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Item U10
BOARD OF COUNTY COMMISSIONERS COUNTY of MONROE ��a�� `` Ullti � Mayor Michelle Lincoln,District 2 The Florida Keys Mayor Pro Tern David Rice,District 4 p Craig Cates,District 1 .lames K.Scholl,District 3 -� Holly Merrill Raschein,District 5 Regular Meeting April 15, 2026 Agenda Item Number: U10 26-1646 BULK ITEM: No DEPARTMENT: Fire Rescue TIME APPROXIMATE: N/A STAFF CONTACT: R.L. Colina, Fire Chief AGENDA ITEM WORDING: A Public Hearing to consider an application for issuance of a new Class A Certificate of Public Convenience and Necessity (COPCN) to the Key Largo Fire Rescue and Emergency Medical Services District for the operation of Advanced Life Support (ALS) and Basic Life Support (BLS) emergency medical transport and non-transport services provided within the boundaries of the Key Largo Fire Rescue and Emergency Medical Services District for the period 04/16/2026 through 04/15/2028. ITEM BACKGROUND: Key Largo Fire Rescue and Emergency Medical Services District ("KLFREMSD") is an independent special fire control district having powers, duties, obligations, and immunities as set forth in its enabling special law, Chapter 2005-329, Laws of Florida, and pursuant to the general laws established in Chapters 189, "Uniform Special District Accountability Act," and 191, "Independent Special Fire Control Districts," Fla. Stat. The KLFREMSD was created to establish and operate fire rescue and emergency medical services within the District's jurisdictional boundaries, located within Monroe County, and such land is specifically described as "[a]ll of Cross Key and that part of Key Largo from South Bay Harbor Drive and Lobster Lane to the southern boundary of the right-of-way County Roads 905 and 905A." As such, the KLFREMSD has submitted an application for a new Class A COPCN for the operation of ALS and BLS emergency medical transport and non- transport services. If approved, the Class A COPCN will become effective starting on April 16, 2026 for a period of two years, and will end on April 15, 2028 at 11:59pm. Pursuant to Section 11-173(d)(1), Monroe County Code, the BOCC is required to schedule a public hearing to consider a new COPCN application. Formal notice of this public hearing was placed in the appropriate newspaper publications. Additionally, consistent with the Monroe County Code, Staff has notified the applicant and all current COPCN holders of the date, time, and place of this public hearing. As such, all procedural prerequisites that are necessary to consider this item have been performed. PREVIOUS RELEVANT BOCC ACTION: N/A INSURANCE REQUIRED: Mandated by SOF. CONTRACT/AGREEMENT CHANGES:N/A STAFF RECOMMENDATION: Approval. DOCUMENTATION: NEW KLFREMSD COPCN Application- Updated 3-19-2026 Redacted Key Largo Fire Rescue and Emergency Medical Services District COPCN KLFREMSD New COPCN application Notice of Public Hearing Chapter 2005-329, Laws of Florida KLFREMSD Resolution 2026-0002- Consolidation FINANCIAL IMPACT: Effective Date: 04.16.2026 Expiration Date: 04.15.2028 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: Mandated pursuant to State of Florida licensing requirements. MONROE COUNTY, FLORIDA APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) CLASS A- EMERGENCY MEDICAL SERVICE (PRINT OR TYPE) INITIAL APPLICATION-$950.00 [:1 RENEWAL APPLICATION-$475.00 ***A[,[,APPIACA'110N FEES ARE NON-FEEFUNI)ABI,E*** IF RENEWAL,PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE. # Part 1: General Information L LEGAL NAME OF SERVICE. KEY LARGO FIRE RESCUE AND EMERGENCY MEDICAL SERVICES DISTRICT BUSINESS MAILING ADDRESS: I EAST DRIVE KEY LARGO,FL 33037 BUSINESS PHONE NUMBER: 305A51-2700 EMERGENCY PHONE NUMBER. 305A51-2700 EMAIL ADDRESS. HR@Keylargofirerescue-fl.gov (To be used for all correspondence,) 1 TYPE OF OWNERSHIP(i.e.Sole Proprietor,Partnership,Corporation,etc.)-. N/A DATE OF INCORPORATION OR FORMATION OFT E BUSINESS ASSOCIATION: 06/08/2005 NOTE- NO 911 EMERGENCY SCENE RESPONSE WORK WITHIN ON CIE COUNTY WILL BE PERMITTED FOR AGENCIES OTHER THAN MUNICIPALITIES AND SPECIAL TAXING DISTRICTS. IS THE ENTITY A MUNICIPALITY? NO IS THE ENTITY A SPECIAL TAXING DISTRICT? Yes 3, LIST ALL OWNERS,OFFICERS,DIRECTORS,AND SHAREHOLDERS(Use separate sheet,if necessary): NAME gg XGE ADDRESS TELEPHO # EMAIL ADD SS POSITION/T1 ANTHONY ALLEN 46 1 East Drive Key Largo,FL 33037 305-451-2700 9onyy,aVWgi@keyiargofirerosri,x O pv CHAIRMAN GEORGE MIRABELLA 70 1 East Drive Key Large,FL 33037 305-451-2700 VICE CHAIRMAN MIKE JEN KIN S 58 1 Easi Drive Key Largo,FL 33037 305-451-2700 BOARD MEMBER FRANK CONKLIN 54 1 East Drive Key Largo,FL 33037 305-451-2700 frank, BOARD MEMBER KENNY EDGE 66 1 East Drive Key Largo,FL 33037 305-451-2700 TREASURER 4. LEVEL OF CARE TO BE PROVIDED: El BLS only or IN ALS& BLS air EIALS only IFALS: N TRANSPORT or NON TRANSPORT El Air Ambulance 5. DESCRIBE THE GEOGRAPHIC AREAS OR ZONE(S)THAT YOUR SERVICE DESIRES TO SERVE: (Use separate sheet if necessary) LOBSTER LANEISOUTH BAR HARBOR DRIVE(95MM)NORTH TO MORRIS LANE OR MIAMI-DADE COUNTY LINIE,(I 13MW ALSO FROM CR90(5 ANDUSI NOR7H TO THE 3 WAY STOP CRIO, We can provide boundary shape files if necessary, P,4V,c 1 of7 b. LIST THE ADDRESS AND/OR DESCRIBE THE LOCATION OF YOUR BASE STATION LOCATED IN MONROE COUNTY,AND ALI,SUB-STATIONS(Use separate sheet if necessary): BASE STATION 1 EAST DRIVE KEY LARGO, FL 33037 - STATION 24 - HEADQUARTERS SUB• TATION(S) 220"REEF DRIVE KEY LARGO, FL 33037 STATION 25 98600 OVERSEAS HIGHWAY KEY LARGO, FL 33037 - NATION 23 7. DESCRIBE YOUR COMMUNICATION SYSTEM(Attach copy of all.FCC licenses): ........................................................._........._...............,.. �............................................_..........................................................................................,.._._,......................................................._.....�........... .,.,.,.,.,., FREa CE CALL NUMBERS OF MOBILES OF PORTABLES 8001 MHz:MONROE CA7LbI "ry�dhX�'.RW OFFF E 24.1C?4.AR24.If;25,IL25,UTZS,UTV25,R2"3,RI23,R25 I 1 0 42 .................................................................._............................................__..._.. ............................................................................................_..................... 8. LIST THE NAMES AND ADDRESSES OF THREE(3) U.S.CITIZENS WHO WILL ACT AS REFERENCES FOR YOUR SERVICE: NAME ADDRESS AWN DeBRULE 56 BASS AVENUE KEY LARGO, FL 33037 HOMAS MORRISON 105030 OVERSEAS HIGHWAY KEY LARGO, FL 303 CAROL G IECO 1632 O MONTH LANE KEY LARGO, FL 33037 9. ATTACH THE SCHEDULE OF RATES THAT YOUR SERVICE WILL CHARGE DURING THE COPCN PERIOD FOR ALL PROPOSED SERVICES. 10. PROVIDE VERIFICATION OF ADEQUATE INSURANCE COVERAGE DURING THE COPCN PERIOD. NOTE: Pursuant to Section 401.25, F.S.,adequate insurance means the level of insurance or certificate of self-insurance required by DOH to issue an ALS/BLS license in the State of Florida. Currently, DOH has established MINIMUM insurance limits for Bodily Injury at $100,000/$300,00 and property damage at $50,000 for non-government owned services. Bodily injury and property damage for government services is $200,000 total. For air ambulance licenses, medical malpractice/professional liability insurance for all air medical crew members and medical director is required. 11. ATTACH A COPY OF YOUR SERVICE'S CONTRACT WITH A MEDICAL DIRECTOR FOR THE COPCN PERIOD. 12. ATTACH A COPY OF AL.I,STANDING ORDERS AS ISSUED BY YOUR MEDICAL.DIRECTOR. 13. ATTACH A CHECK OR MONEY ORDER IN THE APPROPRIATE,APPLICATION FEE AMOUNT,MADE PAYABLE TO THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. 14. ATTACH A COPY OF AN AUDIT PERFORMED BY AN INDEPENDENT CERTIFIED PUBLIC; ACCOUNTANT OF THE ANNUAL, OPERATING STATISTICS, ACCOUNTS, AND RECORDS OF THE SERVICE INVOLVED; SAID AUDIT IS TO BE DONE ANNUALLY TO COINCIDE WITH THE END OF THE BUSINESS YEAR OF THE SERVICE. 15. BY COMPLETING AND SIGNING THIS APPLICATION, THE SERVICE, ACTING BY AND THROUGH ITS AUTHORIZED REPRESENTATIVE, HEREBY ACKNOWLEDGES, UNDERSTANDS, AND AGREES T COMPLY WITH SECTIONS 11-151 THROUGH 11-178, MONROE. COUNTY CODE, AS SAME MAY BE AMENDED FROM TIME TO TIME.. A PENALTY FOR FAILURE TO COMPLY WITH THE LAW MAY INCLUDE, BUT IS NOT LIMITED TO,RECOVATION OF ANY COPCN PREVIOUSLY GRANTED. [Proceed to the following pages for Part 11: Personnel& Vehicle information] Page 2 of 7 Part II: Personnel &Vehicle Information PERSONNEL—PARAMEDICS ------------------------------------------------ ................... .................................. ............................ NAME PARAMEDIC CERTIFICATION .................Firsts�M11AKtInt..................................S.00IAL..SECURITV# CERTIFICATION# EXPIRATION DATE .. ................ .. -------- Enrique Abilleira PMD531835 12/01/2026 ----------------- Jaime Aran a PMD513116 12/01/2026 ............ ------------------- Andrew Bohl PMD533521 12/01/2026 ------- ------------------------------------------------ Pedro Fernandez PMD530562 12/01/2026 --------------............. .............................Bradley Galvin PMD534400 12/01/2026 ---------------- Sergio Garcia PMD530690 12/01/2026 ----------- -------------------------------------------------.--........ Fernando Garcia PMD530770 12/01/2026 ............... ............... David Garrido PMD526992 12/01/2026 —----------------------------- -- ---- - ....................................... ............ Giuliano Gonzalez PMD544849 12/01/2026 ..................... Marcos Gonzales PMD538055 12/01/2026 ...................................................................................................................................................................................... ......................................... Chris Jones PMD519528 12/01/2026 ........................................................................................................................................................--.......... .............................. ............ ................. Thomas Mirabella PMD542524 12/01/2026 .......................... ......................................................... ........................................................................................................................................-................... Jason Mumper PMD526457 12/01/2026 ..........................................................................................--.................................................................... ........... .......-,................... Daniel Alarez PMD578342 12/01/2026 ......................................................---.................................................................................................................................................................. ...........................................I.-.......... ........................................................................................... ......................................................... David Artega PMD541722 12/01/2026 ............................................................................................................................................................................................... ............................................................... Edwardo Gonzalez PMD535771 12/01/2026 ............................................................................................................................................................ ................................................................. Ozzie Opporta ......... PMD530520 12/01/2026 .........................................................-..,.................................................................................................................... ---------------------- ------------- Michael Sao-Pagan PMD515180 12/01/2026 ---------------- .................................=, .................................................................................................................................... ................. Roxana Perez PMD530680 12/01/2026 ................................................................................................... ------------------------ --------------------------------------------------------------- ------- Oscar Pizon PMD514901 12/01/2026 Adam Schusshe'im' ------------------ PMD515180 12/01/2026 ................... .............................................. ............................................................................................................................................................................................................................................................................................................................... Luis Tuero PMD532000 12/01/2026 ....................................................................................................................................................................................................... Fernando Flores PMD545446 12/01/2026 -------------------------------------------------- .............................................................................................................................................................. Arley Gonzalez PMD523011 12/01/2026 ........... —-------------------------------------------- ------------ ------------------------------------------------ -'7- 7...................................... ......................................................................----............................................. ............ .......................- .........................-................... ...............I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I................-........................................................................I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.I.............. ..................... ................... ........................................ -------------------....................................... ............................................. --------------- —-- ----------- ......................... 11agc 3 of'7 PERSONNEL—EMERGENCY EDICAL TECHNICIANS NAME EMT CERTIFICATION Middle CERTIFICATION# EXPIRATION DATE � First Midd1 . Lawsf SOCIAL � CIJRITY# CER� � n Andres Alvarez _.., EMT583743 12/01/2026 Michael Baez .... ....... EMT534281 12/01/2026 _w..... Gabriel Belgiovine E T582324 1 12/01/206 Jorge Braceras EMT593935 12/01/2026 Rodolfo Cabrera EMT581942 12/01/2026 Frank Dias _...._ ET88402 12/01/2026 Carlos Ferreira E T53281 12/01/2026 Chris Fischman EMT571728 12/01/2026 Nick Garcia .. E T588112 12/01/2026 Joseph Hanna ��EMT537568 12/01/2026 _. .....................w..P w. ___ _____ __.v_m_...ww........._ ......................... _..� Samuel Hutig EMT545732 12/01/2026 _wwwwww w.w............... ...... .... ......._..................... ............._ .. ..._.._.._ .._._...... -- Chris Martinez EMT57425 12/01/2026 Sebastian Morenoy EMT88027 12/01/2026 Christian Rico EMT586627 12/01/2026 Leonardo Rodrigues EMT595813 12/01/2026 Curtis Tucker EMT557593 12/01/2026 Travis Wilson EMT582747 12/01/2026 Charles Berrane EMT58568 1 /01/2026 Daniel Gomez EMT581542 12/01/2026 Melanie Isaza EMT58392 12/01/2026 Christopher Sefcik .. .X.-��.µ.....��...,.,��,.. EMT586003 12/01/2026 Rokaerto� ........... ....... _._. .. -----___. Ycaza EMT58387 12/01/2026. ..... ......... Nee 41 44 7 PERSONNEL DRIVERS ----------- _....... _.�..._._.. ._ ....... ..._ _............ ......,_................................._............,.... ._..............�.._......_...,. . "1 ._ _ . .STA....................... .............. .�..... NAME First,Middle,Last SOCIAL DATE OF DRIVER LICENSE# OF EXPIRATION SECURITY# BIRTH ISSUANCE DATE _....Andrew Bohl Florida 12/09f2029 ...................:..... ............................_.... Bradley Galvin _w._.w.w Florida 07/01/2028 Carlos Ferreira Florida 09f 1 0f2028 Christian Rico Florida 12/08/2027 ............. ......... ......... ........... Christopher Fischman w. ._w..w Florida 02/15/2033 ._w Enrique Abilieira u. w-.w.Mw-.u. Florida 08/19/2026 ... Gabriel elgiovine w..". w.w._w._.w.w... .ry Florida 01/26/2033 .........................._ Giuliano Gonzalez Florida 09/30/2028 Joseph Hanna w Florida 01/27/2033 Marcos Gonzales Florida 06/15/2029 Michael Baez .. . . Florida 04/01/2033 u.. Samuel Huttig w.Mw._w._.._w Florida 07/15/2033 .. .. Thomas Mirabella Florida 07f17f2027 . ..... Travis Wilson " Florida 01f08f2034 Adam Schussheim w.u._w. Florida 10/29/2026 _.mm._.... .....................................w ................,,,,.................................................................:..M . . ....._w oxana Perez Florida 07/24/2031 .............................: ......_............. Arley Gonzalez _w. . . .u. Florida 01/22/2033 David Artega Florida 02/15/2031 Fernando Flores Florida 02/13/2028 Pursuant to Section 92.525(2),Fla.Stat.,under penalties of perjury,I declare that I have read the foregoing list of named drivers,and I hereby certify that the above-named drivers, and any named on a separate sheet, meet all of the requirements of Section 401.281, Fla.Stat.,and Rule 64,14.013, F.A.C.,and that the facts stated herein are -------,............,....a................................................... _.........,a....a Chairman ..... . VEHICLES For Each Veh heet If NecessaLyl ---------- DOH Specify. LICENSE VEHICLE ALS or BLS; VEHICLE TYPE MODEL YEAR MILEAGE CHASSIS# TAG PERMIT# Transport or NUMBER Blatt-'Trans ENFORCER 2018 67711 4EWAAA881-11 00 1128 TE6997 0026266 NON-TRAM'SPORT ALS E-ONE ENFORCER 2019 37477 4EN6AAA8XK1002031 TA3546 0026265 NON-TRANSPORT ALS Type Ford 2022 39642 1FDUD,9GT8NDA06671 TD5409 24400 Transport-ALS ................... -----———-------- Type l Ford 2022 42611 1FDUF5GI-6NDA06247 TD4508 24401 Transport-ALS ------ - ------- ------- ------------------------------- 7:Type III Chevy 2015 104223 1GB6G5CL8F1157923 TE7171 24113 Transport-ALS ----------- —---------— Type III Chevyv 2016 132660 1GB6GUCL2G1141812 TA1874 19546 Transport-ALS ------- ——--------——------------ ----------- ---------- ---------- ----------- —---------- --------- ................... ........... ................................. ............ ...................... 1, THE UNDERSIGNED REPRESENTATIVE OFTHE ABOVE-NAMED SERVICE, AM SOMEONE WHO POSSESSES THE REQUISITE LEGAL AUTHORITY TO SUBMIT THIS APPLICATION ON BEHALF OF THE SERVICE, AND I DO HEREBY ATTEST THAT THE SERVICE MEETS ALL OF THE REQUIREMENTS FOR OPERATION OF AN EMERGENCY MEDICAL SERVICES PROVIDER IN MONROE COUNTY AND THE STATE OF FLORIDA. I FURTHER ATTEST THAT ALL, OF THE INFORMATION CONTAINED IN TEAS APPLICATION,AND ALL INFORMATION PROVIDED IN ANY SEPARATE SHEET'S ATTACHED HERETO,IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. or . ............... I.. ................ Signa- T A 4? NT NY LLEN Pri t anie CHAIRMAN STATE OF FLORIDA Title of authorized representative of company COUNTY OF ,j applicable The foregoing document was acknowledged before me, by means of [N physical presence or online notarization, this day of N"? ""_'_'_'20 Z(o, by as [Person's Title] of T [ENTITY], a Florida (Not for , profit / For profit) Corporation / LLC, if applicable. Why ) pe0aw Ily known to me or has produced a driver's license as identification, V�el LA Qkc� V:I"* 14 at% Dit-rou CC Print/Stamp Commissioned Name of Notary: SIGNATURE OF NOTARY Name of Notary: State of Florida RMWOL GRECO Pag,6 of 7 NOtaq PoblIC-State of Florida I C=mksIon#HW7P548 My Comm.E*ros Oct is,2029 d#4 through National"Ary Asm ----------- FOR USE BY MONROE COUNTY OFFICE STAFF ONLY : The Monroe County Fire Rescue Department shall perform a life safety inspection of each business location placed on the application prior to the beginning of operations within Monroe County, The COPCN applicant is required to maintain a business location in Monroe County throughout the to the COPCN remains active. The COPCN applicant/awardee is required to notify the Administrator of any change to the business location,any changes in the fee schedule,and notify the Administrator least 30 days prior to termination or reduction of any service, or be subject to cancellation of the issued COPCN. Notes of Inspection for each facility listed in Section 6 of the application. Location#I: Date Inspection occurred Inspection Results Location#2: Date Inspection occurred Inspection Results [Add additional sheets for additional locations.] Y 7 Key Larger Fire Fescue & EMS District Serving the Comn-wity of Key Largo, PaIda Sta ion : t It:apt Dr.,Key t,r,�u° �o, W Il,a;�)"�°� ro Station 2 22tt Reef Dr., FL.33037 ` Adrrrirnistirafi ��, � �� ��m�� frtur,r���r;�wttba�i��dt�R tt�tt�:V � ��r.���irr�or �t'ur�rr�� aic..t"V.gc)v March 31, 2025 Monroe County Board of County Commissioners 1100 Simonton Street Key West, Florida 33040 Monroe County Fire Rescue 0 53rd Street ocean Marathon, Florida 33050 Geographical Area To whom it may concern; This letter serves to formally clarify the geographic area or zones that our District serves. The areas served byte District is as follows: Ch. 2005-329 LAWS OF FLORIDA Ch. 2005-329 s t i cl e it i the district arethe following de- scribedlands on the islano e ar i ro o it: l of Cross e t t of e a th Ba Harbor Drive ando star e to t o so our ?!mmmm ri t-o - .Y,., pnfy loads 995 and 9U5 A. 2 i rdo District nager Key Largo Fire Rescue & EMS District (3 ) 41-270 wlom bard o keylargofirerescue-fl.gov )KO Lars jl'ire ttao��r:ue yet E.,MS District - t"�°r:,orr�r�rrurt�ted to t�::�Ae�,i eryas rrr Fire,t�oMsr��ue&t.�rroo�rite�nc ecfirra�i Serllr�°��s Key srgo Fire RescueDistrict Sprving Ihe t",ornmu pity of Ke L w�igo, Florida Stafion 244 1 East Dr., Key Largo, FL 33037 - Staflrun'25 220 Reef Dr.„ Ft 33037 Adrruuristt"Live Officez (305)4 'i•.i�7700 W www.key� urge ,,)tarerr su„uuu,•ti.go)o March 31, 2026 Monroe County Board of County Commissioners 110 Simonton Street Key West, Florida 33040 Monroe County Fire Rescue 490 63rd Street Ocean Marathon, Florida 3050 FCC License Status and Radio Communications Operations To whom it may concern: This letter serves to formally clarify the radio communications status of the Key Largo Fire Department. The Key Largo Fire Rescue & EMS District does not hold any Federal Communications Commission (FCC) licenses. Our agency operates exclusively within the Monroe County 911 communications system as the designated responding agency for fire rescue and emergency medical services in the Key Largo service area. All radio communications utilized by our personnel are conducted through infrastructure licensed to and maintained by Monroe County. This arrangement ensures seamless coordination with Monroe County 911 dispatch and interoperability with other emergency response agencies throughout the county. Should you require any additional information regarding our communications operations or designated response area, please do not hesitate to contact me. III istric Manager Key Largo Fire Rescue & EMS District (305) 51-2 00 wlombardo@keylargofirerescue-fl.gov Key Largo Frre Rescue&EMS District . Committed to Excellence in Fire, Rescue Frroruago)uTc)r Meech rut,!`ervdces Page 1 of I AGREEMENT BETWEEN KEY LARGO FIRE RESCUE AND EMERGENCY MEDICAL SERVICES DISTRICT AND KEY LARGO VOLUNTEER AMBULANCE CORPS,INC. This AGREEMENT made this 9`h day of March,2026,by and between the Key Largo Fire Rescue and Emergency Medical Services District("DISTRICT")and Key Largo Volunteer Ambulance Corps,Inc. ("AMBULANCE CORPS"), RECITALS WHEREAS,the DISTRICT has lawful authority granted to it in Chapter 2005 329,organized and existing under Chapters 189 and 191,Laws of Florida,to provide advanced life support ambulance services and control of hazardous situations(hereinafter called "Ambulance Services"), either directly or by contract with the Key Largo Volunteer Ambulance, Corps., Inc.,pursuant to Chapter 2005-329, Laws of Florida,primarily for the benefit of the taxpayers residing within said DISTRICT;and WHEREAS,the DISTRICT is charged with responsibility for provision of Emergency Medical Services(Basic and Advanced Life Support primary response),and WHEREAS, the DISTRICT and the AMBULANCE CORPS desire to provide basic and advanced life support ambulance services from premises in Key Largo, to serve the area generally described as being from South Bay Harbor Drive and Lobster Lane(Approx. MM#95) North on US[ to the Dade County Line and North on S.R.905 to the intersection of S.R. 905 and Card Sound Road, Monroe County,Florida(hereafter the "response area");and WHEREAS, within the said DISTRICT,the AMBULANCE CORPS has been organized as a non-profit corporation for the purpose of providing Ambulance Services within the DISTRICT; and WHEREAS,such Ambulance Services constitute essential services necessary to the health and safety of the residents and visitors of the KLFR& EMS District;and WHEREAS, the parties desire to enter into an AGREEMENT for the reimbursement of expenses relating to the services provided by the AMBULANCE CORPS and other related matters, and WHEREAS, the DISTRICT and the AMBULANCE CORPS recognize that volunteers serve the community without promise,expectation,or receipt of compensation and that the panics wish to thank them for performing this traditional government function;and WHEREAS, the parries desire to enter into an AGREEMENT for the reimbursement of expenses relating to the services provided by the AMBULANCE CORPS,and other related matters; NOW, THEREFORE, in consideration of the covenants contained herein and other good and valuable considerations,the parties agree as follows: 1, TERM OF AGREEMENT: The term of this AGREEMENT shall commence on March 9, 2026, and shall terminate on July 1, 2026, unless terminated earlier in accordance with the terms and conditions hereafter provided. The parties may mutually agree in writing to extend the term of this AGREEMENT 1 on a month-to-month basis. Unless otherwise terminated or modified as provided herein, this AGREEMENT shall not automatically renew. 2. TERMINATION• The DISTRICT may terminate this AGREEMENT at any time during its term if the AMBULANCE CORPS defaults under any provisions specified herein, or violates any standard specified in this AGREEMENT, or violates any other law, regulation or standard applicable to the famishing of Ambulance Services in Monroe County, In such event the DISTRICT shall furnish the AMBULANCE CORPS written notice of any such default or violation and the AMBULANCE CORPS shall have thirty(30) days from receipt of said notice to correct or remedy such default or violation.However,if correction of the default or violation requires permitting or outside authorization from any State or Local Governmental Agency, the AMBULANCE CORPS shall apply for the required permit or authorization within thirty(30)days and the time period for correction of the violation shall commence on the date that the AMBULANCE CORPS received the necessary permit or authorization.Additionally,if any act of nature should occur during the period of time within the time the AMBULANCE CORPS was to correct the default or violation,the period of time within which correction is to occur shall be extended a reasonable amount of time,using the reasonable person standard for determination of what is a reasonable time. If such violation is not corrected or such default is not remedied, within the aforesaid time, or is of such nature that it cannot be corrected or remedied, this AGREEMENT shall be considered void.This AGREEMENT may be terminated unilaterally for the refusal of the AMBULANCE CORPS to allow public access to all documents, papers, letters, or other material, as allowed or required by law, excluding any and all material protected under the Health Information Portability and Accountability Act (HIPAA), made or received by the contractor in conjunction with duties performed under this AGREEMENT, after 30 days written notice of request and opportunity to provide same by the DISTRICT, unless such records are exempt from public access under F.S. 119.07 and 24(a) of Art. I of the State Constitution. This AGREEMENT may be terminated by the DISTRICT for any reason upon at least sixty(60)days written notice to the AMBULANCE CORPS at the addresses set forth below. If said AGREEMENT should be terminated as provided in this paragraph of the Contract,the DISTRICT will be relieved of all obligations under said contract unless otherwise provided herein. Upon termination of the AGREEMENT, the DISTRICT will only be required to pay that amount of the contract actually performed to the date of termination with no payment due for unperformed work or lost profits, 3. EFFECT OF DISTRICT POLICIES: The AMBULANCE CORPS shall not create or enforce internal policies that conflict with any policies of the District Personnel Manual,as amended.Should such a conflict arise,the policies of the District's Personnel Manual shall control, unless otherwise provided by law or by the District's Personnel Manual. The DISTRICT shall solicit comments from the AMBULANCE CORPS regarding any proposed amendments to the Personnel Manual the DISTRICT deems might materially affect the AMBULANCE CORPS. 4. RESPONSE AREA AND MUTUAL AID: 2 The AMBULANCE CORPS shall be the exclusive provider of Ambulance Services (basic and advanced life support) within their response area. The AMBULANCE CORPS shall also provide mutual aid response to any other emergency service upon request and/or in accordance with existing protocol,applicable laws,rules, regulations,and standards. S. AMBULANCE CORPS ORGANIZATION AND BY-LAWS., The AMBULANCE CORPS shall revisit its corporate roles,distribution of authority,and executive or administrative oversight and shall create an organizational structure that provides for checks and balances between executiveiadministrative oversight and operational functions.The structure shall also reflect the efficient assignment of responsibility and authority, allowing the AMBULANCE CORPS to accomplish effectiveness by maximizing distribution of workload and allocate resources equitably and with emphasis on safety. The AMBULANCE CORPS' Board shall provide to the DISTRICT an organizational plan of the AMBULANCE CORPS and shall review the structure as needed due to internal restructuring. If the AMBULANCE CORPS effects revisions to the organizational plan the AMBULANCE CORPS shall notify the DISTRICT clerk and present the revised plan to the DISTRICT upon request.To the extent the DISTRICT board provides comments or advice on the organizational plan, the AMBULANCE CORPS shall give significant weight and consideration to the DISTRICT'S comments and advice.No revisions to the organizational plan that would have a significant fiscal impact on the DISTRICT shall be approved by the AMBULANCE CORPS without first obtaining DISTRICT approval. The plan shall include an organizational chart, indicating any subordinate(s) or supervisor(s)of each position. The chart shall be accompanied by thorough job descriptions for each position. The job descriptions shall clearly and adequately describe the primary functions and activities, critical tasks, levels of supervision,and accountability,as well as reasonable qualifications of each class or position within the AMBULANCE CORPS, All persons working under accepted job descriptions will receive a performance appraisal,as outlined in AMBULANCE CORPS'Policies annually,without exception. The plan shall also contain eligibility lists for required positions based on merit, experience, and qualifications. Selections shall be made based on merit and qualification and should include practice guidelines for a Drug Free Workplace and a Smoke Free Workplace. The AMBULANCE CORPS shall maintain an active corporation status with the State of Florida,and shall produce evidence to the DISTRICT confirming its corporate standing under Florida law upon request. The AMBULANCE CORPS' membership shall review and/or revise its by-laws as needed and shall present one dated,typed copy of its by-laws to the DISTRICT within thirty(30)days of such revisions being adopted by the AMBULANCE CORPS. The AMBULANCE CORPS shall confirm the enabling documents providing for the appointment of corporate officers.The AMBULANCE CORPS shall provide the DISTRICT a dated,typed copy of its updated by-laws upon any update thereof Notwithstanding the requirements of this section, the AMBULANCE CORPS shall conduct a job analysis of all Job Classifications to confirm the incumbents are working within their job descriptions and expectations. 6. MISSION, VISION, VALUES-STRATEGIC PLANNING OUTCOMES, GOALS, AND OBJECTIVES: 3 The AMBULANCE CORPS shall, with the DISTRICT, develop a Strategic Plan. The purpose of the Plan shall be to evaluate service improvement opportunities,develop goals for future service delivery, and to establish critical tasks and timelines to accomplish those goals.The Plan shall contain a critical tasking analysis for common community risk types and ensure that the number of personnel dispatched to calls equals the identified critical tasks. 7. FOUNDATIONAL POLICY OF AMBULANCE CORPS: The AMBULANCE CORPS shall create clear policies that lay the foundation for effective organizational culture. The policies shall take the form of Administrative Rules and. Standard Operating Guidelines("SOGs").The AMBULANCE CORPS shall within thirty(30)days promulgate its initial Administrative Rules and SOGs and provide a hardcopy of the same to the DISTRICT. The AMBULANCE CORPS shall thereafter provide the DISTRICT an updated copy of the AMBULANCE CORPS'Administrative Rules and SOGs upon any modification or update thereof 7.1. Administrative Rules: The AMBULANCE CORPS' Board shall adopt or approve, with a review by the DISTRICT, Administrative Rules that personnel in the AMBULANCE CORPS are required to comply with at all times.The AMBULANCE CORPS shall present such proposed rules to the DISTRICT on a semi-annual basis, via written submission of all revised rules to the DISTRICT Clerk and report to the DISTRICT board at a regularly scheduled meeting. The AMBULANCE CORPS shall additionally make such proposed rules available to the DISTRICT upon the request of any sitting District Commissioner. The AMBULANCE CORPS shall give significant weight and consideration to the DISTRICT'S advice and comments and shall revise previously enacted Administrative Rules to the extent such revisions are warranted following advice and comment from the DISTRICT board. The Administrative Rules shall govern all members of AMBULANCE CORPS,whether paid,volunteer,or civilian,and including the Chief. The AMBULANCE CORPS' Board may delegate authority to the Chief to enforce Administrative Rules on AMBULANCE CORPS personnel. Where rules and policies,by their nature, require different application or provisions for different classifications of members, these differences shall be clearly indicated and explained in writing. The Administrative Rules shall contain sections which address: • Public records access and retention in accordance with the DISTRICTs Record Retention Schedule; • Contracting and purchasing authority; • Safety and loss prevention; • Personal Protective Equipment program; • I-Ia7ard communication program; • Harassment and discrimination; • Personnel appointment and promotion; • Disciplinary and grievance procedures; • Uniforms and personal appearance;and • Other personnel management issues, 7.2. Standard Operating Guidelines("SOGs"): 4 The AMBULANCE CORPS shall develop and,under the direction of the EMS Chief, enforce, SOGs. SOGs shall contain street-level operational standards of practice for personnel of the AMBULANCE CORPS.The AMBULANCE CORPS shall present such proposed rules to the DISTRICT on a semi-annual basis, via written submission of all revised rules to the DISTRICT Clerk and report to the DISTRICT board at a regularly scheduled meeting. The AMBULANCE CORPS shall additionally make such proposed SOG's available to the DISTRICT upon the request of any sitting District Commissioner.The AMBULANCE CORPS shall give significant weight and consideration to the DISTRICT'S advice and comments and shall revise previously enacted SOG's to the extent such revisions are warranted following advice and comment from the DISTRICT hoard.Unlike Administrative Rules,variances shall be allowed in unique or unusual circumstances where strict application of the SOG would be less effective. The AMBULANCE CORPS shall develop a program for regular,systematic updating of SOGs to ensure they remain current,practical, and relevant. 73. Availability of Rules and SOGs: The AMBULANCE CORPS shall make all Administrative Rules and SOGs readily available to all members of the AMBULANCE CORPS and shall furnish each member with his/her copy. In doing so, the AMBULANCE CORPS shall ensure that no confusion exists as to which Rules or SOGs are currently in force. Additionally, the AMBULANCE CORPS shall develop a written procedure to ensure and to govern the distribution of all new Rules,SOGs,and other memos to members of the AMBULANCE CORPS. The written procedure shall include a method to verify distribution. 8. INCIDENT REPORTS: Within twenty-four (24) hours of the occurrence of the following types of incidents, the AMBULANCE CORPS shall provide a written report to the DISTRICT clerk and Board Chair: • Any incident involving damage to property estimated to be equal to or greater than$5,000.00; • Any incident involving the hospitalization or death of any AMBULANCE CORPS personnel; Any incident likely to result in litigation against the AMBULANCE CORPS, its personnel, or the DISTRICT; Within thirty (30) days of the occurrence of(or at the next regularly scheduled meeting of the DISTRICT Board) any incident response which the Chief determines to have an inordinately or unusually long response time, the AMBULANCE CORPS shall provide a written report to the DISTRICT clerk and Board Chair: 9. PERSONNEL• The AMBULANCE CORPS shall maintain volunteer and/or paid personnel so as to make sure a complement of personnel are available to provide Ambulance Services on a twenty-four(24)hour basis to the DISTRICT. In accordance with the current practices of the AMBULANCE CORPS, scheduling and assignment of personnel shall be arranged so as to ensure that sufficient staffing for at least two(2) advanced life support permitted ambulances are available at all times.The AMBULANCE CORPS shall ensure that at all times sufficient personnel are scheduled to comply with the requirements of Florida Statute Section 401.25(7),as may be amended from time to time,The backup shall perform to the ninety- 5 fifth percentile(95%)of availability. Scheduling and assignment of personnel shall be arranged so as to utilize volunteer personnel to the maximum extent possible. Only in the event the AMBULANCE CORPS deems it necessary to maintain coverage or to meet administrative needs and obtains permission from the DISTRICT shall paid part-time or full-time employees be employed in addition to those approved in the budget. 10. MINIMUM STANDARD AND TRAINING: The AMBULANCE CORPS shall require that all volunteer personnel engaged in Ambulance Services comply with the minimum training,education,and performance requirements of the State of Florida for Ambulance Corps personnel. On the date of hire all AMBULANCE CORPS personnel shall meet the minimum state certification and eligibility standards required for that position The AMBULANCE CORPS shall establish and maintain training and continuing education program designed to maintain a high degree of competency and skill on the part of all volunteer and/or paid Ambulance Corps personnel.The AMBULANCE CORPS shall also facilitate and encourage attendance by all volunteer and/or paid Ambulance Corps personnel at proficiency training programs provided by the AMBULANCE CORPS or other agency deemed appropriate. The AMBULANCE CORPS shall maintain current and accurate training and proficiency records for all volunteer and/or paid Ambulance Corps personnel evidencing compliance with this provision. The AMBULANCE CORPS shall appoint an AMBULANCE CORPS training officer. The AMBULANCE CORPS shall develop and implement a comprehensive AMBULANCE CORPS Training Plan including minimum training and certification requirements for members and employees. The Plan shall provide for regular training of, and implement a comprehensive, structured, skills maintenance training program for all of AMBULANCE CORPS' officers and employees. The AMBULANCE CORPS shall design and implement a pre-promotion training program. The AMBULANCE CORPS shall require lesson plans for all training sessions and immediately implement the requirement for an assigned safety officer in attendance at all manipulative training sessions, as applicable to the specific exercise. The AMBULANCE CORPS shall continue multi-company and multi-agency drills and training as frequently as is required by Florida law to enhance mutual aid operations and improve relationships and planning efforts. The AMBULANCE CORPS shall develop and implement a plan to evaluate member/employee technical and manipulative skills on a regular basis. The AMBULANCE CORPS shall develop and implement a formal performance evaluation system for all members and employees. The AMBULANCE CORPS shall conduct an ongoing analysis of on-scene staffing strength to confirm the AMBULANCE CORPS's standard of coverage, The AMBULANCE CORPS shall continue the centralized, consistent, training data collection and shall maintain up-to-date records on training data collection and reporting under direct oversight of the training officer.The AMBULANCE CORPS shall establish a training reference,equipment and props inventory and member checkout procedure. The AMBULANCE CORPS shall consider implementing a formal competency-based approach to the AMBULANCE CORPS'training program. On at least a quarterly basis,the AMBULANCE CORPS shall provide to the DTSTRTCT at a regularly scheduled DISTRICT Board meeting a written report detailing AMBULANCE CORPS compliance with this paragraph, specifically with regard to the adequacy of on-scene staffing. 6 -11. COMPLIANCE: At all times in the performance of its duties under this AGREEMENT, the AMBULANCE CORPS shall comply with all applicable State and Federal regulations,and all applicable local laws,ordinances and procedures pertaining to the operation of equipment, direction of personnel, transportation of patients,and medical care of persons. 12. DISCIPLINE• The AMBULANCE CORPS has previously adopted a clearly identifiable, formal, progressive disciplinary process with an appropriate appeal procedure. Within thirty (30) days of the adoption of revisions to this disciplinary procedure, the AMBULANCE CORPS shall notify the DISTRICT clerk and shall present such proposed modifications to the DISTRICT upon request. The AMBULANCE CORPS shall give significant weight and consideration to the DISTRICT's advice and comments and shall revise the previously adopted disciplinary procedure to the extent such revisions are warranted following advice and comment from the DISTRICT board. 13. PAID EMPLOYEES: Subject to the provisions of Section Nine(9),the AMBULANCE CORPS may employ such part-time or full-time employees as it determines is necessary to carry out its Ambulance Services. Part-time or full-time employees of the AMBULANCE CORPS shall be compensated by the DISTRICT at a rate commensurate with that of other similarly trained and experienced personnel employed within Monroe County. 14. SELECTION OF NEW MEMBERSHIP: The AMBULANCE CORPS shall make membership selections based on merit and qualifications. The AMBULANCE CORPS shall maintain and update a list of active AMBULANCE CORPS membership. 15. HARASSMENT POLICY: The AMBULANCE CORPS shall establish a disciplinary policy and procedure for reporting harassment that conforms to State and Federal law,including Title VII of the Civil Rights Act of 1964, the Age Discrimination in Employment Act, and the Americans with Disabilities Act. The AMBULANCE CORPS shall instruct employees/volunteers to report any complaints in accordance with the DISTRICT'S harassment policy. 16. EQUAL EMPLOYMENT OPPORTUNITIES AND HARASSMENT: The AMBULANCE CORPS must comply with all State and Federal and local laws relating to nondiscrimination, including, but not limited to: (a) Title VI of the Civil Rights Act of 1964(P.L. 88- 352) which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S,C. Sections 1681-1683, and 16851686), which prohibits discrimination on the basis of sex;(c)Section 504 of the Rehabilitation Act of 1973,as amended (29 U.S.C. Section 794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975,as amended(42 U.S.C.Sections 6101-6107),which prohibits discrimination 7 on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972(P.L. 92-255),as amended, relating to nondiscrimination on the basis of drug abuse; (1) the Comprehensive Alcohol Abuse and Alcoholism Prevention,Treatment and Rehabilitation Act of 1970(P.L. 91-616),as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism;(g)Sections 523 and 527 of the Public Health Service Act of 1912(42 U.S.C. 290-dd-3 and 290-ee-3),as amended,relating to confidentiality of alcohol and drug abuse patient records; (h)Title VIII of the Civil Rights Acts of 1968 (42 U.S.C. Section 3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (i)any other nondiscrimination provisions in the specific statutes) under which application for Federal assistance is being made;and 0)the requirements of any other nondiscrimination statute(s) which may apply to the application. 17. DRUG-FREE WORKPLACE: The AMBULANCE CORPS shall comply with the requirements of the Drug-Free Workplace Act of 1988,and implemented at 44 C.F.R. Part 17,Subpart F. 18. FREEDOM FROM POLITICAL COERCION: No paid AMBULANCE CORPS employee who exercises functions in connection with an activity financed in whole or in part by loans or grants made by the United States or a Federal agency shall(1) use his or her official authority or influence for the purpose of interfering with or affecting the result of an election or a nomination for office,(2)directly or indirectly coerce,command, or advise a State or local officer or employee to pay, tend, or contribute anything of value to a party, committee, organization, agency, or person for political purposes,provided,however,that an individual may be a candidate for elective office. Provided, further, that an AMBULANCE CORPS officer or employee may be a candidate for elective office in an election as provided by 5 U.S.C. 1502(a)(3),as amended. This provision does not in any way limit the rights of an AMBULANCE CORPS officer or employee to vote as he or she chooses and to express his or her opinions on political subjects and candidates. 19. POLITICAL ACTIVITIES: In consultation with the DISTRICT,the AMBULANCE CORPS shall adopt a"Political Activity Policy" which requires its personnel to make reasonably clear that any personal political opinion expressed in a public forum is their own and not attributable to the AMBULANCE CORPS. if the AMBULANCE CORPS should revise,suspend,or revoke the Political Activity Policy,the AMBULANCE CORPS shall notify the DISTRICT Clerk within thirty(30)days of such decision. To the "tent that the DISTRICT board provides comments or advice on the revision, suspension, or revocation of the Political Activity Policy,the AMBULANCE CORPS shall give significant weight and consideration to the DISTRICT'S comments and advice. 20. MAINTENANCE OF AMBULANCE CORPS HISTORY: The AMBULANCE CORPS shall clearly assign responsibility for maintaining a Faccbook or other social media page or file containing items of historical significance, including pictures, newspaper articles,etc. Additionally,the AMBULANCE CORPS shall prepare an annual report to be presented to the DISTRICT on August Ist of each year. The annual report shall also be distributed to the community and made available on the AMBULANCE CORPS' website. At minimum, each annual report shall include: 8 • Brief history of the AMBULANCE CORPS; • Summary of events and activities during the report year; • Description of major incidents handled by the AMBULANCE CORPS; • Descriptions of new or improved services and programs; • List of people who served with the AMBULANCE CORPS during the year; • Awards received by the AMBULANCE CORPS or individuals; • Financial summary including revenues and expenditures,grants,etc.; and • Statistical analysis, with trends,of key community service level indicators. 21. OVERALL ALERTNESS, INCLUDING VOLUNTEER ALERTNESS: The AMBULANCE CORPS shall establish a duty officer system, including using volunteer officers, to ensure that an individual designated for incident command will be available 24 hours a day. 22. PUBLIC COMPLAINTS: The AMBULANCE CORPS shall establish a formal procedure for handling complaints from the public. The AMBULANCE CORPS shall immediately provide the DISTRICT with a written description of any written complaints received from the public within twenty-four (24) hours of receiving such complaints, or as soon as is practicable thereafter. Notwithstanding the foregoing,the AMBULANCE CORPS shall report any complaint, written or otherwise, that concerns any matter specified in Section 8 of this Agreement. Subsequent remedial actions relating to the complaint shall likewise be immediately provided to the DISTRICT. 23. VEHI!CLE, EQUIPMENT AND FACILITIES: The DISTRICT shall provide to the AMBULANCE CORPS sufficient vehicles, equipment, and facilities to enable the AMBULANCE CORPS to carry out its Ambulance Services with the DISTRICT as provided for in the Monroe County Year 2030 Comprehensive Plan or any other plans or documents relating to the Ambulance Services that are adopted by Monroe County.The DISTRICT shall be responsible for the general maintenance and repair of the vehicles, equipment, and facilities owned and/or leased by the DISTRICT as well as required periodic testing and certification of all equipment, as necessary, used by the AMBULANCE CORPS in connection with its Ambulance Services. The AMBULANCE CORPS shall be responsible for proper control of all assigned vehicles, equipment, and facilities and shall develop and implement an aggressive driver/operator annual training program and checkout program for all AMBULANCE CORPS vehicles.The AMBULANCE CORPS shall be responsible for notifying the Chair of the DISTRICT of needed repairs for vehicles, equipment, and facilities and shall assist in arrangements for said repairs.The DISTRICT shall have the right to inspect the vehicles,equipment,or facilities at any time, 24. PROPERTY CONTROL: The AMBULANCE CORPS shall provide a system for property control of the vehicles and equipment owned and/or leased by the DISTRICT and used by the AMBULANCE CORPS to provide Ambulance Services. The AMBULANCE CORPS shall assist in the performance of the annual inventory of the vehicles and equipment. 25. SUBCONTRACTS: 9 The AMBULANCE CORPS may subcontract its services when the DISTRICT determines such subcontracts are beneficial to the AMBULANCE CORPS,the DISTRICT,and/or the community.The AMBULANCE CORPS may utilize equipment and vehicles owned and/or leased by the DISTRICT in conjunction with the above subcontractors provided that no reduction in the level of services to their respective service area results from the utilization of said equipment for sub-contracted services.Notice of intent to subcontract,when DISTRICT equipment and/or vehicles will be used,must be provided to the DISTRICT at least thirty (30) days prior to execution of said subcontract in order to allow for proper review and comment concerning same and to allow the DISTRICT to decide whether to approve or disapprove of the same.A signed copy of all subcontracts shall be provided to the DISTRICT. The AMBULANCE CORPS shall comply with all regulations promulgated pursuant to 40 U.S.C. §3145 relating to contractors' and subcontractors! furnishing statements on the wages paid each employee during the previous pay period. No AMBULANCE CORPS employee shall receive kickbacks from public works employees,as provided by 18 U.S.C. §874.The AMBULANCE CORPS shall comply with all applicable provisions of 40 USC §§ 3701-3708. 26. BUDGET REQUEST AND AGREEMENT: As requested by the DISTRICT as part of its annual budget adoption process, the AMBULANCE CORPS shall submit a proposed budget appropriations request, by line item account in a format specified by the DISTRICT, for the forthcoming fiscal year. The AMBULANCE CORPS budget request should include personnel, supplies, materials, utilities and other internal costs, charges, or expenditures necessary or incidental to the operation of the Ambulance Services,including a reasonable stipend for professional services contemplated within this AGREEMENT, which have not been previously specified herein as being provided by the DISTRICT.This budget request shall also include, based on statistical analysis of the usage,mileage,serviceability,and/or level of service,a Five year plan for refurbishment, replacement, or additional apparatus to be provided to the AMBULANCE CORPS by the DISTRICT. Once formally adopted by the DISTRICT prior to October I"of each year,the budget establishes an initial limitation on expenditures by the AMBULANCE CORPS by line item total. The DISTRICT and AMBULANCE CORPS acknowledge that the annual budget may be amended from time to time to reflect increases in actual expenses,and to reflect the increase or decrease in the level of services provided to the District due to hurricanes,other emergencies or requirements for additional staffing. If subsequent to the passage and adoption of the budget,the AMBULANCE CORPS determines that a line item will exceed its original allocation,the AMBULANCE CORPS shall prepare for the DISTRICT's approval a budget amendment request to reflect its additional funding requirements. The AMBULANCE CORPS is not authorized to receive payment in excess of the budgeted line item amounts until the DISTRICT approves such on amendment. The AMBULANCE CORPS may, however, make budget transfers which increase or decrease budgeted line item amounts without DISTRICT approval,provided that such line item changes do not require an increase to the adopted total amount of the AMBULANCE CORPS budget and that such transfer is in accordance with the District's Budget Transfer Policy. Budget line items for capital expenditures and those line items which include personnel and payroll related costs may not be modified by the AMBULANCE CORPS without DISTRICT Board approval. 27. CONTRACT PAYMENTS: 10 The AMBULANCE CORPS shall receive funding for budgeted expenditures incurred in the performance of this CONTRACT by the following methods: 27.1 Advances: The DISTRICT shall retain the option to provide the AMBULANCE CORPS with advance funding for minor recurring expenditures.If such advance payments are made the AMBULANCE CORPS will provide the DISTRICT with monthly financial reports, by the 15" day of each month for the prior month in a format deemed acceptable by the DISTRICT, which show all costs incurred by the AMBULANCE CORPS against this advance. At the end of each fiscal year, incurred costs will be reconciled with total advance payments made by the DISTRICT, The DISTRICT'S external auditors will determine the final balance. If incurred costs exceed total payments,the DISTRICT will reimburse the AMBULANCE CORPS for the excess costs, provided that such reimbursement does not exceed the total adopted budget for the AMBULANCE CORPS. If total payments exceed incurred costs, the AMBULANCE CORPS will reimburse the DISTRICT for the excess payment amount. 27.2 Direct Payment: The DISTRICT can provide for direct payment of any expenses of the AMBULANCE CORPS which are part of the approved budget. If desired by the AMBULANCE CORPS,the DISTRICT will provide for direct payment of payroll prepared by a third party payroll service through withdrawal from a DISTRICT account. Direct payment for other expenses will be made by the DISTRICT based on the AMBULANCE CORPS' submittal of purchase orders and/or check requests in accordance with the DISTRICT's adopted Purchasing Policies and Procedures or Travel Authorization and Expense Policy as may be amended by the DISTRICT from time to time. 27.3 Reimbursement; In the event thatan expenditure which is part of the adopted budget must be incurred by the AMBULANCE CORPS rather than paid directly by the DISTRICT,the AMBULANCE CORPS can request reimbursement from the DISTRICT's funds by submitting a check request in accordance with the DISTRICT'S adopted Purchasing Policies and Procedures,The DISTRICT will not reimburse the AMBULANCE CORPS for capital expenditures that were incurred prior to execution of an approved purchase order or contract in accordance with the DISTRICT's purchasing policies. In no event shall the DES IRICT reimburse the AMBULANCE CORPS for expenditures that exceed budgeted line item allocations or that were made in violation of the DISTRICT's Policies and Procedures.Travel expenses must be submitted in accordance with the DISTRICT's adopted Travel Authorization and Expense policy. 28. ANNUAL AUDIT REPORT: The AMBULANCE CORPS shall allow the DISTRICT and its external auditors access to its records related to expenditures under this contract to conduct an annual audit report,in accordance with Florida Statutes.The DISTRICT will be responsible to procure the services of the auditor and the cost of such audit shall be a cost,charge,or expenditure of the DISTRICT. 29. DISTRICT INSURANCE: The DISTRICT shall provide the following insurance coverage on and for the volunteers of the AMBULANCE CORPS: A. Workers Compensation Insurance as required by Florida Statutes Chapter 440, including minimum$1,000,000 Employer's Liability Coverage; B. General Liability Insurance,with minimum limits of$2,000,000;and C. Automobile Liability Insurance with minimum limits of $2,000,000 including Physical Damage Insurance on all vehicles owned or teased by the DISTRICT and used by the AMBULANCE CORPS.The policy shall provide secondary coverage on private vehicles only during such time as they are operated in response to a call,and ending, either at such time as the volunteer returns to his/her home, or to the first location to which a volunteer stops on the way home,after completion of participation in the emergency services that were subject to the call,whichever occurs first. All DISTRICT liability insurance policies shall name the AMBULANCE CORPS as an additional insured. Proof of all insurance in a form acceptable to the AMBULANCE CORPS shall be provided by the DISTRICT upon request. 30. AMBULANCE CORPS INSURANCE: 30.1 Part-Time and Full Time Employees: The AMBULANCE CORPS shall provide the following insurance on all part-time and full-time employees of the AMBULANCE CORPS: A. Workers Compensation Insurance in compliance with Florida Statutes Chapter 440 including minimum$1,000,000 Employees Liability Coverage; B. Unemployment Compensation in compliance with Florida Statutes Chapter 443; C. General Liability Insurance with minimum limits of$2,000,000 combined single limit; D. Disability income insurance for a minimum of three hundred dollars($300.00)weekly upon total disability for the first thirty(30)days and thereafter,in an amount up to six hundred dollars($600.00)weekly,not to exceed the employees net income.Said benefit shall continue until otherwise terminated according to the provisions of the applicable disability policy;and E. Death benefits insurance with a minimum amount of seventy-five thousand ($75,000.00) death/permanent disability benefits for the employee while engaged in the performance of his/her duties. F. Labor and Employment Practices Liability insurance with a minimum limit of one million dollars($1,000.000). 30.2 Volunteers: 12 The AMBULANCE CORPS shall provide the following insurance on all volunteers of the AMBULANCE CORPS: A. Disability income insurance for a minimum of three hundred dollars($300.00)weekly upon total disability for the first thirty(30)days and thereafter,in an amount up to six hundred dollars($600.00)weekly, not to exceed the volunteers'average reimbursement. Said benefit shall continue until otherwise terminated according to the provisions of the applicable disability policy; B. Death benefits insurance with a minimum amount of seventy-five thousand dollars ($75,000.00) death/permanent disability benefit for the employee while engaged in the performance of his/her duties;and C. Workers Compensation insurance as required by Florida Statutes Chapter 440, including minimum $1,000,000 Employer's Liability Coverage. 30.3 Vehicles The AMBULANCE CORPS shall provide the following insurance on all vehicles owned and/or leased by the AMBULANCE CORPS and used in providing Ambulance Services within the DISTRICT: Automobile Liability Insurance with minimum limits of$300,000 combined single limit. All liability policies are to name the DISTRICT as an additional insured,and shall provide for no less than thirty(30)days notice ofcancellation,non-rencwal,or reduction in coverage.Proof of all insurance in a form acceptable to the DISTRICT shall be provided by the AMBULANCE CORPS upon request. 31. PRIVATE VEHICLE INSURANCE: Any and all AMBULANCE CORPS personnel who utilize a private vehicle in the course and scope of their duties shall keep in full force and effect a policy of liability insurance on his/her private vehicle(s) in at least such minimum amounts of coverage as are required under Florida law.Proof of insurance in a form acceptable to the DISTRICT shall be provided by each volunteer and maintained on file in the business office of the AMBULANCE CORPS. The AMBULANCE CORPS shall provide copies of proof of insurance to the DISTRICT upon request. 32. VOLUNTEER PERSONNEL: The DISTRICT shall reimburse the AMBULANCE CORPS for the volunteer personnel in accordance with an annual budget agreed upon by both parties, the failure of which results in the previous year schedule applying. The AMBULANCE CORPS shall have the right to establish its own eligibility requirements for disbursement of reimbursement based on participation in AMBULANCE CORPS activities. DISTRICT funding for the reimbursement of volunteers shall not exceed the budgeted allocation for such reimbursement.Said amounts may be changed or adjusted by approval of the DISTRICT and the AMBULANCE CORPS, during the term of this AGREEMENT without cause to void, cancel, or violate this AGREEMENT. 13 33. MAINTENANCE AND RECORDS CUSTODIAN: The following shall be obligations of the AMBULANCE CORPS: A. Maintaining of detailed, accurate, and current records of all maintenance and repairs performed on all vehicles and equipment used by the AMBULANCE CORPS; B. Ensuring that detailed, accurate, and current records of all required testing and certification of rescue,emergency,and medical equipment testing and certification are maintained by the AMBULANCE CORPS; C. Maintaining of accurate and current records of training, testing,and certification of all volunteer personnel and part-time and full-time employees. D. Keeping an accurate and current inventory of all vehicles and equipment used by the AMBULANCE CORPS; E. Preparing and maintaining complete and accurate records of incident details,such as response times.The AMBULANCE CORPS shall develop a written procedure governing the methods by which to document and record incident details, which procedure shall include a list of required information to be recorded about each incident.The AMBULANCE CORPS shall file with the State of Florida in a timely fashion,an incident report for each response by the AMBULANCE CORPS to all Ambulance Corps personnel rescue,mutual aid,or other miscellaneous calls as required by the State of Florida;and F. Preparing and maintaining complete and accurate personnel records,such as records on employment history,discipline,commendations,work assignments,injuries,exposures, and leave time. The AMBULANCE CORPS, has developed a written procedure for maintaining the preceding records. Within thirty (30) days of a revised records maintenance procedure being adopted,the AMBULANCE CORPS shall notify the DISTRICT clerk and present such procedure to the DISTRICT Board upon request. The AMBULANCE CORPS has formalized its process of responding to public requests for access to records. It shall maintain a current version of this policy and procedure in writing and shall ensure that all legal requirements concerning maintenance of records are met. Within thirty (30) days of a revised records maintenance procedure being adopted, the AMBULANCE CORPS shall notify the DISTRICT clerk and present such procedure to the DISTRICT Board upon request. IF AMBULANCE CORPS HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE AMBULANCE CORPS DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE DISTRICT RECORDS CUSTODIAN, CAROL GRECO, AT (305) 394-1719, !CLFgRK64KLFREMS.ORG 14 The AMBULANCE CORPS shall ensure proper security of its records by using passage and/or container locks with limited access as needed. The AMBULANCE CORPS shall back up important computer files every month. The AMBULANCE CORPS shall establish a written procedure designed to ensure that the AMBULANCE CORPS facilities are adequately locked and secured from unauthorized entry.The AMBULANCE CORPS shall limit public access to its facilities to business areas. 34. 'PUBLIC MEETINGS: The AMBULANCE CORPS shall comply with public notice and Sunshine Law requirement regarding public access to information, as if the AMBULANCE CORPS were a government entity, excluding confidential protected medical information and employee records. Requests for information from the public shall be directed through the District and not directly to the AMBULANCE CORPS. 35. RELATIONSHIP WITH MONROE COUNTY: The AMBULANCE CORPS shall cooperate and maintain a good relationship with Monroe County and other neighboring AMBULANCE CORPS and municipalities,their officials,and their ambulance corps members. 36. DISTRICT MEDICAL DIRECTOR: The DISTRICT, after consulting with the Ambulance Corps, shall contract with a Florida licensed physician(s)to serve as the Ambulance Corps Medical Director.The Medical Director shall secure and provide to the DISTRICT medical malpractice insurance with minimum limits of $300,000 per occurrence, $1,000,000 annual aggregate to cover the negligent acts and/or omissions of the Medical Director of the Ambulance Corps when said Director is acting within the scope and in furtherance of the duties of the Medical Director as set forth in Florida Statute 401.265. 37. ACCOUNTABILITV: The AMBULANCE CORPS shall be accountable to the DISTRICT as required by this AGREEMENT. The Monroe County Emergency Management Agency shall have the authority to coordinate and control all Ambulance Services during a State of Local Emergency. The Monroe County Emergency Management Agency shall also have the authority to coordinate and control Ambulance Services during other major incidents if requested by the AMBULANCE CORPS, or under any authority granted to the AMBULANCE CORPS by any applicable laws and/or ordinances or under any protocols,rules,regulations,standards,plans,policies,and/or procedures approved by the DISTRICT. The AMBULANCE CORPS shall have the duties and responsibilities in its respective service area which are applicable to Ambulance Services. The DISTRICT shall provide administrative and technical assistance, as requested, to the AMBULANCE CORPS in matters relating to the operation of the Ambulance Services. Representatives of both the DISTRICT and the AMBULANCE CORPS shall meet on a regular basis for discussions regarding the operation of the Ambulance Services contemplated within this AGREEMENT and other related matters;meeting dates to be jointly agreed upon. All administrative correspondence shall be sent to: To the DISIRICT: Attn: Chairperson Is Key Largo Fire Rescue and EMS District P.O. Box 371023 Key Largo,FL 33037-1023 To the AMBULANCE CORPS Attn: President Key Largo Volunteer Ambulance Corps, Inc. 98600 Overseas Highway Key Largo,FL 33037 38. INDEMINIFICATION The AMBULANCE CORPS,to the fullest extent by law,shall indemnify and forever hold harmless the DISTRICT, its officers, agents, and employees, from all claims of any sort whatsoever that may arise from negligence, acts, or omissions of the paid part-time and/or full-time employees of the AMBULANCE CORPS, not related to the provision of the Ambulance Services or Fire and Rescue Services. 39. MISCELLANEOUS: The AMBULANCE CORPS shall comply with all applicable environmental laws and regulations. The AMBULANCE CORPS shall comply with all applicable provisions of the Federal Fair Labor Standards Act (29 U.S.C. 201). The AMBULANCE CORPS shall perform all financial and compliance audits required by law. 40. NOTICES: Any notice required or permitted to be given hereunder shall be deemed properly given at the time it is personally delivered or mailed, property addressed and postmarked to the respective address specified below or to such other addresses as may be specified in writing: To the DISIRICT: Attn: Chairperson Key Largo Fire Rescue and EMS District P.O. Box 371023 Key Largo,FL 33037-1023 To the AMBULANCE CORPS Attn: President Key Largo Volunteer Ambulance Corps,Inc. 98600 Overseas Highway Key Largo,FL 33037 All vehicles and equipment owned and for leased by the DISTRICT and used by the AMBULANCE CORPS to provide Ambulance Services shall be returned to the DISTRICT when requested upon expiration or termination of this AGREEMENT.During the interim period between expiration of this AGREEMENT and the execution of a new AGREEMENT, the AMBULANCE CORPS shall be authorized to use the vehicles and equipment for continued provision of Ambulance Services. 41. CALL HANDLING AND PROCESSING: The AMBULANCE CORPS shall formally establish standards for call answering and call processing times and shall regularly monitor compliance with such standards. The AMBULANCE CORPS shall 16 provide the DISTRICT a written performance report identifying 90th percentile call handling and processing times on at least a quarterly basis. 42. INVALIDITY: If any section, subsection, sentence, clause, or provision of this AGREEMENT is held invalid, the remainder of this AGREEMENT shall not be affected by such invalidity. 43. DISPUTE RESOLUTION: The DISTRICT and the AMBULANCE CORPS agree that any dispute to this contract will be submitted to binding arbitration for resolution if the DISTRICT and AMBULANCE CORPS are unable to come to agreement through informal means. However,the DISTRICT'S determination on the use of funds, and the AMBULANCE CORPS' determination on the Chief of the AMBULANCE CORPS (subject to the provisions of Section 42)are not subject to binding arbitration. 44. CHIEFS OF AMBULANCE CORPS: If the DISTRICT'S Board of Commissioners votes upon a duly noticed resolution to require the AMBULANCE CORPS to terminate the employment of its Chief and such resolution passes with the votes of at least four(4) out of the five (5)Commissioners, the AMBULANCE CORPS shall immediately and unconditionally terminate the employment of the same. Furthermore, the re-employment of any Chief terminated under this provision shall be forbidden absent express permission of the DISTRICT.Nothing herein shall prevent the AMBULANCE CORPS,on its own initiative,from terminating the employment of its Chief. IN WITNESS WHEREOF, the parties hereto have caused this AGREEMENT to be executed the day and year first above. KEY LARGO FIRE RESCUE AND EMERGENCY MEDICAL SERVICES KEY LARGO VOLUNTEER DISTRICT AMBULANCE COUP&INC. "" _ r : &- Anthony 6Wn,qair President Date. Date: ................ 17 AGREEMENT BETWEEN KEY LARGO FIRE RESCUE AND EMERGENCV MEDICAL SERVICES DISTRICT AND KEY LARGO VOLUNTEER FIRE DEPARTMENT, INC. This AGREEMENT made this 9"' day of March, 2026, by and between the Key Largo Fire Rescue and Emergency Medical Services District ("DISTRICT") and Key Largo Volunteer Fire Department ("FIR17- DEPAR'l-MET" T") RECITALS WHEREAS, the DISTRICT has lawful authority granted to it in Chapter 2005-329, organized and existing under Chapters 189 and 191, Laws of Florida, to provide fire and rescue set-vices (hereinafter "Fire Services") either directly or by contract with the Key Largo Volunteer Fire Department., pursuant to Chapter 2005-329, Laws offlorida, primarily for the benefit of the taxpayers residing within said DISTRICT-,and WHEREAS, the DISTRICT is charged with responsibility for provision of Fire Services, and WHEREAS, the DISTRICT and the FIRE DEPARTMENT desire to provide basic and Fire services from premises in Key Largo, to serve the area generally described as being from South Bay Harbor Drive and Lobster Lane(Approx. MM#95) North on US I to the Dade County Lille and North on S.R. 905 to the intersection of S,R. 905 and Card Sound Road, Monroe County, Florida (hereafter the "response area"); and WHEREAS, within the said DISTRICT, the FIRE DEPARTMENT has been organized as a non-profit corporation for the purpose of providing Fire Services within the DISTRICT; and WHEREAS, such Fire Services constitute essential services necessary to the health and safety of the residents and visitors of the KLFR& EMS District; and WHEREAS, pursuant to F.S. § 633.025, the FIRE DEPARTMENT, on behalf of the DISTRICT shall enforce the Florida Life Safety Code as the minimurn Life Safety Code for the DISTRICT;and WHEREAS, the parties desire to enter into an AGREEMEN'I` for the reimbursement of expenses relating to the set-vices provided by the FIRE DEPARTMENTand other related matters, and WHEREAS, the DISTRICT and the FIRE DEPARTMENT recognize that volunteers serve the community without promise, expectation, or receipt of compensation and that the parties wish to thank them for performing this traditional government function; and WHEREAS, the parties desire to enter into an AGREEMENT for the reirribursernent of expenses relating to the services provided by the FIRE DEPARTMENT,and other related matters; I NOW, THEREFORE, in consideration of the covenants contained herein and other good and valuable considerations, the parties agree as follows: 1. TERM OF AGREEMENT: The term of this AGREEMENT shall commence on March 9, 2026, and terminate on July 1, 2026, unless terminated earlier in accordance with the terms and conditions hereafter provided. The Parties may mutually agree in writing to extend the term of this AGREEMENT on a month-to-month basis. Unless otherwise terminated or extended as provided herein, this AGREEMENT shall not automatically renew. 2. TERMINATION: The DISTRICT may terminate this AGREEMENT at any time during its term if the FIRE DEPARTMENT defaults under any provisions specified herein,or violates any standard specified in this AGREEMENT,or violates any other law,regulation or standard applicable to the furnishing of Fire Set-vices in Monroe County. In such event the DISTRICT shall furnish the FIRE DEPARTMENT written notice of any such default or violation and the FIRE DEPARTMENT shall have thirty(30) days from receipt of said notice to correct or remedy such default or violation. However, if correction of the default or violation requires permitting or outside authorization from any State or Local Governmental Agency,the FIRE DEPARTMENT shall apply for the required permit or authorization within thirty (30) days and the time period for correction of the violation shall commence on the date that the FIRE DEPARTMENT received the necessary permit or authorization. Additionally, if any act of nature should occur during the period of time within the time the FIRE DEPARTMENT was to correct the default or violation, the period of time within which correction is to occur shall be extended a reasonable amount of time, using the reasonable person standard for determination of what is a reasonable time. If such violation is not corrected or such default is not remedied, within the aforesaid time, or is of such nature that it cannot be corrected or remedied, this AGREEMENT shall be considered void. This AGREEMENT may be terminated unilaterally for the refusal of the FIRE DEPARTMENT to allow public access to all documents, papers, letters, or other material, as allowed or required by law, excluding any and all material protected under the Health Information Portability and Accountability Act (HIPAA), made or received by the contractor in conjunction with duties performed under this AGREEMENT, after 30 days written notice of request and opportunity to provide same by the DISTRICT, unless such records are exempt from public access under FS, 119.07 and 24(a)of Art. I of the State Constitution. This AGREEMENT may be terminated by the DISTRICT for any reason upon at least sixty(60) days written notice to the FIRE DEPARTMENT at the addresses set forth below. If said AGREEMENT should be terminated as provided in this paragraph of the Contract, the DISTRICT will be relieved of all obligations under said contract unless otherwise provided herein. Upon termination of the AGREEMENT,the DISTRICT will only be required to pay that amount of the 2 contract actually performed to the date of termination with no payment due for unperformed work or lost profits, 3. EFFECT OF DISTRICT POLICIES: The FIR-E DEPARTMENT shall not create or enforce internal policies that conflict with any policies of the District Personnel Manual, as amended. Should such a conflict arise, the policies of the District's Personnel Manual shall control, unless otherwise provided by law or by the District's Personnel Manual, The DISTRICT shall solicit comments From the FIRE DEPARTMENT regarding any proposed amendments to the Personnel Manual the DISTRICT deems might materially affect the FIRE DEPARTMENT. 4. RESPONSE AREA AND MUWA L AID: The FIRE DEPARTMENT shall be the exclusive provider of Fire Services within their response area. The FIRE DEPARTMENT shall also provide mutual aid response to any other emergency service upon request and/or in accordance with existing protocol, applicable laws, rules, regulations, and standards. 5. FIRE DEPARTMENT ORGANIZATION AND BY-LAWS: The FIRE DEPARTMENBT shall revisit its corporate roles, distribution of authority, and executive or administrative oversight and shall create an organizational structure that provides for checks and balances between executive/adrninistrative oversight and operational functions. The structure shall also reflect the efficient assignment of responsibility and authority, allowing the FIRE DEPARTMENT to accomplish effectiveness by maximizing distribution of workload and allocate resources equitably and with emphasis on safety, The FIRE DEPARTMENT'S Board shall provide to the DISTRICT an organizational plan of the FIRE DEPARTMENT and shall review the structure as needed due to internal restructuring. If the FIRE DEPARTMENT effects revisions to the organizational plan the FIRE DEPARTMENT shall notify the DISTRICT clerk and present the revised plan to the DISTRICT upon request.To the extent the DISTRICT board provides comments or advice on the organizational plan, the FIRE DEPARTMENT shall give significant weight and consideration to the DISTRICT's comments and advice. No revisions to the organizational plan that would have a significant fiscal impact on the DISTRICT shall be approved by the FIRE DEPARTMENT without first obtaining DISTRICT approval, The plan shall include an organizational chart, indicating any subordinate(s) or supervisor(s) of each position. The chart shall be accompanied by thorough job descriptions for each position. The job descriptions shall clearly and adequately describe the primary functions and activities, critical tasks, levels of supervision,and accountability,as well as reasonable qualifications of each class or position within the FIRE DEPARTMENT. All persons working under accepted job descriptions will receive a performance appraisal, as outlined in FIRE DEPARTMENT Policies annually, without exception, 3 The plan shall also contain eligibility lists for required positions based on merit, experience, and qualifications, Selections shall be made based on merit and qualification and should include practice guidelines for a Drug Free Workplace and a Smoke Free Workplace, The FIRE DEPARTMENT shall maintain all active corporation status with the State of Florida, and shall produce evidence to the DISTRICT confirming its corporate standing under Florida law upon request. The FIRE DEPARTMENT'S membership shall, review and/or revise its by-laws as needed and shall present one dated,typed copy of its by-laws to the DISTRICT within thirty(30) days of such revisions being adopted by the FIRE DEPARTMENT. The FIRE DEPARTMENT shall confirm the enabling documents providing for the appointment of corporate officers,The FIRE DEPARTMENT shall provide the DISTRICT a dated, typed copy of its updated by-laws upon any update thereof Notwithstanding the requirements of this section, the FIRE DEPARTMENT shall conduct a job analysis of all Job Classifications to confirm the incumbents are working within their job descriptions and expectations. 6. NNING OUTCOMES,, GOALS AND OBJECTIVES: The FIRE DEPARTMENT shall, with the DISTRICT, develop a Strategic Plan. The purpose of the Plan shall be to evaluate service improvement opportunities,develop goals for future set-vice delivery, and to establish critical tasks and timelines to accomplish those goals. The Plan shall contain a critical tasking analysis for common community risk types and ensure that the number of personnel dispatched to calls equals the identified critical tasks. 7. FOUNDATIONAL POLICY OF FIRE DEPARTMENT: The FIRE DEPARTMENT shall create clear policies that lay the foundation for effective organizational culture. The policies shall take the form of Administrative Rules and Standard Operating Guidelines ("SOGs"), The FIRE DEPARTMENT shall within thirty (30) days promulgate its initial Administrative Rules and SOGs and provide a hardcopy of the same to tile DISTRICT, The FIRE DEPARTMENT shall thereafter provide the DISTRICT an updated copy of the FIRE DEPARTMENT'S Administrative Rules and SOGs upon any modification or update thereof 7.1 Administrative Rules: The FIRE DEPARTMENT'S Board shall adopt or approve,with a review by the DISTRICT, Administrative Rules that personnel in the FIRE DEPARTMENT are required to comply with at all times. The FIRE DEPARTMENT shall present such proposed rules to the DISTRICT on a semi- annual basis, via written submission of all revised rules to the DISTRICT Clerk and report to the DISTRICT board at a regularly scheduled meeting. The FIRE DEPARTMENT shall additionally make such proposed rules available to the DISTRICT upon the request of any sitting District Commissioner, The FIRE DEPARTMENT shall give significant weight and consideration to the DISTRICT'S advice and comments and shall revise previously 4, enacted Administrative Rules to the extent such revisions are warranted following advice and comment from the DISTRICT board, The Administrative Rules shall govern all members of FIRE DEPARTMENT, whether paid, volunteer, or civilian, and including the Chief. The FIRE DEPARTMENT Board may delegate authority to the Chief to enforce Administrative Rules on FIRE DEPARTMENT personnel. Where rules and policies, by their nature, require different application or provisions for different classifications of members, these differences shall be clearly indicated and explained in writing. The Administrative Rules shall contain sections which address: • Public records access and retention in accordance with the DISTRICT's Record Retention Schedule; • Contracting and purchasing authority; • Safety and loss prevention; • Personal Protective Equipment program; • Hazard communication program-, • Harassment and discrimination; • Personnel appointment and promotion; • Disciplinary and grievance procedures; • Uniforms and personal appearance; and • Other personnel management issues. 7.2 Standard Operating Guidelines("SOGs"): The FIRE DEPARTMENT shall develop and, under the direction of the Fire Chief, enforce, SOGs. SOGs shall contain street-level operational standards of practice for personnel of the FIRE DEPARTMENT. The FIRE DEPARTMENT shall present such proposed rules to the DISTRICT on a semi-annual basis, via written submission of all revised rules to the DISTRICT Clerk and report to the DISTRICT board at a regularly scheduled meeting. The FIRE DEPARTMENT shall additionally make such proposed SOG's available to the DISTRICT upon the request of any sitting District Commissioner. The FIRE DEPARTMENT shall give significant weight and consideration to the DISTRICT'S advice and comments and shall revise previously enacted SOG's to the extent such revisions are warranted following advice and comment from the DISTRICT board, Unlike Administrative Rules, variances shall be allowed in unique or unusual circumstances where strict application of the SLOG would be less effective, The FIRE DEPARTMENT shall develop a program for regular, systematic updating of SOGs to ensure they remain current, practical, and relevant. 7.3 Availabilitv of Rules and SOGs: The FIRE DEPARTMENT shall make all Administrative Rules and SOGs readily available to all members of the FIRE DEPARTMENT and shall furnish each member with his/her copy. In doing so,the FIRE DEPARTMENT shall ensure that no confusion exists as to which Rules or SOGs are currently in force. Additionally, the FIRE DEPARTMENT shall develop a written procedure to ensure and to govern the distribution of all new Rules, SOGs, and other memos to members of the FIRE DEPARTMENT. The written procedure shall include a method to verify distribution. 8. INCIDENT REPORTS Within twenty-four (24) hours of the occurrence of the following types of incidents, the FIRE DEPARTMENT shall provide a written report to the DISTRICT clerk and Board Chair: • Any incident involving damage to property estimated to be equal to or greater than $5,000.00; • Any incident involving the hospitalization or death of any FIRE DEPARTMENT personnel, • Any incident likely to result in litigation against the FIRE DEPARTMENT, its personnel, or the DISTRICT; Within thirty(30)days of the occurrence of(or at the next regularly scheduled meeting of the DISTRICT Board) any incident response which the Chief determines to have an inordinately or unusually long response time, the FIRE DEPARTMENT shall provide a written report to the DISTRICT clerk and Board Chair; 9. PERSONNEL: The FIRE DEPARTMENT shall maintain volunteer and/or paid personnel so as to make sure a complement of personnel are available to provide Fire Services oil a twenty- four(24) hour basis to the DISTRICT. In accordance with the current practices of the FIRE DEPARTMENT, scheduling and assignment of personnel shall be arranged so as to ensure that all applicable legal requirements are met at all times.The FIRE DEPARTMENT shall ensure that at all times sufficient personnel are scheduled to comply with the requirements of Florida Statute Section 633 as may be amended from time to time. The backup shall perform to the ninety-fifth percentile (959,'O) of availability. Scheduling and assignment of personnel shall be arranged so as to utilize volunteer personnel to the maximurn extent possible. Only in the event the FIRE DEPARTMENT deems it necessary to maintain coverage or to meet administrative needs and obtains permission from the DISTRICT shall paid part-time or full-time employees be employed in addition to those approved in the budget, 10. MINIMUM STANDARD AND TRAINING: The FIRE DEPARTMENT shall require that all volunteer personnel engaged in Fire Services comply with the minimurn training,education,and perfon-nance requirements of the State of Florida for fire department personnel.On the date of hire,all FIRE DEPARTMENT personnel slial I meet the minimum state certification and eligibility standards required for that position. The FIRE DEPARTMENT shall establish and maintain training and continuing education prograrn designed to maintain a high degree of competency and skill on the part of all volunteer and/or paid FIRE DEPARTMENT personnel, The FIRE DEPARTMENT shall also facilitate and encourage attendance by all volunteer and/or paid FIRE DEPARTMENT personnel at proficiency training programs provided by the FIRE DEPARTMENT or other agency deemed appropriate. The FIRE 6 DEPARTMENT shall maintain current and accurate training and proficiency records for all volunteer and/or paid FIRE DEPARTMENT personnel evidencing compliance with this provision. The FIRE DEPARTMENT shall appoint a FIRE DEPARTMENT training officer. Tile FIRE DEPARTMENT shall develop and implement a comprehensive FIRE DEPARTMENT Training Plan including minimum training and certification requirements for members and employees. The Plan shall provide for regular training of, and implernent a comprehensive, structured, skills maintenance training program for all of FIRE DEPARTMENT officers and employees. The FIRE DEPARTMENT shall design and implement a pre-promotion training prograrn, The FIRE DEPARTMENT shall require lesson plans for all training sessions and immediately implement the requirement for ail assigned safety officer in attendance at all manipulative training sessions, as applicable to the specific exercise. The FIRE DEPARTMENT shall continue multi-company and multi-agency drills and training as frequently as is required by Florida law to enhance mutual aid operations and improve relationships and planning efforts.The FIRE DEPARTMENT shall develop and implement a plan to evaluate member/employee technical and manipulative skills on a regular basis. The FIRE DEPARTMENT shall develop and implement a formal performance evaluation system for all members and employees,The FIRE DEPARTMENT shall conduct an ongoing analysis of on-scene staffing strength to confirm the FIRE DEPARTMENT'S standard of coverage. The FIRE DEPARTMENT shall continue the centralized, consistent, training data collection and shall maintain up-to-date records on training data collection and reporting under direct oversight of the training officer. The FIRE DEPARTMENT shall establish a training reference, equipment and props inventory and member checkout procedure. The FIRE DEPARTMENT shall consider implementing a formal competency-based approach to the FIRE DEPARTMENT'S training program. On at least a quarterly basis, the FIRE DEPARTMENT shall provide to the DISTRICT at a regularly scheduled DISTRICT Board meeting a written report detailing FIRE DEPARTMENT compliance with this paragraph, specifically with regard to the adequacy of on-scene staffing. 11. COMPLIANCE: At all times in the performance of its duties under this AGREEMENT, the FIRE DEPARTMENT shall comply with all applicable State and Federal regulations, and all applicable local laws, ordinances and procedures pertaining to the operation of equipment,direction of personnel,transportation of patients, and medical care of persons. 12. DISCIPLINE: The FIRE DEPARTMENT has previously adopted a clearly identifiable, formal, progressive disciplinary process with an appropriate appeal procedure. Within thirty(30)days of the adoption of revisions to this disciplinary procedure,the FIRE DEPARTMENT shall notify the DISTRICT clerk, and shall present such proposed modifications to the DISTRICT upon request. The FIRE 7 DEPARTMENT shall give significant weight and consideration to the DISTRICT's advice and comments and shall revise the previously adopted disciplinary procedure to the extent such revisions are warranted following advice and comment from the DISTRICT Board. 13. PAID EMPLOYEES: Subject to the provisions of Section Nine (9), the FIRE DEPARTMENT may employ such part-time or full-time employees as it determines is necessary to carry out its Fire Services. Part- time or full-time employees of the FIRE DEPARTMENT shall be compensated by the DISTRICT at a rate commensurate with that of other similarly trained and experienced personnel employed within Monroe County. 14. SELECTION OF NEW MEMBERSHIP: The FIRE DEPARTMENT shall make membership selections based on merit and qualifications. The FIRE DEPARTMENT shall maintain and update a list of active FIRE DEPARTMENT membership. 15. HARASSMENT POLICY: The FIRE DEPARTMENT shall establish a disciplinary policy and procedure for reporting harassment that conforms to State and Federal law, including Title VII of the Civil Rights Act of 1964, the Age Discrimination in Employment Act, and the Americans with Disabilities Act. The FIRE DEPARTMENT shall instruct employees/volunteers to report any complaints in accordance with the DISTRICT'S harassment policy. 16. EQUAL,EMPLOYMENT OPPORTUNITIES AND HARASSMENT: The FIRE DEPARTMENT must comply with all State and Federal and local laws relating to nondiscrimination,including,but not limited to: (a)Title VI of the Civil Rights Act of 1964(P.L. 88- 352)which prohibits discrimination on the basis of race, color or national origin; (b)Title IX of the Education Amendments of 1972,as amended(20 U.S,,C, Sections 1681-1683,and 16851686),which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. Section 794), which prohibits discrimination on the basis of handicaps; (d)the Age Discrimination Act of 1975, as amended (42 U.S.C. Sections 6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92- 255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention,Treatment and Rehabilitation Act of 1970(RL 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) Sections 523 and 527 of the Public Health Service Act of 1912(42 U.S.C,290-dd-3 and 290-ee-3),as amended, relating to confidentiality of alcohol and drug abuse patient records;(h)Title VIII of the Civil Rights Acts of 1968(42 U.S-C, Section 3601 et seq), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (i)any other 8 nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made;and 0)the requirements of any other nondiscrimination statute(s)which may apply to the application. 17. DRUG-FREE WORKPLACE: The FIRE DEPARTMENT shall comply with the requirements of the Drug-Free Workplace Act of 1988,and implemented at 44 C.F.R. Part 17, Subpart F. 18. FREEDOM FROM POLITICAL COERCION: No paid FIRE DEPARTMENT employee who exercises functions in connection with all activity financed in whole or in part by loans or grants made by the United States or a Federal agency shall (1) use his or her official authority or influence for the purpose of interfering with or affecting the result of an election or a nomination for office, (2) directly or indirectly coerce, command, or advise a State or local officer or employee to pay, lend, or contribute anything of value to a party, committee, organization, agency, or person for political purposes, provided, however, that an individual may be a candidate for elective office. Provided, further, that an FIRE DEPARTMENT officer or employee may be a candidate for elective office in an election as provided by 5 U.S.C. 1502(a)(3), as amended, This provision does not in any way limit the rights of an FIRE DEPARTMENT officer or employee to vote as he or she chooses and to express his or her opinions on political subjects and candidates, 19. POLITICAL ACTIVITIES: In consultation with the DISTRICT, the FIRE DEPARTMENT shall adopt a "Political Activity Policy" which requires its personnel to make reasonably clear that any personal political opinion expressed in a public forum is their own and not attributable to the FIRE DEPARTMENT. If the FIRE DEPARTMENT should revise, suspend, or revoke the Political Activity Policy, the FIRE DEPARTMENT shall notify the DISTRICT Clerk within thirty (30) days of such decision. To the extent that the DISTRICT board provides comments or advice on the revision, suspension, or revocation of the Political Activity Policy, the FIRE DEPARTMENT shall give significant weight and consideration to the DISTRICT'S comments and advice. 20. MAINTENANCE OF FIRE DEPARTMENT HISTORY: The FIRE DEPARTMENT shall clearly assign responsibility for maintaining a Facebook or other social media page or file containing items of historical significance, including pictures, newspaper articles,e1c. Additionally, the FIRE DEPARTMENT shall prepare an annual report to be presented to the DISTRICT on August Ist of each year. The annual report shall also be distributed to the community and made available on the FIRE DEPARTMENT'S website. At minimum,each annual report shall include: • Brief history of the FIRE DEPARTMENT; • Summary of events and activities during the report year; 9 • Description of major incidents handled by the FIRE DEPARTMENT; • Descriptions of new or improved services and programs; • List of people who served with the FIRE DEPARTMENT during the year; • Awards received by the FIRE DEPARTMENT or individuals; • Financial summary including revenues and expenditures,grants,etc.,- and • Statistical analysis, with trends, of key community service level indicators, 21. ALL ALERTNESS INCLUDING VOLUNTEER ALE RTNESS, The FIRE DEPARTMENT shall establish a duty officer system, including using volunteer officers, to ensure that an individual designated for incident command will be available 24 hours a day. 22. PUBLIC COMPLAINTS: The FIRE DEPARTMENT shall establish a formal procedure for handling complaints from the public. The FIRE, DEPARTMENT shall immediately provide the DISTRICT with a written description of any written complaints received from the public within twenty-four (24) hours of receiving such complaints, or as soon as is practicable thereafter. Notwithstanding the foregoing, the FIRE DEPARTMENT shall report any complaint,written or otherwise,that concerns any matter specified in Section 8 of this Agreement. Subsequent remedial actions relating to the complaint shall likewise be immediately provided to the DISTRICT. 23. VEHICLE, EQUIPMENT AND FACILITIES: The DISTRICTshall provide to the FIRE DEPARTMENT sufficient vehicles, equipment, and facilities to enable the FIRE DEPARTMENT to carry out its Fire Services with the DISTRICT as provided for in the Monroe County Year 2030 Comprehensive Plan or any other plans or documents relating to the Fire Services that are adopted by Monroe County.The DISTRICT shall be responsible for the general maintenance and repair of the vehicles,equipment,and facilities owned arid/or leased by the DISTRICT as well as required periodic testing and certification of all equipment,as necessary, used by the FIRE DEPARTMENT in connection with its Fire Services. The FIRE DEPARTMENT shall be responsible for proper control of all assigned vehicles, equipment, and facilities and shall develop and implement an aggressive driver,�'operator annual training program and checkout program for all FIRE DEPARTMENT vehicles.The FIRE DEPARTMENT shall be responsible for notifying the Chair of the DISTRICT of needed repairs for vehicles, equipment, and facilities and shall assist in arrangements for said repairs. The DISTRICT shall have the right to inspect the vehicles, equipment,or facilities at any time. 24. PROPERTY CONTROL: The FIRE DEPARTMENT shall provide a system for property control of the vehicles and equipment owned and/or leased by the DISTRICT and used by the FIRE DEPARTMENT to provide Fire Services, The FIRE DEPARTMENT shall assist in the performance of the annual inventory of the vehicles and equipment. 25. SUBCONTRACTS: The FIRE DEPARTMENT may subcontract its services when the DISTRICT determines such subcontracts are beneficial to the FIRE DEPARTMENT, the DISTRICT, and/or the community. The FIRE DEPARTMENT may utilize equipment and vehicles owned and/or leased by the DISTRICT in conjunction with the above subcontractors provided that no reduction in the level of services to their respective service area results from the utilization of said equipment for sub,, contracted services. Notice of intent to subcontract, when DISTRICT equipment and/or vehicles will be used,must be provided to the DISTRICT at least thirty(30)days prior to execution of said subcontract in order to allow for proper review and comment concerning same and to allow the DISTRICT to decide whether to approve or disapprove of the same. A signed copy of all subcontracts shall be provided to the DISTRICT, The FIRE DEPARTMENT shall comply with all regulations promulgated pursuant to 40 U.S.C. §3145 relating to contractors' and subcontractors' furnishing statements on the wages paid each employee during the previous pay period. No FIRE DEPARTMENT employee shall receive kickbacks from public works employees, as provided by 18 U.S.C. §874. The FIRE DEPARTMENT shall comply with all applicable provisions of 40 USC §§ 3701-3708. 26. BUDGET As requested by the DISTRICT as part of its annual budget adoption process, the FIRE DEPARTMENT shall submit a proposed budget appropriations request, by line itern account in a format specified by the DISTRICT, for the forthcoming fiscal year. Tile FIRE DEPARTMENT budget request should include personnel, supplies, materials, utilities and other internal costs,charges,or expenditures necessary or incidental to the operation of the Fire Services, including a reasonable stipend for professional services conternplated within this AGREEMENT, which have riot been previously specified herein as being provided by the DISTRICT. This budget request shall also include, based on statistical analysis of the usage, mileage, serviceability, and/or level of service, a five year plan for refurbishment, replacernent, or additional apparatus to be provided to the FIRE DEPARTMENT by the DISTRICT. Once formally adopted by the DISTRICT prior to October IS' of each year, the budget establishes an initial limitation on expenditures by the FIRE DEPARTMENT by line item total. The DISTRICT and FIRE DEPARTMENT acknowledge that the annual budget may be amended from time to time to reflect increases in actual expenses, and to reflect the increase or decrease in the level of services provided to the District due to hurricanes,other emergencies or requirements for additional staffing. If subsequent to the passage and adoption of the budget, the FIRE DEPARTMENT determines that a line item will exceed its original allocation, the FIRE DEPARTMENT shall prepare for the DISTRICT' s approval a budget amendment request to reflect its additional funding requirements,The FIRE DEPARTMENT is not authorized to receive payment in excess of the budgeted line item amounts until the DISTRICT approves such an amendment, The FIRE DEPARTMENT may,however,make budget transfers which increase or decrease budgeted line item amounts without DISTRICT approval, provided that such line item changes do not require all increase to the adopted total amount of the FIRE DEPARTMENT budget and that such transfer is in accordance with the District's Budget Transfer Policy. Budget line items for capital expenditures and those line items which include personnel and payroll related costs may not be modified by the FIRE DEPARTMENT without DISTRICT Board approval. 27. CONTRACT PAYMENTS: The FIRE DEPARTMENT shall receive funding for budgeted expenditures incurred in the performance of this CONTRACT by the following methods: 27.1 Advances: The DISTRICT shall retain the option to provide the FIRE DEPARTMENT with advance funding for minor recurring expenditures. If such advance payments are rnade the FIRE DEPARTMENT will provide the DISTRICT with monthly financial reports, by the 15th day of each month for the prior month in a format deemed acceptable by the DISTRICT,which show all costs incurred by the FIRE DEPARTMENT against this advance. At the end of each fiscal year, incurred costs will be reconciled with total advance payments made by the DISTRICT. The DISTRICT'S external auditors will determine the final balance. If incurred costs exceed total payments, the DISTRICT will reimburse the FIRE DEPARTMENT for the excess costs, provided that such reimbursement does not exceed the total adopted budget for the FIRE DEPARTMENT. If total payments exceed incurred costs, the FIRE DEPARTMENT will reimburse the DISTRICT for the excess payment amount. 27.2 Direct Pay The DISTRICT can provide for direct payment of any expenses of the FIRE DEPARTMENT which are part of the approved budget. If desired by the FIRE DEPARTMENT, the DISTRICT will provide for direct payment of payroll prepared by a third party payroll service through withdrawal from a DISTRICT account, Direct payment for other expenses will be made by the DISTRICT based on the FIRE DEPARTMENT'S submittal of purchase orders and/or check requests in accordance with the DISTRICT's adopted Purchasing Policies and Procedures or Travel Authorization and Expense Policy as may be amended by the DISTRICT from time to time. 27.3 Reimbursement- In the event that all expenditure which is part of the adopted budget must be incurred by the FIRE DEPARTMENT rather than paid directly by the DISTRICT,the FIRE DEPARTMENT can request reimbursement from the DISTRICT's funds by submitting a check request in accordance with the DISTRICT'S adopted Purchasing Policies and Procedures. The DISTRICT will not reimburse the FIRE DEPARTMENT for capital expenditures that were incurred prior to execution of an approved purchase order or contract in accordance with the DISTRICT's purchasing policies. 12 In no event shall the DISTRICT reimburse the FIRE DEPARTMENT for expenditures that exceed budgeted line item allocations or that were made in violation of the DISTRICT's Policies and Procedures, Travel expenses must be submitted in accordance with the DISTRicr's adopted Travel Authorization and Expense policy. 28. ANNUAL AUDIT REPORT: The FIRE DEPARTMENT shall allow the DISTRICT and its external auditors access to its records related to expenditures under this contract to conduct an annual audit report,in accordance with Florida Statutes, The DISTRICT will be responsible to procure the services of the auditor and the cost of'such audit shall be a cost,charge, or expenditure of the DISTRICT, 29, DISTRICT INSURANCE: The DISTRICT shall provide the following insurance coverage on and for the volunteers of the FIRE DEPARTMENT: A. Workers Compensation Insurance as required by Florida Statutes Chapter 440, including minimum$1,000,000 Employer's Liability Coverage, B. General Liability Insurance, with minimum limits of$2,000,000; and C. Automobile Liability Insurance with minimurn limits of $2,000,000 including Physical Damage Insurance on all vehicles owned or leased by the DISTRICT and used by the FIRE DEPARTMENT. The policy shall provide secondary coverage on private vehicles only during such time as they are operated in response to a call, and ending, either at such time as the volunteer returns to his/her home, or to the first location to which a volunteer stops on the way home,after completion of participation in the emergency services that were subject to the call, whichever occurs first. All DISTRICT liability insurance policies shall name the FIRE DEPARTMENT as an additional insured. Proof of all insurance in a form acceptable to the FIRE DEPARTMENT shall be provided by the DISTRICT upon request, 30, FIRE DEPARTMENT INSURANCE: 30.1 Part-Time and Full TirnLErnploLeev. The FIRE DEPARTMENT shall provide the following insurance on all part-time and full-time employees of the FIRE DEPARTMENT: A. Workers Compensation Insurance in compliance with Florida Statutes Chapter 440 including minimurn $1,000,000 Employer's Liability Coverage; 13. Unemployment Compensation in compliance with Florida Statutes Chapter 443; 13, C. General Liability Insurance with minimum limits of$2,000,000 combined single limit; D. Disability income insurance for a minimum of three hundred dollars($300.00)weekly upon total disability for the first thirty(30)days and thereafter, if)all amount Lip to Six hundred dollars($600.00)weekly,not to exceed the employee's net income. Said benefit shall continue until otherwise terminated according to the provisions of the applicable disability policy; and E. Death benefits insurance with a minimum amount of seventy-five thousand ($75,000.00) death/perinarient disability benefits for the employee while engaged in the performance of his/her duties. F. Labor and Employment Practices Liability insurance with a minimum limit of one million dollars($1,000.000). 30.2 Volunteers: The FIRE DEPARTMENT shall provide the following insurance on all volunteers of the FIRE DEPARTMENT: A. Disability income insurance for a minimum of three hundred dollars ($300.00) weekly upon total disability for the first thirty(30) days and thereafter, in an amount Lip to six hundred dollars($600,00)weekly,not to exceed the volunteers'average reimbursement. Said benefit shall continue until otherwise terminated according to the provisions of the applicable disability policy; B. Death benefits insurance with a minimum arnount of seventy-five thousand dollars ($75,000,00) death/permanent disability benefit for the employee while engaged in the performance of his/her duties; and C. Workers Compensation Insurance as required by Florida Statutes Chapter 440, including minimum$1,000,000 Employer's Liability Coverage. 30.3 Vehicles: The FIRE DEPARTMENT shall provide the following insurance on all vehicles owned and/or leased by the FIRE DEPARTMENT and used in providing Fire Services within the DISTRICT: Automobile Liability Insurance with minimum lit-nits of$300,000 combined single limit. All liability policies are to name the DISTRICT as an additional insured, and shall provide for no less than thirty(30) days notice of cancellation, non-renewal,or reduction in coverage. Proof of all insurance in a form acceptable to the DISTRICT shall be provided by the FIRE DEPARTMENT upon request. 14 31. PRIVATE VEHICLE INSURANCE- Any and all FIRE DEPARTMENT personnel who utilize a private vehicle in the Course and scope of their duties shall keep in full force and effect a policy of liability insurance on his/her private vehicle(s) in at least such minimum amounts of coverage as are required under Florida law. Proof of insurance in a form acceptable to the DISTRICT shall be provided by each volunteer and maintained on file in the business office of the FIRE DEPATMENT. The FIRE DEPARTMENT shall provide copies of proof of insurance to the DISTRICT upon request. 32. VOLUNTEERPERSONNEL: The DISTRICT shall reimburse the FIRE DEPARTMENT for the volunteer personnel in accordance with an annual budget agreed upon by both parties, the failure of which results in the previous year schedule applying. The FIRE DEPARTMENT shall have the right to establish its own eligibility requirements for disbursement of reimbursement based oil participation in FIRE DEPARTMENT activities. DISTRICT funding for the reimbursement of volunteers shall not exceed the budgeted allocation for such reimbursement. Said amounts may be changed or adjusted by approval of the DISTRICT and the FIRE DEPARTMENT, during the to of this AGREEMENT without cause to void, cancel, or violate this AGREEMENT, 33. MAINTENANCE AND RECORDS CUSTODIAN: The following shall be obligations of the FIRE DEPARTMENT: A. Maintaining of detailed, accurate, and Current records of all maintenance and repairs performed on all vehicles and equipment used by the FIRE DEPARTMENT; B, Ensuring that detailed, accurate, and current records of all required testing and certification of rescue, emergency, and medical equipment testing and certification are maintained by the FIRE DEPARTMENT,- C. Maintaining of accurate and current records of training, testing, and certification of all volunteer personnel and part-time and full-time employees. D. Keeping an accurate and current inventory of all vehicles and equipment used by the FIRE DEPARTMENT; E. Preparing and maintaining complete and accurate records of incident details, such as response times. The FIRE DEPARTMENT shall develop a written procedure governing the methods by which to document and record incident details,which procedure shall include a list of required information to be recorded about each incident. The FIRE DEPARTMENT shall file with the State of Florida in a timely fashion, an incident report for each response by 15 the FIRE DEPARTMENT to all FIRE DEPARTMENT personnel rescue,mutual aid, or other miscellaneous calls as required by the State of Florida; and F. Preparing and maintaining complete and accurate personnel records, such as records on employment history, discipline, commendations, work assignments, injuries, exposures, and leave time. The FIRE DEPARTMENT, has developed a written procedure for maintaining the preceding records. Within thirty (30) days of a revised records maintenance procedure being adopted, the FIRE DEPARTMENT" shall notify the DISTRICT clerk and present such procedure to the DISTRICT Board upon request. The FIRE DEPARTMENT has tonnalized its process of responding to public requests for access to records. It shall maintain a current version of this policy and procedure in writing and shall ensure that all legal requirements concerning maintenance of records are met. Within thirty (30) days of a revised records maintenance procedure being adopted,the FIRE DEPARTMENT shall notify the DISTRICT clerk and present such procedure to the DISTRICT Board upon request. IF FIRE DEPARTMENT HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE AMBULANCE CORP'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE DISTRICT RECORDS CUSTODIAN, CAROL GRECO, AT (305) 394-1719, The FIRE DEPARTMENT shall ensure proper security of its records by using passage and/or container locks with limited access as needed. The FIRE DEPARTMENT shall back tip important computer files every month, The FIRE DEPARTMENT shall establish a written procedure designed to ensure that the FIRE DEPARTMENT facilities are adequately locked and secured from unauthorized entry, The FIRE DEPARTMENT shall limit public access to its facilities to business areas. 34. PUBLIC MEETINGS: The FIRE DEPARTMENT shall comply with public notice and Sunshine Law requirement regarding public access to information, as if the FIRE DEPARTMENT were a government entity, excluding confidential protected medical information and employee records. Requests for information from the public shall be directed through the District and not directly to the FIRE DEPARTMENT, 35. RELATIONSHIP WITH MONROE COUNTY:, The FIRE DEPARTMENT shall cooperate and maintain a good relationship with Monroe County and other neighboring fire departments and municipalities, their officials, and their fire department members. 1,6 36. DISTRICT MEDICAL DIRECTOR: The DISTRICT, after consulting With the FIRE DEPARTMENT, shall contract with a Florida licensed physiciants)to serve as the FIRE DEPARTMENT Medical Director. The Medical Director shall secure and provide to the DISTRICT medical malpractice insurance with minimum limits of $300,000 per occurrence,$1,000,000 annual aggregate to cover the negligent acts and/or omissions of the Medical Director of the FIRE DEPARTMENT when said Director is acting within the scope and in furtherance of the duties of the Medical Director as set forth in Florida Statute 401.265. 37. ACCOUNTABILITY: The FIRE DEPARTMENT shall be accountable to the DISTRICT as required by this AGREEMENT, The Monroe County Emergency Management Agency shall have the authority to coordinate and control all Fire Services during a State of Local Emergency, The Monroe County Emergency Management Agency shall also have the authority to coordinate and control Fire Services during other major incidents if requested by the FIRE- DEPARTMENT, or tinder any authority granted to the FIRE DEPARTMENT by any applicable laws and/or ordinances or under any protocols, rules, regulations, standards, plans, policies, and/or procedures approved by the DISTRICT. The FIRE DEPARTMENT shall have the duties and responsibilities in its respective service area which are applicable to Fire Services. The DISTRICT shall provide administrative and technical assistance, as requested, to the FIRE DEPARTMENT in matters relating to the operation of the Fire Services. Representatives of both the DISTRICT and the FIRE DEPARTMENT shall meet on a regular basis for discussions regarding the operation of the Fire Services contemplated within this AGREEMENT and other related matters; meeting dates to be jointly agreed upon. All administrative correspondence shall be sent to: To the DISTRICT: Attn: Chairperson Key Largo Fire Rescue and EMS District P.O. Box 371023 Key Largo, FL 33037-1023 To the FIRE DEPARTMENT Attn: President Key Largo Volunteer Fire Department, Inc, 98600 Overseas Highway Key Largo, FL 33037 38. INDEMNIFICATION: The FIRE DEPARTMENT, to the fullest extent by law, shall indemnify and forever hold Harmless the DISTRICT, its officers,agents, and employees, from all claims of any sort whatsoever that may arise front negligence, acts, or omissions of the paid part-time and/or full-time employees of the FIRE DEPARTMENT, not related to the provision of the Fire and Rescue Services. 1.7' 39. MISCELLANEOUS: The FIRE DEPARTMENT shall comply with all applicable environmental laws and regulations. The FIRE DEPARTMENT shall comply with all applicable provisions of the Federal Fair Labor Standards Act (29 U.S.C. 201). The FIRE DEPARTMENT shall perform all financial and compliance audits required by law. 40. NOTICES: Any notice required or permitted to be given hereunder shall be deemed properly given at the tune it is personally delivered or mailed, properly addressed and postmarked to the respective address specified below or to such other addresses as may be specified in writing: To the DISIRICT: Attn: Chairperson Key Largo Fire Rescue and EMS District P.O. Box 371023 Key Largo, FL 33037•1023 To the FIRE DEPARTMENT. Attn: President Key Largo Volunteer Fire Department, Inc. 98600 Overseas Highway Key Largo, FL 33037 All vehicles and equipment owned and/or ]eased by the DISTRICT and used by the FIRE DEPARTMENT to provide Fire Services shall be returned to the DISTRICT when requested upon expiration or tennination of this AGREEMENT. During the interim period between expiration of this AGREEMENT and the execution of a new AGREEMENT, the FIRE DEPARTMENT shall be authorized to use the vehicles and equipment for continued provision of Fire Services. 41. CALL HANDLING AND PROCESSING: The FIRE DEPARTMENT shall formally establish standards for call answering and call processing times and shall regularly monitor compliance with such standards. The FIRE DEPARTMENT shall provide the DISTRICT a written performance report identifying 90th percentile call handling and processing times on at least a quarterly basis, 42. INVALIDITY: If any section, subsection, sentence, clause,or provision of this AGREEMENT is held invalid, the remainder of this AGREEMENT shall not be affected by such invalidity. 18 43. DISPUTE RESOLUTION: The DISTRICT and the FIRE DEPARTMENT agree that any dispute to this contract will be submitted to binding arbitration for resolution if the DISTRICT and FIRE DEPARTMENT are unable to come to agreement through informal means. However, the DISTRICT'S determination on the use of funds, and the FIRE DEPARTMENT determination on the Chief of the FIRE DEPARTMENT (subject to the provisions of Section 42) are not subject to binding arbitration. 44. CHIEFS OF FIRE DISTRICT: If the DISTRICT'S Board of Commissioners votes upon a duly noticed resolution to require the FIRE DEPARTMENT to terminate the employment of its Chief and such resolution passes with the votes of at least four (4) out of the five (5) Commissioners, the FIRE DEPARTMENT shall immediately and unconditionally terminate the employment of the same. Furthermore, the rc-employment of any Chief terminated under this provision shall be forbidden absent express permission of the DISTRICT. Nothing herein shall prevent the FIRE DEPARTMENT on its own initiative, from terminating the employment of its Chief. IN WITNESS WHEREOF, the parties hereto have caused this AGREEMENT to be executed the day and year las executed below: KEY LARGO FIRE RESCUE AND EMERGENCY MEDICAL SERVICES KEY LARGO VOLUNTEER DISTRICT FIRE DEPARTMENT, INC. 5� X'n-ito 'A"I'l Ch...a'i'i................................. ... resident Date: 3 Date:r- — xm�dDISTRICT Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Table of Contents Acknowledgments.....................................................................................................................4 Introduction ................................................................................................................................5 Overview of the Communities Served......................................................................................9 SECTION 1: EVALUATION OF CURRENT CONDITIONS...................................................... 11 Overview of the Organizations................................................................................................ 12 Key Largo Fire Rescue & EMS District .................................................................................. 12 Key Largo Emergency Medical Services............................................................................ 13 Key Largo Fire Department.................................................................................................. 14 Other Public Safety Resources ............................................................................................ 17 Organizational Management & Planning...............................................................................20 Management & Administration...........................................................................................20 Internal Assessment of Critical Issues...................................................................................23 Planning for Fire Protection & EMS ......................................................................................28 Introduction to the Stakeholder Input.....................................................................................30 Personnel Management & Staffing .........................................................................................31 Administrative & Support Staffing........................................................................................ 31 OperationalStaffing.............................................................................................................33 Overall Staffing & Personnel Comparison Summary..........................................................40 Health, Wellness, & Safety Programs...................................................................................41 FinancialOverview ..................................................................................................................47 Collective Financial Summary of the Agencies.................................................................49 Capital Facilities & Equipment................................................................................................63 KeyLargo EMS Station.......................................................................................................... 65 KeyLargo Fire Stations ......................................................................................................... 66 KLEMS & KLFD Fleet Inventories............................................................................................ 68 OtherCapital Equipment .................................................................................................... 72 Service Delivery & Performance.............................................................................................73 DataSources ........................................................................................................................ 73 Key Largo Fire Department Service Demand .................................................................... 75 KLFD Operational Performance Analyses .......................................................................... 96 Emergency Medical Services System .................................................................................. 104 EMS Oversight & Medical Direction .................................................................................. 104 KLFD Medical First Response.............................................................................................. 105 KLEMS Administration & Operations.................................................................................. 105 Key Largo EMS Service Demand....................................................................................... 107 KLEMS Operational Performance Analyses...................................................................... Ill KLEMS Patient Transport Analyses ..................................................................................... 113 JA' W ngle 2 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS SECTION I: SUPPORT PROGRAMS.................................................................................. 11 Training & Continuing Medical Education Programs........................................................... 119 General Training Competencies....................................................................................... 121 PersonnelTrained ............................................................................................................... 124 Life Safety & Public Education Programs.............................................................................. 125 Public Education Programs................................................................................................ 125 SECTION III: OPERATIONAL & GOVERNANCE OPTIONS 26 ............................................... 1 Governance & Organizational Structure Options................................................................ 127 Option 1: Maintain Status Quo (Independent Fire and EMS Agencies) ........................ 127 Option 2: Complete Consolidation of KLFD and KLEMS into the District........................ 128 JAG's Recommended Option .......................................................................................... 128 Projected Cost of the Options............................................................................................... 129 Financial Forecast for Option 1 (Maintain Status Quo) ................................................... 130 Financials Forecast for Option 2 (Consolidation)............................................................. 142 Comparison of Status Quo & Consolidation Models....................................................... 155 SECTION IV: STRATEGIES & RECOMMENDATIONS......................................................... 1 58 Example Organizational Structure........................................................................................ 159 General Recommendations.................................................................................................. 161 Conclusion.............................................................................................................................. 166 SECTION V: APPENDICES 69 ................................................................................................ 1 Appendix A: Results from the Stakeholder Input................................................................. 170 InternalSurvey Results ........................................................................................................ 170 External Survey Results........................................................................................................ 181 Appendix B: Sample Data Outlier Policy.............................................................................. 184 Appendix C: Retirement-Type Summary Example.............................................................. 185 Appendix D: Table of Figures ................................................................................................ 187 JA' W ngle 3 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS IAcknowledgments The J. Angle Group, LLC, wishes to extend its sincere appreciation to each individual and organization representing the agencies involved in this study, whose contributions and assistance made this project possible. Our sincere appreciation is extended to each of you... Key Largo Fire i Anthony Allen Frank Conklin Commissioner 1 - Board Chair Commissioner 2 Kenny Edge George Mirabella Commissioner 3 Commissioner 4 Michael Jenkins Carol Greco Commissioner 5 District Clerk Key Largo Fire Department Don Bock Fire/EMS Chief Sergio Garcia David Garrido Chris Jones Captain Captain Captain MedicalKey Largo Emergency i Don Bock Fire/EMS Chief Roxanna Perez Adam Schussheim Lieutenant Lieutenant ...and to each of the firefighters, officers, EMS providers, support staff, and elected and appointed officials that daily serve the citizens and visitors of Key Largo and Monroe County. JA' * ngle 4 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Introduction This Operational Analysis and Consolidation Study for the Key Largo Fire Rescue & EMS District (KLFREMS) provides a comprehensive evaluation of current conditions, governance structures, financial sustainability, and service delivery performance for the district and its contracted agencies—Key Largo Volunteer Fire Department (KLFD) and Key Largo Volunteer Ambulance Corps (KLEMS). The purpose of this study is not only to document existing challenges and opportunities but also to present actionable recommendations that will guide decision-makers toward improved efficiency, enhanced service quality, and long-term fiscal responsibility. It is important to first recognize the women and men of the two contracted agencies— KLFD and KLEMS—who are a dedicated group of both volunteer and career members that provide a high level of care to the community. Regardless of whether the recommendations outlined is this document are adopted and implemented, the residents, business owners, and visitors to Key Largo can expect to continue to receive the high level of service to which they are accustomed. Critical Issues The analysis identifies critical issues, including staffing shortages, funding limitations, organizational structure, and mental health concerns, that impact operational effectiveness. It also highlights areas where duplication of effort and fragmented governance hinder optimal resource utilization. Based on these findings, the study explores multiple governance and operational models, including maintaining the status quo and pursuing full consolidation under the district. Summary of Key Findings • KLFD and KLEMS operate as independent 501 (c)(3) corporations under contract with the district, creating overlapping administrative functions. • Financial analysis shows growth in recurring expenses, primarily driven by personnel costs. • Facilities and apparatus are generally in good condition, but aging infrastructure and equipment require planned capital investment. • Service demand is dominated by EMS calls (approximately 70%), with peak activity between 9:00 a.m. and 8:00 p.m. JA' * C GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Response times exceed NFPA 1710 benchmarks for turnout and travel, indicating opportunities for improvement. Recommended Option After evaluating multiple governance and operational models, Option 2-C: Complete Consolidation with Fire/EMS Chief, Additional Staff, and Florida Retirement System (FRS) participation is recommended. This option provides the greatest potential for: • Operational Efficiency: Eliminates duplication and streamlines decision-making. • Improved Service Delivery: Enhances staffing flexibility and resource deployment. Staffing with dual-certified members would allow the district to increase the effective response force using current EMS employees that are also firefighter certified. • Financial Transparency: Consolidates all revenue streams and expenditures under one entity. • Workforce Stability: Offers competitive benefits through FRS, improving recruitment and retention. Financial Implications of Option 2-C • Personnel Costs: Consolidation will require full integration of KLFD and KLEMS staff under the district, with FRS benefits. Personnel costs are projected to increase by approximately $400,000 annually for each four-person staffing increment, with cumulative additions reaching $2.38 million by FY 2030. • Operating Expenses: These are expected to rise at an annual rate of 13.6%, consistent with historical trends but offset by efficiencies from unified operations. • Capital Costs: An annual minimum capital reserve of $375,000 can be maintained, with planned apparatus and facility upgrades. • Revenue: Ad valorem tax revenue will remain the primary source, supplemented by ambulance billing revenue (estimated at $325,000 annually, increasing by 3% per year). • Millage Rate Impact: Forecast models indicate a gradual increase in millage rates from 1.1975 to approximately 1.60 mills by FY 2030 to sustain operations and reserves under the Consolidated model. JA' * C GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Fund Balance: The district will maintain a strong reserve policy aligned with Government Finance Officers Association (GFOA) best practices, ensuring financial stability and disaster readiness. General Recommendations • Service Delivery & Performance (Data Analysis) ■ Recommendation A-1: Continue preparing for the implementation of the National Emergency Response Information System. ■ Recommendation A-2: Consider developing and adopting a Data Outlier Management Policy to help ensure the accuracy of incident records. ■ Recommendation A-3: As part of the implementation of NERIS, adopt a system and written policy for incident data review and quality improvement. • Financial Recommendations ■ Recommendation B-1: Consider participation in the Public Emergency Medical Transportation Program. • Management Components ■ Recommendation C-1: Complete a Community-Driven Strategic Plan. ■ Recommendation C-2: Conduct regularly scheduled staff meetings with administrative staff. • Health, Wellness, & Safety Program ■ Recommendation D-1: Develop a Risk Management Plan. ■ Recommendation D-2: Install apparatus-mounted filtration systems on diesel vehicles. ■ Recommendation D-3: Ensure initial and annual physicals are conducted for all personnel. ■ Recommendation D-4: Establish a tracking program for traumatic events. Like many fire service organizations, KLFREMS, KLFD, and KLEMS continually improve and evolve their operations. This report provides a snapshot of these agencies as of the time the information was gathered—beginning in late 2024 through 2025. It was not possible to capture all changes that may have been made during the report's development. The following sections provide detailed analyses and supporting data for these recommendations, along with projected financial impacts and implementation strategies. JA- W ngle 7 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Together, these elements form a roadmap for creating a unified, resilient, and sustainable emergency services system for Key Largo. JA' W ngle 8 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Overviewii The following section provides a basic demographic overview of those communities served by the three agencies participating in this study. Monroe County The Key Largo Fire Rescue & EMS District (KLFREMS), the Key Largo Volunteer Fire Department or Key Largo Fire Department (KLFD), and Key Largo Volunteer Ambulance Corps or Key Largo Emergency Medical Services (KLEMS) provide their respective services to residents and visitors of Monroe County. Monroe County comprises 3,738 square miles, of which 983 square miles are land and 2,754 square miles consist of water.' As of July 1, 2023, the county's estimated population was 80,614.2 This was a decline of 2,258 persons, or 2,7%, since 2020. Key Largo The Key Largo Fire Rescue & EMS District covers just over 20 square miles and has an estimated population of 11,674 residents as of 2023.3 Nearly 4% of the population is age 4 or younger, while nearly 27% are seniors, are 65 and older.4 Nearly 95% of the population lives in rural areas.5 Data from Esri° indicated that the 2024 daytime population of workers was 5,427, while the daytime population of residents was 5,500. The district has 5,163 households and 8,260 housing units, and an average household size of 2.26 individuals.6 The average home value in 2024 was $866,574, with a median value of $741,766. In 2024, over 70% of homes were owner-occupied.? In 2022, at least 24% of households in the district had one person with a disability.$ English was the primary language spoken at home by the majority of residents, followed by Spanish and a combination of English and Spanish.9 ' Wikipedia. 2 American Community Survey, United State Census Bureau. 3 Esri 2024. 4Ibid. 5 Esri 2024. 1Ibid. 7 Esri 2024. 81bid. 9 Ibid. JA- * ngle 9 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Income & Poverty The 2024 median household income was $77,378, with a median net worth of $321,864.10 The per capita income in 2024 was $57,332.11 Nearly 19% of the population had an annual income of $200,000 or more. About 5% of the population in 2022 was below the poverty level, with a very small percentage being provided public assistance income.12 Business & Employment Not surprisingly, most businesses in the district involve service organizations, retail trade, eating and drinking businesses, finance and real estate, and construction. Unemployment in 2024 was approximately 2%. Figure 1 illustrates the population density of the study area. Figure 1: Key Largor l tin Density c: hGbP'IXh h 9 ! r 1 qq �g� jf k�lU f fi A / J h i' drrPra V"tlPPSFP:kaerrv'i K .25 4:rtrwl OiaPa;V abalut tl"dtlM1t Nee Key Largo �Flo teict Uuranetl.rr6a5 / KI i REM S Plant stavoin St.von f''crEsulaticait DO:ns y A V.owest ow 1213 Moderate 00 H h. h hcFhmt R151 2 3 4 NGA'Uw ,rlv,,roy Pri ,ru,:uPr Dist "Pf,r ,i,. r,r aVz III N✓r•ROS /r e,;Ya,Fr J,r Apr.,I "Mf/NA91,l A,6 HIA NN Ili6),'Wfl VA' 10 Esri 2024. 11 Ibid. 12 U.S. Department of Health & Human Services. JA' W ngle 10 GROUP/= Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS EVALUATION OF CURRENT CONDITIONS J* Section I.: GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Overviewi i This section provides a brief overview of each organization's current conditions. Key Largo Fire Rescue & EMS District The Key Largo Fire Rescue & EMS District is a special district in accordance with Florida law. The district functions as an umbrella organization for KLFD and KLEMS, providing legal and financial services, a District Clerk, and the Medical Director under contract. Florida ecial Districts The Florida Constitution defines a "special district" as a unit of local government created for a special purpose, as opposed to a general purpose, which has jurisdiction to operate within a limited geographic boundary and is created by general law, special act, local ordinance, or by rule of the Governor and Cabinet."13 Governance & Lines of Authority Special districts are units of local special-purpose government, such as counties and municipalities. Special districts, such as KLFREMS, provide local specialized governmental services and have limited, related, and explicitly prescribed powers. A five-member elected Board of Commissioners oversees KLFREMS. Figure 2 illustrates the Key Largo Fire Rescue & EMS District. Figure r i i I Chart :i*Rr OF r • LargoKey Fire Rescue&EMS District ................................. Legal Services DISTRACT CLERK� Finance • � e a� , n„ ���,,"hhhhhhhh BOARD VI 1F DIRECTORS IIi li BOARD OF DIRECTORS Key ILargo u9,er llllAmbulance•orp Key Largo , Department 13 Section 189.012(6), Florida Statutes. JA' * ngle 12 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS As shown in Figure 2, Key Largo EMS and the Key Largo Fire Department are overseen by their respective Boards of Directors. The EMS Chief and the Fire Chief (both positions held by the same individual) answer to their respective Boards of Directors. Key Largo Emergency Medical Services The Key Largo Volunteer Ambulance Corps, Inc.—also known as Key Largo Emergency Medical Services—is a 501 (c)(3) non-profit corporation established around 1955 and currently operating under the auspices of KLFREMS. Governance Lines of Authority Figure 3 shows the current organizational chart of Key Largo Emergency Medical Services. As shown, the Chief answers directly to the five-member KLEMS Board of Directors and is responsible for managing the organization. Figure r i i I Chart ) BOARD OF �Sh9ft 8 3hff6 S ftf ®ISM m m pM" i Position currently not filled. These duties performed by Operations staff and are not separate FTEs. As shown in Figure 3, the Chief supervises a Deputy Chief of Administration and a Deputy Chief of Operations (currently vacant). The Operations Division comprises three shifts, with a Lieutenant responsible for a total of five Lead Paramedics per shift. The Deputy Chief of Administration supervises several Lieutenants assigned to training, safety, logistics, and other administrative support functions. The Chief manages infection control. Key Largo EMS maintains a membership ranging from 35 to 40 personnel. JA' W ngle 13 GROUP,rrC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Deployment & Oerai s Key Largo EMS deploys its personnel and rescue trucks (ambulances) from Station 23 and Station 25. It serves an area of approximately 25 linear miles with an estimated resident population ranging from 13,188 to 14,000—which does not include the influx of year-round visitors.14 KLEMS maintains four rescue trucks equipped to provide advanced life support (ALS). Three rescues operate 24 hours daily. The rescue trucks are staffed with EMT-Basics (EMT-B) and EMT-Paramedics (EMT-P). Medical Direction & AdministrativeSupport Medical Director & Quality Improvement Key Largo EMS personnel provide patient care in accordance with the protocols promulgated by the Medical Director. The Medical Director participates in hands-on training and quality improvement through quarterly case reviews. A Lieutenant is assigned as the Quality Assurance Officer and conducts reviews of electronic patient-care reports (ePCR) to ensure accuracy and compliance with the patient-care protocols. Administrative Support Administrative support consists of an on-shift Training Officer (TO) who implements monthly online continuing medical education (CME). In addition, the TO conducts in-service training on new equipment and arranges training sessions with external instructors. The duties of the Logistics Officer include maintaining medical and other supplies necessary for patient care and general operations. Key Largo Fire Department The Key Largo Fire Department, Inc. is a combination fire department functioning under the auspices of the Key Largo Fire Rescue & EMS District. The original volunteer fire department was established in 1950 and, in 2013, reformed as a new corporation after the district discontinued the old corporation's contract. KLFD is also a non-profit 501 (c)(3) corporation. 14 Key Largo EMS 2023 Annual Report. JA' W ngle 14 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Governance i e of Authority Figure 4 is an illustration of the current KLFD organization. The Fire Chief—who also serves as the Emergency Management Coordinator and Infection Control Officer—reports directly to the Board of Directors. Figure L r i i I Chart ) BOARD OF r- Key g. Volunteer Fire Department r r• . AA Shift fi Shift C� hlft Moms in r• �e a a s o AAlso performs Emergency Management & Infection Control duties. BAlso performs Logistics functions. C=Also performs Training & Public Information functions. UAlso performs Fire Prevention duties. e EMS MFR Program duties. The Fire Chief maintains direct supervision over three Captains—each of whom is assigned to one of three shifts in operations. The Captains oversee the four shift Lieutenants, who supervise the Drivers/Engineers and Firefighters. The Firefighters may be certified as EMT- Basic or EMT-Paramedic. As shown in the organizational chart, the Fire Chief and Captains perform other duties. The Fire Chief also serves as the Emergency Management Coordinator and Infection Control Officer. The AA Shift Captain is responsible for Logistics, the BB Shift Captain performs the Training and Public Information Officer (PIO) functions, and the CC Shift Captain is responsible for fire prevention activities. JA' W ngle 15 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Operations & Deployment KLFD provides traditional fire suppression and wildland firefighting, medical first response (MFR) at the ALS level, and basic response to hazardous materials incidents. It serves an area of approximately 17 square miles with an estimated resident population of 12,443 persons—which does not include the influx of year-round visitors. Figure 5 shows the study area boundaries. Figure r r Boundaries North Key argo x N rl fV fYGla I..'p6'.0 YY JYi S yU'I to IP-',E!kil ,p KLV -25 a arral Wt-11>fkAPfi F1,dda teey,'.. uVSC Key Largo ® District.Boundaries KLFREMS Fire Stations ij VF -24 KLFREMS EMS KLVA Station M 00,51 2 3 4 Err'NASA,NK'e II GS,FEW,PvlWrrr o--D,,,6�County,MEP hii,lE,,wT nf,C,w,,rf,Sid In,AIWh; Miles l r 1,x i,-,In,,,Bvt1 P/ 6A USG,USA NYS USNkd4,UI d W',, The Key Largo Fire Department deploys its apparatus and personnel from two fire stations, both staffed 24 hours a day. In 2024, KLFD was assigned a Public Protection Classification (PPC®) rating of Class 4/4X by the Insurances Services Office (ISO). The PPC rating primarily impacts the insurance costs to businesses. Class 1 represents the highest and 10 the lowest. Figure 5 shows the service areas of KLEMS and KLFD. JA' W ngle 16 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Other Services Provided by KLFD KLFD provides very limited public education, usually restricted to Fire Safety Week. Fire inspections, code enforcement, plan reviews, and fire-cause and arson investigations are done by the Monroe County Fire Marshal's Office. Other Public Safety Resources Dispatch er e cy Communications The Communications Division of the Monroe County Sheriff's Office (MCSO) serves as the county's primary Public Safety Answering Point (PSAP) by answering 9-1-1 calls (including non-emergency calls) and providing dispatch services and emergency communications for all public safety agencies—except for Ocean Reef and the City of Key West, which have their own dispatch centers. MCSO is responsible for dispatching EMS, fire/rescue agencies, and sheriff's deputies. Key Largo residents do not pay any additional fees beyond property taxes for MSCO communication services. The Communications Division is headquartered in Marathon but has recently added a second facility in Plantation Key. The Communications Division staff are trained to provide pre-arrival instructions to callers in medical emergencies and fire incidents. The Communications Division also serves as a control specialist for Trauma Star. Mutual Aid Resources The Key Largo Fire Department and Key Largo EMS have multiple options for obtaining mutual aid or automatic aid for fire suppression, rescues, ground emergency medical transport (GEMT), and other services. Figure 6 lists adjacent fire departments that will provide mutual aid to KLEMS and KLFD, along with the apparatus and staff available at those facilities. JA' * ngle 17 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure l Aid ResourcesAvailable Miami-Dade Fire Rescue #65 1 0 Rescue 7 Ocean Reef Public Safety #26 1 1 Rescues (2) 8 Monroe County Fire Rescue #22 1 0 Tanker, Rescue 4 #21 1 0 Rescue 4 Islamorada Fire Rescue #20 1 1 Rescues (2) 4 #19 1 0 Rescue 4 JA' W ngle 18 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 7 shows the locations of those stations listed in Figure 6. Figure tic & Mutual Aid Stationsj rAgencies MDFR Station 65 Southern G�ades waned Station 26 °rrvuu'aitlurvaituoW Area n;,r+Stay J rhhrreunra Key l.JKgn P Iar nniuck B.arr¢CM State 6'•^avrk Coco e ke � NIX}r P C '(9 e fuge FD-25 Ho Eli0�5 o r' r s TraO FD-24 LVAC Key Largo ® District Boundaries Station 22 KLFREMS Fire Station 21 Stations KLFREMS EMS Station Automatic Aid Station 20 Mutual Aid Station 15 JA' * ngle 19 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Organizational I Management & Administration Managing a public safety organization effectively is complex, often impacted by financial constraints, political pressures, and demanding community expectations. Today, such organizations must address these complexities by ensuring an efficient, flexible organizational structure; maintaining competencies; providing adequate responses; ensuring a qualified workforce; and achieving financial sustainability. A well-organized and efficiently administered fire department or EMS organization has appropriate documentation, policies, and procedures. It clearly understands, acknowledges, and addresses internal and external organizational issues. Processes must also be established to address the flow of information and communication between the Key Largo public safety agencies and the citizens they serve. The J. Angle Group has analyzed each agency's management efforts in the following section. Managementtructur As discussed previously, KLFREMS, as a Special Fire Control Taxing District in accordance with Florida Law, maintains an elected five-member Board of Commissioners. In addition, KLEMS has a five-member Board of Directors, and KLFD has a five-member Corporate Board of Directors. Therefore, 15 individuals are responsible for overseeing these organizations. Strategic I ire To be effective, the management of a public safety organization must be grounded in accepting and adopting solid Mission, Vision, Values, Goals, and Objectives Statements as a key part of creating a relevant and contemporary Strategic Plan. Fire service and EMS organizations should create and maintain a Strategic Plan, complete with established and communicated goals and objectives, as well as metrics to measure effectiveness and achievement. Mission, Vision, Values, Goals, and Objectives Statements are typically developed during a formal strategic planning process, leading to the creation and formal adoption of a written Strategic Plan. This process often includes the following components: • Internal and external environmental scan (e.g., SWOT Analysis). • Mission, Vision, and Values Statements. JA' * ngle 20 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS • Initiatives, goals, and subordinate objectives with performance metrics or outcomes. • Timelines assigned to each objective. • The initiative manager assigned to each initiative. • Responsible personnel are assigned to coordinate the achievement of objectives. The Strategic Plan establishes timelines for accomplishing the goals and objectives and assigns them to appropriate personnel. In creating a Strategic Plan, goals and objectives are prioritized, and timelines are established to define a realistic, achievable workflow. Personnel are then assigned to manage progress toward achieving each objective and to be accountable for their progress. All work and organizational activities should support the mission, propel the agency toward its vision, and reinforce its values. Key Largo Fire Rescue & Emergency Medical Services District While the Key Largo Fire & EMS District has not adopted specific Mission or Vision Statements, it does list the following goals for originally establishing the district: • Offer residents a higher level of service at a lower cost. • Provide more direct control over revenue and expenses. • Streamline existing work processes to reduce administrative tasks. • Foster volunteerism. • Remain as volunteer departments. Key Largo EMS Mission, Vision, & Values Statements KLEMS has adopted a Mission Statement, Vision Statement, and a Values Statement. These are found in the Key Largo EMS Annual Report 2023. Its formal Mission Statement is as follows: Mission Statement The mission of the Key Largo Volunteer Ambulance Corps is to provide excellent, professional, and compassionate medical care for our community. JA' * ngle 21 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS K111 EMS Vision Statement • It is the goal of Key Largo Volunteer Ambulance Corps to provide the highest level of care to the citizens and visitors of Key Largo. • To create an environment that will help our members further their goals. • Making a difference...one patient at a time. KIII...IF S Values Statement • Safety: Safety in our Operations and in our Community through education, through training, and leading by example. • Professionalism: To be viewed in the eyes of our community as professionals both on and off duty. • Caring & Compassion: Being supportive of our patients and their families, our members, friends, and neighbors through teamwork. • Advocacy: Performing in the best interests of our patients, our community, our Corps, and its members. • Progressive: To be known as a quality organization focusing on training, mentoring, best practices, and community relations. • Teamwork: There is no failure through teamwork. We always look forward and learn from the past. Key Largo Fire Department Mission As stated on the department's website, the Mission Statement of KLFD is as follows: Mission Statement The Mission of the Key Largo Volunteer Fire Department is to provide the highest level of fire and rescue services possible through community involvement, education, and prevention. Their team of friendly and dedicated professionals will strive for excellence to serve our community in paradise. JA- * ngle 22 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Management Documents & Processes Documentation of activities is necessary to meet a public safety organization's mission and is also a legal requirement in many aspects of fire department and EMS operations. Detailed and consistent documentation also provides a mechanism for measuring performance. In organizations that provide some form of EMS, this can entail both clinical and operational performance. Developing and maintaining policies and procedures is critical to ensuring a stable, effective, and cohesive organization. Figure 8 lists the KLEMS and KLFD elements concerning management documents and processes. Figure LRegulatory Documents NERNM r ® gi Standard Operating Guidelines (SOG) in place Yes Yes SOGs regularly updated Yes Yes SOGs used in training evolutions Yes Yes Organizational Policies in place Yes Yes Policies internally reviewed for legal mandate Yes Yes Internally reviewed for consistency No Yes Training on policies provided regularly Online No Process to ensure compliance with regulations No No Internal Assessment of Critical Issues The following discussion describes the critical issues facing KLEMS and KLFD from each agency's leadership perspective. y Largo EMS Critical Issue 1 m Staffing. There are not enough applicants to meet current staffing needs. Critical Issue 2e Funding. With limited budgetary resources, it is difficult to meet all the department's needs while controlling spending. JA- * ngle 23 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Critical Issue 3: Retention. It takes a minimum of three months for a Paramedic to become a lead medic. Many leave for larger departments in search of opportunities that KLEMS cannot offer. Critical Issue 4: Structure. [We] need a better chain of command to handle daily activities and incidents. Critical Issue 5: Mental Health. Stress, home life issues, finances, and post-traumatic stress disorder (PTSID) are becoming more common and need to be addressed. Key Largo Fire Department Critical Issue 1: Funding. [Lack of funding] limits our ability to increase staffing, training, and infrastructure, among other things. Critical Issue 2: Staffing. [Additional staffing would improve] our ability to adequately respond to incidents and manage department needs. Critical Issue 3: Training. The better educated the staff is, the better their ability to perform the necessary jobs. Critical Issue 4: Structure. [KLVD is a] small department, thus limiting the number of advancements without becoming "top heavy." This also requires more advanced work from everyone. Critical Issue 5: Mental Health. Stress, home life issues, finances, and post-traumatic stress disorder (PTSD) are becoming more common and need to be addressed. Except for "Training" and "Retention," both agencies identified the same critical issues: • Staffing • Funding • Structure • Mental Health The four issues listed previously should be prioritized when considering the potential consolidation of the two agencies, along with issues related to training and retention. JA' * ngle 24 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Internal xer t Communications In today's communication environment, the public expects strategic, frequent, responsive, and thoughtful communication from its government and public safety agencies. Likewise, employees expect the same when disseminating internal messages. Without it, public and employee confidence in each respective organization can be severely damaged, and informal communication channels may be created to spread false and misleading information throughout the community and organizations. External l or» munications The Key Largo Fire Rescue & EMS District, KLEMS, and KLFD each maintain separate websites that provide basic information on their respective services and programs. Key Largo Fire Rescue & EMS District • About the District • Commissioners • Meetings/Minutes • Departments (links to KLEMS and KLFD) • Budgets & Audit • Links & Resources • Links to KLEMS and KLFD statistics ■ Statistics are outdated, from 2018 • Legislation Key Largo EMS In addition to its website, KLEMS maintains a FacebookO site. Its website contains the following: • About the Organization • Resources • A link to the 2023 Annual Report JA- * ngle 25 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Key Largo Fire Department In addition to its website, KLFD maintains a Facebooka site. Its website contains the following: • About Us • Fire Station Locations • Staff Directory • Emergency Services • Informational Bulletin • Incident Report Request • Meetings • Downloadable Files & Reports • Links & Resources • Contact The Key Largo Fire Department website appears to be the most comprehensive of the three and utilizes updated web design technology. Its Facebook® pages are up to date. The Key Largo EMS website is very limited and contains outdated reports. The latest post on its FacebooO site is dated May 25, 2024. Neither KLFD or KLEMS publishes a regular community newsletter about their activities, available fire safety and illness and injury prevention training, or other important information for the public. Illinteirirmalll Communications Regular internal communications are important to an adequately functioning public safety organization. Staff should be kept informed of significant issues or changes and should also have a means of communicating with management. Key Largo EMS KLEMS does not have regularly scheduled staff meetings but will meet when needed or requested. Only primary personnel and officers are provided with a KLEMS-assigned e-mail address. Other members utilize personal e-mail. The agency does not publish a staff newsletter or maintain an Intranet site for employees. Written memos are utilized when needed, and "all-hands" meetings are scheduled when necessary. JA' * ngle 26 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Key Largo Fire Department KLFD does not have regularly scheduled staff meetings. All members are assigned a fire department e-mail address. The department does not publish an internal agency newsletter. Written memos are used when necessary. Management has an informal "open- door" policy, and the chain of command has been clearly communicated to the members. KLFD has an internal network which was implemented in August of 2024. Each employee and volunteer receives a log in and can access SOP's, policies, memos, etc. Record Keeping oo Control Diligent and thorough documentation and analysis of public safety agency activities are critical in making sound management decisions and maintaining public transparency when presenting issues to the electorate or approving expenditures. Taxpayers and elected officials expect current and accurate data and information to make good decisions. Both Key Largo EMS and the Key Largo Fire Department utilize a records management system (RMS) from ESO° Solutions. Key Largo EMS KLEMS uses the ESO® Emergency Medical Services RMS to generate electronic patient care records (ePCR). The software is password-protected. Data from the system is used to generate monthly operational reports and annual reports, both of which include various statistics. Paper records of cases involving KLEMS staff exposures are kept in a locked file. A process is in place for public records access requests. Computers with access to the ESO° RMS are available to staff. Hard copies of any records are kept in a locked file cabinet. Vehicle records are kept by Ten-8 Fire & Safety, which maintains the KLEMS vehicles. Key Largo Fire Department KLFD uses the ESO° Fire RMS system to document fire, EMS, and other incidents, including staff exposures. The system is password-protected, the fire stations are secure with RIFD card locks, and the offices have key locks. Incident data is used to publish monthly and annual reports. Vehicle records are kept internally by Ten-8 Fire & Safety. A process is in place for public records access requests. Contract providers maintain the following testing and associated records: SCBA testing JA' * ngle 27 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS • Hose testing • Ladder testing • Pump testing • Breathing air testing Planning for Fire Protection & EMS Well-managed public safety organizations spend considerable time and effort analyzing data to evaluate their effectiveness and efficiency in delivering high-quality emergency services. The two main areas of planning are: • Emergency preparedness and response planning • Administrative and organizational planning Key Largo KLEMS reported that it relies on the Key Largo Fire Department for most of its planning. Key Largo Fire Department Administrative IPlllanniing Administrative planning is critical to ensuring effective and efficient public safety service delivery to a community, yet emergency response planning efforts often overshadow it. Administrative planning can take many different forms, including: • Master Planning • Strategic Planning • Succession Planning • Community Development Planning • Capital Equipment/Facilities/Apparatus Planning • Community Risk Assessment/Standards of Cover • Community Risk Reduction A collaborative strategic planning process involving all levels within the organization and community stakeholders can lead to the formulation and adoption of realistic and achievable goals. A successful strategic planning process and outcomes should result in organizational improvements in policies and procedures, internal and external JA' * ngle 28 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS communications practices, operational deployment, recordkeeping, and sustainable financial practices. For mission, vision, and values, and strategic planning to be effective, they must be part of a "living" process, consciously evolving as KLFD grows and changes. KLFD does not have an all-hazards Emergency Preparedness Plan, a contemporary Community Risk Assessment/Standards of Cover (CRA/SOC) document, or a Community Risk Reduction (CRR) plan. Operational Tactic lllIll1lll ininiiin KLFD maintains the following operational plans: • Response planning • Operational and incident command SOPS • Mutual aid planning and agreements • Disaster plan Tactical planning includes: • Pre-incident planning • Pre-incident planning based on NFPA 1620 • Specific hazard plans • Hazardous materials planning JA' W ngle 29 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Introduction During the initial stages of planning this study, it became evident that engaging both internal and external stakeholders would be crucial for the following reasons: 1 . Bringing Diverse Perspectives: Involving Firefighters, administrators, community members, and local officials brings varied insights, ensuring a comprehensive understanding of the merger's potential impacts and benefits. 2. Addressing Needs and Concerns: Engaging stakeholders helps identify specific needs, expectations, and concerns, enabling anticipation of challenges and potential resistance. 3. Building Trust and Support: Transparency through stakeholder involvement fosters trust and garners community and department members' support, streamlining implementation. 4. Facilitating Communication: Open dialogue ensures stakeholders stay informed, resolves misunderstandings, and enables active participation throughout the process. 5. Improving Decision-Making: Feedback from stakeholders enables better-informed decisions that align with community priorities and departmental needs. b. Fostering Collaboration: Engagement encourages teamwork among departments and the community, fostering innovative solutions and a shared vision for future services. 7. Assessing Community Impact: Understanding community perspectives is crucial for evaluating potential effects. The first step in the feedback process was to identify the internal and external stakeholders. The groups included: • Internal Stakeholder Groups ■ Board members of KLFREMS ■ All members, including Board members of KLFD ■ All members, including Board members of KLEMS ■ Contract services (legal, financial, etc.) • External Groups ■ Residents of the district ■ Business owners in the district Face-to-face meetings and online surveys were utilized to maximize participation in the process. A comprehensive summary of the results, along with further descriptions of each, is available in Appendix A. JA' * ngle 30 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS IPersonnel Management & Staffing The greatest asset for any organization is its personnel. Therefore, managing an organization's human capital is essential to achieving maximum production while ensuring employees enjoy a high level of job satisfaction. Job satisfaction is typically a combined result of several factors, including consistent management practices, a safe working environment, recognition of positive workforce practices, inclusion, equitable treatment, and the encouragement of workforce input. The size and structure of an organization's staff depend on the organization's specific needs. Organizational priorities should align with the community they serve. Several national organizations provide staffing guidance and recommendations, including the Occupational Health and Safety Administration (OSHA), the National Fire Protection Association (NFPA), and the Center for Public Safety Excellence (CPSE). Since the Key Largo Fire Rescue & EMS District contracts with KLFD and KLEMS, this section provides an overview of KLFD's and KLEMS's staffing configurations. Two distinct staff groups are common in most fire and EMS organizations. The first is the administrative and support staff that directly serves internal customers by providing the management and support needed to deliver effective and efficient emergency services. Some support staff members provide direct specialty functions, such as public education and fire prevention functions, to external customers. The second group is the operational staff, or internal customers, who provide emergency services to external customers and are typically the most recognized group among the citizens. Ensuring a balance between these two groups is essential for providing effective, efficient emergency services and high-quality customer service. For KLFD and KLEMS, this includes both paid staff and volunteers, who are also referred to as "paid-on-call." Administrative & Support Staffing Providing operational staff with the means and ability to respond to and mitigate emergencies safely, effectively, and efficiently is a primary responsibility of administrative and support staff. JA' * ngle 31 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Additional responsibilities of this group include planning, organizing, directing, coordinating, and evaluating the various programs utilized within the KLFREMS. In many cases, administrative and support staff concurrently handle a variety of responsibilities, some of which were not previously mentioned. y Largo Fire Rescue & Emergency Medical Services District As previously discussed, KLFREMS contracts with KLFD and KLEMS for fire and EMS. Aside from the five-member Board of Commissioners and contractual agreements for legal, financial, clerical, and health services, KLFREMS has no administrative or support staff. Key Largo Fire Department KLFD operates as a combination fire department with paid full-time staff and volunteers (paid-on-call). From an administrative and support staffing perspective, limited resources are dedicated to these functions. Currently, only a Fire Chief is in place, who is a volunteer. While the three Captains handle many administrative responsibilities, they serve in operational roles and are included in the Operational Staffing section. Figure 9 illustrates the administrative and support staffing structure for KLFD. Figure : KLFD AdministrativerStaffing IMUNSMISIM Fire Chief 1 VolunteerA Total: 1 A This position is strictly a volunteer position which is allotted for a stipend only.Also serves as the KLEMS Chief. Administrative and support staffing represents 4% of the total KLFD personnel. This percentage does not include KLFD volunteer operational personnel, as their numbers fluctuate. While the Fire Chief position is entitled to a salary, the current member does not accept it; thus, the previous notation was that of a volunteer. Key Largo Emergency Medical Services KLEMS operates as a combination EMS department with paid full-time staff, part-time staff, and paid-on-call personnel. Like KLFD, KLEMS operates with limited administrative and support staffing resources. Currently, the only full-time support staff member is the Office Manager. Administration includes the EMS Chief and Deputy Chief of Administration serving in volunteer roles. JA' * ngle 32 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Administrative and support functions such as information technology and EMS billing are contracted to third-party vendors. While the two Lieutenants handle many administrative responsibilities, they serve in operational roles and are included in the Operational Staffing section. Figure 10 illustrates the administrative and support staffing structure for KLEMS. Figure Administrative rStaffing IMIZINSMEMM EMS Chief 1 Volunteer^ Deputy Chief 1 Volunteer Office Manager 1 40 Total: 3 A The EMS Chief is a part-time Paramedic who receives compensation per hours worked. One person holds both Fire and EMS Chief positions. Administrative and support staffing accounts for 13% of total KLEMS personnel. This percentage does not include KLEMS volunteer operational personnel, as their numbers fluctuate. Additionally, the same individual holds the position of Fire Chief and EMS Chief. Operational Staffing As previously discussed, the operational staff is typically the face of any fire service organization due to their increased interaction with the citizens they serve. This group is involved with nearly every facet of the organization's operations. Key Largo Fire Rescue & Emergency Medical Services District Due to contractual agreements with KLFD and KLEMS for both fire and EMS services, KLFREMS has no operational employees. Key Largo Fire Department As previously discussed, KLFD operates as a combination fire department with paid full-time staff and paid-on-call personnel. JA' * ngle 33 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 1 1 illustrates KLFD's paid operational staffing structure. Figure 11: KLFD Paidr i l Staffing Room Captains/Paramedics 3 56 48/96 Lieutenants/Paramedics 3 56 48/96 Lieu tenants/EMTs 1 56 48/96 Driver Engineers/Paramedics 6 56 48/96 Driver Engineers/EMTs 5 56 48/96 Firefighter/EMTs 5 56 48/96 Totals: 23 A three-platoon system working 48-hour rotations, which yields an average 56-hour workweek, accomplishes shift operations for KLFD. KLFD operational personnel are paid on a 40-hour FLSA Work Period, and any hours over 40 are paid at 1.5 times the regular pay rate. Currently, the minimum operational daily staffing goal for KLFD is six personnel responding from two fire stations on two front-line apparatus. However, the department reported that the minimum staffing goal was being increased to eight personnel at the time of this report. Additional apparatus is staffed and utilized depending on incident types and available personnel. Figure 12 illustrates KLFD's volunteer operational staffing structure. It should be noted that volunteer staffing in KLFD fluctuates, and the number of members in Figure 12 was based on the relevant data provided at the time of this study. JA' * ngle 34 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 1 : KLFD Volunteer Operational Staffing NIZ=EMEMEM Firefighter/EMTs 3 Varies — Firefighter/Paramedics 1 Varies — Total: 4 As previously discussed, the KLFD volunteers are considered paid-on-call personnel. All members receive a stipend of $84 per 12 hours worked, up to a maximum of 240 hours, with a cap of $1,800 per month. Key Largo Emergency Medical Services As previously discussed, KLEMS operates as a combination EMS department with both paid full-time staff, paid part-time staff, and volunteers. Figure 13 illustrates the paid operational staffing of KLEMS. Figure KLEMS Paidr i l Staffing NUMININEBM Lieutenants/Paramedics 2 48 48/96 Paramedics 17 48 48/96 Total: 19 A three-platoon system of paid Paramedics working 48-hour shift rotations that yield an average 48-hour workweek—due to a "Kelly Day" cycle—accomplishes shift operations. However, at the time of this study, it was reported that current staffing levels do not allow for rotation. KLEMS operational personnel are paid on a 40-hour FLSA Work Period, and any more than 40 hours are paid at 1 .5 times the regular pay rate. The minimum operational daily staffing goal for KLEMS is six personnel, with responses from two stations on three ambulances. Staffing can be supplemented by volunteer personnel. JA' * ngle 35 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 14 illustrates the operational staffing structure for KLEMS volunteers. It should be noted that volunteer staffing in KLEMS fluctuates, and the number of members in Figure 14 was based on relevant data provided at the time of this study. Figure Volunteer Operational Staffing IZIESEMMM EMTs 7 Varies — Paramedics 4 Varies — Total: 11 All members are entitled to $175.00 per 24-hour shift, with an average of 4-6 shifts per month. Methodology for Incident Staffing Providing the appropriate units with sufficient responders is critical for all emergency incidents, but it is especially true for fire suppression operations and high-acuity emergency medical incidents. From a fire suppression operations perspective, staffing methodologies are typically derived from the aforementioned national organizations. For example, OSHA safety regulations (CFR 1910.120) require that personnel entering a building involved in a fire must do so in groups of two. Further, before personnel can enter a building, at least two additional Firefighters must be on-scene and assigned to conduct search and rescue in case the initial crew becomes trapped. This is referred to as the "two-in, two-out rule." From an EMS incident perspective, in Florida, staffing laws are defined in Statutes 401 and Administrative Code Rule 64J. These documents mandate that at least two qualified individuals staff every ambulance. For advanced life support (ALS) services, such as those provided by KLEMS, at least one crew member must be a certified Paramedic. Key Largo Fire Department As previously discussed, KLFD has a minimum staffing requirement of six personnel per day. Several fire suppression apparatus are housed at the two KLFD fire stations, and cross- staffing is utilized to respond to specific dispatched emergencies. KLFD's actual response to incidents and performance will be analyzed separately in this report. JA' W ngle 36 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 15 illustrates the current staffing model for KLFD. Figure : KLFD CurrentStaffing I Station 24 Engine 24 3 personnel Station 25 Engine 25 3 personnel Total: 6 personnel As previously discussed, cross-staffing is utilized to respond to specific dispatched emergencies. For Engine 24's crew, this can include an approved member responding in the tanker unit (T24) to a confirmed fire. For Engine 25's crew, this can include an approved member responding in the ladder truck (L25) to a confirmed fire. Key Largo Emergency Medical Services As previously discussed, KLEMS has a minimum staffing requirement of six personnel per day. As shown in Figure 16, two rescue units are housed at KLEMS's base station, and one rescue unit is housed at KLFD Fire Station 25. KLEMS's actual response to incidents and performance will be analyzed in a separate section of the report. Figure Current Staffing 0=1��Wmcm Rescue 23 2 personnel Station 23 Rescue 123 2 personnel Station 25 Rescue 25 2 personnel Total: 6 personnel Staffing Practices The following section provides a general overview of the staffing practices at KLFD and KLEMS. Since KLFREMS does not currently employ personnel, district-specific staffing practices are not included. JA' W ngle 37 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Application ecrui aProcess Human capital is a fire or EMS organization's greatest asset, and hiring and retaining high- quality, capable employees is critical to organizational success. Therefore, a comprehensive hiring process begins long before a new employee becomes a member of either KLFD or KLEMS. Although KLFD does not have an official recruitment program, job openings are listed on its website, along with a detailed flyer that defines minimum job qualifications and the application process. Additionally, KLFD posts job openings on the Florida State Fire Marshal's A-List Announcements. A-List Announcements include training notices, public hearings,job openings, pertinent news, and important notices from the Bureau of Fire Standards and Training. The application process includes a minimum qualifications check, a reference check, a background check, a physical agility test, a written test, and an interview. Currently, no pre-employment physical is required as a condition of hire. For volunteer positions—paid-on-call—KLFD advertises and requires the following documentation: CPAT certification from a nationally recognized organization (such as National Testing Network), completed within one year of application Completion of a 100-question written test FDLE background check Verification of employment 1-9 verification Driver's license verification Certification history verification Physician's authorization Pre-employment drug test Currently, the volunteer recruitment process does not include an interview. JA' W ngle 38 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Like KLFD, KLEMS does not have an official recruitment program, but job openings are found on its website, and a link to an employment application is included. KLEMS also posts job openings on the Florida State Fire Marshal's A-List Announcements and the department's Facebook page. The application process includes a minimum qualifications check, a reference check, a background check, a written test, and an interview. No pre- employment physical is required as a condition of hire, except for drug screening. Disciplinary Process Accountability is vital to accomplish a fire or EMS department's mission while ensuring an effective and efficient operation. Therefore, KLFD and KLEMS have disciplinary processes in place, communicated to their members through standard operating policies (KLFD) and policy manuals (KLEMS). An appeals process is also part of the disciplinary process when disagreements arise. For KLFD, the appeals process is defined in the employee handbook. KLEMS's bylaws allow for an appeal to the Board of Directors. At the time of this report, KLFD had one recent litigation involving the termination of a volunteer member. KLEMS has no recent or pending litigation. Testing, Measuring, ra i a ress Both KLFD and KLEMS have limited functional testing and measuring. For example, KLFD conducts in-house skills and performance evaluations every February through self- evaluations. A supervisory review follows this in August of each year. Additionally, KLFD conducts fitness-for-duty evaluations as part of the annual LIFESCAN®Physicals. KLEMS-only testing and measuring occur during an employee's probationary period. Assessment center formats are not utilized in promotions in either organization. Labor Agreements As previously discussed, KLFD and KLEMS are 501 (c)(3) non-profit corporations. As such, neither department's employees are represented by a labor organization, and no collective bargaining agreements (CBAs) are in place. Reports Records KLFD and KLEMS securely archive personnel records, including injury and accident reports, as well as medical and exposure records. KLFD personnel, performance, and health-based files are confidential and are electronically secured using ESO software. Hard copies of files are securely locked in file cabinets. The three operational Captains manage records responsibilities. JA' W ngle 39 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS KLEMS personnel and health-based files are confidential and stored in hard copies, securely locked in file cabinets at the main office. A software system is utilized for personnel certifications. The Office Manager and the Recording Secretary are responsible for record- keeping. Overall Staffing & Personnel Comparison Summary Figure 17 provides a comparison of staffing and personnel practices for KLFD and KLEMS. Figure 1Staffing Personnel Comparisons INNIZZIE12=03=10M= KLFD/KLEMS Chief & Administrative &Support Staffing 1 3 KLEMS Deputy Chief are volunteers % of Administrative/Support Staffing vs. 4% 13% — Operational Staffing Paid Operational Staffing 23 21 Combined operational staffing of 44 Minimum Daily Operational Staffing 6 6 KLFD in process of moving to 8 Operational Shift Schedule 48/96 48/96 56-hour workweek for KLFD & 48-hour for KLEMS Application & Recruitment Process Yes Yes Both utilize A-List Labor Agreements No No Neither is affiliated with a labor organization Personnel Records Management Yes Yes — Discipline Process Yes Yes Communicated through policy by KLFD & KLEMS Testing, Measuring, & Promotional Process Yes Yes Limited for both organizations JA' W C 40 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Health, Wellness, & Safety Programs Fire and EMS organizations operate in inherently hazardous environments, necessitating the implementation of all reasonable precautions to limit exposure to hazards and ensure consistent medical monitoring. Therefore, wellness programs must include education on various topics, such as healthy lifestyles, illness and injury prevention, and—most recently— an emphasis on cancer prevention and mental health support. Typically, the vital health and wellness task is addressed through numerous ongoing processes and comprehensive policies and procedures. The following section explains the health, wellness, and safety programs currently in place for KLFD and KLEMS. Since KLFREMS contracts out all services, no health and wellness programs are in place specifically for the district. Medical xc s (Physicals) Ensuring the health and wellness of fire and EMS personnel typically includes initial and ongoing medical exams. Within the fire service, medical exam programs should follow NFPA 1582: Standard on Comprehensive Occupational Medical Programs for Fire Departments. A comprehensive medical exam program should also include an infectious control program based on NFPA 1581: Standard on Fire Department Infection Control Program, and a fitness-for-duty evaluation program that provides a process for return to duty. These best practice documents are also valuable when developing a comprehensive medical exam program for EMS providers. Figure 18 compares the current medical exams programs. Figure : Medical Exams Programs - 1 0 0 Medical Standards Established Yes No Based on NFPA 1582 Standard Yes N/A Initial Medical Exam Required Yes No Periodic Medical Exams Annually No Infection Control Program Meets NFPA 1581 Yes Yes Process in place for a Fitness for Duty Evaluation' Yes No I Includes return to work. JA' * ngle 41 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Cancer As rates of specific types of cancer continue to increase among Firefighters, scientifically proven by educational institutions like the University of Miami's Sylvester Comprehensive Cancer Center's Firefighter Cancer Initiative (FCI), fire service organizations are beginning to take a proactive approach toward protecting their members.15 A comprehensive cancer prevention program should offer a holistic approach to addressing this disease in the fire service, encompassing mitigation activities at fire stations, during on-scene incidents, and after incidents. Besides the cancer risks associated with combating fire incidents, diesel exhaust is a significant threat to fire service personnel. According to the American Cancer Society16, the Environmental Protection Agency (EPA) has classified diesel exhaust as "likely to be carcinogenic to humans." In addition, the National Institute for Occupational Safety and Health (NIOSH) has determined that diesel exhaust is a "potential occupational carcinogen." Based on these factors and other overwhelming evidence, diesel exhaust is a likely pathway for exposures within the fire service. While EMS providers have limited exposure to fire incidents, diesel exhaust is still a significant threat. In 2019, the Florida Legislature acknowledged scientific evidence linking firefighting to certain cancers. Based on this, Senate Bill 426 created Florida Statutes 1 12.1816, which mandated employer-funded cancer benefits for Firefighters. Under the terms of this law, eligible Firefighters diagnosed with certain types of cancer automatically are entitled to cancer-related benefits at no cost to the Firefighter, enhanced retirement disability and death benefits, and duty-related death benefits. It should be noted that Florida Statutes 112.1816 does not specifically address 501 (c)(3) non-profit corporations such as KLFD. 15 https://umiamihealth.org/sylvester-comprehensive-cancer-center/accomplishment-reports/2021/building- healthier-communities/firefighter-cancer-initiative 16 www.concer.org/cancer/risk-prevention/chemicals/diesel-exhaust-and-cancer.html. JA' * ngle 42 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 19 compares cancer prevention programs currently in place for KLFD and KLEMS. Figure 1 r Prevention Program Contamination Reduction Policy/Procedures in Place Yes Yes Diesel Exhaust Protection Yes No Decontamination Policy/Procedures in Place (PPE & SCBA) Yes Yes (PPE) Extractors Provided Yes N/A Training Provided (Awareness, Prevention, Mitigation, Risk) Yes Yes Cancer Benefits in Compliance with Florida Chapter 2019-21 Yes N/A Exposure Tracking Yes N/A Mental Health An emphasis has recently been placed on mental health support for first responders. Notable increases in diagnosed post-traumatic disorders and suicide rates have been driving increased awareness of mental health support. Comprehensive mental health programs should include components such as critical incident stress debriefings, employee assistance programs, substance abuse programs, and chaplain programs. Fire and EMS organizations should also be tracking exposures related to traumatic events. Florida Statutes 112.181517 provides first responders with post-traumatic stress disorder (PTSD) provisions under workers' compensation coverage. However, benefits depend on specific qualifying events, making overall exposure tracking a critical component in protecting the first responder. 17 www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0400- 0499/0440/Sections/0440.151.html JA' W ngle 43 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 20 compares the mental health programs of KLFD and KLEMS. Figure I Health Programs - 0 - 0 M Critical Incident Stress Debriefing (CISD) Available Yes Yes Member Assistance Program (MAP) Yes Yes Substance Abuse Policy/Program Yes Yes Occupational Exposure Policy (Traumatic Events) No No Chaplain Available Yes Yes Exposure Tracking No No Safetyr r Providing and maintaining safe working conditions requires a variety of programs and initiatives. Developing and adhering to a comprehensive Risk Management Plan is critical. Such a plan should address risks associated with the following: • Administration • Facilities • Training • Vehicle operations • Protective clothing and equipment • Operations at emergency incidents • Non-emergency services or activities • Products of combustion, carcinogens, and other incident-related health hazards The Risk Management Plan should include risk identification, risk evaluation, risk control, risk management monitoring, and the establishment of priorities. Additionally, fire organizations should have a personal accountability procedure, an incident management system, and a rehabilitation system that meets NFPA standards. JA' W ngle 44 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Per Florida Statutes 633.522, Florida Administrative Code 69A-62.043, and NFPA 1550: Standard for Emergency Responder Health and Safety, Chapter 6, fire organizations shall establish a Safety Committee that meets quarterly. Additionally, all fire facilities should be inspected quarterly to address safety concerns and ensure compliance with applicable codes and regulations. These best-practice documents are also valuable when developing comprehensive safety programs for EMS providers. Figure 21 compares the safety programs currently in place for KLFD and KLEMS. Figure 1: Safety Programs Comprehensive Risk Management Plan Yes No Safety & Health Policy Yes No Personal Accountability Procedure (NFPA 1550) Yes N/A Incident Management System (NFPA 1550) Yes N/A Rehabilitation System (NFPA 1584) Yes N/A Traffic Incident Management Yes Yes Post-Incident Analysis Yes No Quarterly Facility Inspections Yes (monthly) No Established Safety Committee Yes No JA' W ngle 45 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Health, ell es , & Safety Programs Comparisons Figure 22 summarizes the health, wellness, and safety programs currently in place for KLFD and KLEMS. Figure Programs Medical Standards Established Based Yes No on NFPA 1582 Cancer Contamination Reduction EMS does not currently Policy/Procedures in Place Yes Yes have a cancer contamination policy. Position is deferred until Designated Health &Safety Officer Yes Yes the Deputy Chief position is filled. Comprehensive Risk Management Plan Yes No KLEMS uses KLFD's Plan Safety & Health Policy Yes Yes Established Safety Committee Yes No KLFD meets every three months or post-injury. Floridaie se Presumption In Florida, there are statutory disease presumptions (like cancer, heart disease, hypertension, tuberculosis, and certain communicable diseases) that apply only to Firefighters—and for some conditions, EMS personnel—that are employed by public agencies, municipal, county, special fire districts, or other governmental entities. Private- sector employes do not receive these presumptions, meaning they must prove direct work- related causation to access benefits. JA' W ngle 46 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Financial i This section of the study provides background information on the historical and current financial condition of the Key Largo Fire Rescue & Emergency Medical Services District, as well as its contracted service providers, the Key Largo Fire Department and the Key Largo Emergency Medical Services. The KLFREMS District is an independent special district created by the Florida legislature in 2005 in accordance with Chapters 189 and 191, Florida Statutes, for the purpose of providing fire, rescue, and EMS services, specifically through contractual relationships with KLFD and KLEMS.18 The district originally had a millage cap of 1 mill but may exceed it—as it has done in both FY 24 and FY 25—only with voter approval.19 Voters approved an increase in the district's maximum millage rate to 2 mills in the election on November 8, 2022. The purpose of the requested increase was outlined fully in Resolution 2022-02 adopted by the District Board on May 23, 2022.20 The district's fiscal year (FY) runs from October 1 through September 30. As part of its annual budget process, the district requires each contractor to prepare and submit detailed line- item budgets for approval. Once approved, these are then used as a basis for district budget preparation. The district budget is divided into three parts: a district administrative budget, a fire/rescue budget, and an EMS budget. 18 Chapter 2005-329,State of Florida House Bill No. 1291.Section 2. Creation;status; charter amendments; boundaries; district purposes—(3) The Key Largo Fire Rescue and Emergency Medical Services District is organized and exists for all purposes set forth in this act and chapter 191, Florida Statutes, including, but not limited to, providing fire protection and firefighting services,rescue services, and emergency medical services. Such emergency medical services shall not be the primary function of the district.The district shall have all other powers necessary to carry out these purposes, including the authority to contract with the Key Largo Volunteer Fire and Rescue Department, Inc., and the Key Largo Volunteer Ambulance Corps [emphasis added], Florida not-for-profit corporations,which corporations currently provide fire, rescue, and emergency medical services within the district boundaries... 19 Chapter 2005-329,State of Florida House Bill No. 1291.Section 6. Ad valorem taxes.j (3). Upon the approval of a majority of the electors voting at the initial election or at an election called by the Board, the rate of taxation shall thereafter be fixed annually by resolution of the Board without further approval by the electors, provided the rate of taxation shall not exceed 1 mill.The Board shall have the authority to increase the millage rate above 1 mill only if a majority of the electors voting in a referendum election approve the increased millage rate [emphasis added] in an amount not to exceed the limit provided in chapter 191, Florida Statutes. 20 See FREMS District Resolution 2022-2 signed May 23, 2022. JA- * ngle 47 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Pursuant to the separate service agreements with KLFD and KLEMS, the Board funds respective expenditures in the adopted budgets in one of three ways: (1) advance payment for minor recurring expenses, (2) direct payment of any approved expenses, and/or (3) reimbursement for budgeted expenses paid for by either KLFD or KLEMS.21,22 Documentation is required in all cases, and purchasing procedures adopted by the district must be followed. JAG was provided with detailed district-adopted and/or actual budget data for fiscal years 2020-2025, as well as financial audits for fiscal years 2020-2024. Although neither actual nor adopted budget data was provided separately for KLFD or KLEMS, district data was sufficient—with minor exceptions addressed later—to develop both individual agency and composite district financial analyses. To fully understand the district's financial resources and costs, JAG first reviewed its historical revenues, expenditures, and fund balance. This involved a five-year historical review to the extent that data was available. Historical trend data were later used to develop key assumptions, leading to financial forecasts of revenue, expenses, and fund balance for FY 26-30 under both status quo and potential alternative configurations. This comparative snapshot of historical financial results sets the stage for modeling potential financial outcomes of various service delivery models. It includes the complete integration of contract providers under the district, which helps assess the fiscal viability of alternatives, both now and in the future. Financial analysis is important in determining the best path forward, including the potential for full integration of the agencies within the district. Therefore, JAG has developed data- driven models to test the respective options using the provided data. A modeled budget fairly represents monetary policy and practices, neutralizing differences or accounting for financial peculiarities. This modeling approach enables a fair comparison of the options, provides realistic public costs for each, assesses their impact on operations, and enables effective evaluation of the financial impact of integration. 21 Agreement Between Key Largo Fire Rescue and Emergency Medical Services District and Key Largo Volunteer Fire Department, Inc., 7/13/20.Section 26. Budget Request and Agreement,and Section 27 Contract Payments. 22 Agreement Between Key Largo Fire Rescue and Emergency Medical Services District and Key Largo Volunteer Ambulance Corps, Inc., 6/22/20.Section 26. Budget Request and Agreement, and Section 27 Contract Payments. JA' W ngle 48 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Collective Financial Summary of the Agencies As stated previously, KLFREMS is an independent special district governed by an elected Board. At the same time, the fire rescue (KLFD) and EMS (KLEMS) providers are volunteer, not-for-profit corporations, each with its own Board of Directors. The district operates on a fiscal year from October 1 to September 30 while the two not-for-profits operate on a calendar year end. The district uses a modified accrual basis of accounting for governmental funds, which follows generally accepted accounting principles (GAAP) used by cities, counties, and many larger independent special districts, recognizing revenues when they are measurable and available and expenses when a transaction occurs. As shown in Figure 23, KLFREMS adopted a General Fund millage rate of $1.1975/$1,000 taxable value for FY 25. KLFREMS maintains one fund as of FY 25, the General Fund, which is its primary operating fund. Figure iOverview OWNS r ® Fiscal Year October 1-September 30 Assessed Property Value (FY 25) $5,909,212,657 Operating Budget $7,432,573 Adopted Millage Rate 1 .1975 Mills JA' W C 49 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 24 summarizes actual KLFREMS revenues for FY 20-24 and adopted revenues for FY 25. The primary source of district revenue is property taxes. Figure i ri I Revenue Ad Valorem Tax 3,487,044 3,696,809 3,888,194 4,569,524 6,089,730 6,863,994 ILA Monroe County 150,000 150,000 150,000 — — 150,000 Interest 16,256 11,177 5,311 63,331 212,907 200,000 Recurring Revenue: 3,653,300 3,857,986 4,043,505 4,632,854 6,302,637 7,213,994 Grants 94,338 164,869 — — — 300,000 Miscellaneous — 31,731 3,765 2,990 5,000 — Non-Recurring Rev.: 94,338 196,599 3,765 2,990 5,000 300,000 TOTAL REVENUE: 3,747,638 4,054,585 4,047,270 4,635,845 6,307,637 7,513,994 JAG was not provided with financial data specific to each volunteer corporation serving the district, either for KLFD or KLEMS. Therefore, it is unknown whether KLFD has other sources of revenue and whether it uses them to fund any part of its operations. However, the district's adopted budget documents indicate that KLEMS collects ambulance billing revenue, which is used to reduce the total Paramedic payroll before submitting its proposed budget and requesting reimbursement from the district.23 The impact of this offset is shown in Figure 25. KLEMS subtracts proposed ambulance revenue from proposed Paramedic compensation and then submits the result to the district in its proposed budget. It is unknown what the actual revenues were for the historical period, or whether KLEMS retains any excess transport revenues if actual wages are less than budgeted wages. Annual district audits do not address this issue. 23 Supported by district finance staff through personal communication of 8121125 and KFREMS proposed budget documents FY 20-25,which show total Paramedic regular salary costs less proposed ambulance transport revenue. JA' W ngle 50 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure L l Paramedic r II E=IMEMEM Ambulance Fees 292,300 268,000 150,000 250,000 285,000 325,000 Admin. Salary/Wages 56,813 58,801 43,520 45,994 46,051 47,611 Medic Salary/Wages 367,300 362,376 445,982 597,919 1,293,222 1,464,250 (total proposed) Medic Salary/Wages 75,000 94,376 295,982 347,919 1,008,222 1,139,250 (fewer fees) KL District EMS Adopted 131,813 153,177 339,502 393,913 1,054,273 1,186,861 Salary/Wages KL District EMS Actual 93,750 158,517 283,443 355,360 619,810 1,186,861 Salary/Wages Figure 26 compares the district's recurring and non-recurring revenue to total revenue. Recurring revenue, primarily ad valorem taxes, make up the majority of the district's annual revenue. This revenue has grown each year from FY 20 through FY 24, with overall revenue increasing from $3.75 million in FY 20 to $7.51 million in FY 25, representing a 50% increase. Between FY 20 and FY 23, total revenue increased at an average annual rate of approximately 9.4%, while the millage rate remained at the original 1 mill cap. Figure Recurring -Recurring Revenues (FY 20 Actual-FY 8,000,000 6,000,000 .. _6. $3;747 688 $4 054 585 $4 047 27" 4,,000,000 2,000,000 0 2020 20211 2022 2028 2024 05 mmm Recurring Revenue Inumm I@V in Recurring Revenue JO AIL RII:vII INUII: AgGROUP arc Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Revenue increased significantly in subsequent years, as a result of increases in both taxable value and millage rate, as shown in Figure 27. Total preliminary taxable values increased at an average annual rate of approximately 7.4% between 2017 and 2022 and then rose significantly to an average annual rate of almost 13.8% between 2022 and 2025. An increased taxable value drove the revenue increase between FY 20 and FY 22. The increase from FY 22 through FY 25 resulted from both increased values and a rise in the millage rate from 1 mill in FY 23 to 1.1975 mills in the FY 25 adopted budget. Figure District r li i r Ie Value Versusill 7,000,000,000 1.5000 6,000,000,000 1.4000 3,000,000,000 1,000,000,000 0.9000 0A000 2017 2018 2019 2020 2021 2022 2023 2024 2025 mmm iillll ge Rat 1161,— II'lirelliiim[iinair'y'raxalblle Vallu (IDIR4,20) Minor non-recurring revenues to the district include reimbursement from Monroe County of up to $150,000 annually in sales tax revenue for infrastructure improvements, as well as various federal grants, such as SAFER and AFG. The district entered a five-year interlocal agreement with Monroe County in 2016, originally intended to reimburse the district up to $150,000 annually for the installation of fire hydrants.24 24 Interlocal Agreement Monroe County and Key Largo Fire Rescue and Emergency Medical Services District, 12/14/16.Section 3.1 states that the district will purchase and install fire hydrants within its service area. Section 4.1 states that the county shall reimburse the district, upon submittal of proper documentation, for costs up to an annual amount of$150,000. Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS The original agreement was amended in 2017 for an additional five years, extending to 2021 . It was expanded to include other public safety capital items with a lifespan of five or more years, such as replacing fire and EMS vehicles and constructing facilities. In 2022, the agreement was renewed for an additional five years from October 1, 2021, through September 30, 2026, under the original terms. While still authorizing reimbursement of up to $150,000 annually with proper documentation, the updated agreement allows unused funds to be carried forward, with a maximum expenditure of $750,000 over the additional five-year period.25 Figure 28 shows KLFREMS expenses for FY 20 through FY 24, actual, and FY 25 adopted. Figure 29 and Figure 30 show the two contract providers of the district-KLFD and KLEMS. Figure try Division-District DISTRICT Salaries &Wages 12,000 20,770 21,000 21,000 21,000 106,000 Benefits 1,670 2,370 2,359 2,359 2,367 16,309 Personnel Services: 13,670 23,140 23,359 23,359 23,367 122,309 Professional Services 95,609 94,769 74,096 168,460 138,284 155,500 Admin. Supplies/Services 115,031 108,089 112,681 137,097 164,593 307,788 Insurance 1,936 1,951 1,959 1,888 1,883 2,233 Travel/Training 2,115 4,320 5,314 5,528 5,661 10,000 Operating: 214,691 209,130 194,050 312,972 310,421 475,521 Recurring Expenses: 228,361 232,269 217,409 336,331 333,788 597,830 DISTRICT EXPENSES: 228,361 232,269 217,409 336,331 333,788 597,830 25 First Amendment to Interlocal Agreement Monroe County and Key Largo Fire Rescue and Emergency Medical Services District,10/0 1/21. JA' * ngle 53 GROuwArC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure try Division-Fire W=Mmmmmm Salaries &rWages71,045,092 1,182,573 1,310,980 1,446,937 1,886,882 2,081,169 Benefits 222,375 284,836 340,917 358,814 460,827 623,498 Personnel Services: 1,267,467 1,467,408 1,651,898 1,805,751 2,347,708 2,704,667 Professional Services 33,966 28,141 26,864 28,268 32,913 41,206 Admin.Supplies/Services 40,604 37,970 51,989 42,333 147,971 88,989 Insurance 58,718 61,065 63,296 69,724 81,017 80,082 Utilities 50,674 50,599 43,646 58,757 55,402 59,600 Repairs/Maintenance 126,661 160,449 153,989 123,623 140,543 165,995 Travel/Training 27,262 28,753 19,223 25,217 38,036 76,428 Operating Supplies/Fuel 103,316 124,458 100,094 168,468 173,235 188,000 Operating: 441,201 491,435 459,102 516,390 669,118 700,300 Recurring Expenses: 1,708,668 1,958,844 2,111,000 2,322,142 3,016,826 3,404,967 Buildings/Improvements 191,650 148,035 200,850 8,377 22,500 0 Small Tools/Equipment 15,478 42,795 27,358 60,419 271,378 589,406 Apparatus 24,524 24,524 24,524 24,524 24,524 24,524 Non-Recurring Expenses: 231,652 215,354 252,732 93,320 318,402 613,930 LFID EXPENSES: 1,940, 21 2,174,197 2,363,732 2,415,461 3,335,228 4,018,897 JA' W ngle 54 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure tryDivision-EMS Department Salaries &Wages 289,175 347,887 486,040 516,526 946,690 1,571,861 Benefits 47,660 67,085 101,968 128,677 213,844 399,010 Personnel Services: 336,835 414,972 588,007 645,203 1,160,535 1,970,871 Professional Services 29,346 29,940 31,220 31,615 34,301 42,750 Admin. 23,193 29,891 30,105 28,075 20,064 64,650 Supplies/Services Insurance 48,069 48,168 62,450 97,804 104,416 88,649 Utilities 15,099 13,637 15,759 16,781 16,057 14,500 Repairs/Maintenance 77,402 116,005 81,534 51,324 102,335 120,000 Travel/Training 6,673 13,467 11,101 27,676 26,145 32,700 Operating 102,694 87,890 128,750 97,801 122,787 191,500 Supplies/Fuel Operating: 302,476 338,998 360,918 351,076 426,104 554,749 Recurring Expenses: 639,311 753,970 948,925 996,279 1,586,639 2,525,620 Buildings/Improvements 4,850 5,500 2,559 2,559 7,500 0 Small Tools/Equipment 16,545 11,297 4,589 98,705 69,642 39,750 Apparatus 0 0 467,630 0 0 275,000 Non-Recurring Expenses: 21,395 16,797 474,779 101,265 77,142 314,750 KLEMS EXPENSES: 660,706 770,767 1,423,704 1,097,544 1,663,781 2,840,370 JA' * ngle 55 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 31 illustrates the graphical relationship between the district's total recurring and non- recurring expenses for FY 20-24 (actual) and FY 25 (as adopted). Recurring expenses include personnel and operating costs expected to continue annually, while non-recurring expenses are one-time costs, such as apparatus, equipment, and infrastructure. Total expenses increased from $2.8 million in FY 20 to $3.8 million in FY 23, rising at an average annual rate of 10.9%. This growth accelerated to a more rapid annual rate of 34.4% in subsequent years, primarily due to increased personnel costs as staff were added and compensation rates rose. Figure 1: KLFREMS Recurring -Recurring ExpensesI to FY 25 Adopted 8,000,000 ............. __ _ _ _.... ...... 6,000,000 $3 488 638.......$3,824,812„_._,. 4,000,000 _. 7;804 864 2,000,000 .........,. 0 2020 2021 2022 2023 2024 2025 Personnel Services �aii�i/in Operating Non-Recurring Expenses TOTAL DISTRICT EXPENSES Figure 32 provides an overview of staffing costs26 between the district and its two contract providers versus total personnel cost in the district budget for the period FY 20-25. District costs are relatively minor and include Board Members' pay and benefits. These averaged just over$23,000 from FY 21-24, before increasing to just over $37,000 in FY 25 due to rises in FICA/Medicare and unemployment benefit costs with the addition of a district clerk position budgeted at $85,000. The largest increases in personnel costs are due to the addition of staff for KLFD and KLEMS. 26 This includes costs for full-time and part-time personnel of salary (regular and overtime wages are included) and benefit costs, as well as volunteer stipends. JA' W i 56 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure / L / r l Expenses 6,000,00 ...........................................................4;712; 47...._. 4,,000®000 1...,..,. „2 263 263 2�474,�1�3��....905,520 1,61"7"972.............. 2,000,000 0 2020 2021 2022 2023 2024 2025 If'91::D I111eirso nin ll S irAces vi�i�11i11io II!ii SIP rsoininell SerAces IDist IPersonin ll Services — — IPersonin ll Services To gain insight into how personnel costs have risen due to factors such as annual salary and benefit increases, the average cost per career27 employee per fiscal year was calculated. This was only done for KLFD, as the proposed Paramedic costs submitted to the district during the annual budget process were offset by proposed ambulance revenue. Because annual district audits did not include the full cost of Paramedic compensation or full total personnel services costs excluding the ambulance revenue offset, it is not known what the actual fully burdened average cost per KLEMS career member was during the historical period. Figure 33 shows total career personnel versus total personnel services expenses from FY 20 through FY 25 for KLFD only. The average cost per KLFD employee has risen annually from $84,498 in FY 20 to $100,173 in FY 25, resulting in an average annual increase of 3.5%. This average cost per career employee should not be construed as reflecting actual compensation for a given employee or the typical average annual increase by position. 27 "Career" is defined as full-time personnel only and does not include either part-time or volunteer personnel. JA' W ngle 57 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 33: KLFD Career Operational Staff vs. WREMS Personnel Expenses 3,000,000 - 60 2,704,667 ................................. 2,347;'708.....................................................;0 .0 805,751 -6 2,000,000 - 40 axe CL 1,467,408 E 1,267,467 0 U �� 4P 1,000,000 - 20 0 LN RIL 0 2020 2021 2022 2023 2024 2025 ON= KLVFD Career Staff —*—FD Personnel Services Figure 34 shows the annual operating cost for the district and its two contract providers, compared with the combined total district cost, from FY 20 through FY 25. District operating costs include property appraiser and tax collector fees, which have increased from $103,879 in FY 20 to $297,888 in FY 25. Other significant district operating expenses include accounting and financial services as well as legal services, which have increased from a total of $78,498 in FY 20 to $155,500 in FY 25. Operating expenses for KLFD and KLEMS include additional categories such as insurance, professional services, utilities, repairs and maintenance, training, fuel, operating supplies and equipment, and typical office operating costs. Total district operating expenses rose from $958,639 in FY 20 to $1,730,570 in FY 25, as adopted, representing an average annual increase of 13.6%. The largest increases occurred between FY 22 and FY 25. These large increases were driven by professional services (24% of the total increase), administrative supplies/services (33.3% of total), travel/training (10.2% of total), and fuel/operating supplies (18.8% of total). Composite operating expenses for the district have been grouped in the following categories which have increased annually over the historical period at the rates shown respectively in parentheses for each: Professional Services (15.34%), Administrative Supplies and Services (20.88%), Insurance (9.47%), Utilities (2.4%), Repairs and Maintenance (6.98%), Travel and Training (27.2%), and Operating Supplies and Fuel (13.28%). JA' W ngle 58 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS The distribution of operating costs between the district and its two contract providers has remained relatively constant until FY 25, with the district spending approximately 20-25%, KLEMS approximately 30-35%, and KLFD approximately 45% of the total. Figure / L / r l Expenses 2,000,000 1 15 570 ......... ......... .. ......... ........1 0,5;'643......... .� ._,. 1,500,000 00 31% .............1,1 ,439., ..... .. 22% 958 ��......... .1 039 563.._. 070 1,.000,000 — ——-* 27% 20% 19% .................... 22%............... ......... . ............................. 500,000 0 2020 20211 2022 2023 2024 202 mmomII:"III Ip ira-11-in li S 01[:)eirall-iing Dist Operating — operating Capital expenses are considered non-recurring and have ranged from $170,000 to $711,000 from FY 2020-2024, averaging $375,000 annually. Afterward, they increased significantly in the FY 25 adopted budget to $904,000. All capital expenditures are budgeted in either the KLFD or KLEMS budgets, with none attributed to the district itself. Figure 35 illustrates the distribution of capital expenditures between KLFD and KLEMS, with 63% of the expenses through FY 24 incurred by KLFD. JA' W ngle 59 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure District Capital Expenses by Compositenit 1,000,000 904,156 7fiY;304.......... 500,000 384,1375 371,020 � � .._._._._._._._._._._._._._ ® Lot 228 523 % 170,061 ...........ii.................. 0 2020 2021 2022 2023 2024 2025 FD Non-Recurring Expenses Emm EMS Recurring Expenses Non-Recurring Expenses Figure 36 shows capital expenses by category of expense. Facility expenses averaged close to $200,000 annually from FY 20-22, with apparatus expenditures increasing in FY 21 and FY 22, while tools and equipment costs were relatively minor. Small tools and equipment comprised the bulk of expenditures from FY 23-24 and a large part of the FY 25 adopted budget, along with apparatus. Figure : District Capital Expenses by Category 11,000,000 800,000 7„11,3 4 r► 600,000 .......................................... ���1 ������������������� ��.m.m 7 ....................... ��.a..© o 4.00,000 .� 200n000 0 .. 2020 2021 2022 2023 2024 2025 11� ullldlirngs/Ilirxnlproveii-neirits ioi�m/m/m/SlrmnaIIII Tos/11:.:qul'11pir nein# Appairataus ••• IMoin11 ecuirrhng 11;laclpernses JA' W ngle 60 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS The District Board has set aside a reserve for capital expenditures, which averaged approximately 21% of total reserves over the period FY 20-25 as adopted. According to the Board's annual financial report for FY 24 as audited externally by Citrin Cooperman and Company, LLP28, the Board has determined that its "...targeted ending fund balance [estimated at $6.18 million] for fiscal year 2024-2025 would be a prudent reserve for unanticipated events, such as hurricanes, and if necessary, the committed funds for the vehicle and equipment replacement reserves could be utilized to cover any shortfalls due to unanticipated emergencies." Based upon this policy statement, the Board's total fund balance would equal approximately 83% of the total expenditure budget for that year. The Government Finance Officers Association (GFOA) recommends that governmental entities maintain a minimum reserve sufficient to fund two months of recurring expenses (approximately 16.67%). JAG has noted that some Florida districts maintain a three-month operating reserve, along with reserves for emergency or disaster funding, which equal a 30- day all-out operational response, totaling four months of recurring expenses (33.3% of the annual recurring expenditure budget). For comparison with current district policy, the red-dashed line in Figure 37 shows a four- month operating reserve plus an additional $500,000 per year in capital reserve (slightly more than the district's average annual capital expenditures of $370,000). The actual undesignated fund balance exceeds that recommended by the GFOA, as shown in the figure. The district is in a sound financial position given its current fiscal policy. 28 Key Largo Fire Rescue and Emergency Medical Services District, Basic Financial Statements For the Year Ended September 30, 2024, as audited by Citrin Cooperman &Company, LLP, May 20,2025. JA' W ngle 61 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 37: KUREMS Fund Balance Analysis (FY 20 Actual-FY 25 Projected) 8,000,000 - ................. 6,000,000 - 4,000,000 - ........................................................................................ 2,000,000 - 0 .............;,;",,/""""","/................................................................ ............................................................ 2020 2021 2022 2023 2024 2025 =M= Non-Recurring Revenue o/o/o/s/n/w/m, Non-Recurring Expenses —Recurring Revenue Recurring Expenses Beginning Fund Balance(Calculated) ——— Recommended Fund Balance JA' W ngle 62 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS I Capital Facilities & Equipment Apparatus and other vehicles, trained personnel, firefighting and emergency medical equipment, and fire and EMS stations are the essential capital resources necessary for public safety organizations to carry out their missions. No matter how competent or numerous the Firefighters and EMS providers are, if appropriate capital equipment is unavailable for operations personnel, it would be impossible for Key Largo EMS and the Key Largo Fire Department to perform their varied responsibilities effectively. Since the essential capital assets for emergency operations are facilities, apparatus, ambulances, and other emergency response vehicles, this report section will address those in the following discussion. Basic Features of Fire & EMS Stations Fire and EMS stations are integral to delivering emergency services for several reasons. To a large degree, a station's location will dictate response times to emergencies. A poorly located station can mean the difference between confining a fire to a single room and losing the structure, or between surviving sudden cardiac arrest and death. Fire and EMS stations also need to be designed to adequately house equipment, ambulances, apparatus, and other vehicles to meet the organization's and its personnel's needs. Fire and EMS station activities should be closely examined to ensure the facilities are adequately sized and functionally adequate. Examples of these functions can include: • Residential living space and sleeping quarters for on-duty personnel (all genders). • Bathrooms and showers (all genders). • Proper space for storing uniforms and turnout gear. • Kitchen facilities and appliances. • Secure storage of medical supplies, durable medical equipment, fire equipment, and general supplies. • Housing and cleaning apparatus and equipment, including decontamination and biohazard disposal. • System(s) for vehicle exhaust extraction. • Administrative and management offices, computer stations, and office facilities. JA' * ngle 63 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS • Fitness area. • Training, classroom, and library areas. • Public meeting space. JAG asked KLEMS and KLFD to rate their stations' conditions using the criteria shown in Figure 38. Figure Criteria ili Determine ite Station Condition Like-new condition. No visible structural defects. The facility is clean and well-maintained. The interior layout is conducive to function, with no unnecessary impediments to the apparatus bays or offices. No significant defect history. Building design and construction match the building's purposes. Age is typically less than ten years. The exterior has a good appearance, with minor or no defects. Clean lines, good workflow design, and only minor wear on the building interior. The roof and apparatus apron are in good working order, absent any significant full- thickness cracks, crumbling of the apron surface, or visible roof patches or leaks. Building design and construction match the building's purposes. Age is typically less than 20 years. The building appears structurally sound, with a weathered appearance and minor to moderate non-structural defects. The interior condition shows normal wear and tear but flows effectively to the apparatus bay or offices. ® Mechanical systems are in working order. Building design and construction may not align well with the building's intended purposes. Shows increasing age-related maintenance, but with no critical defects. Age is typically 30 years or more. The building appears cosmetically weathered and worn, with potential structural defects, though none are imminently dangerous or unsafe. Large, multiple full-thickness cracks and crumbling concrete on the apron may exist. The roof has evidence of leaking and has been repaired multiple ® times. The interior is poorly maintained or showing signs of advanced deterioration, with moderate to significant non-structural defects. Problematic age-related maintenance and major defects are evident. It may not be well-suited to its intended purpose. Age is typically greater than 40 years. JA' W ngle 64 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Key Largo EMS Station Figure 39 lists the features of KLEMS Station 23. Figure : KLEMS Station Address/Physical Location: 98600 Overseas Highway, Key Largo, FL 33037 itiv Structure Date of Original Construction 1979 Renovation Dates Added crew quarters in 2003; new roof in 2021 . Auxiliary Power Two propane generators General Condition Good Number of Apparatus Bays Drive-through Bays 0 Back-in Bays 4 ADA Compliant Yes Total Square Footage 12,100 square feet Facilities Available Sleeping Quarters 3 Bedrooms 6 Beds 6 Dorm Beds Maximum Staffing Capability 8 Exercise/Workout Facilities Yes Kitchen Facilities Yes Bathroom/Shower Facilities Yes Training/Meeting Rooms Yes Washer/Dryer Clothes Yes Washer/Dryer PPE (Extractor) No Safety & Security Station Sprinklered No Smoke/CO Detection Yes Decontamination/Bio. Disposal Yes Security System No Apparatus Exhaust System Exhaust fan in the apparatus bay to the outside. Contamination Control Zones None, other than biohazard waste area. JA' * ngle 65 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Key Largo Fire Stations Figure 40 and Figure 41 list the various features of KLFD Station 24 and Station 25. Figure L i (Headquarters) Address/Physical Location: 1 East Drive, Key Largo, FL 33037 %//ii --------------------------------------------------------------- Structure Date of Original Construction 1992 Renovation Dates Working on renovation; in the planning phase. Auxiliary Power Yes General Condition Fair Number of Apparatus Bays Drive-through Bays 3 Back-in Bays 0 ADA Compliant Yes Total Square Footage 10,000 square feet Facilities Available Sleeping Quarters 3 Bedrooms 1 Beds 7 Dorm Beds Maximum Staffing Capability 8 Exercise/Workout Facilities Yes Kitchen Facilities Yes Bathroom/Shower Facilities Yes Training/Meeting Rooms Yes Washer/Dryer Clothes Yes Washer/Dryer PPE (Extractor) Yes Safety & Security Station Sprinklered No Smoke/CO Detection Yes Decontamination/Bio. Disposal Yes Security System No Apparatus Exhaust System Yes Contamination Control Zones No JA' * ngle 66 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 1: KLFD Station Address/Physical Location: 220 Reef Drive, Key Largo, FL 33037 i a Structure Date of Original Construction 2005 Renovation Dates N/A Auxiliary Power Yes General Condition Good Number of Apparatus Bays Drive-through Bays 0 Back-in Bays 2 ADA Compliant Yes Total Square Footage 10,000 square feet Facilities Available Sleeping Quarters 7 Bedrooms 1 Beds 12 Dorm Beds Maximum Staffing Capability 13 Exercise/Workout Facilities Yes Kitchen Facilities Yes Bathroom/Shower Facilities Yes Training/Meeting Rooms No Washer/Dryer Clothes Yes Washer/Dryer PPE (Extractor) Yes Safety & Security Station Sprinklered Yes Smoke/CO Detection Yes Decontamination/Bio. Disposal Yes Security System No Apparatus Exhaust System Yes Contamination Control Zones No Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Collective Summary of the Key Largo Fire Rescue & EMS Stations Figure 42 lists the collective basic features of the KLFD and KLEMS stations. Figure i r Fire Stations KLEMS Station 23 12,100 4 8 Good 46 years KLFD Station 24 10,000 3 8 Fair 33 years KLFD Station 25 10,000 2 13 Good 20 years Grand Totals: 32,100 9 bays 29 beds As shown in Figure 42, the combined stations of Key Largo EMS and the Key Largo Fire Department range in age from 20 to 46, with an average age of 33. None of these stations was rated as "Excellent." Combined, the stations could accommodate up to nine apparatus and ambulances, depending on each configuration, and up to 29 staff. KLEMS & KLFD Fleet Inventories Apparatus and ambulances must be sufficiently reliable to transport Firefighters, EMS personnel, and necessary equipment rapidly and safely to an incident scene. In addition, such vehicles must be properly equipped and function appropriately to ensure that the delivery of emergency services is not compromised. The unique features of fire and EMS apparatus and ambulances tend to make them expensive and offer minimal flexibility in use and reassignment to other emergency services missions. As a part of this study, the J. Angle Group requested that KLEMS and KLFD provide a complete fleet inventory (apparatus, medic units, command vehicles, support units, specialty units, etc.). Each agency was asked to rate the condition of its apparatus, ambulances, and vehicles using the criteria in Figure 43. JA- W ngle 68 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure Criteria r iCondition rAmbulances EMIZZ=0000MEMMEMEMENEM Age: One point for every year of age, based on the in-service date. Miles/Hours: One point for every 10,000 miles or 1,000 hours. One, three, or five points are assigned based on the service Service: type received (e.g., a pumper would be given a `5' since it is classified as severe-duty service). This category considers body condition, rust interior condition, Condition: accident history, anticipated repairs, etc. The better the condition, the lower the points assigned. Points are assigned as 1, 3, or 5, depending on the frequency a vehicle is in for repair (e.g., a `5' would be assigned to a Reliability: vehicle in the shop two or more times per month on average, while a `1 ' would be assigned if in the shop on average of once every three months or less. Under 18 points Condition I Excellent 18-22 points Condition 11 Good 23-27 points Condition III Fair (consider replacement) 28 points or higher Condition IV Poor (immediate replacement) KLEMS Rescue Fleet inventory Figure 44 shows the current KLEMS rescue fleet inventory. Figure r Inventory Z==12=0=N1111z= Rescue 23/72 Type I Horton 2022 Excellent ALS equipment Rescue 25/75 Type I Horton 2022 Excellent ALS equipment Rescue 123/74 Type III AEV 2016 Fair ALS equipment Backup/73 Type III AEV 2015 Fair Reserve unit; ALS Figure 44 shows that two of Key Largo EMS' frontline rescues are relatively new and in "Excellent" condition. JA' W ngle 69 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS KLFD Apparatus Inventory Figure 45 lists KLFD's current frontline apparatus inventory. Figure r ite Department Apparatus Inventory (2025) 00000lool000000 Engine 24 Type 1 E-One 2019 Excellent 1,500 GPM/1,500 gal. Engine 25 Type 1 E-One 2018 Good 1,500 GPM/1,500 gal. Ladder 25 Aerial Ferrero 2013 Fair 1,250 GPM/500 gal. Tanker 24 Tanker Ferrera 2013 Excellent 1,000 GPM/3,000 gal. Air 24 Special Ford 2022 Excellent Air/Light/Rehab Figure 45 shows that most of KLFD's apparatus are in "Excellent" or "Good" condition. KLFD's fleet is relatively young, with the apparatus ranging in age from 3-12 years, averaging 8 years. Its two frontline engines have a combined average age of 6.5 years. In addition to its frontline apparatus, KLFD maintains a 2013 Ferrara engine and a 2002 Ford utility vehicle—both of which are in "Fair" condition. The Key Largo Fire Department is currently in the process of purchasing a 30-foot, dual- or triple-engine fire boat with an aluminum hull and water pump. The boat will be purchased from Silver Ships, Inc. in Mobile, Alabama, with grant money and other funds. Fleet Maintenance No piece of mechanical equipment or vehicle can be expected to last indefinitely. Repairs tend to become more frequent and complex as apparatus and vehicles age. Parts may become more difficult to obtain, leading to increased downtime for repair and maintenance. Since fire protection, EMS, and other emergencies prove critical to a community, downtime is one of the most frequently identified reasons for apparatus replacement. Most communities develop replacement plans because ambulances, fire apparatus, and other vehicles are expensive. To enable such planning, fire and EMS organizations often adopt the accepted practice of establishing a vehicle life cycle that yields an anticipated replacement date for each vehicle. JA' W ngle 70 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS The reality is that it may be best to establish a life cycle for planning purposes—such as developing replacement funding for various types of vehicles, while applying a different method—such as a maintenance and performance review, to determine the actual replacement date, thereby achieving greater cost-effectiveness when possible. Futureru Serviceability An important consideration for public safety providers is the cost of replacing major equipment in the future. The life of apparatus and ambulances can be readily predicted based on factors such as vehicle type, call volume, age, and maintenance considerations. NFPA 1900 recommends that fire apparatus 15 years or older be placed into reserve status and apparatus 25 years or older be replaced.29 The preceding is a general guideline, and the standard recommends using the following objective criteria in evaluating fire apparatus lifespan: • Vehicle road mileage • Engine operating hours • Quality of preventative maintenance and availability of replacement parts • Quality of the driver-training program • Whether the fire apparatus was used within its design parameters • Whether the fire apparatus was manufactured on a custom or commercial chassis • Quality of workmanship by the original manufacturer • Quality of the components used in the manufacturing process It is important to note that age is not the only factor for evaluating serviceability and replacement. Vehicle mileage and engine pump hours must also be considered. A two- year-old engine with 250,000 road miles may need replacement sooner than a 10-year-old engine with 2,500 miles. Ambulances typically have much shorter life spans than fire apparatus because of their more frequent use and higher mileage. 29 NFPA 1900:Standard for Aircraft Rescue and Firefighting Vehicles, Automotive Fire Apparatus, Wildland Fire Apparatus, and Automotive Ambulances. JA' * ngle 71 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Maintenance e KLEMS & KLFD Fleets Both KLEMS and KLFD have their apparatus and rescues maintained by the mechanical service at Ten-8 Fire & Safety service center in Pompano Beach. This facility is approximately 100 miles from the district. Other Capital Equipment Self-Contained Br i i t s Figure 46 lists the manufacturers, models, and quantities of self-contained breathing apparatus (SCBA) utilized by KLFD. In addition, they maintain 90 spare bottles. Figure Largo ite Department SCBA Inventory ScottTm Air-PakTm X3 Pro 25 ScottTm RIT-Pak III System 4 Cardiac & Patientr s a vices The current combined inventories of cardiac monitor/defibrillators and automated external defibrillators (AEDs) used by each agency are shown in Figure 47. This information is important for determining compatibility between the two. Figure in Inventories of Cardiac Devices r - � Zo=== Physio-Control LIFEPAK151 1000 AED 0 6 6 Physio-Control LIFEPAK°15 Cardiac Monitor 4 2 6 Key Largo EMS maintains four Stryker Power-PRO ambulance cots and the Power-LOAD cot fasteners. In addition, they carry three Stryker LUCAS chest compression systems. Extrication Tols KLFD utilizes a Hurst extrication system with spreaders, cutters, rams, and other tools. In addition, it maintains TeleCrib®Strut Rescue Kits and Vetter lift bags. JA' W C 72 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Servicei In this section, JAG reviewed the current service delivery and performance of KLFD and KLEMS. JAG analyzed the operational components of service delivery and performance from multiple perspectives, including: • Service demand • Resource distribution NEPIS • Resource concentration • Resource reliability THE U.S.FIRE ADMINISTRATION (USFA) HAS PARTNERED WITH THE U.S.DEPARTMENT OF • Response performance HOMELAND SECURITY'S(DHS)SCIENCE AND TECHNOLOGY DIRECTORATE(S&T),AND THE To provide the highest level of service to the FIRE SAFETY RESEARCH INSTITUTE (FSRI)TO citizens and visitors of the districts, the sum of all DEVELOP AND LAUNCH A NEW INTEROPERABLE these components must be effective and efficient. FIRE INFORMATION AND ANALYTICS PLATFORM, KLFD and KLEMS will achieve this through efficient KNOWN AS THE NATIONAL EMERGENCY incident notifications and rapid responses from RESPONSE INFORMATION SYSTEM(NERIS). facilities that are effectively located, equipped THE GOAL OF NERIS IS TO EMPOWER THE LOCAL with the appropriate type of apparatus, and FIRE AND EMERGENCY SERVICES COMMUNITY BY staffed with an adequate number of properly EQUIPPING THEM WITH NEAR REAL-TIME INFORMATION AND ANALYTIC TOOLS THAT trained personnel. SUPPORT DATA-INFORMED DECISION-MAKING FOR ENHANCED PREPAREDNESS AND RESPONSE This section provides a current analysis of service TO INCIDENTS INVOLVING ALL HAZARDS. delivery and response performance in the fire district's service area, offering a snapshot of its HTTPS://WWW.USFA.FEMA.GOV/DOWNLOADS/P various components. In addition to this analysis, DF/NERIS/NERIS-INFORMATION-SHEET.PDF KLFD and KLEMS leadership should continuously monitor performance and incorporate it into their planning processes. Data Sources The data for this study, obtained from KLFD and KLEMS, was sourced from the district's records management system (RMS). Both agencies currently use ESO®Software's Emergency Reporting application for the National Fire Incident Reporting System (NFIRS) and the National EMS Information System (NEMSIS). KLFD began to use the ESOO platform on May 1, 2024. Data prior to that is somewhat limited because of a ransomware attack. Due to this limitation, the data analysis was based on data from a 2023 performance review. JA' * ngle 73 GROUP,= Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Some metrics could not be analyzed due to data loss. In general, the analysis from these data sources covered the period from January 1, 2020, through December 31, 2024. Figure 48 summarizes the incident data available for analysis from KLFD. JAG utilized the dataset best suited for each analysis. Figure L rSources ® r r r r r r NFIRS-All Units 1,006 1,226 1,528 N/A 882 NFIRS-Single Calls 798 821 957 774 761 Figure 49 summarizes the incident data available for analysis from KLEMS. As with KLFD, JAG used the dataset best suited for each analysis. Figure : KLEMS SummarySources 1NNMM2=N=1 !E1MZM NFIRS All (Units) 1,660 1,551 1,420 NFIRS Single (Incidents) 1,389 1,507 1,370 For both NFIRS and NEMSIS data, regardless of the source, it is crucial to ensure that the data collected is complete and accurate. This information is utilized at all levels, from local budget development to the identification of national preparedness initiatives. Accurate fire incident reports are crucial and can significantly impact a local department and the entire U.S. When incidents are documented for NFIRS and NEMSIS, there is the potential for data entry errors—mistakes that can alter the intended meaning of the information. Several mistakes across a region may not be significant. Still, multiple mistakes in the same region—or worse, widespread mistakes across the entire country—can dramatically affect the meaning of the data. The same result occurs when data is generalized, such as the overuse of the codes for "unknown," "none," or "other." JA' * ngle 74 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Key Largo Fire Department Service Demand The service demand analysis reviews current and historical service demand by incident type and temporal variation. GIS software provides a geographic display of demand. Figure 50 displays historical KLFD service demand for the previous five calendar years. Overall, it remained relatively stable throughout the study period, with a spike in 2022. Service demand decreased by just under 5% from 2020 to 2024. Figure L Incident Volume 1,200 1,000 800 600 400 200 2020 2021 2022 2023 2024 NFIRS has developed a classification system to categorize incident types. These codes identify the various types of incidents to which fire departments respond. When analyzed in this manner, an agency can better determine the demand for service and what training may be of priority for its responders. This information is also valuable for guiding community risk reduction programs. JA' * ngle 75 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS The codes consist of three digits and are grouped into series by the first digit, as shown in Figure 51 . Figure 1: NFIRS Incident Descriptions Em 100 Series Fires 200 Series Overpressure Rupture, Explosion, Overheat (No Fire) 300 Series Rescue and Emergency Medical Service (EMS) Incidents 400 Series Hazardous Condition (No Fire) 500 Series Service Call 600 Series Canceled, Good Intent 700 Series False Alarm, False Call 800 Series Severe Weather, Natural Disaster 900 Series Special Incident Type Incidents typed as Fires (NFIRS 100s) include all types of fires, such as structure, wildland, vehicle, etc. False Alarms (NFIRS 700s) include both manual and automatic fire alarms where no fire problem was identified. The category titled Other includes NFIRS codes such as Overpressure Rupture (No Fire) (NFIRS 200s), Severe Weather and Natural Disaster (NFIRS 800s), and Special Incidents (NFIRS 900s). Hazardous Condition (NFIRS 400s), Service Call (NFIRS 500s), and Canceled or Good Intent (NFIRS 600s) incidents in which the district's services were not needed after units were dispatched comprise the balance of the incidents. Figure 52 shows the analysis of overall service demand, with incident demand based on NFIRS incident type, over the preceding five calendar years. In general, the demand by type was stable. The most significant increase in service demand was for incidents coded as Service Calls (500 series), with a 43% increase. However, since Rescue and EMS incidents account for the highest percentage of KLFD's overall volume, it is important to note the 21% increase in these incidents during the period. JA' * ngle 76 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure L n I Demand by Incident 1,200 1,000 800 600 400 200 0 2020 2021 2022 2023 2024 100 .... 20 38 38 18 24 .... Em...300 332 414 519 414 401 400 .... 53 41 50 48 43 .... 500 .... 61 63 70 38 87 .... 600 186 145 146 109 98 700 .... 76 83 95 83 84 .... Other 70 37 39 64 24 Total 798 821 957 774 761 While Figure 52 analyzes overall demand for services, it is also essential to examine how the various incident types compare to the overall number. As shown, most of the demand for services was within the EMS and Rescue category, at 50%. Good Intent incidents followed this at 17%, and False Alarm calls at 10%. As depicted in Figure 53, emergency medical incidents accounted for the largest percentage of calls for service, consistent with what is typically observed nationwide. JA' * ngle 77 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Fig ureL I RS Service other 2-8-9 Fires 6% 3% False Alarm/Calls 10% Good Intent 17% EMS&Rescues 50% Service Calls^ Hazardous Conditions 6% Figure 54 shows the relationship between counts and cumulative percentage by type. Figure L rice Demand by Type with CumulativePercentage - ) 2,500 100% 2 90% 2,000 80% 70% 1,500 60% 50% 1,000 40% 684 30% 500 319 20% IN M 235 234 138 10% 0 0% a y a `�� Va Va �`°c a' (�°° O a°JA' W ngle 78 �a GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 55 illustrates service demand for KLFD based on property type. Residential occupancies accounted for the highest demand within all reported incident-type categories. Figure Service I r r (2023-2024) 0-Property use, other 0.00%. 0.007 0.07. 0.837. 1-Assembly (restaurant, bar, theater, library, 4.88% 5.37% 5.99% 5.81% church, airport) 2-Educational (school, daycare center) 0.00% 0.87% 5.39% 2.07% 3-Healthcare, detention, correction (nursing 0.00% 0.50% 0,00% 0.41% home, hospital, medical office, jail) 4-Residential (private residence, hotel/motel, 41 .46% 44.69% 74.25% 35.687o residential board) 5-Mercantile, business (grocery store, service 4.887o 7.74% 1 1.38% 17.43% station, office, retail) 6-Industrial, utility, agriculture, mining 0.00% 0.00% 1 .80% 0.41% 7-Manufacturing 0.00% 0.00% 0.00% 0.00% 8-Storage 12.20% 7.37% 0.00% 3.73% 9-Outside property, highway, street 36.59% 33.46% 1 .20% 33.6% 1 NFIRS 100s.2 NFIRS 300s.3 NFIRS 700s.4 All other incident types. Temporal Analysis After analyzing the number and types of incidents, the next step is to consider temporal analysis. The temporal component becomes essential when leadership plans for the current and future delivery of services. With this knowledge, the districts can better determine staffing needs and non-response activities such as hose testing, hydrant testing, incident pre-plans, training, and apparatus maintenance. Unless noted, each temporal component is presented as a percentage relative to the total service demand during the five calendar years of the study period. JA' * ngle 79 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS The first temporal component determines the service demand for each month of the year. Understanding this component allows leadership to schedule non-response activities during the lower service-demand months. As illustrated in Figure 56, service demand fluctuated throughout the year, with a 4.21% difference between the busiest and slowest months. On average, the lowest demand for services occurred in September, while demand increased in July to reach the highest average level. Figure I ri nth (2020-2024) 14% 12% 10% 8% .. 4% 2% 0% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Em 2020 E=2021 2022 2023 111111111111111111111111112024 (Average The second temporal component analyzed the day of the week to determine which day indicated greater demand for service. Typically, the most noticeable variation occurred on weekends, when service demand decreased. This is expected, as greater activity occurs during the workweek, such as an increase in the transient population associated with the retail and commercial labor force. JA' W ngle 80 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Generally, activity levels increased during the workweek. However, weekends tend to show higher activity in the KLFD's service area, which has a significant population increase due to tourism. As illustrated in Figure 57, Tuesdays had the lowest service demand for KLFD. Weekends showed the highest demand, with a peak on Saturdays. The difference between the busiest day—Saturday—and the slowest day—Tuesday—was 4.07%. Figure L I is (2020-2024) 20 18% „ 16% _ 12% % .............. j ///.............. j.............. 10%67o NO % % l .............. l - 2% / l 0% ® — ® SUN MON TUE WED THU FRI SAT mm 2020 m=2021 2022 iiiiiiiiiiiiiiiiiii 2023 nollso 2024 (Average The final temporal component concerns determining the time of day that service demand occurs. As illustrated in Figure 58, average service demand began to increase in the early morning hours—coinciding with the community waking up and preparing for the day. Throughout the morning, service demand continued to increase—coinciding with the movement of the population from their homes and the resumption of their daily activities. Demand peaked at 11 a.m. and then gradually decreased, coinciding with the population completing their daily activities and returning home. The decrease continued until reaching its lowest point at 3 a.m. JA' * ngle 81 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 58: KLFD NFIRS Service Demand by Hour (2020-2024) 9% 8% 7% 6% 5% 4% 3% 2% � � � j j j � � j r j � j 0% 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 2223 Em 2020 E=2021 2022 111111111111111111111111112023 mm 2024 —0--Average Although service demand is lowest during the early morning hours, according to the National Fire Data Center, fatal residential fires occur most frequently late at night or in the early morning hours when most people are asleep, a significant factor contributing to fatalities. From 2018 to 2020, fatal fires were highest from midnight to I a.m. Fatal fires were most prevalent when residential fire incidents were generally at their lowest, making nighttime fires the deadliest. The eight-hour peak period (I I p.m. to 7 a.m.) accounted for 45% of fatal residential fire S30. Charting the temporal demands for service by both day and time is valuable. Figure 59 compares average demand by day and hour, with relative values shown by color. The darker greens indicate lower demand, while the darker reds indicate the highest demand. 30 Fatal Fires in Residential Buildings (2018-2020), National Fire Data Center. JA' W ngle 82 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure is i (2022-2024) © iioioi i 2,07% �IIIIIIIIIIIIIIIII // 2.98% 1,7 2.98/065 �' IIIIIIIIIII�IIIIIIIIIII ��� t��„ 2 09°fob o p �% 2.55. 2 5 5% 2.88% 4.68% 2.13% 2.07%' 3.37% 5.96% 4.26% 3.72% 5.09% 5.29% 6.28% 4.81% 7.23% 3.40% 2.48% 2.78%JIIIIJIIIIIJJJ 5.24% / /{f 2 13% �IIIIIIIIIIIJ�III ° ������ 6.25% 6 38%1 7,2 % 3.31% 673/0�j 721% . 4.68% 7 02% s� 6.94% 6.73% 6.81% 3.37% 5.11%OR ii ® 6 02% 5 24%IIIIIIII�I It jI� 6.81°fo� y�� 3.72% 6 94% 6 73°/a/" „7,33 6.73% 4.68%IIIIIIII�II�lllllllll�� �rl 4.13% ®IIIIIIII������ 5.77% 6.81% 7.21416, 6.81%i 6.38% 5.37% 4.17% 6.73% 5.76% 7;21%, 2.98% 4.26% 5.37% 6.48% 6 73% `, ..... 3 ,, 6.25% 2.98%I 5.09% 4.81% 3.14% 4.33% 5.11% 2.98% 5.37% 2.78% 3.85% 3.14%1111���I,�� 3.83% 5.53% 6.20% o 03.14W6111112 0 6.3$%, 7.02°5.56/0 4.33/0 3.14/0 // ® 4.63% 192%: 1 5 x, 4.81% 4.26% 2,13%' 3.72% ® 1.85%//// 1.92% 2.98% 2.55% 3.31% 3.14% 4.33% 3.40% 2.98% 4.55% As noted, 11 a.m. coincided with the highest average daily demand. An additional analysis depicts that the 1 1 a.m. demand was highest on Tuesdays compared to the other days and times. Figure 60 captures the busiest consecutive periods. The information can be used to identify periods for increased staffing or placing additional apparatus in service. Figure i iService Delivery Periods - ) E=E= - - Hours 0900-1700 0900-1900 0900-2100 Percentage of Total: 51% 61% 71 JA' W ngle 83 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Resource isri uiAnalysis While incident-type and temporal analyses provide valuable insights into the types and timing of service demand, understanding its geographic distribution is also essential. JAG used geographic information systems (GIS) software to map incident locations within the KLFD service areas and calculate incident density. Figure 61 illustrates the densities for all incidents within KLFD service areas for calendar years 2023-2024. Figure L ni II Incidents — J Angle Group r��a I North Ke,y es W S I' Cdit �'kn rr�,wF dl Pa•.Na^ru.Va" �xp4nri ,y/ l fuo 25Gine U oru6 P2xOrW Stuurwr Pok fj Key Largo Study Incident Density All Incidents L� District Boundaries l � KLFREMS Fire i Stations ® KLFREMS EMS Station 24 Sparse Dense 00,51 2 3 4 W!%ii Miles L.,i,NASA,NGA fUSG"S,Nfix,,LM,k.C,ar my,(TUI,L,6, f.iry(Nero ,4,rfr:Giajh,MLT4INASA U,CS, U PS,I0S,USDA,UbW'W AgGROUP,= Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 62 shows the location of fire incidents within the KLFD service areas for the 2023-2024 calendar years. Figure Density-Fire Incidents H Angle Grotip N,aarNar i North Ke,y -a s W+E C—dit N,,kn (II ra:R,r,prr �xp4nri ko ine4,grwarn KL -25C—A NO Stdurwr ,.. Pak M= h`. Key Large Study Incident Density ti. Fire Incidents 0 District Boundaries A ' Atih Ki.FREMS Fire Stations Fire Incident ' � 24 Density rti 00.51 2 3 4 miles r4rcl,4 S NGA,USES,rUTAA,Mh MYS A),,JL(tbt my,I XR U fl,Ir:IITI YYh.G.-i YIr 1 hUa G,aj.,h,P111{fNASA, AgGROUP.LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 63 shows EMS incident density within the KLFD service area for 2023-2024. Figure : KLFD Density—EMSIncidents rra u,arrrar Angle Gronp ar�a i North Ke,y es W+E S Cdillo,'kn rraa,wF (lira:R'r„pqw b �s4nri / � fuk inm4rrwerp 25C—A N10 Stdurw^ Pak Key Largo Study Incident Density EMS Incidents © District Boundaries /. KLFRFMS Fire Stations KLFRFMS EMS Station 24 Sparse Dense 00.61 2 3 4 �)Miles I:xrll,�gr/41.�1C;k0.,II�,v4a°r,Kl.k�aF C'V�Ii.MXYSV-n.1h�L(..4 YYl�,rid Ll,Q,fP,�r:lITI�JYYh,G. ir,, U111T/NASA, ISO Distribution The Insurance Services Office, Inc. (ISO), a subsidiary of Verisk Analytics, is a national data analytics provider that evaluates fire protection for communities nationwide. ISO assesses all areas of fire protection and breaks them down into four major categories: Emergency Communications, Fire Department, Water Supply, and Community Risk Reduction. Following an on-site evaluation, an ISO rating—specifically, a Public Protection Classification (PPC°) number ranging from 1 (best protection) to 10 (no protection)—is assigned to a community. JA' * ngle 86 GROuw,rrC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS The PPC°score is developed using the Fire Suppression Rating Schedule (FSRS), which outlines sub-sections for each of the four major categories and details the specific requirements for each evaluation area. A community's ISO rating is important when considering fire station and apparatus distribution and deployment, as it impacts the cost of fire insurance for residents and business owners. The ability of a fire district to arrive on the scene of an incident equipped with personnel, equipment, and water to mitigate a fire effectively is a critical factor in an ISO evaluation. To determine whether a structure is eligible to receive a PPC rating higher than ten, it cannot be more than five road miles from a fire station. Typically, areas outside of five road miles may be subject to a split ISO rating if the fire district can demonstrate that sufficient fire flow is available. In addition, to receive maximum credit for the station and apparatus distribution, ISO evaluates the percentage of the community (contiguously built-upon area) within specific distances of both engine/pumper companies (1.5 miles) and aerial/ladder apparatus (2.5 miles). Figure 64 illustrates fire station distribution for the KLFD service area and the roadways within the ISO's required five miles of travel distance. Of the 1 1 1 miles of roads in the KLFD service area, all 106 miles (95 %) are within five miles of a fire station. JA' W ngle 87 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure L iDistribution—ISO Five-Mile r v I Distance Criteria c�r~a Angle Group N Nn"h Key E S , .t. —2S C¢ro'II OEmeT.:4ate 1 i if j Key Cargo Study ISO STATION COVERAGE [district Boundaries aq KLFREMS Fire Stations KLFREMS EMS p-�4 Station gCI.1/ 5 Mile Coverage r � C � 0(1.51 2 3 4 ®Milo$ t Ai,NASA,NGA 1.605,n,9v,r n,�D.dr CnAuvrhy,f l U1,E i Y.r for x,Gjj irr i ii r, ,ffr)G,i ajA%PAIL"IE/'UA SA U 5G S, Um,I05,U,;JA USM AgGROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 65 illustrates the engine company distribution for KLFD and the roadways within the ISO-required 1 .5-mile travel distance. In this case, 44 miles, or 44% of the roadways, are within 1.5 miles of a fire station with an assigned engine company or a pump-capable apparatus. Figure L i Distribution—ISOion—ISO 1.5-Mile Travel Distance Criteria Iia.,rock Bot'l IcM Ya rlr Angle Group North Key �p jry arg N! dll�� IW�M Cray'dilc LA, �MM �tlonal 'IIPe R'�f da �.y karnp 25c,,r,,ReerSiwe Park I � � Key Largo Study ISO ENGINE COVERAGE o„r•:r, 0 District Boundaries KLFREMS Fire Stations j KLFREMS EMS L D_24 Station 1.5 Mile Coverage 0051 2 3 4 Miles L,rd,NASA Nr,A USGs,Mr rr-CBacla,r ouu ty,FC'�Cf',Sir Iorri'I'am,f, mu `n(rrC;ral,lr,Ou7 C'I'I/NASA USC:B, HIA,NP";,USDA,USPA n AgGROUP,= Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 66 illustrates the truck (aerial/ladder) company distribution for KLFD and the roadways within the ISO-required 2.5-mile travel distance. In this case, 26 miles or 23% of the roadways are within 2.5 miles of Station 25, the only KLFD fire station with an assigned truck company (Ladder 25). Figure L i Distribution—ISOion—ISO 2.5-Mile Travel Distance Criteria_ 1 I rnn,n¢k. fsntvl tuiemV SCate P,�rk J.Angle Cny'6'D'lDp North Key ar9 Irk E S Lroi, Hanel ,Ite��tr,a , Erna fyr Pr+ n knmp / { 25cor R rl uY'.md 1„ O.nle i M �r �! Key Largo Study ISO LADDER COVERAGE PIry id,,r:K2 District Boundaries a a� KLFREMS Fire Stations KLFREMS EMS KLV D-24 Station 3 2.5 Mile Coverage KLV C uD 51 2 3 4 W5f6iWT6Ni Miles L,H,NASA NUA,LP!i:,5,K LMA,Muni D- de r-11'1ty,rIUL',B,r,'Nc+rnl r ,t rmin, ole(3,nj,1,MM/NASA, USGS,PA NPS,USDA USPA S ,' gGROUP,= Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS NFPA Distribution NFPA 1710: Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments, defines a career fire department as a fire department that utilizes full-time or full-time-equivalent (FTE) station-based personnel immediately available to comprise at least 50% of an initial full alarm assignment. This standard specifies that career-staffed fire departments—such as the KLFD—deploy resources such that the first-arriving unit can reach 90% of emergency service demand within 4 minutes or less of travel time. Additionally, the standard recommends that the second-due engine arrive in 6 minutes or less and that the full first-alarm assignment should arrive within 8 minutes or less of travel time at a low- to medium-hazard fire suppression incident (measured at the 90th percentile) and in 10 minutes, 10 seconds or less of travel time for high-hazard incidents. This means that all units required to conduct fire suppression operations must arrive on the scene and commence operations within the specified travel time. Figure 67 illustrates the performance standards from NFPA 1710. The Response Performance section will discuss the actual alarm processing (call processing), turnout, first-due engine (travel time), response time, and total response time performance of KLFD. Figure 1 rd Response Process ALARM ALARM PRGGGSSWGt Pao seconds M 9% W, 106 sdkast nds sI,99% FM TURNOUT MRST»IDUF FHGME 80 t eemi tls st Pa'% 240 a�aaaa:snds�aat tYW'�P% rya:60 sscmads at Fast (A ninuate2«sp SFGGNI.9 DIJS IFMGIRF 360 sst„C,daaQt„s at tal% (F tldakwtus INMIAL FULL ALARM [!48:0 U &iA AF2CI HIGH HAZARD €ts stW9a19 F'tltpsa aa�aaaLs aalS69f aQ to,g� �to rrotnaabs'110 sscannds) °Bharc+r NPA 1710,wnNd,ra^Pnr—,N BNA➢221 Q2019),whirl,,orate,h,gh�p,i...ty iror:V&m,,ch.Wd ata a6 ss mir..ds.,I..m WN, AgGROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS As illustrated in Figure 68, using GIS to estimate travel time, approximately 56% (62 miles) of the KLFD service area is within 4 minutes of a fire station, and an additional 42% (47 miles) is within 8 minutes of one of the two KLFD stations. In addition to KLFD staffing, the district participates in mutual and automatic aid programs. These programs enable neighboring agencies to respond to initial alarms and allow KLFD to use these resources to augment the effective response force, as described later in the following section. Figure i iri i - i / - i Travel Time KLFID Stations lia mrnack ESaeairvlcx+.V T,cuem Yarrlr J.AtYgl9',Gfl"6'D'Il1p 114 Nnrt.Key �yy,, ,9 �W.�:o �r f S Cro— rS �k ,a rr J ZSc• np r.:rn ral h,ef',tnra ti� f a Y Key Largo Study f NFPA COVERAGE Flr iar District Boundaries KLFREMS Fire Stations KLFREMS EMS Station D-24 4 Minutes L 'C 8 Minutes OD,51 2 3 4 A�Miles P Gksri,NASA NC,A,iJ,L9fb,OLMA M wni-DLIdu r.`naInty,FULk"Lsr 1-n-i,f rrrnln,Sro S(,rajph,MDli/NAiA, U;C6,FfA Nr";,USDA,USPAn AgGROUP,= Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS KLFD Response elii iliiy Study The workload of emergency response units can affect response time performance. If a response unit is unavailable for any reason, then a unit from a more distant station (or mutual/automatic aid agency) must respond. This can increase the overall response time. Although fire stations and units may be strategically distributed to provide quick responses, that level of performance can be achieved only when the response unit is available in its primary service area. IIIl Concurrency Concurrent incidents and the time that individual units are committed to an incident can affect a jurisdiction's ability to assemble sufficient resources to respond to additional emergencies. A higher number of simultaneous calls can drastically strain available resources, leading to longer response times for more distant resources. Figure 69 examines incidents that KLFD responded to from 2023 through 2024 to determine the frequency of concurrent calls handled by KLFD. Figure Incident rr (2023-2024) One Incident 81% 87% 84% Two Incidents 17% 12% 15% Three or more Incidents 2% 1% 217o On average, single incidents accounted for 84% of the overall incidents handled by KLFD during the three-year study period. Two incidents occurred and were handled by KLFD 15% of the time, which indicates that 2% of the time (on average), KLFD mitigated three or more incidents simultaneously. o mrm iltinrment Tliirne Commitment time, also known as unit hour utilization, is the time a unit is unavailable for response because it has already been committed to another incident. The larger the number, the higher its utilization, and the less available it is for assignment to subsequent calls for service. Commitment rates are expressed as a percentage of the total hours in a year, or total hours in a study period. JA' W ngle 93 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 70 and Figure 71 illustrate the total time that KLFD's primary units were committed to an incident during the study period, calculated from data provided by KLFD. Figure nit Commitment Times1 rr i Engine 24 513 1 19:37:56 0:24:25 1.36% 307 70:10:26 0:24:20 0.80% Engine 25 420 104:51:35 0:25:10 1.19% 379 78:00:18 0:23:53 0.89% Ladder 25 46 10:23:26 0:44:32 0.12% 256 31:39:31 0:25:40 0.36% Figure 1: KLFD Unit Commitment Times — )A Engine 24 456 147:24:31 0:41:43 1.68% 228 107:58:32 0:28:25 1.84% Engine 25 557 148:34:01 0:42:39 1.70% 187 83:32:30 0:26:48 1.42% Ladder 25 180 17:04:09 0:24:23 0.19% 11 7:29:42 0:40:53 0.13% A Data for this metric was not available in 2023. a For the period May 1, 2024-December 31,2024. The average time that each of KLFD's primary units was committed to an incident during 2024 was just over 32 minutes. The commitment factors for KLFD's primary units ranged from a high of 1 .84% for Engine 24 to a low of 0.13% for Ladder 25 in 2024. JAG has found that commitment rates of 257-30% for units deployed on a 24-hour shift can negatively affect response performance and possibly lead to personnel burnout. Commitment rates higher than 30% tend to cause system failures in other areas, such as response time performance, and the degradation of effective response force (ERF) delivery. When commitment times approach and exceed 30%, it implies that units are available only 70% of the time in their first-due areas. Notably, this analysis includes only incident activity and does not measure time dedicated to training, public education programs and events, station duties, or additional duties as assigned. JA' * ngle 94 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS In May 2016, the Henrico County, VA, Division of Fire published an article regarding the department's EMS workload.31 As a result of the study, Henrico County developed a general commitment factor scale for its department. JAG calculated the commitment factors for KLFD using the scale described in the Henrico County article. Figure 72 summarizes these findings in relation to commitment factors. Figure Commitment Factors Source: Henrico County, VA, Division of Fire (2016) Personnel can maintain training requirements and 0.1760.71dealRa7ngephysical fitness while consistently achieving response 0.16-0. time benchmarks. Units are available to the community more than 75% of the day. Community availability and unit sustainability are not questioned. First-due units respond to their assigned 0.25 System Stress community 75% of the time, and response benchmarks are rarely missed. The community served will experience delayed incident responses. Just under 30% of the day, first- 0.26-0.29 Evaluation Range due ambulances are unavailable; thus, neighboring responders will likely exceed goals. Not Sustainable: Commitment Threshold. The community has a less than 70% chance of timely emergency service, and immediate relief is vital. 0.30 "Line in the Sand" Personnel assigned to units at or exceeding 0.3 may show signs of fatigue and burnout and may be at increased risk of errors. Required training and physical fitness sessions are not completed consistently. 31 How Busy Is Busy?from www.fireengineering.com JA' W ngle 95 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS KLFD Operational Performance Analyses In this analysis, JAG examines emergency incident response time performance across the district's service areas, as provided by its units. The data used for this analysis are emergency responses extracted from the available district data from May 1, 2024, through December 31, 2024. Mutual and automatic aid incidents outside the service area, along with data outliers and invalid data, were removed from the dataset whenever possible. Response performance is measured from the time the fire apparatus is dispatched until the first fire department unit arrives on the scene. To analyze response performance, a percentile measure of KLFD response time is generated. Using percentile calculations for response performance follows industry best practices and is considered a more accurate performance measure than "average" calculations. The "average" measure is commonly used as a descriptive statistic and is also called the "mean" of a dataset. The reason for not using averages for performance standards is that they may not accurately reflect the performance of the entire dataset and may be skewed by data outliers. One particularly good or bad value could skew the average for the entire set. Percentile measurements are more accurate, as they indicate that most of the dataset has achieved a given level of performance. Fire service best-practice documents, such as those from the Center for Public Safety Excellence (CPSE)32 and NFPA 1710, recommend measuring emergency response time performance at the 90t" percentile, meaning that 90% of emergency responses occur in the stated value or Iess.13 In basic terms, the 90t" percentile means that 10% of the values are greater than the stated value, and all other data are at or below this level. This can then be compared to the desired performance objective to determine the degree of success in achieving the goal. Industry best practices recommend measuring total response performance from the time an emergency call is received at a dispatch center to the time the first emergency response unit arrives and initiates action or intervenes to control the incident. 32 Center for Public Safety Excellence (CPSE) Quality Improvement for the Fire and Emergency Services.(2020) 33 NFPA 1710:Standard for the Organization &Deployment of Fire Suppression Operations, Emergency Medical Operations, &Special Operations to the Public by Career Fire Departments (NFPA,2020). JA' W ngle 96 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Tracking the individual components of the total response time allows for identifying deficiencies and areas for improvement. While progressing through the performance analysis, it is important to understand that each component of response performance is not cumulative. Each is analyzed as an individual component, and the point at which the "fractile" percentile is calculated exists in a set of data unto itself. The response time continuum, which spans the time between when a caller dials 9-1-1 and when assistance arrives, comprises several key components. Figure 73 lists the individual components analyzed by JAG, which meet the NFPA 1710 benchmark of 90%. Figure 74 shows the response time measurements. Figure : Response TimeiDefinitions FPA IJZ0 Alarm Processing Time: The time interval between when a dispatcher 60 Seconds or Less answers a 9-1-1 call and resources are dispatched. enchmark & 60 Seconds or Less Turnout Time: The interval between the time that an emergency response facility (ERF) and emergency response unit (ERU) are notified NFPA 3>,o. (by an audible alarm, visual annunciation, or both) and the time a unit 80 Seconds or Less begins to respond. enPCM1mark A`FP�1]lp Flrz[ 240 Seconds or Less Travel Time: The time a responding unit spends driving to an incident. nckmark Response Time: The combination of turnout time and travel time. This measurement may indicate a system's capability to staff, locate, and �FPA 3I10 deploy response resources adequately. It may also indicate the 300 or 320 Seconds responding personnel's knowledge of the area or dispatcher BencM1mark instructions for efficient travel. This is often utilized as the measure of fire department response performance. Total Response Time: According to NFPA 1710, total response time is the interval between receiving an alarm at dispatch and the arrival of a unit on the scene to initiate an action or intervene to control an incident. This is the true measure of response-time performance. JA' * ngle 97 GROUP,= Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 1710 Response TimeMeasurements .il l l l Call Pro es i g Travel Time Initiating Action ILI Total Response Time Total response time is the amount of time a resident or business waits for emergency resources to arrive at the scene, starting from the moment they first call 9-1-1 . This process begins for KLFD once a call is dispatched from the 9-1-1 communications center (MCSO). While ISO does not specify these particular numbers under its "Fire Department" section of the FSRS PPC° review, it does describe the expectation under "Deployment Analysis." Specifically, ISO states, "The timing is in accordance with the general criteria in NFPA 1710." Allairim Processing The alarm processing component includes the time the MCSO Dispatch Center receives a call and when resources are dispatched. It should be noted that KLFD has no direct control over the operations of the MCSO Dispatch Center. Based on this, alarm processing was not evaluated in this report. Turn ut Tiim The turnout time component begins when emergency personnel are notified to respond by a dispatch center and ends when an apparatus begins to respond. Turnout time is a crucial component of total response performance and can be influenced by factors such as station design, apparatus staffing, and the performance of assigned personnel. Because of this, turnout time is one area of the overall response time that field personnel can influence. Figure 75 summarizes KLFD's 901" percentile turnout time performance for the two primary staffed engines. Due to data limitations, the small population of incidents to analyze means these results may not reflect actual performance. JA- * ngle 98 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure L Turnout Times - r 31, 2024) ® - Fire Incidents Engine 24 3 Minutes, 10 Seconds 80 Seconds Engine 25 2 Minutes, 28 Seconds EMS Incidents Engine 24 6 Minutes, 20 Seconds 60 Seconds Engine 25 4 Minutes, 11 Seconds During the 2024 study period, the response times for KLFD's units to both fire- and EMS- related incidents exceeded the NFPA benchmarks of 80 seconds and 60 seconds, respectively. Tr velll 't'iirne Travel time starts when an apparatus leaves a station and when it reaches the scene of an emergency. Travel time is one component of total response time that is rarely under the control of fire department personnel. The existing road network, traffic congestion, geographic barriers, and the size of the service area all play critical roles in travel time performance. JA' W ngle 99 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 76 illustrates travel time performance for the first-arriving KLFD unit throughout KLFD's service area at the 90th percentile. Figure 76: KLFD Travel Times (May 1, 2024-December 31, 2024) All Calls Fires EMS Alarms Other 0:00:00 0:02:00 0:04:00 0:06:00 0:08:00 KLFD's performance exceeded the NFPA recommendations in all noted categories. On average, for all incident types during the study period, travel time performance exceeded the NFPA benchmark of 0:04:00 by 2 minutes, 37 seconds (+0:02:37). Respo ins eTfirne As previously discussed, the most commonly used measure of fire district response performance combines turnout time and travel time, referred to as response time or response performance. This period starts when fire personnel are notified of an incident by dispatch and ends when the first apparatus arrives on the scene. JA' W ngle 100 GROUPALC .eu,e ,, K„o Response Times (May , 2024-oecemee, 31 ,a,,, Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 78 illustrates the closest aid partners to KLFD. Figure L I & Automatic Aid Partners "I Ai tgle Group M DFR station 69 N I E A[Par`r rra Station 26 u'rro,��y�mo,a,�nn Wdtim P�'tllhf:IC IiNdet.nriFr:drl.ifafCu i YVAC 2SKey Largo Study AUTO/MUTUAL AID O District Boundaries KLFREMS Fire Stations KLFREMS EMS Station Station 22: Automatic Aid Station 21 Mutual Aid 11-51 2 s 4 i;x Mhos station 20 is 3 haytrnn E,1:,i,NASA f GA,U G,4 Mi,�w L o&r S,r inty,I`fD[P,r,n n -,, ,wfprr'S jph,(A0,IALTI/NA SA, 11¢5 AA,POS USM'M S AgGaouw,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 79 summarizes the mutual and automatic aid given and received by KLFD for the period 2020-2024. Figure I/ i iSummary 7,11 ir Mutual Aid Received 39 19 12 9 28 Automatic Aid Received 16 19 12 3 8 Mutual Aid Given 85 78 21 15 64 Automatic Aid Given 23 21 13 1 15 Net (Given/Received): 53 61 10 4 43 JA' W ngle 103 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS MedicalI Emergency i The Key Largo Fire Department and Key Largo EMS provide prehospital emergency medical services in different formats to the Key Largo community. EMS Oversight & Medical Direction The State of Florida Department of Health (DOH) EMS Section is responsible for the licensure and oversight of EMS personnel, provider agencies, and vehicles. The DOH EMS Section has a wide range of EMS-related programs and services. Chapter 11, Article V, of the Monroe County Code of Ordinances provides additional local EMS regulations. The purpose of the section is to promote the health, safety, and welfare of Monroe County residents in need of EMS by establishing standards for issuing certificates of public convenience and necessity for ALS and BLS providers and by providing for the adoption of rules and regulations governing the operation of services. KLFD and KLEMS share the same EMS Medical Director (EMSMD), who is a Board-Certified Emergency Physician under contract with and paid by the Key Largo Fire Rescue & EMS District. According to KLFD, the EMSMD meets regularly with the department, while KLEMS reports that the EMSMD meets twice a month with the agency and occasionally responds to field incidents. On-duty Emergency Physicians provide online medical control at the hospital. Offline medical control is provided through written patient-care protocols. EMS Communications The KLEMS rescue units can communicate with the Key Largo Fire Department apparatus. Each vehicle is equipped with a mobile data computer (MDC) for generating electronic patient care records (ePCRs). Ambulance crews may use mobile radios or their own cell phones for hospital communications. Clinical Facilities Many KLEMS patients are transported to Baptist Health Mariners Hospital (BHMH) in Tavernier. The hospital is a 25-bed, critical-access hospital with medical-surgical and intensive care units. JA' * C 104 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS High-acuity trauma and medical patients typically require helicopter transport to Ryder Trauma Center at Jackson Memorial Hospital (a Level 1 Trauma Center/Stroke Center with a PCl/cath lab), HCA Kendall Regional Hospital (a Level 1 Trauma Center/Stroke Center, with a PCl/cath lab), or one of two other Level II designated Trauma Centers. Air Medical Transport Trauma Star is the only air ambulance service in Monroe County. It has helicopter bases in Marathon and Key West, staffed 24 hours daily with a pilot, Flight Firefighter/Paramedic, and Flight Nurse. Helicopters are configured for and capable of transporting two critical patients. If necessary, the Miami-Dade County Air Rescue Bureau can provide patient transport. KLFD Medical First Response Administration Quality Management The Key Largo Fire Department maintains an EMS Division overseen by a Shift Lieutenant. The division does not have a separate budget for administration or EMS operations. The department has a Quality Management (QM) Program in place. Electronic patient- care reports are integrated with its fire incident reporting in the ESO°software. Patient refusals are documented. EMS equipment and supplies inventory are maintained through the ESO® application. Equipment, supplies, and controlled medications stored on the apparatus are checked daily. S Operations KLFD provides medical first-response service at both the BLS and ALS levels. The demand for EMS represents about 70% of its calls. KLFD utilizes three-person engine companies to respond to EMS calls and works with Key Largo EMS for patient transport. KLEMS Administration & Operations Administration Quality Management The Chief, Deputy Chief of Administration, and two Lieutenants manage KLEMS. Administration includes an Office Manager and a Training Officer. JA' * ngle 105 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS A Quality Assurance (QA) Officer manages a Quality Management (QM) Program that monitors the EMS system performance and identifies areas for improvement. The EMSMD reviews ePCRs flagged by the QA Officer and provides feedback to individual EMS providers. The QA Officer spot-checks ePCRs and reviews patient refusals. A system is in place to address patient complaints. KLEMS does not provide annual or regular reports on the QM program's results, cannot obtain patient outcome data from the hospital, and lacks a program to address frequent EMS system users. The organization provides input on the development of patient care protocols. KLEMS utilizes the ESO°software application to generate ePCRs and complies with the National Emergency Medical Services Information System (NEMSIS) and Health Insurance Portability and Accountability Act (HIPAA) standards. The software is integrated with the CAD system. Patient refusals are documented, and a system is in place for patient requests for ePCRs. Equipment and supplies are checked on all primary units daily, and controlled medications are verified during the daily shift changes. Use of any controlled drugs is documented on an electronic form and signed by a witness. S Operations & Transport Key Largo EMS is a licensed ground ALS ambulance service whose units are staffed with two Paramedics and an occasional volunteer. Staff work a 48-hour schedule with overtime when required. The shift begins at 0700 hours. Rescue ( rnbulll nce) IDeplll yrnent & Staffing KLEMS deploys three rescue units (ambulances) 24 hours daily, resulting in 72 daily unit hours and 26,280 annual unit hours. The system generally does not utilize system status management (SSM) or staff peak-demand rescue units. Although KLEMS provides 9-1-1 EMS responses, it does not conduct scheduled interfacility or long-distance transports. However, KLEMS occasionally provides some non-emergency transports. JA' W ngle 106 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Key Largo EMS Service Demand During the period January 1, 2022, through December 31, 2024, KLEMS was dispatched to 4,266 incidents. Of those responses, 65% of the patients were ultimately transported by KLEMS. Less than 2% of those were transported by other means—by an air unit or another EMS agency. As shown in Figure 80, Rescue 23 was assigned and dispatched to the most incidents during the 36-month study period. The dataset showed that 96% of the responses by the rescue units were emergent (with lights and sirens). Figure Service L nit (2022-2024) 1,400 1,200 1,000 1,004' 800 600 400 200 1.32 0 0 0 234 Rescue 23 Rescue 123 Rescue 25 2022 m 2023 2024 JA' W ngle 107 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS KLEMS Temporal Analyses The following section addresses the various temporal analyses of KLEMS during the 36- month study period. Figure 81 illustrates the volume of EMS calls by month. On average, the busiest month during the study period was March, while June was the least busy. There is just over a 3.5% difference between the two months. Figure 81: KLEMS Service Demand by Month (2022-2024) 14% - 1217. . .......I 9% 10% 10% f 0 %o 8% . ...................... % 0 6 . ....................... 7 E 8 17o 11..................... 4176 ........... 2176 076 ............. JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC mm 2022 iiiiiiiiiiiiiiiiiiiiiillillillillillillI 2023 2024 —40---Average Figure 82 shows that Saturdays tended to have a slightly higher service demand. Figure 82: KLEMS Service Demand by Day of Week (2022-2024) 20% - 18% 1 6'C"7"0.......... 16% 14 4% 147 476................. 76.......................1-570 0 14% 12% 10% 8% 6% 4% 2% 0% SUN MON TUE WED THU FRI SAT mm 2022 iiiiiiiiiiiiiiiiiiiiiillillillillillillI 2023 2024 --*--Average JA' * ngle 108 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS One of the most important temporal analyses is service demand by hour of day, as this can affect staff and rescue unit scheduling. Figure 83 illustrates historical EMS call volumes by hour during 2022-2024. Figure 83: KLEMS Service Demand by Hour of Day (2022-2024) 9% 8% 7% .............. . . . .............................................................................................................................................................. 6% . ...... . ..... 4% 3% 2% ..... . ..... 1% 070 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 mm 2022 11111111111111111111111111111111111111112023 2024 -0--Average During this period, service demand began to increase around 0700 hours and steadily increased through 1700 hours, after which the number of calls decreased until 0500 hours. This is the typical pattern of EMS calls found in many systems, as demand is most influenced during times when humans are most active. The data showed that the busiest 12 consecutive hours were between 0900-2000 hours, representing approximately 68% of service demand. The busiest I 0-hour period was between 1000-1900 hours, accounting for 58% of the call volume. Finally, the busiest 8-hour period occurred from 1100-1800 hours, accounting for 49% of the call volume. This information is useful when examining the need to schedule additional rescue units or a peak-demand unit. JA' W ngle 109 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 84 compares the average demand for each day and each hour, with relative values shown by color. The darker greens indicate lower demand, while the darker reds indicate the highest demand. Figure L ri r (2024) 2.43% 231% 2.2a° � m .. ........ 2,43% 2;31°/a 4.40% � � 196% ///,� 2.48% D 1112.75 3.30%o 3.40% 3.24% 2.75% 4.32% 1.96% 4.00% 2.97% 1,94%'' 5.09% 5.49% 5.41% 3.92% 4.00% 2.97%' 7-,V 2.78% 6.04%: 5.41% 3.92% 4.00% 4.46% 7 a 6.94% 6.049/. 6 49%1IN 6.86% 2 48% 5.83% 6949,o' 4.95% 7 03% ? 5 4.57% ® 5.83% 5.09% 6,04%"'% iiiiiiiiii 0 0 0 ;��i� 5.39% 4.57%- 7'4l ® 4.37% 6:94% 5.49% 4.86% 4.90% 5.14% 3.47% 4.85% 6 5.95% 4.90% 6 29% 5.94% 0 4 is o o '''////,/I!!4.85/0"" r �,/0 2 75/0 5 95/0; 3.88%..: 5.95% 4.37/0 5.09/0 7.14/0 5.41/0 5.39/0 5.14/0 3.88% 6;48% 3.85% 4.86% 6:86%' 3.43% 4.95% 5.83% 4.63% 4.40% 3.24% 3.92% 4.00% 4.85% 4.63% 3.30% j 4.41% 6.29%' 3.96% ® 5.34% 7 41%; 3.30% 5.95% 4.90% 5.14% 4.95% ® 3.88% 3.70% 3.30% 4.32% 4.41% 4.00% 4.95% 6.80% 4.32% 4.41% 4.00% 4.46% Temporal Analyses Discussion Historical KLEMS data analyses indicated that monthly EMS service demand tended to be slightly higher from January through the end of May. However, in 2024, the difference between the lowest number of incidents in September and the highest in February was 65 calls. JA' W ngle 110 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS When considering calls by the day of the week, in 2024, Fridays were the slowest days, while Mondays were the busiest at 41 more calls for the year—or an average of less than one additional call per week. About 68% of KLEMS' service demand per hour occurred during the 12-hour period between 0900 hours (9 a.m.) and 2000 hours (8 p.m.). It is important to regularly monitor hourly service demand, as it can affect the need to add more resources, such as peak- demand units. However, the need to add resources based on any of the temporal analyses will ultimately require a decision by the KLEMS leadership. KLEMS Operational Performance Analyses As with KLFD, several performance metrics were analyzed for KLEMS. As noted in the figure captions, some of the metrics were based on data from the 2024 fiscal year rather than the calendar year. II Concurrency Concurrent incidents and the time that individual units are committed to an incident can affect a jurisdiction's ability to assemble sufficient resources to respond to additional emergencies. A higher number of simultaneous calls can drastically strain available resources, leading to longer response times for more distant resources. Figure 85 examines incidents that KLEMS responded to in the 2024 fiscal year to determine the frequency of multiple calls handled by the organization. Figure L Incident rr n One Incident 86% Two or more Incidents 14% In FY 24, single incidents accounted for 86% of the overall incidents handled by KLEMS. Two or more incidents occurred and were handled by the agency 14% of the time. JA- * e GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Commitment i e Figure 86 illustrates the total time that KLEMS' primary units were committed to an incident during the study period, calculated from KLEMS data. As described in the KLFD Commitment section, these KLEMS commitment times do not currently pose any concerns but should be monitored. Figure L nit Commitment Times � a Rescue 23 1,071 943:47:1 1 0:52:52 10.74% Rescue 123 162 143:51 :16 0:53:17 1.64% Rescue 25 154 123:12:21 0:48:00 1.4017o Response Time Metrics Because of data limitations, turnout and response times could not be evaluated. However, travel time could be analyzed. The results are shown in Figure 87. Figure Travel Time at the 901h Percentile (FY 24) All Calls ® i Fires Medical ® w r MVC ------------- f Trauma Other r 0:00:00 0:03:00 0:06:00 0:09:00 0:12:00 0:15:00 JA' W ngle 112 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS KLEMS Patient Transport Analyses KLEMS documents the mode of transport in two separate data fields: "Transport Mode" and "Disposition." There were differences between the results found in each. A review of the Transport Mode data showed that 77% of patients were transported with lights and siren, while the Disposition data indicated that, of those transported, 75%were transported emergently. From this data, it can be concluded that most patients were transported with lights and siren during the 36-month study period—despite 56% being documented as low- acuity incidents. Transport Dsin tip s Nearly all (about 98%) of the patients transported by KLEMS were sent to Baptist Health Mariner's Hospital. Most of the remaining patients (at less than 1% each) were taken to Baptist Health Homestead Hospital or Jackson South Trauma Center. In addition, about 1 of the cases were transported to the Key Largo Ranger Station helipad or to one of several other helipads in the area, from which they were flown to a facility. Patient rTimes Transport times were analyzed and defined as the interval between leaving the incident scene and arrival at the hospital or other location. Figure 88 illustrates the KLEMS patient transport times by rescue unit at the 90th percentile during 2022-2024. Figure Patient ransport Times at thegoth Percentile Rescue 123 ui��uiqu!� �� �����gmuuuuuuuuuuuuuuuuuuuuuuu��uuuou�u'u�u���uuuuuu�uu,�u, Vuuutliuui iuillillul Rescue 23 Fluum ® tt Rescue 25 0:05:00 0:10:00 0:15:00 0:20:00 0:25:00 2024 1111111111112023 m 2022 JA' W ngle 113 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS As shown in Figure 88, the time required to transport patients from the scene to their final destinations (hospitals, helipads, etc.) ranged from 20 minutes to just over 27 minutes at the 90'h percentile during the 36-month study period. When looking at average transport times, the results showed a low of just over 14 minutes and the longest at approximately 19 minutes, 34 seconds. Hospital Turnaround Times Hospital turnaround time, or "ambulance patient offload time" (APOT), is defined as the interval between the transport unit's arrival at the hospital or clinical facility and its departure from the facility. It is important for EMS transport agencies to consistently monitor these times, as rescue units could be occupied at the hospital for significant periods and unable to respond to other calls. EMS personnel cannot leave a patient at a facility until the patient is transferred to another qualified healthcare professional. Figure 89 shows the ambulance patient offload times by rescue units at the 901h percentile for the 36-month study period. As shown, the times tended to increase between 2022-2024. Figure nit at the 901h Percentile (2022-2024) 0:20:00 Rescue 123 liiuill iufiiuliiliiluu m ul miuu 0:19:00 Rescue 23 f uu�lll III uu��lul I uul i°ill Rescue 25 Iluml uiiilu ul miiilllll 0:05:00 0:10:00 0:15:00 0:20:00 0:25:00 0:30:00 2022 m2023 1111111111112024 As mentioned, about 98% of the patients transported went to Mariners Hospital. At that facility, hospital turnaround times ranged from nearly 21 minutes to 22 minutes at the 90'h percentile during 2022-2024. JA- * ngle 114 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Patient Characteristics KLEMS reported its "Primary Impression" of patients in 3,961 cases. The top ten impressions are illustrated in Figure 90. The figure shows that some type of injury was the most common impression, followed by generalized weakness and syncope. Figure 90: Top 10 Most Frequent Patient Impressions (2022-2024) 8% -- 7% -- 6% 4% -- 3% 2% 070 - ,A 0 Oq 4 ,01 oco 01\0 \0 s" 0 411� (Po Other higher-acuity conditions, such as strokes, cardiac arrhythmias, status epilepticus, cardiac arrest, anaphylaxis, septicemia, and other conditions at higher acuity levels, were listed but not among the ten most frequent impressions. Most of those accounted for less than 1-2% of the total. There were 49 cases of cardiopulmonary arrest. Of those, 41 patients were arrested before the arrival of the rescue unit, and 13 were arrested after the arrival of EMS personnel. The analysis in Figure 90 did not include 196 (5%) patients listed as having no complaints. The dataset included a list of cases identified by MCSO as having a condition, as recorded in the emergency medical dispatch (EMID) system. As shown in Figure 91, there were significant differences between provider impressions and those identified by the dispatch center. JA' W ngle 115 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 1: Top 10 Most FrequentConditions Identified - 20% 19% 18% 16% t ...........,14% 14% 12% 8% 7%������������������������6�...................................................................................................................................................................................................................................................................................................... 5 0 11111111�5% 5% 47, 2% �, 0% .5 e ea Py� G� e "t' �a p`e Qe c�5 s e° vc °c ° �G` dye `c` °O `c0 Gre��Qo Jam Pad°c� KLEMS documented mechanisms of injury (MOI) in 981 patients. As shown in Figure 92, at 43%, the category "Blunt Trauma" represented the most common mechanism of injury. However, the etiology—such as a blunt instrument, blunt force from another object, or some other cause—was not specifically identified. The same was true for "Penetrating Trauma." Whether the cause was from a knife, bullet wound, or another object was not documented. Assorted falls represented the second most common MOI at 20% of the total. If combined with "Other Falls," those would be the second-highest number of mechanisms at 25%. "Traffic Accidents" accounted for the fifth-highest MOls at 6%. JA' * ngle 116 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure r i Injury - ) m1% 3% S%ulll III �rrllhhll ■ Blurnt'frauirnna ■Assortted II"'alllls Cttlhner Mechanisms Motor Velhicle Accident Gttlhner II"'alllls IFeirnettrattiurng'Traurmna ■Assault 11,1 II„acerattiorn Cttliner Ilrnlury Motorcycle Accident Finaltie t Acuity KLEMS documented the patient's final acuity level in 1,219 cases. As shown in Figure 93, 55% of the patients transported had a low acuity level, while 4%were considered critical. The deceased patients included seven who had resuscitation efforts and four without resuscitation. Figure : Final Patient AcuityLevels - ) 60% 50% 40% 37% 30% 20% 10% 4% 0% Low Acuity Emergent Critical (Red) Non-Acute Deceased (Green) (Yellow) (Black) JA' W ngle 117 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Section II-. SUPPORT PROGRAMS J*ngle 118 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS ITraining & Continuing Medical Education Programs Training is the foundation of all aspects of emergency services. An EMS provider's or Firefighter's ability to effectively utilize resources and equipment depends on the level and quality of training received and provided by the organization. The following section provides an overview of the Training and Continuing Medical Education (CME) Programs at KLFD and KLEMS. Training Administration & Resources A significant component of an efficient and capable public safety agency is ensuring that adequate, regular training and continuing education is available to its personnel. This can be accomplished by effectively utilizing internal staff assigned to manage and provide training, external resources, or a combination of both. One well-known and respected research consultant emphasizes the need to focus on "high-risk/low frequency" events.34 This concept is evident in the amount of training required for structure fires or cases of complex illnesses or injuries compared to call volumes. Therefore, fire departments and EMS agencies must prioritize effective training and continuing education. KLFD Training Administration KLFD has a Training Committee made up of Officers and Instructors from within the department who meet regularly to discuss upcoming training and to update current training. The Training Program is managed by one of the Shift Captains. KLFD utilizes Florida State Fire Instructors certified as Instructor I, II, or III. The department adopts and publishes annual training goals and objectives and produces an annual training report. KLFD has budgeted nearly $100,000 for training each year. The department reports having "good" training administration facilities and adequate office space, equipment, and supplies. KLFD maintains a training procedures manual. 34 Quote from author and lecturer Gordan Graham. JA' * ngle 119 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Training Records KLFD maintains computerized training records on all operations staff. The Training Captain is responsible for entering and maintaining training records. In addition, KLFD tracks certifications for fire, EMS, and other personnel. Records are available to staff and are kept in accordance with the NFPA 1401.35 Training Ilf:: illlit1es & Resources The Key Largo Fire Department does not maintain a standalone training center; instead, it uses Monroe County Fire Rescue's Joe London Fire Training Academy in Marathon. This is a state-of-the-art fire training center with classrooms, computerized audiovisual equipment, EMS and live-fire training props, a burn building, a tower, space for driver training, and many other resources. KLEMS Training Adi isr tip The responsibility for training and continuing medical education is assigned to the KLEMS Training Officer. The department identifies and publishes annual training goals and objectives, and a monthly training report is published. KLEMS indicates it has sufficient office space, equipment, and supplies to manage training administration. The department did not list a budget specifically for training and CME. "ll"raining Records KLEMS maintains computerized training records regarding its individual EMS personnel. The Training Officer is responsible for maintaining internal and online training records. The Training Officer and Lieutenants can enter training records, which can be made available to staff. KLEMS maintains personnel EMS certification records. Training Ilf:: illlit1es & Resources KLEMS utilizes an EMS training room and believes it has sufficient space and equipment for conducting training sessions. The department maintains numerous manikins for CPR, endotracheal intubation, and intravenous and intraosseous placement; and an ALS manikin for 12-lead and ECG training and other activities. 35 NFPA 1401:Recommended Practice for Fire Service Training Reports and Records (2017). JA' W ngle 120 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS General Training Competencies Key Largo Fire Department Traininge e cies Figure 94 summarizes the general training topics and certification levels provided by the Key Largo Fire Department. KLFD did not provide specific details on each topic. In addition, KLEMS did not provide a list of competencies. Figure n r l Training CompetenciesL MIN Incident Command System Yes Accountability Procedures Yes Training SOGs Yes Training Safety Procedures Yes Emergency Scene Operations Yes Respiratory Protection Training Yes Rapid Intervention Crew Training Yes Thermal Imaging Training Yes—NFPA 1408 Recruit Academy Yes Special Rescue Training Yes Hazardous Materials Certifications Operations Level Wildland Certifications Awareness & Operations Levels Vehicle Extrication Training Vehicle and Machinery Rescue Operations Emergency Driving VFIS Emergency Vehicle Driving Vehicle Operations Yes—NFPA 1451 Small Tools & Power Equipment Yes Communications & Dispatch Yes EMS CME Online by Kaplan® Fire & EMS Training BLS & ALS Skills Practice In-house practical skills Other EMS Training ACS, PHTLS, PALS, ACLS, CPR Training Methodologies & Delivery At the time that data was gathered for this report, KLEMS did not provide the J. Angle Group with a list of methodologies utilized for training. Figure 95 summarizes the training methodologies utilized by the Key Largo Fire Department. JA' W ngle 121 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure Training I i Manipulative skills & tasks Annually Skills performance evaluations Yes Fire training hours requirements HAZMAT Refresher (12 hours State & 8 hours ISO) EMS training hours requirements 30 hours for EMT & Paramedic by FLDOHI Annual training hours tracked Yes Use of formal lesson plans In-house & commercial versions Night drills No Multi-agency drills No Disaster drills No Inter-station drill Bi-weekly Pre-fire planning included Yes, per NFPA 1620 Safety policies/practices Yes Post-incident analyses done Yes I Florida Department of Health. Balanced EMS & Fire Training A balanced fire and EMS training program would likely be valuable for KLFD and KLEMS, including focused, required recertification, immersion, and repetitive training. Figure 96 illustrates the components of a balanced training program. Figure I r inin Program JA' W ngle 122 i o, GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Recertification r i i Regional and Florida EMS certifications, as well as some fire-related certification requirements, are generally not an option for non-compliance. Fire departments and EMS organizations should perform a cost-benefit analysis of the various optional certifications when an opportunity arises. Repetitive rai i Another perspective concerns the success achieved over the past ten years in King County, Washington. Efficacy has been demonstrated through the use of repetitive skills training to master specific skills. King County has demonstrated one of the highest advanced airway success rates in the country, attributed to redundant skills training.36 Numerous organizations have pursued and purchased high-fidelity simulators for enhanced EMS training. The simulators provide excellent real-time feedback during a training scenario. The devices cost between $60,000 and $110,000, and limitations include extensive maintenance requirements and limited mobility. They have proven effective in a hospital setting or a training facility where end users are in one location. A more cost-effective and proficient solution is the use of mid-fidelity manikins. Multiple manikins can be purchased and deployed throughout the organization for the same amount of funding. This option can provide training without significant drive times to central training facilities, allowing EMS providers to have repetitive skill practice sessions. Another benefit of mid-fidelity manikins is the opportunity to develop proper sequencing. Identifying the order of critical interventions is crucial to successful patient outcomes. The previous concepts also apply to fireground training and the need for repetitive evolutions. Individuals can perform multiple evolutions and develop proper sequencing for critical tasks and objectives by decentralizing the training of fire or special teams. 36 FireEMS,Training for Success. JA' * ngle 123 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Focused r i i Another component of a balanced training program includes focused training. An organization's training schedule should include a percentage of training based on retrospective statistical data from actual incidents. KLEMS and KLFD should consider identifying areas for improvement in actual emergency responses. Organizations must allocate disproportionate training to high-risk/low-frequency incidents to maintain fireground safety. The J. Angle Group recognizes these limitations. Still, when possible, there should be a focus on training related to service demand. The training program should look for additional patient care or service-level opportunities. Immersion rai i A common challenge for any training program is developing training that translates to improved efficacy. Current research supports the effectiveness of immersion training in creating the illusion of an actual event. Individuals experience changes with a high level of realism, leading to a metaphorical immunization against some of the event's stress and challenges. An example would be an active shooter exercise that involves volunteer victims wearing "cut suits," which allows a Paramedic to perform advanced procedures while law enforcement stabilizes the scene.37 There are difficulties associated with these types of events. They tend to be labor-intensive and can be cost-prohibitive due to the overtime required. A solution to the problem is to create immersion training on a smaller scale and to design it to be mobile. Personnel Trained In 2024, the Key Largo Fire Department trained 24 (entire staff) personnel. A total of 730 hours of training was delivered to the department's staff. • Fire-Related Training: 312 hours of classroom/online training; 313 hours of practical skills training • EMS-Related Training: 52 hours of classroom/online training; 53 hours of practical skills At the time that data was gathered for this report, KLEMS did not provide a complete accounting of the 2024 training of its staff. 37 American Journal of Disaster Medicine,Active Shooter Training. JA' W ngle 124 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Life Safety & PublicEducation The following section describes the various fire prevention and public education programs provided by the Key Largo Fire Department and the Key Largo EMS. Life Safety & Fire Prevention Programs The Key Largo Fire Department is limited in its capacity to deliver and manage life-safety and fire-prevention programs. Instead, such programs are provided primarily through the Monroe County Fire Rescue (MCFR) Fire Marshal's Office (FMO). General Inspection r ram & New Construction KLFD conducts annual fire planning on all commercial properties in its response area. All Officers are expected to participate in these inspections. If potential violations are identified, they are forwarded to the MCFR. Inspections are documented using the ESO° Fire Records Management application. The MCFR Fire Marshal's Office provides KLFD with updates on the following activities: • Consultation on proposed new construction. • Consultation on proposed occupancy changes. • Consultation on tenant improvements. • Perform fire and life-safety plan reviews. • Sign-off on new construction. MCFR also provides existing occupancy inspections, special risk inspections, and storage tank inspections. The MCFR Fire Marshal's Office also handles fire-cause determinations and arson investigations. KLFD has not completed a Community Risk Assessment (CRA) or a subsequent Community Risk Reduction (CRR) Plan. Public Education Programs Neither KLFD nor KLEMS provide regular public education or fire prevention programs. However, KLFD has an active AHA Training Center. Currently, they have received all supplies from an EMS Grant and are setting up a 2026 schedule for community classes for the Heart Saver and Stop the Bleed trainings. KLFD is also working to achieve the ability to train all KLFD staff in-house for CPR, ACLS, PALS, and Stop the Bleed. JA' * ngle 125 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Section III: OPERATIONAL & GOVERNANCE OPTIONS J*ngle 126 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Organizational Structure Op Sections I and II of this report consist of a baseline assessment of the current conditions of the Key Largo Fire Rescue & EMS District and its subcontractors, Key Largo Emergency Medical Services and the Key Largo Fire Department. Based on this comprehensive analysis, JAG evaluated opportunities to either maintain the status quo or pursue consolidation within KLFREMS. The following section entails various options that the participating organizations could consider. Option 1: Maintain Status Quo (Independent Fire and EMS Agencies) In some cases, maintaining the status quo (current system) is the most desirable approach. The district and its subcontractors may choose to continue as separate entities and not pursue any further changes. Under this strategy, it appears that it would not be advantageous for KLEMS and KLFD to remain separate, each with its own Board of Directors. The disadvantage of this approach is that any challenges facing the participating fire and EMS organizations remain unchanged. Any opportunities for efficiency, either financial or service-level, through greater collaboration are not realized, and continued duplication and overlap will persist. In today's environment, taxpayers typically hold their elected officials accountable for delivering a quality service at an affordable rate and expect creative thinking to solve problems or achieve those ends. Option 1® : Maintain Status Quo with Fire/EMS Chief Appointed This option would maintain the status quo, except for appointing a full-time career Fire/EMS Chief, employed by the district, to manage and supervise both KLEMS and KLFD. Appointing an individual not currently affiliated with the district or the subcontractor agencies may be the ideal option. The Fire/EMS Chief would report to the KLFREMS Board of Fire Commissioners. Option 1-B: Maintain Status Quo with Fire/EMS ChiefAppointed itio I Staff This option is the same as Option 1-A, but with the addition of employing four new career staff per year through FY 30. JA' * ngle 127 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Option 2: Complete Consolidation of KLFD and KLEMS into the District Under this option, the district would stop contracting with KLFD and KLEMS and begin directly providing the services detailed in their Charter, operating in accordance with the policies and governance of a single-elected Board of Fire Commissioners. Option -A: Complete Consolidation withChief Fire/EMS Appointed (No Additional Staff) This option would entail the full consolidation of the two corporations and the appointment of a full-time career Fire/EMS Chief. Appointing an individual not currently affiliated with the district or the subcontractor agencies may be the ideal option. Option 2- : Complete Consolidation with Fire/EMS Fire/EMS Chief Appointed and Florida Retirement Systemeire en (No Additional St This option would be the same as Option 2-A, but with the addition of the Florida Retirement System. Option -C: Complete Consolidation with Fire/EMS Chief, Additional Staff, and FIRS Retirement Same as Option 2-B, but with four staff added each year. JAG's Recommended Option Based on its comprehensive analyses, observations, and evaluations, JAG recommends that "Option 2-C: Complete Consolidation with Fire/EMS Chief, Additional Staff, and FRS Retirement" be considered as the first alternative. If that option is rejected, JAG recommends selecting Option 2-B as the next option for consideration, and lastly, Option 2- A. JAG does not recommend any of the Status Quo Model. JA' W C 128 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS IProjected Cost of the Options As discussed previously, the district already exerts tight financial and budgetary control over KLFD and KLEMS through the respective contracts with each entity.38.39 While the respective contracts address many aspects of the organization and management of each agency, requiring strict compliance with Board policy and procedures, this section addresses only fiscal issues. One key consideration for any potential consolidation of the agencies with the district is how career personnel will be treated. Should the entities consolidate with the district, KLFD and KLEMS employees would become district employees and thus become eligible for alternative retirement programs such as the Florida Retirement System's (FRS) defined benefit or defined contribution plans, or the so-called Chapter 175 plan (available only to Firefighter-certified personnel). Alternatively, the district could provide a 457(b) plan similar to the current 401 (k) program, or it could choose a combination of plans. The district's current budget process is rigorous, and transparent to taxpayers. Each entity is required to submit a proposed budget— including personnel, operating, and capital costs—to the district for approval and integration into the overall budget. However, KLEMS collects ambulance billing revenue separately from the district and then offsets proposed Paramedic costs in its budget submittal to the district. This revenue collection and expenditure offset does not appear in annual district audits, and it is not clear what the actual impact is each year. Integration with the district would close this loop and provide a more complete financial picture of the cost of providing EMS to the community. 38 Agreement Between Key Largo Fire Rescue and Emergency Medical Services District and Key Largo Volunteer Fire Department, Inc., 7/13/20. 39 Agreement Between Key Largo Fire Rescue and Emergency Medical Services District and Key Largo Volunteer Ambulance Corps, Inc., 6/22/20. JA' * ngle 129 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Although there may be significant financial differences between the status quo and integrated district options, it is instructive to examine several potential forecast models and variations to determine their impact on taxpayers within the district. Various revenue, expense, and fund balance assumptions have been made to develop forecasts through FY 30 for each model. These assumptions are generally based upon the historical analysis presented earlier, and the resulting trend data is used where appropriate. A five-year forecast with calculated millage rates for taxpayers within the district is provided for each model, allowing for a comparison of the high-level financial impacts. Financial Forecast for Option 1 (Maintain Status Quo) The following discussion identifies key revenue, expense, and fund balance assumptions used to project a calculated millage rate necessary to sustain KLFREMS over the next five years. The calculated millage rate may differ from the final adopted rate. It is calculated using the adopted or projected taxable value (for example, the preliminary taxable value obtained from form DR420), less approximately 3%, divided by the tax revenue needed to fund total expenditures and fund balance levels based upon district policy and considering other projected revenues (both recurring and non-recurring), as well as a total fund balance carried forward each year. The same process is used here in the Status Quo models and later in the Integrated models to ensure a consistent comparison. Revenue ss ion The primary source of funding for KLFREMS is ad valorem revenue; therefore, the district's total taxable value over the forecast period is a key variable in the model. Since a major change in total taxable value occurred between 2022 and 2023, predicting future trends based on the most recent five-year historical taxable value and resulting ad valorem revenue is somewhat problematic. Figure 97 shows the district's total taxable value from 2017 to 2025. Total preliminary taxable values increased at an average annual rate of approximately 7.4% between 2017 and 2022, then rose significantly to an average annual rate of almost 13.8% between 2022 and 2025. JA' W ngle 130 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure I Preliminary Total Taxable Valuer KILFREMS (2017-2025) 8,000,000,000 6,000,000,000 .. > 4,000,000,000 ID a 2,000,000,000 2017 2018 2019 2020 2021 2022 2023 2024 2025 Preliminary Taxable Value(DR420) The average annual rate of taxable value increase for the district from 2017 to 2025 is 9.74%. It is reasonable to assume, based upon current and past spikes in taxable value lasting several years, that the annual rate of change will not continue at the high rate experienced between 2022 and 2025. The State of Florida estimates the total taxable value for each Florida county for public education funding purposes.40 The Department of Revenue acknowledges the increase in taxable values in Monroe County with year-over-year increases from 2022 to 2025. The annual rate of change is expected to decline from 2025 through 2030 as follows: 7.94% (2026), 5.88% (2027), 5.53% (2028), 5.36% (2029), and 5.28% (2030). This trend is projected throughout the State of Florida. Although the actual annual rate of change for the district may differ, the state-projected rates for Monroe County are used in the following models. Therefore, the relative impacts of each model can be compared, even though the actual revenues and needed millages differ. The forecast model adjusts the required ad valorem revenue based on the estimated initial total fund balance target, along with other recurring and non-recurring revenues forecasted to offset estimated recurring and capital expenses. 40Florida Department of Revenue, Revenue Estimating Conference Ad Valorem Assessments, March 5, 2025 JA' W ngle 131 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS A millage rate is then projected using the estimated total taxable value and ad valorem revenue. Other revenues are increased as follows: • Intergovernmental Revenue—Assumes the interlocal sales fax revenue sharing agreement with Monroe County continues with annual funding at $150,000. It should be noted, however, that the current agreement expires on September 30, 2026, and the modeled revenue will not be available unless the agreement is extended. • Interest—Based upon the projected carryforward amounts and the FY 25 adopted amount of $200,000, which is 3.5% of the carryforward. The forecasted carryforward for FY 26 is increased by 3.5%, and this amount is then decreased each year so that by FY 30, the annual increase is 2.5% of the projected fund balance carryforward. Non-recurring revenues comprise grants and miscellaneous income. These sources are combined and held at $25,000 each year of the projection. Expense Assumptions Personnel services are a significant recurring expenditure, with total compensation costs for each service provider comprised of stipends for Board and volunteer members, part-time pay with limited benefits for part-time personnel, and full salary and benefits for full-time personnel. However, in the case of KLEMS, full-time Paramedic costs were reduced in the KLFREMS budget by ambulance revenue, as discussed previously. JA' W ngle 132 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS As shown in Figure 98, staff-estimated full-time employee numbers have increased for each provider from FY 20-25. Figure Full-Time r i l Staff EmployedL20-25) Fire Department Captain/Paramedic 3 3 3 3 3 3 Lieutenant/EMT 1 1 1 1 1 1 Lieutenant/Paramedic 2 3 3 3 3 3 Driver Engineer/EMT 5 6 4 4 6 5 Engineer/Paramedic 4 4 7 6 7 8 Firefighter/EMT 0 0 0 2 3 3 Firefighter Probationary 0 0 0 0 0 4 KLFD Career Staff: 15 17 18 19 23 27 EMS Department Lieutenant/Paramedic 2 2 2 2 2 2 Paramedic 3 8 14 7 12 10 KLEMS Career Staff: 5 10 16 9 14 12 Combined Total Career Staff: 20 27 34 28 37 39 Full-time staffing numbers from Figure 98 are shown by service provider, compared to the district's total personnel services costs for the period FY 20 through FY 25 in Figure 99. Total costs increased at an annual rate of approximately 15.2% between FY 20 and FY 23, then rose more rapidly through FY 25 at an average annual rate of 38%. JA' W ngle 133 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure Career Operational Staff v . Total District Personnel20-25) 5,000,000 100 4,500,000 4� 12;84 c 4,000,000 80 3,500,000 609 247431 74 3��3r c3,000,000 ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������ �� , 60 H a2,500,000 617,972 1 905;520.......,2,,,,,,6,,,,3,,,,2,,,,,,6,,,,,,3........................................... 2 1 U 2,000,000 40 U a 1,500,000 10 1,000,000 20 500,000 0 0 2020 2021 2022 2023 2024 2025 KLVFD Career Staff Em KLVAC Career Staff Personnel Services However, total costs do not correlate with full-time staff count. Given the full-time Paramedic compensation offset by ambulance revenue, which does not appear in the KLFREMS audits, a different approach was used to develop personnel cost trends in the following models. Since the KLFD total budgeted personnel services costs included the full cost of each career Firefighter, the KLFD cost and staffing figures were used to determine annual increases in the models, with no additional future staff added. Figure 100 shows full-time operational KLFD staff versus total personnel costs for the period FY 20-24, as audited, and FY 25 as adopted. Figure Career Operational KLFD Staff vs. Total District Personnel20-25) 3,000,000 2,704,667 60 Z:; 2,500,000 2,347--- r_ac 1,80 5,751 2,000,000 � 1 651 8� , ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 40 1,467,408 wc h m 1,500,000 1,2�►7,4677 v a a, E U 1,000,000 20 U 16 500,000 0 0 2020 2021 2022 2023 2024 2025 Em KLVFD Career Staff FD Personnel Services JA' W ngle 134 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Data from KLFD was used to determine a weighted total compensation cost per full-time employee from FY 20-25. The FY 20 cost per employee was $84,498, which increased to $100,173 in FY 25. This represents an average annual increase of 3.5% in cost per full-time employee. According to the U.S. Bureau of Labor Statistics' modeling, the annual rate of inflation is expected to continue trending downward from its current rate of nearly 2.5% to 2.3% by 2027. The model assumes an annual increase in total personnel services of 3.5% over the prior year for each forecast year, provided no other staff are added. Operating expense categories are combined in the model and comprise professional/contractual services, administrative supplies/services, insurance, utilities, repairs/maintenance, travel/training, and operating supplies/fuel. Due to variability and often non-linear behavior over the historical period, these categories were treated as a composite in the forecast. Historical composite operating expenses have increased at an average annual rate of approximately 13.6%, as shown in Figure 101 . Total operating expenses in the adopted FY 25 budget served as the basis for the forecast and were projected to increase at an annual rate of 13.6% through FY 30. No debt service is forecast in any of the models for FY 26-30. Figure 1 1: Total District Operating 2,000,000 1,815,570 1,750,000 1,405,643 1,500,000 31% 1,18 ,439 11„250,000 0 958,369 1,039,563 1,014,070 1,000,000 � � 27% 750,000 22% 500,000 250,000 0 2020 2021 2022 2023 2024 2025 mom II"'ll) 01p it ilin Ii S Operating IfAstt Operating ttin 1per ttin JA' W ngle 135 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Non-recurring expenses include land, buildings/improvements/furniture, fixtures, equipment, and apparatus. The district relies upon each service provider to plan for replacement of capital items, but there does not appear to be a consolidated district Capital Improvement Plan (CIP). However, the district's fund balance policy does require a capital replacement reserve. The district has spent an average of approximately $373,000 annually for all categories of capital. The District did not provide a five-year Capital Improvement Plan (CIP) outlining its plans and capital costs either to expand Station #24 or to build and equip a fourth fire station. Nor was debt service information available on four new apparatus obligated in FY 25. This obligation included three new leases covering two ambulances under one agreement, and separate leases for a tanker and a ladder truck. Therefore, the models below all use an annual total of $375,000 for new and replacement capital. Lease purchase payments for the four new apparatus will add $484,043 in debt service to recurring expenses through FY 30 for each of the following models (which is not shown in this analysis). Further, fund balance as shown in all models would be reduced by additional capital infrastructure dependent upon amount and timing of those expenditures. The capital reserve portion of the fund balance is a somewhat flexible target and can be adjusted depending on the actual timing of various large-scale capital expenditures. Fund Balance Assumptions The total fund balance is presented in three ways in the following models. The first is a calculated target amount based on district policy as of FY 25, which sets aside 83% of the total expenditure budget. The second is a calculated amount equal to four months of recurring expenses— equivalent to those of several coastal fire districts in Florida—along with an annual capital reserve of $500,000. The third is based upon modeled revenue plus total fund balance forward minus all expenditures. Millage rates are adjusted each year to bring the calculated fund balance as close as possible to the district target. Should the district adopt a lower fund balance goal than modeled here, all millage rates shown will be proportionately reduced. However, the relative differences between models would remain constant. Option I- Maintain i WelIMI Chiefinled 'No Additional Staff) JA' W ngle 136 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 102 illustrates the FY 25 adopted amounts, as well as the FY 26 and FY 27 status quo forecasts based on the previous assumptions. Model 1-A assumes that no staff are added during the forecast period. Figure 102: KLFREMS Status Quo Option I-A—Forecast (FY 25-27) i . r 0001=1 ® ® ® _ Preliminary Taxable Value 5,909,212,657 6,378,412,134 6,753,202,889 Millage Rate 1.1975 1.1649 1.1772 Ad Valorem Tax 6,863,994 7,207,194 7,71 1,697 ILA Monroe County 150,000 150,000 150,000 Interest 200,000 216,426 194,008 Recurring Revenue 7,213,994 7,573,620 8,055,705 Non-Recurring Revenue 300,000 25,000 25,000 Total Revenue (FY 25-27): 7,513,994 111 7,598,620 111 8,080,705 Personnel Services 4,712,847 4,877,797 5,048,520 Operating 1,815,570 2,062,488 2,342,986 Recurring: 6,528,417 6,940,284 7,391,505 Non-Recurring 904,156 375,000 375,000 Total Expenses (FY 25-27): 7,432,573 7,315,284 7,766,505 JA' W ngle 137 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 103 illustrates the next three fiscal years, showing the FY 28 through FY 30 status quo forecast based on the previous assumptions. Figure 103: KLFREMS Status Quo Option - r28-30) ® Preliminary Taxable Value 7,126,959,414 7,509,248,335 7,905,605,130 Millage Rate 1.2048 1.2235 1.2435 Ad Valorem Tax 81328,633 8,911,637 9,535,452 ILA Monroe County 150,000 150,000 150,000 Interest 223,777 181,167 192,695 Recurring Revenue 8,702,410 9,242,805 9,878,147 Non-Recurring Revenue 25,000 25,000 25,000 Total Revenue (FY 28-30): 8,727,410 9,267,805 9,903,147 Personnel Services 5,225,218 5,408,100 5,597,384 Operating 2,661,632 3,023,614 3,434,825 Recurring: 7,886,850 8,431,714 9,032,209 Non-Recurring 375,000 375,000 375,000 Total Expenses (FY 28-30): 8,261,850 8,806,714 9,407,209 Figure 104 summarizes the data from the preceding figure in graphical format. The district's calculated total fund balance tracks closely with its current target (83% of the total expenditure budget) through FY 30. Should the district wish to deviate from this policy and perhaps carry a lower fund balance, the associated millage rate could be reduced each year from those shown. The total fund balance well exceeds a notional three-month recurring expenditure, a one- month emergency reserve, and a $500,000 capital reserve. Again, this was based upon prior historical capital expenditures without the benefit of a five-year CIP. Therefore, this recommended capital reserve may be low. As previously mentioned, variations in capital JA' W ngle 138 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS expenditure timing and the Board's fund balance policy significantly impact modeled fund balances. Figure 104: Reven u e/Expenses Projections—Status Quo Option I-A (FY 25-30) $12,000,000 $10,000,000 $8,000,000 ........... $6,000,000 $4,000,000 -- - -- - - - - - - - . . ..... . . . . . . ..... .................... $2,000,000 $0 2025 2026 2027 2028 2029 2030 Non-Recurring Revenue MENEM Non-Recurring Expenses Recurring Revenue Recurring Expenses Beginning Fund Balance(Calculated) Recommended Fund Balance KLFREMS Fund Balance Goal This simple scenario, based on consistent assumptions across both the Status Quo and Consolidated district models, allows staff and elected officials to compare and contrast the relative impacts of the two models on district taxpayers. Option I-B: Maintain Status Quo with Fire/EMS Chief Appointed and Additional Staff An alternative Status Quo model provides for the addition of staff by one or both service providers during the forecast period. As shown earlier in Figure 99, an average of almost four career staff were added by the two service providers each year between FY 20 and FY 25. Further, the average cost of a career operational staff member was $100,173. Therefore, the cost of four additional career personnel in FY 25 would be $400,691. These figures would increase by the 3.5% average annual increase in personnel costs each year of the forecast. Figure 105 shows costs per year from FY 26 through FY 30. Adding four personnel per year would have a cumulative effect on recurring expenses, resulting in a total of 20 additional career operational staff in FY 30 and adding approximately $2.38 million to the KLFREMS budget. This assumes that each position is a fully burdened expense, which may not be the case, since KLEMS might still offset some costs with ambulance revenue before submitting to KLFREMS. JA' W ngle 139 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 105: Cost of Adding Career Operational Staff (FY - Avg. Cost Per Career 1073,679 107,308 1 1 1,063 114,951 118,974 Operations Staff Four New Ops. Staff 414,716 429,231 444,254 459,803 475,896 Cumul. Add. 4/year 414,716 858,461 1,332,761 1,839,210 2,379,478 Figure 106 illustrates the FY 25 adopted amounts, as well as the first two years of status quo forecasts for FY 26 and FY 27 based on the previous assumptions. Status Quo Model 1-B represents the addition of four personnel. Figure 106: KLFREMS Status Quo Option - 26-27) ® 1 Preliminary Taxable Value (DR420) 5,909,212,657 6,378,412,134 6,753,202,889 Millage Rate 1.1975 1.3313 1.3832 Ad Valorem Tax 6,863,994 8,236,793 9,060,472 ILA Monroe County 150,000 150,000 150,000 Interest 200,000 216,426 212,455 Recurring Revenue 7,213,994 8,603,219 9,422,927 Non-Recurring Revenue 300,000 25,000 25,000 Total Revenue (FY 25-27): 7,513,994 8,628,219 9,447,927 Personnel Services 4,712,847 5,292,512 5,906,981 Operating 1,815,570 2,062,488 2,342,986 Recurring Expenses 6,528,417 7,355,000 8,249,967 Non-Recurring Expenses 904,156 375,000 375,000 Total District Expenses (FY 25-27): 7,432,573 7,730,000 8,624,967 JA' W ngle 140 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 107 illustrates the status quo forecast for the remaining three years of FY 28 through FY 30, based on the previous assumptions. Figure 107: KLFREMS Status Quo Option - 28-30) Preliminary Taxable Value (DR420) 7,126,959,414 7,509,248,335 7,905,605,130 Millage Rate 1.4417 1.5325 1.6012 Ad Valorem Tax 9,966,519 11,162,502 12,278,752 ILA Monroe County 150,000 150,000 150,000 Interest 260,858 217,814 240,548 Recurring Revenue 10,377,377 11,530,315 12,669,300 Non-Recurring Revenue 25,000 25,000 25,000 Total Revenue (FY 28-30): $10,402,377 $11,555,315 $12,694,300 Personnel Services 6,557,979 7,247,311 7,976,862 Operating 2,661,632 3,023,614 3,434,825 Recurring Expenses 9,219,611 10,270,925 11,411,688 Non-Recurring Expenses 375,000 375,000 375,000 Total District Expenses (FY 28-30): 9,594,611 10,645,925 11,786,688 Figure 108 summarizes the data from the preceding figures in graphical format. The district's total calculated fund balance closely approximates its current target (83% of the total expenditure budget) in FY 27-30. Should the district wish to deviate from its current fund balance policy and carry a lower total fund balance, the associated millage rates could be reduced from those shown in Figure 106 and Figure 107. JA' W ngle 141 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS The total fund balance well exceeds a notional three-month recurring expenditure, a one- month emergency reserve, and a $500,000 capital reserve. As previously mentioned, variations in capital expenditure timing and the Board's fund balance policy significantly impact modeled fund balances. Figure 108: Revenue/Expenses Projections—Option1- - ) 15,000,000 10,000,000 5,000,000 0 2025 2026 2027 2028 2029 2030 Non-Recurring Revenue mmom Non-Recurring Expenses Recurring Revenue Recurring Expenses Beginning Fund Balance(Calculated) Recommended Fund Balance KLFREMS Fund Balance Goal Again, this is a simple scenario based on assumptions consistent across both the Status Quo and Consolidated district models. This setup allows staff and elected officials to compare the relative impacts of both models, with and without the addition of staff, on district taxpayers. Financial Forecast for Option 2 (Consolidation) The following discussion identifies key revenue, expense, and fund balance assumptions used to project a calculated millage rate necessary to sustain KLFREMS over the next five years in the Consolidated model, where the two service providers merge with the district. As stated earlier, there is very little difference between the two models from a financial perspective. JA' W ngle 142 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Two significant differences involve potential changes to retirement benefits (as employees will be eligible for alternative retirement programs under the district) and the consolidation of all revenue streams/expenditures (with no personnel cost offsets, and ambulance revenue being the major change). The calculated millage rate may differ from the final adopted rate. It is calculated using adopted or projected taxable value (for example, the preliminary taxable value obtained from the Form DR420), less approximately 3%, divided by the tax revenue needed to fund total expenditures and fund balance levels based upon district policy and considering other projected revenues, both recurring and non- recurring, as well as a total fund balance carried forward each year. Revenue Assumptions The primary source of funding for KLFREMS remains ad valorem revenue in the Consolidated model; therefore, the district's total taxable value over the forecast period is a key variable in the model. The Monroe County trend in taxable value, used in the Status Quo model, is also applied in the Consolidated model. Although the actual annual rate of change for the district may differ, the rates projected for Monroe County by the State of Florida (7.94% for 2026, 5.88% for 2027, 5.53% for 2028, 5.36% for 2029, and 5.28% for 2030) are used in each of the following models. Therefore, the relative impacts of each model can be compared, even though the actual revenues and needed millages differ. The forecast model adjusts the required ad valorem revenue based on the estimated initial total fund balance target, along with other recurring and non-recurring revenues projected to offset estimated recurring and capital expenses. A millage rate is then projected using the estimated total taxable value and ad valorem revenue. Other revenues are increased as follows: • Intergovernmental Revenue—Assumes interlocal sales tax revenue sharing agreement with Monroe County continues with annual funding at $150,000. • Ambulance Billing—Although no audited figures for ambulance revenue were available, JAG used $325,000 as an approximate figure for FY 25 (from the adopted budget), which was then increased by 3% annually thereafter. • Interest—Based upon the projected carryforward amounts and the FY 25 adopted amount of $200,000, which is 3.5% of the carryforward for that year. The forecast interest amount for FY 26 is calculated at 3.5% of the carryforward. This amount is then decreased each year, so that by FY 30, the annual interest is calculated at 2.5% of the projected carryforward fund balance. JA' W ngle 143 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Non-recurring revenues comprise grants and miscellaneous income. These sources are combined and held at $25,000 each year of the projection. Expense Assumptions Personnel services are a significant recurring expenditure, with total compensation costs for each service provider comprised of stipends for Board and volunteer members, part-time pay with limited benefits for part-time personnel, and full salary and benefits for full-time personnel. Full-time Paramedic costs in the consolidated model are the full costs and are not offset by ambulance revenue. Both this revenue stream (ambulance billing) and the portion of the full Paramedic costs equal to the ambulance revenue are shown in the following figures. As with the Status Quo model, data from KLFD was used to determine a weighted cost per full-time employee for FY 20-25. Over the historical period, this resulted in an average annual increase of 3.5% in cost per full-time employee. The model assumes an annual increase in total personnel services of 3.5% over the prior year for each forecast year, provided no other staff are added. Operating expense categories are combined in the model and comprise professional/contractual services, administrative supplies/services, insurance, utilities, repairs/maintenance, travel/training, and operating supplies/fuel. Due to variability and often non-linear behavior over the historical period, these categories were treated as a composite in the forecast. Historical composite operating expenses have increased at an average annual rate of approximately 13.6%. Total operating expenses in the adopted FY 25 budget served as the basis for the forecast and were projected to increase at an annual rate of 13.6% through FY 30. Although there may be additional costs in the first year of the integrated system, it is assumed these costs will not be significant and can be absorbed within the existing projected operating budget. No debt service is forecast in any of the models for the FY 26-30 period. Non-recurring expenses include land, buildings/improvements/furniture, fixtures, equipment, and apparatus. The district relies upon each service provider to plan for replacement of capital items, but there does not appear to be a consolidated district Capital Improvement Plan (CIP). However, the district's fund balance policy does require a capital replacement reserve. The district has spent approximately $373,000 annually across all capital categories. JA' W ngle 144 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS The following models all use an annual total of $375,000 for new and replacement capital. The capital reserve portion of the fund balance is somewhat flexible and can be adjusted based on the actual timing of large-scale capital expenditures. Fund Balance ssu tip The total fund balance is presented in three ways in the following models. The first is a calculated target amount based on district policy as of FY 25, which sets aside 83% of the total expenditure budget. The second is a calculated amount equal to four months of recurring expenses, equivalent to those of several coastal fire districts in Florida, along with an annual capital reserve of $500,000. The third is based upon modeled revenue plus total fund balance forward minus all expenditures. Millage rates are adjusted each year to bring the calculated fund balance as close as possible to the district target. Should the district adopt a lower fund balance goal than modeled here, all millage rates shown will be proportionately reduced. However, the relative differences between models would remain constant. Optionlet Consolidation wit ire/EMS Chief AppointedAdditional Staff) Figure 109 illustrates the FY 25 adopted amounts, as well as the FY 26 and FY 27 Consolidated model forecasts based on the previous assumptions. Figure 110 shows the remaining FY 28 through FY 30 Consolidated model forecast based on the previous assumptions. Model A assumes that no staff are added during the forecast period. JA' W ngle 145 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 109: KLFREMS Consolidated Option 2-A Forecast (FY 25-27) Preliminary Taxable Value (DR420) 5,909,212,657 6,378,412,13 6,753,202,889 Millage Rate 1.1975 1.2093 1.2221 Ad Valorem Tax 6,863,994 7,481,753 8,005,476 ILA Monroe County 150,000 150,000 150,000 Ambulance Revenue — 334,750 344,793 Interest 200,000 216,426 199,684 Recurring Revenue 7,213,994 8,182,929 8,699,952 Non-Recurring Revenue 300,000 25,000 25,000 Total Revenue (FY 26-27): 7,513,994 8,207,929 8,724,952 Personnel Services 4,712,847 5,297,915 5,483,342 Operating 1,815,570 2,062,488 2,342,986 Recurring Expenses 6,528,417 7,360,403 7,826,328 Non-Recurring Expenses 904,156 375,000 375,000 Total District Expenses (FY 26-27): 7,432,573 7,735,403 8,201,328 JA' W ngle 146 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure I 10: KLFREMS Consolidated Option 2-A Forecast (FY 28-30) Preliminary Taxable Value (DR420) 7,126,959,414 7,509,248,335 7,905,605,130 Millage Rate 1.2275 1.2232 1.2200 Ad Valorem Tax 8,485,805 8,910,095 9,355,600 ILA Monroe County 150,000 150,000 150,000 Interest 355,136 365,790 376,764 Ambulance Revenue 236,932 193,018 202,303 Recurring Revenue 9,227,873 9,618,904 10,084,667 Non-Recurring Revenue 25,000 25,000 25,000 Total Revenue (FY 28-30): 9,252,873 9,643,904 10,109,667 ® M- EE Personnel Services 5,675,259 5,873,893 6,079,479 Operating 2,661,632 3,023,614 3,434,825 Recurring Expenses 8,336,891 8,897,507 9,514,305 Non-Recurring Expenses 375,000 375,000 375,000 Total District Expenses (FY 28-30): 8,711,891 9,272,507 9,889,305 Figure 1 1 1 summarizes the data from the preceding figures in graphical format. The district's calculated fund balance closely tracks its current target (83% of the total expenditure budget). Should the district wish to change its current fund balance policy, the associated millage rate could be reduced each year of the forecast, as in Status Quo Model A. The total fund balance well exceeds a notional three-month recurring expenditure and a one-month emergency reserve, plus $500,000 for a capital reserve. As previously mentioned, variations in capital expenditure timing and the Board's fund balance policy significantly impact modeled fund balances. JA' W ngle 147 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure I 11: Revenue/Expenses Projections—Consolidated Option 2-A (FY 25-30) 12,000,000 10,000,000 ... ....................................... 111.............., 8,000,000 . ............................................ ............... 6,000,000 4,000,000 . .......... 2,000,000 0 ....................................................................... 2025 2026 2027 2028 2029 2030 Non-Recurring Revenue mmom Non-Recurring Expenses —&—Recurring Revenue --a—Recurring Expenses Beginning Fund Balance(Calculated) Recommended Fund Balance KLFREMS Fund Balance Goal This simple scenario, based on consistent assumptions across both the Status Quo and Consolidated district models, allows staff and elected officials to compare and contrast the relative impacts of the two models on district taxpayers. This model is virtually indistinguishable from the Status Quo Model A, which adds no staff. Option 2-13: Complete Consolidation with Fire/EMS Chief Appointed and FPS Retirement (No Additional Staff An alternative Consolidated model (Model 13) can be compared to the Status Quo Model A, where no staff are added. In this model, all employees are now eligible for various alternative retirement programs, including the Florida Retirement System (FRS). The current retirement package offered to employees of both service providers is a 401 (k) program with a 10% employer match. In the previous model, it is assumed that employees will convert from a 401 (k) program to its approximate equivalent governmental program, a 457(b) program with similar employer costs. The most expensive potential retirement program available to all district employees in the Consolidated model is the FRS program (all employees join it), which is included for comparison purposes. JA' W ngle 148 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS The employer's cost would increase from approximately 10% in the case of a 457(b) program to either 14.03% for Regular Class employees or 35.19% for Special Risk Class employees. For purposes of the forecast, all employees are considered Special Risk Class. The FRS employer contribution includes 2% for the Retiree Health Insurance Subsidy (HIS). To calculate the impact of a change from the 401 (k) retirement program to the FRS program, the FY 25 adopted budget figures were used. Multiplying the total district salary by the FRS employer contribution (35.19% of salary) gives a total retirement figure for FY 25 of $1,292,891 . Adding this to the FY 25 benefits, minus the employer's 401 (k) contribution, yields a total benefit amount of $2,202,654 for FY 25, versus the current amount of $1,039,750 under the existing 401 (k) program. The calculated FY 25 benefit and wage amount was then increased by the 3.5% compensation inflationary figure previously discussed. Figure 112 illustrates the FY 25 adopted amounts, as well as the Status Quo forecast based on the previous assumptions on FY 26 and FY 27. Figure 113 shows the remaining three-year forecast for FY 28 through FY 30. Consolidated Model B assumes only that the current 401 (k) retirement program is converted to the State of Florida FRS retirement program. JA' W ngle 149 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 112: KLFREMS ConsolidatedOption - Forecast - Preliminary Taxable Value (DR420) 5,909,212,657 6,378,412,134 6,753,202,889 Millage Rate 1.1975 1.4977 1.4853 Ad Valorem Tax 6,863,994 9,266,392 9,729,711 ILA Monroe County 150,000 150,000 150,000 Ambulance Revenue — 334,750 344,793 Interest 200,000 216,426 213,551 Recurring Revenue 7,213,994 9,967,568 10,438,055 Non-Recurring Revenue 300,000 25,000 25,000 Total Revenue (FY 25-27): 7,513,994 9,992,568 10,463,055 Salaries & Wages 3,674,030 4,138,996 — Benefits 1,038,817 2,481,328 — Personnel Services 4,712,847 6,620,324 6,852,036 Operating 1,815,570 2,062,488 2,342,986 Recurring Expenses 6,528,417 8,682,812 9,195,021 Non-Recurring Expenses 904,156 375,000 375,000 Total District Expenses (FY 25-27): 7,432,573 9,057,812 9,570,021 JA' * ngle 150 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 113: KLFREMS ConsolidatedOption - Forecast - Preliminary Taxable Value (DR420) 7,126,959,414 7,509,248,335 7,905,605,130 Millage Rate 1.4778 1.4446 1.4038 Ad Valorem Tax 10,216,197 10,522,683 10,764,705 ILA Monroe County 150,000 150,000 150,000 Ambulance Revenue 355,136 365,790 376,764 Interest 264,376 222,340 236,018 Recurring Revenue 10,985,709 11,260,814 11,527,487 Non-Recurring Revenue 25,000 25,000 25,000 Total Revenue (FY 28-30): 11,010,709 11,285,814 11,552,487 ® M- EE Personnel Services 7,091,857 7,340,072 7,596,974 Operating 2,661,632 3,023,614 3,434,825 Recurring Expenses 9,753,489 10,363,686 11,031,800 Non-Recurring Expenses 375,000 375,000 375,000 Total District Expenses (FY 28-30): 10,128,489 10,738,686 11,406,800 Figure 114 summarizes the data from the preceding tables in graphical form. The district's total fund balance decreases significantly in FY 26 due to changes in the retirement programs. It begins to move toward its current target (83% of the total expenditure budget) in FY 27, with the rate of increase accelerating thereafter. Total fund balance, while below the district target early in the projection, still well exceeds a notional three-month recurring expenditure, a one-month emergency reserve, and $500,000 in capital reserve. As mentioned previously, the district could choose to lower its total fund balance target, and the resulting millage rates could be reduced from those shown. Variation in the timing of capital expenditures, as well as the Board's fund balance policy, both significantly impact the modeled fund balances. JA' W ngle 151 GROUP,LC Operational Ana kab/Conso|idotionStudy Key Largo Fire Rescue & EMS Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 115 illustrates the FY 25 adopted amounts, as well as the Status Quo forecast based on the previous assumptions on FY 26 and FY 27. Figure 116 shows the remaining three-year forecast for FY 28 through FY 30. Consolidated Model B assumes only that the current 401 (k) retirement program is converted to the State of Florida FRS retirement program. Figure 115: KLFREMS Consolidated Option 2-C Forecast (FY 25-27) r r � Preliminary Taxable Value (DR420) 5,909,212,657 6,378,412,134 6,753,202,889 Millage Rate 1.1975 1.7751 1.7436 Ad Valorem Tax 6,863,994 10,982,390 11,421,686 ILA Monroe County 150,000 150,000 150,000 Ambulance Revenue — 334,750 344,793 Interest 200,000 216,426 249,718 Recurring Revenue 7,213,994 11,683,566 12,166,197 Non-Recurring Revenue 300,000 25,000 25,000 Total Revenue (FY 25-27): 7,513,994 11,708,566 12,191,197 r r � Personnel Services 4,712,847 7,130,745 7,908,606 Operating 1,815,570 2,062,488 2,342,986 Recurring Expenses 6,528,417 9,193,232 10,251,592 Non-Recurring Expenses 904,156 375,000 375,000 Total District Expenses (FY 25-27): 7,432,573 9,568,232 10,626,592 JA' W ngle 153 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 11Consolidated ion 2-C Forecast ) Preliminary Taxable Value (DR420) 7,126,959,414 7,509,248,335 7,905,605,130 Millage Rate 1.7348 1.7946 1.8240 Ad Valorem Tax 11,992,770 13,072,120 13,987,168 ILA Monroe County 150,000 150,000 150,000 Ambulance Revenue 355,136 365,790 376,764 Interest 326,322 274,224 296,344 Recurring Revenue 12,824,228 13,862,134 14,810,276 Non-Recurring Revenue 25,000 25,000 25,000 Total Revenue (FY 28-30): 12,849,228 13,887,134 14,835,276 ® M- EE Personnel Services 8,732,183 9,603,721 10,525,571 Operating 2,661,632 3,023,614 3,434,825 Recurring Expenses 11,393,815 12,627,335 13,960,396 Non-Recurring Expenses 375,000 375,000 375,000 Total District Expenses (FY 28-30): 11,768,815 13,002,335 14,335,396 Figure 117 summarizes the data from the preceding figures. The district's total calculated fund balance decreases significantly in FY 26 due to changes in the retirement program and the annual addition of staff. It begins moving toward its current target (83% of the total expenditure budget) in FY 27, tracking it through FY 28-30. Total fund balance, while below the district target early in the projection, still well exceeds a notional three-month recurring expenditure, a one-month emergency reserve, and $500,000 in capital reserve. As mentioned previously, the district could choose to lower its total fund balance target, and the resulting millage rates could be reduced from those shown. Variation in the timing of capital expenditures, as well as the Board's fund balance policy, both significantly impact modeled fund balances. JA' W ngle 154 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 117: Revenue/Expenses Projections—Consolidated Option 2-C (FY 25-30) 16,000,000 "I..................... .............................................. 14,000,000 ................................. ................. .................. ....................................................................... .............................. ................................................................................. 12,000,000 ................................. 0 7....................... ...................... ............................................. ........ ................. 10,000,000 ........... . . ......... ............................... 8,000,000 ............................... .. ...................... .............................................................................................................................................................................................................................................. ............-7-...... .......... 6,000,000 .................... .......................................... 4,000,000 ................................. .......................... ... ............................................................................................................................................................................................................................................................................... 2,000,000 ............................................................................ ........................................................................................................................................................................................................ ........... 0 .............................................................................................................................................................................................. ...........................................................1 2025 2026 2027 2028 2029 2030 Non-Recurring Revenue mmom Non-Recurring Expenses Recurring Revenue --m—Recurring Expenses Beginning Fund Balance(Calculated) Recommended Fund Balance ..... KLFREMS Fund Balance Goal Comparison of Status Quo & Consolidation Models Figure 118 compares forecast millage rates and personnel services costs of various Status Quo and Consolidated models for the period FY 26-30 from least to most costly. Capital expenses are the same for all models, and operating expenses are virtually identical. Therefore, the differences between the models lie in personnel costs, which drive the millage rates. As mentioned previously, the calculated millage rates shown are based upon achieving the current district target total fund balance of approximately 83% of the total expenditure budget. Should the Board choose to lower its total fund balance target, all of the millage rates shown would decrease proportionately. However, the relative impacts of each model would remain the same. JA' W ngle 155 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 11Comparison illage Rates/Personnel Costs for Various Models Adopted Foreca Forecast Forecast Forecast Forecast WOMEW SQ A-Millage Rate 1.1975 1 .1649 1 .1772 1.2048 1 .2235 1 .2435 SQ A-Personnel Serv. 4,712,847 4,877,797 5,048,520 5,225,218 5,408,100 5,597,384 / ON, %/f MRG A-Millage Rate 1.1975 1 .2093 1 .2221 1.2275 1 .2232 1 .2200 MRG A-Person. Serv. 4,712,847 5,297,915 5,483,342 5,675,259 5,873,893 6,079,479 IN InIII 11 CIMII, I. III 1=11 I ilill SQ B-Millage Rate 1,1975 1 .3313 1 .3832 1,4417 1 .5325 1 .6012 SQ B-Personnel Serv. 4,712,847 5,292,512 5,906,981 6,557,979 7,247,311 7,976,862 !MRG B-Mill7Rate 1.1975 1 .4977 1 . 371.4778 1 .4446 1 .4038 MRG B—Pe4,712,847 6,620,324 6,852,03 7,340,072 7,596,974 Consolidated Forecast C: Add Four(4) Staff Per Year/Florida Retirement System Participation MRG C-Millage Rate 1.1975 1 .7751 1 .7436 1.7348 1 .7946 1 .8240 MRG C-Person Serv. 4,712,847 7,130,745 7,908,606 8,732,183 9,603,721 10,525,571 Figure 119 shows the preceding data in graphical format. Status Quo Model A is a continuation of the historical trajectory of the existing district and its two service providers, with no addition of personnel. This differs slightly from Consolidated Model A, which includes ambulance billing revenue and the full cost of Paramedics, although these offset each other. Otherwise, these two models are the same. Employees in the merged model would be eligible for a 457(b) retirement program, similar to a private-sector 401 (k) program. Realistically, however, there may be some differences in operating costs in the first year if the district needs to standardize equipment and supplies between the two service providers. JAG has observed that operating costs can increase by as much as 10% over the Status Quo forecast in the first year of consolidation when two or more entities are merged. Generally, there will be some economies of scale with a full consolidation after the first year. JA' W ngle 156 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Consolidated Model B can be compared to Status Quo Model A, with the primary difference being that employees under the Consolidated model are shown as enrolled in the FRS retirement program rather than the 401 (k) program. The millage difference can be as high as approximately 0.3 mills. The costliest models shown are Status Quo Model B and Consolidated Model C, in which the service providers or the district, respectively, continue to add personnel at an average annual rate of four personnel. Status Quo Model B continues the current retirement program, which consists of a 401 (k) system with an employer contribution of 10% per employee, while Consolidated Model C provides employees with the FRS retirement system with an employer contribution of 35.19%. Figure 11 illage Rate/Personnel Services Cost ComparisonModels 15,000,000 2.0000 1.8000 1.6000 10,000,000 1.4000 D O / 1.2000 1.00000.8000 � LU — 5,000,000 O O O O O O 0.4000 O O O O O O 0.2000 IN IN 2025 2026 2027 2028 2029 2030 %Ifffm SQ A-Millage Rate i mmmimmimm SQ B-Millage Rate o/m/i�i,MRG A-Millage Rate MRG B-Millage Rate MRG C-Milloge Rate --SQ A-Personnel Services — — SQ B-Personnel Services MRG A-Personnel Services MRG C- Personnel Services MRG B-Personnel Services JA' W ngle 157 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Section IV: STRATEGIES & RECOMMENDATIONS J*ngle 158 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS IExample Organizational In this section, JAG presents an example organizational configuration for the full consolidation of KLFD and KLEMS into the KLFREMS District. These models are offered for discussion should the District choose to pursue consolidation. Final decisions regarding the organizational structure will rest with the Fire District Board and leadership following detailed analysis and planning. As illustrated in Figure 120, the example structure incorporates existing positions while identifying potential future staffing needs. A formal needs assessment and job-task analysis should be conducted to determine priorities for new positions. A further description of the example structure is provided below. Figure l20: Example Organizational Structure EEMF mew, MEN IIN d�Ytr riV+ �h +°i forrrraa r calplofins ptcwrin f d to Ks!,Recommencled,mPok""hall 005,ffion arG9m evcAmflol'p&S1P cornpleted ti"'crtw p6!v,,d prirnaarky of ckrrllan EMS pcovklars,I ,,A cems l in,r b rle gonld'u,ad rlrawf2,0,J r5_ ""F>l*ulr.0 yr^rra•: rtlm inn FNAf Pa.afarll d 'lur.lJti..ra;a rnu d n['aUnr ¢r wear wr i}lut r qe l�oaro,uil;�a amrrli i pr',r ry. The consolidated district would be led by the Board of Commissioners, which provides oversight for key administrative functions including Legal Services, Finance, and the Fire & EMS Chief. Reporting directly to the Fire & EMS Chief are the Medical Director, the District JA' * ngle 159 GROUP,= Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Clerk, and two Deputy Chiefs—one overseeing Emergency Operations and the other overseeing Support Services. The Deputy Chief of Emergency Operations supervises three Battalion Chiefs assigned to the A, B, and C shifts. Each Battalion Chief manages both the Fire Division and the EMS Division on their respective shift. The Fire Division includes Lieutenants, Engineer/EMT-Bs, Engineer/EMT-Ps, and Firefighters certified at the EMT-B or EMT-P level. The EMS Division includes Lieutenants, Lead Paramedics, and EMS Volunteers. The Deputy Chief of Support Services oversees the Emergency Management Coordinator and several specialized functions, including Training, Public Education, Health & Safety, Logistics &Supplies, and Maintenance. These roles should be evaluated further as part of a strategic planning process. Until then, these responsibilities may continue to be assigned to existing leadership staff, consistent with current practice. JA' W ngle 160 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS General Recommendations Service Delivery & Performance (Data Analysis) KLVFD Recommendation A-1: Continue preparing for the implementation of the National Emergency Response Information System Description: KLVFD should begin preparing for the implementation of the National Emergency Response Information System (NERIS). This process entails configuring KLFD (or KLFREMS if merged) for a smooth transition from NFIRS to a more modern, data-driven system. Key steps to prepare for NERIS include: • Identify the required implementation timeline. • Designate a NERIS lead. • Evaluate the current records management system (IRMS). • Identify the district's reporting method. • Engage members on the value and need for data collection. • Educate and train the members on the new system and changes. • Identify a date to go live. Outcome: Improved accuracy and availability of incident data; better insight into operational performance. Cost Estimate: Primarily staff time; possibly expenses from the RMS vendor. AgeIncyi: KLVFD & KLEMS (KLFREMS if Merged) Recommendation A-2: Consider developing and adopting a Data Outlier Management Policy to help ensure the accuracy of incident records Description: In the district data analysis, an outlier is a data point that significantly deviates from other observations in the dataset. These outliers can arise for various reasons, such as data entry errors, unusual events, or genuine data variability. Addressing outliers is crucial for maintaining data integrity and ensuring statistical accuracy. Examples of outliers in fire department data can include: Unusual Incident Counts: For example, if a particular fire station reports an exceptionally high or low number of incident volume compared to historical data or other stations, this could be an outlier. JA' * ngle 161 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS • Response Times: Extremely short or long response times compared to the average can be considered outliers. • Damage Estimates: Very high or low fire damage estimates might be outliers, especially if they differ significantly from typical values. • Casualty Numbers: Anomalously high or low numbers of injuries or fatalities in incidents can also be outliers. Outcome: The outcome would result in a better reflection of the districts' performance. Handling outliers is crucial for maintaining data integrity and ensuring statistical accuracy. A sample outlier policy is presented in Appendix B. Cost Estimate: Staff time only. At eiino °yis KLVFD & KLEMS (KLFREMS if Merged) Recommendation - s part of the implementation of NERI system written policy r incident review li improvement Description: Consider developing a quality improvement (QI) system to review completed incident reports regularly. Reports should be evaluated for timely completion, accuracy, and thoroughness. This should include feedback to the report authors. Both agencies should have a written policy describing the minimum requirements for completing an incident report. Outcome: Improved incident documentation and accuracy that can assist in planning, as well as informing the public and elected officials regarding the operations and performance of KVFD and KLEMS. Cost Estimate: Staff time only. Financial Recommendations Ali r KLFREMS (if Merged) Recommendation -1: Consider participation in the Publicr is I Transportation Program Description: 'The Public Emergency Medical Transportation (PEMT) Program is a supplemental reimbursement initiative that helps government-owned EMS providers (including fire districts) recover the true costs of transporting Medicaid patients. It bridges the gap between Medicaid's low transport payments and the actual cost of emergency medical services. PEMT may also be referred to as the Governmental Emergency Medical Transportation (GEMT) program. JA' * ngle 162 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS In Florida, the program is only available to government-owned or-operated EMS providers (state, city, county, or fire districts) enrolled as Florida Medicaid providers and that deliver fee-for-service emergency medical transports to Medicaid patients. The Florida Agency on Health Care Administration website provides distribution information about PEMT. According to the website, in the State of Florida from FY 2023-2024, a total of $50,806,476 was distributed to public EMS provider agencies. Local examples included Monroe County EMS and the City of Key West Fire Department, which received $376,414 and $132,473, respectively. Outcome: Additional ambulance revenue from the transport of Medicaid patients. Cost Estimate: Staff time if done in-house; contract fees if outsourced. S Management 't Ali r KLFREMS Recommendation -1: Complete a Community-Driven Strategic Plan Description: The district should make formal plans to ensure a Strategic Plan is in place. A Community-Driven Strategic Plan should be modeled after the Center for Public Safety Excellence's guidelines. A comprehensive Strategic Plan would allow the district to develop foundational statements, such as a Mission Statement, Vision Statement, and Values Statement that are currently not in place. Upon completion of the Strategic Plan document, it should be formally adopted by the district's Board of Commissioners, who should provide periodic updates on progress. Additionally, KLFREMS should encourage KLVFD and KLEMS to ensure a current Strategic Plan is in place and reported to the district. Outcome: A three-to-five-year planning document that is designed to meet the needs of the community in which the districts serve. Cost Estimate: Staff time if completed in-house; approximately $25,000-$30,000 if contracted to a third party. Aiii eiiil°m Z-11'lu' KLVFD & KLEMS Recommendation - regularly scheduled staff meetings with administrative Description: KLFREMS should encourage KLVFD and KLEMS to conduct regularly scheduled staff meetings and provide the meeting minutes to the district Board. Communication within an organization is a critical component in achieving an effective, efficient, and responsive fire and EMS service organization. Internal members expect strategic, frequent, responsive, and transparent communication. This starts at the top of an organization, and JA' * ngle 163 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS regularly scheduled administrative staff meetings can aid this endeavor and ensure the organization reaches its ultimate potential. Outcome: Increased communication within each organization's command staff to better inform the entire district. Cost Estimate: Staff time. Health, Program Ag a ii v,,,u,?: KLEMS Recommendation -1: Develop a Riskn I n Description: While it was reported that KLEMS utilizes KLVFD's plan, KLFREMS should ensure KLEMS develops and implements a Risk Management Plan. The plan should be updated and monitored annually. Recommendations and revisions should be based on annual accident and injury data, significant incidents, and feedback from administrative staff and personnel. An independent source should evaluate the plan. As part of the plan, KLEMS should ensure that best practices are in place, including a post-incident analysis policy, quarterly facility inspections, and quarterly Safety Committee meetings. Outcome: A safe and healthy work environment for all district employees. Cost Estimate: Staff time and the cost of an independent review. '11t a iiii m °w°�uoo'" KLEMS Recommendation - : Install apparatus-mounted filtration systems on diesel vehicles Description: KLFREMS should encourage KLEMS to purchase and install vehicle-mounted filtration systems for any diesel-powered units. The advantages of a vehicle-mounted filtration system are numerous, including that it is fully automated and requires no human intervention while also protecting the general public and personnel when the units are outside the stations. Therefore, this approach should be prioritized for all current units and any newly purchased units moving forward. Outcome: Better protection for personnel and the general public from the carcinogens caused by diesel exhausts, which the EPA classifies as "likely to be carcinogenic to humans." Cost Estimate: $8,000 to $10,000 per vehicle, including installation. JA' * ngle 164 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS KLEMS Recommendationsr initial and annual physicals arer all personnel Description: KLFREMS should encourage KLEMS to establish a comprehensive Medical Exam Program. EMS providers are at a higher risk of on-duty injuries and long-term illnesses than many other professions. Ensuring a comprehensive Medical Exam Program—including initial and ongoing physicals—is in place is a critical component to minimizing the negative effects on personnel. This program should also include fit-for-duty criteria. Outcome: Ensuring the health of KLEMS operational staff enables effective service delivery while minimizing on-duty injuries and long-term illnesses. Cost Estimate: The cost would depend on the provider's rates for the selected medical provider. However, substantial long-term cost savings would likely be expected from preventing cardiovascular disease and certain cancers, and from reducing early disability from musculoskeletal and back injuries. Aigeiiir°v:,,Vi: KLVFD & KLEMS RecommendationEstablish Tracking r r r traumatic events Description: KLFREMS should encourage KLVFD and KLEMS to establish a comprehensive Tracking Program for personnel exposed to traumatic events. Florida Statutes 112.181517 provides first responders with post-traumatic stress disorder (PTSD) provisions under workers' compensation coverage. However, benefits depend on specific qualifying events, making overall exposure tracking a critical component in protecting the first responder. Outcome: Ensuring workers' compensation coverage is available to personnel who are dealing with PTSD secondary to exposure to traumatic events. Cost Estimate: Staff time if developed in-house; many free software applications are also available. JA' W ngle 165 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Iconclusion The J. Angle Group, LLC, appreciates the opportunity to have been able to collaborate with the district on this program. As noted in the report, all three agencies face similar challenges both now and in the future. Some of these include staffing, funding, governance, and operational efficiency. While both KLFD and KLEMS have demonstrated strong commitment to the highest level of community service, the current fragmented structure creates duplication, limits resource flexibility, and may strain financial sustainability. After comprehensive analysis, full consolidation under the district (Option 2-C)—including appointment of a Fire/EMS Chief, additional staffing, and participation in the Florida Retirement System—emerges as the most effective strategy. This model offers: • Operational Efficiency: Streamlined governance and elimination of redundant administrative functions. • Enhanced Service Delivery: Improved deployment and staffing flexibility using dual- certified personnel. • Increased Financial Transparency and Stability: Unified budgeting, clear accountability, and strong reserve policies aligned with GFOA best practices. • Workforce Retention: Competitive benefits to attract and retain skilled personnel. The projected financial impacts include gradual millage increases to approximately 1 .60 mills by FY 2030, offset by potential efficiencies and sustained revenue growth. The capital reserves and fund balance policies will ensure readiness for emergencies and long- term infrastructure needs. If the recommended action (Option 2-C) is selected, the following example next steps is a good general implementation strategy that can be utilized. There may be additional steps identified by the Transition Committee. JA' * ngle 166 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Next Steps: Implementation Roadmap To achieve a successful outcome, the following example phased actions are recommended: Phase 1: Governance and Planning (0-6 Months) • Take Fire Commission Action: Secure Board approval and complete legal review. • Form Transition Committee: Include representatives from KLFD, KLEMS, and the district. • Develop Consolidation Timeline: Define milestones, responsibilities, and communication protocols. • Appoint a Fire/EMS Chief: Recruit and onboard a qualified leader to oversee unified operations. Phase 2: Organizational Integration (6-12 Months) • Align Policies and Procedures: Standardize SOPS, HR policies, and compliance frameworks. • Adopt Strategic Initiatives: Adopt initiatives for health, safety, and training programs to support a unified workforce. • Integrate Financial Systems: Consolidate budgets, payroll, and procurement under district control. • Plan Workforce Transition: Define roles, benefits, and FRS enrollment for all personnel. • Align Website: Merge the information from the existing three websites into one district website. Phase 3: Operational Enhancements (12-24 Months) • Expand Staffing: Begin phased hiring to meet NFPA standards and improve response reliability. • Upgrade Training Programs: Implement balanced fire/EMS training and simulation- based learning. • Enhance Health and Wellness Programs: Introduce mental health support, cancer prevention, and fitness initiatives. JA' * ngle 167 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Improve Technology: Upgrade RMS for interoperability and implement data-driven performance monitoring. Phase 4: Long-Term Sustainability (24+ Months) • Develop Strategic Plan: Establish goals for service delivery, capital needs, risk reduction, and community engagement. • Implement Capital Improvement Plan: Address aging facilities and apparatus replacement schedules. • Monitor Performance Metrics: Track response times, staffing levels, and financial health. • Maintain Community Transparency: Publish annual reports and other State of Florida requirements for special districts, keeping the district website up to date. JA' W ngle 168 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Section V-. APPENDICES J*ngle 169 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS IAppendix A: Results from the Stakeholder Input Internal Survey Results The following section provides the results of the internal survey of staff. Question #1® In your opinion, what are the advantages/positives Istrengths of the existing emergency service delivery system between the KLFD and KLEMS? Document Summary: This document highlights several advantages, positives, and strengths of the existing emergency service delivery system between the Key Largo Volunteer Fire Department and the Key Largo Volunteer Ambulance Corps. One of the primary strengths is the clarity of services, which reduces overlap and government intervention. The current system allows each department to focus on its specific role: KLFD on fire calls and KLEMS on medical calls, ensuring specialized, proficient responses. Additionally, the system always guarantees minimum staffing levels on both fire and EMS apparatus, preventing any reduction in staffing. The separation also provides guaranteed medical presence at accident or fire scenes without pulling firefighters from their duties. Furthermore, the existing setup offers cost savings through reduced overtime and administrative costs. Overall, the document suggests that while the current system has its strengths, there is potential for improvement through unification and expanded training opportunities. Prioritized Summary afthe feedback based on frequency of statements: 1. Operational clarity and specialization: The current system clearly defines service roles, with KLFD focusing on fire and KLEMS on EMS, allowing each to specialize in its core competencies. This separation guarantees minimum fire and EMS staffing without overlapping responses. 2. Cost savings and staffing benefits: Some respondents note cost savings, increased overall staffing with less overtime, and the availability of many open shifts and overtime opportunities within KLEMS. 3. Unified services potential: A few comments recognize the benefits of a unified EMS/Fire service, suggesting that a merger could improve training and certification, reduce administrative duplication, and enhance response times and overall service quality. JA' * ngle 170 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS 4. Challenges with separation: Some view the current separation as limiting efficiency due to coordination delays, inconsistent training, and scheduling challenges, which could be mitigated through integration. 5. Specialization and passion in EMS: KLEMS members are highlighted as specialized medical providers focused on high-quality care. Many paramedics aspire to be firefighters, indicating a potential benefit from merged training and career opportunities. 6. Facility and operational concerns: The EMS building and resources are dedicated to KLEMS under the County agreement, which might be jeopardized by consolidation, raising concerns about properly housing EMS vehicles, staff, and supplies. 7. Volunteer and community service: Both departments provide multiple units ready to respond and offer diverse volunteer opportunities, ensuring coverage for nearly 2,000 medical calls annually at a reasonable cost. 8. Leadership and training gaps: Some respondents emphasize the need for improved leadership, qualified command staff, better training, clear SOPs, and thorough background checks to ensure effective emergency response and reduce liability. 9. Mixed views on advantages: Several comments note that there are no current advantages of the existing system, citing complacency and the need to restructure or merge to enhance service delivery. Question # hat are the disadvantageslnegativeslweaknesses of the existing emergency service deilvery system between the KLFD are S? DocumentSummary: The current system between KLFD and KLEMS faces several significant challenges. One major issue is the lack of a unified command structure, which leads to delays in communication, duplication of leadership, and inconsistent protocols during joint responses. This separation creates confusion, limits efficiency and accountability, and impacts patient care and scene safety. Additionally, duplicating services and tools results in wasteful spending and higher costs for the community. The fragmented approach also undermines coordination among training, resource allocation, and standardized protocols, further hindering the effectiveness of emergency responses. There are concerns about the lower standard of medical care provided by the fire department compared to EMS, with inexperienced personnel affecting the quality of prehospital care. JA' W ngle 171 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Staffing and retention issues are also prevalent, with comments highlighting the need for better benefits and the challenges of maintaining adequate personnel. Separation between the departments fosters animosity and a lack of camaraderie, which can negatively impact morale and efficiency on incident scenes. Overall, the existing system is seen as outdated and inefficient, with many comments suggesting that a more unified structure would better serve the community and improve quality. Prioritized summary of the feedback ase on frequency of statements: 1. Operational Inefficiency: The separation of EMS and Fire departments leads to duplication of services, tools, and administrative functions, resulting in higher costs and delayed emergency responses. 2. Communication and Coordination Problems: The lack of a unified command structure and poor interdepartmental communication cause confusion during emergencies and hinder effective teamwork. 3. Staffing and Retention Issues: Both departments face understaffing, high overtime costs, and difficulties in employee retention, exacerbated by limited cross-training opportunities. 4. Cultural and Leadership Challenges: Animosity between departments, weak leadership, and poor workplace culture undermine morale and operational effectiveness. 5. Inconsistent Protocols and Training: Different policies and procedures reduce the level of care and create confusion, with inadequate training and support across departments. 6. Concerns About Medical Care Quality: The fire department's recent ALS status has been criticized for reducing the quality of frontline medical care due to inexperience and poor coordination with EMS. 7. Financial and Resource Concerns: The dual system is more expensive for taxpayers, with questionable budgeting decisions and duplication of efforts resulting in wasteful spending. 8. Impact on Community Service: The current structure is seen as outdated and less effective for meeting community needs, with suggestions that consolidation could improve response times and service quality. 9. Employee Benefits and Morale Issues: Employees desire better benefits and retirement plans, but ego and departmental divisions hinder progress toward unified improvements. JA- W ngle 172 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Question #3m to your opinion, what are the advantages/p ositivesIstren the of how the KLFD and KLEMS currently interact/operate with each other? This document discusses the advantages, strengths, and current interactions between the Key Largo Volunteer Fire Department and the Key Largo Volunteer Ambulance Corps. Many comments emphasize the strong professional relationships and mutual respect between the departments, which contribute to effective collaboration during emergency responses. The long-standing familiarity and trust built over time facilitate smooth coordination and communication on scene, ensuring that both departments work well together to achieve their shared goal of public safety and providing quality emergency response services. Additionally, the existing camaraderie and teamwork at the operational level demonstrate that the foundation for successful integration is already in place. However, these strengths are often based on individual cooperation rather than a unified system, suggesting that a more formal merger could enhance overall efficiency and effectiveness. Prioritized summary of feedback sed on frequency of statements: 1. Professional Interaction on Scene: KLFD and KLEMS generally work well together on calls, with a shared goal of public safety. Their long-standing relationship has fostered familiarity and respect. 2. Positive Working Relationships: At the street level, employees from both departments interact professionally and maintain strong working relationships, fostering a positive, collaborative environment during emergency responses. 3. Camaraderie and Teamwork: The existing camaraderie and teamwork demonstrate that the foundation for successful integration is already in place. Personnel have established trust and effective communication patterns, enabling smooth coordination during joint operations. 4. Commitment to Community Service: Both departments are committed to serving the community, and when on scene, they do what they can to make it work. The shared experience and familiarity built over time help with general communication and efficiency. JA' * ngle 173 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Question m What, if any, do you believe would be the likely advantages to merging the KLFD and KLEMS with the KLF ? Document Summary: Merging KLFD and KLEMS with KLFREMS would likely yield numerous advantages. Integration would ensure a unified command structure, leading to better communication and coordination among the departments. This would streamline operations, eliminate duplication of services, and standardize policies and procedures, resulting in substantial cost savings and improved efficiency. The merger would enhance the level of care provided to the community by ensuring dual-certified personnel on all apparatus, thereby improving response times and overall service delivery. Additionally, the merger would provide personnel with better career development opportunities and long-term financial security through a comprehensive pension system. The existing strong working relationships between the departments would facilitate a smooth transition and build upon established trust and collaboration. Overall, combining into a single agency would create a more cohesive, efficient team, ultimately benefiting the community through better emergency preparedness and service delivery. Prioritized summary of feedback se on frequency of statements: 1. Improved Service Delivery: Many comments highlighted that the merger would lead to better service delivery for the community. This includes having more capable and qualified personnel on fire scenes, better standards of care, and more consistent service delivery. 2. Financial Benefits: Several comments noted the merger's financial advantages, including cost reductions, budgetary relief, and savings from eliminating service, tool, and equipment duplication. 3. Enhanced Collaboration and Efficiency: The merger would streamline operations, improve communication, and ensure consistent protocols across Fire and EMS services. This would eliminate duplication in leadership, training, and equipment management. 4. Career Development and Stability: The merger would provide long-term financial security and career stability for personnel by establishing a comprehensive pension system. It would also improve scheduling and career development by allowing dual- certified firefighters to rotate between the engine and the rescue box. JA' W ngle 174 GROUPALC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS 5. Unified Training and Teamwork: The merger would promote team-based training and integration, resulting in greater productivity when responding to calls together. It would also enhance the overall service to the community by creating one cohesive, efficient team. 6. Community Benefits: The community would benefit from more consistent service delivery, better cost efficiency through shared administrative functions, enhanced emergency preparedness capabilities, and simplified communication with a single point of contact for all emergency services. 7. Positive Working Relationships: The existing strong working relationships between all departments at the street level provide an excellent foundation for integration. Personnel already interact well and maintain mutual respect, which means the merger would build upon established trust and collaboration. Question #5m What, if any, do your believe would be the likely disadvantages to merging the KLFD and L with the KLF S? Document u ry: The comments on the likely disadvantages of merging KLFD and KLEMS with KLFREMS reveal a range of perspectives. Some individuals believe there are no significant disadvantages, citing strong existing relationships and operational benefits. However, others highlight potential challenges, including transitional issues such as aligning policies, managing personnel concerns, and addressing resistance to change. Logistical hurdles in integrating administrative systems and the need for a larger station to accommodate new staff are also mentioned. Additionally, there are concerns about the impact on part-time medics and EMT volunteers who may not have the required certifications. Some comments also mention the possibility of increased costs, control issues, and reduced staffing levels, which could affect service quality. Overall, the document highlights both the short-term challenges and the long-term benefits of the merger, emphasizing the importance of proper planning and strong leadership to address these issues. JA' * ngle 175 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Prioritized summary oft e feedback based on frequency of statements: 1. Transitional Challenges: Many respondents highlighted the difficulties associated with the transition period. This includes adapting to new leadership, new routines, and integrating different organizational cultures. 2. Logistical Hurdles: Several individuals mentioned the logistical issues that could arise from the merger. This includes the need for a larger station and the complexities of coordinating resources and personnel. 3. Resistance to Change: Some feedback pointed out potential resistance from members of the organizations involved. This resistance could stem from hurt feelings or reluctance to adopt new procedures and policies. 4. Short-term Disruptions: A few respondents were concerned about short-term disruptions that might affect the efficiency and effectiveness of emergency services during the initial phase of the merger. 5. Long-term Benefits: Although not often mentioned, some feedback acknowledged the merger's potential long-term benefits, emphasizing the importance of proper planning and leadership to address the initial challenges. Question 6m If a merger is deemed to be feasible as well as operationally and financially beneficial to the taxpayers and members, what are the critical issues that you believe will need to be addressed prior to moving forward with a merger? DocumentSummary: This document discusses the feasibility and benefits of a merger between two departments, focusing on operational and financial advantages for taxpayers and members. Key issues to address include ensuring high service levels, protecting job security for current employees, and dispelling rumors and false narratives about job losses. The document also emphasizes the importance of hiring a Fire Chief and District Manager, housing both departments under one station, and maintaining morale and clear communication with all stakeholders. It also highlights the need for standardized policies, efficient operations, and a detailed financial plan to support the merger. Prioritized summary oft the feedback ased on frequency of statements: 1. Rumors and False Narratives: Addressing these issues about job losses is mentioned multiple times. It is crucial to ensure that current staff who are not dual certified have the right to continue working for the department, regardless of their desire to become fire certified. JA' W ngle 176 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS 2. Hiring and Leadership: The need to hire a Fire Chief and a District Manager is emphasized. Establishing leadership positions before the merger is finalized is vital for providing clear direction, accountability, and professional management. 3. Job Security: Ensuring job security for current employees is a recurring theme. It is suggested that a grandfather system be implemented, allowing people to retain their current positions and ensuring that future employees are dually certified. 4. Communication and Transparency: Clear communication with all stakeholders and transparency about staffing and leadership roles are critical. Maintaining morale and ensuring that current members feel supported and valued throughout the transition is important. 5. Operational and Financial Benefits: The merger's feasibility and operational and financial benefits are highlighted. Ensuring the highest level of services, paid staff, equipment, and housing for both departments under one station is necessary. 6. Standardized Policies and Efficient Operations: The need for standardized policies and procedures, efficient operations, and a detailed financial plan to support the merger is important. 7. Leadership: Implementing operational-level chief officers and ensuring unified leadership is essential. Question ##7: If a full merger of KLFD and KLEMSi KLFREMS is deemed impractical or not advantageous in terms of operations or finances, what potential system improvements, shared services, or operational collaborations between the districts should a explored? Document Summary: This document discusses the potential merger of the Key Largo Volunteer Fire Department and Key Largo Volunteer Ambulance Corps with the Key Largo Fire Rescue and Emergency Medical Services District. It explores various perspectives on whether a full merger is practical or beneficial, and if not, what alternative improvements or shared services could be implemented. Some believe that a full merger is the only viable solution to address operational inefficiencies, duplication of services, and inconsistent policies. Others suggest shared services such as joint training programs, unified command structures, and combined purchasing for equipment and supplies. There are also opinions on the need for better communication, standardized operations, eliminating duplicated resources, and generating revenue streams. JA' W ngle 177 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS The document also emphasizes the importance of formal collaboration agreements to bridge gaps and move towards a more unified system over time. Prioritized summary oft the feedback se on frequency of statements: 1. Operational and Financial Feasibility: The most frequently mentioned concern is whether a full merger of the Key Largo Volunteer Fire Department and Key Largo Volunteer Ambulance Corps with the Key Largo Fire Rescue and Emergency District is practical and financially advantageous. 2. System Improvements: If a full merger is not feasible, the document suggests several potential system improvements. These include: a. Joint Training Programs: Implementing joint training programs to ensure that all personnel are equally skilled and prepared for emergencies. b. Unified Command Structures: Establishing unified command structures during incidents to improve coordination and response times. c. Shared Administrative Support: Combining administrative support to streamline operations and reduce redundancy. d. Combined Purchasing: Pooling resources for purchasing equipment and supplies to achieve cost savings. e. Creating Revenue Streams: Collecting money for inspections, fire plans, code review, and improving EMS billing returns can help address financial inefficiencies. f. Personnel: Some comments suggest that if the Fire and EMS departments do not merge with the district, the Fire Department should continue with the process and be accepted as district employees. This will ensure that the commissioners are responsible for the important and final decisions that directly affect personnel and the department as a whole. 3. Formalized Collaboration Agreements: Emphasizing the importance of formalized collaboration agreements to bridge gaps and move towards a more unified system over time. Additionally, allowing members certified in both fire and EMS to rotate between the engine and rescue box would improve coverage and provide members with a more well-rounded experience. JA' W ngle 178 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Survey Questions Results I believe that the merger will create new opportunities for career growth and development within the district. NPIPIMM Agree 5 1 1% Strongly Agree 30 64% Disagree 2 4% Strongly Disagree 4 9% Neutral or No Opinion 6 13% Integrating leadership and command structures will improve operational effectiveness. 0 NEEMENE=M. Agree 8 17% Strongly Agree 31 65% Disagree 1 2% Strongly Disagree 4 8% Neutral or No Opinion 4 8% The merger w►1/enhance teamwork and collaboration on [the] fire department and ambulance Corp members. gi Agree 10 21% Strongly Agree 27 56% Disagree 3 6% Strongly Disagree 3 6% Neutral or No Opinion 5 10% JA' * ngle 179 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS 1 trust that the merger will be managed transparently and fairly® Agree 6 13% Strongly Agree 21 447o Disagree 4 8% Strongly Disagree 4 8% Neutral or No Opinion 13 27% The merger will provide better access to resources and equipment. ENIECOMMI --=. - - Agree 10 21% Strongly Agree 29 6217o Disagree 2 4% Strongly Disagree 2 4% Neutral or No Opinion 4 9% ►strict leadership has provided sufficient support during the merger discovery process. Agree 9 19% Strongly Agree 16 337o Disagree 7 15% Strongly Disagree 4 8% Neutral or No Opinion 12 25% JA' W ngle 180 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS External Survey Results The following section represents the results of the external survey of community members, business owners, and others. Question m Positives—What ene i s might you expect from r in the KLPD andL with the KLF E S? Document Summary: This document discusses the potential benefits of merging the Key Largo Volunteer Fire Department and Key Largo Volunteer Ambulance Corps with the Key Largo Fire Rescue and Emergency Medical Services District. The perspectives shared include: • Lower Costs and Shared Resources: The merger is expected to lower costs and ensure the efficient use of emergency resources for the community. Examples cited were the consolidation of equipment, personnel, training, and medical control. • Enhanced Communication and Coordination: Enhanced information sharing and unity are anticipated to lead to better communication and coordination, serving Key Largo as a whole best. • Improved Shift Coverage and Employee Benefits: The merger is expected to provide better shift coverage and improved benefits for employees. • Modernization and Streamlined Administration: The combined departments are expected to be modernized and managed by an organizational structure that understands the community's needs, unlike the current, old, and inefficient structure. Overall, the document reflects a mix of support and alternative ideas regarding the merger. Question # m Concerns—What concerns might you have when considering er in the KLFD and KLE S with the KLF S? Document Summary: This document discusses various concerns regarding the potential merger of the Key Largo Volunteer Fire Department and Key Largo Volunteer Ambulance Corps with the Key Largo Fire Rescue and Emergency Department. Some of the key points mentioned include: Professional Leadership: There is a concern about the cost of fresh professional leadership (which might be around $200k). JA' * ngle 181 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS • Management Experience: There is concern that the merger might involve the current management team, which lacks experience running a modern career fire rescue department. • Emergency Resources: One individual opposes any action that would relocate emergency resources away from East Drive, citing high taxes and the proximity to the fire station as key benefits. • Unity and Agreement: There is a concern about possibly not having everyone on board with the decision, and the need for unity. Overall, the document highlights various concerns and considerations that should be addressed when considering the merger of these emergency services. Question #3m Other Thoughts—What other ideas do your have to share regarding a merger of the KLFD and KLEMS with the KLV This y o in the survey, it should v referenced ? Document Summary: This document contains various thoughts and opinions regarding a potential merger between KLFD and KLEMS. The perspectives shared include: • Support for the Merger: Some individuals see the merger as a positive step for the community. • Opposition to the Merger: Others oppose the merger, citing reasons such as the timing being too late or insufficient information. • Operational Considerations: There are suggestions to reduce overhead by eliminating the EMS building and increasing crew size on fire trucks. • Alternative Proposals: One suggestion is to combine Marathon North with Tavernier and Key Largo. Overall, the document reflects a mix of support, opposition, and alternative ideas regarding the merger. JA' * ngle 182 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS is of the following best describes your relationship with the District? Islamorada 1 14% Resident of the District 5 7 1% Both resident and business owner in the District 1 14% Note: Percentages rounded to the nearest integer. Are you currently affiliated (in any capacity) with any of the following agencies that are a part of this study? None or Prefer Not to Say 17 100% JA' * ngle 183 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS AppendixiPolicy The fire district has established a series of thresholds for including data in ongoing analyses of fire district operations. The purpose of these thresholds is to identify data outliers and exclude them from analysis designed to assist the organization in discerning trends and operations. Anomalous data makes that process more difficult. These will include, but are not limited to: • The upper threshold for first-unit emergency response times in the jurisdiction, under normal operating conditions and without staging, is 20 minutes. • The on-duty Battalion Chief or Company Officer shall ensure that, for any response time exceeding 10 minutes that meets the criteria above, the stated reason for or explanation of the response time is documented in the report. • Any response time greater than 15 minutes and meeting the criteria above, including those values outside the 20-minute threshold, shall be documented with an explanation of the response time and a determination as to whether the causes are correctable. • If the cause of the outlier is correctable, the Battalion Chief or Company Officer shall determine what action should be taken and who will be responsible. JA' * ngle 184 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Should the Fire Commission opt to consolidate KLFD and KLEMS into the district, there will be three options for employee retirement: a 457(b) defined contribution plan, a Florida Chapter 175 plan, and the Florida Retirement System. If no action is taken, the current 401 (k) plan can be continued. The three options for a 457(b) plan are a private, employer-sponsored defined-contribution plan with tax advantages and investment flexibility. The second option is a Florida Chapter 175 plan, a state-mandated pension trust fund specifically for municipal and district Firefighters, funded partly by insurance premium taxes. Lastly, the Florida Retirement System (FRS) Special Risk Class is a statewide pension/investment plan for high-risk public safety employees (Firefighters, law enforcement, EMTs), offering earlier retirement ages and enhanced benefits compared to regular FRS members. Figure 121 provides a high-level overview of these three plans. Figure 1 1: Retirement PlansComparisons 0=10MEM Defined contribution, Defined-benefit, State-administered tax-advantaged local Firefighter-only system (Pension + Type of Plan deferred plans under Ch. 175; Investment Plan can be "chapter" or compensation. "local law" plans. options). Guaranteed pension Pension Plan: monthly Account balance based on years of benefit formula (years grows with service, salary, and of service x % accrual investments; statutory formulas; X average final Benefit withdrawals taxed as disability and death compensation). income; flexible benefits included. Investment Plan: payout options. Chapter 175 account balance establishes Firefighter with investment minimum benefits. choice. Local Boards of Division of Retirement Employer/ (Pension Plan) & State Administration government sponsor; trustees with state Board of oversight by the IRS rules. Division of Retirement. Administration Investment Plan). JA' * ngle 185 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Local contributions Employee contributes Funding Employee + employer plus state premium tax 3% of salary; match. on property insurance employer contributes 1 .85% . the remainder. Tax Benefits Pre-tax or Roth Pension income Pension income options. taxable. taxable. No 10% penalty for early withdrawals Retirement 55 years of age, with Age before age 59/2 Varies, often earlier. 8 yrs. or 25 yrs. service. (unique vs. 401 k/403b). Investment None (fixed pension Limited (investment Control Employee-directed. formula). plan option). Guaranteed pension Risk Market risk borne by Guaranteed pension. (if pension plan the employee. chosen). Local actuarial experience and Funding Risk N/A. funding risks borne at Pooled at state level. the plan level; premium tax helps offset. Special Employer match, Disability, death, HIS Early retirement, Benefits portability. subsidy. higher accrual, HIS subsidy. State/local government Firefighters of Statewide—covers Eligibility employees, certain participating many classes Scope nonprofits (e.g., municipalities/special (including Special Risk Firefighters, police, fire districts only. Class). civil servants). Transfer provisions to Portability for other state retirement Between FRS options, Portability systems exist, but transfers in/out are governmental plans. depend on local plan subject to rules. terms. Covering multiple Offers flexibility and Provides guaranteed public safety roles, portability but places pensions for Florida with enhanced Summary investment risk on the Firefighters, funded by retirement benefits employee. insurance premium and earlier retirement taxes. ages compared to regular FRS members. JA' W ngle 186 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS IAppendix D: Table of Figures Figure 1: Key Largo Study Area Population Density.................................................................. 10 Figure 2: KLFREMS Organizational Chart (2025)......................................................................... 12 Figure 3: KLEMS Organizational Chart (2025)............................................................................. 13 Figure 4: KLFD Organizational Chart (2025) ............................................................................... 15 Figure 5: Key Largo Study Area Boundaries............................................................................... 16 Figure 6: Mutual Aid Resources Available to KLFREMS ............................................................. 18 Figure 7: Automatic & Mutual Aid Stations Adjacent to Key Largo Agencies ....................... 19 Figure 8: KLEMS & KLFD Regulatory Documents........................................................................23 Figure 9: KLFD Administrative & Support Staffing ...................................................................... 32 Figure 10: KLEMS Administrative & Support Staffing..................................................................33 Figure 11 : KLFD Paid Operational Staffing ................................................................................. 34 Figure 12: KLFD Volunteer Operational Staffing ........................................................................ 35 Figure 13: KLEMS Paid Operational Staffing............................................................................... 35 Figure 14: KLEMS Volunteer Operational Staffing...................................................................... 36 Figure 15: KLFD Current Staffing Model...................................................................................... 37 Figure 16: KLEMS Current Staffing ............................................................................................... 37 Figure 17: Staffing & Personnel Comparisons Summary ...........................................................40 Figure 18: Medical Exams Programs...........................................................................................41 Figure 19: Cancer Prevention Program......................................................................................43 Figure 20: Mental Health Programs ............................................................................................44 Figure21 : Safety Programs..........................................................................................................45 Figure 22: Summary of Health, Wellness, & Safety Programs....................................................46 Figure 23: KFREMS Budget & Finance Overview........................................................................49 Figure 24: KFREMS Historical Revenue........................................................................................ 50 Figure 25: KLEMS Ambulance Fees Used to Offset Paramedic Payroll.................................... 51 Figure 26: Recurring vs. Non-Recurring Revenues (FY 20 Actual-FY 25 Adopted) ................. 51 Figure 27: KLFREMS District Preliminary Taxable Value Versus Millage Rate............................ 52 Figure 28: KLFREMS Expenses by Component—District............................................................. 53 Figure 29: KLFREMS Expenses by Component—Fire Department............................................ 54 Figure 30: KLFREMS Expenses by Component—EMS Department........................................... 55 Figure 31 : KLFREMS Recurring vs Non-Recurring Expenses FY 20 Actual to FY 25 Adopted... 56 Figure 32: KLFREMS/KLFD/KLEMS Personnel Expenses ............................................................... 57 Figure 33: KLFD Career Operational Staff vs. KLFREMS Personnel Expenses............................ 58 JA' * ngle 187 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 34: KLFREMS/KLFD/KLEMS Personnel Expenses ............................................................... 59 Figure 35: District Capital Expenses by Composite Unit............................................................ 60 Figure 36: District Capital Expenses by Category ..................................................................... 60 Figure 37: KLFREMS Fund Balance Analysis (FY 20 Actual-FY 25 Projected) ........................... 62 Figure 38: Criteria Utilized to Determine Fire Station Condition................................................ 64 Figure39: KLEMS Station 23......................................................................................................... 65 Figure 40: KLFD Station 24 (Headquarters)................................................................................. 66 Figure 41 : KLFD Station 25............................................................................................................ 67 Figure 42: Combined Features of the EMS & Fire Stations (2025)............................................. 68 Figure 43: Criteria Used to Determine the Condition of Apparatus & Ambulances .............. 69 Figure 44: Key Largo EMS Rescue Inventory (2025)................................................................... 69 Figure 45: Key Largo Fire Department Apparatus Inventory (2025)......................................... 70 Figure 46: Key Largo Fire Department SCBA Inventory (2025) ................................................. 72 Figure 47: Combined Inventories of Cardiac Devices (2025) .................................................. 72 Figure 48: KLFD Summary of Data Sources ................................................................................ 74 Figure 49: KLEMS Summary of Data Sources.............................................................................. 74 Figure 50: KLFD Incident Volume (2020-2024) ........................................................................... 75 Figure 51 : NFIRS Incident Code & Descriptions ......................................................................... 76 Figure 52: KLFD Annual Demand by Incident Type (2020-2024).............................................. 77 Figure 53: KLFD NFIRS Service Demand by Type (2020-2024) .................................................. 78 Figure 54: KLFD NFIRS Service Demand by Type with Cumulative Percentage (2020-2024) 78 Figure 55: KLFD Service Demand by NFIRS Property Type (2023-2024) ................................... 79 Figure 56: KLFD NFIRS Service Demand by Month (2020-2024)................................................ 80 Figure 57: KLFD NFIRS Service Demand by Day of Week (2020-2024)..................................... 81 Figure 58: KLFD NFIRS Service Demand by Hour (2020-2024)................................................... 82 Figure 59: KLFD Service Demand by Day &Time (2022-2024) ................................................. 83 Figure 60: KLFD Busiest Consecutive Service Delivery Periods (2023-2024)............................. 83 Figure 61 : KLFD Density—All Incidents (2023-2024) ................................................................... 84 Figure 62: KLFD Density—Fire Incidents (2023-2024) ................................................................. 85 Figure 63: KLFD Density—EMS Incidents (2023-2024) ................................................................ 86 Figure 64: KLFD Station Distribution—ISO Five-Mile Travel Distance Criteria............................ 88 Figure 65: KLFD Station Distribution—ISO 1.5-Mile Travel Distance Criteria.............................. 89 Figure 66: KLFD Station Distribution—ISO 2.5-Mile Travel Distance Criteria.............................. 90 Figure 67: NFPA 1710 Standard Response Process.................................................................... 91 JA' * ngle 188 GROUP LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 68: Station Distribution-4-Minute/8-Minute Travel Time KLFD Stations......................... 92 Figure 69: KLFD Incident Concurrency (2023-2024) .................................................................. 93 Figure 70: KLFD Unit Commitment Times (2020-2021) ............................................................... 94 Figure 71 : KLFD Unit Commitment Times (2022-2024)A.............................................................. 94 Figure 72: Commitment Factors ................................................................................................. 95 Figure 73: Response Time Continuum Definitions...................................................................... 97 Figure 74: NFPA 1710 Response Time Measurements ............................................................... 98 Figure 75: KLFD Turnout Times (May 1, 2024-December 31, 2024)........................................... 99 Figure 76: KLFD Travel Times (May 1, 2024-December 31, 2024) ........................................... 100 Figure 77: KLFD Response Times (May 1, 2024-December 31, 2024) ..................................... 101 Figure 78: KLFD Mutual & Automatic Aid Partners .................................................................. 102 Figure 79: KLFD Mutual/Automatic Aid Summary (2020-2024) .............................................. 103 Figure 80: Service Demand by KLEMS Rescue Unit (2022-2024) ............................................ 107 Figure 81 : KLEMS Service Demand by Month (2022-2024) ..................................................... 108 Figure 82: KLEMS Service Demand by Day of Week (2022-2024) .......................................... 108 Figure 83: KLEMS Service Demand by Hour of Day (2022-2024)............................................ 109 Figure 84: KLEMS Service Demand by Day & Hour (2024) ...................................................... 110 Figure 85: KLEMS Incident Concurrency (FY 2024) .................................................................. III Figure 86: KLEMS Unit Commitment Times (FY 24) ................................................................... 112 Figure 87: KLEMS Travel Time at the 901h Percentile (FY 24)..................................................... 112 Figure 88: KLEMS Patient Transport Times at the 901h Percentile............................................. 113 Figure 89: APOT by Rescue Unit at the 901h Percentile (2022-2024)....................................... 114 Figure 90: Top 10 Most Frequent Patient Impressions (2022-2024)......................................... 115 Figure 91 : Top 10 Most Frequent Conditions Identified by MSCO (2022-2024)..................... 116 Figure 92: Ten Most Frequent Mechanisms of Injury (2022-2024)........................................... 117 Figure 93: Final Patient Acuity Levels (2022-2024)................................................................... 117 Figure 94: General Training Competencies by KLFD............................................................... 121 Figure 95: KLFD Training Methodologies................................................................................... 122 Figure 96: Balanced Training Program Components.............................................................. 122 Figure 97: Annual Preliminary Total Taxable Value for KLFREMS (2017-2025) ....................... 131 Figure 98: Full-Time Operational Staff Employed by KLFD & KLEMS (FY 20-25) ..................... 133 Figure 99: Career Operational Staff vs. Total District Personnel Costs (FY 20-25) ................. 134 Figure 100: Career Operational KLFD Staff vs. Total District FD Personnel Costs (FY 20-25) . 134 Figure 10 1: Total District Operating Expense (FY 20-25) ......................................................... 135 JA' * ngle 189 GROUP,LC Operational Analysis/Consolidation Study Key Largo Fire Rescue & EMS Figure 102: KLFREMS Status Quo Option 1-A—Forecast (FY 25-27)........................................ 137 Figure 103: KLFREMS Status Quo Option 1-A—Forecast (FY 28-30)........................................ 138 Figure 104: Revenue/Expenses Projections—Status Quo Option 1-A (FY 25-30) .................. 139 Figure 105: Cost of Adding Career Operational Staff (FY 26-30)........................................... 140 Figure 106: KLFREMS Status Quo Option 1-13—Forecast (FY 26-27) ........................................ 140 Figure 107: KLFREMS Status Quo Option 1-13—Forecast (FY 28-30) ........................................ 141 Figure 108: Revenue/Expenses Projections—Option 1-B (FY 25-30) ...................................... 142 Figure 109: KLFREMS Consolidated Option 2-A Forecast (FY 25-27)...................................... 146 Figure 1 10: KLFREMS Consolidated Option 2-A Forecast (FY 28-30)...................................... 147 Figure 1 1 1: Revenue/Expenses Projections—Consolidated Option 2-A (FY 25-30).............. 148 Figure 1 12: KLFREMS Consolidated Option 2-B Forecast (FY 25-27) ...................................... 150 Figure 113: KLFREMS Consolidated Option 2-B Forecast (FY 28-30) ...................................... 151 Figure 1 14: Revenue/Expenses Projections—Consolidated Option 2-B (FY 25-30) .............. 152 Figure 1 15: KLFREMS Consolidated Option 2-C Forecast (FY 25-27)...................................... 153 Figure 1 16: KLFREMS Consolidated Option 2-C Forecast (FY 28-30)...................................... 154 Figure 1 17: Revenue/Expenses Projections—Consolidated Option 2-C (FY 25-30) ............. 155 Figure 1 18: Comparison of Millage Rates/Personnel Costs for Various Models.................... 156 Figure 1 19: Millage Rate/Personnel Services Cost Comparison of Models........................... 157 Figure 120: Example Organizational Structure ........................................................................ 159 Figure 121: Retirement Plans Comparisons.............................................................................. 185 JA' W ngle 190 GROUP LC RESOLUTION NO, 2026-0002 A RESOLUTION OF THE KEY LARGO FIRE RESC UE AND EMERGENCY MEDICAL SERVICES DISTRICT,FLORIDA, PROVIDING FOR THE CONSOLIDATION OF FIRE, RESCUE AND EMERGENCY MANAGEMENT SERVICES CURRENTLY PROVIDED BY CONTRACTS WITH THE KEY LARGO VOLUNTEER FIRE DEPARTMENT, INC. ("VFD") AND KEY LARC.O VOLUNTEER AMBULANCE CORPS, INC. ("VAC"), AND AN EFFECTIVE DATE FOR THE SAME; PROVIDING FOR THE RATIFICATION AND READOPTION OF ACTIONS PREVIOUSLY TAKEN FOR PURPOSES OF CONSOLIDATION, INCLUDING EVALUATING, HIRING AND ON-BOARDING OF A FIRE- EMS CJII EFIDISTRICT MANAGER AND OTHER PERSONNEL; PROM DINC. FOR THE RATIFICATION AND READ OPTION OF VFD AND VAC STANDARD OPE RATING GIJIDELINFS, OPERATIONAL POLK."IES AND PROCEDURES, MEDICAL POLICIES AND PROTOCOLS, AND ALL OTHER SIMILAR POLICIES AND PROCEDURES FOR PURPOSES OF CONSOLIDATION; PROVIDING FOR THE ADOPTION OF AN AMBULANCE FEE SCHEDULE FOR PURPOSES OF CONSOLIDATION; PROVIDING FOR THE APPLICATION OFA CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY, AND AN APPLICATION FOR AN ADVANCED LIFE SUPPORT LICENSE FOR PURPOSES OF CONS OIADXIJON; PROVIDING FOR THE ACQUISITION OF CERTAIN INSURANCE FOR PURPOSES OF CONSOLIDATION; PROVIDING FOR SCRIVENER'S ERRORS; PROVIDING FOR SEVERABILITY; PROVIDING FOR CONFLICTS; PROVIDING FOR CONSTRUCTION; AND PROVIDING FOR AN EFFECTIVE DATE WHEREAS, the Key l_,argo Fire R.escue and Emergency kledical Services District (hereinafter, the "District") was created on June 8, 2005, when ("Jovernor Bush approved Florida Statute 2005-329 that created the 68th Special l'ire Taxing District in the State offlorida; and Resolution No.2026-0002 Page No. 2 WHEREAS,the District provides fire protection,firefighting services,rescue services and emergency medical services for all of Cross Key and that part of Key Largo from South Bay Harbor Drive and Lobster Lane to the southern boundary of the right-of-way County Roads 905 and 905A (hereinafter,the "Services"); and WHEREAS, the District currently contracts with the Key Largo Volunteer Fire Department, Inc. (hereinafter, the "VFD"), whereby the VFD contractually provides for the provision of fire and rescue services within the District; and WHEREAS, the District currently contracts with the Key Largo Volunteer Ambulance Corps, Inc. (hereinafter, the "VAC"), whereby the VAC contractually provides for the provision of basic and advanced life support ambulance services within the District; and WHEREAS, on January 19, 2026, the District received an "Operational Analysis Consolidation Study," prepared by J. Angle Group, LLC (hereinafter, the "Study"); and WHEREAS, the Study provided a comprehensive evaluation of the current conditions, governance structures, financial sustainability, and service delivery performance for the District and its contracted entities the VFD and VAC; and WHEREAS,the Study provided recommendations and options including consolidation of the VFD and VAC personnel into the District, and the termination of the District's contracts with the VFD and VAC (hereinafter,the "Consolidation"); and WHEREAS, on January 19, 2026, the District, through its Board of Commissioners (hereinafter, the `Board"), adopted and approved a motion to proceed with implementing Option 2-C of the Study,directing Interim District Manager William Lombardo(hereinafter,the"Interim District Manager"), along with teams from Fire and Rescue (VFD) and EMS (VAC),to formulate a timeline and to identify all steps and actions necessary for Consolidation under Option 2-C; and WHEREAS,the District, its Board, staff, and agents, as well as members of the VFD and VAC, have diligently pursued all matters and actions required for the Consolidation; and WHEREAS,the District finds that it would be in the best interests of the District at large and the citizens it serves to proceed with implementing all or a portion of Option 2-C of the Study for the Consolidation with the VFD and VAC. NOW THEREFORE, BE IT RESOLVED BY THE KEY LARGO FIRE RESCUE AND EMERGENCY MEDICAL SERVICES DISTRICT,FLORIDA,AS FOLLOWS: Section 1. The above recitals are true and correct and incorporated into this Resolution by reference. Section 2. The Board hereby confirms, ratifies, and readopts the following actions previously taken by the Board: Resolution No.2026-0002 Page No. 3 A. Unless subsequently amended, the effective date for Consolidation is July 1, 2026. B. The Interim District Manager is authorized to begin the hiring process for the position of Fire-EMS Chief/District Manager; C. The Interim District Manager is authorized to take all actions necessary to evaluate, hire and on-board personnel as District employees, including but not limited to personnel who are necessary for the District to qualify for a Certificate of Public Convenience and Necessity (hereinafter, the "COPCN") License and an Advanced Live Support ("ALS")/Basic Life Support ("BLS") License.To this end,the Board directs the Interim District Manager to give preference to qualifying applicants who are currently employed with the VAC and VFD. D. The District adopts the VAC's current ambulance fee schedule; E. The District adopts both the VFD and VAC's Standard Operating Guidelines ("SOGs"), operational policies and procedures, medical policies and protocols, and all other procedures,protocols and policies,not inconsistent with those of the District.However,the District reserves the right to modify any of the same at any time. This action excludes any policy, procedure, protocol, or guideline related to District procurement, to the District Board itself, or which is not otherwise related to the purposes of the Consolidation; and F. The District adopts the current employee pay scale, rank, seniority, and benefits of VFD and VAC personnel, respectively. However, the District reserves the right to modify any of the same at any time. Section 3. The Interim District Manager, and his designees, are authorized to take all the following actions: A. Apply for a Certificate of Public Convenience and Necessity - Class A with Monroe County, Florida; B. Apply for an Advanced Life Support (ALS) and Basic Life Support (BLS) License from the Florida Department of Health; C. Apply for and otherwise acquire any and all other federal, state, regional or local governments, agencies, and authorities' approvals, registrations, and similar which are necessary for the purposes of Consolidation. D. To apply for and to negotiate the terms for all necessary insurance for the District as may be required for the Consolidation. Further, the Interim District Manager is authorized to enter into such insurance coverage contract(s)on behalf ofthe District if they provide equal or better coverage and do not exceed an annual premium equal to the current budgeted amount for the VFD and VAC, respectively; Section 4. The Interim District Manager, and his designees, are directed to conduct a review of all SOGs, policies, procedures, and protocols, and to make recommendations to the Board to better achieve the purposes of Consolidation. Resolution No.2026-0002 Page No.4 Section 5. The District authorizes all other actions necessary to be taken fior purposes of achieving Consolidation as set forth in Option 2-C contained in the Study. Section 6. The District hereby ratifies and reconfirms all its previous actions taken for put-poses of(7,onsolidation. Section 7. Sections of this Resolution may be renumbered or re-lettered and corrections of typographical errors which do not affect the intent may be authorized by the Interim District Manager,, or his designee, without need of a public meeting or Board decision making action, by the Interim District Manager filing a corrected or re-codified copy of'same with the District's records Custodian. Section 8. The provisions of this Resolution are declared to be severable and if any section, sentence, clause or phrase of this Resolution shall lor any reason be held to be invalid or unconstitutional, Such decision shall not affect the validity of the remaining sections. sentences, clauses, and phrases of this Resolution but they shall remain in effect, it being the legislative intent that this Resolution shall stand notwithstanding the invalidity of any part, Section 9. The Board of onu-nissioners hereby rescinds all prior resolutions and ofl-ier official action of the Board of'Cornrylissioners to the extent ofany conflict with any part of this Resolution. Section 10. This Rcsoluti(,)n shall be liberally construed to affect the purposes herec)f and shall bec(-inie effectively immediately upon its adoption. PASSED AND ADOPTED this 23'd day of March, 2026, ............ — ----- Chairman ATTEST: ................................................ District Clerk APPROVED AS TO FORM AND LEG'ALITV FOR THE USE AND BENEFIT OF KEV LARGO FIRE RESCUE AND EMERGENCY MEDICAL SERVICES DISTRICT ONLY: E Y Resolution No.2026-0002 Page No. 5 Motion to adopt by Commissioner Jenkins, Seconded by Commissioner Conklin FINAL VOTE AT ADOPTION Chairman Tony Allen Yes Vice-Chair George Mirabella No Commissioner Frank Conklin Yes Commissioner Kenny Edge No Commissioner Michael Jenkins Yes CHAPTER 2005-329 House Bill No. 1291 An act relating to the Key Largo Fire Rescue and Emergency Medical Services District,Monroe County; creating a special district;provid- ing definitions; providing for creation, status, charter amendments, boundaries, and purposes; providing for a board of commissioners; providing for election and terms of commissioners; providing for employment of district personnel; providing for election of board officers;providing for compensation,oath,and bonds of commission- ers; providing for powers, duties, and responsibilities of the board; providing for ad valorem taxes; providing a cap on the rate of taxa- tion;providing for user charges;providing for impact fees;providing for authority to disburse funds; authorizing the board to borrow money; providing for use of district funds; requiring a record of all board meetings; authorizing the board to adopt policies and regula- tions; providing for the board to make an annual budget; requiring an annual report; authorizing the board to enact fire prevention ordinances;authorizing the district to appoint a fire marshal;autho- rizing the district to conduct inspections, establish and operate fire, rescue, and emergency medical services; providing for district au- thority upon annexation of district lands; providing for dissolution; providing immunity from tort liability for officers, agents, and em- ployees; providing for district expansion; providing for construction and effect; providing for an exclusive charter; requiring a referen- dum; providing an effective date. Be It Enacted by the Legislature of the State of Florida: Section 1. Definitions.—As used in this act, unless otherwise specified: (1) "Board" means the board of commissioners created pursuant to this act and chapter 191, Florida Statutes. (2) "Commissioner" means a member of the board of commissioners of and for the district. (3) "District"means the Key Largo Fire Rescue and Emergency Medical Services District. Section 2. Creation; status; charter amendments; boundaries; district purposes.— (1) There is hereby created an independent special fire control district incorporating lands in Monroe County described in subsection (2), which shall be a public corporation having the powers, duties, obligations, and immunities herein set forth under the name of the Key Largo Fire Rescue and Emergyency Medical Services District. The district is orgyanized and exists for all purposes and shall hold all powers set forth in this act and chapters 189 and 191, Florida Statutes. 1 CODING: Words semen are deletions; words underlined are additions. Ch. 2005-329 LAWS OF FLORIDA Ch. 2005-329 (2) The lands to be included within the district are the following de- scribed lands on the island of Key Largo, in Monroe County, to wit: All of Cross Key and that part of Key Largo from South Bay Harbor Drive and Lobster Lane to the southern boundary of the right-of-way County Roads 905 and 905A. (3) The Key Largo Fire Rescue and Emergency Medical Services District is organized and exists for all purposes set forth in this act and chanter 191, Florida Statutes, including, but not limited to,providin_a fire protection and firefighting services, rescue services, and emergency medical services. Such emergency medical services shall not be the primary function of the district. The district shall have all other powers necessary to carry out these pur- poses,including the authority to contract with the Key Largo Volunteer Fire and Rescue Department, Inc., and the Key Largo Volunteer Ambulance Corps,Florida not-for-profit corporations,which corporations currently pro- vide fire,rescue,and emergency medical services within the district bounda- ries; to purchase all necessary real and personal Property; to purchase and carry standard insurance policies on all such equipment; to employ personnel as may be necessary to carry out the purpose of said fire district; to provide adequate insurance for said employees; to purchase and carry appropriate insurance for the protection of all firefighters and personnel as well as all equipment and personal property on loan to the district; to sell surplus real and personal property in the same manner and subject to the same restrictions as provided for such sales by counties; and to enter into contracts with qualified service providers to carry out the purposes of the district. (4) Nothing herein shall prevent the district from cooperating with the state or other local governments to render such services to communities adjacent to the land described in this section as evidenced by an executed agreement between the cooperating agencies as approved by the board. (5) The district charter maybe amended only by special act of the Legis- lature. Section 3. Board of commissioners.— (1) Pursuant to chapter 191, Florida Statutes, the business and affairs of the district shall be governed and administered by a board of five commis- sioners,who shall be qualified electors residing within the district and shall be elected by the qualified electors residing within the district,subject to the provisions of chapters 189 and 191, Florida Statutes, and this act. Each commissioner shall hold office until his or her successor is elected and qualified under the provisions of this act. The procedures for conducting district elections and for qualification of candidates and electors shall be pursuant to chapters 189 and 191, Florida Statutes. The members of the board shall serve on a nonpartisan basis for a term of 4 years each and shall be eligible for reelection. (2) Notwithstanding section 191.005, Florida Statutes,the five members of the initial board shall be elected by the qualified electors residing within the district at a special election conducted by the Supervisor of Elections of 2 CODING: Words semen are deletions; words underlined are additions. Ch. 2005-329 LAWS OF FLORIDA Ch. 2005-329 Monroe County to be held on or before October 4,2005.At the initial election of the governing board, the candidate receivin the highest number of votes shall hold seat 1,the candidate receiving the second highest number of votes shall hold seat 3, the candidate receiving the third highest number of votes shall hold seat 5,the candidate receiving the fourth highest number of votes shall hold seat 2, and the candidate receiving the fifth highest number of votes shall hold seat 4. The three elected members for seats 1, 3, and 5 in the initial election under this act shall serve terms of 3 years each. The remaining two elected members for seats 2 and 4 in the initial election shall serve terms of 1 year each. (3) Subsequent elections of board members shall coincide with the Gen- eral elections of this state. (4) Vacancies in office shall be filled by election, said election to be held coincidental with the next countywide general election to fill the remaining term of the seat vacated. The board may appoint a qualified elector of the district to act as commissioner until the vacancy is filled by election. A commissioner may be removed from office as provided by chapter 191, Flor- ida Statutes,or for any reason that a state or county officer may be removed. (5) All elections shall be noticed, called, and held pursuant to the provi- sions of the general laws of the state.The board shall, to the extent possible, coordinate all elections with count, wy ide general or special elections in order to minimize cost. Elections shall be called through the adoption of an appro- priate resolution of the district directed to the Board of County Commission- ers of Monroe County, the Supervisor of Elections of Monroe County, and other appropriate officers of the county. The district shall reimburse county government for the actual cost of district elections. No commissioner shall be a paid employee of the district while holding said position. (6) The board may employ such personnel as deemed necessary for the proper function and operation of the district. (7) The salaries of district personnel and any other wages shall be deter- mined by the board. Section 4. Officers; board compensation; bond.— (1) In accordance with chapter 191, Florida Statutes, each elected mem- ber of the board shall assume office 10 days following the member's election. Within 60 days after election of new members of said board as herein pro- vided, the newly elected members shall organize by electing from their number a chair, vice chair, secretary, and treasurer. However, the same member may be both secretary and treasurer, in accordance with chapter 191, Florida Statutes. Nothing shall prevent the commissioners from elect- ing a chair, vice chair, secretary, and treasurer annually. (2) Three members of the board shall constitute a quorum. A quorum shall be necessary for the transaction of business. (3) The commissioners may receive reimbursement for actual expenses incurred while performin.- the duties of their offices in accordance with 3 CODING: Words st:Pivken are deletions; words underlined are additions. Ch. 2005-329 LAWS OF FLORIDA Ch. 2005-329 general law governing per diem for public officials.Each commissioner shall receive from the funds of the district compensation for his or her services in the amount of$200 per month. Members may be reimbursed for travel and per diem expense as provided in section 112.061, Florida Statutes.Authori- zation for any additional compensation shall be pursuant to chapter 191, Florida Statutes. (4) Each commissioner upon taking office shall take and subscribe to the oath of office prescribed by s. 5(b), Art. II, of the State Constitution and general law. Upon taking office and in accordance with chapters 189 and 191, Florida Statutes, each commissioner shall execute to the Governor, for the benefit of the district, a bond of $5,000 with a qualified personal or corporate surety, conditioned upon the faithful performance of the duties of the commissioner's office and upon an accounting for all funds which come into his or her hands as commissioner. The premium for such bonds shall be paid from district funds. Section 5. Powers; duties, responsibilities.— (1) The district shall have and the board may exercise by majority all the powers and comply with the duties set forth in this act and chapters 189, 191,and 197,Florida Statutes,including,but not limited to,ad valorem taxation,bond issuance, and other revenue capabilities;budget preparation and approval;liens and foreclosure of liens;contractual agreements;and the adoption of ordinances and resolutions that are necessary to conduct district business if such ordinances do not conflict with any ordinance of a local general-purpose government within whose jurisdiction the district is lo- cated. (2) The board shall have the right,power, and authority to levy annually ad valorem taxes against the taxable property within the district to provide funds for the purposes of the district in an amount not to exceed the limit provided in chapter 191, Florida Statues. (3) The methods for assessing and collecting ad valorem taxes, impact fees,or user charges shall be as set forth in this act and chapter 170,chapter 189, chapter 191, chapter 197, or chapter 200, Florida Statues. (4) The district's planning requirements shall be as set forth in this act and chapters 189 and 191, Florida Statutes. (5) Requirements for financial disclosure, meeting notices, reporting, public records maintenance, and per diem expenses for officers and employ- ees shall be as set forth in this act and chapters 112, 119, 189, 191, and 286, Florida Statutes. Section 6. Ad valorem taxes.— (1) The board shall have the authority to levy ad valorem taxes annually against all taxable property within the district to provide funds for the purposes of the district only upon the approval by a majority vote of those qualified electors of the district voting in a referendum election authorizing the use of ad valorem taxation not to exceed 1 mill. 4 CODING: Words stream are deletions; words underlined are additions. Ch. 2005-329 LAWS OF FLORIDA Ch. 2005-329 (2) A referendum election of the electors of the district to authorize the use of ad valorem taxation not to exceed 1 mill shall be held by the supervi- sor of elections at the same time as the initial election of district commission- ers in accordance with the provisions of general law relating to elections. (3) Upon the approval of a majority of the electors voting at the initial election or at an election called by the board, the rate of taxation shall thereafter be fixed annually by resolution of the board without further approval by the electors,provided the rate of taxation shall not exceed 1 mill. The board shall have the authority to increase the millage rate above 1 mill only if a majority of the electors voting in a referendum election approve the increased millage rate in an amount not to exceed the limit provided in chapter 191, Florida Statutes. (4) The levy and collection of ad valorem taxes shall proceed pursuant to general law. Section 7. User charges.—The board shall have the authority to provide a reasonable schedule of chargesfor providing the following services: (1) Special emergency services, including firefighting occurring in or to structures outside the district, motor vehicles, marine vessels, or aircraft or as a result of the operation of such motor vessels or marine vessels to which the district is called to render such emergency service. (2) Fighting fires occurring in or at refuse dumps or as a result of an illegal burn,which fire,dump,or burn is not authorized by general or special law, rule regulation, order, or ordinance and which the district is called upon to fight or extinguish. (3) Responding to or assisting or mitia'atina emeraences that either threaten or could threaten the health and safety of persons,property, or the environment to which the district has been called, includingcharze for responding to false alarms. (4) Inspecting structures,plans,and equipment to determine compliance with fire safety codes. Section 8. Impact fees.— (1) Pursuant to section 191.009(4),Florida Statutes,it is hereby declared that the cost of new facilities should be borne by new users of the district's services to the extent new construction requires new facilities, but only to that extent. It is the legislative intent of this section to transfer to the new users of the district's fire protection and emergency services a fair share of the costs that new users impose on the district for new facilities. This shall only apply in the event that the general-purpose local government in which the district is located has not adopted an impact fee for fire services which is distributed to the district for construction within its jurisdictional bounda- ries. (2) The impact fees collected by the district pursuant to this section shall be kept as a separate fund from other revenues of the district and shall be 5 CODING: Words str4eken are deletions; words underlined are additions. Ch. 2005-329 LAWS OF FLORIDA Ch. 2005-329 used exclusively for the acquisition, purchase, or construction of new facili- ties or portions thereof required to provide fire protection and emergency services to new construction. "New facilities" means land, buildings, and capital equipment,including,but not limited to,fire and emergency vehicles and radio telemetry equipment. The fees shall not be used for the acquisi- tion, purchase, or construction of facilities which must be obtained in any event,re-ardless of growth within the district.The board of fire commission- ers shall maintain adequate records to ensure that impact fees are expended onlypermissible new facilities. Section 9. Authority to borrow money. — (1) The board of commissioners shall have the power and authority to borrow money or issue other evidences of indebtedness for the purpose of the district in accordance with chapters 189 and 191,Florida Statutes,provided, however, that the total payments in any one year, including principal and interest, on any indebtedness incurred by the district shall not exceed 50 percent of the total annual budgeted revenues of the district. (2) The board of commissioners as a body, or any of the members of the board as individuals, shall not be personally or individually liable for the repayment of such loan. Such repayment shall be made out of the receipts of the district, except as provided in this subsection. The commissioners shall not create any indebtedness or incur obligations for any sum or amount which they are unable to repay out of district funds available to them at that time, except as otherwise provided in this act, provided, however, that the commissioners may make purchases of equipment on an installment basis as necessary if funds are available for the payment of the current year's installment on such equipment plus the amount due in that year on any other installments and the repayment of any bank loan or other existing indebtedness which may be due that year. Section 10. Use of district funds.—No funds of the district shall be used for any purposes other than the administration of the affairs and business of the district; the payment of salaries and expenses to commissioners; the construction, care, maintenance, upkeep, operation, and purchase of fire- fi�-,htin-, and rescue equipment or a fire station or emergency medical sta- tion; the payment of public utilities; the payment of salaries of district personnel; the payment of expenses of volunteers; the payment to the Key Largo Volunteer Fire and Rescue Department, Inc., and the Key Largo Volunteer Ambulance Corps; and such other payment and expenses as the board may from time to time determine to be necessary for the operations and effectiveness of the district. Section 11. Record of board meetings; authority to adopt rules and regu- lations; annual reports; budget.— (1) A record shall be kept of all meetings of the board, and in such meetings concurrence of a majority of the commissioners present shall be necessary to any affirmative action by the board. (2) The board shall have the authority to adopt and amend policies and regulations for the administration of the affairs of the district under the 6 CODING: Words semen are deletions; words underlined are additions. Ch. 2005-329 LAWS OF FLORIDA Ch. 2005-329 terms of this act and chapters 189 and 191, Florida Statues, which shall include,but not be limited to,the authority to adopt the necessary rules and regulations for the administration and supervision of the property and per- sonnel of the district; for the prevention of fires, fire control, fire hydrant placement, and flow testing in accordance with current NFPA rules; and for rescue work within the district. (3) The board of commissioners shall have the authority to adopt uniform fire prevention ordinances. Such ordinances shall be sinned, dated, and recorded with the Clerk of the Court of Monroe County and published as Provided by state law. Ordinances shall be effective after publication,which constitutes legal notice of same. (4) The board shall, on or before November 1, make an annual report of its actions and accountin-a of its funds as of September of that year and shall file said report in the office of the Clerk of the Circuit Court of Monroe County, whose duty it shall be to receive and file said report and hold and keep the same as a public record. (5) For the purposes of carrying into effect this act,the board shall annu- allyprepare,consider,and adopt a district budget pursuant to the applicable requirements of chapters 189 and 191, Florida Statutes. The board shall, at the same time as it makes its annual report,file its estimated budget for the fiscal year beOnnin, October 1, which budget shall show the estimated revenue to be received by the district and the estimated expenditures to be incurred by the district in carrying out its operations. The commissioners shall adopt a fiscal year for said fire district, which shall be October 1 to September 30. Section 12. Authority to enact fire prevention ordinances and enter land; authority to provide fire, rescue, and emergency medical services.— (1) The board of commissioners shall have the ri-aht and power to enact fire prevention ordinances as provided by General law. When the provisions of such fire prevention ordinances are determined by the board to be vio- lated, the office of the state attorney, upon written notice of such violation issued by the board, is authorized to prosecute such person or persons held to be in violation thereof. Any person found guilty of a violation may be punished as provided in chapter 775, Florida Statutes, as a misdemeanor of the second degree. The cost of such prosecution shall be paid out of the district funds, unless otherwise provided by law. The district shall have the authority to appoint a fire marshal,who may be a member of the Key Largo Fire Rescue Department, to carry out the responsibilities of the district fire marshal. (2) The fire marshal or duly authorized inspector shall be authorized to enter, at all reasonable hours, any building or premises for the purpose of making any inspection or investigation which the State Fire Marshal is authorized to make pursuant to state law and regulation. The owner,lessee, manaVer, or operator of any building or premises shall permit the district fire marshal or duly authorized inspector to enter and inspect the building or premises at all reasonable hours. The fire marshal or duly authorized 7 CODING: Words stamen are deletions; words underlined are additions. Ch. 2005-329 LAWS OF FLORIDA Ch. 2005-329 inspector shall report any violations of state fire safety laws or regulations to the appropriate officials. (3) The district is authorized to establish and maintain emergency medi- cal and rescue response services and acquire and maintain rescue, medical, and other emergency equipment, subject to the provisions of chapter 401, Florida Statutes. Section 13. Annexations.—If any municipality or other fire control dis- trict annexes any land included in the district, such annexation shall follow the procedures set forth in section 171.093, Florida Statutes. Section 14. Dissolution.—The district shall exist until dissolved in the same manner as it was created. Section 15. Immunity from tort liability.— (1) The district and its officers, agents, and employees shall have the same immunity from tort liability as other agencies and subdivisions of the state. The provisions of chapter 768, Florida Statutes, shall apply to all claims asserted against the district. (2) The district commissioners and all officers, agents, and employees of the district shall have the same immunity and exemption from personal liability as is provided by chapter 768, Florida Statutes. (3) In accordance with chapter 768, Florida Statutes, the district shall defend all claims against the commissioners,officers, agents,and employees which arise within the scope of employment or purposes of the district and shall pay all judgments against said persons, except where said persons acted in bad faith or with malicious purpose or in a manner exhibiting wanton and willful disregard of human rights, safety, or property. Section 16. District expansion.—The corporate limits of the Key Largo Fire Rescue and Emergency Medical Services District may be extended and enlarged from time to time pursuant to the following_procedure: (1)(a) A definitely described tract of land lying contiguous to the bounda- ries of the district described in section 1, or as the same may from time to time exist, or one or more tracts of land loin contiguous ontiguous to the boundaries, or one or more tracts of land lying contiguous to each other with one of the tracts lying contiguous to the boundaries of the district, may be included in the district when a written petition for inclusion signed by a majority of the owners of the real property within the tract or tracts to be included in the district has been presented to the board of commissioners and the proposal has been approved by the affirmative vote of no fewer than three members of the board of commissioners at a regular meeting. (b) The petition must contain the legal description of the property Sought to be added to the District and the names and addresses of the owners of the property. (2) If a proposal to add an area to the district as defined in subsection(1) is approved by the affirmative vote of no fewer than three members of the 8 CODING: Words are deletions; words underlined are additions. Ch. 2005-329 LAWS OF FLORIDA Ch. 2005-329 board of commissioners at a regular meeting, the board of commissioners shall thereafter adopt a resolution describing the lands to be included within the district and shall cause such resolution to be duly enrolled in the record of the meeting and a certified copy of the resolution to be recorded in the office of the Clerk of the Circuit Court in Monroe County. (3) Upon adoption of the resolution by the board,the district shall,pursu- ant to chapter 191, Florida Statutes, request its legislative delegation to approve said addition and sponsor legislation amending the district bound- ary. Upon approval by the Legislature, the boundary shall be amended. (4) In lieu of a petition from the property owners, the Board of County Commissioners of Monroe County by affirmative resolution and the Board of Commissioners of the Key Largo Fire Rescue and Emergency Medical Services District by affirmative resolution may jointly request its legislative delegation to approve the addition of land lyingcontiguous ontiguous to the boundaries of the district and sponsor legislation amending the district boundary.Upon approval by the Legislature, the boundary shall be amended. Section 17. Construction.—This act shall be construed as remedial and shall be liberally construed to promote the purpose for which it is intended. Section 18. Effect.—In the event that any part of this act should be held void for any reason, such holding shall not affect any other part thereof. Section 19. Exclusive charter.—This act constitutes the exclusive charter of the Key Largo Fire Rescue and Emergency Medical Services District. Section 20. On or before October 4, 2005, the Board of County Commis- sioners of Monroe County shall call and the Supervisor of Elections of Mon- roe County shall conduct a referendum, to be held in coniunction with a special election, of the qualified voters of the Key Largo Fire Rescue and Emer_aency Medical Services District on the question of whether the Key Lar-ao Fire Rescue and Emergency Medical Services District may levy ad valorem taxation up to 1 mill pursuant to section 6 of this act. Section 21. This act shall take effect upon becoming a law, except that the provisions of section 6 which authorize the levy of ad valorem taxation shall take effect only upon express approval by a majority vote of those qualified electors of the Key Largo Fire Rescue and Emergency Medical Services District, as required by Section 9 of Article VII of the State Consti- tution, voting in the referendum held pursuant to section 20. Such election shall be held in accordance with the provisions of general law relating to elections. Approved by the Governor June 8, 2005. Filed in Office Secretary of State June 8, 2005. 9 CODING: Words are deletions; words underlined are additions. FLORID Official List of Special Districts .COMMERCE Report Created January 23, 2026 Key Largo Fire Rescue and Emergency Medical Services District Registered Agent's Name: Mr. Tony Allen Registered Office Address: C/O Vernis and Bowling 81990 Overseas Highway Islamorada, Florida 33036 Job Title: Telephone: (850) 393-2427 Fax: (305)451-3125 E-Mail: jjohnson(a-)keyscr)a.com Website: klfrems.org Active or Inactive: Active Status: Independent County(ies): Monroe Local Governing Authority: Monroe County Special Purpose(s): Emergency Medical Services, Fire Control and Rescue Date Created/Established: June 8, 2005 Creation Documents: Chapter 2005-329, Laws of Florida Statutory Authority: Section 189.031 and Chapter 191, Florida Statutes Governing Body: Elected Authority to Issue Bonds: Yes Revenue Source: Ad Valorem Most Recent Update: November 17, 2025 Creation Method: Special Act 1 LA l KEY LARGO FIRE RESCUE AND EMERGENCY MEDICAL SERVICES DISTRICT SCHEDULE OF RATES Effective Date: July 01, 2026 The Key Largo Fire Rescue and Emergency Medical Services District hereby establishes the following rates for emergency medical transport services provided within the district. These rates are applicable to all Advanced Life Support (ALS) and Basic Life Support (BLS) ambulance transports. .......................................Service ...Description ....................................... .....................................................................Rate.................................................................... Advanced Life�Support�Level l�(ALS�I)����������� $675.00� .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Advanced Life Support Level II (ALS 11) $921.00 .. .. . ....._ .._ ......................................... ............................................................................ .. Basic Life su ........................................................................Support....................(BLS......................) �627.00 .......................................................................................................................................................................................................................................................................................................................................................... Mileage (per mile from incident site to $11.27 receiving facility) Service Level Definitions: • Advanced Life Support Level I (ALS 1): Emergency medical transport involving the assessment and treatment of patients requiring advanced life support interventions, including cardiac monitoring, IV therapy, and medication administration. • Advanced Life Support Level II (ALS 11): Emergency medical transport requiring advanced interventions beyond ALS I, including endotracheal intubation, central line placement, or other critical care procedures. • Basic Life Support (BLS): Emergency medical transport involving basic emergency medical care and transportation without the need for advanced life support interventions. Notes: 1. Mileage is calculated from the incident site to the receiving medical facility. 2. All rates are subject to applicable insurance coverage and billing practices. 3. These rates may be adjusted periodically by the Key Largo Fire Rescue and Emergency Medical Services District Board. 1LITY INSURANCE DATE I WODtYYVY) CERTIFICATE OF LIAB04/06/2026 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,the pollcy(Ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement, A statement on this certificate does not confer rights to the certificate holder In lieu of such end soment(s), PRODUCER NAME IeSSICa Conway Fisk Management Associates,Inc. PHONE (386)252-6176 � (386)239 4049 P C,Sax 2416 E-MAIL jessica.conway@bbrown.com ADDRESS: INSURERS)AFFORDING COVERAGE NAIL d Daytona Beach FL 32115 INSURER A: National Union Fire Insurance Company of Pittsburgh,Pa. 19445 INSURED INSURER R; Key Largo Volunteer Fire Department,Inc. INSURER C:: 1 East Drive INSURER D INSURER ICay Largc FL 33g37 NstJRER F COVERAGES CERTIFICATE NUMBER. CL261795351 REVISION NUMBER, THIS IS TO CERTIFY"I`WAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMIT'S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN SR POLICY EFF _'F_0UCYEXP LTR TYPE OF INSURANCE IN SD WV0 POLICY NUMBER JMMRqrYYYYL lMWDDryYYY) LIMITS COMMERCIAL GENE LLIABILITY EACH OCCURRENCE S 1,0010,000 CLAIMS-MADE 19 OCCUR PRERAISES �currence � 1,000.000 MEDExPIAm p redn) 5,000 " A VFNU-TR-0019768-05/000 10/01/2025 10/0112026 PERSONAL,&ADV INJURY g 1,000,000 C,EN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2.000,000 POLICY ❑PRC- 2,000.000 JECT LOC PRODUCTS•OOMPfOPAGG $ OTHER: $ AUTOMOBILE LIABILITB COMk31NED SINGLE @ MIT S 1,000,000 Ea ecradsnt ANY AUTO BODILY INJURY(Per person) S A OWNED E ONLY SCSCHHEDULED VFNU-TR-0019768.0 1000 10/0112025 10/0112026 BODILY INJURY(Per accident) $ tiIREO NON-OWNED PROPERTY DAh4AGE $ A UTO3 ONLY AUTOS ONLY P r eGr,�den4 ZAGGREGATE ts sE UMBRELLA LIAR OCCUR E SA EXCESSLIAa VFNU-TR-0019768.051000 10/01/2025 10/01/2026 CL�aIMs-MADE t DED rdETENTIGPd$ $ WORKERSC:OMPENSATION OHAAfiD EMPLOYERS.LIABILITYER ANY PROPRIF.TORIPARTNER/EXECUTIVE YdN OFFiCERIMEMBER EXCLUDED? N f A E_L.ESC:N ACCIDENT 5 IErendstory In NH) E.L.DISEASE»EA EMPLOYEE $ If yes.desenbe�under DESCRIPTION OF DPERATIONS belts E.L.DISEASE-POLICY LIMIT 5 Management Liability Each Wrongful Act $1.000,000 A VFNU-TR-0019768-05/000 10101/2025 10/01/2026 or Offense DESCRIPTION OF OPERATIONS t LOCATIONS d VEHICLES(ACCORD 1011,AddltD anal Remarks Schedule,may be attached bf mmore space is requI ed) Certificate Molder included as an additional insured with respect to the COPCN application. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TIME ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF„NOTICE WILL BE DELIVERED IN Key Largo Fire Rescue&Emergency Medical Services Distract ACCORDANCE WITH THE POLICY PROVISIONS, 1 East Drive AUTHORIZED REPRESENTATIVE. Key Largo FL 33037 / 0 19 8-201 ACORD CORPORATION. All rights reserved. ACORD 2 (2016103) The ACORD name and logo are registered marks of ACORD CERTIFICATE LIABILITY INSURANCE D ATE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. it the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed, If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy„certain pollcles may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsermoerlt(s). PRODUCER N T TEA T Lisa Magwre Regan Insurance Agency ArcNNo Ext: (306)652-3234 c No (305)652-3703 90144 Overseas Hwy, AC§��ESs: Imaguire@reganinsuaranceilnc.com IWSURERQS)AFFORDING COVERAGE NAIC S Tavernier FL 33070 INSURER A; National Union Fire Iris Co of Pittsburg PA 19445 INSURED ________ INSURER e: National Union Fire ins Cc of Pittsburg PA 19445 Key Larva Volunteer Ambulance Carps INSURER C: 98600 Overseas Hwy INSURER O INSURER E Itey Largo F'L 33037 INSURER F COVERAGE$ CERTIFICATE NUMBER.- 25-26 CL S Auto REVISION NUMBER- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY'THE POLICIES DESCRMED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIL]CLAIMS, AM SUBR ILTR TYPE OF INSUR CE NSO D POUCY NU BER __ ICY nYBPd'Y'Y � �yyy ESP LIMIT$ ____ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 �"°+«CLAIMS-MADE OCCUR PRE:ASS' S_LE,aocrunasn MEO EXP(Anyone person) $ 5,000 A VFNU-TR-0014338-05/000 06/06/2025 06/0612026 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGAT'E LIMIT APPLIES PER GENERAL AGGREGATE S 3,000,000 POLICY El PRO- 3.000 000 JEGT LOC PRODUCTS-COMP1bPAL",G S _E OTHER, $ AUTOMOBILE LIABILITY COMBINED$INGL.E LINT S 1,000,000 Ee;accident ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED Y VFNU-CM-0014337"05/000 06/06/2025 06/06/2026 BODILY INJURY(Per a;cidam) $ rem AUTOS ONLY AUTOS HIRED NON-OWNED PR,OPERTI CDAMAGE AUTOS ONLY AUTOS ONLY Per accident __ PRP-Basic s 10,(y00__ UMBRELLALIAS OCCUR EACH OCCURRENCE S 1,000,000 A �EXCESSL" CLAIISs:IUADE VFNU-TR-0014338-05/000 06/06/2025 06/06/2026 AGGREGATE s 2,00a,Q4C8ON S WORKERS COMPENSATION AND EMPLOYERS'LIAS ILrrY YIN ------ ANY PROPRIIETOR(PARTC9ER/EKECUTIVE: )""") NIA E,IL.EACH ACCIDENT _ $_ OFFIOERDIMEMBER EXCLUDED') i J - (Mandatory in NH) E,L.DISEASE-EA EMPLOYEE S IF yes.describe under ----- DESCRnPTIC?N OF C>PERATi<7idS b E.L.INSEASE-POLICY LIMIT $ CRIME Employee Dishonesty 25,000 A VFNU-TR-0014338-051000 06/06/2025 06/06/2026 DESCRIPTION OF OPERATIONS t LOCATIONS I VEHICLES(ACOR[D 9I1,Additional Remarks Schedule,maybe aduched It more space,Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE MLL BE DELIVERED IN Key Largo Fire Rescue Emergency ACCORDANCE WITH THE POLICY PROVISIONS, Medical Service District 1 East Drive AUTHOR. B REPRESENTATIVE Ivey Largo FL 33037 01955-2015 ACORD CORPORATION. All rights reserved. ACORC 25(201610 ) The ACORD name and loge are registered marks of ACORCD ADDITIONAL COVERAGES Fief# Description7 e�erge rrde Naeu Ica. Edition Date lirwirusuard rncatcrris4 ccsrroNirru*ut 6rugNe IwrrniQ llP�lSL limit 1 mMLimit 2 FLUmit 3 Deductible er toi! i Deductible Type Premium 50,000 $570.00 lfief ff Description Coverage Cade Fru Edition[Date Limit I Limit 2 Limit 3 Ded'uo-ctib' Deductible Type Premium Ref Descriptiearawwwwwwwwwwwwwwwwwwwwwwwwwwww,. Coverage Cade Form No. Edition Cate ._.._ wwwwwwwwwwwwwwwwwwwwwwwwwwww www�ww__ ... �,_. t unit t Limit 2 limit 3 Deductible mount Deductible Type Premium ERefE# Desc-5ripfion over ge Code Form[No. Edition CDete Limit 2 _._._._._._._._. Limit 3 edurctible Amount Deductible Type .............Premium __: Fief# Description _. overage erode-w-w For MNo. ditio Date Limit 1 liruNit 2 Limit 3 Deductible Amount Deductible T"'ype Premiuuru� Ref# Description overage code Ferret 1Z. Edition Date,w w [,limit 3 Deductible AtraCuuurht Deductible Types PremiumLimit 1 Limit 2 :�Ref ff CDescripticrerr __ erege ode Fcu rn-No.- �Edltionate Lirrait t lirroNt 2 ^^�FLimit 3 Ltedwctab9e A�ovu�utwot l7edumctible Type Premium Ref# escription _ _ ewerage Code Foam N o. Ed'ation(Date Limit 1 _ Liruoit 2 llm'lt 3 Deduoctible Amouurrt De uuctitupe Type Pr iuum =# Defscripfl=on „Coverage oade Foarm l ea �NEdition mete^^^^^^limit t Limit 3 Dedcuctible Amo�uuu1t CDeduuctibN'ou"Type Premiaum ref Description _________. _ Coverage Code F�___� WJrz- ___________ Edition Date Litman 1 Limitm Limit Deductible Amount Deductible Type Premium .._._._._._.__...........................................................-- ........ _r_.................................-- l�ef p.Descripticru _......................... .......... .m��ersge ode Fcrm No. EditionDate 77 Limit t Limit 2 Limit'3 Deduuctible AAmoDuun Deductible Type Premium [0FADTLCV Copyright 2001, a services,lace ............ 0 C) co E 0 0 Lo CV c5 c5 0 CD >1 LID Lo C4 C) ca m CID CY)Lo co co a N m o 0 C-4 a iz: T E 41, CD (D C) = CD 00 a) Lo c 0 co C) co C) co z E cCD R q w Lo CL 0 LL 0 U) co Uj CD4 CN CL C-6 zmc.,;� c LU z Lu ou 21 R 0 0 0 0 08 aS a. C� LLj Q r- z 0 <C,) o U)OX LL 0 0 CD L) CD CD n Lu 3 coo CT Ce) L) 0 C-9 en ce) 0^ m 050 0 c IT %Ff 0 co , -uj ��,(Y- 0 0 U) LU LU Lu c -P a. a) CF tea_ m 0 0 LLJ 0 a.— iTL (D > 0 L) a) 0 C- 10 'D 2 CL 0 0 a C 0 co 0 CL LL 2 o c CD 0 0 cli 04 LU LU 0 m U- iz -j 0 a) LU 0 a X: I LU � LU IL 0 ............. ................- q,.' BOARD OF COUNTY COMMISSIONERS County of MonroeMayor Michelle Lincoln,District 2 The Florida eys Mayor Pro Tenn David Rice,District 4 { Craig Cates,District 1 James K. Scholl,District 3 Holly Merrill Raschein,District 5 Monroe Comity 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: March 3, 2026 Attached please find Check_dated January 27, 2026 in the amount of$950.00 to be deposited in revenue account 141-342000-RC 00345. This check has been issued for the initial application of a Class A Certificate of Public Convenience for Key Largo Fire Rescue and Emergency Medical Services District. Thank you, ca4"' i6ZQBHi Cara Johnson AAGREEMENT FOR MEDICAL DIRECTOR SERVICES This Agreement for Medical Director Services is made and entered into as of the date last written below, by and between the Key Largo Fire Rescue and Emergency Medical Services District ("DISTRICT"), and TGM Medical Corp., 105030 Overseas Highway, Key Largo, FL 33037 ("DOCTOR"), licensed to practice medicine in the State of Florida with a principle location of Monroe County. In exchange for good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties hereto agree as follows: WITNESSETH: 1. Provision of Service. DISTRICT provides emergency services in the Key Largo area through its DISTRICT charter under Florida Law. DOCTOR is a medical doctor licensed and insured to practice medicine in the State of Florida. DISTRICT desires to enter into this Agreement with DOCTOR to serve as Medical Director and provide medical supervision and control for the DISTRICT, Key Largo Volunteer Ambulance Corps, and Key Largo Volunteer Fire Department, in Key Largo Florida, and DOCTOR is willing to accept such engagement upon the terms set forth in this Agreement. 2. Designation and Duties as Medical Director. By execution hereof, DISTRICT hereby designates DOCTOR as the Medical Director for DISTRICT operations within DISTRICT'S jurisdiction. In that capacity, DOCTOR will be responsible to provide all necessary and appropriate medical authority and direction for the Medical Teams operating in the area. DOCTOR shall be responsible for all medical aspects of, and all medical decisions and directions relating to, Basic Life Support, Advanced Life Support, and immunizations. DOCTOR shall meet at least once each month with the DISTRICT and Page I of I 1 appropriate Medical Team(s) personnel on site to review, among other things, patient records for appropriateness of transport, patient care, and other areas of quality improvement. DOCTOR shall carry out training pursuant to the Proposed Training Program attached hereto as Attachment "A." DOCTOR shall meet all standards of the Florida Department of Health and the Commission on the Accreditation of Medical Transport Systems (CAMTS) for a Medical Director. DOCTOR will also be responsible for compliance with federal, state and other governmental requirements pertaining to the operation and provision of the emergency medical care services. DOCTOR shall also serve as liaison between DISTRICT and the various health care facilities or other health care providers for whom DISTRICT provides service in the area covered by this Agreement. Such liaison shall include coordinating the medical operations of DISTRICT to comply with the by-laws, policies, rules and regulations applicable to any such health care facility or health care provider for whom DISTRICT is providing services. DOCTOR shall also assist in evaluating the technical medical aspects of DISTRICT medical personnel working for DISTRICT who may assist in providing emergency medical assistance. DOCTOR will carry out and put into effect its improvement plan entitled Commitment to Clinical Performance and attached hereto as Attachment 11B.11 3. a. Insurance Requirements. The Parties shall provide, during the term of this Agreement, the following minimum insurance coverage and provide appropriate certificates of insurance to the other Party: i. DISTRICT will provide all risk insurance, as provided herein. ii. DISTRICT has liability insurance and to the extent that its existing policy will allow it, will provide coverage to DOCTOR. Page 2 of I I DISTRICT will provide liability insurance to DOCTOR acting within the scope of his duties to the extent that its present policy allows. iv. Both Parties agree to provide workers' compensation insurance for their employees as required by law. b. Communications Equipment. DISTRICT will provide all necessary communication equipment, upon approval of written request(s) presented to DISTRICT for review; including but not limited to: cellular phone, two-way radio, or pager. 4. Indemnification. DISTRICT shall indemnify and hold DOCTOR and his employees and agents harmless from and against claims, damages, liabilities and expenses (including reasonable attorneys' fees and costs) (collectively, "Losses") arising directly from DISTRICT'S performance of emergency services to the extent such Losses arise out of negligent or intentional act of omission of DISTRICT or its officers, directors, employees or agents, except and to the extent such Losses directly result from DOCTOR's failure to perform his duties as outlined in this agreement. DOCTOR shall indemnify and hold DISTRICT and its officers, directors, employees and agents harmless from and against Losses arising directly from DOCTOR'S performance of services hereunder to the extent such Losses arise out of negligent or intentional acts or omissions of DOCTOR,except and to the extent such Losses directly result from DISTRICT'S failure to comply with DOCTOR'S directives hereunder. DISTRICT and DOCTOR shall promptly notify the other of any event or circumstance that may lead to a request for indemnification hereunder, provided that, no failure to provide such notice shall prevent either party from obtaining Page 3 of 11 indemnification hereunder unless and only to extent that the indemnifying party was demonstrably prejudiced by such failure to provide notice. 5. Relationship of the Parties. The relationship between DISTRICT and DOCTOR will be that of contractor and independent contractor. Nothing in this Agreement is intended or shall be construed as creating any kind of partnership,joint venture, employer-employee relationship or any other agency relationship between DOCTOR and DISTRICT. The parties shall be solely responsible for the method and manner in which they or their respective employees carry out the duties imposed by this Agreement, and neither party shall exercise any control or direction over the methods by which the other party performs their respective functions hereunder, except as may otherwise be provided in this Agreement. DOCTOR specifically acknowledges that he is not an employee of DISTRICT. 6. Compensation for Medical Director Services. DISTRICT agrees to pay to DOCTOR the sum of$67,000 per year during the term of this Agreement. A cost of living adjustment of 4 (four)percent as determined by the DISTRICT will be added to the annual fee each year at the beginning of the respective budget year. Payment shall be made biweekly. 7. Payment of_.Expenses. DISTRICT agrees to reimburse DOCTOR for DOCTOR's reasonable and necessary travel and business expenses in accordance with state and federal law, and further, pursuant to any DISTRICT travel policies. Any conflict between requirements set out by law and a DISTRICT travel policy shall result in the provisions created by law controlling resolution of the conflict. A copy of any DISTRICT travel policy, whenever created if not already in existence at the time of this Agreement, will be provided to DOCTOR. DOCTOR may also be reimbursed for expenditures made on behalf of the DISTRICT program, with the prior approval of the DISTRICT. Bills or invoices for Page 4 of 11 fees or compensation under this Agreement shall be submitted in detail sufficient for a proper pre-audit and post-audit thereof 8. Term of Agreement. This Agreement shall commence on September 22, 2025, and shall continue for a period of three (3) years, and will automatically renew an additional three (3)years, unless terminated by either party as contained in this paragraph. This Agreement may be terminated by either party by giving ninety (90) days written notice to the other party, termination effective upon the other party's receipt of the notice of termination, said receipt of the notice being documented by a return receipt other than via electronic mail. DOCTOR shall be entitled to compensation through the effective date of termination of this Agreement, provided services continue to be provided through such date as contained herein. 9. Limitation of Liability. In no event, whether as a result of contract, tort, strict liability or otherwise, shall either Party be liable to the other for any punitive, special, indirect, incidental or consequential damages, including without limitation, loss of profits, loss of use or loss of contract. 10. Severability. In the event that any provision of this Agreement is determined to be unlawful or contrary to public policy, such provision shall be severed herefrom and shall be deemed null and void, but shall in no way affect the remaining provisions outlined herein. 11. Comolete Agreement. This Agreement, inclusive of attachments, sets forth the complete understanding of the parties hereto and any modification of the terms hereof must be in a writing signed by both parties hereto. Page 5 of I 1 12. Governing Law. The terms of this Agreement shall be governed by and interpreted in accordance with the laws of the State of Florida, with venue agreeably set in Monroe County, Florida. 13. Contract Records Retention. DOCTOR agrees to comply with all state and federal regulations governing contracts with public entities, including but not limited to cooperation with public records requests as provided by law, and cooperation with comptrollers and auditors as provided by law. 14. Waiver.Any act or lack thereof that is detennined to be a waiver by either party of a breach or failure to perform hereunder shall not constitute a waiver of any subsequent breach or failure to perform. 15. Representations and Warranties. DOCTOR represents and warrants to DISTRICT, upon execution and throughout the term of this Agreement that: a. DOCTOR is not bound by any contract or arrangement which would preclude him from entering into, or from fully performing the services required under this Agreement; b. None of DOCTOR'S agents, employees or officers have ever had his or her professional license or certification in the State of Florida, or of any other jurisdiction, denied, suspended, revoked, terminated and/or voluntarily relinquished under threat of disciplinary action, or restricted in any way; C. DOCTOR has not been convicted of a public entity crime as provided in F.S. §287.133; and d. DOCTOR and DOCTOR'S agents, employees and officers have, and shall maintain throughout the term of this Agreement, all appropriate licenses, Page 6 of 11 certifications and insurance coverage that are required in order for DOCTOR to perform the functions assigned to him in connection with the provisions of this Agreement. 16. Assignment. Neither DISTRICT nor DOCTOR may assign or transfer any interest in this Agreement without the prior written consent of both parties. Should an assignment occur upon mutual written consent, this Agreement shall inure to the benefit of and be binding upon the parties hereto and their respective heirs, representatives, successors and assigns. 17. Sovereign Immunity. Nothing in this Agreement shall be construed so as to waive, negate or otherwise affect the immunities, exemptions, and limitations of liability of DISTRICT provided under Florida law, including but not limited to Section 768.28, Florida Statutes, and other applicable state laws. 18. E-Verifv. Pursuant to Florida Statute § 448.095, DOCTOR shall be required to register with and use the United States Department of Homeland Security's E-Verify system to verify the work authorization status of all employees hired after January 1, 2021, If DOCTOR enters into any contract with a subcontractor, DOCTOR shall be required to obtain an affidavit from the subcontractor confirming that the subcontractor does not employ, contract with, or subcontract with any person who is not authorized under federal law to be employed in the United States. DOCTOR shall be required to maintain a copy of said affidavit for the duration of the Contract Tenn and shall produce said affidavit to the DISTRICT upon request. Notwithstanding any other provision herein, DISTRICT reserves the right to immediately terminate this Contract upon notice to DOCTOR that the DISTRICT has developed a good faith belief that DOCTOR has knowingly violated this section. Page 7 of I I 19. Public Records. Pursuant to section 119.070 1, Florida Statutes, for any tasks performed by DOCTOR on behalf of the District, DOCTOR shall• (a) keep and maintain all public records, as that term is defined in chapter 119,Florida Statutes("Public Records"),required by the District to perform the work contemplated by this Agreement; (b) upon request from the District's custodian of public records, provide the District with a copy of the requested Public Records or allow the Public Records to be inspected or copied within a reasonable time at a cost that does not exceed the costs provided in chapter 119, Florida Statutes, 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 term of this Agreement and following completion or termination of this Agreement, if DOCTOR does not transfer the records to the District in accordance with (d) below; and (d) upon completion or termination of this Agreement, (i) if the District, in its sole and absolute discretion, requests that all Public Records in possession of DOCTOR be transferred to the District, DOCTOR shall transfer, at no cost, to the District, all Public Records in possession of DOCTOR within thirty(30) days of such request or(ii) if no such request is made by the District, DOCTOR shall keep and maintain the Public Records required by the District to perform the work contemplated by this Agreement. If DOCTOR transfers all Public Records to the District pursuant to (d)(i) above, DOCTOR shall destroy any duplicate Public Records that are exempt or confidential and exempt from Public Records disclosure requirements within thirty (30) days of transferring the Public Records to the District and provide the District with written confirmation that such records have been destroyed within thirty (30) days of transferring the Public Records. If DOCTOR keeps and maintains Public Records pursuant to (d)(ii) above, DOCTOR shall meet all applicable requirements for retaining Public Records, All Page ofI1 Public Records stored electronically must be provided to the District, upon request from the District's custodian of public records, in a format that is compatible with the information technology of the District. If DOCTOR does not comply with a Public Records request, or does not comply with a Public Records request within a reasonable amount of time, the District may pursue any and all remedies available in law or equity including, but not limited to, specific perfon-nance. IF THE DOCTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE DOCTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC ECG SAT: Telephone number: 305-664-4675 E-mail address: LgLt ��afflordia-�Iwxom Mailing Address: 81990 Overseas Highway, 3rd Floor, Islamorada, FL 33036 20. Notices. All notices required by this Agreement, unless otherwise provided herein, by either party to the other shall be in writing, delivered personally, by certified or registered mail, return receipt requested, or by Federal Express or Express Mail, and shall be deemed to have been duly given when delivered personally or when deposited in the United States mail, postage prepaid, addressed as follows: DISTRICT: Key Largo Fire Rescue & Emergency Medical Services District P.O. Box 371023 Key Largo, Florida 33037-1023 Attention: District Clerk DOCTOR: TGM Medical Corporation c/o Thomas Morrison, M.D. 105030 Overseas Highway Key Largo, FL 33037 Page 9 of I I IN WITNESS WHEREOF, the parties hereto have executed this agreement, as of the day and year first written above. Key La r o ue an �r envy TGM Medical Corp. _._ Medi Services By: By: rint• nthony Allen Chairman Print: Thomas Morrison, MD Date Dated: 44-L'x Z Attest: Distric Clerk Dated: __ ,2Z, 2 Approved as to form and sufficiency: District Legal Counsel Print: u'dc 2 �6r'( Dated: 0912 ZI 1 Page 1.0 of I I r Affidavit Regarding the Use of Coercion for Labor and Services Respondent Vendor Name: LI-SA Vendor FEIN: Respondent n Vendor Narne� -spo L L ndor FE N Authorized Vendor's Authorized r' t Re resentative Name and Title: Address: (0 f7 o a City: State:ZIP: Phone Number: -- _ — Email Address: Section 787.06(13), Florida Statutes requires all nongovernmental entities executing, renewing, or extending a contract with a governmental entity to provide an affidavit signed by an officer or representative of the nongovernmental entity under penalty of perjury that the nongovernmental entity does not use coercion for labor or services as defined in that statute. The Key Largo Fire Rescue and Emergency Medical Services District is a governmental entity for purposes of this statute. As the person authorized to sign on behalf of Respondent, I certify that the company identified does not: • Use or threaten to use physical force against any person; • Restrain, isolate, or confine or threaten to restrain, isolate, or confine any person without lawful authority and against her or his will; - Use 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 services are not respectively limited and defined; • Destroy, conceal, remove, confiscate, withhold, or possess any actual or purported passport, visa, or other immigration document, or any other actual or purported government identification document, of any person; • Cause or threaten to cause financial harm to any person; • Entice or lure any person by fraud or deceit; or • Provide a controlled substance as outlined in Schedule I or Schedule 11 of s. 893.03 to any person for the purpose of exploitation of that person. Under penalties of perjury, I that I have read the foregoing document and that the facts stated in it are t By: AUTHORIZE SIGNATURE e'LV Print Name and Title: Date: Page I 1 of I I January 28, 2026 Monroe County Board of County Commissioners 1100 Simonton Street Key West, Florida 33040 RE: Medical Protocol Approval for Key Largo Fire Rescue&Emergency Medical Services District Certificate of Public Convenience and Necessity(COPCN) Dear Honorable Members of the Board of County Commissioners: 1,Dr.Thomas Morrison,MD,serve as the Medical Director for the Key Lai-go Fire Department,In this capacity, I am responsible for the oversight, development,and approval of all emergency medical treatment protocols utilized by the department's emergency medical personnel. I am writing to formally confirm my approval of the Key Largo Fire Department Emergency Medical Treatment Protocols (Version 2025-001,effective June 11, 2025) for use by the Key Largo Fire Rescue& Emergency Medical Services District in connection with its Certificate of Public Convenience and Necessity(COPCN) application. These protocols have been developed in accordance with current medical standards and best practices for pre-hospital emergency medical care.They are designed to ensure that all Emergency Medical Technicians and Paramedics operating under the license and authority of the Key Largo Fire Department provide safe, effective,and consistent patient care. I hereby authorize and approve the use of the Key Largo Fire Department's medical protocols for all emergency medical services provided by the Key Largo Fire Rescue&Emergency Medical Services District within the scope of its COPCN. Should you require any additional information or documentation regarding these protocols or my approval,please do not hesitate to contact me. Respectfully submitted, .......... Dr.Thomas Morrison,MD Medical Director Key Largo Fire Department Florida Medical License#: ME79946 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-SOB4-ED231 F655DE1 LA Key Medical Services District Florida Medical Treatment Protocols Version: 2026-001 Ilk �� Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 KEY LARGO FIRE RESCUE & EMERGENCY MEDICAL SERVICES DISTRICT — FL MEDICAL EFFECTIVE DATE: 3/12/2026 VERSION: 2026-001 MEDICAL DIRECTOR DocuSigned by: Dr. Thomas Morrison _JA` TUM&S Aum,s&& 3/13/2026 MD/DO License#: ME79946 C77012D869C4470... CONFIDENTIAL This document contains confidential medical protocols and procedures for the Key Largo Fire Department. These protocols are to be used only by authorized emergency medical personnel operating under the department's license and medical direction. PROTOCOL REVIEW HISTORY Review Date Reviewer Changes Made Next Review Date Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 NOTES: This document shall be maintained as part of the official medical protocols of the Key Largo Fire Department and shall be retained according to department policy and applicable regulations. DOCUMENT ID: KLFD-MED-PROTOCOLS-2026-001 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Foreword The following protocols outline the care that emergency medical technicians and paramedics should administer to patients. These protocols are implemented under two conditions: (1) with the approval of our medical director, and (2) as part of a comprehensive medical oversight program. For a practicing provider to be proficient with these protocols, he/she must be certified and licensed at the appropriate level and demonstrate and document all the skills and knowledge the protocols require. A provider's scope of practice may expand (e.g., administration of intravenous therapy by Basic Life Support providers) only with additional training and confirmation of competency by a medical director. The protocols in this set use the following format: • A Review of Injury/Illness that provides an overview of the condition and any special issues that should be considered • Signs and Symptoms presented in a bullet list • Management divided into Basic Life Support (BLS) and Advanced Life Support (ALS) It is all-too common to discover that a patient's clinical presentation does not obviously conform to any of the available EMS'S protocols. In such cases, a provider is encouraged to consult online medical direction for additional guidance. Opportunities to review patient presentations and treatment options with local medical directors and/or other supervisory staff will be available to all providers as needed. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 1 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 llf'ablle of Contents Foreword 1 I. General Procedural Protocols 6 A. Scene and Patient Assessment Protocol 6 ............................................................... B. Airway Management-------------------------------------------------------------------------------------------- 9 C. Pain Management..................................................................................................14 D. Emergency Incident Rehabilitation------------------------------------------------------------------------17 II. Altered Mental Status and Unconsciousness 23 A. Unconscious person--------------------------------------------------------------------------------------------- 23 B. Seizure 25 C. Diabetic Emergencies---------------------------------------------------------------------------------------------28 D. Confusion, Agitation ----------------------------------------------------------------------------------------------31 III. Acute Respiratory Distress-----------------------------------------------------------------------------------34 A. Asthma -------------------------------------------------------------------------------------------------------------------34 B. COPD (Chronic Bronchitis and/or Emphysema)----------------------------------------------------36 C. Hyperventilation ---------------------------------------------------------------------------------------------------39 IV. Behavioral Emergencies------------------------------------------------------------------------------------- 41 V. Burns 44 VI. Cardiac Emergencies------------------------------------------------------------------------------------------ 48 A. Chest Pain (Angina, Acute Coronary Syndrome)---------------------------------------------------48 B. Cardiogenic Shock----------------------------------------------------------------------------------------------- 50 C. Congestive Heart Failure (Pulmonary Edema)-------------------------------------------------------51 D. Cardiac Arrest 53 -------------------------------------------------------------------------------------------------------- E. Other Cardiac Arrhythmias------------------------------------------------------------------------------------60 VII. Childbirth and Newborn Care 68 ---------------------------------------------------------------------------- A. Uncomplicated Delivery--------------------------------------------------------------------------------------- 68 KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 2 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 B. Complicated Delivery.............................................................................................70 C. Newborn Care 74 Vill. Environmental Emergencies______________________________________________________________________________77 A. Dehydration -----------------------------------------------------------------------------------------------------------77 B. Drowning— Near Drowning...................................................................................78 C. Heat-related Illness (Hyperthermia)______________________________________________________________________80 D. Hypothermia -------------------------------------------------------------------------------------------------------- 83 E. Diving-related Emergencies-----------------------------------------------------------------------------------86 F. Decompression Sickness (DCS)----------------------------------------------------------------------------- 87 G. Arterial Gas Emboli (AGE)------------------------------------------------------------------------------------ 88 H. Barotrauma of the Ear 90 I. Envenomation 92 --------------------------------------------------------------------------------------------------------- J. Marine Bites and Stings..........................................................................................95 IX. Trauma------------------------------------------------------------------------------------------------------------------100 A. Extremity wound hemorrhage------------------------------------------------------------------------------.100 B. Amputations----------------------------------------------------------------------------------------------------------.102 C. Multi-system Trauma---------------------------------------------------------------------------------------------103 D. Chest and Abdominal Injuries_______________________________________________________________________________.106 E. Spinal Cord Injuries------------------------------------------------------------------------------------------------108 F. Selective Spinal Immobilization______________________________________________________________________________109 G. Electrical Burns and Lightning Injuries__________________________________________________________________110 H. Orthopedic Bone and Joint Injuries_______________________________________________________________________112 I. Head, Neck and Facial Injuries________________________________________________________________________________114 X. Other Medical Emergencies----------------------------------------------------------------------------------118 A. Allergic Reaction ----------------------------------------------------------------------------------------------------118 KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 13 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 B. Hypertensive Crisis------------------------------------------------------------------------------------------------.121 C. Epistaxis-----------------------------------------------------------------------------------------------------------------.122 D. Nausea/Vomiting---------------------------------------------------------------------------------------------------123 E. GI Bleeding-------------------------------------------------------------------------------------------------------------125 F. Abdominal Pain 127 G. Poisoning/Overdose----------------------------------------------------------------------------------------------129 H. Stroke, TIA-------------------------------------------------------------------------------------------------------------.131 I. Shock 133 XI. Special Medical/Legal Protocols_________________________________________________________________________.137 A. Documentation Requirements..............................................................................137 B. Abuse/Neglect-------------------------------------------------------------------------------------------------------138 C. Withholding or Terminating Resuscitation (Non-trauma).....................................140 D. Withholding or Terminating Resuscitation (Trauma).............................................141 E. Do Not Resuscitate (DNR)--------------------------------------------------------------------------------------142 F. Refusal of Care or Transport-----------------------------------------------------------------------------------143 G. Blood Alcohol Sampling.........................................................................................144 XII. Specialty Skills-----------------------------------------------------------------------------------------------------145 A. 10 Procedures 145 B. Oral Endotracheal Intubation 147 C. i-Gel Device Procedure 148 D. Intranasal Administration Technique (Narcan)......................................................150 E. Combat Application Tourniquet_____________________________________________________________________________153 F. Full Spinal Immobilization Technique_____________________________________________________________________153 G. APGAR Scores 155 H. Rule of Nines 156 I. Adult Trauma Scorecard Methodology___________________________________________________________________157 KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 4 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 J. Pediatric Trauma Scorecard Methodology_____________________________________________________________158 K. RAD- 57 Pulse C Oximeter 159 L. Glasgow Coma Scales---------------------------------------------------------------------------------------------162 M. Pediatric Vital Signs----------------------------------------------------------------------------------------------.163 N. ETCO2 Waveforms 164 0. 12 Lead Quick Reference Guide 164 P. Synchronized Cardioversion-----------------------------------------------------------------------------------165 Q. Transcutaneous External Pacing............................................................................165 R. Cincinnati Prehospital Stroke Scale________________________________________________________________________166 S. Indications for Helmet Retention 166 --------------------------------------------------------------------------- T. CPAP Overview 169 U. Morgan Lens----------------------------------------------------------------------------------------------------------171 V. Boguie- Endotracheal Tube Introducer__________________________________________________________________171 W. Video Laryngoscope----------------------------------------------------------------------------------------------172 X. Chest Decompression--------------------------------------------------------------------------------------------173 Z. NG Tube- Nasogastric Tube------------------------------------------------------------------------------------175 XIII. Appendix A. Approved Drug List................................................................................................176-214 B. Trauma Transport Protocols...................................................................................1-14 KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 15 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 II "erter,4l IIIC:Iiurocedur,WI Iltiurotocol A. Scene Size-Up and Patient Assessment Protocol Scene Size-Up Conduct safety assessment of scene for hazards to EMS personnel. If the scene is unsafe and cannot be made safe, DO NOT enter. Patient Assessment BLS 1. Institute appropriate measures for prevention of infectious exposure as outlined in Protocol I.A. 2. If appropriate, begin triage and initiate Mass Casualty Incident (MCI). 3. Determine mechanisms of injury (MOI), nature of illness, and number of patients. 4. Perform primary assessment (airway, breathing, circulation). Then control serious bleeding and assess level of consciousness with "AVPU"—Alert and aware, Verbal stimuli, Painful stimuli, and Unresponsive—and the Glasgow Coma Scale (Refer to Protocol XII.L.). 5. Initiate BLS measures as outlined by the American Heart Association, including CPR, and use of automated electrical defibrillator (AED), for cardiac arrest. (Refer to Protocol VI.D.) 6. Be prepared to assist ventilation with a bag valve or mechanical ventilator 7. Administer oxygen at the appropriate flow rate via endotracheal tube (ETT) if inserted by paramedic on scene, bag valve mask, non-rebreathing mask, or nasal cannula if indicated; 8. Apply pulse oximeter if available. 9. Correct other life-threatening problems if possible and according to protocol. 10. Monitor and repeat vital signs at 15-minute intervals for stable patients, and 5 minutes intervals for unstable patients. 11. Consider cervical immobilization if appropriate (see "Selective Spine Immobilization"). 12. Obtain full patient history in SAMPLE & OPQRST format. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 16 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 S—Signs/Symptoms O—Onset A—Allergies P— Provocation/Palliative M — Medications Q—Quality P—Past Med Hx/Past Surgical Hx R—Region/Radiation/Referral L—Last Oral Intake S—Severity E—Precipitating Events T—Timing 13. Perform focused exam. 14. Continue assessment employing (DCAPBTLS). a. D— Deformities b. C—Contusions c. A—Abrasions d. P— Punctures e. B— Burns f. T—Tenderness g. L— Laceration h. S—Swelling 15. Determine the patient's transport priority and whether paramedic care is required. Priority conditions include: a. Unable to obtain or maintain open airway. b. Clinical deterioration or death appears imminent. c. Altered mental status, includes not following commands. d. Difficulty breathing/inadequate ventilation and oxygenation. e. Hypoperfusion (Shock). f. Complicated childbirth. g. Chest pain with Systolic BP < 100 mm Hg. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 7 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 h. Uncontrolled bleeding. i. Severe pain. 16. Treat according to applicable protocols; transport, if capable. 17. Determine the need for ALS care, ground transport. 18. Consider the need for additional resources. 19. Document all findings and medical interventions on patient care report. 20. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. AILS 1. Confirm completion of BLS steps 1-19. 2. Assess the need for advanced airway management. (Refer to Protocol I.B.). 3. Institute ALS measures for resuscitation as outlined in the most recent guidelines for Advanced Cardiac Life Support (ACLS) by the American Heart Association. 4. Obtain 12-lead ECG and maintain cardiac monitoring, if appropriate. 5. Initiate fluid line of 0.9% Normal Saline IV/10 at KVO or saline lock or as required by local protocol. 6. Administer medications as required by local protocol. ALWAYS ask about allergies to medication before administering any drug to a patient. 7. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. Consider the need for Aeromedical evacuation to the nearest Trauma Center. Pediatrics 1. Follow BLS guidelines, adjusting for patient age/size. 2. Adjust medication dosage, as appropriate, for patient age/size. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 18 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 B. Airway Management Review of Iniury/Illness The obstruction or compromise of an airway can be caused by: (1) a variety of injuries and illnesses that result in narrowed air passages or excessive secretions or (2) the presence of solid foreign bodies that block air flow to the lungs. Signs and Symptoms * Wheezing * Stridor * Gasping- (when ineffective, sometimes called agonal respirations) * "Tripoding" or other positioning * Anxious * Skin color changes (cyanosis) * Nasal flaring, accessory muscle use, diminished or absent breath sounds * Difficulty swallowing—swollen tongue, and lips, drooling * Inability to breathe—weak respirations * Inability to speak * Abnormal respiratory rate * Rapid heart rate * Altered mental status Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 9 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 4. If choking, attempt Heimlich maneuver. 5. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 6. Assess adequacy of airway and ventilatory effort: a. Ability to speak. b. Color (note pallor or cyanosis) c. Vigor of cough/cry d. Rate and depth of respirations e. Unusual breath sounds on auscultation, including rales, wheezing, stridor f. Accessory muscle use and/or nasal flaring 7. For respiratory distress, apply pulse oximeter and administer 100% oxygen via non- rebreathing mask at high flow rate. 8. Assist ventilations with bag valve mask (BVM) as required. 9. Complete vital signs and determine likely cause of airway difficulty, such as: a. Potential aspiration of small objects or food b. Fever or cough c. Chest pain d. History of asthma, COPD, CHF e. In infants, a history of prematurity 10. Place patient in a position of comfort. 11. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. AILS (Advanced Airways and Ventilation) 1. Confirm completion of BLS steps 1-11. These guidelines should be followed for all attempts at advanced airway management, or when assuming responsibility for an airway already established by another agency or provider. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 110 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 2. The term "advanced airway" refers to endotracheal tube and devices such as the supraglottic i-Gel Airway. Securing an airway with these devices is a lifesaving measure that has the potential for devastating harm if not performed or maintained correctly. 3. Advanced airways may be used ONLY by paramedics who have received training and been certified by local medical direction. Advanced airways should be attempted ONLY if BLS ventilatory support and oxygen are insufficient to sustain respirations. 4. i-Gel airway devices may be deployed as either preferred or "rescue" methods for airway control only after all providers have been trained on them according to the manufacturer's instructions and certified as "competent" in the technique by local medical direction. 5. Forceps (e.g., Magill) should be available during laryngoscopy of a choking patient so that a solid object obstructing the airway can be mechanically removed. If unable to remove an object obstructing airway using forceps, immediately consider surgical airway. 6. Mobile or portable suction devices should be available during placement of advanced airways to clear airway secretions present in the tube or oral pharynx. i-Gel Airways Indication 1. Unconscious patient who is not breathing without a gag reflex. 2. Apneic patient without a gag reflex 3. A difficult airway is anticipated: a. Small mouth which obstructs visualization b. Short neck c. Mallampati or Cormack- Lehane score > 3 d. Any obstruction that could impair visualization of the glottic opening. e. Impaired neck mobility f. Access to the airway is impeded (entrapment, helicopter cabin etc.) Contraindications 1. Responsive patients with an intact gag reflex 2. Esophageal tissue damage from trauma, chemical ingestion or thermal injury KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 111 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 3. Known esophageal disease or ingestion of caustic substances Procedure BLS ALS 1. Select appropriate size: a. #1 (Pink): Patient 2-5kg * No gastric Channel b. #1.5 (Blue): Patients 5-12kg NG Tube Size 10 Fr c. #2 (Grey): Patients 10-25kg NG Tube Size 10-12 Fr d. #2.5 (White): Patients 25-35kg NG Tube Size 10-12 Fr e. #3 (Yellow): Patients 30-60kg NG Tube Size 10-12 Fr f. #4 (Green): Patients 50-80kg NG Tube Size 12 Fr g. #5 (Orange): Patients 90+ kg NG Tube Size 12-14 Fr 2. Open and maintain the airway. Ventilate with 100% oxygen before attempting the i-Gel. 3. Open i-Gel package and take i-Gel out of the protective cradle. 4. Lubricate the back, sides, and front of the cuff by rubbing it on the smooth surface of the protective cradle containing the water- based lubricant. vo roq r 5. Remove dentures or removable plates from the mouth prior insertion. 6. Grasp the lubricated i-Gel firmly along the integral bite block. Position the device so that the i-Gel is facing towards the chin of the patient. 7. Maintain the head in a neutral position for trauma patients. For non-traumatic patients, the patient's head should be in the "sniffing" position with the head extended and neck flexed. The chin should be gently pressed down before proceeding to insert the i-Gel. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 12 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 8. Introduce the leading soft tip into the mouth of the patient in a direction towards the hard palate. 9. Glide the device downward and backward along the hard palate with continuous but gentle push until a definitive resistance is felt. 10. Attach the End-tidal CO2 device to the i-Gel and BVM and confirm placement. Location of bite block Tracheal opening D!/a Oesophageal opening Confirming Secure Airway 1. Confirmation of objective methods for tube placement (quantitative electronic capnography) must be used to continuously ensure that an advanced airway is positioned correctly. 2. The following steps are designed to assist the paramedic in verifying initial airway placement and maintaining the airway until the emergency department (ED) staff assumes patient care. a. The paramedic who initially establishes an advanced airway is responsible for maintaining it until the patient is transferred to transport paramedic. While mechanical ventilation may be delegated to another provider, the paramedic is responsible for all aspects of tube placement (lung sounds, capnography, and pulse oximetry). • The transporting paramedic should re-confirm tube placement before assuming responsibility for the patient. b. Quantitative ETCO2 confirmation and continuous monitoring are required for all field intubations (adult and pediatric and supraglottic devices). • Quantitative capnography should include continuous display of the ETCO2 waveform and numerical value (normal = 35-40 mm Hg). Documentation Documentation is a key component in protecting an EMT against claims of a misplaced airway device or inadequate respiratory care. The documentation should include initial and final KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 13 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 assessment of airway placement, regardless of transportation decision (hospital transport or field termination). Documentation should also reflect a reassessment performed after each patient's movement and should be included in the patient care report. C. Pain Management GENERAL GUIDELINES Many illnesses and injuries produce moderate to severe pain that must be evaluated, quantified on a standardized scale, documented, and treated in the pre-hospital environment. Patients vary greatly both in their perception and tolerance of pain and their response to pain medications. ISOLATED EXTREMITY FRACTURE The purpose of this procedure is to manage pain associated with isolated extremity fractures. ACUTE BACK STRAIN This procedure should be used in the isolated back strain. ABDOMINAL PAIN/RENAL COLIC This procedure can be used for abdominal pain or with flank pain that is associated with kidney stones SOFT-TISSUE INJURIES, BURNS, BITES, AND STINGS This procedure is used for pain associated with multisystem trauma, soft-tissue injuries, burns, bites, and stings TREATMENT GUIDELINES Supportive Care For Isolated Extremity Fractures • Any extremity fracture should be immobilized as described in Protocol IX. Trauma, Section H, Orthopedic Bone and Joint Injuries. • Extremity fractures should be elevated, if possible, and cold applied. • Distal circulation, sensation, and movement in the injured extremity should be noted and recorded. ALS When treating patients with altered mental status use CAUTION when considering any pain management medication Patients should be asked to quantify their pain on an analog pain KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 14 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 scale (from 0 = least severe, to 10 = most severe). This number should be documented and used to measure the effectiveness of analgesia: Morphine 1. May be given via slow IV in 5 mg increments may repeat once, titrated to pain and BP above 100 mm Hg, up to a maximum of 10 mg OR Fentanyl May be given 100 mcg increments every 3-5 minutes to a maximum of 200 mcg IN, IM. IV dose is 1 mcg/kg (slow IV increments every 3-5 minutes, maximum initial dose of 100 mcg, titrated to pain and BP remains above 100 mm Hg Note 1. When administering Morphine Sulfate or Fentanyl, closely monitor the patient's respiratory status. In the event that the patient's respirations/oxygenation is suppressed (Sp02 less than 94%), utilize basic airway maneuvers (open airway), administer oxygen and if no improvement consider Narcan. 2. If Fentanyl was initially given IN and an IV is then established, then one IV dose of 50 mcg. can be given if needed. Pediatric BLS ALS 1. Follow BLS guidelines, adjusting for patient age/size ALS • If pain persists and systolic BP is adequate, Administer: 1. Morphine Sulfate - may be given IV titrated to pain, pediatric dose: 0.1 mg/kg; infant dose: 0.05 mg/kg. Maximum single dose of 4 mg. If pain persists and systolic BP is adequate, may repeat dose x 1 in 3-5 minutes, (repeat single dose maximum of 4 mg). Administer at a rate not to exceed 1 mg/min OR Fentanyl 0.5 mcg/I<g (maximum 25 mcg) SLOW IV; repeat once after 5 minutes as needed (max 50 mcg total dose) OR IN 1.5 mcg/kg (max 100 mcg) KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 15 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 (a) Extreme caution should be used with administering narcotic analgesics to a patient with a Sp02 less than 94%. (b) When administering Morphine Sulfate/Fentanyl, closely monitor the patient's respiratory status. In the event that the patient's respirations/oxygenation is suppressed (Sp02 less than 94%), utilize basic airway maneuvers (open airway), administer oxygen and if no improvement consider Narcan. (c) May have to assist administration with younger children PA1N MBA ►URIIEHPA1IIEENT ..4:5 CC ,AkL_IFE (- �9) (a) - - %% (M 0 2 4 6 8 10 "C7 "UFG.T "UF2:TS HLl F2:TS H1LJF2TS HLI F.,TS "Li Ft.T9 1_.lTT4_..E �!T L.MTTL.E Ml CY12E E1,/EN M9C}F2E WHC>t_E 1_.C3-r MVC0 M__3T I I l�_ li I_ 1_ 1 1 CJ -1 2 3 4 5 6 7 8 9 '10 r4c> Rr irs Mild Nlcsd ra..ta� ,�w✓�r+ Wcsrst Barre irnaa irvala1� ASSESSMENT OF SCORE 0 Relaxed: infant comfortable, not distressed. 1-2 Some transitory distress caused: returns immediately to "relaxed" 3-4 Transitory distress; likely to respond to consolation. 5 Infant experiences pain; if no response to consolation, may require analgesia. 6 "Anguished" and "exaggerated": infant experiencing acute pain; is unlikely to respond to consolation, will probably benefit from analgesia. 7-8 "Inert": no response to traumatic procedure; infant is habituated to pain; will not respond to consolation; systematic pain control by analgesia should be considered. FACIAL EXPRESSION 0 Relaxed - Smooth muscled; relaxed expression; either in deep sleep or quietly alert. 1 Anxious -Anxious expression; frown; REM behind closed lids; wandering gaze; eyes narrowed; lips parted; pursed lips as if"oo" is pronounced. 2 Anguished -Anguished expression/crumpled face; brow bulge; eye squeeze; nasolabial furrow pronounced; square-stretched mouth; cupped tongue; "silent cry." KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 16 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 3 Inert - No response to trauma; no crying; rigidity; gaze avoidance; fixed/staring gaze; apathy; diminished alertness (only during or immediately after traumatic procedure). BODY MOVEMENT 0 Relaxed - Relaxed trunk and limbs; body in tucked position; hands in cupped position or willing to grasp a finger. Restless - Moro reflex; startles;jerky or uncoordinated movement of limbs; flexion/extension of limbs; attempt to withdraw limb from site of injury. 2 Exaggerated -Abnormal position of limbs, limb/neck extension; splaying of fingers and/or toes; flailing or thrashing of limbs; arching of back; side swiping/guarding site of injury. 3 Inert - No response to trauma; inertia; limpness/ rigidity; immobility (only during or immediately after traumatic procedure) COLOR 0 Normal skin color. 1 Redness; congestion. 2 Pallor; mottling; gray. D. Emergency Incident Rehabilitation Review of Injury/Illness: This protocol describes the roles of Fire Department personnel in the process of rehabilitating firefighters. Rehab is designed to prevent, detect, and treat such conditions as heat exhaustion, hyperthermia, and dehydration among the workforce, and to remove operational personnel from duty if they cannot safely rotate back into emergency response efforts. 1. An Emergency Incident Rehabilitation (EIR) area: a. Should be designated by the incident commander (IC) or designated sector officer. It should be in a safe location, and upwind and uphill from the hot zone if the incident involves airborne or waterborne threats. b. The specific incident will dictate the type and configuration of the rehab area to be established. For example, if hazardous materials are involved, a decontamination corridor must separate the hot zone from the rehab area. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 17 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 2. Responsibilities: a. Incident Commander: The incident commander has discretion as to how to implement formal emergency incident rehabilitation (EIR). The IC should consider the circumstances of each incident and make adequate provisions early in the incident for the rest and rehabilitation of all members operating at the scene. These provisions may include physical and mental rest; fluid and food replenishment; relief from extreme climatic conditions and other environmental parameters of the incident; and medical evaluation, treatment, and monitoring. b. Rehab Officer: An EMT-B, EMT-P, should/may be assigned to the rehab area, and, if appropriate, may be designated by the IC as the Rehab Officer (RO). If available and practical, it is preferable that ALS-level personnel and equipment be present, as indicated in NFPA 1500. Rehab sector medical personnel and other assets should be dedicated to support of firefighters and other operational emergency responders and should be assigned no other responsibilities. c. Rehab Team: Should include sufficient personnel to perform rehab sector functions for the maximum number of personnel anticipated to be in the Rehab Area at any given time. A ratio of one Rehab Team member for every 10 personnel on scene is recommended. The team should include sufficient EMS personnel to perform medical monitoring tasks but may include non-EMS personnel also. d. Supervisors/Company Officers: All supervisors and company officers should maintain their awareness of the condition of all personnel operating within their span of control and ensure that adequate steps are taken to provide for each member's safety and health. The ICS structure should be used to request relief and/or reassignment of fatigued crews. e. Personnel: Any member who believes that fatigue or exposure to heat or cold is approaching a level that could affect his performance or the operation in which he/she is involved should advise his supervisor or company officer. Personnel should also remain aware of the health and safety of other members of the crew. 3. Establishing the Rehabilitation Sector: a. The IC should establish a Rehab Sector or Group when conditions indicate that rest and rehabilitation is needed for personnel operating at an incident scene or training exercise. This determination should be made based upon the anticipated duration of the operation, level of physical exertion, and environmental conditions, including temperature, humidity, and windchill. Guidelines to consider include: • Heat stress index > 90° F KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 18 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 • Wind chill index< 10° F • Personnel have completed (or will complete) exertional work with second 30-minute SCBA cylinder, if firefighting involved • Personnel have used (or will use) SCBA or other protective breathing devices for>45 minutes of physical exertion • It is recommended that an EMS vehicle, not otherwise involved in emergency operations at the scene, be positioned at the Rehab Area. If required, an additional ambulance should be requested to the scene for this purpose. Except under extreme circumstances, this ambulance should not be used for transport of civilian patients. b. The location of the Rehab Area will be designated by the IC and/or the RO, and should: • Be far enough from the scene to allow personnel to safely remove (and leave outside the area) SCBA and/or PPE, and remove personnel from the imminent dangers the scene presents, yet close enough to allow prompt re-entry completion • Provide adequate protection from environmental conditions and exhaust fumes • Be easily accessible by EMS units • Be large enough to accommodate several crew members. • For extreme heat conditions, have shaded areas, misting systems and/or fans, and an area to sit down • For extreme cold and/or wet conditions, have dry, protected, heated areas, and dry clothing • Be integrated with departmental system for personnel accountability, using a single entry and exit point when feasible. Sites that have been used include a nearby building, garage, or lobby; a school bus or large van; and an open, shaded area. 4. Rehab Operations: a. Resources: The RO should secure, through the IC or Logistics Officer, all necessary resources to properly supply the sector. These may include oral fluids, foods, medical supplies, paperwork, lighting, heaters, fans, a means of access to toilet facilities, and other assets as appropriate to the incident. b. Rotation of Personnel/Accountability: Working units will be assigned to the Rehab Sector by the IC or his designee (e.g., Operations Officer). When possible, the entire unit should be KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 19 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 assigned to the Rehab Sector as a group. The crew designation, names of members, times of entry and exit, and appropriate medical information should be documented by the Rehab Officer or designee on a PCR form or similar document. Personnel rotated to the Rehab Sector should not leave until directed by the RO. If any member requires transport to a medical facility, the IC shall be notified immediately. c. Hydration: During exertional activity, in both hot and cold weather, personnel should consume at least one quart per hour of water, activity beverage, or combination. Carbonated and caffeinated beverages should be avoided. During a typical 20-minute rehab cycle, 12-32 ounces of fluids are recommended. d. Nutrition: Food should be provided whenever operations exceed 3 hours. Fatty and salty foods should be avoided. 5. Medical Evaluation: a. Ask members arriving at the Rehab Area if they have any symptoms of dehydration, heat/cold stress, physical exhaustion, cardiopulmonary abnormalities, or emotional/mental stress. b. Complete a medical evaluation, and appropriate treatment and/or transport, for all members who report such symptoms. c. A medical evaluation, with appropriate treatment and/or transport, should also be completed for any member meeting any of the following criteria: • The RO or Rehab Sector EMS staff observes evidence of one of the above conditions displayed by a member. • Another member, officer, or supervisor indicates he/she does not appear well. • The member had to leave an evolution for reasons of excessive fatigue or symptoms. d. Consider the possibility of toxic exposure in ill or injured responders at fi re, hazmat, and certain law enforcement operational scenes. e. Carbon monoxide levels can be determined non-invasively when pulse oximetry with this capability (CO-oximetry) is available. Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 20 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. For personnel with signs or symptoms of dehydration or fatigue, check for toxic exposure, heat-related illness, chest pain, and/or change in mental status. These are medical emergencies; obtain ALS treatment if available and transport to a hospital emergency department. 6. For symptomatic personnel with no evidence of the conditions listed in step 5 and vital signs within the following ranges: a. Systolic BP > 90 and < 200 mm Hg b. Pulse rate > 50 and < 100 bpm c. Respirations > 12 and < 24 per minute d. Temperature < 100.5° F Then manage them in rehab as follows: a. Remove as much clothing as possible and minimize exposure to sun and wind. b. Limit as much energy exertion as possible. c. Oral hydration may be administered using a carbohydrate/electrolyte drink, diluted 1:4 with water. d. Place members in cool place and apply evaporative measures. Avoid shivering as this may raise the core temperature. (Apply cool—not cold—water-soaked towels to as much exposed skin as possible.) e. Administer oxygen and apply pulse oximetry. f. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-6. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 121 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 2. Initiate 0.9% Normal Saline via IVIIO at 10 ml/kg/hr., up to a maximum of 3 L if the patient is severely dehydrated. If the patient's condition does not improve or worsens at any time during the trial of rehydration, he/she should be transported to the hospital. Oral hydration may be administered using a carbohydrate/electrolyte drink, diluted 1:4 with water. 3. Continue to monitor vital signs, administer oxygen, and pulse oximetry. 4. Continue cold packs and maintain a cool environment. Avoid shivering, as this may raise body core temperature. 5. Obtain 12-lead ECG to check for myocardial ischemia and monitor cardiac rhythm, as necessary. 6. If elevated carbon monoxide levels are documented or suspected, ensure that the patient is on high flow oxygen via non-rebreathing mask (NRBM) and IV access is established. 7. If cyanide exposure is suspected refer to Protocol X. Other Medical Emergencies, section J. Cyanide (CN) Poisoning. 8. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. Review of Injury/Illness The term "altered mental status" (AMS) indicates a dysfunction of the central nervous system. Common causes of altered mental status in the field include seizures, shock, diabetic emergencies, drug or alcohol intoxication, medication overdose, stroke, infection, environmental exposure (heat or cold), and traumatic brain injuries. AMS may present anywhere on the spectrum from minimal impairment to unconsciousness. Signs and Symptoms * Slurring or other change in speech * Memory loss (inability to recall recent events) * Unsteady gait * Seizure activity * Impaired judgment * Inability to verbally respond or follow commands (unresponsiveness) * Unconsciousness KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 122 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 11. Altered i eiui�Aalll Status and Liar°icc�i"'ts4°��iOLlsiu.me^ss A. Unconscious person Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care treatment. 5. Attempt to determine cause of altered mental status (e.g., overdose, intoxication, stroke, diabetes, trauma). 6. Check for hypoxia and provide supplemental oxygen via non-rebreathing mask at high concentration 7. Check blood sugar level with a glucometer, if available and part of the scope of practice: a. If hypoglycemic (blood sugar< 60 mg/dQ and conscious, administer glucose paste (10-15 gm) between cheek and teeth. May repeat x1 after 10 minutes, if no response. DO NOT give glucose paste to patients who are unconscious and/or do not have the capacity to swallow. Be cautious of vomiting/aspiration after administration and protect the airway. b. Recheck blood sugar after all interventions, every 30 minutes during transport, and with any change in mental status. 8. Check temperature, if a thermometer is available. 9. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. AILS 1. Confirm completion of BLS steps 1-8. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.). 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. If hypotensive, administer a fluid bolus at 20 ml/kg of 0.9% Normal Saline via IV/10. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 123 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 4. If hypoglycemic, administer D50W 50 ml (25 gm) slow IV push. a. Important to have free flowing IV access due to risk of vein sclerosis. 5. If unconscious, or with depressed respiratory function, consider narcotic overdose and administer naloxone 0.4-2.0 mg IV/10/IM every 2-3 minutes as needed, up to a maximum of 6 Mg. 6. Obtain 12-lead ECG and treat dysrhythmias, as appropriate. Continue monitoring cardiac rhythm. Pediatric BLS 1. Follow BLS guidelines. 2. Assess for possible closed head injury. 3. If hypoglycemic: Administer glucose paste (10-15 gm) between cheek and teeth, if awake and able to swallow. AILS 1. Follow BLS guidelines. 2. If hypoglycemic (1- 30 days: BGL<40) and (31 days—8 years: BGL< 60) a. Newborn-2 months: D10W 2.0-4.0 ml/kg IV/10. b. 2 months-2 years: D2SW 2.0-4.0 ml/kg IV/10. c. > 2 years: DSOW 1.0-2.0 ml/kg to max of SO ml IV/10. 3. If overdose of narcotic is suspected, administer one dose of naloxone 0.1 mg/kg up to 2.0 mg IV/IM/10. 4. If hypo perfusing, initiate 0.9% Normal Saline fluid therapy 20 ml/kg bolus IV/10, except in volume-sensitive children. Titrate to a systolic pressure of 100 mm Hg. a. Volume-sensitive children: Administer an initial fluid bolus of 10 ml/kg 0.9% Normal Saline via IV/10. If patient's condition does not improve, administer the second bolus of fluid at 10 ml/kg 0.9% Normal Saline via IV/10. Volume-sensitive children include neonates (0-28 days) and children with congenital heart disease, chronic lung disease, or chronic renal failure. b. If the patient's condition does not improve, and the lung sounds clear, administer the second bolus of fluid at 20 ml/kg 0.9% Normal Saline via IV/10. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 124 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 c. Administer third (and subsequent) fluid boluses at 10 ml/kg IV/10, while monitoring lung sounds. d. Consider additional fluid administration, up to a maximum of 3,000 ml, without consulting on-line medical directions. 5. Consider obtaining a blood sample, using a closed system. 6. If a patient has constricted pupils and respiratory depression, or is unresponsive, consider narcotic overdose. a. Administer naloxone 0.4-2.0 mg slow IV/IM/10/lntranasal (if delivery device is available). Titrate to adequate respiratory effort. b. If there is no improvement in respiratory function or level of consciousness, consider an additional dose of naloxone, every 2-3 minutes as needed, up to a maximum of 6 mg. 7. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. B. Seizure Review of Iniury/Illness: Seizures are caused by abnormal electrical bursts in the brain. Partial, or focal, seizures may cause uncontrolled movements of one or more limbs or the face, though patients typically remain conscious during focal seizure activity. Generalized seizures, sometimes referred to as "fits" or "convulsions," involve both sides of the brain, and therefore typically produce unconsciousness. Generalized seizures may involve tonic (rigid stretching of the body and limbs) and/or clonic (rhythmic jerking of the limbs and/or head) activity. Many, but not all, patients experience an "aura" of symptoms that warn them of a coming seizure, allowing them to sit or lie down to prevent injury. Others have no warning, and may be seriously injured by falls, blunt trauma, motor vehicle accidents, near drowning, or other incidents caused by their sudden loss of consciousness and body control. Seizures may be caused by head trauma, low blood sugar, infections, fevers, tumors, hypoxia, environmental exposure, toxic chemical exposure (e.g., a nerve agent, insecticide), or other metabolic abnormalities. They may also occur periodically in individuals without evidence of one of these causes—a condition called "epilepsy," which typically is controlled to some extent by medication. Febrile seizures in children do not predict underlying epilepsy and seldom last long enough to require treatment in the field but should always be evaluated by a physician when they occur. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 125 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Epileptic seizures generally last from 30 seconds to a couple of minutes and may be followed by a postictal state of deep sleep or agitation lasting from a few minutes to several hours. Generalized seizures that last for 5 minutes, or more are considered "prolonged seizures" These may require treatment to be stopped, and the patient should be transported as expeditiously as possible. Continuous or recurrent generalized seizures without regaining consciousness over a period of 30 minutes is called "status epilepticus" or "status seizure" This is a true medical emergency, with the potential for permanent brain damage. Signs and Symptoms Focal seizures * Uncontrolled, rhythmic jerking of one or more limbs or facial muscles * Abnormal, but stereotyped behavior or sensations such as smells not related to the environment * Patients typically remain awake and may be variably responsive during focal seizures Generalized seizures * May be preceded by an aura * Patients are unconscious * Tonic/clonic muscle activity * Likely to have associated injuries Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. For generalized (typically tonic-clonic) seizure, monitor airway: a. DO NOT attempt to restrain a patient that is actively seizing. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 126 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 b. DO NOT force any device into the patient's mouth, if the patient is still seizing. c. Position patient to maintain open airway; turn onto side if patient is at risk for aspirating excess secretions or is vomiting. 6. For prolonged seizures or status epilepticus (status seizure), request ALS support for medication, and/or transport to hospital ASAP. 7. When seizure activity has stopped: a. Identify and treat injuries. b. If the patient is a known diabetic, and patient is awake/able to control airway, glucose paste (10-15 gm) should be administered between the gum and cheek. Consider a single additional dose of glucose paste if condition does not improve after 10 minutes. 8. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. ALS 1. Confirm completion of BLS steps 1-7. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Check blood sugar. 4. For prolonged seizure or status epilepticus, treat with the IV/10 benzodiazepine, according to local protocols: a. Midazolam: 5.0 mg IV/10, administer over 1-2 min b. Patients >_ 69 years: Reduce any of these medications by 50%. c. If IV is unavailable, check with on-line medical direction for alternative route and dosing. 5. Pregnant women require on-line medical consultation prior to the administration of any benzodiazepines. (Refer to Protocols VILA and VII.B.) 6. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 127 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 AILS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Check blood sugar. 4. For prolonged seizure or status epilepticus, treat with the IV/10 benzodiazepine, according to local protocols: a. Midazolam: Administer 1.0-5.0 mg (0.05 mg/kg) IV/10/I1VI; repeat every 5 minutes, up to a maximum of 0.1 mg/kg, if needed. b. If medications are administered, monitor cardiac rhythm and pulse oximetry. C. Diabetic Emergencies Review of Illness/Injury Diabetes mellitus is a group of conditions in which the body does not produce enough or cannot properly use insulin. Insulin shock (hypoglycemia or low blood sugar) occurs when a patient has received more insulin than was needed. This causes low blood sugar levels, so metabolically active cells (e.g., brain) do not have enough energy to function normally. An altered mental status, including unconsciousness, may occur and is treated by administering glucose. Diabetic coma (hyperglycemia, diabetic ketoacidosis, and hyperosmolar coma) occurs when insulin is insufficient or not working. This results in excessive sugar circulating in the bloodstream, and other metabolic changes. Signs and Symptoms Insulin Shock * Rapid respirations and/or heartbeat * Dizziness * Sweating * Headache * Confusion * May progress to unresponsiveness KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 128 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Diabetic Coma * Drowsiness * Confusion * Thirst, dehydration * Change in level of consciousness * Sweet or fruity-smelling breath Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Determine blood sugar level using a glucometer, if available and usage permitted by local protocols. 6. If hypoglycemic (blood sugar< 60 mg/dL) and conscious, administer glucose paste (10-15 gm) between cheek and teeth. May repeat x1 after 10 minutes, if no response. DO NOT give glucose paste to patients who are unconscious and/or do not have the capacity to swallow. Be cautious of vomiting/aspiration after administration and protect the airway. 7. If a patient's condition improves, and he/she does not wish further evaluation, no medical direction is required, if all the following are present: a. This was an acute hypoglycemic event in a diabetic patient and he/she has returned to an alert and oriented mental status. b. Oral glucose was administered. c. The current glucose reading is > 80 mg/dL. d. A responsible adult is present. e. Further caloric intake is assured. f. There are no clinical findings consistent with acute illness. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 129 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 8. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. Patients on oral hypoglycemic agents who have a hypoglycemic's episode must be transported for further monitoring. AILS 1. Confirm completion of BLS steps 1-8. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. If hypoglycemic (blood sugar< 60 mg/dL): Administer Dextrose (D50W) 50 ml of 50% solution slow IV push. a. If unable to obtain IV/10 access, administer Glucagon (1.0 mg) IM. b. Patients on oral hypoglycemic agents who have a hypoglycemic's episode must be transported for further monitoring. 4. If hyperglycemic (blood sugar>400 mg/dL): Run IV 0.9% Normal Saline or open. a. Reassess bilateral lung sounds and pulse oximetry after each 250 ml of fluid. b. Do not exceed 2 L of IV fluid without consulting on-line medical direction. 5. Re-check glucometer reading every 30 minutes, or for altered mental status, during transport. 6. Refer to "Refusal of Further Evaluation" in this section, if patient does not wish further evaluation or transport. Pediatric BLS ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Re-check glucometer reading: a. If hypoglycemic (blood sugar< 60 mg/dL): Administer glucose paste (10-15 gm) between cheek and teeth. May repeat x1 after 10 minutes, if no response. DO NOT give glucose paste to patients who are unconscious and/or do not have the capacity to swallow. Be cautious of vomiting/aspiration after administration and protect the airway. b. If hyperglycemic (blood sugar>400 mg/dL): Contact on-line medical direction. Refusal of Further Evaluation 1. If a patient's condition improves, and he/she does not wish further evaluation, no assistance from on-line medical direction is required if all the following are present: KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 130 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 a. This was an acute hypoglycemic event in a diabetic patient and he/she has returned to an alert and oriented mental status. b. Oral glucose was administered. c. The current glucose reading is > 80 mg/dL. d. A responsible adult is present. e. Further caloric intake is assured. f. There are no clinical findings consistent with acute illness. g. The patient is not using prescribed oral hypoglycemic agents. D. Confusion,Agitation Review of Iniury/Illness "Confusion" is a state in which a patient has difficulty both understanding his surroundings and ascertaining a response. "Agitation" suggests heightened anxiety and frequently includes combative behavior. There are many causes for acute onset of confusion and/or agitation. These include but are not limited to behavioral emergencies, metabolic emergencies including hypoxia and hypoglycemia, hypo/hyperthermia intoxication or over-medication, and head injury. All these conditions are covered elsewhere in these protocols, and all require transportation for full medical evaluation and treatment. Signs and Symptoms This protocol pertains to patients who are awake and alert, but present with an acute change from their normal mental status. It is important to establish and convey to the transport unit whether the patient is oriented (knows who and where he/she is and the day and date). This can only be established by asking these questions. Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 131 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. a. Restrain only if necessary for patient and staff safety, following local protocols for methods of restraint and documentation requirements. 5. Check for hypoxia and provide supplemental oxygen via a non-rebreathing mask at high concentration if present. 6. Assess patient for possible closed head injury and follow trauma protocol if appropriate. 7. Check blood sugar level. a. If hypoglycemic (blood sugar less than 60 mg/dQ, administer glucose paste. (Refer to Protocol II.C.) b. Recheck blood sugar after all interventions. 8. Check for signs of dehydration and provide oral or IV rehydration. (Refer to Protocol VIII.A.) 9. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. AILS 1. Confirm completion of BLS Steps 1-9 (above). 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. If hypotensive, administer a fluid bolus at 20 ml/kg of 0.9% Normal Saline via IV/10. 3. If hypoglycemic, refer to Protocol II.C. 4. If a patient has constricted pupils and respiratory depression, or is unresponsive, consider narcotic overdose. a. Administer naloxone 0.4-2.0 mg slow IV/IM/10/lntranasal (if delivery device is available). Titrate to adequate respiratory effort. b. If there is no improvement in respiratory function or level of consciousness, consider an additional dose of naloxone, every 2-3 minutes as needed, up to a maximum of 6 mg. 5. Obtain 12-lead ECG and treat dysrhythmias, as appropriate. Continue monitoring cardiac rhythm. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 132 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Assess for possible closed head injury. 3. If hypoglycemic: Administer glucose paste (10-15 gm) between cheek and gum, if awake and able to swallow. AILS 1. Follow BLS guidelines, adjusting for patient age/size KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 133 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 IIII Actite III''hslh�: s,s General Review A variety of conditions can cause acute difficulty breathing or inadequate oxygenation. Examples include asthma (including allergic reactions involving the airway or allergic bronchospasm), chronic obstructive pulmonary disease (including emphysema), congestive heart failure, respiratory tract infections, pulmonary emboli, and others. Any of these processes can lead to respiratory failure, or loss of the ability to inhale oxygen and exhale carbon dioxide. EMS care of patients in acute respiratory distress should determine what is causing the difficulty breathing and use the appropriate protocols to improve ventilation and oxygenation in the field environment. A. Asthma Review of Iniury/Illness Asthma is a chronic lung disease that causes inflammation and narrows the air passages (bronchospasm). It affects people of all ages but usually begins in childhood. In the field, all causes of acute bronchospasm are treated essentially the same. Signs and Symptoms * Coughing * Wheezing * Difficulty exhaling * Shortness of breath * Chest tightness * Retractions and nasal flaring in pediatric patients Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 134 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 4. Determine need for ALS care and/or transport to hospital for further evaluation 5. Provide supplemental oxygen. 6. Be prepared to assist ventilations with a bag valve mask (BVM), if necessary. 7. Allow patient to assume position of comfort. 8. If the patient has prescribed inhaler available, assist the patient to administer; repeat once in a 30-minute period, if difficulty breathing persists. 9. If a patient's asthma is historically precipitated by allergies, and he/she has an EpiPen® prescribed by a physician for that purpose, assistance may be offered for administration. 10. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. AILS 1. Confirm the completion of BLS steps 1-9. 2. Administer Albuterol 2.5 mg in 3 ml 0.9% Normal Saline via nebulizer. Repeat nebulizer treatments, with Albuterol only, twice as needed. • If bronchodilators are administered, may add Ipratoprium bromide (Atrovent) 0.5 mg (0.5 ml-) to Albuterol nebulizer treatment. 3. Consider the need for advanced airway management (Refer to Protocol I.B.). NOTE: Although sometimes needed, intubation further narrows the airway restriction in a severe asthma exacerbation, and this may worsen some cases. Aggressive use of bronchodilators is generally the most important therapy for severe asthma exacerbation. 4. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 5. If patient continues to have severe respiratory distress, consider the following: • Administer M ethyl prednisolone sodium succinate (Solu-Medrol) 125mg IV • Administer Epinephrine (1:1000) 0.3 mg IM 6. If severe respiratory distress continues, consider the following: KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 135 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 • Administer Magnesium Sulfate 2 g IV (mixed in 50 mL or 100ml-of D5W) given over 5-10 minutes. • Repeat Epinephrine (1:1000) 0.3 mg IM • Administer CPAP with 2.5- 5 cm H2O PEEP. 7. When administering Epinephrine caution should be used when the patient is older than 40 years of age or has a history of hypertension or heart disease. Pediatric BLS 1. Follow BLS guidelines, adjusting to patient age/size. AILS 1. Follow BLS guidelines, adjusting to patient age/size. 2. Initiate 0.9% Normal Saline via IV/IO at KVO or saline lock. 3. Administer Albuterol adjusting for patient age/size, via nebulizer. Repeat nebulizer treatments, with Albuterol only, every 5 minutes as needed. 4. If respiratory distress is severe: • M ethyl prednisolone sodium succinate (Solu-Medrol) 2mg/kg not to exceed 60 mg • Epinephrine: 0.01 mg/kg IM, up to a maximum of 0.5 mg. • For severe dyspnea, administer Magnesium Sulfate 40 mg/kg (maximum dose of 2 g) IV (mixed in 50 mL of D5W given over 30 minutes), as needed B. COPD (Chronic Bronchitis and/or Emphysema) Review of Iniury/Illness Chronic obstructive pulmonary disease (COPD) comprises several problems that impede the flow of gases through the airways and gas exchange in the lungs. Most, but not all, cases result from smoking or long-time asthma. Acute exacerbations of COPD are frequently caused by bronchospasm, which may in turn be triggered by infections, changes in air quality, or other environmental factors. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 136 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Signs and Symptoms * Shortness of breath * Wheezing, rhonchi, or sometimes severely decreased breath sounds * Chronic cough with large amounts of mucus * Frequent respiratory infections Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Provide supplemental oxygen. a. Administer oxygen at a high-flow rate to all patients in severe respiratory distress. b. COPD patients not in respiratory distress should be given oxygen to maintain adequate 02 saturation (e.g., > 90%). 6. Be prepared to assist ventilation, if necessary, with a bag valve mask. 7. Allow patient to assume position of comfort. 8. If the patient has a prescribed inhaler available, assist the patient to administer. 9. Continue supportive care and monitor vital signs until patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-8. 2. Initiate 0.9% Normal Saline via IV/IO at KVO or saline lock. 3. Administer Albuterol adjusting for patient age/size, via nebulizer. Repeat nebulizer treatments, with Albuterol only, every 5 minutes as needed. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 137 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 • If bronchodilators are administered, may add Ipratoprium bromide (Atrovent) 0.5 mg (0.5 mL) to Albuterol nebulizer treatment. 4. If patient has severe respiratory distress you may administer: • Administer M ethyl prednisolone sodium succinate (Solu-Medrol) 125mg IV 5. Administer CPAP with 2.5-5 cm H2O PEEP. 6. Provide advanced airway support, if necessary. (Refer to Protocol I.B.). 7. Obtain 12-lead ECG and treat dysrhythmias, as appropriate. Continue monitoring cardiac rhythm. 8. Monitor pulse oximetry. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Administer Albuterol adjusting for patient age/size, via nebulizer. Repeat nebulizer treatments, with Albuterol only, every 5 minutes as needed. • If a bronchodilator is administered, add Ipratropium Bromide (Atrovent) to Albuterol nebulizer treatment. 3. If respiratory distress is severe: • Methylprednisolone sodium succinate (Solu-Medrol) 2mg/kg not to exceed 60 mg • Epinephrine: Administer 0.01 mg/kg IM, up to a maximum of 0.5 mg. • For severe dyspnea, administer Magnesium Sulfate 40 mg/kg (maximum dose of 2 g) IV (mixed in 50 mL of D5W given over 30 minutes), as needed 4. Monitor cardiac rhythm and pulse oximetry. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 138 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 C. Hyperventilation Review of Injury/Illness Hyperventilation is rapid, deep breathing. It may be seen in panic or anxiety attacks. Signs and Symptoms * Agitation * Weakness * Dizziness * Confusion * Numbness or parasthesia of fingers and around the mouth * Syncope Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Allow patients to assume a position of comfort. 6. Administer oxygen via non-rebreathing mask, if needed. 7. Coach patient to slow breathing with a calm demeanor. 8. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-8. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 139 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 3. Confirm patient is not hypoxic with pulse oximetry, and coach to slow breathing. 4. Consider any of the following sedatives as a last resort: a. Midazolam: 2.0 mg IV/10, up to maximum of 4.0 mg; repeat once, if needed. b. If medications are administered, place them on cardiac monitor. Pediatric BLS ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Confirm patient is not hypoxic with pulse oximetry, and coach to slow breathing. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 140 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 IBehaviiic)4 III'I ii iii°°iuiergeiunm ies Review of Iniury/Illness Many factors can influence a person's behavior. A pattern of disruptive behavior can become an emergency at any time. Behavioral emergencies may be psychiatric or medical. Always search for underlying medical causes such as head trauma, hypoxia, drug overdose, postictal following a seizure, or hypoglycemia. Signs and Symptoms * Talking to imaginary person or object * Agitation * Threat of suicide or homicide * Inability to care for self * Threatening or violent behavior BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. REQUEST LAW ENFORCEMENT. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Maintain calm demeanor and respect the dignity of the patient. 6. Move slowly and deliberately. 7. Assess underlying medical issues. 8. Check blood sugar and monitor pulse oximetry, if possible. 9. Obtain body temperature. • If patient has elevated temperature above 100 degrees, consider cooling patient using cold packs to patient's head, axilla and groin. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 41 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 10. If the patient is spitting, cover his/her face with a surgical mask or non-rebreathing mask (NRBM) with high flow oxygen. 11. Continue supportive care, monitor vital signs and expedite transport. AILS 1. Confirm the completion of BLS steps 1-10. 2. Establish IV/10 of 0.9% Normal Saline via IV/10 at KVO or saline lock, if appropriate. 3. If patient remains combative, belligerent, or uncontrollable, consider any of the following sedatives as a last resort, according to local protocols: • Midazolam: Administer 2.0 mg IV, IM; repeat once, up to maximum of 10 mg. OR • Lorazepam (Ativan) 2 mg IV, IM; may repeat once (maximum dose of 4 mg. b. If medications are administered, place the patient on a cardiac monitor. Monitor cardiac rhythm and pulse oximetry. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Attempt to locate parent or guardian, if not on scene. AILS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Establish IV/10 of 0.9% Normal Saline via IV/10 at KVO or saline lock, if appropriate. 3. If patient remains combative, belligerent, or uncontrollable, consider any of the following sedatives as a last resort, according to local protocols: • Midazolam: Administer 1.0-5.0 mg (0.05 mg/kg) IV/10/IM; repeat every 5 minutes, up to a maximum of 0.1 mg/kg, if needed. OR • Lorazepam (Ativan) 0.1mg/kg IV or IN, max 2 mg per dose if not effect after 5 minutes may be repeated once to a maximum total dose of 4 mg KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 142 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 4. If medications are administered, place the patient on a cardiac monitor. Monitor cardiac rhythm and pulse oximetry. 5. Administer Benzodiazepines slowly, titrate to effect, and be aware of associated hypotension. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 143 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 V. Burn Review of Iniury/Illness A burn injury can result from direct or indirect contact with any heat source, including a flame, electrical, chemical, lightning, flammable liquid, flashes, radiation, or scalding liquids. Injuries can range from minor (1st and 2nd degree) to life-threatening (3rd and 4th degree burns). (Also refer to Protocol IX.G - Electrical Burns and Lightning Injuries.) Signs and Symptoms Inhalation (airway burns) * Difficulty breathing and/or swallowing * Hoarseness * Stridor * Wheezing * Soot/singed hairs * May or may not exhibit facial burns First degree (superficial thickness burn to skin) * Redness * Pain * Swelling Second degree (partial thickness burn to skin) * Redness * Pain * Swelling * Blistering Third degree (full thickness burn to skin) * May be white, leathery or charred appearance * Swelling * Underlying tissue is damaged * May or may not have pain KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 44 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Fourth degree (full thickness burn to skin; not universally used term) * Burns extend through skin and muscle, sometimes into bone. Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Provision of supplemental oxygen is crucial to patients with smoke inhalation due to possible carbon monoxide poisoning. Start with 100% 02 by non-rebreathing mask (NRBM) if patient has altered mental status. 6. Be prepared to assist ventilation with a bag-valve-mask, if necessary. 7. For singed nasal hair or burns around the mouth or nose, request ALS support and transport as quickly as possible, as airway burns, and edema can result in rapid loss of airway. 8. Evaluate burn surface area (BSA) using the "Rule of Nines" or estimate using the patient's palm as 1%. Measuring BSA does not predict severity of injury for electrical burns. 9. Determine if there is any associated traumatic injury. 10. Remove jewelry and any clothing that is not stuck to the wound. 11. Cool burned skin with room temperature saline, do not apply ice to burned tissues. 12. Cover burns with dry, sterile dressing if irrigation is discontinued. 13. Keep patient warm to protect against hypothermia. 14. For a chemical burn, wear protective equipment as needed, and consider fi eld decontaminant. Remove contaminated clothing and irrigate areas with copious amounts of water. If dry/powdered chemical, brush off prior to any irrigation. * Cherntrec -262-8 00, call Poison Control 80 -222-1 22 KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 45 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 AILS 1. Confirm the completion of BLS steps 1-15. 2. Continue high flow 100% 02 by non-rebreathing mask (NRBM) if CO poisoning is possible or if it is documented by CO-oximetry. 3. Monitor airway as airway edema may progress rapidly to complete obstruction. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 4. Initiate 0.9% Normal Saline via IV/10 through unburned skin, if possible. If BSA> 20% second degree or higher burns, administer fluid bolus with 250 ml of 0.9% Normal Saline via IV/10. a. Check lung sounds after each 250 ml fluid bolus. b. If hypotensive, repeat fluid bolus, as needed. c. Use caution with IV fluids to avoid hypothermia and fluid overload. d. Calculate IV fluid resuscitation using Parkland formula. • Total IV fluid for first 24 hours = 4 x% BSA x Weight (kg) • Deliver first half of IV fluids in the first 8 hours, second half in the following 16 hours. 5. Pain Management (Refer to Protocol I. C.). 6. Obtain 12-lead ECG and monitor cardiac rhythm. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Adjust estimates of involved BSA for pediatric patients using the Lurd-Broaden chart for age- adjusted Rule of Nines. a. For patients < 1 year, head = 18% and each leg is 15%. b. Add 0.5%to each leg and subtract 1%from head for each year over age 1. 3. Suspect child abuse when injuries and/or story are inconsistent. Report to authorities, as required by state or local laws. 4. Consider Aeromedical evacuation to a Pediatric Trauma Center or Burn Center. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 146 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 AILS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Adjust estimates of involved BSA for pediatric patients using the Lurd-Broaden chart for age- adjusted Rule of Nines. a. For patients < 1 year, head = 18% and each leg is 15%. b. Add 0.5%to each leg and subtract 1%from head for each year over age 1. 3. Initiate 0.9% Normal Saline IV/10 through unburned skin, if possible. If BSA > 20% second degree or higher burns, administer fluid bolus with 20 ml/kg of 0.9% Normal Saline via IV/10. a. Check lung sounds after each fluid bolus. b. If hypotensive, repeat fluid bolus 20 ml/kg, as needed. c. Use caution with IV fluids to avoid hypothermia and fluid overload. • Total IV fluid for first 24 hours = 4 x% BSA x Weight (kg) • Deliver first half of IV fluids in the first 8 hours, second half in the following 16 hours. 4. Pain Management (Refer to Protocol 1. C.). 5. Suspect child abuse when injuries and/or story are inconsistent. Report to authorities as required by state or local laws. 6. Consider the need for Aeromedical evacuation to the nearest Burn Center or Pediatric Trauma Center. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 147 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 I. Cardiac IIII'Illlurneiurge:.ides A. Chest Pain (Angina, Acute Coronary Syndrome) Review of Injury/Illness In addition to cardiac ischemia, chest pain may be caused by inflammation of the lungs or pleural linings, pneumothorax, pulmonary embolus, indigestion, gastric reflux, and other problems. It is sometimes difficult to distinguish cardiac chest pain from these other problems. "Acute coronary" syndrome (ACS) refers to a set of symptoms resulting from inadequate blood flow to the heart muscle. The blood supply for the myocardium is provided by the coronary arteries, and when one or more of the coronaries is narrowed or blocked, ACS results. ACS includes angina pectoris, or chest pain, indicating inadequate blood flow to the myocardium. Myocardial infarction (MI) occurs when the muscle has been deprived of blood and oxygen long enough for it to be permanently damaged. Electrocardiograms (ECG) of patients having acute MI may show elevation of the ST segment in leads corresponding to the part of the heart that is being damaged. This is called ST elevation, MI, or STEMI. NOTE: Many patients who are having acute MI do not show ST elevations. Signs and Symptoms * Chest pain/discomfort that may radiate to the left or right arm, shoulders,jaw, or back * Frequently described as pressure or a crushing pain * Shortness of breath, sweating, nausea, or vomiting * Diaphoresis * Women, elderly, and diabetic patients have a higher incidence of atypical presentations such as generalized weakness or fatigue, nausea, and epigastric pain Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine need for ALS care and/or transport to hospital for further evaluation and treatment KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 148 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 5. Provide supplemental oxygen: a. 2.0-6.0 L/min via nasal cannula, if pulse oximetry is normal and the patient is not short of breath. b. 100% by non-rebreathing mask if 02 saturation is < 90% or if patient is subjectively short of breath. 6. Be prepared to assist ventilations with a bag valve mask (BVM), if necessary. 7. Allow patient to assume position of comfort. 8. If the patient has prescribed nitroglycerin, and there are no contraindications, assist the patient to administer nitroglycerin 0.4 mg sublingual (SL); may repeat every 5 minutes up to a maximum of 3 doses, provided Systolic BP >_ 100 mm Hg and chest pain persists. a. Contraindications to first dose of SL nitroglycerin: • Use of erectile dysfunction medications in previous 24 hours • Systolic BP < 100 mm Hg 9. For chest pain consistent with ACS, administer aspirin 162-325 mg, after confirming the following: a. No history of ulcers or gastrointestinal bleeding b. No history of allergy or sensitivity to aspirin 10. Continue to assess pain level. 11. Assess and treat for hypotension or shock, if indicated. (Refer to Protocol X.I.) 12. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. AILS 1. Confirm the completion of BLS steps 1-12. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Obtain a 12-lead ECG and monitor cardiac rhythm. 4. Administer aspirin (162-324 mg) orally, if patient is awake, able to swallow, and denies aspirin allergy. 5. If patient does not have a prescription or previous history of nitroglycerin use: KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 149 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 a. Establish a 0.9% Normal Saline via IV/10 at KVO prior to administration. b. Administer nitroglycerin 0.4 mg sublingual (SL); may repeat every 5 minutes up to a maximum of 3 doses, provided Systolic BP >_ 100 mm Hg and chest pain persists. c. If IV/10 or saline lock cannot be established, consult on-line medical direction before nitroglycerin use. 6. Withhold administration of nitroglycerin if the patient has an obvious inferior MI (> 1 mm ST segment elevation in at least 2 of the inferior leads 11, III, AVF) or with ECG evidence of a right ventricular infarct. 7. If Systolic BP < 90 mm Hg, place patient in supine position with legs elevated and administer 250 ml fluid bolus of 0.9% Normal Saline via IV/10. 8. Consider repeating ECG every 15 minutes, as indicated by changes in chest pain. 9. Monitor cardiac rhythm and treat any dysrhythmia according to current AHA/ACLS guidelines. B. Cardiogenic Shock Review of Injury/Illness Cardiogenic shock indicates failure of the heart's pump function. Like other forms of shock, it presents with low blood pressure and evidence of inadequate perfusion of the brain and other vital organs. It is caused by profound weakness of the left ventricular muscle, most often due to a large area of myocardial ischemia or infarct, or to a severe inflammatory process (myocarditis). In cardiogenic shock, the low blood pressure is due entirely to loss of pump function, not to hypovolemia. Therefore, patients are often in congestive heart failure with distended neck veins and pulmonary edema despite the hypotension. Other processes that impede cardiac pump function (e.g., tension pneumothorax, cardiac tamponade) may cause patient presentations similar to cardiogenic shock. Signs and Symptoms * Distended neck veins * Pulmonary edema (rales on auscultation) * Decreased heart sounds * Hypotension * Tachycardia * Electrocardiographic changes consistent with current or recent MI KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 150 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 * Sudden deterioration in condition (respiratory failure, decreased mentation) Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Provide supplemental oxygen (100% by non-rebreathing mask [NRBM]). 6. Be prepared to assist ventilations, if necessary, with a bag valve mask. 7. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. ALS 1. Confirm the completion of BLS steps 1-6. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock; titrate to achieve a Systolic BP >_ 100 mm Hg. 3. If Systolic BP < 90 mm Hg, administer 250 ml fluid bolus with 0.9% Normal Saline via IV/10, and re-assess both BP and lung sounds. If lung sounds are clear, repeat with a second 250 ml fluid bolus with 0.9% Normal Saline via IV/10. 4. Consider other causes of the patient's shock. 5. Obtain 12-lead ECG and monitor cardiac rhythm. 6. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) C. Congestive Heart Failure (Pulmonary Edema) Review of Injury/Illness Congestive heart failure (CHF) occurs when the heart is not strong enough to pump the blood that returns to it via the venous system out to the rest of the body against the resistance produced by the arteries. This causes the body to retain fluid as it tries to build up enough "head pressure" to compensate for the failing pump. Eventually, the combination of increased KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 151 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 circulating volume and ineffective pumping action causes fluid to build up in the limbs and abdomen (right-sided CHF), and the lungs (left-sided CHF, pulmonary edema). Patients may present with biventricular, or both right and left-sided CHF. This protocol deals primarily with pulmonary edema, a life-threatening emergency. The pump failure of CHF can be caused by long-standing hypertension, damage to the heart's valves, and loss of myocardial muscle strength due to inflammation or infarct. Signs and Symptoms * Edema, most often in legs and ankles * Fatigue * Difficulty breathing on exertion or when lying down * Pulmonary edema causes severe shortness of breath and hypoxia at rest; may be improved by sitting upright * Frothy sputum, may be pink-tinged Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Provide supplemental oxygen (100% by non-rebreathing mask [NRBM]). 6. Assist ventilations with a bag valve mask (BVM), if necessary. 7. If the patient has prescribed nitroglycerin, and there are no contraindications, assist the patient to administer nitroglycerin 0.4 mg sublingual (SL); may repeat every 5 minutes up to a maximum of 3 doses, provided Systolic BP >_ 100 mm Hg and chest pain persists. a. Contraindications to first dose of SL nitroglycerin: • Use of erectile dysfunction medications in previous 24 hours • Systolic BP < 100 mm Hg KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 152 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 8. Continue to monitor vital signs, including pulse oximetry, if available. 9. Continue supportive care and monitor vital signs until patient is turned over to a higher level of medical care. AILS 1. Confirm the completion of BLS steps 1-9. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Obtain a 12-lead ECG and monitor cardiac rhythm. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) AILS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Administer Albuterol 2.5 mg in 3.0 ml Normal Saline. 4. Monitor cardiac status and pulse oximetry. D. Cardiac Arrest Ventricular Fibrillation, Non-Perfusing Ventricular Tachycardia,Asystole, Pulseless Electrical Activity Review of Injury/Illness BLS and AILS protocols to resuscitate patients in cardiac arrest should be based on the most recent American Heart Association guidelines and approved by local medical direction. The protocols below require that all BLS providers be trained to use and have access to automatic or semi-automatic defibrillators (AED). Signs and Symptoms * Unresponsive * No palpable pulse KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 153 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 * Electrical activity on ECG is absent or shows course/fi ne ventricular fibrillation or ventricular tachycardia * No respirations (possible agonal gasping in initial stage Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. If witnessed arrest: Defibrillate one time prior to starting CPR. (Refer to step 6.) 6. If unwitnessed arrest: Start CPR according to current American Heart Association (AHA) guidelines. a. Resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). • Push hard and fast (chest compression of 2 inches at a ratio of 30:2 with a rate of 100 compressions/min. (DO NOT wait to check rhythm or pulses.) Apply an AED as soon as possible. • Change compressors every 2 minutes. • Ensure complete chest recoil during CPR b. Defibrillate one time, ASAP, if indicated; resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). c. Re-check rhythm on AED or cardiac monitor and check pulses. d. Defibrillate one time, ASAP, if indicated; resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). e. Re-check rhythm and pulses. f. Defibrillate one time, ASAP, if indicated; resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). g. Re-check rhythm and pulses. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 54 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 7. Manually ventilate with a bag valve mask (BVM) and high flow 02 every 6-8 seconds with minimal interruption (< 10 seconds) ASAP. Avoid excessive ventilation. 8. Continue CPR until the patient is turned over to an AILS transport unit. 9. If there is no return of spontaneous circulation, refer to Protocol XI.C. AILS (VF, Pulseless VT-Adult) 1. Confirm the completion of BLS steps 1-6. 2. Resume CPR, administer supplemental oxygen, attach manual defibrillator, and verify that VF/VT is present on the monitor. 3. Defibrillate one time. If a shockable rhythm (VF/VT) develops, resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). 4. Initiate intubation, or provide advanced airway support, and verify correct placement with capnography with minimal interruption of CPR (< 10 seconds). 5. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock with minimal interruption of CPR (< 10 seconds). 6. Administer epinephrine 1.0 mg IV/10/ET, every 3-5 minutes, with minimal interruption of CPR (< 10 seconds). 7. Defibrillate one time. If a shockable rhythm (VF/VT) develops, resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). 8. If refractory VF/VT: Administer Amiodarone 300 mg bolus IV/10; may repeat x1 at 150 mg bolus IV/10. 9. Defibrillate one time. If a shockable rhythm (VF/VT) develops, resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). 10. Identify and treat reversible causes: • Hypovolemia • Hypoxia • Hydrogen Ion (acidosis) • Hypo/hyperkalemia • Hypothermia • Tamponade, cardiac KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 155 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 • Tension Pneumothorax • Thrombosis, coronary • Thrombosis, pulmonary • Toxins 13. If spontaneous circulation returns, monitor vital signs, support airway and breathing per local protocols. 14. If there is no return of spontaneous circulation, refer to Protocol XI.C. AILS (Asystole/PEA-Adult) 1. Confirm the completion of BLS steps 1-6. 2. Resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). 3. Administer supplemental oxygen, attach manual defibrillator, and verify that Asystole is present on the monitor. 4. Continue to monitor cardiac rhythms. S. Defibrillate one time, if a shockable rhythm (VF/VT) develops. Follow the guidelines for "ALS (VF, Pulseless VT-Adult)." 6. Initiate intubation, or provide advanced airway support, and verify correct placement with capnography with minimal interruption of CPR (< 10 seconds). 7. Initiate 0.9% Normal Saline or via IV/10 at KVO or saline lock with minimal interruption of CPR (< 10 seconds). 8. Administer epinephrine 1.0 mg IV/10/ET, every 3-5 minutes, with minimal interruption of CPR (< 10 seconds). 9. Identify and treat reversible causes: • Hypovolemia • Hypoxia • Hydrogen Ion (acidosis) • Hypo/hyperkalemia • Hypothermia • Tamponade, cardiac KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 156 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 • Tension Pneumothorax • Thrombosis, coronary • Thrombosis, pulmonary • Toxins 10. Give all medications with minimal interruption of CPR (< 10 seconds). 11. If spontaneous circulation returns, monitor vital signs, support airway and breathing, and provide medications appropriate for BP, heart rate, and rhythm per local protocol. 12. If there is no return of spontaneous circulation, refer to Protocol XI.C. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Start CPR according to current American Heart Association (AHA) guidelines (30:2 with one rescuer [15:2 with two rescuers]): a. Compress chest at a rate of 100 compressions/min. • Neonates< 28 days: Compress lower third of the sternum 1/3 of the anterior-posterior diameter of the chest. • Infants 28 days-1 year: Compress chest 1% inches. • Children 1-8 years: Compress chest 2 inches. b. Manually ventilate with appropriate-sized bag valve mask (BVM), if available. If not, use a mouth-to-mask/barrier device. Administer supplemental oxygen. c. Defibrillate one time, if a shockable rhythm (VF/VT) develops; resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds); if possible, use AED with pediatric pads. d. Defibrillate one time, if a shockable rhythm (VF/VT) develops; resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds) 3. If spontaneous circulation returns, monitor vital signs, support airway and breathing per local protocols. 4. If there is no return of spontaneous circulation, refer to Protocol XI.C. AILS (VF, Pulseless VT- Pediatric) 1. Follow Pediatric BLS guidelines, adjusting for patient age/size. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 157 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 2. Attach manual defibrillator and verify that VF/VT is present on the monitor. 3. Defibrillate one time at 2 J/kg. If a shockable rhythm develops; resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). 4. Initiate intubation, or provide advanced airway support, and verify correct placement with capnography with minimal interruption of CPR (< 10 seconds). 5. Initiate 0.9% Normal Saline or LR via IV/10 at KVO or saline lock with minimal interruption of CPR (< 10 seconds): a. IV/10: 0.01 mg/kg (0.1 ml/kg 1:10,000), up to a maximum of 1.0 mg b. ET: 0.01 mg/kg (0.1 ml/kg 1:1,000), up to a maximum of 2.5 mg. Flush with 5 ml of Normal Saline and follow with 5 ventilations. 7. Defibrillate one time at 4 J/kg. If a shockable rhythm develops; resume 5 cycles of CPR (2 minutes) with minimal interruption (< 10 seconds). 8. Defibrillate third and subsequent times at >_4 J/kg, up to a maximum of 10 J/kg or adult dose. 9. If refractory VF/VT: Administer Amiodarone 5 mg/kg IV/10; may repeat x2 at 15 mg/kg, up to a maximum single dose of 300 mg. 10. Identify and treat reversible causes: • Hypovolemia • Hypoxia • Hydrogen Ion (acidosis) • Hypo/hyperkalemia • Hypothermia • Tamponade, cardiac • Tension Pneumothorax • Thrombosis, coronary • Thrombosis, pulmonary • Toxins 11. Give all medications with minimal interruption of CPR (< 10 seconds). KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 158 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 12. If spontaneous circulation returns, monitor vital signs, support airway and breathing, and provide medications appropriate for BP, heart rate, and rhythm per local protocols. 13. If there is no return of spontaneous circulation, refer to Protocol XI.C. AILS (Asystole/PEA- Pediatric) 1. Follow Pediatric BLS guidelines, adjusting for patient age/size. 2. Attach manual defibrillator and verify that Asystole is present on the monitor. 3. Defibrillate one time at 2 J/kg, if a shockable rhythm develops. Follow the guidelines for "ALS (VF, Pulseless VT- Pediatric)" 4. Initiate intubation, or provide advanced airway support, and verify correct placement with capnography with minimal interruption of CPR (< 10 seconds). 5. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock with minimal interruption of CPR (< 10 seconds). 6. Administer epinephrine, every 3-5 minutes, with minimal interruption of CPR (< 10 seconds): a. IV/10: 0.01 mg/kg (0.1 ml/kg 1:10,000), up to a maximum of 1.0 mg b. ET: 0.01 mg/kg (0.1 ml/kg 1:1,000), up to a maximum of 2.5 mg. Flush with 5 ml of Normal Saline and follow with 5 ventilations. 7. Identify and treat reversible causes: • Hypovolemia • Hypoxia • Hydrogen Ion (acidosis) • Hypo/hyperkalemia • Hypothermia • Tamponade, cardiac • Tension Pneumothorax • Thrombosis, coronary • Thrombosis, pulmonary • Toxins KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 159 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 8. Give all medications with minimal interruption of CPR (< 10 seconds). 9. If spontaneous circulation returns, monitor vital signs, support airway and breathing, and provide medications appropriate for BP, heart rate, and rhythm per local protocols. 10. If there is no return of spontaneous circulation, refer to Protocol XI.C. E. Other Cardiac Arrhythmias Premature Ventricular Contractions Review of Injury/Illness Premature ventricular complexes (PVCs) have three characteristics: • They occur earlier than the expected sinus beat. • They do not start with a positive P wave. • They have an abnormal QRS width (>_ 0.12 seconds). PVCs in the presence of cardiac symptoms that are and that have the following characteristics are indications for treatment: • Near the "T" wave • Multi-focal (different shapes on the monitor tracing) • Sequential or closely coupled • Runs of ventricular tachycardia (5 or more consecutive beats) • Ventricular tachycardia with a pulse • Once successful electrical conversion from ventricular tachycardia • Ventricular fibrillation to a supraventricular rhythm Signs and Symptoms * Irregular heartbeat of ventricular origin (may or may not be felt by the patient) * Sensation of irregular heartbeats or pounding/fluttering in chest BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 160 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Monitor airway, administer supplemental oxygen, if necessary, and monitor pulse oximetry. 6. Assess and treat for shock, if indicated. (Refer to Protocol X.I.) 7. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-6. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Obtain a 12-lead ECG and monitor cardiac rhythm. Providers may perform a 15-lead ECG, if trained. 4. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 5. Patients who are symptomatic (e.g., hypotensive, syncope, dizziness): a. Administer Amiodarone 150 mg IV mixed in NS 50 cc on a macro drip. (Administer over 10 minutes using Dial-A-Flow set at 300 which yields 5cc/min). 6. Continue supportive care, monitoring cardiac status and 02 saturation, and transport. Bradycardia Review of Injury/Illness Patients may present with a slow heart rate and chest pain, shortness of breath, decreased level of consciousness, hypotension, hypoperfusion, pulmonary congestion, congestive heart failure, and/or acute myocardial infarction. It is not unusual for young, healthy athletes to have a resting heart rate below 60 beats per minute. Bradycardia has a number of causes, including damage to the conduction pathways in the heart, medications, hypoxia, and hypothermia. Signs and Symptoms * Light-headedness * Syncope * Fatigue * Chest pain * Shortness of breath KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 161 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Assess and treat for shock, if indicated. (Refer to Protocol X.I.) 6. Monitor airway, administer supplemental oxygen, if necessary, and monitor pulse oximetry. 7. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. AILS 1. Confirm the completion of BLS steps 1-6. 2. Obtain 12-lead ECG and monitor cardiac rhythm. 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 4. If hypotensive, and lungs are clear, initiate a 250 ml bolus of 0.9% Normal Saline or LR; repeat to bring Systolic BP > 90 mm Hg, as needed. 5. If symptomatic, with heart rate < 50 bpm, apply pacer pads and treat any underlying causes. 6. If symptomatic, administer atropine 1.0 mg slow IV/10 push; repeat every 3-5 minutes, up to a maximum total dose of 3.0 mg. a. DO NOT administer atropine to patients who have had cardiac transplants. b. Hypothermic patients with a pulse should generally be re-warmed before atropine or pacing is attempted. 7. If the patient is hemodynamically unstable, with NO response to atropine: a. Administer transcutaneous pacing (TCP). KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 162 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 8. If patient is hemodynamically stable and in Type 11, second-degree AV Block or third-degree AV Block: a. Consider TCP after consulting on-line medical direction. • If the patient develops discomfort with TCP, and Systolic BP > 110 mm Hg: • Consider midazolam 0.1 mg/kg in 2.0 mg increments slow IV/IO push over 1-2 minutes, up to a maximum single dose of 5.0 mg to reduce pain/anxiety of pacing. Reduce dosage by 50%for patients >_ 69 years. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Obtain 12-lead ECG and monitor cardiac rhythm. 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 4. Identify and treat any reversible causes. 5. If hypotensive, and lungs are clear, initiate a 20 mg/kg fluid bolus of 0.9% Normal Saline or LR; repeat to bring Systolic BP > 90 mm Hg, as needed. 6. If the patient is hemodynamically unstable (with a pulse and poor perfusion): a. Start CPR, if heart rate < 60 bpm, with poor perfusion, despite oxygenation and ventilation. b. Administer epinephrine, every 3-5 minutes, with minimal interruption of CPR (< 10 seconds): • IV/10: 0.01 mg/kg (0.1 ml/kg 1:10,000), up to a maximum of 1.0 mg • ET: 0.01 mg/kg (0.1 ml/kg 1:1,000), up to a maximum of 2.5 mg. Flush with 5 ml of Normal Saline and follow with 5 ventilations. c. If symptomatic, administer atropine 0.02 mg/kg IV/10 (minimum dose 0.1 mg); may repeat x1, up to a maximum single dose of 0.5 mg. • DO NOT administer atropine to patients who have had cardiac transplants. • Hypothermic patients with a pulse should generally be re-warmed before atropine or pacing is attempted. • If the patient DOES NOT respond to epinephrine and atropine, administer transcutaneous pacing (TCP) after consulting on-line medical direction. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 163 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Tachycardia Review of Injury/Illness Tachycardia is defined as a heart rate > 100 bpm. Symptoms and potential hemodynamic compromise typically occur when heart rates > 150 bpm. The most common tachycardia is sinus tach, and it is treated by correcting the underlying causes. Atrial tachycardias require transport if they produce hypotension. Signs and Symptoms * Chest pain (may or may not be felt by the patient) * Shortness of breath * Decreased level of consciousness * Heart failure and/or acute myocardial infarction * Light-headedness * Syncope * Fatigue Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Monitor airway, administer supplemental oxygen, if necessary, and monitor pulse oximetry. 6. Assess and treat for shock, if indicated. (Refer to Protocol X.I.) 7. Continue supportive care and monitor vital signs (every 15 minutes, if stable; every 5 minutes, if unstable) until patient is turned over to a higher level of medical care. ALS KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 164 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 1. Confirm the completion of BLS steps 1-6. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Obtain a 12-lead ECG and monitor cardiac rhythm. Identify the rhythm and QRS duration. Providers may perform a 15-lead ECG, if trained. 4. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 5. If no pulse is present, treat as Asystole PEA. (Refer to Protocol VI.D "ALS [Asystole/PEA- Adult]") 6. If the patient is hemodynamically stable, identify the rhythm and treat according to current AHA/ACLS guidelines. 7. If patient is hemodynamically unstable with a ventricular rate > 150 bpm, identify and treat reversible causes: • Hypovolemia • Hypoxia • Hydrogen Ion (acidosis) • Hypo/hyperkalemia • Hypothermia • Tamponade, cardiac • Tension Pneumothorax • Thrombosis, coronary • Thrombosis, pulmonary • Toxins. 8. Consider vagal maneuvers. 9. If the QRS duration is a regular narrow complex: a. Consider administering adenosine 6.0 mg rapid IV/10 push and follow with 20 ml Normal Saline flush. b. If the rhythm does not convert in 1-2 minutes, administer a second dose at 12 mg IV/10. c. If the rhythm does not convert in 1-2 minutes, administer a third dose at 12 mg IV/10. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 165 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 d. If the patient has a history of WPW, a defibrillator must be available when adenosine is administered. 10. Consider the following for sedation prior to synchronized cardioversion, after consulting on- line medical direction. DO NOT delay, if hemodynamically unstable, as low blood pressure may affect ability to administer sedative. a. Midazolam (Versed"): 2.0-5.0 mg slow IV/10 or 0.2 mg/kg IM, if no IV access. 11. Synchronized cardioversion doses: a. Narrow regular: 50-100 J b. Narrow irregular: 120-200 J c. Wide regular: 100 J d. Wide irregular: defibrillation dose (NOT synchronized) Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. If the patient is hemodynamically stable (with a pulse and appears well perfused): a. Administer oxygen to obtain a saturation of 90-100%. b. Attach cardiac monitor and identify rhythm and QRS duration. c. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. d. Identify and treat reversible causes. 3. If the patient is hemodynamically unstable (with a pulse and poor perfusion) with a heart rate > 220 bpm for an infant, or> 180 bpm for a child: a. Consider vagal maneuvers. b. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. c. If cardiac rhythm is regular and narrow and the QRS duration <_ 0.09 seconds: KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 166 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 • Administer Adenosine 0.1 mg/kg rapid IV/10 push, up to a maximum of 6.0 mg. Follow with 20 ml Normal Saline flush. • If the rhythm does not convert in 1-2 minutes, administer a second dose at 0.2 mg/I<g rapid IV/10, up to a maximum of 12 mg. • If the rhythm does not convert in 1-2 minutes, administer a third dose at 0.2 mg/kg rapid IV/10, up to a maximum of 12 mg. • ET dosage is 2-2.5 times the IV/10 dosage. d. If the patient is not improved with Adenosine, or if IV/10 is unavailable, consider immediate synchronized cardioversion. • Consider the following for sedation prior to synchronized cardioversion, after consulting on- line medical direction. DO NOT delay, if hemodynamically unstable, as low blood pressure may affect ability to administer sedative. • Midazolam (Versed°): 0.1 mg/kg slow IV/10, up to a maximum of 4.0 mg or 0.2 mg/kg IM, up to a maximum of 4.0 mg, if no IV access. • Start cardioversion with 0.5-1.0 J/kg. If a patient's condition does not improve, or worsens, increase to 2.0 J/kg • If a calculated joule setting is lower than the cardioversion device is able to deliver, use the lowest power setting possible or consult on-line medical direction. • Be prepared for up to 40 seconds of Asystole after cardioversion. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 167 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 II d'I°miiilllWbiiirthi hind New oul°n dare A. Uncomplicated Delivery Review of Injury/Illness Full-term gestation lasts 40 weeks. Babies may be born at any time before or after 40 weeks, but the earlier the birth occurs in the gestation process, the likelier it is that complications, including fetal demise, will arise. Signs and Symptoms * Abdominal, pelvic pain * Low back pain * Vaginal discharge—this may be the mucus plug or it may be a large volume of clear liquid from the amniotic sac * Urge to defecate Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Time the duration of contractions and the length of the interval between them. 6. Obtain pre-natal history, including the number of previous pregnancies and births. 7. Assess for crowning. 8. If crowning is not present, allow patient to assume position of comfort. 9. If crowning is present, delivery is imminent. 10. In addition to gloves, don splash protection garments, if possible, to assist delivery. 11. Alert medical direction and/or receiving hospital of procedure in progress if possible. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 68 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 12. Assist delivery: a. Apply gentle pressure to the baby's head to prevent tearing of perineum. b. Once the head is delivered, suction mouth and nose with bulb syringe. c. Check to see if the umbilical cord is wrapped around the baby's neck. d. Apply gentle pressure downward while supporting baby's head to ease delivery of superior (upper position) shoulder. e. Once superior shoulder is delivered, apply gentle pressure upward to ease delivery of inferior (lower) shoulder. f. Upon delivery of both shoulders, the rest of the baby should follow quickly. g. Keep the baby at the level of the vagina until the cord is clamped and cut. h. Once fully delivered, clamp the umbilical cord at 8" and 10" from baby, and cut the cord between the two clamps. i. After clamping and cutting the cord, wrap the baby in a warm blanket, place the baby on the mother's abdomen, and allow for delivery of placenta. j. Record time of delivery. k. Refer to "Newborn Care Protocol" (Protocol VII.C). I. Watch for excessive bleeding; perform uterine massage and apply pressure to any lacerations that may be bleeding. m. Encourage mothers to breastfeed to help control hemorrhage. All patients in labor with evidence of imminent delivery will be 13. Continue supportive care and monitor vital signs until the transported to the closest Hospital. patient is turned over to a higher level of medical care. OB Patients not at risk of imminent delivery may be transported to ALS Homestead Hospital. Imminent 1. Confirm the completion of BLS steps 1-12. delivery is defined as: a. Contractions less than two (2) 2. Administer oxygen and monitor pulse oximetry. minutes apart 3. Resuscitate neonate, if needed. (Refer to Protocol VII.C). b. Spontaneous rupture of membranes has occurred 4. Initiate 0.9% Normal Saline via IV/IO at KVO or saline lock. c. Crowning is present d. Active labor KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 169 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 B. Complicated Delivery Review of Injury/Illness Labor and delivery can be complicated by abnormal presentation of the fetus, including: • Breech presentation • Prolapsed cord • Multiple births • Vaginal hemorrhage None of these is optimally handled in the fi eld, and every attempt must be made to move the patient to a higher level of care while EMS care is in progress. Breech Delivery Signs and Symptoms * Fetal buttocks visible at vaginal opening (breech presentation) * Prolapsed umbilical cord Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. S. Provide supplemental oxygen. 6. Support the baby's body as it is delivered. 7. If the head delivers normally, refer to Protocol VII.A. 8. If the head does not deliver within 2 minutes, insert gloved hand into the vagina, keeping palm toward the baby's face and forming a "V" with your fingers. Push the vaginal wall away from the baby's face to allow room for an airway. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 170 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 9. Maintain this airway until the baby is delivered or turned over to an ALS transport unit. 10. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. ALS 1. Confirm the completion of BLS steps 1-9. 2. Resuscitate neonate, if needed. (Refer to Protocol VII.C). 3. Initiate 0.9% Normal Saline via IV/IO at KVO or saline lock. Limb Presentation Signs and Symptoms * Fetal arm or foot visible at vaginal opening Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Administer oxygen and monitor pulse oximetry. 6. Place mother in the Trendelenburg position. 7. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. AILS 1. Confirm the completion of BLS steps 1-6. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 171 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Prolapsed Cord Signs and Symptoms * Cord presents first at vaginal opening Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Administer oxygen and monitor pulse oximetry. 6. Place the mother in the knee-to-chest position. 7. Wrap the cord in gauze moistened with saline. 8. Check the cord for a pulse. 9. If no pulse present, insert gloved hand into the vagina and push up on the baby until a pulse returns to the cord. 10. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. ALS 1. Confirm the completion of BLS steps 1-9. 2. Initiate 0.9% Normal Saline via IV/IO at KVO or saline lock. Multiple Births Review of Injury/Illness Most patients can report whether the impending delivery involves twins or multiple births. Signs and Symptoms KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 172 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 * Ongoing labor after first newborn delivered Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Administer oxygen and monitor pulse oximetry. 6. Follow normal delivery protocol for each neonate as it presents. (Refer to Protocol VII.A.) 7. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. ALS 1. Confirm the completion of BLS steps 1-6. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. Vaginal Hemorrhage Review of Injury/Illness Vaginal hemorrhage can be a sign of miscarriage or can be a pre- or post-partum complication. Signs and Symptoms * Unusually heavy vaginal bleeding * May be hypotensive Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 173 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Administer oxygen and monitor pulse oximetry. 6. Apply bandages/dressings appropriate for bleeding control in the vaginal area. 7. If pre-delivery, place mother in the left lateral recumbent position for third trimester. Prior to third trimester, place in shock position. 8. If before 20 weeks gestation and baby delivers without vital signs, do not begin resuscitation. If> 20 weeks gestation and baby deliver without vital signs, begin CPR. If unsure of gestational age, begin CPR. (Refer to Protocol VI.D.) 9. If post-partum, begin fi rm uterine massage. 10. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. AILS 1. Confirm the completion of BLS steps 1-9. 2. Initiate Normal Saline via IV/10 at KVO or saline lock. 3. Assess and treat for hypotension or shock, if indicated. (Refer to Protocol X.I.) C. Newborn Care Review of Iniury/Illness EMS care for a newborn follows a delivery at which the providers have just assisted or may be initiated on arrival at the scene of a recent out-of-hospital birth. Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 174 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A., and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Warm and dry the newborn. 6. Stimulate breathing by tapping the heels of the feet or rubbing the newborn's back. 7. If breathing does not begin, or is labored, suction the airway with a bulb syringe to remove mucus and secretions. 8. If no spontaneous respirations occur: Begin manual respirations, as needed, with an appropriate-sized bag valve mask (BVM) at 40-60 breaths per minute with 100% 02. 9. Assess heart rate. 10. If heart rate is absent or< 60 bpm at 30 seconds, after assisted respirations and supplemental oxygen, begin resuscitation according to current American Heart Association (AHA) Neonatal Resuscitation guidelines. 11. Assess APGAR score at 1 minute and 5 minutes post birth. (Refer to chart.) 12. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. AILS 1. Confirm the completion of BLS steps 1-9. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. If heart rate remains< 60 bpm, despite adequate ventilation with 100% 02 and chest compressions, administer epinephrine (1:10,000) 0.01-0.03 mg/kg IV/10 or 0.05-0.1 mg/kg ET. 4. Consider hypovolemia and pneumothorax, if condition does not improve. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 175 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 D. APGAR Score Appearance(Color) Blue, pale Body pink,extremities Completely pink Blue or pink Grimace No response Grimace Crying Respirations Absent Slow, irregular Good,crying (respiratory effort) Point total Infant's Condition Treatment Considerations 7-9 Good Re-assess 0-3 Poor Requires CPR KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 176 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 t iiiw. Euiiiviiirou°ivaiiiieuiiitalll IIII' a°iuneugerici( s A. Dehydration Review of Injury/Illness Dehydration can be caused by inadequate fluid intake, inapparent loss of fluids through sweating and evaporation, obvious fluid loss such as vomiting, diarrhea, excessive urination due to diuretic medication, or a combination of these factors. There is an increased risk of dehydration in both hot and cold climates and at high altitudes. Signs and Symptoms * Dry mucosa * Decreased urine output * Headache * Loss of coordination * Altered mental status * Decreased blood pressure, increased heart rate * May progress to shock Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. If dehydration is associated with heat exposure, move the patient to a cool shaded area. 6. Loosen patient's clothing. 7. If possible, take orthostatic vital signs. If mental status or blood pressure are abnormal with the patient lying down, DO NOT attempt to take an orthostatic set of vital signs. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 177 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 8. Continue supportive care and monitor vital signs until the patient is turned over to an AILS transport unit. ALS 1. Confirm the completion of BLS steps 1-11. 2. Monitor for change in mental status. 3. Initiate 0.9% Normal Saline via IV/10 and administer 500 ml fluid bolus. a. If the patient's age is < 40, repeat 500 ml bolus as needed up to 3,000 ml. b. If the patient's age is > 40, repeat 500 ml bolus as needed up to 2,000 ml. 4. After each bolus, monitor vital signs, including auscultation of lung sounds, and pulse oximetry, if available. 5. Obtain 12-lead ECG and monitor cardiac rhythm. (An electrolyte imbalance may cause dysrhythmia.) Pediatric BLS 1. Follow BLS guidelines, adjusting for age/size of patient. Expanded Scope BLS AILS 1. Follow Expanded Scope BLS guidelines, adjusting for age/size of patient. 2. Initiate 0.9% Normal Saline via IV/10. Infuse 20 ml/kg bolus. Reevaluate and repeat 20 ml/kg bolus, up to a maximum total infusion of 40 ml/kg. After each bolus, monitor vital signs, lung sounds, and pulse oximetry, if available. B. Drowning— Near Drowning Review of Iniury/Illness Drowning and near drowning involve respiratory impairment due to submersion or immersion in liquid. Hypothermia and/or cervical spine injury are frequently associated with drowning and near drowning and should be considered when caring for such patients. Signs and Symptoms * Respiratory distress/arrest KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 178 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 * Hypoxia * Cough with clear or frothy pink sputum * Decreased level or loss of consciousness * Decreased or absent pulses Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Administer oxygen and monitor pulse oximetry. 6. Assist respirations, if necessary, with a bag valve mask and high-flow 02. 7. Position patient on side to prevent aspiration if coughing/choking, with or without assisted ventilations. Otherwise, allow patients to assume a position of comfort. 8. Protect from hypothermia. (Refer to Protocol VIII.D.) 9. Evaluate for additional illness or injury including c-spine injury, diabetes, seizure, cardiac event, or stroke. 10. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. ALS 1. Confirm the completion of BLS steps 1-9. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. Use warm fluids, if available. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 179 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 5. Start CPR according to current AHA guidelines, if indicated. 6. If a patient is resuscitated from VF or Asystole cardiac arrest, consider therapeutic hypothermia and have receiving facility continue therapy, if available. 7. Continuously monitor vital signs and pulse oximetry. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. AILS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. Use warm fluids, if available. 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 5. Start CPR according to current AHA guidelines, if indicated. 6. If a patient is resuscitated from VF or Asystole cardiac arrest, consider therapeutic hypothermia and have receiving facility continue therapy, if available. 7. Continuously monitor vital signs and pulse oximetry. C. Heat-related Illness (Hyperthermia) Review of Iniury/Illness Heat-related illness is a group of acute conditions in which the body produces or absorbs more heat than it can effectively dissipate into the environment, causing a dangerous increase in core body temperature. The two most common forms of heat-related illness that require EMS treatment are heat exhaustion and heat stroke. These conditions may be associated with dehydration and electrolyte abnormalities, rarely including life-threatening hypernatremia. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 180 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Signs and Symptoms Heat exhaustion * Nausea * Clammy skin * Dizziness * Muscle cramps * Elevated core temperature Heat stroke * Altered mental status * Elevated core temperature (> 1050 F) * Skin may be hot and dry or sweaty * Dilated pupils * Rapid heart rate (sometimes with arrhythmia) Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Have the patient stop doing any work or physical exertion. 6. Remove as much clothing from patients as possible. 7. Have the patient rest in shaded or cooler area. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 181 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 8. Aggressively cool patient with tepid or cool (not cold or iced) water and/or towels soaked with tepid water; the more skin surface actively cooled, the better. a. Increase airflow over the moist skin to increase evaporation. b. Avoid inducing shivering, which is one of the body's mechanisms for warming itself. c. Monitor mental status and core body temperature (rectal) temperature to avoid over-cooling, if possible. d. Watch for rebound hyperthermia when measures are discontinued after initial cooling, and restart if core body temperature exceeds 101' F. e. Provide supplemental oxygen to keep 02 saturation at a minimum of 94%. 9. Provide oral hydration with water, diluted fruit juice, or diluted sports drink (50:50 with water), if patient is awake and able to swallow and mental status is intact. 10. For heat stroke, consider ground transportation to the nearest hospital as rapidly as possible. 11. Monitor core body temperature, oxygen saturation, lung sounds, and mental status. 12. Continue supportive care and monitor vital signs until patient is turned over to an ALS transport unit. AILS 1. Confirm the completion of BLS steps 1-11. 2. Initiate 0.9% Normal Saline via IV/10 at 250 ml/hr., up to a maximum total of 3,000 ml. 3. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 4. If patient is seizing or combative and Systolic BP > 100 mm Hg, consider Midazolam (Versed): 2.0-5.0 mg IV/10, up to a maximum of 10 mg. Pediatric BLS 1. Follow BLS guidelines, adjusting for age/size of patient. 2. Pediatric patients are more susceptible to heat extremes than adults. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 182 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 3. Monitor core body temperature. AILS 1. Follow BLS guidelines, adjusting for age/size of patient. 2. Pediatric patients are more susceptible to heat extremes than adults. 3. Monitor core body temperature. 4. Initiate 0.9% Normal Saline via IV/10 at 20 ml/kg fluid bolus, up to a maximum total infusion of 40 ml/kg. 5. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 7. If patient is combative, belligerent, or uncontrollable, consider any of the following sedative as a last resort, according to local protocols: a. Midazolam: Administer 1.0-5.0 mg (0.05 mg/kg) IV/10/IM; repeat every 5 minutes, up to a maximum of 0.1 mg/kg, if needed. d. If medications are administered, place them on cardiac monitor. Monitor cardiac rhythm and pulse oximetry. D. Hypothermia Review of Injury/Illness Hypothermia results when the body loses more heat to the environment than it can generate metabolically. Hypothermia is a cold injury of greatest significance. Signs and Symptoms Mild hypothermia (core body temperature 98.6-920 F) * Shivering * Unable to perform complex tasks with hands * Poor judgment * Amnesia Moderate hypothermia (core body temperature 91-860 F) * Violent shivering to potential loss of shivering reflex KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 183 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 * Dazed consciousness, slurred speech, irrational behavior * Loss of fine motor coordination * Dilated pupils * Mild to moderate hypotension * Diminished respiratory rate and effort Severe hypothermia (core body temperature <_ 850 F) * Shivering occurs in waves until it ceases as body temp drops * Severe altered mental status * Absent response to pain * Muscle rigidity, skin becomes pale * Pupils dilate, pulse rate decreases, breathing becomes erratic * Cardiac abnormalities, hypotension Hypothermia Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Monitor core body temperature. 6. Assess for possible hypoglycemia and treat. (Refer to Protocol II.C.) 7. Move patient to warm place if feasible: a. Handle gently in moderate to severe hypothermia as jostling can precipitate cardiac arrhythmias. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 184 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 b. DO NOT massage or vigorously manipulate the patient. 8. Minimize patient's exposure to weather. 9. Replace wet clothing with dry, if possible. 10. Passive re-warming: a. Wrap in rescue blanket if available. b. Ensure adequate insulation between patient and ground. 11. Active re-warming: a. Hot packs to neck, groin, and armpits, if available. b. Discourage PO intake if hypothermia is moderate or severe. c. Assist ventilations with BVM and 02. d. Begin CPR if the patient deteriorates and loses spontaneous respiration or pulses. In general, CPR should not be considered unsuccessful and terminated until patient has been warmed (core body temperature > 95' F. 12. Continue supportive care and monitor vital signs, including core body temperature (rectal), until patient is turned over to a higher level of medical care. AILS 1. Confirm the completion of BLS steps 1-11. 2. Initiate 0.9% Normal Saline via IV/10. Administer initial bolus of 250 ml. Use warm fluids, if available. 3. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 4. If hypoglycemic: a. Administer D50W: 25 gm IV/10. 5. If there is suspected opiate overdose, administer naloxone 0.4-2.0 mg slow IV/10/IM/Intranasal (if delivery device is available), up to a maximum of 6 mg, every 2-3 minutes. Titrate to adequate respiratory effort. 6. Continue re-warming and monitoring. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 185 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. AILS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10. Administer initial bolus of 20 ml/kg. 3. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 4. Continue re-warming and monitoring. E. Diving-related Emergencies Review of Iniury/Illness The most common dive-related medical presentations involve minor ear disorders, but systemic and life-threatening emergencies occur every year. These include arterial gas emboli (AGE), decompression sickness (DCS), and barotraumas to the ears and other locations. 1. When dealing with a diving-related incident, it is important to transport the diver's equipment with him during evacuation, so it can be inspected and possibly analyzed. DO NOT clear patient's dive computer. The dive history obtained from a patient by an EMS provider should include at a minimum: the times, duration and depth of dives (includes bottom time), as well as the number of dives over the previous 3 days, surface intervals, activity performed while diving, and whether the dive(s) were complicated by events such as entrapment, running out of air, or rapid ascent. It is also important to record the time and rapidity of onset of symptoms. 2. Flying too soon after diving increases the risk of decompression sickness (DCS) and other dive-related problems. (Refer to Protocol VI11.F, Protocol VIII.G, Protocol VI11.H.) 3. Contact the Diver's Alert Network (DA ) at Duke University Medical Center, by calling 919- 684-4326, for further assistance. Minimum Flight Delay Dive History 12 hrs. Single, no-decompression dive 18 hrs Multi-day, no-decompression dives 24 hrs. Decompression required dive(s) 3 days If treated for DCS or arterial embolism (AGE) KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 186 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 F. Decompression Sickness (DCS) Review of Injury/Illness DCS, commonly known as "the Bends," is an emergency condition requiring treatment in a decompression chamber. DCS most often occurs within the first 1-6 hours after diving; further deterioration is unlikely to occur after 24 hours. The onset of symptoms is directly related to the severity of the DCS; in severe cases, symptoms occur more rapidly. Several forms of DCS primarily affect the nervous system, muscles,joints, skin, inner ear and cardiopulmonary system. At depth and under pressure (P), gas is absorbed into the tissues proportionate to depth and exposure time. Significant absorption most likely occurs following dives to depths > 33 feet of sea water (FSW). DCS results from the formation of bubbles of inert gas (e.g., nitrogen) within the intravascular and extravascular spaces as the diver ascends to the surface, when the ascent is too rapid to allow nitrogen to be released that is absorbed in the tissues during the dive. Signs and Symptoms Depending on the distribution of gas bubbles throughout the body, DCS may create a variety of symptoms: * Pruritus (early symptom), skin rash * Unusual fatigue * Joint pain, abdominal or thoracic pain ("girdling" pain) * Shortness of breath, frothy sputum, hemoptysis * Dizziness, vertigo, tinnitus, parasthesia, paralysis, seizures,tremors, staggering * Altered mental status, confusion, amnesia, behavioral changes Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 187 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Primary treatment is recompression in a hyperbaric chamber. 6. Keep patient supine. 7. Administer oxygen, if available: 10-15 L/min by non-rebreathing mask to keep 02 saturation at a minimum of 94%. 8. Transport diver's equipment with patient during evacuation for inspection and possible analysis. DO NOT clear patient's dive computer. AILS 1. Confirm the completion of BLS steps 1-8. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. If seizures develop, consult medical control before administering IV benzodiazepines (e.g., midazolam). G. Arterial Gas Emboli (AGE) Review of Injury/Illness Arterial gas emboli (AGE) are the most common cause of sudden death in diving. Sudden collapse or loss of consciousness immediately or soon after surfacing should always be treated as AGE until proven otherwise. A complication of pulmonary barotrauma (PBT), AGE may cause near-drowning during ascent. It is most commonly seen in panicked or inexperienced divers making a rapid ascent while holding their breath, as the rapidly expanding air ruptures the pulmonary alveoli and allows gas bubbles to enter the blood stream across the capillary membranes. These bubbles may cause sudden loss of perfusion to the brain, heart, and other vital organs. Massive gas loading of the vasculature causes cardiac arrest that is refractory to resuscitation efforts. Signs and Symptoms * Abrupt onset of symptoms occurring during ascent or within 10 minutes after surfacing * Stupor, confusion,vertigo, coma, convulsions * Unilateral or bilateral motor or sensory deficits * Visual disturbances KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 188 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Symptoms may also include: * Aphasia * Headache * Chest pain related to myocardial ischemia * Cardiac arrhythmias, cardiac arrest * Symptoms of other barotrauma and decompression sickness (DCS) may also be present Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. S. Primary treatment is recompression in a hyperbaric chamber. 6. Keep patient supine. 7. Administer oxygen, if available: 10-1S L/min NRBM to keep 02 saturation at a minimum of 94%. 8. Transport diver equipment with patient during evacuation for inspection and possible analysis. DO NOT clear patient's dive computer. Urgently transport for decompression. AILS 1. Confirm the completion of BLS steps 1-9. 2. Initiate 0.9% Normal Saline via IV/IO at KVO or saline lock. a. DCS patients are often hypovolemic. 3. If seizures develop, consult medical control before administering IV benzodiazepines (e.g., midazolam). KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 189 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 H. Barotrauma of the Ear Review of Injury/Illness There are 3 barotraumas related to the ear: 1. External ear barotrauma: Also known as barotitis externa media interna or "ear canal squeeze"; caused by air trapped in the external auditory canal (EAC) by: a. Cerumen impaction. b. Exocytoses (chronic narrowing of the EAC). c. The use of ear plugs or a tight wet suit hood. 2. Middle Ear Barotrauma: a. Barotitis media or "ear squeeze" and "reverse ear squeeze." b. Caused by failure of middle ear to equalize to ambient pressure (P). 3. Inner Ear Barotrauma (IEB): a. Also known as barotitis interna or labyrinthine window rupture. b. Caused by the pressure differential between the inner ear and ambient pressure. c. IEB may cause injury to the cochleovestibular system of the inner ear, may lead to permanent vestibular dysfunction or deafness. d. It is important to distinguish IEB from the dizziness, balance problems, nausea, and vomiting that are also symptoms of decompression sickness (DCS). Signs and Symptoms External Ear Barotrauma * Pain, swelling, and erythema to the EAC * Petechiae or hemorrhagic blebs may be seen on the walls of the EAC Middle Ear Barotrauma * Pain, begins as slight pain and progressively worsens on descent/ascent * Impaired hearing * Nasal congestion KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 190 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 * Tympanic membrane (ear drum) rupture • Sudden severe pain • Vertigo, as water enters into the middle ear * Total loss of hearing in the affected ear * Blood may be seen around the mouth and nose as well as in the EAC Inner Ear Barotrauma * Sudden pain, dizziness,vertigo, may be extreme * Nausea and vomiting (vomiting underwater may lead to drowning) * "Roaring"tinnitus, hearing loss * Nystagmus, ataxia, facial nerve paralysis * Pallor, diaphoresis, disorientation * Ear may feel "blocked" or patient may relate a feeling of"fullness" in the ear * Differentiation from inner ear Decompression Sickness (DCS): • IEB is usually associated with ear pain and clearing difficulties upon descent • In IEB, evidence of other barotraumas may be seen on ear exam • In inner ear DCS, symptoms are often noted upon ascent or shortly after surfacing • Other symptoms of decompression sickness are often present with inner ear DCS Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 191 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 8. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. ALS 1. Confirm the completion of BLS steps. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. I. Envenomations Snakes and Spiders Review of Injury/Illness Snake and spider bites can cause damage to body tissue at the location of the bite and, if venomous, can cause both local tissue injury and systemic reactions. A snakebite, whether from a venomous or non-venomous snake, may cause severe fright reactions (e.g., nausea, tachycardia, diaphoresis), which may be difficult to distinguish from systemic manifestations of envenomation. Non -venomous snakebites cause only local injury, usually pain and 2-4 rows of scratches from the snake's upper jaw at the bite site. It is important to know and recognize all species of venomous snakes that are indigenous to areas of operation. Spiders are identified by location and markings. Black widow spiders live outdoors in protected spaces (e.g., rock piles, firewood cords, hay bales, outhouses) and have a red or orange hourglass marking on the ventral (upper side) abdomen. Brown recluse spiders live indoors in protected spaces (e.g., in clothing, behind furniture, under baseboards) and have a fiddle- or violin-like marking from the eyes to the abdomen. This marking may be difficult to recognize even in the intact spider. Signs and Symptoms *Contact Poison Control Center * Local bite wound 1-800-222-1222 for assistance in managing * Swelling, severe allergic reaction specific envenomations * Bleeding * Ecchymosis at site *Contact Miami Dade Fire Rescue for * Localized pain Anti-Venom (Venom 1) Unit: If Needed: * Weakness 786-336-6600 * Tachycardia * Nausea KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 192 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 * Shortness of breath * Respiratory arrest * Dim vision * Vomiting and/or shock Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure the patient. 6. Assess and treat for anaphylaxis. (Refer to Protocol X.A.) 7. Secure and maintain airway and administer supplemental oxygen via non-rebreathing mask (NRBM), as needed. 8. Assess and treat for shock. (Refer to Protocol X.I.) 9. Prepare for immediate transport. (DO NOT delay transport for any first aid/treatment measures or wait for signs of envenomation to occur.) 9. DO NOT apply any constricting bands, ice, or suction to the bite. 10. Remove ALL watches, rings and jewelry, not just from affected limbs. 11. Mark the proximal edge of any discoloration or swelling in ink and write the time on the line. If signs increase during treatment, make new marks with the times, if possible. 12. Dress the wound and immobilize the extremity. 13. If the snake or spider is identified in the field, notify receiving facility of type of bite and patient's condition ASAP in case they need to initiate acquisition of antivenin. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 193 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 14. Notify on-line medical direction of the situation so that antivenins can be obtained. 15. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. ALS 1. Confirm completion of BLS steps 1-14. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock 3. Monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 4. BLACK WIDOW SPIDER BITES • For severe muscle spasms, administer Ativan 1-2mg Max 5mg IV/IM/I 5. SCORPION STINGS • Avoid the use of narcotic analgesic such as Morphine which may increase potential for seizures and respiratory failure • Provide rapid transport to hospital and notify receiving facility of species for availability of antivenin Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 194 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 J. Marine/ Bites/Stings Corals and Jellyfish Review of Injury/Illness Most marine bites and stings are at least transiently painful, while some involve envenomation as well. All create wounds at risk of infection with marine organisms. The most common encounters are with a class of marine animals called Cnidaria and they include the following: • Corals • Sea anemones • Jellyfish (e.g., sea nettles) • Hydroids (e.g., Portuguese man-of-war) Cnidarians are responsible for more envenomation's than any other marine animal. However, of the 9,000 species, only about 100 are toxic to humans. The multiple, highly developed stinging units (nematocysts) on Cnidaria tentacles can penetrate human skin; one tentacle may fi re thousands of nematocysts into the skin on contact. Signs and Symptoms * Lesions vary with the type of Cnidaria. * Usually, lesions initially appear as small, linear, papular eruptions that develop rapidly in one or several discontinuous lines, at times surrounded by a raised erythematous zone. * Pain is immediate and may be severe; itching is common. * The papules may blister and proceed to formation of painful, raised pustules, hemorrhage, and eventual peeling of the skin. * Systemic manifestations include weakness, nausea, headache, muscle pain and spasms, tearing of the eyes and nasal discharge, increased perspiration, changes in pulse rate, and pleuritic chest pain. * Uncommonly,fatal injuries have been inflicted by the Portuguese man-of-war in North American waters and by the box jellyfish (sea wasp, Chironex fleckeri), in Indo-Pacific waters. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 195 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure the patient. 6. Assess and treat for anaphylaxis. (Refer to Protocol X.A.) 7. Secure and maintain airway and administer supplemental oxygen via non-rebreathing mask (NRBM), as needed. 8. Assess and treat for shock. (Refer to Protocol X.I.) 9. For pain relief due to stings, administer hot water or cold packs (whichever feels better). 10. Pain caused by jellyfish, usually short-lived, can be relieved with baking soda in a 50:50 slurry applied to the skin, or by papain (meat tenderizer) applied as a paste for a period not to exceed 15 minutes. 11. Jellyfish-type sting treatment includes removal of adherent tentacles with forceps (preferably) or fingers (double-gloved if possible) and liberal rinsing to remove invisible stinging cells (nematocysts). The type of rinse varies by the stinging organism: a. For jellyfish stings sustained in non-tropical waters and for coral stings, seawater rinse can be used. b. For jellyfish stings sustained in tropical waters, vinegar rinse followed by seawater rinse should be used. Fresh water should not be used because it can activate undischarged nematocysts. c. For box jellyfish stings, vinegar inhibits nematocyst firing and is used as the initial rinse if available, followed by seawater rinse. Fresh water should not be used because it can activate undischarged nematocysts. Notify on-line medical direction of the situation so that antivenins can be obtained. (Antivenin is only available for C. fleckeri species.) KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 196 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 d. For Portuguese man-of-war stings, saltwater rinse can be used. Vinegar should not be used because it can activate undischarged nematocysts. 13. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS Steps 1-12. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Seabather's Eruption Review of Injury/Illness This condition affects swimmers in some Atlantic locales (e.g., Florida, Caribbean, Long Island). It is caused by hypersensitivity to stings from the larvae of the sea anemone (e.g., Edwardsiella lineate) or the thimble jellyfish (Linuche unguiculata). Signs and Symptoms * Itchy, stinging rash typically appearing where the bathing suit contacts the skin Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 197 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure the patient. 6. Assess and treat for anaphylaxis. (Refer to Protocol X.A.) 7. Encourage patients to sit in a shaded area and wait for conditions to ease. 8. People exposed to these larvae should shower after taking off their bathing suit. 9. Cutaneous manifestations can be treated with hydrocortisone lotion and an oral antihistamine, if needed. 10. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. AILS 1. Confirm the completion of BLS steps 1-9. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock, if necessary. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. AILS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock, if necessary. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 198 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 iij i orf Brown Recluse Spider Black Widow Spider Highly venomous Scorpion They have thick tails and thin pincers. Not usually in the Keys. Non-venomous Wolf Spider Brown Widow Spider Non-venomous Scorpion-They have thin tails and broad, well- developed pincers. Common in the Keys- both black and brown KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 199 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 �IIIX I ra ILIiiiirilia The following patients should be transported to a Trauma Center: • Trauma patients with unstable or abnormal vital signs • Patients with major and/or multiple system trauma • Complex or extensive injury to hands, tissues, and nerves of low extremity • Contraindication for Referral to Pediatric or Adult Trauma Center— Patients with toe amputation (partial or complete) A. Extremity wound hemorrhage Review of Injury/Illness Uncontrolled bleeding from an extremity wound, especially one involving major or deep arteries, can result in life threatening blood loss. Massive, rapid swelling of an extremity following blunt trauma with or without bruising or discoloration may suggest bleeding even without obvious surface laceration. Personnel engaged in military and law enforcement operations are at increased risk for penetrating trauma and exsanguinating wounds. Tourniquets are sometimes the best way to manage life-threatening bleeding from an extremity. Tourniquets placed on conscious patients can be painful and pain management should be considered. Signs and Symptoms * Obvious bleeding at the site of wound * Deep scraping of extremity area (e.g., road rash from a motorcycle accident) with substantial, oozing blood * Swelling of the extremity, usually with obvious bruising * Altered mental status from blood loss and ensuing shock Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 100 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain airway and administer supplemental oxygen, as needed. 7. Assess and treat for shock. (Refer to Protocol X.I.) 8. Check for obvious glass or foreign body that could cause further injury, if pressed into wound. 9. Wrap bleeding area with trauma pads or dressing appropriate for the size and location of the wound. 10. Apply direct pressure and elevate until bleeding is controlled, if possible. If the patient is able, have him/her apply direct pressure after dressing the wound. 11. If bleeding CANNOT be controlled by direct pressure: a. Apply a tourniquet proximal to the wound. • Use a commercially available tourniquet, Combat Application Tourniquet (CAT), 2-4 inches proximal to the wound. b. DO NOT apply tourniquet directly over a joint. c. Tighten the tourniquet just enough to control/stop the bleeding. This is generally tight enough so that pulses distal to the tourniquet are not palpable. d. Document the time that the tourniquet was applied to the patient. NEVER skip these steps when a tourniquet is in place. e. Always leave the wound and tourniquet sites uncovered so that any additional bleeding can be observed and treated accordingly. 12. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. Consider the need for Aeromedical evacuation. AILS 1. Confirm the completion of BLS Steps 1-11. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Pediatric KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 101 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 BLS 1. Follow BLS guidelines, adjusting for patient age/size. AILS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. B. Amputations Review of Injury/Illness Patients with severe bone and/or soft tissue injury at or distal to the level of the mid-humerus, including complete or incomplete amputations of the hand, crush or degloving injuries, and other trauma resulting in loss of perfusion or suspected nerve injury (e.g., compartment syndrome) should be referred to nearest Trauma Center if: • They are stable with an isolated upper extremity injury at or below the mid-humerus • They have complete/incomplete hand or upper extremity amputation • There is partial/complete finger or thumb amputation • There is degloving, crushing, or devascularization injuries of hand or upper extremity • There is high-pressure injection injury to hand or upper extremity • There is complicated nerve, vessel, or compartment syndrome (excessive swelling and pain of extremity with possible evolving nerve deficit) injury of the forearm and hand. Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 102 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 6. Secure and maintain airway and administer supplemental oxygen, as needed. 7. Assess and treat for shock. (Refer to Protocol X.I.) 8. Control extremity wound hemorrhage. (Refer to Protocol IX.A.) 9. Package amputated extremity in sealed plastic bag (keep dry) and place on top of ice to keep cool. DO NOT submerge in water or freeze amputated part. 10. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. Consider the need for Aeromedical evacuation to the nearest Trauma Center. AILS 1. Confirm the completion of BLS steps 1-9. 2. Initiate 0.9% Normal Saline via IV/IO 250 ml fluid bolus, up to a maximum total infusion of 2,000 ml without consulting on-line medical direction. (Maintain systolic BP 90 palp) 3. Provide pain relief with *Morphine 4mg increments up to 12 mg ** Fentanyl may be used 3. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current as an alternative to American Heart Association (AHA) ACLS guidelines. Morphine. Pediatric Fentanyl 25-50mcg/ Max BLS 100mcg 1. Follow BLS guidelines, adjusting for patient age/size. AILS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at 20 ml/kg fluid bolus, up to a maximum total infusion of 40 ml/kg. C. Multi-system Trauma Review of Injury/Illness Multi-system trauma refers to injuries involving more than one organ system and/or more than one area of the body. A patient with limb fracture(s) and significant head/neck injury, or one with trauma to both the chest and abdomen are examples of multi-system trauma. It is associated with an injury severity score > 17 and increased likelihood of death or a complicated KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 103 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 clinical course and protracted time to recovery. It is important that EMS providers report scene findings that help estimate the severity of the injury. Signs and Symptoms * Hypovolemic or neurogenic shock * Pain, bruising, bleeding * Hypertension * Rapid or slow heart rate * Shallow or absent respirations * Decreased distal pulses * Decreased motor and sensory function in extremities * Deformities or obvious fractures/lacerations * Altered mental states or unconsciousness * Intercranial herniation • Posturing (decerebrate or decorticate) • Unequal pupils • Paralysis • Decreasing Glasgow Coma Scale Scores Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 104 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 6. Secure and maintain airway and administer supplemental oxygen via non-rebreathing mask (NRBM) at high concentration. Assist ventilations with a bag valve mask (BVM) device, as needed. 7. If patient exhibits signs of intercranial herniation, hyperventilate at 20 breaths/minute, after consulting on-line medical direction. 8. Control extremity wound hemorrhage. (Refer to Protocol IX.A.) 9. Assess and treat for shock. (Refer to Protocol X.I.) 10. Maintain appropriate spine immobilization, according to Protocol IX.E. (Any trauma patient with suspected spinal injuries based on mechanism of injury should have full body spinal immobilization.) 11. Consider pelvic stabilization, if indicated. 12. Continue supportive care and monitor vital signs until the patient is turned over to higher level of medical care. Consider the need for Aeromedical evacuation to the nearest Trauma Center. AILS 1. Confirm the completion of BLS steps 1-9. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline IV/10 250-500 ml bolus, up to a maximum total infusion of 2,000 ml without consulting on-line medical direction. Titrate to a Systolic BP = 100 mm Hg. 4. Provide pain relief(Refer to Protocol I.C.) 5. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. If patient exhibits signs of intercranial herniation, hyperventilate at 30 breaths/minute (child) or 35 breaths/minute (infant), after consulting on-line medical direction. AILS 1. Follow the BLS guidelines, adjusting for patient age/size. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 105 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. If patient exhibits signs of intercranial herniation, hyperventilate at 30 breaths/minute (child) or 35 breaths/minute (infant), after consulting on-line medical direction. 4. Initiate 0.9% Normal Saline via IV/10 at 20 ml/kg fluid bolus, up to a maximum total infusion of 40 ml/kg. D. Chest and Abdominal Injuries Review of Injury/Illness Chest and abdominal injuries are caused by penetrating or blunt forces applied to the torso. Respiratory distress may indicate pneumothorax; hypotension suggests tension pneumothorax or internal bleeding, both of which can cause rapid death if not treated promptly. Myocardial contusion can result in sudden arrythmias, including ventricular tachycardia and ventricular fibrillation with cardiac arrest. Signs and Symptoms * Pain, bruising, deformity of chest/abdomen following rapid deceleration (impact) injuries * Evidence of penetrating wound to the chest/abdomen by knife, bullet, or sharp object * Difficulty breathing and/or hypotension/shock Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Perform airway management for unconscious patients— Chin lift or jaw thrust maneuver NP or OP airway and ventilate if necessary. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 106 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 7. Secure and maintain airway and administer supplemental oxygen via non-rebreathing mask (NRBM) at high concentration. Assist ventilations with a bag valve mask (BVM) device, as needed. 8. All open and/or sucking chest wounds should be treated by immediately applying a Chest Seal (Entry/ Exit). Monitor lung sounds and trachea position for development of tension pneumothorax. 9. Control extremity wound hemorrhage. (Refer to Protocol IX.A.) 10. Assess and treat for shock. (Refer to Protocol X.I.) 11. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. Consider the need for Aeromedical evacuation to the nearest Trauma Center. AILS 1. Confirm the completion of BLS steps 1-10. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline IV/10 250-500 ml bolus, up to a maximum total infusion of 2,000 ml without consulting on-line medical direction. Titrate to a Systolic BP = 100 mm Hg. 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Pediatric BLS 1. Follow the BLS guidelines, adjusting for patient age/size. AILS 1. Follow the BLS guidelines, adjusting for patient age/size. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 at 20 ml/kg fluid bolus, up to a maximum total infusion of 40 ml/kg. 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Apply pediatric pads. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 107 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 E. Spinal Cord Injuries Review of Injury/Illness EMS responders are most likely to see spinal cord injuries, resulting from motor vehicle crashes, diving accidents, and falls. Young children and the elderly are especially vulnerable. Signs and Symptoms * Paralysis, numbness, or tingling sensation in one or more extremities * Obvious head or facial trauma * Loss of consciousness (may or may not be present) Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain airway and administer supplemental oxygen via non-rebreathing mask (NRBM) at high concentration. Assist ventilations with a bag valve mask (BVM) device, as needed. 7. Maintain appropriate spine immobilization, according to Protocol IX.E. (Any trauma patient with suspected spinal injuries based on mechanism of injury should have full body spinal immobilization.) 8. Consider pelvic stabilization, if indicated. 9. Assess and treat for shock. (Refer to Protocol X.I.) 10. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. Consider the need for Aeromedical evacuation to the nearest Trauma Center. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 108 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 ALS 1. Confirm the completion of BLS steps 1-8. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline IV/10 250-500 ml bolus, up to a maximum total infusion of 2,000 ml without consulting on-line medical direction. Titrate to a Systolic BP = 100 mm Hg. 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Pediatric BLS 1. Follow the BLS guidelines, adjusting for patient age/size. ALS 1. Follow the BLS guidelines, adjusting for patient age/size. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 at 20 ml/kg fluid bolus, up to a maximum total infusion of 40 ml/kg. F. Selective Spinal Immobilization Review of Injury/Illness In rescue situations, field evacuation of an immobilized patient on a backboard significantly extends the time required and increases the risk of further injury to both the patient and the rescuers. Under the circumstances, it is imperative that the patient's C-spine be evaluated and if possible, cleared, allowing the patient to participate more in the evacuation and reducing the travel time to definitive care. C-spine clearance can be performed in the fi eld with approximately 99% certainty, for all eligible and injured patients using the NEXUS protocol. Procedure (NEXUS Protocol) BLS ALS 1. Assess and treat for possible spinal cord injury. (Refer to Protocol IX.E.) 2. It is not necessary to immobilize the C-spine if the patient meets ALL the following criteria: a. The patient is conscious and not under the influence of drugs or alcohol. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 109 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 b. No other distracting injury that might mask the pain of a cervical injury is present. c. No neck pain is present. d. No cervical tenderness or bony "step off" of the cervical spine is present upon examination and palpation. e. The patient can move all four extremities. f. The patient denies numbness or parasthesia and has intact sensation to light touch in all four extremities. 3. Contact on-line medical direction for further guidance. 4. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. Special Rescue Considerations 1. There may still be instances when the patient can or must be evacuated ambulatory, even though the patient cannot be cleared using the NEXUS protocol (e.g., neck pain with no other findings). 2. The medical provider must use good judgment and balance the clinical findings and mechanism of injury with the risks versus benefits of evacuating an immobilized patient on a backboard. G. Electrical Burns and Lightning Injuries Review of Injury/Illness Electrical burns may be associated with other traumatic injuries, due to being thrown clear of the source and severe muscle contraction, especially following high voltage DC contact. Longer exposure to lower energy current results in skin and deep tissue burns. Signs and Symptoms * "Entry" and "exit" site burns * Confusion and/or amnesia, with or without temporary loss of consciousness * Ear drum rupture * Fractures * Cardiac dysrhythmias/arrest KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 110 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Lightning injuries can range from minor wounds to serious traumatic injuries that can result in death. Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol LA, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain airway and administer supplemental oxygen, if necessary. Assist ventilations with a bag valve mask (BVM) device, as needed. 7. Maintain appropriate spine immobilization, according to Protocol IX.E. 8. Splint any fractures. 9. Dress any open wounds and/or burns. (Refer to Protocol V.) 10. Assess and treat for shock. (Refer to Protocol X.I.) 11. Provide pain relief(Refer to Protocol I.C.) 12. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. Consider the need for Aeromedical evacuation to the nearest Trauma or Burn Center. ALS 1. Confirm the completion of BLS steps 1-8. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 111 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Pediatric BLS 1. Follow the BLS guidelines, adjusting for patient age/size. ALS 1. Follow the BLS guidelines, adjusting for patient age/size. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. If hypotensive, initiate 0.9% Normal Saline via IV/10 at 20 ml/kg fluid bolus, up to a maximum total infusion of 40 ml/kg. 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Apply pediatric pads. H. Orthopedic Bone and Joint Injuries Review of Injury/Illness These injuries are a result of a traumatic direct force or twisting action on a bone or joint. Other than neck or back injuries involving the spinal cord, orthopedic injuries are often not life threatening. Signs and Symptoms * Pain near injury * Swelling and/or bruising near injury * Obvious bony deformity * Limited range of motion Identify any life-threatening injuries. Pelvic and femur fractures can cause severe internal and external hemorrhaging that can lead to death. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 112 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain airway and administer supplemental oxygen, as needed. 7. Control extremity wound hemorrhage. (Refer to Protocol IX.A.) 8. Apply ice or cold packs to sites of swelling/deformity. 9. Splint obvious fractures and dislocations after checking for pulses distal to the fracture site: a. Splint the joints above and below the fracture site. b. If fracture/dislocation is open (compound), cover the open area with sterile dressing. DO NOT push bone back in if it is protruding. c. If fracture is angulated and the distal limb is pulseless, attempt to realign to neutral position using mild traction. If significant resistance is met, stop immediately and splint in position found. d. If fracture/dislocation is angulated with pulse, splint in position found. e. Reassess distal circulation before and after splinting. 10. Treat cervical injury, if indicated. (Refer to Protocol IX.E.) 11. Treat pelvic injury with pelvic stabilization device, if available. 12. Treat femur fracture with a traction splint, if available. Traction splint is contraindicated if: a. Suspected pelvic fracture b. Femoral neck (hip) fracture c. Avulsion or amputation of the ankle and foot d. Fractures distal to knee KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 113 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 13. Treat clavicle injury by "sling and swathe" with the patient's arm in a position of comfort. 14. Assess and treat for shock. (Refer to Protocol X.I.) 15. Provide pain relief(Refer to Protocol I.C.) 16. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. AILS 1. Confirm the completion of BLS Steps 1-14. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. AILS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. I. Head, Neck and Facial Injuries Review of Injury/Illness Head, neck, and facial injuries can also cause Traumatic Brain Injury (TBI), which can be life- threatening. TBIs can present with loss of consciousness or changes in mental status ranging from confusion and combativeness to lethargy. Signs and Symptoms Head * Visible Wounds * AMS * Unequal Pupils * "Raccoon Eyes" * CSF or blood drainage from ear, nose, throat * Convulsions/seizures KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 114 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 * Paralysis * Bruising behind the ear Neck * Hemorrhage * AMS * Hoarseness * Dyspnea, strider * Head fixed in an abnormal position * Vomiting/spitting blood * Paralysis, weakness, or abnormal sensation in upper or lower extremities Facial * Lacerated gums * Misaligned/broken teeth * Nosebleed * Limited eye movements * Massive hemorrhage even with minor wounds * Facial asymmetry * Difficulty swallowing * CSF drainage from nose Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions. as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 115 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain airway and administer supplemental oxygen, if necessary. Assist ventilations with a bag valve mask (BVM) device, as needed. 7. Maintain appropriate spine immobilization, according to Protocol IX.E. 8. Assess and treat for shock. (Refer to Protocol X.I.) 9. If a penetrating eye injury is noted or suspected: a. Leave object in eye. b. Perform a rapid field test of visual acuity. c. If an object is protruding from the eye socket, stabilize the object with bulky dressings and tape; then surround object with cup to prevent jarring. d. If an object is not protruding, cover the eye with a soft patch that does not touch eye. e. Protruding Globe— DO NOT put eye back in socket—Apply bulky dressing around eye, moist gauze over globe, and cover with a cup. f. If CSF is found, do not pack or suction nose/ear and transport in upright position. g. Use extreme caution with head injury and esophageal injury. 10. In cases of nasal injury, DO NOT tilt head back to control bleeding. Pinch the patient's nostrils and apply ice to the bridge of nose. 11. If CNS injury, perform and record full neurological assessment, including the Glasgow Coma Scales. Repeat and record every 5-10 min. (Refer to Protocol XII.L.) 12. Resuscitation for victims of a blast or penetrating trauma who have no pulse, no respiration, and no other signs of life should not be initiated. (Refer to Protocol XI.D.) 13. Provide pain relief(Refer to Protocol I.C.) 14. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. ALS 1. Confirm the completion of BLS steps 1-12. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 116 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 4. Nasal Injury: DO NOT attempt nasal intubation. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. AILS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 117 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 X. tlieiu°° I e liical III'IIIIiiiiiiiergeuides A. Allergic Reaction Review of Injury/Illness The body's immune system normally helps it to recognize, inactivate and eliminate threats such as bacterial or viral infections. Sometimes the components of that system are activated by foods, medications, or environmental elements like pets, latex, or other chemicals causing allergic reactions. Allergic reactions range from mild cold-like symptoms and rashes to life- threatening airway emergencies and shock (acute anaphylaxis). Signs and Symptoms * Itching, Hives * Swelling * Difficulty breathing (hoarseness, stridor) * Difficulty swallowing * Chest pain * Weakness * Flushing/redness * Wheezing * Unconsciousness Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol LA, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 118 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 6. Acute Anaphylaxis: a. If a patient has signs of cardiovascular or respiratory compromise (e.g., difficulty breathing, stridor, hypotension) and has a prescribed epinephrine auto-injector (EpiPen°), assistance may be offered for administration; may repeat x1 after 3-5 minutes. b. If the patient is wheezing, and has a prescribed MDI, assistance may be offered for administration. c. Continue to monitor vital signs, including pulse oximetry, if available. 7. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. AILS 1. Confirm the completion of BLS steps 1-6. 2. Secure and maintain airway and administer supplemental oxygen, if necessary. Assist ventilations with a bag valve mask (BVM) device, as needed. 3. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 4. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. MILD REACTIONS • Diphenhydramine HCI (Benadryl) 50 mg IM or SLOW IV • If bronchospasm is present, administer Albuterol: one nebulizer treatment containing 2.5 mg of Albuterol premixed with 2.5 mL normal saline. May be repeated twice as needed • If bronchodilators are administered, may add Ipratoprium bromide (Atrovent) 0.5 mg (0.5 mL) to Albuterol nebulizer treatment • Epinephrine (1:1000) 0.3 mg IM • Consider the need for advanced airway management • SOLU MEDROL 125 mg IV push over 2 min MODERATE REACTIONS • Epinephrine (1:1000) 0.3 mg IM • Diphenhydramine HCI (Benadryl) 50 mg IM or SLOW IV KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 119 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 • If bronchospasm is present, administer Albuterol: one nebulizer treatment containing 2.5 mg of Albuterol premixed with 2.5 mL normal saline • If bronchodilators are administered, may add Ipratoprium bromide (Atrovent) 0.5 mg (0.5 mL) to Albuterol nebulizer treatment • Consider the need for advanced airway management • SOLU MEDROL 125 mg IV/IM • May repeat Epinephrine (1:1000) 0.3 mg IM 5. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 6. For patients taking beta blockers, who are unresponsive to epinephrine, consider Glucagon 1.0 mg IV/10/IM, every 5 minutes; may repeat x2. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. If pediatric patient is in anaphylaxis, and has a prescribed EpiPen,° assistance may be offered for administration. a. Patients weighing < 30 kg may have been prescribed EpiPen Jr° (0.15 mg of epinephrine) for IM administration; may repeat x1. b. Patients weighing > 30 kg may have been prescribed an adult dose EpiPen° (0.3 mg of epinephrine); may repeat x1. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Secure and maintain airway and administer supplemental oxygen, if necessary. Assist ventilations with a bag valve mask (BVM) device, as needed. 3. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 4. Initiate 0.9% Normal Saline via IV/10 at 20 ml/kg fluid bolus, up to a maximum total infusion of 40 ml/kg. MILD REACTIONS Mild reactions consist of redness and/or itching, but normal perfusion without dyspnea. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 120 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 • For severe itching, administer Diphenhydramine (Benadryl®) 1 mg/kg IM or SLOW IV (maximum dose 50 mg). If administering Benadryl IV dilute amount in 9mL of normal saline MODERATE REACTIONS Moderate reactions are characterized by edema, hives, dyspnea, wheezing, and normal perfusion • Epinephrine (1:1000) 0.01 mg/kg IM lateral thigh (maximum dose of 0.3 mg) • Diphenhydramine (Benadryl°) 1 mg/kg IM lateral thigh or SLOW IV (maximum dose of 50 mg). If administering Benadryl IV dilute amount in 9 mL of normal saline. • Albuterol: If the patient remains in respiratory distress, administer one nebulizer treatment. * If less than 1 year or less than 10 kg: 1.25 mg/1.5 mL (0.083%). * If greater than 1 year or greater than 10 kg: 2.5 mg/3 mL (0.083%). B. Hypertensive Crisis Review of Illness/Iniury A severe increase in blood pressure accompanied by evidence of an organ damage that can lead to a stroke or another neurological manifestation. Signs and Symptoms * Systolic BP usually > 180 mm Hg * Headache with or without AMS * Chest pain/ECG changes * Pulmonary edema * Neurologic changes consistent with stroke Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 121 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain airway and administer supplemental oxygen, if necessary. Assist ventilations with a bag valve mask (BVM) device, as needed. 7. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. AILS 1. Confirm the completion of BLS steps 1-6. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 4. If Systolic BP > 180 mm Hg or Diastolic BP >_ 110 mm Hg, monitor blood pressure every 5 minutes Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Contact on-line medical direction for further guidance. AILS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Apply pediatric pads. 4. Contact on-line medical direction for further guidance C. Epistaxis Review of Injury/Illness It is important to recognize when nose bleeds result from head or face trauma. (Refer to Protocol IX.I.) KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 122 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Signs and Symptoms * Bleeding from one or both nares Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain airway and administer supplemental oxygen, as needed. 7. Assess and treat for shock. (Refer to Protocol X.I.) 8. With patient in seated position, and head neutral, squeeze nostrils together with a dressing. If patient is able, he/she can hold compression on the nostrils; monitor for compliance and assist as needed (Must hold constant pressure for a minimum of 5 minutes.) 9. Apply cold pack to forehead/nose bridge area, if possible. 10. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. ALS 1. Confirm the completion of BLS steps 1-9. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 3. DO NOT attempt nasal intubation. D. Nausea/Vomiting Review of Injury/Illness Patients can present with nausea and/or vomiting due to underlying injury, medical condition, active motion sickness, or medication side effect/complication. Sometimes, vomiting or intense KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 123 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 nausea can complicate the existing injury or medical condition (e.g., penetrating eye injury, high risk for aspiration, side effects of narcotic administration). Signs and Symptoms * Vomiting or sensation of imminent vomiting * Inability to tolerate food or liquids * Retching or"dry heaves" Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain the airway. 7. Place patient either in position of comfort or in left lateral position to prevent aspiration, if not contraindicated by spinal immobilization or packaging. 8. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. ALS 1. Confirm the completion of BLS steps 1-7. 2. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. • Administer Zofran° (Ondansetron hydrochloride) * Injection 4 mg slow IV push over 2-3 minutes KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 124 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at 20 ml/kg fluid bolus, up to a maximum total infusion of 40 ml/kg. • Administer Zofran° (Ondansetron hydrochloride) Infection * Less than 40 kg: 0.1 mg/kg SLOW IV push over 2-3 minutes * 40 kg or more: 4 mg SLOW IV push over 2-3 minutes E. GI Bleeding Review of Injury/Illness Upper or lower GI bleeding can rapidly become a life-threatening medical emergency as a result of substantial blood loss with hypotension and shock. There are many potential sources of GI bleeding; most commonly: • Upper • Lower • Peptic ulcer disease • Infectious diarrhea • Hemorrhoids • Esophageal varices • Colon cancer • Esophageal tears due to vomiting • Diverticulitis • Rectal varices Signs and Symptoms * Vomiting bright red blood or material that resembles coffee grounds * Bloody diarrhea (may be infectious) * Blood visible on the outside of formed stool or noticed on toilet paper after wiping * Black, "tarry" stools (typically indicates upper GI source of bleed) KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 125 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 * Occult blood loss— May present with fatigue, general weakness, or syncope due to bleeding into the GI tract which is only found after testing for occult fecal blood Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Bloody vomiting: a. DO NOT allow patients to eat or drink anything. b. Administer supplemental oxygen, as needed. c. Ensure the airway is not threatened by severe vomiting; use advanced airway to prevent aspiration, if needed. d. If dehydrated, refer to Protocol VIII.A. 6. Bloody diarrhea: a. Provide oral hydration with water, diluted fruit juice, or diluted sports drink (50:50 with water), if patient is awake, able to swallow and mental status is intact. b. If dehydrated, refer to Protocol VIII.A. 7. If possible, take orthostatic vital signs. If mental status or blood pressure are abnormal with the patient lying down, DO NOT attempt to take an orthostatic set of vital signs. 8. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. ALS 1. Confirm the completion of BLS steps 1-7. 2. Initiate 0.9% Normal Saline via IV/10 250 ml fluid bolus, up to a maximum total infusion of 2,000 ml without consulting on-line medical direction. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 126 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. AILS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at 20 ml/kg fluid bolus, up to a maximum total infusion of 40 ml/kg. F. Abdominal Pain Abdominal pain can indicate many different conditions such as ulcers, appendicitis, colitis, inflammation of the gall bladder or pancreas, kidney stone and internal masses that cause obstruction. Any of these conditions generate moderate or severe abdominal pain. The acute (surgical) abdomen indicates an intra-abdominal emergency that requires urgent transport for immediate surgical intervention. Signs and Symptoms Peritoneal Inflammation * Abdominal pain, with or without vomiting * Tenderness with guarding * Rebound/percussive tenderness * "Rigid" abdomen * Patient lying perfectly still (movement causes severe pain) Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 127 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. DO NOT allow patients to eat or drink anything. 7. Ensure the airway is not threatened by severe vomiting; use advanced airway to prevent aspiration, if needed. 8. Administer supplemental oxygen, if needed. 9. For suspected GI bleeding, refer to Protocol X.E. 10. Assess and treat for shock. (Refer to Protocol X.I.) 11. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. AILS 1. Confirm completion of BLS steps 1-10. 2. Initiate 0.9% Normal Saline via IV/10 250 ml fluid bolus, up to a maximum total infusion of 2,000 ml without consulting on-line medical direction. Titrate to maintain Systolic BP > 90 mm Hg. 3. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. AILS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Initiate 0.9% Normal Saline via IV/10 at 20 ml/kg fluid bolus, up to a maximum total infusion of 40 ml/kg. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 128 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 G. Poisoning/Overdose Review of Illness/Injury Depression and other serious mental illness may cause a suicide attempt by overdose. Poisoning may occur by exposure to toxic substances via inhalation, injection, ingestion, or skin absorption. Children may be accidentally poisoned by medications, alcohol or household cleaners left unsecured. Poisoning may occur in the setting of a hazardous materials incident. Acute or chronic poisoning may also be a result of criminal and/or terrorist activity. Signs and Symptoms * Altered mental status (AMS) - Lethargy or unconsciousness vs. hyper-excitability * Vomiting and/or diarrhea * Tachycardia or bradycardia * Sweating * Dilated or constricted pupils * Difficulty breathing, with or without increased bronchial secretion * Cardiac dysrhythmias/arrest Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Remove patient from the toxic environment, using appropriately trained personnel wearing proper level PPE, if necessary; decontaminate as appropriate. 6. In case of ingestion, identify the source, substance, medication and/or amount ingested or inhaled, if possible. 7. Administer supplemental oxygen and monitor pulse oximetry, as needed. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 129 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 8. Contact Poison Control and follow their instructions 1-800-222-1222. 9. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. AILS 1. Confirm the completion of BLS steps 1-9. 2. Secure and maintain airway and administer supplemental oxygen, as needed. 3. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 4. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 5. Perform a glucose test with a finger stick. If glucose is less than 60 mg/dL (Refer to Protocol 11. C. Diabetic Emergencies). 6. Administer Narcan 0.4- 2 mg IV/10, IM, or IN, titrated to effect. Usual dose should not exceed 10mg. Fentanyl may require large doses of Naloxone to reverse Fentanyl's effects. 6. If the patient is seizing, administer one of the following benzodiazepines: • Midazolam (Versed) 2 mg increments IV, 10, IM maximum dose of 10 mg. • Lorazepam (Ativan) 2 mg IV, 10, IM may repeat once, up to a max dose of 4 mg. 6. If the patient is hypotensive (systolic BP less than 100 mm Hg), administer a fluid challenge of 500 m L. 7. Maintain contact with the Poison Control Center. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Contact the Poison Information Center (1-800-222-1222). AILS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Secure and maintain airway and administer supplemental oxygen, as needed. 3. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 4. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 130 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 5. Perform a glucose test with a finger stick. If glucose less than 60 mg/dL, (Refer o Protocol II. C. Diabetic Emergencies). 6. If narcotic overdose is suspected in a non-neonate, administer Narcan 0.1 mg/kg (maximum dose of 2 mg) IV/10/IM/IN. May repeat every 5 minutes as needed. 7. If tricyclic antidepressant overdose is suspected, administer Sodium Bicarbonate 1 mEq/I<g IV/10 8. Maintain contact with the Poison Control Center. H. Stroke, TIA Review of Injury/Illness A stroke is a loss of brain function due to insufficient blood flow and decreased oxygen reaching the affected area, usually caused by obstruction or rupture of one or more blood vessels in the brain. A TIA or Transient Ischemic Attack is a temporary disruption of function with stroke-like symptoms that typically resolves completely within 24 hours of onset. A TIA is generally considered a warning that a stroke could occur in the same distribution in the near future. Signs and Symptoms * Slurred speech * Facial droop * Unequal grips/arms drift or other extremity weakness * Change in mental status—as documented by friend or family member * Sudden change in vision * Sudden severe or unexplained headache * Syncope/vertigo * Ataxia Management BLS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 131 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure the patient. 6. Secure and maintain airway and administer supplemental oxygen, as needed. 7. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 8. Establish and relay time of symptom onset to receiving facility or transporting service. 9. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. ALS 1. Confirm the completion of BLS steps 1-8. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 4. Perform a glucose test with a finger stick (Medical Procedure 4.17). If glucose is less than 60 mg/dL, (Refer to Protocol II. C. Diabetic Emergencies). 5. If drug overdose is suspected, (Refer to Protocol X. G. Poisoning/Overdose). 6. Perform a neurological exam, including assessment of the patient's level of consciousness, Glasgow Coma Scale (GCS), and Cincinnati Pre-Hospital Stroke Scale 7. If seizures occur, treat according to seizure protocol. (Refer to Protocol II.B.) 8. Minimize the Stroke Alert on-scene time to 10 minutes or less. 9. Continually reassess the patient to determine if his/her symptoms are worsening or improving, and advise the stroke center of any changes. Pediatric BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Evaluate for overdose (e.g., cocaine, methamphetamine, street drugs). If suspected, refer to Protocol X.G. AILS 1. Follow BLS guidelines, adjusting for patient age/size. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 132 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 2. Evaluate for overdose (e.g., cocaine, methamphetamine, street drugs). If suspected, refer to Protocol X.G. 3. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 4. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. 5. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. Apply pediatric pads. 6. If seizures occur, treat according to seizure protocol. (Refer to Protocol II.B.) I. Shock Review of Iniury/Illness The body responds in various ways when blood flow cannot meet the oxygen demands of the cells, depending on the severity and duration of the decreased blood flow/oxygen delivery. Some of the common causes of shock include gastrointestinal bleeding, sepsis, severe dehydration, cardiac dysfunction, or blunt/penetrating trauma. Signs and Symptoms * General weakness * Cool, clammy skin (diaphoresis) * Dilated pupils * Rapid, weak pulse * Shallow, labored respirations * Decreasing pulse pressure * Altered mental status * Multi-system organ failure Management 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 133 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Calm and reassure patient. 6. Secure and maintain airway and administer supplemental oxygen via non-rebreathing mask (NRBM) at high concentration. Assist ventilations with a bag valve mask (BVM) device, as needed. 7. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 8. Initiate IV fluid resuscitation, if permitted by local protocol. (Refer to Protocol VIII.A.) 9. Control extremity wound hemorrhage, if necessary. (Refer to Protocol IX.A.) 10. Maintain appropriate spine immobilization, according to Protocol IKE, if indicated. (Any trauma patient with suspected spinal injuries based on mechanism of injury should have full- body spinal immobilization.) 11. Consider pelvic stabilization, if indicated. 12. Continue supportive care and monitor vital signs until the patient is turned over to a higher level of medical care. 13. Consider Aeromedical evacuation to the nearest Trauma Center, if available. AILS 1. Confirm the completion of BLS steps 1-11. 2. Provide advanced airway support, if necessary. (Refer to Protocol I.B.) 3. Initiate 0.9% Normal Saline via IV/10 250 ml fluid bolus, up to a maximum total infusion of 2,000 ml without consulting on-line medical direction. Titrate to maintain Systolic BP > 90 mm Hg. If rales are present, infuse up to 250 ml. Additional fluid requires consulting on-line medical direction. 4. Obtain 12-lead ECG and monitor cardiac rhythm and treat any dysrhythmia according to current American Heart Association (AHA) ACLS guidelines. 5. Patient combativeness secondary to trauma may be controlled with: • Lorazepam (Ativan) 2 mg IV, 10, IM; may repeat once, up to a max dose of 4 mg. OR • Midazolam (Versed) 4 mg increments IV, 10, IM KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 134 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Pediatric The pediatric patient may present hemodynamically unstable or with hypoperfusion as evidenced by altered mental status, delayed capillary refi II (> 2 seconds), pallor, peripheral cyanosis, hypotension. Hypotension is defined as a Systolic BP < 60 mm Hg in neonates (patients < 28 days old), < 70 mm Hg in infants (patients < 1 year old), < [70 + (2 x years) = Systolic BP] for patients > 1 year old. BLS 1. Follow BLS guidelines, adjusting for patient age/size. 2. Consider Aeromedical evacuation to the nearest Trauma Center or Pediatric Trauma Center, if available. BLS Extended Scope/ALS 1. Follow BLS guidelines, adjusting for patient age/size. 2. If age-related vital signs and patient's condition indicate hypoperfusion, administer initial fluid bolus of 20 ml/kg 0.9% Normal Saline via IV/10. (Refer to Protocol VIII.A.) 3. If patient's condition does not improve: a. Administer the second bolus of fluid at 20 ml/kg 0.9% Normal Saline via IV/10. If patient's condition still does not improve, administer third and subsequent fluid boluses at 10 ml/kg. b. For volume sensitive children (e.g., neonates [0-28 days], children with congenital heart disease, chronic lung disease, or chronic renal failure), administer initial fluid bolus of 10 ml/kg 0.9% Normal Saline IV/10. If a patient's condition still does not improve, contact on-line medical direction. 4. Consider Aeromedical evacuation to the nearest Trauma Center. J.Toxemia of Pregnancy This protocol should be used for the patient in her second or third trimester of pregnancy (above 20 weeks gestation) who is exhibiting signs of pre-eclampsia or eclampsia. The signs of toxemia include proteinuria (dark-colored urine), excessive weight gain, and hypertension. The presence of two of these signs constitutes pre-eclampsia; the presence of all three constitutes eclampsia. The seizing patient in her second or third trimester of pregnancy should be assumed to be eclampsc and treated as specified below. However, consideration of another underlying etiology, such as hypoglycemia, drug overdose, head injury, or fever, should also be considered. Eclamptic seizures can also occur postpartum (<_ 6 week after giving birth). Witnessed continuous convulsions (generalized tonic-clonic seizure or grand mal) or repeating episodes KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 135 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 without regaining consciousness or sufficient respiratory decompensation demonstrate a need for immediate treatment. BLS 1. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. AILS a. Initiate 0.9% Normal Saline via IV/10 at KVO or saline lock. b. If the patient is seizing, administer Magnesium Sulfate 4 g IV (mixed in 50 mL or 100 mL of D5W given over 5-10 minutes). May repeat once at 2 g IV (mixed in 50 mL or 100 mL of D5W given over 5-10 minutes) as needed. c. If the patient continues to seize, administer one of the following benzodiazepines: * Midazolam (Versed) 5-10 mg increments IV, 10, IM, maximum dose of 10 mg. OR * Lorazepam (Ativan) 2 mg IV, 10, IM; may repeat once, up to a max dose of 4 mg. d. Perform a glucose test with a finger stick (Medical Procedure 4.17) if glucose is less than 60 mg/dL (Refer to Protocol 11. C. Diabetic Emergencies). KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 136 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 l SIlpeciiia Mediiik:ziIl 11 e,gg iiul Flrotocols A. Documentation Requirements The patient care report (ePCR), or run report, is an official report provided by pre-hospital personnel. All requests for emergency medical services require that an ePCR be completed. Documentation must accurately reflect observations, orders, treatments, and outcomes throughout the patient encounter. Proper documentation is critical to proving adherence to standards of care. 1. Each ePCR should contain the following information: a. Date and time of event b. Chief complaint includes: • Patient description of problem • Mechanism of injury if trauma related c. History includes: • Onset- When did symptoms begin? • Provocation/Palliation - What makes them worse? What makes them better? • Quality-What do these symptoms feel like? • Radiation - Can it be felt in any other body location? • Pain Severity- How bad does it hurt? (rate pain using a 0-10 scale) • Time - Is the pain constant or does it come and go? Have you had this occur before? How was it treated? • Pertinent past medical history, related to complaint • Past surgical history 2. Documentation of patient assessment should include a. Scene survey and mechanism of injury if trauma related. b. Initial primary survey, to include signs, symptoms and immediate interventions related to the following: • Airway • Breathing KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 137 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 • Circulation • Level of Consciousness • Spinal precautions (if appropriate) 3. Documentation of focused history and physical findings should include signs and symptoms of presenting problem and review of body systems as needed: a. Vital signs, including postural vital signs if indicated. b. Color, temperature, appearance of skin c. Blood pressure, both arms if indicated. d. Capillary refill e. Pupillary response f. Motor, sensory, circulatory status of extremities, if appropriate g. Orders received, treatment and/or drug therapy initiated and patient response to treatment. h. On-going assessment of patient 4. Transfer summary should include: a. Condition of patient on transfer b. Name and signature of receiving agency/person assuming care of the patient. c. Time of transfer d . Legible signature of EMS provider of record, and names of all personnel who performed care, especially if they performed or attempted any procedure. B. Abuse/Neglect Review of Iniury/Illness Abuse may involve physical, verbal, sexual mistreatment and/or neglect. Abuse may cause serious injury to the patient's mental and/or physical well-being. Perpetrators will often try to cover up, hide or alter information related to the nature of the injury. Victims may have been coached to give an alternate story about how an injury occurred. Particularly at-risk populations include pediatric, elderly, and pregnant patients. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 138 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Signs and Symptoms * Bruising * Burns * Broken bones * Lethargy or other AMS * Dehydration, malnutrition * Injuries inconsistent with the history provided * Delay in seeking medical care * Information passed on by family friends * Information passed on by the victim's friend(s) Management BLS ALS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Triage and treat patient according to appropriate protocol for injuries sustained. 6. Do not confront suspected abuser. 7. Document all findings including visual inspection of location where patient was found, and any interaction between patient and caregiver. 8. Relay all findings upon transfer of care. 9. All suspected cases of abuse, exploitation, or neglect should be reported to appropriate Law Enforcement, Adult and/or Child Protective Services according to state and local laws or regulations. 10. If the individual or caregiver is refusing treatment and transport, authorities and on-line medical direction should be notified prior to clearing the scene. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 139 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 11. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit, if indicated. C. Withholding or Terminating Resuscitation (Non-trauma) Review of Injury/Illness In the pre-hospital setting, there are times when it is appropriate or necessary to consider discontinuing cardiopulmonary resuscitation and other lifesaving interventions. Management BLS ALS 1. Discontinuation of cardiopulmonary resuscitation and other potentially lifesaving interventions may be considered when ALL of the following criteria have been met a. Arrest was not witnessed by an EMS provider or first responder. b. Adequate CPR has been administered according to current American Heart Association (AHA) guidelines. c. There is no spontaneous circulation (palpable pulse) and no neurological activity (e.g., spontaneous respiration, eye opening, or motor response) present after appropriate BLS resuscitation efforts. d. The patient is at least 18 years of age. e. Core body temperature is at least 95' F for a patient who was hypothermic due to cold exposure (e.g., submersion). f. All health care providers on scene agree with the decision to cease efforts. g. Family members and others present must be acknowledged and assisted in dealing with this death. h. Contact on-line medical direction prior to termination of efforts. Documentation 1. The following must be legibly documented (e.g., printed) in addition to documentation protocol requirements. (Refer to Protocol XI.A.): a. Time resuscitation was started and discontinued. b. Run Number c. Any procedures performed (e.g., shocks administered by AED, airway management) KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 140 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 d. Name, identifying number, and agency of law enforcement official and/or patient's private physician, and/or on-line medical direction contacted, and time of contact. D. Withholding or Terminating Resuscitation (Trauma) Review of Injury/Illness Early cardiac arrest in trauma patients is usually due to severe hypoxia, neurologic injury, or massive hemorrhage. If a trauma patient is unresponsive, pulseless, and apneic, the prognosis is generally very poor. As outlined below, there are circumstances where it is appropriate not to initiate resuscitation of a trauma patient, as well as criteria for discontinuing unsuccessful efforts in the fi eld. Signs and Symptoms * No response * No pulse * No respirations Management BLS ALS 1. For patients with penetrating trauma (e.g., stab or gunshot wounds) it is acceptable NOT to attempt resuscitation if the patient has: a. No respirations or respiratory effort; and b. No palpable pulses and no organized electrical activity on AED or ECG; and c. No papillary reflexes; and d. No spontaneous movement. 2. If ANY signs of life are present, or if mechanism of injury indicates blunt trauma, the patient should undergo aggressive attempts at resuscitation. (Refer to Protocol IX.C.) a. Continue supportive care and monitor vital signs until the patient is turned over to an ALS transport unit. Consider the need for Aeromedical evacuation to the nearest Trauma Center. 3. For patients with either blunt or penetrating trauma, it is acceptable NOT to attempt resuscitation if the patient has: a. Injuries such as decapitation, hemicorporectomy, incineration, or submersion > 12 hours, that are obviously incompatible with life, OR KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 141 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 b. Evidence that he/she has been pulseless and apneic for a prolonged period (e.g., dependent lividity, rigor mortis, or decomposition). 4. For patients in cardiac arrest, but without injuries or apparent mechanism of injury to account for death, resuscitate according to current American Heart Association (AHA) guidelines. 5. For patients with either blunt or penetrating trauma, it is acceptable to terminate resuscitation in the field if the patient: a. Remains in cardiac arrest (after 15 minutes of appropriate resuscitation efforts), OR b. Remains in cardiac arrest and is located more than 15 minutes from a trauma center. 6. Always document findings and leave scene under Law Enforcement control after presuming an out-of-hospital death. a. Include name, identifying number, and agency of law enforcement officer. E. Do Not Resuscitate (DNR) Review of Injury/Illness 1. A DNR or "Do Not Resuscitate Order" is a valid physician's order to forgo resuscitative efforts. The presence of a valid Withholding Care Form allows providers to withhold specified care on patients. 2. When such a document is produced by the patient, patient's guardian, or agent designated to act on the patient's behalf, it should conform to the relevant, state or local requirements. The form must be signed by a physician or medical provider with authority to do so. 3. An Advanced Directive, otherwise known as a living will or health care directive, is a letter to a physician from the patient or responsible party outlining what care they wish to receive or not receive in the event they are incapacitated. Management BLS ALS 1. If presented with a valid DNR form, do not begin resuscitative measures on a patient in or near cardiac or respiratory arrest. 2. If the EMS provider is unsure as to the validity of the DNR contact medical direction for orders. If unable to contact, resuscitative efforts should be initiated until clarification of the Directive is made by a medical direction authority. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 142 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 3. Proper law enforcement agencies should be notified upon death of the patient when: a. Resuscitative efforts are cancelled by a medical direction authority. b. A valid DNR Form is presented, and resuscitative efforts are withheld. c. A patient is being left rather than transported after death has occurred. 4. Documentation regarding the validity of a Pre-hospital Medical Care Directive Form must be included in the patient care reporting document. 5. Take into consideration the sensitivities of family members, whether or not transporting the patient. Special Considerations 1. Emergency Medical Services (EMS) personnel are not required to accept or interpret medical care directives, if uncertain of their validity. 2. Authorization for the withholding of resuscitative efforts DOES NOT include withholding other medical interventions (e.g., IV fluids, pain control) prior to cardiac or respiratory arrest. F. Refusal of Care or Transport Review of Injury/Illness An adult patient with normal mental status and intact judgment (competent) has the right to refuse care if properly informed of the potential consequences of that refusal. A parent or legal guardian must refuse care on behalf of a minor. Signs and Symptoms * Patient refusing medical care or transport for illness or injury * Not under the influence of mind-altering substances (e.g., alcohol, drugs) * Not demented * Oriented x 4 (person, place, time, event) Management BLS/AILS 1. Evaluate scene safety. DO NOT approach patient if scene cannot be rendered safe. 2. Institute appropriate Body Substance Isolation (BSI) measures/Universal Precautions, as outlined in Protocol I.A. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 143 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 3. Perform patient assessment and initiate routine BLS care, as outlined in Protocol I.A, and as indicated by the patient's condition. 4. Determine the need for ALS care and/or transport to hospital for further evaluation and treatment. 5. Upon determination of illness or injury, if patient is refusing care, has a GCS of 15 is oriented x4, explain the potential risks and dangers of not accepting medical intervention to the patient or other authorized responsible party, that could reasonably be expected to occur (e.g., infection of an open wound, pain, death from heart attack). 6. Have the patient verbalize understanding of the consequences, and then sign REFUSAL OF CARE form or patient care record (PCR) and obtain witness signature(s), if possible. G. Blood Alcohol Sampling Paramedics ONLY are to perform blood draws requested by Law Enforcement Officers provided the patient is going to be transported by EMS to the hospital and they are requested to draw blood by a Law Enforcement Officer. Also, if the patient agrees to the blood draw and the EMS unit is already on scene, a legal blood draw may be performed by EMS personnel. The rescue unit is not to respond to a scene for the sole purpose of performing a legal blood draw when there are no confirmed or suspected injuries; or when there is no need for medical evaluation, treatment or transport. It is more appropriate to have these types of legal blood draws performed at a hospital. Field Paramedics are to perform legal blood testing only under the following circumstances: • The request is made by a duly sworn Law Enforcement Officer. • The Law Enforcement Officer provides the blood testing kit and takes custody of the sample once it is drawn. • The Law Enforcement Officer advises the patient of the purpose of the blood test and their legal rights regarding the test. • The Paramedic reiterates the purpose of the test and gains patient consent. • The Law Enforcement Officer remains present during the entire procedure. • If a patent refuses to have their blood drawn for legal blood testing, and a Law Enforcement Officer requests the use of force to obtain the blood sample, the paramedic WILL contact the Medical Director or Medical Control (ER Physician) for orders prior to performing the blood draw. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 144 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 I „ SIllte "iiiWty Si illHN A. 10 Procedures Intraosseous Infusion EZ 10 Insertion The administration of fluids and medications via intraosseous infusion has long been known to be a relatively safe and effective procedure in the treatment of critically ill patients. Equipment needed: EZ-10 driver and appropriate needle, Betadine, NS with drip set, 10 cc syringe, EZ-10 connector tubing, pressure infuser and 2-inch tape. Indications Patients in which the following conditions are present: 1. Cardiac arrest, or 2. Profound hypovolemia, or 3. No available vascular access, or 4. Following two unsuccessful peripheral IV attempts for patients with any other life-threatening illness or injury requiring immediate pharmacological or volume intervention, or 5. In pediatric patients in cardiac arrest, go directly to 10 if no peripheral sites are obvious. Contraindications 1. Conscious patient with stable vital signs 2. Peripheral vascular access available 3. Suspected or known fractures in the extremity targeted for 10 infusion 4. Previous attempt in the same bone 5. Cellulitis at the intended site of procedure 6. Patient with known bone disorder 7. Prior knee or shoulder joint replacement Select appropriate needle: 1. Adult: >40 kg—there are two lengths: regular and long 2. Pediatric: 3-39 kg or patients that fit on the Broselow Tape (if child has excessive tissue, adult needle may be used) KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 145 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Procedure 1. Locate landmarks: • Proximal Tibia: identify patella, approximately 2 fingers widths, below is the tibial tuberosity. Then 1 finger width medial is the final landmark. • The proximal humerus insertion site is located directly on the most prominent aspect of the greater tubercle. Ensure that the patient's hand is resting on the abdomen and that the elbow is adducted (close to the body). Slide thumb up the anterior shaft of the humerus until you feel the greater tubercle, this is the surgical neck. Approximately 1 cm (depending on patient anatomy) above the surgical neck is the insertion site. This is the preferred site for patients who are responsive to pain. Once the insertion is completed secure the arm in place to prevent movement and accidental dislodgement of the 10 catheter. 2. Prepare the skin with antiseptic (Betadine)solution. 3. Select appropriate needle and prepare driver 4. Stabilize leg and power the needle set through the skin at a 90-degree angle to the surface of the bone until you feel the needle set tip encounter the bone itself 5. The 5 mm mark on the catheter (mark closest to the flange) should be visible 6. If 5 mm mark not visible abandon the procedure, the needle is not long enough 7. Apply firm and steady pressure on the driver and power through the cortex (hard, outer surface of the bone), ensuring the driver is maintained at a 90-degree angle 8. Stop when the flange touches the skin or sudden decrease in resistance is felt 9. Remove the driver from needle set and withdraw Stylet from catheter 10. If patient is unable to tolerate pain due to fluid pressure inside the bone, consider administering Lidocaine 25 mg 10, up to 50 mg to reduce the pain 11. Attach primed EZ-10 extension tubing and confirm placement with fluid bolus: failure to flush will result in no flow • Adults: 10 cc fluid bolus • Pediatrics: 5 cc fluid bolus Secure tubing and catheter with tape and document time of insertion as the EZ-10 is good for 24 hours. Pressure infuser may be used to maintain adequate flow rates. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 146 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 EZ-10 LANDMARKS t r Locate landmark. Clean insertion site. Power driver through the cortex. X Remove needle. Attach tubing,flush,and Pressure infusion for adequate consider Lido(25 mg to 50 mg 10) flow rates for bone pain in conscious patients B. Oral Endotracheal Intubation Equipment Needed: OPA or NPA, BVM, oxygen, appropriate size endotracheal tube, stylet, stethoscope, ETCO2 detector, suction and laryngscope 1. Use the 3-3-2 rule for the airway to estimate the likelihood of success; the first look is the best. Pre-oxynate gives you the time to gently look. a. Attach pulse oximeter and have suction readily available b. Perform appropriate BLS airway manaeuver to open airway c. Head tilt chin lift or jaw maneuver to open airway d. Insert oropharyngeal airway and/or nasopharyngeal airway e. Check the integrity of the ET tube by inflating the cuff and deflate f. Pre-oxynate with BVM 15 Ipm 02 at a rate of 10-12 per minute g. Using the laryngoscope, insert ET tube with direct visualization of the vocal cords KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 147 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 YOU MUST SEE ET TUBE PASS THROUGH THE VOCAL CORDS h. Inflate the cuff on the ET tube i. Auscultate epigastric area to confirm no sounds present j. If breath sounds are absent, withdraw the tube and re-oxynate k. If left breath sounds are absent, withdraw ET tube slightly and asculate again I. If bilateral breath sounds are present, secure ET tube and record cm depth at lips m. Attach ETCO2 detector, square waveforms should appear on the monitor: pulse ox should improve and chest should rise with insuflation n. Secure the patient's neck with C-collar and CID on backboard Basic Airway Management (BAM): is defined as follows: Assisted Ventilations while using basic airway adjuncts (OPA, NPA), i-Gel and a Bag Valve Mask. Advanced Airway Management (AAM): Includes all Basic procedures with the addition of Endotracheal (ET). C.-i-Gel Airway Device Procedure The i-Gel is a supraglottic airway management device used as an alternate means of establishing an airway. I-Gel has a soft, gel-like, non-inflatable cuff, designed to provide an anatomical impression fit over the laryngeal inlet. Indication 1. Unconscious patient who is not breathing without a gag reflex. 2. Apneic patient without a gag reflex. 3. A difficult airway is anticipated: a. Small mouth which obstructs visualization b. Short neck c. Mallampatti or Cormack-Lehane score > 3 d. Any obstruction that could impair visualization of the glottic opening. e. Impaired neck mobility. 4. Access to the airway is impeded (entrapment, helicopter cabin etc.) Contraindications 1. Patient has a gag reflex. 2. Esophageal tissue damage from trauma, chemical ingestion or thermal injury. 3. Esophageal or airway obstruction. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 148 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 4. Airway burns or chemical inhalation injury. Procedure Equipment 1. Appropriate i-Gel Size (SEE CHART BELOW) 2. Water based lubricant (surgilube) 3. Suction 4. Sp02 Monitor 5. ETCO2 detector Insertion Technique 1. Open and maintain the airway. Ventilate with 100% oxygen before attempting of the i-Gel. 2. Select the appropriately sized i-Gel based on weight. Open i-Gel package and take i-Gel out of the protective cradle. 3. Lubricate the back, sides, and front of the cuff by rubbing it on the smooth surface of the protective cradle containing the water-based lubricant. �d 0011,11111 J r 4. Remove dentures or removable plates from the mouth prior insertion. 5. Grasp the lubricated i-Gel firmly along the integral bite block. Position the device so that the i-Gel cuff is facing towards the chin of the patient. 6. Maintain the head in a neutral position for trauma patients. For non-traumatic patients, the patient's head should be in the "sniffing" position with the head extended and neck flexed. The chin should be gently pressed down before proceeding to insert the i-Gel. 404 �yyar d� A 7. Introduce the leading soft tip into the mouth of the patient in the direction towards the hard palate. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 149 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 8. Glide the device downward and backward along the hard palate with continuous but gentle push until a definitive resistance is felt. 9. The front teeth should be resting on the integral bite block. (The black lineon the i-Gel). 10. Attach the End tidal CO2 Device to the i-Gel and BVM, and confirm placement. i�'16�N1,• `yv w`"" III PI _. "v" Securing the Device 1. Secure the i-Gel with the airway support strap provided. i-Gel Tube Sizing Chart: 2 - Si-nall Pediatric 10-25, 2.5 Large Pediatric 25-35 3 Small adult 30-60 S Large adult+ 90+ Basic Airway Management (BAM): is defined as follows: Assisted Ventilations while using basic airway adjuncts (OPA, NPA), i-Gel and a Bag Valve Mask. Advanced Airway Management (AAM): Includes all Basic procedures with the addition of Endotracheal (ET). D. Intranasal Administration Technique (Narcan) CLASS Synthetic opioid antagonist DOSAGES Vial has 2mg of Naloxone in 2mL KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1150 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 • Give 1mg (1ml) in each nostril, quickly • Medication is atomized and absorbed through vessels in the nasal cavity ACTIONS The mechanism of action is not fully understood. It does appear that Naloxone antagonizes the effects of opiates by competing at same receptor sites. When given IV, the action is apparent within two minutes. IM or SC administration is slightly slower. INDICATIONS Naloxone is indicated for the complete or partial reversal of opiate narcotic depression and respiratory depression secondary to opiate narcotics or related drugs. Look for the Signs... Overdose on opioids typically: • Unconscious • Slow or not breathing (<10/min) • Small "pinpoint" pupils (miosis) • Pulse variable CONTRAINDICATIONS Naloxone is contraindicated in patients known to be hypersensitive to it. Use with extreme caution in narcotic-dependent patients who may experience withdrawal syndrome (including neonates of narcotic-dependent mothers). SIDE EFFECTS CNS: * Tremor * Agitation *Belligerence * Papillary dilation * Seizures * Increased tear production * Sweating * Seizures secondary to withdrawal Cardio: * Hypertension * Hypotension * Ventricular tachycardia * Pulmonary edema, * Ventricular fibrillation. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 151 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 GI: * Nausea,vomiting. WARNINGS Use caution during administration as patient may become violent as level of consciousness increases. Irsl Administration Technigue • The tip of the syringe should be placed near or just inside the nostril • Placement of the syringe too far inside the nasal cavity may traumatize the nasal passage or cause epistaxis u P78VV�I�fl��°°°°°°°°ViVVVV�Vii1u° r / i/i�y rtr� >vhm�� rr� R'GW TO GIVE NASAL SPRAY NARGAN ,. mruae�mrp er�www %. J unrwn mirrgPy wnu�x rawwwawr+na�a �� 's wpwl ��Nw9�Abvr m pq�ratlkrw,xgswm 2 Pam aall¢�V f ,,,,,, ............................................ ..... ...... r f Elraauraw.tirwawuWrt rw n¢ePc�:.cpc'-ems � ,. 3 6�d�n,u�.rwrr AMdmtl�l maw ary wmr * 's .......... ,, Hh�M ror s KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 152 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 E. Combat Application Tourniquet The Combat Application Tourniquet (CAT) is an effective tool to help control severe blood loss from the body's extremities. If used correctly, the CAT can save lives. A general misconception of the CAT is that it will result in the patient requiring amputation of their extremity, THIS IS FALSE. Amputation is more often required as a result of the injury itself, not because of the tourniquet. The CAT as well as any other type of tourniquet should be as a LAST RESORT for blood control management. Applying direct pressure to the injury and elevating the extremity above the heart should be attempted prior to utilizing the CAT. 0- ow F. Full Spinal Immobilization Technique Equipment Needed: Long backboard, 3 immobilization straps, head stabilization device and cervical collar Adults • Determine need for spinal precautions • Assure and maintain manual c-spine immobilization • Assess pulses, motor and sensation of extremities • Apply appropriate sized C-collar and long backboard • Fill voids with padddings/towels as needed • Apply X4 straps using the chest cross-strap technique • Apply head stabilizing device • Reassess pulses, motor and sensation after immobilizing patient • DO NOT strap the patient directly over the abdomen Strap the patient to the backboard BEFORE securing the patients head KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 153 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 M:oost of the body weight ht is be twee n the shoulders and the upper thighs, place : the straps' accordingly,, m*H µ A IJII N �yyy r Use tape to secure the forehead erg nd the;chin area to the backboard Pediatrics • Apply appropriate size c-collar • Pad under the shoulders using pillowcases or towels to prevent flexion of spine • Secure to long backboard Pregnant Patients • Immobilize as above and tilt the backboard Left Lateral recumbent to a 20-degree angle • Assure patient comfort KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 154 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 G. APGAR Scores Appearance Blue, pale Body pink, extremities Completely pink (color) Blue or pale 010M Grimace No response Grimace Crying Respirations (respiratory Absent Slow, irregular effort) Infant's Condition Point total Treatment Consideration Good 7-9 Re-assess Poor 0-3 Requires CPR KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Pagel 155 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 H. Rule of Nines �wh _yD 4 N, 18% Bod 4, Mant o k V 1, W 1 2. ° 5.5% �l1 151f6 Ir�� WV dI I' �,.. h91 KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 156 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 I. Adult Trauma Scorecard Methodology Red, any one (1), transport as trauma alert; Blue, any two (2), transport as trauma alert Component a Airway • Sustained respiratory rate >_ • Active airway assistance (1) 30 Circulation • Sustained heart rate >_ 120 • o radial pulse and a sustained HR > 120 or Systolic < 90 mmHg Best Motor Response • BMR = 5 • GCS :� 12 (BMR) • BMR = 4 or less • Presence of paralysis • Suspicion of spinal cord injury • Loss of sensation Cutaneous • Soft tissue loss (2) • 2- or 3- burns to 15% or more TBSA • Amputation proximal to the wrist or ankle • Any penetrating injury to the head, neck, or torso (3) Long bone Fracture (4) • Sign or symptoms of a single • Sign or symptoms of a fracture site due to MVC or Fall fracture of two or more long 10' or more bone "sites" Age • >_ 55 years or older (7) Mechanism of Injury • Ejection from motor vehicle (5) • Steering wheel deformity (6) Judgement • EMT or Paramedic discretion (R) 1. Airway assistance beyond administration of oxygen. 2. Degloving injuries, major flap avulsion (> 5") 3. Excluding superficial wounds in which the depth can be easily determined. 4. Long bone including humerus, radius/ ulna, femur, tibia/fibula. 5. Excludes: motorcycles, mopeds, ATVs, bicycles or open body of a pick-up truck. 6. Only applies to driver of vehicle. 7. Blunt head, chest, or abdominal trauma on blood thinners with high risk of bleeding or with history of a bleeding disorder KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 157 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 8. If patient does not meet any of the criteria listed above and the on scene EMT, Paramedic believes the patient may benefit from Trauma Alert criteria due to extenuating. circumstances surrounding the incident, the patient may be classified as a "Trauma Alert". J. Pediatric Trauma Scorecard Methodology Red, any one (1), transport as trauma alert; Blue, any two (2) transport as trauma alert; Greeirn ...... follow local protocols Size > 20kg (44...1 12 20kg (22. 43 Ilnis.) eight< 11 g (<22 I s,) Ulbs,) Length < 33 inches can pediatric length-based tape Airway NoirrirualI Supplleirrnr^r ta: l oxygen Assisted (1) Intubated Consciousness Awake o Amnesia e Altered mental status (2) o Loss of consciousness o Coma o Presence of paralysis o Suspicion of spinal cord injury o Loss of sensation Circulation v Good o Carotid ore oral o Faint or non-palpable carotid or rre"'r'iplheirall pulses palpable but femoral pulse pulses SI'3IP °> lack of radial or pedal o SP < 50 mmHg 90 rnrril..l3 pulse BP < 90 mmHg Fracture None seen o Sign or symptom of e Open long bone fracture or,nnunsrinrnn cted single closed long bone e Multiple fracture sites fracture (3)(4) Multiple dislocations (3)(4) Cutaneous o W,) visilbk? o Contusion o Major soft tissue disruption (5) iirnjurry v Abirasio n e 2- or 3- burns to > 10%TBSA Amputation (6) Any penetrating injury to head, neck or torso (7) Judgement 9 EMT or Paramedic discretion (3) 1. Airway assistance includes manual jaw thrust, continuing suctioning, or use of adjuncts to assist ventilator efforts. 2. Altered mental status includes drowsiness, lethargy, inability to follow commands, unresponsiveness to voice, total unresponsive. 3. Long bone including humerus, radius/ ulna, femur, tibia/fibula. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Pagel 158 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 4. Long bone fractures do not include isolated wrist or ankle fractures or dislocations. S. Degloving injuries, major flap avulsions, or major soft tissue disruption. 6. Proximal to wrist or ankle. 7. Excluding superficial wounds in which the depth can be easily determined. 8. If the patient does not meet any of the criteria listed above and the on scene EMT, Paramedic believes the patient may benefit from Trauma Alert criteria due to extenuating circumstances surrounding the incident, the patient may be classified as a "Trauma Alert". K. RAD-57 Pulse CO- Oximeter Purpose Carboxyhemoglobin monitoring is used to determine if carbon monoxide levels are present in firefighters, patients and occupants with possible exposure to carbon monoxide. If levels are present, determine the course of treatment needed. Sco e SpCO readings can be used as an additional screening measure to determine exposure to carbon monoxide. SpCO readings can also be used as a tool of inclusion/exclusion on vague medical complaints to reduce the risk of undiagnosed carbon monoxide poisoning. When SpCO is used in conjunction with SP02 it gives a higher index of suspicion of hypoxia and indicates a need for aggressive treatment. Indications SpCO monitoring shall be indicated for the following conditions: 1. Post-incident firefighter screening on all fires 2. Firefighter rehabilitation in accordance to NFPA 1584. 3. Extended time on or near fire-ground. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 159 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 4. Multiple SCBA bottle use. 5. Suspected carbon monoxide exposure from work performed in confined spaces. 6. Carbon monoxide alarms/gas leaks without symptoms in conjunction with gas detectors to determine presence and exposure. 7. Multi-patient presentation. 8. Headache, dizziness, syncope, weakness, altered mental status, and/or lethargy. 9. Shortness of breath, chest pain. 10. Nausea, vomiting, abdominal complaints. 11. Any ill or injured patient with vague complaints. Recommended Usage For use during firefighter rehabilitation and as a screening tool on occupants without complaints regardless of whether known or unknown exposure. The following guidelines will be used as a baseline for detecting SpCO levels: 1. 0- 3% Normal, no treatment required 2. 3 - 12%Yes - signs and symptoms or history of exposure TREAT 3. 3 -12% No - signs or symptoms, no history of exposure OBSERVE 4. 12% and higher TREAT and CONSIDER TRANSPORT Treatment: 100% oxygen by non-re-breather mask and transport to hospital is highly recommended. 1. Adults with an SpCO level 25% or higher 2. Pediatrics with an SpCO level 15% or higher 3. Pregnant females with an SpCO 15% or higher Procedure: 1. Apply probe to patient's middle finger or any other digit to center of fingernail as recommended by the device manufacturer. If near strobe lights, cover finger to avoid interference and/or move away from lights if possible. 2. Allow machine to register percent circulating carboxyhemoglobin. 3. Record Carboxy Hb procedure in patient care report or on the scene rehabilitation form. Also record Sao2 from RAD 57 4. Verify pulse rate on machine with actual pulse of the patient. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 160 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 5. Monitor critical patients continuously until arrival at the hospital. If recording a one-time reading, monitor patients for a few minutes as oxygen saturation can vary. 6. Document percent of carboxyhemoglobin every time vital signs are recorded and in response to therapy to correct CO exposure. 7. Use the pulse oximetry feature of the device as an added tool for patient evaluation. Treat the patient, not the data provided by the device. 8. The pulse oximeter reading should never be used to withhold oxygen from a patient in respiratory distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings, such as chest pain. 9. Factors which may reduce the reliability of the reading include: • Poor peripheral circulation (blood volume, hypotension, hypothermia and vasoconstrictors) • Excessive external lighting, particularly strobe/flashing lights • Excessive pulse oximeter sensor motion • Fingernail polish (may be removed with acetone pad) Irregular heart rhythms (atrial fibrillation, SVT, etc.) • Jaundice Placement of BP cuff on same extremity as pulse ox probe 0-4% normal value > 5% possibly some exposure > 10% alarm will sound. High CO exposure and start treating patient appropriately and consider transport to the closest appropriate hospital. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 161 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 L. Glasgow Coma Scales Spontaneous 4 To Voice 3 To Pain 2 No Response 1 Obeys Command 6 Localizes Pain 5 Withdraws to Pain 4 Flexion to Pain 3 Extension to Pain 2 No Response 1 Oriented and Converses 5 Disoriented and Converses 4 Inappropriate Words 3 Incomprehensible Sounds 2 No Response 1 Appropriate Words 5 Inappropriate Words 4 Cries/Screams 3 Grunts 2 No Response 1 < 2 YEARS Smiles/Coos/Cries 5 Cries 4 Inappropriate Cries/Screams 3 Grunts 2 No Response 1 Glasgow Coma Score Total = KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 162 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 M. PEDIATRIC VITAL SIGNS Age Weight in kg Minimum Systolic Normal Heart Rate Normal Respiratory Rate BP Premature <2.5 40 120-170 40-60 Term 3.5 60 100-170 40-60 3 months 3.5 60 100-170 30-50 6 months 8 60 100-170 30-50 1year 10 72 100-170 30-40 2 years 13 74 100-160 20-30 4 years 15 78 80-130 20 6 years 20 82 70-115 16 8 years 25 86 70-110 16 10 years 30 90 60-105 16 12 years 40 94 60-100 16 Typical BP in children 1-10 years of age: 80 mmHg+ (child's age in years x 2) Synchronized Cardioversion Initial 0.5 joules per kg followed by 1 joule/ kg then 2 joules/ kg Transcutaneous External Pacing Follow AHA recommendations. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 163 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 N. ETCO2 Waveforms r �. _..�� _.................... :"�'' �orrti m^mrmnm-mi +u�m,ai,.ra�. - .. �m-.-scmTim.�^km oirm. xcn�.aita�mv �ta dvn,�n�om�ap �Mr':n7imm '�nwMmF �mr� 0. 12 LEAD QUICK REFERENCE GUIDE ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. • ST elevation in the following leads include: a. Inferior wall MI— II, III, aVF— Perform V4R on all inferior wall MI (IF V4111 IS POSITIVE, DO NOT GIVE NITRO TO PT.) b. Lateral wall MI —I, aVL, V5 thru V6 c. Anterior wall MI—V1 thru V6 d. Septal wall MI —V1 thru V3 • Inverted T waves and ST depression are indications of ischemia when found in aVL and V1 • Posterior wall MI—ST Depression in V1 thru V4 and a tall R wave;any R wave in V1 is suspicious • Indications for 12 Lead Include: a. Any suspected cardiac event b. Chest pain c. Abdominal pain d. Syncope e. Poor general appearance f. Hypotension g. Dysthymias h. Weakness i. Unexplained nausea, vomiting or diaphoresis. j. Unexplained arm,jaw, or back pain KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Pagel 164 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 P. SYNCHRONIZED CARDIOVERSION Hemodynamically unstable, unconscious or decreased mental status, hypotension, dyspnea, chest pain. If possible, sedate with Midazolam 2.5 mg(up to 10 mg max). Biphasic: • Synchronized cardioversion 100 joules, if unsuccessful • Synchronized cardioversion 200joules, if unsuccessful • Synchronized cardioversion 300 joules, if unsuccessful repeat subsequent shocks at 360 joules If patients' rhythm converts,then re-enters dysrhythmias, repeat cardioversion at last joule setting administered. Q.TRANSCUTANEOUS EXTERNAL PACING • Apply Combo pads to patient's chest. Apply the first pad to anterior right chest,just below clavicle and second pad lower left lateral, mid axillary, or anterior/ posterior. • Connect the multifunction cable to the extremity leads. • Sedate the patient as needed with Midazolam 2.5 mg(up to 10 mg max) • Print an EKG rhythm strip prior to pacing • Turn on the external pacer and set the rate at 70 beats per minute • Turn milliamps to lowest amount and slowly increase until electrical capture is noted * Electrical capture is noted when each pacer spike is followed by a wide R wave • If electrical capture is achieved, check central pulses at the femoral and carotid * If palpable pulses are present, mechanical capture has been achieved and pacing is successful • If both electrical and mechanical capture have not been achieved, pacing should be discontinued and the need for chest compressions assessed • If pacing has been successful the patient's mental status, perfusion and blood pressure should improve • Maintain pacing until transfer of care is given to an ALS transport unit and fully prepare to assume pacing efforts for the patient * It is imperative to have correct placement of pads and good contact to the chest wall to successfully pace. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 165 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 R. CINCINNATI PREHOSPITAL STROKE SCALE Interpretation: if any of these 3 signs is abnormal, the probability of a stroke is 72% Facial Droop nL The patient shows tooth car smile �l * Normal --both sides of the face move equally r X * Abnormal-one side of „ r j the face does not move , f f as well as the other side "N Arm Drift The patient closes eyes and extends both arms Abnormal Speech straiqht out, with palms tap for 10 seconds The patient repeats ".you cant teach an old * Normal- bath arras naave the same or bothdog new tricks". arras do riot move at all (other findings, such * Normal--patient uses correct words with as pronator drift„ may be helpful) no slurring Abnormal -one arm does not move or * Abnormal -patient slurs words, uses the one arm drifts downward wrong words, or is unable to speak S. Indications for Helmet Retention Objective:To identify clinical scenarios where leaving a helmet in place is safer for the patient than removal, ensuring the maintenance of neutral cervical spine alignment and physiological stability, (Refer to Protocol IX.E.). The majority of modern sports helmets consist of a hard polycarbonate shell lined with foam padding, adjustable air cells, or both. Density, strength, and rigidity vary depending on the type of impact that the helmet is designed to protect against. Helmet Types: Full face- Full face- Partial face- Football motorcycle, motocross motorcycle auto racer auto racer �ww�*oM1 �!° ��� IV""�� i'�4�IIp� KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 166 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 1. General Criteria for Retention A helmet should remain in place during extrication and transport if all of the following conditions are met: 1. Airway is Patent: The patient is breathing adequately and can clear their own secretions. 2. Ventilation is Sufficient: No immediate need for advanced airway maneuvers (e.g., intubation) or BVM ventilation that cannot be performed with the helmet on. 3. No Hidden Hemorrhage: There is no evidence of active, uncontrolled bleeding beneath the helmet. 4. C-Spine Alignment: The helmet does not cause the neck to be flexed, extended, or rotated out of a neutral position. 2. Specific Justifications for Leaving Helmet On ME 0111NEREEME= Athletic Gear Shoulder Pad Integration: In football, hockey, or lacrosse, the helmet and shoulder pads create a level plane for the spine. Removing only the helmet causes the head to drop, leading to dangerous cervical hyperextension. Airway Access Removable Face Guards: If the face shield or cage can be removed independently (using a Schutt or Riddell removable tool), the airway can be managed without disturbing the cranium. Fit&Stability Secure Fit: A well-fitted helmet provides excellent internal stabilization. If the helmet does not move independently of the head, it can be secured directly to the transport device. Resource Insufficient Trained Personnel: If two trained rescuers are not available to Constraints perform the two-person removal technique, the risk of causing a secondary spinal cord injury during removal is too high. Patient Absence of Trauma Signs: In low-mechanism incidents where the patient is Condition asymptomatic (no neck pain, no neurological deficits), the helmet can be left until arrival at the ED. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 167 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 3. Required Actions if Helmet is Retained If the decision is made to leave the helmet on, the following steps must be taken: 1. Remove Face Shield: Always remove the visor or face mask to allow for continuous visual monitoring of the airway and skin color. 2. Secure Helmet to Board: Use tape or head blocks to secure the helmet directly to the immobilization device (backboard or vacuum mattress) to prevent the head from "floating" inside the helmet. 3. Pad the Gaps: If there is a gap between the helmet and the board (common in motorcycle helmets), use towels or padding to fill the space and prevent extension. 4. Monitor Neurological Status: Perform frequent checks of distal Pulse, Motor, and Sensory (PMS) functions during transport. 4. Indications for Helmet Removal The helmet should ONLY be removed in the field if it interferes with the rescuer's ability to: • Maintain a patent airway or provide ventilatory support. • Control active hemorrhage hidden by the helmet. • Secure the head for spinal motion restriction if the helmet fits poorly. • Perform resuscitation on a patient in cardiac arrest. Removal Procedure (Two-Person Technique) 1. Initial Stabilization: One rescuer (Rescuer 1) stands at the head of the patient and stabilizes the helmet by placing hands on both sides, ensuring the neck remains in a neutral, in-line position. see Fig. below 2. Access and Assessment: A second rescuer (Rescuer 2) unfastens or cuts the chin straps. see Fig. below 3. Transfer of Stabilization: Rescuer 2 moves to the side or takes over stabilization from below by placing one hand on the patient's mandible (chin) and the other behind the occiput (base of the skull). see Fig. below 4. Lateral Expansion: Rescuer 1 (at the head) expands the sides of the helmet laterally to clear the ears and gently rocks the helmet off. see Fig. below 5. Nose Clearance: For full-face helmets, the helmet may need to be tilted slightly backward to clear the nose without bending the neck. 6. Final Re-stabilization: Once the helmet is removed, Rescuer 1 reassumes manual stabilization from the head. Padding (such as a folded towel) may be placed under the head to maintain neutral alignment since the helmet previously provided height. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 168 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 i i r I ......... .. .... One ra•sCjor �na'rr drM raaM,dww rc.r:uEdrlr'irrr w'r F irml-rs xhn l irr.Itlk— A cUre'wd man ev n ms.an dw xlra imr.d mxw. s" rc,M.nd re.ti.._ a kY1Arrrruj trya Ir w n ms F,rcmK- at Ar ans9e t m 's ch, rnd% M aYe YrmCA niMM de Tin -s s3da xrr Trne rrmd nYd—Mimr—' m daw xAaw r ,smwro h arnl'rm;r mnar,.,d Mlr+e rw.w'.e':e..ma:m r'u+snr'-*vr.nr 15%li M+a-ge if ErwrL sdrra7Nn is loo-%— zrpp:uln M ' s F a dm :,Yrwd N re.r.,ruar.. m'w F r" am.prr '.sg;rrrrmsritm'NNy t.dE w_cn,'d ----- < I ,6v ............. ----------------------------------- n i ...... meaner—tt c Fina,!&.—r.Y 'r'l-nw- Warr t m cw ...... .. ....,ovA MA Itt'z'krn Fn h. 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CPAP Overview Continuous Positive Airway Pressure (CPAP) is a non-invasive mechanically assisted delivery system designed to administer oxygenation of several respirational pathologies. CPAP is not a replacement for any medication or procedure, but a tool which can provide a high level of ventilatory support without the need for RSI or intubation. CPAP is approved for patients 18 years of age and older, with moderate to severe respiratory distress Indications Respiratory distress secondary to suspected congestive heart failure, acute cardiogenic pulmonary edema, and chronic obstructive pulmonary disease (asthma, bronchitis, emphysema). Contraindications • Severely Impaired Consciousness. • Uncooperative Patient or Inability to Follow Instructions (GCS <14) • Respiratory or Cardiac Arrest • Suspected Pneumothorax • Inadequate Respiratory Drive • Shock/Hypotension (BP < 90) KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 169 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 • Facial, Head or Chest Trauma • Chest Wall Trauma • Persistent Nausea/Vomiting and or High Risk of Aspiration • Has Active Upper GI Bleeding or History of Recent Gastric/Esophageal Surgery. • Upper Airway Obstructions Procedures 1. Position patient in fowlers or semi-fowlers. 2. Connect CPAP unit to suitable 02 supply. 3. Place delivery device over mouth and nose. (Leave ETCO2 nasal cannula in place) 4. Patient may require substantial coaching in order to receive compliance with mask seal, but a leak-less mask seal is essential. 5. Titrate CPAP pressure to patient's tolerance until improvement in patient's Sp02 and symptoms 6. Max 5 cm/H20 for Bronchospasm 7. Max 10 cm/H20 for CHF, Pulmonary Edema, and Pneumonia. 8. Max 5 cm/H20 for pediatrics 9. If respiratory drive or level of consciousness deteriorates, discontinue use and prepare to support airway and ventilations 10. Monitor patient every 5 minutes and advise receiving hospital as soon as possible of CPAP use, so they can prepare to continue treatment. 11. In case of a life-threatening complication, stop treatment and consider the need for intubation. Considerations • Continue CPAP at receiving hospital until facility is ready to take over treatment. • Monitor for gastric distension • CPAP is not a replacement for current parenteral medication treatments, but is to be used in conjunction with these treatments. CPAP and Nebulizer: Included with Circuit, attaches to bottom of inlet KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 170 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 U. Morgan Lens Morgan Lens Insertion 1. Remove the patient's contact lenses, if present. 2. Instill topical local anesthetic (tetracaine HCI 0.5% eye drops) to the affected eye(s). 3. Attach the Morgan lens to IV tubing or Morgan lens delivery set. 4. Prime the tubing and lens with irrigation solution. 5. Have the patient look down; insert the Morgan lens under the upper lid. 6. Have the patient look up; retract the lower lid to drop the lens in place. 7. Release the lower lid over the lens. 8. Adjust the flow to the desired rate. 9. Tape the tubing to the patient's forehead to prevent accidental lens removal. 10. Absorb any outflow with towels. Removal of Morgan Lens 1. Have the patient look up; retract the lower lid behind the interior border of the lens. 2. Hold this position. 3. Have the patient look down; retract the upper lid and slide the lens out. V. Bougie- Endotracheal Tube Introducer Equipment Needed: Bougie, Appropriate size endotracheal tube, 20cc syringe, stethoscope, ETCO2 detector, suction, laryngoscope blade and handle, endo-lock Indications: Patient meets clinical indications for oral intubation and initial intubation attempt has been unsuccessful and/or those patients who are predicted to be a difficult intubation. Contraindications: • Three failed attempts at orotracheal intubation • Age less than eight (8) or ETT size less than 6.5m KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 171 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Procedure: • Prepare, position and oxygenate the patient with 100% oxygen; • Select proper ET tube without stylet, test cuff and prepare suction; • Lubricate the distal end cuff of the ETT and the distal 12 of the BOUGIE; • Using laryngoscope techniques, visualize the vocal cords if possible using Sellick's as need • Introduce the Bougie with curved tip anteriorly and visualize the tip passing the vocal cords or above the arytenoids if the cords cannot be visualized; • Once inserted, gently advance the BOUGIE until you meet resistance or "hold-up" (if you do not meet resistance you have a probable esophageal intubation and insertion should be reattempted) • Withdraw the BOUGIE only to a depth sufficient to allow loading of the ETT while maintaining proximal control of the Bougie; • Gently advance the Bougie and loaded ETT until you have "hold-up" again, thereby assuring tracheal placement and minimizing the risk of accidental displacement of the BOUGIE • While maintaining a firm grasp on the proximal BOUGIE, advance the ETT over the BOUGIE, passing the ETT to its appropriate depth �llllllllll�lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll iiiiiiiiiiiiiiiiiiii 1111�1111111111111111111111= W. Video Laryngoscope- UEscope • Positioning: Place the patient in the "sniffing" position or use the Head-Elevated Laryngoscopy Position (HELP), which is particular useful for large patients. • Preparation: Power on the scope to allow 30 seconds for the ant-fog mechanisms to activate. • Insertion &Visualization: 1. Insert the scope blade into the middle of the oral pharynx. 2. Advance the blade directly towards the vocal cords, looking for the epiglottis. 3. Once the epiglottis is visualized, advance the tip of the blade into the vallecular fossa. 4. Manipulate the scope to obtain the best possible glottc view. • Troubleshooting View: If the view is too close (common with beginners), slightly withdraw the blade to gain a better, "bird's eye" view of the glottis. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 172 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 • Tube Delivery: A rigid stylet is highly recommended to steer the endotracheal tube (ETT) "around the corner" to match the blade's curvature. • Technique: While direct visualization is possible, the primary goal is viewing the monitor to guide the ETT. ,mi X. Chest Decompression 1. Assess the patient to make sure that his/her condition is due to a tension pneumothorax: • Mechanism of injury • Absent or decreased breath sounds on the affected side. • Poor ventilation despite an open airway. • Tracheal deviation away from the side of the injury (may not always be present). • Neck vein distention (may not be present if there is associated severe hemorrhage). • Tympany (hype rresonance) to percussion on the affected side. • Shock. • Decreased Sp02/end-tidal CO2. 2. Provide the patient with high-flow oxygen and ventilatory assistance. 3. Identify the second or third intercostal space (i.e., the space between the second and third ribs or between the third and fourth ribs) in the midclavicular line on the same side as the tension pneumothorax. If the mid-clavicular site cannot be accessed due to any reason (obese patient or patient trapped) utilize the mid-axillary site (the space between the 5th and 6th ribs) in the mid-axillary line. 4. Quickly prepare the area with povidone-iodine. 5a. Utilize a 14-gauge, 3-to 3%z-inch needle IV catheter. OR 5b. Use a commercial decompression device. 6. Insert the catheter into the intercostal space. 7. Insert the catheter through the parietal pleura until air escapes. It should exit under pressure. 8. Remove the needle and/or syringe. Leave the plastic catheter in place until it is replaced by a chest tube at the hospital. 9. Place 3-way stop cock on catheter: if tension pneumothorax redevelops, briefly turn valve to KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 173 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 relieve trapped air 10. Monitor the patient, as the initial catheter may clog or kink, requiring reinsertion of another needle Diagnostic bilateral pleural decompressions should be performed on traumatic arrest patients Y. Surgical Airway(Cricothyroidotomy) Paramedic: (Must be trained and signed off by the Medical Director to perform). Equipment Needed: BVM, ETCO2 detector, 1" tape, Surgical Cric Kit, suction unit, stethoscope 1. Hyperextend the patient's neck (unless cervical spine injury is suspected). 2. Locate the cricothyroid membrane between the cricoid and thyroid cartilages by palpating the depression caudal (toward the feet) to the midline Adam's apple. If landmarks cannot be identified, DO NOT ATTEMPT PROCEDURE AND CLEARLY DOCUMENT 3. Clean the area well with a Betadine solution or povidone-iodine swabstick. 4. Using a scalpel, make a vertical incision through the skin and then a horizontal incision through the cricothyroid membrane. 5. Once the scalpel has passed into the membrane, insert the handle into the opening and twist the handle to open a space between the cricoid and thyroid cartilages. Do not aim the knife cephalad (toward the head), because injury to the vocal cords may occur. 6. Insert a size 6.0 endotracheal tube or tracheostomy tube through the incision. 7. Inflate the cuff with the recommended amount of air. 8. Ventilate the patient with a bag-valve device using the 15-mm adaptor; provide high-flow oxygen. 9. Confirm placement: • Negative epigastric sounds. • Positive bilateral breath sounds. 10. Attach an end-tidal CO2 monitoring device. 11. Monitor Sp02 with a pulse oximeter. 12. Provide 100% 02 with positive-pressure oxygen or a bag-valve device. 13. Monitor for changes in breathing or airway status. 14. If necessary, cut several 4 x 4 gauze pads down the middle to the center of the pads. Wrap the pads at the base of the tube and secure them to assist in bleeding control and/or to reduce air escape. Do not perform in children under 12 years old. The cricothyroid membrane is too small and underdeveloped thus refer tO needle cric. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 174 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Z. NG TUBE - NASOGASTRIC TUBE Equipment Needed: Appropriate size NG Tube, 60cc syringe, K-Yjelly, 1" tape, stethoscope, suction • An 18 fr. NG tube is preferred for all adult patients that require a nasogastric tube • Measure the tube from the tip of the patient's nose around his ear and then to the bottom of his xyphoid process • Mark the tube with tape at the nose to maintain appropriate length • Lubricate the tip tube with K-Y jelly and Lidocaine jelly • Insert the tube into the nostril and gently passing it into the posterior pharynx. If the patient is able, instruct them to swallow as you advance the tube. The patient may gag. • Allow the patient to rest for a few moments and continue to insert until marked depth is reached • Confirm the correct placement of the tube: 1. With 60cc syringe aspirate stomach contents. Be sure to replace stomach contents once confirmed. 2. Insert 60cc of air and simultaneously Auscultate over the stomach with a stethoscope • Secure the tube to the nose with tape • Connect the end of the tube to suction on low • If you pass the tube into the trachea, patient will have difficulty talking. If this occurs, remove tube immediately. This procedure should not be attempted if there are facial injuries KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 175 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 i IIII III. Alll'ulliueiii,'id iiix Adenosine Triphosphate (Adenocard°) 11 UV1,11UU1 ��u�lwmmuiiiiu» /j. Mechanism of Action PSVT: Slows conduction through AV node and interrupts AV reentry pathways, which restore normal sinus symptoms. Contraindications Hypersensitivity 2nd or 3rd degree AV block (except those on pacemakers) Sinus node disease, such as sick sinus syndrome or symptomatic bradycardia (except in patients with a functioning artificial pacemaker) Adenoscan: Contraindicated in broncho constrictive or bronchospastic lung disease (eg, asthma) Cautions: Symptomatic bradycardia, cardiac arrest, heart block, heart transplant patients, HTN, hypotension, MI, proarrhythmic events, unstable angina Adenocard: Caution with broncho constrictive or bronchospastic lung disease (i.e asthma) IV Administration: Adenocard: given as a rapid injection (1-3 sec) by peripheral IV route directly into vein or into IV line close (proximal) to patient and is followed by rapid NS flush after each injection (20 mL for adults, 5 mL or more for pediatrics) Place patient in mild reverse Trendelenburg position before giving drug. Record rhythm strip during administration. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 176 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Dirac ells (sellswi!l°wIne syu°'ing s( • Adenosine dose • Flush • Attach both syringes to IV injection port nearest to patient • Clamp IV tubing above injection port • Avoid drug traveling retrograde • Push adenosine as fast as possible (1-3 sec) • While keeping pressure on adenosine syringe plunger, push NS flush as fast as possible • Unclamp IV tubing KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 177 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Albuterol (Proventil. ® Ventolin) i lFWii Mechanism of Action Beta2 receptor agonist with some betal activity; relaxes bronchial smooth muscle with little effect on heart rate. Contraindications Hypersensitivity to albuterol Cautions Some inhalers use hydrofluoroalkane (HFA) as propellant instead of chlorofluorocarbons (CFCs); otherwise, devices are equivalent. Immediate hypersensitivity reactions may occur after administration of albuterol sulfate, as demonstrated by rare cases of urticaria, angioedema, rash, bronchospasm, anaphylaxis, and oropharyngeal edema. Paradoxical bronchospasm may occur. The need for more doses than usual may be a sign of deterioration of asthma and requires reevaluation of treatment. Adverse Reactions and Side Effects: Cardiovascular: Tachycardia, hypertension, and angina. CNS: Nervousness, tremor, headache, dizziness, and insomnia. GI: Drying of oropharynx, nausea, and vomiting, unusual taste. Dosage: Nebulizer solution: If>1 year or< 10 kg: 2.5 in 3 ml of NS (0.083%) to nebulizer and flow oxygen at 6-8 liters/ min. (premixed) If< 1 year or< 10 kg: 1.5 in 3 ml of NS (0.083%) to nebulizer and flow oxygen at 3 liters/ min. (premixed). (2.5) mg divided in half). Delivered in over 5-15 minutes. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 178 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Amiodarone (Cordarone) , nil u fiC�fIOV7Fu�:V'R�'a.A°IGI ,�.1fY;Y7iY,„ of"�U in i�!cm l.l ' 419UY iu'llC6 Gy{4r Mechanism of Action Class III antiarrhythmic agent, which inhibits adrenergic stimulation; affects sodium, potassium, and calcium channels; markedly prolongs action potential and repolarization; decreases AV conduction and sinus node function. Contraindications Hypersensitivity Severe sinus node dysfunction, 2°/3° AV block or bradycardia causing syncope (except with functioning artificial pacemaker), cardiogenic shock. ACLS, Pulseless Ventricular Fibrillation/Ventricular Tachycardia 300 mg IV or intraosseous push after dose epinephrine if no initial response to defibrillation May follow initial dose with 150 mg IV q3-5min. Pediatric dosage: Pulseless Arrest: 5 mg/ kg may be repeated once. No single dose greater than 300 mg. 15 mg/ kg max) KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 179 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Aspirin (Bayer,° BufFerin) Mechanism of Action Aspirin is a salicylate used to treat pain, fever, inflammation, migraines, and reducing the risk of major adverse cardiovascular events. Contraindications: 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. Indications: Aspirin is indicated in Acute Coronary Syndrome setting to prevent further clotting. Adverse Reactions and Side Effects: GI: Nausea, vomiting, heartburn, and stomach pain. OTC: Tinnitus Hypersensitivity: Bronchospasm, tightness in chest, angioedema, urticaria, and anaphylaxis. Dosage: Adult 324 mg (4) 81 mg chewable tablets) for Acute Coronary Syndromes KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1180 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Atropine Sulfate as Cardiac Agent o i Iiii II t°tip Mechanism of Action: Atropine is a potent anticholinergic (parasympathetic blocker, parasympatholytic) that reduces vagal tone and thus increases automatically the SA node and increases AV conduction. Indications: Sinus Bradycardia accompanied by hemodynamic compromise, (i.e. hypotension, confusion, frequent PVCs, pale cold, clammy skin). In children < 1year bradycardia of less than 60 beats/ min should be treated if symptomatic even if BP is normal. Contraindications: None in emergency situations Warnings: Too small of a dose (< 0.5 mg) or if pushed too slowly, may initially cause the heart 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 3rf degree AV block, omit Atropine and go to external pacer. Adverse Reactions and Side Effects: 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, flushing of skin GI: Dry mouth, difficulty swallowing KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 181 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Other: Urinary retention. Can worsen pre-existing glaucoma. Dosage: Adult: 0.5-1 mg IV/ 10, may repeat every 3-5 minutes until improved or total of 2 mg is reached Pediatric: 0.02 mg/ kg IV/ 10 (minimum dose is 01 mg maximum single dose is 0.5 mg child, 1 mg adolescent). May repeat once. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 182 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Calcium Chloride 10% ui»y�U�iy�yyay�y�yyy��»»i»»�i�� Illllfl(IiflOf(III(f(I(fff(((flffiflffffifi( �( ACTIONS Calcium chloride increases the force of myocardial contraction; it 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. INDICATIONS Calcium chloride is indicated during resuscitation for the treatment of hypocalcemia and calcium- channel blocker toxicity (e.g., Verapamil or Cardizem overdose) and magnesium sulfate overdose. It also protects the heart from hyperkalemia, which may occur in patients with endstage renal disease. CONTRAINDICATIONS Cardiopulmonary arrest not associated with calcium-channel blocker toxicity, hypocalcemia, or hyperkalemia. ADVERSE REACTIONS AND SIDE EFFECTS If the heart is beating, rapid administration of calcium can produce slowing of the cardiac rate. WARNINGS Calcium chloride should not be administered in the same infusion with sodium bicarbonate, because 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. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 183 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 DOSAGE Adult: For hypotension following administration of calcium-channel blockers (e.g., Cardizem, Verapamil): 4 mg/I<g IV, slowly. If the patient is taking digitalis, 2 mg/kg IV, slowly. Repeat every 10 minutes PRN. Pediatric: 5 mg/kg or 0.2 mL/I<g IV, slowly, every 10 minutes PRN. For calcium-channel blocker overdose and hyperkalemia: 20 mg/kg IV, slowly. (Required approval from Medical Control) KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 184 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Dextrose 50% and 25% (Pedi) I wnmu�ix iwruunkwa�ai Mechanism of Action A monosaccharide, which provides calories for metabolic needs, spare body proteins and loss of electrolytes. Readily excreted by kidneys producing diuresis. Hypertonic solution. Indications • Hypoglycemia • Coma of unknown origin Contraindications • Intracranial or intraspinal hemorrhage (in a patient with normal BGL). • Blood glucose Level > 60 mg/dl. Adverse Reactions and Side Effects Cardiovascular: Thrombosis Sclerosing if given in peripheral vein. Local: Tissue irritation or necrosis if infiltrates Other: Acidosis, alkalosis, hyperglycemia, and hypokalemia Dosage Adult: (> 30 kg) 50 ml of a 50% solution; (25gm) IV/ 10. Pediatric (< 30 kg) 2 ml / kg slow IV/ 10 of a 25% solution. Newborn: (< 10 kg or< 1 month of age) 5 ml / kg IV/ 10 of 10% solution (dilute D50 4:1 with NS). KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 185 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 * Note- Divide 50 by the type of dextrose solution to arrive at rate in ml / kg Adult (D50): 50/50 = 1 ml /kg Child (D25): 50/25= 2 ml / kg KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 186 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Diphenhydramine Hydrochloride (Benadryl) b� �� r e if i X. Mechanism of Actions Diphenhydramine is an antihistamine with anticholinergic (drying) and sedative side effects. Antihistamines appear to compete with histamines 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 tract, uterus, and blood vessels. Indications • Allergy symptoms, anaphylaxis • Sedation of violent patients. • Dystonic reactions from phenothiazine overdose (i.e Haldol, Compazine, Thorazine, and Stelazine) Contraindications • Diphenhydramine is not to be used in newborn or premature infants. • Diphenhydramine is not to be used in patients with acute asthma attack. Warnings 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) patients. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 187 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Adverse Reactions and Side Effects CNS: Drowsiness, confusion, insomnia, headache, vertigo (especially in the elderly) Cardiovascular: Palpitations, tachycardia, PVCs, and hypotension Respiratory: Thickening of bronchial secretions, tightness of the chest, wheezing, nasal stuffiness. GI: Nausea, vomiting, diarrhea, dry mouth, and constipations GU: Dysuria, urinary retention Dosage Adult: 25- 50 mg IV/ 10 or 50 mg deep IM. Pediatric: 1 mg/ kg IV/ 10 or IM (maximum 25 mg). KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 188 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Epinephrine 1:1,000 1. Mechanism of Actions Epinephrine is a sym path omimetic, 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. Indications • Asthma • Anaphylaxis • Angioneurotic edema • All pulseless Arrest Contraindications None in the cardiac arrest situation. Hyperthyroidism, hypertension, cerebral arteriosclerosis in asthma. Caution should be used with Epi administration when the patient is older >40 years of age or history of heart disease. The benefit must outweigh the risk. Do Not administer Epi if heart is > 150 beats per minute. Adverse Reactions and Side Effects CNS: Anxiety, headache, cerebral hemorrhage. Cardiovascular: Tachycardia, ventricular dysrhythmias, hypertension, angina, palpitations. GI: Nausea and vomiting. Dosage Adult: SQ 0.3 mg (0.3 cc). Repeat every 3-5 minutes (Asthma /Anaphylaxis may repeat once in 15 minutes). Pediatric: SQ 0.01 mg/ kg up to 0.5 mg. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 189 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Epinephrine 1:10,000 ��s//f r J. oi�rnvi�Oo�Jiluo�Nir'6rilU�ffi�r��i//,(tQ;ip��Mechanism of Action 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. Epi increases systemic vascular resistance and thus may enhance defibrillation. Indications • All Pulseless Arrest • Asystole • Ventricular Fibrillation to defibrillation • PEA • Other pediatric indications: hypotension in patients with circulatory instability, bradycardia (before Atropine). Contraindications None in the cardiac arrest situation. Warnings Epi is inactivated by alkaline solutions- Never Mix with SodiumBicarbonate Adverse Reactions and Side Effects CNS: Anxiety, headache, cerebral hemorrhage. Cardiovascular: Tachycardia, ventricular dysrhythmias, hypertension, angina, palpitations. GI: Nausea and vomiting. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1190 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Etomidate �unuol��uz� ,,, .:. Amidate". vsa�m rarwn�r�"` Mechanism of Actions Etomidate is a short acting, nonbarbiturate hypnotic, which lacks analgesic properties and is used for induction of general anesthesia. Its action occurs at the level of reticular activating system in the brain stem. Etomidate is generally considered to have minimal adverse effects on cardiac and respiratory function. The duration of action is 3-5 minutes, and excretion occurs through the renal system. Indications An authorized paramedic may induce general anesthesia to facilitate intubation. Precautions: Etomidate can decrease the adrenal glands production of steroid hormones. Use caution, as this agent may act synergistically with other CNS depressants. Monitor vital signs is important. Adverse Reactions and Side Effects The most commons side effects are nausea and vomiting. Etomidate can also cause uncontrolled skeletal muscle activity. Unstable blood pressures, dyspnea, and chronotropic dysrhythmias are possible as well. Dosage Adult: 20mg slow IVP over 1 minute, repeat after 10minutes max 40mg. Pediatric: 0.3mg/kg (intubation only) KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 191 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Fentanyl [M'hW'LaiFm KKkm„ Mechanism of Actions Fentanyl binds with stereospecific receptors at many sites within the CNS, increases pain threshold, alters pain reception, inhibits ascending pain 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 10mg IM = Fentanyl 0.1-0.2mg; Fentanyl has less hypotensive effects than Morphine due to minimal or no histamine release. Indications • Moderate to severe pain in patients >10kg • Acute coronary syndrome—Chest Pain (Adult) • Pain associated with isolated extremity fracture, renal colic, burns, etc. Contraindications: • Epistaxis or bilateral blocked nares. • Known hypersensitivity to Fentanyl • MAOI use in the past 2 weeks • Unstable hemodynamics or altered Precautions: Use with caution in patients with bradycardia, hepatic, renal or respiratory disease or those with increased ICP, head injuries, or impaired consciousness; patients must be monitored. Adverse Reactions and Side Effects CNS: Drowsiness, sedation, increased intracranial pressure KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 192 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 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: 25-100 mcg slow IV push for pain. Pediatric: call medical control for orders KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1193 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Furosemide (Lasix) AN j ei I i I Mechanism of Actions A sulfonamide derivative and potent diuretic, which inhibits the reabsorption of sodium and chloride in the proximal and distal renal tubules as well as in the Loop of Henley. Has a direct venodilating is generally within 5-10 minutes, diuresis will usually occur in 20-30 minutes. Indications • Pulmonary edema • Hypertension • Cerebral edema Contraindications: Hypotension (BP < 100 systolic) or Anuria. Should be used in pregnancy only when benefits clearly outweigh risks Precautions: Furosemide should be protected from light. Dehydration and electrolyte imbalance can result from excessive dosages. Rapid diuresis can lead to hypotension and thromboembolic episodes. Adverse Reactions and Side Effects CNS: Diziness, tinnitus, hearing loss, headache, blurred vision, weakness GI: Anorexia, vomiting, nausea Cardiovascular: Hypotension Other: Pruritus, urticaria, muscle cramping. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 194 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Dosage Adult: For CHF: 40- 80mg IVP or double the patient dose up to max 100mg For Cardiogenic Shock: 40mg IV slowly over 2 minutes (if systolic blood pressure is >than 100 mmHg) KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 195 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Glucagon ummTiTir%%/%110MI S,"N �rriri/ bke % Trig na o 11Yr U IIIIfiIp '/ w Mechanism of Actions Glucagon, which is produced naturally in the pancreas by the alpha cells of the islets of Langerhans, causes an increase in blood glucose concentrations. It is effective in small doses, and no evidence of toxicity has been reported with its use. Glucagon acts only on the liver glycogen, converting it to glucose if the patient has adequate glycogen reserves. Glucagon possesses positive inotropic and chronotropic properties. Indications Documented hypoglycemia is a true medical emergency, IM glucagon should be administered rapidly if IV access is delayed. Glucagon is indicated for the treatment of hypoglycemia when IV cannot be established and oral glucose is contraindicated. It may be effective in a symptomatic beta-blocker overdose. Contraindications • Pheochromocytoma • Insulinoma • Known hypersensitivity • Should not be routinely used to replace Dextrose when IV access has been obtained Warnings Glucagon should be administered with caution in patients with history of insulinoma and /or pheochromocytoma. ONLY 1 ml of Sterile water should be used for reconstitution. Normal Saline cannot be used as n alternative. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 196 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Possible Adverse Reactions and Side Effects Occasional nausea and vomiting Dosage Adult: 1 mg slow IVP/IM (not less than 30 seconds) Pediatric < 40 kg: 0.025 mg/ kg slow IVP/IM (not as effective in children as in adults) KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 197 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Ipratropium Bromide (Atrovent) fff 'I 4 Mechanism of Actions Ipratropium bromide is an anticholinergic (parasympatholytic) agent, which causes localized bronchodilation. Indications Ipratropium bromide is indicated for relief of bronchospasms associated with asthma and chronic obstructive pulmonary disease, including chronic bronchitis and emphysema that is unresponsive to treatment with albuterol alone. Contraindications Hypersensitivity to atropine or its derivatives. Adverse Reactions and Side Effects • Respiratory: Cough, exacerbation of symptoms • CNS: Nervousness, dizziness, headache • Cardiovascular: Palpitations • GI: Nausea, vomiting, GI distress • Other: Tremor, dry mouth, blurred vision Dosage Adult: .5mg at 6-8L/min (to be added to standard albuterol dose) Pediatric: Not Applicable KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 198 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Lorazepam (Ativan) ���lfrrrflt��r�t � uml Rdc�"F. l� ru�y r, Mechanism of Actions Lorazepam is benzodiazepine, so it depresses the central nervous system. It produces sedation, relieves anxiety, causes lack of recall, and provides for relief of skeletal muscle spasms. Indications • Adjunct seizure control • Control of violent patients Contraindications: Known sensitivity to benzodiazepine; narrow-angle glaucoma. Precautions: May cause respiratory distress Adverse Reactions and Side Effects • CNS: Excessive CNS depression • Cardiovascular: Rarely hypotension/hypertension •Respiratory: Hypoventilation, partial airway obstruction • Local: Pain, burning, and redness at injection site • General: Nausea /vomiting and skin rash Dosage Adult: 1-2mg IV/IM/IN (Max 5mg) Pediatric: 0.05-0.1mg/kg (Max 2mg) KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 199 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Magnesium Sulfate Mechanism of Actions Magnesium prevents or controls convulsions by blocking neuromuscular transmission and decreasing the amount of acetylcholine liberated at the end-plate by the motor nerve impulse. Magnesium is said to have a depressant effect on the central nervous system, but it does not affect the mother, fetus or neonate when used as directed in eclampsia and pre-eclampsia. Magnesium acts peripherally to produce vasodilatation therefore a drop in systolic BP is to be anticipated. Indications • Prevention and control of seizures in eclampsia • Torsade's de Pointes • Suspected hypomagnesemia state (i.e., chronic alcoholism and chronic use of diuretics. • Refractory ventricular fibrillation Precautions: 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. 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. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1200 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Adverse Reactions 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 paralysis. Dosage For eclamptic seizures: 2 gm IV over 1-2 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/ml IV set. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 201 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Methylprednisolone Mechanism of Actions Decreases inflammatory effects via its potent anti-inflammatory synthetic steroid Indications • Asthma • Anaphylaxis • Head injury • COPD • Unconscious with Known Addison's disease Contraindications: None in emergency setting Adverse Reactions and Side Effects GI hemorrhage, reduces leukotrines of immune system, increases potential for infections. Dosage Adult: 125 mg IV slow over 2 minutes Pediatric: 2 mg/I<g (max 125 mg) IV slow over 2 minutes KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Pagel 202 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Midazolam (Versed °) r k id �6QR dPt��p a o i„ I I h Mechanism of Actions Depresses CNS, muscle relaxant, strong sedative, hypnotic, amnesia. Indications Control of seizures, sedation for cardioversion & pacing. Sedation for airway management. Contraindications Respiratory depression Hypotension ETOH and drugs Warnings Monitor patient for respiratory and CNS depression. Monitor vital signs after administration. Adverse Reactions and Side Effects: CNS: Retrograde amnesia altered mental status, dizziness. Cardiovascular: Bradycardia, hypotension, PVCs, tachycardia, nodal rhythms. GI: Nausea and vomiting, hiccoughs, coughing Respiratory: Respiratory depression, laryngospasm, bronchospasm. Dosage Adult: 2.5 mg increments up to 10 mg max Pediatric: > 1 years of age (0.1 mg/ kg) KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Pagel 203 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Morphine Sulfate n Mechanism of Actions Morphine is a narcotic analgesic, which depresses the central nervous and respiratory system and sensitivity to pain. Morphine also increases venous capacitance, decreases venous return and produces mild peripheral vasodilation. Indications • Pain • Pain associated with isolated extremity fracture, renal colic, burns, etc. Contraindications: • Volume depletion or hypotension • Known hypersensitivity to MS • Head trauma • Contact Medical Control if patient • Acute asthma has abdominal pain for orders Precautions: Morphine is detoxified by the liver. It is potentiated by alcohol, antihistamines, barbiturates, sedatives and beta blockers. Adverse Reactions and Side Effects • CNS: Euphoria, drowsiness, pupillary constriction, respiratory arrest. • Cardiovascular: Bradycardia, hypotension • GI: Decreases gastric motility, nausea and vomiting • GU: Urinary retention • Respiratory: Bronchoconstriction, decrease cough reflex. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Pagel 204 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Naloxone Hydrochloride (Narcan°) ��'�r��uUauv�au�uV��r�Y'K�OFi✓ 7Jt/�r;tixl�r�^t�l>r o /oo /� rall gvrywn I,vDl Pond SFm»mrls S.G� /�/J rr cr rrrurcr�curr.nnra� (M'g �/� } rid 41�P A 4 rrr/i rrrl6r/rlldl�l� // / '� 7,,I r sq�4 vrwuur w win r ��j / Mechanism of Actions Naloxone antagonizes the effects of opiates by competing at the same receptor sites. When given IV, the action is apparent within two minutes. IM or SC is slightly slower. Indications • Heroin • Methadone • Meperidine (Demerol) • Lomotil • Codeine • Hydromorphone (Dilaudid) • Morphine • Pentazocine (Talwin) • Propoxyphene (Darvon) • Percodan • Fentanyl (Sublimize) (Also Known As "White China") Contraindications Known hypersensitivity to Narcan. Warnings Naloxone should be administered cautiously to people including newborns of mothers who are known or suspected to be physically dependent on opiates, it may precipitate an acute abstinence syndrome. If the patient is intubated and the airway is controlled do not administer Narcan (excludes cardiac arrest). May repeat Narcan since duration of action of some narcotics may exceed that of Narcan. Naloxone is not effective against respiratory depression due to non- opiate drugs. Use caution during administration as patients may become violent as level of consciousness increases. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Pagel 205 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Adverse Reactions and Side Effects CNS: Tremor, agitation, belligerence, pupillary dilation, seizures, increased tear production, sweating, and seizures secondary to withdrawal Cardiovascular: Hypertension, hypotension, ventricular tachycardia, pulmonary edema, ventricular fibrillation. GI: Nausea and vomiting. Dosage Adult: Initial dose 2 mg may administer IV/10/I1VI/ If no response after 4 mg, then the condition is probably not due to narcotic. (Fentanyl may require large doses of Naloxone to reverse effects). Pediatric: O.1mg/ kg IV/10/I1VI KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Pagel 206 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Nitroglycerin (Nitrostat°, Nitrolingual° Spray) i Mechanism of Actions Nitroglycerin is a direct vasodilator, which acts principally on the venous system although it also produces direct coronary artery vasodilation 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. Indications • Chest pain or discomfort associated with suspected AMI. • Pulmonary edema with hypertension Contraindications • Systolic BP < 100 mmHg • Children under 12 • Patients on erectile dysfunction drugs that fall within time parameters, DO NOT administer Nitro if erectile dysfunction drug use < 48 hours. • Known hypersensitivity to the drug • Evidence of a positive V4R in the setting of an Inferior Wall MI Adverse Reactions and Side Effects CNS: Headache, dizziness, flushing, nausea and vomiting Cardiovascular: Hypotension, reflex tachycardia, bradycardia Dosage Adult: 0.4 mg (1 tablet or 1 spray sublingual). May repeat up to two additional times 3-5 minutes PRN. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Pagel 207 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Norepinephrine ( Levophed) Mechanism of Actions Norepinephrine is a naturally occurring catecholamine that acts on both alpha- and beta- adrenergic receptors. The action on alpha receptors is stronger and results in peripheral vasoconstriction. This increases the blood pressure in hypotensive states such as cardiogenic shock and sepsis. Indications • Hypotension not related to hypovolemia • Neurogenic shock Contraindications: • Hypotension caused by hypovolemia Precautions: • Monitor blood pressure closely • Ensure adequate fluid replacement before starting Norepinephrine • Administer through largest vein possible to reduce risk of tissue necrosis • Use caution in cases of cardiac ischemia as Norepinephrine increases myocardial oxygen demand. Adverse Reactions and Side Effects Usually, dose related but may include tremors, headache, myocardial ischemia, nausea, vomiting, and dizziness. May also cause bradycardia (usually because of increased peripheral vasoconstriction. Dosage KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1208 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Adult: Run infusion at 4mcg/min (lgtts/sec) using micro drip set (60gtts/ml) • If blood pressure increases >12OmmHg systolic, titrate infusion to 2mcg/min (lgtt/2 sec) Preparation: Add 1mg of Levophed into a 25Oml D5W for a concentration of 4mcg/ml ** Fluid Resuscitation: Ensure minimum of(1) Liter or Normal Saline has been administered prior to administration of Norepinehprine. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1209 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Ondansetron (Zofran) 4%' Mechanism of Actions 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. Indications Used for a patient with nausea unrelieved with comfort measures, uncomfortable due to the nausea during transport and/or with a potential for airway compromise related to vomiting. • Nausea and vomiting due to chemotherapy • Prophylactic use prior to administration of pain management medication. *Nausea and vomiting with moderate to severe dehydration or electrolyte imbalance. Contraindications: 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). Precautions: 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. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 210 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Adverse Reactions and Side Effects CNS: Headache, Dizziness, Drowsiness, Fatigue GI: Diarrhea, Constipation, Abdominal pain, Dry Mouth MISC: Rash, Shivering, Fever, Hypoxia, Urinary Retention, Muscle Pain RARE: Bronchospasm, Transient blurred vision after infusion Dosage Adult & Pediatrics >40kg: 4mg slow IVP note: rapid administration will cause hypotension Pediatric: 0.1mg/kg slow IVP KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 211 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Oral Glucose (Insta Glucose) 40 Mechanism of Actions Increases blood glucose levels slowly. Indications BS < 60 mgdl, patients who are altered but alert enough to take the command to swallow. Contraindications Patients unable to swallow or Stroke symptoms. Precautions None when patient can swallow, risk of aspiration if given improperly. Adverse Reactions and Side Effects Cardiovascular: Unknown' CNS: Unknown GI: Nausea Dosage Adult: 1 tube Pediatric: 1 tube KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1212 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80134-ED231 F655DE1 Sodium Bicarbonate m i i 1 l Mechanism of Actions Increases PH to reverse acidosis. Indications: • Metabolic acidosis in cardiac arrest • Tricyclic overdoses with QRS >0.1 • Electrocutions • Hyperkalemia • Methanol/ Ethylene glycol toxicity • Compartment syndrome Contraindications: CHF, Alkalotic states. KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1213 Docusign Envelope ID: 1A9C71 EC-7F8A-82D9-80B4-ED231 F655DE1 Precautions: 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. Adverse Reactions and Side Effects Metabolic alkalosis, may crystalize in IV solutions Dosage Adult: 1 mEq/kg IV push, then % the dose q 10 mins. Electrocutions: 2 mEq/I<g IVP Pediatric: 1-2 mEq/I<g diluted 50:50 with Normal Saline KEY LARGO DISTRICT-WIDE EMS PROTOCOLS Page 1 214 y P v PI Key Largo Fire Rescue Emergency Medical Services District I. COMMUNICATION (DISPATCH) CENTER PROCEDURE A. All EMS systems utilize the E911-phone system in conjunction with Computer Aided Dispatch (CAD) and Emergency Medical Dispatch programs.The taker call confirms all emergency information, including address and callback data prior to the end of the telephone conversation; immediately transmits the emergency call request to the nearest available Fire-Rescue unit(s)for response; and provides all unit(s)with all available information concerning the incident. B. Call taker personnel/dispatcher shall make every attempt to obtain the following information from the 911 caller: 1. Nature of the emergency. 2. Location of the incident. 3. Call back number. 4. Number of patients. 5. Severity of the illness/injury. 6. Name of the caller. 1 C. Monroe County operates a consolidated communications system, encompassing all but the four self-dispatched fire rescue agencies. Should on-scene personnel recognize a need for other emergency agencies (e.g. law enforcement, fire, EMS, Coast Guard),they shall notify Dispatch immediately. On-scene personnel must identify the type of additional equipment/staffing needed/required.The communications center shall contact the appropriate services (mutual aid/automatic aid). II. ON SCENE PROCEDURE—GROUND A. Upon arrival at the scene, Fire Rescue personnel shall conduct a size up of the scene, to include, but not limited to,Trauma Alert Criteria (Section IV), safe entry, severity, and number of patients, the need for extrication, and the need for additional help. Dispatch will be notified, as soon as possible, of"Trauma Alert" patient(s). Dispatchers shall immediately transfer this information, using the words "Trauma Alert", for Aeromedical evacuation to nearest Trauma Center. B. Fire Rescue personnel shall submit the treatment data for each trauma patient to the EMS ground transport unit as required in 64.1- 1.014, F. A. C. and their respective agencies. III.TRANSPORT PROCEDURE (Aeromedical) Three steps to follow when requesting Aeromedical evacuation. The first two are directed toward the safety of the helicopter pilot and crew, ground personnel, patient, and bystanders; and the third is to establish operational guidelines as to when and/or the helicopter may be used to transport these patients. A. Severe weather at scene, helicopter hanger, landing zone (LZ), or Trauma Center reduces the use of the Aeromedical evacuation. B. Safety considerations for landing zone (if any of 5, move the landing zone): 1. Landing Zone (LZ) should be clear of obstacles(obstacles are any object>40 feet tall and within 100 feet of the LZ). 2. Optimum size of the LZ should be 100-foot square (or diameter). 3.The surface should be smooth and hard as possible and should not exceed a 10 degree slope. 4. Pedestrians and large gatherings of civilians in the area. 5. An expectation that area may not remain safe. 2 C.Aeromedical evacuation may be used if: 1.Trauma transport. 2. Extrication time greater than twenty(20) minutes. 3.The helicopter is needed to gain access to a patient for transport from an inaccessible area. 4. Open water incidents (e.g. drowning, boat fires, explosions on the bay or offshore, etc.) 5. Large scale multiple casualty incidents. D. Operational Guidelines by ground Fire Rescue crews for Aeromedical evacuation use: 1. Secure a TAC radio channel through the County's dispatch center and keep it open until helicopter has left scene. 2. Ground Crew PRE-ALERT Trauma Center. 3. Start respective agency's modified patient treatment form. 4. Airway-advise Air Crew on airway status and if airway assistance is or RSI (Rapid Sequence Intubation) is required. 5. Begin Packaging Patient(remove shoes and clothing from vital areas). Advise crew of weight of patient. 6. A pre-designated landing zone should be used first. For roadway landings traffic must be stopped in both directions. 7. LZ Command should ensure that EMS crew personnel are supplemented with an appropriate number of personnel to assist in the safe and efficient loading of patient into the helicopter. 8. Headlights should be turned off at night. 9. Only clear landing zone upon direction of LZ command and helicopter has left the scene. IV.TRAUMA ALERT CRITERIA The following guidelines are to be used to establish the criteria for a "Trauma Alert" patient and determine which patient(s)will be transported to a trauma center. Any patient that meets any one of the "GEED" or any two "BLUE" criterion will be considered a trauma alert. 3 A.ADULT TRAUMA SCORECARD METHODOLOGY 1. Each Fire Rescue personnel shall ensure that upon arrival at the location of an incident, Fire Rescue personnel 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 Fire Rescue personnel shall evaluate the patient's status for each of the following components: airway, circulation, best motor response (i.e. Glasgow Coma Scale), cutaneous, long bone fracture, patient's age, mechanism of injury.The patient's age and mechanism of injury (i.e. ejection from vehicle or deformed steering wheel) shall only be assessment factors when used in conjunction with assessment criteria included in#3 (Level 2) of this section. (NOTE: Glasgow Coma Scale included for quick reference.) 2. Fire Rescue personnel shall assess all adult trauma patients using the following "READ" criteria in the order presented and if any one of the following conditions is identified, the patient shall be considered a trauma alert. a. AIRWAY: Active ventilation assistance required due to injury(ies) causing ineffective or labored breathing beyond the administration of oxygen. b. CIRCULATION: Patient lacks a radial pulse with a sustained heart rate greater than or equal to 120 beats per minute or has a blood pressure of less than 90mmHg systolic. d. LONGBONE FRACTURE: Patient reveals signs or symptoms of two or more long bone fracture sites (humerus, radius/ ulna,femur, or tibia/fibula). e. CUTANEOUS: 2nd or V degree burns to 15 percent or greater of the total body surface area; electrical burns (high voltage/direct lighting) regardless of surface area calculations; an amputation proximal to the wrist or ankle; any penetrating injury to the head, neck, or torso (excluding superficial wounds where the depth of the wound can be determined.) f. BEST MOTOR RESPONSE (I3MR): Patient exhibits a score of 4 or less on the motor assessment component of the Glasgow Comal Scale; exhibits the presence of paralysis; suspicion of a spinal cord injury; or the loss of sensation. 4 g. MISC.: • PARAMEDIC JUDGEMENT—If none of the conditions are identified using the criteria above during the assessment of the adult trauma patient, the paramedic can call a trauma alert if, in his or her judgment, the patient's condition warrants such action. GLASGOW COMA SCORE—12 OR less 3. Should the patient not be identified as a trauma alert using the "RED" criterion listed in#2 of this section, the trauma patient shall be further assessed using the "BLUE" criteria 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. AIRWAY: Respiratory rate of 30 or greater. b. CIRCULATION: Sustained heart rate of 120 beats per minute or greater. c. LONGBONE FRACTURE: Patient reveals signs or symptoms of a single long bone fracture resulting from a motor vehicle collision or a fall from an elevation of 10 feet or greater. d. CUTANEOUS: Soft tissue loss from either a major degloving injury; or major flap avulsion greater than 5 inches;or has sustained a gunshot wound to the extremities of the body. e. BEST MOTOR RESPONSE (BMR): BMR of 5 on the motor component of the Glasgow Coma Scale. f. MECHANISM OF INJURY: Patient has been ejected from a motor vehicle, (excluding any motorcycle, moped, all-terrain vehicle, bicycle or open body of a pick-up truck), or the driver of the motor vehicle has impacted with steering wheel causing steering wheel deformity. g. AGE: Anticoagulated Older Adult>55 h. MISC.: Blunt Abdominal Injury. 4. If the patient is not identified as a trauma alert after evaluation using the criteria in sections 2 or 3 above, the trauma patient will be evaluated using all elements of the Glasgow Coma Scale. If the score is 12 or less, the patient shall be considered a trauma alert (excluding patients whose normal Glasgow Coma Scale is 12 or less, as established by the medical history or pre-existing medical condition when known). 5 5. If paramedic judgement is used as the basis for calling a trauma alert, it shall be documented on all patient data record as required in section 64J-1.014, F.A C. 7.The results of the patient assessment shall be recorded and reported on all patient data records in accordance with the requirements of section 64J-1.014, F.A.C. B. PEDIATRIC TRAUMA SCORECARD METHODOLOGY Pediatric patients are those persons age 15 or younger and will be transported to nearest Trauma Center. 1. Fire Rescue personnel shall assess all pediatric trauma patients using the following RCS" criteria in the order presented and if any of the following conditions is identified, the patient shall be considered a pediatric trauma alert: a. AIRWAY: Active ventilation assistance required due to injury(ies) causing ineffective or labored breathing beyond the administration of oxygen. b. b. CONSCIOUSNESS: Patient exhibits an altered mental status that includes drowsiness; lethargy; inability to follow commands; unresponsiveness to voice or painful stimuli; or suspicion of a spinal cord injury with/without the presence of paralysis or loss of sensation (can include reliable history of loss of consciousness). c. C C LATIO : Faint or non-palpable carotid or femoral pulse or the patient has a systolic blood pressure of less than 50mmHg. d. FRACTURE: Evidence of an open long bone(humerus, radius/ ulna, femur, or tibia/fibula)fracture or there are multiple fractures sites or multiple dislocations (except for isolated wrist or ankle fractures or dislocations). e. CUTANEOUS: Major soft tissue disruption, including major degloving injury; 2nd or 3rd degree burns to 10 percent or more of the total body surface area; electrical burns (high voltage/direct lighting) regardless of surface area calculations; an amputation proximal to the wrist or ankle; any penetrating injury to the head, neck, or torso (excluding superficial wounds where the depth of the wound can be determined). f. PARAMEDIC JUDGEMENT: If none of the conditions are identified using the criteria above during the assessment of the pediatric trauma patient, the paramedic can call a trauma alert if, in his or her judgement, the patient's condition warrants such action. 6 2. In addition to the criteria listed above in (1) of this section, a pediatric trauma alert shall be called when "BLUE" criteria are identified from any two of the components included below: a. CONCIOUSNESS: Exhibits symptoms of amnesia, or there is loss of consciousness. b. CIRCULATION: 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, FRACTURE: Reveals signs or symptoms of a single closed long bone fracture. Long bone fractures do not include wrist or ankle fractures. d. MISC.: Blunt Abdominal Injury. e. SIZE: Pediatric trauma patients weighing 11 kilograms or less, or the body length is equivalent to his weight on a pediatric length and weight emergency tape (the equivalent of 33 inches in measurement or less). 3. In the event paramedic judgment is used as the basis for calling a Trauma Alert, it shall be documented as required in the 64J-1.014 F.A.C., on the patient care report. NOTE m Anytitne KI FREXIS care provider believes a patient would bensfitfrom transport vic an Aen)rnediccil evaluation, the pubent will be transported by Aeromedical. 7 tie patient di5ctission may take place after the transport hos been completed with no(ification of Medical Director V.TRANSFER PROCEDURES FOR EMERGENCY INTER-HOSPITAL TRAUMA TRANSFERS The Key Largo Fire Rescue & Emergency Medical Services District is a non-transport agency and does not provide inter-facility transfers within Monroe County.This information is based on the official records and protocols of the Key Largo Fire Rescue & Emergency Medical Services District as of 01/01/2026. VI. GLASGOW COMA SCALE SCORING The Glasgow Coma Score (GCS) measures cognitive abilities. It is composed of three parameters, (eye, verbal, and motor responses) and uses numerical scoring to assist in the correlation of brain injury.Those scores are as follows: 7 Adult GCS: Best Eye Response: 1. No eye opening 2. Eye opening to pain. 3. Eye opening to verbal command. 4. Eyes open spontaneously. Best Verbal Response: 1. No verbal response. 2. Incomprehensive sounds. 3. Inappropriate words. 4. Confused. 5. Oriented. Best Motor Response 1. No motor response. 2. Extension to pain. 3. Flexion to pain. 4. Withdrawal from pain. 5. Localizing pain. 6. Obeys commands. A GCS score is between 3 and 15, 3 being the worst and 15 the best.A Coma score of 13 or higher correlates with a mild brain injury;9 to 12 is a moderate injury, and 8 or less a severe brain injury. (Note a phrase "GCS of 11"is essentially meaningless, and it is important to break the figure down into its components, such as eye 3+ verbal 3+motor 5=GCS 11) 8 / y Pediatric GCS: Eye Opening < 1 Year >1 Year 4 Spontaneously Spontaneously 3 To verbal To verbal command command 2 To pain To pain 1 No response No response �.. .._ ...� ............ ............................ Motor Response < 1 Year >1 Year 6 Obeys 5 Localizes pain Localizes pain 4 Flexion.—normal Flexion withdrawal 3 Flexion — Flexion— abnormal abnormal (decorticate (decorticate rigidity)w wmmm rigidity)ww 2 Extension Extension (decerebrate (decerebrate _ rigidity) rigidity) 1 No response No response Verbal Response 0-23 Months < 2-5 Years >5 Years 5 Smiles, coos, cries, Appropriate words Oriented and appropriately and phrases converses .. ......... ........wwwww._.wwww ....____............._. 4 Cries Inappropriate Disoriented and words converses 3 Inappropriate Cries and/or Inappropriate crying and/or screams words screaming 2 Grunts Grunts _ Incomprehensive 1 _No response No response No response A GCS score is between 3 and 15, 3 being the worst and 15 the best.A Coma score of 13 or higher correlates with a mild brain injury,9 to 12 is a moderate injury, and 8 or less a severe brain injury. (Note a phrase "GCS of 11"is essentially meaningless, and it is important to break the figure down into its components, such as eye 3+ verbal 3 +motor 5=GCS 11) 9 VII. DESIGNATED FACILITIES Trauma Alert patients will be transported to the nearest appropriate trauma center. Should Aeromedical evacuation not be available, or ETA exceeds more than 30 minutes, the patient will be transported to the next closest facility. Listed below are the closest Trauma Centers: Ryder Trauma Center 1800 NW 10th Ave Miami, Florida 33136 Ryder Trauma Center/Jackson South 9333 SW 152ND Street Miami, Florida 33157 FICA Florida Kendall Hospital 11750 SW 40th Street Miami, Florida 33175 Vill. RUN REPORTS The Fire Rescue provider issuing the "Trauma Alert" shall provide the ALS Ground Unit a copy of the Patient Care Run Report. Non-transport units are required to initiate protocols and procedures until a transport unit assumes treatment.This includes, but is not limited to, medical care, patient packaging and documentation of an ePCR. (See attached) 10 KLFREMS - Patient Care "Evaluation"Report Date: �.........��.._ ..� Unit ...��,_ CreHr.. ......�..�_..�., ._..�...o. ,....�.�........�.00.._...�.....�....�...._......_._,.._..�....�........._..�.......�.. Incident Location: . ...... � . . _. ._�, ._ . .... .. . Incident#. _ . .... .. TIME OF ONSET/ DISPATCH ENROUTE TO SCENE ARRIVAL AT PATIENT ALERT:TRAUMA UNIT AVAILABLE INJURY SCENE CONTACT ............ ............. PATIENT NAME DATE OF BIRTH AGE SEX WEIGHT ADDRESS CITY STATE ZIP PHONE# —L:_......._.. ..... ....... ......_ .... ................... ............. PATIENT.___ ....._.. _.... .........__..............__......................._...... __.._....._...._ ...... P HISTORY .�.�..._..a...a....�a CHIEF COMPLAINT....m�..„_�.�..��..�.�.....�_..m��.�..�...�._.�..�...��..�.�,.,.m. fVIEDICATIONS �..,.�__..__w..........._....�...�.„. SYMPTOMS PAST MEDICAL HISTORY ALLERGIES LAST MEAL EVENTS LEADING _.._,.�.._...�.��_..._.�..�.....__� .�,.�..,,_..�.......,_�..�,...�..�._�PATIENT ASSESSMENT .........w� ....,.,._...,.,.w�.�wmm ,._..�.�_.....,�..... ._.�.,, .__..�.�.�� TIME _ B/P PULSE RESP/MIN SA02..._ _ SKIN GCS GLUCOSE E ....... TIME B/P PULSE RESP/MIN _ SA02 SKIN GCS _._G_.�ww.....SE w LUCOSE INTERVENTIONS ....... TIME OXYGEN/ADJUNCT/LPM ___,�._.,......,.. .._.........�,�....., .,..��... . ...._., .�... ..__.....�.,. . .,,..... ......... TIME SPINAL IMMOBILIZATION TIME I.V./CATH#/SITE TIME OTHER TIME MED/DOSE/ROUTE TIME OTHER " HEAD/NECK --M-MCHESTBACK ABDOMEN PELVIS EXTREMITIES f NARRATIVE: 11 art tad �f01�, Adult Trauma Scorecard Methodology Reap any on (1), transport as trauma alert; Blue, any two (2), transport as trauma alert Component Airway Sustained respiratory rate >_ Active ar rway assist irrrrr (1) 30 Circulation • Sustained heart rate 120 PJo rad4 1puken sustairred il' °,> 120 or yystok< 90 irrrm l Best Motor Response • BMR=5 GCS 12 (BMR) BMR= 4 or Ilress yr s rrce ref 1pars@ysi s Suspir:,ioin of slrrk4ii cord 'iinuury & Loss of sensation Cutaneous • Soft tissue loss (2) * 2- or y,, burns to J. 1p or wore i" y rnputsbon lisr niu"nA to the wrist or male a, Any pen tr������lin hrjr,ry to the head, neck, or toirsu (y) Long bone Fracture (4) • Sign or symptoms of a single yi2urm or syirmrrmrrms of a fracture site due to MVC or Fall firacture of two or imore long 10 or more bone skes" ......... Age • >_55 years or older(7) Mechanism of Injury • Ejection from motor vehicle (5) • Steering wheel deformity(6) Judgement ENA F or IPP rarnedr r di sciretioirr �S6 12 i 1, 1 r Pediatric Trauma Scorecard Methodology Red, any one (1),transport as trauma alert; Blue, any two (2)transport as trauma alert; Green-- follow local protocols Size > 20g ( + 12-20 (22- 3 lbs.) Weight< 11kg (<22 lbs.) lbs.) Length < 33 inches on pediatric length-based tape AirwayNormal Supplemental oxygen + 4ssls d (1) I n hj b t b Consciousness Awake Amnesia v, Mtered rrnentaal status ( ) Loss of consciousness a Comas + Presence of paarasllysls * yusraplrla�)rn of spinal coird dur„jUry ra Loss of sensaabon Circulation Good Carotid or femoral as Faint or non-paalpa We caro .ib or peripheral pulses palpable but fer noraa� pu. se pulses; S P > lack of radial or pedal a SP < 50 rrairni I 90 mmHg pulse SBP < 90 mmHg Fracture o None seen Sign or symptom of % Open ioing brans fraactuire or suspected single closed long bone aa, I ualltipl a fracture si°it s fracture (3)(4) e Muffiple dl slloc doins (3)(4) Cutaneous e No visible 9 Contusion ra pia„ �rar soft dssru �srulption (y) injury a Abrasion Sao .- or - b erns Lirs ':@.0I/( i BSA e, 4rrnlyrats4.r7ur ) ) a Any aM EArsbing uir(usiry to head, neck oir twso ( ) Judgement Aa kl' .I..or Paararrnedlc bias retIon (3) 13 Hn L Attestation of Medical Director's Participation, Review, and Approval of Trauma Transport Protocols "As the Medical Director of Key Largo Fire Rescue&Emergency Medical Services District, I developed and/or directed the development of the Trauma Transport Protocols presented in this document" _ ... 03/04/2026 Thomas Morrison Thomas II0oiruusoin(M air 4,2026'M32M ES') Name of Medical Director Signature of Medical Director Approval Date ME79946 M.D./ D. 0. License Number 14 ��nmimnnn m � m mmm 00000n o00 0 ��OF 0� � ur Transpart 1-: it i IS Final Audit Report 2026-03-04 Created: 2026-03-02 By: Chris Jones(cjones@keylargofire.org) Status: Signed Transaction ID: CBJCHBCAABAAyiAOBEHkb6lVbfutDLhnkHYhvSWaBc2z "KLFREMS Trauma Transport Protocols" History Document created by Chris Jones (cjones@keylargofire.org) 2026-03-02-12:13:38 PM GMT =' Document emailed to Thomas Morrison (tgmmedicalcorp@gmail.com)for signature 2026-03-02-12:13:43 PM GMT Email viewed by Thomas Morrison (tgmmedicalcorp@gmail.com) 2026-03-04-9:31:43 PM GMT Document e-signed by Thomas Morrison (tgmmedicalcorp@gmail.com) Signature Date:2026-03-04-9:32:33 PM GMT-Time Source:server Agreement completed. 2026-03-04-9:32:33 PM GMT Adobe Acrobat Sign � m� nn o) N � ' cd O O O' UC/) U N ) 0 cd CO cd W Z U z) � � � O '' 0 pw CO us W C.) U Q) U �� x Z o u � m oo al o � � � A z ° ° °' ° � ; � � o Z t 0 o � Z GQ Cl) w, o CU N ,;: o U o N N 0 i CL) U Q cry 'co Cd cd ltl� cd a t O N ' cd0 cd cd U Cd W N Z3 N �O Q.) U U 10 O a N o a W � U 0 0 � U Cd J � a � � ® u d NOTICE OF PUBLIC HEARING NOTICE IS HEREBY GIVEN TO WHOM IT MAY CONCERN that on April 15,2026,at 9:00 A.M. or as soon thereafter as the matter may be heard, at the Marathon Government Center, 2798 Overseas Highway, 2nd Floor, Marathon, Florida,the Board of County Commissioners of Monroe County, Florida, intends to consider the following: ISSUANCE OF A CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY TO KEY LARGO FIRE RESCUE AND EMERGENCY MEDICAL SERVICES DISTRICT FOR THE OPERATION OF A CLASS A ALS AND BLS AMBULANCE TRANSPORT SERVICE WITHIN MONROE COUNTY, FOR THE PERIOD OF APRIL 16, 2026 THROUGH APRIL 15,2028. The proposed certificate may be inspected by the public at the Monroe County website by viewing the agenda packet for the April 15, 2026, meeting, which will be posted beginning on April 7, 2026 at: https://www.monroecounty-fl.gov/695/BOCC-Meetings-A eg ndas. The ordinance may also be viewed at the Monroe County Attorney's Office at 1111 12t' Street, Suite 408,Key West,FL 33040. The public can participate in the April 15, 2026, meeting of the Board of County Commissioners of Monroe County,FL by attending in person or via Zoom. The Zoom link can be found in the agenda at: https://mcboce.zoom.us/j/89204098700, or Live Closed Captioning is available via the MCTV portal at https://cloud.castus.tv/vod/monroe/video/60832c9dcf67bb7acOc2l791?page=HOME&type=live. ADA ASSISTANCE: If you are a person with a disability who needs special accommodations in order to participate in this proceeding,please contact the County Administrator's Office,by phoning(305)292-4441, between the hours of 8:30a.m.-5:OOp.m., prior to the scheduled meeting, if you are hearing or voice- impaired, call "711': Pursuant to Section 286.0105, Florida Statutes,notice is given that if a person decides to appeal any decision made by the Board of County Commissioners with respect to any matter considered at such meetings or hearings, that person will need a record of the proceedings, and for such purpose, that person will need to ensure that a verbatim record is made of the proceedings, which record includes the testimony and evidence upon which the appeal is to be based. Dated at Key West, Florida, this 2,,d day of April,2026. (SEAL) KEVIN MADOK, Clerk of the Circuit Court and Ex Officio Clerk of the Board of County Commissioners of Monroe County,Florida Publication Dates: Keys Citizen: Thur., 04/02/2026 Keys Weekly: Thur., 04/02/2026 News Barometer: Fri., 04/03/2026 CHAPTER 2005-329 House Bill No. 1291 An act relating to the Key Largo Fire Rescue and Emergency Medical Services District,Monroe County; creating a special district;provid- ing definitions; providing for creation, status, charter amendments, boundaries, and purposes; providing for a board of commissioners; providing for election and terms of commissioners; providing for employment of district personnel; providing for election of board officers;providing for compensation,oath,and bonds of commission- ers; providing for powers, duties, and responsibilities of the board; providing for ad valorem taxes; providing a cap on the rate of taxa- tion;providing for user charges;providing for impact fees;providing for authority to disburse funds; authorizing the board to borrow money; providing for use of district funds; requiring a record of all board meetings; authorizing the board to adopt policies and regula- tions; providing for the board to make an annual budget; requiring an annual report; authorizing the board to enact fire prevention ordinances;authorizing the district to appoint a fire marshal;autho- rizing the district to conduct inspections, establish and operate fire, rescue, and emergency medical services; providing for district au- thority upon annexation of district lands; providing for dissolution; providing immunity from tort liability for officers, agents, and em- ployees; providing for district expansion; providing for construction and effect; providing for an exclusive charter; requiring a referen- dum; providing an effective date. Be It Enacted by the Legislature of the State of Florida: Section 1. Definitions.—As used in this act, unless otherwise specified: (1) "Board" means the board of commissioners created pursuant to this act and chapter 191, Florida Statutes. (2) "Commissioner" means a member of the board of commissioners of and for the district. (3) "District"means the Key Largo Fire Rescue and Emergency Medical Services District. Section 2. Creation; status; charter amendments; boundaries; district purposes.— (1) There is hereby created an independent special fire control district incorporating lands in Monroe County described in subsection (2), which shall be a public corporation having the powers, duties, obligations, and immunities herein set forth under the name of the Key Largo Fire Rescue and Emergyency Medical Services District. The district is orgyanized and exists for all purposes and shall hold all powers set forth in this act and chapters 189 and 191, Florida Statutes. 1 CODING: Words semen are deletions; words underlined are additions. Ch. 2005-329 LAWS OF FLORIDA Ch. 2005-329 (2) The lands to be included within the district are the following de- scribed lands on the island of Key Largo, in Monroe County, to wit: All of Cross Key and that part of Key Largo from South Bay Harbor Drive and Lobster Lane to the southern boundary of the right-of-way County Roads 905 and 905A. (3) The Key Largo Fire Rescue and Emergency Medical Services District is organized and exists for all purposes set forth in this act and chanter 191, Florida Statutes, including, but not limited to,providin_a fire protection and firefighting services, rescue services, and emergency medical services. Such emergency medical services shall not be the primary function of the district. The district shall have all other powers necessary to carry out these pur- poses,including the authority to contract with the Key Largo Volunteer Fire and Rescue Department, Inc., and the Key Largo Volunteer Ambulance Corps,Florida not-for-profit corporations,which corporations currently pro- vide fire,rescue,and emergency medical services within the district bounda- ries; to purchase all necessary real and personal Property; to purchase and carry standard insurance policies on all such equipment; to employ personnel as may be necessary to carry out the purpose of said fire district; to provide adequate insurance for said employees; to purchase and carry appropriate insurance for the protection of all firefighters and personnel as well as all equipment and personal property on loan to the district; to sell surplus real and personal property in the same manner and subject to the same restrictions as provided for such sales by counties; and to enter into contracts with qualified service providers to carry out the purposes of the district. (4) Nothing herein shall prevent the district from cooperating with the state or other local governments to render such services to communities adjacent to the land described in this section as evidenced by an executed agreement between the cooperating agencies as approved by the board. (5) The district charter maybe amended only by special act of the Legis- lature. Section 3. Board of commissioners.— (1) Pursuant to chapter 191, Florida Statutes, the business and affairs of the district shall be governed and administered by a board of five commis- sioners,who shall be qualified electors residing within the district and shall be elected by the qualified electors residing within the district,subject to the provisions of chapters 189 and 191, Florida Statutes, and this act. Each commissioner shall hold office until his or her successor is elected and qualified under the provisions of this act. The procedures for conducting district elections and for qualification of candidates and electors shall be pursuant to chapters 189 and 191, Florida Statutes. The members of the board shall serve on a nonpartisan basis for a term of 4 years each and shall be eligible for reelection. (2) Notwithstanding section 191.005, Florida Statutes,the five members of the initial board shall be elected by the qualified electors residing within the district at a special election conducted by the Supervisor of Elections of 2 CODING: Words semen are deletions; words underlined are additions. Ch. 2005-329 LAWS OF FLORIDA Ch. 2005-329 Monroe County to be held on or before October 4,2005.At the initial election of the governing board, the candidate receivin the highest number of votes shall hold seat 1,the candidate receiving the second highest number of votes shall hold seat 3, the candidate receiving the third highest number of votes shall hold seat 5,the candidate receiving the fourth highest number of votes shall hold seat 2, and the candidate receiving the fifth highest number of votes shall hold seat 4. The three elected members for seats 1, 3, and 5 in the initial election under this act shall serve terms of 3 years each. The remaining two elected members for seats 2 and 4 in the initial election shall serve terms of 1 year each. (3) Subsequent elections of board members shall coincide with the Gen- eral elections of this state. (4) Vacancies in office shall be filled by election, said election to be held coincidental with the next countywide general election to fill the remaining term of the seat vacated. The board may appoint a qualified elector of the district to act as commissioner until the vacancy is filled by election. A commissioner may be removed from office as provided by chapter 191, Flor- ida Statutes,or for any reason that a state or county officer may be removed. (5) All elections shall be noticed, called, and held pursuant to the provi- sions of the general laws of the state.The board shall, to the extent possible, coordinate all elections with count, wy ide general or special elections in order to minimize cost. Elections shall be called through the adoption of an appro- priate resolution of the district directed to the Board of County Commission- ers of Monroe County, the Supervisor of Elections of Monroe County, and other appropriate officers of the county. The district shall reimburse county government for the actual cost of district elections. No commissioner shall be a paid employee of the district while holding said position. (6) The board may employ such personnel as deemed necessary for the proper function and operation of the district. (7) The salaries of district personnel and any other wages shall be deter- mined by the board. Section 4. Officers; board compensation; bond.— (1) In accordance with chapter 191, Florida Statutes, each elected mem- ber of the board shall assume office 10 days following the member's election. Within 60 days after election of new members of said board as herein pro- vided, the newly elected members shall organize by electing from their number a chair, vice chair, secretary, and treasurer. However, the same member may be both secretary and treasurer, in accordance with chapter 191, Florida Statutes. Nothing shall prevent the commissioners from elect- ing a chair, vice chair, secretary, and treasurer annually. (2) Three members of the board shall constitute a quorum. A quorum shall be necessary for the transaction of business. (3) The commissioners may receive reimbursement for actual expenses incurred while performin.- the duties of their offices in accordance with 3 CODING: Words st:Pivken are deletions; words underlined are additions. Ch. 2005-329 LAWS OF FLORIDA Ch. 2005-329 general law governing per diem for public officials.Each commissioner shall receive from the funds of the district compensation for his or her services in the amount of$200 per month. Members may be reimbursed for travel and per diem expense as provided in section 112.061, Florida Statutes.Authori- zation for any additional compensation shall be pursuant to chapter 191, Florida Statutes. (4) Each commissioner upon taking office shall take and subscribe to the oath of office prescribed by s. 5(b), Art. II, of the State Constitution and general law. Upon taking office and in accordance with chapters 189 and 191, Florida Statutes, each commissioner shall execute to the Governor, for the benefit of the district, a bond of $5,000 with a qualified personal or corporate surety, conditioned upon the faithful performance of the duties of the commissioner's office and upon an accounting for all funds which come into his or her hands as commissioner. The premium for such bonds shall be paid from district funds. Section 5. Powers; duties, responsibilities.— (1) The district shall have and the board may exercise by majority all the powers and comply with the duties set forth in this act and chapters 189, 191,and 197,Florida Statutes,including,but not limited to,ad valorem taxation,bond issuance, and other revenue capabilities;budget preparation and approval;liens and foreclosure of liens;contractual agreements;and the adoption of ordinances and resolutions that are necessary to conduct district business if such ordinances do not conflict with any ordinance of a local general-purpose government within whose jurisdiction the district is lo- cated. (2) The board shall have the right,power, and authority to levy annually ad valorem taxes against the taxable property within the district to provide funds for the purposes of the district in an amount not to exceed the limit provided in chapter 191, Florida Statues. (3) The methods for assessing and collecting ad valorem taxes, impact fees,or user charges shall be as set forth in this act and chapter 170,chapter 189, chapter 191, chapter 197, or chapter 200, Florida Statues. (4) The district's planning requirements shall be as set forth in this act and chapters 189 and 191, Florida Statutes. (5) Requirements for financial disclosure, meeting notices, reporting, public records maintenance, and per diem expenses for officers and employ- ees shall be as set forth in this act and chapters 112, 119, 189, 191, and 286, Florida Statutes. Section 6. Ad valorem taxes.— (1) The board shall have the authority to levy ad valorem taxes annually against all taxable property within the district to provide funds for the purposes of the district only upon the approval by a majority vote of those qualified electors of the district voting in a referendum election authorizing the use of ad valorem taxation not to exceed 1 mill. 4 CODING: Words stream are deletions; words underlined are additions. Ch. 2005-329 LAWS OF FLORIDA Ch. 2005-329 (2) A referendum election of the electors of the district to authorize the use of ad valorem taxation not to exceed 1 mill shall be held by the supervi- sor of elections at the same time as the initial election of district commission- ers in accordance with the provisions of general law relating to elections. (3) Upon the approval of a majority of the electors voting at the initial election or at an election called by the board, the rate of taxation shall thereafter be fixed annually by resolution of the board without further approval by the electors,provided the rate of taxation shall not exceed 1 mill. The board shall have the authority to increase the millage rate above 1 mill only if a majority of the electors voting in a referendum election approve the increased millage rate in an amount not to exceed the limit provided in chapter 191, Florida Statutes. (4) The levy and collection of ad valorem taxes shall proceed pursuant to general law. Section 7. User charges.—The board shall have the authority to provide a reasonable schedule of chargesfor providing the following services: (1) Special emergency services, including firefighting occurring in or to structures outside the district, motor vehicles, marine vessels, or aircraft or as a result of the operation of such motor vessels or marine vessels to which the district is called to render such emergency service. (2) Fighting fires occurring in or at refuse dumps or as a result of an illegal burn,which fire,dump,or burn is not authorized by general or special law, rule regulation, order, or ordinance and which the district is called upon to fight or extinguish. (3) Responding to or assisting or mitia'atina emeraences that either threaten or could threaten the health and safety of persons,property, or the environment to which the district has been called, includingcharze for responding to false alarms. (4) Inspecting structures,plans,and equipment to determine compliance with fire safety codes. Section 8. Impact fees.— (1) Pursuant to section 191.009(4),Florida Statutes,it is hereby declared that the cost of new facilities should be borne by new users of the district's services to the extent new construction requires new facilities, but only to that extent. It is the legislative intent of this section to transfer to the new users of the district's fire protection and emergency services a fair share of the costs that new users impose on the district for new facilities. This shall only apply in the event that the general-purpose local government in which the district is located has not adopted an impact fee for fire services which is distributed to the district for construction within its jurisdictional bounda- ries. (2) The impact fees collected by the district pursuant to this section shall be kept as a separate fund from other revenues of the district and shall be 5 CODING: Words str4eken are deletions; words underlined are additions. Ch. 2005-329 LAWS OF FLORIDA Ch. 2005-329 used exclusively for the acquisition, purchase, or construction of new facili- ties or portions thereof required to provide fire protection and emergency services to new construction. "New facilities" means land, buildings, and capital equipment,including,but not limited to,fire and emergency vehicles and radio telemetry equipment. The fees shall not be used for the acquisi- tion, purchase, or construction of facilities which must be obtained in any event,re-ardless of growth within the district.The board of fire commission- ers shall maintain adequate records to ensure that impact fees are expended onlypermissible new facilities. Section 9. Authority to borrow money. — (1) The board of commissioners shall have the power and authority to borrow money or issue other evidences of indebtedness for the purpose of the district in accordance with chapters 189 and 191,Florida Statutes,provided, however, that the total payments in any one year, including principal and interest, on any indebtedness incurred by the district shall not exceed 50 percent of the total annual budgeted revenues of the district. (2) The board of commissioners as a body, or any of the members of the board as individuals, shall not be personally or individually liable for the repayment of such loan. Such repayment shall be made out of the receipts of the district, except as provided in this subsection. The commissioners shall not create any indebtedness or incur obligations for any sum or amount which they are unable to repay out of district funds available to them at that time, except as otherwise provided in this act, provided, however, that the commissioners may make purchases of equipment on an installment basis as necessary if funds are available for the payment of the current year's installment on such equipment plus the amount due in that year on any other installments and the repayment of any bank loan or other existing indebtedness which may be due that year. Section 10. Use of district funds.—No funds of the district shall be used for any purposes other than the administration of the affairs and business of the district; the payment of salaries and expenses to commissioners; the construction, care, maintenance, upkeep, operation, and purchase of fire- fi�-,htin-, and rescue equipment or a fire station or emergency medical sta- tion; the payment of public utilities; the payment of salaries of district personnel; the payment of expenses of volunteers; the payment to the Key Largo Volunteer Fire and Rescue Department, Inc., and the Key Largo Volunteer Ambulance Corps; and such other payment and expenses as the board may from time to time determine to be necessary for the operations and effectiveness of the district. Section 11. Record of board meetings; authority to adopt rules and regu- lations; annual reports; budget.— (1) A record shall be kept of all meetings of the board, and in such meetings concurrence of a majority of the commissioners present shall be necessary to any affirmative action by the board. (2) The board shall have the authority to adopt and amend policies and regulations for the administration of the affairs of the district under the 6 CODING: Words semen are deletions; words underlined are additions. Ch. 2005-329 LAWS OF FLORIDA Ch. 2005-329 terms of this act and chapters 189 and 191, Florida Statues, which shall include,but not be limited to,the authority to adopt the necessary rules and regulations for the administration and supervision of the property and per- sonnel of the district; for the prevention of fires, fire control, fire hydrant placement, and flow testing in accordance with current NFPA rules; and for rescue work within the district. (3) The board of commissioners shall have the authority to adopt uniform fire prevention ordinances. Such ordinances shall be sinned, dated, and recorded with the Clerk of the Court of Monroe County and published as Provided by state law. Ordinances shall be effective after publication,which constitutes legal notice of same. (4) The board shall, on or before November 1, make an annual report of its actions and accountin-a of its funds as of September of that year and shall file said report in the office of the Clerk of the Circuit Court of Monroe County, whose duty it shall be to receive and file said report and hold and keep the same as a public record. (5) For the purposes of carrying into effect this act,the board shall annu- allyprepare,consider,and adopt a district budget pursuant to the applicable requirements of chapters 189 and 191, Florida Statutes. The board shall, at the same time as it makes its annual report,file its estimated budget for the fiscal year beOnnin, October 1, which budget shall show the estimated revenue to be received by the district and the estimated expenditures to be incurred by the district in carrying out its operations. The commissioners shall adopt a fiscal year for said fire district, which shall be October 1 to September 30. Section 12. Authority to enact fire prevention ordinances and enter land; authority to provide fire, rescue, and emergency medical services.— (1) The board of commissioners shall have the ri-aht and power to enact fire prevention ordinances as provided by General law. When the provisions of such fire prevention ordinances are determined by the board to be vio- lated, the office of the state attorney, upon written notice of such violation issued by the board, is authorized to prosecute such person or persons held to be in violation thereof. Any person found guilty of a violation may be punished as provided in chapter 775, Florida Statutes, as a misdemeanor of the second degree. The cost of such prosecution shall be paid out of the district funds, unless otherwise provided by law. The district shall have the authority to appoint a fire marshal,who may be a member of the Key Largo Fire Rescue Department, to carry out the responsibilities of the district fire marshal. (2) The fire marshal or duly authorized inspector shall be authorized to enter, at all reasonable hours, any building or premises for the purpose of making any inspection or investigation which the State Fire Marshal is authorized to make pursuant to state law and regulation. The owner,lessee, manaVer, or operator of any building or premises shall permit the district fire marshal or duly authorized inspector to enter and inspect the building or premises at all reasonable hours. The fire marshal or duly authorized 7 CODING: Words stamen are deletions; words underlined are additions. Ch. 2005-329 LAWS OF FLORIDA Ch. 2005-329 inspector shall report any violations of state fire safety laws or regulations to the appropriate officials. (3) The district is authorized to establish and maintain emergency medi- cal and rescue response services and acquire and maintain rescue, medical, and other emergency equipment, subject to the provisions of chapter 401, Florida Statutes. Section 13. Annexations.—If any municipality or other fire control dis- trict annexes any land included in the district, such annexation shall follow the procedures set forth in section 171.093, Florida Statutes. Section 14. Dissolution.—The district shall exist until dissolved in the same manner as it was created. Section 15. Immunity from tort liability.— (1) The district and its officers, agents, and employees shall have the same immunity from tort liability as other agencies and subdivisions of the state. The provisions of chapter 768, Florida Statutes, shall apply to all claims asserted against the district. (2) The district commissioners and all officers, agents, and employees of the district shall have the same immunity and exemption from personal liability as is provided by chapter 768, Florida Statutes. (3) In accordance with chapter 768, Florida Statutes, the district shall defend all claims against the commissioners,officers, agents,and employees which arise within the scope of employment or purposes of the district and shall pay all judgments against said persons, except where said persons acted in bad faith or with malicious purpose or in a manner exhibiting wanton and willful disregard of human rights, safety, or property. Section 16. District expansion.—The corporate limits of the Key Largo Fire Rescue and Emergency Medical Services District may be extended and enlarged from time to time pursuant to the following_procedure: (1)(a) A definitely described tract of land lying contiguous to the bounda- ries of the district described in section 1, or as the same may from time to time exist, or one or more tracts of land loin contiguous ontiguous to the boundaries, or one or more tracts of land lying contiguous to each other with one of the tracts lying contiguous to the boundaries of the district, may be included in the district when a written petition for inclusion signed by a majority of the owners of the real property within the tract or tracts to be included in the district has been presented to the board of commissioners and the proposal has been approved by the affirmative vote of no fewer than three members of the board of commissioners at a regular meeting. (b) The petition must contain the legal description of the property Sought to be added to the District and the names and addresses of the owners of the property. (2) If a proposal to add an area to the district as defined in subsection(1) is approved by the affirmative vote of no fewer than three members of the 8 CODING: Words are deletions; words underlined are additions. Ch. 2005-329 LAWS OF FLORIDA Ch. 2005-329 board of commissioners at a regular meeting, the board of commissioners shall thereafter adopt a resolution describing the lands to be included within the district and shall cause such resolution to be duly enrolled in the record of the meeting and a certified copy of the resolution to be recorded in the office of the Clerk of the Circuit Court in Monroe County. (3) Upon adoption of the resolution by the board,the district shall,pursu- ant to chapter 191, Florida Statutes, request its legislative delegation to approve said addition and sponsor legislation amending the district bound- ary. Upon approval by the Legislature, the boundary shall be amended. (4) In lieu of a petition from the property owners, the Board of County Commissioners of Monroe County by affirmative resolution and the Board of Commissioners of the Key Largo Fire Rescue and Emergency Medical Services District by affirmative resolution may jointly request its legislative delegation to approve the addition of land lyingcontiguous ontiguous to the boundaries of the district and sponsor legislation amending the district boundary.Upon approval by the Legislature, the boundary shall be amended. Section 17. Construction.—This act shall be construed as remedial and shall be liberally construed to promote the purpose for which it is intended. Section 18. Effect.—In the event that any part of this act should be held void for any reason, such holding shall not affect any other part thereof. Section 19. Exclusive charter.—This act constitutes the exclusive charter of the Key Largo Fire Rescue and Emergency Medical Services District. Section 20. On or before October 4, 2005, the Board of County Commis- sioners of Monroe County shall call and the Supervisor of Elections of Mon- roe County shall conduct a referendum, to be held in coniunction with a special election, of the qualified voters of the Key Largo Fire Rescue and Emer_aency Medical Services District on the question of whether the Key Lar-ao Fire Rescue and Emergency Medical Services District may levy ad valorem taxation up to 1 mill pursuant to section 6 of this act. Section 21. This act shall take effect upon becoming a law, except that the provisions of section 6 which authorize the levy of ad valorem taxation shall take effect only upon express approval by a majority vote of those qualified electors of the Key Largo Fire Rescue and Emergency Medical Services District, as required by Section 9 of Article VII of the State Consti- tution, voting in the referendum held pursuant to section 20. Such election shall be held in accordance with the provisions of general law relating to elections. Approved by the Governor June 8, 2005. Filed in Office Secretary of State June 8, 2005. 9 CODING: Words are deletions; words underlined are additions. RESOLUTION NO, 2026-0002 A RESOLUTION OF THE KEY LARGO FIRE RESC UE AND EMERGENCY MEDICAL SERVICES DISTRICT,FLORIDA, PROVIDING FOR THE CONSOLIDATION OF FIRE, RESCUE AND EMERGENCY MANAGEMENT SERVICES CURRENTLY PROVIDED BY CONTRACTS WITH THE KEY LARGO VOLUNTEER FIRE DEPARTMENT, INC. ("VFD") AND KEY LARC.O VOLUNTEER AMBULANCE CORPS, INC. ("VAC"), AND AN EFFECTIVE DATE FOR THE SAME; PROVIDING FOR THE RATIFICATION AND READOPTION OF ACTIONS PREVIOUSLY TAKEN FOR PURPOSES OF CONSOLIDATION, INCLUDING EVALUATING, HIRING AND ON-BOARDING OF A FIRE- EMS CJII EFIDISTRICT MANAGER AND OTHER PERSONNEL; PROM DINC. FOR THE RATIFICATION AND READ OPTION OF VFD AND VAC STANDARD OPE RATING GIJIDELINFS, OPERATIONAL POLK."IES AND PROCEDURES, MEDICAL POLICIES AND PROTOCOLS, AND ALL OTHER SIMILAR POLICIES AND PROCEDURES FOR PURPOSES OF CONSOLIDATION; PROVIDING FOR THE ADOPTION OF AN AMBULANCE FEE SCHEDULE FOR PURPOSES OF CONSOLIDATION; PROVIDING FOR THE APPLICATION OFA CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY, AND AN APPLICATION FOR AN ADVANCED LIFE SUPPORT LICENSE FOR PURPOSES OF CONS OIADXIJON; PROVIDING FOR THE ACQUISITION OF CERTAIN INSURANCE FOR PURPOSES OF CONSOLIDATION; PROVIDING FOR SCRIVENER'S ERRORS; PROVIDING FOR SEVERABILITY; PROVIDING FOR CONFLICTS; PROVIDING FOR CONSTRUCTION; AND PROVIDING FOR AN EFFECTIVE DATE WHEREAS, the Key l_,argo Fire R.escue and Emergency kledical Services District (hereinafter, the "District") was created on June 8, 2005, when ("Jovernor Bush approved Florida Statute 2005-329 that created the 68th Special l'ire Taxing District in the State offlorida; and Resolution No.2026-0002 Page No. 2 WHEREAS,the District provides fire protection,firefighting services,rescue services and emergency medical services for all of Cross Key and that part of Key Largo from South Bay Harbor Drive and Lobster Lane to the southern boundary of the right-of-way County Roads 905 and 905A (hereinafter,the "Services"); and WHEREAS, the District currently contracts with the Key Largo Volunteer Fire Department, Inc. (hereinafter, the "VFD"), whereby the VFD contractually provides for the provision of fire and rescue services within the District; and WHEREAS, the District currently contracts with the Key Largo Volunteer Ambulance Corps, Inc. (hereinafter, the "VAC"), whereby the VAC contractually provides for the provision of basic and advanced life support ambulance services within the District; and WHEREAS, on January 19, 2026, the District received an "Operational Analysis Consolidation Study," prepared by J. Angle Group, LLC (hereinafter, the "Study"); and WHEREAS, the Study provided a comprehensive evaluation of the current conditions, governance structures, financial sustainability, and service delivery performance for the District and its contracted entities the VFD and VAC; and WHEREAS,the Study provided recommendations and options including consolidation of the VFD and VAC personnel into the District, and the termination of the District's contracts with the VFD and VAC (hereinafter,the "Consolidation"); and WHEREAS, on January 19, 2026, the District, through its Board of Commissioners (hereinafter, the `Board"), adopted and approved a motion to proceed with implementing Option 2-C of the Study,directing Interim District Manager William Lombardo(hereinafter,the"Interim District Manager"), along with teams from Fire and Rescue (VFD) and EMS (VAC),to formulate a timeline and to identify all steps and actions necessary for Consolidation under Option 2-C; and WHEREAS,the District, its Board, staff, and agents, as well as members of the VFD and VAC, have diligently pursued all matters and actions required for the Consolidation; and WHEREAS,the District finds that it would be in the best interests of the District at large and the citizens it serves to proceed with implementing all or a portion of Option 2-C of the Study for the Consolidation with the VFD and VAC. NOW THEREFORE, BE IT RESOLVED BY THE KEY LARGO FIRE RESCUE AND EMERGENCY MEDICAL SERVICES DISTRICT,FLORIDA,AS FOLLOWS: Section 1. The above recitals are true and correct and incorporated into this Resolution by reference. Section 2. The Board hereby confirms, ratifies, and readopts the following actions previously taken by the Board: Resolution No.2026-0002 Page No. 3 A. Unless subsequently amended, the effective date for Consolidation is July 1, 2026. B. The Interim District Manager is authorized to begin the hiring process for the position of Fire-EMS Chief/District Manager; C. The Interim District Manager is authorized to take all actions necessary to evaluate, hire and on-board personnel as District employees, including but not limited to personnel who are necessary for the District to qualify for a Certificate of Public Convenience and Necessity (hereinafter, the "COPCN") License and an Advanced Live Support ("ALS")/Basic Life Support ("BLS") License.To this end,the Board directs the Interim District Manager to give preference to qualifying applicants who are currently employed with the VAC and VFD. D. The District adopts the VAC's current ambulance fee schedule; E. The District adopts both the VFD and VAC's Standard Operating Guidelines ("SOGs"), operational policies and procedures, medical policies and protocols, and all other procedures,protocols and policies,not inconsistent with those of the District.However,the District reserves the right to modify any of the same at any time. This action excludes any policy, procedure, protocol, or guideline related to District procurement, to the District Board itself, or which is not otherwise related to the purposes of the Consolidation; and F. The District adopts the current employee pay scale, rank, seniority, and benefits of VFD and VAC personnel, respectively. However, the District reserves the right to modify any of the same at any time. Section 3. The Interim District Manager, and his designees, are authorized to take all the following actions: A. Apply for a Certificate of Public Convenience and Necessity - Class A with Monroe County, Florida; B. Apply for an Advanced Life Support (ALS) and Basic Life Support (BLS) License from the Florida Department of Health; C. Apply for and otherwise acquire any and all other federal, state, regional or local governments, agencies, and authorities' approvals, registrations, and similar which are necessary for the purposes of Consolidation. D. To apply for and to negotiate the terms for all necessary insurance for the District as may be required for the Consolidation. Further, the Interim District Manager is authorized to enter into such insurance coverage contract(s)on behalf ofthe District if they provide equal or better coverage and do not exceed an annual premium equal to the current budgeted amount for the VFD and VAC, respectively; Section 4. The Interim District Manager, and his designees, are directed to conduct a review of all SOGs, policies, procedures, and protocols, and to make recommendations to the Board to better achieve the purposes of Consolidation. Resolution No.2026-0002 Page No.4 Section 5. The District authorizes all other actions necessary to be taken fior purposes of achieving Consolidation as set forth in Option 2-C contained in the Study. Section 6. The District hereby ratifies and reconfirms all its previous actions taken for put-poses of(7,onsolidation. Section 7. Sections of this Resolution may be renumbered or re-lettered and corrections of typographical errors which do not affect the intent may be authorized by the Interim District Manager,, or his designee, without need of a public meeting or Board decision making action, by the Interim District Manager filing a corrected or re-codified copy of'same with the District's records Custodian. Section 8. The provisions of this Resolution are declared to be severable and if any section, sentence, clause or phrase of this Resolution shall lor any reason be held to be invalid or unconstitutional, Such decision shall not affect the validity of the remaining sections. sentences, clauses, and phrases of this Resolution but they shall remain in effect, it being the legislative intent that this Resolution shall stand notwithstanding the invalidity of any part, Section 9. The Board of onu-nissioners hereby rescinds all prior resolutions and ofl-ier official action of the Board of'Cornrylissioners to the extent ofany conflict with any part of this Resolution. Section 10. This Rcsoluti(,)n shall be liberally construed to affect the purposes herec)f and shall bec(-inie effectively immediately upon its adoption. PASSED AND ADOPTED this 23'd day of March, 2026, ............ — ----- Chairman ATTEST: ................................................ District Clerk APPROVED AS TO FORM AND LEG'ALITV FOR THE USE AND BENEFIT OF KEV LARGO FIRE RESCUE AND EMERGENCY MEDICAL SERVICES DISTRICT ONLY: E Y Resolution No.2026-0002 Page No. 5 Motion to adopt by Commissioner Jenkins, Seconded by Commissioner Conklin FINAL VOTE AT ADOPTION Chairman Tony Allen Yes Vice-Chair George Mirabella No Commissioner Frank Conklin Yes Commissioner Kenny Edge No Commissioner Michael Jenkins Yes Key Largo Fire Rescue & EMS District ervirrq ttie Comr r,rnfly of they Largo, Pr r°trya Station"24' t East.Dr_,Key Largo,FL 33037 . St atron 25:220 F`eerlt tam., FL 33037 Adam'ruriistratt Offuce:(Wt05)4fg t.;700 wwwww.V�(eyl ao' oforrrp;sctie fN giGw/ April 7, 202 Response to COPCN Personnel Inquiry To Whom It May Concern, This letter is submitted in response to your inquiry regarding the Key Largo Fire Rescue District's Certificate of Public Convenience and Necessity (C PC )application, specifically addressing questions related to personnel commitment and overlap between the District and the Corporations. Please find our formal responses to each question below. 1. Personnel Commitment The District hereby confirms that all individuals listed on the COPCN application have formally committed to employment with Key Largo Fire Rescue & EMS District. Each listed individual has acknowledged and accepted their employment with the District, and no individual remains uncommitted. No removals from the application are necessary or warranted at this time. L_Oyerlap in Personnel The District confirms that there is no overlap in personnel between the District and the Corporations. All individuals identified in the application are committed exclusively to employment with the District and are not simultaneously employed by or operationally committed to the Corporations. 3. Disclosure of verN i INc N As confirmed in the response to Question 2 above, there is no overlap in personnel between the District and the Corporations. Accordingly, no individual disclosures or explanations o circumstances are applicable. No District employees are serving in, dual capacities, volunteering with the Corporations during off-duty hours, or otherwise engaged in arrangements that would constitute personnel overlap. e trust that this response adequately addresses your inquiry. Should you require any additional information or documentation, please do not hesitate to contact our office directly. NN �a� ;rdcr District PO ,iager Key Largo Fire fescue & EMS District 05- 5 t-2 00 wlo barrio ke lar ofirerescue� . ov Key Largo F;.a e Rescue EMS District m (3br"u mitt d to Excellence in Fire,Rescue&Ern rgeracy Medical Services Page I of 91