EMS Scope of Practice

(a)Principles:

(1)In order to function as an EMS Provider, an individual must be certified/licensed from the Department of Public Health and Social Services Office of Emergency Medical Services as an NREMR, NREMT, NRAEMT or NRP.

(2)EMS Providers are responsible to adhere to the scope of practice while functioning as an EMS Provider on Guam.

(3)During training, while at the scene of an emergency, during transport of the sick or injured, or during interfacility transfer, a certified EMS Provider or supervised EMS provider student is authorized to do any of the following:

(b)Policies:

(1)Scope of Practice of a National Registry Emergency Medical Responder:

(A)conduct primary and secondary patient examinations;

(B)take and record vital signs;

(C)utilize non-invasive diagnostic devices in accordance with manufacturer’s recommendation;

(D)open and maintain an airway by positioning the patient’s head;

(E)provide external cardiopulmonary resuscitation and obstructed airway care for infants, COL 6/21/2023 CH. 84 EMERGENCY MEDICAL SERVICES children, and adults;

(F)provide immobilization musculoskeletal injuries; care for

(G)assist with prehospital childbirth;

(H)complete a clear and accurate prehospital emergency care report form on all patient contacts and provide a copy of that report to the senior emergency medical services provider with the transporting ambulance;

(I)administer medical oxygen;

(J)maintain an open airway through the use of:

(i)a nasopharyngeal airway device;

(ii)a device; noncuffed oropharyngeal airway

(iii)a pharyngeal suctioning device;

(K)operate a bag mask ventilation device with reservoir;

(L)provide care for suspected medical emergencies, including administering liquid oral glucose for hypoglycemia;

(M)prepare and administer aspirin by mouth for suspected myocardial infarction

(MI)in patients with no known history of allergy to aspirin or recent gastrointestinal bleed;

(N)prepare and administer epinephrine by automatic injection device for anaphylaxis; and

(O)perform cardiac defibrillation automatic or semi-automatic defibrillator. with an

(2)Scope of Practice of a National Registry Emergency Medical Technician:

(A)evaluate the ill and injured;

(B)render basic life support, rescue, and COL 6/21/2023 CH. 84 EMERGENCY MEDICAL SERVICES emergency medical care to patients;

(C)obtain diagnostic signs to include, but not be limited to, temperature, blood pressure, pulse and respiration rates, pulse oximetry, level of consciousness, and pupil status;

(D)perform cardiopulmonary resuscitation (CPR), including the use of mechanical adjuncts to basic cardiopulmonary resuscitation;

(E)administer oxygen;

(F)use the following adjunctive airway and breathing aids:

(i)oropharyngeal airway;

(ii)nasopharyngeal airway;

(iii)suction devices;

(iv)basic oxygen delivery devices for supplemental oxygen therapy including, but not limited to, humidifiers, partial rebreathers, and venturi masks; and

(iv)manual and mechanical ventilating devices designed for prehospital use including continuous positive airway pressure;

(G)use various types of stretchers and spinal motion restriction or immobilization devices;

(H)provide initial prehospital emergency care to patients, including, but not limited to:

(i)bleeding control through the application of tourniquets;

(ii)use of hemostatic dressings from a list approved by the Authority;

(iv)spinal immobilization; motion restriction or

(iv)seated spinal motion restriction or COL 6/21/2023 CH. 84 EMERGENCY MEDICAL SERVICES immobilization;

(v)extremity splinting; and

(vi)traction splinting;

(I)administer oral glucose or sugar solutions;

(J)extricate entrapped persons;

(K)perform field triage;

(L)transport patients;

(M)apply mechanical patient restraint;

(N)set up for ALS procedures, under the direction of an Advanced EMT or Paramedic;

(O)perform automated external defibrillation;.

(P)assist patients with the administration of physician-prescribed devices including, but not limited to, patient-operated medication pumps, sublingual nitroglycerin, and self-administered emergency medications, including epinephrine devices;

(Q)administer naloxone or other opioid antagonist by intranasal and/or intramuscular routes for suspected narcotic overdose;

(R)administer epinephrine by auto-injector for suspected anaphylaxis and/or severe asthma;

(S)perform finger stick blood glucose testing; and

(T)administer over the counter medications, when approved by the Medical Director, including, but not limited to:

(i)aspirin.

(U)The scope of practice of an EMT shall not exceed those activities authorized in this Section.

(V)Special Procedures: Institute intraosseous

(IO)needles or catheters for cardiac arrest patients if specifically trained and authorized by a local agency COL 6/21/2023 CH. 84 EMERGENCY MEDICAL SERVICES EMS Medical Director.

(3)Scope of Practice of a National Registry Advanced Emergency Medical Technician:

(A)perform all procedures that an EMT may perform;

(B)initiate peripheral intravenous

(IV)lines in unconscious patients;

(C)maintain peripheral intravenous

(IV)lines;

(D)initiate saline or similar locks in unconscious patients;

(E)draw peripheral blood specimens;

(F)insert an uncuffed pharyngeal airway device in the practice of airway maintenance. A cuffed pharyngeal airway device is:

(i)a single lumen airway device designed for blind insertion into the esophagus providing airway protection where the cuffed tube prevents gastric contents from entering the pharyngeal space; or

(ii)a multi-lumen airway device designed to function either as the single lumen device when placed in the esophagus, or by insertion into the trachea where the distal cuff creates an endotracheal seal around the ventilatory tube preventing aspiration of gastric contents;

(G)perform tracheobronchial suctioning of an already intubated patient; and

(H)prepare and administer the following medications under specific written protocols authorized by the Medical Director or direct orders from a licensed consultant physician:

(i)Physiologic isotonic crystalloid solution IV or IO; COL 6/21/2023 CH. 84 EMERGENCY MEDICAL SERVICES

(ii)Anaphylaxis: epinephrine IM;

(iii)Antidotes: Naloxone hydrochloride SL, IM, or IV;

(iv)Anti-hypoglycemics: glucose IV; Hypertonic

(v)Catecholamine: Epinephrine Epinephrine 1:10,000 IM or IV; 1:1000;

(vi)Parasympathetic Blocker: Atropine IV;

(vii)Nebulized bronchodilators as determined by the Medical Director;

(viii)Non-Opioid Analgesics for acute pain as determined by the Medical Director;

(I)prepare and administer immunizations in the event of an outbreak or epidemic as declared by the Chief Public Health Officer or designated public health officer, as part of an emergency immunization program, under the Medical Director’s standing order;

(J)prepare and administer immunizations for seasonal and pandemic influenza vaccinations according to the Chief Public Health Officer’s recommended immunization guidelines as directed by the agency’s Medical Director’s standing order;

(K)distribute medications at the direction of the Medical Director as a component of a mass distribution effort;

(L)maintain during transport any intravenous medication infusions or other procedures which were initiated in a medical facility, if clear and understandable written instructions for such maintenance have been provided by the physician at the sending medical facility;

(M)perform electrocardiographic rhythm interpretation of ventricular fibrillation, ventricular tachycardia, pulseless electrical activity, and asystole; COL 6/21/2023 CH. 84 EMERGENCY MEDICAL SERVICES and

(N)perform cardiac defibrillation with a manual defibrillator.

(4)Scope of Practice of a National Registry Paramedic:

(A)a paramedic may perform any activity identified in the scope of practice of an NREMT, or any activity identified in the scope of practice of an NRAEMT;

(B)a paramedic shall be affiliated with an approved paramedic service provider in order to perform the scope of practice specified in this Chapter;

(C)a paramedic student or a licensed paramedic, as part of an organized EMS system, while caring for patients in a hospital as part of his/her training or continuing education

(CE)under the direct supervision of a physician, registered nurse, or physician assistant, or while at the scene of a medical emergency or during transport, or during interfacility transfer, or while working in a hospital, may perform the following procedures or administer the following medications when such are approved by the Medical Director of the Guam EMSC, and are included in the written policies and procedures of the Guam EMSC.

(D)Scope of Practice includes, but is not limited to:

(i)utilize electrocardiographic devices and monitor electrocardiograms, including 12- lead electrocardiograms (ECG);

(ii)perform defibrillation, synchronized cardioversion, and external cardiac pacing;

(iii)visualize the airway by use of the laryngoscope and remove foreign bodies with Magill forceps;

(iv)perform pulmonary ventilation by use of COL 6/21/2023 CH. 84 EMERGENCY MEDICAL SERVICES lower airway multi-lumen adjuncts, the esophageal airway, perilaryngeal airways, stomal intubation, and adult oral endotracheal intubation;

(v)utilize mechanical ventilation devices for continuous positive airway pressure (CPAP)/bilevel positive airway pressure

(BPAP)and positive end expiratory pressure

(PEEP)in the spontaneously breathing patient;

(vi)institute intravenous

(IV)catheters, saline locks, needles, or other cannulae (IV lines), in peripheral veins and monitor and administer medications through pre-existing vascular access;

(vii)institute intraosseous

(IO)needles or catheters;

(viii)administer IV or IO glucose solutions or isotonic balanced salt solutions, including Ringer’s lactate solution;

(ix)obtain venous blood samples;

(x)use laboratory devices, including point of care testing, for pre-hospital screening use to measure lab values including, but not limited to, glucose, capnometry, capnography, and carbon monoxide when appropriate authorization is obtained from the Guam EMSC Medical Director;

(xi)utilize Valsalva maneuver;

(xii)perform cricothyroidotomy; percutaneous needle

(xiii)perform needle thoracostomy; (xiv)perform nasogastric and orogastric tube insertion and suction;

(xv)monitor thoracostomy tubes;

(xvi)monitor and adjust IV solutions containing potassium, equal to or less than 40 mEq/L; COL 6/21/2023 CH. 84 EMERGENCY MEDICAL SERVICES

(xvii)administer approved medications by the following routes: IV, IO, intramuscular, subcutaneous, inhalation, transcutaneous, rectal, sublingual, endotracheal, intranasal, oral or topical; (xviii) administer, using pre-packaged products when available, the following medications:

(1)10%, 25% and 50% dextrose;

(2)activated charcoal;

(3)acetaminophen;

(4)adenosine;

(5)aerosolized or nebulized beta-2 specific bronchodilators;

(6)amiodarone;

(7)aspirin;

(8)ATNAA/MARK 1;

(9)atropine sulfate;

(10)pralidoxime chloride;

(11)calcium chloride;

(12)diazepam;

(13)diphenhydramine hydrochloride;

(14)dopamine hydrochloride;

(15)epinephrine;

(16)fentanyl;

(17)glucagon;

(18)glucose (oral);

(19)haloperidol;

(20)ipratropium bromide;

(21)ketamine; COL 6/21/2023 CH. 84 EMERGENCY MEDICAL SERVICES

(22)lorazepam;

(23)midazolam;

(24)lidocaine hydrochloride;

(25)magnesium sulfate;

(26)morphine sulfate;

(27)naloxone hydrochloride;

(28)nitroglycerine preparations (I.V., Oral);

(29)norepinephrine;

(30)ondansetron;

(31)sodium bicarbonate;

(32)Tranexamic Acid (TXA).