EMT-Block 2

Patient Consent

permission from patient to asses, treat, and transport

expressed consent

must be informed by patient

implied consent

assumed consent

used with unconscious patients

consent for children

minors are not permitted to provide consent for treatment

Possible exceptions for treating children without consent from parents

In loco parentis (acting on behalf of guardian; school nurse)

emancipated minors (allowed no matter what age)

life threatening injuries (reason to believe parent would consent)

consent for mentally incompetent adults

adults incapable of making informed decisions about care
state and local laws and protocol permit transport of such patients. under imp[lied consent

Involuntary transportation

patient is considered threat to self or others

court order needed

usually requires decision by mental health professional or police officer

if patient is restrained, must not risk legal liability

refusal of care

• patient may refuse care or transport

  • legally able to consent

  • mentally competent and oriented

  • fully informed of risks

  • sign release form

  • make sure patient knows all risks

If in doubt about refusal

discuss decision with patient

ensure patient understands risks

consult medical direction

ask to contact a family member

contact law enforcement

listen to patient to determine why refusing care

Advanced directives

• legal documents expressing patient’s wishes if patient unable to speak for self

  • Do no resuscitate order

  • living will

  • health care proxy

    • Power of attorney

• still take vitals and make sure they’re stable

• patient can revoke orders at any point

• these do not prevent EMT from providing comfort measures

Scope of practice

regulations and ethical considerations that define extent or limits of job duties

may include skills and procedures

determined by national, state, local laws, statues and protocols

what you can do

standard of care

care expected from EMT with similar training for patient in a similar situation

how you should do it

Scope of practice vs. standard of care

what you can do vs. how you should do it

Duty to act

obligation to provide care

while on duty, EMT obligated to provide care of no threat to safety

negligence

• something was not done or was done incorrectly

• Must prove:

  • EMT had duty to act

  • breach of duty- EMT failed to provide standard of care expected or failed to act

  • proximate causation- patient suffered harm because of EMT action or inaction

• Negligent EMT may be required to pay damages

Abandonment

Once care initiated, may not be discontinued until transferred to medical personnel of equal or greater training

Good Samaritan Laws

grant immunity from liability if person acts in good faith within level of training

rarely applies to on-duty personnel

may not cover EMTs in some situations

does not protect persons from gross negligence or violations of law

Confidentiality

Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA)

information on patient’s history, condition, treatment considered confidential

can be shared with other health care personnel as part of patient’s continuing care

organ donor

Person with completed legal document allowing donation of organs and tissues in event of death

may be identified by family members, donor card, driver’s license

receiving hospital and/or medical direction should be advised per protocol

Safe Haven Laws

allow person to drop an infant or child at any fire, police or EMS station

states have different guidelines for ages of children included

protect children who may otherwise be abandoned or harmed by parents unwilling or unable to care for them

Crime scenes

location where crime was committed or anywhere evidence may be found

once police have made scene safe, EMT’s priority is patient care

know what evidence is

take steps to preserve evidence

Examples of evidence

condition of scene

patient

fingerprints and footprints

microscopic evidence

Evidence preservation

remember what you touch

minimize impact on scene

work with police

if patient transported on your stretcher, stretcher sheet may be valuable source of evidence

document thoroughly

Mandatory reporting guidelines

child, elderly or domestic abuse

sexual assault

stab/gunshot wounds

animal attacks

Ethics

morals or standards governing actions

not always required by law

“golden rule” standard

very important in EMS

Communication systems

radios

one way pagers

cell phones

landlines

radio systems

base station

mobile radios

portbale radios

repeaters

radio communication

• Regulated by the Federal Communications Commissions (FCC)

  • assigns and licenses designated radio frequencies

  • prevents interference with emergency radio traffic

  • prohibits profanities and offensive language

Before you speak on radio

radio on and volume adjusted properly

reduce background noise

ensure frequency is clear before starting

lips 2-3 inches from microphone

Press PTT button on radio; wait 1 second before speaking

While on radio

use units names or numbers

call units attention first; wait for “go ahead”

unit may say “stand by” until ready

speak slowly and clearly

keep it brief

use plain English, avoid codes

avoid unnecessary words

While speaking on radio DO:

If number might be unclear, say number and repeat individual digits

use objective, impartial statements

use “we” instead of “I”

“affirmative” and “negative” preferred over “yes” and “no”

While speaking on radio DON’T

use patients name

use profanities or slander

give assessment information about patient; avoid offering diagnosis

use EMS frequencies for unauthorized communication

use slang or unauthorized abbreviations

Other radio procedues

If two units transmit simultaneously, only one will be heard

carry portable radio whenever you leave unit

hospotal notification

report given to the destination hospital so it can prepare fro arrival

hospital notificaton components

unit identification and level of provider

ETA

patients age and sex

chief complaint

brief history of present illness/ injury

mental status

baseline vital signs

pertinent findings of physical exam

emergency care gicen

response to medical care

medical direction of required

Medical command consult

• On line medical direction

• Possible resons:

  • medication administration

  • destination assistance

  • patient refusal

• Give info clearly and accurately

• after receive order/denial repeat back word for word

• if order is unclear, ask physician to repeat

• if order seems inappropriate, question physician

Verbal report

AKA bedside report

given upon arrival at destination

'introduce patient by name

give complete and detailed report

Elements of Detailed Verbal Report

chief complain

history of present illness/injury

assessment findings, including pertinent negatives

treatment given and response

complete vital signs

communication techniques

Use eye contact

be aware of position and body language

listen

use appropriate language

be honest

use patient’s proper name

always be compassionate and respectful

Prehospital care report (PCR)

written documentation of everything that happened during call

Functions of PCR

• Patient care report

  • assessment and treatment

  • conveys picture of scene entered into patient’s permanent medical record

• legal document

  • can be subpoenaed and used as evidence

  • may help patient win a case

  • may be used against you in case of negligence

• administrative

  • demographic information

  • insurance information

  • billing address

• education and research

  • clinical research

  • stats

  • continuing education

  • tracking EMT’s personal experience

• quality improvement

  • routine call review

  • ensures compliance to standards

  • can reveal providers deserving special recognition

  • can reveal opportunities for improvement

Elements of PCR

• run data

• agency name, date, times, call number, unit personnel, certification levels, other info mandated by service

• use official time given by dispatch

• Patient info

  • name, address, phone number

  • gender, age, DOB

  • weight

  • race/ethnicity

  • billing and insurance info

• info gathered during call

• general impression of patient

• narrative summary of call

• patient history and treatment as required by service

• transport info

Elements of narrative summary

Objective info

subjective info

Chief complain

pertinent negatives

plain english and approved abbreviations

legible; correct spelling and grammar

appropritate medical terminology

Objective information

observable, measurable, verifiable

Subjective information

subject to interpretation or opinion (often reported by patient)

Chief complain

primary complain, as stated by patient

best recorded as a direct quote

pertinent negatives

important negative findings

Refusals

high liability

document all details in a refusal of care form

falsification

covering up errors

recording something you forgot to do

correction of errors

mistakes in documentation

additions

Special situation reports

provider exposures

provider injuries

hazardous or unsafe scenes

referrals to social service agencies

reports of abuse

Dugs have at least 3 names

chemical name

generic name

brand (trade) name

What do we need to know about each medication?

indications

contraindications

side effects (nausea)

untoward effects/ adverse effects (something considered life threatening)

Off line medical direction

do not speak to physician

use standing orders

on line medical directiobn

speak directly to physician

listen to order; then repeat order back

ask for clarification of necessary

six rights

right patient

right medication

right dose

right time

right route

right documentation

TRAMP-ED

Time

route

amount

medication

patient

expired

documentation

Routes of adminitration

oral

sublingual

inhaled

intramuscular

intranasal

subcutaneous

intraosseous

endotracheal

intravenous

pharmacodynamics (PD)

study of effects of meds on the body

Pharmacokinetics (PK)

study of the absorption and elimination in the body

patient specific factors change how a medication is absorbed, works and eliminated

Administered vs assisted

• Administered- meds we carry on the ambulance that we can administer

  • asprin

  • oral glucose

  • activated charcoal

  • oxygen

  • narcan

  • epi pen

  • albuterol

• Assisted- patients own meds that we can administer

  • inhaler

  • nitroglycerin

  • epi pen

Asprin dose

Dose 4 baby asprin (324mg) or one adult (325 mg)

Asprin route

oral (chewable)

Asprin mechanism of action

prevents further aggregation of platelets

prevents clots from getting bigger

Asprin indications

cardiac nature chest pain/ discomfort

ability to safely swallow

Asprin contraindication

asthma, recent trauma, GI bleeding, use in children

inability to swallow

allergy

active bleeding

Asprin side effects

GI upset, N/V, heart burn

Asprin medical command needed?

no

Asprin notes

patients often already take 81 mg daily. Typically PA wants us to still give 4 chewable

Oral glucose dose

15 grams

1 single dose tube or 1/3 of triple dose tube

Oral glucose route

buccual

Oral glucose mechanism of action

increases blood sugar

Oral glucose indications

AMS with a history of DM, with suspected hypoglycemia

blood sugar less than 60 mg/dl

awake enough to swallow and protect airway

Oral glucose contraindication

unable to follow simple commands, unable to protect airway

Oral glucose side effects

possible hyperglycemia

Oral glucose medical command needed?

not needed

Oral glucose notes

make sure to protect patients airway, may be possible to give patient with severely altered mental status (AMS), decreased LOC, remember that hypoglycemia is a stroke mimic.

Oxygen dose

aim for SPO2% of 94-99% in cardiac and stroke patients

nasal cannula- 0-6lmp

non-rebreather- 15lpm

Oxygen route

inhalation

Oxygen mechanism of action

provides increased % of oxygen in inhaled air

Oxygen indications

any patient in respiratory distress or suspected shock

Oxygen contraindications

none for emergency use

Oxygen side effects

long term, non humidified use can cause dehydration or nose bleeds

Oxygen medical command

not needed

Activated charcoal dose

adults 25-50 grams

pedi 12.5-25 grams

Activated charcoal route

oral

Activated charcoal mechanism of action

binds to ingested particulate

not an antidote or reversal agent

prevents or reduces amount of poison absorbed by body

Activated charcoal indications

ingestion of poison/toxin with medical command order

Activated charcoal contraindication

unable to swallow, protect airway, or follow simple commands

ingestion of caustic substance

exposure to toxin/ poison via means other than ingestion

avoid with acidic or alkali substances

do not use with food poisoning

Activated charcoal side effcets

vomiting, black tar/stool a few days post administration

Activated charcoal medical command

need to contact medical command prior to administration

Activated charcoal notes

if vomiting occurs, must repeat dise once

vomiting is NOT the desired effect but a very frequence complication

Albuterol dose

Inhaler: 2 puffs (one dose)

Albuterol treatment: 2.5 mg

Albuterol route

oral

Albuterol mechanism of action

causes bronchodilation, allowing air to more easily pass through airway structures, B-2 antagonist

Albuterol indications

respiratory distress with signs of bronchoconstriction, wheezing

Albuterol contraindications

broncho-constriction not suspected cause of respiratory distress, people over age of 55

Albuterol side effects

increases HR, anxiety, shaking, nervousness

Albuterol medical command

Must call after first administration for any subsequent administrations

Albuterol notes

you do not need a full set of vitals or assessment

Albuterol treatment that is given in a nebulizer is an administered medication