chapter 3

Duty to Act & Standard of Care

• Motto: Don't do harm.
• Duty to act in good faith and within the standard of care (SOP).
• SOP: Standard Operating Procedure.
• Standard of care is established by:
  • Local customs
  • Laws, statutes, ordinances
  • Administration, regulation within the agency
  • Case law (previous lawsuits)
• Example of finding SOPs: Google "North Carolina protocols, EMS".

Consent

• Can be sued for assault if you touch someone who doesn't want to be touched.
• Obtain consent before rendering care.
• Consent is permission to render care.
• Be honest with patients.
• Patients able to answer questions appropriately can make decisions for their care.

Patient's Decision-Making Capability

• Must be able to answer questions appropriately to prove decision making capacity before refusing care.
  • Examples: How many quarters in a dollar? What year is it? Who's the president?
  • Determine if patient is alert and oriented.
• Must understand information and make informed choices regarding medical care.
• Identify person, place, time, and thing.

Patient Refusals

• Most litigated calls in EMS.
• Document extremely well.
• Determine if patient is intellectually capable or impaired.
  • Consider mental limitations or dementia.
  • Even patients with dementia can refuse if they have a moment of clarity.
  • UTIs can alter mental status.
• If altered, they cannot refuse.
• Under 18 cannot refuse unless emancipated.
  • Emancipation: having a child, being married, or serving in the armed forces (in North Carolina).
• Parents can refuse for minors (hard situations).
• If impaired by alcohol, drugs, or serious injury, they typically cannot refuse.
  • However, if they are impaired but can prove without a shadow of a doubt they understand the consequences of their decisions, there can be a gray area.
• The refusal conversation:
  • State: "You are welcome to refuse because you've answered all my questions appropriately. If you choose to do so, you are taking responsibility for your health, any potential worsening of it, that is up to and including death. Do you understand?"
• Document refusal conversations, especially with body cams when available; CYA (Cover Your Ass).
• Advocate for the patient.
• If ALS questions the need for their assistance, state: "It's what's best for the patient."

Language Barriers

• If there's a language barrier, call for an interpreter.
• Dispatch centers are required to keep interpreters on payroll 24/7.
• Determine if the patient understands what you're saying, asks rational questions, and understands why you're providing treatment.

Types of Consent

• Expressed Consent: Patient acknowledges they want treatment.
• Implied Consent:
  • Patients unable to make an informed decision when there is a threat to life or limb.
  • Applies to children and unconscious patients.
  • Example: Child choking and doing the universal sign for choking implies consent for you to perform the Heimlich maneuver.

Expressed Consent for a Child

• Doesn't just have to be parents.
• Can be legal guardians:
  • teachers
  • school nurses
  • family relatives
  • babysitters
• A babysitter can give or refuse permission to treat a child, but care can be ceased at any point.
• Example: Patients can agree to go to the hospital and then change their mind halfway there; you can't force them to go, but don't take them back home. Let them out, and document the situation thoroughly.
• In cases of split parental decisions, if there is no definitive consent, go with your gut and treat the child.

DNR

• DNR doesn't mean "do not treat"; it means "do not resuscitate."

Involuntary Consent

• Applies to mentally ill patients in behavioral crisis.
• EMS cannot involuntarily commit, but law enforcement can.
• If a patient states they will harm themselves or others, they are going to the hospital (with law enforcement assistance).
• Failure to act in this situation is a criminal felony.

Physical Restraints

• Restraining a patient is not ideal unless absolutely necessary.
• May need help of law enforcement or medical control (physician on duty at the hospital).
• Get specialized orders when possible.
• If forcible restraint is needed, push it off on someone who makes more money (paramedic or doctor order).
• Call the hospital to get the doctor's approval and authority to transport or refuse. The decisions are on medical control if you defer to them.
• Patients should be transported supine (on their back, face up), not prone (on their stomach, face down). Transporting prone can cause suffocation.
• Never remove restraints unless there is a life-threatening incident.

HIPAA and Professionalism

• HIPAA: Health Insurance Portability and Accountability Act.
• Keep patient information secret.
• HIPAA covers patient history, assessment findings, treatments, and anything that could disclose their identity.
• To disclose HIPAA:
  • Patient verbally tells you on the scene.
  • Legal subpoena for court.
  • Information needed for billing purposes (handled at an administrative level).
• Be careful with social media.
  • Do not post videos or information that could identify patients.
  • Agencies can terminate employment for social media posts involving agency logos, uniforms, or apparatuses.
• Be professional in all situations.

Freedom of Speech

• Freedom of speech does not protect first responders.
• You are held to a higher standard.

Advanced Directives

• Advanced directives identify the kind of treatment you're able to perform.
• Common forms:
  • DNR (Do Not Resuscitate)
  • POST (Physician Orders for Life-Sustaining Treatment)
  • MOST (Medical Orders for Life-Sustaining Treatment)
  • POA (Power of Attorney)
    • A spouse is the immediate power of attorney and can terminate the effects of any form.
  • The forms give you yes, no's to everything.
• A spouse is the immediate power of attorney, and they can terminate the effects of any form, and it applies to parents as well
• Exception to all forms: A spouse can terminate the effects of any form. A parent can also terminate it if its their child.
• Anoxic Brain Injury will happen after 4 -6 minutes.
• Brain damage is guaranteed at 10 minutes.

Medical ID insignias

• They could be a bracelet as shown with that kid, they could be a key chain, necklaces, cards in the wallet.
• Lately the necklaces and bracelets will be accompanied by a USB flash drive.
• One thing to note is that advanced directives will not be considered if it is not the original form. A tattoo for example will not be considered because it's not the legal document.

SOP and Lawsuits

• SOP outlines care you can provide per your medical director, defined by state law.
• Acting outside SOP is considered negligence and a criminal offense.
• Justify your actions for the betterment of the patient and you may be backed.
• Lawsuits need justification of proving negligence.
• Negligence: Failure to provide care that another provider with similar training would have performed.
• Res Ipsa Loquitur: Injuries/illness was directly your fault.
• Negligence Per Se: EMT knowingly acted in clear violation of SOP.
• Torts: Civil wrongs occurring.
• Gross Negligence: Willful or reckless disregard of patient's health and safety; hard to prove.
• To achieve negligence in North Carolina, all four instances must be proven: Duty, Breach of Duty, Damages, Causation.
• 
  Duty, Breach of Duty, Damages, Causation are needed to put you in court.

The definition of each:

• Duty: obligation to provide care,.

• Breach of Duty where an ENT does not act within the expected or reasonable standard of care.

• Damages: physically/psychological harm in some noticeable way.

• causation that they have to prove where the cause and effect relationship between the breach of duty and the damages suffered of the patient existed.

• Abandonment: Terminating care without consent or provision of future care.

• You can be sued, and they will win. Can happen at a scene. Or in the hospital.

• The EMS agents or the EMS paramedic transport the mothers and leave all the kids with an EMR; the DSS had to get involved, so now you have abandoned your four pediatric patients that will 100% result in is going to court, be careful with your actions and the people that you leave your patients with at the scene.

• Restraints: Unlawfully placing a person in fear of immediate bodily harm is considered assault.

• Batteries: Providing care without consent.

• Kidnapping: transporting patients against their will. (Seizing/confining by force)

• False Imprisonment if the patient is locked in the truck

• Defamation: communicating false information that damage the reputation of a person. (Libel-written, Slander-Spoken)

Protection

• Good Samaritan laws.
  • If you reasonably try to help another person with due regard and with proof that you were actually trying to better their situation, you are protected by good Samaritan laws, even if there are errors or omissions to the care.
• There has to be good faith without the expectation of getting paid. (You will lose your license if you accept payment from the call.)
• It has to be within your scope of practice and not a grossly non-negligent manner.
• Good measure of standard; in good faith, you are trying to help them and the SOP.
• Juror records: if it wasn't documented, it never happened.

Only job is for the person who is gonna review you their job is to make you look like the absolute idiot.

Reasons to BREAK HIPAA

If there is abuse, injury during the commission of a felony, drug-related injuries, childbirth, attempted suicides, dog bites, communicable diseases, assaults, DV situation, sexual assault/rape, exposure to infectious disease, transport of patients in restraints at the scene of the crime or the deceased

In any other situation you cannot communicate back with law enforcement

You will be expected to always be ethical and display moral presummation and bioethics. Bioethics is the philosophy of right and wrong. It is your moral duty and ideal professional behavior of an environment.