Chapter 3

Recognize the importance of medical identification devices in treating the patient. (p 94)

Many patients will carry medical identification and information, often in the form of a bracelet, necklace, key chain, or card that identifies patient history information.This may include a DNR order or information related to medications taken, allergies, diabetes, epilepsy, or some other serious condition. Some patients wear medical bracelets with a USB flash drive.The information on the flash drive is often stored as a PDF file that can be read on most computers.

factors affecting consent

intellectual/substance/injury impairment legal adult? intense pain HOH/vision issues language barrier

Discuss the importance of do not resuscitate (DNR) orders and local protocols as they relate to the EMS environment. (pp 90-92)

A do not resuscitate (DNR) order is also known as a "do not attempt resuscitation" order. An advance directive is a written document that specifies medical treatment for a competent patient, should he or she become unable to make decisions.An advance directive is often referred to as a living will but may also be referred to as a health care directive. To be valid, DNR orders must meet the following requirements:Clear statement of the patient's medical problem(s)Signature of the patient or legal guardianSignature of one or more physicians or other licensed health care providers In some states, DNR orders contain an expiration date.DNR orders with expiration dates must be dated in the preceding 12 months to be valid. You may also encounter Physician Orders for Life- Sustaining Treatment (POLST) and Medical Orders for Life-Sustaining Treatment (MOLST) forms when caring for patients with terminal illnesses.These explicitly describe acceptable interventions for the patient in the form of medical orders.These forms must be signed by an authorized medical provider in order to be valid.This may be a physician, physician assistant, or nurse practitioner and varies by state. If you encounter these documents, contact medical control for guidance. Durable powers of attorney for health care or health care proxies give surrogates the right to make decisions for patients regarding their health care in the event that the patient is incapacitated and unable to make such decisions.Not all are authorized to exercise medical decision making. When presented with a power of attorney at the scene:Read it carefully to ascertain its meaning and validity.If there is any question, contact online medical control for assistance.Do not delay emergency care while efforts to interpret the power of attorney are made. A patient who is conscious and competent does not surrender the right to make medical decisions.The person named in the power of attorney or health care proxy is only authorized to make decisions when the patient is no longer capable of doing so. Specific guidelines vary from state to state, but the following statements may be considered general guidelines:Patients have the right to refuse treatment, including resuscitative efforts, provided that they are able to communicate their wishes.A written order from a physician is required for DNR orders to be valid in a health care facility.You should periodically review state and local protocols and legislation regarding advance directives.When you are in doubt or the written orders are not present, you have an obligation to resuscitate.

abandonment

Abandonment is the unilateral termination of care by the EMT without the patient's consent and without making any provisions for continuing care by a medical professional who is competent to provide care for the patient. Once care is started, you have assumed a duty that must not stop until an equally competent EMS provider assumes responsibility. Consider the following general questions when you are faced with making a decision such as this one:What problems may develop from your actions?How might the patient's condition worsen if you leave?Does the patient need care?Are you neglecting your duty to your patient?Is the person assuming care capable of providing the level of care needed by the patient?Are you abandoning the patient if you leave the scene?Are you violating a standard of care?Are you acting prudently? Part of your obligation as an EMT is to provide hospital personnel with a report of your assessment findings, the care you provided, and any changes in patient status that occurred during transport to the hospital.Failure to do so could result in a delay in treatment or a misdiagnosis.A claim for abandonment might be filed against the EMT who failed to provide the report.You should obtain a signature on your PCR from the person accepting transfer of care at the hospital. This will help protect you from accusations of abandonment. must provide report to licensed individual

Discuss the issues of negligence, abandonment, assault and battery, and kidnapping and their implications for the EMT. (pp 98-99)

Assault is unlawfully placing a person in fear of immediate bodily harm.Threatening to restrain a patient who does not want to be transported could be considered assault. Battery is unlawfully touching a person, including providing emergency care without consent. Assault and battery can be either civil or criminal in nature.Civil lawsuits for battery are common in health care. It is generally necessary to prove the intent to cause harm.The element of intent is rarely present in the case of an EMS provider, so criminal cases of assault and/or battery are rare. Kidnapping is the seizing, confining, abducting, or carrying away of a person by force.Criminal charges of kidnapping are almost unheard of in EMS because the EMT is almost always acting in a good faith effort to provide care to the patient. False imprisonment is defined as the unauthorized confinement of a person that lasts for an appreciable period of time.Consider a patient who rescinds consent during transport and demands to be let out of the ambulance. If you refuse, you may be accused of false imprisonment. Defamation is the communication of false information that damages the reputation of a person.Defamation that is in writing is referred to as libel.Defamation that is spoken is known as slander. A legal claim for defamation could arise out of:A false statement on a run reportInappropriate comments made on social mediaDuring station house conversationsSharing "war stories" with friends, relatives, or neighbors

Describe the EMT's legal duty to act. (pp 97-98)

Duty to act is an EMT's responsibility to provide patient care. There may be a duty to act in certain instances, including:You are charged with emergency medical response.Your service or department's policy states that you must assist in any emergency. Once your ambulance responds to a call or treatment is begun, you have a legal duty to act. In most cases, if you are off duty and come upon a crash, you are not legally obligated to stop and assist patients.If you choose to intervene while off duty, you must continue to provide competent care until an equal or higher medical authority assumes care of the patient.

Describe the relationship between patient communications, confidentiality, and the Health Insurance Portability and Accountability Act (HIPAA). (p 90)

Confidential information includes the patient history, assessment findings, and treatment provided. Disclosure of such information without proper authorization may result in liability for breach of confidentiality. Patient information may be shared with third-party billing personnel.This is not considered a breach of confidentiality. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) strengthened laws for the protection of the privacy of health care information in order to safeguard patient confidentiality.It provides guidance on what types of information is protected, the responsibility of health care providers regarding that protection, and the penalties for breaching that protection. HIPAA considers all patient information that you obtain in the course of providing medical treatment to a patient to be protected health information (PHI). PHI may be disclosed for purposes of treatment, payment, or operations.You are permitted to report your assessment findings and treatment to other health care providers directly involved in the care of the patient.Information may be used for internal quality improvement and training programs.All identifying information must first be removed. Failure to abide by the provisions of HIPAA can result in civil and/or criminal action against your response agency and against you personally. Each EMS system is required to have a policy and procedure manual and a privacy officer who can answer questions.

Explain how to manage patients who are identified as organ donors. (p 94)

Consent to organ donation is voluntary and knowing. Consent is evidenced by either a donor card or a driver's license indicating that the individual wishes to be a donor. You may need to consult with medical control. In specific circumstances, a patient who is not successfully resuscitated may be a potential organ donor.These situations typically occur after in-hospital cardiac arrest but may be associated with certain specific out-of-hospital cardiac arrest situations that occur in close proximity to specialized centers. Treat a potential organ donor in the same way that you would any other patient needing treatment. Use all means necessary to keep that patient alive. Organs that are often donated, such as a kidney, heart, or liver, need oxygen at all times; you must give oxygen to the possible donor or the organs will be damaged and become useless.

Describe the physical, presumptive, and definitive signs of death. (pp 92-93)

In the absence of physician orders, such as DNR orders, the general rule is: If the body is still intact and there are no definitive signs of death, initiate emergency medical care. Definitive or conclusive signs of death that are obvious and clear to even nonmedical people include: Obvious mortal damage, such as decapitation Dependent lividity: blood settling to the lowest point of the body, causing discoloration of the skin Rigor mortis, the stiffening of body muscles caused by chemical changes within muscle tissueDevelops first in the face and jaw, gradually extending downward until the body is in full rigor.The rate of onset is affected by the body's ability to lose heat to its surroundings.The rate of heat loss in a thin body is faster than in a fat body.Rigor mortis occurs sometime between 2 and 12 hours after death. Putrefaction (decomposition of body tissues)Depending on temperature conditions, this occurs sometime between 40 and 96 hours after death.

negligence

Negligence is the failure to provide the same care that a person with similar training would provide in the same or a similar situation. Determination of negligence is based on: all 4 must be present Duty The EMT has an obligation to provide care and to do so in a manner that is consistent with the standard of care established by training and local protocols. Breach of duty There is a breach of duty when the EMT does not act within an expected and reasonable standard of care. Damages There are damages when a patient is physically or psychologically harmed in some noticeable way. Causation There must be a reasonable cause-and-effect relationship between the breach of duty and the damages suffered by the patient. If an EMT has a duty and abuses it, thereby causing harm to another individual, the EMT, the agency, and/or the medical director may be sued for negligence. This is often referred to as proximate causation.

involuntary consent

adult pt, mentally incompetent, unable to provide consent should be obtained from a legal guardian prisoner conscious and able to make decisions does not surrender the ability to consent

role/obligation when pt refuses treatment/transport

adults with decision making capacity may refuse at any time - even if refusing results in death/serious injury involve medical control and document (assessment, treatment believed to help, risks of treatment, consequences of refusal) suicidal or previous SI history pt don't always have full mental capacity ask pt to sign refusal, encourage pcp treatment or call EMS if situation exacerbates

Competence

legal term determined by a court of law

Discuss the scope of practice and standards of care. (pp 94-97)

local custom: The standard of care is how a reasonably prudent person with similar training and experience would act under similar circumstances, with similar equipment, and in the same or similar place. As an EMT, you will not be held to the same standard of care as physicians or other, more highly trained professionals. Your conduct must be judged in the light of the given emergency situation, taking into account:Any issues concerning the safety of the patient or rescuerGeneral confusion at the scene of the emergencyThe needs of other patientsThe type of equipment available An emergency is a serious situation, such as an injury or an illness that arises suddenly, threatens the life or welfare of a person or group of people, and requires immediate intervention. The accepted standard of care can change from one community to another. Examples of prevailing customs include how hospital destinations are selected, when EMS helicopters are used, and protocols for cervical spine immobilization. imposed by law In addition to local customs, standards of emergency medical care may be imposed by statutes, ordinances, administrative regulation, or case law.In many jurisdictions, violating one of these standards is said to create presumptive negligence. You must become familiar with the particular legal standards that may exist in your state. In many states, this may take the form of treatment protocols published by a state agency. professional/industry standards Professional standards include recommendations published by organizations and societies that are involved in emergency medical care. Institutional standards include specific rules and procedures of the EMS system, ambulance service, or organization to which you are affiliated. Two notes of caution:You must be familiar with the standards of your organization.If you are involved in formulating standards for a particular agency, they should be reasonable and realistic. State health department regulations usually govern the scope and level of training. Court decisions have resulted in case law defining standards of care. An example of professional standards is the International Liaison Committee on Resuscitation (ILCOR), along with its member the American Heart Association (AHA), which updates the standard for basic life support (BLS) and cardiopulmonary resuscitation (CPR) on a regular basis. Ordinary care is a minimum standard of care. If you apply the standard practices you have been trained to use, you can likely avoid liability. imposed by textbooks Since virtually all EMS textbooks follow standards established by the National Highway Transportation Safety Administration (NHTSA), these textbooks are often recognized as contributing to the standard of care that is followed by EMTs. Local protocols or state standards may differ from material presented in textbooks.When such differences occur, you are bound to follow local protocols. Standards Imposed by States imposed by states Medical Practices ActIn some states, EMS personnel are exempt from the licensure requirements of the Medical Practices Act because an EMT is regarded as a nonmedical professional.Some states have adopted legislation that establishes the scope of practice for EMS providers so they provide care that is consistent with those standards. Certification and licensureCertification is the process by which an individual, institution, or program is evaluated and recognized as meeting certain predetermined standards to ensure safe and ethical patient care.Licensure is the process by which a competent authority, usually the state, grants permission to practice a job, trade, or profession.Credentialing is an established process to determine the qualifications necessary to be allowed to practice a particular profession, or to function as an organization.Once certified, you are obliged to conform to the standards that are generally recognized nationally by various registry groups and provide an important link in nationwide EMS.You must ensure that your certification or licensure remains current and that your skill levels are kept up to date.

expressed consent

pt verbally or otherwise consents to care/transport must be informed - explain the nature of treatment and pt understands risks

An adult who is conscious, rational, and capable of making informed decisions has a legal right to....

refuse care (some or all aspects)

using forcible restraints

sometimes necessary with a combative patient some states require a police officer to restrain - either way, advisable to wait for law enforcement assistance if possible after applying, do not remove en route unless posing risk to the patient always protect pt airway, monitor respiratory status

Minors - consent to treatment

the law requires that parent or guardian provide consent when available healthcare providers can when a parent is not present emancipated minors provide own consent and treated as adults (married, service members, living away and independent of parents) ex, a teacher may act in loco parents - in place of parents

role/obligation when MINOR pt refuses treatment/transport

try to persuade parent, otherwise same procedure as adult

implied consent

unconscious and/or unable to make a rational decision, the law assumes pt would consent if able to pts intoxicated or mentally impaired can be included applies only with a serious injury - life or limb threat aka emergency doctrine doctrine expires once pt regains consciousness and mental capability