Patient Care theory

What is a mental health crisis

any situation in which a person's behavior puts them at risk of hurtingthemselves or others and/or prevents them from being able to carefor themselves or function effectively in society

causes mental health crisis

4 ways to explain their development• Normally functioning mind experiences a psychosocial stressor (i.e. family, work, schooletc.)• Abnormally in the nervous system causes abnormal events or behaviour• Biological predisposition causes the abnormality• Psychological predisposition causes the abnormality

Spotting thesigns of acrisis

A clear and abrupt change in personalbehavior• Neglect of personal hygiene.• Dramatic change in sleep habits, such a sleepingmore often or not sleeping well.• Weight gain or loss.• Decline in performance at work or school.• Pronounced changes in mood, such asirritability, anger, anxiety or sadness.• Withdrawal from routine activities andrelationships.

BLS PCS-Mental HealthStandard

Applies to all scene calls for emotionally disturbedindividuals where dispatch or bystander informationindicates a psychiatric disorder is known or suspected tobe the cause of patient’s behavio

Recognizing the potential for violence

body language

1000 yard stare

anxiousness

When can a Paramedic use restraints?

• Directed by a physician or police officer ​

• When an unescorted patient becomes violent enroute​

• When required to provide emergency treatment as per the Patient Refusal/Emergency Treatment Standard ​

• Treating a diabetic emergency – potential underlying condition. ​

• Purposes of sedation (Advanced Care) ​

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If restraints have been applied on scene by the direction of a police officer or physician, that person will accompany you to the receiving facility. ​

• If a police officer has handcuffed a patient, you will not transport the patient unless:​

• The patient is taken into custody by the police, or ​

• The officer is accompanying you to the receiving facility. 

Restraints during Inter-facility Transfers​

In cases in which the sending facility is requesting restraints:​

• advise that restraints must be provided and applied by hospital staff or police prior to transport. ​

In cases in which the patient is already restrained, Paramedics shall not proceed with the inter-facility transport unless:​

• The sending physician has decided that the patient can be transported safely without an escort.​

• The patient is not a safety risk.​

• The paramedic feels comfortable with the decision that the patient is not a safety risk. ​

Restraints with regard to Inter-facility transfers continued..​

• If the patient is to be restrained for transport, the Paramedic will document the following on the ACR:​

• that the patient was restrained.​

• describe the patient’s behaviour that lead to the need for restraints to be applied or continued to be applied. ​

• describe the means/method of restraint, ​

• Identify the person who ordered the use of restraints ​

• describe the position of the patient during restraint ​

• note the clinical response to restraint​

• MOH ACR CODE 180 - Restrain Patient-Physical​

• You will NOT transport a patient in the prone position.​

• You will use reasonable and minimal force when applying restraints. ​

The Mental Health Act of Ontario

How the Act relates to Paramedics under the BLS PCS​

• A person who is recommended for admission to a psychiatric facility as an informal or voluntary patient may not be transported without consent​

• The following persons may be transported without consent: ​

• The subject of an application for assessment signed by a physician ​

• Form 1​

• The subject of an order for examination signed by a Justice of the Peace ​

• Form 2​

• A person taken into custody by a police officer ​

• A patient detained in a psychiatric facility under a certificate of involuntary admission ​

• Form 3 or Form 4​

Excited Delirium/Agitated Delirium/Excited Delirium Syndrome​

• What is Excited Delirium??​

• Formally recognized by the American College of Emergency Physicians in 2009. ​

• an acute confused state marked by intense paranoia, hallucinations, and violence toward objects and people typically resulting in death ​

• Not a mental health disorder​

• Induced by a variety of causes:​

• Drug/substance abuse/misuse, acute psychosis​

• Methamphetamine, cocaine, anti-psychotics ​

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Excited Delirium: Signs and Symptoms​

• Impaired thought process​

• Unexpected physical strength/decreased sensitivity to pain. ​

• Sweating, fever, heat intolerance. ​

• Acute psychosis, paranoia with possible hallucinations. ​

• Violence ​

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• Excited Delirium example​

• Recent thoughts about the term​

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Excited Delirium​

Patients with excited delirium will present with abnormal vital signs​

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• Tachycardia​

• Tachypnea​

• Hypertension​

• Hyperthermia ​

Altered LOC: Differential Diagnosis. ​

AEIOU/TIPS  ​

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• Alcohol​

• Endocrine, Encephalopathy, Electrolytes​

• Insulin (Hypoglycemia)​

• Oxygen (hypoxia), Opiates​

• Uremia​

• Toxins, Trauma, Temperature (hyperthermia)​

• Infection​

• Psychiatric, ​

• Stroke, Shock, Subarachnoid Hemorrhage​

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Application of restrains In a perfect world

• Organize a team; 4 or 5 people ​

• Identify a team leader​

• Assign a person to each upper and lower extremities. ​

• A 5th person is idea to control the patients head. ​

• Rehearse the procedure and update arriving personnel briefly. ​

• Time as you can imagine may not allow for a rehearsal. ​

• Prepare your equipment​

• Commercial restraints; if available​

• Triangular application if no other means is available at time. ​

• Inform the patient of the need for restraints and explain the procedure. ​

• Always maintain dignity and treat patients with respect. Provide reassurance to both patient and/or family​

• At the command of the team leader, work in a coordinated effort to immobilize the patient. ​

• Control each limbs main joint with both hands. Proximal and distal to the joint for maximum control.  ​

• Position patient in “spread eagle” or recovery position until stretcher can be made available. ​

• Secure extremities to stretcher as per Mental Health Standard. ​

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Post Application​ of restraints

• Assess distal pulses in the extremities after restraints have been applied.​

• Elevate the patients head and be mindful of potential respiratory complications. ​

• Beware of spitting patients. Health and safety. ​

• Never leave a restrained patient unattended. ​

• Never remove restraints once applied. ​

• Be empathetic. ​

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Paramedic Safety Tips

• Turn off lights and siren a few bocks from scene​

• Ensure a clear vehicle exit route​

• Carry your portable radio​

• Park a safe distance from the scene​

• Walk on soft ground or grass if possible, avoid making noise​

• If using a flashlight, hold it by your side, not in front of you​

• If more than one paramedic approaches the scene, walk single file with the one in front holding the flashlight, and the one behind carrying equipment​

• Note areas of concealment which could offer protection if necessary​

• Stand to the side of a door when knocking, never in front​

• If no one answers, call dispatch. Check the back door​

• Stay out of kitchens – they are full of weapons​

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C.T.A.S - Introduction​

• First developed for use in Canadian hospital emergency departments as a tool to help define a patient’s need for care. ​

• CTAS assists hospital staff to assign a level of acuity for patients based on the presenting complaint and the type and severity of their presenting signs and symptoms.  ​

• Patients are triaged using CTAS to ensure that they are managed based on their needs for care.​

• One major difference between ED CTAS and Pre-hospital CTAS is that, in the ED, the CTAS assessment is used as a triage tool while in the pre-hospital care setting it is used solely as an indicator of acuity. ​

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The Benefits of a Standardized System​

• Assists with determining the most appropriate destination based on the acuity of the patient ​

• Creates a common language for paramedics, ambulance communications officers and ED staff  ​

• Removes individual interpretation of a patient’s acuity.​

• Assists EDs with preparation of resources based on a needs​

Pre-hospital CTAS - Levels​

• CTAS is based on a five-level scale:​

• Level 1 (Resuscitation) representing the “sickest” patients ​

• Level 5 (Non urgent) representing the least ill group of patients.  ​

• The assignment levels is achieved by establishing a relationship between a patient’s Chief Complaint and the potential causes of presentation.​

• Contributing factors, known as modifiers, help to refine the application of the acuity level.  ​

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C.T.A.S Level 1 – Resuscitation ​

• Conditions that are considered threats to life or limb or have an imminent risk of deterioration requiring immediate aggressive interventions.  ​

• These are patients that have arrested, or require active and aggressive resuscitation, or are in pre arrest or post arrest states.  ​

• Any patient requiring airway support and ventilation or circulatory support.  ​

• Examples include: Cardiac arrest, Unconsciousness, Complete Airway obstruction, Respiratory arrest (or pre-arrest), extremity amputation. ​

C.T.A.S Level 2 – Emergent ​

• Conditions that are a potential threat to life, limb or function requiring rapid medical interventions and the use of condition specific controlled medical acts.​

• These patients have serious illness or injury and have the potential for further deterioration that may then require resuscitation.​

• They need prompt treatment to stabilize developing problems and treat acute conditions.  These patients often have had controlled acts applied in the field.​

• Examples include: Chest pain with cardiac features, CVA within 6 hour window, partially occlude airway, falls > 6 meters, vomiting blood/rectal bleeds (active). ​

C.T.A.S Level 3 – Urgent ​

• Conditions that could potentially progress to a serious problem requiring emergency interventions.​

• May be associated with significant discomfort or affect ability to function at work or activities of daily living.  ​

• These patients have normal vital signs but their presenting problem suggests a more serious acute process.  ​

• They often have moderate acute pain (pain scale 4-7/10) and it is this category of patients where the pain scales are used more often in the assignment of acuity. ​

• Examples include: Chest pain without cardiac features, Hypothermia with moderate symptoms, depression/suicidal ideation, Post seizure (normal mentation), mild SOB (on exertion) ​

• 62 with abdominal pain worsening over last 12 hrs, 5/10​

C.T.A.S Level 4 – Less Urgent  ​

• Conditions that relate to patient age, distress, potential for deterioration or complications that would benefit from intervention or reassurance.​

• These patients will typically have stable vital signs and lower pain scales. ​

• The potential seriousness of their problem based on the chief complaint is not as acute.  The need for acute intervention is not as great and patients may not require the use of medical directives.  ​

• Many patients with chronic illness without significant acute exacerbation of their illness may fall into this category. ​

• Examples include: anxiety, depression, UTI’s ​

Rules for applying CTAS: Rule #1

• Paramedics will assign a minimum of 2 CTAS scores to each patient. ​

• These are MANDATORY and will be documented on your ACR. ​

• The first score will be determined on arrival of the patient and will reflect the initial condition of the patient prior to paramedic interventions.​

• This additionally helps serve as a marker for response times as they relate to the patient’s acuity and will be useful when reviewing dispatch procedures, vehicle resources and patient care standards. ​

• The second score will be determined at the time of departure from the scene. ​

• The second score will reflect any change in the patient’s condition as a result of interventions provided on scene prior to transport.   ​

• Will also assist in determining the most appropriate destination for patients. ​

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Rules for applying CTAS: Rule #2​

• The CTAS score reported to the receiving institution is the level at departure from the scene (Departure CTAS) or if the patient’s condition deteriorates after transport has been initiated. ​

• Based on the patient’s initial complaint, including the application of first and second order modifiers as determined by the information obtained from the primary survey and secondary survey​

• Consideration includes response to treatment administered on scene. ​

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Rules for applying CTAS: Rule #3​

• When considering the patient’s response to treatment, any subsequent CTAS level must not be any greater than two levels below the pre treatment (Arrival CTAS)​

• A patients condition may improve significantly with certain pre-hospital interventions, however, there is always the possibility that their condition may deteriorate or significantly change.  ​

• CTAS is applied over time and many factors can affect the patient’s acuity (e.g transport time)​

• This rule creates a safety margin in cases where a patient’s condition may deteriorate over time. 

Rules for applying CTAS: Rule #4

• Patients who are VSA on arrival, and where resuscitation in provided, the CTAS will remain a CTAS level 1. ​

• Even if ROSC is achieved. ​

Rules for applying CTAS: Rule #5​

• If a Paramedic receives a Termination of Resuscitation (TOR) order while managing a cardiac arrest, the CTAS scores will reflect acuity of the patient on arrival and departure.  ​

• If the patient is initially VSA, the arriving CTAS level is a 1. If a TOR is granted, the departure CTAS is a 0. ​

• If the patient is not initially VSA, but experiences a witnessed cardiac arrest, the appropriate arrival CTAS will be assigned and the departure CTAS will be 1. ​

Rules for applying CTAS: Rule #6​

• In cases where a patient is deemed to be “obviously dead”, as per the BLS PCS, no CTAS level is required (arrival or departure).  ​

• The CTAS level of zero is required to be documented on the ACR regardless of whether the patient is transported or not. ​

How to Assign C.T.A.S Levels​

1. Conduct a “Look Test” ​

• In some cases, the CTAS level can be determined by a look test when the presenting complaint is obvious.  ​

• This applies primarily to critically ill patients who appear in extremis on initial contact. ​

• The look test application only applies to level 1 patients. ​

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2. Presenting Chief Complaint. ​

• Determine the presenting complaint based on the CEDIS category.  ​

• the presenting complaint will begin to guide you on an appropriate score.   ​

• Apply First and Second Order Modifiers ​

• In many cases it may not be obvious what the CTAS level should from the “Look Test” and the presenting chief complaint alone.  ​

• First and second order modifiers are required to assign a CTAS score.​

• These modifiers are determined during the primary and secondary surveys and will help refine the severity of the presenting complaint to accurately determine the CTAS level.  ​

• Many presenting complaints will fall within more than one CTAS level and modifiers will be needed to accurately determine the CTAS level.​

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First Order Modifiers​ CTAS

• First order modifiers are applied once the presenting complaint has been determined.​

• They include the following considerations: ​

• oxygen saturation (respiratory status)​

• hemodynamic stability (perfusion status)​

• GSC (mentation) ​

• temperature (immunocompromise or infection)​

• Pain (acuity of underlying condition) ​

• Bleeding (bleeding disorders, issues with clotting etc.)​

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Second Order Modifiers​ CTAS

• Second Order Modifiers are more complaint-specific and are applied after the presenting complaint is determined and the first order modifiers have been applied.  ​

• A second order modifier should not be used to downgrade the CTAS level​

•  Second order modifiers include the following considerations:​

• Blood glucose (< 3 or > 18 mmol/L?)​

• Blood pressure (>220 SBP?)​

• Dehydration (shock?)​

• Mental Health (physical, mental abuse?)​

• Meant to assist. Not to supersede assessment findings or first order modifiers. ​

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Death Scenes​

• Some deaths are crime scenes or may be investigated as such​

• Coroners' investigations take place- remember when they are performed​

• When waiting for police at a death scene​

• do your best to protect scene from contamination by bystanders, family, media and others​

• Not transporting the deceased means that the body remains where it was when medical examiner or coroner arrives​

• Always Tx according to Medical Directives & Standards – do not ever withhold Tx for this reason​

• This is addressed in the Deceased Patient Standard; in the unexpected death procedure​

General Rules ​ CRIME SCENESE

• Move only what you have to​

• Keep this in mind with MVC responses too​

• Be mindful of entrance and egress routes. ​

• Don’t drive over debris or tire marks​

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• Use caution. Try not to disturb or destroy evidence​

• This may not always be possible ​

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• Limit your contact to the patient only. Don’t touch things that you do not need to​

• Risk of altering finger prints​

• Do not ​

• Use the phone​

• Use the toilet​

• Run water in a sink​

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• Minimize the number of EMS personnel who enter the room with you​

• Each person further contaminates the scene​

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• Preserve clothing etc. removed from pt.​

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• Make every attempt to preserve evidence on the clothing​

• Do not cut through  bullet holes for example​

• Some suggestions- don’t throw away dressings, O2 devices, ECG dots​

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Think About Where You Walk​ crime scene

• Walk around blood pools or splatters​

• Choose a path away from the one that victim/suspect may have use​

Specific to Hangings​

• The Police Notification Standard speaks to the following precautions:​

• Preserve the knot ​

• Rope should only be cut if it cannot be readily slipped off and in such a way that the rope would be preserved​

• Ensure that your observations of the rope is documented in your general impression section of the ACR. ​

• From a care perspective, hangings should be considered a medical cause of cardiac arrest and should be managed as such. 

Highway Incidents (1 of 4)​

• Approach and vehicle positioning​

• Consider requesting police assistance.​

• Remain a safe distance away.​

• Minimum of 6 m behind, 10 angle​

• Front wheels turned to the left​

• Ask the IC where to park or park downstream.​

• After dark​

• Use high beams and spotlights. ​

• Before leaving your vehicle​

• Record license plate number.​

• Ensure law enforcement is on scene.​

Sexual Assault (1 of 2)​

• Crimes of power, force, and violence​

• Legal definitions vary from jurisdiction to jurisdiction​

• Sexual assault​

• Rape​

• Statutory rape​

• Victims​

• Mostly women​

• Men and children may also be attacked sexually.​

• Sexual offenders are often known by the victim.​

• Desire to shower or douche is common.​

• Encourage the patient to wait until evidence has been properly gathered.​

• Look for signs that drugs were used to facilitate assault.​

• May have multiple system trauma​

Treatment and Documentation​ crime scenes

• Be professional and compassionate.​

• You should know the specific protocols for victims and assist police and any medical or social services personnel on the scene. ​

• Trust-building, respect, and empathy are keys to prehospital care.​

• Foster empowerment of the victim. ​

Specific Treatment and Documentation (1 of 5)​ crimes

• Consider the victim’s psychological and physical state, but also help preserve evidence. ​

• May be hysterical, embarrassed, and/or frightened ​

• Denial and disbelief are common.​

• Provide care.​

• Observe routine precautions.​

• Take the patient’s history.​

• Perform a limited physical examination.​

• Shield the patient from onlookers.​

• Provide treatment as quickly, quietly, and calmly as possible.​

• Help the patient regain a sense of control.​

• Refrain from seeking details that are not necessary to provide emergent care. 

• Preserve evidence.​

• If possible, if genital or anal penetration, advise the patient not to bathe, douche, urinate, or defecate. ​

• If oral penetration, advise the patient not to eat, drink, brush teeth, or use mouthwash. ​

• Leave evidence untouched (bring unwashed clothes). ​

• Establish chain of custody.​

• Notify police, per protocol.​

• May refuse assistance or transport​

• Maintain privacy and avoid public exposure.​

• Adult patients have the right to decline care.​

• Documentation​

• You may be asked to appear in court 2 to 3 years later.​

• Record only objective facts.​

• Subjective statements should be in quotation marks.​

• Thoroughly document all patient statements pertaining to the crime and witnesses.​

Human Trafficking

• No one can consent to trafficking​

• Domestic vs International​

• Commercial sexual exploitation- people by pimps, gangs, organized crime network; long hours no limited pay; street level prostitution, porn, hotels, all walks of life.  Primarily women and girls.​

• Forced labour- any work service or employment; penalty involved (threats, violence, sanctions); not voluntary​

• Domestic Servitude-  housekeeping, long working hours, little to no pay, documents withheld, poor living conditions; international victims entering Canada through live-in caregiver program.​

• Human Trafficking for Forced Illegal Activities- drug mule, petty theft, credit card fraud​

Things to look out for: Sexual exploitation​

• Fear, anxiety, depression, hyper-viligence or intimidation​

• Physical abuse​

• Poor health​

• Clothing not appropriate for weather​

• With someone who speaks on their behalf​

• No personal identification​

• Do know their address​

• Limited contact with friends or family​

• Branding or scarring​

Labour Exploitation​

• Live in groups​

• Make little to no money​

• Appropriate equipment for job not around​

• High recruiting fees to work in Canada​

• Feelings of owning money to employer

Domestic Servitude​

• No private space​

• Sleep in shared space or inappropriate locations​

• No social interactions with people outside of the family​

• Forced marriage situations involving exploitation looks similar to domestic servitude

Child Trafficking

• Behaviors does not match typical behavior for age​

• Travelling with adults or groups that are not relatives​

• No access to education or play​

• Separated from parents or guardians

Maltreatment, Neglect, and Assault​

• All too common​

• Important to recognize the signs and symptoms​

• Differentiate among maltreatment, neglect, and assault.​

• Prevention and early detection are key.​

Child Maltreatment (1 of 4)​

• Improper or excessive action that injures or otherwise harms ​

• Physical abuse​

• Sexual abuse​

• Neglect​

• Emotional abuse​

• Child neglect​

• Caregiver fails to supply basic necessities ​

• Engages in inadequate or dangerous child-rearing practices​

• Failure to provide adequate food, clothing, or shelter​

• Caregiver’s misuse of drugs or alcohol​

• Failure to provide support or affection ​

• Child abandonment​

• Maltreated children​

• May have permanent or life-threatening injuries​

• If maltreatment is not reported, child likely to be victimized again.​

• Always better to err on the side of caution to protect the victim.​

• Withdrawing a child from the family environment is a last resort option to assure his or her safety.​

Profile of an At-Risk Child (1 of 2)​

• Occurs in all communities and among all socioeconomic strata.​

• Younger children are at higher risk for fatal abuse and neglect.​

• Children from low-income or single-parent families have more reported occurrences of abuse and neglect.​

• Assessing a potential child maltreatment case​

• Be attuned to suspicious behavioural traits​

• Does not become agitated when a parent leaves the room ​

• Does not look to a parent for reassurance ​

• May cry excessively or not at all​

• Wary of physical contact​

• May appear apprehensive​

People Who Maltreat Children (1 of 3)​

• Can be anyone​

• Who has care, custody, or control of the child​

• Parents, step-parents, foster parents, babysitters, and relatives​

• Abusive parents​

• Receive little enjoyment from parenting ​

• Isolated from the community​

• Afraid of sources of support in their community​

• Most were maltreated or neglected themselves​

• View themselves as victims in life or in the parent–child relationship​

• Shared characteristics​

• Drug use​

• Poor self-concept​

• Immaturity​

• Lack of parenting knowledge​

• Lack of interpersonal skills​

Assessment and Management of Child ​
Maltreatment (1 of 5)​

Physical examination​

Keen ear for inconsistencies in the history​

Take into consideration the mental and emotional age ​
of the child.​

Do the examination with another colleague, if possible.​

• Consistency of the injury with the child’s developmental age​

• History inconsistent with injury​

• Inappropriate parental concerns​

• Lack of supervision​

• Delay in seeking care​

• Affect​

• Bruises of varying ages​

• Unusual injury patterns​

• Suspicious circumstances​

• Environmental clues​

• Soft-tissue injuries​

• Most common findings in the physical examination of an abused child​

• Multiple bruises in various stages of healing​

• Bruises in unexpected locations ​

• Bites and burns​

• Stocking or glove burns and doughnut burns (hot water)​

• Fractures from fall, twisting, or jerking injuries​

• Head injuries ​

• Abdominal injuries​
  Observe the scene.​

  Household dynamics​

  More than one victim may be encountered.​

  Keep the scene as safe and calm as possible.​

Assessment and Management of Child ​
Maltreatment (5 of 5)​

• Patient care reports (PCRs)​

• Objective observations​

• Very important for the police and child​

   protective services​

• Mandated reporter​

General Information ​ child family service act

• Ontario’s Child and Family Services Act (CFSA) requires those who perform professional or official duties with respect to children to report suspected child abuse where there are reasonable grounds. ​

• A child is anyone under 16 (or appears to be) or who is 16 or 17 and subject to a child protection order. ​

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• You don’t have to be certain that a child may need protection. Suspicion on reasonable grounds is sufficient.​

• Information that an average person, using normal and honest judgment would need to decide.​

• All incidences of abuse/neglect must be report to Children's Aid Society in order for a determination to be made regarding the child's needs. ​

What is Abuse?​

• “Abuse occurs when a child is hurt intentionally or when a parent or caregiver does not provide the protection a child needs. Physical and sexual abuse are often the most recognizable, but neglect and emotional abuse can be just as damaging.”  ​

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-The Ontario Association of Children’s Aid Societies​

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• The CFSA requires that you report suspicions of physical, sexual and emotional abuse, neglect and risk of harm to a children’s aid society. ​

Educational Context​
​abuse

• All professionals have a legal duty to report and an ethical and moral duty to take responsibility for carrying out such actions.​

• A provincial coroner’s inquest into the death of Jeffrey Baldwin from abuse, maltreatment, and neglect resulted in 103 jury recommendations for a number of professionals, including doctors, police, paramedics and teachers. ​

• The report directs regulators, to promote the duty to report and ensure that the legal obligations health care professionals are given adequate attention. ​

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Duty to Report​

• Everyone has a duty to protect children and a duty to report suspected child abuse or neglect, according to the CFSA.​

• Become familiar with the legislation and your employer’s policies and protocols (BLS PCS v 3.4)​

• The duty to report supersedes all other obligations. ​

• You do not have to prove suspected abuse or neglect. Your report enables the children’s aid society to investigate the information.​

• You cannot be held liable for making a report as long as you have reasonable grounds for your suspicion and are not acting maliciously. (CYFSA, s. 72 (7))​

• Protection of Informant. ​

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Executing the Plan – Recognize​
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• The signs of abuse and neglect ​

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• Children may not know their rights and what constitutes abuse and neglect​

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• Your duty to report is initiated when you have reasonable grounds to suspect that a child is or may be in need of protection. Abuse or neglect may include: ​

• a child is hurt intentionally​

• a parent or caregiver does not adequately care for or protect the child or protect the child from others​

• a child has suffered emotional harm demonstrated by serious anxiety, depression, withdrawal, self-destructive or aggressive behavior or delayed development. ​

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• Not all symptoms of poverty constitute neglect. Poverty is a reality for many marginalized children and their families. ​

• The duty to report is ongoing, which means that if you have made a report about a child and suspect further abuse or neglect, you must report to the CAS again.​

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Signs of Abuse/Neglect​

Physical Abuse ​

• the use or threat of deliberate physical force ​

• punching, slapping, shaking, burning, biting, throwing, hair pulling, beating, kicking, cutting and throwing objects. ​

• Signs or indicators may include such things as bruising, burns, bites and cuts ​

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Sexual Abuse​

• sexual touching, exposure, sexual suggestiveness, harassment, underage pregnancy, or observation of sexual behaviour​

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Emotional Abuse​

• repeated treatment that negatively affects the child’s sense of self-worth or self-esteem. ​

• yelling, ignoring, rejecting, demeaning, isolating or exposing the child to domestic violence​

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Domestic Violence​

• violent or abusive behavior occurring within the child’s home, usually involving the abuse of a partner or spouse​

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Neglect​

• failure of a parent or caregiver to provide the child with basic needs such as adequate food, sleep, safety, supervision, clothing or medical treatment​

• failure to provide consent to treatment where a child has a medical, mental, emotional or developmental condition requiring treatment ​

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Caregiver Incapacity​

• substance abuse or mental health concerns that have an impact on a child’s safety or well-being.​

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Physical Signs of Abuse​

• Gross or multiple deformities; incompatible with hx​

• New and/or old bruises​

• Distinctive marks or burns e.g. belt, hand imprint, cigarette burns​

• Bruises in unusual areas​

• Burns in unusual areas​

• Signs of longstanding physical neglect e.g. dirty hair, clothing, severe diaper rash​

• Signs of malnutrition e.g. slack skin folds, pallor, dehydration, dull/thin hair. ​

• Signs of “shaking” syndrome – hemorrhages over whites of eyes, hand or fingerprints on neck, signs of head injury unrelated to incident hx. ​

Stages of Bruising​

• Less than 24 hours: reddish with blue or purple shading​

• 1-3 days: blue to blue-brown​

• 5-7 days: greenish​

• 10-14 days: yellowish​

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Executing the Plan – Report ​

• Know the number of your local child protection agency ahead of time. In some communities, you can dial 411 and ask for a children’s aid society or  family and children’s services​

• The Ontario Association of Children’s Aid Societies’ website at​

http://www.oacas.org ​

• Make and keep accurate and factual notes that lead you to suspect child abuse or neglect. Ensure that suspect Abuse is well documented on your ACR! Store any notes in a secure place as they may be required at a later date. ​

• When possible, have family information available such as names, addresses, dates of birth, and other children in the household when making the call to a children’s aid society​

• Remember that abuse and neglect shared in confidence is still subject to your duty to report.​

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Legal and Disciplinary Implications​
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• Under the CFSA, every person who performs professional or official duties with respect to children, including Paramedics and other first responders, is liable on conviction to a fine of up to $5,000 if they fail to report a suspicion based on information obtained in the course of their professional or official duties. (s. 72(4), CFSA) ​

​

Elder Maltreatment (1 of 4)​

• Incidence is growing ​

• Strains on caregivers and nursing home systems ​

• Older patients present much differently than children.

• People are living longer​

• Responsibility of care falls to their children.​

• Physical and emotional stress​

• Financial burdens​

• Violence may be a learned response.​

• Stress of caring for an older person ​

• Diminishing social network, frailty, and medical illness ​

• Increased risk for maltreatment in nursing facilities​

Signs of Elder Maltreatment (1 of 5)​

• Evaluate each situation. ​

• Fearful patient with unexplained bruises or sores ​

• Unkempt, dirty patient while the caregiver is clean​

• Caregiver answers all your questions.​

• Patient complains of items being taken or money confiscation.​

• Not allowed to socialize with peers and is kept in isolation​

• Older people do not generally seek help.​

  Fear of being institutionalized​

  Fear of getting the person performing the maltreatment into trouble ​

  Polypharmacy, confusion, or brain disorders​

• Physical examination and history should address:​

• Patient’s capacity to answer questions​

• Patient’s level of fear​

• Patient’s cleanliness​

• Appropriately and consistently marked pill bottles​

• Patient’s bruises or sores​

• Consistent current history between patient and caregiver​

• Objectively record observations on the PCR.​

• Adult protective services

• Questions about the scene​

• Is the home tidy, and are the surroundings orderly?​

• Is there food in the refrigerator?​

• What is the heating or cooling situation, and is it appropriate to the weather?​

• Does the patient use a walking or wheelchair device?​

• Patients residing in nursing homes​

• Undocumented decubitus ulcers​

• Tied-off catheters​

• Dangerous use of restraints​

• May not have a way to report the maltreatment​

• May be victims of maltreatment by visiting family members​

When is it mandatory to report elder abuse?​
​

Reporting is mandatory when an older adult resides in a Long-term Care Home or a Retirement Home and elder abuse is suspected or has occurred. The law requires reporting by anyone who knows or has reasonable grounds to suspect that a resident has been, or might be, harmed.

Retirement Homes Act,2010

• he legislation (s.75. (1), states a person who has reasonable grounds to suspect that any of the following has occurred or may occur shall immediately report the suspicion and information upon which it is based to the Registrar:​

• Improper or incompetent treatment or care of a resident that resulted in harm or a risk of harm to the resident.​

• Abuse of a resident by anyone or neglect of a resident by the licensee or the staff of the retirement home of the resident if it results in harm or a risk of harm to the resident.​

• Unlawful conduct that resulted in harm or a risk of harm to a resident.​

• Misuse or misappropriation of a resident’s money.​

• The abuse must be reported to the Registrar of the Retirement Homes Regulatory Authority​

Long-Term Care Homes Act,2007​

• Mandatory to report to the MOHLTC abuse when suspected or evidence of such is taking place in a long-term care home​

• “The LTCH Act (s.24) states if a person who has reasonable grounds to suspect abuse has occurred or may occur shall immediately report the suspicion and the information to the Ministry of Health and Long-Term Care Director.”

Must report if Known or Suspect harm by:​

• mproper or incompetent treatment or care​

• abuse by anyone, including staff, family, other visitors, or other residents​

• neglect by staff or the owner of the home​

• someone misusing their money or committing fraud against them​

• someone misusing or committing fraud with public funds given to a long-term care home​

• other illegal behaviour​

Who Must Report abuse in LTC home​

• Mandatory reporting by any person except a resident​

• Social workers and members of regulated health professionals must report, even if information they would normally keep confidential​

• Report to Director at the MOHLTC: Tel:  [phone](7 days a week, 8:30 a.m. – 7:00 p.m.)

Assessment

The Hamilton Verdict​

​

• Instructions and Rubric are located on Blackboard under Assignments​

• Papers will be due the first class after Student Success Week​

• December 8, 2023​

• Assignment total grade value – 2.5%​

OCCUPATIONAL HEALTH AND SAFETY ACT​

• Established in 1979 ​

• Outlines the rights and duties of all those the workplace​

• Establishes procedures for dealing with workplace hazards​

• Establishes procedures for dealing with harassment and violence in the workplace​

• Provides the enforcement of the law where compliance has not been achieved voluntarily by workplace parties​

• Participating Organizations​

• Duties of Employers​

• Duties of Workers​

• Workplace Harassment/Violence​

• Toxic Substances​

• Rights of Employees. ​

• ​The act states that employers have the greatest responsibility with respect to health and safety in the workplace.

Participating Organizations

Parties and organizations external to the workplace also contribute to workplace health and safety. ​

• The Ministry of Labor ​

• The Workplace Safety and Insurance Board (WSIB)​

• The Health and Safety Associations (HSAs)​

• ​

• As of April 2012, in addition to the enforcement responsibilities, the Ministry is also responsible for developing, coordinating and implementing strategies to prevent workplace injuries and illnesses and set standards for health and safety training.​

DUTIES OF EMPLOYERS:​

An employer shall ensure that,​

​

• Equipment, materials and protective devices as prescribed are provided​

• Maintained in good condition.​

• Used as prescribed.​

• Policies and procedures prescribed are carried out in the workplace​

• Any buildings or structure, whether temporary or permanent, is capable of supporting any loads that may be applied to it.​

• Determined by the applicable design requirements/Building Code that was in force at the time of its construction.​

• ​Provide information, instruction and supervision to a worker to protect the health or safety of the worker​

• Afford assistance and co-operation to Health and Safety Committees. ​

• Take every precaution reasonable in the circumstances for the protection of a worker;​

• Post, in the workplace, a copy of this Act and any explanatory material prepared by the Ministry, outlining the rights, responsibilities and duties of workers​

• Review a written occupational health and safety policy and develop and maintain a program to implement that policy​

• Post at a conspicuous location in the workplace a copy of the occupational health and safety policy​

• Provide to the Health and Safety Committee the results of a report respecting occupational health and safety​

• Advise workers of the results of said report.​

• ​

DUTIES OF WORKERS​

A worker shall, ​

​

• Work in compliance with the Act and regulations​

• ​

• Use or wear any equipment, protective devices or clothing required by the employer ​

• ​

• Report to the employer or supervisor any known missing or defective equipment or protective device that may endanger the worker or another worker​

• ​

• Report any hazard or contravention of the Act or regulations to the employer or supervisor​

• ​

DUTIES OF WORKERS CONTINUED..​

A worker shall NOT,​

​

• Remove or make ineffective any protective device ​

• the protective device shall be replaced immediately​

• ​

• Use or operate any equipment etc, in a manner that may endanger himself, herself or any other worker​

• ​

• Engage in any prank, contest, feat of strength, unnecessary running or rough and boisterous conduct.​

• ​

BOISTEROUS CONDUCT EXAMPLE

• Boisterous behaviour includes rough or noisy behaviour or playing practical jokes which may affect the concentration or performance of other persons at the work place​

INTERNAL RESPONSIBILITY SYSTEM​

• Everyone in the workplace has a role to play in keeping workplaces safe and healthy​

• ​

• Workers in the workplace who see a health and safety problem have a duty to report the situation to the employer or a supervisor​

• ​

• Employers and supervisors are, in turn, required to acquaint workers with any hazard in the work that they do​

• ​

• The employer, typically represented by senior management, is responsible for ensuring that the Internal Responsibility System is established, promoted, and that it functions successfully.​

WORKPLACE HARASSMENT/VIOLENCE​

The OHSA sets out the duties of workplace parties in respect of workplace violence and workplace harassment ​

​

• Violence or harassment in the workplace may originate from anyone the worker comes into contact within a workplace​

• i.e.  A client, a customer, a student, a patient, a co-worker, an employer, or a supervisor ​

• ​

• Or the person may be someone with no formal connection to the workplace,​

• i.e. A stranger or a domestic/intimate partner, who brings violence or harassment into the workplace​

• ​

WORKPLACE HARASSMENT​

• Workplace harassment is defined: ​

“Engaging in a course of vexatious comment(s) or conduct against a worker in a workplace that is known or ought reasonably to be known to be unwelcome”​

• Vexatious – to cause annoyance, frustration or worry. ​

Workplace harassment can involve unwelcome words or actions that are known or should be known to be ​

• Offensive​

• Embarrassing, ​

• Humiliating ​

• Demeaning ​

To a worker or group of workers. It can also include behavior that intimidates, isolates or even discriminates against a particular individual

WORKPLACE VIOLENCE​

Workplace violence is defined in the OHSA as:​

​

“ The exercise or attempted exercise of physical force by a person against a worker, in a workplace, that causes or could cause physical injury to the worker”​

​

• A statement or behavior where it is reasonable for a worker to interpret as a threat of force that could cause physical injury to the worker. ​

• This definition of workplace violence is broad enough to include acts that would constitute offences under Canada's Criminal Code.​

• ​

OCCUPATIONAL HEALTH AND SAFETY ACT, R.S.O. 1990,C.0.1  PART III.01 VIOLENCE AND HARASSMENT​

• Prevention policies​

• Prevention programs​

• Assessment of risks for violence​

• Domestic violence​

• Duties regarding violence​

• Harassment prevention program/ Duties regarding harassment (investigations, annual review)​

• Instruction regarding harassment​

​

TOXIC SUBSTANCES​

• The subsections of the OHSA that deal with toxic substances have two main purposes: ​

• ​

1. To ensure that exposure to toxic substances is controlled ​

2. To ensure that toxic substances in the workplace are clearly identified and that workers receive enough information about them to be able to handle them safely.​

• ​Workers Rights:​

• ​

• The right to know about hazardous materials in the workplace. ​

• This right has always been part of the Act, but it was significantly expanded in 1988.​

• Canada wide implementation of the Workplace Hazardous Materials Information System. (WHMIS)​

• ​Employer Duties:​

• ​Identify hazardous materials in the prescribed manner.​

• Obtain or prepare (as may be prescribed) Material Safety Data Sheets (MSDSs)​

• Provide information and prescribed instruction and training to workers who are exposed or likely to be exposed to hazardous materials ​

• Ensure that workers participate in such training.​

• ​

THE 3 RIGHTS OF WORKERS​

1. The right to know about hazards in their work and get information, supervision and instruction to protect their health and safety on the job​

2. ​

2. The right to participate in identifying and solving health and safety problems or through a health and safety representative or worker member of a joint health and safety committee​

3. ​

3. The right to refuse work that they believe is dangerous to their health and safety or that of any other worker in the workplace​

​

THE RIGHT TO REFUSE​

• Section 43 of the Act describes the exact process for refusing work and the responsibilities of the employer/supervisor in responding to such a refusal; does not apply to subsection (2. fire, police, health, corrections, etc)​

• In certain circumstances, members of a joint health and safety committee who are “certified” have the right to stop work that is dangerous to any worker. ​

• Sections 45 – 47 of the Act sets out these circumstances and how the right to stop work can be exercised.​

• ​The right to refuse unsafe work applies to all workers other than specified types of workers in specified circumstances​

• ​

• In specified circumstances, the right to refuse unsafe work is limited for:​

• Police Officers​

• Fire Fighters​

• Correctional Officers​

• Health Care workers or persons employed in health care facilities ​

• Including Paramedics. ​

• ​A worker can refuse to work if he or she has reason to believe that:​

  ​

  • any machine, equipment or tool that the worker is using or is told to use is likely to endanger himself or herself or another worker​

  • the physical condition of the workplace or workstation is likely to endanger himself or herself​

  • workplace violence is likely to endanger himself or herself ​

  ​

  • Consider limitations of these rights with Paramedics​

  • ​Can an employer discipline a worker for refusing work?​

    ​

    • NO ​

    • ​

    • The employer is expressly prohibited from penalizing, dismissing, disciplining, suspending or threatening to do any of these things to a worker who has obeyed or sought enforcement of the OHSA.​

    • ​

WORK REFUSAL​

• Is situation unsafe for you or your co-workers​

• Report to supervisor your refusal and why you believe the condition is unsafe​

• Supervisor, OHS member and yourself will investigate why it is unsafe​

• If problem is resolved, you return to work​

• If not, a government OHS inspector is notified​

• Alternate work may be assigned​

• Investigation and decision is made by inspector​

APPLICATION FOR BLOOD SAMPLE AND ANALYSIS​
​

• Any person may apply to a medical officer of health to have a blood sample of another person analysed if the applicant came into contact with a bodily substance of the other person in any of the following circumstances: (within 30 days)​

• As a result of being the victim of a crime.​

• While providing emergency health care services or emergency first aid to the person, if the person was ill, injured or unconscious as a result of an accident or other emergency.​

• In the course of his or her duties, if the person belongs to a prescribed class.​

• While being involved in a prescribed circumstance or while carrying out a prescribed activity. ​

• ​

TRANSMISSION THROUGH BLOOD OR OTHER BODY FLUIDS:​
​

• Some infections are spread when blood or other body fluids  (urine, saliva, breast milk, semen and vaginal secretions) from an infected person comes into contact with:​

• the mucous membranes or the bloodstream of an uninfected person, such as through a needle stick injury or a break in the skin.​

Examples of diseases spread through blood or other body fluids:​

• hepatitis B - blood, saliva, semen and vaginal fluids​

• hepatitis C - blood​

• human immunodeficiency virus (HIV) infection - blood, semen and vaginal fluids, breast milk​

• cytomegalovirus (CMV) infection - saliva, breast milk, semen and vaginal fluids, urine​

• glandular fever - saliva​

REQUEST FOR VOLUNTARY BLOOD SAMPLE AND ANALYSIS​
​

Upon the receipt of an application, the medical officer of health shall attempt to contact the respondent and request that the respondent provide either,​

• a blood sample for the purpose of having it analysed ​

• other evidence of his or her seropositivity respecting the listed communicable diseases​

Notice of possible referral to Board​

• Where the medical officer of health contacts the respondent, the medical officer of health shall advise the respondent that if he or she fails to provide a blood sample or other evidence voluntarily, the application will be referred to the Board and that an order to provide a blood sample may be made. ​

• Consent and Capacity Board - the Health Care Consent Act​

DECISION OF BOARD​
​blood sample analyiss

Upon the conclusion of the hearing, the Board shall decide whether the respondent should be ordered to provide a blood sample for analysis if the Board believes, on reasonable and probable grounds, that,​

• the applicant came into contact with a bodily substance of the respondent ​

•  the applicant may have become infected with a virus that causes a listed communicable disease​

• by reason of lengthy incubation periods for certain communicable diseases and the methods available for ascertaining the presence in the human body, an analysis of the applicant’s blood would not accurately determine whether the person had become infected​

• taking a blood sample from the respondent would not endanger his or her life or health​

• the applicant has submitted a physician report, made within seven days after coming into contact with the bodily substance of the respondent ​

• the taking and analysis of a blood sample from the respondent is necessary to decrease or eliminate the risk to the health of the applicant​

DECISIONS MADE​ blood sample analyisi

• The Board shall make its decision within one day after the day the hearing ends.​

• The Board shall provide all parties involved notice of the decision, including the applicant, respondent and the medical officer of health who referred the application ​

• The decision of the Board is final. ​

Court order for compliance​

• If a respondent does not comply with an order made by the Board by the date or within the time specified in the order, the applicant may apply to a judge of the Superior Court of Justice for an order requiring the respondent to,​

• comply with the order of the Board within the time specified in the order of the court and,​

• take whatever other action the court considers appropriate in the circumstances. ​

EMERGENCY EXPOSURE STEPS​

If you experienced a needlestick or sharps injury or were exposed to the blood or other body fluid of a patient during the course of your work, immediately follow these steps:​

• Wash needlestick and cuts with soap and water​

• Flush splashes to the nose, mouth, or skin with water​

• Irrigate eyes with clean water, saline, or sterile irritants​

• Report the incident to your supervisor​

• Immediately seek medical treatment​

• Post Exposure Prophylactic screening​

REPORT TO EMPLOYER​

• Fill out an Incident Report ​

• Employer must report to WSIB if work lost, modified work at less pay, modified work at regular pay for more than 7 days.​

• If there is not a surveillance protocol, the employer must report to WSIB when exposed or suspected exposure to infectious disease.​

• Hospitals- surveillance protocols for needle stick injuries​

OTHER PATHOLOGIES SPREAD BY SHARPS​

• Blastomycosis​

• Brucellosis​

• Cryptococcosis ​

• Diphtheria ​

• Cutaneous gonorrhea ​

• Herpes ​

• Malaria ​

• Mycobacteriosis ​

• Mycoplasma caviae​

needles

• Don’t recap needles​

• Place in proper container​

• Hand hygiene​

• Cover wounds​

• Protect your head​

PRESUMPTIVE LEGISLATION​

accepts disease or disorder claims from a worker without the worker having to prove that the disease or disorder – be it physical or psychological – necessarily resulted from the job ​

​

PTSD​

PTSD arising out of course of employment​

• Dx by psychiatrist or psychologist​

• Employed in field​

Employer's work-related decisions or actions​

A first responder is not entitled to benefits for PTSD if it is shown that their PTSD was caused by their employer's decisions or actions that are part of the employment function, such as:​

• terminations​

• demotions​

• transfers​

• ​discipline​

• changes in working hours, or​

• changes in productivity expectations.​

However, first responders may be entitled to benefits for PTSD due to an employer's decisions or actions that are not part of the employment function, such as:​

• violence or threats of violence, or​

• conduct that a reasonable person would perceive as egregious or abusive.​

• ​

The Highway Traffic Act.​

Applies to the provisional use of both motorized/non-motorized commercial and non-commercial motor vehicles on the roads and highways of Ontario.​

​

• Must be adhered to at all times​

• Infringements are noted on the Paramedic’s driving record​

• Services have the right to investigate any employee’s driving record​

• Suspension of a driver’s license will result in the termination of full-time employment​

Demerit Points​

• Some services do license checks every 6 months​

• ​

• Six or more demerit points will prevent a person from being hired by an ambulance service​

• ​

• +15 demerit points=license suspension​

• ​

Emergency Vehicles 

• An emergency vehicle means an ambulance while responding to an emergency call or being used to transport a patient or injured person in an emergency situation.​

• …WHEN A SIREN IS SOUNDING CONTINUOUSLY AND FROM WHICH INTERMITTENT FLASHES OF RED LIGHTS ARE VISIBLE ​

Activation of Lights and Sirens. ​

• Lights and sirens should remain on continuously on emergency calls​

• Intermittent use leads to confusion of the other drivers​

• Sirens are not always audible, use emergency lights and headlights to alert other motorists ​

How to proceed with a Red light? (exemption) ​

• Full stop, ensure the way is clear​

• Red warning lights must be flashing and sirens must be operational​

• Correct turn signals must be used​

• Proceed when it is safe to do so!