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LEGAL IMPLICATIONS LEGAL IMPLICATIONS PSYCHIATRIC PSYCHIATRIC
CONSIDERATIONSCONSIDERATIONSEBOLAEBOLA
Mod IV 2014 ECRN CEMod IV 2014 ECRN 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, BSN1
OBJECTIVESOBJECTIVES
Upon successful completion of this module, the ECRN will Upon successful completion of this module, the ECRN will be able to:be able to:
1. Define Munchausen by proxy syndrome, anorexia, bulimia 1. Define Munchausen by proxy syndrome, anorexia, bulimia 2. Describe situations when it is appropriate to obtain consent for medical care 2. 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 3. Describe characteristics and EMS interventions for a variety of behavioral 3. Describe characteristics and EMS interventions for a variety of behavioral emergencies.emergencies.4. Describe the difference between voluntary and involuntary committal and 4. Describe the difference between voluntary and involuntary committal and EMS responsibilities.EMS responsibilities.
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OBJECTIVES CONT’DOBJECTIVES CONT’D
5. Describe the assessment and field care of the patient that has been 5. Describe the assessment and field care of the patient that has been Tasered.Tasered.
66. Describe the restraining of a patient via physical and . Describe the restraining of a patient via physical and
chemical chemical
methods when in the field.methods when in the field.
7. Review a variety of advanced directives.7. Review a variety of advanced directives.
8. Describe the State of Illinois revised POLST form and 8. Describe the State of Illinois revised POLST form and
implications for EMS.implications for EMS. 3
OBJECTIVES CONT’DOBJECTIVES CONT’D
9. Describe the implications of the Ebola virus and EMS care of the patient9. Describe the implications of the Ebola virus and EMS care of the patient
10. Review the case scenarios presented.10. Review the case scenarios presented.
11. Review selected Region X SOP’s included in the module.11. Review selected Region X SOP’s included in the module.
12. Evaluate and review a variety of EKG rhythms and 12 lead 12. Evaluate and review a variety of EKG rhythms and 12 lead
EKG’s.EKG’s.
13. Successfully complete the post quiz with a score of 80% or 13. Successfully complete the post quiz with a score of 80% or
better.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 team/peersFor your team/peers
• For other responding personnelFor other responding personnel
• For the patientFor the patient
• For others aroundFor others around
5
SCENE SAFETYSCENE SAFETY
• Establish a safe perimeterEstablish a safe perimeter
• Evaluate the safety of the environment before enteringEvaluate the safety of the environment before entering
• Call for help as necessaryCall for help as necessary
• EMS may need to stage which could delay patient contactEMS may need to stage which could delay patient contact
• EMS to document any delays EMS to document any delays • 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
• FYI -This information also applies to ED staffFYI -This information also applies to ED staff6
SCENE SAFETYSCENE SAFETY
• 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 enter an areaIf it doesn’t feel right, do not enter an area
• 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
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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 report and documentationBe objective in report and documentation
• Need to site source of information provided (“_____ states…”)Need to site source of information provided (“_____ states…”)
• May take years to prove the presence of this mental illnessMay take years to prove the presence of this mental illness
so EMS and ED staff may not have knowledge of this diagnosisso EMS and ED staff 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 to Psychological and physical damage to victim could lead to
poor long-term prognosis 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
• Has an intense fear of gaining weightHas an 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 of laxatives, diuretics Purge – self-induce vomiting or misuse of laxatives, diuretics or enemas after binging or fastor enemas after binging or fast
• Can follow a strict diet or participates in excessive exerciseCan follow a strict diet 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 harm if pregnantFetal harm if pregnant
• 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
• Works with a nutritionist for an eating planWorks 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 & ED IMPLICATIONS FOR EMS & ED
• 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 should be considered due to potential for Note: Cardiac monitoring should be considered due to potential for
electrolyte imbalance and resulting cardiac dysrhythmiaselectrolyte imbalance 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 consentThey are emancipated from parental careThey are emancipated from parental careThey are or have been marriedThey are or have been marriedThey are pregnantThey are pregnantThey are a parent with custody of their child (extends to They are a parent with custody of their child (extends to
the mother and the father if they are a custodial parent) the mother and the father if they are a custodial parent) 24
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 if able to do soreasonable person would consent to emergency care if 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 conditions that are posing an Treatment rendered limited for emergent conditions that are posing an
immediate threat to child immediate 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 BARRIER DURING EMS CAREBARRIER DURING EMS CARE
• 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
SITUATIONS OKAY TO OBTAIN CONSENT SITUATIONS OKAY TO OBTAIN CONSENT FROM A MINORFROM A MINOR
• Emancipated minor by court orderEmancipated minor by court order
• Married minorMarried minor
• Pregnant minorPregnant minor
• Minor (mother and/or father) who is a custodial parent Minor (mother and/or father) who is a custodial parent
• 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 must know what The paramedic is medically trained so they must know what
they are talking about; they 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
• Transport can be expensive; some paramedics may Transport can be expensive; some paramedics may
capitalize on the patient’s financial fearscapitalize on the patient’s financial fears
• EMS needs to consider: Do you want to be responsible for EMS needs to consider: Do you want to be responsible for
the one call you talked down who had a bad outcome???the one call you talked down who had a bad outcome??? 30
CASE REPORTSCASE REPORTS
• The following 3 cases are real eventsThe following 3 cases are real events
• They DID NOT happen in this areaThey DID NOT happen in this area
• Be open to learn lessons from other’s mistakesBe open to learn lessons from other’s mistakes
• Decide how you would have handled the call if EMS Decide how you would have handled the call if EMS
had contacted you for directionshad contacted you for directions
31
CASE REPORT #1CASE REPORT #1
• EMS was called for an adult patient with chest pain past few EMS was called for an adult patient with chest pain past few hourshours
• 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
Was this call handled appropriately?Was this call handled appropriately?32
OUTCOME CASE REPORT #1OUTCOME CASE REPORT #1
• Hopefully, EMS would do a cardiac work-up and transport Hopefully, EMS would do a cardiac work-up and transport this patientthis patient
Outcome report:Outcome report:
• 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 evaluated by EMSThe patient died 3 hours after being evaluated by EMS 33
CASE REPORT #2CASE REPORT #2
• 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 were auscultatedBilateral wheezes were 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
Was this call handled appropriately?Was this call handled appropriately?34
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 due to a severe asthma attackThe child died due to a severe asthma attack
35
CASE REPORT #3CASE REPORT #3
• 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
Was this call handled appropriately?Was this call handled appropriately? 36
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
• Should EMS have involved Medical Control in dialogue???Should EMS have involved Medical Control in dialogue???• Hopefully, yes. Doesn’t mean the outcome would have Hopefully, yes. Doesn’t mean the outcome would have
been differentbeen different 37
RELEASES/REFUSALSRELEASES/REFUSALS
• EMS to respond to each call assuming every one will be a transportEMS to respond to each call assuming every one will be a transport
• EMS to work harder at convincing them to be transported than EMS to work harder at convincing them to be transported than
accepting them as a refusal/releaseaccepting them as a refusal/release
• Patients are aware of your attitude – show yours as positivePatients are aware of your attitude – show yours as positive
• EMS to contact Medical Control for all controversial or questionable EMS to contact Medical Control for all controversial or questionable
releases/refusalsreleases/refusals
38
OBTAINING A RELEASEOBTAINING A RELEASE
• Patient must demonstrate decisional capacity in order to give Patient must demonstrate decisional capacity in order to give consent for a release or refusalconsent for a release or refusal
• A patient who is decisional, awake & oriented and understands A patient who is decisional, awake & oriented and understands the risks and benefits has the right to refuse consent (even the risks and benefits has the right to refuse consent (even when you feel the decision made is not in their best interest)when you feel the decision made is not in their best interest)
• Police do not have the right to make the person in custody Police do not have the right to make the person in custody receive medical assistance if they refuse it (i.e.: laceration, pain)receive medical assistance if they refuse it (i.e.: laceration, pain)
• Just because a person has had alcohol does not make them Just because a person has had alcohol does not make them non-decisional non-decisional
• Every case needs to be evaluated on its ownEvery case needs to be evaluated on its own39
EMS AND REFUSALSEMS AND REFUSALS
• Medical Control cannot “order” a patient to receive care and/or Medical Control cannot “order” a patient to receive care and/or be transported if they have decisional capacity and are refusingbe transported if they have decisional capacity and are refusing
• Transporting a patient with decisional capacity against their will Transporting a patient with decisional capacity against their will could be kidnappingcould be kidnapping
• People have the right to make poor decisionsPeople have the right to make poor decisions• The medical team must make sure we have explained the risks and The medical team must make sure we have explained the risks and
benefits to the patient and this is documentedbenefits to the patient and this is documented
• We all have horror stories of the patient who refused We all have horror stories of the patient who refused care/transportation and then had a negative outcome but it is care/transportation and then had a negative outcome but it is the patient’s right to refuse IF they are decisionalthe patient’s right to refuse IF they are decisional
40
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
41
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
42
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 disorder / neurological conditionBrain disorder / neurological conditionMedication influenceMedication influenceRecreational drug useRecreational drug use
43
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 consciousness44
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 45
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 46
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 contributes to development of coronary artery disease Cocaine abuse contributes to development of coronary artery disease
and damage to the heart muscleand damage to the heart muscle
• AggressiveAggressive chemical sedation required chemical sedation required• Continued physical struggle increases catecholamine surge and Continued physical struggle increases catecholamine surge and
metabolic acidosis; sedation at this point can be life-savingmetabolic acidosis; sedation at this point can be life-saving
• Per Region X SOP’s for sedation, EMS will administer Versed 2 mg INPer Region X SOP’s for sedation, EMS will administer Versed 2 mg IN• Can repeat every 2 minutes up to 10 mgCan repeat every 2 minutes up to 10 mg
• For additional sedation, Valium is given; IV or IM For additional sedation, Valium is given; IV or IM 47
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 48
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 49
FIELD TREATMENT RHABDOMYOLYSISFIELD TREATMENT 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
imbalanceimbalance50
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
51
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 patient’s will for a minimum of 72Admitted against patient’s will for a minimum of 7200 and then must and then must
be examined and then can be kept or must be dischargedbe examined and then can be kept or must be discharged
• 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 52
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 officers53
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 comments mustmust be involved in completing the documentation 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
• To keep information objective and descriptiveTo keep information objective and descriptive
• May be asked to complete witness observations only if EMS was May be asked to complete witness observations only if EMS was
direct witness to behavior/language and ED staff is notdirect witness to behavior/language and ED staff is not54
PETITION FOR INVOLUNTARY/JUDICIAL PETITION FOR INVOLUNTARY/JUDICIAL ADMISSIONADMISSION
• Witness to state in detail signs and symptoms of mental illness Witness to state in detail signs and symptoms of mental illness displayeddisplayed
• Can include prior diagnosis, treatment and hospitalizationsCan include prior diagnosis, treatment and hospitalizations
• Objectively describe any threats, behavior or pattern of behavior Objectively describe any threats, behavior or pattern of behavior which supports the complaintwhich supports the complaint
• Can include personal observations that lead to your belief for Can include personal observations that lead to your belief for involuntary admissioninvoluntary admission
• The address and phone number on commitment papers can be The address and phone number on commitment papers can be given as your work informationgiven as your work information 55
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 often pin one person against anotherThey often pin one person against another
• They sometimes come down to a “he said/she said” struggleThey sometimes come down to a “he said/she said” struggle
• Always act in the best interest of the patientAlways act in the best interest of the patient
• EMS should involve Medical Control for these unclear callsEMS should involve Medical Control for these unclear calls
56
FIELD CARE OF PATIENT TASEDFIELD CARE OF PATIENT TASED
• EMS to evaluate depth of skin penetrationEMS to evaluate depth of skin penetration
• Darts NOT removed if patient is not under controlDarts NOT removed if patient is not under control
• Darts NOT removed but stabilized and patient Darts NOT removed but stabilized and patient transported if:transported if:
• 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
57
REMOVAL OF DARTSREMOVAL OF DARTS
• Taser cartridge removed from gun or wires cutTaser cartridge removed from gun or wires cut
• One hand placed on patient next to embedded dart to stabilize surrounding skinOne hand placed on patient next to embedded dart to stabilize surrounding skin
• Probe firmly grasped with other handProbe firmly grasped with other hand
• Dart removed by gently pulling straight outDart removed by gently pulling straight out
• Dart is inspected to assure it is intact; take sharps precautionsDart is inspected to assure it is intact; take sharps precautions
• Darts returned to law enforcement or disposed of as a sharpsDarts returned to law enforcement or disposed of as a sharps
• Wound cleansed with salineWound cleansed with saline
• Site covered with a dry dressing (i.e.: band aid)Site covered with a dry dressing (i.e.: band aid)
58
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 symptoms of the illness or injuryCombative issues are symptoms of the illness or injury
59
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
60
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
61
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
62
RESTRAINT PRINCIPLESRESTRAINT PRINCIPLES
• Objective and detailed reasons need to be documented Objective and detailed reasons need to be documented
indicating need of restraintsindicating need of restraints
• Document alternative methods attempted to avoid Document alternative methods attempted to avoid
restraintsrestraints
• i.e.: verbal de-escalationi.e.: verbal de-escalation
• Document type of restraint appliedDocument type of restraint applied
• Document periodic assessment/reassessment of patientDocument periodic assessment/reassessment of patient
• Include assessment of airway status and distal circulation of Include assessment of airway status and distal circulation of
restrained extremitiesrestrained extremities63
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
64
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 65
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
• EMS must begin resuscitation as they contact Medical ControlEMS must begin resuscitation as they contact Medical Control
• 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
66
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
completedcompleted67
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
68
CASE SCENARIOSCASE SCENARIOS
• Review the following casesReview the following cases
• Prepare to discuss how YOU would respond to EMS Prepare to discuss how YOU would respond to EMS in that situation if they contacted Medical Controlin that situation if they contacted Medical Control
• Be prepared to support your decisions/orders to EMSBe prepared to support your decisions/orders to EMS• 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
69
CASE #1CASE #1
• EMS was called to the scene for a 32 year old EMS was called to the scene for a 32 year old
female with dizziness who passed out female 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
• What’s your general impression?What’s your general impression?
• What is the treatment of choice?What is the treatment of choice?
70
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 systolic71
CASE #1CASE #1
• What is the treatment for unstable sinus bradycardia What is the treatment for unstable sinus bradycardia
per Region X SOP’s?per Region X SOP’s?• 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 confirmed 72
CASE #1CASE #1
• What could be used as listed in the Region X SOP’s for What could be used as listed in the Region X SOP’s for
discomfort caused during the use of the TCP?discomfort caused during the use of the 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 be repeated every 2 minutes as needed to a max of 10 mgMay be repeated every 2 minutes as needed to a max of 10 mg
• What would be used for management of pain per Region X What would be used for management of pain per Region X
SOP’s?SOP’s?
• 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
73
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
74
CASE #1CASE #1
• Patient is pulseless and apneic with polymorphic VTPatient is pulseless and apneic with polymorphic VT
• What is the treatment plan now per Region X SOP’s?What is the treatment plan now per Region X SOP’s?• 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
• Repeated every 3-5 minutesRepeated 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 in 3-5 minutes dose in 3-5 minutes
• Antidysrhythmic alternated with the vasopressor usedAntidysrhythmic alternated with the vasopressor used 75
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 EMS do per Region X pulse (therefore a B/P), what would EMS do per Region X
SOP’s?SOP’s?• 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 EMS do?If patient was unstable, what would EMS do?
• Synchronized cardioversion with sedation (if time to give)Synchronized cardioversion with sedation (if time to give)
76
CASE #1 – UNSTABLE VTCASE #1 – UNSTABLE VT
• Consider sedation if time to administerConsider sedation if time to administer
• 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
77
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 DNR (but not present)Family states the patient has a DNR (but not present)
• Patient confirmed 0-0-0Patient confirmed 0-0-0
• What should EMS do?What should EMS do?
• Ask to see the DNRAsk to see the DNR
• EMS needs to begin CPR in absence of DNR paperworkEMS needs to begin CPR in absence of DNR paperwork
78
CASE #2CASE #2
• What would EMS do if the family could not produce the DNR form?What would EMS do if the family could not produce the DNR form?
• EMS needs to begin CPR and then contact Medical Control for ordersEMS needs to begin CPR and then 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
• EMS should be specific and request permission to withdraw CPR EMS should be specific and request permission to withdraw CPR
efforts if that is what they wantefforts if that is what they want
79
CASE #2 – WITHDRAWING CASE #2 – WITHDRAWING RESUSCITATION SOPRESUSCITATION SOP
• EMS to include in report to Medical ControlEMS to include 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
80
CASE #2CASE #2
• EMS documentation of withdrawing resuscitationEMS documentation 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 EMS does not need to remain at the scene if scene turned over to policeturned over to police
• If leaving the body at the scene is a problem, EMS is to If leaving the body at the scene is a problem, EMS is to contact the hospital to inform of transport to get the contact the hospital to inform of transport to get the patient off the scenepatient off the scene
81
CASE #2CASE #2
• What if EMS is ordered to work the call???What if EMS is ordered to work the call???
• What is the rhythm?What is the rhythm?
• What does EMS (and in general, medical personnel) do What does EMS (and in general, medical personnel) do
for asystole?for asystole?82
Asystole
CASE #2 - ASYSTOLECASE #2 - ASYSTOLE
• Lots of CPR; 10 second pauses every 2 minutes to reevaluate the Lots of CPR; 10 second pauses every 2 minutes to reevaluate the rhythmrhythm
• 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
• May be substituted with Vasopressin 40 units one time 1May be substituted with Vasopressin 40 units one time 1stst or 2 or 2ndnd round round dosedose
• Region X EMS does not carry Vasopressin – FYI: some Regions doRegion X EMS does not carry Vasopressin – FYI: some Regions do
• Every 3- 5 minutes for the durationEvery 3- 5 minutes for the duration
83
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 should EMS do???Now what should EMS do???
84
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?85
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 refusalAny EMS concerns about accepting a refusal
• Risks and benefits provided to the patientRisks and benefits provided 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
86
CASE #4CASE #4
• EMS is called to the scene of a MVC – category III trauma EMS is called to the scene of a MVC – category III trauma (non-I and non-II category trauma)(non-I and non-II category trauma)
• EMS has a 17 year-old patient who is refusing EMS has a 17 year-old patient who is refusing transportationtransportation
• The patient states she is 3 months pregnantThe patient states she is 3 months pregnant
• EMS has the 17 year-old boyfriend also refusing EMS has the 17 year-old boyfriend also refusing transportationtransportation
• Can these patients sign refusals?Can these patients sign refusals? 87
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 custodial parent who is a minor can grant permission A custodial parent who is a minor can grant permission
for themselves and their childfor themselves and their child
• The boyfriend cannot sign a refusal unless he becomes a The boyfriend cannot sign a refusal unless he becomes a
custodial parent of his childcustodial parent of his child
88
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 The patient is refusing transportation for herself and
her childher child
• How would you handle this call from EMS?How would you handle this call from EMS?
• A minor who is a custodial parent of their child has the A minor who is a custodial parent of their child has the
right to refuse medial care for themselves and their childright to refuse medial care for themselves and their child89
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 should EMS do if the patient refuses transport?What should EMS do if the patient refuses transport?
• Can this patient refuse transport?Can this patient refuse transport?
90
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
91
ADDITIONAL REMINDERS OF LEGAL ADDITIONAL REMINDERS OF LEGAL IMPLICATIONS AND EMSIMPLICATIONS AND EMS
• Hospital on by-passHospital on by-pass• Must still accept all critical/unstable patients in life Must still accept all critical/unstable patients in life
threatening conditionsthreatening conditions• May need to clarify in report what the patient’s condition isMay need to clarify in report what the patient’s condition is
• Of course, this is usually the worst time for ED to receive Of course, this is usually the worst time for ED to receive another patientanother patient
• But these patients need to be transported to the closest But these patients need to be transported to the closest appropriate hospitalappropriate hospital
92
ADDITIONAL RADIO ETIQUETTEADDITIONAL RADIO ETIQUETTE
• Focus attention on the report being providedFocus attention on the report being provided
• Formulate clarifying questions on what is NOT said in reportFormulate clarifying questions on what is NOT said in report
• ECRN should appropriately activate codes (per ED ECRN should appropriately activate codes (per ED
policies/procedures) (i.e.: trauma, cardiac, stroke) based on EMS policies/procedures) (i.e.: trauma, cardiac, stroke) based on EMS
reportreport
• Know the radio calls are recorded – keep them professionalKnow the radio calls are recorded – keep them professional
• Complete the Radio Log Report – they are periodically pulled and Complete the Radio Log Report – they are periodically pulled and
reviewed as apart of case reviewreviewed as apart of case review 93
THE EBOLA VIRUSTHE EBOLA VIRUS
• Important to understand…Important to understand…
• Information continues to be shared and is generally Information continues to be shared and is generally
generated by CDC and IDPHgenerated by CDC and IDPH
• As information is received at the EMS Resource As information is received at the EMS Resource
Hospitals, it is disseminated as soon as feasible to EMSHospitals, it is disseminated as soon as feasible to EMS
94
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 95
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
96
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
97
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…
• HANDWASHINGHANDWASHING98
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 99
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
100
EBOLA QUESTIONS FOR EVERY PATIENT EBOLA QUESTIONS FOR EVERY PATIENT CALLCALL
• ED’s and EMS being requested to ask screening ED’s and EMS being requested to ask screening
questionsquestions
• Yes/no to presence of any signs or symptomsYes/no to presence of any signs or symptoms
• Yes/no to travel history in past 3 weeks out of the Yes/no to travel history in past 3 weeks out of the
country by patient or close family memberscountry 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 101
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 102
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, intubation103
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)104
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
DICDIC105
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 carried out following the care and transport of each and every patientand every patient
• For possible Ebola infection, bleach and Cavicide wipes For possible Ebola infection, bleach and Cavicide wipes to be usedto be used
• Reminder: bleach based product required for use Reminder: bleach based product required for use following care of patient with diarrheafollowing care of patient with diarrhea
106
DISCUSSION OF PPE PRODUCTSDISCUSSION OF PPE PRODUCTS
• Minimum use of PPE products for suspected Ebola patient:Minimum use of PPE products 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 107
HOSPITAL ISOLATIONHOSPITAL ISOLATION
• Hospitals have established set procedures internally to Hospitals have established set procedures internally to
accept patients suspected of Ebola virusaccept patients suspected of Ebola virus
• Need to direct EMS to the selected roomNeed to direct EMS to the selected room• Best to minimize travel through patiBest to minimize travel through patient care areasent care areas
• Know what your facility policy is and if you are Know what your facility policy is and if you are
transferring patient out what that process istransferring patient out what that process is
108
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
109
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=17800000110
