EMT Chapter 3
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.
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.
licensure
Licensure is the process by which a competent authority, usually the state, grants permission to practice a job, trade, or profession.
depositions
oral questions asked of parties and witnesses under oath
confidential info includes:
patient history, assessment findings, and treatment provided. HIPAA considers all patient information that you obtain in the course of providing medical treatment to a patient to be protected health information (PHI).
Consent
permission for treatment, actual or implied
An adult who is conscious, rational, and capable of making informed decisions has a legal right to refuse care.
* may consent to some aspects of care and deny consent for others
As a witness in a civil case, you may be called to testify about the condition of the plaintiff when you arrived at the scene and about the treatment that you provided.
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If the patient appears confused or delusional, do not assume that the decision to refuse is an informed refusal.
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In a civil lawsuit, your service or its insurance company generally will provide you with legal counsel.
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In a criminal case, you may be asked to describe a crime scene, the injuries that you found when you examined a crime victim, or to testify concerning any admissions or statements made to you by a criminal defendant.
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Many states have laws requiring the reporting of any injury that is likely to have occurred during the commission of a crime, such as gunshot wounds, knife wounds, or poisonings.
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PHI may be disclosed for purposes of treatment, payment, or operations.
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Remember, DNR does not mean "do not treat." Even in the presence of a DNR order, you are still obligated to provide supportive measures (oxygen, pain relief, and comfort) to a patient who is not in cardiac arrest.
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misconduct should be promptly reported to the appropriate chain of command
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only communicate info about your patients to authorized people
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expressed consent
=actual consent; verbal or otherwise acknowledgement only valid when patient is provided with informed consent
A legal claim for defamation could arise out of:
A false statement on a run report Inappropriate comments made on social media During station house conversations Sharing "war stories" with friends, relatives, or neighbors
Decision-making capacity and competence are often used interchangeably, but there is a distinction:
Competence is generally regarded as a legal term. Determinations regarding competence are typically made by a court of law. Decision-making capacity is the term more commonly used in health care to determine whether or not a patient is capable of making health care decisions.
Involuntary consent
An adult patient who is mentally incompetent is not able to give informed consent. Consent should be obtained from someone who is legally responsible for the patient
An EMT can be held liable if it can be shown that:
An injury occurred The cause of the injury was in the control of the EMT Such injuries generally do not occur unless there is negligence
Whenever you're subpoenaed to testify, notify the director of your service and legal counsel.
As a witness you should remain neutral during your testimony.
other reporting requirements
Attempted suicides Dog bites Certain communicable diseases Assaults Domestic violence Sexual assault or rape exposures to infectious diseases transport of patients in restraints
certification
Certification 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.
to protect yourself of charges make sure to get expressed or implied consent
Civil lawsuits for battery are common in health care.
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 guardian Signature of one or more physicians or other licensed health care providers
credentialing
Credentialing is an established process to determine the qualifications necessary to be allowed to practice a particular profession, or to function as an organization.
Before leaving the scene where a patient has refused care:
Encourage the patient to permit treatment and remind him or her to call 9-1-1 if he or she changes his or her mind or his or her condition worsens. Advise the patient to contact his or her personal physician as soon as possible. Ask the patient to sign a refusal of treatment form and to thoroughly document all refusals
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.
Patient care reports (PCRs):
Help the EMS system evaluate individual and service provider performance Are an integral part of most quality assurance programs Are used to conduct prehospital emergency care research, which may improve patient outcomes
proximate causation
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
A civil lawsuit begins with the service of a summons and complaint. The response to the complaint is called an answer
If served with a summons, you must bring this to the attention of the head of your service immediately, because the complaint must be responded to within a set period of time that is usually within 30 days.
In most states, EMTs do not have the authority to pronounce a patient dead.
If there is any chance that life exists or that the patient can be resuscitated, you must make every effort to save the patient at the scene and during transport.
adults who refuse treatment pose a high risk for litigation
Involve online medical control and document this consultation. Document the following information in your patient care report: Your assessment of what might be wrong with the patient A description of the treatment that you feel is necessary Any possible risks of treatment The availability of alternative treatments The possible consequences of refusing treatment
Immunity laws, which vary from state to state, do not provide immunity when injury or damage is caused by gross negligence or willful misconduct. In most cases, immunity statutes apply to EMS systems that are considered governmental agencies.
Many states grant partial immunity to EMTs and physicians and nurses who give emergency instructions to EMS personnel via radio or other forms of communication.
childbirth
Many states require that anyone who attends at a live birth in any place other than a licensed medical facility report the birth.
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.
When you are not able to persuade the patient, guardian, or parent to proceed with treatment:
Obtain the signature of the individual who is refusing treatment on an official release form that acknowledges refusal. Document: Any assessment findings The emergency care you provided Your efforts to obtain consent Your consultation with medical control The responses to your efforts Obtain a signature from a witness to the refusal.
Professional and Institutional 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.
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.
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.
Standards Imposed by 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. Emts not held to the same standard of care as physicians/more highly trained professionals Conduct judged taking into account the emergency situatoin
Breach of duty
There is a breach of duty when the EMT does not act within an expected and reasonable standard of care.
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.
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.
Many states have also adopted "brain death" provisions.
These provisions refer to irreversible cessation of all functions of the brain and brain stem.
To be protected by the provisions of a Good Samaritan law, several conditions must generally be met:
You acted in good faith in rendering care. You rendered care without expectation of compensation. You acted within the scope of your training. You did not act in a grossly negligent manner.
morality
a code of conduct that can be defined by society, religion, or a person, affecting character and conscience
contributory negligence
a legal defense that may be raised when the defendant feels that the conduct of the plaintiff somehow contributed to any injuries or damages that were sustained by the plaintiff.
advance directive
a written document that specifies medical treatment for a competent patient, should he or she become unable to make decisions. aka health care directive
special mandatory reporting requirements
abuse of children, older people, and others injury during the commission of a felony drug-related injuries childbirth
Bioethics
addresses issues that arise in the practice of health care
presumptive signs of death
adequate in cases of sudden death due to hypothermia, acute poisoning, or cardiac arrest Usually, in these cases, some combination of the signs is needed to declare death, not just one of them alone. ex. unresponsive to painful stimuli no pulse/heartbeat no chest rise/fall no deep tendon/corneal reflexes no pupillary response no systolic blood pressure profound cyanosis lowered body temp
emergency doctrine
aka The principle of implied consent
Duty to act
an Emt's responsibility to provide patient care
discovery
an opportunity for both sides to obtain information that will give attorneys a better understanding of the case and assist in negotiating a possible settlement or in preparing for trial most cases are settled and do not go to trial
if judgment is rendered against you or your service, plaintiff may be awarded:
compensatory damages: intended to compensate the plaintiff for the injuries sustained punitive damages: reserved for cases where the defendant acted intentionally or with reckless disregard for the safety of the public
definitive signs of death
conclusive signs of death that are obvious and clear to even nonmedical people include: Obvious mortal damage (ex. decapitation) dependent lividity- blood settling to the lowest point of the body, causes discoloration of the skin rigor mortis- stiffening of body muscles cause by chemical changes in muscle tissue, Rigor mortis occurs sometime between 2 and 12 hours after death. putrefaction- decomposition of body tissues
gross negligence
conduct that constitutes a willful or reckless disregard for a duty or standard of care
organ donors
consent to organ donation is voluntary and knowing 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.
Death
defined as the absence of circulatory or respiratory function
false imprisonment
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.
determination of negligence is base on:
duty breach of duty damages causation
3 kinds of consent
expressed implied involuntary
governmental immunity
generally applies only to EMS systems operated by municipalities or other governmental entities If your service is covered by immunity, it may mean that you cannot be sued at all or it may limit the amount of the monetary judgment that the plaintiff may recover
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.
Things to think about regarding decision making capacity
intellectual capacity (mentally ill? dementia or something?) age (legal or nah?) impairment (drugs? serious injury/illness?) pain significant injury hearing/visual problems language barrier
minors and consent
law requires that a parent or legal guardian, when available, give consent for treatment or transport of a child, unless emancipated--then can be legally treated as adults based on certain circumstances Consent implied if parent/guardian not availble to consent, but should be reached asap
Standard of care is established in many ways.
local custom law professional and institutional standards textbooks states
informed consent
nature of the treatment being offered was explained including potential risks, benefits, and alternatives to treatment, as well as potential consequences of refusing treatment, and the patient has given consent
Implied consent
person is unconscious or otherwise incapable of making a rational, informed decision about care, and unable to give consent, the law assumes that the patient would consent to care and transport to a medical facility if he or she were able to do so. applies only in cases of serious medical condition--threat to life or limb
negligence per se
plaintiff may be able to establish liability by using this theory when the conduct of the person being sued is alleged to have occurred in clear violation of a statute
statute of limitations
refers to the time within which a case must be commenced--sometimes the case may be after too long a time span to commence
forcible restraint
sometimes necessary when you are confronted with a combative patient. Physically prevents combative people from initiating any physical action In some states, only a police officer may forcibly restrain an individual. Protect the patient's airway and monitor the patient's respiratory status while restrained to avoid asphyxia, aspiration, and other complications.
possible defenses include:
statutes of limitations governmental immunity contributory negligence
If a minor is injured and requires medical treatment in a school or camp setting
teachers and school officials may act in loco parentis.
decision-making capacity
the ability of a patient to understand the information you are providing, coupled with the ability to process that information and make an informed choice regarding medical care.
good samaritan laws
the common law principle that when you reasonably help another person, you should not be liable for errors and omissions that are made in giving good faith emergency care. you aren't necessarily protected from a lawsuit
defamation
the communication of false information that damages the reputation of a person
applied ethics
the manner in which principles of ethics are incorporated into professional conduct basically professional/workplace ethics
Standard of care
the manner in which you must act or behave- you must be concerned about the safety and welfare of others when your actions/behaviors have the potential to cause harm
ethics
the philosophy of right and wrong, moral duties, ideal professional behavior
patient autonomy
the right of a patient to make decisions concerning his or her health
kidnapping
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.
abandonment
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.
Damages
there are damages when a patient is physically or psychologically harmed in some noticeable way.
All forms of negligence come under a general category:
torts or civil wrongs
Assault
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
unlawfully touching a person, including providing emergency care without consent
involvement of medical examiner/coroner depends on nature and scene of death
when m.e./coroner assumes responsibility of scene, it supercedes all other authority of scene make an effort to limit disturbance of scene In most states, when trauma is a factor or the death involves suspected criminal or unusual situations such as hanging or poisoning, the medical examiner must be notified.
res ipsa loquitor
when the emt/ems system is held liable even when the plaintiff is unable to clearly demonstrate how an injury occurred
interrogatories
written questions each side sends to the other