EMS AND LEGAL IMPLICATIONS PSYCHIATRIC SITUATIONS EBOLA October 2014 CE Condell Medical Center EMS...

EMS AND EMS AND LEGAL IMPLICATIONS LEGAL IMPLICATIONS

PSYCHIATRIC SITUATIONSPSYCHIATRIC SITUATIONSEBOLAEBOLA

October 2014 CEOctober 2014 CE

Condell Medical Center EMS SystemCondell Medical Center EMS System

Site Code #107200E-1214Site Code #107200E-1214

Prepared by: Sharon Hopkins, RN, EMT-P, BSNPrepared by: Sharon Hopkins, RN, EMT-P, BSN

Revised 10.30.14Revised 10.30.141

OBJECTIVESOBJECTIVES

Upon successful completion of this module, the EMS Upon successful completion of this module, the EMS provider will be able to:provider will be able to:

1. Review scene safety as the first step in every call.1. Review scene safety as the first step in every call.2. Define Munchausen by proxy syndrome, anorexia, bulimia 2. Define Munchausen by proxy syndrome, anorexia, bulimia 3. Describe situations when it is appropriate to obtain consent for medical care 3. Describe situations when it is appropriate to obtain consent for medical care from emancipated minors versus pregnant minor versus minor parent from emancipated minors versus pregnant minor versus minor parent 4. Describe characteristics and EMS interventions for a variety of behavioral 4. Describe characteristics and EMS interventions for a variety of behavioral emergencies.emergencies.5. Describe the difference between voluntary and involuntary committal and 5. Describe the difference between voluntary and involuntary committal and EMS responsibilities.EMS responsibilities. 2

OBJECTIVES CONT’DOBJECTIVES CONT’D

6. Describe the assessment and care of the patient that has been Tasered.6. Describe the assessment and care of the patient that has been Tasered.

77. Describe the restraining of a patient via physical and chemical . Describe the restraining of a patient via physical and chemical

methods.methods.

8. Describe documentation of the patient that has been physically 8. Describe documentation of the patient that has been physically

restrained.restrained.

9. Review a variety of advanced directives.9. Review a variety of advanced directives.

10. Describe the State of Illinois revised POLST form and 10. Describe the State of Illinois revised POLST form and implications for implications for

EMS.EMS.3

OBJECTIVES CONT’DOBJECTIVES CONT’D

11. Describe the implications of the Ebola virus and EMS care of the patient11. Describe the implications of the Ebola virus and EMS care of the patient

12. Actively participate in case scenario discussion.12. Actively participate in case scenario discussion.

13. Actively participate in review of selected Region X SOP’s.13. Actively participate in review of selected Region X SOP’s.

14. Actively participate in review of a variety of EKG rhythms and 12 lead 14. Actively participate in review of a variety of EKG rhythms and 12 lead

EKG’s.EKG’s.

15. Successfully complete the post quiz with a score of 80% or better.15. Successfully complete the post quiz with a score of 80% or better.

4

SCENE SAFETYSCENE SAFETY

• First step in any patient approachFirst step in any patient approach

• You do everything possible to make the environment safeYou do everything possible to make the environment safe• For yourselfFor yourself

• For your crewFor your crew

• For other responding personnelFor other responding personnel

• For the patientFor the patient

• For others aroundFor others around

5


• Establish a safe perimeterEstablish a safe perimeter

• Evaluate the safety of the environmentEvaluate the safety of the environment

• Call for help as necessaryCall for help as necessary

• If you need to stage, document If you need to stage, document • The reason for stagingThe reason for staging

• Interventions taken to make the environment safeInterventions taken to make the environment safe

• When you made patient contactWhen you made patient contact

6


• Never let your guard downNever let your guard down

• Use those eyes in the back of your headUse those eyes in the back of your head

• If it doesn’t feel right, do not enterIf it doesn’t feel right, do not enter

• Keep yourself closest to the means of exitKeep yourself closest to the means of exit

• Never let yourself be cut off from egressNever let yourself be cut off from egress

7

MUNCHAUSEN SYNDROMEMUNCHAUSEN SYNDROME

• A mental disorderA mental disorder

• Sufferer causes or pretends to have physical or Sufferer causes or pretends to have physical or

psychological symptomspsychological symptoms

• Typical patient is an adult 20-40 years oldTypical patient is an adult 20-40 years old

• Thought to be motivated by a desire to be seen as ill Thought to be motivated by a desire to be seen as ill

versus other benefitversus other benefit

8

MUNCHAUSEN SYNDROME BY PROXYMUNCHAUSEN SYNDROME BY PROXY

• Considered a mental illness of factitious disordersConsidered a mental illness of factitious disorders

• Considered a relatively rare form of child abuse Considered a relatively rare form of child abuse

• Caretaker fakes or causes symptoms in a childCaretaker fakes or causes symptoms in a child

• Often caretaker has familiarity with medical knowledgeOften caretaker has familiarity with medical knowledge

• Affected persons usually under 4 years oldAffected persons usually under 4 years old

• Most of the time the mothers are the perpetratorsMost of the time the mothers are the perpetrators

• Often more than one child victimized per householdOften more than one child victimized per household 9

EMS ROLE IN MUNCHAUSEN’SEMS ROLE IN MUNCHAUSEN’S

• Be objective in documentationBe objective in documentation

• Site source of information provided (“_____ states…”)Site source of information provided (“_____ states…”)

• May take years to prove the presence of this mental May take years to prove the presence of this mental illnessillness

so EMS may not have knowledge of this diagnosisso EMS may not have knowledge of this diagnosis

• Caregiver must admit to the abuse and be willing to seek Caregiver must admit to the abuse and be willing to seek psychological treatmentpsychological treatment

• Psychological and physical damage to victim could lead Psychological and physical damage to victim could lead to poor long-term prognosis to poor long-term prognosis

10

ANOREXIAANOREXIA

• An eating disorder that is a real, treatable medical illnessAn eating disorder that is a real, treatable medical illness

• Has distorted body image of self; typically femaleHas distorted body image of self; typically female

• An intense fear of gaining weightAn intense fear of gaining weight

• Thinks about food a lot but limits intakeThinks about food a lot but limits intake

• Uses starvation to feel more in control of lifeUses starvation to feel more in control of life

• Uses starvation to ease tension, anger, anxietyUses starvation to ease tension, anger, anxiety

11

FACE OF ANOREXIAFACE OF ANOREXIA

12

ANOREXIAANOREXIA

• Body slows down due to lack of source of energy to Body slows down due to lack of source of energy to

continue to functioncontinue to function

• Patient suffers impairmentsPatient suffers impairmentsBrain functionBrain function

InfertilityInfertility

Dental decayDental decay

Kidney failureKidney failure

Cardiac arrestCardiac arrest 13

BULIMIABULIMIA

• Serious, potentially life-threatening eating disorderSerious, potentially life-threatening eating disorder

• Preoccupied with body shape and weightPreoccupied with body shape and weight

• Patients usually secretly binge and purgePatients usually secretly binge and purge• Binge – eat large amounts of foodBinge – eat large amounts of food

• Purge – self-induce vomiting or misuse laxatives, Purge – self-induce vomiting or misuse laxatives, diuretics or enemas after binging or fast, follows a strict diuretics or enemas after binging or fast, follows a strict diet or participates in excessive exercisediet or participates in excessive exercise

14

BULIMIABULIMIA

• Serious and life-threatening complicationsSerious and life-threatening complicationsDehydrationDehydration

Heart problemsHeart problems

Severe tooth decay and gum diseaseSevere tooth decay and gum disease

Absence of periods in femalesAbsence of periods in females

Digestive problems; possible dependence on laxativesDigestive problems; possible dependence on laxatives

Anxiety and depressionAnxiety and depression

Drug and alcohol abuseDrug and alcohol abuse 15

CYCLE OF BULIMIACYCLE OF BULIMIA

16

COMPLICATIONS OF EATING DISORDERSCOMPLICATIONS OF EATING DISORDERS

• Self-induced vomitingSelf-induced vomiting – oral complications – oral complications

• Erosion of tooth enamel from exposure to gastric acidErosion of tooth enamel from exposure to gastric acid

• Sensitivity to hot/cold foodsSensitivity to hot/cold foods

• Oral swelling or sorenessOral swelling or soreness

• GI tract complications especially with bulimiaGI tract complications especially with bulimia• Ulcers, ruptures, strictures of esophagus from repeated Ulcers, ruptures, strictures of esophagus from repeated

vomitingvomiting

17

COMPLICATIONS CONT’DCOMPLICATIONS CONT’D

• Infertility due to lack of periodsInfertility due to lack of periods

• Continual use of laxatives – colon function problemsContinual use of laxatives – colon function problems

• Loss of normal functionLoss of normal function

• Electrolyte imbalance with misuse of diuretics and laxativesElectrolyte imbalance with misuse of diuretics and laxatives

• Fetal harmFetal harm

• Low birth weight, premature labor, post-partum depressionLow birth weight, premature labor, post-partum depression

18

THE DESTRUCTION FROM ANOREXIATHE DESTRUCTION FROM ANOREXIA

• Body and muscles are being starvedBody and muscles are being starved

• Heart muscle atrophies; high risk for heart failureHeart muscle atrophies; high risk for heart failure

• Drop in sodium, zinc, potassium and calcium put the patient at Drop in sodium, zinc, potassium and calcium put the patient at

increased risk for abnormal heart rhythms (SVT, VT, increased risk for abnormal heart rhythms (SVT, VT,

bradycardia)bradycardia)

• Kidney failure can develop due to dehydrationKidney failure can develop due to dehydration

• Sudden cardiac death often due to dysrhythmias due to Sudden cardiac death often due to dysrhythmias due to

electrolyte imbalance and mineral disturbanceelectrolyte imbalance and mineral disturbance

• Common presentations: orthostatic hypotension, shock, CHF, Common presentations: orthostatic hypotension, shock, CHF,

sudden deathsudden death

19

TREATMENT FOR EATING DISORDERSTREATMENT FOR EATING DISORDERS

• Counseling is a must for psychotherapyCounseling is a must for psychotherapy

• Antidepressants may helpAntidepressants may help

• Work with a nutritionist for an eating planWork with a nutritionist for an eating plan

• Hospitalization may be necessaryHospitalization may be necessary

• Slightly higher recovery rate and better long-term Slightly higher recovery rate and better long-term

prognosis for bulimia than anorexiaprognosis for bulimia than anorexia20

IMPLICATIONS FOR EMS IMPLICATIONS FOR EMS

• Maintain heightened awareness for the situationMaintain heightened awareness for the situation

• Overall low body weightOverall low body weight

• Poor dentitionPoor dentition

• From repeated vomiting and poor nutritional stateFrom repeated vomiting and poor nutritional state

• Incomplete/inaccurate history provided by patientIncomplete/inaccurate history provided by patient

• Denial of any problems by patientDenial of any problems by patient

• Note: Cardiac monitoring essential due to potential for electrolyte Note: Cardiac monitoring essential due to potential for electrolyte

imbalance and resulting cardiac dysrhythmiasimbalance and resulting cardiac dysrhythmias

21

DEFINITIONSDEFINITIONS

• Emancipated minor – minor of any age who is or has been Emancipated minor – minor of any age who is or has been married or minor over 16 and under 18 who by court order married or minor over 16 and under 18 who by court order has been freed from care, custody, and control of parentshas been freed from care, custody, and control of parents

• Did you know - Emancipation does NOT extend to specific Did you know - Emancipation does NOT extend to specific constitutional and statutory age requirements regarding constitutional and statutory age requirements regarding voting, use of alcoholic beverages, possession of firearmsvoting, use of alcoholic beverages, possession of firearms

22

CONSENT FOR MEDICAL CARECONSENT FOR MEDICAL CARE

• May be obtained fromMay be obtained fromAny person 18 and olderAny person 18 and olderEmancipated minorEmancipated minorMinor who is marriedMinor who is marriedMinor who is pregnantMinor who is pregnantMinor who is a parentMinor who is a parent

23

OBTAINING CONSENT FROM MINOROBTAINING CONSENT FROM MINOR

• Healthcare professionals shall not incur civil or criminal liability Healthcare professionals shall not incur civil or criminal liability

for failure to obtain valid consent when they relied in good faith for failure to obtain valid consent when they relied in good faith

on the representation made by the minoron the representation made by the minor

• This means you can take consent at face value when the This means you can take consent at face value when the

minor states they have the authority to provide consentminor states they have the authority to provide consent

They are emancipated from parental careThey are emancipated from parental care

They are or have been marriedThey are or have been married

They are pregnantThey are pregnant

They are a parent with custody of their childThey are a parent with custody of their child24

IMPLIED CONSENTIMPLIED CONSENT

• Emergency exception rule based on the assumption that a Emergency exception rule based on the assumption that a

reasonable person would consent to emergency care is able to do soreasonable person would consent to emergency care is able to do so

• Medical professional may presume consent and proceed with Medical professional may presume consent and proceed with

appropriate treatment:appropriate treatment:

• Child is suffering from emergent condition and life or health is in dangerChild is suffering from emergent condition and life or health is in danger

• Legal guardian unavailable or unable to provide consentLegal guardian unavailable or unable to provide consent

• Treatment or transport cannot be safely delayed waiting for consentTreatment or transport cannot be safely delayed waiting for consent

• Treatment rendered limited for emergent condition posing immediate Treatment rendered limited for emergent condition posing immediate

threat to child threat to child 25

EMS AND CONSENTEMS AND CONSENT

• Burden of proof falls on medical professional when treating minor Burden of proof falls on medical professional when treating minor

without proper consentwithout proper consent

• Need to justify and document that emergency actions were necessary Need to justify and document that emergency actions were necessary

to prevent imminent and significant harm to childto prevent imminent and significant harm to child

• Generally considered as emergent conditions includes treatment of Generally considered as emergent conditions includes treatment of

fractures, infections, pain controlfractures, infections, pain control

• Always act in best interest of patientAlways act in best interest of patient

• Clearly document nature of emergency and reason minor required Clearly document nature of emergency and reason minor required

immediate treatment and/or transportation and efforts made to immediate treatment and/or transportation and efforts made to

contact legal guardiancontact legal guardian 26

INFORMED CONSENT AND LANGUAGE INFORMED CONSENT AND LANGUAGE BARRIERBARRIER

• Interpretation can be performed in person, via Interpretation can be performed in person, via

videoconferencing or by telephonevideoconferencing or by telephone

• Certified medical interpreter preferredCertified medical interpreter preferred

• Using family members should be avoided unless absolutely Using family members should be avoided unless absolutely

necessarynecessary

• Translation may not be accurateTranslation may not be accurate

• Document use of interpreterDocument use of interpreter

27

IN LOCO PARENTISIN LOCO PARENTIS

• A Latin term meaning in place of or instead of the parentA Latin term meaning in place of or instead of the parent

• Relationship is similar to that of a parent and a child, but with Relationship is similar to that of a parent and a child, but with

limitationslimitations

• Original intent was for the care, supervision, and discipline of a Original intent was for the care, supervision, and discipline of a

childchild

• Parent, guardian, or person in loco parentis can Parent, guardian, or person in loco parentis can consentconsent to to

emergent medical treatmentemergent medical treatment

• Generally inferred most commonly onto teachers but also could Generally inferred most commonly onto teachers but also could

include babysitter include babysitter 28

CONSENT FROM A MINORCONSENT FROM A MINOR

• Emancipated minor by court orderEmancipated minor by court order

• Married minorMarried minor

• Pregnant minorPregnant minor

• Parent of a minor childParent of a minor child

• For treatment of a sexually transmitted disease (12 years or For treatment of a sexually transmitted disease (12 years or

older)older)

• For treatment of alcohol or substance abuse (12 years or older)For treatment of alcohol or substance abuse (12 years or older)

• For psychiatric admission and treatment (16 years or older)For psychiatric admission and treatment (16 years or older)

• For outpatient mental health treatment (12 years or older)For outpatient mental health treatment (12 years or older)

29

PUBLIC ASSUMPTIONSPUBLIC ASSUMPTIONS

• The paramedic is medically trained so they know what they The paramedic is medically trained so they know what they

are talking about; are talking about;

• ““if they say I don’t have to go to the hospital, then I’m okay”if they say I don’t have to go to the hospital, then I’m okay”

• Patients want to believe nothing is wrong so will easily be Patients want to believe nothing is wrong so will easily be

swayed that nothing is wrong and transport is not warrantedswayed that nothing is wrong and transport is not warranted

• This transport is going to be expensive; some paramedics This transport is going to be expensive; some paramedics

may capitalize on the patient’s financial fearsmay capitalize on the patient’s financial fears

• Do you want to be responsible for the one call you talked Do you want to be responsible for the one call you talked

down who had a bad outcome???down who had a bad outcome??? 30

CASE REPORT #1CASE REPORT #1

• EMS called for an adult patient with chest pain past few hoursEMS called for an adult patient with chest pain past few hours

• EKG showed sinus rhythmEKG showed sinus rhythm

• Vital signs were stableVital signs were stable

• Lung sounds were clearLung sounds were clear

• The patient was convinced by EMS it was acid refluxThe patient was convinced by EMS it was acid reflux

• A release was obtainedA release was obtained

How would you have handled this call?How would you have handled this call?31

OUTCOME CASE REPORT #1OUTCOME CASE REPORT #1

• Hopefully, you’ve done a cardiac work-up and transported Hopefully, you’ve done a cardiac work-up and transported this patientthis patient

• The responding paramedic’s general impression was that The responding paramedic’s general impression was that the patient had acid reflux, suggested antacids and left the the patient had acid reflux, suggested antacids and left the scene after the patient signed AMAscene after the patient signed AMA

• The patient took the antacidsThe patient took the antacids

• The patient died 3 hours after being evaluatedThe patient died 3 hours after being evaluated

32


• EMS was called for a 4 year-old child having an asthma attackEMS was called for a 4 year-old child having an asthma attack

• Bilateral wheezes auscultatedBilateral wheezes auscultated

• EMS convinced the mother the patient was only suffering from EMS convinced the mother the patient was only suffering from

croupcroup

• The mother was instructed to put the child in the bathroom and run The mother was instructed to put the child in the bathroom and run

the shower for the steamthe shower for the steam

• A release was obtainedA release was obtained

How would you have handled this call?How would you have handled this call?33

OUTCOME CASE REPORT #2OUTCOME CASE REPORT #2

• The mother followed instructions and placed the child The mother followed instructions and placed the child

in a steamy bathroomin a steamy bathroom

• The child “fell asleep”; “breathing wasn’t a struggle”The child “fell asleep”; “breathing wasn’t a struggle”

• The mother assumed her child was more relaxedThe mother assumed her child was more relaxed

• The child died from a severe asthma attackThe child died from a severe asthma attack

34


• EMS summoned by police to respond to a reported suicide EMS summoned by police to respond to a reported suicide attemptattempt

• Dispatch states they received a call from the patient's friend Dispatch states they received a call from the patient's friend who stated they were threatening to commit suicide by overdosewho stated they were threatening to commit suicide by overdose

• EMS assesses the patient who has stable vital signsEMS assesses the patient who has stable vital signs

• Patient states they were just venting to their friend and didn’t Patient states they were just venting to their friend and didn’t really take any pillsreally take any pills

• Pill bottles offered were checked and levels seemed appropriatePill bottles offered were checked and levels seemed appropriate

• EMS obtained a releaseEMS obtained a release

How would you have handled this call?How would you have handled this call? 35

OUTCOME CASE #3OUTCOME CASE #3

• Boy, this one is TOUGH!!!Boy, this one is TOUGH!!!

• This paramedic did not talk patient out of going to the This paramedic did not talk patient out of going to the

hospital but neither did they encourage her to gohospital but neither did they encourage her to go

• Patient was left at home alonePatient was left at home alone

• The patient was found dead the next morningThe patient was found dead the next morning

• Would you have involved Medical Control in dialogue???Would you have involved Medical Control in dialogue???

• Hopefully, yesHopefully, yes36

TALKING PEOPLE OUT OF TRANSPORTTALKING PEOPLE OUT OF TRANSPORT

• Which person are you:Which person are you:

• Every call you take is with the assumption that you will be Every call you take is with the assumption that you will be

transporting a patienttransporting a patient

OROR

• You work harder at convincing someone You work harder at convincing someone notnot to go to the hospital to go to the hospital

than to be transportedthan to be transported

• Accepting refusals increases the risk of contribution to a Accepting refusals increases the risk of contribution to a

preventable tragedypreventable tragedy

• There is a right way and wrong way to get a refusalThere is a right way and wrong way to get a refusal 37

RELEASES/REFUSALSRELEASES/REFUSALS

• Respond to each call assuming every one will be a transportRespond to each call assuming every one will be a transport

• Work harder at convincing them to be transported than accepting them Work harder at convincing them to be transported than accepting them

as a refusal/releaseas a refusal/release

• Patients are aware of your attitude – show yours as positivePatients are aware of your attitude – show yours as positive

• If someone called you, they usually are expecting transportIf someone called you, they usually are expecting transport

• So, just take themSo, just take them

• Of all calls, make these the most detailed and complete Of all calls, make these the most detailed and complete

documentationdocumentation

• Show what patient looked like when you arrived and then again when Show what patient looked like when you arrived and then again when

you leftyou left

• Contact Medical Control for all controversial or questionable Contact Medical Control for all controversial or questionable

releases/refusalsreleases/refusals

38

CHARACTERISTICS OF BEHAVIORAL CHARACTERISTICS OF BEHAVIORAL EMERGENCIESEMERGENCIES

• A call involving interaction with a patient whose behavior is A call involving interaction with a patient whose behavior is UnusualUnusualBizarreBizarreThreateningThreateningDangerousDangerous

• Behavior not generally accepted by society Behavior not generally accepted by society

• Requires intervention from medical personnelRequires intervention from medical personnel

39

OBJECTIVE INDICATIONS OF BEHAVIORAL OBJECTIVE INDICATIONS OF BEHAVIORAL ISSUEISSUE

• Actions or situations that:Actions or situations that:

• Interfere with activities of daily living (dressing, eating Interfere with activities of daily living (dressing, eating

sleeping, maintaining housing)sleeping, maintaining housing)

• Pose a threat to the life or well-being of the patient or Pose a threat to the life or well-being of the patient or

othersothers

• Significant deviation from society’s expectations or Significant deviation from society’s expectations or

normsnorms

40

AVOID TUNNEL VISIONAVOID TUNNEL VISION

• Always keep in mind medical conditions that may be Always keep in mind medical conditions that may be presenting as a behavioral issuepresenting as a behavioral issueDiabetesDiabetesTraumaTraumaBrain disorderBrain disorderMedication influenceMedication influenceRecreational drug useRecreational drug use

41

DELIRIUMDELIRIUM

• Relatively rapid, acute onset (hours to days)of widespread Relatively rapid, acute onset (hours to days)of widespread

disorganized thoughtdisorganized thought

• May be reversibleMay be reversible

• Patient has inattentivenessPatient has inattentiveness

• Memory impairmentMemory impairment

• DisorientationDisorientation

• Clouding of consciousnessClouding of consciousness42

DEMENTIADEMENTIA

• Irreversible process that develops slowly over monthsIrreversible process that develops slowly over months

• Consists of memory impairment and cognitive disturbanceConsists of memory impairment and cognitive disturbance

• Many common causesMany common causes• Alzheimer’s diseaseAlzheimer’s disease

• Vascular problemsVascular problems

• AIDSAIDS

• Head traumaHead trauma

• Parkinson’s diseaseParkinson’s disease

• Substance abuseSubstance abuse 43

SCHIZOPHRENIASCHIZOPHRENIA

• A significant change in behavior and loss of contact A significant change in behavior and loss of contact with realitywith reality

• Common signs, symptoms, typesCommon signs, symptoms, types• HallucinationsHallucinations

• DelusionsDelusions

• DepressionDepression

• Flat affectFlat affect

• ParanoidParanoid

• Disorganized behavior, dress, speechDisorganized behavior, dress, speech 44

EXCITED DELIRIUMEXCITED DELIRIUM

• Sudden onset of unexplained aggressive behaviorSudden onset of unexplained aggressive behavior

• Often accompanied by profuse sweating, high body temp, and Often accompanied by profuse sweating, high body temp, and

delusional behaviordelusional behavior

• Often linked to a history of chronic cocaine abuseOften linked to a history of chronic cocaine abuse

• Cocaine abuse contributed to development of coronary artery Cocaine abuse contributed to development of coronary artery

disease and damage to the heart muscledisease and damage to the heart muscle

• Aggressive chemical sedation requiredAggressive chemical sedation required

• Continued physical struggle increases catecholamine surge and Continued physical struggle increases catecholamine surge and

metabolic acidosismetabolic acidosis 45

CASCADE OF EVENTS OF EXCITED CASCADE OF EVENTS OF EXCITED DELIRIUMDELIRIUM

• Patient is agitatedPatient is agitated

• There is a struggle with the patientThere is a struggle with the patient

• Increased OIncreased O22 demand; if compromised airway cannot increase O demand; if compromised airway cannot increase O22 supply supply

• Energy stores (i.e.: glucose) are quickly depletedEnergy stores (i.e.: glucose) are quickly depleted

• There is an adrenalin overdose from the increased & aggressive activityThere is an adrenalin overdose from the increased & aggressive activity

• Excessive lactic acid created as a by-productExcessive lactic acid created as a by-product

• Heart is stressed from the exertion and adrenalin rushHeart is stressed from the exertion and adrenalin rush

• Respiratory muscles will begin to failRespiratory muscles will begin to fail 46

RHABDOMYOLYSIS – RHABDOMYOLYSIS – RESULTS FROM THE STRUGGLERESULTS FROM THE STRUGGLE

• Breakdown of myoglobin – a by-product in musclesBreakdown of myoglobin – a by-product in muscles

• Causes myoglobinemia – the protein myoglobin released Causes myoglobinemia – the protein myoglobin released into bloodinto blood

• Intramuscular acidosis developsIntramuscular acidosis develops

• Kidneys try to filter the dead muscle cells, eventually clog Kidneys try to filter the dead muscle cells, eventually clog and then begin to failand then begin to fail

• Patient presents with muscle weakness or flaccidityPatient presents with muscle weakness or flaccidity

• May present with nausea and vomitingMay present with nausea and vomiting• Vomiting increases the risk of aspirationVomiting increases the risk of aspiration 47

TREATMENT RHABDOMYOLYSISTREATMENT RHABDOMYOLYSIS

• Fluid hydrationFluid hydration• 200 ml increments; repeated as necessary200 ml increments; repeated as necessary

• Watch for fluid overloadWatch for fluid overload• Monitor breath soundsMonitor breath sounds

• Monitor cardiac rhythmMonitor cardiac rhythm• Watch for dysrhythmias induced by acidosis and electrolyte Watch for dysrhythmias induced by acidosis and electrolyte

imbalanceimbalance

48

Urine sample due to rhabdomyolysis

EMS APPROACH FOR COGNITIVE EMS APPROACH FOR COGNITIVE DISORDERSDISORDERS

• Patient suffers from significant impaired social or Patient suffers from significant impaired social or

occupational functioningoccupational functioning

• Approach in the field is supportiveApproach in the field is supportive

• Additionally assess and manage for medical conditionsAdditionally assess and manage for medical conditions

• Don’t get tunnel vision or distractedDon’t get tunnel vision or distracted

49

TYPES OF PSYCHIATRIC COMMITTALTYPES OF PSYCHIATRIC COMMITTAL

• Informal voluntary admissionInformal voluntary admission• Patient can terminate stay after 24Patient can terminate stay after 2400

• Formal voluntary admissionFormal voluntary admission• Patient signs self in and agrees to stay until MD discharges themPatient signs self in and agrees to stay until MD discharges them

• Patient has right to request discharge at any time Patient has right to request discharge at any time

• Involuntary admissionInvoluntary admission• Admitted against your will for a minimum of 72Admitted against your will for a minimum of 7200 and then must be and then must be

examined and keep or discharge patientexamined and keep or discharge patient

• If suicidal, homicidal, psychotic, unable to care for self, MD must If suicidal, homicidal, psychotic, unable to care for self, MD must arrange court hearing within 5 days for a judge to keep or discharge arrange court hearing within 5 days for a judge to keep or discharge patientpatient 50

INVOLUNTARY COMMITTAL LAWINVOLUNTARY COMMITTAL LAW

• Allows placement of any individual in treatment that because of Allows placement of any individual in treatment that because of

the nature of their illness, is unable to understand their need for the nature of their illness, is unable to understand their need for

treatment and who, if not treated, is at risk of suffering or treatment and who, if not treated, is at risk of suffering or

continuing to suffer mental deterioration or emotional continuing to suffer mental deterioration or emotional

deterioration, or both, to the point that the person is at risk of deterioration, or both, to the point that the person is at risk of

engaging in dangerous conductengaging in dangerous conduct

• Involuntary commitment can be made by family members, Involuntary commitment can be made by family members,

mental health professionals, and police officersmental health professionals, and police officers51

COMMITTAL PAPERWORKCOMMITTAL PAPERWORK

• ED practice is to transfer patients to psych facilities ED practice is to transfer patients to psych facilities withwith

involuntary paperwork completedinvoluntary paperwork completed

• This prevents the “voluntary “ patient from getting to the in-This prevents the “voluntary “ patient from getting to the in-

patient facility and then “changing their mind” about admissionpatient facility and then “changing their mind” about admission

• The person directly witnessing the behavior or hearing the The person directly witnessing the behavior or hearing the

comments must be involved in completing the documentationcomments must be involved in completing the documentation

• Hearsay is not valid or allowable in these situationsHearsay is not valid or allowable in these situations

• EMS will complete their own patient care run reportEMS will complete their own patient care run report

• Keep information objective and descriptiveKeep information objective and descriptive52

PETITION FOR INVOLUNTARY/JUDICIAL PETITION FOR INVOLUNTARY/JUDICIAL ADMISSIONADMISSION

• EMS to state in detail signs and symptoms of mental illness EMS to state in detail signs and symptoms of mental illness

displayeddisplayed

• Can include prior diagnosis, treatment and hospitalizationsCan include prior diagnosis, treatment and hospitalizations

• Describe any threats, behavior or pattern of behavior which Describe any threats, behavior or pattern of behavior which

support your complaintsupport your complaint

• Include personal observations that lead to your belief for Include personal observations that lead to your belief for

involuntary admissioninvoluntary admission

• Your address and phone number on commitment papers can be Your address and phone number on commitment papers can be

given as your work informationgiven as your work information53

TRANSPORTS OF PSYCH PATIENTSTRANSPORTS OF PSYCH PATIENTS

• When EMS does not witness the “psych” behaviorWhen EMS does not witness the “psych” behavior• These cases are VERY difficultThese cases are VERY difficult

• They sometimes come down to a “he said/she said” They sometimes come down to a “he said/she said”

strugglestruggle

• Always act in the best interest of the patientAlways act in the best interest of the patient

• Involve Medical Control for these unclear callsInvolve Medical Control for these unclear calls

54

CARE OF PATIENT TASEDCARE OF PATIENT TASED

• Evaluate depth of skin penetrationEvaluate depth of skin penetration

• DO NOT remove darts if patient is not under controlDO NOT remove darts if patient is not under control

• DO NOT remove darts but stabilize and transportDO NOT remove darts but stabilize and transport• Dart in lid/globe of eyeDart in lid/globe of eye

• Dart in face or neckDart in face or neck

• Dart in genitaliaDart in genitalia

• Dart in bony prominenceDart in bony prominence

• Dart in spinal columnDart in spinal column 55

REMOVAL OF DARTSREMOVAL OF DARTS

• Remove Taser cartridge from gun or cut wiresRemove Taser cartridge from gun or cut wires

• Place one hand on patient next to embedded dart to stabilize surrounding skinPlace one hand on patient next to embedded dart to stabilize surrounding skin

• Firmly grasp probe with other handFirmly grasp probe with other hand

• Remove dart by gently pulling straight outRemove dart by gently pulling straight out

• Assure dart is intact; take sharps precautionsAssure dart is intact; take sharps precautions

• Return darts to law enforcement or dispose of sharpsReturn darts to law enforcement or dispose of sharps

• Cleanse wound with salineCleanse wound with saline

• Cover with a dry dressing (i.e.: band aid)Cover with a dry dressing (i.e.: band aid)

56

RESTRAINTSRESTRAINTS

• High risk, low volume taskHigh risk, low volume task

• Use of restraints puts the provider and organization at Use of restraints puts the provider and organization at

risk legally AND in the court of public opinionrisk legally AND in the court of public opinion

• Remember:Remember:

• You are treating a patient, not a criminalYou are treating a patient, not a criminal

• Combative issues are symptom of the illness or injuryCombative issues are symptom of the illness or injury

57

PRINCIPLES OF USE OF RESTRAINTS PRINCIPLES OF USE OF RESTRAINTS

• Restraints used only after verbal de-escalation attemptedRestraints used only after verbal de-escalation attempted

• Situations exist where immediate use of restraints is requiredSituations exist where immediate use of restraints is required

• Restraints should be individualizedRestraints should be individualized

• Make reasonable attempts to protect patient’s privacy and Make reasonable attempts to protect patient’s privacy and

dignitydignity

• Method used should be least restrictive necessary for Method used should be least restrictive necessary for

protection of patient and othersprotection of patient and others

• Need to be trained in use and application and monitoring of Need to be trained in use and application and monitoring of

patientpatient

58

PRINCIPLES CONSIDERED WHEN USING PRINCIPLES CONSIDERED WHEN USING RESTRAINTSRESTRAINTS

• Medical and legal issuesMedical and legal issues

• Medical ethicsMedical ethics

• Scene safety and assessmentScene safety and assessment

• Patient assessmentPatient assessment

• Psychological causes of Psychological causes of

combative patientscombative patients

• Proper team patient-Proper team patient-

restraining techniquesrestraining techniques

• Knowledge of chemical-Knowledge of chemical-

restraint pharmacologyrestraint pharmacology

• Airway controlAirway control

• ReassessmentReassessment

• DocumentationDocumentation

59

CONSIDERATIONSCONSIDERATIONS

• Once a patient is restrained, providers must take full Once a patient is restrained, providers must take full

responsibility for the patient’s welfareresponsibility for the patient’s welfare• Frequent reassessment of airway and breathingFrequent reassessment of airway and breathing

• Frequent reassessment of distal movement, sensation, and Frequent reassessment of distal movement, sensation, and

circulation of extremitiescirculation of extremities

• The same standard of care that would have been The same standard of care that would have been

provided for the unrestrained patient would still need to provided for the unrestrained patient would still need to

be performedbe performed• Clear documentation is required if any expected care was Clear documentation is required if any expected care was

withheldwithheld

60

RESTRAINT DOCUMENTATIONRESTRAINT DOCUMENTATION

• Objective reasons for need of restraintsObjective reasons for need of restraints

• Detailed description of the situationDetailed description of the situation

• Alternatives attempted to avoid restraintsAlternatives attempted to avoid restraints

• i.e.: verbal de-escalationi.e.: verbal de-escalation

• Type of restraints appliedType of restraints applied

• Periodic assessment/reassessment of patientPeriodic assessment/reassessment of patient

• Include assessment of airway status and distal Include assessment of airway status and distal

circulation of restrained extremitiescirculation of restrained extremities61

ADVANCED DIRECTIVESADVANCED DIRECTIVES• Legal documentsLegal documents

• Spells out your wishes for end-of-life careSpells out your wishes for end-of-life care

• Several types/forms availableSeveral types/forms available

• Living will – describes care when dying or unconsciousLiving will – describes care when dying or unconscious• Cannot be honored by pre-hospital providersCannot be honored by pre-hospital providers

• Durable Power of Attorney for HealthcareDurable Power of Attorney for Healthcare• Allows patient to name health care proxyAllows patient to name health care proxy

• Proxy can speak up only when patient is unconscious or unable to Proxy can speak up only when patient is unconscious or unable to make medical decisionsmake medical decisions

62

POLSTPOLST

• PPhysician hysician OOrders for rders for LLife-ife-SSustaining ustaining TTreatmentreatment

• A signed medical order that travels with patientA signed medical order that travels with patient

• In Illinois, POLST is the revision of the IDPH Uniform DNR In Illinois, POLST is the revision of the IDPH Uniform DNR

Advanced DirectiveAdvanced Directive

• Allows patient to create medical orders reflecting Allows patient to create medical orders reflecting

treatment wishes at end-of-lifetreatment wishes at end-of-life

• Helps health professionals know and honor wishes of Helps health professionals know and honor wishes of

patientpatient

• Allows emergency personnel to facilitate patient wishesAllows emergency personnel to facilitate patient wishes 63

POLSTPOLST

• Does not take place of Power of Attorney for Healthcare formDoes not take place of Power of Attorney for Healthcare form• Used in addition to that formUsed in addition to that form

• Without a POLST or IDPH Uniform DNR Advanced Directive, Without a POLST or IDPH Uniform DNR Advanced Directive, EMS must do what they can to attempt to save a person’s EMS must do what they can to attempt to save a person’s lifelife

• EMS cannot accept the word of the family regarding what the EMS cannot accept the word of the family regarding what the wishes of the patient would have beenwishes of the patient would have been

• POLST photocopies are acceptablePOLST photocopies are acceptable

• 22ndnd page of POLST form does page of POLST form does notnot have to be completed; can have to be completed; can be left blankbe left blank

64

COMPLETING POLST FORMSCOMPLETING POLST FORMS

• Signed by patient or representative Signed by patient or representative

• As a physician order, signed by a physicianAs a physician order, signed by a physician

• Effective date is notedEffective date is noted

• Witness signature is obtainedWitness signature is obtained

• On page #1, section A, B, C, D, and/or E must be On page #1, section A, B, C, D, and/or E must be

completedcompleted65

FOLLOWING POLST/DNR GUIDELINESFOLLOWING POLST/DNR GUIDELINES

• Healthcare professional or healthcare provider may Healthcare professional or healthcare provider may

presume a DNR is validpresume a DNR is valid

• ……who in good faith complies with a DNR order is not who in good faith complies with a DNR order is not

subject to any criminal or civil liability except for willful or subject to any criminal or civil liability except for willful or

wanton misconduct and may not be found to have wanton misconduct and may not be found to have

committed an act of unprofessional conductcommitted an act of unprofessional conduct

• Subsection (d) of Section 65 HealthCare Surrogate Act, 755 ILCS Subsection (d) of Section 65 HealthCare Surrogate Act, 755 ILCS

40/6540/65

66

CASE SCENARIOSCASE SCENARIOS

• Review the following casesReview the following cases

• Prepare to discuss how YOU and your crew would Prepare to discuss how YOU and your crew would handle the situationhandle the situation

• Be prepared to support your decisionsBe prepared to support your decisions• Region X SOP’sRegion X SOP’s• Standard of CareStandard of Care• By what is just the right thing to doBy what is just the right thing to do

67

CASE #1CASE #1

• EMS called to the scene for a 32 year old female EMS called to the scene for a 32 year old female

with dizziness who passed out with dizziness who passed out

• Patient appears very thin, warm and palePatient appears very thin, warm and pale

• Is awake, answering all questions, cooperativeIs awake, answering all questions, cooperative

• Take this callTake this call

• Decide general impressionDecide general impression

• Determine choice of treatmentDetermine choice of treatment68

CASE #1 – WHAT’S THE RHYTHM???CASE #1 – WHAT’S THE RHYTHM???

• Sinus bradycardiaSinus bradycardia

• What would make you consider that the patient is What would make you consider that the patient is symptomatic, in need of intervention?symptomatic, in need of intervention?

• Decreased level of consciousness, blood pressure <90 systolicDecreased level of consciousness, blood pressure <90 systolic69

CASE #1CASE #1

• What is the treatment for unstable sinus bradycardia?What is the treatment for unstable sinus bradycardia?• Atropine 0.5 mg rapid IVP/IOAtropine 0.5 mg rapid IVP/IO

• Prepare for TCPPrepare for TCP

• If atropine is ineffective, administer sedation with Valium If atropine is ineffective, administer sedation with Valium

2mg IVP/IO over 2 minutes2mg IVP/IO over 2 minutes

• Begin TCPBegin TCP

• Rate 80/minute, sensitivity auto/demandRate 80/minute, sensitivity auto/demand

• Start mA at 0 and increase until capture is confirmedStart mA at 0 and increase until capture is confirmed70

CASE #1CASE #1

• What could be used for discomfort caused by use of the What could be used for discomfort caused by use of the

TCP?TCP?

• Valium 2 mg IVP/IO over 2 minutesValium 2 mg IVP/IO over 2 minutes

• This takes the edge off and relaxes patientThis takes the edge off and relaxes patient

• May repeat every 2 minutes as needed to a max of 10 mgMay repeat every 2 minutes as needed to a max of 10 mg

• What would be used for management of pain?What would be used for management of pain?

• Fentanyl 1 mcg/kg IVP/IO/INFentanyl 1 mcg/kg IVP/IO/IN

• May repeat same dose in 5 minutesMay repeat same dose in 5 minutes

• Max total is 200 mcgMax total is 200 mcg

71

CASE #1CASE #1

• Patient’s rhythm changes and patient loses consciousnessPatient’s rhythm changes and patient loses consciousness

• Now what is the rhythm?Now what is the rhythm?

• Polymorphic VT / Torsades de pointes Polymorphic VT / Torsades de pointes

• What determines which treatment to follow?What determines which treatment to follow?• If patient has a pulse or not; if patient is relatively stable or unstableIf patient has a pulse or not; if patient is relatively stable or unstable

72

CASE #1CASE #1

• Patient is pulseless and apneic with polymorphic VTPatient is pulseless and apneic with polymorphic VT

• What is the treatment plan now?What is the treatment plan now?• Immediate defibrillationImmediate defibrillation

• Followed by rapid initiation of CPR (30:2)Followed by rapid initiation of CPR (30:2)

• Establishment of IV accessEstablishment of IV access

• Epinephrine 1:10,000 1 mg IVP/IOEpinephrine 1:10,000 1 mg IVP/IO

• Repealed every 3-5 minutesRepealed every 3-5 minutes

• Amiodarone 300 mg IVP/IO 1Amiodarone 300 mg IVP/IO 1stst dose dose

• 150 mg for 2150 mg for 2ndnd dose dose

• Antidysrhythmic alternated with the vasopressor usedAntidysrhythmic alternated with the vasopressor used 73

CASE #1CASE #1

• If the patient with polymorphic VT had a pulse and was If the patient with polymorphic VT had a pulse and was

relatively stable (talking to you, had a palpable radial relatively stable (talking to you, had a palpable radial

pulse (therefore a B/P), what would you do?pulse (therefore a B/P), what would you do?• Amiodarone 150 mg Amiodarone 150 mg

• Diluted in 100 ml D5WDiluted in 100 ml D5W

• Administered IVPB over a minimum of 10 minutesAdministered IVPB over a minimum of 10 minutes

• If patient was unstable, what would you do?If patient was unstable, what would you do?

• Synchronized cardioversion with sedation if time to giveSynchronized cardioversion with sedation if time to give 74

CASE #1 – UNSTABLE VTCASE #1 – UNSTABLE VT

• Consider sedation Consider sedation

• Versed 2 mg IVP/IO every 2 minutes titrated to max of 10 mgVersed 2 mg IVP/IO every 2 minutes titrated to max of 10 mg

• Begin electrical therapyBegin electrical therapy

• Synchronized cardioversion 100 joulesSynchronized cardioversion 100 joules

• Antidysrhythmic medication to begin – to give time to be Antidysrhythmic medication to begin – to give time to be

effectiveeffective

• Amiodarone 150 mg diluted in 100 ml D5W IVPBAmiodarone 150 mg diluted in 100 ml D5W IVPB

• Run over at least 10 minutesRun over at least 10 minutes

• Watch for hypotension – slow rate down if occursWatch for hypotension – slow rate down if occurs

• Continue cardioversion attempts at 200 j, then 300 j, then 360 jContinue cardioversion attempts at 200 j, then 300 j, then 360 j

75

CASE #2CASE #2

• EMS is on the scene for a 72 year-old patient who “stopped EMS is on the scene for a 72 year-old patient who “stopped

breathing”breathing”

• Upon arrival family is present; patient last seen a few minutes Upon arrival family is present; patient last seen a few minutes

agoago

• Family states the patient has a DNRFamily states the patient has a DNR

• Patient confirmed 0-0-0Patient confirmed 0-0-0

• What would you do?What would you do?

• Ask to see the DNRAsk to see the DNR

• You need to begin CPR as you contact Medical ControlYou need to begin CPR as you contact Medical Control

76

CASE #2CASE #2

• What would you do if the family could not produce the DNR form?What would you do if the family could not produce the DNR form?

• You need to begin CPR and contact Medical Control for ordersYou need to begin CPR and contact Medical Control for orders

• What information would be important to provide to Medical What information would be important to provide to Medical

Control?Control?

• Circumstance of how patient foundCircumstance of how patient found

• Patient historyPatient history

• Family verbalizing that there is a DNR but unable to produceFamily verbalizing that there is a DNR but unable to produce

• Fact that CPR has been begunFact that CPR has been begun

• Initial rhythm on the monitorInitial rhythm on the monitor

• Be specific and request permission to withdraw CPR efforts if Be specific and request permission to withdraw CPR efforts if

that is your impressionthat is your impression

77

CASE #2 – WITHDRAWING CASE #2 – WITHDRAWING RESUSCITATIONRESUSCITATION

• Include in report to Medical ControlInclude in report to Medical Control• Patient is normothermicPatient is normothermic

• If arrest was witnessed or unwitnessedIf arrest was witnessed or unwitnessed

• How airway is secured and if IV access is establishedHow airway is secured and if IV access is established

• That rhythm remains asystoleThat rhythm remains asystole

• Any interventions performed up to that pointAny interventions performed up to that point

78

CASE #2CASE #2

• Documentation of withdrawing resuscitationDocumentation of withdrawing resuscitation• Note time of withdrawal of effortsNote time of withdrawal of efforts

• Document name of physician on run reportDocument name of physician on run report

• Document notification of coroner or Medical ExaminerDocument notification of coroner or Medical Examiner

• EMS does not need to remain at the scene if scene turned EMS does not need to remain at the scene if scene turned

over to policeover to police

• If leaving the body at the scene is a problem contact the If leaving the body at the scene is a problem contact the

hospital to inform of transport to get the patient off the hospital to inform of transport to get the patient off the

scenescene79

CASE #2CASE #2

• What if ordered to work the call???What if ordered to work the call???

• What is the rhythm?What is the rhythm?

• What do you do for asystole?What do you do for asystole?80

Asystole

CASE #2 - ASYSTOLECASE #2 - ASYSTOLE

• Lots of CPR; 10 second pauses every 2 minutes to Lots of CPR; 10 second pauses every 2 minutes to reevaluate the rhythmreevaluate the rhythm

• NO PULSE CHECKSNO PULSE CHECKS• Unless a rhythm is produced that should provide a pulse!Unless a rhythm is produced that should provide a pulse!

• Consider possible causes – the H’s and T’sConsider possible causes – the H’s and T’s

• 200 ml fluid challenge if breath sounds clear200 ml fluid challenge if breath sounds clear• Repeat as neededRepeat as needed

• A vasopressor is the only med interventionA vasopressor is the only med intervention• Epinephrine 1:10,000 – 1 mg IVP/IOEpinephrine 1:10,000 – 1 mg IVP/IO

• Every 3- 5 minutes for the durationEvery 3- 5 minutes for the duration 81

CASE #3CASE #3

• EMS responds to a bar for an injured patronEMS responds to a bar for an injured patron

• Patron tripped and fellPatron tripped and fell• Received laceration to palm; bleeding controlledReceived laceration to palm; bleeding controlled

• Admits to having 2 beersAdmits to having 2 beers

• Patron does not want your carePatron does not want your care

• Now what do you do???Now what do you do???

82

CASE #3CASE #3

• EMS needs to determine the decisional capacity of the patronEMS needs to determine the decisional capacity of the patron• Does the patient have the ability to understand and appreciate the Does the patient have the ability to understand and appreciate the

nature and consequences of refusing assessment and care?nature and consequences of refusing assessment and care?

• EMS assessment for decisional capacityEMS assessment for decisional capacity• Affect – behavior appropriate for the environment?Affect – behavior appropriate for the environment?

• Behavior –patient remains in control?Behavior –patient remains in control?

• Cognition / judgment – can patient understand the information?Cognition / judgment – can patient understand the information?

• Patient insight – does patient appreciate the implications of Patient insight – does patient appreciate the implications of

situation?situation?83

CASE #3 – THOROUGH DOCUMENTATIONCASE #3 – THOROUGH DOCUMENTATION

• Decisional capacityDecisional capacity

• Assessment performedAssessment performed

• Understanding of EMS impression and attempts by EMS to convince Understanding of EMS impression and attempts by EMS to convince

patient to accept treatment and/or transportationpatient to accept treatment and/or transportation

• Any EMS concerns about accepting a refusal risks and benefits Any EMS concerns about accepting a refusal risks and benefits

provided to the patientprovided to the patient

• Involvement of Medical ControlInvolvement of Medical Control

• Instructions to patient to seek medical care if condition changesInstructions to patient to seek medical care if condition changes

84

CASE #4CASE #4

• EMS is called to the scene of a MVC – category III trauma (non-I EMS is called to the scene of a MVC – category III trauma (non-I

and non-II category trauma)and non-II category trauma)

• You have a 17 year-old patient who is refusing transportationYou have a 17 year-old patient who is refusing transportation

• Your patient states she is 3 months pregnantYour patient states she is 3 months pregnant

• You have the 17 year-old boyfriend also refusing transportationYou have the 17 year-old boyfriend also refusing transportation

• Can these patients sign refusals?Can these patients sign refusals?

85

CASE #4CASE #4

• Who can sign a refusal in this scenario?Who can sign a refusal in this scenario?

• A pregnant minor can sign a refusalA pregnant minor can sign a refusal

• A parent who is a minor can grant permission for A parent who is a minor can grant permission for

themselves and their childthemselves and their child

• The boyfriend cannot sign a refusal until he becomes a The boyfriend cannot sign a refusal until he becomes a

parent with custody of his childparent with custody of his child

86

CASE #5CASE #5

• EMS is called for a 16 year-old female patient and her EMS is called for a 16 year-old female patient and her

4 month-old child 4 month-old child

• They were involved in a minor MVCThey were involved in a minor MVC

• The patient is refusing transportation for herself and her The patient is refusing transportation for herself and her

childchild

• How would you handle this call?How would you handle this call?

• A minor who is a parent with custody of their child has the A minor who is a parent with custody of their child has the

right to refuse medial care for themselves and their childright to refuse medial care for themselves and their child 87

CASE #6CASE #6

• EMS is called to the scene for a patient who is EMS is called to the scene for a patient who is

threatening to hurt themselvesthreatening to hurt themselves

• The threats were witnessed by family and police; not The threats were witnessed by family and police; not

by EMSby EMS

• What would you do if the patient refuses transport?What would you do if the patient refuses transport?

• Can this patient refuse transport?Can this patient refuse transport?

88

CASE #6CASE #6

• This patient made threats witnessed by police and familyThis patient made threats witnessed by police and family

• Therefore, patient not allowed to sign a refusalTherefore, patient not allowed to sign a refusal

• EMS CANNOT be the one to complete an involuntary EMS CANNOT be the one to complete an involuntary petitionpetition

• Only those persons who have first hand knowledge as Only those persons who have first hand knowledge as witnesses can complete the involuntary documentation of witnesses can complete the involuntary documentation of the behaviorthe behavior

• The police or family would be involved in completing the The police or family would be involved in completing the form with hospital staffform with hospital staff

89

THE EBOLA VIRUSTHE EBOLA VIRUS

• Important to understand…Important to understand…

• Information is coming out on a daily basis and often Information is coming out on a daily basis and often multiple times per daymultiple times per day

• Information is coming from the CDC and IDPHInformation is coming from the CDC and IDPH

• As information is received at the EMS Resource As information is received at the EMS Resource Hospitals, it will be disseminated as soon as feasibleHospitals, it will be disseminated as soon as feasible

• The goal from the CMC EMS office is to date and time The goal from the CMC EMS office is to date and time each memo to help in determining most current memoeach memo to help in determining most current memo 90

GOALS OF DISSEMINATING INFORMATIONGOALS OF DISSEMINATING INFORMATION

• Educate/inform to increase detection of possible Educate/inform to increase detection of possible

Ebola casesEbola cases

• Protect healthcare workers and general publicProtect healthcare workers and general public

• Provide guidelines directing appropriate Provide guidelines directing appropriate

response for caring of patientsresponse for caring of patients

• Imperative to keep up to date with revised material Imperative to keep up to date with revised material 91

EBOLA VIRUS DISEASE/ EBOLA VIRUS DISEASE/ EBOLA HEMORRHAGIC FEVEREBOLA HEMORRHAGIC FEVER

• A rare, deadly disease caused by infection with the virus strainA rare, deadly disease caused by infection with the virus strain• 4 of 5 strains can cause disease in humans4 of 5 strains can cause disease in humans

• Virus found in several countries in West AfricaVirus found in several countries in West Africa

• First discovered in 1976First discovered in 1976

• Unknown who the natural host site is but most likely animal Unknown who the natural host site is but most likely animal borneborne

• Bats the most likely reservoirBats the most likely reservoir

• 2 – 21 day incubation period (average 8-10 days) after contact 2 – 21 day incubation period (average 8-10 days) after contact with Ebola patientwith Ebola patient

92

EBOLA TRANSMISSIONEBOLA TRANSMISSION

• Direct contact with broken skin or via mucous Direct contact with broken skin or via mucous membranes (eyes, nose, mouth) with contaminated blood membranes (eyes, nose, mouth) with contaminated blood or body fluidsor body fluids

• Ebola is NOT spread via casual contactEbola is NOT spread via casual contact

• Contact with contaminated objectsContact with contaminated objects

• Contact with infected animalsContact with infected animals

• NOT spread via air, water, or general foodNOT spread via air, water, or general food

• In Africa, could be spread after handling bushmeat or In Africa, could be spread after handling bushmeat or contact with infected batscontact with infected bats

93

STANDARD PRECAUTIONS FOR STANDARD PRECAUTIONS FOR EVERYEVERY CALLCALL

• Taking blood and body fluid precautionsTaking blood and body fluid precautions

• Reduces risk of transmission of bloodborne pathogensReduces risk of transmission of bloodborne pathogens

• Need to apply these principles to ALL patients you care forNeed to apply these principles to ALL patients you care for

• Appropriate PPE’s need to be available AND usedAppropriate PPE’s need to be available AND used

• The process of removing protective gear is just as important as The process of removing protective gear is just as important as

donning themdonning them

• Remember the simplest standard precaution which is often the Remember the simplest standard precaution which is often the

most neglected…most neglected…

• HANDWASHINGHANDWASHING94

EBOLA SCREENINGEBOLA SCREENINGSIGNS & SYMPTOMSSIGNS & SYMPTOMS

ANY OR ALL MAY BE PRESENTANY OR ALL MAY BE PRESENT

• Fever Fever

> 38.6 > 38.600C or 101.5C or 101.500FF

• Severe headacheSevere headache

• Muscle/joint painMuscle/joint pain

• Weakness/fatigueWeakness/fatigue

• DiarrheaDiarrhea

• VomitingVomiting

• Abdominal painAbdominal pain

• Hemorrhage – Hemorrhage –

bleeding or bruisingbleeding or bruising

• Lack of appetiteLack of appetite 95

EBOLA SCREENING QUESTIONSEBOLA SCREENING QUESTIONS

• After/while screening for signs and symptoms, inquire After/while screening for signs and symptoms, inquire

about travelabout travel

• West Africa (Guinea, Liberia, Sierra Leone, Senegal, West Africa (Guinea, Liberia, Sierra Leone, Senegal,

Nigeria, or other countries where Ebola transmission has Nigeria, or other countries where Ebola transmission has

been reported by WHObeen reported by WHO

• Travel would have been within past 21 days/3 weeks of Travel would have been within past 21 days/3 weeks of

symptom onsetsymptom onset

96

EBOLA QUESTIONS FOR EVERY PATIENT EBOLA QUESTIONS FOR EVERY PATIENT CALLCALL

• ED’s being requested and now EMS to specifically ED’s being requested and now EMS to specifically

document yes/no answers to the screening processdocument yes/no answers to the screening process

• Document yes/no to presence of any signs or symptomsDocument yes/no to presence of any signs or symptoms

• Document yes/no to travel history in past 3 weeks out of Document yes/no to travel history in past 3 weeks out of

the country by patient or close family membersthe country by patient or close family members

• Also question regarding the history of a coughAlso question regarding the history of a cough

• Remember, there are still other diseases we need to be Remember, there are still other diseases we need to be

vigilant about like TBvigilant about like TB 97

ISOLATION FOR SUSPECTED CASES OF ISOLATION FOR SUSPECTED CASES OF EBOLAEBOLA

• If patient has positive signs and symptoms AND travel If patient has positive signs and symptoms AND travel within past 21 days, then isolate patientwithin past 21 days, then isolate patient

• Standard precautionsStandard precautions• Performed for every patient contactPerformed for every patient contact

• Handwashing still very importantHandwashing still very important

• Contact isolation – fluid impermeable gown and glovesContact isolation – fluid impermeable gown and gloves• Add shoe covers in certain situationsAdd shoe covers in certain situations

• Eye and face masks/shieldsEye and face masks/shields 98

ISOLATION CONT’DISOLATION CONT’D

• Droplet precautionsDroplet precautions• Particles are heavy and do not stay suspended in air for Particles are heavy and do not stay suspended in air for

longlong

• Transmission via talking, coughing, sneezingTransmission via talking, coughing, sneezing

• 6 feet is safer distance than 3 feet6 feet is safer distance than 3 feet

• In general droplet precautions, can wear surgical mask if In general droplet precautions, can wear surgical mask if within 6 feet of patient within 6 feet of patient

• If Ebola virus suspected, must wear N95 mask If Ebola virus suspected, must wear N95 mask • Not just if providing aerosol-generating proceduresNot just if providing aerosol-generating procedures

• Nebulizer treatmentsNebulizer treatments

• Suctioning, intubationSuctioning, intubation99

HAND HYGIENEHAND HYGIENE

• Remains extremely importantRemains extremely important

• If hands not visibly soiled, can use 60-95% alcohol If hands not visibly soiled, can use 60-95% alcohol based hand sanitizerbased hand sanitizer

• Use soap and water for 15 secondsUse soap and water for 15 seconds• When hands visibly soiledWhen hands visibly soiled

Did you remember hand washing over hand sanitizer for:Did you remember hand washing over hand sanitizer for:For contact with clostridium (infection in colon)For contact with clostridium (infection in colon)For contact with norovirus (inflammation of stomach For contact with norovirus (inflammation of stomach

&/or intestines)&/or intestines)100

TREATMENT OF EBOLATREATMENT OF EBOLA

• No approved specific treatments currently availableNo approved specific treatments currently available

• Clinical management focused on supportive care of Clinical management focused on supportive care of

complicationscomplicationsHypovolemiaHypovolemia

Electrolyte abnormalityElectrolyte abnormality

Bleeding disorders and hemorrhageBleeding disorders and hemorrhage

ShockShock

HypoxiaHypoxia

Multi-organ failureMulti-organ failure

DICDIC101

CLEANING EQUIPMENTCLEANING EQUIPMENT

• Need to reinforce cleaning procedures that should be Need to reinforce cleaning procedures that should be

carried out following the care and transport of each and carried out following the care and transport of each and

every patientevery patient

• For possible Ebola infection, use bleach and Cavicide For possible Ebola infection, use bleach and Cavicide

wipeswipes

• Reminder: bleach based product required for use Reminder: bleach based product required for use

following care of patient with diarrheafollowing care of patient with diarrhea102

DISCUSSION OF PPE PRODUCTSDISCUSSION OF PPE PRODUCTS

• At the Medical Officer meeting 10.14.14 discussed the minimum At the Medical Officer meeting 10.14.14 discussed the minimum

use for suspected Ebola patient:use for suspected Ebola patient:

• Gloves – double gloving recommendedGloves – double gloving recommended

• Face mask with eye shield or gogglesFace mask with eye shield or goggles

• Gown – impermeable especially in presence of body fluidsGown – impermeable especially in presence of body fluids

• Booties – especially in presence of body fluidsBooties – especially in presence of body fluids

• Linen contaminated with body fluids to be double bagged and Linen contaminated with body fluids to be double bagged and

remain with patient in their roomremain with patient in their room

• Hospital to make notification to the Health Department Hospital to make notification to the Health Department 103

BIBLIOGRAPHYBIBLIOGRAPHY

• Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th edition. Brady. 2013.Practices, 4th edition. Brady. 2013.

• Region X SOP’s; IDPH Approved April 10, 2014.Region X SOP’s; IDPH Approved April 10, 2014.

• Steingart, J. EMS…Caring. Article 2014Steingart, J. EMS…Caring. Article 2014

• http://thelegalguardian.com/resources/ems-case-law/http://thelegalguardian.com/resources/ems-case-law/

• http://www.idph.state.il.us/public/books/UniformDNRAdanceDirectives.pdfhttp://www.idph.state.il.us/public/books/UniformDNRAdanceDirectives.pdf

• http://www.mayoclinic.org/diseases-conditions/bulimia/basics/definition/CON-http://www.mayoclinic.org/diseases-conditions/bulimia/basics/definition/CON-20033050?p=120033050?p=1

• http://www.womenshealth.gov/publications/our-publications/fact-sheet/http://www.womenshealth.gov/publications/our-publications/fact-sheet/anorexia-nervosa.htmlanorexia-nervosa.html

104

BIBLIOGRAPHY CONT’DBIBLIOGRAPHY CONT’D

• http://kidshealth.org/parent/general/sick/munchausen.htmlhttp://kidshealth.org/parent/general/sick/munchausen.html

• http://www.jems.com/article/training/proper-restraint-technique-stahttp://www.jems.com/article/training/proper-restraint-technique-sta

• http://www.acep.org/Clinical---Practice-Management/Use-of-Patient-Restraints/http://www.acep.org/Clinical---Practice-Management/Use-of-Patient-Restraints/

• http://www.emsmdc.com/pdf/prehospital-restraint-final.pdfhttp://www.emsmdc.com/pdf/prehospital-restraint-final.pdf

• http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1539&ChapterID=35http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1539&ChapterID=35

• http://www.legis.state.il.us/http://www.legis.state.il.us/

• 410 ILCS 210/ - Consent by Minors to Medical Procedures Act410 ILCS 210/ - Consent by Minors to Medical Procedures Act

• http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/qa.htmlhttp://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/qa.html

• http://www.ilga.gov/legislation/ilcs/ilcs4.asp?DocName=040500050HChhttp://www.ilga.gov/legislation/ilcs/ilcs4.asp?DocName=040500050HCh

%2E+III&ActID=1496&ChapterID=34&SeqStart=7400000&SeqEnd=17800000%2E+III&ActID=1496&ChapterID=34&SeqStart=7400000&SeqEnd=17800000105

EMS AND LEGAL IMPLICATIONS PSYCHIATRIC SITUATIONS EBOLA October 2014 CE Condell Medical Center EMS...

Documents

Transcript of EMS AND LEGAL IMPLICATIONS PSYCHIATRIC SITUATIONS EBOLA October 2014 CE Condell Medical Center EMS...