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Item C02
C2 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 March 25, 2025 Agenda Item Number: C2 2023-3715 BULK ITEM: Yes DEPARTMENT: Fire Rescue TIME APPROXIMATE: STAFF CONTACT: R.L. Colina N/A AGENDA ITEM WORDING: Approval for issuance (renewal) of a Class A Certificate of Public Convenience and Necessity (COPCN) to the City of Marathon Fire Rescue for the operation of an advanced life support (ALS) and basic life support (BLS) transport ambulance service for the period of April 15, 2025 through April 14, 2027. ITEM BACKGROUND: On March 22, 2023, a Class A COPCN renewal was issued to the City of Marathon Fire Rescue to operate an ALS and BLS transport ambulance service. This certificate expires on April 14, 2025. In view of the foregoing, the City of Marathon Fire Rescue has applied to renew this COPCN which will become effective on April 15, 2025 and expire on April 14, 2027. PREVIOUS RELEVANT BOCC ACTION: 3/18/15: MCBOCC approved the issuance(renewal) of a Class A COPCN to the City of Marathon Fire Rescue for the operation of an ALS/BLS transport ambulance service for the period April 15, 2015 through April 14, 2017. 3/15/17: MCBOCC approved renewal of the Class A COPCN to the City of Marathon Fire Rescue for the period April 15, 2017 through April 14, 2019. 3/21/19: MCBOCC approved renewal of the Class A COPCN to the City of Marathon Fire Rescue for the period April 15, 2019 through April 14, 2021. 3/17/21: MCBOCC approved renewal of the Class A COPCN to the City of Marathon Fire Rescue for the period April 15, 2021 through April 14, 2023. 3/22/23: MCBOCC approved renewal of the Class A COPCN to the City of Marathon Fire Rescue for 135 the period April 15, 2023 through April 14, 2025. INSURANCE REQUIRED: Yes CONTRACT/AGREEMENT CHANGES: The renewal will cover the period of April 15, 2025 through April 14, 2027. STAFF RECOMMENDATION: Approval. DOCUMENTATION: Marathon Fire Rescue Class A COPCN Application- Combined file—Redacted.pdf City_of 1Vlarathon—COPCN_Expires-04.14.2027(LegaI Apprd).pdf FINANCIAL IMPACT: Effective Date: 4/15/2025 Expiration Date: 4/14/2027 Total Dollar Value of Contract: N/A Total Cost to County: N/A Current Year Portion: N/A Budgeted: N/A Source of Funds: N/A CPI: N/A Indirect Costs: N/A Estimated Ongoing Costs Not Included in above dollar amounts: N/A Revenue Producing: N/A If yes, amount: N/A Grant: N/A County Match: N/A Insurance Required: N/A 136 Additional Details: N/A 137 CITY OF MARATHON FIRE RESCUE 8900 Overseas; Highway, Marathon, FL 33050 "Dedicated to Community Fire Protection" ✓, 4�w Emergency 911 Office 305-74 -5266 Fax 305-289-983 4 February 11, 2025 Cheri Tamborski, Executive Administrator Monroe County Fire Fescue 490 5311 Street, Ocean, Suite 140 M'arathion, FL 33050 Dear Cheri, Enclosed you will find the City of Marathon Fire Rescue's application for the renewal of COPCN #15-02, A check request in the amount of$475.00 has been sent to our Finance Department, and shall foillow this application. Please include Mairathon Fire Rescue for the March 251h, 2025, BOCC meeting. Should you have any questions, please do not hesitate to contact me. Sincerely, � m Ashley Nixon ,f City of Marathon Fire Rescue Administrative Officer 138 MONROE COUNTY, FLORIDA APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY(COPCN) CLASS A EMERGENCY MEDICAL SERVICE (PRINT OR TYPE) ❑ INITIAL APPLICATION-$950.00 X RENEWAL APPLICATION-$475.00 IF RENEWAL,PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE:# 15-02 1. NAME OF SERVICE City of Marathon Fire Rescue BUSINESS MAILING ADDRESS 8900 Overseas Hwy, Marathon, FL 33050 BUSINESS PHONE NUMBER 305-743-5266 EMERGENCY PHONE NUMBER 305-304-9959 2. TYPE OF OWNERSHIP(i.e.,Sole Proprietor,Partnership,Corporation,etc.) Municipality DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION 1 1/30/1999 3. LIST ALL OFFICERS,DIRECTORS,AND SHAREHOLDERS(Use separate sheet if necessary): NAME AGE ADDRESS TELEPHONE# POSITION/TITLE Lynn Landry 57 9805 Overseas Hwy 305-743-0033 City Mayor George Garrett 61 9805 Overseas Hwy 305-743-0033 City Manager James Muro 56 8900 Overseas Hwy 305-304-9959 Fire Chief 4. LEVEL OF CARE TO BE PROVIDED: ❑BLS or H ALS IF ALS: ❑■ TRANSPORT or❑NON TRANSPORT 5. DESCRIBE THE ZONES(S)THAT YOUR SERVICE DESIRES TO SERVE(Use separate sheet if necessary): Fireboxes 1391, 1401 to 1406, 1481 and 1491 - West end of the 7 Mile Bridge (approx. MM40) to the West end of Tom's Harbor Bridge (approx. MM 60) and the City of Key Colony Beach FL, or as otherwise directed by Monroe County Dispatch. 6. LIST THE ADDRESS AND/OR DESCRIBE THE LOCATION OF YOUR BASE STATION AND ALL SUB- STATIONS(Use separate sheet if necessary): BASE STATION Station 14, 8900 Oversease Hwy, Marathon, FL 33050 SUB-STATION Station 15, 59265 Overseas Hwy, Marathon, FL 33050 Page l of 6 139 7, DESCRIBE YOUR COMMUNICATION SYSTEM (Attach copy of all FCC ficervies): XEAFUENCIE,S CALL NUMBERS #OF MOBILES 017 PORTA B LES Morro Couwy Public,SarL y Communicauon Syatcm Chief 14,DCf 4,FM 14,FM 114, LOG 14,T 14 15 25 ......................... 800 MHZP25trunking system - R15, ARFF14, E14, E114, R14, E15 806.00 MHZ -860,00, MHZ MED 16, MED 116, MED 216, TR14 8. LIST THE NAMES AND ADDRESSES OF THREE(3) U.S.CITJZFNS WHO WILL ACT AS REFERENCES 1,011 YOUR SERVICE'. NAME ADDRESS Dr. Antonio Gandia 8900 Overseas Hwy, Marathon, FL 33050 Terry Abel 8680.0 Overseas Hwy, Marathon, FL 33050 William Kelly P.O. Box 523401, Marathon, FL 33050 J. ATTACH A SCHEDULE OF RATES WHICI�-I YOUR SERVICE WILL CHARGE DURING THE COPCN PERIOD. 10. PROVIDE VERIFICATION OF ADEQUATE INSURANCE COVERAGE DURING'IIIE COPCN PERIOD. IL 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 C'OUNTYBOARD OF COUNTY COMMISSIONERS. 1,T14E UNDERSIGNED REPRESENTATIVE CIF THE ABOVE NAMED SERVICE, DO IrTEREBY 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 ATTESTTIIAT ALI.,THE, INFORMAL ION CONTAINED IN THIS APPLICATION,TO THE BEST'OF MY KNOWLEDGE, IS TRUE AND CORRECT. SIGNATURE OF APPLXANT/AUTIrj()IjIZE[)REPRESENTATIVE ASHLEY NIXON ON 0 HH 518323 Commission#HH 518323 Expires Aptili 21,2028 NOTAR"i"SEAL E� L2,s 'ARY SIG XTURE DATE flago 2 of 6 140 PERSONNEL—PARAMEDICS NAME PARAMEDIC CERTIFICATION First,Middle Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE Nelson Arro Diaz 545565 12/01/2026 Alexander Bobadilla 518322 12/01/2026 Christopher Cameron 526487 12/01/2026 Marcos Caraballo 542337 12/01/2026 Michael Card 206903 12/01/2026 Ramon Delacruz 521719 12/01/2026 Shane Edward 529034 12/01/2026 David Fernandez 533722 12/01/2026 Joseph Forcine 17313 12/01/2026 Jesse Fossum 525346 12/01/2026 Joel Fraga Acosta 546738 12/01/2026 Delvis Garcia 545970 12/01/2026 Daniel Gonzalez 527595 12/01/2026 Trace Goodwin 537855 12/01/2026 Matthew lacobelli 522529 12/01/2026 John Johnson 6281 12/01/2026 Samantha Manetta 544695 12/01/2026 Edwin Marquez 509842 12/01/2026 Peter Meneses 514250 12/01/2026 Cesar Moreton 205535 12/01/2026 Daniel Murciano 510515 12/01/2026 James Muro 10146 12/01/2026 Julio Nunez 11919 12/01/2026 Carlos Ornelas 532470 12/01/2026 Alejandro Ortega 546252 12/01/2026 Javier Pachas 522860 12/01/2026 Tchaka Pullen 510428 12/01/2026 Reynaldo Rodriguez 531506 12/01/2026 Shana Rogers 504441 12/01/2026 Christopher Sanchez 516768 12/01/2026 Page 3 of 6 141 PERSONNEL—PARAMEDICS NAME PARAMEDIC CERTIFICATION First Middle Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE Isabella Sanchez 531640 12/01/2026 Eustacio Sanchez 206311 12/01/2026 Shaheem Sutherland 546555 12/01/2026 Denis Timothy 532231 12/01/2026 Steven Torna 546642 12/01/2026 Richard Traybsza 543200 12/01/2026 Israel Vasquez 530452 12/01/2026 Thomas Wohlers 528291 12/01/2026 Orpheus Woodbury 521708 12/01/2026 Page 3 of 6 142 PERSONNEL—EMERGENCY MEDICAL TECHNICIANS NAME EMT CERTIFICATION First Middle Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE David Conde 590528 12/01/2026 Alexander Martinez 589539 12/01/2026 Enmanuel Martinez 590337 12/01/2026 Giancarlo Rodriguez 586194 12/01/2026 Page 4 of 6 143 qq ............ .......... 4 0c) (D OD 0) m r 00 C\j 0) N Cq z F5o�o,, Fo.co4 co,, C,2 rcj r\l r z u U- LL LL U- LL U-, U- LL LL U- LL LL LL H LL U- LL LL U- ................. u 04 m Ua 04 > 0 nn z ........... < 4 ........... 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Copy of FCC" license /A MEMO: FCC licenses are owned by Monroe County. Copy of FCC license does not apply. James Muro Fire Chief' Marathon Fire Rescue 8900 Overseas Flwy Marathon, F'L, 33050 305.74 -5266 148 �� BOARD OF COUNTY COMMISSIONERS County of Monroe ' 'IP t Mayor James K.Scholl,District 3 The Florida Keys 1 Mayor Pro Tem Michelle Lincoln,District 2 f Craig Cates,District 1 David Rice,District 4 Holly Merrill Raschein,District 5 Monroe County 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: February 24, 2025 ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Attached please find Check-dated February 13, 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 City of Marathon. Thank you, ca4'c'- ?Zze-� Cara Johnson 149 I VdShR69bI�ddG1'�dG�g^;�CvligyR4P0 VdcddM108e+„u�„nJNtt?fie u.N .•.,.. O LO f � � j C O O O O O E LO d V c2 * � ° o c # I 0 LO -W a' a 49 # # tz # 1 4m) U ' # 49 UW. N uj W OD tp # W # cn w # 3 # # c LO # N LO O # NO FW- \ rA N TA I LO O FW CO o O �. c rL z �" (Y) O w 0)(Y) o LL d 0 U _0 UU W 0 0 w. LL { W yam+ t a Z O W m Z Ln W 0 (Y m N �i g 0 ' O 0 o C O P4 co LO t` ,r", I ! 4: \ l' O W o O N GV Ii 0 0 O-0 Exhibit"A" City of Marathon Fire Rescue Ambulance Fee Schedule Effective June 14, 2022 Transport Base Fee—Basic Life Support (BLS) $500.00 Transport Base Fee—Advanced Life Support 1 (ALS1) $600.00 Transport Base Fee—Advanced Life Support 2 (ALS2) $875.00 Transport Base Fee— Special Care Transport (SCT) $900.00 Medicare Mileage Fees*for 2022 Mileage 1-17 $ 12.15 (per mile) Mileage 18+ $ 8.10 (per mile) *Fees to be automatically adjusted with Medicare fee schedules effective January of every year. 151 CN LO o uui 4x LL EL P a to w -, U m Z z UJ u z d: z E g r cr 0 o QC CL w a or,uj 0 :3 IT :2 7 uj 'B a G LL "RE" T 2 0. E> uj L"W w z m El NISREPREWNTATIPON OF INSURANCE ISATRMD DEGREE FELONY IN CASE OFACCUWXT 1. Obmm o end addteu of otber driver.ieuaeaoe mfonmedM liomtee mtmbetofodw cm detmis ofudda d ead C==aad addm mof iamm . 2. Do not&CM damis ofdm wddCM tb=YOM but dw mveedgatbtg o>Sow Maim no admiadoos or offar symams. 3• Comaa yam'sa WVieor immediataly to FW"the eedd=L ... . ........... .... . .. .. a THIS CARD MUST BE KEPT 1N THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your Agent/Company as Soon as possible. Obtain the following information: 1. Name and address of each d6ver,passenger and witness. ' 2. Name of Insurance Company and policy number for each vehide Involved. ❑ RataetemmvetagabpmvWB&tlnmialCffMM aisXGWWeCL tafartaeteormereoloaveregaastooreaatedsoret, dwmmga WIREPRIMSMI=OF I OWIAMM IS A RRST CMEG MODE MEAxOR WCARaFL P3M3f ar�w3o5tw 33L1J`30 JSi V$I 3:3Nvans 0 30 mwv'N3S3HcSHs 1N .pea[tuw!GPLIOA tpea io}164umu hallod Pue fuedwon aouell"M 16 eN Z .Mupm pUe ia&wssed'jenl1P tPOD IO SMPP2 Pue aw :uopetluolu!Bui+ao!!o)M u940'oil ssod se ttoos se µtaftjAuedwao mop(of Sluappae 0 pods»jN3GI00V do 3SVG Nl ONVIN3d NOdfl a31N3S3'8d CINV 313043A a3>:nsm 3H1 Nt ldWI 391SRW a SIHI 153 rred ' OVFIRNMEND'O PUBLIC ENTITY u N( f h�I J('",T GENERAL LIABILITY COVERAGE PART DECLARATIONS COVERED PARTY: City of Marathon AGREEMENT NO.: PK FL1 0442900 22-07 SCHEDULE OF COVERAGES AND LIMITS OF COVERAGE Deductibles Bodily Injury, Property Damage $0 Employee Benefits Liability $0 Fire Damage Limit $0 Sewer Backup & Water Damage Coverage $0 Pesticide/ Herbicide Limit $0 Law Enforcement Liability N/A Coverage is only provided for the coverages, indicated by an X. Coverage F—x-1 Bodily Injury and Property Damage $1,000,000 Per Occurrence Personal Injury and Advertising Injury Included Per Person or Organization Products,/ Completed Operation Included General Aggregate Limit N/A Medical Payments $2,500 MEmployee Benefits Liability $1,000,000 Per Occurrence N/A Aggregate Limit Fire Damage Limit Included Any One Premise Sewer Backup &Water Damage Coverage $10,000 No Fault Per Claimant $200,000 At Fault Per Claimant $200,,000 Annual Aggregate I "" II Pesticide i Herbicide Limit $1,000,000 Aggregate Limit = Law Enforcement N/A Per Occurrence FORMS AND ENDORSMENTS Forms and, Endorsements applying to this Coverage Part and made part of the coverage agreement at this time of issue: See PGIT MN-00 Premium: $ INCLUDED THIS SUPPLEMENTAL DECLARATIONS AND THE COMMON AGREEMENT DECLARATIONS,TOGETHER WITH THE COMMON AGREEMENT CONDITIONS,COVERAGE PART(S), FORMS AND ENDORSMENTS, IF ANY,COMPLETE THE ABOVE NUMBERED AGREEMENT. PGIT MN-020(10 18) Page I Pnnt Date:1 1/1120 22 PGIT MN 020 18,rpi 154 ,�u' I rred' E I PUBLIC ENTITY AUTOMOBILE COVERAGE PART DECLARATIONS ITEM ONE COVERED PARTY: City of Marathon AGREEMENT NO.: PK FL1 0442900 22-07 ITEM TWO SCHEDULE OF COVERAGES AND LIMITS OF COVERAGE This agreement provides only those coverages where a charge rs,shown in the premium column below.Each of these coverages wilt apply only to those"autos"shown as covered"autos.""" "Autos"are shown as covered"'autos"for a particular coverage by the entry of one or more ofthe symbols from the Covered Autos Section of the Public Entity Automobile Coverage Form next to the name of the coverage. COVERED AUTOS (Entry of one or more of Me symbols from the Covered LIMIT COVERAGES Auto Section of the Public THE MOST WE WILL PAY FOR ANY PREMIUM' Entity Automobile Coverage ONE ACCIDENT OR LOSS Form shows which autos are covered autos) LIABILITY 1 Total Any One Accident $1,000,000 Included $0 Deductible Subject to PGIT MIN-306 PERSONAL INJURY PROTECTION 5 STATUTORY Included or equivaiient No-fault Coveraqe) -AUTO, MEDICAL PAYMENTS 2 $5,000 Included -UNINSURED MOTORISTS 2 $100,000 Included UNDERINSURED MOTORISTS 2 $100,000 Included PHYSICAL DAMAGE 10,8 ACTUAL CASH VALUE OR COST OF REPAIR, Included COMPREHENSIVE COVERAGE WHICHEVER IS LESS,MINUS DED.AS SCHEDULED FOR EACH COVERED AUTO PER ATTACHED SCHEDULE,BUT NO DEDUCTIBLE APPLIES TO LOSS CAUSED BY FIRE OR LIGHTNING.See ITEM FOUR For Hired Or Borrowed"Autos." PHYSICAL DAMAGE SPECIFIED NIA ACTUAL CASH VALUE OR COST OF REPAIR Not Included CAUSES OF LOSS COVERAGE WHICHEVER IS LESS,MINUS$__DED, FOR EACH COVERED AUTO FOR LOSS CAUSED BY MISCHIEF OR VANDALISM.See ITEM FOUR For Hired Or Borrowed"'Autos' PHYSICAL DAMAGE COLLISION 10,8 ACTUAL CASH VALUE OR COST OF REPAIR, Included COVERAGE WHICHEVER IS LESS,MINUS DED.AS SCHEDULED FOR EACH COVERED AUTO PER ATTACHED SCHEDULE.See ITEM FOUR For Hired Or Borrowed"Autos." PHYSICAL DAMAGE TOWING AND NIA N/A For Each Disablement of A Private Not Included -LABOR Not available in Califomia) Passenger"Auto" I PREMIUM I INCLUDE PGIT MN-030(10 13) Includes Copyrighted material of Insurance Services,Office, Inc. with its permission Page 1 PiriM Date 11/112022 PGIT MN 0%)rpt 155 ITEM THREE SCHEDULE OF COVERED AUTOS YOU OWN F_ SEE ATTACHED SCHEDULE ITEM FOUR SCHEDULE FOR HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS LIABILITY COVERAGE STATE ESTIMATED COST OF HIRE FOR EACH RATE FACTOR(if Liability PREMIUM STATE Cov.Is Prima FL $IF ANY FLAT CHARGE I I Included PHYSICAL DAMAGE COVERAGE COVERAGES LIMIT OF COVERAGE ESTIMATED ANNUAL RATE PER EACH$100 PREMIUM THE MOST WE WILL PAY DEDUCTIBLE COST OF HIRE ANNUAL COST OF HIRE ACTUAL CASH VALUE OR COST OF REPAIRS Included COMPREHENSIVE OR$100.000 WHICHEVER IS LESS,MINUS $IF ANY $ $1.000 DED.FOR EACH COVERED AUTO. ACTUAL CASH VALUE OR COST OF REPAIR, SPECIFIED CAUSES WHICHEVER IS LESS,MINUS$DED.FOR $ $ $ OF LOSS EACH COVERED AUTO FOR LOSS CAUSED BY MISCHIEF OR VANDALISM ACTUAL CASH VALUE OR COST OF REPAIRS Included COLLISION OR $100,000 WHICHEVER IS LESS,MINUS $IF ANY $ $1,000 DED.FOR EACH COVERED AUTO PREMIUM Included ITEM FIVE SCHEDULE FOR NON-OWNERSHIP LIABILITY NAMED COVERED PARTY'S BUSINESS RATING BASIS PREMIUM Municipality $IF ANY Included �Ed FORMS AND ENDORSEMENTS Farms and endorsements applying to this Coverage Part and made part of the coverage agreement at this time of issue: See PGIT MN-002 Premium:$ INCLUDED THIS SUPPLEMENTAL DECLARATIONS AND THE COMMON AGREEMENT DECLARATIONS,TOGETHER WITH THE COMMON AGREEMENT CONDITIONS, COVERAGE PART(S), FORMS AND ENDORSEMENTS, IF ANY, COMPLETE THE ABOVE NUMBERED AGREEMENT. PGIT MN-030(1013) Includes Copyrighted material of Insurance Services Office, Inc.with its permission Page 2 Print Dale:11/1l2022 PGIT MN 030.rpt 156 CONTRACT BETWEEN THE CITY OF MARATHON, FLORIDA AND ANTI ONIO GANDIA, M.D. TO SERVE AS MEDICAL DIRECTOR FOR MARATHON FIRE RESCUE DEPARTMENT 'THIS CONTRACT is made and entered into this collective day of August 2024, by and between the City of Marathon, Florida, hereinafter V referred to as the ``CITY'," and Antonio Gandia, M.D. hereinafter referred to as "MEDICAL DIRECTOR". wrrN r ESSETH: WHEREAS,CITY provides fire and/or emergency medical services pursuant to Chapter 401, F.S. and Chapter 64J-1, FAC; and WHEREAS, CITY is required to employ or contract with a MEDICAL DIRECTOR who shall be a Florida licensed physician, Board Certified in Emergency Medicine with added qualification in Emergency Medical Services (EMS) and pre-hospital care experience, or a business entity that employs or contracts with similarly qualified physicians; and WHEREAS, CITY has determined it to be in the best interests of the residents of and visitors to the City of Marathon to contract with MEDICAL, DIREC 11'OR for the purpose of providing direction to the Fire and Emergency Medical Services; and WHEREAS, MEDICAL DIRECTOR desires to provide professional services according to the terms and conditions stated herein. NOW THEREFORE, in consideration of the mutual Understandings and Contracts set z:1 forth herein, CITY and MEDICAL DIRECTOR agree as follows: I. Term This Conti-act shall become effective on August 1-3, 2024, and shall run for an initial term of sixty. (60) days, through October 121, 2024 (Initial Term), The agreement may thereafter be renewed an additional number of times as the Mutual written agreement of the parties. 2. Compensation 2.1 Ground Ambulance MEDICAL DIRECTOR shall be paid at a rate of$5,000 per month to provide ground ambulance medical direction. Payments shall be made monthly in arrears by CITY pursuant to the Florida Local Government Prompt Payment Act after receipt of proper invoice submitted by MEDICAL DIRECTOR. 157 �,..� 2.2 If required, physician"'peer to peer" services for collection of denied medical claims will be paid, subject to administrative review, at a rate of$250.00/hour in order to collect funds that would otherwise be unpaid. 2.3 CITY will reimburse MEDICAL DIRECTOR for any direct expenses associated with meetings required by the CITY. For the purpose of this paragraph, the term "direct expenses" means per diem or subsistence allowances, transportation costs or mileage allowances, and miscellaneous travel expenses, as those terms are defined by Section 112.061, Florida Statutes. All compensation shall be according to City Ordinance and State law. 2.4 a. MEDICAL DIRECTOR will be provided a City phone and any other equipment required as approved by the Chief of Fire Rescue. b. CITY will reimburse MEDICAL DIRECTOR for the yearly application fee required for renewal of the City's Drug Enforcement Administration (DEA) certificate, if the MEDICAL DIRECTOR has paid the application fee in advance on behalf of the CITY. 2.5 Invoices received from MEDICAL DIRECTOR shall be reviewed and approved by the CITY Fire Chief or his designee, indicating that services have been rendered in conformity with the Contract, and then will be sent to the Finance Department for payment. 2.6 In order for both parties to close their books and records, MEDICAL DIRECTOR must clearly state "FINAL INVOICE" on MEDICAL DIRECTOR's final and last billing to CITY. This certifies that all services have been properly performed and all charges and costs have been invoiced to CITY. Since this account will thereupon be closed, any and other future charges if not properly included in this final invoice are waived by MEDICAL DIRECTOR. 2.7 Nothing in this Contract prohibits MEDICAL DIRECTOR from billing any third party for medical services rendered outside the scope of this Contract that may arise during or after the term of this Contract. 3. Purpose The purpose of this Contract is to assure compliance of CITY in Medical Direction of Marathon Fire Rescue Department in accordance with the provisions of F.S., Chapter 401, and FAC Chapter 64J-1.004. 4. Duties and Responsibilities. 4.1 MEDICAL DIRECTOR shall be responsible to Marathon Fire Rescue Department and report directly to the Fire Chief, and/or his/her designee. 2 158 4.2 /Oft\ MEDICAL DIRECTOR shall adhere to the responsibilities as set forth in Chapter 401, F.S., and Rule 64J-1.004, FAC; the applicable rules of any government agency implementing said chapter; and any duties upon written notice from the Florida Department of Health that such additional duties are required of MEDICAL DIRECTOR. These include supervising and accepting responsibility for the medical performance of all certified/license response personnel functioning within the scope of their official duties while on duty with Marathon Fire Rescue Department, including, but not Iimited to, members of volunteer fire department under contract with CITY. While these duties will typically occur within the geographical borders of the City of Marathon, they also include duties during mutual aid to requesting municipalities outside those geographical borders and while transporting patient to out of City medical facilities. For the purpose of this Contract, MEDICAL DIRECTOR is the individual who meets the licensing and registration requirements of Chapter 401, F.S. and FAC Chapter 64J-1.004. 4.3 MEDICAL DIRECTOR shall be knowledgeable with the standards set by National Fire Protection Association, and in particular, Standard 1582: Standard on Comprehensive Occupational Medical Program for Fire Departments. 4.4 Standards of Care MEDICAL DIRECTOR shall establish and maintain standards of care for EMS providers. 4.4.1 4.4.1 MEDICAL DIRECTOR shall gather agency input in the review and development of standards of care on an annual basis and establish and revise agency performance standards as necessary. 4.4.2 Develop pre-hospital practice parameters for Fire Rescue Personnel of all levels. The parameters shall be developed with consideration to budgetary and staffing limitations and the fiscal impact on Marathon Fire Rescue Department and the citizens of the City. 4.5 Patient Advocate MEDICAL DIRECTOR shall be a patient advocate in the fire rescue system and shall ensure that all aspects of the EMS systems are developed to place the needs of the patient first. 4.6 Protocols and Standing Orders. 4.6.1 MEDICAL DIRECTOR shall develop, revise, implement, and maintain basic and advanced life support protocols and standing orders under which Marathon Fire Rescue Department personnel will function under medical control. 3 159 4.6.2 MEDICAL DIRECTOR shall review and revise existing protocols and standing orders to ensure that they meet nationally accepted standards of practice for use by all system providers, which permit specified ALS and BLS procedures when communication cannot be established with a supervising physician, or when any delay in patient care would threaten the life or health of the patient. These standards include, but are not limited to, Advanced Cardiac Life Support (ACLS), Basic Trauma Life Support(BTLS),and Pediatric Advanced Life Support(PALS). In addition to medical treatment, protocols shall address determination of patient destination. 4.6.3 Marathon Fire Rescue Department shall publish and distribute, at its own cost, all protocols and standing orders. The protocols and standing orders shall be published in a form consistent with agency Standard Operating Procedures. Copies of the protocols and standing orders will be maintained on all Marathon Fire Rescue Department ambulances and ALS engines, and will be distributed to certified/licensed response personnel. Personnel copies may be provided electronically. Marathon Fire Rescue Department shall obtain and retain a receipt from each personnel member verifying receipt of the protocols and any changes. These receipts may be electronic, and shall state clearly that each person is individually accountable and obligated to follow all rules, regulations and protocols. All protocols and standing orders shall become public domain upon implementation. 4.6.4 MEDICAL DIRECTOR shall develop, review, and revise, when necessary, Trauma Transport Protocols(TTP)for submission to the Florida Department of Health,Bureau of Emergency Medical Services for approval in accordance with Rule 64J-2,FAC. 4.6.5 MEDICAL DIRECTOR shall develop enhanced protocols for specialty procedures or services. 4.6.6 MEDICAL DIRECTOR shall conduct an on-going review of all protocols and standing orders as may be necessary to ensure reliable service delivery,appropriate patient care,and the maintenance of the current standard of care. This shall include, at a minimum, a comprehensive annual review and written approval of all protocols and standing orders. While conducting the annual review, MEDICAL DIRECTOR shall take into consideration the results of quality assurance reviews, review of current medical literature, and input from Marathon Fire Rescue Department response personnel. Changes shall be developed with consideration to budgetary limitations and the fiscal impact on Marathon Fire Rescue Department and the citizens of the City. The annual review shall be completed, and all proposed changes forwarded to the Fire Chief, prior to the end of each Fiscal Year. 4.6.7 MEDICAL DIRECTOR shall ensure that appropriate training for new protocols and standing orders is conducted prior to implementation; shall ensure compliance with protocols and standing orders by all Marathon Fire Rescue Department personnel; and ensure that additional training is conducted for any identified needs. 4 160 4.7 Availability. MEDICAL DIRECTOR or his/her previously approved designee shall be available twenty-four (24)hours a day,seven(7)days a week for medical direction to Marathon Fire Rescue Department personnel in order to resolve problems, system conflicts, and provide services in an emergency as that term is defined in Section 252.34(3), F.S. 4.8 Trauma Scorecard Methodologies. MEDICAL DIRECTOR shall ensure that all certified/licensed response personnel are trained in the use of the trauma scorecard methodologies, as provided in Chapter 64J-2.004, FAC, for adult trauma patients and 64J-2.005, FAC,for pediatric trauma patients. 4.9 Oversight of Medical Qualifications And Proficiency of Marathon Fire Rescue Personnel 4.9.1 MEDICAL DIRECTOR shall ensure initial and continued medical qualifications and proficiency of Marathon Fire Rescue Department personnel. 4.9.2 MEDICAL DIRECTOR shall establish and periodically update the minimum personnel training standards and certification requirements for all Marathon Fire Rescue Department personnel who provide emergency medical care. Such standards shall include the requirements for orientation and initial training, continuing medical education, standards for professional conduct and evaluation standards and procedures. 4.9.3 'OWN MEDICAL DIRECTOR shall ensure that all field personnel meet the initial requirements and continuously comply with established standards to attain and maintain approval to operate within the Marathon Fire Rescue Department system. 4.9.4 MEDICAL DIRECTOR shall establish procedures for issuance, renewal, suspension, and revocation of practice privileges for Marathon Fire Rescue Department personnel in concert with the Fire Chief, to include a process for remediation4 The procedures shall contain due process provisions and all such provisions shall be approved,in advance,by the Fire Chief. 4.9.5 MEDICAL DIRECTOR shall provide for direct observation of field level providers while performing their duties that meets or exceeds Section 401.265, F.S.,and Rule 64J-1.004, FAC. 4.10 Quality Assurance 4.10.1 MEDICAL DIRECTOR, in coordination with Marathon Fire Rescue Department, shall develop, implement, and maintain an effective patient care Quality Assurance System to assess the medical performance of all certified/licensed Marathon Fire Rescue Department response personnel. 5 161 4.10.2 MEDICAL DIRECTOR shall develop, implement, and supervise a formal patient care Quality Assurance System in accordance with Section 401.265(2), F.S. and Rule 64J-1.004, FAC, to include the formation and supervision of a quality assurance committee. 4.10.2.1 The purpose and tone of the quality assurance review process shall be positive and educational; however, MEDICAL DIRECTOR may, at any time and without limitation, conduct a quality assurance review investigation or audit to ensure that Marathon Fire Rescue Department personnel comply with the Protocols and Standard of Care. 4.10.2.2 The method and extent of the investigation employed during any given quality assurance review shall be determined by MEDICAL DIRECTOR in consultation with the Fire Chief. As a result of said investigation, MEDICAL DIRECTOR may require remedial training of Marathon Fire Rescue Department personnel and/or revocation of practice privileges. Remedial training may be conducted by MEDICAL DIRECTOR, Marathon Fire Rescue Department personnel, or other personnel at MEDICAL DIRECTOR's discretion. 4.10.3 MEDICAL DIRECTOR or designee may also conduct special audits in response to observations or customer feedback provided by patients, family members, caregivers, bystanders, crew members,physicians and hospital personnel. 4.10.4 MEDICAL DIRECTOR may also develop procedures for routine auditing of EMS system performance and adherence to protocols on individual EMS incidents and overall EMS system compliance. 4.10.5 MEDICAL DIRECTOR or designee shall review, in conjunction with Marathon Fire Rescue Department, patient care reports on an ongoing basis;review all protocol deviations and initiate or recommend corrective action. MEDICAL DIRECTOR or designee shall review at least 40 patient care reports per month. Marathon Fire Rescue Department shall provide electronic copies of patient care reports. 4.10.6 MEDICAL DIRECTOR shall periodically visit and communicate with the hospital emergency departments to exchange information and review the quality of care provided by the Marathon Fire Rescue Department personnel. 4.10.7 MEDICAL DIRECTOR shall participate in field activity and system monitoring to include the following: 4.10.7.1 Ride along and observe field activity as a crew member on a rescue as needed. System monitoring shall include visiting fire stations when needed to discuss issues with Marathon Fire Rescue Department personnel. 6 162 4.10.8 MEDICAL DIRECTOR shall document in a quarterly status report to the Fire Chief,evidence of the following required activities: 4.10.8.1 Reporting on issues identified with Marathon Fire Rescue Department personnel;and 4.10.8.2 Communicating with hospital emergency department staff,and other medical and public safety personnel for quality assurance and education activities. 4.11 Educational Programs 4.11.1 MEDICAL DIRECTOR shall participate in educational programs at all levels, to include all certified/licensed response personnel. 4.11.2 MEDICAL DIRECTOR or designee shall oversee a minimum of ten(10)hours a year of continuing medical education related to pre-hospital care or teaching or a combination of both. 4.11.3 MEDICAL DIRECTOR shall actively participate in the development and presentation of EMS continuing education programs by identifying educational topics,presenting lectures and providing other educational opportunities for the enhancement of the fire rescue system. Marathon Fire Rescue Department shall pay the actual direct cost of any course materials, instructors, and certificates. 4.11.").1 Education should be geared to reach the specific needs of the audience. As some providers are volunteers,consideration shall be given to scheduling some training on nights or weekends. 4.11.3.2 Course content should include system-specific issues and items resulting from audit and review. 4.11.4 Where MEDICAL DIRECTOR is not the presenter, and training services are conducted by other CITY personnel and/or are subcontracted to an outside provider, MEDICAL DIRECTOR will ensure the quality of the Continuing Medical Education(CME)training provided to EMS personnel by: 4.11.4.1 Reviewing and approving all curriculum and courses for continuing education units(CEU's)prior to Marathon Fire Rescue Department personnel being trained; 4.11.4.2 Monitoring and auditing at least one (1) class session of every CME course held in which MEDICAL DIRECTOR is issuing CME; and 7 163 4.11.4.3 Evaluating the educational effectiveness of instruction,courses and programs in consultation with the CME contractor. 4.11.5 MEDICAL DIRECTOR shall maintain necessary and appropriate instructor certifications and participate as Medical Director for educational programs sponsored by Marathon Fire Rescue Department such as ACLS, PALS, BTLS, etc. 4.11.6 Upon proof of completion, MEDICAL DIRECTOR shall sign documents and approve CME to those EMT's and EMT-P's that have completed a minimum of 30 hours of biannual recertification training,as set forth in Section 401.2715, F.S. 4.12 Agency Liaison 4.12.1 MEDICAL DIRECTOR shall participate in interagency discussions about specific issues or problems as necessary. 4.12.2 MEDICAL DIRECTOR shall notify Marathon Fire Rescue Department of any pertinent concerns regarding patient care raised by other agencies and provide advice on a resolution. MEDICAL DIRECTOR shall also notify other agencies of any concerns regarding patient care, raised either by Marathon Fire Rescue Department or MEDICAL DIRECTOR. 4.12.3 MEDICAL DIRECTOR shall develop and maintain liaisons with the local medical community: hospitals, emergency departments, mental health agencies, physicians, providers, ambulance services, and other agencies impacting Marathon Fire Rescue Department. 4.12.4 MEDICAL DIRECTOR shall assist in resolution of problems involving the delivery of pre-hospital care and other services in accordance with Rule 64J-1.004, FAC. 4.12.5 MEDICAL DIRECTOR shall interact with and inform local government officials on an as needed basis. 4.12.6 MEDICAL DIRECTOR shall participate in the Florida EMS Medical Director's Association or a statewide physician's group involved in pre-hospital care, 4.12.7 MEDICAL DIRECTOR shall be an active member of at least one national emergency medicine constituency group such as the National Association of EMS Physicians, the American College of Emergency Physicians,etc. s 164 4.12.8 MEDICAL DIRECTOR shall interact with City, county, regional, state, and federal authorities, regulators and legislators to ensure standards, needs, and requirements are met, and resource utilization is optimized. 4.12.9 MEDICAL DIRECTOR shall participate in grant application process for system funding, expansion, and research. 4.13 Stress Management Programs. MEDICAL DIRECTOR shall participate in stress management programs for providers within the system, as needed. 4.14 Community Access to Healthcare Initiatives. MEDICAL DIRECTOR, in conjunction with Marathon Fire Rescue Department, shall coordinate community access to healthcare initiatives as needed. 4.15 EMT Oversight. 4.15.1 In accordance with Rules 64J-1.004 (g) and (h), FAC, assume direct responsibility for: the use of an automatic or semi-automatic defibrillator;the use of a glucometer;the administration of aspirin; the use of any medicated auto injector; the performance of airway patency techniques including airway adjuncts, not to include endotracheal intubation; and on routine interfacility transports, the monitoring and maintenance of non-medicated I.V.s by an EMT. 4.15.2 MEDICAL DIRECTOR shall ensure that all EMTs are trained to perform these procedures; shall establish and/or maintain written protocols for performance of these procedures; and shall provide written evidence to the Florida Department of Health documenting compliance with provisions of these administrative rules. 4.16 Disaster Assistance and Planning 4.16.1 MEDICAL DIRECTOR shall be available for consultation and/or response during a disaster situation occurring in the City. 4.16.2 MEDICAL DIRECTOR shall function as a liaison between field EMS operations, hospitals,and public health agencies during disaster situations. 4.16.3 MEDICAL DIRECTOR shall provide specific information to assist in the mitigation of the EMS aspects during a disaster situation. 9 165 4.16.4 MEDICAL DIRECTOR shall cooperate in planning, updating, and following applicable sections of the City of Marathon Comprehensive Emergency Management Plan, including, but not limited to, participation in disaster drill and emergency management drills. 4.17 Controlled Substances,Medical Equipment and Supplies. 4.17.1 In accordance with F.S., Chapter 401 and Rule 64J-1.004(4)(c), FAC, MEDICAL DIRECTOR shall possess proof of current registration as a medical director with the U.S.Department of Justice, DEA, to provide controlled substances to an EMS provider. The DEA registration shall include each address at which controlled substances are stored. Proof of such registration shall be maintained on file with Marathon Fire Rescue Department, which shall maintain the copies and make them readily available for inspection. Marathon Fire Rescue Department will forward all renewal documents as received from DEA to MEDICAL DIRECTOR in order to ensure continuous registration and will reimburse MEDICAL DIRECTOR for the cost of such registration. Copies of physician license and registrations must be provided to Marathon Fire Rescue Department. 4.17.2 MEDICAL DIRECTOR shall formulate and ensure adherence to detailed written procedures to cover the purchase, storage, use, and accountability for medications, fluids, and controlled substances used by Marathon Fire Rescue Department personnel, in accordance with Chapters 499 and 893, F.S.,and Rule 64J-1.021,FAC. 4.17.3 MEDICAL DIRECTOR shall ensure and certify that security procedures of all Marathon Fire Rescue Department providers for medications, fluids and controlled substances are in accordance with Chapters 499 and 893, F.S., and Rule 64J-1.021„ FAC. 4.17.4 MEDICAL DIRECTOR shall establish a list of mandatory equipment, medications and medical supplies that must be on board a Rescue or ALS Engine for it to respond to EMS incidents. 4.17.5 MEDICAL DIRECTOR shall advise Marathon Fire Rescue Department on appropriate staffing, structural requirements, equipment and supplies necessary to ensure that the air ambulance complies with Rule 64J-1.005, FAC,and Section 401.251(4),F.S. 4.17.6 MEDICAL DIRECTOR shall conduct an on-going and comprehensive review of all EMS medical equipment, medications and medical supplies as may be necessary to ensure reliable service delivery in the fire rescue System and excellence in patient care. 4.17.6.1 In conducting the review, MEDICAL DIRECTOR shall take into consideration the results of Quality Assurance Reviews, review of medical literature, input from interested physicians, and Marathon Fire Rescue Department personnel. 10 166 4.17.6.2 MEDICAL DIRECTOR, in conjunction with Marathon Fire Rescue Department, shall complete the comprehensive review of all EMS System medical supplies and equipment and present the proposed changes to the Fire Chief for approval prior to the end of each Fiscal Year. 4.17.7 MEDICAL DIRECTOR shall ensure that the following criteria are met prior to activating new medical equipment or supplies within the EMS System: 4.17.7.1 Proposed medical equipment or supplies have been thoroughly researched, supported by medical literature,a field evaluation completed when applicable,and the analysis of available system data; 4.17.7.2 All Protocols related to the medical equipment or supplies have been evaluated and updated as appropriate,to ensure consistency and accuracy;and 4.17.7.3 Protocols, supporting documents and implementation instructions are distributed to Marathon Fire Rescue Department personnel prior to training or implementation, and training has been completed,if necessary,prior to implementation. 4.18 Infectious Disease Control Policy 4.18.1 MEDICAL DIRECTOR shall formulate, monitor, evaluate and update as necessary, a policy complying with all applicable laws and rules necessary to control exposure of Marathon Fire Rescue Department personnel to infectious diseases. This policy shall cover protective measures to be taken on incidents, inoculation procedures and recommendations,record keeping,follow up care recommendations as well as storage and disposal policies for contaminated materials. 4.18.2 MEDICAL DIRECTOR shall be available, in conjunction with the Marathon Fire Rescue Department Infection Control Officer, for consultation from field personnel to determine the significance of any body fluid exposure and suggest appropriate action for such an exposure in accordance with Marathon Fire Rescue Department's existing Workers' Compensation policies and procedures. 4.19 This Contract is a professional services contract based on the qualifications of Dr. Gandia and the services required hereunder shall be performed by MEDICAL DIRECTOR. or under his/her supervision. Any additional personnel necessary for the fulfillment of the services required under this Contract shall be secured at MEDICAL DIRECTOR's sole expense and such personnel shall be fully qualified and, if required, authorized, or permitted under State and local law to perform such services. 11 167 5. Insurance MEDICAL DIRECTOR shall supply a copy of his professional and general liability insurances to the CITY. The Contractor shall be responsible for all necessary Workers'Compensation and Vehicle Liability insurance coverage. Certificates of Insurance must be provided to City within fifteen (15) days after award of contract, with City of Marathon City Council listed as additional insured as indicated. Policies shall be written by insurers admitted and licensed to do business in the State of Florida and having an agent for service of process in the State of Florida. Companies shall have an A.M. Best rating of VI or better. The required insurance shall be maintained at all times while Respondent is providing service to City. Prior to commencement of work governed by this contract,the CONTRACTOR must obtain: Worker's Compensation Insurance with limits sufficient to respond to applicable state statutes. In addition,the Respondent must obtain Employer's Liability insurance with limits of not less than: $500,000 Bodily Injury by accident, $500,000 Bodily Injury by Disease policy limits, and$500,000 Bodily Injury by Disease,each employee. Coverage must be maintained throughout the entire term of the contract. Workers' compensation and employers' liability insurance can be waived by the City upon receipt of information showing that the MEDICAL DIRECTOR is exempt under state statute. Prior to commencement of work governed by this contract,the CONTRACTOR must obtain: Vehicle Liability Insurance which shall cover owned,non-owned and hired vehicles. The minimum acceptable limits shall be$300,000 Combined Single Limit(CSL). If split limits are provided,the minimum limits acceptable shall be: $100,000 per Person $300,000 per Occurrence $50,000 Property Damage City of Marathon City Council shall be named as an Additional insured on Vehicle Liability policies. 12 168 /"'� 6. Termination 6.1 Early termination may occur as follows: A. This Contract may be terminated by MEDICAL DIRECTOR,with or without cause, upon not less than thirty (30)days written notice delivered to CITY. B. CITY may terminate this Contract in whole or in part and without cause,upon written notice,delivered to MEDICAL DIRECTOR. C. CITY may terminate this Contract immediately in the event that MEDICAL DIRECTOR fails to fulfill any of the terms, understandings or covenants of this Contract. 6.2 At such time as this Contract is terminated,whether at the natural ending date or at an earlier time, MEDICAL DIRECTOR shall: A. Stop work on the date and to the extent specified. B. Terminate and settle all orders and subcontracts relating to the performance of the work. C. Transfer all work in process,completed work,and other materials related to the terminated work to CITY. D. Continue and complete all parts of that work which have not been terminated,if any. 7. Payments Payments shall be made by CITY pursuant to the Florida Local Government Prompt Payment Act after the completion of the rendered services and proper invoicing by MEDICAL DIRECTOR. 8. Contingency CITY's performance and obligation to pay under this Contract is contingent upon an annual appropriation by the City Council. 9. Section Headings Section headings have been inserted in this Contract as a matter of convenience of reference only, and it is agreed that such section headings are not a part of this Contract and will not be used in the interpretation of any provision of this Contract. 10. Ownership of the Proiect Document Any documents submitted by MEDICAL DIRECTOR for this professional services contract belong to CITY and may be reproduced and copied without acknowledgement or permission of MEDICAL DIRECTOR. 13 169 11. Successors and Assigns MEDICAL DIRECTOR shall not assign its right hereunder, except its right to payment, nor shall it delegate any of its duties hereunder without the written consent of CITY. Subject to the provisions of the immediately preceding sentence, each party hereto binds itself, its successors, assigns and legal representatives to the other and to the successors, assigns and legal representatives of such other party. 12. No Third Party Beneficiaries Nothing contained herein shall create any relationship,contractual or otherwise, with or any rights in favor of, any third party. 13. Public Entities Crimes 13.1 A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a bid on contracts to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work, may not submit bids on leases of real property to public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or MEDICAL DIRECTOR under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017 of the F.S., for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list. 13.2 By signing this Contract, MEDICAL DIRECTOR represents that the execution of this Contract will not violate the Public Entity Crimes Act (Section 287.133, F.S.). Violation of this section shall result in termination of this Contract and recovery of all monies paid hereto, and may result in debarment from CITY's competitive procurement activities. 13.3 In addition to the foregoing, MEDICAL DIRECTOR further represents that there has been no determination, based on an audit, that it or any SUBCONTRACTOR has committed an act defined by Section 287.133, F.S., as a "public entity crime" and that it has not been formally charged with committing an act defined as a "public entity crime" regardless of the amount of money involved or whether CONSULTANT has been placed on the convicted vendor list. 13.4 MEDICAL DIRECTOR will promptly notify CITY if MEDICAL DIRECTOR or any subcontractor is formally charged with an act defined as a"public entity crime"or has been placed on the convicted vendor Iist. 14 170 'AMIN 14. Records MEDICAL DIRECTOR shall maintain all books, records, and documents directly pertinent to performance under this Contract in accordance with generally accepted accounting principles. Upon ten (10) business days written notice to the other party, representatives of either party shall have access, at all reasonable times, to all the other parry's books, records, correspondence, instructions,receipts, vouchers and memoranda(excluding computer software)pertaining to work under this Contract for the purpose of conducting a complete independent fiscal audit. MEDICAL DIRECTOR shall retain all records required to be kept under this Contract for a minimum of five years, and for at least four years after the termination of this Contract. Storage of medical records required by Federal or State statute in excess of the times stated herein and subsequent to the termination of this Contract shall be revisited by the parties at such time as any transition period is established to accommodate the termination of this Contract. MEDICAL DIRECTOR shall keep such records as are necessary to document the provision of services under this contract and expenses as incurred, and give access to these records at the request of CITY, the State of Florida or authorized agents and representatives of said government bodies. It is the responsibility of MEDICAL DIRECTOR to maintain appropriate records to insure a proper accounting of all collections and remittances. MEDICAL DIRECTOR shall be responsible for repayment of any and all audit exceptions which are identified by the Auditor General for the State of Florida, the Clerk of Court for the City,the City Council,or their agents and representatives. 15. Governing Law,Venue,Interpretation,Costs,and Fees This Contract shall be governed by and construed in accordance with the laws of the State of Florida applicable to contracts made and to be performed entirely in the State. In the event that any cause of action or administrative proceeding is instituted for the enforcement or interpretation of this Contract, CITY and MEDICAL DIRECTOR agree that venue shall lie in Monroe County, Florida, in the appropriate court or before the appropriate administrative body. The Parties waive their rights to a trial by jury. This Contract is not subject to arbitration. 16. Severabifty If any term, covenant, condition or provision of this Contract (or the application thereof to any circumstance or person) shall be declared invalid or unenforceable to any extent by a court of competent jurisdiction,the remaining terms, covenants,conditions and provisions of this Contract, shall not be affected thereby; and each remaining term, covenant, condition and provision of this Contract shall be valid and shall be enforceable to the fullest extent permitted by law unless the enforcement of the remaining terms, covenants, conditions and provisions of this Contract would prevent the accomplishment of the original intent of this Contract. CITY and MEDICAL DIRECTOR agree to reform the Contract to replace any stricken provision with a valid provision that comes as close as possible to the intent of the stricken provision. 15 171 17. Attorney's Fees and Costs CITY and MEDICAL DIRECTOR agree that in the event any cause of action or administrative proceeding is initiated or defended by any party relative to the enforcement or interpretation of this Contract, the prevailing party shall be entitled to reasonable attorney's fees, court costs, investigative, and out-of-pocket expenses, as an award against the non-prevailing party, and shall include attorney's fees, courts costs, investigative, and out-of-pocket expenses in appellate proceedings. Mediation proceedings initiated and conducted pursuant to this Contract shall be in accordance with the Florida Rules of Civil Procedure and usual and customary procedures required by the circuit court of Monroe County. 18. Binding Effect The terms,covenants,conditions,and provisions of this Contract shall bind and inure to the benefit of CITY and MEDICAL DIRECTOR and their respective legal representatives, successors, and assigns. 19. Authority Each party represents and warrants to the other that the execution,delivery and performance of this Contract have been duly authorized by all necessary City and corporate action, as required by law. 20. Claims for Federal or State Aid MEDICAL DIRECTOR and CITY agree that each shall be, and is, empowered to apply for,seek, and obtain federal and state funds to further the purpose of this Contract; provided that all applications, requests, grant proposals, and funding solicitations shall be approved by each party prior to submission. 21. Adiadication of Disputes CITY and MEDICAL DIRECTOR agree that all disputes shall be attempted to be resolved by meet and confer sessions between representatives of each of the parties. If the issue or issues are still not resolved to the satisfaction of the parties, then any party shall have the right to seek such relief or remedy as may be provided by this Contract or by Florida law. 22. Cooperation In the event any administrative or legal proceeding is instituted against either party relating to the formation,execution, performance, or breach of this Contract, CITY and MEDICAL DIRECTOR agree to participate, to the extent required by the other party, in all proceedings, hearings, processes, meetings, and other activities related to the substance of this Contract or provision of the services under this Contract. CITY and MEDICAL DIRECTOR specifically agree that no party to this Contract shall be required to enter into any arbitration proceedings related to this Contract. /00"N 16 172 23. Nondiscrimination MEDICAL DIRECTOR and CITY agree that there will be no discrimination against any person, and it is expressly understood that upon a determination by a court of competent jurisdiction that discrimination has occurred, this Contract automatically terminates without any further action on the part of any party, effective the date of the court order. MEDICAL DIRECTOR and CITY agree to comply with all Federal and F.S., and all local ordinances, as applicable, relating to nondiscrimination. These include but are not limited to: 1) Title VI of the Civil Rights Act of 1964(PL 88-352), which prohibits discrimination on the basis of race, color or national origin; 2) Title IX of the Education Amendment of 1972, as amended (20 USC §§ 1681-1683, and 1685- 1686), which prohibits discrimination on the basis of sex; 3) Section 504 of the Rehabilitation Act of 1973, as amended(20 USC § 794),which prohibits discrimination on the basis of handicaps;4) The Age Discrimination Act of 1975, as amended (42 USC §§ 6101-6107), which prohibits discrimination on the basis of age; 5)The Drug Abuse Office and Treatment Act of 1972 (PL 92- 255),as amended,relating to nondiscrimination on the basis of drug abuse;6)The Comprehensive Alcohol Abuse and Alcoholism Prevention,Treatment and Rehabilitation Act of 1970(PL 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; 7) The Public Health Service Act of 1912,§§ 523 and 527(42 USC §§ 690dd-3 and 290ee-3),as amended, relating to confidentiality of alcohol and drug abuse patent records;8)Title Vlll of the Civil Rights Act of 1968(42 USC §§ 3601 et seq.),as amended,relating to nondiscrimination in the sale,rental or financing of housing; 9) The Americans with Disabilities Act of 1990 (42 USC §§ 1201), as amended from time to time,relating to nondiscrimination in employment on the basis of disability; 10) Monroe City Code Chapter 13, Article VI, which prohibits discrimination on the basis of race,color,sex,religion,national origin,ancestry,sexual orientation,gender identity or expression, familial status or age;and 11)any other nondiscrimination provisions in any federal or state statutes which may apply to the parties to, or the subject matter of, this Contract. 24. Covenant of No Interest MEDICAL DIRECTOR and CITY covenant that neither presently has any interest, and shall not acquire any interest,which would conflict in any manner or degree with its performance under this Contract, and that only interest of each is to perform and receive benefits as recited in this Contract. 25. Code of Ethics MEDICAL DIRECTOR agrees that officers and employees of CITY recognize and will be required to comply with the standards of conduct for public officers and employees as delineated in Section 112.313, F.S., regarding, but not limited to, solicitation or acceptance of gifts; doing business with one's agency; unauthorized compensation; misuse of public position, conflicting employment or contractual relationship; and disclosure or use of certain information. 26. No Solicitation/Payment MEDICAL DIRECTOR and CITY warrant that, in respect to itself, it has neither employed nor retained any company or person,other than a bona fide employee working solely for it,to solicit or secure this Contract and that it has not paid or agreed to pay any person, company, corporation, individual, or firm, other than a bona fide employee working solely for it, any fee, commission, percentage, gift, or other consideration contingent upon or resulting from the award or making of this Contract. For the breach or violation of the provision, MEDICAL DIRECTOR agrees that 17 173 CITY shall have the right to terminate this Contract without liability and, at its discretion, to loo''\ offset from monies owed, or otherwise recover, the full amount of such fee, commission, percentage,gift, or consideration. 27. Public Access MEDICAL DIRECTOR and CITY shall allow and permit reasonable access to,and inspection of, all documents, papers, letters or other materials in its possession or under its control subject to the provisions of Chapter 119, F.S., and made or received by MEDICAL DIRECTOR and CITY in connection with this Contract; and CITY shall have the right to unilaterally cancel this Contract upon violation of this provision by MEDICAL DIRECTOR. 28. Non-Waiver of Immunity Notwithstanding the provisions of Section 768.28, F.S., the participation of MEDICAL DIRECTOR and CITY in this Contract and the acquisition of any commercial liability insurance coverage, self-insurance coverage,or local government Iiability insurance pool coverage shall not be deemed a waiver of immunity to the extent of liability coverage, nor shall any contract entered into by CITY be required to contain any provision for waiver. 29. Privileges and Immunities All of the privileges and immunities from liability, exemptions from laws, ordinances, and rules and pensions and relief, disability, workers' compensation, and other benefits which apply to the activity of officers, agents, or employees of any public agents or employees of CITY, when performing their respective functions under this Contract within the territorial limits of CITY shall apply to the same degree and extent to the performance of such functions and duties of such officers,agents, volunteers,or employees outside the territorial limits of CITY. 30. Legal Obligations and Responsibilities This Contract is not intended to,nor shall it be construed as,relieving any participating entity from any obligation or responsibility imposed upon the entity by law except to the extent of actual and timely performance thereof by any participating entity, in which case the performance may be offered in satisfaction of the obligation or responsibility. Further, this Contract is not intended to, nor shall it be construed as, authorizing the delegation of the constitutional or statutory duties of CITY, except to the extent permitted by the Florida constitution, state statute,and case law. 31. Non-Reliance by Non-Parties No person or entity shall be entitled to rely upon the terms, or any of them, of this Contract to enforce or attempt to enforce any third-party claim or entitlement to or benefit of any service or program contemplated hereunder, and MEDICAL DIRECTOR MEDICAL DIRECTOR and CITY agree that neither MEDICAL DIRECTOR nor CITY or any agent, officer, or employee of either shall have the authority to inform, counsel, or otherwise indicate that any particular individual or group of individuals, entity or entities, have entitlements or benefits under this Contract separate and apart, inferior to, or superior to the community in general or for the purposes contemplated in this Contract. 18 174 32. Attestations and Truth in Negotiation MEDICAL DIRECTOR agrees to execute such documents as CITY may reasonably require, including a Public Entity Crime Statement, an Ethics Statement, and a Drug-Free Workplace Statement. Signature of this Contract by MEDICAL DIRECTOR shall act as the execution of a truth in negotiation certificate stating that wage rates and other factual unit costs supporting the compensation pursuant to the Contract are accurate, complete, and current at the time of contracting. 33. No Personal Liability No covenant or Contract contained herein shall be deemed to be a covenant or Contract of any member, officer, agent or employee of CITY in his or her individual capacity, and no member, officer, agent or employee of CITY shall be liable personally on this Contract or be subject to any personal liability or accountability by reason of the execution of this Contract. 34. Execution of Counterparts This Contract may be executed in any number of counterparts,each of which shall be regarded as an original, all of which taken together shall constitute one and the same instrument and any of the parties hereto may execute this Contract by signing any such counterpart. 35. Amendments and Assimments. No amendment or assignment of this Contract shall be valid without the prior written consent from CITY. 36. Independent Contractor. At all times and for all purposes hereunder,MEDICAL DIRECTOR is an independent contractor and not an employee of the City of Marathon. No statement contained in this Contract shall be construed as to find MEDICAL DIRECTOR or any of its employees, contractors, servants or agents to the employees of the City of Marathon, and they shall be entitled to none of the rights, privileges or benefits of employees of the City of Marathon. 37. Compliance with Law. In carrying out its obligations under this Contract, MEDICAL DIRECTOR shall abide by all statutes,ordinances,rules and regulations pertaining to or regulating the provisions of this Contract, including those now in effect and hereafter adopted. Any violation of said statutes, ordinances, rules or regulations shall constitute a material breach of this Contract and shall entitle CITY to terminate this Contract immediately upon delivery of written notice of termination to MEDICAL DIRECTOR. 19 175 38. Licensing and Permits. AlUNN MEDICAL DIRECTOR shall have,prior to commencement of work under this Contract and at all times during said work, all required licenses and permits whether federal, state, City or municipal. 39. Signatures of Parties Required. THIS CONTRACT SHALL NOT BE EFFECTIVE UNTIL EXECUTED BY BOTH PARTIES AND RECEIVED IN FINAL EXECUTED FORM BY AN AUTHORIZED REPRESENTATIVE OF MEDICAL DIRECTOR AT ITS PRINCIPAL PLACE OF BUSINESS. 40. City Authority. By execution hereof the signer below hereby certifies that signer is duly authorized to execute this Contract on behalf of the CITY. 41. Federal and State Tax. CITY is exempt from payment of Florida State Use and Sales Taxes. CITY will sign an exemption certificate submitted by MEDICAL DIRECTOR. MEDICAL DIRECTOR will not be exempted from paying state sales tax to its suppliers for materials used to fulfill contractual obligations with CITY, nor is MEDICAL DIRECTOR authorized to use CITY's Tax Exemption Number in securing such materials. 42. Florida Public Records law(F.S. 119.0701). RECORDS- ACCESS AND AUDITS: Pursuant to F.S. 119.0701, Contractor and its subcontractors shall comply with all public records laws of the State of Florida,including but not limited to: a. Keep and maintain public records required by Monroe City in order to perform the service. b. Upon request from the public agency's custodian of public records, provide the public agency with a copy of the requested records or allow the records to be inspected or copied within a reasonable time at a cost that does not exceed the cost provided in Florida Statutes,Chapter 119 or as otherwise provided by law. c. Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law for the duration of the contract term and following completion of the contract if the contractor does not transfer the records to the public agency. d. Upon completion of the contract, transfer, at no cost, to Monroe City all public records in possession of the contractor or keep and maintain public records required by the public agency to perform the service. If the contractor transfers all public records to the public agency upon completion of the contract,the contractor shall destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. If the contractor keeps and maintains public records upon completion of the contract, the contractor shall meet all applicable requirements for retaining public records. Ail records stored electronically must be provided to Monroe City, upon request from the public agency's custodian of records, in a format that is compatible with the information technology systems of Monroe City. zo 176 IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC RECORDS, DIANE CLAVIER, AT (305) 289-4130, cityclerk@ci . marathon . fl . us , c/o City of Marathon, 9805 Overseas Highway, Marathon, Florida 33050. 43. Public Entity Crime Statement (required for all procurement documents and contracts by F.S. 287.133 and Monroe City Purchasing PolicO: A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a bid on a contract to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work,may not submit bids on leases of real property to public entity,may not be awarded or perform work as a CONTRACTOR, supplier, subcontractor, or CONTRACTOR under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287,017, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list. As used herein,the term"convicted vendor list"means a list maintained by the Florida Department of Management Services, as defined in F.S. 287.133. By entering in this Agreement, the vendor acknowledges that it has read the above and states that neither the vendor nor any Affiliate has been placed on the convicted vendor list within the last 36 months. 44. E-verify requirement(required by F.S.448.095): Beginning January 1, 2021,every public employer, contractor, and subcontractor shall register with and use the E-Verify system to verify the work authorization status of all newly hired employees. By entering into this Agreement, the vendor certifies that it registers with and uses the E-Verify system. If the contractor enters into a contract with a subcontractor, the subcontractor must provide the contractor with an affidavit stating that the subcontractor does not employ, contract with, or subcontract with an unauthorized alien. The contractor shall maintain a copy of such affidavit for the duration of the contract. 45. Human Trafficking (F.S. 787.06): Whenever a contract is executed, renewed, or extended between a nongovernmental entity and a governmental entity, the nongovernmental entity must provide an affidavit signed by an officer or a representative of the nongovernmental entity under penalty of perjury, attesting to that the nongovernmental entity does not use coercion for labor or services. A copy of the affidavit is attached. 21 177 46. Foreign Entities Affidavit(F.S.287.138): a. Beginning I/1/2024, a governmental entity may not accept a bid or proposal from, or enter into a contract with, an entity which would grant the entity access to individual personal identifying information ("PIP) unless the entity provides an affidavit signed by an officer or representative under penalty of perjury attesting that the entity does not meet any of the criteria in F.S. 287.138(2)(a)-(c): • Entity owned by a country of concern (China, Russia, Iran, North Korea, Venezuela, Syria) • Controlling interest by government of foreign country of concern; • Entity organized under the laws of or has principal place of business in foreign country of concern. b. Beginning 7/l/2025, a governmental entity cannot renew a contract with an entity which would grant the access to PII unless the entity provides the affidavit. c. Beginning 7/1/2025,a governmental entity cannot extend or renew a contract with an entity meeting the above criteria if the contract would give access to PII to that entity. The affidavit is attached. zz 178 INN WITNESS WIEREOF,the parties hereto have set their hands and sealed the day and year first written above. THE CITY OF MARATHON,FLORIDA arei Diane Clavier �' �'Manager City Clerk (City Sear APPROVED AS TO FORM AND LEGALITY FOR THE USE AND RELIANCE OF THE CITY OF MARATHON,T!LO11IIDA ONLY �e" . '..'9,-- Steve Williams,City Attorney p1mYMn:.,,. ANTONIO GANDICA,M.D. By: By: Anto Fitness 10 179 SECTION TWO: ,^ FORMS Attachment A Non-Collusion Affidavit Attachment B Public Entity Crime Statement Attachment C Drug Free Workplace Form Attachment D Insurance Documents Attachment E Affidavit Attachment F Affidavit 24 180 NUN-COLLUSION AFFIDAVIT I, " tsYt d'�Ar of the city of according to law on my oath,and under Penalty of perjury,depose and say t; 1) lam /lf/l� r'��rf•L �j/'P.�i��rar the respondent making the Proposal for the project described as follows: 2) The prices in this proposal have been arrived at independently without collusion, consultation,communication or Contract for the purpose of restricting competition,as to any matter relating to such prices with any other respondent or with any competitor; . 3) Unless otherwise required by law,the prices which have been quoted in this proposal have not been knowingly disclosed by the respondent and will not knowingly be disclosed by the respondent prior to proposal opening,directly or indirectly,to any other respondent or to any competitor;and 4) No attempt has been made or will be made by the respondent to induce any other person,partnership or corporation to submit,or not to submit,a proposal for the purpose of restricting competition;and 5) The statements contained in this affidavit are true and correct,and made with full knowledge that Monroe City relies upon the truth of the statements contained in this affidavit in awarding contracts for said project. STATE OF f I a It p er 1 J Respondent) CITY OF 094 Wd 113�z�Lys Irate PERSONALLY APPEARED BEFORE ME,the undersigned authority, �;aN i o 6,WA t A who,after first being sworn by me,(name of individual signing)affixed his/her signature in the space provided above on this f- A-L)r Q 3 T- 20 Z�( %iMy commission 10 Nary pups g lace of Flortde A/Y / '" NOTARY PUBLIC wuuam McGrath UMS-MCP FORM#1 illy Coffmft Eon HH 4te"a ExpIM W2412027 Attachment A 10 181 PUBLIC ENTITY CRIME STATEMENT "A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a proposal on a contract to provide any goods or services to a public entity,may not submit a proposal on a contract with a public entity for the construction or repair of a public building or public work,may not submit proposals on leases of real property to public entity,may not be awarded or perform work as a bidder,supplier,subbidder,or RESPONDENT under a contract with any public entity,and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017,Florida Statutes,for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list" By executing this form,I acknowledge that I/my company is in compliance with the above. STATE OF i spondent) CITY OF A�'►Y`�kor-� P113 { � Date PERSONALLY APPEARED BEFORE ME,the undersigned authority, A4-,CtJ,o (AfjZ,V-4 who,after first being sworn by me,(name of individual signing)affixed his/her signature in the space provided above on this 3 day of AV G v5' 20--w'ha Z� Mcemtb My commissio expires: aFG NOTARY PUBLIC E0MMS OW12osT Attachment B /'N ao 182 '^ DRUG-FREE WORKPLACE FORM The undersigned Respond t in accordance with Florida Statute 287.087 hereby certifies that: TM t o 6"(& (Name of Business) 1. Publishes a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. 2. Informs employees about the dangers of drug abuse in the workplace,the business's policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations. 3. Gives each employee engaged in providing the commodities or contractual services that are under proposal a copy of the statement specified in subsection(1). 4. In the statement specified in subsection (1), notifies the employees that, as a condition of working on the commodities or contractual services that are under proposal, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendre to, any violation of Chapter 993 (Florida Statutes) or of any controlled substance law of the United States or any state,for a violation occurring in the workplace no later than five(5)days after such conviction. 5. Imposes a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community,or any employee who is so convicted. 6. Makes a good faith effort to continue to maintain a drug-free workplace through implementation of this section. As the person authorized to sign the statement,I certify that this firm complies fully with the above requirements. Respondents Signature Date Attachment C 10 183 VEHICLE LIABILITY INSURANCE REQUIREMENTS FOR CONTRACT MEDICAL DIRECTOR BETWEEN CITY OF MARATHON,FLORIDA AND ANTONIO GANDIA,M.D. Recognizing that the work governed by this contract requires the use of vehicles, the Contractor, prior to the commencement of work,shall obtain Vehicle Liability Insurance. Coverage shall be maintained throughout the life of the contract and include,as a minimum, liability coverage for: • Owned,Non-Owned,and Hired Vehicles The minimum limits acceptable shall be: $300,000 Combined Single Limit(CSL) If split limits are provided,the minimum limits acceptable shall be: $100,000 per Person $300,000 per Occurrence $ 50,000 Property Damage The Monroe City Board of City Commissioners shall be named as Additional Insured on all policies issued to satisfy the above requirements. VL2 Attachment D 28 184 WORKERS' COMPENSATION INSURANCE REQUIREMENTS FOR CONTRACT MEDICAL DIRECTOR BETWEEN CITY OF MARATHON,FLORIDA AND ANTONIO GANDIA,M.D. Prior to the commencement of work governed by this contract, the Contractor shall obtain Workers' Compensation Insurance with limits sufficient to respond to the applicable state statutes. In addition,the Contractor shall obtain Employers' Liability Insurance with limits of not less than: $500,000 Bodily Injury by Accident $500,000 Bodily Injury by Disease,policy limits $500,000 Bodily Injury by Disease,each employee Coverage shall be maintained throughout the entire term of the contract. Coverage shall be provided by a company or companies authorized to transact business in the state of Florida. If the Contractor has been approved by the Florida's Department of Labor,as an authorized self- insurer,the City shall recognize and honor the Contractor's status. The Contractor may be required to submit a Letter of Authorization issued by the Department of Labor and a Certificate of Insurance,providing details on the Contractor's Excess Insurance Program. If the Contractor participates in a self-insurance fund,a Certificate of Insurance will be required. In addition,the Contractor may be required to submit updated financial statements from the fund upon request from the City. WC2 Attachment D 29 185 CITY OF MARATHON, FLORIDA REQUEST FOR WArVER OF INSURANCE REQUIREMENTS It is requested that the insurance requirements,as specified in the City's Schedule of Insurance Requirements,be waived or modified on the follo tract. ContractorNendor 1 J'71 * -A. yt 6 I 0 4t)Z/I Project or Service: ContractorNeador Address fit.Phone#r: /6 LIP —e , De-q-4e,-i 6e1rrA, General Scope of Work. 491 �1/1 Reason for Waiver or Modification: Policies Waiver or Modification will apply to: Signature of ContrwtorNendor: ooft, Date, 'I(+ Approved CNot-&Rro,vd Risk Management Signature:_ Date: City Administrator appeal, Approved: Not Approved: Date: Board of City Commissioners appeal. 10 186 r'1 AFFIDAVIT ATTESTING TO NONCOERCIVE CONDUCT EntityNendor Name: FOR LABO OR SERVICES Vendor FEiN: Vendor's Authonzed Representative: Address: a Name and Title) Cry: State: ZP= Phone Number: Email Address: A. MrZ , ce'" As a nongovernmental entity executing, renewing, or extending a contract with a government entity, Vendor is required to provide an affidavit under penalty of perjury attesting that Vendor does not use coercion for labor or services in accordance with Section 787.06, Florida Statutes. As defined in Section 787.06(2)(a), coercion means: I. Using or threating to use physical force against any person; 2. Restraining, isolating, or confining or threating to restrain, isolate, or confine any person without lawful authority and against her or his will; 3. Using lending or other credit methods to establish a debt by any person when ,,.,\ labor or services are pledged as a security for the debt, if the value of the labor or services as reasonably assessed is not applied toward the liquidation of the debt, the length and nature of the labor or service are not respectively limited and defined; 4. Destroying,concealing, removing,confiscating,withholding,or possessing any actual or purported passport,visa, or other immigration document,or any other actual or purported government identification document, of any person; S. Causing or threating to cause financial harm to any person; 6. Enticing or luring any person by fraud or deceit; or 7. Providing a controlled substance as outlined in Schedule 1 or Schedule 11 of Section 893.03 to any person for the purpose of exploitation of that person. As a person authorized to sign on behalf of Vendor, I certify under penalties of perjury that Vendor does not use coercion for labor or services in accordance with Section 787.06.Additionally, Vendor has reviewed Section 787.06, Florida Statutes, and agrees to abide by same. Certified By: ^ i W,-A who is authorized to sign on be f above referenced company. Authorized Si ature: Print a ;n Titre: ` Attachment E io 187 FOREIGN ENTITIES AFFIDAVIT F.S.287.138 I, -4 _of the city of DP_plC.e CX � according to law on my oath, and under penalty of perjury, depose and say that: a. I am d of the firm of 0 -OL ("Entity"), the bidder making the Proposal for the p 'act des bed in th Request for Proposals for .� d that I executed the said proposal with full a ority to do so; b. In accordance with section 287.138, Florida Statutes, the Entity is not owned by the government of a Foreign Country of Concern, as that term is defined in F.S_ 287.138, is not organized under the laws of nor has its Principal Place of Business in a Foreign Country of Concern, and the government of a Foreign Country of Concern does not have a Controlling Interest in the entity. c. The statements contained in this affidavit are true and correct, and made with full knowledge that Monroe City relies upon the truth of the statements contained in this affidavit in awarding contra for said project. (Signature) Date: STATE OF: CITY OF: Subscribed and sworn to(or affirmed)before me by means of physical presence or❑ online notarization, . on S-) 13 lzaz`( (date) by M • p GA-ri t Or (name of atffiant). He/She is personally known to me or has produced l�s i<0 Guiti (type of identification)as identification. NOTARY PUBLIC MygigCo Expires: f Florida m N 41a8�gOI? Attachmerd F f.00*1 10 188 Re: Proposed Agreement for Medical Director @ Marathon Antonio Gandia <agandiarnd@,gmail.corn> Aomft" Sun 8/18/2024 10:25 PM To-James Muro <rnuroj@ci.marathon,fI,us> External (agandiamd@glmail.com) Reppf(.This Emaill E FLqtgqt[g�y_jE�ssenfiaNet Solutions Chief, Hope you had a great weekend. I will forward the notarized paperwork Monday morning, Chief, I had a scheduled few days off but I am available 24/7, I would like to speak to someone from the office to sign up to the [)EA Cert, I would like to get the contacts for the Battalions and officers so I can touch base with them and offer them my cell number, ,,A/,//J"0,0,,,/I,, prresa,l)O,(,,wijl be my,coveO,,), n; 1,,have known Aldo for close to 10 years, first he was one of my resident physician at Mount Sinai., Aldo has been an attending at Baptist Main for the last 6 or so years. He will be an excellent contact for us in regards to Fishermen and Mariners Hospital. Our info to share with the bepartment; Antonio Gandia 954-326-1946 Aldo Manresa 786-597-0771 Let's catch up some time tomorrow whenever it is convenient for you, thank you, antonio On Fri, Aug 16, 2024 at 1.-40 PIVI James MUI-0 <rl)Urgj(EDci.i-nai,atlioii.fl.Ljs> wrote: Thanks Dr. have a great weekend- Jarnes Sent from my iPad On Aug 16, 2024, at 120 FIVI, Antonio Gandia <aga,ndiamd.@gmauI.call'i> wrote: Chief Thank you will get on it asap Antonio Sent from my iPhone 189 AFFIDAVIT ATTESTING TO NONCOERCIVE CONDUCT Entity/Vendor Name: FOR LABOR OR SERVICES Vendor FEIN: Vendor's Authorized Representative: .1 •o � , Address: Aye Name and Tifie) City: State: 7 Phone Number: Email Address: As a nongovernmental entity executing, renewing, or extending a contract with a government entity, Vendor is required to provide an affidavit under penalty of perjury attesting that Vendor does not use coercion for labor or services in accordance with Section 787.06, Florida Statutes. As defined in Section 787.06(2)(a), coercion means: 1. Using or threating to use physical force against any person; 2. Restraining, isolating, or confining or threating to restrain, isolate, or confine any person without lawful authority and against her or his will; 3. Using lending or other credit methods to establish a debt by any person when `,O%` labor or services are pledged as a security for the debt, if the value of the labor or services as reasonably assessed is not applied toward the liquidation of the debt, the length and nature of the labor or service are not respectively limited and defined; 4. Destroying, concealing, removing, confiscating,withholding, or possessing any actual or purported passport, visa, or other immigration document, or any other actual or purported government identification document, of any person; 5. Causing or threating to cause financial harm to any person; 6. Enticing or luring any person by fraud or deceit; or 7. Providing a controlled substance as outlined in Schedule I or Schedule II of Section 893.03 to any person for the purpose of exploitation of that person. As a person authorized to sign on behalf of Vendor, I certify under penalties of perjury that Vendor does not use coercion for labor or services in accordance with Section 787.06. Additionally, Vendor has reviewed Section 787.06, Florida Statutes, and agrees to abide by same�4ATm Certified By: i G� who is authorized to sign on be f above referenced company. Authorized Sig ature. Print Na Title: Attachment E 10 190 FOREIGN ENTITIES AFFIDAVIT F.S. 287.138 I, "k of the city of etd according to law on my oath, and under penalty of perjury, depo a and say that: a. I am of the firm of ("Entity"), the bidder making the Proposal for the p 'ect des 'bed in th Request for Proposals for r lld that I executed the said proposal with full aut ority to do so; 19 b. In accordance with section 287.138, Florida Statutes, the Entity is not owned by the government of a Foreign Country of Concern, as that term is defined in F.S. 287.138, is not organized under the laws of nor has its Principal Place of Business in a Foreign Country of Concern, and the government of a Foreign Country of Concern does not have a Controlling Interest in the entity. c. The statements contained in this affidavit are true and correct, and made with full knowledge that Monroe City relies upon the truth of the statements contained in this affidavit in awarding contra for said project. (Signature) Date: STATE OF: ( o Dot�-SN CITY OF: �,- Subscribed and sworn to(or affirmed) before me by means of®physical presence or❑ online notarization, . on f ul-( (date) by INN'712(2, 2 6 "a{°" (name of affiant). He/She is personally known to me or has produced _ tip. �,N*�C�, << llw (type of identification) as identification. (VOTARY PUBLIC My Coll Expires: Notary Pubtl07. s�DG Wif1lem it My Exp{rmgs 912 Attachment F 10 191 NON-COLLUSION AFFIDAVIT AI, o-n . difCc. of the city of according to law on my oath,and under penalty of perjury,depose and say that; 1) I am y4-'ew r� the respondent making the Proposal for the project described as follows: l2 / Le 2) The prices in this proposal have been arrived at independently without collusion, consultation,communication or Contract for the purpose of restricting competition,as to any matter relating to such prices with any other respondent or with any competitor; 3) Unless otherwise required by law,the prices which have been quoted in this proposal have not been knowingly disclosed by the respondent and will not knowingly be disclosed by the respondent prior to proposal opening,directly or indirectly,to any other respondent or to any competitor;and 4) No attempt has been made or will be made by the respondent to induce any other person,partnership or corporation to submit, or not to submit, a proposal for the purpose of restricting competition;and ,.•� 5) The statements contained in this affidavit are true and correct,and made with full knowledge that Monroe City relies upon the truth of the statements contained in this affidavit in awarding contracts for said project. STATE OF 16 X t er __E _� — (;:�iv i e f Respondent) CITY OF_ A4_*-fJo Date PERSONALLY APPEARED BEFORE ME,the undersigned authority, �r`J' o 6A,,vfl`.4 who,after first being sworn by me,(name of individual signing) affixed his/her signature in the space provided above on this —dnf v T_ 20��, v'L My commission ex � Notary Public State of Florida NOTARY PUBLIC wintem McGrath OMB-MCP FORM 41 My COtnariaslon HM 418948 Expires 8I2412027 Arrachment A /'nW, 10 192 /Oft\ PUBLIC ENTITY CRIME STATEMENT "A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a proposal on a contract to provide any goods or services to a public entity,may not submit a proposal on a contract with a public entity for the construction or repair of a public building or public work,may not submit proposals on leases of real property to public entity,may not be awarded or perform work as a bidder, supplier, subbidder, or RESPONDENT under a contract with any public entity,and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017,Florida Statutes, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list." By executing this form,I acknowledge that I/my company is in compliance with the above. STATE OF �l a Q t t � i espondent} CITY OF Ajaie�Y or-> _ P)13 Date PERSONALLY APPEARED BEFORE ME,the undersigned authority, P&n-0�j'o G A-njA`A who,after first being sworn by me,(name of individual signing)affixed his/her signature in the space provided above on this 3 day of Aj G vSr 20 Z-F =N.taly AlcOretic State of loridaMy commissio expires:NOTARYPUBLICA a 2412027 seas Attachment B 10 193 /"1 DRUG-FREE WORKPLACE FORM The undersigned Respond t in accordance with Florida Statute 287.087 hereby certifies that: TbYt i u �dt,vtd�l� (Name of Business) 1. Publishes a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. 2. Informs employees about the dangers of drug abuse in the workplace,the business's policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations. 3. Gives each employee engaged in providing the commodities or contractual services that are under proposal a copy of the statement specified in subsection(1). 4. In the statement specified in subsection (1), notifies the employees that, as a condition of working on the commodities or contractual services that are under proposal, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendre to, any violation of Chapter 893 (Florida Statutes) or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five(5) days after such conviction. 5. Imposes a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community, or any employee who is so convicted. 6. Makes a good faith effort to continue to maintain a drug-free workplace through implementation of this section. As the person authorized to sign the statement,I certify that this firm complies fully with the above requirements. Respondents Signature Date Attachment C /'� 10 194 CITY OF MARATHON, /''% FLORIDA REQUEST FOR WAIVER OF INSURANCE REQUIREMENTS It is requested that the insurance requirements,as specified in the City's Schedule of Insurance Requirements,be waived or modified on the following contract. ContractorNendor: ! 1 c/J A. Project or Service: AO,&WIZOet /2v6 JtC r! ContractorNendor l ��� ' L Address&Phone#: l o ye C w ��e . (D,,� d ggry Q' Z- General Scope of Work: Reason for Waiver or Modification: Policies Waiver or Modification will apply to: Signature of ContractorNendor. Date: Approved Not Approved Risk Management Signature:_ Date: City Administrator appeal: Approved: Not Approved: Date: Board of City Commissioners appeal: r"1 10 195 IN WITNESS WHEREOF,the parties hereto have set their hands and sealed the day and year first written above. THE CITY OF MARATHON,FLORIDA Diane Clavier George Garrett,City Manager City CIerk (City Seal) APPROVED AS TO FORM AND LEGALITY FOR THE USE AND RELIANCE OF THE CITY OF MARATHON,FLORIDA ONLY: Steve Williams,City Attorney ANTONIO GANDIA,M.D. By: By: Anto FACEP Witness 10 196 Completed Internet Form-NOT FOR SUBMISSION APPLICATION FOR REGISTRATION UNDER Form DEA 224 DEA/Control Number: W24123671C CONTROLLED SUBSTANCES ACT OF 1970 Completed Internet Receipt. Submission Date: Tue Aug 2712:0325 EDT 2024 NOT FOR SUBMISSION NAME:Applicant or Business(LAST) (First,MI) Application Complete. GANDIA ANTONIO Tracking Number:13359136 Fee Paid: 0 TAX IDENTIFYING NUMBER and/or Fi6CIAL SECURITY NUMBER For more information regarding XXX-XX-XX88 SSN/TIN,See Note 3 under PROPOSED BUSINESS ADDRESS.(When entering a P.O.box,you are required to enter a street address) ADDITIONAL INFORMATION below 8900 OVERSEAS HWY CITY MARATHON STATE FL ZIP CODE 33050 APPLICANT'S BUSINESS PHONE NUMBER 3057435266 POC CELL PHONE NUMBER 9543261946 POC NAME ANTONIO GANDIA POC EMAIL ADDRESS AGANDIAMD@GMAIL.COM REGISTRATION CLASSIFICATION BUSINESS ACTIVITY: PRACTITIONER INDICATE HERE IF YOU REQUIRE ORDER FORMS. N Drug Schedules: 2 2N 3 3N 4 5 State License/Liability Information You must be currently authorized to prescribe,distribute,dispense,conduct research,or otherwise handle the controlled substances in the schedules for which you are applying under the laws of the state orjurisdiction in which you are operating or propose to operate. Failure to provide VALID and ACTIVE state licenses will be cause to declare the application as defective and it will be withdrawn WITHOUT refund. State License No. ME53887 State: FL Expire Date: 01-31-2025 State Controlled License No. Expire Date: 1.Has the applicant ever been convicted of a crime in connection with controlled substance(s)under state or federal law,or N been excluded or directed to be excluded from participation in a medicare or state health care program,or any such action pending? 2.Has the applicant ever surrendered(for cause)or had a federal controlled substance registration revoked,suspended, N restricted or denied,or is any such action pending? 3.Has the applicant ever surrendered(for cause)or had a state professional license or controlled substance registration N revoked,suspended,denied,restricted,or placed on probation,or Is any such action pending? 4.If the applicant is a corporation(other than a corporation whose stock is owned and traded by the public),association, N partnership,or pharmacy,has any officer,partner,stockholder or proprietor been convicted of a crime in connection with controlled substance(s)under state or federal law,or ever surrendered or had a federal controlled substance registration revoked,suspended,restricted or denied,or ever had a state professional license or controlled substance registration revoked, suspended,denied,restricted,or placed on probation,or is any such action ending? Registration Fee: Fee Exempt Certification for Fee Exemption(if applicable) Certifying Official's Name JAMES MURO Certifying Official's Title FIRE CHIEF Certifying Official's Phone 13053049959 Certifying Official's Email MUROJ@CI.MARATHON.FL.US Name of Fee Exempt Institution CITY OF MARATHON FIRE RESCUE Practitioner Information(if applicable) National Provider ID 1992896898 Professional Degree MD Date of Birth 09.12-1954 Graduation Year 1981 (Medical/Professional School) Medical/Professional School ROSS SCHOOL OF MEDICINE Manufacturer Details(if applicable) Category/Schedule 1 2 2N 3 3N 4 5 L1 Bulk,Synthesizer-Extractor Dosage Form Repacker-Relabeler Non-Human Consumption Page 1 of 3 197 ATTESTATION QUESTIONS 1. Do you hold a board certification in addiction psychiatry or addiction medicine from one of the following associations;American Board of Medical Specialties, American Board of Addiction Medicine, American Osteopathic Association? [ ] Yes [X] No 2. Have you graduated, in good standing, from an accredited school of allopathic medicine, osteopathic medicine, dental surgery, dental medicine, physician assistant,or advance practice nursing in the United States during the 5-year period immediately preceding the date on which you first submitted a registration or renewal and the curriculum included not less than 8 hours of training?*** [X] Yes [ ] No *** A. Treating and managing patients with opioid or other substance use disorders, including the appropriate clinical use of all drugs approved by the Food and Drug Administration for the treatment of opioid use disorder or B.The safe pharmacological management of dental pain and screening, brief intervention, and referral for appropriate treatment of patients with or at risk of developing opioid and other substance use disorders 3. Have you completed not less than 8 hours of training with one or more of the following from the approved training requirements?*** [X] Yes [ ] No *** The American Society of Addiction Medicine, the American Academy of Addiction Psychiatry, the American Medical Association, the American Osteopathic Association, the American Dental Association, the American Association of Oral and Maxillofacial Surgeons, the American Psychiatric Association, or any other organization accredited by the Accreditation Council for Continuing Medical Education (ACCME)of the Commission for Continuing Education Provider Recognition (CCEPR) r►. Page 2 of 3 198 Application Certification: WARNING:21 USC 843(d),states that any person who knowingly or intentionally furnishes false or fraudulent information in the application is subject to a term of imprisonment of not more than 4 years,and a fine under Title 18 of not more than$250,000,or both. By typing my full name in the space below, I hereby certify that the foregoing information furnished on this electronic DEA application is true and correct and understand that this constitutes an electronic signature for purposes of this electronic DEA application only. * Name of Applicant(For individual registrants,the registrant themselves MUST complete this E-Signature)or name of Officer of the Corporation/Company e-Signature: ANTONIO GANDIA This electronic DEA application must be certified by the applicant/registrant,if an individual;by a partner of the applicant,if a partnership;or by an officer of the applicant,if a corporation,corporate division,association,trust,or other entity.See 21 C.F.R§ 1301.130)for more information on who can certify this application ADDITIONAL INFORMATION Form 224 Form 224 ApprovedOMB Form No. 1117.0014 Expires:06/30/2026(12 minutes) 1. No registration will be issued unless a completed application form has been received(21 CFR 1301.13). 2. In accordance with the Paperwork Reduction Act of 1995,no person is required to respond to a collection of information unless it displays a valid OMB control number.The OMB number for this collection is(See Above).Public reporting burden for this collection of information is estimated to average(See Above)per response,including the time for reviewing instructions, searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the information. 3. The Debt Collection Improvements Act of 1996(31 U.S.C.§7701)requires that you furnish your Taxpayer Identification Number (TIN)or Social Security Number(SSN)on this application.This number is required for debt collection procedures if your fee is not collectible. 4. PRIVACY ACT NOTICE: Providing information other than your SSN or TIN is voluntary;however,failure to furnish it will preclude processing of the application.The authorities for collection of this information are§§302 and 303 of the Controlled Substances Act(CSA)(21 U.S.C.§§822 and 823).The principle purpose for which the information will be used is to register applicants pursuant to the CSA.The information may be disclosed to other Federal law enforcement and regulatory agencies for law enforcement and regulatory purposes,State and local law enforcement and regulatory agencies for law enforcement and regulatory purposes, and person registered under the CSA for the purpose of verifying registration.For further guidance regarding how your information may be used or disclosed,and a complete list of the routine uses of this collection,please see the DEA System of Records Notice"Controlled Substances Act Registration Records"(DEA-005),52 FR 47208, December 11, 1987,as modified. Page 3 of 3 199 -774NF MARATHON FIAT jlJ " FIRE RESCUE 8900 Overseas Highway, Marathon, FL 33050 "Dedicated to Community Fire Protection" Ln�er e xcy 911 Office 3t)5-743-5266 Fax 305-289-9834 December 23, 2024 Antonio Gandia, MD, FAC:"EP 1080 SW 42N D Ave. Deerfield Beach, Florida 33442 To 'whom It May Concern: There have been no changes in the Trauma Transport Protocols for Marathon lire Rescue in the past year, and I have approved the Trauma Transport Protocols for use. Should you need any additional information, please do not hesitate to contact me. Sincerely, tonicl-atn C a, D, FACEP Medical Dire for Cell; (954) 3 (i-➢ 46 Email: agandiamd@,1,grnail.corn Marathon Fire Rescue 900 Overseas Hwy Marathon, FL 33050 200 7* - I AM �j H 2024 MEDICAL PROTOCOLS The following Marathon Fire Rescue 2024 Medical Treatment Protocols are the official protocols for this Agency and are approved for use by EMT's & Paramedics of this agency for the care of the sick and injured. Antonio Gandia Medical Director, Marathon Fire Rescue 202 MARATHON FIRE RESCUE MEDICAL PROTOCOLS Dr. Antonio Gandia, MD, FACEP TABLE OF CONTENTS Response Algorithm Page 1 Universal Patient Assessment/ Care Page 2 to 7 AIRWAY MANAGEMENT/RESPIRATORY EMERGENCIES SECTION I Airway Management Basic &Advanced 1-1 Endangered / Difficult Airway 1-2 Respiratory Distress (Asthma, COPD, CHF) 1-3 Tracheostomy Emergencies 1-4 ADULT CARDIAC EMERGENCIES SECTION 2 Bradycardia 2-1 Chest Pain /Acute Coronary Syndromes 2-2 ACS Alert Checklist (MCFRF- 074) 2-2 STEMI Alert Checklist (MCFRF - 075) 2-2 PEA (Pulseless Electrical Activity) 2-3 Pulseless Arrest (V-Fib, V-Tach) 2-4 PVC's 2-5 ROSC - Post Arrest 2-6 ROSC - Induced Hypothermia 2-7 Tachycardia - Acute with Pulses 2-8 ENVIRONMENTAL EMERGENCIES SECTION 3 Anaphylaxis /Allergic Reactions 3-1 Dive Injuries / Barotrauma / Decompression Illness-Sickness 3-2 Electrocution/ Lightning 3-3 Envenomation / Bites/ Stings 3-4 Envenomation's - Marine 3-5 Heat Emergencies 3-6 Hypothermia 3-7 203 MARATHON FIRE RESCUE MEDICAL PROTOCOLS Dr. Antonio Gandia, MD, FACEP TABLE OF CONTENTS MEDICAL EMERGENCIES SECTION 4 Abdominal Pain /Acute Abdomen 4-1 Altered Mental Status / Unconscious States/ ETOH 4-2 GI Bleed 4-3 Hyperkalemia 4-4 Hypoglycemia/ Hyperglycemia 4-5 Nausea/Vomiting 4-6 Pain Management 4-7 Psychiatric/ Behavioral 4-8 Seizures 4-9 Sepsis 4-10 Shock 4-11 Stroke 4-12 Stroke Alert Checklist (MCFRF-073) 4-12 Violent/ Combative 4-13 OVERDOSE/'POISIONING EMERGENCIES SECTION 5 Beta Blocker Overdose 5-1 Calcium Channel Blocker Overdose 5-2 Cyanide Poisoning / Smoke Inhalation 5-3 Overdose — Narc/ Benzo/ Stimulant 5-4 Pepper Spray Exposure 5-5 Poisoning 5-6 Tricyclic Overdose 5-7 TRAUMA EMERGENCIES SECTION 6 Abdomino-Pelvic Injuries 6-1 Amputations 6-2 Burns 1 sc and 2nd Degree 6-3 Burns 2nd and 31d Degree 6-4 Burns Chemical & Electrical 6-5 Chest Trauma 6-6 C-Spine Range of Motion 6-7 Extremity Trauma — Fractures 6-8 Eye Injuries 6-9 Hip Fractures — Dislocations 6-10 Head Injury/ Increased ICP / Combativeness 6-11 Non-Fatal Drowning 6-12 Taser Injury 6-13 Trauma Alert Criteria 6-14 Trauma Alert Criteria Form (MCFRF-095) 6-14 204 MARATHON FIRE RESCUE MEDICAL PROTOCOLS Dr. Antonio Gandia, MD, FACEP TABLE OF CONTENTS OBSTETRICAL/GYNECOLOGICAL EMERGENCIES SECTION 7 APGAR - Newborn Scoring 7-1 Childbirth - Labor and Delivery 7-2 Childbirth - Complications 7-3 Childbirth - Illustrations 7-4 Postpartum Vaginal Bleed /Vaginal Bleed Unknown Origin 7-5 Pre-Eclampsia/ Eclampsia 7-6 PEDIATRIC/ADOLESCENT EMERGENCIES SECTION AIRWAY MANAGEMENT/ RESPIRATORY EMERGENCIES Respiratory Distress—Pediatric 8-1 CARDIAC EMERGENCIES Bradycardiia — Pediatric 8-2 PEA (Pullselless Ellectriicall Activity) - Pediatric 8-3 Pullselless Arrest (V-Fib, V- ..fach) - Pediatric 8-4 ROSC (Post Arrest) - Pediatric 3-5 fachycardiia - Pediatric 8-6 ENVIRONMENTAL EMERGENCIES Anaphyllaxiis /Allergic Reactions - Pediatric 8-7 MEDICAL EMERGENCIES Seiizure - Pediatric 8-8 TRAUMA EMERGENCIES Acute fraumatiic Pain - Pediatric 8-9 Trauma Alert Criteria - Pediatric 8-10 Trauma Alert Criteria Form (IVICFRF- 097)- Pediatric 8-10 PEDIATRIC/ADOLECENT PROCEDURES SECTION 8P'. Criicothyroiidotomy - Needle Pediatric 8P-1 PEDIATRIC/ADOLECENT REFERENCE SECTION 8R Glasgow- Pediatric 3R-1 Glucose Values - Pediatric 3R-2 Pain Scale FLACC 3R-3 Pain Scale Faces 3R-4 Vitalls (Normal) Range) - Pediatric 3R-5 205 MARATHON FIRE RESCUE MEDICAL PROTOCOLS Dr. Antonio Gandia, MD, FACEP TABLE OF CONTENTS PROCEDURES SECTION 9 Bougie - Endotracheal Tube Introducer 9-1 Chest Needle Decompression 9-2 CPAP Assembly with Nebulizer 9-3 CPAP Concepts 9-3 Cricothyroidotomy - Surgical 9-4 Endotracheal Intubation (Oral) 9-5 External Jugular IV Access 9-6 EZ-10 Insertion 9-7 EZ-10 Landmarks 9-7 I-Gel 9-8 Infectious Diseases IC ernove 9-9 Lucas Device 9-10 Nasal Atomizer 9-11 Nasotracheal Intubation 9-12 Nasogastric Tube (NG Tube) 9-13 Spinal Motion Restriction 9-14 Synchronized Cardioversion 9-15 Tourniquet - C.A.T. (Combat Application Tourniquet) 9-16 Transcutaneous External Pacing 9-17 Ventilator Concepts (Page 1 of 3) 9-18 Ventilator Control Module (Page 2 of 3) 9-18 Ventilator Diagram (Page 3 of 3) 9-18 Video Laryngoscope - King Vision 9-19 REFERENCE SECTION 10 12 Lead Reference Guide 10-1 Determination of Death /Obvious Death 10-2 DNRO — Do Not Resuscitate Order (DH Form 1896, 2004 Revision) 10-2 ETCO2 Waveform 10-3 Glasgow Coma Score 10-4 Refusal of Care (Page 1 of 2) 10-5 Refusal of Care (Page 2 of 2) 10-5 Rule of Nines 10-6 Stroke Scale (Cincinnati, Mend) 10-7 Termination of Efforts 10-8 Trauma Transport Protocols 10-9 206 MARATHON FIRE RESCUE MEDICAL PROTOCOLS Dr. Antonio Gandia, MD, FACEP TABLE OF CONTENTS DRUG FORMULARY SECTION 1 I Adenosine Triphosphate (Adenocard) 11-1 Albuterol (Proventil, Ventolin) 11-2 Amiodarone (Nexterone) 11-3 Aspirin 11-4 Atropine Sulfate as Cardiac Agent 11-5 Atropine Sulfate as Antidote for Poisonings 11-6 Calcium Chloride 10% 11-7 Cyanokit 11-8 Dextrose 10% and 5% (d-glucose) 11-9 Diphenhydramine HCL (Benadryl) 11-10 Dopamine Hydrochloride (Intropin) 11-11 Duo-Dote 11-12 Epinephrine 1:1000 11-13 Epinephrine 1: 10,000 11-14 Fentanyl 11-15 Furosemide (Lasix) 11-16 Ketamine (Ketalar) 11-17 Magnesium Sulfate 50% 11-18 M ethyl prednisone (Solu-Medral, A-Methapred) 11-19 Midazolam (Versed) 11-20 Naloxone Hydrochloride (Narcan) 11-21 Nitroglycerin (Nitrostat, Nitrolingual Spray) 11-22 Odansetron (Zofran) 11-23 Oral Glucose (Insta Glucose) 11-24 Sodium Bicarbonate 11-25 207 MARATHON FIRE RESCUE MEDICAL PROTOCOLS Dr. Antonio Gandia, MD, FACEP TABLE OF CONTENTS TRAUMA STAR GENERAL PROTOCOLS SECTION 12' Ilkiht I Ir"nyslblow 12..1 Irnll ial sse sir°neit 12..2 AIRWAY—TRAUMA STAR SECTION 13' .a plkJ Se(jUeirnce Ilitdba ioirn 0I .Sh 13..1 MEDICAL EMERGENCIES,—TRAUMA STAR SECTION 14 weir°fic I[",Xlssec ioirn 14-2 C�irtr°I II Veir LI S Il.Jlirn s 1 4...3 OBSTETRICAL—HIGH RISK SECTION 15', HI lig Ih I Ji sIk OB ..I..ir°a irn s poir t s 15..1 Ilrnllveirsal IHIliqlr"n...IJwJsk OIB ssessir°neit / Caire IPirotocol 15..2 Ibir°V�:r !0 I Ilaceita / ljteirrlirne I .V�:rWir°e 15..3 Bir°eech IPir seirn a ioirn / SIr"nOd1deir II[)y todla 154. [",Xla fret s I e l 11 li W S li irn IPir°eg irarn y 15.. a l irn IM a irm qe rneit / INaLlsea li irn IPir°eg irarn y 15.. I st...IPairtUrn IHleir"norir°Iha(ie /Arnirnbfic IIUld IErnlbdlLI S /Ceirv° i al Peirrlirneal Il...aceir°a ioirn s 15. Pir°e.._I..erir°n Il...dboir°/ IPir°e.._I..erir°n IPir°eirnatUir°e I .V�)Wir°e of IlMernbir°airs s (RRp,,0IW 15. 10 NEONATAL EMERGENCIES SECTION 16 Neornatal I irdotra oJr"neal IIitdba ioirn 16.2 Neornatal IPeir slsteit IPLdir"noirar°y IHIypeir°teirn slbirn (RRHI..I.N) 164. 208 MARATHON FIRE RESCUE MEDICAL PROTOCOLS Dr. Antonio Gandia, MD, FACEP TABLE OF CONTENTS PROCEDURES-TRAUMA STAR*INDICATES TRAUMA STAR ONLY SECTION 17' 1V IC::'Uml (AS5(':) Syrliril'.je If::�LJiml 1 °...gip. C::l IlVlic IRlrideir° 17.. 1 V�firi lil1atoir° REFERENCE-TRAUMA STAR/MARATHON FIDE RESCUE GROUND TRANSPORT SECTION 18 DRUG FORMULARY-TRAUMA STAR/MARATHON FIRE RESCUE GROUND TRANSPORT SECTION 19 Ca it°dizeir°n ([",XIilllifiazeir°n) 1 9.4- I[",X111a Udd (Hydir°ornoirll:blhoirne) 19.. Esir"noldl (Bir°evIblo ) 19.7 ...evoll:blr"ned (INoir°eIp:lirnell:blhiri iirne) 19..9 wir°na�r lcoirn (I klir°nazeirnlill) 1 f. -14 �u SLICdiirnyll lr"dlhiirne ( irnediirne) 19-1 .1..eirlbLlt 111iirne (Bir°etIh"lime) 1 a. -17 MARATHON FIRE RESCUE Universal Patient Care �II' �IIIIIIIIIII S III°'°'� �I S�IIIIIIIIIII Review the dispatch information and select appropriate response. SC III �I III I.. III III II4 N I S IIL III I II°' • Consider Body Substance Isolation (BSI) • Consider Personal Protective Equipment (PPE) • Evaluate the scene safety • Determine the number of patients • Consider the need for additional resources III°� lllf""Ilf�IIIIIIIIIII�I °°'lllf°" III°"�III°"�III' C�Ih� • Determine the Mechanism of Injury (MOI) / Nature of illness (NOI) • If appropriate, begin triage and initiate Mas Casualty Incident (MCI) procedures. N IIl II4AL ASSIIIIIISSIII IIIIII]I • Correct life-threatening problems as identified • Stabilize cervical spine when appropriate 1111111111l lllrAL SlllrA S 1!! Alert- to person, place, time, and event (AAOX4) Verbal- responds only to verbal stimuli Pain- responds only to painful stimuli Unresponsive III!!!!oir I du4tui uic IIIa'tuie uiil, ,Hcouiiuideui .t Lhe III edu4tui1ic Assessin,°iue aIIIe PEDIATRIC ASSESSMENT TRIANGLE r � f li !� ' � Abnormal Breath Sounds Toner1Crl7lal Position, In eractiveness Head Bobsb I rlg . Con o l a b ihty Retractions " i Look/Gaze Gasping Speech/Cry Nasal Flaring uioimmm mu uu I�m�iwi� uoWU �mN I IIII IIIII�IIII ���VIWium��� Pallor Absent or Weak Pulses IC otflingi Abnormal Blood Pressure Cyanosis Obvious Sigins of Bleeding 210 MARATHON FIRE RESCUE Universal Patient Care If III' • Open and establish airway using appropriate adjunct • Place patient in appropriate position • Suction airway as needed, including tracheostomy tubes Positioning: Head-tilt/chin-lift or modified jaw thrust for suspected spinal cord injury. Semi-conscious patients with an intact gag reflex: shall have a nasopharyngeal airway inserted, unless contraindicated. Unresponsive patients without a gag reflex: shall have an oropharyngeal airway inserted, unless contraindicated. Supraglottic Airway (SGA): If ventilation is required for more than two minutes, an I-Gel should be inserted Exception -primary cardiac arrest. Recovery position for spontaneously breathing patients: Altered mental status, postictal, suspected drug overdose, etc., if no suspected spinal cord injury. Suction as needed. II,,,,,,5 AIRWAY I ararnediic Oinly Intubation: Patients who require ventilatory support (and are unlikely to regain consciousness) for more than two minutes should be incubated (or other advanced airway), Exception -patients in cardiac arrest. Unsuccessful Intubation: If an airway cannot be secured within three ETT incubation attempts, an I-Gel should be inserted. Surgical Cricothyrotomy: if an airway cannot be secured by any other means, and the patient cannot be effectively oxygenated or ventilated, a surgical cricothyrotomy should be performed on adult patients (or needle cricothyrotomy for pediatrics). OXYG111111111]4III' III IHI 114 S""IIII"'"11A0 N Except as noted below, oxygen should ONLY be administered in order to maintain Sp02 of 95% or 90% for COPD & asthma patients. Do not withhold oxygen if the patient is dyspneic or hypoxic. Stroke patients shall be treated with a minimum of 2 Lpm NC regardless of pulse oximetry reading. Increase oxygen therapy as needed. Suspected Traumatic Brain Injury (TBI) patients shall receive 15 Lpm via NRB. 3rd trimester pregnancy trauma patients shall receive 15 Lpm via NRB. Pulse oximetry should be documented (pre and post oxygen administration) and applied for continuous monitoring on all ALS patients. If oxygen saturation cannot be maintained, ventilatory support should be provided. 211 MARATHON FIRE RESCUE Universal Patient Care SA02 III �I Ilf lllf01ZH4G 02 Saturation Ranges General Patient Care 91 - 93% Mid Give oxygen as necessary Hpoxia 86 - 90% Moderate Give100% oxygen assisting ventilation if necessary Hypoxia INACURATE OR MISLEADING Sp02 READINGS MAY OCCUR IN THE FOLLOWING PATIENTS: Hypothermic,Hypoperfusion(Shock),CO Poisoning(SpCO), Hemoglobin Abnormality(SpMet),Anemia, and/or Vasoconstriction. 111111111ICO2 I �I II4""IIII""' III 114 NG Should be applied to all patients meeting the following criteria. MANDATORY • Requiring ventilatory support (ETT, 1-gel (SGA), CPAP, etc.) The following patients should be monitored if EtCO2 is available: • Respiratory distress • Altered mental status • Sedated or receiving pain medication (including Ketamine) • Seizure patients o '� I no a Normal l t �. � �� n )�*0 � or , i Ear "n rinva,ar' c;ipnogniant, is a wavefoirm roi),proments lhovary6g 002 Wei tlhrouilhico % thrr bioath n-- CI(i. Wavelorm Characteristics.. -C E ptrstr ry t,tipntrrr n D-E Ilnspirnt rt -C� E pirgitiory Plateau 212 MARATHON FIRE RESCUE Universal Patient Care III �I lllr III LA II0I • Ventilatory support shall be accomplished via BVM with either an NPA/OPA, 1-gel, or ETT incubation. • The goal is to maintain an Sp02 of 95% and EtCO2 levels between 35-45 mmHg (with the exception of COPD and asthma patients). • Any patient with a pulse who requires ventilation with a BVM for greater than two minutes, should be incubated (excluding pediatrics). • Endotracheal incubation shall be confirmed by: visualization of the ETT passing through the vocal cords and continuous EtCO2 monitoring. 1IIIIIIIII1I °"'llll'°"IlfLA 011YIII' °"'llll'°"1IIIIIIIII S (11111lt 111 ) Adults: 10 breaths/minute (1 breath every 6 seconds) Patients with an advanced airway should be ventilated at a rate of 8-10 breaths/minute (1 breath every 6-8 seconds) Children: 20 breaths/minute (1 breath every 3 seconds) Neonates: 40 breaths/minute OIRCULA Ilf N Carotid and radial pulse present, assess: • capillary refill • skin color, condition and temperature. Unconscious patients - Apply AED, LIFEPAK 15, or Tempus Pro on all unconscious patients. Cardiac Arrest patients - Perform continuous chest compressions (CCC) and apply the LUCAS 3 Chest Compression System (if available) on all cardiac arrest patients and defibrillate as needed. Infants/children/Neonates: After oxygenation and ventilation of 1 minute for infants/children and 30 seconds for neonates (birth to 1 month), begin chest compressions if the heart rate remains below 60 BPM with signs of poor perfusion (AMS). 1IIIIIIIII C w III �I Ilf lllf0 11I' If N G All ALS patients shall be continuously monitored in lead 11. Patients who present with any of the following: shall have a 12-lead ECG performed: • Cardiac or possible cardiac symptoms • Chest/arm/neck/jaw/upper back/shoulder/epigastric pain or discomfort • Palpitations 213 MARATHON FIRE RESCUE Universal Patient Care • Syncope, lightheadedness, general weakness, or fatigue • CHF, SOB, hypertension, or hypotension • Unexplained diaphoresis or nausea 12 lead ECGs shall be repeated every 10 minutes and upon a ROSC 111°°'lllf°"AL S IIL w NS A complete set of vital signs shall be documented as follows • Respiratory (rate and quality) • Pulse (rate and quality) • Skin (color, condition, and temperature) • Pulse Oximetry • Capillary Refill • Blood Pressure ➢ Priority 3 patients at least two sets or every 15 minutes ➢ Priority 2 patients every 5 minutes ➢ A blood pressure shall be checked before and 5 minutes after the administration of a drug known to effect blood pressure. ➢ For the purposes of these protocols, adult hypotension is defined as a systolic blood pressure less than 90 mmHg. ➢ Initially, all blood pressures shall be taken manually. A manual blood pressure should be taken to confirm any abnormal or significant change of an automatic blood pressure cuff reading. U C SIIIIIIIIII A BGL shall be documented for patients with any of the following: • History of Diabetes • Altered Mental Status • General Weakness • Seizure • Syncope/lightheadedness • Dizziness • Poisoning • Stroke • Cardiac Arrest 214 MARATHON FIRE RESCUE Universal Patient Care III°' III �I °"IIII'°" III IIL S°"'llll'°' III' CAL 111111111 M CHIEF COMPLAINT: Why did the person call 911 HISTORY OF THE PRESENT ILLNESS (O, P, Q, R, S, T, A) • Onset- Did the symptoms appear gradually or suddenly? • Palliative- What makes the symptoms better? • Provoke- What makes the symptoms worse? • Previous- previous similar episodes? • Quality- (what kind of pain?) pressure, squeezing, aching, dull, etc. • Radiation- does the pain or discomfort radiate? where? • Severity of Pain: 1-10 scale, faces pain scale for pediatrics. • Time: what time did the symptoms begin? • Associated- what are the associated signs and symptoms? S.A.M.P.L.E HISTORY • Signs & Symptoms • Allergies • II edications: Prescribed, over the counter, or not prescribed to patient • IPast medical history: ➢ Heart attack, asthma, COPD, diabetes, hypertension, stroke, etc. • Ill,,,,,,,ast Oral Intake • IILvents Preceding DCAP- BTLS • IDeformities & Discoloration • Contusions • Abrasions • Punctures & Penetrations • IBurns • Tenderness • Ill,,,,,,,acerations • welling 215 _ cfl o" 04 w — j o X Q > Q y LL � E Q o m O Q z x 0- 0 _0) O z d0 _O � a W w -0 -0 oQ Q C j U E O s U) O X � o Q c U Q 0- W > z °S O m � (6 Q CL - Q 0 of 0- 0 O Ow O Q L Q V m f �-h > O 0 0 c o J' �, fC L � o u L a' m m A W 00 > � T 0 � c `° a zz z � < 0- 0 > C .� w 4-' Q � N (1) Q C N L W Q N E R W U N r z = W � L E UWr c4'.) w O YCYa : _ 5 w N O o d y m o 0- O O n U o 'L (D m � c � .E U) > � ate° — �' a c o 0 o x � m W c F T � E E N p n U) ? :� U) CY o V _ ) � U) Q U W in Q 0 w U �; ti N O v O 4.0 L- 0. d E d co co co Q N O U w O 0 L QC� CG G Q� V cn L cn L 0 00 d � N LU CL EJ} ,,,, CL E a) w IC L a) w.. 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O � O N •X > U)cl) E ; U 0 � � 0 U Q Q x 0 < LU 0 N N N L V L m O 0 a� E E a� 3 U C 0 MARATHON FIRE RESCUE MEDICAL PROTOCOL CV N ACS AILE�IRT' IHIIE ' ':LI T' F''OI � 'T �AUIMA STkR� Date Patient Nainne DOB Age Phil M,r"IIM Fescue Cirew ,t° p u � 0 A V P Ul GL,UICOSE -�-_ R0,5 firaturr a Seta &Illsir jivii�-co fiiiuiin rV..':5 llem-t , criteida hrquuiin a"CU .ection(iii-ninimiimoin) QPQR T Clieck all tlh'ill =at aIII w'Dimset.of IEvents: r CASH Provccatimm: C. hest IFaiin> ,20,inIll"nd < :12 lruc"uiu.uars QluallI t : Region: I alnluaw f a XiI ........ ......... ................. Severi (1-1�0): ���Ii a ed Irnul�u�lli Status s Time �,IDur�tic�nu�; Cons,tain�t or Ilhterrmiittent s1"ortiless ruf Iltlrrr at m TPA IExclusion Criterim II�I �ul��u u4n�ur�ar�tu�r a�ailll o�r�ban m�I�lr rtm 'I�� ,r�;l Bleeding Problems: eb (Low IB , ���;Ilt �°��r�Iiiu u���p���u�rt�����rrtlur:'�,�rwr��:rN�m�rr��E�p IPremmusStroke: Streptokilnase: PIn°mall 1101E/priolir!,.,p erits Receint'Suurguy 1wj"nu 6 months is Diabetes Blood Thinner: Cairci,ini unry 11-le.airt Disease., (,AD) Pertinent History Atnrliiall IIFlibu,!1111111allk.:r�iul Prior MIl Date: III r te insli.:piin ngiina: IIl J tD itro Taken(Prior to ArriwI: � Sexual IEnhaimcemeint Reds c:24hrs YE-S NO S,T Elevatlnorut(SHIP(( III Field 'Treatment dV nId1hyt1 murm"uul a'~r "IN l e art. 1b ]k A 24nn g: liI. 1:� .Yi- im x 2 �r�T��.. 11��11r"Ii�"� �� Etw�':,�Ill��u��lll�'tannu Pain IMechicati n: IFt ,uar�ullG Ilr uln�u�INm�t 111 ��� I�IIN Total Ruaidl Given: imi ,ILL IJIM N'rI'i IP'T REIPC)RT& ETA. 30,15- -21: 71**:"': III-(- ,I:`:IH C()[YE SIL.,lMlIll HIIINK TO RESCUE WHITE TO,(FLIGHT CREW YELLOW TO HOSPITAL. MCIFR,-074(0 /2018) Dr. Sandra Schwemmer, D.O. ACS ALERT CHECKLIST 223 co CN (V U IML = o N O N 0 o o L O 7 ~ o U CO 3: 0- o Nto Cu U o X 0 uJ = LL o O O U U 4—co E co E Z a U ., O III° �L- o „ U i ; N07 O O U) U co E O O a 0) (n Q Q Illld U(D o cn - � a) N U o II.0 w iiill Q O 0 0 O O �� = N U � o co co IIIG m N m E o co O IIIIIIIIIU U 0 0 i Uwco co v e - W — a) cn > c c O a� w > _ O V U) V Q cn o + Q LL Q LL O b. C a a + l N : s L a) co U 4-0 C o �, IIII' �s L '� L 0 L '� p ` . E, .n O Cu V o o IIIGco Cn O m �� Hill to 23 p (6 pp� ,,, c as O � O> a U o = III� �-` B Y O 06 L c6 IIII" o cD i w a> o cr CD E COx () cn � L � � � N � old L {,� a) im m o Z E w " _0Q J > > o x �s�`� z E U) — p u) m CL E 0) a) � pU) u a OQOwa `° :s ) < o MARATHON FIRE RESCUE MEDICAL PROTOCOL � TIE iII AILIE 'T CHECKLIST FOIR TIRAVIVI�A STAR Date Patient Name, a08 Age_ IP ul Mm Rescue Crew d A V F U1 GLUCOSE ®- 1. unc.,,ll1 - imagni "St, it IIff Any Of Tllh�e IBdlr.tv �.o ittail li���o re II3i !,.en�t TPA IE��I�u��l�rn� Criteria Bl eciiin IPrlroblenns: II III = m ;anldl., Previous Stroke,: Streptokinase: T)( Nevv Onset ILI�I B wit Cardiac �� LR',,e,ceint:Surg ry jw1'iun� i m jonthsim��t lrmt ? ood Thinner: 2)( RBBB with ST elevatiomt? ❑ Pertinent IHistory Prior Pit (Date: GkEle-v onsiniZar mote Leads, Angina: Mabetes Mellliitu,s: "DES/NO 3)( ,IntenitlikaiII '; Nitro Take n Prior to� � ivalll: "IL ..k.. � ❑ Sexual Ean=emenieds -1;24hirs: YES 1 ..................... _ ......... ....................4)( Ill lerii r 'Walk ElRe ld 'Tr�eatrrment II II III � �VF: SA 324nnig: Ewa via NPIE: IInferi-olir W&H I II —obt, ifiin V41R. Nitrnglllyi`eriinu° ail—!K2' If V4R IPOSIT11IVIE WITHHOLD NITRATES IT, atin I a�iirLatii�an: Obtain 2R4 II give,ffuriHds ill i� ypotensive olalll FllUids Giivem niI OP QRST Comments: eints: Onset of Events: P rovocati cm� Region: Severiityl1-1%r Time lD'rnr�atic�n,lc Constaint: or Intermittent CALIL VUH W/ IPTf REPORT REPORT& ETA CGI:: IIF M:..II IIM I 1A RY PIINIK TO RESCUE WHITE TO FLIGHT CREW YELLOW TO HOSPITAL M FR-0a .(Oa,/201 Dr. Sandra Schwemmer, D.O. STEMI ALERT CHECKLIST 225 co N N 2 y Y v � Cu Q O Q 70 (1)Cu (1) .> > .y 70 Z � °k' r. 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O V (if 0 CL OLu a) O c, O E Lo O c a) 0 w O O Z N m E Z J � +-� N a (if � O � = o U � � � •0 co N � U) ,�- �.+ (n CD COQ E M O V 0 ' QE N v Lo � p E E •� C1, N "'"" a II 0 ,0 a) U Q © — CU 0 a) •D E m p 0 = � 0 W E � E O U- QL O c 0) � E > O O O� � cp Q 'M- a) O O OO N r Rf a) � Gp L t r Cl) c 0 o CL a) O � r m O): E_ EE V O E O a�m � O � Rf uW � � U •0 v -j U) �> i -, O W O to J � (nU > co • E `- o J o Rf N LO N (�3 2 N d. i (t5 a) d- 0 — X O 0 O co O c 0 0 0 CL ccs Z WCD Ncu N Q cf) m U m CD a) W o o a c o 1 �Www oa) am _0 Co a) cu m co m o 70 N N + ` p 0 U N co 0 co (n CL �Www Cf) a) a O (0_N 0 cD a .� p nco Cf) N o ~ N CD � = N to m _� >' Z o o W co 0 w o o V �t5 J o +, LL ZC - C U U Q 4- E o Cl) D U W N p o 3 R m a 0 MARATHON FIRE RESCUE MEDICAL PROTOCOL S I ROKE ClI T,0,0 IS I I IIl, flV[A S`[`XI'k I)ate 1!!"t j4arri* I Age I!!"MIII'AM Riescill le w [" LZ� III ew e�g ,t ..............."I'l""I'll""I'll'll""I'll""I'll",'ll""I'll""I'll""I'll""I'll'll""I'll""I'll",'ll""I'll""I'll",'ll""I'll""'ll""I'll""I'll'll""I'll""I'll",'ll""I'll""I'll",'ll""IlI............... �ASTTIIIME PT SEEN WITHOUT SYMPTOMS V P U� GLUCOSE 24 RFM� CIII CIfiN .„I„I StiI Scal 111., IExaiin z CL M SPEECH ftbeek box indicating response) O�nilly Check Box IIIIE A13NOIRIIMAL I "You can't teach an old dog new tricks" SPEECH Repeats Sentence Correctly 'You can't teach an oIld dog new tricks" Aphasic(Wroing or I nappropriate Words) Question Patient for: Age, Month, Dysarthriai(Slurred or Unable to Speak) Commands:Close Eyes,Open Eyes CRANIAL NERVES CRANIJAIL NERVES L i R, Fadidl Droop:Show Teeth or Sirnfle FaiciIal Droolp:M,iow Teeth,or Simile Normal=No Facial Df oop Visuirl Fields:I Quadrants AbnorrnalI=Left Sided Droolp Horizontal Gaze:,Slde To 54de, AbnorrI=gkkt Sided Droop LIAM,(Mlotor) I R, LIMBS(,Motdir) Arm Drift:Close eyes,Hold both airins oust Arni Dirift: Close eyes,H61d both arni,s out Leg Drift: 011liens eyes and fifts each leg sepwately, Normal=No drift SENSORY(As,k Ipat'ilent to close eyes) Arms:Check sensatiIon,Iby touch then phtch AbnormaII+Left drift or unaible to move Legs:Checksensation by touch then liniruclr Abnormall+Rkint drift or unable,to move COORDINATION:! ArI I to unose ...118. �.N......D....... Legs:Heel to SlAn 'IIII I ElY rrhove 1111F to I III clicunplIcAe AiIs LAUNCi I "T'iraluirna Star KIM:II:�xaini, IV NS I �Gauge Y N - --I Site LEAD PARAMIED�IIC SIGNIATURE: I Oz LIPM Y N COMMENTS: .................................................................................................................................................................................................................. ELEVATE HIEAD 30P Y N ..................................................................................................................................................................................... ETA HOSIP: H O�SP Contacted Y N ....................................................................................................................................................................................................................................................................................................................................................................... III n II11 1r l 0 Bi I"w�CJI JJ 11:: W 1111111111:::: 11 D 11111116 111 III (111i I:::W V:1111(M,� 111 11 10SP11 11 Al n73 Dr. Sandra Schwerrimer, D.O. STROKE ALERT CHECKLIST 253 dq Ln N O c0 t O O i o co U � (�3 ! o •� cu Q ,to © X L 2 a) a) L ,O (t5 � >' X _ a) O� Q wowo _ cu O -Q a �, o v a� ca O > W ©' p a) O •� D c� O ayi W U p ° aa) U 0 cn cn W U cu -a a cn Q W 0 U, i _ cn U. a c (0E a) O 0o v O Z cu Q O) w ca d .S a) > 'a v O ca cn Z Q W EC a) a) U cu O U W U '" J p W CV wowo _0I O Q CD c O > -0 0 a) N I Q U a U O 6 or) ,,,, 2 � O > m = N i — •— � cn a) cu O � `� > � O U = a CD to c +� Q u. _ a .' w CO . . . . . °' . . . N v N co cn t= CO Q CO y as � � Q O Q LO LO N O O O m O (t5 O CU L cn CU QL U o 0 0 O o L a a) U E cn c ° W CU D p cn ° a) a) to Q i U O Q (Q 70 J O O 70 "O W �' O a ca W 0 O -0 a) CU > uj p '' o � E O U. O L U m O Z J uj E o U N cu C0 _0OO O O Q cCf a) O � = U N a) cn a) CD Q W ( o 0 U wOw, m ,i..r to Q V p Q W a m CL L =_ �L-+ O U O_ J Y O cn O CU �C (Cf cu C O 3 .3 m 70 O CL O_ _ L U U 0 M (B O C .� W 4— ,� umi U N L CoLcu E to • � O • • • • O cu p J J U Q U m Q U = Z m 0 i o E E 3 U C 0 co N m = J E CD Q} p (6 - p LO a) > (6 � U a) m Q co � O O O 0 oc 70 7 L U W W a1) O o ) O W V Cu W Y U (o70 GWC ~O a 0 O J Z ° J Q W o >, a) = o Cu Z -0 _ Z Q w •� Q co o a) a 2 Q w L ui lie a a 0 Mom V o O — Cu a) a761 ori U c U J CL o U u�i V O t U o - a) CL •- 0 0 Q 04 a) E O a 0 (n — — a) N — 5 — U U 11 ICU U r. V UCL i LU U U U Im JE � - J o J o m Z Q = o a� E E a� t U (6 U C (0 0 ti Ln N L O (� C •O i O O •F N O a U o (l) C: (1) L U • O a � � ?^ N OUcn G� O c6 Q (� to �+ O Uz U ^ � cn Qom— L U (� N ,- C: M D Q Q U = O cn Q O O cn a� E E '� � � � cn � � � Ica -0 � � � o � a, N Q� N CD- O Q c con Q N N L L -0 O N O S 0 0 }, Z L cn � O c -0 QU) c N Q ff .N U CD- E- QU O N O Z w E (6 to a> +� �, L �, O N (� > X c O a ±' O = 0C) E Q m2 > c/ H2U •� � w u� c� cnQ � Al O V0 • • • 0 • • • • • • w • w ,+��•' E • • • • • Q Q W V 'a , V V V _ W O O Z H � LU w LL 1 a s O Ov V � W Q 7 0 Q Z [L s W U v c� Q � 0 � � 70 O 0 Z < cn N o d [L can W E s.. ) C/) CU •— N _ a Q o J • J • U 00 Q co LO N a) 70 a) a) a c _ CLI CU2 i to Z = E = J can) E �o 5 Lo sZ, W o D p a) M WO 0 J \ p � zo O N p N cn o W a' N N O > cn ce p m ZNJ � � 4 O U Oa N O a) UO U Q = C U -a = � W t!S W �' Z co iE � Q U co cn c i 0) cn _ cn L O L]. o rn L c = N Ocn _ C 7 c p° a) N a w cu > = w �co N , =3 C _ Q Zco CN Cl) W U CO AA A Z AAAA ov A m • • Q Z m N H o 0 a� E E a� 3 U C 0 0) LO N CL cu � L O 0- M co L Q) 0) 0 'i O) cu O y- "' O a) M a) 0- (n cu >j q O -0 _ �. >+ Ocu _ >-0 cu+ L O L (u O a) cu a) L 0cn O) A (u cn > > (u v (n O O ( 0 j L O � O) a- (n U (n a) E cu U (- O _ L (n CO Q) O > _ � � Q N "- cu U "- OU cu O (n -0 -Q s. Q) O7 O "- Z E O L O a) � a) ++ cu a) CLI J 0) > a) U €2: Co (B O >+ � U r p 0 cu X o cu - (n 0 a) a) cu U a) o � wo- in 0- = cu w (nU) D- U) amQU Z 75 u7 O uj D © Q Q co J [L ~ Z w0 Q W0 � Z wc > O U. a = a, cu V Z Q a) O cn a) 00 > Q OU w cn � E �O dCU co ) � a) o -0 -a E cu cu (n O 0 - Q E toN o o cn — c W � o f m U U a) 0. CL O a) m a) O (n N (On 0- cocu c W 42 Z a) — to v 0- 0 0. U L LP O ,N 0 (tf 0 a) E cu co: cu 0 C L (u to L O O (tf a) cu 0 0 0 cn 0 'L 'a U E a) �, -a aa) �_ p .L , = Co >, cu r �-� U cu 0 U O 0) Q 1=0- U � � � U a) � O r c W cn U O O — O a) E s cu Co -04 Co 0- O a) (n c a) c .L 0 Q O O a) Co � 0 O (u a) Z O a) .� a) 0) O O O -0 -0 L 0- 0 u LU Q U 7 0 0 0 `= C0 CO • • • • • J J c m Q o 0 (D N � W z �? = a� "— J E Cl) � •L O � z- 0 y-+ O /w to� O � BYO/I Y .-+ O Q ,� O O W ca .r v cn C > o a) W O _ cuCC: DEo— D — CO -j L � O U cn LY J co O � � O cu 0 W ~ o E Z a N N cn Z U.ZJ 0 Cl) Q N _ = v ' N E ¢ N L fl. Q W N u a) CN 0- mL (Q N O E "O a) Q cn 11 a) O CD cn co > . . O 0- D a) Y �E O W N L " yU a) O a) �u O cn LE cn (� 0- a) O) E -0O CU (Q cn a (Q -0 a) z W w a) >, (— cQ Ln a) W v � d � � � L 0 a) cn co z c , a) � c 4— UmL z0. � _ a) z a j O — p n � -00 aOa) � a >L a) a) r O a) O CO M 0) a) E O a) � z O a cn N a) o a) E E a) � a) w O o n O O .O ( Z Lu U) O ca -,cn 0 cn D Z 0 Z o N J W J • • • > • W • • V • • • • 2= a Q E 3 U C 0 cfl N cr W cu E x - co -p ( > a) 70 4) L Qcu - a) s. to cu > 0 cn " a) L 13 O CV a) cu _ a) U G1 W © � W m U Q © cu -a W W to cu o co co O N (q o cn = 0 LO 7 Q W Ca) o o W O o N > O) N 70 CN Z U. a N Q Q O O O Q , N vi06 cn L J = U N E Lcu cu > U Q W N �_ Q -a y � V CDcu L O to CD Q N11 co cu N N O ,C V cu - - C U ... ++ a) L a] a) C X70 CDM `O� W z U p O N p co z >, cu O a) CO = 0 a] a cu V N a) Nu O C? a) C cu r pcu O U U) a)CL v C to �' r W LL a) U cu O_ m O O U cu a) cna) -Q V _ L MO a) C , OX t ca) c > cnW > in J CO 4- 0 �V L o E o m • • U p O U) ""U O U O co E v m Q E "- a E 0 • • • cn • M 0 N (G N O O L- a) O cn (if N -� O � O r.Lcn — �+ cn a) i §� O N N a) c � � X � O 0-0a) a) a) cn > 0)� E a) w O — ti UJ �� a) � r W0 M.0 BOO U >,L cn E o) a) z w O (t5 a) a) m O cn O.E L W � U Coco Oc� � U_ O cu ccs E > o a) > L L 000 w � -0 m Q Z � E � a hCl) N ccl) CL N °n) z — }, — Q O, 70 N O, � Q.O a) p cn � � w— m aCl) o Cl) Cl) � ( �� c Q cn �> > a .�M a) co CU LLm> � 0- 4+- (LU� V O ) �0 O •0 V � N O CCLm L- � �© as c cn -0 o - a) u.. v •� a- L c� CL o m � >+ a� c m m m 0 a) �� C U) o > O O O j O (if cn � � o U U U D O Q 0 (n Q c E W •/ W V 0 a Uji a aM 0 M tG N (u E O n3 Z N _0 - joy o a) w ° 0 E %l Q mcn j 0 V � O V a) 0 % a) 0DL V) 0 � j O N W uj U M a) d // Q V O Z O cn .� N U. a q) d / _� a) 0 Q E a) i — (u cu Om N a) Q CL c�S L L _0 O Q m O � fn,N 0) Q > .O O L a) O 0 a) cn O can CD ) ® ' L a) �' E _0 N Q u � O Q � � cu O .;� U cu V cu N 5 � O �, a) a) � � M -0 cu . Q 4 .— v v �E o (D a) oUD Q i a a a > E m Q 0 Iq co N U �' O C O N O N 0 00 O cn � W O L +� 1 L — 1— v W f2. 0 —>, cn O a) Q '- N O Q c LU 0 Ui .- + _ p U N O a) lO z E cn - �. U � � U O � � N °M O •— Z3 � c� 0 CL � aZv o w Co cn ° ca O U- a W � 0) ° L 0) M Z_ Oa - E cn C 0 U U CU — 0)-- " O O � O 4.0 p < .L E O U 4 o O cn W m04 cn cn 0 00 � a �u Q 4— 0 W O N O (- N 4 > 4- N L W N � O � ° N •U � (� 0 O U O N -0 cn cn O >' cn 761 -0 cLn I: c _ O (� U N U r E _ M i — 0 aDo � °' tea--- ° O E L >� •� U 0 cn cn O > _ �_ N ° N N L >' O O N L E O N U-1 � Q E O � w- .E cn cn M Q O N cn C 0 .� Q Q cn � Q O > 0 0 • • • • • • 2 .E E U c�a o J J • • • • E m Q E U (6 C (6 co N — 0 m co �- E O O (o L L 0 > m 0 >' O L a) O > O O O L m ' L Z O L Q. 0 Z M U o L L O O _ 0 LU V U N 6oU� ° � $ m n r � ZC7 � co o p o o 0m O WL N � E � o DC p L GCS � of < o -0 o0 0' M Z J L L to m 0 _ c6 U U a) Z L N Z N O M a) ~ L O Ica � Z O o � Q ° O M Z Uo � Q O U a LL -0 .L m -0 O p >' N U O J O LCL (i3 to J 0 Cn U L Z O �' 6O m � Z O m aN oZa) U to o U ON(D ) O ) O . E L U U �� z a ° >, 0 W L W 0- L LL m u 0 - co E °' L c�l U 0 > p a) © L H (6 () a) O L Q O a) L Q O a) W L LL" to to O �. > L `o (6 O -0 O a) .� to to — Z O O a) O CLU - L cn U) U) 0- 0 O a) O M N Q > O U) O O O Q Q Q 0 0 � Cn cn cn Q > `� U W o J • • • • • • • • • • • • O J ' • E m a a U (6 U C (6 0 cfl cfl N O cu O) L L 70 0 >CU O U O p E a� �. cn a) L a) 0 E sZ (t5 + O a) U O0 O p i0 -0 E V C2; +_� Q 0 a) cn J U cu o m � Z V W O Q a) N © cu _ CU 'O h U J CL a) ca w V N O N °� o avi J W (� s. a)) o = w 0 n3 E O uJ cz W O O L O (� 06 a) OU O J U. a � � a) a) � oco Q Z E ° � o U Q - cu o = U ° '0 a 0- W h W LD a)70 cu _ Q O L Zcu N � o co o Z CU CL O 0 0) (Q p 76 p - E O� O0 m s.� Q D .0- v Ofit U d O 70 a) > to — D E C: 70 cn a) 4) (6 c U O (Q L LIM O) (Q 0 V to (Q J 0 2 L 0 o � U L � -° U— E U upi cu "0 E a) a) U w a) a) O Z ca .� Z (D U (Q a) O .� O m Q CU cr E U) J N L Q +- J E O Q 00 D O U) V CO • _ L W J • • • m Q • • W U) 0 ti cfl N 70 a) N -p to a) cu O v .§. 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W F.F., O O o U � �° Q V O U) O V O W O tUJ O � a i >,0 U) 0 h 0 U) E Z o a U U uj ccO Z p y p � O O M 70 Cl) rF— W O JQQ cu s= Dcu V o O Rf O Q � c o r a) O) CU Iv a to L. + " Iv cu = O O U = Q � � Q� h 0 E Q L -O O t4 = O O O c In h p 43 O Q M Q cn O O O _ > U O - Z 2 O > t4 0 V Q U .-, p (tf .-, a) O fq O S= J U U S= E = t4 = U) a� fn J s= O a) a U 1- Q � O � Ivy I— cu cu U cu N cu s s= t4 = 3 7> (D J 75 J cu C� Ri Ri Z rr� J G • • • _ • • • • • _ 0 Q MARATHON FIRE RESCUE MEDICAL PROTOCOL ADULTTRAUMA �RITERIA Date Crew Launch 'Traumia Star etay: Patient Name D1013 Age � �:. t l: Time O,f 111j r t N Mm Rescue UlIr t# LZ[:G�C 11 4 AIR ie u'ymkwal ss�stancer L)R Fe, ITurrutory Rate < tit w> 29 CIRCULATION ItNmm Nrtu'udm mt IPr lle,e Etta <90L!j BP < 110 Ilan F'wmt9ent i;rwmer(55 y10 DN FtINIH.NT1t GCS e 13 �'r"raly sin S usp on wit Sp m M mt.rmrrd un' ,ruly r a LOSS OfrTe1'm�nrutm>nn ",m'd or 3rd DLgree Burns 1'5 94 TBSA immNrm.utruturuuw n r. wi Wrist.cw Ankle FT TISSUE AnyIP'ene ratirnrrT uuij ury to the eu wt Neck, or, T r sw��'u w G�,SW or,Pe"neor ttnwt un uryr fain Em,,'Verntme,s rilee o-"'D'.FNItr y * Chest"""w`a fl mui tnb4fity or Deformity tFU4 1.,he'st:;h Crw,usned, IH"wNumingd ,,ed, De-gloved or Puffspless Extre,,mms,ty r WING BONE FRA T URE 2 or ur'mwurm t_urummT IH i rmme Fr,mr,tlulre u' r NttIFuM,INNI, uIt I N t Severe FacW urr,tur,lFrwrlr,tmurenw hrd,tt'srrlerrNtr 11 Aw may Ccii,,1'rgturo mice OF CRAM" w Ele-ctr a '##,t'onf or UgrVNIYm inr Wqnry wi N..m.,,C or V vti,4e wpm m'!4s of Nlmlltkwur II;;,;yturwZlmt AFtO or Chest tr runty mmw patment nwrrt; X of Par m1y, .@s. Pregnancy 12,10 weeks»arum ABD pMn arrid I bumit Tnal.mm"l 1 Y T Ft =TRAUMA t ERA a� t rr' 0RCULATION Patents wl'Rem"W F rllrure curve I uraty t" DISABILITY Head rnjuri'MiLOC, Amines l or NewAftered,Mental Statllu S"oft Tissue It ss injury (crush, de-g)owri nr t oir i)eep IFlap viulsion w SOFT TISSUE mzh aw Penetra�mj tlnju ry to the Extremfttps Di1 twat to the Elbow or Knee LONG BONE F ACJU FS Sung e Lor'V, Done Fracture IFue t VC r�°u Nan errt on s ntif nnlguut uut'" 55 Years Old w Ejection from AIL4104110bide, Moliarcycle, r nHf Cart or Horse - r Blunt Head, CWre utor BD Iruauiniu"Ai Uin Patwe,imte nn ritl 'uta,nt8 Death in Sarne as; enuger Co nFnrtnmelnt MECHANISM * Intrusion, tnictudum gRoof 12 bc1hen on Occupant Site or> tF t,rjche�s of OF INJURY JURY n"y Sote into Passenger Comp,airtment. Fall> t Feet ruto vets IPem estn nt i y llet Thrown„ IRun Over or'wit un°wpa t > G W rutorc rle, G61t m.Nrmmt or ATV Crash >20 Wli tr 04"ore wrrturrmurw are not rrr(iu&pation't warrants a rrmrrrrrra amerm, Spkx,,1 w ea,",,r rrrrwru'mr,. Pairamrn'w,Wrttn" JUK1 m"1114rru"t 2,ExckdO79 superftpahoour4z an h4ch aw'e, din of wound can be dara d, 3 ems bone fray"day ade aawa wine&wd as vita II I)sW or ov ha ,IIZt raaw aind Whd P m,p ry a;94!,, r as ai r Rbuta * (A1.L TRAU, EN 'TER T R F P01 R T ,TT ACH C 01DE S U M MA RY`w w WHITE -FLIGHT CREAN IVELLONV- TR.-k1'MA CENTER PUNK- RESCUE rrw:rrr 0 +':0i''r'u'r'p Dr. Sandra Schwemmer, D.O. 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Age..........._ ()C;A#m 1 0l, ,1-inre of mjilury PA) Rm Rescue Unit# W xj�tt, A,IRWAY Alc�,five ,Auirm,iy Awstance. ,tR Respratory Ralp <20 qifaiv",,, Tyi,)j Rv, iaatory Ratf� 1< 10 iojr-v,5yri CIRCULAT*N F aint ot N(,.1N-PWpab* r arotid cyr,Fen, !f wf Pul,4Sie "ter" sto kc, 6 P< 50 DISABILITY Al eat Mentai S atfjS2 1* alys�s Loss ofSensah4ar"i Pan, m Suspivon of 1,`33,pinaf Ccfrd injui`7 2rr,dcxr 3rd Degree Burns t* 10 IN% TSSA Whstivr ArAfle Any Penietialing wijury to the �-Iead, P*ck, oi 'lam S(),FT TISSIJIE * �,3SW oT Penetrating in�fUry to Knee oir Elbiovo & Chest WMI' ir;jsta,",;fllfty or ICdetcurr,mWty,(FU4 Chest) & Q`tJSjijA it, Its Aaj[)gf[�k -Iiw�ls,p E.—tr ,fty ,d, �Dip 40ovi'd�,,;r F Iles s Fy em 5 0 K"Ajor SdA,7?,sS1ue Dwsrupt;,W 01rMajoc AvLflmnof Skin �LOIN G ON FX e,),pen Loncj B01jr,,e4 OR tortuuVtpl IDWk.ocruruons or Firacture SRes /SKELIETAL e, Severie Faoal tt*�uryfFjractiuires w1potenbril Airway Compromise * Electrocommi or Ught'ning 0jury wvl LC)',.,' or Visbve `imps Of("ttfUry MECHANISM , Bliur'l ABD or, Chest traiuma fn ,,,.ifient(w ArAiwai"PAawits of,wl H.Xicif OF INJURY ParWy�a�s # Auto wis Thremn, Run(.`u,varx.,)vw/impact> 20 MPHIL ANY TWO = TRAUMA ALERT J21j1_t chocose ItA2 SVE Weugtl <2,0 kg LJ j CIRCULATION Radia]or Pedal IPlullsp riot Palpable OR Systolic IRP<90 j DISABUTY Amnesia or Loss of Consciotisness SOFT TISSUE GSW or Penetrating inptnry below the Elbow Cw Kir*e I-ONG BONE FX Sirg[e Long Bonp Firactwe Site or Disbicatkin I SKELETAL # Dpath IWur gram IFlasseng,eir Compartment MECMNISM Intrusmin, �ncluchng Rcx)f>12 inches on Ociciipant Site,or> 18 41ches OF INJURY of Ary Site jinto Passenoer Compartmerq. Falf> '10 Fleet 2-3 Tilmes the he�giht of thie Chfid, Mott v cyc[e, Gio I f Cart or ATIV Crash > 20 %RH ff a&.wp cfitwifa wo niot An'ot I&palk.,bal cc-snffibovga wan ants a Usuma akpil, 150Q0 pammedic,pidyir*,VA i�ochodp bfief dascrrpt,�,JDM Pairaimedic Judginent: 2, Aftered sates mcka Sus,s.Wtt ss erhajrgy hibaky b Wow wnriwands,minm[p.mmenes's to vn cej tablAy umpvonswe 3, EmcWdinq,%**ecW wow~ P0*NrPT d*dep ofthe iwound un be dotemkmd, 4, Long bome frwture s0es arp Mined as rum to shaft of the Am*w 429 radpus,and Wna,�,T)Mnwr)(4)tba'and fibUa, COMMENTS CALL TRAUMA CENTER W/ PT REPORT ArTACH C,O,D,E SUMMARY Sew ITE—FLIGHTCRE,NV YELLOW—TRAUMA CENTER ,PENS,—RESCUE TRAUMA CRITERIA FORM - 11P111=111DIAT11111C Dr. Sandra Schwernmer,DO 297 co 0) N r O ca _ 00 D (1) 7 N > ~ o ca am W p � U) Rf O D C a U O Q E 3 U) o a) O J c N a) o s O Q >, •-' O 0 m . 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DISPATCH PROCEDURES Monroe County is unique in the state of Florida, in that it is comprised of a chain of islands stretching one hundred and thirteen miles in length and connected by only one main highway. Monroe County Fire Rescue ALS transport vehicles are located at strategic points throughout the County and are supplemented by numerous BLS Fire/Rescue vehicles, which may be activated as first responder support for Fire Rescue personnel. 1. Calls are received via an enhanced 911 system (Monroe County Sheriffs Office Central Dispatch Center) located in Marathon, which dispatches the appropriate Fire Rescue 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 Fire Rescue 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 Fire Rescue crew members, and all Fire Rescue Supervisory personnel. The Dispatcher may also elect to activate a BLS Fire Rescue 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 a Monroe County Fire Rescue Battalion Chief 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-agency resource support (e.g. manpower, equipment, additional vehicles, supervisory personnel), via the Dispatch Center. Requests for inter-agency support (e.g., law enforcement, utility company, fire suppression equipment and personnel, Marine Patrol, Coast Guard), may also be communicated via the Dispatch Center. Dr. Sandra Schwemmer, D.O. Revised May 2016 Page 1 of 14 339 CA MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS O' II. PRE-HOSPITAL PROCEDURES 1. Upon arrival at the incident, Fire Rescue 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; long bone 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 FIRE RESCUE 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 Monroe County Fire Rescue 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 Monroe County Fire Rescue Form MCFRF-011 "Street Form Worksheet" shall be completed for each patient and a copy shall accompany the patient to the receiving faci I ity. 5 A Monroe County Fire Rescue 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 onscene. Dr. Sandra Schwemmer, D.O. Revised May 2016 Page 2 of 14 340 CA MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS O' 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 helicopter will not be used) A. Severe weather (as determined by the pilot orS.O.) B. Landing area obstructions: (as determined by the pilot or LZCommand) • 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 Battalion Chief. C. The Paramedic on scene will notify the Battalion Chief when TRAUMA STAR is requested under the circumstances listed in B above. Dr. Sandra Schwemmer, D.O. Revised May 2016 Page 3 of 14 341 CA MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS O' 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 long bone fracture sites. Long bone fracture sites are defined as the (1) shaft of the humerus, (2) radius and ulna, (3) shaft of the femur, (4) tibia and fibula. Dr. Sandra Schwemmer, D.O. Revised May 2016 Page 4 of 14 342 CA MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS O' 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 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; Dr. Sandra Schwemmer, D.O. Revised May 2016 Page 5 of 14 343 CA MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS O' 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 paramediccan 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. Dr. Sandra Schwemmer, D.O. Revised May 2016 Page 6 of 14 344 Cn MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS O' Monroe County Fire Rescue 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). IR'.w!Ia BLUE All III AC IIvl AIfWvavA;,'',I;1ANCl,!'.Ic,, 'I.0 1Y 1A 11„'. �1()of ''e29 S°k Vl CIlli-�CULJ�'�-11Q"" J: 1 PATIENTS WTH RENAL FAILURE ON DIALYSIS �bIIN .. Cn r .,� ) .. , [,i S� I irrrrr c, 1()IN ::1A I N 1 OV '4 65 Y A 43 DII^iAIBIILIITY GC+ ,�13 o1 I'I dl ^,Ii,IINCI 01: 1::AI dAI Y31,'�'�r [n 3 I;::11CIt 11N 01'::' HEAD INJURY WTH LOSS OF CONSCIOUSNESS, N,I'''IINAI col::41)III I1::y[n 1 033 01 3Ii,IIN3A I ION AMNESIA or NEW ALTERED MENTAL STATUS ^iOlI I II^iSU11I 21NI)0143"I:)I!ICldl dlNs1"015%olfloldl IIS,''sA SOFT TISSUELOSS2 AfVII'I11AIIONAI01:::::dA1NMVI "I"'111 Wl::413'IoiAlNlNl.1i,'. PENETRATING INJURY TO THE EXTREMITIES DISTALTO THE ELBOW or KNEE ANY I'I NI."1"'I dA'1"'IINN;IIN�lI I I'dY"1)1 I II AI::),NI CI<,c�i""1�11 d^r�;)M1 C Woi I'Ii,llNl IIdA"I"'INGINJI 1::1Y 10 1111i11 Alldli::VlIIYA"I 01"'4 AI S(]VI!"I III NINI.II! 014 1 1:3(:I C111 31"'WA II I IIN31A1:311 11Y of [::)I l 01::::1I1/11"IY(I 1 All CI 11 3 1") CI'::::113111 ::),VIIAING1 ::) I)I CI.OVl 1)[n I:':'ll1 31: 1 1 3 3 l'X I dl:.f1/11"I"'Y LQMbIING, I11301IINIIM ':::1AC I I Il dli,'.01: I" O of I ONG I ONI 31 SINGLE LONG BONE FX SITE DUE TO MVC' IILACmI'UIILII 1 `iIKII~.LIE:1fAI_n. SINGLE LONG BONE FX IN PT ON HIGH RISK ANTICOAGULANTS' AG,llii 55 YEARS OR OLDER IVI1I=.CI11-1AIINI11SIVI VI 141 ACIAI.,IIN!I„II4Y/I I4AC 11 I141 ;^ Y 11 N IIAI.., EJECTON FROM AUTOMOBILE,MOTORCYCLE,GOLF oF III Al l'4WAY C1Yf//II'14 7f//IIc I,; CART or HORSE C I l i�c�C I ]IN 01,,,4 I ICI°I"I"'ININC II%fl 1:4Y W1 I"I°°°I 1 033 ill' BLUNT HEAD,CHEST,OR ABDOMINAL TRAUMA IN CCNGC1 Ml,lc NI YY 01'4 V13113I 1',;;SIGNN CI II%fl II'4Y PATIENTS ON HIGH RISKANTICOAGULANTS' 1:31L IIN 1 AI&I:)OVIIINAI..of Cl I:::31"' 111AI,.1VIA 11N I'A I Ili,llN I W1 I I DEATH IN SAME PASSENGER COMPARTMENT 1 113 101:dY 01:: A11AL.Y^,I^,(I':ZAI'l l::GIA of C',11,.1AIDIdll'1 I::::GIA) INTRUSION INCLUDING ROOF>12 INCHES OCCUPANT SITE;>18 INCHES ANY SITE INTO THE PASSENGER 11 CINAINCY >NC',)�NI V Y 11 1 A1!!!SI'))„ f//II INAI IDAIN ANI)I SI UN"I"' COMPARTMENT I"'I'"4AI,.IVIA FALL 10 FT or MORE AUTO VS.PEDESTRIAN/BICYCIST THROWN,RUN OVER or WTH IMPACT GREATER THAN 20 MPH MOTORCYCYLE,GOLF CART OR ATV CRASH>20rnph VEHICLE TELEMETRY DATA CONSISTENT WTH HIGH RISK OF INJURY,IF AVAILABLE' •;I I;:k=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. 6. See attached list of Anticoagulants with High Risk of Bleeding Dr. Sandra Schwemmer, D.O. Revised May 2016 Page 7 of 14 345 Cn MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS O' 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) Dr. Sandra Schwemmer, D.O. Revised May 2016 Page 8 of 14 346 Cn MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS O' 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. Dr. Sandra Schwemmer, D.O. Revised May 2016 Page 9 of 14 347 Cn MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS O' Monroe County Fire Rescue 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). I I'.w!Ia BLUE >IIZ_ WEIGHT<20 Kg AHR AY AC I IV1,;All:W1/AY ANNIN"1"FUNGI;;' 41 NI'14A1I.":3()IN IINI'AIN"I 1 YI'4 41 NI'14A1I 1()IINCI III I)I'41 IN1Y1,,,,4 13YI'4 C R'Ct.J A 111 C'k AIIN'1"'[�i.INS SIN I'A1 I'AI SI I.'.CAl d�11'll::)[,i H'4AI I'I II ''.,I [�r. CAROTID or FEMORAL PULSES PALPABLE,BUT THE RADIAL OR PEDAL 31 SI'''<3()inirrl k PULSE NOT PALPABLE or SBP<90-mmHg �DIISAII$IIII.II'(("Y AI 11 Idli,ll)f III IN"I"AI 31AIl,,,,l;3'o1 I'Id1:::31: INCI.01: I'AIIAIY313 AMNESIA [n 3 13::11CIt 11N 01'::'3::111NAI C01:dlI IINJ II dY of 1 0 33 01'::' NI 1NGA"I"'I(:)IN LOSS OF CONSCIOUSNESS VIIAJ MI':1 3()I 1 113s;r II 31'il II'I IONGoi VIIAJOI::d AVI II '�'�,I��>IN or GSW TO THE EXTREMITY BELOW ELBOW OR KNEE >0-((" ((III>SLJ ;^INIIN 3"ui 3"1.'.3UI::dlNG 'I0 >1(I% I I!33A AVIII'III"AIIOINA"I"'nIEA I3(:)V1 1111'WR131 oiAININ11i,' AINY I'Ii,llNl 11dA"I"'IING IINJ II':::1Y 10 111::A I INI!.CIN,oI 10i:d3�:)r NI 11':::1A'I"'IING IINJ II dY 10 11 11 X"I"'I dl VIII"I"'Y A I [n AI S()VIi,' 11 (:)woI KIN 1::::::Ii,' VIIAJ 11' I',)1 GI.OVIING 11N%ll.,l1'4Y L0IING,I1130IIN11I: 01'I IN LONG IN NNI [n f1/II„II 11111 I 1)131 OCAI (')NG,of SINGLE LONG BONE'FRACTURE SITE°or DISLOCATION II II��"�Lwm�'��.!II�II:/ I I dAG 1"I,.11 dl rl 11 „', `ilIll~':I_I111AL VHECI-WVSN� UF G I I'dOcC 11�:':NN I IGI I"I'INIING 3"1"'I d11N1 1"I"'I I 1 033 01'::' DEATH IN SAME PASSENGER COMPARTMENT CONGClt fl IGNI 3s3[n V1311i:31 1 SIGING 01: IINJI,,,,II1Y INTRUSION INCLUDING ROOF>12 INCHES OCCUPANT SITE;>18 NI VI 141,; ACIA1..11N fl II'4Y WI I I I A11'4WAY G(3f//II'14 f//IINI,; INCHES ANY SITE INTO THE PASSENGER COMPARTMENT J1 C I ION I'1(„VII AI I I OVIIO1 S11 VIIO I 01'1CYC1 GOO 1'::' VEHICLE TELEMETRY DATA CONSISTENT WTH HIGH RISK OF INJURY? CAId"1 AIV01dI I"I'IIAINA'I"'OVIC11N%�ll.,,Ih:dY FALL>10 FT or 2-3 TIMES THE HEIGHT OF THE CHILD 1 I N"I"'AI:310 VIIIINAI [n CI 11'i,131 111AI,.,IVIIA IN 1::'A 111:N I WI I I 1113101:::::dY 01: I AI':::1AI Y313iY(I:'AIZA1'1 111'.GIA[n ()l,AI1:dll'1 1'i,IGIA) 1 I I IIN'I"'h 11:::AI),CI 11 31 AI&I::)OVIIIINAI,V1 I^,CI,,,,IIAI d 3K1 I.I!1 I'AI I I4AI,,,IVIIA IN I'A III;;IN I OIN AIN I ICOAG1 II AIN 13 W I I I I IIIGI II 1131N 01'::'I SI I I ::)IINGn AI I O V;';r I'IAN20VIII"kl =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. Dr. Sandra Schwemmer, D.O. Revised May 2016 Page 10 of 14 348 Cn MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS O' V. TRANSPORT DESTINATION CRITERIA 64J-2.002 F.A.C. 1. There are no state approved trauma centers in Monroe County. Therefore, it is the decision of the Medical Director, Dr. Sandra Schwemmer, 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. Monroe County Fire Rescue has an agreement with the Monroe County Sheriff for the use of a rotor wing aircraft "TRAUMA STAR" for use in c r it i c a I medical and TRAUMA ALERT patients in Monroe County. TRAUMA STAR is a county supported air ambulance based in Marathon and will respond, when called to the trauma scene or local hospital to transport TRAUMA ALERT patients to a State of Florida, Department of Health approved trauma center as noted in the "Trauma Transport Protocols (TTP). 3. 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 airtransport. 4. Trauma patients in full cardiac arrest on the scene should be taken by ground ALS to the nearest Hospital. 5. 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. 6. All TRAUMA ALERT patient air transport run reports will be forwarded to the MCFR Battalion Chief of EMS and Medical Director within 72 hours for QA review. 7. A hand written "Patient Care Field Report" containing information pertinent to the patient's identification, patient assessment and care given will be provided by The EMS ground crew to accompany all Trauma patients transported by Trauma Star. A final ePCR report must then be sent to the receiving Trauma Center as soon as completed, or within 24 hours of the incident. VI. INTER-FACILITY TRANSFER OF TRAUMA PATIENTS As previously noted, there are no state approved trauma centers in Monroe County. 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 the MCFR Rescue crew for optimal patient care, the transferring hospital will coordinate the necessary personnel to accompany the Fire Rescue ground transport personnel. Dr. Sandra Schwemmer, D.O. Revised May 2016 Page 11 of 14 349 CA MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS O' VII. 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 careonly) Receiving Facilities 1. Lower Keys: Lower Keys Medical Center, Stock Island 2. Middle Keys: Fishermen's Hospital,Marathon 3. Upper Keys: Mariner's Hospital, Tavernier VIII. DISTRIBUTION OF TRAUMA TRANSPORT POLICY The SATC, SAPTC, and receiving facilities to which Monroe County Fire Rescue routinely transports patients have been provided with a copy of the criteria which are used to determine trauma transport destinations. IX.TRAUMA TRANSPORT PROTOCOLS MEDICAL DIRECTOR APPROVAL 64J-2.003 These protocols have been submitted by Monroe County Emergency Medical Services and have the approval of the agency Medical Director, Sandra Schwemmer, D.O., FACOEP, FACEP. Dr. Sandra Schwemmer, D.O. Revised May 2016 Page 12 of 14 350 CA MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS O' 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) Aggrastat(tirofiban) Angiomax(bivalirudin) Argatroban Arixtra (fondaparinux) Fragmin (dalteparin) Heparin Innohep (tinzaparin) Integrilin (eptifibatide) Iprivask(desirudin) Lovenox(enoxaparin) Reopro (abciximab) Streptokinase Tenecteplase (TNKase) Urokinase Revised April 2016 Dr. Sandra Schwemmer, D.O. Revised May 2016 Page 13 of 14 351 CA MONROE COUNTY FIRE RESCUE TRAUMA TRANSPORT AND TREATMENT PROTOCOLS O' TRAUMA TRANSPORT PROTOCOLS MEDICAL DIRECTOR APPROVAL I, Sandra Schwemmer, D.O., Pre-hospital Medical Director for Monroe County Fire Rescue certify to the Department of Health, Bureau of Emergency Medical Services that I have reviewed and approve the Trauma Transport Protocols, dated May 5, 2016. 'f uk 1 5/5/16 Sandra Schwemmer, D.O, FACOEP, FACEP Date FL OS 4022 Dr. Sandra Schwemmer, D.O. Revised May 2016 Page 14 of 14 352 MARATHON FIRE RESCUE DRUG FORMULARY Adenosine Triphosphate (Adenocard®) +uhP{IY�! I'V1IHf rdkUJ* AC II IIMS 4 W1,1610(r 14WNyS"*d Iw CUM Adenosine exerts its effects by decreasing conduction through the AV 0c mode.The half-life of Adenocard is less than 10 seconds.Thus, its effects, desired and undesired, are self-limited. DI � DItAT`IIONS o"01 ��"° � �° Adenocard is indicated for paroxysmal supraventricular tachycardia (PSVT), Nw PapW Bolus For Rapid Bolus JoIr4mmous Use including that associated with accessory bypass tracts (Wolf-Parkinson- Mrrftave aus Use White Syndrome). n rrir4{Ydu+¢H�rcevrN�, ,?'rf:'�.1N hl 15r4P/i lu4fl1 tlWbGA A" Ind II"�11.1k'"�A 11"I II N CAT] II"��';U1m "o"I"' d tl ire nni rrc w u[tlr':fl v iH wroa y 7 e", t@ 6 k�Lk;'NI t HALF Own SIR*pm�N �F�r������n��"�N Adenocard is contraindicated in second or third degree AV block and sick �..iup"Ve U"I rrp.H; r Ia"iN r"MmOov""w"d sinus syndrome (except in patients with a functioning artificial pacemaker), �,�,��J Y ( p p g p ) pares""'"" Url and known hypersensitivity to Adenosine. WAJR II\If II\M r ........................................................ Adenocard may produce a short lasting first, second, or third degree heart block. In extreme cases transient asystole 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 I I„I Av,0 NA ,ON N 4I p ' IHe,er P1140tI IAA, l QN�J OH t� 1* 353 MARATHON FIRE RESCUE DRUG FORMULARY Hydralazine HY these lImI PER 1101111, 1�/1� TE , NSI % VE � EM ER GE NCI IN No0 63323-614-01 ES hydrALA INE Nor HYDROCHLORIDE. mal INJECF10N, USP blo 20 egg/mL od FOR IM OR IIV'US E pre SIngle Dose ViaV WARNING.DISCARD ssu UNUSED PoRTICId. re ,I LIM ITS are syst olic 160 m mH 9 and dia stol is 85 m mH 9. Wh en blo od pre ssu re is sev erel y ele vat ed ove r 354 MARATHON FIRE RESCUE DRUG FORMULARY Adult: 10-20 mg per dose, slow IV push, Max dose:40mg, repeat prn ** Consider in patients with HR less than 60 bpm. Pregnancy-associated: 5-10mg IV, repeat q20-30min prn Pediatric: 0.1-0.2mg/kg IV/IM q4-6hr max dose 20mg I"1iiorr'i m tiolin Ills irm; � III e: Onset e a ll< ID u.,:ura fl:���)n IV/10: 5-20 min 1-4 hours ACTIONS: Decreases blood pressure and reduces cardiac afterload by reduces i peripheral ts, acute end-organ damage may result. In these cases, it is important to vasoclilaarterioles in the smooth control elevated BP before and during flight. muscle by direct relaxation. In cases of mild blood pressure elevation without other underlying illness, Decreases Systemic Vascular treatment can be deferred until patient is delivered to destination facility. Resistance subsequently Remember that fever, pain and anxiety are frequent causes of moderately reducing blood pressure. elevated BP and should be treated appropriately. Also, indirectly increases renin Hypertensive end-organ damage is often marked by symptoms such as secretion, ultimately leading altered mental status and intracerebral hemorrhage. to sodium reabsorption. INDICATIONS: Treatment: Moderate to severe hypertension, Heart Failure. The goal (in the treatment of malignant hypertension) should be CONTRAINDICATIONS: decreasing mean arterial blood pressure (MAP) or the diastolic blood Hypersensitivity, Coronary pressure (DBP) by 25%over one hour.Then decrease the MAP to 120- Artery Disease, rheumatic 130mmHg or the DBP to less than 110mmHg and maintain within heart disease affecting the parameter. May multiply DBP by 0.75 to quickly calculate 25%. (Example: mitral valve and products that DBP 120 x 0.75=90). contain tartrazine, avoid use in right side heart failure. Malignant Hypertension—MUST ADDRESS EMERGENTLY POSSIBLE ADVERSE • SBP>220mmHG or DBP>120mmHg REACTIONS AND SIDE EFFECTS: May use any of the following medications as indicated for patient Reflex Tachycardia, dizziness, condition: headache, tremors, CALCIUM CHANNEL BLOCKADE: orthostatic hypotension, • Cardene(Nicardipine): 5 mg/hr. (MIX 50 MG/250 NS=0.2 MG/ML) If desired sodium retention, blood pressure reduction is not achieved at this dose,the infusion rate may be palpitations, drug induced increased by 2.5mg every 5 minutes(for rapid titration)to 15 minutes (for gradual lupus syndrome, nausea, and titration) up to a maximum 15 mg/hr, until desired blood pressure reduction is vomiting. achieved. (Goal is to reduce BP by 25%over 1 hour) CONCENTRATION BETA BLOCKADE: 20mg/1mL via' Labetalol 10mg IVP over 1-2 minutes May repeat as 20mg again in 10 minutes. If necessary, may repeat every 20 minutes thereafter as 40 mg up to a total max DOSAGE: dose of 300mg.Target for 10-20% reduction in the systolic BP. Hypertensive crisis: • Metoprolol (Lopressor): 1.25-5 mg IV every 6 hours. In HTN associated with 355 MARATHON FIRE RESCUE DRUG FORMULARY STEMI/Non max 40mg. -STEMI MI: Consider in patient with HR less than 60bpm. May administer 5mg every Pregnancy induced: 5-10mg slow IV push, repeat q20-30min prn, max 5 (five) 40mg. minutes as tolerated MAGNESIUM SULFATE: up to 3 Female patients that have been pregnant within 1 year: (three) doses in early Administer loading dose of Magnesium Sulfate: treatment. Titrate to Mix4g(8ml of 50%solution)in 100ml NS and infuse as tolerated over 20- heart rate 30 minutes; and blood . Follow with maintenance infusion of Magnesium Sulfate(diluted) 2- pressure. 4gm/hr.4-6g of a 20%solution is suggested. (Dilute the 50%solution by half to obtain the 20%dilution required). HY Example:8ml(4g of the 50%solution diluted with 20ml of NS would give a PER 20%solution) TE NSI VE EM ER GE NCI ES VA SO DIL AT OR: Hy d ra lazi ne: 5- 20 mg /do se, slo w IV pus h, q20 -30 min PR N, 356 MARATHON FIRE RESCUE DRUG FORMULARY var g degrees of AV block) and generally last only a few seconds without yin intervention. 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®SSOIR�.IE AIOVIERSIE REAC'�"IONS AND S.!2E 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: AdUIlt dosage„ 12 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. 1ll'edoafidc 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®) 11 -1 Dr. Sandra Schwemmer, D.O. 357 MARATHON FIRE RESCUE DRUG FORMULARY .......................... Albuterol (Proventil®, Ventolin®) �10�� 1 � IWffM� @.WOi01N00VVr49WVNWlum, �,,,,z,�71V1G����� � AC II IONS: 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. I IN D I "Ao,l" aNS: Albuterol inhaler is indicated for relief of bronchospasm in patients with reversible obstructive airway disease including asthma, and COPD. COIII "I""III' IIIIIIII' IIIC "I""IIIOIIIS: ..................................................................................................................... Albuterol is contraindicated in patients with a history of hypersensitivity. WA IIC3�'I`YYi III I`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. .P.OSSI.B.L.E...ADYE.R..S..E.....R.E.AC"I.I.O.N.S...AN.D....SI.DE.....E. . .E..C.."..I.."..S.:.. . Cardiovascular:Tachycardia, hypertension, and angina. CNS: Nervousness, tremor, headache, dizziness, and insomnia. GI: Drying of oropharynx, nausea, and vomiting, unusualtaste. DOSAGE: Adult dosage., 2.5 mg of Albuterol in 3ml of NS to nebulizer and flow oxygen 8 Lpm. Child dosage: If> 1 year or > 10 kg: 2.5 mg of Albuterol in 3 ml of NS (0.083%) to nebulizer and flow oxygen 6 Lpm If< 1 year or< 10 kg: 1.25 mg of Albuterol in 1.5ml of NS (0.083%) to nebulizer and flowoxygen 3 Lpm (half of 2.5 mg).Treatment will be delivered over approx. 5-15 mins. Time/Action (Profile: Onset Desk Duration Inhaled 5-15 minutes 60-90 minutes 3-6 hours Albuterol (Proventil®, Ventolin®) 11 -2 Dr. Sandra Schwemmer, D.O. 358 Amiodarone (NexteroneTM) Amiodarone suppresses recurrent VF, prolongs intranodal 1II IIO I,�y conduction and refractoriness, negative inotropic effect. ILI ' m111w KV'I V INDICATIONS: WO :�����e W/ Ventricular Fibrillation NO Pulseless VT • PVC's greater than (>) 12 min • Ventricular Tachycardias (Wide and Narrow) with a pulse . eon Cii l'llAl FICA l'lQ N° nix r Any known allergy .... 0 Cardiogenic Shock • Sinus Bradycardia • 2nd and 3rd degree AVblocks POSSIBI..E ADVERSE IZ.E.Afl10N5 AND SIDE EFF C I" : 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 mins1.5gtts/sec. ��'n1"" 'M14111a���III III:: M14 �aioa�l� &1:" Pulseless Arrest: 5mg/kg IV/10 may be repeated once. No single dose greater than 300 mg. (15mg/kg max) Time/Action Profile: Onset Peak Duration IV/10: Unknown Unknown Unknown Amiodarone (NexteroneTM) 11 -3 Dr. Sandra Schwemmer, D.O. 359 Aspirin (Bayer, ° Bufferin°) AC."IFIONS: Aspirin is an analgesic, anti-inflammatory and anti-pyretic, which also appears to cause an inhibition of synthesis and release of prostaglandins. 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. um ------------------------ Aspirin is indicated in the Acute Coronary Syndrome setting to prevent further clotting. II �III° IIII � II �IIII �m ..................................................................................................................... A known allergy to Aspirin (i.e. urticaria, dyspnea, 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. YE.. ..S..E.....R.E.AL.".I.I.O.N.S...AN.D....SI.. E...E. . E C..".1.".5 . GI: Nausea, vomiting, heartburn, and stomach pain. OTIC: Tinnitus. Hypersensitivity: Bronchospasm, tightness in chest, angioedema, urticaria, and anaphylaxis. DOSAGE: Adult dosage., 324 mg (4) 81mg chewable tablets for Acute Coronary Syndromes Time/Action IPro-Me: Onset Desk Duration (Oral) PO: 5-30 minutes 1-3 hours 3-6 hours Aspirin (Bayer, ® Bufferin®) 11 -4 Dr. Sandra Schwemmer, D.O. 360 Atropine Sulfate as Cardiac Agent IIUIIIIIUIIIIIIIIUIUIIIIVUUpV�lll �plirY,.�.w�yyy��yg �//���� � ,//�/��� ; � �; j IUUIUUIIIIII I uoilllVlllf Atropine is a potent anticholinergic (parasympathetic blocker, parasympatholytic) that reduces vagal tone and thus increases automatically the SA node and increases A-V conduction. IINDI "Ao,l"I�; INS: • Sinus Bradycardia accompanied by hemodynamic compromise, (i.e. hypotension, confusion, frequent PVC's, pale, cold, clammy skin). • In children (< 1 year) bradycardia of less than 60 beats/minute should be treated if symptomatic even if BP is normal. C0111 "1""III' IIIIIIU�' IIIC "1""11101115: None in emergency situations �,��,f'A IIC 1`YYi III 1`YYi(il�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 maximum 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 RE.AC"1"IONS AND SIDE E F F.E.C.".1E.S.11 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 dosage,: Bradycardia: 1 mg IV/10, may repeat every 3-5 minutes until improved or total of 3mg is reached. 1��'°e64tii,loc dosage: 0.02 mg/kg IV/10 (minimum dose is 0.1 mg and maximum single dose is 0.5mg child, 1 mg adolescent). May repeat once. Time/Action (Profile: Onset Peak Duration IV/10: Unknown Unknown Unknown Atropine Sulfate as Cardiac Agent 11 -5 Dr. Sandra Schwemmer, D.O. 361 MARATHON FIRE RESCUE DRUG FORMULARY ............................................... Atropine Sulfate as Antidote for Poisoning Atropine is a potent parasympatholytic that binds to acetylcholine receptors thus diminishing the actions of acetylcholine. 11Nl ICAo,r- INS: 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. COIII 1 I1XHNIYCXI""III 0 N S m ..................................................................................................................... None when used in the management of severe organophosphate poisoning. IIC3�'1"YI III 1"YI(„3 m°'1ii: .................................. 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. .POSS..I...B.L.E....AD.V.E.R.S..E...... ..E..A. .."]I...O.NS AN.D....SI.DE....E..... E.. .w.I..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 dosage,, 0.03 mg/kg IV/10, repeat every 5-10 minutes until atropinization occurs. F�'Ie64Itii,,k dosage: 0.05 mg/kg (maximum 3 mg) IV/IO, repeat every 5-10 minutes until atropinization occurs. Time/Action IPuroflle: Onset Peak Duration IV/IO: Immediate 2-4 minutes 4-6 hours Atropine Sulfate as Antidote for Poisoning 11 -6 Dr. Sandra Schwemmer, D.O. 362 MARATHON FIRE RESCUE DRUG FORMULARY .......................... Calcium Chloride 10% open lut NBC 76329-3304-1 UPVWW PrCM��ngs 10% Calcitim Chloride Injection, USP" 1 g/10 mL (100 mg/mL) (1.4 mLq/mL) Single use,do rat reuse or resterIlIze. Rx only FOR SLOW INTRAVENOUS USE iD Mi.Single Dane LUER-JETT"LUE,R-LOCK Prefilled Syringe AC"IFIOINS. Calcium chloride increases the force of myocardial contraction; calcium may either increase or decrease systemic vascular resistance. In normal hearts, calcium's positive inotropic and vasoconstricting effects produce a predictable rise in systemic arterial pressure. IINI I "Ar_nNS: Calcium chloride is indicated during resuscitation for the treatment of hypocalcemia 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. C0111 "I""III' IIIIII �' IIIC "I""1110111Sm ..................................................................................................................... Cardiopulmonary arrest not associated with calcium channel blocker toxicity, hypocalcemia, or hyperkalemia. WA IIC3�'�I`YYI III�I`YYI(3 m"1ii t ................................................................. Calcium chloride should not be administered in the same infusion with Sodium Bicarbonate, since calcium will combine with sodium bicarbonate 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 REA "I"IONS AND SIDE Eff E "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 IProflle: Onset Desk Duration IV/10: Immediate Immediate 2-5 hours Calcium Chloride 10% 11 -7 Dr. Sandra Schwemmer, D.O. 363 Cyanokit® AC;WIFIONS: Hydroxocobalamin (CYANOKIT°) is an antidote to cyanide. It removes cyanide directly from the blood without converting any of the hemoglobin and therefore does not interfere with oxygen transport. It combines with the cyanide to form cyanocobalamin which is a derivative of vitamin B-12. Both the Hydroxocobalamin and B-12 are harmlessly excreted in urine. IINDICAn INS: >> • Exposed to products of combustion in an enclosed space • Soot present in their nose, mouth, or sputum • Altered mentation • Does not meet trauma alert criteria • At least 18 >years old DO NOT RELY ON PULSE OXIMETRY FOR ACCURATE READINGS "'"""" COIII I"III'°� IIIIII �' IIIC "I""IIIOIIISm None WA III I I`YYi III I`YYi(o S: n, Do not use any other medications in the same IV line: There are several drugs and blood products that are incompatible with Cyanokit, thus Cyanokit requires a separate intravenous line for administration. PROCEDURE for Cyano it Administration: (See next page for additional information Each Cyanokit contains: (1) Vial (5 gm of IHYDRO OCABALAII IIIN) (1) Intravenous administration set (1) Transfer spikes Reconstitute vial of the Cyanoki-O)with 200 mi of NS via the transfer spike that is provided. Do not remove the vial from the box it is contained in, because it will serve as a hanger for the medication. Gently rock the vial back and forth for 30 seconds to allow for mixing. Shaking should be avoided, as it will cause the medication to foam. Insert a macro-drip infusion set (provided) and drain as normal. DOSAGE: Infuse the vial over15 minutes. If the patient is critical use a faster rate and titrate to effect. Multi-dose kits are carried in the Battalion Chiefs vehicle Cyanokit® 11 -8 Dr. Sandra Schwemmer, D.O. 364 1. One 250 ml glass vial containing 5g of lyophilized hydroxocobalamin for injection 2. One sterile transfer spike 3. One sterile intravenous infusion set pN rl J 'r 4. One quick use reference guide AL 5. One package insert 0 ,OR .... . . . . . . . . . . .,. mcmovo t IN 11111 For Intravenous use To be reconstituted with 200 m,L of 0.9 odium Chloride In e tJon ilium loot tnuldld Complete Starting Dose: 5 girants 1,Reconstitute Acid �tyr���uu WN�91 Bn a����i��G V�dhghl position, �m � Fill tl did 200 L of�.�i CVM S:G'dU�if n Chloride in nectlan to the vial using the transfer s�Ddl"n�lur Fill t the fine. '.Miix 1� The vial%"rind t, *repeatedly lnverked or rocked,not shaken foir at least,60 seconds prior to infuslion. Yo4r W 3,Infuse Vial ,u. Use vented rntra rernrnus tr hind,hang and infuse over 115 minutes. One 5 g AM is a complete starting dose See Package Insert for rslterrnetie duluents,incornpatiblifies ywith ether drugs and N1111 prescrnhirna information, For more infornietncru visit r w w cyanukit.n rwr or call 1.800,438-1985 e._ir ran u�ri..." r�� wt;t�,n n�fit rrrtian r°r'�i�utt.. Sep reverse fur addrfiieuna�i urnbrrnutirorr uweMALT115CRI OLOOESw P,�Pem .eeeeeeeee .eeeeeeee, .eeeeeeee, .eeeeeeeee .eeeeeeeee .eeeeeeeee .eeeeeeee, .eeeeeeeee .eeeeeeeee .eeeeeeeee .eeeeeeee, .eeeeeeee, .eeeeeeeee .eeeeeeeee .eeeeeeeee eeeeeeee,,,, Cyanokit® 11 -8 Dr. Sandra Schwemmer, D.O. 365 Dextrose 10 % AC"II"IONS: A monosaccharide, which provides calories for metabolic needs, spare body proteins and loss of electrolytes. Readily excreted by kidneys producing diuresis. Hypertonic solution. I N D ICA"°nO NS: ------------------------ • Hypoglycemia Coma of unknown origin. IRELA°I`IIVE CON"I`RA III'.DIICA"i`IIOINS: • Intracranial or intra-spinal hemorrhage (ina patient with normal BGL) • Blood glucose Level > 60 mg/dl. POSSIBLE ADVERSE REAL"I"IONS AND SIDE EEC"I"S: ........................................................................................................................................................................................................................................................................ • Cardiovascular:Thrombosis Sclerosing if given in peripheral vein • Local:Tissue irritation or necrosis if infiltrates. • Others: Acidosis, alkalosis, hyperglycemia,and hypokalemia. Diabetes Insipidus: Is the inadequate secretion or resistance of the kidney to the action of the antidiuretic hormone (ADH). Major S/S are polydipsia (thirst) and polyuria (frequent urination). Diabetes Mellitus Type I: Insulin-dependent. Usually occurs before the age of 30. The patient may need Insulin injections and dietary modifications to control blood sugar levels. Cells in the pancreas that produce Insulin are damaged —so they may produce little or no insulin. Diabetes Mellitus Type II: Non-insulin-dependent. Usually occurs in obese adults over the age of 40. The cells in the pancreas are able to produce insulin,just not enough. DOSAGE: Adult: (> 40 kg) 100 ml of 10% solution; IV/10. OR 250ml of 5%Solution F'''I e64tii,'io:::: (< 40 kg) 2.5ml/kg slow IV/10 of 10%solution. OR 6ml/Kg of 5%Solution I`\JeyvA�tI°:o ii,' (< 10 kg or< 1 month old) 2.5 ml/kg IV/10 of 10%solution OR 6ml/kg of 5%Solution Time/Action (Profile: Onset Desk Duration IV/10: < 1 minute Depends on degree of hypoglycemia Dextrose 10% (D10) 11 -9 Dr. Sandra Schwemmer, D.O. 366 DILUTE D501NTO D10 If using 1350 and you want D10, for every 1 part of 1350, use 4 parts of NS. (1 ml of 1350, 4ml of NS.) D50% NORMAL SALINE TOTAL D10 ' 50ML 10ML 40ML 50ML 20ML 80ML 100ML (DRAW 20ML OUT F I OOCC NS , AND REPLACE II-1 20ML OF 50ML 200ML 250ML (DRAW 50ML OUT F 250CC NS , AND REPLACE II-1 50ML OF Dextrose 10% (D10) 11 -9 Dr. Sandra Schwemmer, D.O. 367 MARATHON FIRE RESCUE DRUG FORMULARY .......................... Diphenhydramine Hydrochloride (Benadryl°) AM�f f16 t 0376 21 i 10Injectiion,USIA 50 m /gym i ^p AC II DOGS: 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. VNIMCA;TMNS: • Allergy symptoms, anaphylaxis • Sedation of violent patient • Dystonic reactions from phenothiazine overdose (i.e. Haldol, Compazine,Thorazine, and Stelazine) CO IP'�"III"III'tA III IP'�IIC'. III CA"III"III O IP'�S: ........................................................................................................... Diphenhydramine is not to be used in newborn or premature infants. Diphenhydramine is not to be used in patients with acute asthma attack WA II1 IV III IV G S ........................................................... 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 POSSdRt,E ADVPRSP RPACI.ONS AND SIDE EEEECTS: .................................................................................................................................................................................................................................................. 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: Adult: 25-50 mg IWICI OR 50 mg deep IM Pediatric: 1 mg/kg IWICI or IM (maximum 25 mg) Time/Action Proffle: Onset Beak Duration IV/IO: Rapid Unknown 4-8 hours IM: 20-30 minutes 1-4 hours 4-8 hours Diphenhydramine Hydrochloride (Benadryl®) Dr. Sandra Schwemmer, D.O. 11 -10 3ss MARATHON FIRE RESCUE DRUG FORMULARY Dopamine Hydrochloride (Intropin°) U °IPIO : 1 1 i 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 II P; stimulating actions that result in increases in cardiac output without marked increases in pulmonary occlusive pressure. At high doses, Dopamine has alpha receptor stimulating actions that result in peripheral vasoconstriction and v marked increases in pulmonary occlusive pressure. IMCA O S To treat shock and correct hemodynamic imbalances, improve perfusion to vital f organs and to increase cardiac output. CO IP'�"III"III'tA III IP'�IIC'. III CA"III"III O IP'�5: ........................................................................................................... Dopamine should not be used in patients with pheochromocytoma or hypovolemic shock. WAII1IV III IV G S ........................................................... Do not 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 if /l r� 11 ii�/l hydrochloride (Matulane°), tranylcypromine sulfate (Parnate°) I BIE AP / ... :Td. 7.N.S AN.P _SJP E...E F.E.K.C.T..S..:.. 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 @)eu;Niiatri(: 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 Profirlle: Onset Beak Duration 4 minutes 10-15 minutes Continuous with infusion t I Hydrochloride H nro in® 11 -11 Dr. Sandra Schwemmer, D.O. Dopamine y � p � 369 MARATHON FIRE RESCUE DRUG FORMULARY I f DOPAMINE 400 mg in 250 mL D5W (1600 mcg/mL) Drops per minute Patient Weight In kg. (60 gtts/mL chamber) 30 40 50 60 70 80 90 100 6 8 9 11 13 15 17 19 11 15 19 23 26 30 34 38 17 23 28 34 39 45 51 56 23 30 38 45 53 60 68 75 I Hydrochloride H ntro in® 11 -11 Dr. Sandra Schwemmer, D.O. Dopamine y � p � 370 Duo-Dote TM (Atropine and Pralidoxime Chloride) ro " f ` P' $ � %; w � .nlfll�MY�"' .... ACT101" S: ......................................... • Blocks nerve agents effects and relieves airway constriction and secretions in the lungs and gastrointestinal tract. • Acts to restore normal functions at the nerve ending by removing the nerve agent and reactivating natural function 1114QK'.'A1'1Q114S., • Suspected or confirmed nerve agent exposure COIII ""I""III'° Illlllf' IIIC ""I""IIIOIIIS: ..................................................................................................................... • Both medications in the kit should be used with caution (but not withheld) in patients with preexisting cardiac disease, HTN, or CVA history. POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS Chest pain, exacerbation of angina, Myocardial infarction, Blurred vision , Headache, Drowsiness, Nausea , Tachycardia, Hypertension , 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 Dr. Sandra Schwemmer, D.O. (Atropine and Pralidoxime Chloride) 11 -12 Page 1 of 2 371 0 o not remove � I�wm�marllm n�wria�rm,rqr9rr mroprritV��Lfinwad;wav,1 im ro until re dy to, use, NEVER t+x uch a n tip%*dte End Mtht fingeTM n NDC I nY110t-��� a�� ri aw 2 r � �4�t mdmm frm.� a .AO IrrRA A,W ah�l�Jlf N i mn k P"f AS'A S o <'antduh, Il Wmurmmwd 1 m)'r ar.... iD s v'xtttm'FL tIadenww:k ah� PTIrrtii n :w .+: r w a ro" f n 014 r m�,�.w" ftr� �� r � ,j; � umJwru dm,n�w &mr Vr� i tmfimd., .. �m rm n re�Ngw u2m mmt2r.�iie~ire i,Y Vrm+^mu dr �k h�m,r rm r!qgx�fxxm. l DuoDO1tEk""' AUTO-INJECTOR (atropine and prall do ime 0,0oricle nlrtljectinort) Car *4Iivviry hriG m mvtahris 1247 mtr 14mar tirt,�'m.8 yr w��.+�uM:q'uwi o Gwmi�rfered rr,o,lh u;rrt;rixxr��i F ica ffai(�pw O cA rfimti a dd r'P n 8, ,rwt` O umun MERIDIAN,,,, uh �n R9vmpr°rra��me�Imrm"a nmtu rrxt� tVrairn. kaki.t4i.bV ,uC!rr4.t�QRIW�';� MIEDI AL TECHNIIOILOG rlE5 �u��tarr me �GFmrta�wpkt mumot rr��antyr ml�c In V,����mm s�ng ttWymrrlm�r amtnm4llmh wax fhmawam.�mtd to Aat�wmn ph�.� Do Not apen the plastic tt4r rp all I rht vrm the IDuoDotel" p, Arnt lerlttTOOr frr.unr the polucIh uI liM ready tilt ui,e � IMPORTANT Do Not n emoIie the,Gray Safety Riel eme run(tul ready tl)use C t " Not p4ize t^okv f i npr„ks on the Gire,en t up Neecflie(hilt, � AUTO-INJECTORrp,ian a nu~'���ei kcin,the I�t�t wire extends s r� �w dfl f�r�m the tip e n rip Needle C~nd W IC" k "Y M 'R� tl 4,} ti N W '� 11 INFORMATION « ft is okay to,in i"t ttrfwgihu cilo�tk�lhnq, 9 r t`q 7�0t 2001 r t. - Seek miedicaill attention Immedlately for0lowing Injectlon. 3 "I� 11" ", r> ot 1 -"� �, <° Move 010 Object* wrmrim f �Il � � � tmuwu+mi Isom�"tr m�wumr,mug^ 1, i cerG � �mxrd�u llwra �„ � � xf Mrkm)mbar IWOM19 andfim l rs�u t �„ rll r 4�rr mh t�em a Ir,v ors me u R dm 1�I 'Wd st pull Off t w i 6mm �xr oGV�rana��,d iu� FYvmmmh Gpr x tl�umrmU� x mAkmurm 4Uu ur, I�+� ma�tdromunm�uuti,I�axru�Do�d>¢ myr�"nh uisn<i���k��w�: �mna�xbrra4%P"u 10mlu14y � ��xrummld�g�px>ws i OMOV*OmJarNMA)0 0,t4uto4p rure,xd�irxdmz �wM���k�um cm.uYN,wma�'m�d nr lm�r ni, �' 1OMPO VAMT� ��Wdl�rtlroa+�Gr ate 1 &�udaxlCkrratef Awmnnm4rlecim Plham VYuw.urwxaox ��Iramr�u,. d A,041"YX301rtxmwmmY011PILK Uta��mwr;�!xthe nt -t',m aiwY,ri miramt I t pr um°n a°e a m zluxnmiY irw,n V°iumruu, mMh,(hip Ckemwm> hutv�ll olovxrtlr muwrx`iio-€n mtmmumrrdm'rllrmm,+k;e 'c4i"cUi r"Ore Wnrr *,IIQ s s roman mxrrk �Namv m,wwu^J'#e,huoor4,rmairmrmownani,'r � rrowhUa��b llli�rk fro aue ud�rmt vdwti rt, mtl rmpn°ma y Irvrvrvry,rvrvrv„ M.�,.��,w. 1. Remove the DuoDoteTM from its protective pouch. III UDI Vm411l.;IlrvrkCAII T 1",,C tf IN 0k,0iYwllE,'5, 2. Hold the unit in your dominant hand like a pencil with the Green Tip (needle end) pointing down. 3. With your other hand remove the Gray Safety Release. The DuoDoteTm Auto-Injector is now � ready to be administered. �hVI 4. Grasp the unit like a pen and position the green tip of the on the DuoDoteTM on the outer thigh, midway between waist and knee. 5. Dispose of Auto-Injector or leave with the patient for identification purposes, document how many where used on the patient. Duo-Dote TM Dr. Sandra Schwemmer, D.O. (Atropine and Pralidoxime Chloride) 11 -12 Page 2 of 2 372 Epinephrine 1:1,000 APO rm�a, � drrro�m��,���m1� �, ".... Aft / ACIPIONS: 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. INDICA;TMNS: .____ Asthma • Anaphylaxis • Angioneurotic edema • All Pulseless Arrest CCI IP'�"III"III'tAIII IP'�IIC'. IIICA'11C'II0l'9S: ........................................................................................................... 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. WA III IV III IV G S ........................................................... Epinephrine is inactivated by alkaline solutions - never mix with Sodium Bicarbonate. Do not mix Isoproterenol and Epinephrine- results in exaggerated response. Actions of catecholamine is depressed by acidosis-attention to ventilation and circulation is essential. Antidepressants potentiate the effects of epinephrine. P SSIB. E ADVERSE REACI. NS AND SIDE EPPECTS: .................................................................................................................................................................................................................................................. • CNS: Anxiety, headache and cerebral hemorrhage. • Cardiovascular:Tachycardia, ventricular dysrhythmias, hypertension, angina and palpitations. DOSAGE: Adult:: SQ0.1-0.3 mg(0.3 cc). Repeat every 3-5 minutes (Asthma/Anaphylaxis may repeat once in 15 minutes). F)Ie,u;Niiatrii(� IM 0.01 mg/kg up to 0.5 mg. Time/Action IProfirle: Onset Peak Duration SQ: 6-12 minutes 20 minutes 1-3 hours Epinephrine 1 :1,000 Dr. Sandra Schwemmer, D.O. 11 -13 373 Epinephrine 1:10,000 N�� aa�yr m EMIN"INE n (0J,M ) ACIPIONS: 11 Epinephrine 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. INDICATIONS: • All Pulseless Arrest • Asystole • Ventricular Fibrillation unresponsive to defibrillation; • PEA • Other pediatric indications: hypotension in patients with circulatory instability, bradycardia (before Atropine). TO1191II"IIIR III'TIC'.lIIICXIII"IIIO1'9S: ........................................................................................................... None in the cardiac arrest situation. WA II'il IN III IN G S ........................................................... 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. DOSAGE: Adullt:: (1:10,000) 1 mg(10 ml) IV or 10, 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: 0.011. mg/kg, (0.1 ml/I<g IV or 10). Repeat every 3-5 mirILAt�s. Pediatric : POST ARRIEST: 0ALrncg/kg/min IVlix tmg of Epi into 1000ml NS == Concentration of I mcg/ml Time/Action Profiule: Onset Peak Duration IV/10: Rapid 1-2 minutes 20 minutes Epinephrine 1 :10,000 Dr. Sandra Schwemmer, D.O. 11 -14 374 Fentanyl A I IOI : Fentanyl Binds with stereospecific receptors at many sites within the CNS, increases pain threshold, alters pain reception, inhibits ascending pain -� �u% 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 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 NOCOMYYA, histamine release. I IMre"a Fentanyl Chime MMCA'flONS: inP 100wtF maywr Moderate to severe pain in patients>10kg How, Acute Coronary Syndrome—Chest Pain (Adult) Pt-`ds Pain associated with isolated extremity fracture, renal colic, burns, etc. �' COII"�"III"III'tAlllll"�IIC'. IIICAIII"IIIOII"�S: • Epistaxis or bilateral blocked nares • Known hypersensitivity to fentanyl • MAOI use in past 2 weeks CONCENTRATION 0 Unstable hemodynamics or altered 100mcg/2ml WA 50mcg/ml . ......L.. . I........ . Use with cau tion 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 eliminating ability to ventilate. DOSAGE: Adult: 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 Profiule: Onset Beak Duration IN: 2-10 mins 30-60 mins IV: Immediate 30-60 mins Fentanyl Dr. Sandra Schwemmer, D.O. 11 -15 375 Furosemide (Lasix®) 4 mL i��� i��ii o� i��i AC"II"IIOI" S: Fur A sulfonamide derivative and potent diuretic, which inhibits the reabsorption of Inj sodium and chloride in the proximal and distal renal tubules as well as in the Loop of 40 m /4 mL Henley. Has a direct vasodilating effect in acute pulmonary edema.With IV (nil m / y) administration, onset of vasodilating is generally within 5-10 minutes; diuresis will usually occur in 20-30 minutes INIMCATMNS: • Pulmonary edema II" „'III',.,III. .IIIII" IIf „III ';III','„III„ „II" m Anuria. Should be used in pregnancy only when benefits clearly outweigh risks. WA111 INl III INl GS ........................................................... Furosemide should be protected from light. Dehydration and electrolyte imbalance can result from excessive dosages. Rapid diuresis can lead to hypotension and thromboembolic episodes. POSSIBLE 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. IEEE DOSAGE: 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 100mmHg.) Time/Action IProfiulle: Onset Beak Duration IV/IO: 5 minutes 30 minutes 2 hours Furosemide (Lasix®) Dr. Sandra Schwemmer, D.O. 11 -16 37s MARATHON FIRE RESCUE DRUG FORMULARY Ketamine (Ketalar®) tACIA01 Rapid acting general anesthetic, characterized by profound analgesia, normal pharyngeal- laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and �w t� 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 advantageous in patients with k hemodynamic compromise (trauma, sepsis, etc.). A patent airway is maintained partly by virtue of unimpaired pharyngeal and laryngeal reflexes. Ketaniin II I ICA° I I :° ���'��� �� °� ��� • Facilitation of pain control in patients with isolated extremity trauma, burns rtr�ltiir�in��a e:u : �,�rwurrus��r and/or entrapped patients. " " ' " • Procedural Sedation • Violent/Combative/Aggressive Patients or"Excited Delirium" COMIC I C1XI ICL IIIC "I""IIIOIIICSm • Hypersensitivity to Ketamine • Condition in which an increase in Blood Pressure would be hazardous. • Acute Coronary Syndrome or STEM CONCENTRATION • Ocular trauma (globe injury) 500mg/5ml 100mg/ml .III:."!�'"v.II.�'.`YY..°;dl.m!p..tt. IVP over 1-2 min, Ketamine may cause apnea if given too rapidly IV POSSIBLE ADVERSE REA "I"IONS AND SIDE EE "I"S: ........................................................................................................................................................................................................................................................................ CNS: "Emergence Reaction" or hallucinations upon recovering Cardiovascular:Tachycardia, hypertension GI: Nausea and vomiting Respiratory: Hypersalivation, Respiratory depression/apnea, Laryngospasm. lll''''LIII'°'C III CIII''''I III C 4C111''''I. .IIIC III IIIC III'.'.'.'... Hypersalivation: A iropine O..5img IIV/1111 /110 Laryngospasm/Stridor: High flow 02, BVM assisted ventilations Laryngospasm is uncommon and is usually self-limiting. It almost always resolves with high flow 02 or brief ventilation via BVM. DOSAGE: Adult: Procedural Sedation/Pain:0.5mg/kg IWIO over 1-2 min may repeat prn. Airway Management: 2mg/kg IWIO over 1-2 min_may repeat prn. (Trismus/Endangered Airway/RSI/post intubation sedation for inhalation airway control) Violent/Combative/Aggressive Adult Patient 400mg-800mg IM may repeat prn. @')ediiatrii(� Procedural Sedation/Airway management 1mg/kg 1WIO/IM over 1-2 min may repeat prn. Time/Action Profile: Onset Beak Duration IV 1-2 minutes 3-5 minutes Weight dependent Dr. Sandra Schwemmer, D.O. Ketamine (Ketalar®) 1 1 —1 7 377 MARATHON FIRE RESCUE DRUG FORMULARY Magnesium Sulfate ACIPIO S: 1g mL 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, Magnesium but it does not affect the mother, fetus or neonate when used as directed in eclampsia Sulfate and pre-eclampsia. Magnesium acts peripherally to produce vasodilatation therefore a Injection,USP drop in systolic BP is to be anticipated. VNMCA'flONSµ ---------------------- 5g/1'0mLi500mg/niQ Prevention and control of seizures in eclampsia {4mEq Mg"°/mLi Torsades de Pointes • Suspected hypo-magnesemic state (i.e. chronic alcoholism and chronic use of diuretics) • Refractory ventricular fibrillation • Refractory Asthma CCU IP'�"III"III'tAIII IP'�IIC'. IIIAC'11C'IIIQ'19S ........................................................................................................... Pa enteral administration of the drug is contraindicated in patients with heart block or CAID°1.I(ft myocardial damage. Hurd be ckiofted WA 1IN lNGS ........................................................... o hitr venaU Rise. 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 diluted to a concentration of 20%or less prior to IV infusion I II'1 E CA YTIII )INS'� ........................................................................ 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. P SSdBLE ADVERSE RBACI. NS AND SIDE 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 ®SAGE: paralysis. A¢ ulVt: 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 Proffle: Onset Peak Duration IV Drip: Immediate Unknown 30 minutes Magnesium Sulfate Dr. Sandra Schwemmer, D.O. 11 -18 37s Methylprednisolone (Solu-MedrolO, A Methapred) AC"IFI N ., Decreases inflammatory effects via its potent anti-inflammatory synthetic steroid. i INDICA`°naNS: 0Asthma Ai • Anaphylaxis • Head injury • COPD • Unconscious with known Addison's disease COIII 1"III' IIII II' IIIC "I""IIIOIIIMS ..................................................................................................................... None in the emergency setting. POSSIBLE ADVERSE REACwI"IONS AND SIDE EFFEC"h.S GI hemorrhage reduces leukotrienes of immune system and increases ... potential for infections. DOSAGE: Adult: 125 mg IV slow over 2 minutes F''Il a64Ilr,oT c: 2 mg/kg (max 125 mg) IV slow over 2 minutes Time/Action IPro-Me: Onset Desk Duration IV/IO: Unknown Unknown Unknown M ethyl prednisolone (Solu-Medrol®, A Methapred) Dr. Sandra Schwemmer, D.O. 11 -19 379 Midazolam (Versed®) AC."IFIONS: Depresses CNS, muscle relaxant, strong sedative, hypnotic, and amnesia. IINDICAo,I" aNS: Control of seizures, sedation for cardioversion & pacing, sedation for airway management. sedation of violent/combative patients. r a OIIN ,IIResllp rant rIl..OeN S. p ession Hypotension S: Monitor patient for respiratory and CNS depression and vital signs after 91 administration, particularly in patients with recent ETOH and Drug use. POSSIBLE ADVERSE REAL"I"IONS AND SIDE E F F.E.C.".1E.S.11 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: Pacing • 1-2 mg IV Endangered Airway, Passive Cooling, Violent/Combative Patients, Stimulant OD • 5 mg IV/IM/IN/10 up to 10 mg (max single dose) Seizures • 5-10mg IM/IN OR 2.5mg IV F'''Ie64Itii,'k: > 1 years of age (0.1 mg/kg) Time/Action Profile: Onset Peak Duration IV 1-2 minutes 3-5 minutes Weight dependent Midazolam (Versed®) Dr. Sandra Schwemmer, D.O. 11 -20 3so Naloxone Hydrochloride (Narcan®) r►open f R'x Only FNDC 76 29-3369-7 1 STOCK NO. 33 9 1:C Leer-LockPreliiled Syringe NA LOXON 2 rng HYDROCHLORIDE per INJ., USfr (t rngJrnL) FOR INTRAVENOUS iNTRAMNUSCULAR LUIER-JETW LUER-LUCID PREFI,LLEIU SYRINGE OR SUSCUTANECUS USE 2 mL s mla dose disposable psfiiBled AC'TIIN S: syrirr pr A.S AN OPIOM ANTAGONIST 1gfa use,du riot rervsG nu reskY,,i ��. 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. IlND-l-.ATI-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") CCUNT]RAll NII NV CAT]VONS ...................................................................................................... Known hypersensitivity to Narcan. WC,IR II\,If II\,M S: ........................................................ 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. POssoI�LE ADVERSE REA."1oONs AND SODS EFu=EC.Ts: ....................................................................................................................................................................................................................................... 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 lWl0/IM/IN 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). @'')eu;Niiatari( 0.1 mg/kg lW10/IM PRN. Time/Action IPlrofiille: Onset Beak Duration IV: 1-2 minutes unknown 45 minutes Naloxone Hydrochloride (Narcan®) Dr. Sandra Schwemmer, D.O. 11 -21381 ----------------------- ---------------------------------- -----------------------------------------` Nitroglycerin (Nitrostat® Nitrolingual® Spray) AC IFIONS: 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. I IN D I "A°r I oIN : ufl�u8 • Chest pain or discomfort associated with suspected AMI. • Pulmonary edema with hypertension. • w OIII I IIIi II NIYI CAI IIIOIIIS„m N • Systolic BP <� 100 mmHg • Children under 12 Patients on erectile dysfunction drugs that fall within time parameters (i.e. ' 36 hours) • Know hypersensitivity to the drug • Evidence of a positive V4R in the setting of an Inferior wall MI PIRECAU"I'lOINS: ....................................... 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 vasodilating and hypotensive effects. POSSIBLE ADVERSE REAL"I"IONS AND SIDE Eff 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. Sandra Schwemmer, D.O. 1 1 22 3s2 Odansetron (Zofran®) pp ry I 07 � / y,� % 4�Nq%i1Vb �NPo6 ib� P Y Af°;1 SONS: 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. ��fi k1ludl�n, tJjsp � r��� Z; L Ru '� I° Dlf A I ° a° 1NNOTECTPHhoIM,�LMVa Used for patient with nausea unrelieved with comfort measures, uncomfortable due to �'arti r�iInG L�kM ��d, the nausea during transport and/or with a potential for airway compromise related to vomiting. CONCENTRATION • Nausea and vomiting due to chemotherapy. 4g/2rnl • Prophylactic use prior to administration of pain management medication. 2rng/rnl • Nausea and vomiting with moderate to severe dehydration or electrolyte imbalance. COIII "I""III' Illlllf' IIIC "I""IIIOIIIS: 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 IIC3i'�I\l III�\l(3 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 ADVERSE RE.ACwm"IONS AND SIDE E F F.E.C.".1E.S.11 CNS: Headache, Dizziness, Drowsiness, Fatigue GI: Diarrhea, Constipation, Abdominal pain, Dry Mouth MISC: Rash, Shivering, Fever, Hypoxia, Urinary Retention, Muscle Pain DOSAGE: Adult & Pediatrics>40kgo, 4mg slow IVP (not less than 30 sec) max dose 8mg 1'''Ie64tii,i�c 4(Y(g: 0.1mg/kg slow IVP Time/Action Puroflle: Onset Peak Duration IV 1-2 min 14-30 minutes Weight dependent Dr. Sandra Schwemmer, D.O. Odansetron (Zofran®) 11 -23 383 Oral Glucose (Insta Glucose) f4 J� AC"IFI INS: Increases blood glucose levels slowly. IINI I " o,l" oNS: BS > 60 mg/dl, patients who are altered but alert enough to take the command to swallow. CIII "I""III'( IIII1IIIC "I""IIIIIIS: .................................................................................................................... Patients unable to swallow or Stroke symptoms. None when patient can swallow, risk of aspiration if given improperly. A �/ERSE REAC"II"INS AND SIDE EFFECwm"S: .................................................................................................................................................................................................................... GI: Nausea DOSAGE: Adult: 1 tube F''I ,64tii,,' mc: 1 tube Time/Action Profiled Onset: Peal4 Duration PO: 10 minutes unknown Unknown Oral Glucose (Insta Glucose) Dr. Sandra Schwemmer, D.O. 11 -24 3s4 Sodium Bicarbonate .._ �.. x m*ly 0.�'kreJ"r i aM ro a a� t LUF.1R- 'T"*ILI.ER-I OCK PIREFILL ID SYRINGE I IN METABOLICAC1iD S � A "I'll 0 1Y S: Increases PH to reverse acidosis. IINDI "Ao,l" oNS: • Metabolic acidosis in cardiac arrest • Tricyclic overdoses with QRS > 0.1 • Electrocutions • Hyperkalemia • Methanol / Ethylene glycol toxicity • Severe ketoacidosis CQVI""III' IIII II' IIIC "I""1110111CS: .................................................................................................................... CHF and Alkalotic states �,��,f'A IIC3�'I"YI III I"YI('„3 m°1ii: ............................................................... 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 other medication, flush the line before and after administration. POSSIBLE ADVERSE REAL"1"IONS AND SIDE E E "1"S: ....................................................................................................................................................................................................................................................................... Metabolic alkalosis, and may crystallize in IV solutions. SODIUM BICARBONATE 4.2%(PEDI): DISCARD 25ML OF 8.4% AND DRAW UP 25ML OF NORMAL SALINE DOSAGE: Adult: 8.4% - 1 mEq/kg IV push, then %the dose q 10 mins. Adult Electrocutions: 2 mEq/kg IVP F'�'I a64Itii,'loc: 4.2%- 1-2 mEq /kg diluted 1:1 with Normal Saline to make Sodium bicarb 4.2% Pedi Electrocutions: 1mEq/kg IVP (Sodium Bicarb 4.2%) Time/Action Pero- le: Onset Peak Duration IV/10: Unknown Unknown Unknown Sodium Bicarbonate Dr. Sandra Schwemmer, D.O. 11 -25 385 MONROE C UNI"'Y' RESC U'E 2020 Air M'f","idl')ICAL PROTOCOLS l be lbllo grsvctions are affilitiona I p a:) f,')c ) that pertain tc) aercunedica 17�,sgrhts and critic critica I carvsgrround t f,-)rts� e tc) he utilized 386 Monroe County Fire Rescue AI R YWAN§PTMfcd d1ba1I`V ES Trauma Star is intended for use in in Monroe County as a primary air transport ambulance for: • Trauma Alert • STEMI Alert • ACS Alert • Stroke Alert • Interfacility transfers Fliaht Limitations Any special considerations regarding the patient or patients (Weight/ height/special equipment needs, etc.) must be discussed with the Pilot in Command prior to loading the patient in to the aircraft. • Critical Neonates (newborns <28days of age or <5kg in weight requiring transfer to a NICU-neonatal ICU) • High risk OB patients with imminent delivery. Special consideration maybe given to complicated pregnancies, where the mother or infant's life is at risk if not transferred to a higher level of care.(No obstetric patient will be transported without internal exam to determine the state of labor, and an evaluation/monitoring of the fetus prior to transport) • Contaminated Hazmat patients • Patients with CPR in progress *Exception- when TS is 1st response • Ventricular Assist Devices (VAD/BIVAD) • Deceased patients Interfacility Transfers All requests for interfacility transfers must go through the Monroe County Central Dispatch 911 System. Critical Care/ALS interfacility patients transported by Trauma Star include, but are not limited to: • Any State of FL recognized "Trauma Alert" criteria patients and/or patients that meet the State of Florida Interfacility Transfer Guidelines • Cardiac care not available in Monroe County • Respiratory conditions requiring care not available in Monroe County • GI Bleed with unstable vital signs and/or active hemorrhage • Metabolic emergencies, including DKA • Sepsis patients • Complicated OB patients who are not in active labor • Vascular emergencies, including DVT, PE AIR TRANSPORT GUIDELINES 2-� 3s7 Dr. Sandra Schwemmer, DO Page 1 of 2 Monroe County Fire Rescue Trauma Star Medical Protocols • Dissecting or leaking aneurysms 45 Request for emergency air interfacility transfer, Flight Crew shall: • Contact the sending facility to determine the patient's condition and need for air transportation. • If patient meets criteria, weather is favorable and flight is accepted, the sending facility will be given an approximate ETA. Prior to departure • History of Present Illness/Injury • Past Medical History • Care/Procedures Received Prior to Arrival • Results of Pertinent Diagnostic Studies • Any medications required or possibly required and not carried on Trauma Star should be sent by the sending hospital with the flight crew. • Obtain a completed MCFRF-101 "Trauma Star Medical Necessity for Air Transport" • Obtain two (2) copies of the patient medical record and face sheet Field Transfers • Trauma Star to shall provide stabilization and any needed or anticipated critical interventions prior to departing the location of patient loading. • Assessment, treatment and transfer of the patient is to be completed by the flight team. • When possible, patients should be advised of the transport process, destination, safety and care procedures that will continue throughout the flight. • Trauma patients are required to have adequate spinal immobilization prior to transport. • Active bleeding sources must be identified and controlled prior to transport. • Confirm patient report including alert type, status, critical interventions, and vitals are relayed to the receiving specialty resource center by the ground crew. • Flight crew will make the ultimate decision on destination facility for MCFR field alerts.(Closest appropriate hospital to provide definitive care) Flight crew will honor destination requests by other fire rescue agencies when prior communication with the receiving facility has occurred prior to Trauma Star arrival. AIR TRANSPORT GUIDELINES 2-� ass Dr. Sandra Schwemmer, DO Page 2 of 2 de is FLIGHT PHYSIOLOGY OVERVIEW Patients who require air medical transport can present with a variety of disease processes, as well as varying degrees of physiologic alteration. The flight crew need to be aware of, and able to anticipate, the potential problems that may arise from changes in altitude and barometric pressure. By understanding the basics of altitude physiology, and being able to anticipate, correlate, and react to such alterations in the patients' physiology, will ensure a safe and uneventful transport. Flights will be completed at ambient air pressures of less than 7000 feet in most helicopter transport situations, due to the unpressurized cabin. HOWEVER, the flight crew must understand that rapid, explosive-type barotraumas occur most frequently with the rapid ascents and descents associated with rotor-wing transports. The following general information is to aid the flight crew with planning, designing, and delivering appropriate therapeutic modalities. Altitude affects the delivery and utilization of oxygen Aircraft altitude adjustments may be necessary to provide the patient with optimal oxygen delivery. Remain alert for the early signs of hypoxia Trapped gases EXPAND as the aircraft ASCENDS, and CONTRACT as the aircraft DESCENDS; this phenomenon is known as "Boyle's Law" Patient populations as risk include: • Thoracic injuries/problems ("air-leak" potential). • Gastrointestinal injuries/problems. • Penetrating head injuries/severe CHI. • Ocular and/or severe facial injuries. • Orthopedic injuries • "Crushing-type" soft tissue injuries and/or severe soft tissue swelling Medical equipment effected include: • ETT pilot balloons. • Foley catheter balloons. • BP cuffs. • Air splints/orthopedic "casts"/MAST. FLIGHT PHYSIOLOGY OVERVIEW 12-2 389 Dr. Sandra Schwemmer, DO Ce Monroe County Fire Rescue Trauma Star Medical Protocols lot FLIGHT PHYSIOLOGY OVERVIEW Humidity and temperature decrease as you increase altitude. For every 1000 ft. increase in altitude, the outside temperature drops 2 degrees Celsius. Physiologic changes As the aircraft accelerates, multiple physiologic changes can occur *Effects on HR, BP, RR, SVR, and ICP can be seen. Increased noise and vibration levels occur especially in helicopters; protect your patient accordingly. Unconscious patients respond physically to these stressors as well and should be provided hearing protection if able. All the factors discussed previously can lead to the development of motion sickness, and/or spatial disorientation. Treatment of motion sickness includes: • Loosening of restrictive clothing. • Visual fixation on a stationary object. • Passive cooling measures. • Oxygen administration. • Supine positioning and restriction of head movement. • Antiemetic therapy. FLIGHT PHYSIOLOGY OVERVIEW 12-2 390 Dr. Sandra Schwemmer, DO de Monroe County Fire Rescue RAPTUSE 6b it_aI1 TUffATION Securing the airway for air transport is one of the most critical and important events. Incubation should be considered appropriate for any patient that has an unsecured airway, ventilatory compromise, or at risk for aspiration RSI Indications: • Respiratory rate <10 or >30 • GCS < 8 • Burn, inhalation injuries, blast injuries • Suspected acute loss or impending airway failure • Head/injury patient exhibiting combative behavior (unsafe for air transport) Contraindications for RSI: • Anticipated difficulty ventilating with a BVM after paralysis Caution RSI use in: • Major facial or laryngeal trauma • Distorted facial or airway anatomy • Soft tissue/penetrating injury to the neck (gunshot wound, stab wound withhematoma compromising airway) Pre-oxygenate and prepare for incubation • See endotracheal incubation procedure 9-6 Sedate patient as indicated with ONE of the following medications: • Midazolarn (Versed) 0051rne /key (2 5 img) slow IV push over 1 -2 minutes Hold if BP less than 80 mmHg • E-t rnui ate 03 mg/kg (1230 img) IVP over 30 — 60 seconds • l etarniine 21rne /key slow IV push over 1-2 minutes • If patient is less than 8 yrs. (or if age is unknown and using ET tube smaller than 60), pretreat with -tir puiirie 002 mg/kg II I (minimum dose of 01 mg, maximum dose of 05mg) • In line cervical spine stabilization by second caregiver (in trauma setting) Administer short acting paralytic: • Succuiinyllch llu"iine ( inec-pine) 15 mg/kg (60 — 150 mg) rapid IVP May repeat Succuiinyllch llu"iine ( inec-twine) at 051rne /key (20-50mg) if inadequate relaxation Dr Sandra Schwemmer, DO RAPID SEQUENCE INTUBATION 13-1 391 Monroe County Fire Rescue Trauma Star Medical Protocols RAPID SEQUENCE INTUBATION After successful incubation administer ONE of the following long acting paralytics: • ecur inkffn 0051rng/lie IVP duration 20-30 min • R cur inkffn 0051rng/lie IVP duration 20-30 min • l airmur inkffn 0051rng/lie IVP duration 90 — 180 minutes Attach patient to ventilator when indicated, maintain end tidal CO2 of 35 — 45 mmHg (See Ventilated Patients protocol 13-2) Unsuccessful Incubation: • Resume ventilations for 30 seconds • Re- attempt incubation • If unsuccessful, resume ventilations for 30 seconds and insert I-Gel airway • Monitor ETCo2 If Unable to Ventilate: If still unable to ventilate, remove I-Gel and perform cricothyroidotomy (see cricothyroidotomy- surgical procedure 9-4) Dr Sandra Schwemmer, DO RAPID SEQUENCE INTUBATION 13-1 392 ce lot VENTILATED PATIENT / USE OF PEEP All incubated patients will be transported on a ventilator if possible. • Patients will have continuous cardiac monitoring. IV's will be maintained on infusion control devices or monitored closely. • Multiple parameters will be documented at least every 10 minutes. These include PIP, Sa02, ETCO2 reading, chest rise and fall, etc. • A BVM with appropriate face mask and manometer will be kept in close proximity to any ventilated patient ventilated patient. PEEP attachment for BVM will be used if patient's condition warrants. • Suction will be set up and readily available. • The medical crew must verify ETT placement. This may be done by noting the depth of the tube (appropriate depth for patient), ETCO2 detector, breath sounds, epigastric check and mist in the tube may be documented. Prior to an interfacility transport • Chest x-ray may be obtained if there is any question regarding the correct placement of the tube. • The medical crew may request arterial blood gases. In the presence of any abnormal values, the medical team may consult with the Medical Director or referring physician in an attempt to stabilize the patient's respiratory/acid-base status prior to departure. Upon arrival at the receiving facility • The medical crew must document the confirmation of tube placement. Sedation • Appropriate sedation/analgesia with Morphine, Fentanyl, Ativan, Versed or sedation/paralysis with Etomidate, Succinylcholine may be necessary for safe transport. • Initially, the medical crew may medicate the patient with Morphine 2-5mg, Versed 2-4mg, Ativan 1-2mg, or Fentanyl 1 mcq/kg. • Both analgesia and sedation must be considered in the chemically paralyzed patient. Dr. Sandra Schwemmer, Do VENTILATED PATIENT / USE OF PEEP 13-2 393 Monroe County Fire Rescue Trauma Star Medical Protocols VENTILATED PATIENT / USE OF PEEP Ventilator Settings • Settings should be managed to maintain ETCO2 35-45mmHg (in the absence of COPD) and oxygen saturation > 96%. • Attempt to bring down PIP as much as possible by lowering TV to maintain parameters above. General guideline for TV is 6-10ml/kg/minute. Recommended Ventilator Settings: Tidal Volume 6-10ml/kg/minute Rate 12-20 breaths per minute. Higher rates may be necessary in pediatrics and some adults Fi02 50-100% PEEP 5cm/H20 average adult settings. May increase to 10cm/H20 for pulmonary edema, ARDS and near-drowning patients L-time 0.5-1.0 seconds with I/E ratio of 1:2 PIP 20-25cm/H2O. Increase settings to obtain adequate chest rise and oxygen exchange to maximum setting of 40cm/H2O. Indications for use of PEEP: • Patient with decreased Sa02 with use of 100% Fi02. • Any patient with evidence of moderate to severe alveolar infiltrate specifically: • Pulmonary edema, near-drowning, COPD and ARDS Contraindications for PEEP: • Hypotension Equipment and Supplies: • PEEP Valve • Appropriate size BVM with Manometer • Intubation Equipment • Cardiac monitor • Oxygen Dr. Sandra Schwemmer, Do VENTILATED PATIENT / USE OF PEEP 13-2 394 Monroe County Fire Rescue Trauma Star Medical Protocols VENTILATED PATIENT / USE OF PEEP Procedure: • Perform oral incubation of patient. • Attach PEEP valve to adapter end of BVM. • Set PEEP pressures as follows: Adult: • Begin at 5cm/H20 • May increase to a maximum of 10cm/H2O. COPD-Asthma patients: • Begin at 5cm/H20 • Increase to maximum of 8cm/H20 Pediatric: • Begin at 2cm/H20 • Titrate to effect to a maximum of 5cm/H2O. • Attach BVM to oxygen and ET tube in usual manner. • Ventilate patient in normal manner. • Observe ECG and vital signs. PEEP may cause dysrhythmia and/or changes in vital signs. • Discontinue or decrease PEEP if any significant adverse responses occur. Dr. Sandra Schwemmer, Do VENTILATED PATIENT / USE OF PEEP 13-2 395 Monroe County Fire Rescue Trauma Star Medical Protocols ANXIETY ui az llarn (Versed) Route: IV/IO/IM/IN Onset of action in 2-3 minutes; Peak occurs within 5 minutes; Most amnestic of benzodiazepines. • Adult: 0.5-.5 img • Pediatric: 0.1-- 0.2rn /key max. 5mg. ll,,,,,, irazeparn ( twain) Route: IWO Much longer half-life than Versed, peak effect occurs in 30 minutes; Half-life is 10-12 hours; Less likely to cause hypotension than Versed. • Adult: 1-.4 img - titrate to effect • Pediatric: 0.05-.0.1 mg/kg IV. NOTE: Narcotic antagonist = Narcan (Naloxone) 0.4 — 2mg slow IVP (maximum of 10mg) Benzodiazepine Antagonist = Flumazenil (Romazicon) 0.2mg IVP over 30 sec, after 30 sec., 0.3mg IVP over 30 sec, After 1 min 0.5 over 30 sec., May repeat g20min to a total of 3mg ANXIETY Dr. Sandra Schwemmer, DO 14-1 396 Monroe County Fire Rescue Trauma Star Medical Protocols AORTIC DISSECTION Have a `high-index' of suspicion when treating patients with history of an aortic dissection. Indications: Patients presenting with sharp tearing like chest and/or back pain. Patients usually have history of HTN and/or aortic dissection. There are three types. DeBakey I, II, & III. Patient's usually present with varied pulse pressures in upper extremities, possible decreased carotid pulses on one or both sides, rupture may include AMS or neurologic deficits from vascular disruption. Commonly originate in the thoracic aorta. May extend through entire aorta. Caused by arterial HTN. RUPTURED AORTIC DISSECTION IS A TRUE SURGICAL EMERGENCY • Maintain ABC's, oxygenation/ ventilation. • Minimum 2 large bore Ws. • KEEP PATIENT CALM!!! • Consider Pain Management Protocol 4-7 • Full VS parameters will be initiated and continued until patient is delivered to receiving facility. FOR HYPOTENSION If a ruptured aortic dissection is suspected • FlUiid challlleinge wide open uin ill 2 liters adirniinistered then adirniiin. 500cc boluses x2 to max of 3 liters and re-evaluate hem odynamicstatus. If volume replacement is ineffective • Consider IDoparniiine @ 3-15 imcg/kg/rniiin to maintain SBP >90mmHg. FOR HYPERTENSION • Consider ll,,,,,,albetalloll 1 Orng slow IVP q 5 min. intervals, max dose = 300mg. Target HR 60-80 bpm and SBP 100-130 mmHg. • Consider ll,,,,,,albetalloll llinfusiioin @ 28 img/rniiin (Mix 200mg (40ml) in 160cc of D5W for a concentration of 1 mg/ml. Start @ 2mg/min. Or • Consider Niitroprussii e @ 0.2-10 ug/kg/irniiin IV (50mg in 250ml D5W) to keep SBP 100-120 mmHg. Or • Can be used by itself. IEsirnolloll (IBreviilblloc) iinfusiioin @ 50-200 imcg/kg/rniiin and do not drop HR to low. Do not administer if heart rate is already low. AORTIC DISSECTION Dr. Sandra Schwemmer, DO 14-2 397 Monroe County Fire Rescue is Trauma Star Medical Protocols CENTRAL VENOUS LINES Central venous lines are indicated for administration of medications, delivery of chemotherapy, nutritional support, infusion of blood products, and blood draws. Types of central venous lines include: Broviac/Hickman, Port-acath/Med-a-port, and percutaneous intravenous catheters (PIC). Signs of blood embolus, thrombus, air embolus, and internal bleeding: • Chest pain. • Cyanosis. • Dyspnea. • Shock Central venous line emergencies include: catheter coming completely out, bleeding at the site, catheter broken in half, blood embolus, thrombus, air embolus, and internal bleeding. Catheter is completely out • Apply direct pressure to site. Bleeding at the site • Apply direct pressure. Catheter is broken in half • Clamp end of remaining tube Suspected blood embolus, thrombus, or internal bleeding: • Clamp line Suspected air embolism • Clamp line and place patient on left side. CENTRAL VENOUS LINES Dr. Sandra Schwemmer, DO 14-3 398 Monroe County Fire Rescue Trauma Star Medical Protocols HYPERTENSIVE EMERGENCIES Normal blood pressure LIMITS are systolic 160mmHg and diastolic 85mmHg. When blood pressure is severely elevated over these limits, acute end-organ damage may result. In these cases, it is important to control elevated BP before and during flight. In cases of mild blood pressure elevation without other underlying illness, treatment can be deferred until patient is delivered to destination facility. Remember that fever, pain and anxiety are frequent causes of moderately elevated BP and should be treated appropriately. Hypertensive end-organ damage is often marked by symptoms such as altered mental status and intracerebral hemorrhage. Treatment: The goal (in the treatment of malignant hypertension) should be decreasing mean arterial blood pressure (MAP) or the diastolic blood pressure (DBP) by 25% over one hour. Then decrease the MAP to 120 -130mmHg or the DBP to less than 110mmHg and maintain within parameter. May multiply DBP by 0.75 to quickly calculate 25%. (Example: DBP 120 x 0.75 = 90). Malignant Hypertension — MUST ADDRESS EMERGENTLY ❑ SBP >220mmHG or DBP >120mmHg May use any of the following medications as indicated for patient condition: CALCIUM CHANNEL BLOCKADE: • Car erne ( I Nuicardu"ipuiine): 5 img/hr. (MIX 50 MG/250 NS = 0.2 MG/MIL) If desired blood pressure reduction is not achieved at this dose, the infusion rate may be increased by 2.5mg every 5 minutes (for rapid titration) to 15 minutes (for gradual titration) up to a maximum 15 mg/hr., until desired blood pressure reduction is achieved. (Goal is to reduce BP by 25% over 1 hour) BETA BLOCKADE: • Il,,,,,,albetalloll 1Orng IVP over 1-.2 irniinUtes May repeat as 20mg again in 20 minutes. If necessary, may repeat every 20 minutes thereafter as 40 mg up to a total max dose of 150mg. Target for 10-20% reduction in the systolic BP. • Metoprolol (Il,,,,,,opiressor)r 1.25-5 img IV every 6 hours. In HTN associated with STEMI/Non-STEMI ML May administer 5mg every 5 (five) minutes as tolerated up to 3 (three) doses in early treatment. Titrate to heart rate and blood pressure. CENTRAL VENOUS LINES Dr. Sandra Schwemmer, DO 14-4 399 Monroe County Fire Rescue Trauma Star Medical Protocols HYPERTENSIVE EMERGENCIES Esirnolloll 30 img (approximately 1 mg/kg) bolus dose over 30 seconds Followed by a 150 imcg/kg/rniiin iinfusiioin, if necessary. Adjust the infusion rate as required up to 300 mcg/kg/min to maintain desired heart rate and/or blood pressure. Can be used by itself: Esirnolloll (Il reviiblloc) iinfusiioin @ 50- 00 imcg/kg/rniiin Do not drop HR to low. Do not administer if heart rate is already low ACE INHIBITION: Einallapriillat 1.25 img/dose. Give over 5 minutes every 6 hours. Doses as high as 5 mg/dose have been tolerated. CENTRAL VENOUS LINES Dr. Sandra Schwemmer, DO 14-4 400 Monroe County Fire Rescue Trauma Star Medical Protocols HIGH RISK OB TRANSPORTS Sending Facility /Acceptance Procedure for JMH: JMH Women's Hospital will accept all high-risk obstetrical patients in need of transfer from the Keys to a higher level of service. Since these transfers are typically time sensitive, the following procedure should be followed on every patient transferred: 1. The Transfer Center for JMH Women's Hospital must be called on 855-462- 4658 immediately by the referring physician, and caller should state "we are requesting transfer of a High-Risk OB patient from the Keys'. The sending physician's direct contact phone number should be given to the Transfer Center along with any other contact information. 2. Trauma Star Dispatch should be notified of the OB transfer and Trauma Star should proceed to the sending hospital. 3. Within 15 minutes, the sending physician should receive a call back from the Transfer Center to connect for peer-to-peer discussion, with the on-call JMH MFM accepting the patient and providing additional instruction if necessary, to stabilize the patient prior to transport. Physician-to-physician communication is required prior to transport in order to allow JMH adequate preparation for the patient. Internal Transfer Center escalation protocol is executed as needed to expedite transfer. 4. Complete patient medical records, along with any lab or any diagnostic testing should be prepared by the sending hospital and should include fetal monitor recording verifying fetal heart rate, contractions and/or any variability. Records should be ready for the Trauma Star flight crew upon arrival to avoid delay. Federal transfer regulations require patient medical records to accompany the patient at time of transfer. S. Upon arrival at the sending hospital Trauma Star flight crew will receive information, any patient specific orders/medications, and proceed with patient stabilization and transport to JMH. • Flight crew must contact JMH Transfer Center at 855-462-4658to provide ETA. • Flight nurse will provide follow-up call to sending physician/hospital after transport is completed. • 15 minutes prior to arrival, Flight crew must notify JMH Trauma Resus Dispatch at 305-585-1148 to clear arrival at helipad. HIGH RISK OB TRANSPORTS 15-1 Dr. Sandra Schwemmer, DO Page 1 of 2 401 Monroe County Fire Rescue Trauma Star Medical Protocols HIGH RISK OB TRANSPORTS The need for transfer by air should be discussed with the sending OB physician, via the labor nurse, or MCFR Medical Director prior to initiation of transport if the Flight Nurse has questions about patient's needs beyond available resources and/or medical necessity for air transport. Prior to lift off, the sending and receiving physicians should have communicated and established that the receiving facility and physician have the specialized medically necessary resources to take care of the pregnant patient and newborn. Additional details and orders for transport, as well as the need for appropriate transport personnel may be needed prior to lift off and once the patient has been stabilized. Contraindications to flight: Trauma Star crews should NOT transport patients when delivery is imminent. Suspected imminent delivery • Patient response to contractions is changing (i.e., increase vaginal pressure, increased pain with contractions, difference in pain from prior contraction pattern experience) • Vaginal bleeding beyond spotting • Bloody show (may or may not indicate imminent delivery, however should be followed up with further exam) • Uterine contractions greater than 6 per hour • Cervical dilatation of 4-5 cm or greater (especially significant when patient is multiparous) • Station = 0, fetal presenting part is engaged in the birth canal • Any presenting fetal part observed • Prolapsed umbilical cord observed If any of the above criteria are observed, the medical crew may decline the patient until the patient has been stabilized/delivered and they are able to determine transport/transfer needs based upon an updated assessment of the patient and newborn. HIGH RISK OB TRANSPORTS 15-1 Dr. Sandra Schwemmer, DO Page 2 of 2 402 Monroe County Fire Rescue Trauma Star Medical Protocols Follow Universal Patient Assessment/Care Protocol as appropriate UNIVERSAL HIGH-RISK OB ASSESSMENT / CARE PROTOCOL MCFR Flight Crew should perform basic patient assessment and initiate standard medical care. OBSTETRICAL HISTORY • Prenatal care, obstetrician and delivery hospital; • Number of pregnancies and live births (Gravida, para, multiple gestations, miscarriages); • Problems with this pregnancy or previous pregnancies; • Last menstrual period (LMP) and due date (EDD); • Contraction status, frequency, duration and quality, • Membranes intact/ruptured; • Current medications and IV fluids and amounts, • Lab values including Glucose level; • Copy of all medical and surgical records; • Pertinent social/medical HX and medications taken; • Blood type and Rh factor, if known; • Determination of presentation, station, effacement and cervical dilation and time of last vaginal or speculum exam; • Vaginal bleeding/ bloody show/discharge (color, odor, etc.) VITAL SIGNS • VS's q 15 minutes or more frequently as patient's condition warrants • Pt. weight • Maternal VS's including EKG, Temp Sp02, EtCO2, and Fetal HR pattern AIRWAY • Maximize oxygenation/ ventilation and provide oxygen as indicated by patient's condition. URINARY OUTPUT • Void/ Foley. If there is no need for fluid resuscitation during transport, clamp Foley (a full bladder can delay fetal descent to slow delivery) UNIVERSAL HIGH-RISK OB ASSESSMENT / CARE 15-2 Dr. Sandra Schwemmer, DO Page 1 of 2 403 Ce Monroe County Fire Rescue Trauma Star Medical Protocols lot HEMODYNAMICS • Maintain large bore IV or 10 access and infuse INS at 1 0irnll/hir (unless otherwise ordered) Hemorrhage, Shock or profound Hypotension • Maintain bilateral IV's or 10 access • Administer fluid boluses of INS 00irnll as needed for hypotension, maintaining a systolic BP at least 90mmHg. If BP is dropping quickly; Vasopressors maybe needed to maintain BP: o Dopairniiine rncg/kg/rniiin up 'to 20 imcg/kg/rniiin tl-tirated OR o ll,,,,,,evophed 4-12 mcghmiiin TRANSPORT ❑ Position patient in left lateral tilt to maximize uteroptacental blood flow; ❑ Secure patient with safety straps- low on pelvic girdle (not across abdomen); ❑ Topolytics to slow or stop labor as indicated by patient status or referring facility; 11 Fetal monitor applied; ❑ There is always the possibility of having to DIVERT during'transport. UNIVERSAL HIGH-RISK OB ASSESSMENT / CARE 15-2 Dr. Sandra Schwemmer, DO Page 2 of 2 404 od Monroe County Fire Rescue Trauma Star Medical Protocols Fallow Universal Patient & Universal High-Risk 013 Assessment/Care Protocols as appropriate ABRUPTIO PLACENTA The separation of the placenta from the uterine wall occurring as early as 20 weeks gestation, at various stages, and before delivery. There may be an internal or concealed hemorrhage, external hemorrhage, or complete separation of the placenta from the uterine wall. Signs and symptoms may be: vaginal bleeding, extremely tender or rigid abdomen or an increase size of the abdomen. Treatment: • Monitor for signs of shock • Observe for signs/symptoms of impending DIC: bruising or petechia, oozing from venipuncture sites, hematuria, epistaxis, hemoptysis, and bleeding gums and document. UTERINE RUPTURE The complete disruption of all layers of the uterine wall. This allows abnormal communication between the uterine and peritoneal cavities, the majority of which occur in women with previous c-section. Rupture can occur before or during labor and in the total absence of any risk factors. Sharp sudden abdominal pain, report of tearing sensation, loss of FHR, cessation of contractions, referred shoulder or chest pain, pallor, hypotension, tachypnea, and hemorrhagic shock. Should this occur during transport proceed with the following: DIVERSION WILL BE NECESSARY. THIS IS A SURGICAL EMERGENCY. Treatment: • Monitor/ Treat for Hypotension and Hemorrhagic Shock • Monitor for vaginal blood loss. ABRUPTIO PLACENTA / UTERINE RUPTURE 15-3 Dr. Sandra Schwemmer, DO Page 1 of 1 405 Monroe County Fire Rescue Trauma Star Medical Protocols lot Follow Universal Patient & Universal High-Risk OB Assessment/Care Protocols as appropriate BREECH PRESENTATION Breech presentation is used to describe the situation when the fetus's buttocks or legs present first. Treatment: • If delivery is in progress, allow the buttocks and trunk of the baby to deliver spontaneously; • Direct the mother to push with contractions; • Do not pull on the newborn; • Once the legs and arms are delivered, support the body on the palm of your hand; • Insert your finger into the baby's mouth and bring chin down to allow the head to deliver; • Have an assistant provide supra-pubic pressure to facilitate delivery of the head; • If the head is not delivered within 3 minutes, place gloved hand in the vagina with your palm towards the newborn's face; • Form a `V' with your index and middle fingers on either side of the newborn's nose and push the vaginal wall away from the face to create an airspace for the newborn until delivery of the head; • Suction as needed; • Transport and divert immediately while maintaining the airspace for the newborn. SHOULDER DYSTOCIA In cases of shoulder dystocia, delivery of the fetal head is followed by impaction of the fetal shoulders against the pubic symphysis and sacrum, within the pelvis. This complication becomes obvious when the head retracts slightly as it is pulled against the perineum (turtle sign). Treatment: • Place the pt.in a semi-fowlers position; flex the pts. legs with the knees pulled back up onto the thighs. Hips are abducted out as much as possible increasing the AP diameter of the pelvis. • Suprapubic pressure can be used to attempt and push the anterior shoulder under the symphysis pubis; • DO NOT USE FUNDAL PRESSURE; • Consider reaching into the vagina to deliver the anterior shoulder by trying to rotate it in the pelvis, extraction of the posterior arm, or using the Woods' corkscrew maneuver to rotate the shoulders 180 degrees out of the pelvis; • Delivery of the anterior shoulder must occur within several minutes. BREECH PRESENTATION / SHOULDER DYSTOCIA 15-4 Dr. Sandra Schwemmer, Do Page 1 of 1 406 Monroe County Fire Rescue Trauma Star Medical Protocols Follow Universal Patient & Universal High-Risk ©B Assessment/Care Protocols as appropriate DIABETES MELLITUS IN PREGNANCY A common medical complication in pregnancy. Diabetes in pregnancy increases the risk of several maternal and fetal complications and even mild maternal hyperglycemia is associated with adverse pregnancy outcomes. Continuous monitoring is important because the fetus can be affected if mom is not properly monitored and treated when the need arises. Treatment: • Current BG >250mg/dl determines need for insulin before leaving facility • Obtain last dose of insulin Time/Type (short or long acting) • Monitor for Hypertension • Fetal Monitor - FHR, baseline and any variability, • Monitor Contractions — duration /frequency/strength • Monitor for DKA / Hypoglycemia • Blood sugar <40mg/dl treat with o D10100imII DIABETES MELLITUS IN PREGNANCY 15-5 Dr. Sandra Schwemmer, Do Page 1 of 1 407 PAIN MANGAGEMENT Pregnant patients who have pain from labor or from an illness or injury who are HEMODYNAMICALLY STABLE. These patients may be medicated to help reduce or alleviate pain. Treatment: Assess patient's hemodynamic status and level of pain ❑ Fein-tainyll 0.5-1 irncg/kg (max dose 100mcg) over 1-2 minutes IV q 30 minutes x 1 Reassess and document level of relief of pain and/or nausea; If Morphine is used, anticipate possible CNS depression in the infant at birth (especially respiratory depression). NAUSEA Pregnant patients who have nausea and/or vomiting may be treated to relieve symptoms and increase comfort. • indainse-troin (Zofirain) @ 41rng IV over 2-5 muiin PAIN MANGAGEME Ne 1 o / NAUSEA IN PREGNANCY 15-6 408 Dr. Sandra Schwemmer, DO g PLACENTA PREVIA The implantation of the placenta in the lower segment of the uterus. With this condition, the placenta is located on or near the uterine opening. The previa may be complete, partial, or marginal. Signs and symptoms: Bright red, painless vaginal bleeding usually beginning in the third trimester. Treatment: • Monitor uterine activity every 5-10 min. • Transport in a lateral position, preferably left, or with a left pelvic tilt. DO NOT PERFORM VAGINAL EXAM. • Monitor/ Treat for hypotension • Continuously monitor fetal heart rate and record any variability. PROLAPSED CORD Prolapsed cord occurs when the umbilical cord is at or below the level of the presenting fetal part. Fetal brain damage or death may result if the blood and oxygen supply are obstructed or cut off. Signs and symptoms: cord protruding from vagina, slowing of FHR, meconium stained amniotic fluid, pulsating cord felt on vaginal exam by sending OB physician. Treatment: • FHR continuously, and record every 5 minutes. • To stop/slow uterine contractions Teirlbutalliiine 0. 51rng SQ q 15-30 min PRN, max 3 doses max, • Position patient in a left recumbent position with pelvis elevated on two pillows. • If FHR slows (less than 100 bpm), insert a sterile gloved hand into the vagina and exert continuous pressure on the presenting part in attempt to push the presenting part away from the cord to allow blood flow to the umbilical cord. Do not attempt to place the cord inside the vagina. Do not permit additional cord to escape from vagina. Hand must remain in vagina until baby is delivered, or continuous monitoring shows normal fetal heart tones with contractions. • If the cord is protruding from the vagina, cover it with sterile saline dressing. • Definitive therapy for a prolapsed cord is Caesarean Section. PLACENTA PREVIA / PROLAPSED CORD 15-7 Dr. Sandra Schwemmer, DO Page 1 of 1 409 ce Monroe County Fire Rescue Trauma Star Medical Protocols Follow Universal Patient & Universal High-Risk OB Assessment/Care Protocols as appropriate POST-PARTUM HEMORRHAGE (PPH) Blood loss >500ml's after vaginal delivery or >1000ml's of blood after c- section is considered a post-partum hemorrhage. Signs and symptoms include, flaccid and no uterine contractions, indications of shock post-delivery. Treatment: • Determine onset of bleeding • Evaluate perineum, vagina, cervix for injuries and bleeding and apply direct pressure or ice packs for hematomas; • May require bi-manual fundal massage q 5-15 min as indicated by bleeding and clots; • Left lateral tilt to relieve pressure of the vena cava AMNIOTIC FLUID EMBOLUS Occurs when amniotic fluid gains access to the maternal circulation during labor or delivery resulting in obstruction of the pulmonary vasculature. Signs and Symptoms: Acute shortness of breath, agitation, signs of hypoxia, chest pain, cyanosis, etc. Treatment: • Intubation may be indicated for rapidly deteriorating patient; • Ventilator supported patients may require PEEP: start @ 5cmH2O; • Monitor mother and fetus (fetal monitor) frequently and treat mother's symptoms as indicated; • Watch for evidence of D.I.C. CERVICAL OR PERINEAL LACERATIONS Treatment: • Direct pressure until it can be repaired; • Make note on how many CC's of blood and how many pads and/or dressings used to control bleeding; • Fluid resuscitation as indicated POST PARTUM HEMORAGE / AMNIOTIC FLUID EMBOLUS / CERVICAL OR PERINEAL LACERATIONS Dr. Sandra Schwemmer, Do Page 1 of 1 =5- g 410 Monroe County Fire Rescue Trauma Star Medical Protocols Follow Universal Patient & Universal High-Risk OB Assessment/Care Protocols as appropriate PRE-ECLAMPSIA A condition of pregnancy characterized by hypertension, edema, and proteinuria, which occurs usually after 20 weeks gestation. Treatment: • Assess uterine activity initially and get recording, if available. • Change in FHR, re-position patient • If labor is not present and seizures occur, observe for sudden onset of labor or evidence of abruption of placenta. Treat systolic BP greater than160mmHg and/or diastolic BP greater than 100mmHg: Administer: ❑ Il,,,,,,albetalloll 5-10irng II I If patient's BP does not normalize. Administer • loading dose of MaginesiUrn Sulfate: o Mix 4g (8ml of 50% solution) in 100ml NS and infuse as tolerated over 20- 30 minutes; followed by a maintenance 2-4g/hr. infusion (4g in 1000 ml NS), if needed. Discontinue infusion If signs/symptoms of Magnesium Sulfate Toxicity develop: • if respiratory rate becomes less than 12/minute o Calcium Chloride 10%, 1 girn slow IVP over 3 irn iinUtes. o Assist ventilations with supplemental oxygen and ventilatory support as needed. o Have airway, suction, and oxygen ready for immediate use should seizures occur. o Assess for the development of or increasing severity of frontal headache, blurred vision, spots before the eyes, nausea, vomiting and/or epigastric pain. These indicate central nervous system involvement and worsening condition. Epigastric pain frequently precedes seizures. PRE-ECLAMPSIA / ECLAMPSIA Dr. Sandra Schwemmer, DO 15-9 Page 1 of 2 411 Monroe County Fire Rescue Trauma Star Medical Protocols Follow Universal Patient & Universal High-Risk OB Assessment/Care Protocols as appropriate ECLAMPSIA Signs and Symptoms: Grand Mal seizure / Coma in patients with severe pre-eclampsia If Seizure Occurs: • Make sure the patient is in a lateral position and protect from injury. • Secure airway as necessary. Administer high-flow oxygen via NRB. Suction as needed to maintain an open airway. • Administer o Versed 2-.5irng every 23 irniiinUtes II I OR o tivain 1-21rng II I If loading dose of Magnesium Sulfate was not previously given during pre-eclamptic phase • Administer loading dose of MaginesiUrn Sulfate: o Mix 4g (81rnl of 50% solutionn) in 100im! INS and infuse as tolerated over 20-30 minutes; • Followed by maintenance infusion of MaginesiUrn Sulfate (diilluted) 24girn/hr. o 4-.5g of a 20% sollutioin is suggested. (Dilute the 50% solution by half to obtain the 20% dilution required). Example: 8ml (4g of the 50% solution diluted with 20ml of NS would give a 20% solution) Discontinue infusion If signs/symptoms of Magnesium Sulfate Toxicity develop: • if respiratory rate becomes less than 12/minute o Calcium Chloride 10%, 1 girn slow IVP over 3 irniiinUtes. o Assist ventilations with supplemental oxygen and ventilatory support as needed. PRE-ECLAMPSIA / ECLAMPSIA Dr. Sandra Schwemmer, DO 15-9 Page 2 of 2 412 Monroe County Fire Rescue Trauma Star Medical Protocols Follow Universal Patient & Universal High-Risk OB Assessment/Care Protocols as appropriate PRETERM LABOR Preterm labor is labor that occurs between 20 and 37 weeks gestation. To assess maternal/fetal status, provide physiological and psychological support and monitor tocolytic effects when attempts are made to slow/stop labor. Tocolytic drugs are used to delay labor for a short time (< 48hr) and include terbutaline, nifedipine, and NAISDs and are not usually used before 24 wks. gestation. Treatment: • Contractions can be caused by dehydration in the mother so initiate 500cc bolus, prior -to tocolly-tic therapy when there is a history of fluid depletion; • Monitor contraction frequency and duration, observe for pooling of possible amniotic fluid and collect a sample if possible. Vaginal exams are not to be performed by Trauma Star crewmembers unless delivery is imminent • Be prepared for delivery; • Maintain antibiotics if sending hospital initiated; • Antepartum steroids may have been administered to the patient prior to your arrival to accelerate fetal lung maturity this information should be provided to receiving facility. Contractions occurring every 10 minutes or less and lasting at least 30 seconds administer • Terlbutalliiine 0.251rng SQ if maternal HR is <120 bpm and there is no history of cardiac disease. Second dose may be administered within 15-30min if needed and patient HR remains <120 bpm and show no signs of tremors, flushing or restlessness. o If Terbutaline has been administered >60 min prior to take off, may repeat dose as needed and tolerated by patient every 15-30 min. up to a maximum total dose of 0.75 mg. ❑ MaginesiUnl Sulfate o Loading DOSE: 4girns in 100/cc INS over 20 30 irniiinUtes. o Maintenance DOSE: 24girn/hr. (diluted to 20% solution) (Dilute the 50% solution by half to obtain the 20% dilution required). Example: 8ml (4g of the 50% solution diluted with 20ml of NS would give a 20% solution) Discontinue infusion If signs/symptoms of Magnesium Sulfate Toxicity develop: • if respiratory rate becomes less than 12/minute o Calcium Chloride 10%, 1 girn slow IVP over 3 irniiinUtes. PRETERM LABOR / PPROM Dr. Sandra Schwemmer, DO 115-10 413 ed Monroe County Fire Rescue is Trauma Star Medical Protocols PRE-TERM PREMATURE RUPTURE OF MEMBRANES (PPROM) Rupture of the amniotic membranes in a pregnancy of preterm gestation (prior to 37 weeks). • Obtain History of PPROM- time, color, amount, and odor • Avoid letting the patient sit or bend to avoid pressure on the cervix during transport. • Monitor contraction frequency and duration without vaginal exams if the membranes are ruptured, unless delivery is imminent, fetal bradycardia or prolapsed cord; • The major complication associated with pre-term labor is delivery ofan immature fetus: Be prepared for delivery and resuscitation. PRETERM LABOR / PPROM Dr. Sandra Schwemmer, DO 15-10 414 de is Follow Universal Patient& Universal High-Risk,013 Assessment/Care Protocols as appropriate VAGINAL DELIVERY Every attempt should be made to determine if delivery is imminent prior to accepting patient for air transport. However, delivery should always be anticipated. If in flight delivery occurs consider DIVERSION if newborn is in distress. Prior to departure from Hospital: • Obtain additional blankets, multiple towels from hosp. • Ensure a body bag is placed on stretcher to contain membranes / amniotic fluid • Move OB kit and Handtevy Pediatric bag to main patient compartment Treatment: • Determine if delivery is imminent o Visible presenting part, bulging perineum, pt. stating `I have to push' • Assess perineum- bulging, bleeding, cord, meconium, presenting part • Apply pressure/ support to perineum • If membranes are intact and the fetus is crowning, then perforate them before the head is delivered, remove them from face • Slowly deliver the head, firmly supporting it and the perineum • Bulb suction the infant's mouth than nose before delivering the body • Guide baby's head down to assist delivery of anterior shoulder then up to assist with posterior shoulder Nuchal Cord — cord wrapped around infants' neck • During delivery of head, check for nuchal cord, if present and loose, attempt to reduce it by slipping over the baby's head; • If cord is tight, unable to reduce- clamp twice and carefully cutbetween clamps • Once cord is removed or cut then prepare for delivery Once delivery is complete Late cord clamping (performed approximately 1-3 min after birth) is recommended for all births, while initiating simultaneous essential neonatal care. Early umbilical cord clamping (less than 1 min after birth) is not recommended • Hold baby securely and stimulate by drying or flicking soles of feet • Place baby on mother's chest or stomach and assess airway / need for resuscitation. VAGINAL DELIVERY Dr. Sandra Schwemmer, DO Page 1 of 2 15-1 1 415 de is • Do not clamp / cut cord unless the neonate is asphyxiated and needs to be moved immediately for resuscitation. For basic newborn resuscitation, if youcan provide effective positive-pressure ventilation without cutting the umbilical cord, ventilation can be initiated before cutting the cord. • If the placental circulation is not intact, such as in the case of abnormal placentation, placental abruption, umbilical cord avulsion, maternal hemodynamic instability or the need for immediate resuscitation of the newborn immediate cord clamping is appropriate. ❑ Second flight crew member - assess / treat neonate according to appropriate neonatal protocol (Section 16) 1-3 minutes after birth Clamping "not earlier than one minute" should be understood as the lower limit period supported by published evidence. • Clamp the cord at least 1" from the stump and again 1" from thatclamp and cut between them • If possible, retain sample of cord blood • Assess perineum for tears/ lacerations and bleeding • Allow placenta to separate on its own • Apply fundal pressure/ massage as needed for bleeding/ placenta delivery • Apply ice to perineum for control of swelling and/or bleeding from tears/ lacerations needing repair • Watch for signs of postpartum hemorrhage; frequent fundal checks with massage as needed VAGINAL DELIVERY Dr. Sandra Schwemmer, DO Page 2 of 2 15-11 416 Monroe County Fire Rescue Trauma Star Medical Protocols COMPROMISED NEWBORN Treatment: • Dry, warm, and stimulate infant. • Clear and maintain a patent airway • If infant is not responding, rub vigorously and administer oxygen by mask. • Suction mouth first and then nose with bulb syringe. If the infant is not effectively breathing after 15-30 seconds of stimulation and oxygen • Ventilate with BVM. Use neutral or sniffing position, ventilating enough to observe good rise and fall of the chest. Ventilations should be at a rate of 40- 60/minute. Monitor response: chest movement, breath sounds, color, tone, and heart rate. • Insert NG/OG tube to prevent gastric distention if prolonged ventilation. If heart rate does not improve and infant does not begin to breath • Intubate and continue to ventilate. • Begin chest compressions at a rate of at least 100/min if heart rate is less than 60 despite adequate ventilation for 30-60seconds. • Monitor cardiac rhythm as possible. • Establish IV/IO access. • Continue resuscitation COMPRIMISED NEWBORN Dr. Sandra Schwemmer, Do Page 1 of 1 16-1 417 Monroe County Fire Rescue Trauma Star Medical Protocols NEONATAL ENDOTRACHEAL INTUBATION While preparing for incubation, ventilate via BVM and supplemental oxygen to restore good skin color and adequate heart rate. Select proper tube size: o Tiny premature (<2.5lbs): 2.5mm o Other premature and average size (3-7lbs): 3.Omm o Larger infants: 3.5mm Treatment: • Place patient's head in proper head positioning which is the neutral or sniffing position. • Insert laryngoscope with small straight blade along the right side of the mouth; push tongue to left. • Prolonged pharyngeal stimulation will induce bradycardia and even heart block in some infants. • Visualize cords and suction as required. • Insert tip of endotracheal tube 1-2cm past glottis. Stabilize endotracheal tube with fingers. • Confirm endotracheal tube placement via no auscultation of epigastric sounds and auscultation of clear, equal breath sounds. • Secure endotracheal tube via tape. Until tube is secured, place middle finger of dominant hand on endotracheal tube and press tube into hard palate to secure tube. The rest of the hand will hold the jaw and provide a secure hold on endotracheal tube. • Document endotracheal tube depth marking at gum line. • Utilize ETCO2 detector and document waveform. • Insert Ng/OG tube and decompress stomach to allow for more effective ventilations. NEONATAL ENDOTRACHEAL INTUBATION Dr. Sandra Schwemmer, Do Page 1 of 1 =6- 418 Monroe County Fire Rescue Trauma Star Medical Protocols NEONATAL STABILIZATION Provide warmth • dry thoroughly • remove wet towels • cover head • keep out of draft Open airway, sniffing position: • bulb suction, suction both mouth and nares, avoid prolonged suction • Particulate meconium or depressed baby- incubate and perform direct tracheal suctioning • Stimulate respirations- rub back, flick soles of feet No active response- respirations or crying after two attempts • Provide PPV via BVM-15-40 cm/H20 @ 40-60 bpm with Fi02=100% for 30 seconds and observe easy rise and fall of chest Pause to evaluate: APGAR @ 1 minute and 5 minutes • 02 blow-by of 80% for HR >80, RR adequate w/central cyanosis- DO NOT OVERSTIMULATE, slowly withdraw 02 if baby stays pink; • 02 PPV/BVM @ 100% HR <80 not increasing, RR- gasping/apneic w/central cyanosis; • Continue PPV/BVM until HR>100 w/adequate respirations; • PPV >5 min consider OG tube, if available, for gastric decompression; • Reassess HR after 30 seconds and @ 2 minutes • BVM/PPV ineffective or prolonged need for ventilation, then ETI • HR<60 or 60-80 and not increasing w/vent. and stimulation, begin chest compressions Respiratory depressed infant known or suspected maternal drug use • Narcain 0.1 img/kg IV, IM, SQ or ET q 2-3 min up to 1 mg. Glucose <40 mg/dl: • D10W 24 cc/kg IV/ IO over 3-5 min • Re-check BS q 15-30 minutes NEONATAL STABILIZATION Dr. Sandra Schwemmer, Do Page 1 of 1 =6-3419 Monroe County Fire Rescue Trauma Star Medical Protocols NEONATAL PERSISTANT PULMONARY HYPERTENSION Avoid stressors: Hypoxia, acidosis, pain, agitation, hypoglycemia, hypovolemia Assess respiratory status closely and support with R02& ventilation as necessary. Monitor pre- and post-ductal oxygen saturations. Treatment • Correct metabolic acidosis. • Sedate: o Feintainyll 1-.2 irnce /k and/or Midazolarn 0.1 mg/kg mg/kg if blood pressure stable. • Monitor glucose level closely. • Monitor for hypotension & hypoperfusion. o D pare iine 1020 imce /k /rn iin may be initiated, however, consult with medical control before starting Dobutamine o Consider ROCUroinkffn 0.6-1.2 mg/kg mg/kg IV to facilitate ventilation. Consult receiving neonatologist prior to administration. Dr. Sandra Schwemmer, DO 16-4 420 Monroe County Fire Rescue Trauma Star Medical Protocols BLOOD TRANSFUSION Step Action 1 Obtain Consent from patient or family if possible 2 0- (0 negative) PRBC will be used for transfusion Ensure PRBCs have been maintained per policy (temperature WNL, ports WNL) 3 Verify Unit number and blood type are the same on unit and transfusion form. If there are any problems with blood temperature, ports, or discrepancy in unit number or blood type, document problem and return to Oneblood. Ensure IV access and patency. 18 gauge or larger preferred. IO is acceptable 4 No other medications can be given through blood administration IV line. Ensure you have a 2nd IV line for all other medication. 5 Adults give 1-2 units Pediatrics <13 give 1-2 10m1/1kg bolus Ensure appropriate equipment and supplies 1 L bag 0.9% NS 6 Pressure bag Y Blood tubing Blood filter Blood warmer. Adult Prime Blood tubing and filter with 0.9% NS and insert filter into blood warmer. Ensure all clamps on blood tubing and filter are clamped off. 7 Pediatric Prime syringe pump tubing and filter and insert into blood warmer. Ensure all clamps on blood tubing and filter are clamped off. Prime 1000ml bag of 0.9% NS with 10gtt set and have ready to infuse. Adult Place blood on pressure bag and Spike blood bag. 8 Pressure bag should not exceed 300mmHg of pressure Pediatric Draw up blood amount into 60cc syringe and attach to syringe pump tubing. 9 Obtain baseline Temperature, B/P, HR, RR, and Sa02 Start Blood Transfusion. Monitor for cardiac rhythm, and signs and symptoms of reaction. 10 If reaction occurs, document reaction and follow transfusion reaction guidelines. Document Temperature with VS every 15 minutes during transfusion. (Temperature should not exceed 39 C) When the transfusion is complete Flush blood line with NS Document final Temperature with VS 11 Remove blood tubing and discard. Flush IV site Continue to monitor for reactions. Complete Uncrossmatched Emergency Blood Release Form and Transfusion Record Completed and partially used units and original completed transfusion report is to be given 12 to receiving facility nurse. (make copy of transfusion report for TS records). Have receiving nurse sign Uncrossmatched Emergency blood release form. 13 Complete and fax or email completed 842 form to Oneblood. BLOOD TRANSFUSION 17-1 421 Dr. Sandra Schwemmer, DO Page 1 of 6 Monroe County Fire Rescue Trauma Star Medical Protocols Blood Transfusion Reaction Guidelines Reaction Treatment For mild skin itching, do not stop transfusion Allergic Reaction administer Diphenhydramine. • Adults o 25mg IVP. • Pediatric o 1 mg/kg not to exceed 25mg • Immediately Discontinue transfusion. Fever and Chills • Hang 0.9% NS to keep vein open. (If SBP less than 90 administer NS at a rate to maintain SBP >90.) • Notify Medical Director • Closely monitor VS and 1&0 • Give remaining blood to receiving facility • Immediately Discontinue transfusion. Anaphylactic Reaction • Hang 0.9% NS to keep vein open. (If SBP less than 90 administer NS at a rate to maintain SBP >90.) • Notify Medical Director • Follow Anaphylactic protocol • Closely monitor VS and 1&0 • Give remaining blood to receiving facility Febrile Transfusion Reaction • Immediately Discontinue transfusion. Defined as increase in temperature during Hang 0.9% NS to keep vein open. (If SBP transfusion. less than 90 administer NS at a rate to maintain SBP >90.) Symptoms include temperature increase of 1- 0Notify Medical Director degree C greater than baseline. Other symptoms • Administer in 2nd IV line include chills, headache, facial flushing, Diphenhydramine 25mg IVP palpitations, cough, chest tightness, increase in pulse rate and flank pain. Closely monitor VS and I&O • Give remaining blood to receiving facility Hemolytic Transfusion Reaction • Aggressive NS infusion Defined as immediate lysis of transfused red 0Notify Medical Director blood cells can result in fever and or tachycardia. 0 Closely monitor VS and 1&0 Immediately Discontinue transfusion Symptoms include chills, back/flank pain, 0 Give remaining blood to receiving facility nausea/vomiting, dyspnea, flushing, bleeding, hypotension, increase in baseline temperature by 1-degree C, headache, facial flushing, palpitation, chest tightness, and cough. BLOOD TRANSFUSION 17-1 422 Dr. Sandra Schwemmer, DO Page 2 of 6 Monroe County Fire Rescue Trauma Star Medical Protocols Reaction Treatment Dilutional Thrombocytopenia Defined as platelet loss due to absence of viable platelets in PRBC. Generally seen in large 0 Immediately Discontinue transfusion. quantities of PRBC transfusions to treat trauma or Hang 0.9% NS to keep vein open. (If SBP massive hemorrhage. It is caused by platelet loss less than 90 administer NS at a rate to out of the body and platelet dilution with replaced red cells and crystalloids. maintain SBP >90.) • Notify Medical Director This is generally not seen with infusion of 1-2 0 Closely monitor VS and I&O units, unless a patient has pre-existing 0 Give remaining blood to receiving facility thrombocytopenia or disseminated intravascular coagulation(DIC). Symptoms include oozing from mucosa, wounds or puncture sites, petechial spots, ecchymosis, and S/S of DIC Potassium Intoxication • Hold Transfusion Defined as hyperkalemia, and is a common 0 Consult Medical director to see if infusion complication in mass transfusion of stored blood. should be continued. Stored RBC usually contains more than 60MEQ/L . Initiate Hyperkalemia protocol of potassium. Closely Monitor VS, and I&O Symptoms include flaccidity, muscle twitching, • If cardiac arrest occurs, follow cardiac bradycardia, EKG changes, (tall peaked T-waves, arrest protocol prolonged P-R interval, and QRS)and cardiac arrest. Hypocalcemia • Hold Transfusion (from citrate intoxicity that binds Ca) 0 Consult Medical director to see if infusion Patients with acute or chronic hepatic insufficiency should be continued. are at relatively higher risk of citrate toxicity. To • Administer Calcium Gluconate 1 gm slow avoid Citrate toxicity, administer PRBC at a IVP in 2nd IV. minimum rate of 1 unit over 6 minutes and avoid 0Closely Monitor VS, and I&O rapid transfusion. Symptoms include arrhythmias, hypotension, muscle cramping, nausea, vomiting seizure activity, and tingling sensation in the fingers. Hypothermia 0 Hold Transfusion Symptom include chills, shivering, hypotension, 0Consult Medical director to see if infusion arrhythmias, bradycardia, cardiac arrest. should be continued. • Warm patient • Obtain 12 lead EKG • Warm blood if transfusion is resumed • If cardiac arrest occurs, follow cardiac arrest protocol BLOOD TRANSFUSION 17-1 423 Dr. Sandra Schwemmer, DO Page 3 of 6 95d Monroe County Fire Rescue Trauma Star Medical Protocols 842 Form E Locale your transfused unit &Complete all f orm for t[ Locate your the selected unit number Mood C inponeint Msposifloll Log ,Lt (Air Med Base) ............................... .................................... ...... ......... .... ��P .............01111— di by On, 0 "To becompteted by Air Med;Base Unit Number ISKIL Ptod t I'. 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FinalOneWood Review: Date:------------------------------------------------------------------------------ ------------------------------ 00 NOT transfuse if temperalure iriftator is RED 0 on I I Jo lm(,"10 Fu"m (,mieblood I 16 Once form is complete call Oneblood and let them know that a unit of blood was transfused, and then either email or fax completed form to Oneblood. Oneblood Information Phone # 954-777-2677 Fax # 954-970-3286 Email: BLOOD TRANSFUSION 17-1 Dr. Sandra Schwernmer, DO Page 4 of 6 424 Ce Monroe County Fire Rescue Trauma Star Medical Protocols Documentation of Transfusion Form !P MIi,Msa / fir'fS.Yu°=i;i.Agi.'.`, r.Yi�a,ly ��f�r�nl,✓.f,mr� . .. r ;/7// 7595fien tr mvg. , I mi,w�cravawi l lr. r'I.,7.!;�.S�I re;a a�iaiti.r"rm I';ur':9 r:: rrECL I—ar �Vw{NknX f'Gk,aVA E413 ArinrrvrusnxlM d:.Gr�wSy'rVn;w1 W..wa�am,Yro-rr Law frIra, m-'1v,N'F'i�;X�Xa B"��uaarrr rh I�0,114JI Lh,iurb '' ^'d1r.�Csf NffiS3?CIY aJ', -t➢ un it r"mi9.0019d:h EW182 mtua"' LNCU i-4 EN, 43 ua i .1pt— 1121311/20'MI aria x.i a�I.S nim VIA :3,06-L.. �.:"rug wuaa7��t:m�m l9�n�nhre>•L� t�unu. ft,ceiviui..n rd0T I G' IIAI N;—,"I �=7d,arnax'enar'irts 1111pLl;aSIIIINnIF7 V1"iBGPnIIC.".W."H'IIOe"•d A'a°IIIC"q"Gilll:a 6Po11.N`1a"SIGY-+'C„CF8M17Vi"1^+"4'!:NI"Y' T`#Yu01ar`,Yamr'"..,S>Y;.wlat i"2^` ^ "k1.�,��mw�li7:m..w �.tG14� for GNl7 i5;Ipafiwm.uw G aanul I�i GaGsmrrcl parwaa:�Gc.icf reqauesGe,d. fJn f�hpl]17_;...14.,rauv^r.�,t�m•It crrl r:f"Ia-r°'f The recipBent ina me aird the i,yleritifyIYng Boa,um b r('s) :- .L4af5,.�wuj!1 on the,p akweirf e uor,,M,.11LSImI.Q afe idanimal. The r.rnt rrvrigluf7dm°;and und:Fla.�'r,�"iJ"RAni s°rlY.q..tda ...�.r�a�.rraawrcn IMudig nar?ax lm'road t rlrri"i, ry enf I5' qd,,,, , Y : ViisiIual mn5pecfieni is satlzfac r . The afircrwew2ll,",Varufied at bedside lbe'Gui�e trmnsfusion,by .'ItlRA Neal"�IFUS"I bdI IIR rACTH:)NiI.� $T�°"P 7F-IC'7R�.+"tih�l 4a) l.i IlC,fW�p "IN`ran�ru.urMaurim ................................ wf di,wrtg infasirm or in the post pmansfwlsresn period the Patie-nt. exhmlgmt5 an'y symptorras,caf a po", ble mrarne,foasmnrr�reanww'J'.n.n. 1 Perform c1lerica:l cMveck, AIDPAIfV11''vs'IIITIRAT10<111. 2 I"dcyawG'py the Ph1y sictaani end Transfuejarm'^aerwic'er ur role iiatel°y, YIall sygns,at.-to II lakn&n before aJiaimrng mrsirisfusicmmn„ 115 3 Inrfre;fe Uwe i'rnarnsfa.wsla:ariu toaactio,1'n wr wre .sfuglaPoR;oln. rtrulnnuGe,s afarar iln%ii'alirnm'afrW r:rn^sf Gfarl,'kisio 1'm.. In r-addAiion, d Document Observation-b"flow Vit"I egm':rmiaryr bQ tawaron pgoeancrrlic°naNy iaccardiing to III. Rerord beiuow or they May be Irecorded in ellectrorMibe GridN{'aG: 4rli.9erW trmrr'pIs by r~hoclkiniq fhie tyex bellow AN D rraeriar al m'imroc¢:od decu rnerl4 morsing ac:fla."nnl On polltlienit`s chart. Teat YI: '1",+'4f2 I F IV:9 at on r; Gn'amr^ir rrmaW l"than t;at'a,»r,ual ic�21N= .1.:„a":: nn..rewe e above y 9 rlrafer'than or 'f">aG.fnll ENDED atl on R8 61,IF iJ aC"',I�e lr Iiyrror�wrialiumwaa. If lfaaaellll�ire iig d�.tnr1;Illlnfu ertl Ma equal G^IR`Y;37'+L"; See F'lac,lpraa°rG r0edic.zam Record pIENIR') rn Shiun s of Br ofes I ath y r If,orfmcarl� G�,+'F' M'rm air,,{�e r�EaWM'uil� spn,ea II r''frfa IllNim, li fM1VV... . ... ... -'rJLSC .............,_ tm S,i^ + aa9±nraa leurancNYcae f'a n is rr-arl�rf ..'"...,..,. Phi. I& ia1r riotifi' shun"y" � " '. er'9 rtmf Itraro m;rn reartion'. - 'f` S � Tral I'Sk mon 13e+rm ce notified of�reacfliani, �.. YE .... .... �w ir�ry irub'aR�9.n'�' Send reinaindef of bletc'ud WiNhi I,orwllefi"le Araansfumslizarn,�ra1,i,r:vi'ms+r .........,of phra s rvI-.gjrO and Fresh sample tc�the.7ranli utsion,5er'dce m.,..,..,..'. ,N i ,"-icoon G:bSA�* rve _ L...... Verrmorii I Vr rmImne in,pnrt a r T.Pi w. nned rm ............................. . n�G ru,u aas'd. ptr ovrar spo,cmm�:i. Tw. td yyv¢:m9u r,nna.n.'dar.a®...lrurir al thus Y?Ga vv 1,11,5 Q"rs,cp�awyi iatrdwa:Ilnaa.:Nl U.l,l ua r.uniivl, re. ,ia mn :Pwm n*Illall well, Gne. ana lhiw¢mtliii 116G N' f.rG;r eR 0111 Cywrn@e f^^RlVadf IB^NNN£y rA�l9 rmi'iniAxIInGuuP f"rrcae4.1,�tilra„mr'irin a,rrar.a�.m=.rrine.G'I 4:� k"f:q &.wroirtwata "'fr4Hf„p,768111'ki,.37J d 5-0 'dnlipl'.1 l Sll It MIN This form is attached to blood unit and must be completed during transfusion. Bottom portion MUST remain attached to blood unit bag. Original Farm and blood unit bag is given to Receiving Hospital. A copy of the completed form is needed for TS record. BLOOD TRANSFUSION 17-1 425 Dr. Sandra Schwemmer, DO Page 5 of 6 Monroe County Fire Rescue Trauma Star Medical Protocols Uncrossmatched Emergency Blood Release Form i i Fr w i.: r Blood ' Patient's Name- Date: Time: F'hi ght Number: crew: � Receiirv^ing Hospital Fie Room l Attending IPh,y31CPZn Blood Certif'iied as Comrpatiblie four this parent cannot he suuppillied due,to urgent:needl.Corrmpatiih idlitya testing!JABOo,/Rh,Antibody dlletewctiiiron and crmss atching,;,�waras nwot preforrmedi Iprior to tranislfiusioon. Patient ireceived wnfids of (Red(Blood Celllls a=0 positive- E3 0 Neg'atu'�'��ure Uqu id Plasma wuniit,s Famiallle of chillld bearing age ireceived units of 0 Positive Red Celllls and rn;my ineed jRhl,,g, The Bb wre unity were infused iu a the interest of protecting this(patient from exsanguinati;ofw„we do not take responsibility for completion of compatibility of the Idluod with tthe patient:, The uiniut nu nbemrgs)transfused acre: 11-I1,rri®t4 11laod!. Co m-apcvnent ',iStaurt End Time, $Mllnfuiaad Type Tirne Vitalll Signs at IReuceiw+ing IHospitalll Tirne: HR: EP RESP TElfuf'P /. Patient ekNbiiited signs/sympt;onms of transfusion ireactoxwn during transport eo YES e NO(innairk ones If Yes Signs and symptoms inotedi: I Tur e of reaction: Date: Flight Crew I signature Printed nuarne Date: Flight Crew 2 signature, Printed name understand the Wpfp�'ry7:,p,gy,p. ,,�p,Y,e regarding the emergency adrninGstltrat:'icn of LAip,;F,95ATryR,t�gg blood and airni aviare of the need to complete compatitsility testing and the(possible ineed for ad'mmnistuation of Mg., Signed: RN Date: IReceiwin,E Ihuhurse The ciiiniiical condiition four the abo%r a named patient is sufficiently urgent to necessitate this emer,gencV transfusion(before compatibility testing could be completed.The benefits of the t�ransficusion outweai,gh, the,put)entoial rink. Signed: fug1) Dat-- ReceiVing P'Ih siciaun **(Flight crew vwr'rlllll proaide a photocopy of tihairs fofim„in addit,,on't'o the coumlpllleted PCR including all vital s'i,gnsm to th,e receiru^iurag:..The iourigiinalll wawillll the nmai nta'inued°,with t9he Ipatiienut's fii,g;ht recoirds""' 6:::;1 LN:>CoIn ,.'nt t II ro"nni x"": Pop::' N. a i:1,. NMWRIRNRNNWNWRILW Form needs to be completed and signature of receiving nurse obtained. MD signature is not required. This form is for TS records...; BLOOD TRANSFUSION 17-1 426 Dr. Sandra Schwemmer, DO Page 6 of 6 Monroe County Fire Rescue Trauma Star Medical Protocols BELMONT BUDDY BLOOD WARMER 6i ���tuC�&�r�li i nua�ra��art��r!�t"�✓���NUn„�a`w" JUea�rrrrr `�' i%///,. J'il hlJi �Nlhlr�� U w ����� /� ii��a�wmwu�i�eau»w�ooGtl��wrouN�iw�r�;wwJr��tontu�o��n���rsm�ura�aG�wmtawwn�// /� J�, � J 1 .Battery Pack 2.Dual heater plates 3.1-arge venting membrane Filter 4.Clamp to close line off 5.Pressure regulating valve 6.One-way valve 7.13ed sheet clamps BELMONT BUDDY BLOOD WARMER 7-2 427 Dr. Sandra Schwemmer, DO Page 1 of 2 Monroe County Fire Rescue Trauma Star Medical Protocols BELMONT BUDDY BLOOD WARMER Action Step ctn o • Place buddy set into heater • Align ured end of filter with ured end of heater. ,,,,-,iriV uu v^u ui' mi ii iuuuuuuu �uuuuuu "", f Set Up �� f � 4 • Close the heater. Click should be heard when closed. • Prime Blood tubing with Normal Saline Priming • Connect blood tubing to Ill,�ulll�i��au ,���� end of buddy set. • Prime the set by running NS through set tap heater while priming set to discourage bubbles. There is no need to remove red cap for priming. • Turn the heater on. A IIWlUue light confirms Operation operation. • Connect the red end to patient IV site. • Secure the heater to the sheet with the green clip. • Start Blood infusion. • Alarms are indicated by ured LED on battery Alarm housing. • Alarm cleared by turning off and on again. • Indicator is located on the base of the unit Battery Charge BELMONT BUDDY BLOOD WARMER 7-2 42s Dr. Sandra Schwemmer, DO Page 2 of 2 Monroe County Fire Rescue Trauma Star Medical Protocols LIFENET EKG - 12 LEAD TRANSMISSION SYSTEM ,p Transmit ��i��ll�IlliYlal�IIII ll lillll 'iV'9 W 11 't9� ���i�G?I'�� � � r i ; l A i rr rr rfrcrirrr,i riiuirrrirri ir,rrirr ,,,r rrrrrr,. n,r i.a r iarl� Daily Test — Must be done every morning during Helo checkout • Turn LP15 on • Press TRANSMIT button on Left side • Scroll down to SITE and depress selector knob • Scroll down to TEST *** IV' . IIIX IIII III III .......Y S...II... • Depress Selector knob • Scroll up to SEND • Depress selector knob • A message at the bottom of the screen will read Transmitting, it will run up to 99%, and will then say Transmission Complete. A confirmation will also print out*** EKG TRANSMISSION 17-3 429 Dr. Sandra Schwemmer, DO Page 1 of 2 Monroe County Fire Rescue Trauma Star Medical Protocols 12 LEAD TRANSMISSION TO LIVE SITE • Load Pt into HELO • Place Pt on LP15 • Press 12 LEAD • Enter Pt AGE and SEX • Press OPTIONS • Depress selector knob on PATIENT and enter PATIENT LAST NAME • Press HOME button • When 12 LEAD has Acquired, and PT name is entered • Press TRANSMIT button on Left side • Depress selector knob to SEND 12 lead to desired destination • A message at the bottom of the screen will read Transmitting, it will run up to 99%, and will then say Transmission Complete. A confirmation will also print out. EKG TRANSMISSION 17-3 430 Dr. Sandra Schwemmer, DO Page 2 of 2 M d' O 0 a� E E a� 3 U C 0 BAXTER AS50 SYRINGE PUMP 17-4 432 Dr. Sandra Schwemmer, DO Page 1 of 6 Monroe County Fire Rescue Trauma Star Medical Protocols BAXTER AS50 SYRINGE PUMP 17-4 433 Dr. Sandra Schwemmer, DO Page 2 of 6 Monroe County Fire Rescue Trauma Star Medical Protocols Step Action 1 Draw up medication/Fluid into syringe. Secure IV tubing to luer lock end of syringe. Prime medication through IV tube. Clamp tubing. 2 Release Barrel Clamp and ensure plunger clamp is at the top of the pump. 3 Place Flange of syringe into Flange slot and press barrel clamp firmly against syringe, then pull plunger clamp, pull plunger clamp out all the way, slide clamp down to the end of plunger then release, then press clamp firmly around plunger so plunger captures. 4 Turn on Pump. Check battery power by pressing and holding confirm button while pump turns on. 5 First menu that will appear will be the Library menu use down arrow on key pad and select None and press confirm button 6 Mode Menu will be your next menu use down arrows to select ML/HR and press Confirm button. 7 MFR with will be the next menu use down arrows to select the brand of syringe you have with will either B-D or Monojet press Confirm button once brand has been selected. 8 Select size will be the next menu use down arrows to select to the syringe size and press Confirm button once size has been selected. 9 Enter Rate will be the next menu. Enter your desired rate by using the number on the key pad and press Confirm button once the rate has been entered. 10 Vol Limit will be the next menu. Enter desired volume limited using the numbers on the key pad, limit will dependent upon the size of syringe you have chosen, and can not exceed the amount of the size of the syringe chosen. Press Confirm button once volume limit as been entered. 11 Once all menu have been completed and confirmed. Assess IV tubing and IV site to make sure all clamps are unclamped and tubing is not kinked, then press Start button. Pump should show running on screen and Green light should show in Run section on pump. BAXTER AS50 SYRINGE PUMP 17-4 434 Dr. Sandra Schwemmer, DO Page 3 of 6 Monroe County Fire Rescue Trauma Star Medical Protocols BAXTER AS50 SYRINGE PUMP 17-4 435 Dr. Sandra Schwemmer, DO Page 4 of 6 i To Select j MFR � » down arro=se u syringe COMMON ype either BD or nojet and then press BAXTER AS50 SYRINGE PUMP 17-4 436 Dr. Sandra Schwemmer, DO Page 5 of 6 To Select To Enter syringe Rate, size type the usarrow, desired select rate;..and i size of f then syringe press and then ,,u Confirm p Button Confirm I IJ i,! nnJwenwarrwwwiiwn»armtsmnniik err Once all menus have been To Enter selected Volume 1 and confirmed Limit, type Pressthe f Start amount o / Button. based on Y t ���i Green size and light 1 � should � then press q � appear in Confirm Run Button 110 L. onvvw- BAXTER AS50 SYRINGE PUMP 17-4 437 Dr. Sandra Schwemmer, DO Page 6 of 6 co M I r '' a „ ns i x a m 1 � FN W W U ~ LU wO WU 0 � O w F a LLO � w LU w z a N J J Q V a O 02 2 z o O w 2 a F a� _ �.✓ .. ... �;ll",; .ter Ab '` °: -✓ d a -- 014 O CL pq /. ! W a 0 Dr. Sandra Schwemmer, DO PELVIC BINDER 17-7 Page 1 of 3 439 Monroe County Fire Rescue Trauma Star Procedures Dr. Sandra Schwemmer, DO PELVIC BINDER 17-7 Page 2 of 3 440 Monroe County Fire Rescue Trauma Star Procedures Dr. Sandra Schwemmer, DO PELVIC BINDER 17-7 Page 3 of 3 441 N d' d' ----------------------------- I r a r 0 � �,� 9mop '#J 16, owwRy ry 4 40, «in „emu 41 A, w q w �� m a 0 "cl. cl Pop Z n Of %f O U � to f U yW W O �, �, LL 0 H a Z J f Z O U � m ❑ O W W O ., ,, a w Z to a W r 3 U C 0 de is S R Q P 0 N A Screen with screen pages for the speafic L Key Ilrnsp. HoW foir initiating a manual inspilra- appllcaflon tion or for extending the current inspuratolry time B Key Alarms C>(> to display the alarrn settings M Key 0 Stairl/Standbly, in the Settings sand Alarms"window and to N Dispgay symbols for the power su:pply chainge scireen,pages r-----+) Charge status,of the internal battery C Key Setflngs C>E> to dispWy vent0ation :D Mains power supipilly,coinnected pararrieters(ventHation screen)in the"Settings 01 Rotary knob,for imaking selections, changing and AlanTIS"Mridow and to,change screen and confirming settings pages Pl Control knob for setting the 0 2 concentraflon I IKey for setting,the ventilation mode SpnCPAP R02 E Key for setbrig Me ventilation modes VC-C hit V Q Control knob for setting the maxiinlLUT1 VC-AC inspiratory presSUre Prnax F lKey for setting:the ventilation mode VC-SICKV R Control knob for setting the respiratory rate RIR G they for setfing the ventOatmn mode PC-181PAP S Control knob foir setfing the tidat vollume VT HI Red,and yellow agalirrn indicator's T Explanation of color codes for qUiCk pre-setting I Key � foir suppressvng the acoustic alarim s ig- of RR and VT nail for 2 minutes Ul Key Curves to change between the J Key Alarms Reset for acknowledging Warm PreSSUM,flOW Or CO 2 (optionaq)cufve in sinaH messages and Large presentation K Key 0 2 inha)altjon for 0 2 inhalation or key V'Key Vallules X> to change screen pages in 100%0 2 for 100% 0 2 application, depending the"Measured ValUes"window on the option installed at manUfaCture VENTILATOR — DRAGER OXYLOG 17-9 Dr. Sandra Schwemmer, DO Page 3 of 3 443 dq dq d� �ry � o 1 u, rrF + k tZ pp� k CLo W , " c u W J � Kv � m Z � O 0 2 c � �u OW O 0 0 0 0 L13 W U 8 " � E �� W O 20 � o U Z > H's a u 0 a 10, 5 � aTj � H OU W W Z O w M W m 47 RR Ct LLJ ,' as u w w� s % 0 a) 0 LO dq d� lip i ti /„iuiiaiuuaaar IF W � U LU Q U W U Mu Z a O0 ' O U Q W � J Z W O �, ❑ l ,a 5 "v4 cl) Ul. W O 0 a� E E a� 3 U C 0 Monroe County Fire Rescue Trauma Star Medical Protocols OB ABBREVIATION LIST ACD- advanced cervical dilation AFI- amniotic fluid index (measure of fluid around fetus) AMA- advanced maternal age (generally >35 y/o) AROM- artificial rupture of membranes ASVD- assisted vaginal delivery- forceps, vacuum, manual rotation BBOW- bulging bag of water (bulging membranes) C/S- cesarean section CEFM- continuous external fetal monitoring CPD- cephalopelvic disproportion CTXS- contractions D&C- dilation and curettage DIC- disseminated intravascular coagulation DTR's- deep tendon reflexes EDC- estimated date of confinement (due date) FHT- fetal heart tones FM- fetal movement G/P- gravida=(pregnancies) / parity=(deliveries >20 weeks GA) GA- gestational age (weeks/days i.e. 24 2/7= 24 wks. 2 days) GBS- group Beta streptococcus (vaginal) GDM- gestational diabetes mellitus IUFD- intrauterine fetal demise IUGR- intrauterine growth restriction LGA- large for gestational age LMP- last menstrual period LTV- low transverse abdominal approach cesarean section OLIGO- oligohydramnios (low amniotic fluid) PIH- pregnancy induced hypertension POLY- polyhydramnios (>than normal AR) PPH- post-partum hemorrhage (EBL >500cc/vaginal del or >1000cc c/s) PPROM- prolonged premature rupture of membranes PROM- prolonged rupture of membranes PTC- preterm contractions (not considered labor) PTD- preterm delivery PTL- preterm labor SAB- spontaneous abortion (miscarriage) SGA- small for gestational age SROM- spontaneous rupture of membranes SSE- sterile speculum exam SVD- spontaneous vaginal delivery SVE- sterile vaginal exam TAB- therapeutic abortion TOL- trial of labor (attempted VBAC) VBAC- vaginal birth after cesarean section OB ABREVIATION LIST Dr. Sandra Schwemmer, Do Page 1 of 1 18-1 446 Monroe County Fire Rescue Trauma Star Medical Protocols VASOACTIVE MEDICATIONS DRUG NAME ONSET CONC UNIT OF MEASURE DRUG TITRATE CLASS Amiodarone Non-specific 450mg/250mg 150mg IVP over 3 min Antiarrhythmic (1mg/ml) 300mg IVP in cardiac D5W only! arrest Infusion 33.3ml/hr over 6 hours Cardizem Minutes 100mg/100ml Continuous infusion- Ca Channel Increase rate 5mg/hr Q (Dilitazem) Can mix in NS or mg/hr Blocker 15 min to desired HR D5W Dose: 5-15mg/hr Diprivan Seconds 1000mg/100mg Continuous infusion- Conscious Increase 5mcg/kg/min (Propofol) vial Mcg/kg/min sedation every 5 minutes to 10mg/ml Dose range: 5-50 desired sedation Pre-mixed me /k /min 1-10 minutes 500mg/250ml Continuous infusion- Vasopressor Increase rate 1-4 Dobutamine Can mix in NS or mcg/kg/min mcg/kg/hr every 10 D5W Dose range: 2-20 minutes to desired BP me /k /min Dopamine 5 minutes 400mg/250ml Continuous infusion- Vasopressor Increase rate 1- (16mcg/ml) mcg/kg/min 4mcg/kg/hr every 10 Can mix in NS or Dose range:2- minutes to desired BP D5W 20mc /k /min Epinepherine Minutes 4mg/250ml Continuous infusion Vasopressor Increase 0.01 (16mcg/ml) mcg/kg/min OR mcg/min Cardiac mcg/kg/min Q 15 Can mix in NS or Usual range: 1-10 Stimulant minutes.Titrate to BP D5W mcg/min OR 0.05- effect 1mc /k /min Heparin Seconds 25,000u/250ml Continuous infusion Anticoagulant Based on PTT and per Can mix in NS or units/hr protocol D5W Dose:weight or PTT based Insulin 30 minutes 100 units/100ml Continuous infusion Hormone Based on blood glucose NS ONLY units/hr and per protocol Dose based on blood glucose Lovophed Seconds 4mg/250ml Continuous infusion Vasopressor Increase rate by (Norepi) (16mcg/ml)OR mcg/kg/min OR mcg/min 5mcg/min every 3-5 16mg/250ml Usual range: 0.5-30 minutes to desired ((64mcg/ml) mcg/min OR 0.01- systolic BP Can mix in NS or 3mcg/kg/min (or MAP) D5W Seconds 10mg/250ml Continuous infusion- Vasopressor Increase rate 5mcg/min Neosynephrine (40mcg/ml) mcg/min every 3-5 minutes to (Phenylephrine) Can mix in NS Therapeutic dose:40- desired systolic BP and D5W 60mc /min Nitroglycerin Seconds 50mg/250ml Continuous infusion Vasodilator Increase by 5mcg/min (200mcg/ml) mcg/min every 3-5 minutes to Dose range: 1-200 20mcg/min. If no mcg/min response, may increase by 10-20mcg/min every 3-5 minutes <2 minutes 50mg/250ml Continuous infusion: Vasodilator Increase 0.5mcg/kg/min Nipride D5W ONLY mcg/kg/min increments. (Nitroprusside) (200mcg/ml) Dose: 0.3-4mcg/kg/min Maximum 10mcg/kg/min KEEP PROTECTED FROM LIGHT Minutes 20units/100ml Continuous infusion Vasopressor Increase rate in 0.2-0.5 Vasopressin Can mix in NS or units/min Cardiac units/hr every 15 D5W Range: 0.01-0.1units/min Stimulant for minutes Usual dose: 0.04units/min Septic Shock OR 0.2-0.9 units/hr VASOACTIVE MEDICATIONS Dr. Sandra Schwemmer, DO Page 1 of 1 8-2 447 Monroe County Fire Rescue Trauma Star Drug Formulary AMIDATE (ETOMIDATE) AACTII6:�I" S: short acting sedative hypnotic with rapid onset of action and recovery. Minimal cardiac and respiratory depressive l N „ effects causes no histamine release and may be useful in patients with compromised cardiopulmonary function. l III D It°,Ail"1011' S� Short acting intravenous anesthetic agent used for the .:ate induction of general anesthesia, procedural sedation and tracheal intubation r/k 1 ,,� , III �III IIIIII �, III �IIIIIIS Hypersensitivity to Etomidate or any component in the formulation. WA,III/„�`Y I I`Y G S.: Adrenal steroid production: Etomidate inhibits 11-B hydroxylase, an enzyme important in adrenal steroid production. A single induction dose blocks the normal stress induced increase in adrenal cortisol production for up to 8 hours. ADMINISTRATION BY CONTINUOUS INFUSION IS NOT RECOMMENDED BY CONCENTRATION THE MANUFACTURER. 40mg/20ml 2mg/ml Decreases cerebral metabolism and cerebral blood flow while maintaining perfusion pressure. Premedication with opioids or benzodiazepines can decrease myoclonus. POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: CNS: Myoclonus Endocrine: Adrenal Suppression GI: Nausea and vomiting Ophthalmic: Nystagmus DOSAGE: Adult dosage: 0.3mg/kg IVP over 1-2 minutes. Time/Action (Profile: Onset Desk Duration IV/10: 30-60 seconds 1 min 4-10 min 19-1 Dr. Sandra Schwemmer, DO AMIDATE (ETOMIDATE) Page 1 of 1 448 Monroe County Fire Rescue Trauma Star Drug Formulary ANCEF (CEFAZOLIN) ACTIIG Sm A beta-lactam antibiotic similar to penicillin's. Broad spectrum antibiotic. Action due to inhibition of bacterial cell wall synthesis. It attains high serum levels and is excreted quickly via the urine. ill' D1C.'KIFIG S., Antibiotic used to treat a wide variety of bacterial infections. It may be used before and during surgeries to help prevent infection. Used in the pre-hospital setting in mi sepsis, wounds that penetrate the fascia and for open fractures. row IN of VV us qt ]III° 1) "] gy m Hypersensitivity p ltl � ea.. zolin, other cephalosporin antibiotics, pencIlins, or beta-Lactams, or any component of the formulation. WA,III'°t�"Y II�"Y G S ............................................................... May be associated with increased INR. Hypersensitivity reactions including anaphylaxis. If allergic reaction occurs, discontinue treatment and institute appropriate supportive measures. CONCENTRATION POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: 1 gram Vial CNS: Seizure Derm: Rash, pruritus, Stevens-Johnson's Syndrome. GI: N/V/D. Abdominal cramps DOSAGE: Adult dosage: 1 GM IV over 30-60 minutes. Time/Action (Profile: Onset leak Duration IV/10: Within 5 min 19.2 Dr. Sandra Schwemmer, DO ANCEF (CEFAZOLIN) Page 1 of 1 449 Monroe County Fire Rescue Trauma Star Drug Formulary CARDENE (NICARDIPINE) ACTiG : Short acting calcium channel blocker, potent vasodilator 6 that produces more selective responses in the coronary °uu versus the vascular circulation. o lri lilt°,AWIWIOS: Short term treatment of hypertension Nlca.rdipine Hydrochrioride Injection 25 m� /10 ML Patients h advlance m III i""Illi L' � � �' nts with d aortic stenosis due to afterload q�6mmli ° reduction. Reduction of diastolic pressure in these patients may worsen rather than improve myocardial oxygen 10 n t.Sdngl 0a¢l Discard Unused PrJnx balance. For Intravenous USSV",, r WA II°t I`lY III I`lY GS: ............................................................... Reflex tachycardia may occur resulting in angina and or MI in patients with obstructive coronary disease. CONCENTRATION Use in caution. 25irrnd1irrnl 2.5irrnlirrnl POSSIBLE A VERSE REACTIONS A SIDE EFFECTS: CNS: Headache CV: Hypotension, tachycardia, ST segment depression, inverted T wave. GI; N/V, indigestion. Peripheral edema. DOSAGE: Adult dosage: 5 mg/hr. If desired B/P is not achieved at above dose: Infusion rate may be increased by 2.5mg every 5-15 minutes to a maximum of 15 mg/hr. *Administer as a slow continuous infusion, centrally or via a large peripheral vein. Time/Action Profile: Onset Peak Duration V/IO: Rapid 10-15 min 30 min (once discontinued) Dr. Sandra Schwem CARDENE (NICARDIPINE)mer, DO 19-3 Page 1 of 1 450 Monroe County Fire Rescue is Trauma Star Drug Formulary CARDIZEM (DILTIAZEM) ACTIIG : Antianginal, Antiarrhythmic Agent, Anti hypertensive, Calcium Channel Blocker. II114 IOIC.Wfi 0 1114 S. Control of rapid ventricular rate in atrial fibrillation or atrial flutter or conversion of PSVT. I I1XI�N[YICXI ll 0 N Sm 25 ��/5 nt G� �:roipli��l Hypersensitivity to diltiazem or any component of the ::1i:N,rrWBol'rWw�Jjqjr(°1101 formulation. Sick Sinus Syndrome (except in patients with a functioning artificial pacemaker). Second or third degree ':efll ri�4;;I7i �� Jra heart block (except in a patient with a functioning artificial pacemaker), severe hypotension or cardiogenic shock. I I'A,III'°t I`�I I`�I IIS: ............................................................... May cause first, second or third degree AV block or sinus bradycardia. Hypotension/syncope. CONCENTRATION 25mg/5ml 5mg/m POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: Conduction abnormalities, hypotension, dizziness. Potential for transient dermatologic reactions. DOSAGE: Adult dosage: 0.25 MG/KG IV over 2 minutes (average adult dose 20 mg). Repeat bolus dose may be administered after 15 minutes if response is inadequate. Time/Action IPro-Me: Onset Peak Duration V/10: Rapid 3 min 1-3 Hours Dr. Sandra Schwem CARDIZEM (DILTIAZEM)mer, DO 19-4 Page 1 of 1 451 Monroe County Fire Rescue is Trauma Star Drug Formulary DILAUDID (HYDROMORPHONE) us HUB ACT`I01" : ......................................... Narcotic analgesic,which depresses the central nervous and CONCENTRATION respiratory system as well as decreases sensitivity to pain. 2mg/ml Dilaudid also produces mild to moderate peripheral 2mdlml vasodilation. H14QK'.'A1'1Q114S., Moderate to Severe Pain Pain associated with isolated extremity fracture, renal colic, burns, etc. COIII ""i""III III I IIw' III C "Ii"iI OIIICS m .................................................................................................................... Hypotension/volume depletion, Respiratory depression, Gastrointestinal obstruction WA III'°t�"Y III�"Y G S ............................................................... Use in caution in patients with acute MI POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: CNS Depression, Hypotension, Decreased gastric motility. DOSAGE: Adult dosage: 0.5 mg- 1 mg IV (May repeat dose in 0.5 mg increments up to 2 mg max) Time/Action Profile: Onset Peak Duration V/IO: Rapid 3 min 1-3 Hours DILAUDID (HYDROMORPHONE) Dr. Sandra Schwemmer, DO 19-5 Page 1 of 1 452 Monroe County Fire Rescue is Trauma Star Drug Formulary ENALAPRILAT (VASOTEC) AACTIlG : ......................................... Used alone or in combination with other medications to treat hypertension. It is also used in combination with other medications to treat heart failure. Enalaprilat is in a class of medications called angiotensin-converting enzyme (ACE) inhibitors. mA ENA L.AP I LAT;,"W, IIIIDIt°,Ail"IOII S: ` Hypertension, Heart Failure, Asymptomatic LV dysfunction . ' (WM QVI I1XI�N[)IIICXI""1110111S: Fon ausr � �Hypersensitivity to en alapril or any component of the �46ddB formulation. Angioedema related to previous ACE inhibition treatment/idiopathic/hereditary angioedema DO NOT USE IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION CONCENTRATION 1.25mg/ml 1.25mg/1 iml POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: Angioedema, Dry Cough, Hematologic effects including anemia/thrombocytopenia DOSAGE: Adult dosage: 1.25 mg/dose given over 5 minutes. May repeat dose after 30 minutes if effect inadequate. **In profound hypertension: 5 mg/dose is accepted x 1 Time/Action Profile: Onset Peak Duration V/10: 15min 1-4hr 4-6hr Dr. Sandra Schwemmer, DO ENALAPRILAT (VASOTEC) 19-6 Page 1 of 1 453 ne Monroe County Fire Rescue is Trauma Star Drug Formulary ESMOLOL (BREVIBLOC) ACTI01 S: ......................................... Decreases the force and rate of heart contractions by jSllm�i'd"ii'i4il�r� �P,rgIIIVIIdY.ldl�, blocking beta-adrenergic receptors of the sympathetic j� nervous system,which are found in the heart and other organs of the body. Esmolol prevents the action of two naturally occurring substances: epinephrine and norepinephrine. lP4QK'.'A1'1Q114S., For treatment of hypertensive emergencies, SVT, atrial 1,0 fibrillation/flutter or non-compensatory sinus tachycardia. Useful in acute coronary syndromes when relative contraindications to beta blockade exist 0111 ""i""III1 II N IYII "Ii"i1 0 N S: Severe sinus bradycar dia, Heart block greater than first degree (except in patients with functioning artificial pacemaker), Allergy to beta blockers, Pulmonary Hypertension CONCENTRATION POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: 1 001rrnd1 01rrnl �0mdml Anaphylactic reactions (repeated exposure to beta blockade), Extravasation-Vesicant Hyperkalemia (associated with elevations in serum potassium), Hypotension DOSAGE: Adult dosage: Immediate control: BOLUS: 1000 mcg/kg over 30 seconds followed by a 150 mcg/kg/min infusion. Gradual control: BOLUS: 500 mcg/kg over 1 minute followed by a 50 mcg/kg/min infusion. "Adjust infusion rate as needed to maintain desired blood pressure (max 300 mcg/kg/min) Time/Action Profile: Onset Peak Duration V/10: 5-10min 30min 2-6hr Dr. Sandra Schwemmer, DO ESMOLOL (BREVIBLOC) Page 1 of 1 19 7 454 Monroe County Fire Rescue Trauma Star Drug Formulary LABETALOL (TRANDATE) ACTIIG S: ......................................... Beta-b locker that affects the heart and circulation and is used to treat hypertension. U Dlt°,AWIIWIG S: Hypertension (acute/chronic), Arterial hypertension in acute ischemic stroke/intracranial hemorrhage, �Mnd Hypertensive emergency in pregnancy I ' � 'al'a OIII III1 III I1III I IIIIIISInj . Severe bradycardia, Heart block >first degree (except in patients with functioning artificial pacemaker), Cardiogenic shock, Obstructive Airway Disease ugjjj''1110N 00 �. POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: Hypotension/syncope, Anaphylactic reactions(increased sensitivity with repeated exposure to beta blockers) CONCENTRATION 100mg/20m Siang/m DOSAGE: Adult dosage: Acute Hypertensive Emergency: 10-20 mg IV push over 2 minutes. May administer additional injections using double the dose (maximum dose: 80 mg/dose) at 10-minute intervals until target SBP is reached. Total maximum dose 300 mg. Hypertensive Emergency In Pregnancy: (SBP >160 or DBP > 110) 20 mg IV. If BP continues to exceed thresholds, may increase dose every 10 minutes in increments of 20-40 mg to a maximum single dose of 80 mg. Pediatric: 0.2 to 1 mg/kg/dose. Maximum dose 40 mg. Should be reserved for severe hypertension. Time/Action (Profile: Onset Peak Duration IV/IO: 2.5min 15min 3-6hrs Dr. Sandra Schwemmer, DO LABETALOL (TRANDATE) 19-8 Page 1 of 1 455 Monroe County Fire Rescue Trauma Star Drug Formulary LEVOPHED (NO REPINEPHRINE) ACT IlG S: Functions as a peripheral vasoconstrictor (alpha-adrenergic action) and as r an inotropic stimulator of the heart and dilator of coronary arteries(beta- adrenergic action). H14DK'.'A1'1Q114S., For blood pressure control in certain acute hypotensive states (e.g., myocardial infarction, septicemia, blood transfusion, and drug reactions). Used as an adjunct in the treatment of cardiac arrest and profound hypotension. IVIdIN INp V,Npi It 1.;� m ... U uV: nmu�nwb lWc�"a&Bra. wQA ,I 1 �OIl t XI l l�ould no be given patients who are hypotensive from blood volume deficits except as an emergency measure to maintain coronary and cerebral artery perfusion until blood volume replacement therapy can be completed. If Levophed is continuously administered to maintain blood pressure in the absence of blood volume replacement, the CONCENTRATION following may occur severe peripheral and visceral vasoconstriction, 4mg/4ml decreased renal perfusion and urine output, poor systemic blood flow 1img/imI despite "normal" blood pressure, tissue hypoxia, and lactate acidosis. WA,III'°t l`Y II1"Y G S: ............................................................... Use with extreme caution in patients receiving monoamine oxidase inhibitors (MAGI) or antidepressants of the triptyline or imipramine types, because severe, prolonged hypertension may result. POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: Extravasation: Vesicant. Must ensure proper IV catheter placement prior to and during infusion. Use in patients with profound hypoxia or hypercarbia may produce ventricular tachycardia or fibrillation. Use in extreme caution. DOSAGE: Adult dosage., 3-12 mcg/minute. Titrate to desired response. Usual maintenance range: 2-4 mcg/minute. ACLS (ROSC): 7-35 mcg/minute Sepsis/ Septic Shock: 5-35 mcg/min Pediatric: 5-4.1 mcg/kg/min„ 1 iitirate to desliired iresponse. USUaal irnalintenasnce range: 0.1 2 irnc /Ik /irnlin Time/Action (Profile: Onset leak Duration IV/IO: Rapid 1-2 min L Dr. Sandra Schwemmer, DO EVOPHED (NOREPINEPHRINE) 19-9 Page 1 of 1 456 Monroe County Fire Rescue Trauma Star Drug Formulary LOPRESSOR (METOPROLOL TARTRATE) MJ11111 ..SSelective1� treatment blocking agent used for the 6 eatment of hemodynamically stable patients with definite or suspected acute myocardial infarction to reduce cardiovascular mortality. On6 6005 IIII10lC.;AII"IOII' S METOPROLOL Angina, Hypertension, Improved survival post Myocardial TAIRTRAT"E is Infarction INJECTION, USPri � III ( 91ML) dr , SIlluslllBrallldycardia/S Sm F�raa � 9 ignificant first degree heart block/SBP Nonly wx1'�' N�iLSlrgNeUseVW �W <100, Cardiogenic Shock, Severe peripheral arterial .. circulatory disorders POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: AV Block, Bradycardia/Hypotension, CNS depression CONCENTRATION 5mg/5m 1 img/imI DOSAGE: Adult dosage: STEMI: 5 mg IV. May repeat dose every 5 minutes for u to 3 doses as needed based on heart rate and blood pressure. Maximum dose 15 mg. Acute Ventricular Rate Control: 2.5 to 5 mg over 2 minutes. May repeat dose every 5 minutes as needed to a maximum dose of 15 mg Time/Action (Profile: Onset Peak Duration IV/10: Immediate 20 min 5-8 hrs. LOPRESSOR (METOPROLOL TARTRATE) Dr. Sandra Schwemmer, DO 19-10 Page 1 of 1 457 Monroe County Fire Rescue Trauma Star Drug Formulary NITROGLYCERIN DRIP ,2 �„FrY ACTIiG m � Belongs gs to the group of medicines called nitrates. Itworks by relaxing the blood vessels and increasing the supply of blood and oxygen to the heart while reducing itsworkload. .... I11 DIC.;A'1' 011' S., Hypertension, Angina, Congestive Heart Failure 0rI C0111 I I1XI I I['YIIC ""I""IIIOIIINS q oIr�ra Concurrent use with PDE-5 inhibitors (Sildenafil, Viagra, Tadalafil or Vardenafil), Do not use with solutions containing eq,iop, dextrose, Increased Intracranial Pressure, Hypovolemia, 1Il Restricted Cardiomyopathy POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: Headache, Hypotension, Bradycardia, Increased ICP CONCENTRATION 50mg/250ml 200mcg/ml DOSAGE: Adult dosage: ANGINA/CAD: 5 mcg/min, increase by 5 mcg/min every 3-5 minutes to 20 mcg/min. If no response at 20 mcg/min, may increase by 10-20 mcg/min every 3-5 minutes to a maximum dose of 400 mcg/min. Time/Action Profile: Onset Peak Duration IV/10: NITROGLYCERIN DRIP Dr. Sandra Schwemmer, DO 19-11 Page 1 of 1 458 Monroe County Fire Rescue Trauma Star Drug Formulary PAVULON (PANCURONIUM) ACTI01 : ......................................... Non depolarizing neuromuscular blocking agent that causes neuromuscular blockade for endotracheal intubation/mechanical ventilation. Provides skeletal muscle relaxation for endotracheal . .,o, intubation and mechanical intubation W: L " ��"� °'"�"'�� rkv QVI I1XHNIYICXI""1110111 SPancu : irlu� il i Sensitivityo pancuron Iw� fmaim��� �� the formula ium bromide or any component of formulation WINMI009 H*gktAMt WoF""''Wtga�1'Ski POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: Anaphylaxis DISEASE SPECIFIC CONCERNS: BURNS: Resistance may occur in burn patients Conditions that ANTAGONIZE Neuromuscular Blockade: CONCENTRATION Respiratory Alkalosis, Hypercalcemia, peripheral 101mg/101ml neuropathies, denervation and muscle trauma 1 m dmI Conditions that POTENTIATE Neuromuscular Blockade: Severe Hypokalemia, hypocalcemia. Hypermagnesemia. Metabolic Acidosis, Respiratory Acidosis. DOSAGE: Adult dosage: 0.05 mg/kg after dose of Succinylcholine for intubation Time/Action Puroflle: Onset Desk Duration IV/10: 2-3 min 60-100 min Dr. Sandra Schwemmer, DO PAVULON (PANCURONIUM) 19-12 Page 1 of 1 459 Monroe County Fire Rescue is Trauma Star Drug Formulary ROCURONIUM (ZEMURON) ACTI01 S: Aminosteroid non-depolarizing neuromuscular blocker or muscle relaxant used to facilitate tracheal intubation by Y providing skeletal muscle relaxation, most commonly required for surgery or mechanical ventilation. I I' Ili It°;AWII IOII' S: 10 mL Provides skeletal muscle relaxation for endotracheal KJI'51po405�"'lvo O" intubation and mechanical intubation r OIIVI I1A III N 1)III "" 11i 0 N S: jub Hypersensitivity to rocuronium, other neuromuscular in blocking agents or any component of the formulation POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: Anaphylaxis DISEASE SPECIFIC CONCERNS: BURNS: Resistance may occur in burn patients Conditions that ANTAGONIZE Neuromuscular Blockade: CONCENTRATION Respiratory Alkalosis, Hypercalcemia, peripheral 1001mg/101MI neuropathies, denervation and muscle trauma 101mg/ml Conditions that POTENTIATE Neuromuscular Blockade: Severe Hypokalemia, hypocalcemia. Hypermagnesemia. Metabolic Acidosis, Respiratory Acidosis. DOSAGE: Adult IRSII dosage., 0.6 mg/kg IV Time/Action Puroflle: Onset Desk Duration I V/10: 60-70 Sec 30sec- 13 min 15-85 m i n Dr. Sandra Schwemmer, DO ROCURONIUM (ZEMURON) 19-13 Page 1 of 1 460 Monroe County Fire Rescue is Trauma Star Drug Formulary ROMAZICON (FLUMAZENIL) AACTIIG : Used as an antidote in the treatment of benzodiazepine overdoses. It reverses the effects of benzodiazepines by competitive inhibition at the GABAA binding site of benzodiazepine receptors, which are present through about 70% of the body. There are many complications that must be taken into consideration when used. These include lowered seizure threshold, agitation, and anxiousness. Flumazenil's short half-life requires multiple doses. Because lUma1 'tll F of the potential risks of withdrawal symptoms and the Injection, U'SP drug's short half-life, patients must be carefully monitored to prevent recurrence of overdose symptoms or adverse E:: (0.7 mg per mL) a ir.': side effects. Startle For Intravenous Use Unly o z RXonly J a„ 5 rmL 1114 (Multiple®aso vVau lk 7, Benzodiazepine reversal ..................................................................................................................... Hypersensitivity to flumazenil, benzodiazepines. CONCENTRATION POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: 0.5irrnl5irrnl 0.1 mlml Amnesia, CNS depression, Respiratory depression, Seizures DOSAGE: Adult dosage: Initial: 0.2 mg IV over 15 seconds. Repeat doses (maximum 4 doses): Time/Action (profile: Onset Peak Duration IV/IO: 1-2 min 6-10 min ROMAZICON (FLUMAZENIL) Dr. Sandra Schwemmer, DO 19-14 Page 1 of 1 461 Monroe County Fire Rescue Trauma Star Drug Formulary SUCCINYLCHOLINE (ANECTINE) ACTIIG Sm ......................................... Short term neuromuscular blockade ill' DIC.'A1IOII' S., Facilitation of endotracheal intubation/mechanical ventilation UN''I I1XI�NIYCXI""1110111 Sm Hypersensitivity ul tion. s „ ;rut✓ity,� ,,,w cinylcholine or any component of the form Personal or family history of Malignant Hyperthermia, Skeletal muscle myopathies, Injury following CC major burns. WA I ° � May be associated tt s°.... t ap rN�,i9 (AXI % K"1� ociated with acute onset of malignant hyperthermia. POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: Hyperkalemia, Anaphylaxis, Bradycardia, increased intraocular pressure, transient increase in intracranial CONCENTRATION pressure, may increase intragastric pressure, resulting in 2Birrndmirrnl 2BBim d regurgitation and possible aspiration DOSAGE: Adult dosage: RSI: 1.5 MG/KG IV (duration of action 3-5 minutes) Re-dose: 1- 1.5mg/kg at appropriate intervals as needed for effect Time/Action Puroflle: Onset Peak Duration IV/10: Rapid 3-5 min Dr. Sandra Schwemmer, DO SUCCINYLCHOLINE (ANECTINE) 19-15 Page 1 of 1 462 Monroe County Fire Rescue Trauma Star Drug Formulary TRANEXAMIC ACID (TXA) (CYKLOKAPRON) ACTIIG S: Antifibrinolytic hemostatic that competitively inhibits the activation of plasminogen to plasmin, an enzyme `7 that degrades fibrin clots, fibrinogen, and other plasma proteins. A 1 I114 DIt°;AWIFIOII' S: Blunt or penetrating trauma, signs and symptoms of s Tranexar�ric ,� hemorrhagic shock (SBP <90 mmHg and HR > 110, major blunt or penetrating torso or pelvic fracture, one or more Fah aVe1MO�Ru e _ I major amputations, and/or evidence of severe bleeding), 1Y external manual efforts to control the hemorrhage have Rim r been instituted, < 3 hours since incident. OIII ''I I1A Ill N 1)Ii ''I IIi 0 N S: More than 3 hours p orethan3hoursp ost incident. CONCENTRATION WA,III'°tI`YII`Y�;IiIS: 10001mg/l olml Pat ients...t.a,......... king estrogens, progestins, or oral tretinoin (a 100mg/ml chemotherapy agent used to treat leukemia) may have enhanced thrombogenic effects from TXA. Dose reductions are necessary in patients with severe renal impairment. If TXA has been administered, ensure that the receiving facility is aware that the patient has received TXA prior to arrival. POSSIBLE A VERSE REACTIONS AND SIDE EFFECTS: Headaches, back aches, nasal sinus problems, abdominal pain, diarrhea, pulmonary embolism, deep vein thrombosis, anaphylaxis, visual disturbances. DOSAGE: Adult dosage: 1 gram mixed in 100ml NS administered over 10 mins. If TXA has been administered by the sending facility, continue or initiate an additional 1 gram of TXA at a rate to complete the 2nd dose over 8 hours. Time/Action (Profile: Onset Peak Duration IV/IO: 1-2 minutes 3-5 minutes TRANEXAMIC ACID (TXA) (CYKLOKAPRON) Dr. Sandra Schwemmer, DO 19-16 Page 1 of 1 463 Monroe County Fire Rescue Trauma Star Drug Formulary TERBUTALINE ......................................... Terbutaline is a Beta 2 agonist used in the event of preterm labor to help relax uterine muscles and stop contractions. I III D It°,AWIIW 1011' S: Short term treatment of preterm labor 1 � �LlHypersensitivity yp irlllsens t llV tytlo Il .. r H e � � Terbutaline, sympathomimetic amines or any component of the formulation. I WA tll �'r I " e S TMremlabo r: Terbutaline is not FDA approved for prolonged tocolysis (>48-72 hours) POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: Tachycardia,Transient Hyperglycemia, Myocardial -CONCENTRATION ischemia, Pulmonary edema 1 img/imI DOSAGE: Adult dosage: 0.25 MG SQ every 20 minutes to 3 hours for a max dose of 1 mg. Hold for pulse > 120. Time/Action IPro-Me: Onset Peak Duration IV/10: 6-15min 30-60min 90 min-4 hrs. TERBUTALINE Dr. Sandra Schwemmer, DO 119-17 464 Page 1 of 1 Monroe County Fire Rescue Trauma Star Drug Formulary VECURONIUM ACTI01 : ............................ Non-clepolarizing Non-depolarizing Neuromuscular blocking agent used to relax muscles and facilitate endotracheal � intubation/mechanical ventilation. Provides skeletal muscle relaxation for endotracheal pit intubation and mechanical intubation. r� Q I I1A III N 1 III III 0 I Sm„ "r o Hypersensitivity to Vecuronium or any component of the formulation POSSIBLE ADVERSE REACTIONS AND SIDE EFFECTS: Anaphylaxis CONCENTRATION 101mg DISEASE SPECIFIC CONCERNS: 1 mg/ml (Reconstituted to 10 iml) BURNS: Resistance may occur in burn patients Conditions that ANTAGONIZE Neuromuscular Blockade: Respiratory Alkalosis, Hypercalcemia, peripheral neuropathies, denervation and muscle trauma Conditions that POTENTIATE Neuromuscular Blockade: Severe Hypokalemia, hypocalcemia. Hypermagnesemia. Metabolic Acidosis, Respiratory Acidosis DOSAGE: Adult IRSII dosage., 0.08-0.1 mg/kg IV Time/Action Profile: Onset Desk Duration IV/10: 1.5-2 min 3-5 min 25-40 min VECURONIUM Dr. Sandra Schwemmer, DO Page 1 of 1 19-18 465 MARATHON FIRE RESCUE EMERGENCY MEDICAL SERVICES TRAUMATRANSPORT PROTOCOLS EFFECTIVE DATE: March 1, 2021 I. DISPATCH PROCEDURES Monroe County is unique in the state of Florida, in that it is comprised of a chain of islands stretching one hundred and thirteen miles in length, and connected by only one main highway. MFR ALS transport vehicles are located at strategic points throughout the City of Marathon, from M M 40 to M M 60.5 and are supplemented by BLS Fire/Rescue vehicles,which are activated as first responder support for EMS personnel. 1. Calls are received via an enhanced 911 system (Monroe County Sheriff's Office Central Dispatch Center) located in Marathon, Florida. 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 EMS 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 en route to...", after which the nature, location, and known details of the call are transmitted. This information is transmitted via 800 m Hz radios carried by all EMS crewmembers, and all Fire-EMS Supervisory personnel. The Dispatcher may also elect to activate a BLS Fire-EMS vehicle for first response support. 4. With potential trauma patients or injuries that may warrant air transportation a request for emergency air transport service to respond may be made by the MFR Incident Commander, after the on scene Lead Paramedic has declared a "TRAUMA ALERT". 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.). On scene personnel may communicate requests for additional intra-agency resource support (e.g. manpower, equipment, additional vehicles, supervisory personnel), via the Dispatch Center. Requests for inter-agency support(e.g.,law enforcement,trauma transport officers, utility company, Fire Suppression equipment and personnel, Law Enforcement, Coast Guard), may also be communicated via the Dispatch Center. II. PRE-HOSPITAL PROCEDURES—64J-2.002 F.A.C. 1 466 1. Upon arrival at the incident,EMT and Paramedic 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 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 adult 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/cutaneous, longbone fracture/skeletel, patient's age, and mechanism of injury. 2. Upon determination that the patient meets TRAUMA ALERT Criteria, the Paramedic in Charge or Incident Commander will initiate direct radio communications with the SATC, SAPTC or local receiving facility. Communications from field EMS 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 111. ADULT TRAUMA ALERT CRITERIA 64J-2.004, F.A.C. 1. 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. 1. Drowning or near drowning patients. 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 bums to 15 percent or more of the total body surface area; 2. amputation at or above the wrist or ankle; 3. any penetrating injury or GSW to the head, neck, torso or extremity; 4. chest wall instability or deformity (suspected flail chest); 5. crushed, degloved, mangled or pulseless extremity; 6. dislocations of the hip, knee or ankle. Superficial wounds where the depth of the wound can be determined are excluded. e. Longbone Fracture/ Skeletal: The patient reveals signs or symptoms of two or more longbone fracture sites. Long bone fracture sites are defined as the (1) 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. Severe facial injury/fractures with potential airway compromise; 2. Electrocution or lightning injury with loss of consciousness or visible signs of injury; 3. Blunt abdominal trauma or chest trauma in a patient with history of paralysis (paraplegia or quadriplegia); 2 467 4. Pregnant patients > 20 weeks with abdominal pain after blunt trauma. 2. Should the patient not be identified as a Trauma Alert using the RED criteria listed in (1) 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 seven 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; 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"high risk"anticoagulants; e. Age: The patient is 55 years of age or older (special consideration should be given to patients 65 and over with minimal signs/symptoms following a traumatic injury); f. Mechanism of Injury: Patients exhibiting any of the following criteria: i.The patient has been ejected or thrown from an automobile, motorcycle or golf cart; ii. The patient has been ejected from a horse (with or without loss of consciousness) with suspected anatomical injury; iii. Blunt head, chest, or abdominal trauma in patients on Coumadin or anticoagulants with high risk of bleeding (see pg.12 Anticoagulants with High Risk of Bleeding); iv. There is a traumatic death in the same passenger compartment of the motor vehicle; v. 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; vi. Vehicle telemetry data consistent with high risk of injury (vehicle telemetry data, when available, collected at the time of the crash and relayed to dispatch to assist in predicting serious injury); vii. Falls from 10 feet or more; viii. Pedestrians or bicyclists that are struck,thrown, or run over by motorized vehicles traveling at speeds greater than or equal 20 miles per hour; ix. Motorcycle, golf cart or ATV crash at speeds greater than 20 miles per hour. 3. In the event that none of the conditions are identified using the criteria in (1) or(2) 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. 4. Marathon Fire Rescue shall provide the trauma center or hospital with information required under subsection 64J-1.014(5), F.A.0 and the information listed below at the time the patient is transferred to the personnel of the receiving trauma center or hospital: a. Time of injury if different from the time of the call; b. Date of injury if different from day of call; c. County of injury; d. County of residence of patient; e. Cause of injury; f. Injury site/type; g. Trauma alert criteria if met as defined in Rule 64J-2.004 or 64J-2.005, F.A.C.; 3 468 h. Protective devices if motor vehicle crash, bicycle or marine crash. The information listed above shall be documented on the patient care record of the transporting unit that delivered the patient in accordance with the requirements of Rule 64J- 1.014, F.C.A. 5. A Marathon Fire Rescue Patient Care Report will be com pleted as defined in section 64J — 1.001(18) F.A.C. by the Rescue personnel that were on-scene. Additionally, a hand written "Patient Care Field Report" containing information pertinent to the patient's identification, patient assessment, and care given will be provided by the EMS ground crew to accompany all Trauma patients transported by Trauma Star. A final ePCR report must then be sent to the receiving Trauma Center as soon as completed, or within 24 hours of the incident. A Patient Care Report will also be completed for all "dead on the scene"trauma patients, regardless of whether MFR transports the body. Marathon Fire Rescue 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 olderfor the presence of at least one of the following three(3)criteria to determine whether to transport as a Trauma Alert.Thesefour criteria are to be applied in the order listed,and once anyone criterion is met that identifies the patient as a Trauma Alert,no further assessment is required to determine the transport destination: 4 469 1. Meets color-coded triage system (see below) 2. Meets focal criteria(specify):, 3. Patient does not meet the traumia criteria listed,but was transported to a traurna center due to EMT or paramedic judgment(reason for transport must be justified in run report). RED BLUE AIR VAY Ii,r1'vI' MR,1,`,AY AS I STra.NC'F. or I'rhR It, ur ,,) h!P o 17Rd:3VVNII G IDR ITI VIC IbRA')VVNIN ICr:G p.,IRCUL.At{Y: IN I A(r Ki OF 71'k I AI. IP-Sr:or BF 90 rnin A 1 .N V11 H-i F .I4/M FAILURE(DN DU L,YSIS EI'r'I?0 IIE G""+CdW;N„ OVER 65 VI AE ,,5 Iblt;:ABIG .a fruRE,,Ew(E i':£F 0i' SUSPICION OF SPINAL HEAD INJURYW IITH LOSS OF CONSCIC)USNES.S. CORD HN fldIRY rare LOSS OF Vr NSAT OIW AMNESIA tar IVF VJ ALTERED MENTAIL STATUS `i0F T fl.a i ORi'DEGREL- 1'GlfVN MC 95`, MORE EIV,r, SOFT TISSUE LOSS' aU ila^t,.FDf 010Nv Ar OR ABOVE P Ili;W`f,l$"f'or AY',d1,1.tie ANY 1'1I,Il1'T,*.A"i1NG INJURY' 10 HEAD 0RS0 ttr EXlREMOY DISL("CAflON OF LHE H11" K1,JEI l',R,ANKL.IF C11E,S"rVrelK.G.INSrASTI.1'I-v rx UdL.41°,°,aRN41I'"IhLAH I Nik"oT 4 Y USHED MANGLES CI'EGLOVED OR FOLLiE ESS I A'rlVEMITY LONG BCJNE I RACI'IIRE L,tt='v*u.r PVI71RL L.£LCaaG f:ar)Pll:`"," SINGLE LONG BONE Fx SITE DUE TO MVC' G'RAC,T.M RE/ SKELETAL` SINGLE LONG BONE F'X IN PT ON COUMADIN Or ANTICOAGULANTS WITH HIGH RISK OF BLEEDING AGE 'rJ YEARS OR OLDER MECHANISM HEAD rfdP-rUMA I14 1-r1IENTS ON EJECTION FROM AUTOMOBILE MOTORCYCLE, OF play}VARY GOLF CART OR HORSE WITH ANATOOVIICAL INJURY ,1 JER,E Fs"CIAL.IIdtIfRYn I1:RAL,TU1'4, " OII6HPO^ ENflAl AiRlh,,\ C;t:}MP1afyNWIL'F E'LLN'T'HEAD.CHEST OR ABC1OMINA,L.TRAUMA IN PATIENTS ON COUNIADIN or ANTICOAGULANTS EL EL",1°Rf_1l;UlTl034 OR,I.4R:rC-I'INl N(. l� J JRY V,1F 11 1 07 SS OF" WITH HIGH RISK OF BLEEDING f;",Ihq"SCICstI;FPCRcSS OR VII 1111'A E OFF lN,WRY iVll._UNP ';rWl3ptrOMH'4AII )i G:HEST u:1ALAAA IN PA'Tglrl',9ro'1�'WITH FqS� rSFa.V DEATH-9 IN :SAME PASSENGER COMPARTMENT OF.F'PARAL Y,,IS II-aARAPLEGi A or()I.JAIaI IPLEGIA1 INTRUSION INCLUDING ROOF-12¢NCHES 0(,CUPANT[SITE', >r B INCHES ANY SITE INTO THE C19 E^„aN I1RC r.,2I1wks VVI"fI 1 AIIJ30TMNAL F"6r1r,1 AND BLUNT-f6at.,ELXMA PASSENGER COMPARTMENT VEHICLE TELEMETRY DATA CONSISTENT WITH HIGH RISK OF INJURY' FALL 10 F'T air rw1ORE AUTO VS. PEDESTRIANIBICYCI'STTHROWN, RUN! OVER ci WITH IMPACT GREATER THAN 20 MPH MOTG'9RCYCYLE CRASH >20rntah kRI`IlD =any one(1)-Iransport as a t'raw'ma alert BLUE =any two(2)-I anspora.as a trauma alert 1. Airway assistance includes manuaIjaw thrust,continuous suctio6ng,oruse of otheradjunctsto 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 bonefracture sitesare defined as the(1)shaft of the humerus,(2)radius and ulna„(3)femur,(4)tibia and fibula. 5. Vehicie Tel ernetry Data when avaliabiewMbe relayed to dispatch;the data can assist in predicting potentia@ serious injuries from the data collected at the time of:the crash. IV. PROTOCOL FOR PEDIATRIC TRAUMA 64J-2.04'5 1. 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 5 470 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. 1. Drowning or near drowning. 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; or 2"d or 3'd degree burns to 10 percent or more of the total body surface area; any penetrating injury or GSW to the head, neck, torso or extremity; dislocation of the hip, knee or ankle; or amputation at or above the wrist or ankle; or a major de- gloving injury. (Superficial wounds where the depth of the wound can easily be determined are excluded from this criteria), e. 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. f. Mechanism of Injury: Patients exhibiting any of the following criteria will be Trauma Alerts: i.Electrocution or lightning injury with loss of consciousness or visible signs of injury; ii. Severe facial injury with airway compromise or potential airway compromise; iii. Penetrating injury to the extremity at or above the elbow or knee; iv.Blunt abdominal trauma or chest trauma in patient with history of paralysis (parapalegia or quadriplegia); v. Blunt head, abdominal, or chest trauma in patient with bleeding disorder or taking anticoagulants; vi. Auto versus pedestrian or bicyclist thrown, run over, or impact resulting from speeds more than 20 mph; vii. Ejection from automobile,ATV, golf cart or horse with visible signs of injury. 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 five components included in this section: a. Size: The patient weighs <22 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 sustained a dislocation of the upper extremity, excluding fingers. 6 471 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: i. Ejection, partial or complete, from an automobile, ii. Death in the same passenger compartment, iii. 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, iv.Vehicle telemetry data consistent with high risk of injury, v. 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. Marathon Fire Rescue 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): 7 472 I 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). RED BLUE SfZE WEIGHT�L 22 Kq AB WAY RESP RAIE <r2C fN IN FAIN 1 YR REST F,�A TE 1,:IN C1 WLDRELP'4 I' R i 5 YR DRCUL A 1 ON FAH,0 g NON PALPABLE C*iDT)D m FENIORAL CAR(-)tID ar FEMORAL PLfLSES PALPAULE, BW 11HE RADIAL OR BP .Art rrrnHq PEDAL PULSE NOT PALPABLE or SHP c 90-rnr1flHrj DISABR.JTY AL'ERELF-L%IAj,0"q,STAIUS; or IrrFLSENCE: OF AMNESIA or LOSS OF CC)rr�SCICUSNES',3 x SUSI')TCT014 OF SP04,01 GC)R0 PIN UPY ar LOSS OF SLI',SAIIDN SOFT TISSIJE PAAKJR SCd-T HSSUL 015R1[,jP1t(:IN or VIAJOR FLAP AITULSION DESLOCATION OF THE UPPER EXTRrMITY 2 or 3"A�j p','qS 1(1f) I(Y", YraS A Al",dY PENE I RATTNG R4 0JRY-,"SSIN TO HEAID NECK, TOR,Srl) OR, EXIRE'JIflry DiSk,C)GAIRY,J OF ITHF HIP.KNEE OR AtIKI E AMPUIATIOIN AT OR AF30VE THE WRIST or ANKLE MAJOR, DE-CA OViNG INJURY L.C)NG BONZE' 0�`Erq UJNG BONE',i-R),,CTURE w NILW'PLE F)1,ACrURL SINGLE LONG BONE IFRACWRE SITE" FRAC TUBE/SKELE IFAL `p rEs, ra, ItVtJV..TWLE DISLOCAflON Sf ES MECHANISM OF 1,FCTR JCIt)TiON OR LIGHTNING STRIKE WtTii LOSS OF EJECTION(PARTIAL cr COMPLETE) FROM AUTOMOBILE INJURY CONSCIOUSNESS(,IR VIS E,'LE SICr3r4S(DIF INJURY DEAJH IN SAME PAS5EN(:'5ER COMPARTMENT SEVERE FACIAL INJURY W1 I H AIRWAY C110INAPROMISE. kNTRUSION INCLUDING ROOF >12 INGIIE.S OCCUPANT SITT-., P11'I,,IETR,A1VN(j To Tl-1E EXI"RF,LIHY"I or ABOVE 1B INCHES AINY SITE INTO THE PASSENGER COMPARTMENT 8i'4 ECj ()W I)NL KNEE VEHICLE FELEME]rr RY DATA CONSISITIENT WITH H$G-i RISK OF BLUN T /WD0hIiH4A[ jr(',HES1 rRAIUMA IN PA HEN r Wrria INJURYr or PARALYSAS(FIARAIPLEGiA or(DUADRWI EGiA) FALL r 10 FT OR 2-3 TWES TIRE HEIGHT OF T)-IE CHII D BLUNT HEAD CHEST", ABDOMINAL TRAUMA IN FITVVITH RLF4FTHNG DISORDER OR 0114 V,"TH 49K41 RISK DF R'E�)ESTr�[Al!,4/B il(,',IIST lKROVIN RUIr,4 OVER Or A?I T I I IBWUACT GNE A Tr E p fH AN 20 I,,fi1,1H EJECTION FROM AUTO ATV GOlF CART OR HORSE W Ti3 I SIGIAS OF P4JUIR11 RED =--any one(1)-transport as a drauma Mart' BLUE a any two(2)-transport as a trawna allert 1. Airway assistance includes manualjaw thrust,continuous suctioning,or use of other adjuncts to assist ventilatory efforts. 2. Altered mental states conclude drowsiness,lethargy,inabilIty to fo�dow commands,unresponscoveness to voice,totally unresponsive, I Long bone,fracture srtes are defined as the(1)shaft of the humerus, (2)radius and ulna, (3)femur,(4)tilbia and fibula. 4. Long bone fractures do not include isolated wrist or ankle fractures. 5 Includes major de-gloving injLjry, 6, Excluding superficial wounds where the depth of the wound can be determined, 7. Vehicle Telemetry Data wheri available can be relayed to dispatch;the data can assist in predicting SeraOLIS injuries from the data collected at the time of the crash. V. TRANSPORT DESTINATION CRITERIA 1. There are no state approved trauma centers in Monroe County. Therefore, it is the decision of the Medical Director, Dr. Sandra Schwernmer, that it is in the, best medical interest of patients who meet "TRAUMA ALERT" criteria as set forth in 64J-2,004, F.A.C. and 2.00 '.A.C., and as outlined in these Trauma Transport protocols to be transported as expeditiously as possible to a the nearest appropriate SATC, SAPTRC or in certain 8 473 circumstances (air transport not available within 20 minutes) to the local hospital closest to the scene for evaluation and stabilization. 3. M FR has access to a helicopter,"TRAUMA STAR",operated by the Monroe County Sheriff, and licensed for emergency medical transport by Monroe County EMS.TRAUMA STAR is based in Marathon and Key West and will respond to incidents, when summoned, to transport TRAUMA ALERT patients to Ryder Trauma Center, Miami Children's Hospital, Kendall Regional, or to a local receiving hospital for emergent stabilization prior to transport to a SATC, SAPTRC, or other receiving facility. 4. Any patient meeting Trauma Alert Criteria will be considered a TRAUMA ALERT PATIENT and should be transferred as expeditiously as possible from the scene or local receiving hospital (depending on the location of the incident) to Ryder Trauma Center, Kendall Regional Medical Center, Jackson South Community Hospital or Miami Children's Hospital. A TRAUMA ALERT should be flown directly from the scene of the accident provided access to Trauma Star is the most expeditious method of transfer. 5. If circumstances prohibit direct scene transport to Ryder Trauma Center, Kendall Regional Medical Center, Jackson South Community Hospital, or Miami Children's Hospital, then Trauma Alert patients will be taken to the nearest local hospital (Fishermen's) for stabilization and treatment prior to transport to a SATC or SAPTRC. VI. HELICOPTER TRANSPORT PROCEDURES Two(2)sets of 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 patients. 1. OPERATIONAL CRITERIA: (Air Transport will be used) A.) If the patient is considered a TRAUMA ALERT patient as outlined in Section III & IV of this protocol. B.) Blockage of the main road, making ground access to the nearest receiving Hospital impossible. C.) Failure of the drawbridges, making ground access to the nearest Hospital impossible. D.) Extrication time greater than fifteen (15)minutes. E.) If the helicopter is needed to gain access to the patient or needed to transport the patient out of an inaccessible area. F.) If ground transportation is not available and is not expected to be available within a reasonable time(15-20 minutes, depending on injuries). G.)Possible MCI (mass casualty incident). VII. EMERGENCY INTER-FACILITY TRANSFER OF TRAUMA PATIENTS As previously noted, there are no state approved trauma centers in Monroe County.The closest available service for air transport of Interfacility Trauma/Medical Transfers(out of county)is Trauma Star in Marathon, FL. Other air transport services are available in Dade County,and Key West(Life Net).On occasion,a TRAUMAALERT patient may be transported by ground to a local hospital for stabilization/treatment prior to transport to a SATC or SAPTRC. 9 474 If after initial evaluation and stabilization of the patient, the initial receiving facility deems transfer to a SATC or SAPRC to be necessary (patient meets Inter-Facility Trauma Transport Guidelines), in the best medical interest of the patient, air transport should occur as expeditiously as possible. If air transport is unavailable, ground transport should occur as expeditiously as possible to the nearest appropriate facility. Should air transport be deemed to be the appropriate method for the transfer, the initial receiving facility directly contacts TRAUMA STAR, or other air transport services. Landing facilities are available for rotor wing aircraft at all local hospitals. If the initial receiving facility deems ground transport appropriate, the local hospital will arrange transportation of the patient. MFR may be called upon to assist the local hospital in ground transportation of a trauma patient. All Inter-Facility Trauma Transfers must be prioritized and handled as expeditiously as possible. Ground trauma inter-facility transfers should be taken to the nearest SATC, or closest appropriate facility, based upon the patient's condition. Should supplemental personnel, such as medical or nursing staff, respiratory therapy staff, etc. be necessary to assist the EMS crew for optimal patient care,the transferring hospital will coordinate the necessary personnel to accompany the EMS ground transport personnel. Vlll. TRAUMA TRANSPORT PROTOCOLS-MEDICAL DIRECTOR APPROVAL-64J-2 003 These protocols have been submitted by Marathon Fire Rescue and have the approval of the agency Medical Director, Sandra Schwemmer, D.O, FACOEP-D, FACEP. IX. APPROVED TRAUMA CENTERS AND INITIAL RECEIVING HOSPITALS Approved Trauma Centers and Pediatric Trauma Referral Centers 1. Level 1: Ryder Trauma Center, University of Miami/Jackson Memorial Hospital Medical Center(Adult and Pediatric trauma care) 2. Level I: Kendall Regional Hospital,Miami(Adult and Pediatric Trauma care) 3. Level 1: Nicklaus Children's Hospital (Pediatric Trauma only) 4. Provisional Level 2: Jackson South Community Hospital Local Receiving Facilities 1. Fishermen's Hospital, Marathon X. DISTRIBUTION OF TRAUMA TRANSPORT POLICY The SATC, SAPTC, and receiving facilities to which Marathon Fire Rescue routinely transports patients have been provided with a copy of the criteria which are used to determine trauma transport destinations. 10 475 ANTICOAGULANTS High Risk of Bleeding: Trade Names: Generic names: Aggrenox (ASA+ dipyridamole) Anagrelide(Agrylin) Agrylin (anagrelide) Apixaban (Eliquis) Brllinta (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 (Minta) Ticlid (ticlopidine) Ticlopidine( iclid) Trental (pentoxifylline) Vorapaxar (Zontivity) Xarelto (dvaroxaban) Warfarin (Coumadin, Jantoven) Zontivity (vorapaxar) ..................................................................... Injectables: Activase(aitepiase) Aggrastat(drofiban) Angiomax(bivaiirudin) Argatroban Arixtra(fondaparinux) Fragmin(daitepadn) Heparin innohep(tinzaparin) lntegriiin(eptifibatide) 1privask(desirudin) Lovenox(enoxaparin) Reopro(abciximab) Streptokinase Tenectepiase(TNKase) Urokinase April 2017 12 476 TRAUMA TRANSPORT PROTOCOLS AfiWWAL.WRECWRAPPROVAL 1,Sandra Schwerrrrnw,D.O.,ft-hoepHal Medical DWeckw for Marathon Fire Rescue,oetttly to Marathon Fire Rescue and the Department of Heath. Bureau of Emergency Mmkd Services that I have reviewed end approve the Treurns Transport Protocols,dated March 1.2021 10L%-� —J///*to Z/ DID,FACOEP-D,FACEP Date FL 08 4022 13 477 Marathon Fire Rescue Adult Trauma Scorecard Methodology The EMT or paramedic shall assess the condition of those injured persons with anatornical and physiological characteristics of a person sixteen 06l 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.These four cirkeria are to be applied in the order listed,and once any one criterion is met that identifies the patient as a Trauma Alert,no further assessment is required to determine the transport destination: 1. Meets color-coded triage system(see below) 2. Meets local criteria(speciify): 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). FLED BLUE AIR AY AC I IVE A1I1RVVAY,ASS S I AII w RR •�10 or>29 V, DKOWNING OR NEAR DROWMINIGii —CIRCULATION A 7 CIK DF FUUMAI PULSE ar BR<90 rvrrrffly PATIENTS WITH RIENAL FAILURE ON DIALYSIS 81'1<1101 IN PA HENT OVER 65,YEARS DISABILITY GCS 13 m PRESENCE"OF PARAL YS4S,(o SUSPI00N OF SPIN AL HEAD INJURY wl rEl LOSS OF CONSCIOUSNESS,AMNESIA or CORID INJURY w LOSSOFSENSATION NEW ALTERED MEN TAL S T'ATUS .................... Sop-l" SSUE 2,11 OR 3`DFG"VIE MJRNS 10 1 Ir11,,r)r IdORE"I 3SA SOF"T"FISSUE LOSS ANTPU TATION AT OR AW."WE THE WRIS I or Al"WLE I ANY PENE1 RAFING INJUIRY TO HEAD,I TORSO 0 1 Ex rl'lE IVJEIlr Y, DISLOCA N ION OF HIP,KNEE OR AIIJKL 0-4E S;T WAu,INS I ABII.11 Y of DEFORIVItl "Y 0u 11.Ail_CHIF STY CRUS11 IiEID,4 A19GLIES,BE-(AXWED OPT ULSELESS EXI'REMII Y LONG BONE ,U,HflE OF 71NO jai,,MORE LOI4G BONES' SINGLE LONG BONE FX SITE DUE IFO MVC1 FRACTURE,, SKELETAL' SINGLE LONG BONE FX IN PT ON COUMADINI or A TICL) �L SWITH HIGH Rt§ OF BLEEIIINGI 55 YEARS OR OLDER ......... ...............—_ MiECHANISM O, F HEAD TRAIYVA IN FATIEN rs ofq WARFARIN ICOUMAMN)or EJECTION FROM AtJTOMOBILE,MOTORCYCLE,GOLF CART INJURY AN Y]COA(.3ULAN I'S WITH I HIGH RISK OF BLEEDING OR HORSE WFTH ANATOMICAL INJURY SEVERE FA,aAL INJUI1Y7NMAC I URES WITi 11 P01"ENTIAL AIMNAY BLUNT HEAD,CHEST OR ABDOMINAL TRALIMA IN PATIENTS CCHVPR01,vflSE ON ANTICOAGIULANTS WITH HIGH RISK OF BLEEDING ELECl MXtJ YHY1 OR R IGHTNING INJURY Wi I H IA)ISS OF DEATH IN SAME PASSENGER COMPARTMENT CONSCIOUSNESS 011 VISIBLE SIGNS OF ftJURY I INTRUSION INCLUDING ROOF>12 INCHES OCCUPANT SITE; B�AJIITr ABDQM+ NAI,,air CII IRALINIA 111,4 PA FIENT xAIITHI >18 INCHES ANY SITE INTO THE PASSENGER H SICRY OF PARALYSIS(PARAPLEGIAo QUADRIPLEGIAy COMPARTMENT FIREGN0,NiCY>216Dvvks',AT[I I ABD,r`)MINAl, PAIN AND 1311XII114 1 VEHICLE V'ELEME TRY DATA CONSISTENT WITH HIGH RISK OF IRAUIOA INJURY' FALL 10 FT w MORE AUTO VS.PEDESTRIAN/BICYCISTTHROWN,RUN OVER ov WITH IMPACT GREATER THAN 20 MPH MO MIRCYCYLE CRASH>20inph RED :=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 adjuncls,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 hurnerus,(2)radius and ulna,(3)fernur,(4)tibia and fibula. 5. Vehicle Telemetry Data when available,will be relayed to dispatch;the data can assist in predicting potential senOLIS Injuries front the data collected at the tinge of the crash. 6. See list of Anticoagulants with Kgh Risk of Bleeding. 478 Marathon Fire Rescue Pediatric Trauma Scorecard Methodology The EMT or Paramedic shall assess the condition of those injured individuals with anatomical arid 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 rag!meet the trauma criteria fisted,but was transported to a trauma center due to EMT or paramedic judgment(reason for transport must be justified in run report). RED BLUE SIZE WEIGH <22 Kq .............. AIRWAY ACTIVE AlIlVdAY ASSISTANCE RESP RATE �20 IN INFANO'<1:1 YR RESP RATE< W IN 0-1 ILDRI`B,J I YR F,,YR DROWNING OR NEAR DROIANINC, .. ...... CIRCULA rION FAINT or N011,;PAi DAKE CAROTI[)w FEMOFAL Kfl SE Tyr CAROTID or FEMORAL PULSES PALPABLE,BUTT RADIAL PIP<E0 TIMH�J OR FECAL PULSE NOT PALPABLE or SBP,90-imr-niAq DISABILITY AL.rERI.`[)MEN rAL,5TA1rIJS1 a,r PRESENCE OF PARALYSIS or AMNESIA or LOSS OF CONSCIOUSNESS S'USPICION OF SPINAI CORD INJURY oir LOSS OF SEIASA110114 .......... SOFTTISSUE NIAJORSOFI IFISSI F:DISRUPTION,MAADR D11,-GL CV�NG UPPER EXTREMITY DISLOCATION,EXCLUDING FINGERS coi IVAJOR AVLALSK)NI 0 SKIN Vor 3"BURNS TO >I TBSA ANY PENE FRATING,H%IIIRY OR GSW w the I1r1l,,,A0,NECK, TC)RISO OR EXTREMITY1, AMMJ[r A"IlON Al 0R,ABOVF FIrrIlE WFOST or ANKI E DISLOCATION OF THE.HIP,KNEE OR ANKLE LONG BoK_E o T,—LONG(:RONIE.FRACT'UREI or MULTIPLE FRACTY IRE SINGLE LONG BONE'FRACTURE SITE'or DISLOCATION FRACTURE/ S111 ES or MULTIPLE[iiSt-CiCATION S[fES SKELETAL MECHANISM OF ELEC,7RUICUI ION OR,I IGI ITNING ST'RIKE VV014 LOSS OF EJECTION IPARTIAL or COMPLETE)FROM AUTO MOBILE INJURY CONKSCIOUSNE',SS OR VISIBLE SIC;NS OF Al JLMY DEATH IN SAME PASSENGER COMPARTMENT SEVERE FACIAL INJURY VVI I'll I AIRWAY CONIPIRONTSE, INTRUSION INCLUDING ROOF>12 INCHES OCCUPANT SITE; PENETRATING IINJURY'ro"TOIL IFxrrvvrry,u,I,or ABOVE I HE >18 INCHES ANY SITE INTO THE PASSENGER COMPARTMENT ELBOW Dr KNEEL VEHIC C W LE TELEME TRY DATA ONSISTENT ITH HIGH RISK OF BLUNTABC)ONHNAL or(" S�T HIETRAUMA IN PATIENT WITH r INJURY' 011IIY O PARALYSYS TARAPLEGIA w OUADM IEGIA) FALL 10 FT OR 2-3 TIMES THE HEIGIrI OF THE CHILD BLUNT HEAD,CHIEST,ABDOMINAL C RAUMA IN P1 Vqi r'J., M EEDING DISORDER OR ON COUMADIN.ANI ICO, WITH 111GI-d R6K OF BLEEDING` All ()'VS E'Er)ESrRIAN('1144CYC kSl"lU"RO NN 80,401,/ERClan VIMTHIMPA ,f 6JFC7i01'4 F RI;IMAUTO,ATV,GOi,F CAR'[ OR i-IMISE WITH 512 S OF INJURY ny tWp_LZL.1r sport as ak r ir,0% _aULnLdJLJ I Airway assistance includes manual jaw thrust,continuous suctioning,or use of other adjuncts to assist ventilatory efforts. 2. Altered mentaI,states Include drowsiness,,lethargy,inability to follow cortirriands, 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. F. Excluding superficial wounds where the depth of the wound can be determined. T 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. See list of An ticoag ul ants with High Risk of Bleeding. 479 Section 8 Attestation, of Medical irector®s Participation, Review, and Approval of T'TPs Reguirement: (1) The following statement of certification shall be included in the TTPs, "As the medical director of the (Name of EMS Provider or Trauma Agency), I developed and/or directed the development of the trauma transport protocols presented in this document." it Print Name of Medical Director Signature of Medical Director Approval Date M.D./D.O. License Number 10 480 City of Marathon, Florida Annual Comprehensive Financial Report Fiscal Year Ended September 30, 2023 n Prepared by the Finance Department 481 City of Marathon, Florida Table of Contents Introductory Section (Unaudited): Letter of Transmittal i-v List of Principal Officials vi Certificate of Achievement for Excellence in Financial Reporting vii Organizational Chart viii Financial Section: Independent Auditor's Report 1-3 Management's Discussion and Analysis (Not Covered by Independent Auditor's Report) 4-15 Basic Financial Statements: Government-wide Financial Statements: Statement of Net Position 16 Statement of Activities 17 Fund Financial Statements: Balance Sheet - Governmental Funds 18 Reconciliation of the Balance Sheet of Governmental Funds to the Statement of Net Position 19 Statement of Revenues, Expenditures and Changes in Fund Balances -Governmental Funds 20 Reconciliation of the Statement of Revenues, Expenditures and Changes in Fund Balances of Governmental Funds to the Statement of Activities 21 Statement of Net Position - Proprietary Funds 22 Statement of Revenues, Expenses and Changes in Net Position - Proprietary Funds 23 Statement of Cash Flows - Proprietary Funds 24-25 Statement of Fiduciary Net Position - Firefighters' Pension Trust Fund 26 Statement of Changes in Fiduciary Net Position - Firefighters' Pension Trust Fund 27 Notes to Basic Financial Statements 28-52 482 City of Marathon, Florida Table of Contents (continued) Required Supplementary Information: Budgetary Comparison Schedule -General Fund 53 Budgetary Comparison Schedule - Street Maintenance Fund 54 Note to Budgetary Comparison Schedules 55 Schedule of Changes in Net Pension Liability (Asset) and Related Ratios- Firefighters' Pension Trust Fund (Unaudited) 56-57 Schedule of Contributions - Firefighters' Pension Trust Fund (Unaudited) 58 Schedule of Investment Returns - Firefighters' Pension Trust Fund (Unaudited) 59 Schedule of Changes in Total OPEB Liability and Related Ratios 60 Other Financial Information: Combining and Individual Fund Financial Statements and Schedules: Combining Balance Sheet - Nonmajor Governmental Funds 61-62 Combining Statement of Revenues, Expenditures and Changes in Fund Balances - Nonmajor Governmental Funds 63-64 Budgetary Comparison Schedules: Budgetary Comparison Schedule -Capital Infrastructure Fund 65-66 Budgetary Comparison Schedules - Nonmajor Governmental Funds 67-68 Statistical Section (Unaudited): Net Position by Component 69-70 Changes in Net Position 71-74 Fund Balances of Governmental Funds 75-76 Changes in Fund Balances of Governmental Funds 77-78 Net Assessed Value and Estimated Actual Value of Taxable Property 79 Property Tax Rates - Direct and Overlapping Governments 80 Principal Property Taxpayers 81 483 City of Marathon, Florida Table of Contents (continued) Property Tax Levies and Collections 82 Ratios of Outstanding Debt by Type 83 Computation of Direct and Estimated Overlapping Governmental Activities Debt 84 Pledged Revenue Coverage 85 Demographic and Economic Statistics 86 Principal Employers 87 Full-Time Equivalent City Government Employees by Function 88 Operating Indicators by Function/Program 89 Capital Asset Statistics by Function/Program 90 Compliance Section: Independent Auditor's Report on Internal Control over Financial Reporting and on Compliance and Other Matters Based on an Audit of Financial Statements Performed in Accordance with Government Auditing Standards 91-92 Independent Auditor's Report on Compliance for Each Major Federal Program And State Project and on Internal Control over Compliance Required by the Uniform Guidance and Chapter 10.550, Rules of the Auditor General 93-95 Independent Auditor's Report to City Management 96-97 Independent Accountant's Report on Compliance with Section 218.415, Florida Statutes 98 Schedule of Expenditures of Federal Awards and State Financial Assistance 99-101 Notes to Schedule of Expenditures of Federal Awards and State Financial Assistance 102 Schedule of Findings and Questioned Costs 103 484 INTRODUCTORY SECTION 485 CITY OF MARATHONFLORIDA 9805 Overseas Highway, Marathon, Florida 33050 Phone: (305) 743-00 3 Fax: (305) 743-3667 March 27, 2024 To the Honorable Mayor, Members of the Governing Council, and Citizens of the City of Marathon: It is our pleasure to submit to you the Annual Comprehensive Financial Report of the City of Marathon, Florida for the fiscal year ended September 30, 2023. State law requires that all general-purpose local governments publish within nine months of the close of each fiscal year a complete set of financial statements presented in conformity with generally accepted accounting principles (GAAP) and audited in accordance with auditing standards generally accepted in the United States and Government Auditing Standards by a firm of licensed certified public accountants. This report consists of management's representations concerning the finances of the City of Marathon. Consequently, management assumes full responsibility for the completeness and reliability of all of the information presented in this report. To provide a reasonable basis for making these representations, management of the City of Marathon has established a comprehensive internal control framework that is designed both to protect the City's assets from loss, theft, or misuse and to compile sufficient reliable information for the preparation of the City of Marathon's financial statements in conformity with GAAP. Because the cost of internal controls should not outweigh their benefits, the City of Marathon's comprehensive framework of internal controls has been designed to provide reasonable rather than absolute assurance that the financial statements will be free from material misstatement. As management, we assert that, to the best of our knowledge and belief,this financial report is complete and reliable in all material respects. The City of Marathon's financial statements have been audited by Keefe, McCullough & Co. LLP, a firm of licensed certified public accountants. The goal of the independent audit was to provide reasonable assurance that the financial statements of the City of Marathon for the fiscal year ended September 30, 2023, are free of material misstatement. The independent audit involved examining, on a test basis, evidence supporting the amounts and disclosures in the financial statements; assessing the accounting principles used and significant estimates made by management; and evaluating the overall financial statement presentation. The independent auditor concluded, based upon the audit, that there was a reasonable basis for rendering an unmodified opinion that the City of Marathon's financial statements for the fiscal year ended September 30, 2023, are fairly presented in conformity with GAAP. The independent auditor's report is presented as the first component of the financial section of this report. In addition to meeting the requirements set forth above, the independent audit was also designed to meet the special needs of federal and state grantor agencies as provided for in the Federal Single Audit Act, Office of Management and Budget (OMB) Uniform Guidance and Florida Single Audit Act in accordance with Chapter 10.550, Rules of the Auditor General. These standards require the independent auditor to report not only on the fair presentation of the basic financial statements, but also on the audited government's internal controls and compliance with legal requirements,with special emphasis on internal controls and legal requirements involving the administration of federal and state awards. These reports are presented in the compliance section of this report. -i- 486 N1A Ile- CITY 'aa �_, ..... 9i305 Overseas Highway, Marathon, Florida 33050 Phone: (305) 743-0033 Fax: (305) 743-3667 In accordance with Governmental Accounting Standards Board Statement No. 34, Basic Financial Statements andManagement's Discussion and Analysis for State and Local Governments, GAAP requires that management provide a narrative introduction, overview, and analysis to accompany the basic financial statements in the form ofManagement's Discussion and Analysis ( A). This letter of transmittal is designed to complement the MD&A and should be read in conjunction with it. The City of Marathon's MD&A can be found immediately following the independent auditor's report on the basic financial statements. Profile of the Government The City of Marathon, incorporated November 30, 1999, with a population of 9,799 residents, is located approximately one hour from Key West, Florida and Key Largo, Florida. Marathon is known as the"Heart of the Florida Keys." Its boundaries run from the east end of the Seven Mile Bridge, mile marker 47,to the west end of Tom's Harbor Bridge, approximately mile marker 60. The islands of Marathon include Boot Key, Knights Key, Hog Key, Vaca Key, Stirrup Key, Crawl and Little Crawl Key, East and West Sister's Island, Deer Key, Little Deer Key, Fat Deer Key, Long Point Key, and Grassy Key. The City of Marathon is empowered to levy a property tax on both real and personal properties located within its boundaries. It also is empowered by state statute to extend its corporate limits by annexation, which occurs when deemed appropriate by the City Council. The City of Marathon operates under the council-manager form of government. Policy-making and legislative authority are vested in a governing council consisting of the mayor and four other members. The City Council is responsible, among other things,for passing ordinances,resolutions, and regulations governing the city, adopting the budget, and appointing the city manager, city attorney, and members of various boards. The City Manager is responsible for carrying out the policies and ordinances adopted y the City Council, for overseeing the day-to-day operations of the City, appointing the heads of the various departments, and submission of the budget to City Council for approval. The mayor and four council members are elected at large every three years with a term limit of two consecutive terms. The City of Marathon provides a wide variety of services, including police, fire protection, and emergency medical services; the construction and maintenance of highways, streets and other infrastructure; planning and zoning; building and code enforcement; and recreational activities and community events. The City also manages two enterprise funds; a City marina facilities and a wastewater and stormwater utilities fund. The financial reporting entity (the City ofMarathon) includes all of the funds of the City. The City does not have any component units. A component unit is a legally separate entity for which the City is financially accountable or the nature and significance of the relationship between the City and the entity was such that exclusion would cause the City's financial statements to be misleading or incomplete. 487 �rN1A � �r MARATHONCITY OF FLORIDA 9805 Overseas Highway, Marathon, Florida 33050 Phone: (305) 743-0033 Fax: (305) 743-3667 a 1'zPOO The annual budget serves as the foundation for the City of Marathon's financial planning and control. All departments of the City of Marathon are required to submit requests for appropriation to the City Manager. The City Manager uses these requests as the starting point for developing a proposed budget. The City Manager then presents this proposed budget to City Council for review prior to September 1. The City Council is required to hold public hearings on the proposed budget and to adopt a final budget no later than September 30, the close of the City of Marathon's fiscal year. The appropriated budget is prepared by fund, function (e.g. public safety), and department (e.g. police). Department heads may make transfers within a department with the approval of the City Manager. Transfers of appropriations between departments, however, require the approval of the City Council. A budget-to-actual comparison for the general fund is included as Required Supplementary Information on page 5 following the notes to the basic financial statements. A budget-to-actual comparison for the street maintenance fund is also included as Required Supplementary Information following the notes to the basic financial statements on page 59. A budget-to-actual comparison for the capital infrastructure fund is included as other financial information on pages 74 and 75. For governmental funds, other than the general fund, street maintenance fund and capital infrastructure fund, this comparison is presented in the non-major governmental fund subsection of this report, on pages 76 and 77. Factors Affecting Financial Condition Local Econorny The Florida Keys are often referred to as the "American Caribbean" and Marathon is known as "The Heart of the Keys." Marathon's ideal location between Key Largo and Key West makes it a desirable place in which to live and work. Tourism is an important economic engine. The local environment offers excellent sport fishing and recreational diving opportunities. The tropical climate, in addition to the recreational water activities, makes the City a major tourist destination as well as a desirable retirement and second home location. The Florida Keys have continually ranked among the top tourist destinations in the Country. In addition to tourism, commercial seafood harvesting is a significant aspect of the local economy as the Florida Keys are one of the largest providers of seafood products in the country, serving both national and international markets. The City of Marathon's economic outlook is strong. The tourism industry in the Florida Keys is vibrant and has proven to be extremely resilient. The City is experiencing growth in the commercial and residential sector with new; resorts, restaurants, businesses and residences coming online. In December 2023,the area's unemployment rate was 1.8%, compared with the statewide rate of 3%. Long-term financial Planning and RelevantFinancial Policies, The City has a 5-Year Capital Plan and prioritizes needs based on its expected available resources. This effort identifies capital purchases that will be needed to continue its critical core public safety services, as well as other departmental needs. -iii- 488 CITY OF MARATHON, FLORIDA 9805 Overseas Highway, Marathon, Florida 33050 Phone: (305) 743W0033 Fax: (305) 743-3667 HAND ' The City has limited its borrowing to prudent levels that are able to be satisfied with existing revenue and cash flow projections. In order to minimize our debt issuance (and related costs) to when it is absolutely necessary,the City has a pay-as-you-go financing policy for CIP projects which includes: • Projects having a small dollar value • Projects which can be broken into phases with a portion completed each year without impairing the overall effectiveness of the project Projects which are of a recurring natures • Projects where the assets acquired will have relatively short useful lives. The City has adopted a cash management policy that is designed to maintain earnings free from risk, maintain adequate liquidity to meet the City's obligations, and maximize investment return. To ensure the safety of the City's funds, all investments are with depositories that are qualified under Florida law and thus are fully collateralized in accordance with Chapter 20 of the State statutes. jr Initiatives The City will continue to pursue its long-term goals as outlined in the Five-Year Capital Improvement Plan. The City continues to devote resources to affordable housing, transportation and traffic concerns. The City also has various bridge repair, culvert and canal restoration efforts underway. Other major projects currently included in the Five-Year Capital Improvement Plan are: • Seawall and amenities at the Quay property • Improvements at City parks and beaches • The continued implementation of the Fire Safety Program Awards and Acknowledgements The Government Finance Officers Association of the United States and Canada (GFOA) awarded a Certificate of Achievement for Excellence in Financial Reporting to the City of Marathon for its Annual Financial Comprehensive Report for the fiscal year ended September 3 , 2022. This was the twentieth consecutive year that the City of Marathon achieved this prestigious award. In order to be awarded a Certificate of Achievement, a government must publish an easily readable and efficiently organized annual comprehensive financial report. This report must satisfy both generally accepted accounting principles and applicable legal requirements. -iv- 489 MARATHON,CITY OF FLORIDA 9305 Overseas Highway, Marathon, Florida 33050 Phone: (305) 743-0033 Fax: (305) 7 3-3667 A Certificate of Achievement is valid for a period of one year only. We believe that the September 30, 223 Annual Comprehensive Financial Report continues to meet the Certificate of Achievement Pro ram's requirements, and we are submitting it to the GFOA to determine its eligibility for another certificate. The preparation of this report would not have been accomplished without the dedicated and efficient service of the entire staff of the finance department. We would like to express our appreciation to all members of other City departments who assisted and contributed to the preparation of this report. We would also like to express a special note of thanks to our independent certified public accountants, Keefe, McCullough & Co., LLP, for their cooperation and assistance. Their professional approach and high standards in the conduct of their independent audit of the City's financial records and transactions is greatly appreciated. Respectfully submitted, eorge , a r ett City Ma ger ?nmferItho Finance Director -v- 490 CITY OF MARATHON, FLORIDA LIST OF PRINCIPAL OFFICIALS SEPTEMBER 30, 2023 CITY COUNCIL Luis Gonzalez, Mayor Robyn Still, Vice-Mayor Jeff Smith, Councilmember Lynn Landry, Councilmember Kenny Matlock, Councilmember CITY MANAGER George Garrett CITY CLERK Diane Clavier CITY ATTORNEY Steven Williams FINANCE DIRECTOR Jennifer Johnson CITY AUDITORS Keefe McCullough CPA's+Trusted Advisors vi 491 Government Finance Officers Association Certificate of Achievement for Excellence in Financial Reporting Presented to City of Marathon Florida For its Annual Comprehensive Financial Report For the Fiscal Year Ended September 30, 2022 OA—&P,OG P. ;t. Executive Director/CEO vi i 492 e u O ai tlw „�„ �, .... � � w 493 FINANCIAL SECTION 494 INDEPENDENT AUDITOR'S REPORT 495 nuuuuuuuiuui HNIRS u ! C u"As �l II11rusb2iJA"CI n&I II'S INDEPENDENT AUDITOR'S REPORT Honorable Mayor and City Council City of Marathon, Florida Marathon, Florida Opinions We have audited the accompanying financial statements of the governmental activities, the business- type activities, each major fund, and the aggregate remaining fund information of the City of Marathon, Florida (the "City") as of and for the year ended September 30, 2023, and the related notes to the financial statements, which collectively comprise the City's basic financial statements as listed in the table of contents. In our opinion, the financial statements referred to above present fairly, in all material respects, the respective financial position of the governmental activities, the business-type activities, each major fund, and the aggregate remaining fund information of the City as of September 30, 2023, and the respective changes in financial position and, where applicable, cash flows thereof for the year then ended in accordance with accounting principles generally accepted in the United States of America. Basis for Opinions We conducted our audit in accordance with auditing standards generally accepted in the United States of America and the standards applicable to financial audits contained in Government Auditing Standards, issued by the Comptroller General of the United States. Our responsibilities under those standards are further described in the Auditor's Responsibilities for the Audit of the Financial Statements section of our report. We are required to be independent of the City and to meet our other ethical responsibilities, in accordance with the relevant ethical requirements relating to our audit. We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our audit opinions. Responsibilities of Management for the Financial Statements Management is responsible for the preparation and fair presentation of the financial statements in accordance with accounting principles generally accepted in the United States of America, and for the design, implementation, and maintenance of internal control relevant to the preparation and fair presentation of financial statements that are free from material misstatement, whether due to fraud or error. In preparing the financial statements, management is required to evaluate whether there are conditions or events, considered in the aggregate, that raise substantial doubt about the City's ability to continue as a going concern for twelve months beyond the financial statement date, including any currently known information that may raise substantial doubt shortly thereafter. SOUTH FLORIDA BUSINESS JOURNAL � II���" '�ii�i��'�'i�u III uiiu��S61V II c6cixl IIV�nry,/ells II ��rui�, II url II xGa6cr6xlc II II 6�+666 "�C 'w4 771.0896 :`6'ax 4 938.66'36 a6 . airChrTarrfc Business Jowrcl II, m00 AccouinithnigIlhiiiuu uiunu Him U INSIDE P'uklreAeeal:rrrCrrr6 riio 1 BEST PLACES TO WOR1496 City of Marathon, Florida Auditor's Responsibilities for the Audit of the Financial Statements Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue an auditor's report that includes our opinions. Reasonable assurance is a high level of assurance but is not absolute assurance and therefore is not a guarantee that an audit conducted in accordance with generally accepted auditing standards and Government Auditing Standards will always detect a material misstatement when it exists. The risk of not detecting a material misstatement resulting from fraud is higher than for one resulting from error, as fraud may involve collusion, forgery, intentional omissions, misrepresentations, or the override of internal control. Misstatements are considered material if there is a substantial likelihood that, individually or in the aggregate, they would influence the judgment made by a reasonable user based on the financial statements. In performing an audit in accordance with generally accepted auditing standards and Government Auditing Standards, we: • Exercise professional judgment and maintain professional skepticism throughout the audit. • Identify and assess the risks of material misstatement of the financial statements, whether due to fraud or error, and design and perform audit procedures responsive to those risks. Such procedures include examining, on a test basis, evidence regarding the amounts and disclosures in the financial statements. • Obtain an understanding of internal control relevant to the audit in order to design audit procedures that are appropriate in the circumstances, but not for the purpose of expressing an opinion on the effectiveness of the City's internal control. Accordingly, no such opinion is expressed. • Evaluate the appropriateness of accounting policies used and the reasonableness of significant accounting estimates made by management, as well as evaluate the overall presentation of the financial statements. • Conclude whether, in our judgment, there are conditions or events, considered in the aggregate, that raise substantial doubt about the City's ability to continue as a going concern for a reasonable period of time. We are required to communicate with those charged with governance regarding, among other matters, the planned scope and timing of the audit, significant audit findings, and certain internal control-related matters that we identified during the audit. Required Supplementary Information Accounting principles generally accepted in the United States of America require that the management's discussion and analysis and schedules related to pensions and other post-employment benefits be presented to supplement the basic financial statements. Such information is the responsibility of management and, although not a part of the basic financial statements, is required by the Governmental Accounting Standards Board, who considers it to be an essential part of financial reporting for placing the basic financial statements in an appropriate operational, economic, or historical context. We have applied certain limited procedures to the required supplementary information in accordance with auditing standards generally accepted in the United States of America, which consisted of inquiries of management about the methods of preparing the information and comparing the information for consistency with management's responses to our inquiries, the basic financial statements, and other knowledge we obtained during our audit of the basic financial statements. We do not express an opinion or provide any assurance on the information because the limited procedures do not provide us with sufficient evidence to express an opinion or provide any assurance. 2 497 City of Marathon, Florida Supplementary Information Our audit was conducted for the purpose of forming opinions on the financial statements that collectively comprise the City's basic financial statements. The accompanying budgetary comparison schedules, combining and individual nonmajor fund financial statements and schedules and the schedule of expenditures of federal awards and state financial assistance, as required by Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles and Audit Requirements of Federal Awards and Chapter 10.550, Rules of the Florida Auditor General, respectively, are presented for purposes of additional analysis and are not a required part of the basic financial statements. Such information is the responsibility of management and was derived from and relates directly to the underlying accounting and other records used to prepare the basic financial statements. The information has been subjected to the auditing procedures applied in the audit of the basic financial statements and certain additional procedures, including comparing and reconciling such information directly to the underlying accounting and other records used to prepare the basic financial statements or to the basic financial statements themselves, and other additional procedures in accordance with auditing standards generally accepted in the United States of America. In our opinion, the budgetary comparison schedules, combining and individual nonmajor fund financial statements and schedules and the schedule of expenditures of federal awards and state financial assistance are fairly stated, in all material respects, in relation to the basic financial statements as a whole. Other Information Management is responsible for the other information included in the annual report. The other information comprises the introductory and statistical sections but does not include the basic financial statements and our auditor's report thereon. Our opinions on the basic financial statements do not cover the other information, and we do not express an opinion or any form of assurance thereon. In connection with our audit of the basic financial statements, our responsibility is to read the other information and consider whether a material inconsistency exists between the other information and the basic financial statements, or the other information otherwise appears to be materially misstated. If, based on the work performed, we conclude that an uncorrected material misstatement of the other information exists, we are required to describe it in our report. Other Reporting Required by Government Auditing Standards In accordance with Government Auditing Standards, we have also issued our report dated March 27, 2024, on our consideration of the City's internal control over financial reporting and on our tests of its compliance with certain provisions of laws, regulations, contracts, and grant agreements and other matters. The purpose of that report is solely to describe the scope of our testing of internal control over financial reporting and compliance and the results of that testing, and not to provide an opinion on internal control over financial reporting or on compliance. That report is an integral part of an audit performed in accordance with Government Auditing Standards in considering the City's internal control over financial reporting and compliance. KEEFE MCCULLOUGH Fort Lauderdale, Florida March 27, 2024 3 498 MANAGEMENT'S DISCUSSION AND ANALYSIS (M D&A) 499 City of Marathon, Florida Management's Discussion and Analysis September 30, 2023 As management of the City of Marathon, Florida, we offer readers of the City's financial statements this narrative overview and analysis of the financial activities of the City for the fiscal year ended September 30, 2023. We encourage readers to consider the information presented here in conjunction with the additional information that we have furnished in our letter of transmittal, which can be found on pages i through v of this report. Fund-based financial reporting and government-wide reporting are not viewed as being in conflict; however, they are not comparable. A significant portion of this analysis focuses on the changes in the government-wide statements, while still providing information on the City's fund-based comparative changes. Financial Highlights • The assets and deferred outflows of resources of the City of Marathon exceeded its liabilities and deferred inflows of resources at the close of the most recent fiscal year by $ 180,466,231 (net position), as compared with $ 170,444,425 for the previous year. Of this amount, $ 52,144,080 (unrestricted net position) may be used to meet the City's ongoing obligations to citizens and creditors as compared with $ 44,487,059 for the previous year. This increased from the prior year due to an increase in parking and boat ramp fees together with an increase in property taxes. • The City's total net position increased by $ 10,021,806 or 5.88% during the current fiscal year. Included in the total net position is governmental net position that increased by $ 8,192,712 and business-type activities net position that increased by$ 1,829,094. • As of the close of the current fiscal year, the City's governmental funds reported combined ending fund balances of $42,654,418, an increase of $ 7,066,347. $ 22,535,252 (52.8%) of this total amount is available for spending at the City's discretion (unassigned fund balance in the General Fund). • The City's total debt decreased by $ 5,783,918 (13.06%) during the current fiscal year due to annual payments. Overview of the Financial Statements This discussion and analysis is intended to serve as an introduction to the City of Marathon's basic financial statements. The City's basic financial statements contain three components: 1) government- wide financial statements, 2) fund financial statements and 3) notes to the basic financial statements. This report also contains other supplementary information in addition to the basic financial statements themselves. Government-wide Financial Statements The government-wide financial statements are designed to provide readers with a broad overview of the City's finances, in a manner similar to a private-sector business. The statement of net position presents information on all the City's assets and liabilities, with the difference between the two reported as net position. Over time, increases or decreases in net position may serve as a useful indicator of whether the financial position of the City is improving or deteriorating. 4 500 City of Marathon, Florida Management's Discussion and Analysis September 30, 2023 The statement of activities presents information showing how the City's net position changed during the most recent fiscal year. All changes in net position are reported as soon as the underlying event giving rise to the change occurs, regardless of the timing of related cash flows. Thus, revenues and expenditures are reported in this statement for some items that will result in cash flows in future fiscal periods (e.g. earned but unused vacation leave). Both of the government-wide financial statements distinguish functions of the City of Marathon that are principally supported by taxes and intergovernmental revenues (governmental activities) from other functions that are intended to recover all or a significant portion of their costs through user fees and charges (business-type activities). The governmental activities of the City include general government, community services (public works, street and bridge maintenance, parks and recreation, nearshore waters), public safety (fire, EMS, police), and community development (planning, building, code). The business-type activities of the City include a full-service marina and a wastewater and stormwater utility. The government-wide financial statements can be found on pages 16 and 17 of this report. Fund Financial Statements A fund is a grouping of related accounts that is used to maintain control over resources that have been segregated for specific activities or objectives. The City of Marathon, like other state and local governments, uses fund accounting to ensure and demonstrate compliance with finance- related legal requirements. All of the funds of the City of Marathon can be divided into three categories: governmental funds, proprietary funds, and fiduciary funds. Governmental funds. Governmental funds are used to account for essentially the same functions reported as governmental activities in the government-wide financial statements. However, unlike the government-wide financial statements, governmental fund financial statements focus on near- term inflows and outflows of spendable resources, as well as on balances of spendable resources available at the end of the fiscal year. Such information may be useful in evaluating a government's near-term financing requirements. The City of Marathon previously implemented Governmental Accounting and Financial Standards Board (GASB) Statement No. 54 Fund Balance Reporting and Governmental Fund Type Definitions. The objective of Statement No. 54 is to enhance the usefulness of fund balance information by providing clearer fund balance classifications that can be more consistently applied and by clarifying the existing governmental fund type definitions. Fund balances are now presented in the following classifications: Non-Spendable Fund Balance - Amounts that are not in a spendable form (for example, inventory, long-term portion of loans, prepaid expenses, and notes receivable), or are required to be maintained intact (for example, the principal of an endowment fund). Restricted Fund Balance - Amounts that can be spent only for the specific purposes stipulated by external resource providers (i.e. grant providers), constitutionally, or through enabling legislation (legislation that creates a new revenue source and restricts its use). Effectively, a restriction may be changed or lifted only with the consent of resource providers. Committed Fund Balance - Amounts that can be used only for the specific purposes determined by a formal action of the government's highest level of decision-making authority (i.e. City Council). Commitments may be changed or lifted only by the government taking the same formal action that imposed the constraint originally. 5 501 City of Marathon, Florida Management's Discussion and Analysis September 30, 2023 Assigned Fund Balance - Amounts intended to be used by the government for a specific purpose. Intent can be expressed by the governing body or by an official or body to which the governing body delegates the authority (the authority for making an assignment is not required to be the government's highest level of decision making authority). Unassigned Fund Balance - the residual classification for the General Fund and includes all amounts not contained in other classifications. Unassigned amounts are technically available for any purpose. Because the focus of governmental funds is narrower than that of the government-wide financial statements, it is useful to compare the information presented for governmental funds with similar information presented for governmental activities in the government-wide financial statements. By doing so, readers may better understand the long-term impact of the City's near term financing decisions. Both the governmental fund balance sheet and the governmental fund statement of revenues, expenditures, and changes in fund balances provide a reconciliation to facilitate the comparison between governmental funds and governmental activities. The City of Marathon maintains several individual governmental funds. Information is presented separately in the governmental fund balance sheet and in the governmental fund statement of revenues, expenditures, and changes in fund balances for the General Fund, Street Maintenance Fund, and Capital Infrastructure Fund, which are considered to be major funds. Data from the other governmental funds are combined into a single, aggregated presentation. Individual fund data for each of these nonmajor governmental funds is provided in the form of combining statements on pages 61 through 64 of this report. The City of Marathon adopted an annual appropriated budget for its General Fund, six of its special revenue funds, the Capital Project Fund and the Debt Service Fund. A budgetary comparison schedule has been provided for the General Fund to demonstrate compliance with this budget (page 53). A budgetary comparison schedule has also been provided for the major special revenue fund, which is the Street Maintenance Fund (page 54) and the Capital Infrastructure Fund, which is a capital project fund (pages 65 and 66). The governmental fund financial statements can be found on pages 18 through 21 of this report. Proprietary funds. The City of Marathon maintains one type of proprietary fund. Enterprise funds are used to report the same functions presented as business-type activities in the government-wide financial statements. The City uses enterprise funds to account for its wastewater and stormwater utility and its marina. Proprietary funds provide the same type of information as the government-wide statements, only in more detail. The proprietary fund financial statements provide information for the wastewater and stormwater utilities and the marina (nonmajor). The proprietary fund financial statements can be found on pages 22 through 25 of this report. Data from the only nonmajor proprietary fund, the Marina Enterprise Fund, is also included in this presentation. Fiduciary Funds. Fiduciary funds are used to account for resources held for the benefit of parties outside the City. Fiduciary funds are not reflected in the government-wide financial statements because the resources of those funds are not available to support the City's own programs. The accounting used for fiduciary funds is much like that used for proprietary funds. The Firefighters' Pension Trust Fund is the only fiduciary fund for the City. The basic fiduciary fund financial statements can be found on pages 26 and 27 of this report. 6 502 City of Marathon, Florida Management's Discussion and Analysis September 30, 2023 Notes to the Basic Financial Statements The notes provide additional information that is essential to a full understanding of the data provided in the government-wide and fund financial statements. The notes to the financial statements can be found on pages 28 through 52 of this report. Other Information In addition to the basic financial statements and the accompanying notes, this report also presents certain required supplementary information, concerning the City of Marathon's budgetary comparison schedules for the General Fund and major special revenue fund and the progress in funding its obligation to provide pension benefits to certain employees and council members, as well as other post-employment benefits. Required supplementary information can be found on pages 53 through 60 of this report. The combining statements referred to earlier in connection with nonmajor governmental funds are presented immediately following the required supplementary information. Combining and individual fund statements and schedules can be found on pages 61 through 68 of this report. Government-wide Financial Analysis Net Position: As noted earlier, net position may serve over time as a useful indicator of a government's financial position. In the case of the City of Marathon, assets and deferred outflows of resources exceeded liabilities and deferred inflows of resources by $ 180,466,231 at the close of the most recent fiscal year, compared to net position of$ 170,444,425 the prior year. City of Marathon's Net Position Governmental Activities Business-Type Activities Total 2023 2022 2023 2022 2023 2022 Current and other assets $ 47,547,074 $ 44,568,051 $ 18,372,446 $ 20,639,354 $ 65,919,520 $ 65,207,405 Capital assets(net) 44,117,364 44,431,119 112,421,737 112,097,322 156,539,101 156,528,441 Total assets 91,664,438 88,999,170 130,794,183 132,736,676 222,458,621 221,735,846 Deferred outflows of resources 2,725,860 1,184,591 43,879 53,504 2,769,739 1,238,095 Current and other liabilities 4,059,125 5,439,607 6,305,047 5,547,787 10,364,172 10,987,394 Longterm liabilities 3,592,175 4,965,130 29,448,766 33,976,555 33,040,941 38,941,685 Total liabilities 7,651,300 10,404,737 35,753,813 39,524,342 43,405,113 49,929,079 Deferred inflows of resources 1,294,486 2,527,224 62,530 73,213 1,357,016 2,600,437 Net position: Net investment in capital assets 39,415,376 38,410,873 77,528,259 73,530,431 116,943,635 111,941,304 Restricted 11,378,516 14,016,062 - - 11,378,516 14,016,062 Unrestricted 34,650,620 24,824,865 17,493,460 19,662,194 52,144,080 44,487,059 Total net position $ 85,444,512 $ 77,251,800 $ 95,021,719 $ 93,192,625 $ 180,466,231 $ 170,444,425 The largest portion of the City's net position (64.80%) reflects its investment in capital assets (e.g. land, building, and equipment), less any related debt used to acquire those assets that are still outstanding. This investment in capital assets reflects a (4.47%) increase from the prior year. The City uses its capital assets to provide services to citizens; consequently, these assets are not available for future spending. Although the City's investment in capital assets is reported net of related debt, it should be noted that the resources needed to repay this debt must be provided from other sources, since the capital assets themselves cannot be used to liquidate these liabilities. 7 503 City of Marathon, Florida Management's Discussion and Analysis September 30, 2023 An additional portion of the City's net position, $ 11,378,516 (6.31%), represents resources that are subject to external restrictions on how they may be used. This represents a decrease of 18.82% from the previous year's balance of $ 14,016,062. The remaining balance of unrestricted net position $ 52,144,080 (28.89%) may be used to meet the City's ongoing obligations to citizens and creditors. Changes in Net Position Governmental activities and business-type activities increased the City's net position by $ 10,021,806 from the previous fiscal year. The relevant revenue and expense categories and their effect on net position are summarized in the table below. The information presented in this table will be used in the subsequent discussion of governmental and business-type activities: City of Marathon's Changes in Net Position Governmental Activities Business-Type Activities Total 2023 2022 2023 2022 2023 2022 Revenues: Program revenues: Charges for services $ 6,582,231 $ 7,104,071 $ 8,488,092 $ 8,356,476 $ 15,070,323 $ 15,460,547 Operating grants and contributions 2,315,826 1,371,930 - 35,299 2,315,826 1,407,229 Capital grants and contributions 5,992,424 6,716,111 7,732,711 7,202,415 13,725,135 13,918,526 General revenues: Property taxes 9,564,742 8,340,762 - - 9,564,742 8,340,762 Othertaxes 597,349 515,499 597,349 515,499 Intergovernmental revenues 2,980,566 3,007,258 - - 2,980,566 3,007,258 Investment earnings 966,901 84,652 335,981 38,887 1,302,882 123,539 Miscellaneous 127,569 80,717 35,121 - 162,690 80,717 Total revenues 29,127,608 27,221,000 16,591,905 15,633,077 45,719,513 42,854,077 Expenses: General government 4,364,953 3,559,195 - - 4,364,953 3,559,195 Public safety 8,104,119 7,192,119 8,104,119 7,192,119 Community services 6,993,501 4,958,150 6,993,501 4,958,150 Community development 1,149,642 839,282 1,149,642 839,282 Interest on long-term debt 160,233 180,951 - - 160,233 180,951 Marina - - 1,356,116 1,083,047 1,356,116 1,083,047 Wastewater 12,439,615 12,272,525 12,439,615 12,272,525 Stormwater - - 1,129,528 1,168,438 1,129,528 1,168,438 Total expenses 20,772,448 16,729,697 14,925,259 14,524,010 35,697,707 31,253,707 Increase in net position before transfers 8,355,160 10,491,303 1,666,646 1,109,067 10,021,806 11,600,370 Transfers (162,448) (208,322) 162,448 208,322 Increase in net position 8,192,712 10,282,981 1,829,094 1,317,389 10,021,806 11,600,370 Net position-beginning 77,251,800 66,968,819 93,192,625 91,875,236 170,444,425 158,844,055 Net position-ending $ 85,444,512 $ 77,251,800 $ 95,021,719 $ 93,192,625 $ 180,466,231 $ 170,444,425 8 504 City of Marathon, Florida Management's Discussion and Analysis September 30, 2023 Governmental activities increased the City of Marathon's net position by $ 8,192,712 as compared to an increase in net position of $ 10,282,981 in the prior fiscal year. The decrease from the prior year is due to increased personnel costs. Program revenues, comprised of charges for services as well as operating and capital grants, and contributions represent 51.12% of the governmental activities total revenues. Property taxes, which represent 32.84% of total revenues for governmental activities, are non-program specific and are used to fund all activities not covered by program revenues. Revenue Sources - Governmental Activities Investment Earnings& I ntergovernment Miscellaneous Revenue 3.8% 10.2% Chargesfor Services 22.6% Capital Grants&� Contributions 20.6% f' 0perati ng Grants &Contributions Property Taxes 7.9% 32.9% Other Taxes 2.0% Business-Type Activities Business-type activities increased the City of Marathon's net position by$ 1,829,094. This is the twentieth year of operation for the Marina Enterprise Fund, and the eighteenth year of operation for the Wastewater and Stormwater Utility Enterprise Fund. • In total, the City's business-type activities reflected an operating loss of $ 5,610,148. This is primarily due to the Wastewater and Stormwater's operating loss of $ 5,368,016. The operating loss is primarily due to the provision for depreciation of$ 5,317,338. • The Marina Fund's operating loss of $ 242,132 is $ 198,606 more than its operating loss from the previous year of $ 43,526. The operating loss is primarily due to the provision for depreciation of$ 233,184. 9 505 City of Marathon, Florida Management's Discussion and Analysis September 30, 2023 Charges for services represent 51.2% of the total business-tvpe revenues. Charges for Capital Grants& Services Contributions 51.2% 46.6% �j Investment Ea rni ngs& Miscellaneous 2.2% Financial Analysis of the Government's Funds As noted earlier, the City of Marathon uses fund accounting to ensure and demonstrate compliance with finance-related legal requirements. Governmental Funds The focus of the City's governmental funds is to provide information on near-term inflows, outflows, and balances of spendable resources. Such information is useful in assessing the City's financing requirements. In particular, unassigned fund balance may serve as a useful measure of a government's resources available for spending at the end of the fiscal year. As of the end of the current fiscal year, the City of Marathon's governmental funds reported combined ending fund balances of$ 42,654,418 an increase of $ 7,066,347 in comparison with the prior year. Of this total amount, $ 22,535,252 is available for spending at the City's discretion. The remainder of fund balance: $ 115,820 is restricted for police education, $ 1,459,998 is restricted for street maintenance projects, $ 5,185,971 is restricted for capital projects, $ 3,848,406 is restricted for the building department, $ 494,915 is nonspendable fund balance for prepaid items and $ 9,014,056 is committed fund balance to indicate that it is not available for new spending because it is already committed for a variety of restricted purposes. General Fund: The General Fund is the main operating fund of the City of Marathon. At the end of the current fiscal year, unassigned fund balance of the General Fund was $ 22,535,252 while total fund balance was$ 23,130,086. 10 506 City of Marathon, Florida Management's Discussion and Analysis September 30, 2023 The fund balance of the City of Marathon's General Fund increased by $4,416,321 during the current fiscal year. Total General Fund revenues increased approximately 14%. This increased from the prior year due to an increase in parking and boat ramp fees together with an increase in property taxes. The amount of General Fund revenue by type, the percent of the total and the amount of change compared to last fiscal year are shown in the following schedule: Increase Percentage 2023 Percentage 2022 Percentage (Decrease) oflncrease Amount of Total Amount of Total From 2022 (Decrease) Revenues: Property taxes $ 9,564,742 52% $ 8,340,762 53% $ 1,223,980 15% Intergovernmental 3,503,145 19% 3,871,043 24% (367,898) -10% Licenses and permits 1,603,080 9% 1,155,040 7% 448,040 39% Charges for services 1,320,534 7% 1,476,209 9% (155,675) -11% Fines and forfeitures 1,168,151 6% 494,001 3% 674,150 136% Communication services taxes 597,349 3% 515,499 3% 81,850 16% Interest 497,064 3% 44,173 0% 452,891 1025% Miscellaneous 37,431 1% 128,974 1% (91,543) -71% Total revenues $ 18,291,496 100% $ 16,025,701 100% $ 2,265,795 14% • Property tax revenues increased $ 1,223,980 (15%) due to an increase in property values and the adoption of a millage rate that is greater than the roll-back rate. • Fines and forfeitures increased $ 674,150 (136%) due to implementation of new parking and boat ramp usage fees. • Interest increased $ 452,891 (1025%) due to an increased earning rate during the year. Expenditures in the General Fund are shown in the following schedule: Increase Percentage 2023 Percentage 2022 Percentage (Decrease) oflncrease Amount of Total Amount of Total From 2022 (Decrease) Expenditures: City Council $ 553,285 4% $ 415,850 3% $ 137,435 33% Administration 2,902,786 19% 2,321,079 18% 581,707 25% Legal 351,676 2% 339,066 3% 12,610 4% Police services 2,215,128 15% 2,129,773 16% 85,355 4% Fire/EMS 5,318,149 36% 4,905,753 38% 412,396 8% Public works 744,684 5% 486,851 4% 257,833 53% Parks and recreation 1,775,683 12% 1,572,537 12% 203,146 13% Bridge and near shore waters 59,515 0% 56,758 0% 2,757 5% Community development 995,880 7% 826,864 6% 169,016 20% Total expenditures $ 14,916,786 100% $ 13,054,531 100% $ 1,862,255 14% • Public Safety expenditures increased $ 497,751 (7%) due to increased personnel costs. 11 507 City of Marathon, Florida Management's Discussion and Analysis September 30, 2023 Other governmental funds: Significant items pertaining to other governmental funds are as follows: • The Street Maintenance Fund decreased its fund balance by $ 44,707 largely due to increased personnel costs. • The Capital Infrastructure Fund increased its fund balance by $ 2,033,043 due to a decrease in capital outlay activities. Proprietary Funds: In addition to the items already addressed in the discussion of the City's business-type activities, other significant items pertaining to the City's business-type activities are as follows: Wastewater and Stormwater Utility Fund • The City-wide stormwater collection and wastewater collection and treatment systems have been online and operating since the end of fiscal year 2013. This activity resulted in an increase in the Wastewater and Stormwater Utility Fund net position of $ 2,096,697 which is mainly attributed to grant revenue reimbursements. Marina Fund • The activities at the City's marina resulted in a decrease of net position of $ 267,603 due to the provision for depreciation of$ 233,184. General Fund Budgetary Highlights There were $45,000 in differences between the original budget and the final amended budget. The significant changes to the individual departments (budgetary level of control for the General Fund) from the original to the final amended budget can be briefly summarized as follows: • The City Councils' budget was increased by $ 100,000 for the not-for- profit grant program, while the Police budget was decreased by $ 145,000 to a refund of unused fees. Actual expenditures were $ 2,353,367 below the final budgeted amounts. The significant variances can be summarized as follows: • Community Development was $ 964,131 under budget due to operating costs being less than anticipated. • Community Services were $ 830,934 under budget due to operating costs being less than anticipated. • Public Safety expenditures for fire and emergency medical services were $ 310,186 under budget due to personnel costs being lower than anticipated. 12 508 City of Marathon, Florida Management's Discussion and Analysis September 30, 2023 Resources available for appropriations were $ 1,358,650 over the budgeted amount. The significant variance can be summarized as follows: • Licenses and permits were $728,080 over budget due to an increase in vacation rental permit fees as well as an increase in fire inspection fees. • Interest income was $477,064 over budget due to the increase in annual percentage yields. Capital Assets and Debt Administration Capital assets: The City of Marathon's investment in capital assets for its governmental and business-type activities as of September 30, 2023, amounts to $ 156,539,101 (net of accumulated depreciation). This investment in capital assets includes land, buildings and improvements, furniture and equipment, and park facilities. The investment does not include governmental infrastructure assets acquired prior to 2004, as GASB 34 does not require Phase III governments to report infrastructure retroactively. The total net increase in the City's investment in capital assets for the current fiscal year was $ 10,660 as compared to the $ 1,597,374 net increase in the prior yea r. Major capital asset events during the current fiscal year included the following: Governmental Activities: • Improvements other than buildings increased $ 1,742,071 primarily due to bridge improvements. • Furniture and equipment increased $ 144,417 mainly due to the purchase of parking meter machines, and security camera systems. • Construction-in-progress increased $ 106,016 primarily due to ongoing projects at the Quay and 33rd St. Business Activities: • Improvements other than buildings increased by $ 3,631,582 primarily due to disk filter upgrades at the Service Area 7 and Service Area 4 wastewater treatment plants, and new service connections throughout the City. • Construction-in-progress increased by $ 2,059,244 primarily attributable to the ongoing chemical feed system mitigation project. 13 509 City of Marathon, Florida Management's Discussion and Analysis September 30, 2023 Governmental Activities Business-Type Activities Total 2023 2022 2023 2022 2023 2022 Capital assets, net of depreciation: Land $ 16,312,247 $ 16,312,247 $ 4,695,647 $ 4,695,647 $ 21,007,894 $ 21,007,894 Intangibles 3,822 3,822 1,618,093 1,618,093 1,621,915 1,621,915 Construction in progress 182,598 685,618 5,791,253 3,856,899 5,973,851 4,542,517 Buildings 13,157,518 13,774,585 3,347,430 3,528,874 16,504,948 17,303,459 Improvement other than buildings 11,660,297 10,500,063 95,792,891 97,021,885 107,453,188 107,521,948 Land improvements - - 44,804 56,004 44,804 56,004 Fire equipment and vehicles 1,585,420 1,906,211 - - 1,585,420 1,906,211 Vehicles - - 535,805 537,595 535,805 537,595 Furniture and equipment 1,215,462 1,248,573 595,814 782,325 1,811,276 2,030,898 Total $ 44,117,364 $ 44,431,119 $ 112,421,737 $ 112,097,322 $ 156,539,101 $ 156,528,441 Additional information on the City's capital assets can be found in Note 6 on pages 38 through 40 of this report. Long-term liabilities: At the end of the current fiscal year, the City of Marathon had governmental activities improvement revenue bond debt outstanding of $ 3,345,000. This debt is secured by the City's local discretionary sales surtax revenues. Governmental activities also had a note payable for $ 1,300,000. The City's Wastewater and Stormwater Enterprise Fund also had State Revolving Fund debt outstanding of $ 33,875,262. The State Revolving Fund debt is secured by the pledge of future non-ad valorem assessments for utility construction, the capital infrastructure funds, and the gross revenues derived yearly from the operation of the sewer and stormwater systems after payment of operating and maintenance expenses and the satisfaction of all yearly payment senior obligations. Governmental Activities Business-Type Activities Total 2023 2022 2023 2022 2023 2022 Long-term liabilities: Improvement Revenue Bonds $ 3,345,000 $ 3,995,000 $ $ $ 3,345,000 $ 3,995,000 Note payable 1,300,000 2,000,000 1,300,000 2,000,000 State Revolving Fund Loan - - 33,875,262 38,309,180 33,875,262 38,309,180 Compensated absences 249,123 228,949 88,241 78,421 337,364 307,370 Net pension liability - 25,140 - - - 25,140 Other post-employment benefit obligation 97,965 88,936 30,766 27,931 128,731 116,867 Total $ 4,992,088 $ 6,338,025 $ 33,994,269 $ 38,415,532 $ 38,986,357 $ 44,753,557 The City of Marathon's total long-term liabilities decreased by $ 5,767,200 (12.89%) during the current fiscal year. Additional information on the City of Marathon's long-term debt can be found in Note 7 on pages 40 through 42 of this report. Economic Factors and Next Year's Budgets and Rates The unemployment rate for Monroe County was 1.8% in December of 2023, which is a decrease from a rate of 1.9% a year ago. The rate compares favorably to the State's average unemployment rate of 3%. 14 510 City of Marathon, Florida Management's Discussion and Analysis September 30, 2023 An increase in property values resulted in a roll-back rate, which is the tax rate that would bring in the same amount of money as the previous year of 2.4477. For fiscal year 2024, the City adopted a final millage rate of 2.4477 mills which is 0% higher than the roll-back rate. During fiscal year 2024, the City will be working on the following programs/projects: • City Bridge Rehabilitation and Replacement • Canal and Culvert Restoration Projects • Fire Hydrant Installations • Quay property improvements Requests for Information This financial report is designed to provide a general overview of the City of Marathon's finances for all those with an interest in the City's finances. Questions concerning any of the information provided in this report or requests for additional financial information should be addressed to Finance Director, City of Marathon, 9805 Overseas Highway, Marathon, Florida 33050. 15 511 BASIC FINANCIAL STATEMENTS 512 City of Marathon, Florida Statement of Net Position September 30, 2023 Business- Governmental type Activities Activities Total Assets: Cash and cash equivalents $ 42,894,341 $ 15,787,040 $ 58,681,381 Investments 48,745 - 48,745 Receivables, net 1,142,447 467,607 1,610,054 Due from other governments 2,198,305 2,083,796 4,282,101 Prepaid items 494,915 34,003 528,918 Net pension asset 768,321 - 768,321 Capital assets not being depreciated 16,498,667 12,104,993 28,603,660 Capital assets, being depreciated 27,618,697 100,316,744 127,935,441 Total assets 91,664,438 130,794,183 222,458,621 Deferred Outflows of Resources: Deferred outflows related to pension 2,590,982 - 2,590,982 Deferred outflows related to OPEB 134,878 43,879 178,757 Total deferred outflows of resources 2,725,860 43,879 2,769,739 Liabilities: Accounts payable and accrued liabilities 906,252 1,683,029 2,589,281 Accrued interest payable 29,250 76,515 105,765 Unearned revenues 1,723,710 - 1,723,710 Due within one year: Compensated absences payable 24,913 8,824 33,737 Bonds payable 675,000 - 675,000 Loans payable 700,000 4,536,679 5,236,679 Due in more than one year: Other post employment benefits liability(OPEB) 97,965 30,766 128,731 Compensated absences payable 224,210 79,417 303,627 Bonds payable 2,670,000 - 2,670,000 Loans payable 600,000 29,338,583 29,938,583 Total liabilities 7,651,300 35,753,813 43,405,113 Deferred Inflows of Resources: Deferred inflows related to pension 1,083,007 - 1,083,007 Deferred inflows related to OPEB 211,479 62,530 274,009 Total deferred inflows of resources 1,294,486 62,530 1,357,016 Net Position: Net investment in capital assets 39,415,376 77,528,259 116,943,635 Restricted for: Net pension asset 768,321 - 768,321 Capital projects 5,185,971 - 5,185,971 Street maintenance 1,459,998 - 1,459,998 Police education 115,820 - 115,820 Building department 3,848,406 - 3,848,406 Unrestricted 34,650,620 17,493,460 52,144,080 Total net position $ 85,444,512 $ 95,021,719 $ 180,466,231 The accompanying notes to the financial statements are an integral part of these statements. 16 513 ;: ;; al N M I: n N G d' M N al l0 N O al l0 m ci m 1-1 N 00 m l0 Il n O d' N d d l0 00 al N O N m m rl O N N Ol N rl Ln Ln d' I� m Ln 00 10 N 00 d N d' Ln N l0 O c-1 O l0 c-1 Ln l0 d' Il O N N 00 c-1 d' l0 m N m O l0 00 00 m N al 00 l0 al 00 O l0 O N d' l0 d' l0 m ci 00 Ln Cl) N N Ln Ln Ln al m ci l0 O v v c-I Ln ci d' O1 N c-I d' O O O ci ci rl 00 ci ci I- N Ln d' d' ci ci 00 O d' Ln al n n O d' d' 00 N d' Ln al N c-1 H h ' ' ' ' N rl Ln Ln Ln ' ' ' al ci d' Ln O l0 rl "C H O l0 ci Ln Ln Ln Ln N m al N ci 00 m N al al m m l0 m N al N Lp 0 G �-.> Ln al N N N m ci Ln 00 ci O aT+ c-I c-I c-I rf Lr cuC m Q N CU Z al w W h c-I d' 0) N m I, n N al l0 ci al 00 0) N O N +1 al al @ m ci N 00 m l0 l0 d' d' l0 O l0 d' I, ci O ciro X CL 00 f' h m I, O N N al ' ' al Il m Ln 0) Ln d' l0 I, 00 Ln 1 W @ G1 d' Lfl N l0 O �--� �--� d' I� O l0 I� d'N N �--� d' Ln t £ +' m N m O l0 00 00 l0 Ol 00 l0 N l0 I, Ol Ln d' cu U a > d' lfl m ci 00 00 Ln Ln 111 0) -1 ci O ci N d' Ln Z yui c-I m m m N d' 00 I, Ln O Q c r, 00 C cu l7 10 O L (o yL O ci m d' d" O n c-I Ln Q C ' n 00 00 d' 00 Om lc n ci f6 @ M a+ d' Il 0) N Ln l0 O N Ln L ++ H 7 N 0) l0 0) d' l0 N m N Cln a a+ 00 Ol l0 O I, n cu A L Ln Ln Ln N Il m +, U i G C l7 O — U C6 L al (o G G Il l0 d' d' N N , cu ,a 0 d' o0 o0 l0 o0 o0 C l: it @ 7 O N c-I r, chi chi L 4 m Ln N m N m m E I� @ O. i rl N N cu r-I 0O U N CL v to Ln d' 0) m ci 00 d' N m > ro m 00 rn N rn o m v v C al al 00 I, m N N d' m 00 O 76 LO i N N N c-I ci 00 r, ci 00 r, a•, . @ .0 i d' N 00 ci Ln m ci d' O E cu � al rH N N l0 Il rH 00 Ln a•, E U Ln n u c ai 03 > ai cA +� � Ln j 0 •E 0Acu >^ a > O m Ol ci N m 00 Ln 00 l0 Ol rl a W O C C O Ln ci o d m d ci N ci Ln O v + -0 05 h Il ci Ln l0 N d' l0 Ln ci N I� N N O aJ H d' d' m Ol O N Ol Ol l0 Ln Il > •O — _ O a1 O d'l0 O al l0 Il m N Ln N al �1 .� N 0p .O O . �. al m ci i Il c ci I, d- ci m Ilil0 O. .-- .� �- T 00 l0 c-I O N zT Ln s M W N c ci m O DL E i i U 0 00° Q Q ro Q N aaj n. v > > [2 ~ m v v N (D f— u Z Z O Mto L cu O � ai an aJ aj fC G1 ''' •a'' L IA Q u u 41 41 m m ti t N - Q > 10v v E a v = v 'a +' c a E O Q = c�cj�. a1 U i •� a1 W G V C i > .� (6 L O Q 0 O -? 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Q m 514 City of Marathon, Florida Balance Sheet Governmental Funds September 30, 2023 Other Street Capital Nonmajor Total General Maintenance Infrastructure Governmental Governmental Fund Fund Fund Funds Funds Assets: Cash and cash equivalents $ 22,530,312 $ 1,408,962 $ 8,796,162 $ 10,158,905 $ 42,894,341 Investments 31,878 14,778 2,089 - 48,745 Receivables,net 372,447 - - 770,000 1,142,447 Due from other governments 1,139,788 64,887 687,447 306,183 2,198,305 Prepaid items 479,014 7,064 - 8,837 494,915 Total assets $ 24,553,439 $ 1,495,691 $ 9,485,698 $ 11,243,925 $ 46,778,753 Liabilities: Accounts payable and accrued liabilities $ 517,887 $ 28,629 $ 56,988 $ 302,748 $ 906,252 Unearned revenues - - 1,723,710 - 1,723,710 Total liabilities $ 517,887 $ 28,629 $ 1,780,698 $ 302,748 $ 2,629,962 Deferred Inflows of Resources: Unavailable revenue 905,466 - 282,724 306,183 1,494,373 Fund Balances: Nonspendable: Prepaid items 479,014 7,064 - 8,837 494,915 Restricted for: Capital projects - - 5,185,971 - 5,185,971 Street maintenance - 1,459,998 - - 1,459,998 Police education 115,820 - - - 115,820 Building department - - - 3,848,406 3,848,406 Committed to: Vehicle replacement - - 2,236,305 - 21236,305 Infrastructure improvements - - - 3,003,815 3,003,815 Affordable housing - - - 2,815,120 2,815,120 Restoration projects - - - 958,816 958,816 Unassigned 22,535,252 - - - 22535,252 Total fund balances 23,130,086 1,467,062 7,422,276 10,634,994 42,654,418 Total liabilities, deferred inflows of resources and fund balances $ 24,553,439 $ 1,495,691 $ %485,698 $ 11,243,925 $ 46,778,753 The accompanying notes to the financial statements are an integral part of these statements. 18 515 City of Marathon, Florida Reconciliation of the Balance Sheet of Governmental Funds to the Statement of Net Position September 30, 2023 Fund Balances -Total Governmental Funds $ 42,654,418 Amounts Reported for Governmental Activities in the Statement of Net Position are Different Because: Capital assets used in governmental activities are not financial resources and therefore are not reported in the governmental funds: Governmental capital assets 71,518,898 Less accumulated depreciation (27,401,534) Accrued interest payable not reported in the governmental funds (29,250) Unavailable revenue in governmental funds is susceptible to full accrual on the government-wide statements. 1,494,373 Certain assets are not an available resource and certain liabilities are not due and payable in the current period and, therefore, are not reported in the funds. These assets and liabilities are comprised of the following: Net pension asset 768,321 Deferred outflows related to pensions 2,590,982 Deferred inflows related to pensions (1,083,007) Net OPEB obligation (97,965) Deferred outflows related to OPEB 134,878 Deferred inflows related to OPEB (211,479) Compensated absences payable (249,123) Note payable (1,300,000) Governmental revenue bonds payable (3,345,000) Net Position of Governmental Activities $ 85,444,512 The accompanying notes to the financial statements are an integral part of these statements. 19 516 City of Marathon, Florida Statement of Revenues, Expenditures and Changes in Fund Balances - Governmental Funds For the Year Ended September 30, 2023 Other Street Capital Nonmajor Total General Maintenance Infrastructure Governmental Governmental Fund Fund Fund Funds Funds Revenues: Property taxes $ 9,564,742 $ - $ - $ - $ 9,564,742 Intergovernmental 3,503,145 654,661 6,411,943 1,067,285 11,637,034 Licenses and permits 1,603,080 - - 1,382,066 2,985,146 Charges for services 1,320,534 - - - 1,320,534 Fines and forfeitures 1,168,151 - - - 1,168,151 Communications services tax 597,349 - - - 597,349 Impact fees - - - 641,085 641,085 Interest 497,064 34,434 197,331 238,072 966,901 Miscellaneous 37,431 2,500 2,650 - 42,581 Total revenues 18,291,496 691,595 6,611,924 3,328,508 28,923,523 Expenditures: Current: General government 3,692,840 - - - 3,692,840 Public safety 7,533,277 - - - 7,533,277 Community services 2,579,882 725,965 - 2,592,894 5,898,741 Community development 995,880 - - - 995,880 Capital outlay 114,907 17,365 1,929,342 - 2,061,614 Debt service: Principal - - - 1,350,000 1,350,000 Interest and fiscal charges - - - 175,983 175,983 Total expenditures 14,916,786 743,330 1,929,342 4,118,877 21,708,335 Excess of revenues over expenditures 3,374,710 (51,735) 4,682,582 (790,369) 7,215,188 Other Financing Sources(Uses): Insurance proceeds 6,579 7,028 - - 13,607 Transfers in 1,430,691 - - 3,333,050 4,763,741 Transfers out (395,659) - (2,649,539) (1,880,991) (4,926,189) Total other financing sources(uses) 1,041,611 7,028 (2,649,539) 1,452,059 (148,841) Net change in fund balances 4,416,321 (44,707) 2,033,043 661,690 7,066,347 Fund Balances,Beginning 18,713,765 1,511,769 5,389,233 9,973,304 35,588,071 Fund Balances,Ending $ 23,130,086 $ 1,467,062 $ 7,422,276 $ 10,634,994 $ 42,654,418 The accompanying notes to the financial statements are an integral part of these statements. 20 517 City of Marathon, Florida Reconciliation of the Statement of Revenues, Expenditures and Changes in Fund Balances of Governmental Funds to the Statement of Activities For the Year Ended September 30, 2023 Net Change in Fund Balances -Total Governmental Funds $ 7,066,347 Amounts Reported for Governmental Activities in the Statement of Activities are Different Because: Governmental funds report capital outlays as expenditures. However, in the statement of activities, the cost of those assets is depreciated over their estimated useful lives: Expenditures for capital assets 2,061,614 Less current year provision for depreciation (2,375,369) Revenues that are earned but not received within the availability period are recognized in the statement of activities when earned and subsequently in the governmental fund financial statements when they become available. The net difference is recorded as a reconciling item. 108,543 The issuance of long-term debt (e.g. bonds and notes payable) provide current financial resources to governmental funds, while repayment of the principal of long-term debt consumes the current financial resources of governmental funds. Neither transaction has any effect on net position Principal payments 1,350,000 Certain items reported in the statement of activities do not require the use of current financial resources and therefore are not reported as expenditures in the governmental funds: Change in accrued interest payable 15,750 Change in net pension asset (2,804,117) Change in net pension liability 25,140 Change in deferred outflows related to pension 1,570,855 Change in deferred inflows related to pension 1,196,607 Change in net OPEB obligation (9,029) Change in deferred outflows related to OPEB (29,586) Change in deferred inflows related to OPEB 36,131 Change in compensated absences payable (20,174) Change in Net Position of Governmental Activities $ 8,192,712 The accompanying notes to the financial statements are an integral part of these statements. 21 518 City of Marathon, Florida Statement of Net Position Proprietary Funds September 30, 2023 Business-Type Activities Enterprise Funds Nonmajor Major Fund Fund Total wastewater and Marina Enterprise Stormwater Fund Fund Funds Assets: Current assets: Cash and cash equivalents $ 15,026,345 $ 760,695 $ 15,787,040 Receivables, net 467,607 - 467,607 Due from other governments 1,946,307 137,489 2,083,796 Prepaid items 25,403 8,600 34,003 Total current assets 17,465,662 906,784 18,372,446 Noncurrent assets: Capital assets not being depreciated 11,530,736 574,257 12,104,993 Capital assets, net of accumulated depreciation 98,399,047 1,917,697 100,316,744 Total noncurrent assets 109,929,783 2,491,954 112,421,737 Total assets 127,395,445 3,398,738 130,794,183 Deferred Outflows of Resources: Deferred outflows relating to OPEB 33,635 10,244 431879 Liabilities: Current liabilities: Accounts payable and accrued liabilities 1,709,360 50,184 1,759,544 Current portion of loans payable 4,536,679 - 4,536,679 Current portion of compensated absences 6,656 2,168 8,824 Total current liabilities 6,252,695 52,352 6,305,047 Noncurrent liabilities: Compensated absences, net of current portion 59,906 19,511 79,417 Other post employment benefits liability (OPEB) 23,853 6,913 30,766 Loans payable 29,338,583 - 29,338,583 Total noncurrent liabilities 29,422,342 26,424 29,448,766 Total liabilities 35,675,037 78,776 35,753,813 Deferred Inflows of Resources: Deferred inflows relating to OPEB 48,846 13,684 62,530 Net Position: Net investment in capital assets 75,050,732 2,477,527 77,528,259 Unrestricted 16,654,465 838,995 17,493,460 Total net position $ 91,705,197 $ 3,316,522 $ 95,021,719 The accompanying notes to the financial statements are an integral part of these statements. 22 519 City of Marathon, Florida Statement of Revenues, Expenses and Changes in Net Position Proprietary Funds For the Year Ended September 30, 2023 Business-Type Activities Enterprise Funds Major Fund Nonmajor Wastewater and Fund Total Stormwater Marina Enterprise Fund Fund Funds Operating Revenues: Charges for services $ 7,374,108 $ 1,113,984 $ 8,488,092 Total operating revenues 7,374,108 1,113,984 8,488,092 Operating Expenses: Personnel costs 2,408,394 630,207 3,038,601 Operating expenses 5,016,392 492,725 5,509,117 Provision for depreciation 5,317,338 233,184 5,550,522 Total operating expenses 12,742,124 1,356,116 14,098,240 Operating income (loss) (5,368,016) (242,132) (5,610,148) Nonoperating Revenues(Expenses): Insurance proceeds 35,121 - 35,121 Interest income 310,514 25,467 335,981 Interest expense (827,019) - (827,019) Total nonoperating revenues (expenses) (481,384) 25,467 (455,917) Income (loss) before capital contributions (5,849,400) (216,665) (6,066,065) Capital Contributions: Special assessments 5,051,102 - 5,051,102 Grants 2,660,982 20,627 2,681,609 Total capital contributions 7,712,084 20,627 7,732,711 Income before transfers 1,862,684 (196,038) 1,666,646 Transfers: Transfers in 650,000 - 650,000 Transfers out (415,987) (71,565) (487,552) Total transfers 234,013 (71,565) 162,448 Change in net position 2,096,697 (267,603) 1,829,094 Net Position, Beginning 89,608,500 3,584,125 93,192,625 Net Position, Ending $ 911705,197 $ 3,316,522 $ 95,021,719 The accompanying notes to the financial statements are an integral part of these statements. 23 520 City of Marathon, Florida Statement of Cash Flows Proprietary Funds For the Year Ended September 30, 2023 Business-Type Activities Enterprise Funds Major Fund Nonmajor Wastewater and Fund Total Stormwater Marina Enterprise Fund Fund Funds Cash Flows from Operating Activities: Receipts from customers and users $ 7,403,433 $ 1,113,984 $ 8,517,417 Payments to employees (2,398,848) (603,842) (3,002,690) Payments to suppliers (4,260,627) (600,989) (4,861,616) Net cash provided by(used in) operating activities 743,958 (90,847) 653,111 Cash Flows from Non-Capital Financing Activities: Transfers to other funds (415,987) (71,565) (487,552) Net cash provided by(used in) non-capital and related financing activities (415,987) (71,565) (487,552) Cash Flows from Capital and Related Financing Activities: Acquisition of capital assets (5,560,827) (314,110) (5,874,937) Proceeds from capital grants 1,221,775 15,494 1,237,269 Proceeds from capital assessments 5,051,102 - 5,051,102 Insurance proceeds 35,121 - 35,121 Transfers from other funds 650,000 - 650,000 Repayments of capital debt (4,433,918) - (4,433,918) Interest paid (882,103) - (882,103) Net cash provided by(used in)capital and related financing activities (3,918,850) (298,616) (4,217,466) Cash Flows from Investing Activities: Interest received 310,514 25,467 335,981 Net cash provided by(used in) investing activities 310,514 25,467 335,981 Net increase(decrease) in cash and cash equivalents (3,280,365) (435,561) (3,715,926) Cash and Cash Equivalents,Beginning 18,306,710 1,196,256 19,502,966 Cash and Cash Equivalents,Ending $ 15,026,345 $ 760,695 $ 15,787,040 The accompanying notes to the financial statements are an integral part of these statements. 24 521 City of Marathon, Florida Statement of Cash Flows Proprietary Funds (Continued) For the Year Ended September 30, 2023 Business-Type Activities Enterprise Funds Major Fund Nonmajor Wastewater and Fund Total Stormwater Marina Enterprise Fund Fund Funds Reconciliation of Operating Income(Loss)to Net Cash Provided by(Used in)Operating Activities: Operating income(loss) $ (5,368,016) $ (242,132) $ (5,610,148) Adjustments to Reconcile Operating Income (Loss)to Net Cash Provided by(Used in) Operating Activities: Provision for depreciation 5,317,338 233,184 5,550,522 (Increase)decrease in: Receivables 29,325 - 29,325 Prepaids (25,403) (8,600) (34,003) Deferred outflows relating to OPEB 7,378 2,247 9,625 Increase(decrease) in: Accounts payable and accrued liabilities 787,962 (82,144) 705,818 Compensated absences 1,521 8,299 9,820 Deferred inflows relating to OPEB (8,345) (2,338) (10,683) OPEB liability 2,198 637 2,835 Total adjustments 6,111,974 151,285 6,263,259 Net cash provided by(used in) operating activities $ 743,958 $ (90,847) $ 653,111 The accompanying notes to the financial statements are an integral part of these statements. 25 522 City of Marathon, Florida Statement of Fiduciary Net Position Firefighters' Pension Trust Fund September 30, 2023 Assets: Cash $ 188,235 Investments: Bond funds 3,791,587 Equity funds 9,465,523 Total investments 13,257,110 Receivables: Plan members 22,131 City(including State) 231,944 Total receivables 254,075 Total assets 13,699,420 Liabilities: Reserve for Share Plan (Note 10) 321,092 Net Position: Net position restricted for pensions $ 13,378,328 The accompanying notes to the financial statements are an integral part of these statements. 26 523 City of Marathon, Florida Statement of Changes in Fiduciary Net Position Firefighters' Pension Trust Fund For the Year Ended September 30, 2023 Additions: Contributions: Plan members $ 118,535 City (including State) 552,133 Total contributions 670,668 Investment income: Net appreciation in fair value of investments 1,017,748 Less: Investment expenses 23,190 Net investment income 994,558 Total additions 1,665,226 Deductions: Distributions 55,843 Administrative expenses 21,768 Total deductions 77,611 Change in net position 1,587,615 Net Position, Beginning 11,790,713 Net Position, Ending $ 13,378,328 The accompanying notes to the financial statements are an integral part of these statements. 27 524 NOTES TO BASIC FINANCIAL STATEMENTS 525 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 1 - Summary of Significant Accounting Policies The City of Marathon (the "City") is a municipal corporation organized pursuant to Chapter 99-427, Laws of Florida and is located in Monroe County (the "County"). The City was incorporated on November 30, 1999. The City operates under the Council-Manager form of government and provides the following services: general government, public safety, community services and community development. The City also operates two enterprise funds which provide wastewater, stormwater and marina services. The financial statements of the City have been prepared in conformity with accounting principles generally accepted in the United States (GAAP) as applied to governmental units. The Governmental Accounting Standards Board (GASB) is the accepted standard-setting body for establishing governmental accounting and financial reporting principles. The more significant of the City's accounting policies are described below: Financial reporting entity: The financial statements were prepared in accordance with GASB pronouncements for The Financial Reporting Entity, which establishes standards for defining and reporting on the financial reporting entity. The definition of the financial reporting entity is based upon the concept that elected officials are accountable to their constituents for their actions. One of the objectives of financial reporting is to provide users of financial statements with a basis for assessing the accountability of the elected officials. The financial reporting entity consists of the City, organizations for which the City is financially accountable, and other organizations for which the nature and significance of their relationship with the City are such that exclusion would cause the reporting entity's financial statements to be misleading or incomplete. The City is financially accountable for a component unit if it appoints a voting majority of the organization's governing board and it is able to impose its will on that organization or there is a potential for the organization to provide specific financial benefits to, or impose specific financial burdens on, the City. Based upon the application of these criteria, there were no organizations that met the criteria for component units described above. Government-wide and fund financial statements: The government-wide financial statements (i.e., the statement of net position and the statement of activities) report information on all of the non- fiduciary activities of the City. For the most part, the effect of interfund activity has been removed from these statements. Governmental activities, which normally are supported by taxes and intergovernmental revenues, are reported separately from business-type activities, which rely to a significant extent on fees and charges for support. The statement of activities demonstrates the degree to which the direct expenses of a given function or segment is offset by program revenues. Direct expenses are those that are clearly identifiable with a specific function or segment. Program revenues include 1) charges to customers or applicants who purchase, use, or directly benefit from goods, services, or privileges provided by a given function or segment and 2) grants and contributions that are restricted to meeting the operational or capital requirements of a particular function or segment. Taxes and other items not properly included among program revenues are reported instead as general revenues. Separate financial statements are provided for governmental funds, the proprietary funds, and the fiduciary fund, even though the latter are excluded from the government-wide financial statements. Major individual governmental funds and the major individual enterprise funds are reported as separate columns in the fund financial statements. 28 526 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 1 - Summary of Significant Accounting Policies (continued) Measurement focus, basis of accounting and financial statement presentation: The government- wide financial statements are reported using the economic resources measurement focus and the accrual basis of accounting, as are the proprietary funds and fiduciary fund financial statements. Revenues are recorded when earned and expenses are recorded when a liability is incurred, regardless of the timing of related cash flows. Property taxes are recognized as revenues in the year for which they are levied. Grants and similar items are recognized as revenue as soon as all eligibility requirements imposed by the provider have been met. Governmental fund financial statements are reported using the current financial resources measurement focus and the modified accrual basis of accounting. Revenues are recognized as soon as they are both measurable and available. Revenues are considered to be available when they are collectible within the current period or soon enough thereafter to pay liabilities of the current period. For this purpose, the City considers revenues to be available if they are collected within 60 days of the end of the current fiscal period. Expenditures are recorded when a liability is incurred, as under accrual accounting. However, debt service expenditures as well as expenditures related to compensated absences are recorded only when payment is due. Property taxes, other taxes, licenses, and interest associated with the current fiscal period are all considered to be susceptible to accrual and so have been recognized as revenues of the current fiscal period. Revenues for expenditure driven grants are recognized when the qualifying expenditures are incurred. All other revenue items are considered to be measurable and available only when cash is received by the City. The City reports the following major governmental funds: The General Fund is the City's primary operating fund. It accounts for all financial resources of the general government, except those required to be accounted for in another fund. The Street Maintenance Fund, a special revenue fund, is used to account for revenues derived from a portion of state shared revenues, and the local option gas tax. Funds can only be used for road construction and maintenance. The Capital Infrastructure Fund, a capital projects fund, accounts for revenues derived from local government infrastructure surtax levied in the County, as well as other income sources, including grant revenues. Funds can only be expended to finance, plan and construct infrastructure and to acquire land for public recreation, conservation or protection of natural resources. The City reports the following major proprietary fund: The Wastewater and Stormwater Fund accounts for the provision of wastewater services and stormwater control services to City residents, businesses and government agencies. Additionally, the City reports the following fiduciary fund type: The Firefighters' Pension Fund is used to account for the City's single-employer defined benefit pension plan covering its firefighters. 29 527 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 1 - Summary of Significant Accounting Policies (continued) As a general rule, the effect of interfund activity has been eliminated from the government-wide financial statements. Exceptions to this general rule are charges between the City's Proprietary Funds and the General Fund. Elimination of these charges would distort the direct costs and program revenues reported for the various functions concerned. Proprietary funds distinguish operating revenues and expenses from nonoperating items. Operating revenues and expenses generally result from providing services and producing and delivering goods in connection with a proprietary fund's principal ongoing operations. Operating expenses for enterprise funds include the costs of services, personnel costs, administrative expenses, and depreciation on capital assets. All revenues and expenses not meeting this definition are reported as nonoperating revenues and expenses. Deposits and investments: The City's cash and cash equivalents are considered to be cash on hand and short-term investments. Deposits include cash on hand and interest bearing checking accounts. City administration is authorized to invest in those instruments authorized by the Florida Statutes. Investments include the Local Government Surplus Funds Trust Fund. Investment in the Local Government Surplus Funds Trust Fund administered by the State Board of Administration is reported at the fair value of its position in the pool, which is the same as the value of the pool shares. Receivables and payables: Activities between funds that are representative of lending/borrowing arrangements outstanding at the end of the fiscal year are referred to as "due to/from other funds". Any residual balances outstanding between the governmental activities and business-type activities are reported in the government-wide financial statements as "internal balances." Capital assets: Capital assets, which include property, plant and equipment, and certain infrastructure assets (e.g., roads, bridges, sidewalks, and similar items), are reported in the applicable governmental or business-type activities columns in the government-wide financial statements. Capital assets are defined by the City as assets with an initial, individual cost of more than $ 1,000 and an estimated useful life in excess of one year. Such assets are recorded at historical cost or estimated historical cost if purchased or constructed. Donated capital assets are recorded at acquisition value at the date of donation. The costs of normal maintenance and repairs that do not add to the value of the asset or materially extend assets lives are not capitalized. Major outlays for capital assets and improvements are capitalized as projects are constructed. Capital assets of the City are depreciated using the straight line method over the following estimated useful lives: Buildings and structures 10-50 years Leasehold improvements 5-20 years Improvements other than buildings 10-50 years Fire equipment and vehicles 5-12 years Furniture and equipment 3-20 years Prepaid items: Certain payments to vendors reflect costs applicable to future accounting periods and are recorded as prepaid items in both government-wide and fund financial statements. The cost of prepaid items is recorded as expenditures/expenses when consumed rather than purchased. 30 528 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 1 - Summary of Significant Accounting Policies (continued) Deferred outflows/inflows of resources: In addition to assets, the statement of financial position will sometimes report a separate section for deferred outflows of resources. This separate financial statement element, deferred outflows of resources, represents a consumption of net assets that applies to a future period(s) and so will not be recognized as an outflow of resources (expense/expenditure) until then. The City has two items that qualify for reporting in this category. The first item is the deferred outflows related to the pension liability (asset) and is discussed further in Note 10. The second item is the deferred outlfows related to OPEB and is discussed further in Note 11. In addition to liabilities, the statement of financial position will sometimes report a separate section for deferred inflows of resources. This separate financial statement element, deferred inflows of resources, represents an acquisition of net assets that applies to a future period(s) and so will not be recognized as an inflow of resources (revenue) until that time. The City has three items that qualify for reporting in this category. The first item is the deferred inflows related to the net pension liability (asset) and is discussed further in Note 10. The second item is the deferred inflows related to OPEB and is discussed further in Note 11. The third item appears in the governmental funds as unavailable revenues that are deferred and recognized as an inflow of resources in the period that the amounts become available. Compensated absences: It is the City's policy to permit employees to accumulate earned but unused vacation and sick pay benefits. There is no liability for unpaid accumulated sick leave since the City does not have a policy to pay any amounts when employees separate from service with the government. All vacation pay is accrued when incurred in the government-wide and proprietary fund financial statements. A liability for these amounts is reported in governmental funds only if they have matured, for example, as a result of employee resignations or retirements. The General Fund has typically been used to liquidate such amounts. Unearned/unavailable revenue: Governmental funds report unavailable revenue in connection with receivables for revenues that are not considered to be available to liquidate liabilities of the current period. Governmental funds also defer revenue recognition in connection with resources that have been received, but not yet earned. Unearned revenues at the government-wide level arise only when the City receives resources before it has a legal claim to them. Long-term obligations: In the government-wide financial statements, long-term debt and other long-term obligations are reported as liabilities in the applicable governmental activities, business- type activities, or proprietary fund type statement of net position. Bond premiums and discounts are deferred and amortized over the life of the debt. In the fund financial statements, governmental fund types recognize the face amount of debt issued as other financing sources. Premiums received on debt issuances are reported as other financing sources while discounts on debt issuance are reported as other financing uses. Fund balance: The City presents fund balance in accordance with GASB Statement No. 54, Fund Balance Reporting and Governmental Fund Type Definitions. This statement requires that governmental fund financial statements present fund balances based on classifications that comprise a hierarchy that is based primarily on the extent to which the City is bound to honor constraints on the specific purposes for which amounts in the respective governmental funds can be spent. 31 529 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 1 - Summary of Significant Accounting Policies (continued) The classifications used in the governmental fund financial statements are as follows: Nonspendable: This classification includes amounts that cannot be spent because they are either (a) not in spendable form or (b) are legally or contractually required to be maintained intact. "Not in spendable form" includes items that are not expected to be converted to cash (such as inventories and prepaid amounts) and items such as long-term amount of loans and notes receivable, as well as property acquired for resale. The corpus (or principal) of a permanent fund is an example of an amount that is legally or contractually required to be maintained intact. Restricted: This classification includes amounts for which constraints have been placed on the use of the resources either (a) externally imposed by creditors (such as through a debt covenant), grantors, contributors, or laws or regulations of other governments, or (b) imposed by law through constitutional provisions or enabling legislation. Committed: This classification includes amounts that can be used only for specific purposes pursuant to constraints imposed by resolution of the City Council. These amounts cannot be used for any other purpose unless the Council removes or changes the specified use by taking the same type of action (resolution) that was employed when the funds were initially committed. Resources accumulated pursuant to stabilization arrangements sometimes are reported in this category. Assigned: This classification includes amounts that are constrained by the City's intent to be used for a specific purpose but are neither restricted nor committed. The Council has by resolution authorized the City Manager to assign fund balance. The Council may also assign fund balance as it does when appropriating fund balance to cover a gap between estimated revenues and appropriations in the subsequent year's appropriated budget. Unlike commitments, assignments generally only exist temporarily. In other words, an additional action does not normally have to be taken for the removal of an assignment. Unassigned: This classification includes the residual fund balance for the General Fund. This classification represents fund balance that has not been assigned to other funds and that has not been restricted, committed, or assigned to specific purposes within the General Fund. Unassigned fund balance may also include negative balances for any governmental fund if expenditures exceed amounts restricted, committed or assigned for those specific purposes. When an expenditure is incurred for purposes for which both restricted and unrestricted fund balance is available, the City considers restricted funds to have been spent first. When an expenditure is incurred for which committed, assigned, or unassigned fund balances are available, the City considers amounts to have been spent first out of committed funds, then assigned funds, and finally unassigned funds. 32 530 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 1 - Summary of Significant Accounting Policies (continued) Net position: Net position of the government-wide and proprietary funds are categorized as net investment in capital assets; restricted or unrestricted. Net investment in capital assets is that portion of net position that relates to the City's capital assets reduced by accumulated depreciation and by any outstanding debt incurred to acquire, construct or improve those assets, excluding unexpended proceeds. Restricted net position is that portion of net position that has been restricted for general use by external parties (creditors, grantors, contributors, or laws or regulations of other governments) or imposed by law through constitutional provisions or enabling legislation. Unrestricted net position consists of all net position that does not meet the definition of either of the other two components. When an expenditure is incurred for purposes for which both restricted and unrestricted net position are available, the City considers restricted funds to have been spent first. Use of estimates: The preparation of financial statements in conformity with accounting principles generally accepted in the United States requires management to make estimates and assumptions that affect the amounts reported in the financial statements and accompanying notes. Although these estimates are based on management's knowledge of current events and actions it may undertake in the future, they may ultimately differ from actual results. Allowance for doubtful accounts: The City's contracted service provider processes receivables associated with emergency medical services (EMS). An allowance account of $ 3,209,961 is established for EMS receivables based on historical collection rates. Date of management review: Subsequent events were evaluated through March 27, 2024, which is the date the financial statements were available to be issued. Note 2 - Deposits and Investments Deposits: In addition to insurance provided by the Federal Depository Insurance Corporation, deposits which consist of cash on hand and interest bearing checking accounts are held in banking institutions approved by the State Treasurer of the State of Florida to hold public funds. Under Florida Statutes Chapter 280, Florida Security for Public Deposits Act, the State Treasurer requires all Florida qualified public depositories to deposit with the Treasurer or another banking institution eligible collateral. In the event of a failure of a qualified public depository, the remaining public depositories would be responsible for covering any resulting losses. Therefore, all amounts presented as deposits are insured or collateralized. Investments - City: The City is authorized to invest in obligations of the United States Treasury, its agencies, instrumentalities and the Local Government Surplus Funds Trust Fund administered by the State Board of Administration. The investments follow the investment rules defined in Florida Statutes Chapter 215. The investment policy defined in the statutes attempts to promote, through state assistance, the maximization of net investment earnings on invested surplus funds of local units of governments while limiting the risk to which the funds are exposed. The City has funds invested in the Local Government Surplus Funds Trust Fund (the "Florida PRIME"). Florida PRIME is administered by the Florida State Board of Administration ("SBA"), who provides regulatory oversight. Florida PRIME has adopted operating procedures consistent with the requirement for a 2a7-like fund. The City's investment in the Florida PRIME is reported at amortized cost. The fair value of the position in the pool is equal to the value of the pool shares. 33 531 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 2 - Deposits and Investments (continued) As of September 30, 2023, the City had the following investments: Investment Fair Maturities Value (In Years) Florida PRIME $ 48,745 Less than 1 Interest rate risk: The City has an investment policy of structuring the investment portfolio so that the securities mature to meet cash requirements for ongoing operations, thereby avoiding the need to sell securities on the open market prior to maturity and investing operating funds primarily in short-term securities, money market mutual funds, or similar investment pools. The weighted average maturity of the securities held in Florida PRIME is 35 days. Credit risk: The City's investment policy limits investments to the highest ratings issued by a nationally recognized statistical rating organization (NRSRO). Florida PRIME is rated AAAm by Standard and Poor's. Investments - Firefighters' Pension Plan: The Firefighters' Pension Plan is part of the Florida Municipal Pension Trust Fund ("FMPTF") which is an external investment pool (the "Pool") established for the purpose of funding the individually designed employee pension plans of the participating Florida municipalities. The assets of defined benefit plans are invested through the Florida Municipal Investment Trust (FMIvT), an external investment pool open to eligible units of local governments to invest in one or more investment portfolios under the direct and daily supervision of an investment advisor. FMIvT is not subject to SEC or other regulatory oversight. The FMIvT Board of Trustees provides oversight. The fair value of the positions in the FMIvT portfolios is the same as the value of the portfolio shares. The Florida League of Cities, Inc. serves as Administrator for both the Fund and FMIvT. As of September 30, 2023, the City's Firefighters' Pension Plan has the following required disclosures: Credit Risk: Fitch Rating Amount Fixed Income Funds: FMIvT Broad Market High Quality Bond Fund AAf/S4 $ 1,963,020 FMIvT Core Plus Fixed Income Fund Not rated 1,828,567 Equity Portfolios: FMIvT Diversified Large Cap Equity Portfolio Not rated 3,280,664 FMIvT Diversified Small to Mid Cap Equity Portfolio Not rated 1,868,903 FMIvT International Equity Portfolio Not rated 2,594,952 FMIvT Core Real Estate Fund Not rated 1,721,004 $ 13,257,110 Interest Rate Risk(In Years): Fixed Income Funds: Duration WAM FMIvT Broad Market High Quality Bond Fund 5.58 6.90 FMIvT Core Plus Fixed Income Fund 6.80 8.03 34 532 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 2 - Deposits and Investments (continued) Fair Value Hierarchy: GASB Statement No. 72, Fair Value Measurement and Application, establishes a hierarchy disclosure framework which prioritizes and ranks the level of market price observability used in measuring investment at fair value. Various inputs are used in determining the fair value of investments. These inputs are categorized into a fair value hierarchy consisting of three broad levels for financial statement purposes as follows: • Level 1 - investments reflect unadjusted quoted prices in active markets for identical assets. • Level 2 - investments reflect prices that are based on a similar observable asset, either directly or indirectly, which may include inputs in markets that are not considered to be active. • Level 3 - investments reflect prices based upon unobservable sources. The categorization of investments within the hierarchy is based upon the pricing transparency of the instrument and should not be perceived as the particular investment's risk. The following is a general description of the valuation methodologies used for assets measured at fair value. Investments classified as Level 2 for the FMIvT, in the table below, are valued based on significant other observable inputs, which may include, but are not limited to, quoted prices for similar assets or liabilities in markets that are active, quoted prices for identical or similar assets or liabilities in markets that are not active, inputs other than quoted prices that are observable for the assets or liabilities (such as interest rates, yield curves, cash flows, maturity, and credit ratings), or other market corroborated inputs specific to the investment type. Investments classified as Level 3 for the FMlvt, in the table below, are valued based on significant unobservable inputs based on all information available in the circumstances to the extent observable inputs are not available. Shares of the underlying funds of the FMIvT Core Plus Fixed Income Fund are not publicly quoted. These underlying funds invest in a variety of financial instruments, including equity investments, asset-backed securities, swaps, forward exchange contracts, credit-linked notes, escrow accounts and litigation trusts for both U.S. and foreign companies and governments. Shares of the underlying fund of the FMIvT Core Real Estate Fund are also not publicly quoted. The underlying fund invests in core real estate in the U.S. The value of the investments was determined based on quarterly real estate appraisals which were calculated in accordance with generally accepted accounting principles. Fair values of investments held by the City's Firefighters' Pension Plan are classified at September 30, 2023 as follows: Quoted Prices Significant in Active Other Significant Markets for Observable Unobservable Investments Identical Assets Inputs Inputs Valued at Investments Fair Value (Level 1) (Level 2) (Level 3) NAV Florida Municipal Investment Trust Funds $ 13,257,110 $ - $ 9,707,539 $ 3,549,571 $ - 35 533 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 2 - Deposits and Investments (continued) Additional information for investments measured at Level 3 is presented in the table below as of September 30, 2023. Redemption Frequency Redemption Fair Unfunded (If Currently Notice Value Commitments Eligible) Period FMIvT Core Plus Fixed 1 business Income Fund $ 1,828,567 $ Monthly day FMIvT Core Real Estate 5 business Portfolio 1,721,004 Quarterly days $ 3,549,571 $ Given the inherent nature of investments, it is reasonably possible that changes in the value of those investments will occur in the near term and that such changes could materially affect the amounts reported in the financial statements. Note 3 - Property Taxes Property values are assessed on a county-wide basis by the Monroe County Property Appraiser as of January 1, the lien date, of each year and are due the following November 1st (levy date). Taxable value of property within the City is certified by the Property Appraiser and the City levies a tax millage rate upon the taxable value, which will provide revenue required for the fiscal year beginning October 1. Property taxes levied each November 1 by the City and all other taxing authorities within the County, are centrally billed and collected by Monroe County, with remittances to the City of their proportionate share of collected taxes. Taxes for the fiscal year beginning October 1 are billed in the month of November, subject to a 1% per month discount for the periods November through February, and are due no later than March 31. On April 1, unpaid amounts become delinquent with interest and penalties added thereafter. Beginning June 1, tax certificates representing delinquent taxes with interest and penalties are sold by the County, with remittance to the City for its share of those receipts. At September 30, 2023, there were no significant delinquent taxes. Note 4- Receivables and Payables Receivables for the City's individual major funds, nonmajor funds and fiduciary fund in the aggregate, including the applicable allowances for uncollectible accounts, are as follows: Nonmajor Street Capital Governmental General Maintenance Infrastructure Funds Customers billed $ 3,525,105 $ $ $ Intergovernmental 1,139,788 64,887 687,447 306,183 Loans - - - 770,000 Miscellaneous 63,551 - - - Gross receivables 4,728,444 64,887 687,447 1,076,183 Less allowance for uncollectibles (3,216,209) - - - Net receivables $ 1,512,235 $ 64,887 $ 687,447 $ 1,076,183 36 534 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 4- Receivables and Payables (continued) Nonmajor Wastewater/ Enterprise Fiduciary Stormwater Funds Fund Total Customers billed $ 467,607 $ $ $ 3,992,712 Intergovernmental 1,946,307 137,489 4,282,101 Loans - - 770,000 Miscellaneous - 63,551 Contributions - - 254,075 254,075 Gross receivables 2,413,914 137,489 254,075 9,362,439 Less allowance for uncollectibles - - - (3,216,209) Net receivables $ 2,413,914 $ 137,489 $ 254,075 $ 6,146,230 Accounts payable and accrued liabilities for the City's individual major and nonmajor funds are as follows: Nonmajor Nonmajor Street Capital Governmental Wastewater/ Enterprise General Maintenance Infrastructure Fund Stormwater Fund Total Vendors $ 318,767 $ 14,880 $ 56,988 $ 288,173 $ 1,375,172 $ 20,033 $ 2,074,013 Payroll liabilities 199,120 13,749 - 14,575 65,296 15,724 308,464 Retainage - - - 192,377 14,427 206,804 Accrued interest - - - - 76,515 - 76,515 Total $ 517,887 $ 28,629 $ 56,988 $ 302,748 $ 1,709,360 $ 50,184 $ 2,665,796 Note 5 - Interfund Balances and Transfers The composition of interfund transfers is as follows: Transfer In Non-Major Wastewater/ General Governmental Stormwater Transfer Out Fund Funds Fund Total General Fund $ $ 395,659 $ $ 395,659 Capital Infrastructure Fund 473,556 1,525,983 650,000 2,649,539 Nonmajor Governmental Funds 469,583 1,411,408 - 1,880,991 Nonmajor Enterprise Fund 71,565 - 71,565 Wastewater/Stormwater Fund 415,987 - - 415,987 Total $ 1,430,691 $ 3,333,050 $ 650,000 $ 5,413,741 Transfers of$ 487,552 were made from the Marina and Wastewater/Stormwater Utility Enterprise Funds to the General Fund to support general administration costs. Transfers of $ 469,583 were made from the Building Fund to the General Fund to support general administration costs. Transfers of $ 1,525,983 were made from the Capital Infrastructure Fund to the Debt Service Fund in order to satisfy debt service requirements. A transfer of$473,556 from the Capital Infrastructure Fund to the General Fund was made for the fiscal year 2023 10% of discretionary sales tax proceeds in accordance with the exception under Florida Statues for areas of Critical State concern. 37 535 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 5 - Interfund Balances and Transfers (continued) A transfer of $ 693,975 was made from Affordable Housing Fund to the Community Development Block Grant Fund for housing grant activity. Transfers of $450,000 from the Capital Infrastructure Fund to the Vehicle Replacement fund was made for future vehicle purchases. A transfer of $ 717,433 from the Community Development Block Grant Fund to the Affordable Housing Fund was made to repay a cash advance for grant activity for home buyout grant. A transfer of $ 395,659 from the General Fund to the Restoration Fund was made to allocate tree mitigation funds. A transfer of $ 650,000 was made from the Capital Infrastructure Fund to the Wastewater/Stormwater Utility Enterprise Funds for annual debt service requirements. Note 6- Capital Assets Capital asset activity for the year ended September 30, 2023 was as follows: Beginning Ending Balance Increases Decreases Transfers Balance Governmental Activities: Capital assets not being depreciated: Land $ 16,312,247 $ $ $ $ 16,312,247 Intangibles 3,822 3,822 Construction-in-progress 686,618 106,016 (609,036) 182,698 Total capital assets not being depreciated 17,001,687 106,016 (609,036) 16,498,667 Capital assets being depreciated: Buildings and structures 21,089,923 - - 21,089,923 Improvements other than buildings 22,662,066 1,742,071 609,036 24,903,172 Fire equipment and vehicles 6,634,667 69,110 - 6,603,777 Furniture and equipment 3,271,342 144,417 3,416,769 Intangibles 7,600 - - 7,600 Total capital assets being depreciated 62,466,697 1,966,698 609,036 66,020,231 Total capital assets 69,467,284 2,061,614 - 71,618,898 Less accumulated depreciation: Buildings and structures 7,316,338 617,067 7,932,406 Improvements other than buildings 12,062,002 1,190,873 13,242,876 Fire equipment and vehicles 3,628,466 389,901 4,018,367 Furniture and equipment 2,022,769 177,628 2,200,297 Intangibles 7,600 7,600 Total accumulated depreciation 26,026,166 2,376,369 - 27,401,634 Total capital assets being depreciated,net 27,429,432 (419,771) 609,036 27,618,697 Governmental activities,capital assets,net $ 44,431,119 $ (313,766) $ $ $ 44,117,364 38 536 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 6- Capital Assets (continued) Beginning Ending Balance Increases Decreases Transfers Balance Business-Type Activities: Capital assets not being depreciated: Land $ 4,696,647 $ $ $ $ 4,696,647 Intangibles 1,618,093 1,618,093 Construction-in-progress 3,866,899 2,069,244 37,004 (87,886) 6,791,263 Total capital assets not being depreciated 10,170,639 2,069,244 37,004 (87,886) 12,104,993 Capital assets being depreciated: Buildings 6,077,036 - - 6,077,036 Improvements other than buildings 146,176,691 3,631,682 87,886 148,896,169 Land improvements 280,364 - 280,364 Intangibles 16,620 - 16,620 Equipment 2,930,072 81,933 3,012,006 Vehicles 1,SO4,263 139,182 - 1,643,446 Total capital assets being depreciated 164,983,036 3,862,697 - 87,886 168,923,618 Total capital assets 166,163,674 6,911,941 37,004 - 171,028,611 Less accumulated depreciation: Buildings 1,648,161 181,444 - 1,729,606 Improvements other than buildings 48,163,806 4,948,462 63,102,268 Land improvements 224,360 11,200 236,660 Intangibles 16,620 - 16,620 Equipment 2,147,747 268,444 2,416,191 Vehicles 966,668 140,972 1,107,640 Total accumulated depreciation 63,066,362 6,660,622 - 68,606,874 Total capital assets, being depreciated,net 101,926,683 (1,697,826) - 87,886 100,316,744 Business activities capital assets,net $ 112,097,322 $ 361,419 $ 37,004 $ - $ 112,421,737 Depreciation was charged to functions/programs of the City as follows: Governmental activities: General government $ 658,430 Public safety 487,847 Community services 1,087,033 Community development 142,059 Total provision for depreciation - governmental activities $ 2,375,369 39 537 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 6- Capital Assets (continued) Depreciation was charged to the business-type activities of the City as follows: Business-type activities: Enterprise -Wastewater/Stormwater $ 5,317,338 Enterprise - Marina 233,184 Total provision for depreciation - business-type activities $ 5,550,522 Note 7 - Long-Term Liabilities The following is a summary of changes in long-term liabilities of the City for governmental activities for the year ended September 30, 2023: Balance Balance Due October 1, October 1, Within 2022 Increases Decreases 2023 One Year Governmental activities: Direct borrowings and private placements: Bonds payable: Series 2013A $ 3,995,000 $ $ 650,000 $ 3,345,000 $ 675,000 Loan payable-7Mile 2,000,000 700,000 1,300,000 700,000 Compensated absences payable 228,949 94,324 74,150 249,123 24,913 Net pension liability 25,140 - 25,140 - - Other post-employment benefit liability 88,936 9,029 - 97,965 - Governmental activities, long-term debt $ 6,338,025 $ 103,353 $ 1,449,290 $ 4,992,088 $ 1,399,913 Public Improvement Refunding Revenue Bonds, Series 2013A: During fiscal year 2014, the City issued $ 10,000,000 in Public Improvement Refunding Revenue Bonds Series 2013A for the purposes of refinancing the Improvement Revenue Bond, Series 2004 and to finance the construction and acquisition of certain capital projects, including a City Hall. The bonds bear interest at 2.59%, subject to adjustments based on occurrence of a determination of taxability event and by margin factor as calculated by vendor, with quarterly principal and interest payments due through January 1, 2028. Effective November 1, 2018, the interest rate was increased to 3.09% due to a change in the corporate tax rate. The bonds are secured by certain non ad-valorem revenues of the City. The Series 2013A Bond may be prepaid at the option of the City in whole or in part, at any time, together with a prepayment penalty equal to the greater of (i) one percent (1%) of the principal balance being prepaid multiplied by the remaining term in years or (ii) a yield maintenance fee as outlined in the Bond Indenture. If any principal or interest on the Series 2013A Bond is not paid when due, from the date three (3) days after such default, the Series 2013A Bond shall bear interest at the interest rate plus four percent (4.00%). Further, if any principal or interest on the Series 2013A Bond is not paid within fifteen (15) days of the payment date, a late charge of six percent (6%) of the overdue payment shall be assessed. In no event shall the Series 2013A Bond bear interest in excess of the highest rate of interest allowed by applicable law. 40 538 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 7 - Long-Term Liabilities (continued) Annual debt service requirements of the Public Improvement Refunding Revenue Bonds Series 2013A are as follows: September 30, Principal Interest Total 2024 $ 675,000 $ 95,666 $ 770,666 2025 685,000 74,615 759,615 2026 705,000 53,217 758,217 2027 910,000 31,317 941,317 2028 370,000 2,856 372,856 $ 3,345,000 $ 257,671 $ 3,602,671 Note Payable: Previously, the City issued a $ 2,000,000 note payable for the purposes of financing the acquisition of real property. The note bears interest at 3.00%, with annual principal and interest payments due through December 31, 2024. Annual debt service requirements of the note payable are as follows: 2024 $ 700,000 $ 39,000 $ 739,000 2025 600,000 18,000 618,000 $ 1,300,000 $ 57,000 $ 1,357,000 The following is a summary of changes in long-term liabilities of the City's business-type activities for the year ended September 30, 2023: Balance Balance Due October 1, September 30, Within 2022 Increases Decreases 2023 One Year Business-Type Activities: Direct borrowings and private placements: Loans payable: State Revolving Fund Loan Program $ 38,309,180 $ $ 4,433,918 $ 33,875,262 $ 4,536,679 Compensated absences payable 78,421 24,547 14,726 88,241 8,824 Other post-employment benefit liability 27,931 2,835 - 30,766 - Business-type activities, long-term debt $ 38,415,532 $ 27,382 $ 4,448,644 $ 33,994,269 $ 4,545,503 41 539 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 7 - Long-Term Liabilities (continued) State Revolving Fund Loans: As of September 30, 2023, the City has four revolving loan agreements with the State of Florida Department of Environmental Protection Clean Water State Revolving Fund Loan program to finance its wastewater and stormwater utility capital projects. The loans are collateralized by a pledge of the wastewater and stormwater non-ad valorem assessments. The loans require the City to provide pledged revenues equal to or exceeding 1.20 times the sum of the loan amounts due in each fiscal year. For the year ending September 30, 2023, the City did not meet this ratio. The City is in the process of submitting a plan to the Florida Department of Environmental Protection to resolve this issue. The breakdown as of September 30, 2023 of the total amounts authorized, the fixed weighted average interest rates, the estimated semi-annual payment amount and the amounts drawn to date on each loan is as follows: Total Total Loan Semi-Annual Obligation Authorized Interest Payment September 30, SRF Loan Agreement Amount Rate Amount 2023 WW 63702P $ 31,308,211 2.25-2.54% $ 1,010,699 $ 11,232,381 WW 637060 21,541,520 2.08-2.73% 710,253 10,835,980 WW 637090 10,373,801 2.02-2.66% 329,774 4,458,247 WW 637020 17,131,172 2.08% 607,285 7,348,654 Total $ 80,354,704 $ 2,658,011 $ 33,875,262 Annual debt service requirements of the State Revolving Fund loans are approximately as follows: September 30, Principal Interest Total 2024 $ 4,536,679 $ 780,133 $ 5,316,812 2025 4,644,762 672,051 5,316,813 2026 4,755,442 561,371 5,316,813 2027 4,868,783 448,029 5,316,812 2028 4,984,850 331,962 5,316,812 2029-2032 10,084,746 378,973 10,463,719 $ 33,875,262 $ 3,172,519 $ 37,047,781 The State Revolving Fund Loan arrangements discussed above include other financial provisions for events of defaults such as failure to make monthly deposits and semiannual loan payments, violation of covenants or actions required by the arrangements with such failure continuing for a period of sixty days after written notice, insolvency-bankruptcy, and false representations. Non- payment may result in acceleration of the repayment schedule or increasing the financing rate on the unpaid principal balance to as much as 1.667 times the financing rate. The lender may also seek enforcement of and exercise all remedies available and allowed by law. Risk management: The City is exposed to various risks of loss related to torts; theft of, damage to, and destruction of assets; errors and omissions; injuries to employees; and natural disasters for which the City purchases commercial insurance. There was no reduction in insurance coverage from coverages in the prior year. Settlement amounts have not exceeded insurance coverage during the past three years. 42 540 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 8- Commitments and Contingencies Litigation: The City is a defendant in various lawsuits including personal injury, property damage, and other miscellaneous claims. For one of these cases, there is a reasonable possibility that a loss has been incurred. The City estimates its possible exposure could be between $ 2,000,000 and $ 4,000,000. Due to the uncertainty of the outcome, no liability has been recorded in the financial statements for this case. The remainder of the legal proceedings are incidental to the City's operations, the outcome of which, in the opinion of management and legal counsel, would not have a material adverse effect on the financial condition of the City. Consent decree: Subsequent to year end, the City Council of the City entered into a consent decree with the Friends of the Lower Keys, LLC (FOLKS). Under the decree, the City shall construct all infrastructure necessary to permanently convey all of its Advanced Wastewater Treatment Effluent to a Deep Well Injection for disposal by no later than December 31, 2028. The City is required to pay $ 1,000 per day for non-compliance with the Deep Well Injection Project deadline as included in the consent decree. The City estimates the cost of the project to be $43,000,000. The only issue that remains pending is FOLKS claim for attorneys fees and costs. Grant contingency: Amounts received or receivable from grantor agencies are subject to audit and adjustment by grantor agencies, principally the federal government and the State of Florida. Any disallowed claims, including amounts already collected, may constitute a liability of the applicable funds. The amount, if any, of expenditures that may be disallowed by the grantor cannot be determined at this time, although the City expects such amounts, if any, to be immaterial. Construction commitment: At September 30, 2023 the City had the following outstanding construction commitments: Contracts Total Expended at and Project September 30, Retainage Balance to Project Authorization 2023 Payable Complete Generators FS14 and Marina $ 397,197 $ 288,532 $ 14,427 $ 108,665 Chemical Systems Upgrades 2,814,131 2,464,162 123,208 349,969 Area 7 Filter Upgrades 1,225,000 1,047,555 52,378 177,445 Lift Station @ Fairfield Inn 407,445 335,823 59,757 71,622 $ 4,843,773 $ 4,136,072 $ 249,770 $ 707,701 Agreement for Police Services: The City has a contract with Monroe County Sheriff's Office (the "Sheriff") to provide professional police services through September 2024. Pursuant to the agreement, the Sheriff will provide law enforcement coverage within the City. Services for the fiscal year ending September 30, 2024 are budgeted to be approximately $ 2,529,900. Costs for police services for the year ended September 30, 2023 were approximately$ 2,215,100. Collective Bargaining Agreement: The City has a collective bargaining agreement between the City and the professional firefighters of Marathon, International Association of Firefighters Local 4396. The agreement is effective through September 30, 2026 (and shall be renewed on an annual basis thereafter, unless either party provides the other written notice of its intent to terminate or modify the agreement not less than ninety days prior to expiration date). 43 541 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 8- Commitments and Contingencies (continued) Agreement to Provide Fire Rescue and Emergency Medical Services: The City entered into an extension of its interlocal agreement for the provision of fire rescue and emergency medical services to Key Colony Beach ("KCB") by the City's own fire rescue department through September 30, 2026 at an annual rate of$ 700,000 reviewed annually. Fees received for these services for the year ended September 30, 2023 were $ 550,000 from ad valorem revenue and $ 25,000 from KCB's discretionary sales tax revenues. Note 9 - Defined Contribution Plans The City as a single-employer contributes to the City of Marathon Money Purchase Plan, which is a defined contribution plan created in accordance with Internal Revenue Code Section 401(a). Under the Plan, the City contributes 10% for employees hired prior to August 9, 2011 and 5% for those hired thereafter. Normal retirement is defined as age 59-1/2. The employees are not required to make contributions and are fully vested on their first day of employment. Amendments to the Plan must be authorized by the City Council. The City also has a deferred compensation pension plan created in accordance with the Internal Revenue Service Code Section 457(b). The City Manager and City Attorney receive an automatic 10% contribution with no match requirement. The 401(a) and 457(b) plans mentioned above are administered by ICMA Retirement Corporation. The City provided contributions to these plans for the year ended September 30, 2023 of approximately$ 356,668. Note 10 - Employee Pension Plans Firefighters' Pension Plan Plan Description: The City established The City of Marathon Firefighters' Pension Plan and Trust Fund (the Plan) as a Local Law Plan in accordance with Chapter 175, Florida Statutes on October 1, 2005 as per a City adopted ordinance. The Plan is a single-employer, defined benefit plan that covers all full-time firefighters. This replaces the previous Firefighters Pension Fund first created on December 9, 2003 and is treated as a newly created Plan from an actuarial standpoint. From a financial statement perspective, the ending net position of the old Plan became the beginning net position of the new Plan on October 1, 2005. The administrative duties for this Plan are handled through the Florida Municipal Pension Trust Fund ("FMPTF"). A more detailed description of the Plan appears in the ordinances constituting the Plan and in the Summary Plan Description. The Plan does not issue a stand-alone financial report, but is included in the reporting entity of the City as a pension trust fund. Amendments to the Plan document can only be authorized by the City Council. The Board of Trustees is comprised of the following five members: two of the members shall be legal residents of the City and are appointed by the City Council; two of the members shall be full- time firefighters of the City elected by a majority of the active firefighters who are members of the Plan; and the fifth member of the Board shall be chosen by a majority of the previous four Board members. The name of the fifth Board member is then submitted to City Council who appoints such person to the Board. 44 542 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 10 - Employee Pension Plans (continued) Basis of Accounting: The financial statements of the Plan are prepared using the accrual basis of accounting. Plan member contributions are recognized in the period in which the contributions are due. City contributions are recognized when due pursuant to actuarial valuations. State contributions are recognized as revenue in the period in which they are approved by the State of Florida. Benefits and refunds are recognized when due and payable in accordance with the terms of the Plan. Administrative costs of the Plan are financed through investment earnings. Investments: Investment Policy. The policy regarding the allocation of invested assets is established by its Board of Trustees which currently has all of its funds invested in the Florida Municipal Pension Trust Fund, 60% equities and 40% fixed income - Fund A Option. The investment policy may be amended by the Board by a majority vote of its trustees. It is the policy of the Board of Trustees to pursue an investment strategy that reduces risk through the prudent diversification of the portfolio across a broad selection of distinct asset classes. Overall asset allocation targets are reviewed on an annual basis. The following is the adopted asset allocation policy as of September 30, 2023: Target Asset Class/Investment Category Allocation Equity Securities and Similar Funds: U.S. Large Cap Equity 25.00% U.S. Small Cap Equity 14.00% Non- U.S. Equity 21.00% Real Estate 10.00% Fixed Income and Similar Funds: Core Bonds 15.00% Multi-Sector 15.00% Total 100.00% Concentrations: Governmental entities need to disclose the concentration of credit risk with a single issuer. If 5.00% or more of the total assets of the portfolio are invested with one issuer, an additional disclosure is required. Investments issued or explicitly guaranteed by the U.S. government and investments in mutual funds, external investment pools and other pooled investments are excluded from the concentration of credit risk disclosure requirements. There were no individual investments that represent 5.00% or more, at September 30, 2023, that met the criteria for disclosure. Rate of return: For the year ended September 30, 2023, the annual money-weighted rate of return on pension plan investments, net of pension plan investment expense, was 8.61%. The money- weighted rate of return expresses investment performance, net of investment expense, adjusted for the changing amounts actually invested. Method used to value investments: Investments are reported at fair value. Securities traded on a national exchange are valued at the last reported sales price. Net appreciation/depreciation in fair value of investments includes realized and unrealized gains and losses. Interest and dividends are reported in investment earnings. Realized gains and losses are determined on the basis of specific cost. Purchases and sales are recorded on the trade-date basis. 45 543 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 10 - Employee Pension Plans (continued) Reserves: Chapter 175, Florida Statutes, established a revenue sharing program whereby participating local governments can receive a portion of the state excise tax of property and casualty insurance premiums collected in their jurisdictions to fund pension benefits for firefighters. Chapter 99-1, Laws of Florida amended Chapter 175 to require future increases in premium tax revenues over those received in 1997 must be used solely to pay for extra retirement benefits for firefighters. Since these increases in premiums tax revenues do not support current benefits the City has recorded a liability of $ 321,092 for the monies received as of September 30, 2023. With the overage funding, the City agreed to establish a defined contribution shared account (Share Plan) as part of the defined befit plan for each active and future members of the pension plan. Pension benefits: Normal retirement is defined by the Plan as the attainment of age 55 with 6 years of credited service or 20 years of credited service with no age requirement. Upon normal retirement, participants are entitled to 3.5% of their average final compensation for each year of credited service. Benefit options include a ten year certain payout or a life annuity. Early retirement is defined by the Plan as the attainment of age 50 with 6 years of credited service. Upon early retirement, accrued benefits are reduced by 3% per year. At October 1, 2023, the following employees were covered by the pension benefits: Inactive employees or beneficiaries currently receiving benefit 1 Inactive employees entitled to but not receiving benefit 14 Active plan members 29 Total members 44 Deferred Retirement Option Program: Members who continue in employment after reaching their normal retirement date may either accrue larger pensions or freeze their accrued benefit and enter the Deferred Retirement Option Plan (DROP). Each participant in the DROP has an account credited with benefits not received plus interest. Participation in the DROP must end no later than 84 months after normal retirement. These benefit provisions and all other requirements are established by City ordinance. The City had one member participating in the DROP for the year ending September 30, 2023 with a balance of$ 55,057. Contributions and Funding Policy: Firefighters are required to contribute 5% of their salary to the Plan. Contributions from the State of Florida are based on the amount of fire insurance premiums written by private insurers on property within City limits. The City is required to contribute if there is any shortfall between the State's contributions and funding requirements of the Plan. The City executed a collective bargaining agreement with the firefighter's union. A portion of the agreement addresses the City's firefighter pension contributions. The City would like to try and limit its required contribution to 12% of employee's pensionable pay. If the City is unable to achieve and maintain a net required contribution to the Plan at 12% of compensation or less, and the City's required net contribution actually exceeds 12% of compensation, the City will use the stabilization fund to reduce the net contribution to 12%. If the net contribution is still above 12% the Union agrees to use the excess 175 premium money disbursement for the year to decrease the City's required net contribution to 12%. If the City's net contribution is still above 12% after using the stabilization fund and the excess 175 premium money, the Union agrees to automatically increase the member contribution 1% of compensation for each $ 25,000 (or part thereof) by which the City's net required contribution exceeded 12% of compensation not to exceed a total member contribution of 15% of compensation. 46 544 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 10 - Employee Pension Plans (continued) In the event the City's required net contribution is less than 12% of compensation, the difference will be set aside in a stabilization fund to be applied toward the short fall in any future year in which the City's required net contribution exceeds 12% of compensation. As of September 30, 2023, no funding has been set aside in the General Fund. The required contribution including interest to the Plan as determined by the actuarial valuation was $ 552,133 for the year ended September 30, 2023. Contributions from the State totaled $ 348,698, of which $ 193,515 was applied to the Plan, and the balance of$ 155,183 was applied to the Share Plan plus City contributions of $ 330,939. State contributions are recognized as both revenue and expenditure during the period in the General Fund. Net Pension Liability (Asset) of the City: The City's net pension liability (asset) was determined based on a measurement date of September 30, 2022. The components of the net position (asset) liability of the City at September 30, 2023, were as follows: Firefighters' Pension Plan Total pension liability $ 10,968,926 Plan fiduciary net position (11,737,247) City's net pension(asset)liability $ (768,321) Plan fiduciary net position as a percentage of total pension liability 107.00% Actuarial assumptions. The total net pension liability at September 30, 2023 was determined by using (asset) actuarial valuations as of October 1, 2021. The actuarial valuations used the following actuarial assumptions: Salary increases 4.0 percent, average, including inflation Investment rate of return 7.0 percent, net of pension plan investment expense, including inflation Mortality rates PUB-2010 Head Count Mortality Table with Scale MP-2018. The long-term expected rate of return on pension plan investments was determined using a building-block method in which best-estimate ranges of expected future real rates of return (expected returns, net of pension plan investment expense and inflation) are developed for each major asset class. These ranges are combined to produce the long-term expected rate of return by weighting the expected future real rates of return by the target asset allocation percentage and by adding expected inflation. The target allocation and best estimates of arithmetic real rates of return for each major asset class are summarized in the following table: Long-Term Expected Real Asset Class Rate of Return Core Bonds 1.6% Multi-Sector 2.1% U.S. Large Cap Equity 4.6% U.S.Small Cap Equity 5.5% Non-U.S. Equity 6.7% Real Estate 5.0% 47 545 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 10 - Employee Pension Plans (continued) Discount rate. The discount rate used to measure the total pension liability was 7.00 percent. The projection of cash flows used to determine the discount rate assumed that plan member contribution will be made at the current contribution rate and that contributions will be made at rates equal to the difference between actuarially determined contribution rates and the member rate. Based on those assumptions, the pension plan's fiduciary net position was projected to be available to make all projected future benefit payments of current plan members. Therefore, the long-term expected rate of return on pension plan investments was applied to all periods of projected benefit payments to determine the total pension liability. Changes in net pension liability(asset). Increases(Decreases) Total Pension Plan Fiduciary Net Pension Liability Position Liability(Asset) (a) (b) (a)-(b) Balances at September 30,2021 $ 9,638,780 $ 13,211,218 $ (3,S72,438) Changes for the year: Service cost 71S,229 - 71S,229 Interest cost 721,629 936,480 (214,M) Contributions-employer - 304,217 (304,217) Contributions-employee 102,641 (102,641) Contributions-nonemployer contributing member - Differences between expected and actual experience (81,437) (81,437) Changes of assumptions Net increase(decrease)in fair value of investments (2,7S0,348) 2,7S0,348 Benefit payments,including refunds of member contributions (2S,27S) (2S,27S) - Administrative expenses - (41,686) 41,686 Net Changes 1,330,146 (1,473,971) 2,804,117 Balances at September 30,2022, measurement date $ 10,968,926 $ 11,737,247 $ (768,321) Sensitivity of the net pension liability(asset) to changes in the discount rate. The following presents the net pension liability (asset) of the City, calculated using the discount rate of 7.00 percent, as well as what the City's net pension liability (asset) would be if it were calculated using a discount rate that is 1-percentage-point lower (6.00 percent) or 1-percentage-point higher (8.00 percent) than the current rate: 1% Current 1% Decrease Discount Increase (6.00%) Rate(7.00%) (8.00%) City's net pension liability(asset) $ 1,027,946 $ (768,321) $ (2,23S,176) 48 546 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 10 - Employee Pension Plans (continued) Pension Expense and Deferred Outflows of Resources Related to Pensions: For the year ended September 30, 2023, the City recognized pension expense of$ 645,583 for this Plan. At September 30, 2023 the City reported deferred outflow of resources and deferred inflows of resources related to pensions from the following sources: Deferred Deferred Outflows Inflows of Resources of Resources Pension contributions subsequent to year end $ 552,133 $ - Differences between expected and actual experience 236,301 (1,052,526) Changes of assumptions 357,875 (30,481) Net difference between projected and actual earning on pension plan investments 1,444,673 - Total $ 2,590,982 $ (1,083,007) Deferred outflows of resources related to employer contributions paid subsequent to the measurement date and prior to the employer's fiscal year end will be recognized as a reduction of the net pension liability in the subsequent reporting period ending September 30, 2024. Amounts reported as deferred outflows of resources and deferred inflows of resources related to pensions will be recognized in pension expense as follows: Year Ended September 30, 2024 $ 206,354 2025 $ 169,948 2026 $ 157,575 2027 $ 477,998 2028 $ (60,515) Thereafter $ 4,482 Note 11 -Other Post-Employment Health Care Benefits The City previously implemented GASB Statement No. 75, Accounting and Financial Reporting for Postemployment Benefits Other Than Pensions. GASB Statement No. 75 specifies that governments must recognize their total OPEB liability and related deferred outflows of resources, deferred inflows of resources, and OPEB expense in the financial statements based on the actuarial present value of projected benefit payments, rather than the smaller net OPEB obligation based on contribution requirements, under GASB Statement No. 45. Plan Description and Funding Policy: Employees who retire from the City and their dependents are eligible to continue to participate ("single employer plan") in the City's health insurance plan currently offered through the City at the "blended" employee group rate which, is determined annually by the City. The retiree must continue to meet all participation requirements and pay all applicable premiums by the specified due date. 49 547 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 11 -Other Post-Employment Health Care Benefits (continued) The City provides no funding for any portion of the premiums after retirement. However, the City recognizes that there is an "implicit subsidy" arising as a result of the blended rate premium since retiree health care costs, on average are higher than active employee healthcare costs. The plan is not accounted for as a trust fund and an irrevocable trust has not been established to fund this plan. The plan does not issue a separate financial report. It is the City's current policy to fund the plan on a "pay-as-you-go" basis from the General Fund. The following table provides a summary of the number of participants in the plan as of October 1, 2021: Active plan members 83 Actuarial Methods and Assumptions: The actuarial valuation of the calculation of OPEB involves estimates of the value of reported amounts and assumptions about the probability of events in the future. Amounts determined regarding the funded status of the plan and the annual required contributions of the employer are subject to continual revision as actual results are compared to past expectations and new estimates are made about the future. Projections of benefits for financial reporting purposes are based on the substantive plan (the plan as understood by the City and plan members) and include the types of benefits in force at the valuation date and the historical pattern of sharing benefit costs between the City and the plan members to that point. Actuarial calculations reflect a long-term perspective and employ methods and assumptions that are designed to reduce short-term volatility in actuarial accrued liabilities and the actuarial value of assets. The total OPEB liability at September 30, 2023 was based on an actuarial valuation dated October 1, 2021 with a measurement date of September 30, 2023, using the following actuarial assumptions: Actuarial Cost Method Entry Age Normal Discount Rate 4.09% Salary Increases 3.50% Mortality Mortality rates are based on the PUB-2010 General Employees Headcount-Weighted Mortality fully generational using Scale MP-2021,and PUB-2010 General Retirees Headcount-Weighted Mortality fully generational using Scale MP-2021 Healthcare Cost Trend Rates Trend rate of 7.50%gradually decreasing to an ultimate trend rate of 4.54%. Discount Rate: The discount rate used to measure the total OPEB liability at September 30, 2023 was 4.09%. Because the City's OPEB costs are funded on a pay-as-you-go funding structure, a tax- exempt municipal bond rate based on an index of 20 year general obligation bonds with an average AA credit rating as of the measurement date was used to determine the total OPEB liability. The discount rate was 4.02% as of the beginning of the measurement year. 50 548 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 11 -Other Post-Employment Health Care Benefits (continued) Total OPEB Liability of the City: The components of the City's net OPEB liability at September 30, 2023, are as follows: Total OPEB liability $ 128,731 OPEB Plan fiduciary net position - City's net OPEB liability $ 128,731 OPEB Plan fiduciary net position as a percentage of total OPEB liability 0.00% Changes in Total OPEB Liability Measurement year ended September 30, 2023 Total OPEB liability: Service cost $ 18,621 Assumption changes (6,147) Difference between actual and expected experience - Plan change - Interest on total OPEB liability 5,172 Benefit payments (5,782) Net change in total OPEB liability 11,864 Total OPEB liability, beginning 116,867 Total OPEB liability, ending $ 128,731 Sensitivity of the Total OPEB Liability to Changes in the Discount Rate: The following table presents the total OPEB liability, calculated using the discount rate of 4.09%, as well as what the City's total OPEB liability would be if it were calculated using a discount rate that is one percentage- point lower or one percentage-point higher than current discount rate: Current 1% Discount 1% Decrease Rate Increase (3.09%) (4.09%) (5.09%) Total OPEB Liability $ 139,467 $ 128,731 $ 119,075 51 549 City of Marathon, Florida Notes to Basic Financial Statements September 30, 2023 Note 11 -Other Post-Employment Health Care Benefits (continued) Sensitivity of the Total OPEB Liability to Changes in the Healthcare Cost Trend Rates: The following table presents the total OPEB liability of the City, as well as what the City's total OPEB liability would be if it were calculated using a healthcare cost trend rate that is one percentage- point lower or one percentage-point higher than the current trend rate: 1%Trend Trend Rate 1%Trend Decrease Assumption Increase Total OPEB liability $ 112,860 $ 128,731 $ 148,246 OPEB Expense (Income) and Deferred Outflows of Resources and Deferred Inflows of Resources Related to OPEB: For the year ended September 30, 2023 the City recognized OPEB expense (income) of $ (10,044). At September 30, 2023, the City has deferred outflows of resources and deferred inflows of resources related to OPEB from the following sources: Deferred Deferred Outflows of Inflows of Resources Resources Changes in Assumptions $ 162,789 $ (48,740) Differences between expected and actual experience 15,968 (225,269) Total $ 178,757 $ (274,009) Amounts reported as deferred outflows of resources and deferred inflows of resources related to OPEB will be recognized in OPEB expense as follows: Deferred Outflows/ Fiscal Year Ending Inflows of September 30, Resources 2024 $ (13,749) 2025 (13,749) 2026 (2,078) 2027 (372) 2028 (372) Thereafter (64,932) $ (95,252) 52 550 REQUIRED SUPPLEMENTARY INFORMATION 551 City of Marathon, Florida Budgetary Comparison Schedule General Fund For the Year Ended September 30, 2023 Original Final Actual Budget Budget Amounts Variance Revenues: Property taxes $ 9,747,079 $ 9,747,079 $ 9,564,742 $ (182,337) Intergovernmental 3,283,931 3,283,931 3,503,145 219,214 Licenses and permits 875,000 875,000 1,603,080 728,080 Charges for services 1,435,000 1,435,000 1,320,534 (114,466) Fines and forfeitures 937,633 937,633 1,168,151 230,518 Communications services taxes 597,203 597,203 597,349 146 Interest 20,000 20,000 497,064 477,064 Miscellaneous 37,000 37,000 37,431 431 Total revenues 16,932,846 16,932,846 18,291,496 1,358,650 Expenditures: Current: General government: Elected officials 485,306 585,306 553,285 32,021 Administration 2,939,389 2,939,389 2,902,786 36,603 Legal 530,462 530,462 351,676 178,786 Total general government 3,955,157 4,055,157 3,807,747 247,410 Public safety: Police 2,360,834 2,215,834 2,215,128 706 Fire/EMS 5,628,335 5,628,335 5,318,149 310,186 Total public safety 7,989,169 7,844,169 7,533,277 310,892 Community services: Public works 1,332,306 1,332,306 744,684 587,622 Parks and recreation 2,014,910 2,014,910 1,775,683 239,227 Near Shore Waters 63,600 63,600 59,515 4,085 Total community services 3,410,816 3,410,816 2,579,882 830,934 Community development 1,960,011 1,960,011 995,880 964,131 Total expenditures 17,315,153 17,270,153 14,916,786 2,353,367 Excess of revenues over expenditures (382,307) (337,307) 3,374,710 3,712,017 Other Financing Sources(Uses): Insurance proceeds - - 6,579 6,579 Transfers in 1,488,617 1,488,617 1,430,691 (57,926) Transfers out - - (395,659) (395,659) Appropriation of prior year's fund balance (1,106,310) (1,151,310) - 1,151,310 Total other financing sources(uses) 382,307 337,307 1,041,611 704,304 Net change in fund balance $ - $ - $ 4,416,321 $ 4,416,321 53 552 City of Marathon, Florida Budgetary Comparison Schedule Street Maintenance Fund For the Year Ended September 30, 2023 Original and Final Actual Budget Amounts Variance Revenues: Intergovernmental $ 672,904 $ 654,661 $ (18,243) Miscellaneous - 2,500 2,500 Interest 2,100 34,434 32,334 Total revenues 675,004 691,595 16,591 Expenditures: Current: Community services 770,792 725,965 44,827 Capital outlay 23,000 17,365 5,635 Total expenditures 793,792 743,330 50,462 Excess (deficiency) of revenues over expenditures (118,788) (51,735) 67,053 Other Financing Sources (Uses): Transfers out (50,000) - 50,000 Insurance proceeds - 7,028 7,028 Appropriation of prior year's fund balance 168,788 - (168,788) Total other financing sources (uses) 118,788 7,028 (111,760) Net change in fund balance $ - $ (44,707) $ (44,707) 54 553 City of Marathon, Florida Note to Budgetary Comparison Schedules September 30, 2023 Note 1 - Budgets and Budgetary Accounting An annual appropriated budget is adopted for the General Fund, Street Maintenance Fund, Capital Infrastructure Fund, Impact Fees Fund, Vehicle Replacement Fund, Restoration Fund, Affordable Housing Fund, Building Fund, Community Development Block Grant Fund and the Debt Service Fund on a basis consistent with accounting principles generally accepted in the United States. The City follows these procedures in establishing the budgetary data reflected in the financial statements. a. Annually, the City Manager submits to the City Council a proposed operating budget for the fiscal year commencing the following October 1st. The operating budget includes proposed expenditures and the means of financing them. b. Public hearings are conducted to obtain taxpayer comments. C. Prior to October 1st, the budget is legally enacted through passage of a resolution. d. The City Council, by motion, may make supplemental appropriations for the year up to the amount of revenues in excess of those estimated. e. The City Manager is authorized to transfer budget amounts within the departments within any fund. However, any revisions that alter the total appropriations of any department must be approved by the City Council. Therefore, the legal level of control is at the department level. f. Formal budgetary integration is employed as a management control device during the year for all budgeted funds. The final budget included an amendment by City Council to account for unanticipated revenues that took place during the fiscal year. g. 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H LL Q N 7 E 0 a •� } O r ~ S Q Q N O u fl- +j a u a �a aj o f o 72 (D i Q — `~ N N £ ° T a 0 (DO u v v v fC N73 � Q i LL y o - — — a a ++ 0) 4j Qqp ` T o° s a aj 4,5 � ° >- amu in3 ° ° aj ° Q oo E Ev fC 41 � 7 v E c x v v v N a p w o v uac � (ALL -i a u z° > 557 � o r-I L n O Ln N 00 LM 0 r-I L n O O N � LD o r-I � O � N 00 o r-I 00 O Ln N � c-I 00 0 rl M O l0 N �yj cn 0 rl O O � N Ll1 01 O o Lr) N O O l0 N 6 � o N cV O � N Q1 c-I N 00000 N ry O N M c-I C M o O N 4+ O l0 m N 00 L L C O 3 C w iA Ot h L L .O 4a _ C L1 a 1 0 a.o V, E � • N 4-1 a > a E a tLa H O L O W N E °J c v O — C: > rr C t 0) 40 4' Q Lni� Q v 558 00 O rn LD L -tt O -tt —1 Il rn N L.O LA rn 61 rn U) LA O ' U) ' LA U) rn 00 Un 00 N 61 N c-I 61 rn Ln 00 I- \ -i N M 61 O Lr 61 I� N M l0 L.0 O o L.0 m L.0 M 00 61 00 ci O O l0 l0 n n M 00 N O O N O -ti LA O c-I 00 O r- 00 O Ln -i N -1 00 O m N 61 Lz- O M Il l0 Ln 61 N O N N CIA CIA N M CIA ' N N ONO Ln O M qj N Ln L.0 -1 00 Lr O Lr Lr N 61 -1 00 N L.O m Ln 00 M N M 00 Ln L11 ; O co �` N E 4 O O U rn l0 r1 N M M 00 ran O 00 l0 U) crl-I N N r- 00 00 LA Lr N c-I l0 C \ 61 c-I N 00 U) �t �t 00 61 Il (A rl v Z >' m Q Q O N � m c-I N 00 rl l0 M I, U) 0 -0 fB N rn N 0 00 00 O O Il l0 c-I O = c-I .L � l0 61 61 LA 00 rn rl 00 00 Ncu ON 61 ('n -ze Lr Lr N LA O N c\-I 41 \ -i U) N L.0 N c-I L.0 V1 \ L N U) 00 61 c-I 00 L c-I U cu O\l >, >Ln a�J O c v p O 4 +� N fu Qn C 4J co 4J +�+ M c-I N _I. ' ' _N � rl c-I rn 010, Q dcu (p N N Il �t 00 l0 l0 M �t L.O c-I c-I Il 00 00 rl 61 Ln vi 4, ON 00 L r LA L r c-I LA 00 O fB c-I c-I N M N U 4� Ln v fC m N a� O L O (a cu O 7 +J ++ 00 f° fC W +J 7 E CL O cLo E L.. O a 0 41 U bA — v O C C C O C 80 T C LJ C C Qn 4 co •0 ++ '� U W •OJ C f0 O 4� LL G7 G7 i f0 0. -0 OJ Ln vUi vOi dA cC u O co vcu O 41 fOC f�6 +—' WOD N 41 4 �1 41 4, > OJ C L O cu � N * N 41 C 'a Z 3 ^ U f0 U N Q* E .� f0 f0 L p 0J to vi V1 O H +' C � N Nto > OJ m m fT6 m 0J bb u - `~ 0�1 +�+ cu w LL f0 E W O .0 U Q bA W W Q W m N y >- 3 O v �, Q v 4 J = +J O O a, p C 41 '� Q O 3 H U N E L v U S L 0J 0 O O C A t H iN Qu 4141 41 4� ate+ U C H a M � ° cv C N JM O 559cnau COMBINING STATEMENTS 560 NONMAJOR GOVERNMENTAL FUNDS Special Revenue Funds Special revenue funds are used to account for specific revenues that are legally restricted to expenditures for particular purposes. Impact Fees Fund - This fund is used to account for transportation, parks and public safety projects. Revenues are derived from impact fees collected during the building permit process. Affordable Housing Fund - This fund is used to purchase land or homes to be used for affordable housing. These funds are also available to provide down payment assistance to qualified homebuyers. Restoration Fund - This fund is used for restoration and management activities of public resource protection and conservation lands. Building Fund - This find is used to account for the collection of reasonable inspection fees according to a schedule in order to defer the costs of inspection and enforcement of the Florida Building Code. Community Development Block Grant Fund -This find is used to account for the implementation and funding of Community Development Block Grant projects. Debt Service Fund Debt Service Fund - This fund is used to account for the payment of principal, interest and expenditures on the long-term debt of the governmental funds. 561 City of Marathon, Florida Combining Balance Sheet Nonmajor Governmental Funds September 30, 2023 Special Revenue Funds Impact Affordable Fees Housing Restoration Building Fund Fund Fund Fund Assets: Cash and cash equivalents $ 3,003,815 $ 2,045,120 $ 958,816 $ 3,975,955 Receivables - 770,000 - - Due from other governments - - - - Prepaid items - - - 8,837 Total assets $ 3,003,815 $ 2,815,120 $ 958,816 $ 3,984,792 Liabilities, Deferred Inflows of Resources, and Fund Balances: Liabilities $ - $ - $ - $ 127,549 Deferred inflows of resources - - - - Fund balances: Nonspendable: Prepaid items - - - 8,837 Restricted: Building department - - - 3,848,406 Committed for: Infrastructure improvements 31003,815 - - - Affordable housing - 2,815,120 - - Restoration projects - - 958,816 - Total fund balances 3,003,815 2,815,120 958,816 3,857,243 Total liabilities, deferred inflows of resources and fund balances $ 3,003,815 $ 2,815,120 $ 958,816 $ 3,984,792 61 562 Special Revenue Fund Community Total Development Debt Nonmajor Block Grant Service Governmental Fund Fund Funds $ 175,199 $ - $ 10,158,905 - - 770,000 306,183 - 306,183 - - 8,837 $ 481,382 $ - $ 11,243,925 $ 175,199 $ - $ 302,748 306,183 - 306,183 - - 8,837 - - 3,848,406 - - 3,003,815 - - 2,815,120 - - 958,816 - - 10,634,994 $ 481,382 $ - $ 11,243,925 62 563 City of Marathon, Florida Combining Statement of Revenues, Expenditures and Changes in Fund Balances Nonmajor Governmental Funds For the Year Ended September 30, 2023 Special Revenue Funds Impact Affordable Fees Housing Restoration Building Fund Fund Fund Fund Revenues: Intergovernmental $ - $ - $ - $ - Licenses and permits - - - 1,382,066 Impact fees 411,159 227,000 2,926 - Interest 67,845 31,657 13,224 106,117 Total revenues 479,004 258,657 16,150 1,488,183 Expenditures: Current: Community services - 30 1,860 1,246,470 Debt service: Principal - - - - Interest and fiscal charges - - - - Total expenditures - 30 1,860 1,246,470 Excess (deficiency) of revenues over expenditures 479,004 258,627 14,290 241,713 Other Financing Sources (Uses): Transfers in - 717,433 395,659 - Transfers out - (693,975) - (469,583) Total other financing sources (uses) - 23,458 395,659 (469,583) Net change in fund balances 479,004 282,085 409,949 (227,870) Fund Balances, Beginning 2,524,811 2,533,035 548,867 4,085,113 Fund Balances, Ending $ 3,003,815 $ 2,815,120 $ 958,816 $ 3,857,243 63 564 Special Revenue Fund Community Total Development Debt Nonmajor Block Grant Service Governmental Fund Fund Funds $ 1,067,285 $ - $ 1,067,285 - - 1,382,066 - - 641,085 19,229 - 238,072 1,086,514 - 3,328,508 1,344,534 - 2,592,894 - 1,350,000 1,350,000 - 175,983 175,983 1,344,534 1,525,983 4,118,877 (258,020) (1,525,983) (790,369) 693,975 1,525,983 3,333,050 (717,433) - (1,880,991) (23,458) 1,525,983 1,452,059 (281,478) - 661,690 281,478 - 91973,304 $ - $ - $ 10,634,994 64 565 BUDGETARY COMPARISON SCHEDULES 566 City of Marathon, Florida Budgetary Comparison Schedule Capital Infrastructure Fund For the Year Ended September 30, 2023 Original and Final Actual Budget Amounts Variance Revenues: Intergovernmental $ 8,243,678 $ 6,411,943 $ (1,831,735) Miscellaneous - 2,650 2,650 Interest 3,400 153,783 150,383 Total revenues 8,247,078 6,568,376 (1,678,702) Expenditures: Capital outlay 9,573,531 1,929,342 7,644,189 Excess (deficiency) of revenues over expenditures (1,326,453) 4,639,034 5,965,487 Other Financing Sources (Uses): Transfers in 182,500 - (182,500) Transfers out (3,106,387) (3,099,539) 6,848 Appropriation of prior year's fund balance 4,250,340 - (4,250,340) Total other financing sources (uses) 1,326,453 (3,099,539) (4,425,992) Net change in fund balance $ - $ 1,539,495 $ 1,539,495 65 567 City of Marathon, Florida Budgetary Comparison Schedule - Capital Infrastructure Fund (Continued) For the Year Ended September 30, 2023 Explanation of Differences Between Change in Fund Balance Budget to Actual and Statement of Revenues, Expenditures and Changes in Fund Balance - Capital Infrastructure Fund Net change in fund balance, page 65 $ 1,539,495 Amounts reported for budget to actual are different because: The net change in fund balance in the City's Vehicle Replacement Fund are reported in the Vehicle Replacement Fund for budgetary purposes but in the Capital Infrastructure Fund for the purpose of the Statement of Revenues, Expenditures and Changes in Fund Balances- Governmental Funds: Net change in fund balance -Vehicle Replacement Fund 493,548 Net change in fund balance per the Statement of Revenues, Expenditures, and Changes in Fund Balances- Capital Infrastructure Fund, Page 20 $ 2,033,043 66 568 io n m d o ti a io o a o v io io m o0 0 00 ,� oo n oo n rn io 00 � ti ti rn m m in ti oo n N io n m o o m m m o c o ti ti a a n in � 00 �i m 0 0 o d o ti ti rn o ti o 000 000, rn o rn o`l rn Qm ci c-I N N c-I c-I c-I io a o 0 0 0 o ti o � rn v N a n a o a ti a N io a � rn io in rn � N ti ti O1 l0 l0 � W o0 l0 O v c �i N N i°o i°o o°i vO1i v°1i a C � ' 01 N c-I o0 00 N l0 ' l0 01 3 N m l0 c-I c-I a II1 II1 01 v 0 0 0 0 0 0 0 0 0 � 00 00 O O O N O N N p` m O h h O O h h V1 O N V1 d O I V1 r r N O h a a W ' o io io rn rn io o rn a in o on � o n n o o n m in oo in o in in m m N m n � 00 o o6 o6 m rc n N o � � Q O O O O O O O O y o 0 0 0 o a s o 1L N N o0 00 111 00 N 111 p m v vO1i a o 0 0 0 0 0 � n oo io io o io a o � ti ti n m m a v N LL rn � a a a oao 0 0 0 O v ra v� O um vl M E n n O O O O O O O •L C = Q •i E fC C G1 v O Q O 'a v C O 0 W L o. 'o G fC •—. ° Y Y v v o a Y o x o 'o m a` a` `o 0 0 3 =p ii C C S]. t0 *' 0 0 0 o u 0mzLl- W 569 a 0 00 00 00 00 00 y o rn rn rn rn rn i0 0 �n vi vi vi vi a O � � o m m m m m ma y m m m m m o •Q c o i i i i i c I ii m ti O 0a ri ri ri ri ri a a a a o o a R r •� m m m a a a i ^ ^ 00 c £ o0 00 o0 0 0 00 u � m ri ri o o ri a a oc a — •n •n s a > o 0 0 0 0 0 v o 0 0 0 0 0 v m o 0 0 0 0 0 •L 'o io io io o i6 O 0 m a a v m rn a io io o �n n N o0 ar N N o a a a m e C a O M ca a a a o �n m o0 00 N ll N �n N Lr m m N rn N � �n � � �n o a a a a m of io a a oo ri m ,-i O N £ O 41 c U £ 'o m m ,m-i ti ao ao ri ri ri L�1 (a }i U •� 10 iLL 3 N N T T T Q O m LL H E -o n n fC O G7 cn v O la c m c la a o o v v fC a > a o c 0 2 0 r z ' fC i i 41 v > ax > ax o ++ fC G7 > dA ++ a s 6 v E O L = = ' u° o O au 570 u ao Z LL z x O STATISTICAL SECTION 571 STATISTICAL SECTION This part of the City of Marathon's comprehensive annual financial report presents detailed information as a context for understanding what the information in the financial statements, note disclosures, and required supplementary information says about the City's overall financial health. CONTENTS PAGE Financial Trends These schedules contain trend information to help the reader understand how the City's financial performance and well-being have changed over time. 69-78 Revenue Capacity These schedules contain information to help the reader assess the City's most significant local revenue source, the property tax. 79-82 Debt Capacity These schedules present information to help the reader asses the affordability of the City's current levels of outstanding debt and the City's ability to issue additional debt in the future. 83-85 Demographic and Economic Information These schedules offer demographic and economic indicators to help the reader understand the environment within which the City's financial activities take place. 86-87 Operating Information These schedules contain service and infrastructure data to help the reader understand how the information in the City's financial report relates to the services the City provides and the activities it performs. 88-90 Sources: Unless otherwise noted, the information in these schedules is derived from the comprehensive annual financial reports for the relevant year. 572 City of Marathon, Florida Net Position by Component Last Ten Fiscal Years (Accrual Basis of Accounting) 2014 2015 2016 2017 Governmental Activities: Net investment in capital assets $ 30,819,582 $ 30,963,072 $ 31,282,555 $ 31,363,522 Restricted 2,394,851 3,089,957 3,361,757 3,761,611 Unrestricted (Deficit) 7,065,123 9,299,203 10,285,136 8,584,962 Total governmental activities net position 40,279,556 43,352,232 44,929,448 43,710,095 Business-Type Activities: Net investment in capital assets 50,316,306 46,217,299 52,501,721 59,193,929 Restricted - - - - Unrestricted 9,359,636 12,623,760 12,220,979 9,693,724 Total business-type activities net position 59,675,942 58,841,059 64,722,700 68,887,653 Total Government: Net investment in capital assets 81,135,888 77,180,371 83,784,276 90,557,451 Restricted 2,394,851 3,089,957 3,361,757 3,761,611 Unrestricted 16,424,759 21,922,963 22,506,115 18,278,686 Total government net position $ 99,955,498 $ 102,193,291 $ 109,652,148 $ 112,597,748 (1) Fiscal year 2014 unrestricted net assets have been restated due to the implementation of GASB 68. 69 573 Fiscal Year 2018 2019 2020 2021 2022 2023 $ 31,361,460 $ 32,346,880 $ 35,592,849 $ 34,859,087 $ 38,410,873 $ 39,415,376 4,112,540 3,497,273 2,982,465 9,246,822 10,443,624 11,378,516 (374,303) 8,850,552 21,388,072 22,862,910 28,397,303 34,650,620 35,099,697 44,694,705 59,963,386 66,968,819 77,251,800 85,444,512 63,683,687 67,362,414 69,923,370 71,826,562 73,530,431 77,528,259 14,654,425 19,159,607 19,863,336 20,048,674 19,662,194 17,493,460 78,338,112 86,522,021 89,786,706 91,875,236 93,192,625 95,021,719 95,045,147 99,709,294 105,516,219 106,685,649 111,941,304 116,943,635 4,112,540 3,497,273 2,982,465 9,246,822 10,443,624 11,378,516 14,280,122 28,010,159 41,251,408 42,911,584 48,059,497 52,144,080 $ 113,437,809 $ 131,216,726 $ 149,750,092 $ 158,844,055 $ 170,444,425 $ 180,466,231 70 574 City of Marathon, Florida Changes in Net Position Last Ten Fiscal Years (Accrual Basis of Accounting) 2014 2015 2016 2017 Expenses: Governmental activities: General government $ 2,718,127 $ 2,609,926 $ 2,847,773 $ 5,299,558 Public safety 4,713,469 4,883,718 5,202,572 5,633,501 Community services 2,943,294 2,894,577 3,109,362 3,420,249 Community development 875,734 1,060,108 1,408,043 1,387,809 Interest on long-term debt 282,779 241,217 221,828 202,657 Total governmental activities 11,533,403 11,689,546 12,789,578 15,943,774 Business-type activities: Wastewater 9,594,935 12,010,623 9,929,090 9,410,154 Marina 710,071 724,738 1,226,693 1,162,725 Stormwater 1,369,870 1,485,414 796,108 1,273,084 Total business-type activities 11,674,876 14,220,775 11,951,891 11,845,963 Total governmental expenses $ 23,208,279 $ 25,910,321 $ 24,741,469 $ 27,789,737 Program Revenues: Governmental activities: Charges for services: General government $ 194,134 $ 259,699 $ 335,352 $ 392,114 Public safety 912,737 1,206,398 1,309,008 1,354,094 Community services 659,677 793,186 790,447 746,571 Community development 866,310 1,214,500 1,410,332 1,238,110 Operating grants and contributions 480,670 574,785 371,539 260,009 Capital grants and contributions 3,801,181 3,308,682 3,351,896 3,119,967 Total governmental activities program revenues 6,914,709 7,357,250 7,568,574 7,110,865 Business-type activities: Charges for services: Wastewater 5,989,281 6,166,141 6,346,446 6,463,033 Marina 828,357 851,989 904,336 933,084 Stormwater - - - - Operating grants and contributions 41,873 - - - Capital grants and contributions 5,145,621 6,106,989 9,034,879 8,276,373 Total business-type activities program revenues 12,005,132 13,125,119 16,285,661 15,672,490 Total program revenues $ 18,919,841 $ 20,482,369 $ 23,854,235 $ 22,783,355 Net(Expense) Revenue: Governmental activities $ (4,618,694) $ (4,332,296) $ (5,221,004) $ (8,832,909) Business-type activities 330,256 (1,095,656) 4,333,770 3,826,527 Total net(expense) revenue $ (4,288,438) $ (5,427,952) $ (887,234) $ (5,006,382) Continued on next page 71 575 Fiscal Year 2018 2019 2020 2021 2022 2023 $ 16,032,764 $ 3,550,307 $ 3,681,557 $ 3,690,434 $ 3,559,195 $ 4,364,953 6,076,722 6,401,157 6,384,915 6,803,728 7,192,119 8,104,119 2,904,035 3,272,628 3,529,226 4,728,591 4,958,150 6,993,501 1,635,692 1,549,785 1,721,852 875,956 839,282 1,149,642 240,068 282,110 251,504 124,329 180,951 160,233 26,889,281 15,055,987 15,569,054 16,223,038 16,729,697 20,772,448 9,660,919 9,447,716 10,239,572 11,434,006 12,272,525 12,439,615 783,531 816,160 917,801 1,180,250 1,168,438 1,356,116 2,600,382 6,407,316 1,936,696 1,042,003 1,083,047 1,129,528 13,044,832 16,671,192 13,094,069 13,656,259 14,524,010 14,925,259 $ 39,934,113 $ 31,727,179 $ 28,663,123 $ 29,879,297 $ 31,253,707 $ 35,697,707 $ 832,882 $ 1,366,837 $ 523,924 $ 555,714 $ 868,742 $ 1,428,145 1,927,826 2,136,220 1,686,584 2,034,007 1,982,107 2,227,794 793,956 830,003 847,335 866,761 1,055,367 813,859 2,495,302 3,196,058 2,192,809 3,710,347 3,197,855 2,112,433 1,062,030 4,553,389 9,936,824 1,387,783 1,371,930 2,315,826 3,188,292 3,754,846 6,569,796 4,395,382 6,716,111 5,992,424 10,300,288 15,837,353 21,757,272 12,949,994 15,192,112 14,890,481 6,522,387 6,740,858 6,718,556 7,110,115 7,316,955 7,374,108 895,934 953,039 888,546 1,005,431 1,039,521 1,113,984 61,492 - - - - - 942,573 5,022,018 975,811 576,933 35,299 - 13,427,627 11,599,984 7,420,604 6,772,109 7,202,415 7,732,711 21,850,013 24,315,899 16,003,517 15,464,588 15,594,190 16,220,803 $ 32,150,301 $ 40,153,252 $ 37,760,789 $ 28,414,582 $ 30,786,302 $ 31,111,284 $ (16,588,993) $ 781,366 $ 6,188,218 $ (3,273,044) $ (1,537,585) $ (5,881,967) 8,805,181 7,644,707 2,909,448 1,808,329 1,070,180 1,295,544 $ (7,783,812) $ 8,426,073 $ 9,097,666 $ (1,464,715) $ (467,405) $ (4,586,423) 72 576 City of Marathon, Florida Changes in Net Position Last Ten Fiscal Years (Accrual Basis of Accounting) (Continued) 2014 2015 2016 2017 General Revenues: Governmental activities: Taxes: Property taxes $ 3,978,700 $ 4,216,763 $ 4,470,917 $ 5,236,773 Other taxes 508,840 576,608 529,641 515,229 State shared revenues 1,766,483 1,884,755 1,926,237 1,984,812 Investment earnings 14,392 20,755 17,610 67,555 Miscellaneous 41,806 935,331 186,758 95,052 Transfers (315,265) (90,406) (332,943) (285,865) Reassignment of capital assets to business type activities - (138,834) - - Total governmental activities 5,994,956 7,543,806 6,798,220 7,613,556 Business-type activities: Investment earnings 33,250 29,705 30,543 52,561 Miscellaneous - 1,828 1,184,385 - Gain (loss)on disposal of equipment - - - - Transfers 315,265 90,406 332,943 285,865 Reassignment of capital assets from governmental activities - 138,834 - - Total business-type activities 348,515 260,773 1,547,871 338,426 Total general revenues $ 6,343,471 $ 7,804,579 $ 8,346,091 $ 7,951,982 Change in Net Position: Governmental activities $ 1,376,262 $ 3,211,510 $ 1,577,216 $ (1,219,353) Business-type activities 678,771 (834,883) 5,881,641 4,164,953 Total change in net position $ 2,055,033 $ 2,376,627 $ 7,458,857 $ 2,945,600 73 577 Fiscal Year 2018 2019 2020 2021 2022 2023 $ 6,011,774 $ 6,351,257 $ 6,847,271 $ 7,345,310 $ 8,340,762 $ 9,564,742 501,700 472,628 496,713 518,267 515,499 597,349 1,909,914 2,124,983 1,807,035 2,489,658 3,007,258 2,980,566 75,338 76,554 97,297 60,189 84,652 966,901 47,720 78,220 61,902 94,808 80,717 127,569 (653,249) (290,000) (229,755) (229,755) (208,322) (162,448) 7,893,197 8,813,642 9,080,463 10,278,477 11,820,566 14,074,679 87,334 154,963 125,482 50,446 38,887 335,981 - - - - - 35,121 20,637 94,239 - - - - 653,249 290,000 229,755 229,755 208,322 162,448 761,220 539,202 355,237 280,201 247,209 533,550 $ 8,654,417 $ %352,844 $ %435,700 $ 10,558,678 $ 12,067,775 $ 14,608,229 $ (8,695,796) $ %595,008 $ 15,268,681 $ 7,005,433 $ 10,282,981 $ 8,192,712 %566,401 8,183,909 3,264,685 2,088,530 1,317,389 1,829,094 $ 870t6O5 $ 17,778,917 $ 18,533,366 $ 9,093,963 $ 11,600,370 $ 10,021,806 74 578 City of Marathon, Florida Fund Balances of Governmental Funds Last Ten Fiscal Years (Modified Accrual Basis of Accounting) 2014 2015 2016 2017 General Fund: Nonspendable $ 91,443 $ 99,901 $ 98,770 $ 144,042 Restricted 81,995 210,826 235,850 255,897 Committed - - - - Assigned 602,829 834,104 463,756 - Unassigned (Deficit) 2,565,459 3,398,554 4,521,269 3,690,416 Total general fund 3,341,726 4,543,385 5,319,645 4,090,355 All Other Government Funds: Nonspendable 1,500 1,500 5,244 - Restricted 7,844,203 5,661,189 3,125,907 3,505,714 Committed 2,338,268 3,431,379 3,772,815 3,457,850 Unassigned (deficit) - - - - Total all other governmental funds 10,183,971 9,094,068 6,903,966 6,963,564 Total all governmental funds $ 13,525,697 $ 13,637,453 $ 12,223,611 $ 11,053,919 75 579 Fiscal Year 2018 2019 2020 2021 2022 2023 $ 334,294 $ 355,951 $ 29,667 $ 33,342 $ 66,075 $ 479,014 326,131 377,145 335,635 736,190 918,789 115,820 (6,862,727) (1,020,937) 12,291,091 13,396,993 17,728,901 22,535,252 (6,202,302) (287,841) 12,656,393 14,166,525 18,713,765 23,130,086 25 - - - - 15,901 3,786,409 3,120,128 2,646,830 8,454,930 9,524,835 10,494,375 4,141,624 4,855,431 5,463,430 6,508,913 7,349,471 9,014,056 - (5,000) - - - - 7,928,058 7,970,559 8,110,260 14,963,843 16,874,306 19,524,332 $ 1,725,756 $ 7,682,718 $ 20,766,653 $ 29,130,368 $ 35,588,071 $ 42,654,418 76 580 City of Marathon, Florida Changes in Fund Balances of Governmental Funds Last Ten Fiscal Years (Modified Accrual Basis of Accounting) 2014 2015 2016 2017 Revenues: Ad valorem taxes $ 3,978,700 $ 4,216,763 $ 4,470,917 $ 5,236,773 Communication services taxes 508,840 576,608 529,641 515,229 Impact fees 205,288 1,222,462 470,614 489,340 Licenses and permits 966,452 1,347,116 1,553,338 1,506,456 Intergovernmental revenue 6,494,328 5,763,603 6,055,246 5,822,821 Charges for services 840,115 1,026,971 1,057,363 1,040,201 Fines and forfeitures 169,149 274,429 288,331 232,565 Special assessments - - - - Interest 14,392 20,755 17,610 67,555 Miscellaneous 66,308 520,255 98,410 39,878 Total revenues 13,243,572 14,968,962 14,541,470 14,950,818 Expenditures: Current: General government 2,579,453 2,412,107 2,482,091 4,778,448 Public safety 4,257,930 4,438,161 4,645,986 5,015,503 Community services 1,644,411 1,930,436 2,069,478 2,332,785 Community development 825,034 954675 1,314,896 1,263,455 Capital outlay 2,479,661 4,023:290 4,131,176 1,635,184 Debt service: Principal 785,000 770,000 760,000 740,000 Interest and other fiscal charges 279,693 238,131 218,742 199,571 Total expenditures 12,851,182 14,766,800 15,622,369 15,964,946 Excess(Deficiency)of Revenues Over Expenditures 392,390 202,162 (1,080,899) (1,014,128) Other Financing Sources(Uses): Payment to refunded bond escrow agent (4,277,773) - - - Insurance proceeds - - - 130,301 Transfers in 1,772,648 2,107,961 2,127,866 1,727,945 Transfers out (2,087,913) (2,198,367) (2,460,809) (2,013,810) Issuance of debt Bonds Issued 10,335,000 - - - Total other financing sources(uses) 5,741,962 (90,406) (332,943) (155,564) Net Change in Fund Balances $ 6,134,352 $ 111,756 $ (1,413,842) $ (1,169,692) Debt Service as a Percentage of Non-Capital Expenditures 9.96% 9.40% 8.50% 6.56% 77 581 Fiscal Year 2018 2019 2020 2021 2022 2023 $ 6,011,774 $ 6,351,257 $ 6,847,271 $ 7,345,310 $ 8,340,762 $ 9,564,742 501,700 472,628 496,713 518,267 515,499 597,349 621,797 914,021 686,783 1,158,581 1,114,226 641,085 2,944,187 3,756,614 2,721,267 3,207,461 3,246,378 2,985,146 5,864,220 8,242,793 19,720,073 9,528,651 11,654,956 11,637,034 1,500,628 1,388,284 1,257,636 1,513,547 1,476,209 1,320,534 106,266 141,389 126,148 711,911 494,001 1,168,151 75,338 76,554 97,297 60,189 84,652 966,901 76,581 95,485 65,702 108,679 211,874 42,581 17,702,491 21,439,025 32,018,890 24,152,596 27,138,557 28,923,523 15,556,405 3,003,629 3,112,085 3,054,300 3,072,868 3,692,840 5,528,311 5,921,898 5,824,957 6,227,374 7,034,427 7,533,277 1,968,075 2,217,144 2,507,537 3,704,028 4,060,642 5,898,741 1,514,815 1,434,355 1,623,247 731,061 821,561 995,880 1,315,357 4,099,767 4,291,162 527,941 6,343,217 2,061,614 735,000 785,002 1,130,000 1,145,000 1,165,000 1,350,000 236,982 232,565 220,529 186,278 151,439 175,983 26,854,945 17,694,360 18,709,517 15,575,982 22,649,154 21,708,335 (9,152,454) 3,744,665 13,309,373 8,576,614 4,489,403 7,215,188 427,539 877,296 4,317 16,856 176,622 13,607 1,517,128 2,036,301 2,641,842 5,575,603 2,897,353 4,763,741 (2,170,377) (2,326,301) (2,871,597) (5,805,358) (3,105,675) (4,926,189) 50,001 1,625,001 - 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(7 E _ O Uv U ++ c G7 (gyp +� C on hA O tw = m 0 O LL � L O ch L w Q O CL O }Si }Ni U — N fC H ` en ~ ate- C LL m L C 0 d 1:3- M LD N M M O r-I N M 'N 0 r-I r-I r-I r-I r-I r-I N N N N O 4— LnE O O O O O O O O O O 0 0 v W 0) N N N N N N N N N N 0 a O U O u LA z N z 587 City of Marathon, Florida Computation of Direct and Estimated Overlapping Governmental Activities Debt September 30, 2023 Applicable to City of Marathon Debt Outstanding Percentage Amount Direct debt: City of Marathon $ 4,644,734 100.00% $ 4,644,734 Estimated overlapping debt: Monroe County, District School Board (1) 37,921,911 8.46% (2) 3,207,650 Total ad valorem tax supported debt $ 42,566,645 $ 7,852,384 Ratios: Overall debt to 2022 taxable valuation 0.22% Overall debt per capita $ 801 Notes: (1) Monroe County School Board debt is as of June 30, 2023 (2) Overlapping debt percentage was determined by a ratio of the assessed value of property subject to taxation in the City of Marathon to the total assessed value of property subject to taxation in the overlapping unit. 84 588 a, Oa 00 lD 00 N lD M m I, M m i N m 00 Ln N m N � � 'zT ai ri ri o ri ri ri ri ri ri ri O U M N O N O Ln LD 'zT Ql N a+ T lD N Ql Ql 00 I, m zT 0 0 N LD rl O m N I, Ql 00 0 ai i 0 m 00 I- n m Ln N lD m aJ -zT LD N Ln T LD Ql LD -zT 0 +' Cl m 00 lD Ln lzl m N rl O C — ri m ri ri ri ri ri ri ri ri Ql Ln N N O N N m rl OO N -zT rl lD Ql Ln 00 I, m rl V a N O r, 00 Ln N N � Q Ln 1 I- 0 00 I- O 00 0 N N m aJ i 'U lD m -zT 00 00 rl Ln I, Ql 00 D O C LD N O Ln lD 00 N m 'zT I, of a -zT m 00 -zT -zT -zT Ln Ln Ln Ln v N (o rl Ln 'zT N 'zT Ln lD O m m 0 of aJ lD -zT N O -zT Ln Ql N rl 00 o = rnrnrnoLnmrir, r, rn C0y d N N rl lD 00 0 lD lD lD Ln omZ '� aj rnrniDOiD � Ommm aJ � M LD In 00 I, N I, rl I, Ll O Q OC 0606 00 0 I- 0606 0 O 0 7 C 0 C aj tw M M O N 00 0 LD I, rl lD E C O m m N N � m N N 00 H 0 rl M m 'zT Ln m N rl r, > H m C O ro ro ro T O ri O 00 � m O W i W O I, n O m M N O N N a Q J Q Q rl N LD 00 rl Ln Ql N Ql � (/) 00 X Ln Ln Ln Ln LnE O � Q1 > 0 0 Oa tA rl rl LD m 'zT 00 N Ln Ln 00 >. C aj oozT zTmLnTrir -10 to = N rl lzl O 00 Ln Il rl N rl Q L C rnLoLorr, Orn0o� � a y m -1 m � -1 o Lo -1 -1 m O Lri���� ���� � v v t v N 00 00 0 r1 m 00 N m N Lnoor, r0000 -zTLD00 i io aC+ ONiDr, rirnLniDmri 'U C rl I- m a O lD az:l N rl w V1 00 I, Ql Ln -zT rl Ln 00 N Ln N a 0 Ql N O 00 O O I, 00 O O +1 aj N V1 Lr Lr z Lr Lr z zF Lr Lr Q � E f6 Q I, In 0 rl I, 'zT N 0 LD M Q m In m lD mzT n n rl In O U LD LD I, In M A N rl m In U i N N Ln lD rl m I, N 00 Ln a+ N N Ql 00 Ln lD Ql � 00 m 'L i f0 of LD 00 00 Ql 00 N LD Ql 00 I, Q J 0 C U N Ln O45 3 +� fC V M r) � a1 H f0 LL �aJ w � Ln lD I, 00 M 0 rl N m rl rl rl rl rl rl N N N N 0000000000 0 t H W y N N N N N N N N N NCL N aJ u a `n 0 589 City of Marathon, Florida Demographic and Economic Statistics Last Ten Fiscal Years Personal Income (Amounts Per Capita Expressed in Personal Unemployment Year Population(1) Thousands)(2) Income(2) Rate(3) 2014 8,425 4,941,002 65,087 3.2% 2015 8,439 5,477,252 71,606 3.3% 2016 8,546 5,660,751 73,513 3.2% 2017 8,775 6,160,642 79,694 3.4% 2018 8,235 6,417,335 83,328 2.6% 2019 8,593 6,911,436 92,119 1.8% 2020 9,097 7,516,454 101,262 3.8% 2021 9,689 (a) 7,876,486 106,583 2.6% 2022 9,926 8,967,730 109,136 1.9% 2023 9,799 9,734,563 119,138 1.8% Sources: (1) Office of Economic and Demographic Research, FL Legislature. (2) United States Census Bureau for all of Monroe County and Bureau of Economic and Business Research, University of FL. (3) Florida Department of Labor, Agency for Workforce Innovation. Rates are for the entire County of Monroe. (a) Data obtained from 2020 Federal census. Note: When Marathon-specific data has not been available, Monroe County percentage projections were applied to Marathon's actual population figures from prior years. 86 590 City of Marathon, Florida Principal Employers Current Year and Ten Years Ago 2023 Percentage of Total City Employer Employees Rank Employment Monroe County 193 1 N/A Fishermen's Community Hospital 180 2 N/A Monroe County School Board 151 3 N/A Home Depot USA 150 4 N/A City of Marathon 118 5 N/A Winn Dixie 93 6 N/A Publix Supermarkets 93 7 N/A Walgreens Co. 88 8 N/A Florida Keys Aqueduct Authority 45 9 N/A D'Asign Source LLC 35 10 N/A 2014 Percentage of Total City Employer Employees Rank Employment Monroe County 193 1 N/A Monroe County School Board 151 2 N/A Home Depot USA 150 3 N/A Walgreens Co. 114 4 N/A Winn Dixie 93 5 N/A Publix Supermarkets 93 6 N/A K-Mart Corporation 77 7 N/A City of Marathon 70 8 N/A Fishermen's Hospital 50 9 N/A Florida Keys Aqueduct Authority 45 10 N/A 87 591 oo oo am Ln oo oo m ti a ti N O N Q1 to I, m n N m c t c c-I N O N Ql M � oo O ti N O N Ql c V1 Ql oo N m c m O c-I O O N Ql to VI I, oo VI m c m O c-I O N oo :t to to oo N m c m O c-I oo O N 00 00 oo c to :t oo I, m c m Q1 c-I O N Ooo oo :t Vl to c-I }I N c m Ql U � O LL N N T oo oo m r, Ln N c-I N oo 4- _0 rq E E O a W L 4 C 0) 4J E �D �D m rn ID O N c-I c-I I, y U c 0 rq O L.L +� O ++ H t� G1 T v t } v E o a a T v £ y LV y o E v > ° +, aLL > o O t Z Z 0 ` r to 7 7 7 V E E C N y uLi -j (Dauu L° 592 N I, 00 cy 00 O 00 M VI O Ql O to M M M M O I, O a lD I, Vl n N c-I rn Dl lD N m O tD N 0o Ql �o Ql c-I M 't M O O M O to M N ti M M O r, :t lD M O 0o N c-I N lD N M O tD N N Ql M O N I, M M O O N N lD M M Vl M 0o M O 0o lD M O Ql N c-I e-I -:t N M 0o N N M c c O � N N lD 't n VI VI 0o M O 0o O lD M M 0o M -:t M I, lD VI lD N c-I c-I VI O 0o N Q c M O � N N lD I, O 't 't Q1 M I, lD N M lD M M N Ql N 0o r, lD t N O n N c-I ei O c-i c-i oo O VI N L c-I N I, cy lD N I, M lD O 0o N lD M M LD N O 0o Vl Q1 tD N 0o -:t �D N oo N VI N N O M M Lr VI N p p N r, r �D r m r, cn L U o m m N O Q) 'L C p Q) c >`Ln O c-I N r, O Ql c-I M tD 0o . N lD M M N N N Ql c-I M lD N VI Ql O N c-I >`•L 00 tD Lr 00 I, cy rl N N a--� O O M c-I N M N Ln 4- U Q OL 01 QJ aJ �, aJ 00 I, Q1 n VI n VI M Q1 lD 0o lD M L L N lD N lD a lD n M M lD -:t N O p w m Q O c-i m cm 0 N f6 Q1 4 N on O � � > v7 U r, r, r, a Ln m a N m tD tD m N '+ � a) a) N VI N O Vl -:t Vl tD 0o Ql :tM N c-I O I, tD N VI c-I M O It N a--� O c-I M N M N = U L O M" O N O U 4- 0 O > U � O oo tD a) �D am m m r, a) oo a) 'D:t rIj m U N O N �D 00 O v1 :tv1 Ilia (V L ea-I n c-i M c-i 00 O c -0 O M N cn O > i ) Q Q OL tw aJ O U Q L.. L U 0. +, O c6 O LJ � p L L N � f6 m Q W C N O i Q aj U aJ +' aj a m i '> V v u N E w fC LL o = ai n n fl U V a N v m u u S — Q 4- y i v N Q o L � N o o v O N N (6 LL 0 w m i >aj •\L L a� U v ? t v } a, ° o E N u 3 0 £ � a iri d m cn � fC c c ai a - o . aJ i O H o ° v u o L o 0 0 o i aJ aJ aJ aJ dA LL no v £ c W v `y o � L c c c c 0 0 +. +. 0 O o o_ u C v N g 'L o o o o p 0 0 0 0 O d a d a ea v v ea a cn Z Z Z Z u Q� o ( ( ( m - fC c m a v v w a, c c £ ° m o AoDODo iLLLL £ o £ iD � .�.�.�.� o m u o 2 593 rn - w m oo oo r, w _ � � w ƒ - w Ln - E ] 0 u $ _ w _ w _ - - w 7 R ° oo ` ~ & � # 2 u ° - w _ oo - w w w oo 0 0 0 2� rn- w _ - w w _ � � w m \ Ln cn k � � § - w _ - w w _ - - w \ � f E � cc mod - wrn _ w _ - - w } ® _ w ® % u R o 0- 0 � - w —0 t zm �w _ _ _ .g j w _ m / U0 2 � $ rn 2 £ � w _ - w Ln oo _ § $ k C- ° .L wrn - w _ � � w E E E ` ~ °oo \ 0 @ tw « / E 2 E a % (U / 2j2 CL 0 0 0 _ / % � - 0 0 0 o : E � � � � 7 � 2 \ § - § / O O O 0 4, CIO , - °_ k Ln k / - S Haj ! = . . . & \ { { 3 = [ / \ d 2 2 2 � ■ ( y _ § { , \ ) \ /) / /� / \ § @ $ _ o ; 7f � _ - cLEE E 4e > i B / 77 @J 2 = £ § JJ ) \) } j3 } » a / j / ) � 594 COMPLIANCE SECTION 595 nuuuuuuuiuui HNIRS u ! C u"As �l II11rusb2iJA"CI n&I II'S INDEPENDENT AUDITOR'S REPORT ON INTERNAL CONTROL OVER FINANCIAL REPORTING AND ON COMPLIANCE AND OTHER MATTERS BASED ON AN AUDIT OF FINANCIAL STATEMENTS PERFORMED IN ACCORDANCE WITH GOVERNMENT AUDITING STANDARDS To the Honorable Mayor and City Council City of Marathon, Florida Marathon, Florida We have audited, in accordance with the auditing standards generally accepted in the United States of America and the standards applicable to financial audits contained in Government Auditing Standards issued by the Comptroller General of the United States, the financial statements of the governmental activities, the business-type activities, each major fund and the aggregate remaining fund information of the City of Marathon, Florida (the "City") as of and for the year ended September 30, 2023, and the related notes to the financial statements, which collectively comprise the City's basic financial statements, and have issued our report thereon dated March 27, 2024. Internal Control over Financial Reporting In planning and performing our audit of the financial statements, we considered the City's internal control over financial reporting (internal control) as a basis for designing audit procedures that are appropriate in the circumstances for the purpose of expressing our opinions on the financial statements, but not for the purpose of expressing an opinion on the effectiveness of the City's internal control. Accordingly, we do not express an opinion on the effectiveness of the City's internal control. A deficiency in internal control exists when the design or operation of a control does not allow management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct misstatements on a timely basis. A material weakness is a deficiency, or a combination of deficiencies, in internal control such that there is a reasonable possibility that a material misstatement of the entity's financial statements will not be prevented, or detected and corrected on a timely basis. A significant deficiency is a deficiency, or a combination of deficiencies, in internal control that is less severe than a material weakness, yet important enough to merit attention by those charged with governance. Our consideration of internal control was for the limited purpose described in the first paragraph of this section and was not designed to identify all deficiencies in internal control that might be material weaknesses or significant deficiencies. Given these limitations, during our audit we did not identify any deficiencies in internal control that we consider to be material weaknesses. However, material weaknesses or significant deficiencies may exist that were not identified. SOUTH FLORIDA BUSINESS JOURNAL � II���" '�ii�i��'�'i�u III uiiu��S61V II c6cixl IIV�nry,/ells II 1�rui�, II url II xGa6cr6xlc II II 67+666 C 9634,771.0896 ax:`6' 4 938 9 '16 a6 . airChrTarrfc Business Jowrcl II, m00 AccouinithnigIlhiiiuu uiunu Him U INSIDE P'uklreAeeal:rrrCrrr6 riio 91 BEST PLACES TO WORI596 City of Marathon, Florida Compliance and Other Matters As part of obtaining reasonable assurance about whether the City's financial statements are free of material misstatement, we performed tests of its compliance with certain provisions of laws, regulations, contracts and grant agreements, noncompliance with which could have a direct and material effect on the financial statements. However, providing an opinion on compliance with those provisions was not an objective of our audit and, accordingly, we do not express such an opinion. The results of our tests disclosed no instances of noncompliance or other matters that are required to be reported under Government Auditing Standards. Purpose of this Report The purpose of this report is solely to describe the scope of our testing of internal control and compliance and the results of that testing, and not to provide an opinion on the effectiveness of the entity's internal control or on compliance. This report is an integral part of an audit performed in accordance with Government Auditing Standards in considering the entity's internal control and compliance. Accordingly, this communication is not suitable for any other purpose. fie+A BI KEEFE McCULLOUGH Fort Lauderdale, Florida March 27, 2024 92 597 nuuuuuuuiuui HNIRS u ! C u"As �l II usb2iJ A"CIVII&I II'S INDEPENDENT AUDITOR'S REPORT ON COMPLIANCE FOR EACH MAJOR FEDERAL PROGRAM AND STATE PROJECT AND ON INTERNAL CONTROL OVER COMPLIANCE REQUIRED BY THE UNIFORM GUIDANCE AND CHAPTER 10.550, RULES OF THE FLORIDA AUDITOR GENERAL To the Honorable Mayor and City Council City of Marathon, Florida Marathon, Florida Report on Compliance for Each Major Federal Program and State Project Opinion on Each Major Federal Program and State Project We have audited the City of Marathon, Florida's (the "City") compliance with the types of compliance requirements identified as subject to audit in the OMB Compliance Supplement and the Florida Department of Financial Services' Projects Compliance Supplement that could have a direct and material effect on each of the City's major federal programs and state projects for the year ended September 30, 2023. The City's major federal programs and state projects are identified in the summary of auditor's results section of the accompanying schedule of findings and questioned costs. In our opinion, the City complied, in all material respects, with the types of compliance requirements referred to above that could have a direct and material effect on its major federal programs and state projects for the year ended September 30, 2023. Basis for Opinion on Each Major Federal Program and State Project We conducted our audit of compliance in accordance with auditing standards generally accepted in the United States of America; the standards applicable to financial audits contained in Government Auditing Standards, issued by the Comptroller General of the United States; the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance); and Chapter 10.550, Rules of the Florida Auditor General. Our responsibilities under those standards, the Uniform Guidance, and Chapter 10.550, Rules of the Florida Auditor General are further described in the Auditor's Responsibilities for the Audit of Compliance section of our report. We are required to be independent of the City and to meet our other ethical responsibilities, in accordance with relevant ethical requirements relating to our audit. We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our opinion on compliance for the City's major federal program. Our audit does not provide a legal determination of the City's compliance with the compliance requirements referred to above. Responsibilities of Management for Compliance Management is responsible for compliance with the requirements referred to above and for the design, implementation, and maintenance of effective internal control over compliance with the requirements of laws, statutes, regulations, rules, and provisions of contracts or grant agreements applicable to the City's federal programs and state projects. SOUTH FLORIDA BUSINESS JOURNAL llln��"'" ssusii�o����o�u III uiiu�nS6 1V II c6ci sl II V�nry,/el l� II ��rui�, II url II sGa6cr6slc II II 61+666 "�C 'w4 771.0896 :`6'sx 4 938 96'36 a6 s I sollr hr Ala Ida Business Join na/ !' Il,n 400 Accouinithnig 1!!!1IIri ns lin, Him U INSIDEPlublre Aeeal:mCing 93 BEST PLACES TO WORI59$ City of Marathon, Florida Auditor's Responsibilities for the Audit of Compliance Our objectives are to obtain reasonable assurance about whether material noncompliance with the compliance requirements referred to above occurred, whether due to fraud or error, and express an opinion on the City's compliance based on our audit. Reasonable assurance is a high level of assurance but is not absolute assurance and therefore is not a guarantee that an audit conducted in accordance with generally accepted auditing standards, Government Auditing Standards, the Uniform Guidance, and Chapter 10.550, Rules of the Florida Auditor General will always detect material noncompliance when it exists. The risk of not detecting material noncompliance resulting from fraud is higher than for that resulting from error, as fraud may involve collusion, forgery, intentional omissions, misrepresentations, or the override of internal control. Noncompliance with the compliance requirements referred to above is considered material if there is a substantial likelihood that, individually or in the aggregate, it would influence the judgment made by a reasonable user of the report on compliance about the City's compliance with the requirements of its major federal program and state project as a whole. In performing an audit in accordance with generally accepted auditing standards, Government Auditing Standards, the Uniform Guidance, and Chapter 10.550, Rules of the Florida Auditor General we: • Exercise professional judgment and maintain professional skepticism throughout the audit. • Identify and assess the risks of material noncompliance, whether due to fraud or error, and design and perform audit procedures responsive to those risks. Such procedures include examining, on a test basis, evidence regarding the City's compliance with the compliance requirements referred to above and performing such other procedures as we considered necessary in the circumstances. • Obtain an understanding of the City's internal control over compliance relevant to the audit in order to design audit procedures that are appropriate in the circumstances and to test and report on internal control over compliance in accordance with the Uniform Guidance and Chapter 10.550, Rules of the Florida Auditor General, but not for the purpose of expressing an opinion on the effectiveness of the City's internal control over compliance. Accordingly, no such opinion is expressed. We are required to communicate with those charged with governance regarding, among other matters, the planned scope and timing of the audit and any significant deficiencies and material weaknesses in internal control over compliance that we identified during the audit. Report on Internal Control over Compliance A deficiency in internal control over compliance exists when the design or operation of a control over compliance does not allow management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct, noncompliance with a type of compliance requirement of a federal program or state project on a timely basis. A material weakness in internal control over compliance is a deficiency, or a combination of deficiencies, in internal control over compliance, such that there is a reasonable possibility that material noncompliance with a type of compliance requirement of a federal program or state project will not be prevented, or detected and corrected, on a timely basis. A significant deficiency in internal control over compliance is a deficiency, or a combination of deficiencies, in internal control over compliance with a type of compliance requirement of a federal program or state project that is less severe than a material weakness in internal control over compliance, yet important enough to merit attention by those charged with governance. 94 599 City of Marathon, Florida Our consideration of internal control over compliance was for the limited purpose described in the Auditor's Responsibilities for the Audit of Compliance section above and was not designed to identify all deficiencies in internal control over compliance that might be material weaknesses or significant deficiencies in internal control over compliance. Given these limitations, during our audit we did not identify any deficiencies in internal control over compliance that we consider to be material weaknesses, as defined above. However, material weaknesses or significant deficiencies in internal control over compliance may exist that were not identified. Our audit was not designed for the purpose of expressing an opinion on the effectiveness of internal control over compliance. Accordingly, no such opinion is expressed. The purpose of this report on internal control over compliance is solely to describe the scope of our testing of internal control over compliance and the results of that testing based on the requirements of the Uniform Guidance and Chapter 10.550, Rules of the Florida Auditor General. Accordingly, this report is not suitable for any other purpose. KEEFE McCULLOUGH Fort Lauderdale, Florida March 27, 2024 95 600