EMT Basic Lecture Notes: Logistics, Medical-Legal, and Terminology

Course Logistics and Administrative Requirements

• Field Internship Document Handling

  • Students must obtain a signature for the Field Internship Document and upload it to the course system.
  • The document must be signed by a volunteer at the student's station who is either a preceptor, a chief, or a training officer.
  • Signing the document signifies that the individual is responsible for ensuring the student completes their required internship calls.
  • Students should use county-owned vehicles for transportation if they are on county insurance and approved through risk management to save on gas costs.

• Instructor Status and Classroom Conduct

  • The instructor is currently wearing a sling on her left arm due to an injury sustained in a "Firefighters Volleyball and Rescue" class approximately one month prior. The injury has not yet had surgery and causes visible pain (e.g., "bubbly faces") when moving.
  • Food Allergies: The instructor periodically brings treats for the class. Known student allergies include cranberries and nuts. A specific anecdote was shared regarding a student who ate walnut and rosemary cookies, leading to a tingly tongue and facial numbness.
  • Licorice: Defined by the instructor as "Satan's candy" and will not be brought to class.
  • Housekeeping: The facility (Emmitsburg) does not have trash service. Students are responsible for taking full trash cans to the dumpster at the end of every class. Failure to clean up will result in a ban on eating and drinking in the classroom.

• Scheduling and Deadlines

  • Classes: Held Monday, Tuesday, Wednesday, Thursday, and Friday nights, plus four Sundays.
  • End Date: The course must conclude by $August\,31$ because the next EMT class begins on $September\,1$.
  • Course Calendar: All assignments and due dates are populated in the Canvas course calendar.
  • Announcements: Deadlines and specific assignments will be communicated via the Canvas announcements function.
  • The 70% Rule: While some initial assignments require completion regardless of the score to avoid a counseling statement, the second due date requires a score of $70\%$ or better. Failure to meet this threshold leads to a counseling statement, a two-day extension, and potential barring from the module exam.
  • EMS Testing: Students should aim for $70\%$ or higher. The instructor notes that the 100-question actual module exams are drawn word-for-word from the pool of $500$ practice questions in EMS testing.

Medical, Legal, and Ethical Issues in EMS

• Legal Exposure and Standards of Care

  • Healthcare providers generally avoid legal exposure by acting in good faith (without expectation of payment) and following appropriate standards of care.
  • Maryland Protocols: These provide specific algorithms (e.g., cardiac arrest) but often contain "gray areas" for other conditions (e.g., trouble breathing). Providers must use "street smarts" and medical knowledge to transition through the algorithm when conditions worsen (Plan A through Plan Z).
  • Vanilla Ice Cream Metaphor: The classroom teaches "vanilla" (standard) procedures; the real world requires improvisation and "sprinkles" of extra knowledge.

• Confidentiality and HIPAA

  • HIPAA: Failure to abide by the Health Insurance Portability and Accountability Act can result in criminal litigation.
  • Fines: A first-time HIPAA violation carries a fine of $\$10,000$, which the individual (not the county) is responsible for paying.
  • Confidential Information: Includes patient history, assessment findings, and treatments provided.
  • Exemptions: Information can be disclosed if the patient signs a release, a legal subpoena is presented, or billing personnel require it.
  • Press Interaction: EMS providers do not talk to the press. Communications are handled by the Public Information Officer (PIO). The PIO for Frederick County is Sarah Campbell.

• Social Media and Professionalism

  • Providers should avoid posting agency logos, uniforms, or vehicles on social media. Many stations have policies against posting while in uniform or on property.
  • Consequences: Social media posts can notify family members of a death before official notification is made. The First Amendment does not protect a provider from the professional repercussions of the things they say or do (freedom of speech is not freedom from consequences).
  • Case Studies:
    • A nurse in Texas was fired and lost her license for posting about a child's measles diagnosis on an anti-vax blog.
    • A Missouri EMT was suspended for posting ATV crash photos on the internet featuring the victims.

• Consent and Refusal of Care

  • Consent: Permission to render care. Touching a patient without consent is considered battery.
  • Expressed Consent: The patient acknowledges and understands the explanation of care and gives verbal or non-verbal permission.
  • Implied Consent: Applies to patients who are unconscious, altered, or otherwise incapable of making an informed decision. It assumes the person would want care if they were lucid.
  • Involuntary Consent: Applies to patients who are mentally ill, in behavioral crisis, or developmentally delayed. Often involves a 72-hour police hold (Emergency Protection/EP).
  • Emancipated Minors: In Maryland, any female who is pregnant is considered an emancipated minor regardless of age. Providers cannot discuss her health with her parents without her consent.
  • Refusals: These are highly litigated. To document a refusal, the provider must assess decision-making capacity, observe behavior, involve medical control, and obtain a witness signature (preferably not the partner; law enforcement or family is ideal).

• Forcible Restraint

  • Maryland protocol is very specific. Restraint is technically considered kidnapping unless a valid medical/safety reason exists.
  • Providers must use soft padded restraints (e.g., leather with cotton pads). Handcuffs can only be used by law enforcement; if a provider removes them, they may be liable for aiding and abetting an escape.

• Advanced Directives and DNRs

  • DNR Requirements: In Maryland, a DNR form must state the medical problem, have a signature from the patient/guardian, and a signature from a physician (e.g., PCP). Maryland DNRs do not expire.
  • POLST/MOLST: Physician Orders for Life Sustaining Treatment and Medical Orders for Life Sustaining Treatment describe specific interventions (e.g., no intubation but ok to start IV).

• Signs of Death

  • Presumptive Signs: Unresponsive to deep stimuli, lack of carotid pulse (must be confirmed with a LifePak monitor), absence of breath sounds, fixed pupils, no systolic blood pressure, profound cyanosis, and decreased body temperature.
  • Definitive Signs:
    • Decapitation.
    • Dependent Lividity: Blood settling/pooling in the lower parts of the body, appearing dark purple or black.
    • Rigor Mortis: Stiffening of the body occurring $2$ to $12$ hours after death. It moves "head to toe" and breaks in the reverse order.
    • Putrefaction/Decomposition: Generally occurs between $40$ and $96$ hours, accelerated by heat and humidity.

• Duty to Act and Negligence

  • Duty to Act: The responsibility to provide care once an assessment has started or while on duty.
  • Negligence Elements:
    1. Duty to act.
    2. Breach of duty.
    3. Damages (physical or psychological injury).
    4. Proximate Cause (the breach caused the damage).
  • Res Ipsa Loquitur: The injury occurred under the EMT's control and wouldn't happen without negligence.
  • Abandonment: Leaving a patient without a proper handoff signature from someone of equal or higher training at the hospital.

• Defamation

  • Libel: False information in written form.
  • Slander: False information spoken aloud.

• Good Samaritan Laws and Immunity

  • Protects those acting in good faith and within their training.
  • Federal Volunteer Protection Act ($1997$): Specifically protects volunteers acting through nonprofit ($501(c)(3)$) organizations, though it does not cover gross negligence or criminal misconduct.

Medical Terminology

• Language Structure

  • Medical terms are based in Latin and follow a structure of prefix, root word, and suffix.
  • Prefix: Found at the beginning; indicates location, number, color, or intensity (e.g., "Hyper-" means excessive; "Epi-" means above; "Uni-" means one).
  • Root Word: The essential meaning, usually a body part ($Cardio = heart$, $Nephro = kidney$, $Pneumo = lung$).
  • Suffix: Found at the end; indicates condition, disease, or procedure ($itis = inflammation$, $pathy = disease$, $osis = condition$).
  • Combining Vowel: Usually "o," used to connect parts and ease pronunciation (e.g., Cardio + pulmonary \n= Cardiopulmonary).

• Pluralization Rules

  • $A \rightarrow AE$ ($\text{Vertebra} \rightarrow \text{Vertebrae}$).
  • $IS \rightarrow ES$ ($\text{Diagnosis} \rightarrow \text{Diagnoses}$).
  • $EX/IX \rightarrow ICE$ ($\text{Apex} \rightarrow \text{Apices}$).
  • $ON \rightarrow A$ ($\text{Ganglion} \rightarrow \text{Ganglia}$).
  • $US \rightarrow I$ ($\text{Bronchus} \rightarrow \text{Bronchi}$).

• Directional Terms and Movement

  • Anatomical Position: Standing, feet shoulder-width apart, palms facing forward.
  • Medial/Lateral: Medial is toward the midline; Lateral is away from the midline.
  • Proximal/Distal: Proximal is closer to the point of attachment/origin; Distal is further away (e.g., the wrist is distal to the elbow).
  • Superior/Inferior: Superior is toward the head; Inferior is toward the feet.
  • Anterior (Ventral): The front surface.
  • Posterior (Dorsal): The back surface.
  • Apex: The tip of a structure ($\text{Apex of heart}$ is at the bottom; $\text{Apexes of lungs}$ are at the top).
  • Abduction: Movement away from the midline.
  • Adduction: Movement toward the midline.

• Patient Positioning

  • Supine: Face up on the back.
  • Prone: Face down on the stomach.
  • Fowler's Position: Semi-reclining at $45^{\circ}$ to $60^{\circ}$.
  • Semi-Fowler's: $45^{\circ}$ angle.
  • High Fowler's: $90^{\circ}$ angle (used for patients with breathing trouble).

• Common Abbreviations

  • $BP$: Blood Pressure.
  • $HR$: Heart Rate.
  • $RR$: Respiratory Rate.
  • $SpO_2$: Oxygen Saturation.
  • $L/R$ (with a circle): Left and Right.
  • $\uparrow/\downarrow$: Increase and Decrease.
  • $\Delta$: Change.

Questions & Discussion

• Question: Can I get more clarification on the field internship document?

  • Response: It needs to be signed by a volunteer officer (chief, training officer, or preceptor) at your station who takes responsibility for your internship requirements.

• Question: Is there any help getting in contact with the station for assessments?

  • Response: Talk to your training officer (Josh) or mentor (Carolyn Bieber). Check the "watch office" for a list of people authorized to ride.

• Question: What about food allergies?

  • Response: Only cranberries were noted. Licorice is banned. Avoid nuts (specifically walnuts) to prevent reactions like tingly tongues.

• Question: Can the physician on a DNR be a PCP?

  • Response: Yes, it can be a personal care physician or family doctor.

• Question: When dependent lividity is present, do they start to stink?

  • Response: No, the smell of decomposition (putrefaction) depends on conditions and time lapse (40-96 hours), not just lividity.

• Question: At what point do you document vital signs?

  • Response: You should document them during care. Use computer systems or the Maryland "short form" when back at the station.