State of Alaska Model Standing Orders and Treatment Protocols for EMT-1, EMT-2, EMT-3 and MICP Second Edition November, 2003 Reference Manual ACKNOWLEDGEMENTS...........................................................................................................................................VII PREFACE..................................................................................................................................................................IX GENERAL ORDERS..................................................................................................................................................1 PATIENT ASSESSMENT...............................................................................................................................................3 I. SCENE SIZE-UP/ ASSESSMENT...........................................................................................................................3 II. INITIAL ASSESSMENT........................................................................................................................................3 III. FOCUSED HISTORY AND PHYSICAL EXAM - MEDICAL PATIENTS...................................................................5 IV. FOCUSED HISTORY AND PHYSICAL EXAM - TRAUMA PATIENTS....................................................................6 V. DETAILED PHYSICAL EXAM..............................................................................................................................7 VI. ON-GOING ASSESSMENT.............................................................................................................................8 VII. SPECIAL NOTES............................................................................................................................................9 VIII. TRANSPORT...............................................................................................................................................9 PEDIATRIC PATIENT ASSESSMENT...........................................................................................................................11 I. INTRODUCTION..............................................................................................................................................11 II. ASSESSMENT..................................................................................................................................................11 III. GENERAL IMPRESSION...............................................................................................................................12 IV. COMMUNICATE AND TRANSPORT..............................................................................................................12 DEATH IN THE FIELD (DNR/DOA)..........................................................................................................................13 I. GENERAL POINTS...........................................................................................................................................13 II. WITHHOLDING RESUSCITATION:....................................................................................................................13 III. TERMINATING RESUSCITATION:.................................................................................................................13 IV. PRONOUNCEMENT OF DEATH:...................................................................................................................14 V. DOCUMENTATION:.........................................................................................................................................14 VI. NAEMSP TRAUMA CARDIAC ARREST GUIDELINES.................................................................................15 DELAYED TRANSPORT.............................................................................................................................................17 I. GENERAL POINTS...........................................................................................................................................17 II. ASSESSMENT..................................................................................................................................................17 DOCUMENTATION....................................................................................................................................................21 I. GENERAL POINTS...........................................................................................................................................21 II. USE THE SOAP FORMAT.................................................................................................................................21 III. SPECIAL CONSIDERATIONS........................................................................................................................21 REPORTING REQUIREMENTS....................................................................................................................................23 I. AS 47.17.010-REPORTING CHILD ABUSE AND NEGLECT...............................................................................23 II. AS 47.24.010-REPORTS OF HARM.................................................................................................................23 III. AS 08.64.369-HEALTH CARE PROFESSIONALS TO REPORT CERTAIN INJURIES.........................................23 SHOCK.....................................................................................................................................................................25 I. GENERAL POINTS...........................................................................................................................................25 II. ASSESSMENT..................................................................................................................................................25 III. MANAGEMENT..........................................................................................................................................27 IV. TRANSPORT...............................................................................................................................................29 MEDICAL..................................................................................................................................................................31 ABDOMINAL PAIN - NONTRAUMATIC......................................................................................................................32 I. GENERAL POINTS...........................................................................................................................................32 II. ASSESSMENT..................................................................................................................................................32 III. MANAGEMENT..........................................................................................................................................32 IV. SPECIAL CONSIDERATIONS........................................................................................................................33 ALLERGIC REACTION/ANAPHYLAXIS......................................................................................................................35 I. GENERAL POINTS...........................................................................................................................................35 II. ASSESSMENT..................................................................................................................................................35 III. MANAGEMENT..........................................................................................................................................35 ALTERED MENTAL STATUS.....................................................................................................................................37 I. GENERAL POINTS...........................................................................................................................................37 II. ASSESSMENT..................................................................................................................................................37 III. MANAGEMENT..........................................................................................................................................37 i IV. SPECIAL CONSIDERATIONS........................................................................................................................38 ASTHMA/COPD.......................................................................................................................................................41 I. GENERAL POINTS...........................................................................................................................................41 II. ASSESSMENT..................................................................................................................................................41 III. MANAGEMENT..........................................................................................................................................41 IV. SPECIAL CONSIDERATIONS........................................................................................................................42 BEHAVIORAL EMERGENCIES....................................................................................................................................45 I. GENERAL POINTS...........................................................................................................................................45 II. ASSESSMENT..................................................................................................................................................45 III. MANAGEMENT..........................................................................................................................................45 CARDIAC ARREST....................................................................................................................................................47 I. GENERAL POINTS...........................................................................................................................................47 II. ASSESSMENT..................................................................................................................................................47 III. GENERAL MANAGEMENT..........................................................................................................................47 IV. VENTRICULAR FIBRILLATION AND PULSELESS VENTRICULAR TACHYCARDIA-EMT-3.............................48 V. PEDIATRIC VENTRICULAR FIBRILLATION AND PULSELESS VENTRICULAR TACHYCARDIA-EMT-3................49 VI. PULSELESS ELECTRICAL ACTIVITY (PEA)-EMT-3...................................................................................49 VII. ASYSTOLE-EMT-3....................................................................................................................................50 VIII. POST-ARREST-EMT-3...............................................................................................................................50 IX. VENTRICULAR FIBRILLATION AND PULSELESS VENTRICULAR TACHYCARDIA-MICP...............................51 X. PEDIATRIC VENTRICULAR FIBRILLATION AND PULSELESS VENTRICULAR TACHYCARDIA-MICP..................51 XI. PULSELESS ELECTRICAL ACTIVITY (PEA) -MICP.....................................................................................52 XII. ASYSTOLE-MICP......................................................................................................................................53 XIII. POST-ARREST-MICP.................................................................................................................................53 XIV. TRANSPORT-ALL LEVELS..........................................................................................................................54 CHEST PAIN.............................................................................................................................................................55 I. GENERAL POINTS...........................................................................................................................................55 II. ASSESSMENT..................................................................................................................................................55 III. MANAGEMENT..........................................................................................................................................55 IV. TRANSPORT...............................................................................................................................................56 DIABETES................................................................................................................................................................59 I. GENERAL POINTS...........................................................................................................................................59 II. ASSESSMENT..................................................................................................................................................59 III. MANAGEMENT..........................................................................................................................................59 IV. TRANSPORT...............................................................................................................................................60 DYSRHYTHMIAS......................................................................................................................................................61 I. GENERAL POINTS...........................................................................................................................................61 II. ASSESSMENT..................................................................................................................................................61 III. MANAGEMENT...........................................................................................................................................61 IV. PEDIATRIC BRADYCARDIA........................................................................................................................61 V. BRADYCARDIA-EMT-3..................................................................................................................................62 VI. PEDIATRIC BRADYCARDIA-EMT-3...........................................................................................................62 VII. PEDIATRIC TACHYCARDIA-EMT-3...........................................................................................................62 VIII. PREMATURE VENTRICULAR COMPLEXES (PVC’S) -EMT-3......................................................................63 IX. SUPRAVENTRICULAR TACHYCARDIA (SVT) -EMT-3................................................................................63 X. WIDE COMPLEX TACHYCARDIA-UNCERTAIN TYPE (WCT) -EMT-3...............................................................63 XI. VENTRICULAR TACHYCARDIA WITH A PULSE-EMT-3...............................................................................63 XII. BRADYCARDIA-MICP...............................................................................................................................64 XIII. PEDIATRIC BRADYCARDIA-MICP.............................................................................................................64 XIV. PEDIATRIC TACHYCARDIA-MICP.............................................................................................................64 XV. PREMATURE VENTRICULAR COMPLEXES (PVC’S)-MICP.........................................................................66 XVI. SUPRAVENTRICULAR TACHYCARDIA (SVT)-MICP...................................................................................66 XVII. WIDE COMPLEX TACHYCARDIA-UNCERTAIN TYPE (WCT)-MICP.............................................................67 XVIII. VENTRICULAR TACHYCARDIA WITH A PULSE-MICP.............................................................................67 XIX. TRANSPORT...............................................................................................................................................68 GASTROINTESTINAL BLEEDING...............................................................................................................................69 ii I. GENERAL POINTS...........................................................................................................................................69 II. ASSESSMENT..................................................................................................................................................69 III. MANAGEMENT..........................................................................................................................................69 HYPERTENSION........................................................................................................................................................71 I. GENERAL POINTS...........................................................................................................................................71 II. ASSESSMENT..................................................................................................................................................71 III. MANAGEMENT..........................................................................................................................................71 IV. TRANSPORT...............................................................................................................................................72 HYPERVENTILATION................................................................................................................................................73 I. GENERAL POINTS...........................................................................................................................................73 II. ASSESSMENT..................................................................................................................................................73 III. MANAGEMENT..........................................................................................................................................73 NEONATAL RESUSCITATION....................................................................................................................................75 I. GENERAL POINTS...........................................................................................................................................75 II. ASSESSMENT..................................................................................................................................................75 III. MANAGEMENT..........................................................................................................................................75 OBSTETRIC/GYNECOLOGIC......................................................................................................................................77 I. GENERAL POINTS...........................................................................................................................................77 II. ASSESSMENT..................................................................................................................................................77 III. MANAGEMENT..........................................................................................................................................79 OBSTRUCTED AIRWAY............................................................................................................................................81 I. GENERAL POINTS...........................................................................................................................................81 II. ASSESSMENT..................................................................................................................................................81 III. MANAGEMENT-ADEQUATE AIR EXCHANGE...............................................................................................81 IV. MANAGEMENT-POOR AIR EXCHANGE........................................................................................................82 V. CAUTIONS......................................................................................................................................................83 POISONING/OVERDOSE............................................................................................................................................85 I. GENERAL POINTS...........................................................................................................................................85 II. ASSESSMENT..................................................................................................................................................85 III. MANAGEMENT..........................................................................................................................................85 PULMONARY EDEMA...............................................................................................................................................89 I. GENERAL POINTS...........................................................................................................................................89 II. ASSESSMENT..................................................................................................................................................89 III. MANAGEMENT..........................................................................................................................................89 IV. TRANSPORT...............................................................................................................................................90 SEIZURES.................................................................................................................................................................91 I. GENERAL POINTS...........................................................................................................................................91 II. ASSESSMENT..................................................................................................................................................91 III. MANAGEMENT..........................................................................................................................................91 IV. SPECIAL CONSIDERATIONS........................................................................................................................93 STROKE...................................................................................................................................................................95 I. GENERAL POINTS...........................................................................................................................................95 II. ASSESSMENT..................................................................................................................................................95 III. MANAGEMENT..........................................................................................................................................95 IV. TRANSPORT...............................................................................................................................................96 V. SPECIAL CONSIDERATIONS............................................................................................................................96 VAGINAL BLEEDING................................................................................................................................................97 I. GENERAL POINTS...........................................................................................................................................97 II. ASSESSMENT..................................................................................................................................................97 III. MANAGEMENT..........................................................................................................................................97 TRAUMA...................................................................................................................................................................99 MAJOR TRAUMA....................................................................................................................................................101 I. GENERAL POINTS.........................................................................................................................................101 II. ASSESSMENT:...............................................................................................................................................101 III. MANAGEMENT........................................................................................................................................102 iii IV. TRANSPORT.............................................................................................................................................104 ABDOMINAL TRAUMA...........................................................................................................................................105 I. GENERAL POINTS.........................................................................................................................................105 II. ASSESSMENT................................................................................................................................................105 III. MANAGEMENT........................................................................................................................................105 IV. TRANSPORT.............................................................................................................................................106 V. SPECIAL CONSIDERATIONS..........................................................................................................................106 CHEST TRAUMA.....................................................................................................................................................109 I. GENERAL POINTS.........................................................................................................................................109 II. ASSESSMENT................................................................................................................................................109 III. MANAGEMENT........................................................................................................................................110 IV. SPECIAL CONSIDERATIONS......................................................................................................................112 DISLOCATIONS-DELAYED TRANSPORT..................................................................................................................113 I. GENERAL POINTS.........................................................................................................................................113 II. GENERAL TREATMENT.................................................................................................................................113 III. SHOULDER...............................................................................................................................................114 IV. PATELLA.................................................................................................................................................116 V. DIGITS..........................................................................................................................................................117 EXTREMITY TRAUMA............................................................................................................................................119 I. GENERAL POINTS.........................................................................................................................................119 II. ASSESSMENT................................................................................................................................................119 III. MANAGEMENT........................................................................................................................................119 IV. TRANSPORT.............................................................................................................................................121 HEAD TRAUMA......................................................................................................................................................123 I. GENERAL POINTS.........................................................................................................................................123 II. ASSESSMENT................................................................................................................................................123 III. MANAGEMENT........................................................................................................................................124 IV. TRANSPORT.............................................................................................................................................125 SOFT TISSUE TRAUMA...........................................................................................................................................127 I. GENERAL POINTS.........................................................................................................................................127 II. ASSESSMENT................................................................................................................................................127 III. MANAGEMENT........................................................................................................................................127 IV. TRANSPORT.............................................................................................................................................130 V. SPECIAL CONSIDERATIONS..........................................................................................................................130 ENVIRONMENTAL...............................................................................................................................................133 AVALANCHE BURIAL........................................................................................................................................135 I. GENERAL POINTS...................................................................................................................................135 II. EVALUATION AND TREATMENT....................................................................................................................135 COLD WATER NEAR DROWNING:.................................................................................................................137 I. GENERAL POINTS.........................................................................................................................................137 II. EVALUATION AND TREATMENT...................................................................................................................137 DIVING EMERGENCIES...................................................................................................................................139 I. GENERAL POINTS.........................................................................................................................................139 II. ASSESSMENT................................................................................................................................................139 III. GENERAL TREATMENT............................................................................................................................139 IV. MANAGEMENT-ACUTELY SICK DIVE EMERGENCY PATIENTS.................................................................139 V. MANAGEMENT-STABLE DIVE EMERGENCY PATIENTS.................................................................................140 VI. SPECIAL CONSIDERATIONS:.....................................................................................................................140 FROSTBITE.........................................................................................................................................................141 I. GENERAL POINTS.........................................................................................................................................141 II. ASSESSMENT................................................................................................................................................141 III. MANAGEMENT........................................................................................................................................142 IV. SPECIAL CONSIDERATIONS......................................................................................................................142 HEAT EMERGENCIES.......................................................................................................................................145 I. GENERAL POINTS.........................................................................................................................................145 iv II. ASSESSMENT................................................................................................................................................145 III. MANAGEMENT........................................................................................................................................146 IV. SPECIAL CONSIDERATIONS......................................................................................................................148 HYPOTHERMIA.................................................................................................................................................149 I. GENERAL POINTS.........................................................................................................................................149 II. ASSESSMENT................................................................................................................................................150 III. MANAGEMENT...................................................................................................................................150 PROCEDURES........................................................................................................................................................155 BASIC AIRWAY MANAGEMENT.............................................................................................................................156 I. INTRODUCTION............................................................................................................................................156 II. OBJECTIVES.................................................................................................................................................156 III. RECOGNITION..........................................................................................................................................156 IV. MANUAL MANEUVERS:...........................................................................................................................157 V. BASIC MECHANICAL ADJUNCTS:.................................................................................................................159 VI. VENTILATION:.........................................................................................................................................162 VII. SUCTIONING:...........................................................................................................................................165 VIII. TABLE OF TREATMENT ADJUNCTS:.........................................................................................................167 ADVANCED AIRWAY MANAGEMENT......................................................................................................................168 I. GENERAL POINTS.........................................................................................................................................168 II. DUAL LUMEN AIRWAY DEVICE.....................................................................................................................168 III. LARYNGEAL MASK AIRWAY (LMA).......................................................................................................169 IV. ENDOTRACHEAL INTUBATION:................................................................................................................170 V. RAPID SEQUENCE INTUBATION (RSI) (MICP LEVEL ONLY)........................................................................177 VI. RETROGRADE INTUBATION......................................................................................................................179 VII. CRICOTHYROTOMY..........................................................................................................................180 VIII. TABLE OF TREATMENT ADJUNCTS:..........................................................................................................181 IX. MEDICATIONS THAT CAN BE ADMINISTERED BY TRACHEA:.....................................................................181 FAILED AIRWAY ALGORITHM................................................................................................................................182 AUTOMATED EXTERNAL DEFIBRILLATION (AED)................................................................................................183 I. GENERAL POINTS:........................................................................................................................................183 II. OBJECTIVES:................................................................................................................................................183 III. RECOGNITION:.........................................................................................................................................183 IV. PROCEDURE:...........................................................................................................................................183 ASSISTING WITH MEDICATIONS............................................................................................................................187 I. GENERAL POINTS.........................................................................................................................................187 CHEST DECOMPRESSION........................................................................................................................................189 I. GENERAL POINTS.........................................................................................................................................189 II. RECOGNITION..............................................................................................................................................189 III. PROCEDURE.............................................................................................................................................190 IV. CAUTIONS...............................................................................................................................................191 GASTRIC INTUBATION...........................................................................................................................................193 I. GENERAL POINTS.........................................................................................................................................193 II. CONTRAINDICATIONS...................................................................................................................................193 III. EQUIPMENT.............................................................................................................................................193 IV. PROCEDURE.............................................................................................................................................193 V. COMPLICATIONS..........................................................................................................................................194 FOLEY CATHETER INSERTION................................................................................................................................195 I. GENERAL POINTS.........................................................................................................................................195 II. INDICATIONS................................................................................................................................................195 III. EQUIPMENT.............................................................................................................................................195 IV. PROCEDURE:...........................................................................................................................................195 V. COMPLICATIONS:.........................................................................................................................................197 INTRAOSSEOUS ACCESS.........................................................................................................................................198 I. GENERAL POINTS.........................................................................................................................................198 II. INDICATIONS................................................................................................................................................198 v III. SITES.......................................................................................................................................................198 IV. PROCEDURE.............................................................................................................................................198 V. COMPLICATIONS..........................................................................................................................................199 INTRAVENOUS ACCESS..........................................................................................................................................201 I. GENERAL POINTS.........................................................................................................................................201 II. EQUIPMENT..................................................................................................................................................201 III. PROCEDURE.............................................................................................................................................201 IV. COMPLICATIONS......................................................................................................................................202 INJECTED MEDICATION ADMINISTRATION.............................................................................................................203 I. GENERAL POINTS.........................................................................................................................................203 II. PREPARE DOSE.............................................................................................................................................203 III. SUBCUTANEOUS ADMINISTRATION (SQ).................................................................................................204 IV. INTRAMUSCULAR ADMINISTRATION (IM)...............................................................................................204 V. IV BOLUS ADMINISTRATION........................................................................................................................204 VI. IV INFUSION ADMINISTRATION...............................................................................................................204 PNEUMATIC ANTI SHOCK GARMENT (P.A.S.G) GUIDELINES................................................................................207 I. INDICATIONS................................................................................................................................................207 II. CONTRAINDICATIONS...................................................................................................................................207 III. PROCEDURE.............................................................................................................................................207 IV. SPECIAL POINTS......................................................................................................................................207 PULSE OXIMETRY..................................................................................................................................................209 I. GENERAL POINTS.........................................................................................................................................209 II. OBJECTIVES.............................................................................................................................................209 III. INDICATIONS......................................................................................................................................209 IV. PROCEDURE........................................................................................................................................209 V. CAUTIONS.................................................................................................................................................210 VI. TREATMENT GUIDELINES...............................................................................................................210 RESTRAINT............................................................................................................................................................211 I. GENERAL ORDERS.........................................................................................................................................211 II. INDICATIONS...........................................................................................................................................211 III. MANAGEMENT...................................................................................................................................211 IV. ASSESSMENT............................................................................................................................................212 V. RISK MANAGEMENT....................................................................................................................................212 VI. CAUTIONS................................................................................................................................................213 SPINAL IMMOBILIZATION.......................................................................................................................................215 I. GENERAL POINTS:........................................................................................................................................215 II. INDICATIONS:...............................................................................................................................................215 III. ASSESSMENT:..........................................................................................................................................216 IV. DOCUMENTATION:..................................................................................................................................217 V. CAUTIONS:...................................................................................................................................................218 REFERENCE..........................................................................................................................................................215 CELSIUS TO FARENHEIT CONVERSIONS..................................................................................................................221 GLASGOW COMA SCALE........................................................................................................................................222 PEDIATRIC VITAL SIGNS........................................................................................................................................223 TELEPHONE NUMBERS...........................................................................................................................................224 RULE OF NINES.......................................................................................................................................................225 vi ACKNOWLEDGEMENTS This document was prepared by Robert Janik, MICP, as an employee of Southeast Region EMS Council, Inc. SEREMS was awarded grants to create and revise model prehospital emergency medical standing orders from the State of Alaska, Department of Public Health, Division of Community Health and EMS, through the Rural Hospital Flexibility Program Grant. The following persons served as reviewers of this document. The work involved in reviewing this document is an example of their dedication to EMS in Alaska. Their comments shaped the final version. Second Edition reviewers: • Matt Anderson, EMS Unit Manager, State of Alaska • Ken Brown, MD, Bartlett Regional Hospital • Gil Dickie, MD, SREMS • Don Hudson, DO, Alaska Regional Hospital • David Hull, MICP/EMT-3, Ketchikan Fire Department • William Kriegsman, MD • David McCandless, MD, Medical Director SEREMS • Kathy McLeron, PA-C/MICP, CHEMS • Bill O'Brien, EMT-3, Yukon Kuskokwim Region • Karen O’Neil, Norton Sound Health Corporation • Dave Potashnick, MICP/PA-C, North Slope Borough Fire Department • Danny Robinette, MD, IREMS • David Rockney, MICP, IREMS • Charles Trull, NREMT-P, Northwest Arctic Borough Region • Ken Zafren, MD, Alaska Native Medical Center, Stanford University, State EMS Medical Director First Edition reviewers: • Matt Anderson, EMS Unit Manager, State of Alaska • Ken Brown, MD, Bartlett Regional Hospital • Jerry Dzugan, EMT-1, AMSEA • Don Hudson, DO, Alaska Regional Hospital • David Hull, MICP/EMT-3, Ketchikan Fire Department • Bobbi Leichty, MICP, Southeast Region EMS Council Inc. • Mike Motti, EMT-3, SEARHC EMS • Bill O'Brien, EMT-3, Yukon Kuskokwim Region • David Rockney, MICP, IREMS • Jon Thomas, EMT-3, Alaska Fire Service • Charles Trull, NREMT-P, Northwest Arctic Borough Region • Ken Zafren, MD, Alaska Native Medical Center, Providence Alaska Medical Center • The late Scott Dull, MD, State EMS Medical Director Acknowledgements vii As is the case with most protocols, this set of model standing orders was developed through consultation of many resources. The State of Alaska treatment guidelines for Burns, Cold Water Near Drowning, Delayed Transport, Diving Emergencies, Hypothermia, Frostbite, and Trauma were incorporated with little change. Other significant resources were: • Alaska Medevac Manual • Alaska EMS Skill Sheets • American College of Surgeons ATLS Course Manual • American Heart Association – ECC Guidelines 2000 • Anchorage Fire Department Medical Operations Manual • Capital City Fire/Rescue EMS Treatment Guidelines • City of Cleveland Out-of-Hospital Patient Care Protocols • Interior Region EMS Council Regional Standing Orders • Ketchikan Fire Department Standing Orders • NAEMSP Guidelines for Withholding or Termination of Resuscitation in Prehospital Traumatic Cardiac Arrest • RSI protocol - Rick Janik, BSN • Southeast Region EMS Council BLS Treatment Guidelines • Southern Region EMS Council Regional Standing Orders • U.S. Department of Transportation National Standard Curricula for EMS • Wilderness Medical Associate's Wilderness EMT Curriculum • State of Alaska EMS Office-Responding to Behavioral Emergencies Guidelines • Ken Zafren Draft Avalanche Rescue Guidelines Acknowledgements viii PREFACE To the Administrator: These protocols were designed to serve as a model for those services wanting to adopt written protocols or those that need revised protocols. They are model guidelines and are not intended to be interpreted as strict orders. Services may modify this document to meet local needs. Treatments and procedures listed herein follow the State of Alaska curricula with few exceptions. The BLS portion of this protocol may be incorporated into your service immediately. The advanced life support orders in this document must be reviewed and approved by a physician medical director before EMTs and MICPs may perform advanced life support. To the Physician Medical Director: These protocols were developed to assist EMS agencies in establishing written standing orders. They are designed as a model set of medical standing orders. This document was peer reviewed by emergency physicians, mobile intensive care paramedics, and EMTs. The Medical Director approving this set of protocols should be familiar with their content and with the skill level of the providers expected to use them. The orders are meant to be followed as guidelines for patient care. The Medical Director must decide which orders within will be standing orders and which will require on-line direction. As a general style within the text, the items prefaced by "consider" or "anticipate" should be interpreted as requiring on-line medical direction. Medical Directors are encouraged to modify this document to meet local needs. Any deviations from the EMT scope of practice must be arranged through the provisions of 7 AAC 26.670. These arrangements must include a written request to the State EMS Office, a plan for training and evaluation and a list of authorized individuals who have completed the training. For example, EMT-3s may be trained and authorized to administer nebulized albuterol for asthma which is not listed in the scope of certified activities (scope of practice) for an EMT-3 (7 AAC 26.040.) To the EMT/MICP These model standing orders present guidelines for management of common pre-hospital emergencies. As with any protocol, they are not all encompassing. Nor are they meant to be strict "cookbook" orders. It is recognized that patients do not present in textbook fashion and techniques and procedures should be modified to meet the demands of field rescues. These protocols are fairly liberal. They do not require contacting medical control for many orders. This is in recognition of the communication difficulties in this state. As a general style within the text, the items prefaced by "consider" or "anticipate" should be interpreted as requiring on-line medical direction. It is recommended, however, that medical control be contacted by voice when possible for every patient contact. The management section presents sequential instructions. Every provider should follow the BLS section. EMT-2 providers should follow the BLS section and the EMT-2 section. EMT-3 providers should follow the BLS, EMT-2 and EMT-3 sections. MICPs should provide the care listed for all levels plus MICP. The Cardiac Arrest and Dysrhythmias protocols are exceptions to the sequencing. EMT-3 and MICP directions are separate. EMT-3s and MICPs should follow the BLS and EMT-2 orders and then progress directly to the EMT-3 or MICP orders. Treatments and procedures listed herein follow the State of Alaska curricula with few exceptions. You may perform the BLS portion of this protocol. ALS treatments/procedures may only be performed under the direction of a physician, either by direct verbal communications or through physician signed standing orders. Preface ix