS,DIRECTORS,AND SHAREHOLDERS (Use separate sheet if necessary): NAME AGE I ADDRESS TELEPHONE# POSITION/TITLE Daer Serrano 36 15700 Rolling Meadows Cir Wellington FL 33414 7024165853 CEO 4. LEVEL OF CARE TO BE PROVIDED: ■❑BLS or ■❑ALS IF ALS: ■❑ TRANSPORT or❑ NON TRANSPORT 5. DESCRIBE THE ZONES(S) THAT YOUR SERVICE DESIRES TO SERVE(Use separate sheet if necessary): All Monroe County except City of Marathon 6. LIST THE ADDRESS AND/OR DESCRIBE THE LOCATION OF YOUR BASE STATION AND ALL SUB- STATIONS(Use separate sheet if necessary): BASE STATION 91551 Overseas Hwy Tavernier FL 33070 SUB-STATION 21460 Overseas Highway Unit # 6, Cudjoe Key, FL 33042 Page 1 of 6 1252 7. DESCRIBE YOUR COMMUNICATION SYSTEM(Attach copy of all FCC licenses): FREQUENCIES CALL NUMBERS #OF MOBILES #OF PORTABLES Cell Phones 800 863 7023 Radios Ecare 101 to 104, Ecare Dispatch Ecare CEO 6 6 8. LIST THE NAMES AND ADDRESSES OF THREE (3)U.S. CITIZENS WHO WILL ACT AS REFERENCES FOR YOUR SERVICE: NAME ADDRESS Elmer Loaiza [Baptist] [FL] 786-527-9820 Pedro L. Marin [Ocean Reef Fire Rescue] 786-256-5421 Christina Maple [Crystal Health & Rehab] [FL] 305-853-0799 9. ATTACH A SCHEDULE OF RATES WHICH YOUR SERVICE WILL CHARGE DURING THE COPCN PERIOD. 10. PROVIDE VERIFICATION OF ADEQUATE INSURANCE COVERAGE DURING THE COPCN PERIOD. 11. ATTACH A COPY OF YOUR SERVICE'S CONTRACT WITH A MEDICAL DIRECTOR. 12. ATTACH A COPY OF ALL STANDING ORDERS AS ISSUED BY YOUR MEDICAL DIRECTOR. 13. ATTACH A CHECK OR MONEY ORDER IN THE APPROPRIATE AMOUNT,MADE PAYABLE TO THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. I,THE UNDERSIGNED REPRESENTATIVE OF THE ABOVE NAMED SERVICE,DO HEREBY ATTEST MY SERVICE MEETS ALL OF THE REQUIREMENTS FOR OPERATION OF AN EMERGENCY MEDICAL SERVICE IN MONROE COUNTY AND THE STATE OF FLORIDA. I FURTHER ATTEST THAT ALL THE INFORMATION CONTAINED IN THIS AP CA ION, O THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. SIGNATURE LICANT/AUTHORIZED REPRESENTATIVE Notary P ubbic Stew of Norlds MiGhsweB ArguCifea. my Cammi tore mH 5B3n* NOTARY SEAL Exir�ia 114p✓i$fl ^ 01/24/2025 NOTARY SIGNATITAW DATE e Page 2 of 6 1253 PERSONNEL—PARAMEDICS NAME PARAMEDIC CERTIFICATION First,Middle,Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE Acosta Jesus PMD-542159 12/1/2026 Dudamel Rafael A PMD-521228 12/1/2026 Escobar Sebastian A PMD-541640 12/1/2026 Fuentes Brando A PMD-542608 12/1/2026 Gutierrez Jason J PMD-537051 12/1/2026 Hoffman Astrid PMD-546042 12/1/2026 Jamarillo William PMD-529075 12/1/2026 Lacayo Manuel A PMD-544762 12/1/2026 Medina Andrew J PMD-545707 12/1/2026 Miranda Edgard A PMD-206162 12/1/2026 Page 3 of 6 1254 PERSONNEL—EMERGENCY MEDICAL TECHNICIANS NAME EMT CERTIFICATION First,Middle,Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE Hernandez Dominic A EMT-3588796 12/1/2026 Maple Kadeja C EMT-3489797 12/1/2026 Martinez Orlando EMT-550153 12/1/2026 Ramos Andres M EMT-578559 12/1/2026 Rodriguez Edixson EMT-584385 12/1/2026 Sao-Pagan Michael A EMT-572091 12/1/2026 Valledor Campano Jesus EMT-554122 12/1/2026 Abraham Jonathan EMT-578169 12/1/2026 Aguilar Angel L EMT-580717 12/1/2026 Cordova Luis A EMT-580245 12/1/2026 Page 4 of 6 1255 cfl wLo o N A w IC z o w , 5 q w a V w z x H H ° o 0 w A z z x a w w A A wa A aw 0-0 � Aa a ao ° w o � N � o � N ww o � � w x H � a oA w � Nz w -� o x , w w x ti N a a U a p O O O 0 a Ho z J J J J J c W � Cn Cn Cn Cn Cn w U ~�" dN M Nt dco M' w op J J W L Z Z Z Lo 0 o H 3 V. Y LL LL LL Z U N N N M a L U U U LL p m m m Q LL o o T- ppW O o ti LO � LO 00 0) N N a s w O O O O O J J J Uj 0 p > > > U W LL LU LU LU W w U U U 75 w a zw W W W W Monroe County Published Fee Schedule HCPCS Description Rate Code Ambulance Mileage $ 17.00 A0425 Basic Life Support $ 600.00 A0428 Basic Life Support, Immediate Response $ 600.00 A0429 Advanced Life Support $ 800.00 A0426 Advanced Life Support, Immediate Response $ 863.53 A0427 ALS 2 $ 988.38 A0433 CCT& SCT $ 1,849.05 A0434 Non-Medical Stretcher Response $ 175.00 Non-Medical Stretcher Rate Per Mile $ 9.00 Non-Medical Wheelchair Response $ 100.00 Non-Medical Wheelchair Rate Per Mile $ 5.00 BLS ALS Waiting Time each 1/2 hour $ 110.00 $150.00 Oxygen $ 32.55 1258 DATE(MM/DD/YYYY) ACCOR" CERTIFICATE OF LIABILITY INSURANCE 01/19/2025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Roddrelle Sykes Risk Management&Compliance LLC DBA Risk Assist Plus a/c°NN Ext: (945)214-9411 A//C,No): 9355 John W Elliott Dr aooRless: rs kes nemtex ert.com Suite#25460 INSURER(S)AFFORDING COVERAGE NAIC# Frisco,TX 75035 INSURERA: Hudson Insurance Company 25054 INSURED INSURER B: Tokio Marine 10945 E CARE AMBULANCE INC. INSURER C: 91551 Overseas Hwy, INSURER D 7 Tavernier, FL 33070 INSURER E 7 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MMIDD/YYY MMIDD/YYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 CLAIMS-MADE IX I PREMISES OCCUR DAMAGETOEaRENTEDo ccurrence $100,000 MED EXP(Any one person) $5,000 B X H24MSS2269600 04/16/2024 04/16/2025 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $3,000,000 POLICY❑ PRO ❑ JECT LOC PRODUCTS-COMP/OPAGG $1,000,000 X OTHER: SAM $1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ A X OWNED SCHEDULED X HST-000733-00 10/12/2024 10/12/2025 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Each Claim $1,000,000 B PROFESSIONAL LIABILITY X H24MSS2269600 04/16/2024 04/16/2025 Aggregate Limit $3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Monroe County is listed as Additional Insured with regard to Commercial General and Auto Liability policies per written contract. General Liability includes contractual liabilities and sexual abuse and molestation. Waiver of Subrogation also applies for Citrus County. Comp/Coll$2600 CERTIFICATE HOLDER CANCELLATION Monroe County Florida SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 490 63 rd street Ocean THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Marathon FL 33050 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1259 0 W N ME-CARE AMBULANCE MEDICAL DIRECTOR AGREEMENT_ THIS AGREEMENT executed on ! I D1 pad but agreed to take effect starting on: I 1 v 1 , by and between E CARE AMBULANCE INC. (hereinafter"Company"), and EMY G, PLLC who is represented by Dr.Julio M De Pena thereinafter"Medical Director"). NOW, THEREFORE, FOR AND IN CONSIDERATION of the mutual promises and agreements contained herein, Company hires Medical Director, and Medical Director agrees to work for Company under the terms and conditions hereby agreed upon by the parties: DEFINITIONS • "Department" means the Department of Health, Bureau of EMS. • "Emergency medical technician" or"EMT" means a person who is certified by the Department to perform basic life support. • "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. • "Paramedic" means a person who is certified by the Department to perform basic and advanced life support • "Physician" means a practitioner who is licensed under the provisions of Chapter 458 and Chapter 459, Florida Statutes. • "Operations Chief means the highest-ranking Paramedic in charge of the Company's medical transport services. SECTIO 1 -WO _ TO BE ER ORMED 1.1 Term. Company agrees to hire Medical Director, at will, for a term commencing on I 1 101 L aoas and continuing unttl terminated in accordance with Section 4. 1.2 Duties Medical Director agrees to perform work for the Company on the terms and conditions set forth in this agreement and agrees to devote all necessary Page 1 of 11 cfl N time and attention (reasonable periods of illness accepted)to the performance of 1 the duties specified in this agreement. Medical Director's duties shall be as follows: • Ordering Medicines, providing medicines on a timely basis, supervising the use of medications, provide all necessary and required medical director duties including but not limited to participating in inspections, training and certifying employees, being available for any questions or variances requested by vendors, workers, client, etc. • Under the direction of Company: Director of Operations and as defined in Florida Administrative Code Chapter 641-1.004 for medical transport only, the medical director shall provide a qualified-physician-to-serve-us Medical Director for the Company's Emergency Medical Transport Services Program as more particularly set forth herein. • 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 health of the patient. • Medical Director will be available "of--line" to resolve administrative problems, system conflicts, and provide services in an emergency as that ten is defined by Section 252.34(3), FLORIDA Statutes Such "off-line" services will be provided at a rate of per hour or at a rate mutually agreed upon by the Medical Director and the Compay's Chief of Operations. 1- Page 2 of 11 ... __. N W N • Develop and implement a transport patient care quality assurance program to assess the medical performance of the Company's Paramedics and EMT'S Clerical and administrative support will be provided by the Company. • Audit the performance of Company 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. • Provide a DEA registration for the Company in order to provide equipment, medications. including controlled substances to Company, if needed DEA registration shall include the address at which controlled substances are stored. Proof of such registration shall be maintained on file with Company and shall be readily available for inspection. • Company will forward any and all renewal documents and correspondence received regarding the DEA to Medical Director to assure continuous registration and will pay for the cost of the DEA certificate or reimburse Medical Director for cost of such registration. • Review Company security procedures for medications, Fluids and controlled substances to insure they are in compliance with Chapters 499 and 893, Florida Statutes, and Chapter 647-13, Florida Administrative Code. • Assist and coordinate, with the Operations Chief, 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 Company certified personnel in accordance with State and Federal regulations. Page 3 of it M tG N • Notify the Department of Health in writing, when applicable, of each substitution by the Company of equipment or medication. • Review and approve training for EMT/Paramedic continuous education training and/or refresher courses for the purpose of EMT re-certification. • Assume responsibility for the use by an EMT/P of an automatic or semiautomatic defibrillator, the performance of esophageal intubation by an EMT/P; and the monitoring and maintenance of non-medicated Is by an EMT/P, as well as the use of epinephrine for allergic reactions,when necessary. • Advise and implement a plan for prompt medical review of possible infectious exposures reported to the Operations Chief and provide medical follow-up when indicated, in compliance with State and Federal requirements medical follow-up care to Company employees will be billed at • Medical Director shall not provide any services unless requested by Company and Medical Director shall send invoices no later than 30 days after services rendered. Medical Director further agrees that in all such aspects of such work, Medical Director shall comply with the policies, standards, and regulations of the Company from time to time established and shall perform the duties assigned faithfully, intelligently, to the best of his/her/their ability, and in the best interest of the Company. • In accordance with Section 401 265. Florida Statutes, and Rule 64.1-2.004, Florida Administrative Code, the Medical Director shall possess and maintain through the term of this Agreement a Florida license to practice medicine. • The Medical Director may designate an alternate Medical Director, when needed who shall be available in the absence of the Medical Director. The Alternate Page 4 of 11 d cfl N Medical Director will have an understanding of ALS and BLS medical transports and report to the Director of Operations and must be approved by the Company. The Medical Director 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. • Medical Director agrees to comply with all applicable laws, rules and regulations, etc. Ownership of DocumentsfDeliverables. All files, data, documents, files, studies, transport report reviews, training curriculum and other data prepared by the Medical Director, in connection with this Agreement are and shall remain the property of The Company, and shall be delivered to the Company, upon request, no later than sixty (60)days after termination of this Agreement. 1.3 Comapny Dutues: The Company: shall assist the Medical Director by placing at its disposal all available information pertinent to the services to be performed by the Medical Director, including access to all EMT/P and EMTs employment records and patient medical transport records. The Company will also provide Medical Director appropriate administrative support including secretarial support services and other equipment as may be needed from time to time to provide oversight to EMT/P and: EMTs. The Company will comply with FL. Chapter 64J-1 in all aspects related the performance of medical transport operations. SECTION 2—COMPLIANCE Page 5 of 11 W) W N 2.1 SERVICES PROVIDED: Medical Director agrees to perform in a professional manner and to the best of Medical Director's abilities. 2.2 Medical Director will use their own resources such as supplies, equipment, tools, and materials to complete services, unless necessity requires the use of Client's resources and premises and those requirements are limited to the use of items required to perform Medical Director's duties, such as speaking to patients, employees, billing, etc. 2.3 Medical Director shall perform his obligations hereunder in compliance with the terms of this Agreement and any and all applicable laws and regulations. COMPLIANCE WITH LAW Medical Director agrees to comply with governing laws and regulations, including but not limited to, any and all requirements of the State of Florida, Department of Health, etc. Medical Director agrees to provide Client with a Background Check and Local Law Check. 2.4 Indemnification — Medical Director agrees to indemnify Client for any claims brought against the Client in regards to the performance of Medical Director duties, including but not limited to claims for negligence, fraud, unpaid taxes, killing, etc. 2.5 This agreement does not in any way create any type of partnership, association, joint venture, or other business relationship. Nothing in this Agreement shall be construed to give Medical Director any authority (i)to represent that such person is an owner, partner, principal of Client, (ii)to bind Client with respect to contracts or representations or any other matters, or (iii) to represent Client before any court or government or regulatory authority without the express written authorization of Client. Page 6of11 cfl cfl N 2.6 Medical Director agrees to maintain all licenses plus insurance policies and coverage required to perform Medical Director's duties and to indemnify Company fully for all claims that my brought due to Medical Director's duties. SECTION 3 -COMPENSATION 3.1 Compensation. In consideration of all services to be rendered by Medical Director to the Company, the Company shall pay to the Medical Director the sum Of , paid bi-weekly per 12-month period. 3.2 Withholding: Other Benefits. Compensation paid pursuant to this Agreement shall not subject to the customary withholding of income taxes and other employment taxes. Medical Director shall be solely responsible for reporting and paying any such taxes. The Company shall not provide Medical Director with any coverage or participation in the Company's accident and health insurance, life insurance, disability income insurance, medical expense reimbursement, wage continuation plans, or other fringe benefits provided to regular employees. 3.3 Expenses. Company shall reimburse Medical Director all reasonable and necessary expenses incurred by Medical Director in connection with the performance of his duties hereunder, provided, the President or Managing Director of the Company has approved such expenses in advance in writing. SECTION 4 -TERMINATION 4.1 Termination at Wall. This Agreement may be terminated by the Company immediately, at will, and in the sole discretion of the President of the Company. Medical Director may terminate this Agreement upon fourteen twenty-five (25) days written notice to the Company. This Agreement also may be terminated at Page 7 of 11 ti cfl N any time upon the mutual written agreement of the Company and Medical Director. 4.2 Death. In the event Medical Director dies during the term of this Agreement, this Agreement shall terminate, and the Company shall pay to Medical Director's estate the salary which would otherwise be payable to Medical Director. SECTION S-INDEPF.NDEN,I CONSULTING STATUS Medical Director acknowledges that he is an independent contractor and is not an agent, partner,joint venturer nor employee of Company. Medical Director shall have no authority to bind or otherwise obligate Company in any manner nor shall Medical Director represent to anyone that it has a right to do so. Medical Director further agrees that in the event that the Company suffers any loss or damage as a result of a violation of this provision Medical Director shall indemnify and hold harmless the Company from any such loss or damage. SECTION s _ REPRESENTATIONS OF WARRANTIES OF MEDICAL DIRECTOR Medical Director represents and warrants to the Company that there is no employment contract or other contractual obligation to which Medical Director is subject, which prevents Medical Director from entering into this Agreement or from performing fully Medical Director's duties under this Agreement. SECTION 7 ^MISCELLANEOUS PROVISIONS 7.1 The provisions of this Agreement shall be binding upon and inured to the benefit of the heirs, personal representatives, successors, and assigns of the parties. Any provision hereof which imposes upon Medical Director or Company an obligation after termination or expiration of this Agreement shall survive Page 8of11 00 W N termination or expiration hereof and be binding upon Medical Director or Company. 7.2 In the event of a default under this Agreement, the defaulted party shall reimburse the non-defaulting party or parties for all costs and expenses reasonably incurred by the non-defaulting party or parties in connection with the default, including without limitation, attorney's fees. Additionally, in the event, a suit or action is filed to enforce this Agreement or with respect to this Agreement, the prevailing party or parties shall be reimbursed by the other party for all costs and expenses incurred in connection with the suit or action, including without limitation, reasonable attorney's fees at the trial level and on appeal. 7,3 No waiver of any provision of this Agreement shall be deemed, or shall constitute, a waiver of any other provision, whether or not similar, nor shall any waiver constitute a continuing waiver. No waiver shall be binding unless executed in writing by the party making the waiver. 7.4 This Agreement shall be governed by and shall be construed in accordance with the laws of the State of Florida. 7.5 This Agreement constitutes the entire agreement between the parties pertaining to its subject matter and it supersedes all prior contemporaneous agreements, representations, and understandings of the parties. No supplement, modification, or amendment of this Agreement shall be binding unless executed in writing by all parties. 7.6 Partial Invalidity. If any provision of this Agreement is held by a court of competent jurisdiction to be invalid, void, or unenforceable, the remaining Page 9 of 11 cfl , N provisions will continue in full force and effect without being impaired or invalidated in any way. 7.7 Dispute Resolution. The parties agree to mediation prior to any final hearing or filing of any claim. Additionally, any dispute, controversy or claim arising out of or related in any way to this Agreement or any services performed hereunder which cannot be amicably resolved by the parties shall be solely and finally settled by arbitration administered by the (American Bar Association) in accordance with its commercial arbitration rules plus the parties agree to mediate this matter prior to any final hearing. Judgment on the award rendered by the arbitrator(s) may be u entered in any court having jurisdiction thereof. The arbitration shall take place before a panel of one [1] arbitrator sitting in West Palm Beach County, FL. The language of the arbitration shall be English. The arbitrators will be bound to adjudicate all disputes in accordance with the laws of the State of Florida. The decision of the arbitrators shall be in writing with written findings of fact and shall be final and binding on the parties. Each party small bear its own costs relating to the arbitration proceedings irrespective of its outcome. This section provides the sole recourse for the settlement of any disputes arising out of, in connection with, or related to this Agreement. 7.8 Notices. Any notices required to be given under this Agreement by either party to the other shall be in writing and shall be transmitted via electronic mail (E-Mail) addressed to the party to be notified at the following address or to such other address (or person) as such party shall specify by like notice hereunder: Company: Email: contact _EcareAmbulance.com Page 10 of 11 0 ti N Medical Director: E-Mail: imdeoena cC7amail.com 7.9 Insurance Provided by E Care Ambulance Inc. E Care Ambulance Inc will provide or refund the costs to maintain medical director insurance to provide coverage only for the services provided to E Care Ambulance Inc. In witness whe the oartids hereto have executed this A reement on the date set forth beto COMPANY: _%% By: SE&NO GARCIA_ ,DAER ALEJANDRQ President Date: 11/01/2022 JULIO M DE PENA M.D MEDICAL DIRECTOR: By: EMY G. PLLC Date: 11/01/2022 Page 11 of 1111 ti N 12. ATTACH A COPY OF ALL STANDING ORDERS AS ISSUED BY YOUR MEDICAL DIRECTOR. N r` N E- AMB�LANCE E-CARE AMBULANCE (800)863-7023 www.ecareambularice.com 103400 Overseas Hwy, Suite 255A,Key Largo,FL 33037 Nov 01,2022 Protocol s Effective 11/01/2022, 1 am recognizing and authorizing EMTs and Paramedics at E Care Ambulance to adopt the Monroe County Fire protocol standards.This will be in addition to our current Florida Common EMS protocols. Each EMT and Paramedic must have orientation upon hire to each Protocol. Dr.Julio M.De Pena,MD,FAAEM,FACEP,FAWM Medical Director E Care Ambulance lnc- u WWW.E RE4MBULANCECOM eM ti N u u� � k i T •r. � E =CARE ! j f AMBULANCE Nov 2022 o MEDICAL PROTOCOL U c� Dr. Julio M De Pena, MD, FAAEM, FACEP, FAWM Phone Number. (800) 863-7023 Email: contact@)ecareambutance.com I d ti N i Id Nov 1,2022 I approve the most recent version of the Florida Regional Common EMS Protocols for use by E Care Ambulance Inc, personnel for interfacility transports. These protocols may be amended from time to time as needed. Julio M De Pena,M.D,FAAEM,FAC>_P, Medical Director,E Carle Ambulance inc. I Uj ti N E-CARE AMBULANCE CONTROLLED SUBSTANCE ADMINISTRATIVE PROCEDURE .pose of this instruction is to set forth the Standard Operating Procedures for controlled substances inventory which includes storage, security and destruction of controlled substances. 1. ORDERING MEDICATIONS: When the EMS Supervisor determines that additional controlled substances are needed the following will be done: A_ CLASS II CONTROLLED SUBSTANCES Contact the Medical Director with the request. A DEA 222 form for the amount of Class II controlled substance needed will be completed by the Medical Director. The Medical Director will return form to E-care Ambulance and in turn Ecare Ambulance, will submit form to the supplier requesting the controlled substance be sent by registered mail. B. CLASS III OR IV CONTROLLED SUBSTANCES Contact the Medical Director with the request. The Medical Director will then contact the supplier and authorize the purchase of Class III or IV in writing. 2. RECEIPT OF CONTROLLED SUBSTANCES When the supplier ships the controlled substance to Ecare Ambulance, the EMS Supervisor will follow applicable procedures by completing the E-care Ambulance Controlled Substance Safe Narcotic Log. The controlled substances will then be stored as described by Florida Administrative Code 64E-2. 3. STORAGE OF CONTROLLED SUBSTANCES IN MEDICAL SUPPLY OFFICE All In-house controlled substances Class II, Ili and IV will be stored in the safe which is located in the Ecare Ambulance Station. When a controlled substance is placed in the safe an entry will be made in the Ecare Ambulance Control Substance Safe Narcotic Log. The security procedure for opening this safe is as follows: the safe is opened and the contents of the safe are then inventoried by the EMS Supervisor. Once items have been added or removed the new count is entered in the log and the safe is locked/sealed by the EMS Supervisor. 4. STORAGE OF OUTDATED OR LOSS OF SECURITY CONTROLLED SUBSTANCES All outdated controlled substances Class 11, Ill and IV will be stored in a designated lock box located in the safe in the Medical Supply Office. The key for this lock box will be stored in the safe mentioned in Paragraph 3. This will be the only key for the outdated controlled substance storage lock box, When an outdated controlled substance or loss of security substance is placed in this box the procedure outlined in paragraph 3 will be followed. 5. REMOVAL FROM THE MEDICAL SUPPLY OFFICE FOR DELIVERY TO STATIONSITRUCKS The EMS Supervisor will follow the security procedures outlined in paragraph 3 to open the safe.The Safe Narcotic log will be completed showing date,quantity removed,lot It, to ' ti N ECARE AMBULANCE CONTROLLED SUBSTANCE ADMINISTRATIVE PROCEDURE expiration dates and location where controlled substances are being moved to. The vehicle substance control log of the unit requiring the controlled substance will then log these items in their narcotic inventory log noting date, time, quantity, and expiration date. Both the on duty supervisor and on duty paramedic will sign the completed form. 6. DESTRUCTION OF CLASS II, III AND CLASS IV CONTROLLED SUBSTANCES We are in the process of contracting SAI Transport; the following procedure must be followed. All outdated controlled substances and loss of security controlled substances will be stored as described in paragraph 4. Effective with this policy, all controlled substances Class ll, III and IV will be shipped to SAI Transport Company for Destruction. SAI Transport is one of the 27 companies approved by the DEA for destruction of controlled substances. Controlled Substances will be shipped to SAI Transport for destruction as needed. SAI Transport 3420 Youngs Ridge Road Lakeland, FL 33810-0781 A. WHEN IT IS DETERMINED TO MAKE UP A SHIPMENT OF CONTROLLED SUBSTANCE FOR DESTRUCTION. 1. All controlled substances may be shipped in one container. The container must weigh less than 50 lbs. Each classification of controlled substance will be packaged separately in the container. 2. The SAI Certificate of Transfer and Destruction of Controlled Substance will be completed. All schedule II Controlled Substance must be entered on a separate form. The following columns on the SAI Certificate of Transfer and Destruction of Controlled Substance will be completed as follows: Column 1: Enter the name of the drug preparation. Column 2: Enter the number of containers. Column 3: Enter the contents or number of units in each container. Column 4: Enter the controlled substance content. This is the unit dosage. Column 5: Enter the NDC number for the item. Column 6: Enter the manufacturer of each listed item. Column 7: This column is for use by SAI only. ti ti N 3. All items entered on a line must be identical in terms of content, package size, strength and NDC number. 4. The bottom of the form will be completed, the date shall be entered, and the completed by section will be signed by the person completing the form. Distribution of forms is as follows: • Mail the White and Yellow copies of each completed foram to SAI Transport. • Place the Pink copy in the correlating shipping container. • Retain the Gold copy for Marathon Fire Rescue records. 5. SAI will return a one time, date stamped copy as proof of receipt of destruction, along with our invoice. They will also forward a completed ❑EA 222 form when required. 6. All controlled substances will be shipped to SAI Transport via UPS. The tracking number will be attached to the container and a copy of the tracking number will be attached to the Marathon Fire Rescue Outdated or loss of Security Control Log. On the UPS form, check the box for required signature. 7. DAILY VEHICLE CONTROLLED SUBSTANCE INVENTORY PROCEDURE At 0800 Shift change, the incoming and outgoing paramedic will do the vehicle narcotic count in each other's presence, checking for quantity, loss of security, and expiration dates. If no discrepancies are found, a new entry will be made in the narcotic log which will include date, time, quantity, expiration date, and the paramedics completing the count. Both paramedics must be in attendance when the narcotic form is completed. 8. DISCREPANCY FOUND DURING COUNT If a discrepancy is found during a count, all staff on duty that day will remain in station. The EMS Supervisor and Fire Chief will be notified. If the inconsistency is not resolved the Medical Director will be notified immediately. It shall be the responsibility of the Fire Rescue Chief to notify the Monroe County Sheriffs Office of missing controlled substance. Approved 11101/2022 Dr. Julio De Pena M.D, FAAEM, FACEP, FAWM DATE OF APPROVAL Medical Director E-Care Ambulance co ti N 13. ATTACH A CHECK OR MONEY ORDER IN THE APPROPRIATE AMOUNT, MADE PAYABLE TO THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. y" BOARD OF COUNTY COMMISSIONERS County of Monroe `"�� Mayor James K.Scholl,District 3 The Florida Keys Mayor Pro Tem Michelle Lincoln,District 2 Craig Cates,District t David Rice,District 4 Holly Merrill Raschein,District 5 Monroe Cotuitv Fire Rescue '; �� 7280 Overseas Highway Marathon,FL 33050 Phone(305)289-6004 " MEMORANDUM TO: Nicole Lyons FROM: Cara Johnson SUBJECT: Check for Deposit- COPCN DATE: January 30, 2025 ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Attached please find Check= dated January 29, 2025, in the amount of$475.00 per check to be deposited in revenue account 141-342000-RC 00345. This check has been issued for the renewal application of a Class A Certificate of Public Convenience for E Care Ambulance Inc. Thank you, ca4-,e'- ?�6� Cara Johnson 1279 E CARE AMBULANCE INC. 15700 ROLLING MEADOWS CIR E WELLINGTON,FL 33414-9048 DATE pp'qq � 1 —TOTHE CHASE p� � JPMorgan Chase Bank,N.A. www.Chase.com . ._. MEMO ciryp k r 1280 r Il% I- rvm Fa, 1281 Office of:the Secretary 4050 Esp4nade Way TaUlah6ssee, Fl. 32399-0950 MANAGEMENT 850-488-2786 SERVICES�A We ServeThoseMio Serve Florida on DeSantis,Goveniw .......................... ..................... June 6, 2022 Daer Serrano Garcia E-Care Ambulance, Inc. 103400 Overseas Hwy, Suite 255A Key Largo, FL 33037 Dear Mr. Garcia, You have requested us'to make an eligibility determination for the (E-Care Ambulance, Inc.) that will operate as an EMS service provider at 103400 Overseas Hwy,Key Largo, FL 33037 The E-Care Ambulance Inc. has been determined eligible for public safety radio communications within the State of Florida. this letter is to accompany your Federal Communications Commission (FCC) application. If you have any questions or comments regarding this letter, please call Shaun Krueger at 850- 413-9213, or email at Sincerely, Shaun Krueger Engineer III 1282 AGREEMENT between THE MONROE COUNTY SHERIFF'S OFFICE and E Care Ambulance INC for USE OF P25 RADIO SYSTEM THIS AGREEMENT, made and entered into on the day and year last signed below,by the Monroe County Sheriff's Office, a subdivision of the State of Florida("MCSO"), and E Care Ambulance Inc., a private corporation, collectively("the Parties"). WITNESSETH: WHEREAS, MCSO has purchased and is operating a radio system that is used by several local government, and emergency services entities ("Shared Users"), and WHEREAS, E Care Ambulance Inc. provides emergency transport services within Monroe County, Florida; and WHEREAS, the parties have determined that allowing E Care Ambulance Inc. access to MCSO's radio system will result in a public safety benefit of interoperability, and NOW THEREFORE, in conjunction with the mutual covenants,promises and representations contained herein, the Parties agree as follows, SECTION 1: PURPOSE AND DEFINITIONS 1.01 The purpose of this Agreement is to set forth the parameters under which MCSO will make access to its 800 MHz P25 radio system ("System") available to E Care Ambulance Inc. 1.02 System; The 800 MHz P25 radio system funded, purchased, installed,maintained and owned by MCSO. The system includes fixed transmitting and receiving equipment, T-1 telephone lines for communicating between sites, system control and management equipment, dispatch consoles, a controller located at the prime site, and other related equipment. 1.03 Shared User Ecluil merit,, Also known as "agency radios", are E Care Ambulance Inc. or Shared User-owned 800 MHz P25 handheld and mobile radios and control stations that have the ability to be programmed and used on MCSO's 800 MHz P25 radio system. 1.04 System Administrator: The person designated by MCSO to be responsible for administration of the System and serving as designated contact person pursuant to this Agreement. Page 1 of 8 1283 1.05 E Care Ambulance Inc.Reppresentgfye The person designated by E Care Ambulance Inc. as designated contact person pursuant to this Agreement. SECTION 2: SYSTEM ADMINISTRATION AND USE PROCEDURES 2.01 MCSO shall administer shared use of the System. 2.02 The System Administrator will develop policies, procedures and standard operating procedures. E Care Ambulance Inc. agrees to comply with any enforcement actions required by these policies and procedures for misuse or abuse of the System. 2.04 Maintenance costs as described in Section 7 will be reallocated on the first day of October after a new Shared User gains access to the System. SECTION 3: SHARED USER EQUIPMENT AND RESPONSIBILITIES 3.01 All Shared User equipment will be 800 MHz P25 mobile, portable, and control station equipment programmed for use on the System. The equipment used shall be 800 MHz P25 compliant communications systems equipment, and approved by the system administrator. E Care Ambulance Inc. is required to keep their equipment in proper operating condition. E Care Ambulance Inc. is solely responsible for maintenance of their radio equipment. 3.02 Within(15) days of the execution of this Agreement, E Care Ambulance Inc. must designate a Representative who will serve as its single point of contact for matters relating to this Agreement. 3.03 Within(15) days of the execution of this Agreement, E Care Ambulance Inc. must provide MCSO with a list of persons who are authorized to request programming changes to existing units and programming of new units. E Care Ambulance Inc. will not program radios without approval of the System Administrator. 3.04 Written authorization from the System Administrator and E Care Ambulance Inc. Representative are required for the Monroe County Sheriff s Office Emergency Communications Division to program talk groups into Shared User radios. E Care Ambulance Inc. may not request that other User's talk groups be programmed into their radios without written authorization of the other Shared User Representative. 3.05 E Care Ambulance Inc. will be required to program the Common Countywide Talk Groups that reside on the System for use by Shared Users or interagency communications into its radios. These calling talk groups, in addition to one operational talk-group for the applicable discipline, shall be required as a minimum. Shared Users may include additional Common Talk Groups as necessary to meet their operational requirements. Page 2 of 8 1284 These talk groups shall be in addition to the mutual aid channels required by the Florida Regional Plan. 3.06 E Care Ambulance Inc. is solely responsible for the performance and the operation of Shared User equipment and any damages or liability resulting from the use thereof. Should MCSO identify malfunctioning Shared User equipment, MCSO will request the Shared User Representative to discontinue use of the specific device until repairs are completed. If a device is causing interference to the system, MCSO may disable the equipment from the system. In the case of stolen or lost equipment, E Care Ambulance Inc. will immediately notify MCSO Emergency Communications in writing or via e-mail authorizing MCSO to disable the equipment. E Care Ambulance Inc. will provide the Radio ID number and the serial number of the radio. MCSO Emergency Communications will advise back via e-mail when the radio has been disabled. Disabled radios will be reactivated only upon written request from a E Care Ambulance Inc. Representative. 3.07 As of this time, the System does not support the use of roaming,private call, or telephone interconnect. In the future MCSO may activate some or all of these features should the loading of the system allow. E Care Ambulance Inc. may not program these features into their radios. If roaming, private call, or telephone interconnect are allowed on the System in the future, E Care Ambulance Inc. may, at their own expense, reprogram Shared User radios. MCSO will provide an amendment to this Agreement defining the uses and required programming should these features become available on the System. 3.08 E Care Ambulance Inc. is required to provide to MCSO an inventory of the radios on the MCSO system. E Care Ambulance Inc. shall provide the following information to MCSO: 1. Radio manufacturer and model numbers 2. Radio serial numbers 3. Requested aliases to be programmed 4. List of any requested radio programming changes 5. Talk groups required 6. Common talk groups required 7. Other agency talk groups required MCSO will compile this information and transmit back to E Care Ambulance Inc. a matrix of the approved talk groups, aliases, and radio ID numbers prior to radios being programmed into MCSO's 800 MHz P25 radio system. E Care Ambulance Inc. will be responsible for adhering to the talk group and radio ID allocations set up by MCSO. 3.09 Nothing in this Agreement shall represent a commitment by MCSO or be construed as intent by MCSO to fund any portion of E Care Ambulance Inc.'s equipment. SECTION 4: MCSO RESPONSIBILITIES Page 3 of 8 1285 4.01 MCSO shall be responsible for operation of the System 4.02 MCSO shall be responsible for all permitting, licensing, and fees associated with the operation of the System. Page 4 of 8 1286 SECTION 6: ONE-TIME SYSTEM ACCESS CHARGE 6.01 Each subscriber unit added to MCSO System will be charged $50.00 at the time the unit is programmed for system access. 6.02 E Care Ambulance Inc. will pay a fee of$25.00 per subscriber unit for any subsequent reprogramming of radio talk groups. 6.04 In the event of any termination of this Agreement, access and reprogramming charges will not be reimbursed. SECTION 7: MAINTENANCE COSTS 7.01 MCSO relies upon the MCSO Emergency Communications Division to secure routine and preventative maintenance on the System. This maintenance includes trouble shooting and making all repairs on a 24/7/365 basis as well as performing preventive maintenance on the entire System, including,but not limited to, radio equipment, control, management, and alarm systems, towers and equipment shelters,backup power generators, and air conditioners. 7.02 E Care Ambulance Inc. will pay maintenance costs one year in advance. The rate for 2022-2023 is $282.98 per unit. The annual cost of maintenance will be reviewed each year. Future maintenance costs may be adjusted for the following fiscal year. If future maintenance costs are adjusted, MCSO will send written notice to E Care Ambulance Inc. in April before the next fiscal year. Maintenance costs will be shared on a pro rata basis based on the number of radios E Care Ambulance Inc. and Shared Users are authorized to use on the System as of April 1 of each year. SECTION 8: BILLING SCHEDULE 8.01 Access and reprogramming charges are due in full, regardless of the time of the year that the additional unit is added to the System or reprogrammed. These fees will not be pro- rated from the time of programming. 8.02 System Users will pay maintenance charges as described in Section 7. Maintenance charges are due each October 1, one year in advance. Page 5 of 8 1287 8.03 Upon receipt of any invoice, E Care Ambulance Inc. will immediately review it and report any discrepancies to MCSO within 10 days of receipt. Payment will be due to MCSO within 30 days of receipt of the invoice. Payments will be sent to: Radio System Administrator Monroe County Sheriffs Office 5525 College Road Key West, Florida 33040 Attn: 800 MHz P25 Interlocal Agreement SECTION 9: ANNUAL BUDGET INFORMATION TO BE PROVIDED 9.01 MCSO may review and update the fees and charges as identified in Sections 6, 7 and 8 before April 1st of each year for the following fiscal year beginning October I". These revised fees and charges will be applicable for the upcoming fiscal year and will automatically become a part of this Agreement on October 1st of the applicable year. SECTION 10: INDEMNIFICATION AND LIABILITY 10.01 MCSO makes no representations about the design or capabilities of the MCSO System. E Care Ambulance Inc. has decided to enter into this Agreement and use MCSO's system based on its review of the system design, system coverage, manufacturing and installation details contained in MCSO's contract with Motorola and subsequent field measurements and testing data that may exist. MCSO makes no guarantee as to the continual, uninterrupted use of the radio communication system, or its fitness for the communication needs of E Care Ambulance Inc. 10.02 E Care Ambulance Inc. agrees to hold harmless, indemnify and defend the Monroe County Sheriffs Office, Sheriff Richard A. Ramsay, and his predecessors and successors in office, and each and every one of his or their deputies, employees, and attorneys from any and all loss, damage, claim or judgment arising out of this agreement or E Care Ambulance Inc.'s use of the System. 10.03 The terms and conditions of this Agreement incorporate all the rights,responsibilities, and obligations of the parties to each other. Page 6 of 8 1288 SECTION 11: OWNERSHIP OF ASSETS Shared User Equipment will remain assets of the E Care Ambulance Inc. or Shared Users at all times. Any asset now owned by MCSO will remain MCSO's despite the E Care Ambulance Inc. or Shared User's financial contribution to their maintenance,renewal, and replacement. Any asset later incorporated into the System, will be owned by MCSO, regardless of cost reimbursement by E Care Ambulance Inc. or Shared Users. SECTION 12: TERM OF AGREEMENT The initial term of this Agreement begins December 01,2022 and ends September 30, 2025. SECTION 13: TERMINATION 13.01 Either party can terminate this Agreement with or without cause upon(10) days written notice. SECTION 14: APPLICABLE LAW The laws of the State of Florida govern this Agreement. SECTION 15: FILING A copy of this Agreement may be filed with the Clerk of the Circuit Court in and for Monroe County. SECTION 16: ENTIRE AGREEMENT This Agreement and Exhibits attached hereto and forming a part thereof as if fully set forth herein, constitute all agreements, conditions and understandings between MCSO and E Care Ambulance Inc. concerning the System. All representations, either oral or written, shall be deemed to be merged into this Agreement, except as herein otherwise provided, no subsequent alternation, waiver, change or addition to this Agreement shall be binding upon MCSO or E Care Ambulance Inc. unless reduced to writing and signed by both parties. Page 7 of 8 1289 SECTION 17: THIS AGREEMENT SUPERSEDES ALL PREVIOUS AGREEMENTS Any prior agreements, whether oral or written,between E Care Ambulance Inc. regarding the subject matter of this Agreement are hereby terminated effective immediately upon full execution of this Agreement. IN WITNESS WHEREOF, the parties have caused this Agreement to be executed: MONROE COUNTY SHERIFF'S OFFICE B y MONROE COUNT SHERIFF'S OFFICE ____ ... ----- --- AP VE"w 5 TO FORM: Title . - — ........... .. TRCK J. MCCUL...w. Date: " ^� � �, , � � ' LAH GENERAL t�O,(, L DATE E Care Ambulance Inc. By: ��2a rum DaZlr. .. ,...... .meee�... _ Title: CEO Date: 11/10/2022 Page 8 of 8 1290 Mi yy d ' C { I § E = CA,11, E III�II�III�III�III�III ��III AMII� U 1................. o MEDICAL PROTOCOLS U NOV 2022 6 Dr. Julio M De Pena, MD, � FAA E M, FAC E P, FAW M E M a) Phone Number: a)j (800) 863-7023 Email: contact@ecareambutance.com 1291 AMBLYI ANCIE Nov 1,2022 I approve the most recent version of the Florida Regional Common EMS Protocols for use by E Care Ambulance Inc. personnel for interfacility transports. These protocols may be amended from time to time as needed. < I w Julio M De Pena,M.D,FAAEM,FACEP, Medical Director,E Care Ambulance Inc. P.O. Box 378470 Key Largo, FL 33037 * Phone 1-800-863-7023 * Contact@ECareAmbulance.com 1292 E Care Ambulance Inc. MEDICAL PROTOCOL Julio De Pena Medical Director TABLE OF CONTENTS AIRWAY MANAGEMENT J RESPIRATORY EMERGENCIES SECTION I Airway Rescue for the Endangered Airway Revised 1®1 Basic and Advanced Airway Management 1®2 Respiratory Distress (Asthma, COPD, UHF) 1®3 ADULT CARDIAC EMERGENCIES SECTION Asystole 2-1 Eradycardia 2®2 Cardiogenic Shock 2®3 Chest Pain /Acute Coronary Syndromes 2®4 STEMI /ACS Checklist (MDR ® 075) 2®4 Induced Hypothermia / ROSC 2®5 PEA (Pulseless Electrical Activity) 2®6 Post Arrest 2®7 Pulseless Arrest (V-Fib, V-Tach) 2®6 PVC's 2®9 Tachycardia ®Acute with Pulses 2-10 ENVIRONMENTAL EMERGENCIES SECTION 3 Anaphylaxis /Allergic Reactions 3-1 Cyanide Poisoning / Smoke Inhalation 3®2 Diving Sickness 3®3 Electrocution / Lightning 3®4 Envenornation / Bites / Stings 3®5 Hyperthermia 3®6 Hypothermia 3®7 Marine Envenomation's 3®6 Overdose / Poisoning 3®9 Pepper Spray Exposure 3-10 MEDICAL EMERGENCIES SECTION 4 Abdominal Pain /Acute Abdomen 4®1 Altered Mental Status / Unconscious States / ETOH 4®2 GI Bleed 4®3 Psychiatric/ Behavioral 4®4 Seizures 4®5 Stroke 4®6 Stroke Alert Checklist (MAR ®073) 4®6 1293 E Care Ambulance Inc. MEDICAL PROTOCOL Julio De Pena Medical Director TABLE OF CONTENTS OBSTETRICAL/GYNECOLOGICAL EMERGENCIES SECTION APGAR ® Newborn Scoring 5®1 Childbirth ® Labor an 5®2 Childbirth ® Complications 5®2 Childbirth ® Illustrations 5®2 Postpartum Vaginal Sled / Vaginal Sled Unknown Origin 5®3 Pre®Eclampsia / Eclampsia 5®4 PEDIATRIC/ADOLESCENT EMERGENCIES SECTION 6 Acute Traumatic Pain ® Pediatric Addendum°i A6®1 Anaphylaxis /Allergic Reactions ® Pediatric 6®1 Asthma ® Pediatric 6®2 Eradycardia ® Pediatric 6®3 PEA (Pulseless Electrical Activity) ® Pediatric 6®4 Post Arrest ® Pediatric 6®5 Pulseless Arrest (V-Fib, V- Tach) ® Pediatric 6®6 Seizure ® Pediatric 6®7 Stridor ® Pediatric 6®6 Tachycardia ® Pediatric 6®9 Trauma Alert Criteria ® Pediatric 6-10 Trauma Alert Criteria Form (MC R ® 097) ® Pediatric 6-10 PEDIATRIC/ADOLECEN ' PROCEDURES SECTION 6P. Cricothyroidotomy ® Needle Pediatric 6P®1 PEDIATRIC/ADOLECENT REFERENCE SECTION 6R Glasgow ® Pediatric 6R®1 Glucose !dues ® Pediatric 6R®2 Pain Scale FLACC 6R®3 TRAUMA EMERGENCIES SECTION 7 Amputations Revised 7®1 Burns 1st and2nd Degree Revised 7®2 Burns 2nd and 3 d Degree/Chemical Burns Revised 7®3 C®Spine Range Of Motion 7®4 Glasgow®Adult 7®5 Head Injury/ Increased ICP 7®6 Shock ® Trauma ® Combativeness in Trauma 7®7 Taxer Injury 7®6 Tension Pneumothorax/ Hemothorax 7®9 Trauma Alert Criteria 7-10 Trauma Alert Criteria Form (MC R ®096) 7-10 1294 E Care Ambulance Inc. MEDICAL PROTOCOL Julio De Pena Medical Director TABLE OF CONTENTS PROCEDURES SECTION 8 Bougie ® Endotracheal Tube Introducer Addendum°i A6®1 Chest Needle Decompression 6®1 CPAP Concepts 6®2 CPAP Assembly with Nebulizer Revised 6®2 Cricothyroidotorny ® Surgical 6®3 DuoDote Auto Injector 6®4 Endotracheal Intubation (Oral) 6®5 External Jugular IV Access 6®6 EZ-10 Insertion 6®7 EZ-10 Landmarks 6®7 I®Gel Revised 6®6 Infectious Diseases (corning soon) 6®9 Lucas Device 6®10 Nasal Atomizer Addendum°i A6®11 Nasotracheal Intubation 6®11 Nasogastric Tube (NC Tube) 6®12 Spinal Motion Restriction 6®13 Stroke/ Stemi ,fiction Sheet 6®14 Synchronized Cardioversion 6®15 Telemedicine PolyCom 6®16 Tourniquet ® C.A.T. (Combat Application Tourniquet) Addendum°i A6®17 Transcutaneous External Pacing 6®17 Ventilator Concepts (Page 1 of 3) 6®16 Ventilator Control Module (Page 2 of 3) 6®16 Ventilator Diagram (Page 3 of 3) 6®16 Video Laryngoscope ® Bing Vision 6®19 REFERENCE SECTION 9 12 Lead Reference Guide 9®1 Determination of Death / Obvious Death 9®2 Dopamine Drug Formulary 9®3 ETCO2 Waveform 9®4 Refusal of Care (Page 1 of 2) 9®5 Refusal of Care (Page 2 of 2) 9®5 Rule of Nines 9®6 Stroke Scale (Cincinnati, Mend, NISS) 9®7 Termination of Efforts 9®6 Trauma Transport Protocols 9®9 1295 E Care Ambulance Inc. MEDICAL PROTOCOL Julio De Pena Medical Director TABLE OF CONTENTS bRUG'FORMULARY SECTION 10 Adenosine Triphosphate (Adenocard) 10®1 Albuterol (Proventil, Ventolin) 10®2 Arniodarone (Nexterone) 10®3 Aspirin 10®4 Atropine Sulfate as Cardiac Agent 10®5 Atropine Sulfate as Antidote for Poisonings 10®6 Calcium Chloride 10% 10®7 Cyanokit 10®6 Dextrose 50% and 25% (d®glucose) 10®9 Diazepam (Valium) 10-10 Diphenhydramine HCL (Eenadryl) 10-11 Dopamine Hydrochloride (Intropin) 10-12 Duo-Dote 10-13 Epinephrine 1:1000 10-14 Epinephrine 1: 10,000 10-15 entanyl ® Addendum°i A10®1E urosemide (Lasix) 10-16 Ketamine (Ketalar) Addendum°i A10®17 Magnesium Sulfate 50% 10-17 Methylprednisone (Sulu®Medral, A®Methapred) 10-16 Midazolam (Versed) 10-19 Morphine Sulfate (MS) 10-20 Naloxone Hydrochloride (Narcan) 10-21 Nitroglycerin (Nitrostat, Nitrolingual Spray) 10-22 Odansetron (Zofran) Addendum°i A10-22 Oral Glucose (Insta Glucose) 10-23 Sodium Bicarbonate 6.4% and 4.2% 10-24 1296 f� ............................... ii is // / � �'%%%/ x'zz CO // O s LM IL , t 0 --► � w ca Q o a _ a� 0 °� as X U Cco N CO) = w � V ~ ■� � a o ► u� _ , � cn 0 _ 06 CIO) Q Z p o m ^, U � D U L N A' N (0 (n fy _ LL FL �/ rr mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm�3 ,,, E 2 W _ o L N O � C C &° "`" E (� LL L N O OIX AR 0 O _ m ( m ?� a W O v Q ~ m N m UZs Q '� m Q L R N O p olll O L > E 0 ._ 12 v 0 v V i Ca O M s c CO L ca N E ._ Q N � O O O ca m a CO � UCOUQLLHd (n (n (nmmmZ (nHUdLL 1 W PC U R H d R R r 0 ¢ II * a.W .L. 3,/ 1297 g c m CL L 4�A 70�\ �/ 0 4-W 0 L— AL W v AN NW Y` `v 3 Q v A� W W `v W nin 1298 0 L c.� 0 0 � N o (D � i m d %Zl� �_ Wv OE 1........ w ww il�u�u > Q w 0 I-o m chi C �? --► ♦ ♦ /INV CL Jiiii � MiMMM 0 fInn i p ........... v 0 R' If//// LM III��,II � �♦ ///� � 9�`'� ,.................. , a ... Ill�lllluli L T W n �iEEEEEE//////////. i% r/%%///,,,,,, o Y p y w a C W, m d U! C V Q c 4) m 0 ©.ca G L N Lld otS cu 8, Q cr pll C7 u. d c a �Y IIIII 0 p zz a � v CL CL U W lllll�lluullll�� Z � �. I C > -♦ i3 d 0 d w E a7 L w o n 75 CL"a > O N O O_ 7 Q N Q O N (n N p o X W G� � c O N p ♦'lom ♦- ♦ Ct7 x CD :3SIS ?+ E .c p € N 06 s O of pry m 7 N p N � c a) Q ink i� o V 2 N O cfn Qn E N 3 n Q U n LULO O m .� 7 1299 yY M �y A � zam Uu WOOER ERR �. -v yY „ ....... d,,,, —� Q --► of —� ; :::—► r,,,, r 555555555 �. i—� .... g MIR WIN/ mill ,,,, ON L GAT � ,,,, 1 ,,, ,, •6 ' Ap,,,,; „ o 7v , r > T ,,,,,,,,,,,,,,,,,,// � Q N C4 .�.i 'w Q 0 Y/ w Q Q� U rx. z sx ; E 0.mH 01 0 n U Q o i © 0 0, x .0to N O W O d u 4u a cs J G1. CL O �' RS © Cfl O N .. O cC d W d 02 L. mQm xL) ■� omumow >_ Q . . . . . . li w 3 w ._ � z .... � w a 0 - 0 y E3 . E E R O ,N _ U. :2E � xc n - E L) o W .- E � � E a s s y 0 n UoLL m L ° 0 0 F13 N x V 0 z _ o CL 0 Q z 70 � o z - tm � O 0 .. U EOM = 06 cn LO c:) u o.� O � =�=+ > a) N LO T- J O v- o U C9 O a N O .. ,. ........ ;';,,,,,, Q � cu Z Z w. U O O N o O p o U cn 0 m °< cuc C � NI cu o0 -0Ci LL 0)Cl) N 0 0 LL V N o z U m N Q� z <C ^ ° a a) U w c X Q N a� E 0 L ca 2 �.. _c .(P c o N o o *2 o E > 0) �a) 0) Q 2 m :> 0 W N uS c � � 0 ca ca M N cn O_ O O = O > U U c m c�a c c co cn c W cn o O O HHHHHH N oo6 N c C U o � L o '� U o o O Q cn ° c m cn � � U E c � � U °' -a > . . o o� Q U a m o cB 0 „N cn J U o N Q > 0 cn N U � ^ -o cn =3 `O E N .N c Q v p6 o U cn co � � O •O U m U J N E cnCo Co m Q c = ca o 0 co 'E �� c o ?� � JCL � � G� o .M cj > O O 0 N O O QQ-0 QQQ 113011 ........... .......................................... IMMMMMI,M-' ........... 9, yv- .............. mill ors . ................. air 5, v co ...... ........... m 0 olmm-/ co TM CL i wo, to ........................................ rr to 0....................... ............. 0 - co Vrow ) > o w 0 CN 0) 0) C.) ul 04 0 L-- (D 0 E M I CL 0 4) 0 U) E u z cu An r- 1 .0 ,10 c: & & C 'E cr z > 0 E (Dto .2 E o 0 -0 w U_ L. cu c: 0 co o U) C: 0 E - w C: .C14 "a nnm z 0 —x N m Co— 0 0 MmIll c M c4 E C: C: 0 1� �:-v- 0 cu 'a Co " 0) U) 04 0 0 x Lm 0 -0 0 .�5 0 C3) (1) 0 > —LO C: 0 > .0 (D C:) (3) =3 o U) E c: c: 0 C: a) C: a) LO a) - CY) 0 a) 04 a) 0 0 o. � DJ- LU cn cn cn a) a) co M U co v =3 Co cn E > a) CL 0) Q, r- CY) >, co 0 U) U) Co .0 0 1= Uj 70 W (D =3 -CZ 0 co C14 'a c U) c CU (3) Z Co -- c) 0) E C: cu > Co U) (D (n E co Cq U) c X z 0 U) E cu � 5- w w cu L- c: E 0) cu U) 0 0 o Co Q I 0 o cu a > 0) C) V 70 E 0 C/5 70 70 >, o C) x - , (3) _ U) 0 (3) (1) CU 0 LU z w a) z cu E CL o C-6 > co 04 X E 0 > S� co 0) a) o cu LLJ !t= M N f 0 CL 0 o cu U) 0 U) Cu U V U) N .� O c-) _ L- -a a) _ U to -0 a) c N N a)0 IN — a) O V � 'a Q cu �0) � m o o o >' 0) 0 O � O Cu a) Q _N C.) E U a W CuE CIO - -Q O m O Z Q N N (u � N V (� Q to 0- O O „„„ M Ri W cu co cu w N 0 >%m w 4-a 'O N N 0 1° - O C -�-1 L Q V O C UC m z a� U 'cU—n o °vi > o � � a) cu Q c�� m � > oQo0 � � cNn o C: �— Q cm L cn -a cn N U) O >, cn J U O X O Q • • 5 0 0 0 M Q • W • • • • • • �' • • • • 2-3 1303 LL 75 m o N � N c ° o Cl) r��iiiiiiiiiiiiiiiiiiii O cn X = LL 1 O v Y CIL 0 C� c0 E CIL U6 N y— UU. U � min N O 0 > to o co E v' c� Cq tn � u Y 0 N Q III = Zcn " L R3 O III � o o co +y ° C o N m }' (D m o coAND O C fly 0 co V ca '05m -0 0 > Q o 0 c cnCD - N CO acu ) O cU w � = m o V a) o v N U7 a) *L � C� cu °' a a ° CNI o. CL U. a, m o L- L U III�IIIIII -0 U} V o � 0 z Q � � o _ u�� cn C'qmm C m 0 cn 0 c j y c II m o Y O o2S `� O � � L IT, pCN w ' m tom � H m cu m to Z O W c c co Q m (Cf � E i Q O > > � `� I 0 X U) a) Z " 0 m 0 0) a) cv (� cn >+ X +- to -0 Q O µ E2- 1304 E Care Ambulance Inc. MEDICAL PROTOCOL STEMI/A.C.S CHECKLIST FOR TRAUMA STAR Date Patient Name DOB Age P/U MM Rescue Crew / 61it; Hlpfm IF QRS idth>.12 seconds and... ALLERGIES 1) New Onset LBBB with Cardiac Symptoms? To ASA? 2) RBBB with ST elevation? To Morphine? OR Elevations in 2 or more Leas To Other Med.? 3)Anterior Wall: I AVL .V1-V6 4) Inferior Wall: 11 111 .AVF FIELD TREATMENT 1( IF V411 POSITIVE ASA 324mg ---------------------------- WITHHOLDNITRATES OZ via NRB Bain 2'd IV&give fluids if hypotensive Nitroglycerin: x1 x2 x3 -------------------------- Prnce of any of above Morphine: x1_ x2_ BASTE I Alert" criteria A V P U Total fluids given: ml Launch Trauma Stagy & complete this form TPA EXCLUSION CRITERIA OPQRST Bleeding problem? ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------- Onset Of Events: Previous stroke? Provocation: Acute hypertension? Quality: Streptokinase? ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------- Region: Recent surgery(within 6 months)? Radiating: Coumadin/Warfarin? Severity(1-10): Time(Duration): Other medications: ---------------------------------------------- Constant or Intermittent Other medical history: SIGNIFICANT HISTORY A Prior MI? If yes Date: Comments: Angina? Diabetes Mellitus? Nitro taken Prior to Arrival?#Taken Lead Paramedic Signature: ------------------------------------------- Sexual Enhancement Meds Taken <24hrs ***C / PT REPORT & ETA 3 S-5 - * *ATTACH CODE SUMMARY*** PINK TO RESCUE WHITE TO FLIGHT CREW YELLOW TO HOSPITAL MCFR-075(08/2016) Dr.Julio De Pena MD. STEMI / ACS CHECKLIST T�v05 12 CL — cu E 75 E 0 A LLI N 0 cu 0 0 0L (D 5CL 0 _0 E 0 E 0 co CD C) C) 0 a P Ld E w > a 0 E CL 0 —1 0 ILD > -E 0 ci CL o Z 0 CU C: L) O C�I) RS 0 Lm o c U) 7@ L- cu 0 1 C: 0 0 E E m CL cu 0) 4- 0 M o- = a 0 U E L-) u -r L- C: a m c cu 0 Ri -0 a x L- C: 0- 0 L- 0) 0 0 cu E 0 'a E C: 4-1 U a 0 0) z a cu o L- 0 C: cu 0 ol 0 CL .0 z 4-0 =3 ...... ....F.... co 0 7t,— CL L) :3 cn C/) =3 cn 0 a) a) ry cu cn 0 0 cn 0 CL U) Co v 'a L) C3) v 0 ia) U) -a U- L- (3) C: 'a cu cu cu cn :;, 0 co 0 c: 76 E Co corn E O L- -a 0 2 0 F= CE 9) =3 0 U) R - E 0)le- 0 -- (D a) 4-1 0 co �o (D 4- cn E LL 0 -r 0 cn 4) < z U) C6 2 IL a-) E - OD --E 2! 0 E x 0 o cn 40— 0- co > =3 E m a WMI) CY > cn 0 r_ 0 ui 0 0 C? 70 0- F= cn < co 0) A 0) U) cL E 0 04 = (n 0 F cu iii,r) = m =3 E " W p .0 C) 70 o = (D 0 0 ui (n F= coCL w V U) 0 0 ) cnY' � cn cn Z 0 cn 0 00- 0 > C) E E 'a cu QL 0 .,= (.) U) C,) (3) U) E o —0 0 0 c) 2-5 1306 � N x ca o. ..0 t � a CL 70 Q z o z a) iiiiiiiiiiiiiiiii O i O ca 1 o ' _Q . ..... O ? .� E O — o2 cn LOto 4-0 4 M N O N U CUw oa U .. Q Ua N pO O 4- o •> ° 0 U 7 cn i v7 00 N 0o t� N CO _ .— ° Q Q CNIca DE, cu (n . U NL) — (D Cl) CL o N N U �- w C x Q (I) to Q� E .� 2 a o *2 o E T 0. UE (oo5 A= Q) o =3UU0- li Q O 0 CL 5 N uS c � C Oca o � E E co E c U c o L E E UU 0co cn a) O H can) .6 NL co 0) o a) o U) mO m_cn Y .o 0 o c > . . pOQ U a- a) N o n3 cu O to " aa) U E m cn o E Z0 cn o U -0 v co "O c E N Ln C Q v o CLU � co J N U m Q n o = (a cn Co ° o 0 .� E � > G� o .co c j •> o' ooa`) 00 n E1307 m� � CY) cl� '. + r ca 0. mlll a ca ca fF3 cr C S�} W ` 0 C. q C 0-ca 5 ca N OCL 4-4 10 C C C- .. g C N O L a, © O .0 O C Q T o L c w cu O N ' Z cc 11111'11'1,�"Pm 0 cu a) O o (n 0- 8 o Q V� U C N Q) Q) ° U V/ O .� � OCU Rf (QQw � � �W/ �+ ,�, ,;;,,,,,,��iiiiiiiiiiiiiiii .0 a) IL \\ � L �-+ U Q, Y ~= L "- = � � W L O U cu y Q aa) c I�I Q � P ) - Cl)p m � (n O a ` � i � ) CL ) � o. 04z a E Ecu o C _0 o 0 F � U) a)i � C a : L _ E = V Z7 .Q z U �' a) C C u O co a) a) V) 70 C ! p Q 70 a) 70 � C V 0) c A2 In—O V N J C -0 1 � 2 ca C 4- a) N X O v L- - Q C 00 G) C) �+ O -0 (oca 70_ 1 L 1308 k o T �iiaaaaaai o. a kfn ,,,,,,,,,,,.�,,,,, a ,,,,,,,,,.........,,, oCL o a� o cu i tq a � o m ' o m, � O70 of tm tgoEo V � U ca 0 > E E - u a Q C4 ..i o a) a o oo U � Zvi aUi z (n cn ) i o U V m E N 70 G� ui a) 0 o •u a — L Z Q) 0o FLF a CU Q a) (n xCO Ln m p L-, c U U C c a� in 0 0 E E E a � c E o o — ca a) ca (fl o IL A) �`� c m.c ; C 4= O N N N N cn E m U +� o U �0 U) C E + � N c`)� o � °a n3 a 0 0 Q_ N a) O ca C a N U N Q E � U ca i) to W m E CL E a) U m N C) •E Q O N c p Co a -N J �> o' 00 `moo °mo o cn CLCL-0 CLCLCL 0 > N 1309 i � N , L L CU Q 0 0 E c O a CL 7 O O cv70 L E cB cli O cn >, O C CO CD co E \ U O O vcli h ° a) a) c 0. CJCD •• � a) >; co V a) UO `� cu CI a) a) Q 00 cn U E ~ a) a L- O� tio � 0) S w LL Z 7 a a) U 0) w W M >+ a) OV O U � a) W U CO 0) U = W E � cn w � V 0) a N m Q _ Q a) O .� a) ccs N 0U C = co o � a C V ,.r Q O � O > O V .— .— :_ � V O - Ua) .2oa) � oa0 "- U mQL >N � � Ea) Y a, � a Q � mo � > u -0co � _ � � C � � a) u�NNNILn X cn a) � a � aaoa . w a 2-9 1310 U) he r w � V to to to O O _ co > Lo N in in in N r � d La La La o o 4) O � _ m N w CU V ca O m E _ � a LO O O N 0 cu N _ = V V V � Q y V >' j+ >+ > 0 Q +� > U � cncncn m CL o a,V W 70 U) cu cu ° E Xtm QQQLua- ,,,,, fLO r err �... .... i� err; mm LM co 06 O ca yi h ;; CD LO t. CD Ln • Ills ...... .......................... }� 1 1 1 LLI G coa _ .E — 0m O U) � U � N OL µ O (Cf M - „µ Z E 6M 6M cn �", Z", o co _ r Q O a U1 L > Cso O O M C co cn m c M o L2-1 (1 > 1311 i M 0 CL 0 0 0 E L cn G1 p cu O O �� =c a) "= V cu a) = 0 Z - O �4— to 4) 01) O O) U \ h taA O V E N Q V v U ca U o p W OC m O to O as U w 0- '� m y c 0" U Rim O 07 4- E p i _ O i 4— CD co �, 'p ° uj , �I r- "p N O Q O b' E 'tip E co J i ❑ p a) a) cu>, U p p a) p O Cl)— M CU "R��..,, o o Q "= 4 .� cn uj m Lo ) ca N 'i 1) co : Q _00- 70U Cl, + o w 0 cu 'y o � ) $ a) of mI � qG > _ 0_." o s. _O m cn c c Q o > cv a� ""70 U "" 00 v Z coi °' cl a� v a) E as �� -, o k��lkw a� w a) Q O > w Q O .> zCf) ° ° cx E "N cu I— • • • • • Q 'p 0 • • • • • _ • w ate' w E1 1312 a) N cco co m c x,o c � M 0 co voi CL c ^ m � �' ° o (n Q — N m o O :� O N co c cooco o > � o ° Uco (nN N CL O co c E 0 m � co m (n > " N E co co co U = o c `o �° voiu� c E � mN � 0 - U N = O N > co CL to 0 �_ O N .� U ° p Co � N m COO N p � _ - N N (SS p CL c a� n• . • • o f U a � mo L) c Mv + Nco c O Uo l' 0 > No3 > C Oco co E m — > N Co o oa� . o U U E aC Qco eco (nOCL O N N o OO N Co 0 Z to � cis o N C _ c a)co 'oC: 0) _ aco to N QQN +N - QN sn Q c N cO C N O O co > Co ENo > NO Co O N co'(n E .N c c CP � Q� > o m Q� : oLo 3 c 0 — >> � >, O w co0Q ^� o N Y ,� m a� cm - N Z co Q"� = Qo `m 0co o m e o m QE ) IIII m �� o � '� E > a) o � o O C J m w 'QO c � = c c J O w u, U Ceti _ - - H ._ Q vp uj CL � � ® >1 4- E � YC a) a) O U (n Z .- O cu a) Riw }' U � c -0vi W cn cU Q c4 a) � 0 5,Ut X to � >, a) co co V (n to O E o •"= � N C� a) i p i Q m a) m co O a) O c6 U U i OcuN •E E UC: d Q ftS U cu 0 - o - a) w a) cU W >, � >>— o-+ O U to U J m UCU U ca � � m CU ° � � o 0 � m m x uQ Q c C: o00 cU C: � a) m w �� `n c � a) C = L �+ ,F � = to C U L (0 a) coi ``—' o x � Q o � m E ° `u � o 0 oY m � � 0 a) EY .n uEC "_ m o Q. ❑ O I— w0- 0- = 0- > E •E G _� a) 0O ' 1313 M m M � . E CU y O m o cv -0 LM LL > cn O i �+ m o . Y c� � OCL �, i p = � E � a) � `C � N o y= �- a) O � '' > _ cu > to > U (3) t�— U cu c cu cu cu 0 of o cn (n, >cu vi v o cu cu cu m w > ° o � m O m — O 0) >+ p > > 4- cCf O p ,_ 70 to '� a) cu N 0) a) ( OV O "' L p O O a) EO a) p O y0 .� a = O (nUO � � H L O U a) cn U � U Q. O O =3 a) a) > O O a) V � � J CO A • • • • • • • • • • • • O V »»»»»»»»»»»»»»»»»»»»»»»°° LLI C N z Q cu ; a cu G U p cn a,", CIO J C Q U � m U cc CD U a) U � moo cn uJ i � cu � cu in a) C a) O a) C O Q E cc = i L O a) `: U m cn 06 E a) U > I..; C uJ E CO -� 0) a- CO ca ❑ o � E J U C (Q z oo o '� a) CD o E ic=a E ,2 E QUO m r cc U a) �� U Q Jcc 0) C -Q V '- C V Y O Q O CU cc Ox O c o aa)) 0 � cuo- 3 (n 0 U (n co a) L m L c E cn co Q o " L > L . LL fn '� cn a) E (no D- y L z a� o ° CU z NNNN Cn CD ��, _ _ ._ 0 CD CO I— • • • • • • � • • • • • • i • • • • Wa U. 1314 N 0 CL 0 +-' O a) E v 0 LLO O L N to N O L a) - L m to a) � O L N O Z oa) Lccs o '� Z c J ccs C: V cu a) > ~ O = OQ (� O_ L a) (CS J ! N J — m a) O Z Qr ,� L O O � — L (if O O Cl) N V O) E J � � o LLj 0) O = c O h Q Q p J cCo � � z iv Ea0 � U' cn Cod a1211, � *r U ULU OU W > E � Q cu I— m - ; � , a) m Q � � w o c� m O a) m O - L L a) �' m Q EO 70 a 0 m a, m V a 0 L— 0_ — C: m cn (n j V � Q s _ V O z a) O O a- Q X 'C O O 0 CO RR cn � U ca w a 3-4 1315 cn N 73 CL ui co Z cn C: cn 0 (n co X co (11 0 CD —0 cn 0 a) F= CL C� E Co — a) = cn 0 (n E F= 0 E 0 cn ac Co 0 0) CoL -(0D 0C) CL Q .0 00 > a 0 0 a _ comma F0 611,11, >,= 0 = C,� .2 u .0 rcco 0 E > CL lu- " C)_ Q_ C: CL _U) (D U) o E �2 0 C� (n (D Cf) (D N CL C)) > =ui ui Cf) (D 611,11, (D -0 a) 0 C: 0 U) Cu Ui.c: a co E CL 0 (n (n E > F= 0 E (o E :S: E CL 0 (3) 0 cn E cL L E: CL 0 uj 1 1 CDU) CD 2 2, z Co Cocn u F_Q 0Z� a) 0 0 (n C: E N 0 0 a) 4) uj 00 0 co >N C Ri 0 0 0 — co An O 0 " .0 -5 . C: 0 0 a .0 0- U) 0 E j co >N CL :tl_ ";,< a= LU a) CL C: C)_ co uj co (n co 0 uj co (n >1 (n co co CL 0 (n vi a S uj E F 0 C: X > 0 0 co >, 0 F= u �D co CL C%4 0 > > 0) a) co " Co (n 2 cu co cL E co 0 co— a) — " co > 0) V) 0 0 0 (n (D CL C: I�r .4 CL E z M W CL C: N Q. (D In > co c E E in (n U) Z CL (n — a) co co w a) a) (o U 0 0 co 0) (o 0 ui Co (n E V) c z (3) U) C) > co mm o 4 >,W E co co co 0 0 Z 0 4� Co 0 co C>: co 0 CL CL (n 2 co co 10 . " 0 CL 0 co CL 611,11, (n Co 0 CU a) 0 (n a) CL co 0 C (n W (n m (a C (a a Co co - co a) Za a) E -In CI- CL —j E N CL Cc 0, c: a) _ *0 0 a) E E CD -0 > 0 0 aO F 0 0 " a 0 = F= F= a) ai CL a 0 a) a) E > "a z O 'D (n 0 > 0 0 0 2 cL> 0 C: " X a) 0 C: w OL (6 0 > w > w E 2 2 IL co w 7 U O C 0- CM cu 70 o N c � 70 U c 7C 0)-0to 0) CU cu CU U U o to to !n cn �m E4�- = > E cn 0- cu cu c c U O w - L� cu (n � o c E, E CL W E Comoro QO cct o c cC O cu UZ > 0) �o(c6 to cu cu N❑Q E cu m cu C o f c � U C: cu _ -- t�o to o> 0 WUcu a) cu (u ( -0 in o (n E O U o CU c�O c a, OWo a) - C aU o • 7-5 cu o mUc� w cu E = cU cvo � � � U � � CU � �L �� CU cu W amcm,� .� va' E0m LUcu 0- a) � omLi m o m �- cCf o C 70 to E � to O O N o �— x� Emmo m �CU -0UE mocumL- .0) E mcu � — � � 'mo Q = m E U = E cu cu m = U C U cn _ -0 cu ° 2 cn cn W V C J V0 .....................................................................................................................................................................................................................................................................................................................................................................................................................�� a ca O O L O W R +- E co co E J �Q ° a �, O E Xt. QQ mV- ELom E_ a NEtC co = uj co CL VW � ou°i N � u°i oQ'' � o �- CL W w `0 mac " a) E c o � > a� 4 o � °o ate) ate) E ° � o Q � � � E co 'O 0 Y C 0 Q) u) O — O ° v�'i � E >, o -0 `- � a) coN > a) m � 0) cao m � ca � is � a� ocv � � oo � ax � � m ° N U E N aN ':3 R: a to N � � O � � v= O U C a) aLL:) m to E L L IMi c NI o Q QE +C14 � Co a) Q) .� O co Co C C O -�, C O C U. O Eioco � 3 ° 0 Ea) � EE E � Ec}v o ° C � cn C N c0) a) N N a) Q Q O O o C- o • c C).o E C)'o +r C � � E a) Co ComQzm ccoCo a) 0 caai Q E � QioO 0 0 ` � E mO o � � � � C Co Q > o O O E ' cm c`a c o o o � o cow �a) co o m .� C C C C 0 c0 U C a) > C — a) C a) R: O N E ° o � `� D � � ai � QQua'i � M QQ-3vi5a�iu�i OQiac � a� E ° `- K w C0 CO 0 •� p W U 0) 0 C CO m tm O C '� .� C C O L L L ciS .a Y c .N CL m co a�n' E o cc c o o > ° `� E > ° � Q= o �c Q o cn °' m � ° C m `wo ° c O >, � � � . co a o L cfl a o Q- co t� > > C � iao � > `� � �- c° y a) E ° N4- a� E Eocowo O N _ .0 Q) O C Co ° ° >, m .� ° ° >, O _O -p a) E � � � � E •m E � v > Qo E 0 > -a-co m a''i 'o o a) X O .0 O co 0 ° U O co '� E O Q Z .O o O° Q N > > 2 ofoU- CL � �a � � ( Una `- a0 � a � >_ ° oar � cv m W a = 3-6 1317 0 070 m 70 ti L _ O 70 fn .�, fn U o cCf (10 70 O c to to U U 0 7 — � (Cf � � � �� O OU z � cm LJ J a) m OU! > O c V a LJ J cn -o U U) a) - Q W U C: (n (Cf L >_ ccs cn o — > 0 U O O m � E o Q .L L (� W Rf OU m L 0 O 0 Q (Q 0) 0- p U O) ^ o Qp > � 70 —� o ° � li cfl LL � o' cv cn O cv v ai rn V > ° Q O � E m -0 m 0 � � � vi -0 � U O ccs 0' 0 O O oo EoQ C J lip 0- in ° W m -o' a) O Q aO � 5O ocu = co E E a >, E ~ Q Q L E z co O i V (n c (n A ca 0. (n O aU >, cmco W v (n -a n L , _ U � m E � � W � o ns o cn Q cu o U- > aC c Q > o o c cu � UZ � O cn a) '> _ c 'n cn >, cn = U O C N 72 N o C N — co +� a) U) to O Q.� c6 to cu E CU Q V a) p) O Cn cu N N O E x m cn c U o o cu � � = cV cu W C �o O C c6 cn A N Cy O cn O c6 c6 "- LL U to Q +- Lcn CU Q. II O o o a) cn C > a) cn O OO Lo d ZD ono E � a) C p Q a) co Q O N cn C a) CU U " "_ > "_ N N (ll y y C p OV CO O � O U CU N '' C CU � . E > � -� �� cu o cn ° � o ca O o o cn > L o — 0 o o, o , co c a ( v a`)i � m m oU � ,o co O c Q o L CM cn ,. � > > j '� 0 LL C O Q. O Q. C E E o = � r- > � t� > DL :5 c�.o o 0 — 0 � -- a m ma) 2m > oo x '� ° 8- '� (D Z °' o °' 4-- cow (ta Q 00 E a Q Q a n `- � ° � n .cn (D w a cn 11-37 18 00 i M 0 CL 0 0 0 O 0 L -Q O QL co co > a > co `i- 70 o 7 L o cu co co (a to a) ^ to ai p 0-7 a) O C-) a) U) v a) C -0 "� L c� Z 0' O J 4— O j.L L Co 70 "O a) a) O � co O j U o a) cu U F- a) a) Cp : cav � C CoS ON x '50 L C U = a) o (Cf to a �- L � C to O U co c O a) W J O = a) a) a) `� ❑ 0) N O "'" 4— a) 'Q_ co cu c W U W co O E _ � 7 C cc! 4— Z LV c cn c .� a) 4� a) cu U, O "� a) 7 Q O o 7> U) a) ° o a) co >,W O a) c� CU -0 a- co > Q D 0 > a) a) o �/� U — U ) _ v/ Q O 4— it > a) 4_ Co -� a) N U L c a) — CU cCf L O cu 4— U) CO LO -O C a) C -0 & 0 O > 'C- a) cB 0 N o cox a) � Da) 0 —a) �a) >Eto .U>)w � � 0 > � � ) o � m w a [3-8 1319 i o m M 0 E ci L o o c cu o Q �m m o v L w > O O N m C cu to O o O _ F+ - E O to O a) L Q a) '111.11l " N to L a) cc E L cu m A to N O ; `= O O O 0 cn "- o �+ O O _ � — N ._ L otS � N p .� N I— o Co vOi N ( 0 O co � - O ,� _ L W : 0 to \ O CA "' 0) Q -a.o C E u) � a�i O v � � � n n � m � m � a u � � E OU - m m c Z 'O C Q a) C L m O 0 - Z � Z O 0 O W = CA � Q OCn cn C: a CD J Z 00 Z cv O O cu O cn Lo Ea c a Q Q aoi W L /A G� Uco4- 0 U W o aa) cn W -0 N >- ,� LV U E z 0 � a. o c� cu 0 *r � E J c y o _0 o CC,. a) `t 0) cn „. 0 0 E a E a) a�'i to � � � ca c� c � � c cu s2 E cn E —� 75 o x O Q> 0 > U L- ca co W (Cf � _ coQ c """"" cn m Q _ a) �- a) U LL L: /(�Cf _ U O 0cn (Q LO U (Q i /D� uJ Q � '> = L 0 �� V cu 0 4, 0co cocn � a) EOE aa) U � U) CO L -Q � �!1 V J 0 L�/J 0 V_ z U V V 0 LLB) '� •_ L � a� ^��. //�•L� Q a� U mew X o E E 0 > u Z • � cv cv W • • • • • • a a �_Q 1320 y C6 N V J O Q- 0 N V O O a) N (n N c a) O E m " cn EQ n3 c n3 cTJ o m o (n > o E � o' > cz caQ Ems ° mQ o v) N O c0> > vOi Cf) 0 —° Q O 0)-° ca > Q� � cn >1 Q (3) > c c c L O _ U 0 is � a) � > m O ° 0 � •E Q � c ° moo 'a � � a' 10�'� � � m � coo o m E M a) '(n W W = c Q �' w ° � W � c- mU ° w � Q Z h C Z m O vU O I— `m Z Q O 4 Ea a) U 0 Q Q o a) ❑ c N ° CL U W L E ° (n Co a) V) W ° m v7 V O covim-- N � 'p O W c 0. y= V O E V N O W to N (n 0 � O O N N —0Q- 0. N c Q to O _ a) c 0 O ° (n Zco c z a) O V a) O Q E to C14 co 0 Q a) C N O Q O (n Q E O E `o Q E c co N CL N W E oo o �10 'O C 'a c (n o 2 E U p a >, m U Co c co W — .— c cm Q o w Q ° c > x c o v7 > � cn � w = � � cQaOQEa�i �° a�i ° co U ° c n3 '3 m U Q ° O O c ° n3 c n3 c .E (n c ° Z N c w 0 L- = U) O o0JoEo ° c � c ° O -� Ea' n3 > CQ c >; co .0 nc U) m -0 c a) - c (n a) c � a Q .Fa 0 >> ° o `o E > o c > ° o > UZcP (n .c vc, o _ �° E c v •o c Q z u°i m c Nco wli0 :5 0- U)W L ° Q o`_ 2Q> 0 QQ0 � cv W a E3- � 1321 i 0 CL 0 0 0 L (n cn CU C coU 0 (cQ (n (D '"' a) Z 0 `~ U a�i w -0 W aa) cu CU 0-4- O a) v�i 0 V cn Q Q J W 0- cB co cn M a)oc) 0- IL V O -0 W O m J ca C .0) Q C 0 cu 0 L Q J co '� 75 to 75 U E5 a) � O Q co C Q C (Q W E to Z w >1 � cn -0 c- 2- Q o 0 c -0 C L Z_ a—i U 0 0 (n > o a) � U N m0 o� c Q0CU o O C O = _ t� > z o Q L.L LL r LL O / W LL • E G w a 4-1 1322 m o N i cu ° ° i p O ° ° � cu E cu co co o E 7= ° cu cu CD m 4- a, N OCL CD3 c cu cu a) O U o CD cu E 0 CD t CD 'Q (� «t 0. E 0 E E a) � . C> y cB O a) O CU 3 yr � R'j O O J .,_, ,,_ � a) l i � cu m � � � � � ° ai (n Eo Em E W 0Z 0- 0) ° � � ° gym m � �� mm mE � a) � � p � a� E m � U "L O L 0— 75L O U v Z J Q v � U J Z off$ � '50O m N E a 0. LO J o � h cu cu �. i U ° `ts I— cu cu v � O m (n O W O - cn c cn co Q m _ _ E n m E cu Z cn — 0 w L. W 04 E m o co cu •� m = � n. E � O 0 0 c 'cn c o o n. Q W 0- cu m uj E J cnn Y J co c n O .Q J •++ Q �a O cm cu cu C y _ o U -a cu coi c� Q = � o �, W ca = CO co _ o E Un - O O a) J J O LO O Q U � Q Q p a N N J a) c O O m � R9 U L cu CU O m �- O a) O < O C (6 � O O a) Q O O N _ � '�� oa � Y E E E Ems° o x 0- Z Q o aaO > U) 0w a > Q CD w d 4-9 1323 M 0 CL 0 0 0 m L U a) O Y O >+ C LO CU cn cQ tin U U N _ a) cu — = 4— a) a) CU a) Q C 4— L L E cu cu O U to +- •— U -0 cn J O cu 0 O p a) a) V V 0 U 0 O O) a 0 E ate) � .� w -a `~ E a) m W a E LO _i cu � 06 `- JJ J N RT Y � W QQ �0 � � UO (Q � i U c Q o >'W can C7 U W 7 5m U))' a) o cm cu co O � Q cn O_ a) W -0L L E Q �-g a) ' a) 70 c U O L E cu -p CU u� cn > L > a) a) coco U >+ U O "a E CU -0> O (n F a) 0) >, ZEU 0 = Q > x O (Q � cv W a 1324 oo -es cp to oo �U Q Q N QI N Q O ti 17 Q y-+ E co a cu cu a) U 70 01V 0 C "— 2 cu � a) >. �-+ N Fu Q Q a) a) O E cu D V J a) a) E c ) p O O_ (Cf L 00 0 O c O wOCU cuCU _ V ~ a w � Q a _0 VW E c p m a .oa � E �, U L z ° >Q o Uc C: ❑ ,_, a) 0- � •—i A? �' > m — ''I ply Q i W cm _ F —_ _ o O L O U ° O Q � o " uj 0 a) L aa) cn cu a) �- cncu a) 70cn — o >, L 0. co com L ° a ; Lo -° > c a) I uJ a) EcnE a -o = °°cu cu a) UCO Lz U� E � � p O CD CDa_ O > Q > 2= U °AU- ° '> w a � 1325 Lf� i � N ca ) cn ,,", (B U 1 U C a) L V a) U N L J U 70 a) 4) 0 O ��, L � V a) 0- E O 00 O 0 c O _ Cuj l) O m CD CL a) Q J E —! n cu C o N cu 0 � 0 � CD L W Q Uca +-� i W75 Cl) caQ C (Cf W '„ E J m Q 0-- N Q o ate) o r) 4 U L U) U .O � O � L � (n (n > �+ _ m L -Q C Q O O L a) = Q a) ° c a) E (n — U o = c v o �Z ; 'E w O > 0- as N Q > E E o CD L cv o w a W 4-5 1326 ti LL LL cc IL 32 cn 00 00 cn b j................. C) LL O ......................................... LU CL CL > cn C) LuCU 0) C14 LU 0 (D LU m 70 0 (D N 0) a q 0 LU E (D cn (D 0 (D (D 0 L v C/) (D U) a) -o Q Q E- o) _0 (D X 4-- -0 0 0 LU -0 0 0 0 C: o (D > (D E m -0 2 C: 0 (D u) C: < o (D E 0) (D E E E CU (D >s C/) 0 0 0) — 5; 0 z 0 iz 0 0) 0- 0- 0- -o 0- 0 0- 0 > 0- 0- < 0 LU a- 327 E Care Ambulance Inc boo MEDICAL PROTOCOLS STROKE CHECKLIST FOR TRAUMA STAR Date Patient Name DOB Age P/U MM Rescue Crew / OOA '4 Weight., Helis is LASTTIME PT SEEN WITHOUT SYMPTOMS A V P U GLUCOSE (<8 FURS OR"WAKE UP STROKE") CINCINN TI Stroke Scale ✓ MEND Exam SPEECH (Check box indicating response) Only Check Box IF ABNORMAL "You can't teach an old dog new tricks" SPEECH Repeats Sentence Correctly "You can't teach an old dog new tricks" Aphasic(Wrong or Inappropriate Words) Question Patient for: Age, Month Dysarthria(Slurred or Unable to Speak) Commands:Close Eyes,Open Eyes CRANIAL NERVES CRANIAL NERVES L R Facial Droop:Show Teeth or Smile Facial Droop:Show Teeth or Smile Normal=No Facial Droop Visual Fields:Four Quadrants Abnormal=Let Sided Droop Horizontal Gaze:Side To Side Abnormal=Ektt Sided Droop LIMBS(Motor) L R LIMBS(Motor) MOTOR: Arm Drift:Close eyes,Hold both arms out Arm Drift:Close eyes,Hold both arras out Leg Drift: Opens eyes and Ift each leg separately Normal=No drift SENSORY(Ask patient to close eyes) Arms:Check sensation by touch then pinch Abnormal+Let drift or unable to move Legs:Check sensation by touch then pinch Abnormal+flight drift or unable to move COORDINATION: Arms:Finger to nose *Any falls&Glucose>60 put Trauma Star on ALERT Legs:Heel to Shin them complete MEND Exam* IV NS KVO Gauge Site Y N *Anyfalls LAUNCH Trauma Star&RAGE NEUROLOMST&Follow Telemedlclne procedure* ELEVATE HEAD 30' V N ACCEPTING NEUROLOGIST: ETA JMH: JMH Contacted y;__UJ),'_ LEAD PARAMEDIC SIGNATURE: COMMENTS: PINK TO RESCUE WHITE TO FLIGHT CREW YELLOW TO HOSPITAL MCFR-073(08/2016) STROKE CHECKLIST Dr.Julio De Pena MD LL 1328 i Ln 0 CL 0 o O O L V J � c 0 C V 0 � 0 L a CD J Ri 0. i W N N N — p a) CL N O � L � O � � O Q +r L N X ' X X O V C� a) a) a) to a) ,.r a) N m oU L0 � � 0o � � N _ Q aD O ��I�W�� X X 0 (D � p 0 mph _ �Iw all. OE to N� m Oi — all. OLmina z � Qto ' . . . . . . . . . . . . . . . a a c� a oc FF139 »»»»»»»»»»»»,�»»»»»»»»»L»»»......»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»,t,-»»»»»»»»»»»»»»»»>»»»»»»»»»»»»»»»»»»»»»»»»»»».......»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»»......»»»»»» ». N N O O O LO N 'O O_ O_ > O N p cn cn cn O Q p cn cu D CU O L Y cu (0 U (0 cu c0 L N 0) N to O Q Y p L c O O N .� CU 0) C Y U E cu CL Q� f) °; o m o 0 Oho> > o 0 CL cu � 0 � oin N N N �cu -au a0 O 0 N0 CU U N > L N C C 0) N C N Q cn O O N U O OC: Q C 'O OC: N E L (L6 .� r cu a) CUy+ y+ O � m 0 o co r� m m o ono o Q �= m co � � c� m = = caZ .� U = � L� 0 nU � = caDo � c6 cn 0) L L co m cU m cu cu U IL O � O U) C) � 0 a) O O cu cn cu F- a L a Q J `~ CU0 cn 0. G a) a) o C O U m a) o U W `5 O = _0 h 0 U aa)) aa)) cu E c 0) 0) U) = m a) a) cu Z o E V 0- CU o U U V 0) w o cu c c 0 cu o c� cn cu E .: �, o cn �Z a) O o cB � cn a) a) O cu c -o _ Z = E cn -a L cucCf can -Q L 0) � cu Z — a) E(C -0 0 > _ a) L > � O cu Q a) � � cBOO E O) O LO + L a) 70 to O C70 a) C 70 0) c �B >, a) a) cn OL X Q cu EC V N > 2) � cu — � OODCDcn Q � � < -j m W a m 5-9 1330 CV m 0 0, Q _ a is m w L Lcnm co o N N ca O N cn b,p > > � cn tc 0 Co co co _ c� Co a : co ti o > > O N Q LO Coco Q N N N N Q 0 c> co N O >CY cn O � s ^y N N O co �_ N "= U coco Lco E N Q N O O O tOn cn O co N co S .O C� co 0 Co Vco N N CoCo N �O C L > E >, N •O O - O � N O0 N cn u Co w C ca N a > (n X O cn E > = O N N — Co N O co O E O Q 0 co O co co .Q = ca c a E a) O 4 LU CO cnC� "= Q � E Em Q m }LmoQ � Q �� E M o E � mm O w j a a cn cn O � MQ � � U) 30 L-z Q 0- � Q0- ca "= � O � a m Ea Q Q V J 4) G ca F 3 U o m n co W _ m cn o a�i E Q cn p vo c J o c n co _ o = Q c>i am U 0 cu E a=i a°i 0) W >, H c U cn cuw n = am cu >, p c ° 0 � cu co _' co 0- 2 c� v cu >' r_ cn r_ cn cn '� > � C C co U = aa) = 0 Q Y o > 2 > _ — cn Q Z U r N c Z 5 O o c6 O co c o m E 0 = m c N c �{ N ccn 06 03 > o o E cu E N c OC W� v c V I— ca � -0 a � � a a 0 > o (DU) Q a) cQ -cu a a cu cn a) E � cv i.0 a 5-9 1331 N o 0 }pN � cn Z uj r I hl c IL N a �N�'Y�GI yrr7 - g /u!('aj/ ' a v r j%� 1f / f "`/r��L/>,,.,,, uj 06 CU co uj / w N re N w c IL W � tit > err W t Ju V m / CL fC �� r Z 0 i N 3—i H 3—i w !1332 M 0 CL 0 0 0 L cu c ^ La) L\L W M co 'Q a) 0 � vi W 75 C co a) to "O W Q m a) ujU 70 co O U m 00 o c a) l f) J O C) Q � a) :E N Q �Z/ - - fn C'> E j Z i 0 W L O 0) O (' Z a O cQ W cn O) U. J � co '�n ,-, N O) O ch 0 Co UcoQ c -0 ca 0-0 L a) E uj uj I— W � W co N � co Q � va) aa)) c W W Q U O ."_ Co U t z cn 0- m in O tOn a) U 0 m U - "p E a) O a) Z m L -Q C E Q O O � , O) 0. -0 � � .- a) m a) � Q 0 = >; c � 0- V � 2) 8- � O > HQ � � QJ2 -°a � � cv W a 1333 i Lf� L 70 c cu c 0 c L UCL a) O O cu a) 0) 0 (B > E O (Cf O O a) cu a) O) cu cu � = cnv aiz0U) 0. O J 00cu>, UW NO L c W z J cu ,i a) cn Q a) 4- 0. Q U a) Q U �' o w V a) t a) W cn .� p LIJ _0 O L W a) 0- o C E w a) J U (cQ (D a) a) � c 0 0) W cB W cB Q O (a uj �? 0 a) a) CO a)c .� Q > z a - Q � 0z � ' '„ U c � L CISI O 0 a) (Q O O' to -�-� -r- > �+ m L T-- 0 Q p 0 0 ] co a) > _ V .> � � O' NNN x O 4 o , w a R_A 41334 N 0 O c V N O _0 � Q N cm> L In O 0 > c 'a O O O CL a O o W O o S O 7 O V O O :=- O - > cm CO •� °0-O 0- C: 0 o O v c J cv O LU G� U O CL c O p_ a O � Q " CPcu CD a i ❑ ai O w O '� (0 i E «t U a) ool > 1- a) N � O (Q V _0 O O Q U W a) a) O .O cn O L ol CO ti O cu � a) O O O ti _ c"imOw LcnM a) �cn ;_ EQ � c� a� a�iQ O y , of 0 ca O °O .. _ O) O O O C7 (Cf -0Q � N (Q � O LA a)cCf O >+ " � _ to M YcoO Q � (Q CO U O I�wo CD O c U cm a) ww o ioi (� -a c E Q7� ioioi O y (n (n CD i�ioioiw a mum w a � � A 67 1335 i .a Cfl � o p � C V C 3 0 E cmo .0 �� K m m .r 0 0 .� E N 0 0 N o XU) E a0 p —�, o .N a Q C 0. C E '0 (M C 'i ._ � O .0 can) � U C N h '� 0. O W W (a C J I w r- O cu CL coo n acu o �' o A o Q U = cu J (aW cu ° LO "cn CL cn W 0 cu cn 4- � Q a) cn cu CIA m = cuw � o o m m � m n. � m o QU �_ F. N "U I— O `� N N Q — U _ N O ULO O N O U ' >, O �a E N CU W O U c6 O >, p — imp � � u"I�""' u� w � 75 U co Q Nam' � ' � 'w Cl cu 7t. N LLJ T N 0) C O _ 4- U N O h9 U O Qm �� - Q O i O N GD '— w O '— "" _ N �+ �+ 0 p = to Q C (6 C I- Qaa000 aQUIIIi° o 2= n O x � n. o I � cv W . . . . . a . . . . . . . F613 N O O O I— 0 co v) v cn c >+ W cc cu cn C L a�i L _ o m a, di C +�+ i U cn ° •Q cl) CD 0 N' ° N c c cu co c6 O C +' >% _ CD t cn 01 _ 0- L O c0 p N fn to Cl)cu cn U m cm C 0 V c0 �_ �' O 5, L O c0 0 i 'i c0 C O O 0 _ N cn ° N cn O U N co L �C G� N cn N O m w co co m m 0 0 _ O L L a co O C C i W = O O � 0 0 Q N co co +- cn _ O 0 L N N co U cn N U O 3 Q • U - U U c0 O E cmcu . . d- m O O O co, O La) cn n EE � ° U c0 � O cNQ>0' L _ _ L 0 O 'U cu O L � cn N o E O - N U m W cu C U cn 0Q 0-a cn cuwo L) a0C) -0 JlJL- WO v0 ~ I m 0 LU a CL a �, Q W E -0 _ i w cn h Vcn cn cn p U Q N W N U ftS U Q0 0 .� O Q cn N Q U C: U w cn 0 cn co U W cu C%jN mL x cn An E • t co c wn .c6 `nO 75 Q -075 ch w > � � — ° po � x — ° Eca O0 a)xM Q > N O N m ' O N cn O cn CU 0 cn N � � O) n n Zcp > � = Q Q a a) cn III O L I- QaWOa > � • • • • • • III w O _ • w a M M ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;,,,, Cfl 1 U w U 0 011 nll UU nll 7 IIII0111 0111 [[[[[[[[[ss>s1.. 0 x M U +' W . ^ - .Cu C N Q O '2 O 0E `OW U ) � � UU � U ) N .N .N a � O O O N _ Cl) OQEEE � co am � N .N co co cu O co 0 co O O P O cli mm E o 0 C a Q N o a I E c CL U^ Cu c: N N Q E o Co cv 'a _ O O C Co co N N 3 0 0 >, 0 Q S O cj) _ O O 0 >, Q G� m w Ri ♦/ •> O O 2 0 0 0 m Q Q a Q Q Q c E 2 2 2 2 2 2 O42 0 � N ,C O � O N ` I ♦N • m ohL QO CO, M U U W 4-0 U) 0)m 'E co Q � O fn � i LL c0 0 � > - Q6 L �' �--� Y a) L co 0) — O •� 0 Q " O U O �- � a F O L � O (� cn m = mco c . NcQ O � > 0 R O cu � U = = (n � � ` o N to d CU N Q U � > co CL z L 0 cuU O O v N co � o _ CooU) cu cn p 'X CU d-Q � > 4- c6 E UU - U fn CL a, � c E ° _ 0- x +- U �_ 4 O O = Rf CU 0 O .N OO > OW � cn mil— > v = 'L c6 0 a) 1338 i 0 1 U U O N n. U) Q N r Z cu ) roLo Nc O r IIo 00 1 i CL 0 iwwuuu .0 _ .... tl. N LL Cc O lllllp • 7 (Q "wowo m m 0 ' > wo 05 clq � ,,, a� 0 �c 0 � 0.(� w8� U U ca E Q a) v E CL C Y -1—ro 00 O 1 L 1 A,Yr ,,,,,,%,,,,,,,,;. O O \ c y 0 O O O O W .+.* — 0 Q N Q O M `- Q OL U m O o Z' 1 (n CD Z L1. � N O O O Z (U co = (D cQ W ( o N Q s-' < >+_ EL- OE-L Q m me c s-- cn . Ic 3 -a • • • Q N :,..1 v V o ,� a Q c U � •i x Q E co L V V CD O C .� N c D0 2E � W L. 0 L UE 05� U > N U U U C � o ca c a O � O � a� ° QEEE O � � o N c E L L Q O U J 0 0 In N CL m O O ch 0 cu F= U � co O m O E U W Z O — O ° N W E O U U O_ N In N O N v, Co cn� O E U � a� a � 0 � o w N Qco S m In cn 'a c0 Y W F /� E COL E m O C co a) c m > O1 C O •� O O N O O U QQ-0 QQQ L.L _ _ _ _ _ _ 1339 Lf� i ce cc> C, ` W 0. N o - i wp 4- � L a 14= Rj "aC g U f0 of r 4 C Ri 0- 0 ° > O o i O Q N V 0 O � v .Q :3 N Q Rt Ri C UCL .O cn In 0 0) O O cn ° V m � Q � ,, _ UJ _ CU 0. Y E y= c .>_ — 70 0 O cum .�..+ > �cn U O- O �FL E o =30IN. a a o o o o O m U CP > :0o o. O L 0- > c C O> w 4- O 0 0 L =3 0) E N a 0) to O � O O Z U > ° °O E,.. _ 1340 i acM 0 CL x Q C 0 O O o 'o U .0 L co cu � 9C& EEE M10 � cE ° Oco MO M c>3 m c>3 E U > M cr u Y (u to � s.. " co� N � v E ° CL° � E M, 0 ECL Q� N EQ > 00 ° a) 00 50 O � wwowo QQa QQQ V � LL. 0 i Nwowo i L LM C to = 3U > w Q Q Q O O N ca c O uwEji N 4-4 L CL Q � O 4- N C C� U N O > Y O > E N (n �' CY) L dO +1 NO I� NO o V O L O L O N m � O 4= a) v a) � E ZI O � N m M N O O N U o o N in N U n O co N " :S E Q U coo) O m ,n � -0 > � c 0 n n L [;l 41 ti i g L O, O L a) L � O' cn L a) co a) 4— v _ O a) cn " a J O 70 O� ND (� Q L >+ U O .2 a) 0 a) LU co0 O L � a � "Q O O l Q V o m u w � O W E co cu i W a) E U � - Co NE N >, W W .L Q cu O " �to Cl) � � Q � cn -0 U) E c O COco > Q L L �� O O O a) cn 0 >a) cn -p Q O Q E U U 0 U W a 6-7 1342 0 0) 0 0) 00 0 Q- > 0 0 0 (n 0 Q- Q- 0 Q- 0) C) Q- C: 0 0 Q Q- 0 Cf) R 76 0 0 Cf) 2 (3) =3 5 F 0 (3) 0) 0) 0 > 0) 0 > 0 0 Q- .C: M �Q) E Q- C3) Q 0 M- 0 M cf) 0 0 M C: = Q (n Cf) 0 (3) (3) 4-5 0) M M Cf) Cf) (3) 0 M C: Q- M Q M U) M M (3) x (3) (3) 0)(o Q- M 0 0 Cf) E (n M M CL Cf) (3) (3) 0 U) M 0 0) M —0 U) o 2, M M (3) -C)- 0 (3) CL M M (n 0 U) 0 0 E E M >,U, u-0 ) • c c:) Ica (3) >, cf) U) 0 0 U) M E = F= aco 0 0 > U) U) C3) (3) C,) C: (3) x M 0) 0) 0 C: 0 M 0 E 0 0 Cl- 0 z-- 0 0 — 2 Cc: o >"C: 0 a) 0 0 1�5 cf) M M (3) 0 0) 0 " (3) (U 0 (1) C: C: (3) =3 0 0 0 C� C3) E 0- > 0- U) 0 0 11-- 175—0- -1 a x a 0 0 x 0 0 < a 0 0 0 4� C: LU LO C: ca a0 (n 0 (n CL C: E CU cu(n > 0 E Fn (n �m cc CL E m E :tt CU CU 0 w ui cn cn C: 4— ui a) 0 (n Q. CU CC 0 (n cn cu LU =3 z (n E (n O 8 0- a E E E 2 Lq M = C%j LO cu C%j 0 cu 0-.r- 0 cu cu (D cn E C: (N a) 0 cu 0 i� tm CO CU 29 r_ cu CU o- c: E 0) to 2) E P .C: cu tm cu cu L) Am 0- a) tm 0 C: > cu c: - k �-- co c cu E CD C-) CU 0 0 cu 0- cn cn C:> 7t..! z I 'co co w L- o 0 2 N E r (n > >, -a .N a) a) cn C: —a) a) E Au a) t-- a) t-- . — x �s 2 a 8- C: t5 0 0 0 0 0 4) 0 = m > CD 0- Q co E G C) z C: cn ch w CL F(13A43 c O IN I N O >, >, CD co � L cu 70 °o 0 U) O c E O Y CU co O uJ z L'� Vi.I.m CL 70 \ a- L O Co E 0 O cu III __ > O X J III � � 0 � �a� 0 OUOwD- U) w O mom000000n � ' '�` N ��r o E a° „ � , U u O O T— > A > A ,,, i T— CD CO CD LAJ C (if (if Q.T orf ry _ MO -t -t L. M M c N N cn o U `n co E > w _ O O U c O � U ccnn V O c z c N a) C � .N a) coN Q ca )CD O DOOO O0O CL >1 Q E Y N N F N c' � � a) w�w LL m m y E Un a- O W CD co I co O U is O O +- O& O ¢n C O (/1 N - cmc O Op 70 Un C a) > o O co 7 a) �- U O O Q 4 �- O a) a Q Z OCo ,� �-' CD co c o 0 O O + Qr Q C to co d > ca CD �' ma) a) a) — 2LL > Q-' Z 0) O E . . . . . a co > 1344 0 Oc o 0 0 m ca v o w rn M > a) o Q= Q LL Q 4 O O ILL O a) N N a Q O) Z E .21 L V a) N J a) Q O O =3 U. ca -0 W E O _ CU � U U. V C O a) Q S N v 'Z3 LU 0 W o U 0 LCL C J p cn U. ca 0 0 , Rio w Q L +; W Q a) m � U 0 U V O Q O LLI O U V ca _ ID Ja) � IE- a) D W c Q Q cu O O = E a) aa) U CU �' O Q O a) V .a �+ O W O L a) �L -0 U U = E � L -0 _ p o o a) y= aD •. o o 0- = E O c s N O cn ca ''' = o'� � cLc (D O a) U o ) U L E 0 -0 -0 a) Z ) > .O V O 'p a) cu cacu = O L. a- a- V J (n H V Ri Ri E < Z = 4 E cQ • • LV • • • aD N = cv a ... c� 6-10 1345 E Care Ambulance Inc CD MEDICAL PROTOCOLS CRITERIAMCFR PEDIATRIC TRAUMA Date__ _Cre _r_ _ Launch Trauma Star and relay: Pediatric Pt Name DOB Age COCA#-, MOI; Time of Injury ,PfU MM Rescue Unit## Weight: Heli pot: " w ANY ONE =TRAUMA ALERT on khq�L�Le Qoa AIRWAY Active Airway Assistance' OR Respiratory Rate<20(Infant<lyr) ❑ Respiratory Rate< 10 Child'I r-15 r CIRCULATION Faint or NON-Palpable Carotid or Femoral Pulse OR Systolic BP< 50 ❑ DISABILITY Altered Mental Status2 OR e PARALYSIS e Suspicion of Spinal Cord injury [) Loss of Sensation e 2nd or 3rd Degree Burns? 10%TSSA " Amputation at or above the Wrist or Ankle SOFT TISSUE " Any Penetrating injury to the dead, Neck, or Torso3 ❑ s CSW or Penetrating injury to Extremities at or above Knee or Elbow e Chest Wall instability or Deformity(Flail Chest) e Major Soft Tissue Disruption 3 0 Major Avulsion of Skin e Major De-Gloving LONG BONE Open Long Bone OR Multiple Dislocations or Fracture Sites ❑ FX/SKEI...ETAI.... " Severe Facial injury/Fractures w/potential Airway Compromise e Electrocution or Lightning injury w/LOC or Visible Signs of injury e Blunt ABD or Chest trauma in patient w/ HY of Paralysis MECHANISM (Paraplegia/Quadriplegia) OF INJURY " Ejection from Automobile, Motorcycle,Golf Cart or Horse " Blunt Head, Chest or ABD Trauma in Patients on Anticoagulants e Auto vs Pedestrian/Bicyclist,Thrown, Run Over or wl impact>20 MPH ANY MQ=T UMA ALERT lonly choose tol SIZE Weight<20 kg ❑ CIRCULATION Radial or Pedal Pulse not Palpable OR Systolic BP<90 DISABILITY Amnesia or Loss of Consciousness ❑ SOFT TISSUE GSW or Penetrating injury below the Elbow or Knee ❑ LONG BONE Single Long Bone Fracture Site or Dislocation ❑ FX/SELETAL e Death in Same Passenger Compartment MECHANISM " Intrusion, including Roof>12 inches on Occupant Site or> 18 inches of Any ❑ OF INJURY Site into Passenger Compartment. e Fall> 10 Feet OR 2-3 Times the height of the Child Ifabove criteria are neat met&patient condition warrants a trauma alert.Select paramedic judgment,include brief description. Paramedic Judgment: Cl 1.Airway assistance includes manual jaw thrust continuous suctioning,or use of other adjuncts to assist ventilatory efforts. 2.Altered mental states include drowsiness,lethargy,inability to follow commands,unresponsiveness to voice&total unresponsiveness 3.Excluding superficial wounds in which the depth of the wound can be determined. 4.Long bone fracture sites are defined as the(1)shaft of the humerus,(2)radius and ulna,(3)femur,(4)tibia and fibula. COMMENTS; **CALL NICKLAUS CHILDRENS W/PT REPORT 305-003-85 0***ATI"ACH CODE SUMMARY*** PINK-RESCUE WHITE-FLIGHT CREW YELLOW-TRAUMA CENTER MCFRF-097(09/2016) Dr.Julio De Pena MD Revised 11-01-22 TRAUMA CRITERIA FORM - IIII' IIGIII ""II7IIIZC III I'=viisb=:a 1346 O 0 7 N > ~ o �. ca W O s. O U) CL p c Q o N 0 a) 3 Y O - -i o U) -a a) 0 Q O uj J 0 CD � to O_ � U •- ° O CZ s a) V +� a) L o Y 0 Q a) O a) O 0 v 3 � uj cuCU aLU v ) o x j= as W cu a) o cu m cn L �. O L 0 3 O W O �- 0. U N CL O I a cu •— -a � O Q0 2 a) aa)) a) W = L O N _ cu "O �— V E Q 0 � � � a) cu O O L a) U v � ca c�Ea O Ln � o >; L .i W C Z a) O � •0 '0 Q U V U) �- p a) a) cu CU -a k LU W v v m v c aa)) aa)) > - > O p ++ -p cn s c7 � 00 O N a) a) () uj L cu .-, �' W O E � � � 'L0 a) aa)) i `0 W O O a) o ca L -FU y O .-, s O O CL O 0 ,,,,, a) L cu O) a) c� � a. m m N +.� O a) ` a) C � E O s a) a) >, a) 0 ca >+ a)�C «3 a) LLJ 0 V L .� a) c a) O z 0 ^�x♦♦ a) ca = a) � c cu - �Q> -a O_ a) E a) cu c � cu a> E '2 -W = moo E3: < < > U ¢ E q2 O a w a .° a E6-P, 347 3 � ( (6 & $ 7 0 k o 0 2 2 2 ° @ ƒ § c ± o U 0 � / a) 0 k E@ 2 6 20 � ƒ 2 L. E — 0 ao 2 o E @ E o 2 0 0 ci cn @ @ E E E 0-. 'm 0 3 0 0 x o ' E 2 0 $ ocncn ® @ 0- E :^ E @ § 2 f c 0 Q \ k k R / o \ LU « 22 2 CL (D' � # n � I . E J E Z L k � W \ J _0 � UJ m 2 c � cu 0 ¢ 2 E Q @ 0 \ 0 � \ t Cl) E 0 U U 0 c 7 0 2 W E cu 2 o O o � @ -0 o CD � CD � � ) c o c m n £ o o .o Q ° E c @ k ccu J @ CD @ @ E m � 2 � � � @ _ � '0 -0 -0 _0 2 § 2 2 / / @ c c @ _ @ � cn o 2 0 § > § � CU 0- (3) cu (3) 3 U > k .§ § o ƒ XQL @ x � # n � @ @ \ S ® @ ® m ? @ ¢ 0 L o L- o c � @ @ $ 7 0 / CU 2 2 / v o cu � \ \ \ E % .g -0 ° r / cn 0- �_ § E � � cu 0- 0 2 0 7 7 § § § k $ EEE k 22 E 0 § L. m o 0 0 \ ' a. � kk@ k0 @ 2 2 2 2 # n CN W 6D4 � 1348 (N ry 0 CL 0 0 0 W J Q W I� v U) O JZe U -0 0 v Lu CL W J E Ri Z C7 E 0cn 0 W W ill in V ui h m Q W Z C m Q p m O > i W � W cn C) W C) o O Q C7 o p c? aco E asp .vim C O 'O • Z 0. E6-R2 1349 M c o cu . E 0 tn a' O cn O c ?; 810 uu 8 .w0 tea) o0 0 o O �= CID � U a�cr aci c' ' � U m``cn c � � �. w U Q ,o LLU ' W � co Q c oco M CDc� � o U ((n Q) ° m U o _ o a Co U _ i U C) v %C t c Q C� M .F CL 0) ; _ z cE� t CG O a)U te(� a) U Q W z Q Cn ° o (n >' i a) cu M a) >' 0 -0 W U .? o L ca �, U ca J UE �0 a) a) a U O c cn ca U O � c (n a) > L ca U O O U L U O to C- ca O O U (p —� -0 a) =3 z a) LLI c � c- E O � O 0. a) O c — ca U : a) 0 z J O Q U zcliN - O J u 70 cv (73 ( a) U U o LL� o � o E6R-3 1350 i c C6 CLM C E V� c INtc t O,E E � Qii � :w ' CL c � > � di CL > rya o CL r� w (D Q , 0 41 0 c c o u ^� - as Lu t� aoua41 C w CL � � u > 0 � L � � -a >._ C) W uj � Z0 L QD n U � ui c M s U. W c ea co O LL C a0E QW qr Ca 0 , c �+ CL o c � 1` i o � «i ' U W W J E y, Z CL wa" r - E u 0 E 0. CL p' Ql 9�' ^2 1i 4J? o 6 R-4 1351 LO i 0 N X CL _ L 0 co O E 0 0 0 0 0 0 CN �+ i CO CO U-) U-) d' M X 0 0000000000000 00 0 Zi co O a) � co L : QLu 0 to + 0 (D O Z E O c o o o o 00 LU-) a 0 + O N = \ MLn000 O N t� CN000c 00000 oo � �z 0 co i C M O N �• o Cc w c CWj co co a � > Ri Z 0 O cr Q W cn U W E W co 0 y Q U. CD .�+ Q W .� O c y 3 U . o _0 O 2 O LV U a v O N W OOOONd' QONC 0 It d- mmmr-- r-- F- 0000rnrn a) Q y Z U.ai 0 O U) +r cn O �_ U) ' � U a) NLo OMLn0Ln00 70 O C V z M COOO � � � NNM O d ,� O U) � o J U Q a) E > ca L L L L L co co a) E E O O cB cB cCf cCf cCf a) a) 3: a) E E �+ �+ �+ �+ �+�CV O 6-R5 1352 Q 0 co 0 C 70 :m:: C o..a) of c V 0 r.+ cn U) m Ectz L ca L O m z co .C: c� O CD cu cn E 70 c CDcn cn L — A C O U 0 (Cf _0 'O m V a) -0 ( ^ ( w a) a) JCL U a) O O •� Ocn 0 Co L cn _ a O m � o o� �> a) cLaw O Q EQ aui -00co co0c cDL Q O c o cu 0. U L —� co L in 0m a) A CD a) Q W "- a) � c � �" a) a) Q LV �� 0— � � 0 0 cB c75; cn 0 -00 0 : mac ( " ° z a) co � 5 �C c� a> >, „,, : 0- L O O m O cn : CL C —Co 0 >, m i o N 0- 0 0 0 = a) , c a) Q O C cOn C cn ,_ "— O O U �-' (Cf a) V Mn ® .L 0 U a) `IV c O E L m Q cB cn U m a)5 -c a) E a) L .— .5 co -0 O 0- cB Co Co Co � X _ -� OL > OL 0 > E S Q _ E a� L � a W F71 53 I� a) � QFo u aa) 0 (6 N C N C O 0 O'O � N i � 0 w cu 4 W L W (1) ci3 W a) ~ Q � ,,,,,,,,, Z cn L Cl) 70 a) cV m O h a) o � � Q h cu z � O a) a) m w z ( cu C� 0 0 � a oa) L cUo z E J � O a 0 .- CD UJ QL z C m,mum, _ L cn klllllll ZZ 0-W � L cn CD C C (n -0 0) =3 _0 -0 V LV Q V a) co V cu N „X c L •� O a) < L > +-� a) ...r uVM r a) cp cn �: a) E N -o a) .Ln cn cn a) cn a) cn > > _ o cn > � c 0- M 0M z a<<oma > w a F57� 4 ------------------------------------ 0 c1r) a) (3) a) (3) LU .S cu U) 0 0 E 0 0 0 CIL z w 0 cu cu cu .2 011 E 0,6 0) 0') 04 cu a) a) a) (n CD L_ 0 _L =01 0 z o"i CU cu E c 0 C14 04 C) 0 0 cn cu 00 LE 70 csi a) a) 0 a) 00 E cn 4— z ,j cu 0 cz O R a)0) 4w I E CU CU o CU C: , CL >. a) Z 0 a) 0) > 0 0 70 U. cu UJ cn o 0 a) a) QU o E Lu a) u U cu a) >_ > a) 0 CIO Q) 0 cu -0 75 -0 12 Lu 0 Z 4— a) 0 cn 0 06 0 0) (1) a cz Z w CIO 0) 0 i 0 a) CZ CU cn 0 i V $a, 0 CZ 0) a) Wo cn cz cu cu a) cn cu > 0 4". cn a) 0 C 0 cn 0 0 a) a) 3: 0 uJ > uj CU 0 CD Z CD a) CL cn c: E LU cn =3 cu CIO (n 0 a) 70 _0 z > cu a) CD cu 0 ch c: a) (A a) a) a I uJ(n c: C 0- > 1.1c, a) CD x a) a) a) 4— (0 cn 0 0 cu cn cu 0 A 0 0 w m X E c: a") UJ (n 0 X a) 0 m a) _0 C: w a) co =3 Z a) E m 0) -0 a) U. 0 0 -0 4— cn a) 0 06 LLJ (n cn >.. .............. a o ou a) 0 c: i I a) U) w CU a) :3 (n M o C: CU 2= ............. a) > 0 z 4— C14 70 a) 00 0 Fn a) — E 70 0, a) w cu 0 a) bb �z Z L) C) V) a) cu a) 0 0 z 0 0 cn CU 0 0 CU " -0 0 A cu cn _0 2 10, a) CU 0 (n O a) (AC: N01) 1111eLU cnC: >, e cu CA c a) 1 0) 700 cu E (n a) a) cn a) 0 cu a) z 0 CU CU E a) L_ O)o 40— 0 LO E a) cu cu CD LO cu cu (n :3 > CU 0 a) In oi uj a -0 C: > CU Cf) 0) UJ _0 a) 0- CM CD CD CD cu 75 0 U) 0 CO 0 E cn 04 F_ CA to 0 a) > CU > C� 2= 70 E 0 0 cu z 4w @ M 0 75 a) 0 D_ (D 0 a) LU 0 c- a) oo m - > 0- c) CO 2= 70 — 06 w m CD a) o CL a) C: -00 -0 a) >, z 5; 0) _ a) a) — o X 0-0 F_ im 0 im > 2 w a) 70 ti -C c 4� Co Cl) CL cl) m .4� -�e 0 C.) 70 0 0 L) a) a) =3 (D 0) Cl) a) CL 70 (D Co a) 0 a) F .2 D E 0 Z% �p E m §� c 0 CD C� 0 a) 0 _0 _0 m C-) a) a) L- -§� L- cn a) 0 =3 a) > Cl) 0 -2 = _0 r_ -�e 0 cn cn :t-- U 0 U cn 0 m =3 Co Q 0 m cn 0 CD 0- U m =3 E cn a) m 0 a) U x m x m o Fu -,,e .§ —c z cL cnE a) 0 a) c Lf c .0 E 0 o) a)0 0 a C-) _,�e 4- -§� �:, CL 0 0 =3 CD cn U 0 S2 L- _0 L- .- a) m a) a) -0 Co a) cn -§� = a) 0 L- Co .62 a) Fu c c W 0 U. 2! E o L- cl) -C E 0 0 0 t m Cl) o .- .4� 0- a) co x T- L- -�e - L- �5 -a c a) a) cu D- U -�e -§� -C uj CL c a) o 0 70 F- > a) c-) 0 CD UJ a) c C-) z E cu a) c a) Z E o m 0- Co 0 -�e r- CD CD CL a) X E 0-"- a) lz c a) UJ 1 a) c-) C-) z r- ;-, c CL uj a) 0 0) U m Co 4-- 0 -§-� Co Co 0 z 0 f� c c — m a) 4-- C)_ r_ a) -C a) 0- — C 0 cn 0 0. E _0 a) L- o o a) a) uj > -0 ai 0 f - Cl) cn 6� FO 0 0 0 c -1� .- — a) 70 0 Co > C: 0 75 a) U LL- 70 a) — cn 6- a) -0 a) -2) , E c cn -§� a) 00 C " XO) WEEc .Tw cn a) ` cu 0 co c- =3 cu cn cl) o E a) 'c x X C_) L- cn c 0 -0 E 0 a) — E QC = Ec =3 m W :t:! cu = m -0 T -r- = -075 U 0 &- .2 0 C 4-- a) 4-- 1., co x 0 o a) E .2 cn ci) L- cn -§� - m 0- a) a) -t 0 w = o = 0 cr x U 4Z 0 C 0 0 M 0 0 0 C 4-- a) 0 E w E 0 a) 0- a) :t-- a) a) c-) cD > .> a) a) >, 0- 0- cD cL L- 0 = — - L- > cn U C E C-) 4 w w w w > > c 0 o 0 o cn cn CD a- -0 z 0) 0 m m 0- a- m m Im cn Vr L 0- 0- a) E E a) 0 ku Cl a) a) m m r- cn L- r r x %-- — -t:! E c 0- �? .§�0 a) a) - = a) -C 0 M r F17 356 � � a � - � t k E \ \ ƒ Co 0- ® E ± � §0 0- m » o O (n _ / 0) c: � k @ Co . = 7 E Co % 2 E o ® ® ° ° E 'k 0 8 ¢ ° / \ / Co E ƒ o E § f f m U % § .q -0 E 2 \ / .§ o [ @ .§ E @ @ 2 2 a 2 � $ �7 � q § 2 = o O 3 3 k \ / WW) q M q _ \ \ k k § Q / \ / / / = e � ® _ ' 0 2 § C 2 W 0 § \ ® E Co\ V O E -o @ q / Q _E0 � E � ° 7 a3 CO / � 0 U ._ ¥_ 2 Cl) m 3 E Q z / ® E 2 .§ m Q E 2 @ f \ ) � ? Z o « O ¢ o 2 m / \ co % 6 7 § @ ❑ \ \ \\ CO ƒ � Cof o .3 ° m — _ 70 3 \ \ � k \ \ k � k CD uj U) a) @ \ 2 ® § \ 2 Co J v 2 Cl) _m '- o 0@ % 2 2 O U / .\ 2 .§ .k S Q . 0 M q _ 3 \ \ 2 0 ) p Co m m � - a� � mt k / § ® E Q § 0- § £ \ ® o 2 c E § t e \ ® _ 0- 0 & .E t� k 2 m m § � I ) a ® E 2 � co m m � p m 'k 0 c -0 . � / � �f � \ � \ f 7 � coQ @ — @ m -a m m — ._ _ @@ cn o £ � -a � q2 \ � c k 0 § ® k k \ U ° @ o CA Co cn � Q_ 2 / / @ @ # 2 @ c K / Ecn 0 c_ c �2 .g E \ 7 & _ I E 0 a § g @ .§ '@ E E E� \ 3 cn § 0- 0 $ cn 2 @ @ @ o 'e 'e 'e \ �.� / E £ @ E cn o \ \ \ ° 2 2 @ § $ cu $ § ■ ® ® @ c o o o @ @ ch o � � .� @ r- ,U5 p ccc@ £ 2 \ E@ — 2 .0 ■ @ @ @ @ $ $ $ ® @ c 0- 0 E @ § 3 x ® E a. 0- 0- 0- 0 o ' o E 0 0 £ o - 2 2 o 0000 2222 00 z OJ L22 � q M q _ # nq _ LO # nq _ CDLO # nq _ 1357 cC U � Q cr a `r O Q ct can — O cr ' ct �M R cr o Q a) o R cr . . U o. U w � o a � U 00 W c � c � L U w o M � . Z >,� J c� o o (D o E a � (nO N m �_ �- QU c ca coilU— O cu o ❑ cn cn E a) W cn W � c W o o .m o m � ,_ m m o cu co Z cn �- U xx > cuQ W co E cQLO O v o cu E c uj a� 0 0 o f co E _ pa1 cn = An Q cu N O O N o U � C > � � co o � � cn a) W _c cu cn> O a) U , o (D ai n 'c o > _ W _ ca n A -a cu Qoco �co ) a) o o nms E cn � �' m m cU � 0) -a L o � � c� cYi Q o a) co E � U = tea) -a � c � Z U cn o U = 0 - � — � U Q O O o °n' � Cl) > n O cn O Q U m cu U U o o v c = c = Ecn cnO> m m �' _ Tic cn 0 cn z o = 0 o ._ cu E — Z o � cnaaCDO > C� a a '� M �O > o x mcu o `f' d "= Q ..J cnU W d Tr, 1358 ti i ti 0 CL 0 0 cn a) o Q cn 0 coo o m cu 0 � Q m O ° 8 a) -0 E 0 cn >, a) Z cn cn > o cu m cn rn E c U) 0- E Cl)cu ao aa) m >, cn 0 c _ W c co � U <C F— a) z LLI -a �, 0 _0Q t O E p a) a) E cu o a) a ° o cu 0 m � Os � Q � U mm coQ U -a >, o > Q U o E caw p o cn uvi Q O L � ' cn i ❑ >1 W ai m cn � a) 0 ' Lu cu Q U � zQz � � a) 0C a) (D cU QO co E 0) v . cn > W � � � mo Cc: -� � Lo mQ m O > a) a) m c c � Q o a) o k��ll�w (D h � a ° a) E � U) v ,cno o ' _ _ •; � .� •- wuuw L L o EL co z >, cB 'a > a � s_ E s_ M> V i— cn w a — E7 1359 ,,,,,, .. C76 M > o O ' ca (n O Qf O L L o a) '> � ^' a) p\ c O ape W '> � CU e y— 0 U E 0. L 0 a) O O) 0 0 c i CU p _ -0 0) (n U Q 0 0cu E > 0 0 0 U 0 (n 0L 0 ° t- n E (n L U � •cQ U 0--0 _ cu a) U p O ccs 0 cu 0co X 0) _ 0 a) 0) a) m � � � 0 cv -j � a) a) > 0 -0 E _ � �) Q. � cu � LOc � 'E5 � 0mmmM a) CU cv o CU .O p W O W = Q U Q . W (n c W in E U cu • • • • • • 0_ CU • — O � V Q 00 «t O c cu > Z � a E °' - E J cB N aa)) .., o °� W L Q U L) o y > cn 0 W O (n L Q U � 0 - J � 0" aE) 0_ CU a) N L L p c cu 0 F v E W e L 0 J 0 p c (n O E _0 (B a) > L .0 I= cn OE � a) > _ L (CS C Q a) (Q 0_ 0_ D. cu cQ -p 0 a) W CU O) E � O cu m � � >, C,(n L 0 E �' U O 0 0. -a (D 4- 0_ Z p p � CU 0)W 0 cQ W •-' _ c 0 a) 0 W "p CU -0cu a) U cl, to a) (n 0 �; cn O 0 o � q ; cad �cn X :. �, -0 � � � cn � �cn � � Ov) cn � pww0E CU .v) 00_0 L m cB Q 0 > a) s W -0 0 0 a) (n (n m 2 � 0 0cn � —� O � � 0 � � 0 L- 0 � � 0 Q U 0 a) z L U (n G ca ,_, > > ''' a) c 0 '� 0 L ',, m a W a0i 6)•- � 0 a) ,a) 0 u) O a)) > O > •� W O a) 0 0 E L cB 0 cB L -0 (n 0 a) o � 0 > W CU c- � E 0 -a (n CO p C Q O p ,o E 0 0 0_ ;� L p a) a) c 0) a) E co g N 0 L C �' -0 -0 (n C cB v 0 >, a) p W N cp a) ca a) cpi .c > _ CU >� cB > 2) � `ILOt Z upi O L z I— • • • • • • • • J • • Z • • • • • • • W w a m o a 7-8 1360 i ti 0 CL 0 cn 7 o O 0 70 ccu a) cu cu a) a) cu L � � Q cn cucn O a) co a) 70 4- U O L O v a) a) v 0) W m UO a) a) ar °�,' o OAS C 70 N OL c (Q CL X Ri 0 a) 0 � _ O O Q 0 E E -O � a) '-' � ca c a) z O � J � L cn (Q _ � U w O U ca O � -0 O J _ U .y RiW 0 C � � w E 0 U � c � > a) -o cn - W U CO >' L a) W Q .F, L cu Q L cn E a) cu > Z � O _ a) to O p 4) 0. cB Co m Q c O >+"� " Z - cuO z ate) c 2 .cu >.. 'O s o °o a) O cu 0 "O U a) _ �(O a) c 'O Z+O n O —Co _0 W co = N0 c cn Xa) 0) a) E O a) Zcu >O a) 5 O 0- � _ C ( � o � �0 > � Q a) N a) � I— • • • • • • • • 0 CU • • • W a N � o U- ca 7 1361 0 ti oc c � 70 om ca v o a CD a) rn > -0 O = Q -a li Q U s LL � a E CD Q a) L V ti cu y y Q vCD ) ca y a) a) _ CD L Q O cu O H E (n W CU (0 = "a CD 0 E p V �O a) = CDi C O T a) cu C � " � ELL = '� V a L j " Q CD a, w L W L W C Q � a O L co � � '� I Q Ri W V O a) O O m 2 YCL0 cu - E E a) a) � - o � � o CD a) (Q a) 0 a) N Q D o) cn E cQ L a) M U � U a) _ _ i w � � E � L° o " Q = a�i E— a) 0 o a) c° CD o o � � � = E VV Lri cn � ) = � = Q O a) "O a) U L E V �2 O -p = a) -p > O V V —O �-, O a) O M O �.. oi U � cu a CD �., � U � � J ) v cv cv E = CD [7:- 0 1362 CD E Care Ambulance Inc MEDICAL PROTOCOL MCFR ADULT TRAUMA CRITERIA FORM Date Crew Launch 'Trauma Star and relay, Patient Name DOB Age— OCA#: MOI: Time of Injury Plu MM Rescue Unit#— Weight: Helispot: [G:C] ANY ONE =TRAUMA-ALERT-Loly-c-hoose o-n-2.1 AIRWAY Active Airway Assistance' OR Respiratory Rate< 10 or>29 1:1 CIRCULATION No Radial Pulse BP<90 OR BP< 110 in Patient over 65 y/o ❑ DISABILITY GCS< 130 PARALYSIS Suspicion of Spinal Cord injury Loss of Sensation ❑ 0 2nd or 3rd Degree Burns� 15%TBSA e Amputation at or above the Wrist or Ankle I SOFT TISSUE " Any Penetrating injury to the Head, Neck,or Tors02 L1 * GSW or Penetrating injury to Extremities at or above Knee or Elbovv e Chest Wall instability or Deformity(Flail Chest) @ Crushed, Mangled, De-gloved or Pulseless Extremity LONG BTUONE 2 or more Long Bone Fractures3 FRACRES , Severe Facial injury/Fractures w/potential Airway Compromise * Electrocution or Lightning injury wl LOC or Visible Signs of injury MECHANISM - Blunt ABD or Chest trauma in patient w/ HX of Paralysis El OF INJURY (Paraplegia/Quadriplegia) * Pregnancy>20 weeks w/ABD pain and Blunt Trauma ANY TWO=TRAUMA ALERT (only choose two) CIRCULATION Patients w/Renal Failure on Dialysis El DISABILITY Head injury w/LOC,Amnesia or New Altered Mental Status El SOFT TISSUE 9 Soft Tissue Loss injury(crush, de-gloving)or Deep Flap Avulsion > 5 inch , Penetrating injury to the Extremities Distal to the Elbow or Knee El LONG ONE Single Long Bone Fracture due to MVC or in a Patient on Anticoagulants El FRACTURES 55 Years Old ❑ Ejection from Automobile, Motorcycle, Golf Cart or Horse Blunt Head,Chest or ABD Trauma in Patients on Anticoagulants Death in Same Passenger Compartment MECHANISM e Intrusion, including Roof>12 inches on Occupant Site or> 18 inches of Any ❑ OF INJURY Site into Passenger Compartment. e Fall > 10 Feet e Auto vs Pedestrian/Bicyclist,Thrown, Run Over or w/impact> 20 MPH . 0 Motorcycle, Golf Cart or ATV Crash> 20 MPH If above criteria are not met&patient condition warrants a trauma alert.Select paramedic judgment,include brief description. Paramedic Judgment: ❑ 1.Airway assistance includes manual jaw thrust,continuous suctioning,or use of other adjuncts to assist ventilatory efforts. 2.Excluding superficial wounds in which the depth of wound can be determined. 3.Long bone fracture sites are defined as the(I)shaft of the humerus,(2)radius and ulna,(3)femur,(4)tibia and fibula COMMENTS: ***CALL RYDER W/PT REPORT 305-585-1148*"ATTACH CODE SUMMARY*** PINK-RESCUE WHITE- FLIGHT CREW YELLOW-TRAUMA CENTER MCFRF—096(09/2016) Dr.Julio De Pena MD TRAUMA CRITERIA FORM Revised 11-01-22 7 10 iRevised 1363 Oc ai a� > ... � 4' co a C _0 +' O � c C fd yrl d o aa) o � 0 N to �j/y / fU C O N O N O / '- L 4a N L % i / (6 O tJ FCL - O a) N v w O c / a) a) E "I"' 7 N � (6 > N X dA 4- - O V N 0 cc �,,ti,,,, t6 -a t6 in O L LO c tw +a Q cu v N p O w Ld :I.. O to m 4- m (6 O L r,., Ark r i > Q N a) -C U (6 L) -C a) L V N ta N o O c -C c O 11 r- O w C� Jcq tw w C _ W 00 9 O Q c6 tw 7 a) CL E J o o �' o s a) D m U CO *, o ° > 0 Q ca ❑ c r+ � N � � o 0 0 0 � p U W 0, -a c =a o ca N � o m c W cca o Ln `� a� > >� c +� +, W A 4- c L c c Q) c 0 O c +� � +� +� 0 0 O w E m 0 c c -a 4, w U m vi cca O C'J w N a1 }+ N In y� (� C O No Lu vOi CL m Q "a m 4I a) I, a) O C6 .I., to 4- to > F+ c C6 j6 O C 4- I- C = O C V O O c c 4- O `a' ++ L W tw � T_S (� m -0 C6 L O m O O "N O O O C N "C O C w m N � a� a�i Sao c H n o o > a0,o O CL L N - O w m a) O N a) I, N -0 in O -0 c "c6 ca ao .�_ a) O u a) Q c -a II asi Q v o c a0o �, � o _ I- Q -a o- to -i c� O m C'7 ca Q � � O � � L •� .� O V a) ++ • • V • • • • • • • • • W m a) C d U G. 1364 i 00 O � .N CL 0) a) a) m > a� cu 0 m m � > E CL N 0 N a) cno V cn E N N cu m o CL O N C U a) E U) c N !+ 7 0_ .F O (u cu N > C a) co _0 'a C � N N a) E Z cu � X i 0 cu a) m _0 O 0 a) cn L 0 co 0 L a) a) � L E c CL CL a) cu 0) > cu C) W 0 `-- a) _0 'C 'L V � O cif _ 0_ U ❑ N 2 c can � c � m W W V L) 0 L 0 ,0 N U C 70 cu � Cl) 0 t/) W O Q N a) a) a) a) Cl)a C J c 0) a) 4- a) C L i 0 c L .N W m .4+ L 'S cu 'E > L cn W U as m L- a) cn0a) Z W s cn c _0 a) N a) Ov �— .� m cu _0 0) � a) m cn c M E cn U L _0 O w 4-- U cu —0 C —0 C.) v _ 0 � p 0 0 a) U a) c 0) 0 m 0 70 0_ 'C a) N L cu �Cl) Cl) a C.) O 4 � Cl) O O cn a- cn 0_ cu L O L CL 0 L a) a) - � 'S a) L _� N O a > a) fn a) Co 0_ = c r- a) a) cn '''' 0 L 0) V cu `� O cu 'C IS v O_ c� a) L a) in v �' 0) C� L O0 V cL)> .L cn 4) O OJaQ O � m0 � � `- U) O E N C O • • • • • • • • • • _ _ W cn F81316]5 2:1 n. 0 C: cu 5 0 cu x C: QL 0 C: 4— 4— 0 C: 0 0 0 L— 0 0 (n 4? (n -0 cu 2 C: a .L) C: cu C: C: 0) 0 9) 0 cu E 0- cu (n cu — 0- (n x cu cu 0 p C: -a p > C: 0- 0- -a C: co C: 10 t. (6 cu C a 0 cu c CU E CU 0 cu cu E (n cu CO C: 0 > a) = .0 0 CU — cu > .(U cu CU cu cu -0 (D C: CU (n 0 (n 0) 0 C: 0 0) -0 0- (n CU (n > C: m E cu C: 0 cu 0) — — :3 0 0 (n (n .- -5 cn 0- -0 >1 Fa cu Fn U 0: cu 0 (n CU W C: 0 (n C: uj MM T— C: 6 0 4— 0 E cu cu >1 0) cu L) (n 0 An < D- u (n o) 0) 0) a- 0- (n z ui C: E 0 L) <E (n 0 0 E cu E C: cu CU C: 0 0 > C: (n 0- C: < cu 0 CL cu (n 0- — a) L- :3 E 0 0) lcl� :3 0 C: L 0 - 0- 0 N cu (n 4— 0 > .0 CL .0 Up NC: 4— C: 10 L) 0 0 cu — cu cu (n E a) a) 0 -cn E cu E F5 t5 0-zi- 0 0) 0 -0 CD E (n C: > a) Ni >1 0 0 0 0 0) A (n < C: f C: 0 W (n C: C: U) cu 0) CU CU CU cu 3: 0 0) 0- E U) 0 C: 0 (n (n (n (n — C: (n to C: o 0 < cu o — > 0-0- cu > cu cu n 0) > (n =3 cu 0 CU cu cu cn E cu > 4— := -3 — in .- (n (n :3 E 0 w cu C) cu -0 E 0. —c L) 2 cu 0) x 4— CU W cu L- E 0 n 0 0) 0 — C: 4 0 0) L) (n (n 0 %U 0 cu 0 ch >, cu C: CU CU 0 cu LP) o zi- ch cu c: LO E E E 0 (n CU > 0 (n 0- C: 0 (n C: 0- 0 0) 0 0 0 = P C: (n 0) -0 CU :3 0- CU L- C: Q. L- 0 o- — -0 E < CU 7t*! < 0 C) L) E C: 0 E 0 -0 cu -,a C) >, CU z V CU C: cu 0 0 (n 0) 0 L) :n 0 UI U3 cu 0 -ffi CU 0 tz > , — — 0 cu t5 cu 0) f LL cu > - E (n CU CU >, 7t.! -1.1e C: 0) �:� .�= E 75 in T- q CU C: 4— a- 3: 0- :3 - :3 = o = 0) C: (n (n < 4z — >, CU C14 cn 0) .:= N -0 c 0 c "a =3 =3 C: C: =3 E 0- < C: 0) C: t5 Z CU o E o o--U-U o o -0 -a CO 0- < 'n A 0- < U) UUaUQQQ UUQ < Lwu F8 1366 I� a) � QFo 00 a) tea„ L u I uj O J O LV v, Z a� U h CC3 V cn CC3 C UJ M .� m 1 uj '^ a .... V, CL CL U m 7 Q W a G. o- L8 1367 �' o M V v4- Cf) CL N > �' M O W cy > o —'' a) _ j a)0) V � � V E U) as O O O uj V z � o U � >- � V W cn axi v ca V •n o U) > cu a) cn O p U cu O cu 2.� O Z N -0 O U)O Q Cn J W E E as Q 3 � c c�a U v 1 0 c W a) ° cn as O :� ca C� C' � E 2 cn Z a) V V W 0 n; +� OU cu O h Q O � 'ca 0 LL! CL a -0 ate) 's- a O N O U) a) a) U O U a E CU cn E _ w � m M O o N O 0 Z E � U O O � °_' p a) CD a o o 0 U 4) O N � CU N — N 0 N " A V O L- � = cn "a � O .O a c.) ++ -0 a U) to (Cf a V a) U �- O O U) p cu w U r cu �j O +s'+ Q> cu � .� v�i r O "a CD O U C i � U) C: > N C O >+ CU +. U cn O co m ++ c = - � + N r V i cu � cu i 4- �' L1J L- N O N �+ a) co U E 0 = N � +. O f. CL 4- CD CD a a) U U) U 4) m O z a) m 0 = cU = cu � cu co 0 E v O r CU C CL C � � a' � ate) > a O s- to to (Cf O N (Cf to to O E. O E .� Jd � � � U cn � � QQU O " a w U) a .° ca 8-3 1368 i 06 a� O o CL a� o a� ,a cd o o a o c � -o cn r.bo � rs � '= cn cu C OCU O Q = D O NQN O cn w cu ca •= a) E F Q �, Z � ❑ (nJ W 0 E V ;5 U Q O Q Q i CLcz a� U O W � u ° �° o '145 0 C > ctcton a a� cd 4 ID •0 a� 4". 0 Cd .p _ •� � � � 1 IV F V�F �Il�r) I I III IIII i�v,,�"I f/��ll WIII Q0, W � 8-4 1369 LO i 06 = y E O = o 'C O U m v i p cu CL C� 4= Q U o N = E o 0 W 0 � O n t� O 0 O 0 , `~ U = C ca 0 0 J —0 = 0 O ca ca +- Q om-' = Q ;= U L i Y U C0 a) O .0 = G 0 O Z _ 4- c O cu cu Ri 0 (Q (Cf a) .N C.) O a) >, U cu > �, h W .L 0 cu �_ = cu N to � to 0 >, cu "O O_ O E O O p ++ ++ (� cn > W a) O U (Q cu N J Q N L' U >% _ > a) �'' O O -�-� L O Q 0 0 0 "O O U a 6f� 0. 0 �' �Q Q a) r L L -0 - W i s 0. 0 >, O 0 � O L = p -0 -0 O W >, _ V 0 0 0 0 0 CU — _ >, p 0W W to O Q L 0) '"' to 0 0 E W .O i O 0 c a) O1 O L h O 0 0 = 0 H U 0 O Q m>IL 'o = O` 0cCnU ca E 0cC-uU O W N = C �' CU = c W > _ L Q -1-+ U L L 70 Q 0 y U >, O U a 0 O a0a W .'� cu J � _ a) cn cQ O *O' O = L m cu > O_ N 0 cu -0 a W 0 � p a) 0 cu - m o S U q � cu 0 a (D _ E T O � ~= p W 0 ccn cu 0 0 � ' 0 O Q 'O O = W cu U = -0 � "O 0 V x cn N U CU 0 O U 0 cu ca >+ (D N p ca 0 0 0 0 N 0 (n ca .0 > O Z as N C s E "-' ° X "�' 0 cu E a M a U O -a L o + 0 0 0 V (� U C 0 0 — m O 0 0 (D c"l Y � aa) aa) cp 4— -0 -0 = CU CU aD E 0 as O Q � 2 � � � >' � QQ 2= Q D D- E 6. 0 mw o 0 N • • • • • • • • • • • • • • • 0 a w n mm F3870 i 0 0o c CL o °' 0 c s C � c cu o m c o U cu 0 cu 1/0 Q Q, cu Q c i/rim % ii 0 (n Q C V o co j! W > 0 V -0_ ftS vW c`e ca voij,J C rn o o Q m J � V > ° � (n � .� � � cCD 0 Q Q ( m c � N N cu C -0 CU 01� O Q U o _a ``" o o cU ( Z W C °' m c'� coi c6 « -0 -0 c . o -0 c m (n � cU ° W 0) 0 _ > p I— in O >, c6 Qj cn X aoi n c CU > > W n ° m (n0 O s W � .� (n c � 0 � 0 � (n E m m � > c0 (n 0'0n 0 0 c p >' Z vc � � c �- cu9) c E al— UOaQ - UU E a � 'S � a a w Ep8 '371 ti i 06 76 � m c� .> 4 a 0 0 N > N L °c a L o Q m _ =a m m CL o > is co 0 m � E N a� �. co c E E �- 0 o a4- O m Q '= �' o cn co Q o = m cn > 0 Y E o m o 0 w m E �, .N ° m > O aD co- " o cn o , N 3 L 0 cn cn > a W to cna) cn cn Q cn O c0 co p v v O cn � N co a) � v o a' 4- x , cn _ o h m m co ca m a i cn m a) a 3 cn 0 � = O O co a) > co F= coram+ 'a a- '� y Q a) cn O C) WE = O -0 a) � a) . a_ o � W co CoRip Z Q > ai m o co 0 O Y m O p Q cn 0 0) u a) a0'i O a) E a � W L cn •`n o O Q co m cn a L m mo Z c ) ° E is o O Co O O F O s co m p 0 'a � as � 0 a) I— o a) cn ° a�i p - co ccnn _ CoQco U O � -o � m Q ° m W Co cn m = O > c0 O a) 4; O = N � N Z E CO Q Q E N S p � o o o a) co `' a O c O = x O ff = a) O Co 'n Q O c O 0) o L y _c � � CZ L o � � a) mQ) Q- m `° ' � -° `° ' z N L -0 a) a) m � � C � E m Q u a, O y LV a a � o Q � � a 0aa `° oE 'a2 Nays c�a co Q �- -a � "- ° cn C o f cif W i m O C O� N in , CL cn N N a) m m cn a) cn L O Y M Y O C O Q O > a) c N cn a) a) e F > � .� Co c%) o m m o O Q L Q � X m o m 0 N O cn p v iii 00 N N O W N a) E a) !' a) O_ a1-E co �_ c Q a •L W co 'a cn V -O � V O a) a) O O a) m M `' 0 Cl) o m o Q y -a � .� m cam E a �_ O cn � N •�-> m Q a) N c0 d a) co Cn N � 'a 4= > a) U Z �_ +- N •- co a) L a) > a) cp c0 O = > O V 7 _ ' a co X ca m .0 Q o a � � 0 o � m � � Qom m m m co ° U- W 0- � w .� cn ca0 -1co Uc� m caQli (n E L � a CL cn �g cr L all",, W Q F7 1372 ti i 06 ~ , ^^ � ors Gri /(/6I w'M/ V � � V � I W � U E O a 0 Wuj 4%gf w 'kb� R_7 1373 � QFo a) a) a) O V O b L � 0 // CD /i , m N c: i (Q CD O CD cm cQ to 0- O 3 0 � a) a) y •� a) L O cu 'oQ , .L a) U a) U v 0) a) W a) N a) p � U 4— 0 O as cu cn -a c ca W c� ui 'as — CU o U c � �' ca D Y 0 C > o 7 C - N N J a CD o U O O c a) 00 CD o (' Ri v a) ca cn c > �-' -00 a) o o 00 p c:L W CD Li a) .s 7 a) 0 CU o U v U 0) Q O f r cu (n N CU Q C CD E (C U Q � a)N O O U � V _ \ L y U -CD O ++ cD � (� (Q O cu (r� JJ �n rn = a) m m (Cf M c � Z 0) er J co QN a) "-' -g � a) � 0- O = � O c he � N E U .-� a) -O N ' Q Lo wO 0aO c a)Z a) Q CD U — C = 4- Y a) 4) a) U cV N M CD O O U U (Q �, a) cQ Q cu cQ �, a) V _ v U � � tea) o) o -0 0-O � a 3 o a) > 2 � � a) E Z CD Z O E a a cn D) a) c a) U = N U � � 2L QQ L > U) CD �n/uuuimuuu �� ( °uuu �VVV nj Q • • • • • • • • • • • • P W Q R 1374 C) O O 06.e Q C I-- Q U N 7 3 CL 0 U '�� N N N tLo ° c i ,V7 Y' IPA w N a m o 'i �;C�NI ° ° tl.0 > 0' N co 1^ O a o E , 0 U CA Q •� .2 o E m u 3 �„ c U +•� +'' U Q f6 .fl > 7 c6 N >' Q � r6 N f6 H °o O v ' cc U — U U U O a 0 u N Q Y o Q i + a .N N t t ° O 0 t Q •+, +co, 0 ca > i i 3 ) a 3 -- -a ° U 0 CL O a O N O C N O t - E cOi 0 0) -p i +•� t Q .2 N `a O ? N r C ra > Y > 0 M 'C C C ''' N -� O U O O Q aJ N N J' Y U_ u ra Q 'U o C f N 0 u > aJ U Y-C O o a 0 cc`n ` u0 c " o n a0) W Y W � U �_ o\ m i n a) " c u o a LI.I U O 3 " a 0 -acn a O a 3 c •° U � c� Q O ° ° i +•� +•� to Ln Vl O 0 O o CA t Q Y O N N t Q 0 > Q N O •� U co 0 0 N 0 0 -a O v i s :; a E tin " .0 � E �= o p a d u � _ J U �. +•� aJ N s. 0 d 0 t 0 U C� C i O w aJ °j 7 t (6 0 a m u W C: a > u CL 3 N O u- a N 0 +•� O C o i N C 3 " 0 c a E c N r c a ° ° ° — tin o c .� > Q = yE V — ac +� o a a 3 = c c o a U G C +•� U O Q N N 0 2� N 0 lY > +•� Q Q 0 -0 `' to ° a) ' N -0 7 O c6 O N N 4— > 2i v - v 0 O ., �;� c c p t o O ++ C U C aJ 0 fl" J N 6f 'O i = C +•� +•� 0 w �" U- ?- Q t u t C u Q U N O N O + U + u ° O o N o Ln 3 N N i H �C7 i u Vl O N t t CL U N # O N i L aJ +•� aJ CL 0 6 C) O -a Oai N V a U Y i O 0 C c3 N i N .� N �- ca 0 V1 +•� i 0 U a) C U 0 to m > i 075 EA +•� N +% ° a u o a) 1 a am :N w o o ° C N a o p ' zz O J 'a t 7 0 0 O N i' 9, v'�iLn O `- N v o a U N o a '� g O cv a A o c Q c Q N c f6 Q m -C -a o o _ o a y M o) C C 0 tl.0 U N N a (n LL ". N U 0 'a N -0 3 N 0) J = fa .p...e O u 4� d 0 O ca t LL i 5 C 7 +•� +�� t U ca U 'a O v� Q N +•� tLn cU .:) �' U O c a cUo co Q N Q = a a Q ol u a u au H a >°- � Q Q Q u Q 14 -1 � r4 Nm4 � � � 06 a -1 � � 1375 Oc 0 (D CL 0 0 -0 1: (D 0 w CLO 4-) 0 o a 0 N o W 0 'a r- E < o > N to cn co o E w 4-Jo A z w Nw E 0 E 4- .2 0 4-J 4-J 0 0 > 4-J 0 ca -a LL E 4- > 0 0 .0- 0 4-J Ln 4-J .4-J 4w w 10 w 0 p w 4-J w w 4-1 w V) 0 V) 4-J 4-J 0 z to C: C: -0 4-J w w 4-J T co E 7 4-J E E LU (D >� CO 0 co c CL co -a E Ln z Z • w a- a- Ln CL m w .u 0 4.0 0 u 0 0 0 10 C 0 cr C 0 L a.. uj i 00 a� m E cm >7 >, — CL co Y �? co m C co E� m m c a � ? x w m coCL W Z d c v_ N a) o Q co 0 0 m N a Q "- ° ° o — Q 0 co ` > o c coCouNi > a) co m E a3 N •� -ice-.+ y.• =3 co co -IL-• Co0 ?� H � U w o w Em Q- (B a w c' 42 -2N N N U c Qj Y to O ® c O a) 06 N 0 Q- V + U > co Z EO +O co N 0 'O V 5 c a) U N c co O N p '� Q (AU (� O m 'a cv W N co C LO O O O ++ Y c a) a co N a) O co Q Q °C � N O to °O to N O N � ° ` °W cQ - N '2 I— ❑ ao� c - XO > � � o) x ` (n of O Z Q ° cw o ❑ o E o c m c o Co co 0 Q W s c cm 0 a� s m Q O Co E � " Q� 'aa 0 o a� , c c E ° Q CL V O m Co Co c C� U OV O W co c + 'o N W co Q � 0 I— o co O c co N m c 0) `N co >° c > .co cfl c E Q uNi Q. mm N o a� a� m — E ocm Q m >, E CI- co 3 c Cf) a N m E c w o o Z c c >, c c Q � c Q O �, Co ... O c x N ciS to -� � .� to •� N u, � cv3o a ° a� ° cc c om 0 Co o co NQco omm � 0 — � m � � Q 3: o > m o Q � c 0 3 � Q� o co cE a� Nco _ Q cN � Q.ac oCo Qc� mwc x mCo ma,w mmN .amc � oE0m > N 0'm o Co in Co o c c c 0 ul ui m m o ° c' E co a v`_ N 0 (n m Q� QH E m.N �' c �Z m ° c Y o c U Co aim Z ° ? � Co (, Q� ului� cmc s >, co0 ° ° Ew oc a c `m O c-' aEi m N .c 'c Co ° w o o `n -o 0 0 � m Q c U � o � ° � a co Co 0 UmoZ � � � - ° MMC om mc iaca"i ZCL a� ° a iQ� c ° � c °c �o � � o � E O ° m cm E o Q- co c -a m Q Co ul ui (n c c c c c o o ._ c Na� �, > ,� � m o cow > m � o � H �, c � E c co U N � � d C >, Co N 10 ° a) O N Co w O O N ° ° Q m m z x � - 0 > - >,.C- cm o .o - - co — m c U ° ° aNmN mN ° NEo Co m w o N 3 �,N +c E a w (n � Z ciSUw � � C� Q coU > (n `" U +c0 X �- Q.•O O • • • O 0 0 • • • it O = 7 V • • • • • • • • • • • • • • • • • 0 Co 0 E w U! F1381 77 N 06 cn o R9 U E O a) = O a) (Q .a m C a) V X c E (D p N U a) O _ ° 4- CIO O a) Q CIO o V O a) O O_ a) .G C a) to E , a) _0 U a) o � L a) cn CIO r E CIO p � D O m m 44 CIO CIOc a) V L Q U CIO CU as L L cu E Rf V a) O1 O O O_ o a) c U a) a) Y C) W zO O o O a) CIO Cl) cm cu 0- 6 Q >+ O m >W O ca) OCIO O E a) OU CIO Vcn p a) Z - Q CIO L O CIO (Qcn CIO a) (Q a) � W 0 CIO W �- "O � E Q a) �, O CIO O. O ) E (DU a) I— Z ca a) a) o>, �~ E 42 E aa)) ca aa)) +Q Z cn a) (D a) a) . o E a) a) a) L a) -1—+ O L U ch � 4) a) (Q a) p 0 0- a) _ L a a) a) 7a te cc LCU CIO o 0 - y -� a) "� a) oo a) �' 0 - a) "a Z -� to O_ i O CO a) to (D a) a) 0 (Cf CO U a (DZ 4- CU � s c� s a,)- v V y—+ cn _ a) � � (ti O ++ U N E Q � � J v�'iQ E . . v) U `� y a � _ _ o Cr o ., W C) E138- 978 M T— r 06 ��Itlr ��%�arorri�r �Vl� c 11'f ll l � � r uuuuuuuuuuuuuuuuuuuuuuuuuuV a�vm�� a� rr/ CL .2 r, Z v c � U c c N I— N W cu N Q d W R °' 0 > a) R Z CL Q tll = a C O N N d c4 COC +L+ N Y N E E c4 N cn _ x O CL 3 c a 0 A) -Q J uj r_ = co m o cos � N Z N_ to .E `~ 0 0 CD cu �+ _ N 0. co cO Q c6 0N U = O c6 > co O .- O cn co E cu cn CU w E = w cn cn = to O0 N O 0cn q) � N �- iU = d 1 O U P cu M N d N Rf Q N cj �- O cu O Ocn .Q cu o cn _'.N E c4 N a E > -a- cu � � � m � � L � � � 0 - N cn cn co cn v co cn Co .0 0) — m Rf Q Q c4 Q N cu c6 ) _ — 2cu � c0 'O O N QO N N "' O O N = �' co cn cu 0 > c0 J t� = c6 Q Q cn N cn j = 0_ N N N O N N Q N cn co0 � � N � ++ � Q � N cl V v N to tOn c0 = ui > O N O Q Q Q L L Q Q 0 = co — N G1 d d �_ Q � � (n Q� — H Z V �' R3 .a- CL Cco L V co Q. Co C H a d _0W W Q fn 8-1 *1 1379 0 0 aj z E CL ro (D di 0(D .2 o z (U J,Iz tJ'A LU D z u UJ Ix dj i� u F- uj uj uj uj 7 4 1°�: 8 Ilrr 011 vj Zz 41 lip ul la 41 � II iru � rO F6 z UJ 41 0 .41 UJ LU LU fa lu (U (U di M .4.1 T. 0 Li lorta 1, Li zaA a c E 4 1 -F-M vi f' E w lul I E o uj E uj t; E ro ro z CL z (U U) uj he uj 0 UJ cc w. EL uj CL Ix 4 1 ul rp 114 0 ul z T." qj lu op a ro T. qj E 21 n :D qj o z E5 L) 41 EL b bk lu d, () 0 1 �2 `� 4 22 4111 ' Iv=V Z'�Ay E C) dj X, 0.a, m ai E'L Ll ui NII VI vl aj LLV))) Q0 z B 0 dj oj q ai Ij ul u IV z 4' vi Li CL CL rL " 0 6 "i uj C' S r L Li 0 u &C m eq la 1 8-14 - 1380 LO T— i 06 c N m 0 OCl)_ � � � cu CL v O o p O o L .N Cl) Cl) O O =3 CL N � -C Cl) U cli m _ vi cucu CL as 0 L 00 U � U) N E � � � � fn fn ♦+ a) ��NNN V V V V ��+.N 0 V N N E fn fn fn fn �+.a Q W CD m V O W E O vi vi vi vi ♦+ .,.r Q a Cl) a) a) a) a) .,.r N_ a) O O O O O N Z V LO a) 0 oLOo W O N N O U M .� Z o 0 o O LIM' . . . . U) cu 0 0 0 0 c Cl) � � � � p m m cu N N N NC.) c E cn0 cu L O O O o cn cn co >, >, >, >, as E �a O c c c c . aE a) 0- a ca a $-15 1381 M.oce—o .12ZOa00 D N11 06 zo 0 CL o .2 fo I hr ICI' 4-1 0) Z, M U O N O U C) O U O M 4-1 __ O J c � Cl) _ v O a) Cl) (a L' � Z cB 70 70 w m `� cv W o � o m ° W cn o- m O Z 0 z Q O U Y (B O O C cB +� (n E m U W W 0 � m V o W � � � h U o o o — O d U U U 0 C U U U � L �y} Jam' A�n M-3 M uw 8-16 1382 cap N o O O) �81 co co O 0 tm O � O 0 N +-�-• CL O X N O O ° O O O E OL. >C_ E N o -) > N q81 O + > 0 (Y- �� co N N N Q m a E O Co O co Co LA 0 O o O q� b Co to C 0) >i ° �y Q X O .7 v- U O QY Q- N N O O Q� w �81 O -N toCL Q E O V 1 c O "- ~ m ° > = cm m W c o c: � ~ _ N _ O >, cm o o �, o � o C 'a 0 rA O N N — co ��Q wQ o} � U � mN �U o �81 - Z o Q � ` o O-a o oEJ co 0 0)Qom o° . co � � co � Q Q V UW �— mE m `m � o ., � � = ' a U Q • a� o co W2 0 0 U Q aoo Q o m� ° QI_Co 0) — u - Co.- ., � N EmQ 0 ,,,0 E N � 3m O _ N 0- co 0 Q E Q 0 co O "a mE N . 'a > "a 8 CO) O > O O OX > -c Cov O N N co � Q O 0 � Q, H � � """ U .O Co N � E E N U Q o o °E CL o N � Co U o � E � � �j co ° o c -o Co Co 0 Co > a� � � o ,BYO oo �, — o = � a� a� ooco 0 � � a2E Z J ° s � •X ww0 � QN ,,, Y N ` Q t/! V O Co N �81 "" � q� ° U U N N O 0 Co 0(D .0 .0 Z o- V. N M W co o- a. a. a 0 V J (n 2 C) `"- —co Q M co u.l� w coCU a " 1383 ti i 06 O 70 a) O v 0- c 70 a) c 0 70 a) '+�— 00 to m N 0- to CL V O o V _0 O a) y _ to Li N 0 O cu •tT 0 cn ."". _ 3 O *y to -0 o a � a) a) (i (D O � O cu = Z 3 -c U v a) -p > -p Q U cQ - V L * 0- 0 ;O cave cao ( J V a) L °' a) y V °CU 13 W 0 CU a) O cn Q a) s; U -a L cu a) cn `�- a) -0a) m Q a a) > b a) v fn W L O (Q cx cQ > E 4.. Ri >, cu O_ U . a) � a) to uO O 0- a) O L X 0 c "O Qoa LO � a) a) a)W a)a) =a) UQ cu cu s= ca sZ a) v � � o Ooc� 0 -0a) 0- Z O a) L O �' I— aa) L v -0E aOi aa)) (D ca � c�0- XO a) 'L U � 3 0 a 0 cn CU a) O E L ° a) _ CU a) a) o = N aa)) 0)0- � E p L X cn �to 0 s v 0- � O - � a) a(j °) E i � Q ocucu > O U Cn 0- r r 4— y— 4— 02 � w a 8-17 1384 i 00 Q E z �s00 E © ca Q Q 0 cu Q 4U p cn N U N CYa cu N m cu c 4 N CL a) N cu © N o C7 a) fU a) f Q U C4 N pcu 0 rn NO ,� Q 0 in Q N N © cn a) T�3 RS `p 76 cu CO Q Q 0 U q �:, � "' E p N incn V £2 + a) Q c cu C3�1G "" c a) 0. in N � T3 = Q 0 © � a�j U Q C cn CL' 0 m ` c © cn Q v ac°i c' c�nQm c � � c��uC�i � � � � .� � � � 0. Cl) o 00 � � � � � c cum 0) ,ff w CL M � = = M VoQu � °u QE ° � c ca) C❑ � � V ai -il= m Mom' � Q ° Q ° c 0 O � O � ,- a) sz Q u) E in �_ � U z3 U cc Q � CU to cur � n � � c © � .0 � c � = 0 - a U to 0 � icu Qo m `y) E �c .J o J cutom w X � a c� in 0 �' ms ua 0 — ' LV c a 4) E a) (n cu o w 0) ° am a u " E � w � n -a � -c 0 � mcu � � -w CU � E 0 E a D- ' cu "a �=+ a? c. L L �^' "^' o u) w y_ 41? C7 , -a � = -W � O � � � ° w � c � cum c .Qcs� aci ? im in a) m 0L -o c c a) in 4— c � cu ' c? Ema� c00)) j 0cc Q >c �© � r c wcU � QQ © E cu e u� (n > ° E incn CL R U va2 L Z5cua) w 0cc fc s ; N a� 0c Q c a) say arc c m a z � ER85 00 0 Q = ' L s 06 a� ° .a c �, Q a) c � c — C Q c .mac a `t0Q � c>i oQp cu o cu 0 0) cu cu wm .2m O w cs, E c = 0) E w cn c' s >m 0) u c w cn c oE a N � cu .0 « z ) 0) c cq cnc E "> m � Q E w cn OEcu ° a)' = u, o 0) (D " Zx -�' acicu � Ec cLu 4 (0 � w = cn cu si p � cn W aci `n O "� = � 4N- � cum p C: a w � O E -- cu [k E Q U v .2 O ° 0) z ja 75� ' E" vi � u© o) E c° � N ac) Ew "a W > OaciC"`U 4- c � Z . E ""' - cu zcn.c - c0 aci O C E -C C3S cu p X o a? C `' `' > 04 (� CU � O Q c � q' .c E � c W c�a Q Ncw c c ,,,_ c - cyCU Q � Ua E cuw � c � a x � � c o � i c>i i � 0� © O U Cu cn cn 0 E O � wcu ccc E cc , U Ew -cn -c Ewm " O "0O cusz in , CD " cn "Ua� E -acuc W es "' c "Ec>i w EU ° > �, N � 4 acm O © x � cc (n "N -c "~ � cu mac h ' cum' °' _ = D .-- cn 0 - o Q cn c cu .c J c c u Z _j c cu cu u c' > c O202 Accu0) > w p C Q , CD E C �+ 0- co O .0 g � O • s O 0 w �Q �> c Nc ai c N© 8 -0 u © aic �QOQ c : C> s a) 0. n cu � C ca *" o in � _ p .0 cu in w (n N O nc cn E' - cu c m4- MO Lau Q cu a w Qu Q 7-� © w "- 0c w 0 m ci) a E � E O �cu .0 - a - CD E c' cn � CL CL cncu � U �- � a� ALE m U Rf 'o I— I— LL, I— _ _ cu0 In W m �i ri Ci Cu C.k Cu C6 It A. 8-1 1386 E L O E O_ a) Q 00 V) V V) a) 7 00 O O J !f cu Q J V mu„ �i� 0 U 0 m U o 0 O U L (3) r`, LU w U =3a) , , o U a-+ i i U maka i o c E 'LL � . L IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIG > Q 70 r r i a) O � j N � L- '- h E 0 L CU a L � (� 0) m cu E a) m 00m ' I � J ij wl 1 r W i M X L O ❑ � O L U L c cu c 0) 0 cc :-> o C: > a Q a) a j �' _ > U m a) ° o U m uj I cQ I 0. O O O O � M U U 4= U y , C ma) c J J cu O II a U U) i UJ Q w m o m E _ U Q m m > cuLL a) O � �l O U (B cuU X 4— c � LJJ o p cu (3) cuIIIIIIII cu > LU E8-1 Q = w 1 887 a_ 0 m 06 W cu cu a) aa)) u) L) a) 0 � � �' >ca cO O> a) a o U D :5 a) a) L) cU a) � m I c a) a) c6 Q = R3 0 O cu D O to 5 U) 0 : a 0 `~ o a) L a) D �, � '1 � V a a) 0 o L o a) ca _ cu W o 0 (B m U m s- LU O cu U - a) a) a a) cu o lz a) CU _ cu cu U E _ cu �0 a) c 0) I► E m � O U) a) � a) J— a) M O a Q .0 O � to c6 y ~ ui m o cu aa)) o m � L) -a o a) °° m a) a) �_ W a�i O L V O a) r cu cu o /�� O to O y 4``I Y Q 1L U Y Y a) O V a) .Q m - o U) a) cu a) O a) cu O U) ° � U -0 U U a) O cn 0) a) -o U) p D o) cn c o cu CU c ca N a) -a cu > o_ > D H -0 cv ca u) > o Q L >> a) a C a) wo `� O w m � c� � � o o ) -a m DL� V to O U US a) Q CU L m U 70 0 a) cu � � � ��— � 0 p >1 0 ° o �? c6 = a� Q _ _ ca o_ �, .� O W p M u) a) � 0 � o " — cn a) cn o a) CU cu cu a m o cu Q o cu ai 0 —:D co m c -0° � cc ~ � L � �a c ai o_z 4 � 4 J LV � � of am p° ° � °� � � -a � � � Wco G� CL L) �' —°O a) � a) L) E m ° a) 0 0 L a) =LL -0 o W 'O a c 0) cu 0 cu a) = a o ca O cn E O U a) U) a � O O cn z O O Cl) _ cu a cu U) a) �. N - ° L U) o ° O a) UM M n3 Ri O '� .L 70 C D U O o •� L U o a) a) >+-t cu O cv -0 U 4- O U O a) p p cu U j O �. a) �- cu D in O M O O > CO) i o ° � � ° � a�i 0 � 0— o o � o � ° � cu ° y � co a) Q-o o a - U) o O = > i ° U H a) > m d p " •— CU 4 = = ao) ca0 a) W cu E o a) a) O oo a) — U Cuc ., U .Q Q 0 -U o cu -0 cn m cn cu O O a) m Q a) ° >so)p > w cn U V O �. cu U W `� c U � cu L ui ��. ton cOn U cu cu O a) > V Q >+ O J H H U) H � O 2 � 2 U � Q O_ U R3 ) CU cu E O prZ OZ • O_ U) E 1388 i 0 CL w M 0 o 0 O U 0 > Z 0 to W ca > J c > W a 70 c O r 0 a) c W cu 3:_ > Z L vw 0 E 3: Z a) 171 0 LW W D cu a) W W ca 0 cu c o _0 O L Q ry o cu cn a) U U j > 0 CU E a) �_ � LV 0 (0`-- > 2 L cU O W � > 0) Y ca J c Q I ca (0 0 ��—, C N LLLo > M 0 a) L to O > > > � > a) cn a) Q o oU (Cf J L cn V cn _ �-+ a) (Q I^ I I y J V V Q W c/ L L L J V� .� a) .N a) a) cQ cQ O O O N v O OU O L � Y a) x L L L OI a) /� � r �, a) "a c O O_ to to ^a) a) a) a) .^-♦+ 0 L- a) 4— QUQ (n0- = oo Q » � N C) • • • • a) cn _ • • • • • • • • • • • • • > O O E V a - 9-1 1389 N L O O cu a) cu "0 c p L O a) a) U Q cu c +-, 4- a) CL CU U) cu 0 a) o a) c a) a) E p a) Q cu W U � cu cu _ � 5 — Z cup cn Q 0 -W U cn "O otS 13 a) a) -� a) a) �.. a) L E O =3 0') O a) V p Q � Q U) E a) c L U U V U L l O y-+ a) = 4) ) a) v W c 0 cu -a a) c- > V O_ cn a) O m Ri Z 70 a) O a) Q w cn c c cr Z W = O � O Q LL Q W � cp O cn a) 0 cu W U '� cQ Q � a) CU cn a) "a >, cu a) o a) L U vi U. E O U Ea) � °' L a) in O L O O v to "-' W a) D a) x a) a) a) Z a) rn _0 cn cn ca 0o O > " cu y=' OX j Q «s L o � ca -a 0- 0- cu Z �-+ a) a) Ecn " U cu O O L cu O L U — — >, cu >, W L a) a) 2 E O a) o f o i O '- � Rf O "O " "O W a) O �-+ 4) L Z � �-, 0 CU U a) QE 0 " O 0 a) a) ca ca O a) �- O i N > -a -a L w a) U CU ~-' -O -a cu -a o a) CU a) m o a- 3 3 cm � ° � "�' c � c � c a) L a) W ° o 'y y-' cu ) 0) 0) 0) L O O N -a) L = o .� (n � 2 � 00 E 00 cn 00 0 � 0 W .O O'= a > Q_7 1390 M CIV °° �10 0 CL 00 r�s o 0 O 'y oc W � � W OC E00� o Q z uj Fw If 41 Q o 9-3 1391 CL 0(D 2 LUO r- Z w m w E w 1392 LO i c� N — m c o N C m o CL s N c CL a Ln o Z o i2 0 U E c0 (0 m '° N N Q � O O E 0 O O U m O 0) > (UO i E C C O L O E m >,N a) O v T in N in a� (nO) � �_ L cO a) E rn Q' _ L Q m a) a) t U d tm O U c o O a c>0 U c 0)m O p ° a) (n ° U V o N o a o o N Q o z c E W cn >, o o m Dm o N o Cz Q- a) Q- V) Q v, � ) 0 o cm � c GLL U) 0 � LL pO ° ° v°i ccm m � E m = c �° LLB N _ o .L — m o O m c in o a, c m (n `° cd Q m a O m m °c Q Q � � > vQ-0 m aim `° mQ 3 s a � � JCL N O 3 L N Q Loci �, � °r° o 'mo °0 Q � o in T s c � m N , 0 a) O ,� L O L Q � O U N a) C Q m C - 'O a a— m N O ° O a) . C LL c 0 Qo 0 oa) o `4 L m a O 0 > mm w CL o a o � E LV =1 "a 0 ,,.(n m °c a) E C: 0 o co tcoo N `0 in N Q O d O ate. T O U N � AteA♦� A a O 0 � c a) a� a) ° o E .0 a� m E 0 c a) c _ a) c m a) a) 0 U U (0 a) C L (0 C (B C a) Q_ Y .L c i U Q O r m Q m U cOi 0 Q d c d m N E � T ° L d c m a N 2D m Q. O C L O c° C: Lv°i � � m m ° ° N0 m o m a) � 0 3 am p E 0m N m ) Emm L to � } m O m N � cad Q o N .c Q (n . E � oo � a0i `° = m o t� o � � m m �° c o c m a) ( m in 0 � ca � ma mo a > 0wwE - ZNaim ° 0 E Q00 Y a) a�i °c m � Em mo � � o oc � � m �� °) � Q o � � mL °'Ln o � OO .� w E s m e .M- i ° o m o ca m e �a m N N _ m m m ca o aN N oom ocooc c (n (n �' _ = W _c O N W = " c 0 o in Q_ E -0 v) —'' v) (n �° v) 0 3c) � � O � c Do � Uas .Eooav) in in - v) ° T E • • • E . coa) L .� N N N > U in Q (n (n U uNi co d a co c�a 0 0 � o c a) a) v) :�, (n v) L in c c Co a) ca -i c LL 0_ H 0_ O � QQo fyQ � QQ 0Q V) Q Q U U m E m L co Q C o . m L. LL O M C) o O LL P9-5 1393 Ln i m � N m � � c 0 c m � N $ 0 70- c o a N ECL m ° m H o ° O m m N m d E L m N �J 0 m m c C fy0 � N in m c O to O N N G1 N .� E c in N V "� to in N c N t0 in C c i N E G in O s N V O, ► m m i G1 0) in r.+ -C N Q cmi c� (� N �0 Q p E E H � W � E UN Z O c m C O m c (n f0 O RiW LO m `-' O in L W N W o ° E o o V m .a a if N o ; N N- a 0 Q � v ' � � w N � c � m c 0. m Ri Coinm m E -- o o -° ° U mom cy0 `o � �' N � ai � 0 W ago a� E � L � � � U. o E m E m W 'O m U N m -O � N m O .N t=0 _ in m c o in L m c d ZZ L o , c t L E L ° ° ° a o �, L o ° Q m = ° m U L C O = x m m U m cL0 O O O C m � N U � (n — ' aC G�1 � Cc m W m m N a m N a m -0o ' E a m c � c p a x o p E in s E c m m o o m ° E H N O N w L L O N m m s T Co o - c U a c c .L a in a� m m m c � co O § m N N in m N N N N N N m m E m a L mN — O m NL 'UL m e Ids rL HHH L HHHHH � H W R' "= W d "= E p m E a c _ m a cn O WZZ v. U d 1394 .......................... C'4 CV) LLLL. :121 z Boom= co IUD *00 m aolP IS, m w CO w Boom= LL. E ww uj 2c cu 1O .............. ........................... 11395 ti Cal 0- CL r- w .& r_ 0 LU a E CA 2 r 0 CL m to 2 (1) x CL 0 a w 0 0 w 0 LU txo 0 3: z 0 cr r_ 40 LLJ LU - 17,ui (1) 0 (A 0 > 0 w Qj (A LL N W u UJ CL 0 W >- w w 4-1 m Z 0 w W 0 VI W 2 to 0 CA r_ M o LL a 3: -z-u A UJ m m U ui E Is- o th tw w w 0 0 (1) CL LU (1) (1) cr LL > —j 0 _5 —j W OC-) z w cn w Q w 0 cn LU w > > 0 w 0 E E o ucn o 41 m 0 0 0 0 o L .a0 L 0 a a w E 0 0 CC 0 In CA E E E E II II ui 0 0 w 0 0 LU o E X I: I: [-F1796 „,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,............................. � N ° O ° ° o r_ 3 O N Q U U 0 fW i to to _ N N to > co O >_ LCL 0 L o -0_ r_ .' 0- Q O U V 0 cn C/) �o N r co p U ctt o cu 0 ”- U (B _ N �_ p cn > = j L Rf N c0 O O 'er 0- i O O O -0 L fz r cn cu L L 0 r_ O >+ CU cn a) c6 >' O N U 0 co cn O U -0 N L tocn M W ; M 0- i O Q O N N cn > c6 Ncncu c O � Em � o Q z O c0 a) cn ° + _ (6 - r � U N W � � a ° � '� w j � > ° vi O 4- W � O s- cn co r_ c co 0 cn cn cu Z cn � = y i . W = O c6 U N O r CZ ohm � ° _ � � a�'i '� cvi d r_ N cn � 4- r_ r N >. (,u O U ! Q ° N U O W ° ` a ca i � Q- W o' > 00 Q o UIrn W o cu ca W R O Q � " moo ar_ L2Q x W m �' o O i C "= p cn O Q Ri 0 - U �- O � N 5 cB Q W O :w+ ,� O U v v +� ° � cB �, ++ R3 V to O cu H N ° U in co N .�? (� = C W ooJ co > �_ � � � � � co cu QI cn -a ; cn cn cn L cn N O �~ 0 _ E r cn c O r_ to O co U = i �— N N cn c0 N .0 cm �O Q � -a N _ cn N CO co cn O y -Q cn cn ~ N O r N N � �W U c O N J N O O N to > N Q � C) c0 > 1 •c6 L �'y N U Q "_ c6 Q U E ° N c0 r > N O r_ N O C (n to O N n > m to ccn 0 J N N LO c0 cn o O N r- y co ° >+ N U Ncn C O U G,O Q � cucCl) s= � o m0 r_ o m M Z M 3 �o � U o_ r � � cum m o ° Qz c�a 0 0 � >, M8O ^y to co O U N p O i N Q >' >+ c6 O to Q a "_ p LLI 0 cnc� c� 0 � Z � � r cn O ° r �, � o � o � vi O o � � O Q . c cm m o_ o "0 cn a) cn . . . . . . . Ucn j 1397 C� E CARE AMBULANCE INC TRANSPORT TRAUMA AND TREATMENT PROTOCOLS I. DISPATCH PROCEDURES 1. Calls are received via an enhanced dispatch system located in Key Largo FL, which dispatches the appropriate Ambulance response units. 2. The Dispatcher obtains information from the caller regarding: A. Name of person calling B. Nature of incident C. Type of injury D. Call back number E. Number of patients F. Location of incident G. Extent and severity of reported injury 3. The Dispatcher selects the appropriate Ambulance response vehicle(s) closest to the location of the incident. The Dispatcher immediately transmits the appropriate alert tone, followed by the command "Rescue (assigned unit), be enroute to..." after which the nature, location, and known details of the call are transmitted. This information is transmitted via 800 MHz radios carried by all Ambulance crew members, and all Ambulance Supervisory personnel. The Dispatcher may also elect to activate a BLS Ambulance vehicle for first response support. 4. With potential trauma patients or injuries that may warrant air transportation, the Dispatcher will tone the Monroe County "TRAUMA STAR" helicopter to place on alert and/or monitor the scene in case of TRAUMA ALERT patients. A request for "TRAUMA STAR" to respond may be made by an Ambulance EMS Commander or on scene EMT or Paramedic on duty. 5. The Dispatcher is in direct radio contact with the responding unit(s) and monitors the status of the crew (i.e., time enroute, arrival time on scene, time enroute to hospital, etc.). 6. On scene personnel may communicate requests for additional intra- Company resource support (e.g. manpower, equipment, additional vehicles, supervisory personnel), via the Dispatch Center. Requests for inter-Company support (e.g., law enforcement, utility company, fire suppression equipment and personnel, Marine Patrol, Coast Guard), may also be communicated via the Dispatch Center. 9_9 Dr.Julio De Pena MD Page 1 of 15 1398 C� E CARE AMBULANCE INC TRAUMA TRANSPORT AND TREATMENT PROTOCOLS II. PRE-HOSPITAL PROCEDURES 1. Upon arrival at the incident, Ambulance personnel shall conduct a "scene size- up", to include safe entry, severity and number of patients, the need for extrication, and the need for additional resources. Multiple patients shall be immediately triaged. The condition of each trauma patient shall be assessed using the Florida Trauma Scorecard methodology criteria, as outlined in Chapter 64J-2.004 and 64J-2.005 F.A.C., to determine whether the patient should be a TRAUMA ALERT. This information shall be used to determine the patient's transport destination. In assessing the condition of each patient, the paramedic shall evaluate the patient's status for each of the following components: airway, circulation, disability ( motor response/Glasgow Coma Scale), soft tissue injury; Iongbone fracture/skeletal, patient's age, and mechanism of injury. 2- Upon determination that the patient meets Trauma Alert Criteria, the Paramedic in Charge will initiate communication with a State Approved Trauma Center (SATC) or State Approved Pediatric Trauma Center (SAPTC) or the local receiving facility, if circumstances do not allow for helicopter access to a SATC or SAPTC. Communications from field Ambulance personnel to the receiving facility will include the phrase "TRAUMA ALERT", and will include the following information: • Specific Trauma Alert Criteria • Mechanism of injury • Glasgow Coma Score(itemized) • ETA to receiving facility 3. A E Care Ambulance Inc Adult or Pediatric Trauma Street Form will be completed for every trauma alert patient and a copy shall accompany each patient to the receiving facility. 4. A E Care Ambulance Inc Form MCFRF-011 "Street Form Worksheet" shall be completed for each patient and a copy shall accompany the patient to the receiving facility. 5 A E Care Ambulance Inc electronic Patient Care Report will be completed as defined in section 64J — 1.001(18) F.A.C. by the Rescue personnel that were on- scene. A copy of the complete patient care report will be forwarded to the receiving facility when completed. The MCFR electronic Patient Care Report will also be completed for all trauma victims found deceased on scene. 9_9 Dr.Julio De Pena MD Page 2 of 15 1399 C� E CARE AMBULANCE INC TRAUMA TRANSPORT AND TREATMENT PROTOCOLS III. PRE-HOSPITAL FLIGHT PROCEDURES Two (2) sets of flight criteria must be considered. The first is directed toward the safety of the helicopter pilot and crew, the ground personnel, the patient, and bystanders. The second set establishes operational guidelines for when the helicopter should be requested for TRAUMA ALERT patients. 1. SAFETY CRITERIA: (Conditions when the helicopterwill not be used) A. Severe weather (as determined by the pilot orS.O.) B. Landing area obstructions: (as determined by the pilot or LZ Command) • Power lines too close to landing area • Trees, poles, signs, or other obstacles in immediate landing area • Large gathering of civilians in the area C. An expectation that the area may not remain safe 2. OPERATIONAL CRITERIA: (Helicopter will be used) A. If the patient is considered a TRAUMA ALERT patient as outlined in this protocol. B. If the patient sustained a traumatic injury, but does not meet Trauma Alert criteria and any of the following conditions exist: A Blockage of the main road, making ground access to the nearest receiving Hospital impossible. B. Failure of the drawbridges, making ground access to the nearest Hospital impossible. C. Extrication time greater than fifteen (15)minutes. D. If the helicopter is needed to gain access to the patient or needed to transport the patient out of an inaccessible area. E If ground transportation is not available and is not expected to be available within a reasonable time (10 minutes, depending on injuries). F. MCI (mass casualty incident), as determined by on scene MCFR Paramedic/or on duty MCFR EMS Commander. C. The Paramedic on scene will notify the EMS Commander when TRAUMA STAR is requested under the circumstances listed in B above. 9_9 Dr.Julio De Pena MD Page 3 of 15 1400 C� E CARE AMBULANCE INC TRAUMA TRANSPORT AND TREATMENT PROTOCOLS Dr.Julio De Pena MD IV. ADULT and PEDIATRIC TRAUMA ALERT CRITERIA F.A.C. 64J-2.004 ADULT TRAUMA SCORECARD METHODOLOGY 1. Each EMS provider shall ensure that upon arrival at the location of an incident, an EMT or paramedic shall: A. Assess the condition of each adult trauma patient using the adult trauma scorecard methodology, as provided in this section to determine whether the patient should be a "Trauma Alert". B. In assessing the condition of each adult trauma patient, the EMT or paramedic shall evaluate the patient's status for each of the following components: airway, circulation, disability (includes Glasgow Coma Scale), soft tissue (cutaneous) injury, long bone fracture/skeletal, patient's age, and mechanism of injury. The patient's age and mechanism of injury shall be used as assessment factors when used in conjunction with assessment criteria included in (3) of this section. 2. The EMT or paramedic shall assess all adult trauma patients using the following criteria (RED criteria) in the order presented and if any one of the following conditions is identified, the patient shall be considered a Trauma Alert patient: A. Airway: The patient requires active airway assistance beyond the administration of oxygen or has a respiratory rate of less than 10 or greater than 29 breaths per minute. B. Circulation: The patient lacks a radial pulse or has a blood pressure of less than 90 mmHg or patients age 65 or older with a blood pressure of less than 110 mmHg. C. Disability: The patient exhibits a GCS score of 13 or less or exhibits the presence of paralysis or there is the suspicion of a spinal cord injury or the loss of sensation. D. Soft Tissue: Patients exhibiting any of the following are considered Trauma Alerts: 1. 2nd or 3rd degree burns to 15 percent or more of the total body surface area. 2. Amputation at or above the wrist or ankle. 3. Any penetrating injury to the head, neck, or torso. 4. Penetrating injury at or above the elbow or knee. 5. Chest wall instability or deformity (suspected flail chest); 6. Crushed, degloved, mangled or pulseless extremity. Superficial wounds where the depth of the wound can be determined are excluded. E. Long bone Fracture/ Skeletal: The patient reveals signs or symptoms of two or more Iongbone fracture sites. Long bone fracture sites are defined as the (1) 9_9 Dr.Julio De Pena, MD Page 4 of 15 1401 C� E CARE AMBULANCE INC TRAUMA TRANSPORT AND TREATMENT PROTOCOLS shaft of the humerus, (2) radius and ulna, (3) shaft of the femur, (4) tibia and fibula. F. Mechanism of Injury: Patients exhibiting any of the following are considered Trauma Alerts: 1. Head trauma in patients on Coumadin (warfarin); 2. Severe facial injury/fractures with potential airway compromise; 3. Electrocution or lightning injury with loss of consciousness or visible signs of injury; 4. Blunt abdominal trauma or chest trauma in patient with history of paralysis (paraplegia or quadriplegia); 5. Pregnant patients > 20 weeks with abdominal pain after blunt trauma. 3. Should the patient not be identified as a Trauma Alert using the RED criteria listed in (2) of this section, the trauma patient shall be further assessed using the BLUE criteria listed in this section and shall be considered a Trauma Alert patient when a condition is identified from any two of the following blue components included in this section: A. Circulation: The patient has renal failure and is on dialysis. B. Disability: The patient has head injury with loss of consciousness, amnesia or new onset of altered mental status; C. Soft Tissue: The patient has soft tissue loss from either a major de-gloving injury involving muscle and/or nerve, or a major deep flap avulsion greater than 5 inches, or a penetrating injury to the extremities distal to the elbow or knee; D. Long Bone Fracture/Skeletal: The patient has an obvious or suspected single long bone fracture due to MVC, or any patient with an obvious or suspected single long bone fracture on Coumadin or other anticoagulants; E. Age: The patient is 55 years of age or older; special consideration should be given to patients > 65 years of age with minimal signs/symptoms following a traumatic injury; F. Mechanism of Injury: Patients exhibiting any of the following criteria: 1. The patient has been ejected or thrown from an automobile, motorcycle or golf cart; 2. The patient has been ejected from a horse (with or without loss of consciousness) with suspected anatomical injury; 3. Patients with blunt head, chest, or abdominal trauma in patients on Coumadin or other high risk Anticoagulants (see list of Anticoagulants with High Risk of Bleeding); 4. There is a traumatic death in the same passenger compartment of the motor vehicle; 5. There is intrusion of more than 12 inches in the roof or occupant side of the motor vehicle or more than 18 inches intrusion into any site of passenger compartment; 6. Vehicle telemetry data consistent with high risk of injury(vehicle 9_9 Dr.Julio De Pena, MD Page 5 of 15 1402 C� E CARE AMBULANCE INC TRAUMA TRANSPORT AND TREATMENT PROTOCOLS telemetry data, when available, collected at the time of the crash and relayed to dispatch to assist in predicting serious injury); 7. Falls from 10 feet or more; 8. Pedestrians or bicyclists that are struck, thrown, or run over by motorized vehicles traveling at speeds greater than or equal 20 miles per hour; 9. Motorcycle, golf cart or ATV crash at speeds greater than 20 miles per hour; 10. Patients with renal failure on dialysis. 4. In the event that none of the conditions are identified using the criteria in (2) or (3) of this section in the assessment of the adult trauma patient, the EMT or paramedic can call a Trauma Alert if, in his or her judgment, the patient's condition warrants such action. Where EMT or paramedic judgment is used as the basis for calling a Trauma Alert, it shall be documented as required in accordance with the requirements of Rule 64J-1.014, F.A.C. The results of the patient assessment shall be recorded and reported in accordance with the requirements of Rule 64-J-1.014, F.A.C. 9_9 Dr.Julio De Pena, MD Page 6 of 15 1403 E CARE AMBULANCE INC TRAUMA TRANSPORT AND TREATMENT PROTOCOLS E Care Ambulance Inc Adult Trauma Scorecard Methodology The EMT or paramedic shall assess the condition of those injured persons with anatomical and physiological characteristics of a person sixteen (16) years of age or older for the presence of at least one of the following three (3) criteria to determine whether to transport as a Trauma Alert: 1. Meets color-coded triage system(see below) 2. Meets local criteria(specify): 3. Patient does not meet the trauma criteria listed, but was transported to a trauma center due to EMT or paramedic judgment(reason for transport must be justified in run report). 1'u''IIILII1) BLUE All AC IIVI AI1::::::WAY, ;,I,��1ANGIi'.'01 dl ''II''I I dA 111'1Y I dA I I -29 I SI''f//1 CIIIFtCUL.AI�IIQ"' J: '� PATIENTS WTH RENAL FAILURE ON DIALYSIS �, 91N C n r 4 ..) rr��+ [,i S�� 9 I irrirr c, :11()IN 1'A III IN I OVI 14 95 YI'AI 4„9 C:DIISAIf IL III FY G C 3 13 o1 I''1Id1 ;I INCI!1 01: I AI:::1AI Y;1 3,o1 ;I I::11CI IN 01'':' HEAD INJURY WITH LOSS OF CONSCIOUSNESS, il''IINAI col el::)III II:eY[n I 033 01 ;I IN,�i��+A I ION AMNESIA or NEW ALTERED MENTAL STATUS SOIF F FIISS UIE 9"014 3"I)Ii,lC l dl dlN i I"0 15%of I I:33A SOFT TISSUE LOSS2 AVIII'IIIAIIONAI01::1AIS()VI I"'111 WRIS"I"'oiAININIIi,'. PENETRATING INJURY TO THE EXTREMITIES DISTAL TO THE ELBOW or KNEE ANY I'I NI I f:':dA I'INC IINJ II dY I"0 1 11 AI) INI!!I CI of "I C SW of I'I INI;,I'I dA'I"'I NG I%fl 11:1Y"I0 11 11 Ii')/I l dl'.f//11"I"'Y A"I 01:4 AI s(]VI I"'III ININI I' 014 1 1 (:rW CI II:;I,,I WAI..I I N 3 1 A 1:3 1111Y[n 1)1'i,11 01:1f1/11"I"'Y(I 1 All CI11 3 I") CIdI,.,I3111 ::),VAINC ::), 1)1 C,1 OVll I)of I'I,.,II.;I 1 33 V'I"'I':41'.f1/11"I C..OING,IBONIF. 1::1AC I I Ildl.01: IVV)of L.OINC I3ONI:::3' SINGLE LONG BONE FX SITE DUE TO MVC' F I,.FU II II IKLEL..IE F/"tlLd SINGLE LONG BONE FX IN PT ON HIGH RISK ANTICOAGULANTS' AG,IE., 55 YEARS OR OLDER MECHANISM NI',VI'', 141 I ACIAI IIN lI II'DY/I I4AC"I"'I I141 9 VVI"I I I I NI"'IAI.., EJECTON FROM AUTOMOBILE,MOTORCYCLE,GOLF OF III A11':4WAY C( f//II'14 f//IINI'',;; CART or HORSE C I14OCI„I I'I ]IN 014 I.,IGI'°I"I"'NINC,IINJI II'4Y W I I I 1 (INN 01':: BLUNT HEAD,CHEST,OR ABDOMINAL TRAUMA IN CONNCI fl I;;91N1 NN 01:::4 V131151 SIGNG 01'::IN fl II'4Y PATIENTS ON HIGH RISK ANTICOAGULANTS' I 1 1..11N I AISI)I„VIIIINAI.of C111 ;I"'I"'I''1AI,.JVIA IN I'AI :::IN I WWI"'I"'I DEATH IN SAME PASSENGER COMPARTMENT 1113"I"01dY 01':'I'AIdA1 Y,'�IS(I'AI:dAI'1 I.CIA of C',L AI)1411'1 I::GIA) INTRUSION INCLUDING ROOF>12 INCHES OCCUPANT SITE;>18 INCHES ANY SITE INTO THE PASSENGER dli;ICINAINCY >9C',)�NI VVIII ::)�7f�/ANAL.I AINAN1::)ISI UN"I"' COMPARTMENT I"'I'"4AI,.IVIIA FALL 10 FT or MORE AUTO VS. PEDESTRIAN/BICYCIST THROWN,RUN OVER or WITH IMPACT GREATER THAN 20 MPH MOTORCYCYLE,GOLF CART OR ATV CRASH>20rnph VEHICLE TELEMETRY DATA CONSISTENT WITH HIGH RISK OF INJURY,IF AVAILABLE' =any one(1)-transport as a trauma alert; BLUE=any two(2)-transport as a trauma alert. 1. Airway assistance includes manual jaw thrust,continuous suctioning,or use of other adjuncts to assist ventilatory efforts. 2. Crushed,Major de-gloving injures, mangled extremity or deep flap avulsion(>5 in.) 3. Excluding superficial wounds in which the depth of the wound can be determined. 4. Long bone fracture sites are defined as the(1)shaft of the humerus,(2)radius and ulna,(3)femur,(4)tibia and fibula. 5. Vehicle Telemetry Data(if/when available)may be relayed to dispatch and can assist in predicting potential serious injuries from the data collected at the time of the crash. 9_9 Dr.Julio De Pena, MD Page 7 of 15 1404 C� E CARE AMBULANCE INC TRAUMA TRANSPORT AND TREATMENT PROTOCOLS 6 See attached list of Anticoagulants with High Risk of Bleeding 9 9 9 PEDIATRIC TRAUMA SCORECARD METHODOLOGY 1. Each EMS provider shall ensure that upon arrival at the location of an incident, the EMT or paramedic shall assess the pediatric trauma patient by evaluating the patient's status for each of the following components: Size, Airway, Circulation, Disability, Soft Tissue, Long Bone Fracture/Skeletal, and Mechanism of Injury. In assessing the pediatric patient, the criteria for each of the components in (2) and (3) of this section shall be used to determine the transport destination for pediatric trauma patients. 2. The EMT or paramedic shall assess all pediatric trauma patients using the following RED criteria and if any of the following conditions are identified, the patient shall be considered a pediatric Trauma Alert patient: A. Airway: If the patient requires active airway assistance including manual jaw thrust, continuous suctioning, or use of other adjuncts to assist ventilator efforts, has a respiratory rate of < 20 in an infant less than one year of age, or a respiratory rate of < 10 in children age 1-15 years old. B. Circulation: The patient has a faint or non-palpable carotid or femoral pulse or the patient has a systolic blood pressure of less than 50 mmHg. C. Disability: The patient exhibits an altered mental status that includes: drowsiness, lethargy, the inability to follow commands, unresponsiveness to voice, totally unresponsive, or is in a coma or there is the presence of paralysis; or the suspicion of a spinal cord injury; or loss of sensation. D. Soft Tissue: The patient has a major soft tissue disruption, or major skin flap avulsion (greater than 5 cm) or 2nd or 3rd degree burns to 10 percent or more of the total body surface area or amputation at or above the wrist or ankle, or a major de-gloving injury. E. If there is any penetrating injury or GSW to the head, neck or torso or any penetrating injury or GSW to the extremity at or above the elbow or knee (Superficial wounds where the depth of the wound can easily be determined are excluded from this criteria head and torso only), F. Long Bone Fracture/Skeletal: There is evidence of an open long bone fracture or there are multiple fracture sites or multiple dislocations. Long bone sites are defined as the (1) shaft of the humerus, (2) radius and ulna, (3) shaft of the femur, (4) tibia and fibula. G. Mechanism of Injury: Patients exhibiting any of the following criteria will be Trauma Alerts: 1. Electrocution or lightning injury with loss of consciousness or visible signs of injury; 2. Severe facial injury with airway compromise or potential airway compromise; 3. Ejection from automobile, motorcycle, ATV, golf cart or horse with anatomic injury; 4. Blunt abdominal trauma or chest trauma in patient with history of paralysis (paraplegia or quadriplegia) 9_9 Dr.Julio De Pena, MD Page 8 of 15 1405 C� E CARE AMBULANCE INC TRAUMA TRANSPORT AND TREATMENT PROTOCOLS 5. Blunt head, chest or abdominal trauma in a patient with bleeding disorder or on anticoagulants with a high risk of bleeding (see list of Anticoagulants with High Risk of Bleeding). 6. Auto versus pedestrian or bicyclist thrown, run over, or impact resulting from speeds more than 20 mph. 3. Should the pediatric patient not be identified as a Trauma Alert using the RED criteria listed in (2) of this section, the trauma patient shall be further assessed using the BLUE criteria listed in this section and shall be considered a Trauma Alert patient when a condition is identified from any two of the following components included in this section: A. Size: The patient weighs < 20 kilograms (44 pounds). B. Circulation: The carotid or femoral pulse is palpable, but the radial or pedal pulses are not palpable or the systolic blood pressure is less than 90 mmHg. C. Disability: The patient exhibits symptoms of amnesia or there is loss of consciousness. D. Soft tissue: The patient sustains a GSW to the extremity below the elbow or knee, E. Long Bone Fracture/Skeletal: The patient reveals signs or symptoms of a single closed long bone fracture or dislocation. Long bone fractures do not include isolated wrist or ankle fractures. F. Mechanism of Injury: Pediatric patients exhibiting any of the following criteria: 1. Death in the same passenger compartment, 2. Intrusion of more than 12 inches in the roof or occupant side of the motor vehicle or more than 18 inches intrusion into any site of passenger compartment, 3. Vehicle telemetry data consistent with high risk of injury, 4. Fall > 10 feet or 2-3 times the length or height of the child, 4. In the event that none of the criteria in (2) or (3) of this section are identified in the assessment of the pediatric patient, the EMT or paramedic can call a "Trauma Alert" if, in his or her judgment, the trauma patient's condition warrants such action. Where EMT or paramedic judgment is used as the basis for calling a Trauma Alert, it shall be documented as required in accordance with Rule 64J-1.014, Florida Administrative Code. 9_9 Dr.Julio De Pena MD Page 9 of 15 1406 E CARE AMBULANCE INC TRAUMA TRANSPORT AND TREATMENT PROTOCOLS E Care Ambulance Inc Pediatric Trauma Scorecard Methodology The EMT or Paramedic shall assess the condition of those injured individuals with anatomical and physical characteristics of a person fifteen (15)years of age or younger for the presence of one or more of the following three(3) criteria to determine the transport destination per 64J-2.005, Florida Administrative Code, (F.A.C.): 1. Meets color-coded triage system(see below) 2. Meets local criteria(specify): 3. Patient does not meet the trauma criteria listed, but was transported to a trauma center due to EMT or paramedic judgment(reason for transport must be justified in run report). )III....1) BLUE a`Z:—, WEIGHT<20 Kg A II AC I IVI,;A11)WAY ASSIS 1"ANCI;' II� /A1f 41 NI'1')A11.":3()IN IINI'AIN"I 1 YI'4 41 1)A1I 1()IINCI III I)I'41 IN1Y1') 13YI') Cfl:R�CU L,AP((,)NII AIIN I"'of N(IIN I:1A1 I'AI SI I,:.CAl d01111(,I I VII01:::::(AI I'I 11.'1: of CAROTID or FEMORAL PULSES PALPABLE, BUT THE RADIAL OR PEDAL 31 SI' :N()inirrl In PULSE NOT PALPABLE or SBP<90-mmHg YlSADIILJI11Y AI 11 Id1:::1 VII INIA1 31A11.13'[n I'Idl!:.„rI INCI.01: I AI)AIY313 AMNESIA [n 3 31'a1ICI(IIN 01:::'31::111NA1..C01::1[:)IINJ IIdY of 1 033 01:::r NI 1NSA"I"'ION LOSS OF CONSCIOUSNESS VIIAJ 1:::1 ',,(II 1 1133 II 113 l II'I I ING of VIIAJO1:::d AV I 11s1 IN 0r GSW TO THE EXTREMITY BELOW ELBOW OR KNEE S(YI::7 Plaaaa flE 3K11N 3"ui 3"1.!;&III)IN^, '10 >1()% 11!:33A AVIII'U 1"A 11OIN A"1"'0I A15OVI 11 111 WRI;I of AININI Ii,: ANY I'Ii::Nl IIdA"I"'INS,IINJl II1::Y 101IIIAI) INI!.CI ,[n 1111d,'�'�r�ar NI I I::::)A'I"'IING 11N fl II dY 10 11 11 A"I"'I dl VIII"I"'Y A I [n AI SOVli, I I OW[n ININI li, VIIAJ Ili I11: GI.OVIING IINJI,II')Y C OING,IBOINIF. 111'I IN 1 0NG 1:3ONI [n VI I II'1 I 113 0CA'I"'10N3,of SINGLE LONG BONES FRACTURE SITE°or DISLOCATION IFIFtA).;)l!IFtI1 dACI'l..11(1 3111 '�'�,^ S II II ILIF.',,.3AiL WVlad M (;Y:� :� 1 C 111OCI I I I(:':NN(n I IGI I"I"INIINC 3"1"'I:411N1 W1"I"'I I 1 033 01:::' DEATH IN SAME PASSENGER COMPARTMENT Na.UUtY:R Y(" CONGC1(�III^rlNl ,r,',,r[n V1311i:31 1 SIGING 111: I%�lI.,IIdY INTRUSION INCLUDING ROOF>12 INCHES OCCUPANT SITE;>18 NI VI 141 ACIA1..11N fl II')Y W1 I I I A11')WAY C( f//II''14 f//IINI,; INCHES ANY SITE INTO THE PASSENGER COMPARTMENT J1 C'1"'101y4 I I')(„VII AI I I OVII01 S11 I f//IO I111)CYC1,I GOI I:::' VEHICLE TELEMETRY DATA CONSISTENT WITH HIGH RISK OF INJURY CAI d'1 A V 111 d I W1"I"I I AINA'I"'OVII IC I%�fl 1::dY FALL>10 FT or 2-3 TOMES THE HEIGHT OF THE CHILD 1 I IIN"1"'AISI)(„VIIINAI of CI11i,131 11)AI,.,IVIA IN 1::'AIII:.IN"I"'W1I"'I I 1 113 101:::::dY 01 :::AI Y^,IS(I':'AI dAl'I 1::::GIA of ()I,.,IAI)I d11'1 1!!ICIA) 1 I I IIN 1"'1 II:::AI),CI 11 31 AI&I:)OVIIIINAI,VI 113CL I AI d 31N1 I 1 1'AI I1)AI„I VIA INI'AI11';NIONANICOAC IAN1,3W1IIIIIIGI°°°I )131> 01' 1 I )IING AI 10V;',r I'I )I �'�r"1 dIAIN/li,!'SICYCI^r1""'1"'I IId(�3WIN, dlIIN11VIi,lld[��' 'I 1 IAIN 20 VII I::II°I =any one(1)-transport as a trauma alert; BLUE=any two(2)-transport as a trauma alert. 1. Airway assistance includes manual jaw thrust,continuous suctioning,or use of other adjuncts to assist ventilatory efforts. 2. Altered mental states include drowsiness, lethargy, inability to follow commands,unresponsiveness to voice,totally unresponsive. 3. Long bone fracture sites are defined as the(1)shaft of the humerus,(2)radius and ulna,(3)femur,(4)tibia and fibula. 4. Long bone fractures do not include isolated wrist or ankle fractures or dislocations. 5. Includes major de-gloving injury. 6. Excluding superficial wounds where the depth of the wound can be determined. 7. Vehicle Telemetry Data,when available,can be relayed to dispatch;the data can assist in predicting potential serious injuries from the data collected at the time of the crash. 8. See list of Anticoagulants with High Risk of Bleeding. 9_9 Dr.Julio De Pena, MD Page 10 of 15 1407 C� E CARE AMBULANCE INC TRAUMA TRANSPORT AND TREATMENT PROTOCOLS V. TRANSPORT DESTINATION CRITERIA 64J-2.002 F.A.C. 1. There are no state approved trauma centers in Company . Therefore, it is the decision of the Medical Director, Dr. Julio De Pena M, that it is in the best medical interest of trauma patients, who meet the criteria outlined in this protocol for designation as a TRAUMA ALERT, to be transported as expeditiously as possible to a SATC or SAPTC. If air transport is not possible, TRAUMA ALERT patients may be transported to a local hospital for stabilization until transport to the nearest SATC or SAPTC is available. 2. No patient shall be transported from the scene via air transport without appropriate immobilization, secure airway allowing for adequate ventilation, and established IWO access. Inability to secure an airway is a contraindication to air transport. 3. Trauma patients in full cardiac arrest on the scene should be taken by ground ALSto the nearest Hospital. 4. If circumstances prohibit direct scene transport to a Trauma Center (adverse weather conditions, disasters, mass casualties, prolonged TRAUMA STAR ETA) then patients will be taken to the nearest local hospital for stabilization and treatment prior to transport to the nearest Trauma Center. VI. INTER-FACILITY TRANSFER OF TRAUMA PATIENTS As previously noted, there are no state approved trauma centers in Monroecoounty Company . On rare occasion, a patient meeting Trauma Alert Criteria may need to be transported from the scene to a local hospital for stabilization/ treatment until appropriate transportation to the SATC or SAPTC is available. The hospital will arrange for appropriate transportation of the patient. Should supplemental personnel, such as medical or nursing staff, respiratory therapy staff, etc. be necessary to assist E Care Ambulance Inc crew for optimal patient care, the transferring hospital will coordinate the necessary personnel to accompany the Ambulance Crew. Transport personnel. 9_9 Dr.Julio De Pena, MD Page 11 of 15 1408 C� E CARE AMBULANCE INC TRAUMA TRANSPORT AND TREATMENT PROTOCOLS V11 APPROVED TRAUMA CENTERS AND INITIAL RECEIVING HOSPITALS Approved Trauma Centers and Pediatric Trauma Referral Centers 1. Level 1: University of Miami/Jackson Memorial Hospital (Adult and Pediatric trauma care) 2. Provisional Level 1: Kendall Regional Medical Center (Adult and Pediatric trauma care) 3. Provisional Level II: Jackson South Community Hospital 4. Nicklaus Children's Hospital (Pediatric trauma care only) Receivina Facilities 1. Lower Keys: Lower Keys Medical Center, Stock Island 2. Middle Keys: Fishermen's Hospital,Marathon 3. Upper Keys: Mariner's Hospital, Tavernier 9_9 Dr.Julio De Pena, MD Page 12 of 15 1409 C� E CARE AMBULANCE INC TRAUMA TRANSPORT AND TREATMENT PROTOCOLS ANTICOAGULANTS WITH HIGH RISK OF BLEEDING Trade Names: Generic names: Aggrenox (ASA+dipyridamole) Anagrelide(Agrylin) Agrylin (anagrelide) Apixaban (Eliquis) Brilinta (ticagrelor) Cilostazol(Pletal) Coumadin (warfarin) Clopidogrel (Plavix) Effient(prasugrel) Dabigatran (Pradaxa) Eliquis (apixaban) Dipyridamole(Persantine) Jantoven (warfarin) Dipyridamole +ASA (Aggrenox) Plavix (clopidogrel) Edoxaban (Savaysa) Persantine(dipyridamole) Pentoxifylline(Trental) Pletal (cilostazol) Prasugrel (Effient) Pradaxa (dabigatran) Rivaroxaban (Xarelto) Savaysa (Edoxaban Ticagrelor(Brilinta) Ticlid (ticlopidine) Ticlopidine (Ticlid) Trental (pentoxifylline) Vorapaxar (Zontivity) Xarelto (rivaroxaban) Warfarin (Coumadin, Jantoven) Zontivity (vorapaxar) -------------------------------------------------------------------------- Injectables: Activase (alteplase) Aggras tat(tirofiban) Angiomax(bivalirudin) Argatroban Arixtra (fondaparinux) Fragmin (dalteparin) Heparin Innohep (tinzaparin) Integrilin (eptifibatide) Iprivask(desirudin) Lovenox(enoxaparin) Reopro (abciximab) Streptokinase Tenecteplase (TNKase) Urokinase 9_9 Dr.Julio De Pena MD Page 13 of 15 1410 C� E CARE AMBULANCE INC TRAUMA TRANSPORT AND TREATMENT PROTOCOLS TRAUMA TRANSPORT PROTOCOLS MEDICAL DIRECTOR APPROVAL I, Julio De Pena., Pre-hospital Medical Director for E Care Ambulance certify to the Department of Health, Bureau of Emergency Medical Services that I have reviewed and approve the Trauma Transport Protocols, dated Nov 1, 2022. 11/01/2022 Julio De Pena , M.D Date 9_9 Dr.Julio De Pena MD Page 14 of 15 1411 E Care Ambulance Inc DRUG FORMULARY Adenosine Triphosphate (Adenocard®) sal, fir�"Frxq '�j . 1 / : .. Adenosine exerts its effects by decreasing conduction through the AV mode.The half-life of Adenocard is less than 10 seconds.Thus, its effects, desired and undesired, are self-limited. Adenocard is indicated for paroxysmal supraventricular tachycardia (PSVT) including that associated with accessorybypass tracts Wolf-Pa rkinson- �� j White Syndrome). yp ,f NTI.AIINII�IIATII � . .i. Adenocard is contraindicated in second or third degree AV block and sick sinus syndrome (except in patients with a functioning artificial pacemaker), and known hypersensitivity to Adenosine. R�NlHNMS n Adenocard may produce a short lasting first,second, or third degree heart block. In extreme cases transient as stole may result.At the time of conversion to normal sinus rhythm, a variety of new rhythms may appear (PVC's, PAC's, sinus bradycardia, sinus tachycardia, skipped beats,and varying degrees of AV block)and generally last only a few seconds without intervention. P i'`.l=CA t.J" l Q N,1& The effects of Adenosine are antagonized by methylxanthines such as caffeine and theophylline.Thus, larger doses of Adenosine may be required for Adenosine to be effective.Adenosine effects are potentiated by dipyridamole (Persantine).Thus, smaller doses of Adenosine may be effective.Adenosine may produce bronchoconstriction in patients with asthma. P®SSlBlf ADVERSE REACT.0NS AND SIDE EI=I=ECTS: ....................................................................................................................................................................................................................................... Cardiovascular: Facial flushing, headache,and rarely: sweating, palpitations,chest pain,and hypotension. Respiratory: Shortness of breath,chest pressure,and rarely: hyperventilating, metallic taste, tightness in throat and head pressure. CNS: Light headedness and rarely:dizziness, blurred vision,tingling and numbness in extremities,apprehension. DOSAGE: Ade, R dosage: 6 mg rapid IVP, immediately followed by 20 ml NS flush. Repeat in 2 minutes at 12 mg IVP followed by 20 ml NS flush PRN. ll'efflati1c dosage 0.1 mg/kg(maximum 6 mg) rapid IVP immediately followed by 5 ml NSflush. Repeat in 2 minutes, at 0.2 mg/kg (maximum 12 mg) rapid IVP followed by 5 ml NS flush PRN. Time/Action Prof le: Onset: Pealk Duration IV: Immediate Unknown 1-2 minutes Adenosine Triphosphate (Adenocard®) Dr.Julio De Pena MD O 1412 E Care Ambulance Inc N DRUG FORMULARY ............................................... Albuterol (ProventiM, Ventolin@) r A,(;"TlG1" S: Albuterol is primarily a beta-2 sympathomimetic and as such produces bronchodilation. Because of its greater specificity for beta-2 adrenergic receptors it produces fewer cardiovascular side effects and more prolonged bronchodilation than isoproterenol. 11NDICAo,I"IqNS: Albuterol inhaler is indicated for relief of bronchospasm in patients with reversible obstructive airway disease including asthma, and COPD. COIIVI III' III N 1 IIIC ''I I�l 0 N S: .................................................................................................................... Albuterol is contraindicated in patients with a history of hypersensitivity. WA IIC3�'1`YYi III 1`YYi(„3 m°1ii: ............................................................... Use cautiously in patients with coronary artery disease, hypertension, hyperthyroidism, and diabetes. In adults, do not give Albuterol if heart rate is > 150. Exception: If patient remains in sinus tachycardia and systolic blood pressure remains > 100 Albuterol treatments may be continued. The rationale must be clearly documented. The benefits must outweigh the risks. Administer cautiously to patients on MAO inhibitors or tricyclic anti-depressants. Beta-Blockers and Albuterol will inhibit each other. POSSIBLE A VERSE REAL"1"IONS AND SIDE Eff EC".ES: Cardiovascular:Tachycardia, hypertension, and angina. CNS: Nervousness, tremor, headache, dizziness, and insomnia. GI: Drying of oropharynx, nausea, and vomiting, unusualtaste. DOSAGE: Adult: 2.5 mg of Albuterol in 3ml of NS to nebulizer and flow oxygen 8 liters/min. Chlld: .............................. If> 1 year or > 10 kg: 2.5 mg of Albuterol in 3 ml of NS (0.083%) to nebulizer and flow oxygen 6 liters/ min. If< 1 year or< 10 kg: 1.25 mg of Albuterol in 1.5ml of NS (0.083%) to nebulizer and flow oxygen 3 liters/min. (2.5 mg divided in half).Treatment will be delivered over approximately 5 to 15 minutes. Time/Action IProfiie: Onset Desk Duration Inhaled: 5-15 minutes 60-90 minutes 3-6 hours Albuterol (ProventilO, Ventolin@) Dr.Julio De Pena MD O ' 1413 E Care Ambulance Inc M DRUG FORMULARY ..............I Amiodarone (NexteroneT") AI"1 IONS: Amiodarone suppresses recurrent VF, prolongs intranodal conduction and refractoriness, negative inotropic effect. ' AM111111 ON I � IN@.Ii CAT I:I NSI ;� � � �; iwv Ventricular Fibrillation � J' C Pulseless VT • PVC's greater than (>) 12 min • Ventricular Tachycardias (Wide and Narrow) with a pulse y CII FRAI UICXTIii S ,ai��ntl �� r� An known allergy � Cardiogenic Shock Sinus Bradycardia • 2nd and 3rd degree AV blocks POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: None in Ventricular fibrillation. DOSAGE: Adult dosage: Pulseless Arrest: 300 mg IV/10 May repeat with 150 mg IV/ 10 With Pulses: Infusion loading dose: 150 mg IV(150 mg in 100cc NS) infused on a macro drip over 10 minsl.5gtts/sec. ll'h1'"('fiaft III ILA:: Pulseless Arrest: 5mg/kg IV/10 may be repeated once. No single dose greater than 300 mg. (15mg/kg max) Tirane/Action Profile: Onset Peak Duration IV/10: Unknown Unknown Unknown Amiodarone (NexteroneTM) Dr.Julio De Pena MD O ' 1414 E Care Ambulance Inc DRUG FORMULARY ..............I Aspirin (Bayer, ° Bufferin°) A,5 T16 1 : ......................................... Aspirin is an analgesic, anti-inflammatory and anti-pyretic, which also appears to cause an inhibition of synthesis and release of prostaglandins. l� Aspirin also blocks formation of thromboxane A- 2. (Thromboxane A- 2 causes platelets to aggregate and arteries to constrict). Reduces overall mortality from acute myocardial infarction. Aspirin is indicated in the Acute Coronary Syndrome setting to prevent 11Km further clotting. 0, jiyO CUM''I IIIN 1)'� lI CAI""IIIOIIICS: A known allergy to Aspirin (i.e. urticaria, dyspnia, etc.), active GI ulceration or bleeding, hemophilia or other bleeding disorders, during pregnancy, children under 2 years of age. .P.OSSI..B..L.E...A V.E.R..S.E....R.E..AL."I"..I..O.N.S....A..N..D....SI.D.E.. ...... .C."I"..S... GI: Nausea, vomiting, heartburn, and stomach pain. OTIC:Tinnitus. Hypersensitivity: Bronchospasm, tightness in chest, angioedema, urticaria, and anaphylaxis. DOSAGE: Adult: 324 mg (4) 81mg chewable tablets for Acute Coronary Syndromes Time/Action (Profile: Onset Peak Duration (Oral) PO: 5-30 minutes 1-3 hours 3-6 hours Aspirin (Bayer, ® Bufferin®) Dr.Julio De Pena MD O ` 1415 E Care Ambulance Inc u7 DRUG FORMULARY ........................ Atropine Sulfate as Cardiac Agent Atropine is a potent anticholinergic (parasympathetic blocker, parasympatholytic) that reduces vagal tone and thus increases automatically the SA node and increases A-V conduction. • Sinus Bradycardia accompanied by hemodynamic compromise,(i.e. hypotension, confusion, frequent PVC's, pale, cold, clammyskin). • In children (< 1 year) bradycardia of less than 60 beats/minute should be treated if symptomatic even if BP is normal. C0111 1 I1AIII N I1' IIIC ''I"1l10111CS: ..................................................................................................................... None in emergency situations WA,C3�'�I`YYi III�I`YYi(3 m"1ii: ................................................................ Too small of a dose (< 0.5 mg) or if pushed too slowly, may initially cause the heart rate to decrease. Antihistamines and antidepressants potentiate Atropine. A urnaxirnuirn dose of 0.04 mg/kg should not be exceeded. For 2nd degree AV block type II and 3rd degree AV block, omit Atropine and go to external pacer. POSSIBLE ADVERSE REAL"i"IONS AND SIDE EFFEC"II"S: ........................................................................................................................................................................................................................................................................ CNS: Restlessness, agitation, confusion, psychotic reaction, pupil dilation, blurred vision, and headache. Cardiovascular: Increase heart rate, may worsen ischemia or increase area of infarction, ventricular fibrillation, ventricular tachycardia, angina and flushing of skin. GI: Dry mouth and difficulty swallowing. Other: Urinary retention. Can worsen pre-existing glaucoma. DOSAGE: Adult: Bradycardia: 0.5-1 mg IV/10, may repeat every 3-5 minutes until improved or total of 2mg is reached. @'Iledi4ll a i�c: 0.02 mg/kg IV/10 (minimum dose is 0.1 mg and arnaxlrnuirn single dose is 0.5mg child, 1 mg adolescent). May repeat once. Time/Action IProfiie: Onset Peak Duration IV/10: Unknown Unknown Unknown Atropine Sulfate as Cardiac Agent 10-F Dr.Julio De Pena MD ' 1416 E Care Ambulance Inc Q0 DRUG FORMULARY ............................................... Atropine Sulfate as Antidote for Poisoning ACTIONS: ,............................ Atropine is a potent parasympatholytic that binds to acetylcholine receptors thus diminishing the actions of acetylcholine. it i iCA,no S: dr Anticholinesterase syndrome poisoning such as; Organophosphate (e.g. Parathion, Malathion, Rid-a-Bug) and Carbamate (Baygon, Sevin and many common roach & ant sprays). Signs of organophosphate poisoning are: Salivation Lacrimation Urination Defecation GI distress, Emesis, Pinpoint pupils, bradycardia, and excessive sweating. None in the a management of severe organophosphate poisoning. WA III3�'�IIY III�I'Y(„3 S It is important that the patient be adequately oxygenated and ventilated prior to using Atropine as it may precipitate ventricular fibrillation in a poorly oxygenated patient. Even after Atropine is administered, the patient may require intubation and aggressive ventilatory support. .P.OSSI..B.L.E...ADV.E.RS.E....R.E..AL""I.O.N.S....Ah D....SI.DE...E.....E. .wm"..S... Victims of organophosphate poisoning can tolerate large doses (1000 mg) of Atropine. Signs of atropinization are the end point of treatment: flushing, pupil dilation, dry mouth, and tachycardia. DOSAGE: Adult: 0.03 mg/kg IV/IO, repeat every 5-10 minutes until atropinization occurs. F'"edIla t a i�c 0.05 mg/kg (maximum 3 mg) IV/IO, repeat every 5-10 minutes until atropinization occurs. Time/Action IPurofHe: Onset Peak Duration IV/IO: Immediate 2-4 minutes 4-6 hours Atropine Sulfate as Antidote for Poisoning 10-F Dr.Julio De Pena MD 1417 E Care Ambulance Inc I` DRUG FORMULARY .............................. Calcium Chloride 10% ACTIONS: .. Calcium chloride increases the force of myocardial contraction; calcium may either increase or decrease systemic vascular resistance. In normal �t U hearts, calcium's positive inotropic and vasoconstricting effects produce a CALCIUM predictable rise in systemic arterial pressure. i� I N I I ----- a°�N- Calcium chloride is indicated during resuscitation for the treatment of hypocalcaemia and calcium channel blocker toxicity (i.e. Verapamil or Cardizem overdose) and Magnesium Sulfate overdose. It also protects the heart from hyperkalemia as may occur in patients with end-stage renal disease. D � � / , �� , OIII I III IIIIII � III I IIIIIIS Cardiopulmonary arrest not associated with calcium channel blocker toxicity, hypocalcaemia, or hyperkalemia. WAIII 3' ��i m Calcium m chloride � oride should not be administered in the same infusion with Sodium Bicarbonate, since calcium will combine with sodium bicarbonate o � to form an insoluble precipitate (calcium carbonate). Calcium chloride should be given with extreme caution, and in reduced dosage, to persons taking digitalis because it increases ventricular irritability and may precipitate digitalis toxicity. POSSIBLE ADVERSE REAL"I"IONS AND SIDE EFFE "I"Sn If the heart is beating, rapid administration of calcium can produce slowing of cardiac rate. DOSAGE: Adult dosage: For hypotension following administration of calcium channel blockers(i.e. Cardizem, Verapamil): 4mg/kg IV slowly If patient is taking digitalis, 2 mg/kg IV slowly. Repeat every 10 minutes PRN. For calcium channel blocker overdose and hyperkalemia: 8-16 mg/kg IV slowly Asystole/PEA(if on calcium channel blockers) 1gm IVP Time/Action (Profile: Onset Desk Duration IV/IO: Immediate Immediate 2-5 hours Calcium Chloride 10% 10-� Dr.Julio De Pena MD 1418 E Care Ambulance Inc op DRUG FORMULARY ............................. Cyanokit® ?(II i u uuiwYno(�l idl y °� lt° : ,�� II6e:..III S... Hydroxocobalamin is an antidote Y cyanide. It is marketed as CYANOKIT Oin � the US. It removes cyanide direct) from the blood without converting any of the hemoglobin and therefore does not Interfere with oxygen transport. It r Y Y combines with the cyanide to form c anocobalamin which is a derivative of vitamin B-12. Both the H droxocobalamin and B-12 are harmlessly excreted in urine. r 4 • Exposed to products of combustion in an enclosed space 0 Soot present in their nose, mouth, or sputum • Altered mentation • Does not meet trauma alert criteria • At least 18 > years old Common Signs & Symptoms include: Symptoms Signs Headache Altered Mental Status Confusion Seizures Dyspnea Mydriasis (dialated pupils) Chest Tightness Tachypnea (early) Bradypnea (late) Nausea Hypertension (early) hypotension(late) Cardiovascular collapse Vomiting COIII "i""III'° IIIIII �' IIIC "i""IIIOIIISm ..................................................................................................................... None Do not use the following medications in the same IV line: • Diazepam Propofol Ascorbic acid • Dobutamine Thiopental • Fentanyl Sodium Nitrite • Nitroglycerin SodiumThiosulfate • Pentobarbital Whole Blood DO NOT RELY ON PULSE OXIMETRY FOR ACCURATE READINGS DOSAGE: Please refer to detailed infusion instructions located within the CYANOKIT° itself. or in protocol 3-2. Several multi-dose kits are carried in the Battalion Chiefs vehicle Cyanokit® Dr.Julio De Pena MD —� 1419 E Care Ambulance Inc 00 DRUG FORMULARY Dextrose 50 % and 25 % (d-glucose) A(.'"TlG1 : A monosaccharide, which provides calories for metabolic needs, spare body proteins and loss of electrolytes. Readily excreted by kidneys producing diuresis. Hypertonic solution. DEXT !SEiNDICA"n ; N : tion, USP 0Hypoglycemia 0 Coma of unknown origin. 0111 'I III�nlltllracran ally�III�� traspinal hemorrhage (ina patient with normal BGL). • Blood glucose Level > 60 mg/dl. With 11110114)ifuor i�� POSSIBLE ADVERSE REAL"i"IONS AND SIDE EE "i"S: .......................................................................................................................................................................................................... �,:.. • Cardiovascular:Thrombosis Sclerosing if given in peripheral vein . Local:Tissue irritation or necrosis if infiltrates. • Others: Acidosis, alkalosis, hyperglycemia,and hypokalemia. DOSAGE: Adult: ( 30 kg) 50 ml of a 50% solution; (25 gm) IV/10. F'"ediia t a i�::: 30 kg) 2 ml/kg slow IV/10 of a 25% solution. I`\JeyvA�tao 11,' 10 kg or<� 1 month of age) 5 ml/kg IV/10 of 10% solution (dilute D50 4:1 with NS). Time/Action IProfiie: Onset Desk Duration IV/10: < 1 minute Depends on degree of hypoglycemia Dextrose 50 % and 25 % (d-glucose) rl Dr.Julio De Pena MD O ' 1420 E Care Ambulance Inc o DRUG FORMULARY O Diazepam Hydrochloride (Valium®) i � � �A'i , � � ��✓��uw�dmemu , 1 � �fldff(�f(�VWf�9�llI�M01lNM�n�r�a�a(i��r�i�ni�l� � A.C.][uQNS.1 A member of the benzodiazepine family, Diazepam,depresses the limbic system,thalamus,and hypothalamus resulting in calming effects. Diazepam produces a sedative effect and is also a muscle relaxant. I IN DiCATIIOINS: • Status epilepticus, Premedication prior to cardioversion,Agitation due to acute alcohol withdrawal, Drug induced psychosis,Short-term relief of acute anxiety,Cocaine intoxication CON'TRAINDICA"i MSS • Alcohol Intoxication • Pregnancy(except for seizure control associated with eclampsia) • Neonates WA,II°,II"4 II II"4 G S Do not mix Diazepam with any other drug, precipitates with almost all medications.When injecting IV administer slowly through the IV tubing as close as possible to the vein insertion. Do not administer into small veins such as those on dorsum of the hand—causes local irritation and possibly venous thrombosis in small veins. I511II CALL II III:II\,NS: • Pregnancy(except for control of seizures associated with status epilepticus or eclampsia) • Neonates. POSSOBL.E AD.IERSIE REACTOON.S AND SODE Eu=u=ECTS: ....................................................................................................................................................................................................................................... • CNS:Confusion, muscular weakness, blurred vision, drowsiness, respiratory depression, respiratory arrest, and slurred speech. • Cardiovascular: Bradycardia, hypotension, and cardiovascular collapse. • G.I.: Nausea,vomiting, abdominal discomfort and hiccups. • Respiratory: Respiratory depression. • Other: Potentiates MAO's, barbiturates,tricyclics and phenothiazines Potentiated by Cimetidine, ETOH and other CNS depressants. DOSAGE: AdIuK� To be administered in 5 mg increments. Dosing ranges from 5-20 mg IV/IO/IM depending on specific protocol.The IV route should be administered slowly-no faster than 5 mg/min. IM 20 mg maximum dose per injection. IM injections are painful. If IM route used inject deeply into the deltoid for maximum absorption. 1e(,Buell a is Status epilepticus 0.2 mg/kg IV/IO slowly(max 5mg). Rectal Dose 0.5 mg/kg,may repeat either route x 1 in 5 mins. Time/Action IPiroiiile: Onset Pealc Duration (Sedation)IV/IO: 1-5 minutes 15-30 minutes 15-60 minutes IM: 15-20 minutes. 5-1.5 hours Unknown Rectal: Unknown 1-2 hours 4-12 hours Diazepam Hydrochloride (Valium®) 10-1 f Dr.Julio De Pena MD 1421 E Care Ambulance Inc DRUG FORMULARY O Diphenhydramine Hydrochloride (Benadryl°) r A Ta(?N w Diphenhydramine is an antihistamine with anticholinergic(drying)and sedative side effects.Antihistamines appear to compete with histamine for cell receptor sites on effector cells. Diphenhydramine prevents, but does not reverse histamine mediated responses, particularly histamine effects on the smooth muscle of the bronchial airways,gastrointestinal,uterus,and blood vessels. INOC ICATIQNS • Allergy symptoms,anaphylaxis • Sedation of violent patient • Dystonic reactions from phenothiazine overdose(i.e. Haldol,Compazine,Thorazine,and Stelazine) CONTII AIINI[XCATIONS' ...................................................................................................... Diphenhydramine is not to be used in newborn or premature infants. Diphenhydramine is not to be used in patients with acute asthma attack W l,'1IlrwlIlIlrwlGS ......................................................... In infants and children especially,antihistamines in overdose may cause hallucinations,convulsions,or death.As in adults,antihistamines may diminish mental alertness in children. In young children,they may produce excitation. Diphenhydramine has additive effects with alcohol and other CNS depressants(hypnotics,sedatives, tranquilizers,etc.).Antihistamines are more likely to cause dizziness,sedation,and hypotension in the elderly(60 years or older) patient POSSIBLE ADVERSE REACTtlONS AND SVDE EPPECM CNS: Drowsiness,confusion, insomnia, headache and vertigo (especially in the elderly). Cardiovascular: Palpitations,tachycardia, PVC's and hypotension. Respiratory:Thickening of bronchial secretions,tightness of the chest,wheezing and nasal stuffiness. GI: Nausea,vomiting,diarrhea,dry mouth,and constipation. GU: Dysuria and urinary retention. DOSAGE: AdUltV 25-50 mg IV/IO or 50 mg deep I 11e,JiflailuiEc 1 mg/kg IV/IO or IM (maximum 25 mg) Time/Action IPirofiile: Onset Pealc Duration IV/IO: Rapid Unknown 4-8 hours IM: 20-30 minutes 1-4 hours 4-8 hours Diphenhydramine Hydrochloride (Benadryl®) 10 Dr.Julio De Pena MD -1 �422 E Care Ambulance Inc DRUG FORMULARY CV O Dopamine Hydrochloride (Intropin°) & Tay..N l Dopamine stimulates dopaminergic beta-adrenergic and alpha-adrenergic receptors of the sympathetic nervous system. It exerts an inotropic effect on (� the myocardium resulting in an increased cardiac output. Dopamine produces less increase in myocardial oxygen consumption than does Isoproterenol and its use is usually not associated with a tachyarrhythmia. Dopamine dilates renal and mesenteric blood vessels at low doses that may not increase heart rate or blood pressure.Therapeutic doses have predominant beta adrenergic receptor stimulating actions that result in increases in cardiac output without marked increases in pulmonary occlusive pressure.At high doses, Dopamine has alpha y receptor stimulating actions that result in peripheral vasoconstriction and marked increases in pulmonary occlusive pressure. i N D I—CATl—ONS To treat shock and correct hemodynamic imbalances, improve perfusion to vital organs and to increase cardiac output. L CONTIITAIINII�IICATIIONS': { Dopamine should not be used in patients with pheochromocytoma or mil hypovolemic shock. IJI ffffr, Do...nlot,,llll � administer Dopamine in the presence of uncorrected tachydysrhythmias or ventricular fibrillation. Do not add Dopamine to any alkaline diluents solutions since the drug is inactivated in alkaline solution. Patients who have been treated with monoamine oxidase(MAO) inhibitors will require substantially reduced dosage.MAO inhibitors include:furazolidone (Furoxone°),isocarboxazid (Marplan°),pargyline hydrochloride (Eutonyl°),pargyline hydrochloride with methyclothiazide(Eutron°), phenelzine sulfate(Nardil°), procarbazine hydrochloride(Matulane°), tranylcypromine sulfate(Parnate°). POSSIIBLE ADVERSE REACTIIONS AND SIIDE EFFECTS: ............................................................................................................................................................................................................................ Cardiovascular:Tachycardia, palpitations,angina pain,ectopic beats,and hypotension GI: Nausea and vomiting Local: Necrosis and tissue sloughing with extravasations,use a large vein to reduce this incidence Other: Piloerection,dyspnea and headache. DOSAGE: AdUlt and I11,1erM'I aic: Pre-mixed bag Begin infusion at 5 mcg/kg/min.and titrate to effect(Maximum dose 20 mcg/kg/min.) Vial(400 mg)To yield a concentration of 1600 mcg/ml mix 400 mg of Dopamine into 250 ml of D5W. Time/Action IPirofiile: Onset Pealc Duration 4 minutes 10-15 minutes Continuous with infusion Dopamine Hydrochloride (Intropin®) 10-1 ;' Dr.Julio De Pena MD 1423 E Care Ambulance Inc M DRUG FORMULARY O Duo-Dote"' (Atropine and Pralidoxime Chloride) ACT]01 : .... • Blocks nerve agents effects and relieves airway y constriction and secretions in the lungs and gastrointestinal tract. m • Acts to restore normal functions at the nerve ending by removing the nerve agent and reactivating natural function 71� I iNDICA"noNS: ------------------------ Suspected or confirmed nerve agentexposure ,. 6`41 OIII h l1011l � t�� III�BIoIIV..I� III �.. : medications in the kit should be used with caution �w (but not withheld) in patients with preexisting cardiac disease, HTN, or CVA history. — exacerbation of angina, Myocardial infarction, Blurred pain ,�I1 d vision IL ADVERSE REAL"�"IONS AND SIDE EFFE "�"S� e vision , 11 W Headache, Drowsiness , Nausea , Tachycardia , Hypertension , 99 wiu� Hyperventilation DOSAGE: DUODOTE TM — Each auto injector contains BOTH: Atropine 2.1 mg and Pralidoxime 600 mg Adult: For Nerve Agent Exposure (SLUDGE symptoms): Up to 3 auto injectors may be used for one patient based on signs (1-2 kits for self treatment— up to 3 for buddy treatment with severe symptoms) DuoDotes TM are not authorized for the use of children under the age of 9 years. Duo-Dote TM (Atropine and Pralidoxime Chloride) 10-1 ? Dr.Julio De Pena MD 1424 E Care Ambulance Inc DRUG FORMULARY O Epinephrine 1:1,000 I SDI � di�Illl�i ,. I If q ��llli I r,. ACTIONS: ................................... Epinephrine is a sympathomimetic,which stimulates both alpha and beta-adrenergic receptors causing immediate bronchodilation, increase in heart rate and an increase in the force of cardiac contraction. Subcutaneous dose lasts 5-15 minutes. ofNDlt;:A010NS: Asthma • Anaphylaxis • Angioneurotic edema • All Pulseless Arrest CCU I1`IIAII IS II�MCAT IV T ISS': ...................................................................................................... None in the cardiac arrest situation. Hyperthyroidism, hypertension, cerebral arteriosclerosis in asthma. Caution should be used with Epinephrine administration when the patient is older than 40 years old or has a history of heart disease.The benefit must outweigh the risk. Do not administer Epinephrine if heart rate is > 150. WXR II\If IIN,NG S ........................................................ Epinephrine is inactivated by alkaline solutions- never mix with Sodium Bicarbonate. Do not mix Isoproterenol and Epinephrine-results in exaggerated response.Action's of catecholamine is depressed by acidosis - attention to ventilation and circulation is essential.Antidepressants potentiate the effects of epinephrine. P®SSIBL.E AD.IERSIE REACTI®NS AND SODIE EI=I=ECTS: ....................................................................................................................................................................................................................................... • CNS:Anxiety, headache and cerebral hemorrhage. • Cardiovascular:Tachycardia,ventricular dysrhythmias, hypertension, angina and palpitations. • GI: Nausea and vomiting DOSAGE: Ade, R: SQ 0.1-0.3 mg (0.3 cc). Repeat every 3-5 minutes (Asthma/Anaphylaxis may repeat once in 15 minutes). Ill'e:o°:Jiiiatu1c I 0.01 mg/kg up to 0.5 mg. Time/Action Prof le: Onset: Pealk Duration SQ: 6-12 minutes 20 minutes 1-3 hours Epinephrine 1 :1,000 10-1 ' Dr.Julio De Pena MD 1425 E Care Ambulance Inc u7 DRUG FORMULARY O Epinephrine 1:10,000 Enehr.pip 'm e is a sympathomimetic, which stimulates both Alpha and Beta- receptors. As a result of its effects, myocardial and cerebral blood flow are increased during ventilation and chest compression. Epinephrine increases systemic vascular resistance and thus may enhance defibrillation. i u IIttICAMN : All Pulseless Arrest • Asystole • Ventricular Fibrillation unresponsive to defibrillation; uuritlBw pm�lm Ilpuert�m¢Ik • PEA � '""•°� ° �� Other pediatric indications: hypotension in patients with circulatory ryomwobanad��p� instability, bradycardia (before Atropine). I � " : r Il�k�ur��ll rrl CII�III Illt „III II�IIIIIIC III IIOII� None in the cardiac arrest situation. 1 �� Epinephrine is inactivated by alkaline solutions-never mix with Sodium Bicarbonate. Do not mix Isoproterenol and Epinephrine- results in exaggerated response.Actions of catecholamines are depressed by acidosis -attention to ventilation and circulation is essential. Antidepressants potentiate the effects of epinephrine. POSSIBI E ADVERSE REACTIONS AND SIDE EFFECTS: .................................................................................................................................................................................................................................................. CNS:Anxiety, headache and cerebral hemorrhage. Cardiovascular:Tachycardia, ventricular dysrhythmias, hypertension, angina and palpitations. GI: Nausea and vomiting. ®SAGE: Adult: (1:10,000) 1 mg (10 ml) IV or IO, repeat every 3-5 minutes. Repeat every 3-5 minutes. If patient is in SEVERE anaphylaxis with marked hypotension,you may start an IV and administer 3 -5 cc of a 1:10,000 solution IVP slow over 2 minutes. Pediatric: 0.01I. mg/kg, (OAL mI/kg IV or IO). Repeat every 3,,,.5 minutes. Pediatric : POST ARREST: 0.JLrnrocg/kg/rnroin I ix ]Ling of Epi into 1I,.000H INS w Concentration of JLrncg/r I Tiirne/Actiioin Profile: Onset Beak Duration IV/IO: Rapid 1-2 minutes 20 minutes Epinephrine 1 :10,000 —1 Dr.Julio De Pena MD 1426 E Care Ambulance Inc DRUG FORMULARY CD Fentanyl AC'111O S: ...................................... Fentanyl Binds with stereospecific receptors at many sites within the CNS, increases pain threshold, alters pain reception, inhibits ascending pain d pathways. Fentanyl binds to brain receptors, relieving pain. It decreases the feeling of pain and a person's response to pain. Fentanyl is 50-100 times as � ... 1 potent as morphine; morphine 10 mg I.M. =fentanyl 0.1-0.2 mg I.M., fentanyl has less hypotensive effects than morphine due to minimal or no - �u:bu histamine release. I V V, IA,Low bo Fentanyl Citrate 11 DIIC"A'1f"1101 5: hi USF �" 1iM ciop FiontanVV2 ml Moderate to severe pain in patients>10kg C' A'u Acute Coronary Syndrome—Chest Pain (Adult) " PL -:x Pain associated with isolated extremity fracture, renal colic, burns, etc. CO IP'�"III"III''tA lII IP'�IIC'. III CA lll"III O IP'�S: • Epistaxis or bilateral blocked nares • Known hypersensitivity to fentanyl • MAOI use in past 2 weeks CONCENTRATION Unstable hemodynamics or altered 1 cg/ W��tll'�I"w�III I"w�I"Illi��1i1�� 50mcg/ml U.se..w.I t.h...caution in patients with bradycardia, hepatic, renal, or respiratory disease or those with increased ICP, head injuries, or impaired consciousness; patients must be monitored until fully POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: CNS: Drowsiness, sedation, increased intracranial pressure Cardiovascular: Bradycardia, hypotension, peripheral vasodilation GI: Nausea, vomiting GU: Urinary tract spasm Respiratory: Respiratory Depression SLOW IV PUSH- Rapid push may cause chest wall rigidity decreasing,or DOSAGE: eliminating ability to ventilate. Ad ul111:�, 1-3 mcg/kg IV/IO/IN (Typical adult dose 50-100mcg) May repeat half the original dose administered. Pediatric>10KG: 1 mcg/kg IV/IO/IN May repeat half the original dose administered 0.5mcg/kg Time/Action Profile: Onset Beak Duration IN: 2-10 mins 30-60 mins IV: Immediate 30-60 mins Dr.Julio De Pena MD Fentanyl Revised 11-01-22 Addenftrn 1427 E Care Ambulance Inc (.0 DRUG FORMULARY O Furosemide (Lasix®) A.CIOI�S: A sulfonamide derivative and potent diuretic,which inhibits the reabsorption of sodium and chloride in the proximal and distal renal tubules as well as in the Loop of Henley. Has a direct venodilating effect in acute pulmonary edema.With IV administration, onset of venodilating is generally within 5-10 minutes; diuresis will usually occur in 20-30 minutes V IIMCA M • Pulmonary edema COII19111"IIRAIII1 IIC'. CXIIII"IIIOII"9S: Anuria. Should be used in pregnancy only when benefits clearly outweigh risks. WAI N III IN(12& Furosemide should be protected from light. Dehydration and electrolyte imbalance can result from excessive dosages. Rapid diuresis can lead to hypotension and thromboembolic episodes. PQ.SSdOL.E ADVERSE REACTIONS AND SIDE EFFECTS: CNS: Dizziness, tinnitus, hearing loss, headache, blurred vision and weakness GI:Anorexia,vomiting and nausea Cardiovascular: Hypotension Other: Pruritus, urticaria and muscle cramping. GAGE: Adult:CHF: 80 mg IVP or double the patient dose up to max 100 mg. Cardiogenic Shock:40 mg IV slowly over 2 minutes (If systolic blood pressure is than 100 mmHg.) Tiirne/Actiioin Profile: Onset Beak Duration IV/IO: 5 minutes 30 minutes 2 hours Furosemide (Lasix®) Dr.Julio De Pena MD 10-1 �428 E Care Ambulance Inc DRUG FORMULARY CD Ketamine (Ketalar®) ACTIIG m ......................................... ,I Rapid acting general anesthetic, characterized by profound analgesia, normal pharyngeal-laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and respiratory stimulation, and occasionally a transient and minimal respiratory depression. Disassociates the brain form the spinal cord thus inhibiting pain sensation. Ketamine increases cardiac output and may be considered � �' I►� advantageous in patients with hemodynamic compromise (trauma, 51001 rinul p01111 InP 4,, sepsis, etc.). A patent airway is maintained partly by virtue of 111Uf�url�yriruu CIO IM11,11tNfRAIu �� unimpaired pharyngeal and laryngeal reflexes. " V 1 I114 D I(".KI"I 0 I114 S., z rN, so • Facilitation of pain control in patients with isolated extremity trauma, burns and/or entrapped patients. • Procedural Sedation CONCENTRATION • Violent/Combative/Aggressive Patients or"Excited Delirium" 500mg/5ml 100mg/ml GIII ..l.IIC .........IIL III I1)„IIL. .........CAI.IIL III .S..m. • Hypersensitivity to Ketamine • Condition in which an increase in Blood Pressure would be hazardous. • Acute Coronary Syndrome or STEMI • Ocular trauma(globe injury) W 1,III! I`1Y II I`1Y GS: ................................................................ IVP over 1-2 min, Ketamine may cause apnea if given too rapidly IV POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: CNS: "Emergence Reaction" or hallucinations upon recovering Cardiovascular: Tachycardia, hypertension GI: Nausea and vomiting Respiratory: Hypersalivation, Respiratory depression/apnea DOSAGE: AddltV Procedural Sedation/Pain *.0,,aui-n„g/1 g IV/Iq/I!P qv „i„I.,-� I.nil).may repeat prn. Airway Management *2ang/..!�1_V/I_G�„c�v h„�.... ? in„i„n„may repeat prn. (Trismus/Endangered Airway/RS11post intubation sedation for inhalation airway control) Violent/Combative/Aggressive Adult Patient 400ing IM/IIV may repeat prn.Consider combining with intronosol Versed. Il: rlu'ftric Procedural Sedation/Airway management 1 ng/..! 1V/IG (II „/I„IJ c v „i„ Ini„i„may repeat prn.Time/Action(Piro file: Onset Pealc Duration IV 1-2 minutes 3-5 minutes Weight dependent Dr.Julio De Pena MD Ketamine (Ketalar®) D.O. IFReviised 11..01-22 Addenftrn 1429 E Care Ambulance Inc DRUG FORMULARY O Magnesium Sulfate 4ilI AarI .. ..... Magnesium prevents or controls convulsions by blocking neuromuscular transmission and decreasing the amount of acetylcholine liberated at the end-plate by the motor nerve impulse. Magnesium is said to have a depressant effect on the central nervous system, but it does not affect the mother,fetus or neonate when used as directed in eclampsia and pre-eclampsia. Magnesium acts peripherally to produce vasodilatation LWEtherefore a drop in systolic BP is to be anticipated. ,I niatfion USP !IIR I'N A11`II W31N -------------- • Prevention and control of seizures in eclampsia • Torsades de Pointes q Suspected hypomagnesemic state(i.e.chronic alcoholism and chronic use of m �d diuretics) • Refractory ventricular fibrillation p¢!ill jll • Refractory Asthma CON ryRAl NDACryI NS��Parenteral administration of the drug is contraindicated in patients with heart block or myocardial damage. WA,II°,II"4 II II"4 G S W Intravenous use of Magnesium Sulfate should not be given to mothers with toxemia of : pregnancy with imminent delivery. Magnesium Sulfate Injection USP,50%must be VS ditated diluted to a concentration of 20%or less prior to IV infusion for I.V.I use, 111111 E CAI LY II Il 011\1 SW Because magnesium is removed from the body solely by the kidneys,the drug should be used with caution in patients with renal impairment. Monitoring the patient's clinical status is essential to avoid the consequences of overdose in eclampsia.Calcium Chloride should be immediately available to counteract the potential hazards of magnesium intoxication in eclampsia.Signs of hypermagnesium include respiratory depression; absence of patellar reflex,etc. POSSI.BILE.ADVERSE._REACTII(�NS AND SIIDE EFFECTS: ........................................................................................................ Adverse effects of Magnesium Sulfate IV are usually the result of magnesium intoxication. Signs of hypermagnesemia include:flushing,sweating, hypotension,depression of reflexes,flaccid paralysis,hypothermia,and circulatory collapse,depression of cardiac function and central nervous system depression.These symptoms can precede fatal paralysis. DOSAGE: AdUl n • For eclamptic seizures:2 gm in 20 cc IV over 2 minutes • For Torsades de Pointes and refractory VF:1-2 gm(mixed in 50 ml of NS and administered over 1-2 minutes)followed by a maintenance infusion (1 gm in 250 ml of NS administered at 60 gtts/min). Time/Action IPirofiile: Onset Pealc Duration IV Drip: Immediate Unknown 30 minutes Magnesium Sulfate Dr.Julio De Pena MD -� 1430 E Care Ambulance Inc CID DRUG FORMULARY O Methylprednisolone (Solu-MedrolO, A Methapred) jl ACTIONS: Decreases inflammatory effects via its potent anti-inflammatory synthetic steroid. r i IN D_1 AC nN : • Asthma • Anaphylaxis • Head injury i • COPD �,� �� j01 • Unconscious with known Addison's disease CGN1 '" 111N 1 ll C 1"ll0 N S m �t None in the emergency setting. nr nN � r, OSSI L E ADVERSE REAL""IONS AND SIDE Eff E C..".1.".5n GI hemorrhage, reduces leukotrines of immune system and IK increases potential for infections. DOSAGE: Adult: 125 mg IV slow over 2 minutes F'11ediia°II a i�::: 2 mg/kg (max 125 mg) IV slow over 2 minutes Time/Action IPro-ffle: Onset Desk Duration IV/IO: Unknown Unknown Unknown Methylprednisolone (Solu-Medrol®, A Methapred) Dr.Julio De Pena MD -� 1431 E Care Ambulance Inc 00 DRUG FORMULARY O Midazolam (Versed®) ACTIONS: Depresses CNS, muscle relaxant, strong sedative, hypnotic, and amnesia. �i IINDICA°noN : Y Control of seizures, sedation for cardioversion & pacing, and sedation for airway management. OIIN 1`„III1 III N i� 111 CA1 III 0 I S.m. Respiratory depression l� ' 0 Hypotension • ETOH and drugs 41 Monitor` ll�vi(at�.�. ��fA �� q m il6tii patient for respiratory and CNS depression and vital signs after administration. POSSIBLE ADVERSE REAC"I"IONS AND SIDE EFFEC"I"S: CNS: Retrograde amnesia, altered mental status and dizziness Cardiovascular: Bradycardia, hypotension, PVC's,tachycardia and nodal rhythms GI: nausea and vomiting, hiccoughs and coughing Respiratory: Respiratory depression, laryngospasm and bronchospasm DOSAGE: Adult: � . I....I . .....�. ....!L:h::...11 .. ... i..!I1. ." �..... 2.5-5 mg based on patient's weight up to 10 mg amax F'11ediia°II a i�c > 1 years of age (0.1 mg/kg) Do Not Administer to pediatric less than 1 year of age Time/Action (Profile: Onset Desk Duration IV 1-2 minutes 3-5 minutes Weight dependent Midazolam (Versed®) Dr.Julio De Pena MD -1 1432 E Care Ambulance Inc CD DRUG FORMULARY CD Morphine Sulfate (MS) ,w i AC`1 It" NS: ..................................... Morphine is a narcotic analgesic,which depresses the central nervous and respiratory system and sensitivity to pain. Morphine also increases venous capacitance, decreases venous return and produces mild peripheral vasodilatation. II DIWA'IPIO S: • Pain • Pain associated with isolated extremity fracture, renal colic, burns,etc. C IP'T"III"III'tA III IP'T IIC'. III CA"III"III IP'T S: ........................................................................................................... • Volume depletion or hypotension • Acute asthma • Known hypersensitivity to MS WXI' NI III N I"II'�& ........................................................... Morphine is detoxified by the liver. It is potentiated by alcohol, antihistamines, barbiturates, sedatives and beta blockers. POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: CNS: Euphoria, drowsiness, pupillary constriction and respiratory arrest. Cardiovascular: Bradycardia and hypotension. GI: Decreases gastric motility, nausea and vomiting. GU: Urinary retention. Respiratory: Bronchoconstriction, and decrease cough reflex. ®SAGE: Adult: 2 mg increments IV slowly. Repeat every 5 minutes until desired response is achieved (u 1i)Xliu kflrn dose 10 mg). Can be given IM. @)e:;Niiatrk� 0.1 mg/kg IV slowly. May repeat the initial dose X1 in 3-5 minutes. llrifl°airit�� 0.05 mg/kg IV slowly. May repeat the initial dose X1 in 3-5 minutes. Tiirne/Actiion Profile: Onset Peak Duration IV: Rapid 20 minutes 4-5 hour Dr.Julio De Pena MD Morphine Sulfate (MS) 1 Revised 11-01-22 If�b=:vii�6=:a 1433 E Care Ambulance Inc DRUG FORMULARY (V O Naloxone Hydrochloride (Narcan®) ACTIONS: ................................... Naloxone antagonizes the effects of opiates by competing at the same receptor sites. When given IV,the action is apparent within two minutes. I or SC administration is slightly slower. IlNDI- A71-0NS: • Naloxone is indicated for the complete or partial reversal of central nervous and respiratory system depression secondary to opiate narcotics or related drugs such as, but not limited to: — Heroin, Meperidine (Demerol), Codeine, Morphine, Methadone, Lomotil, Hydromorphone (Dilaudid), Pentazocine (Talwin), Propoxyphene (Darvon), Percodan, Fentanyl (Sublimaze) (Known on the street as "White China") CQNT1ISAIIISIIXICATIQNS' ...................................................................................................... Known hypersensitivity to Narcan. WARII\If IIN,NGS ........................................................ Naloxone should be administered cautiously to persons including newborns of mothers who are known or suspected to be physically dependent on opiates it may precipitate an acute abstinence syndrome. If patient is intubated and airway is controlled do not administer Narcan (excludes cardiac arrest). May need to repeat Naloxone since duration of action of some narcotics may exceed that of Naloxone. Naloxone is not effective against a respiratory depression due to non-opiate drugs. Use caution during administration as patient may become violent as level of consciousness increases. POSSll3Lf ADVERSE REACTIONS AND SODS EI=I=EATS: ....................................................................................................................................................................................................................................... CNS:Tremor,agitation, belligerence, pupillary dilation, seizures, increased tear production, sweating and seizures secondary to withdrawal. Cardiovascular: Hypertension, hypotension,ventricular tachycardia, pulmonary edema and ventricular fibrillation. GI: Nausea and vomiting. DOSAGE: Adult: An initial dose of 2 mg may be administered IV/IO/IM/PRN. If no response after 4 mg,then condition is probably not due to narcotic. (Fentanyl may require large doses of Naloxone to reverse effects). Ill'e:o°:Jiiiatu1c 0.1 mg/kg IV/IO/IM/PRN. Time/Action Prof le: Onset: Pealk Duration IV: 1-2 minutes unknown 45 minutes Naloxone Hydrochloride (Narcan®) Dr.Julio De Pena MD 2 1434 E Care Ambulance Inc N DRUG FORMULARY (V O Nitroglycerin (Nitrostat® Nitrolingual® Spray) ..:.......o.....l............. 5 L.� S: Nitroglycerin is a direct vasodilator, which acts principally on the venous system although it also produces direct coronary artery vasodilatation as well. There is a decrease in venous return, which decreases the workload on the heart and thus, decreases myocardial oxygen demand. Sublingual nitroglycerin is rapidly absorbed. Pain relief occurs within one to two minutes and therapeutic effects can last up to 30 minutes. INDICA"n NS: • -Chest pain or discomfort associated with suspected AMI. • Pulmonary edema with hypertension. I . .III .. '.III:........IIL.III ..()„IIL. .........(.`„Ill 0 .S. • Systolic BP <� 100 mmHg • Children under 12 • Patients on erectile dysfunction drugs that fall withintime parameters (i.e. <� 36 hours) • Know hypersensitivity to the drug • Evidence of a positive V4R in the setting of an Inferior wall MI RR_ECACo,nqNS: Nitroglycerin tablets are inactivated by light, heat, air and moisture. Must be kept in amber glass containers with tight-fitting lids. Do not leave cotton in container. Once opened, nitroglycerin has a shelf life of 3 months. Do not shake Nitrolingual spray. Alcohol will accentuate venodilating and hypotensive effects. POSSIBLE ADVERSE REAL][]0NS AND SIDE E EC"I"S: ........................................................................................................................................................................................................................................................................ CNS: Headache, dizziness, flushing, nausea and vomiting. Cardiovascular: Hypotension, reflex tachycardia, and bradycardia. DOSAGE: Adult: 0.4 mg (1 tablet or 1 spray sublingual). May repeat in 3-5 minutes PRN. Time/Action (Profile: Onset Peak Duration SL: 1-3 minutes unknown 30-60 minutes Nitroglycerin (Nitrostat® Nitrolingual® Spray) Dr.Julio De Pena MD 2 1435 E Care Ambulance Inc DRUG FORMULARY O CD Odansetron (Zofran®) ..... ......... F 116: 11 S: Antiemetic, Zofran blocks the actions of chemicals in the body that can trigger nausea and vomiting. Selective 5-HT3 receptor antagonist. Category B in pregnancy. CONCENTRATION g/2 I lllkDlt°,AWIIWIOIIkS: Used for a patient with nausea unrelieved with comfort measures, uncomfortable due to 2 g/ I the nausea during transport and/or with a potential for airway compromise related to vomiting. • Nausea and vomiting due to chemotherapy. • Prophylactic use prior to administration of pain management medication. • Nausea and vomiting with moderate to severe dehydration orelectrolyte imbalance. COIIIk l I1AIll kf' IIIC I""IIIOIIIkS: ..................................................................................................................... Hypersensitivity(anaphylaxis)to Ondansetron or any of components of the formulation. or to any medicine similar to ondansetron, including dolasetron (Anzemet), granisetron (Kytril), or palonosetron (Aloxi). WA III'°t�"Y III�"Y G S: ............................................................... Ondansetron is extensively metabolized in the liver and should be used with caution in patients with hepatic disease, hepatitis, or elevated hepatic enzymes. Patients with a history, or family history, of Long QT syndrome; transient EKG changes have been seen with IV administration including QT interval prolongation. POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: CNS: Headache, Dizziness, Drowsiness, Fatigue GI: Diarrhea, Constipation, Abdominal pain, Dry Mouth MISC: Rash, Shivering, Fever, Hypoxia, Urinary Retention, Muscle Pain RARE: Bronchospasm, Transient blurred vision after infusion DOSAGE: Adult ' Pediatrics >40kg: 4 ; ajQ:E.....:j.yj3.. (not less than 30 sec) I'°ed14Il1111m 4I.flIag: ....:.::.! !..g. .�<.g.......... �..1 .....�. ..°. Time/Action Puroflle: Onset Peak Duration IV 1-2 min 14-30 minutes Weight dependent Dr.Julio De Pena MD Odansetron (Zofran®) F eviised '91..01-22 Addenftrn 1 22 1436 E Care Ambulance Inc co DRUG FORMULARY (V O Oral Glucose (Insta Glucose) ACTIONS: ......................................... Increases blood glucose levels slowly. IINDI " o,l"IqNS: BS > 60 mgdl, patients who are altered but alert enough to take the command to swallow. III "l""III' IIIIII �' III "l""IIIIIIS: Patients unable to swallow or Stroke symptoms. ............................................................................... None when patient can swallow, risk of aspiration if given improperly. AD�/ERSE REAC"II"IONS AND SIDE "II"S: .................................................................................................................................................................................................................... GI: Nausea DOSAGE: Adult: 1 tube l"edIIaII a i�c 1 tube Time/Action Profiled Onset: Pealk Duration PO: 10 minutes unknown Unknown Oral Glucose (Insta Glucose) Dr.Julio De Pena MD 1 0-2 1437 E Care Ambulance Inc It DRUG FORMULARY CV O Sodium Bicarbonate .CJ l..: . gym. Increases PH to reverse acidosis. I IN D I "no N : • Metabolic acidosis in cardiac arrest • Tricyclic overdoses with QRS > 0.1 • Electrocutions • Hyperkalemia • Methanol / Ethylene glycol toxicity p� Severe ketoacidoses i COIII 1 I1AI N I1' IIIC ''I"IlIOIIICSm CHF and Alkalotic states WAIII�3�'JIYll'Y(3S: Excessive therapy inhibits oxygen release, reduces the ability to defibrillate, may precipitate other medications and administration should be guided by blood gases. Do not give concurrently with any 1 other medication, flush the line before and after administration. POSSIBLE ADVERSE REA ][IONS AND SIDE E E "1"Sn ........................................................................................................................................................................................................................................................................ Metabolic alkalosis and may crystallize in IV solutions. DOSAGE: Adult: 1 mEq/kg IV push, then % the dose q 10 mins. Electrocutions: 2 mEq/kg IVP F'"ediall a i�c 1-2 mEq/kg diluted 50:50 with Normal Saline Time/Action IPuroflle: Onset Peak Duration IV/IO: Unknown Unknown Unknown Sodium Bicarbonate Dr.Julio De Pena M 1 O 2 1438 M d' qy E z -0 o U p O o rs w U O a z o ^ ° z o ® a `moo � U as U V N ri, a a ua ID Dmd 61, Q) cowl 0 won U N °U 43 N c a' try° �2, a ® p gym" u k wi is O UIra p � uj .sl O O O �y 04., E c 6S CS _ « El 04 O � v O C � C 04 U 61ID CS p O 4 o us a � oU .� c as r UAll C a rs c .Q DATE(MM/DD/YYYY) ACCOR" CERTIFICATE OF LIABILITY INSURANCE 01/19/2025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Roddrelle Sykes Risk Management&Compliance LLC DBA Risk Assist Plus a/c°NN Ext: (945)214-9411 A//C,No): 9355 John W Elliott Dr aooRless: rs kes nemtex ert.com Suite#25460 INSURER(S)AFFORDING COVERAGE NAIC# Frisco,TX 75035 INSURERA: Hudson Insurance Company 25054 INSURED INSURER B: Tokio Marine 10945 E CARE AMBULANCE INC. INSURER C: 91551 Overseas Hwy, INSURER D 7 Tavernier, FL 33070 INSURER E 7 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MMIDD/YYY MMIDD/YYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 CLAIMS-MADE IX I PREMISES OCCUR DAMAGETOEaRENTEDo ccurrence $100,000 MED EXP(Any one person) $5,000 B X H24MSS2269600 04/16/2024 04/16/2025 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $3,000,000 POLICY❑ PRO ❑ JECT LOC PRODUCTS-COMP/OPAGG $1,000,000 X OTHER: SAM $1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ A X OWNED SCHEDULED X HST-000733-00 10/12/2024 10/12/2025 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Each Claim $1,000,000 B PROFESSIONAL LIABILITY X H24MSS2269600 04/16/2024 04/16/2025 Aggregate Limit $3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Monroe County is listed as Additional Insured with regard to Commercial General and Auto Liability policies per written contract. General Liability includes contractual liabilities and sexual abuse and molestation. Waiver of Subrogation also applies for Citrus County. Comp/Coll$2600 CERTIFICATE HOLDER CANCELLATION Monroe County Florida APPROVED BY RISK MANAGEMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 490 63 rd street Ocean THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BY Marathon FL 33050 ACCORDANCE WITH THE POLICY PROVISIONS. i DATE 02.04.2 WAIVER NIA XYES AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1440