Silver Cross EMS SystemSilver Cross EMS SystemNovember CMENovember CME33rdrd Trimester 2012 Trimester 2012

System announcements Legal aspects of pre-hospital care (ALS and BLS) Nasal medication review (ALS) Strip O’ the Month – Atrial Flutter

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Trimester testing is next month. Much better job pressing “take” on the

Pyxis! Keep it up! On PCR’s, please make sure to properly

indicate destination hospital! ◦ Easy to forget if you go to a hospital you don’t

usually go to.

Your best protection from liability is to perform systematic assessments, provide appropriate medical care, and maintain accurate and complete documentation.

Promptly respond to the needs of every patient.

Treat all patients and their families with respect.

Maintain your skills and medical knowledge. Participate in continuing education.

Critically review your performance, and constantly seek improvement.

Report honestly and with respect for patient confidentiality.

Work cooperatively and with respect for other emergency professionals.

Constitutional◦ Based on the U.S. Constitution

Common◦ Derived from society’s acceptance of customs

and norms

Legislative◦ Created by lawmaking bodies such as Congress

and state assemblies Administrative

◦ Enacted by governmental agencies at either federal or state levels

Criminal◦ Division of the legal system that deals with

wrongs committed against society or its members

Civil◦ Division of the legal system that deals with non-

criminal issues and conflicts between two or more parties

Tort◦ A civil wrong committed by one individual against

another

Incident Investigation Filing of complaint

Answering complaint

Discovery Trial Decision Appeal Settlement

Range of duties and skills EMT-B’s and Paramedics are allowed and expected to perform

Certification ◦ The recognition granted to an individual who has

met predetermined qualifications to participate in a certain activity

Licensure ◦ The process by which a governmental agency

grants permission to engage in a given occupation

Vary from state to state and govern operation of emergency vehicles and the equipment they carry

Federal Regs - KKK – 1822 NFPA 1917 (pending, will replace KKK in 2013) IL Vehicle Code (Chapter 625) IL EMS Act (210 ILCS 50/ ) IL EMS and Trauma Code (77 Ill Adm Code 515)

Spousal abuse (IL Domestic Violence Act - 750 ILCS 60/)

Abused & Neglected Child Reporting Act (325 ILCS 5/)

Elder Abuse & Neglect Act (320 ILCS 20/)

Abused and Neglected Long Term Care Facility Residents Reporting Act (210 ILCS 30/)

Sexual assault (720 ILCS 5/12-13, 14, 14.1, 15, 16)

Gunshot and stab wounds

Animal bites

Communicable diseases

Immunity◦ Exemption from liability granted to

governmental agencies Good Samaritan laws

◦ Provide immunity to certain people who assist at the scene of a medical emergency

Ryan White CARE Act◦ Requires notification and assistance to EMS

workers who have been exposed to certain diseases (has since been changed/worse for EMS)

Local laws and regulations

Deviation from accepted standards of care recognized by law for the protection of others against the unreasonable risk of harm

Duty to act Breach of duty Actual damages Proximate cause

A formal contractual or informal legal obligation to provide care

Breach of Duty

An action or inaction that violates the standard of care expected from a Paramedic

Malfeasance◦ Performance of a wrongful or unlawful act by a

Paramedic Misfeasance

◦ Performance of a legal act in a harmful or injurious manner

Nonfeasance◦ Failure to perform a required act or duty

Refers to compensable physical, psychological, or financial harm

Proximate Cause

An action or inaction that immediately caused or worsened the damage

A Paramedic or EMT’s medical director and on-line physician may be sued if:◦ Medically incorrect orders were given to the

Paramedic or EMT◦ There was a refusal to authorize the

administration of a necessary medication

A Paramedic or EMT’s medical director and on-line physician may be sued if:◦ The Paramedic or EMT was directed to take the

patient to an inappropriate facility◦ Negligent supervision of a Paramedic or EMT is

proven

While supervising an EMT-B or EMT-I, a Paramedic may be liable for any negligent act that person commits.

If medical care is withheld due to any discriminatory reason, a Paramedic or EMT may be sued. ◦Examples: Race Creed Color Gender Sexual orientation National origin Ability to pay (in some cases)

Performing procedures that require delegation from a physician, while off-duty, may constitute practicing medicine without a license.

Confidentiality ◦ The principle of law that prohibits the release of

medical or other personal information about a patient without the patient’s consent

◦ Health Insurance Portability and Accountability Act (HIPAA)

Established in 1996 ◦ Changed the methods EMS providers use to

file for insurance and Medicare payments.◦ Patients are given the right to inspect and

copy their health records.

Privacy protection for EMS patients◦ All EMS employees must be trained in HIPAA

compliance.◦ EMS providers must develop barriers to

unauthorized disclosure of patients’ protected health information.

◦ Disclosures of information—except for treatment, obtaining payment, health care operations, and disclosures mandated or permitted by law—must be preauthorized in writing.

◦ HIPAA requires providers to post notices in prominent places advising patients of their privacy rights.

◦ HIPAA provides both civil and serious criminal penalties for violations of privacy.

Defamation◦ An intentional false communication that injures

another person’s reputation or good name

Libel ◦ The act of injuring a person’s character, name, or

reputation by false statements made in writing or through the mass media With malicious intent or reckless disregard for the

falsity of those statements

Slander ◦ The act of injuring a person’s character, name, or

reputation by false or malicious statements spoken. With malicious intent or reckless disregard for the

falsity of those statements

A Paramedic may be accused of invasion of privacy for releasing confidential information, without legal justification, regarding a patient’s private life.◦ If it might reasonably expose the patient to

ridicule, notoriety, or embarrassment.

The fact that the information released is true is not a defense to an action for

invasion of privacy.

The granting of permission to treat a patient.

You must have consent before treating a patient.

Patient must be competent to give or withhold consent.

Consent based on full disclosure of the nature, risks, and benefits of a procedure.◦ Must be obtained from every competent adult

before treatment may be initiated.◦ In most states a patient must be 18 years old

or older to give or withhold consent.◦ In general, a parent or guardian must give

consent for children.

Verbal, nonverbal, or written communication by a patient who wishes to receive treatment.◦ The act of calling for EMS is generally considered

an expression of the desire to receive treatment.◦ You must obtain consent for each treatment

provided.

Consent for treatment for a patient who is mentally, physically, or emotionally unable to give consent.◦ It is assumed that a reasonable patient would

want life-saving treatment if able to give consent.◦ Another example: a child is injured, and the

parents are not around to give consent to treatment We can assume the parents want the child helped

Consent for treatment granted by a court order.◦ Patients who must be held for mental-health

evaluation or as directed by law enforcement personnel who have the patient under arrest.

◦ May be used on patients whose disease threatens a community at large.

Minors◦ Usually a person under 18 years of age.◦ Consent must be obtained from a parent or legal

guardian. A minor with a child can give consent for the child,

but not for herself (unless emancipated) In Silver Cross EMSS, a 16 year old driver, if involved

in an MVA and uninjured, can consent to a refusal Only the driver, and only in minor MVA’s

Mentally incompetent adult◦ Consent must be obtained from the legal

guardian.◦ If legal guardian cannot be found, treatment may

be rendered under the doctrine of implied consent.

Person under 18 years of age who is:◦ Married◦ Pregnant◦ A parent◦ A member of the armed forces◦ Financially independent living away from home

Emancipated minors may give informed consent.

A patient may withdraw consent for treatment at any time, but it must be an informed refusal of treatment.

Not every EMS run results in the transportation of the patient to the hospital.

Emergency care must always be offered to the patient, no matter how minor the injury or illness.

Is the patient legally permitted to refuse care?

Make multiple, sincere attempts to convince the patient to accept care.

Make sure the patient is informed in his or her decision.

Consult with on-line medical direction.

Have the patient and a disinterested witness sign a release-from-liability form.

Advise the patient he or she may call again for help.

Attempt to get someone to stay with the patient.

Document the entire situation thoroughly.

Violent Victim of drug overdose Intoxicated Ill or injured minor with no adult to provide

consent for treatment

Attempt to develop trust and some rapport with patient.

Regardless of type of problem patient, always document encounter in detail.

Adult psychiatric patients who are… Alert Oriented, Answer questions appropriately And are no danger to themselves or others

…have the right to refuse care.

Must sign refusal like anyone else, mental status must be completely documented on PCR.

Patients who…

display an inability to make a rational judgment

pose a threat to themselves or others

…may be treated/transported without consent and despite their refusal.

Illinois law says police can take patients into custody and transport them to hospitals for mental health reasons.◦ But that doesn’t always happen. ◦ Police often call EMS for psych evals.

If you can talk a psychiatric patient into going to the hospital voluntarily, that’s the ideal solution.

But if they refuse, and they meet transport criteria, someone has to sign a “petition”.

A petition is a paper form.◦ States someone feels someone else is danger to

self or others and requires involuntary treatment.

A petition does not “commit” someone. ◦ Just allows ER docs to move on to next step,

seeking involuntary admission to psych facility. If a judge does not approve the request

from the ER doc, nothing happens. The petition only gets the process rolling…

it’s not the end of the process.

Whomever witnesses dangerous or suicidal behavior can fill out a petition.◦ Family members◦ Bystanders◦ Police◦ Us (EMS)

Sometimes people are reluctant to sign petitions, because they feel like they are responsible for “committing” someone.

Sometimes police don’t want to fill out petitions because they don’t understand the process or were incorrectly told it’s our problem.

So: if paramedics or EMTs are the only witnesses to the behavior willing to fill out a petition, then they should do so… for the sake of their patient.

If you personally haven’t heard or seen dangerous statements/behavior, don’t sign.

◦ RN’s, docs, nursing home staff, police etc who tell you to sign when you have not personally heard/seen statements/behavior are incorrect.

◦ But again, if you personally have witnessed the behavior or heard the statements, you are well within the law to sign the petition yourself.

Find the person who witnessed the dangerous statements or behavior, and have them sign or come to hospital to sign. ◦ Call medical control for direction if not possible

Otherwise, once the patient gets to the ER, docs will have to let the patient go, unless ER staff witness the behavior as well.

Is patient willing to go voluntarily with a little persuasion?◦ Bring them in. Problem solved.

Is patient alert, oriented and appears to pose no harm to self or others?◦ Call medical control to authorize a release.

If family members or police complain:◦ Explain the petition process to them.◦ Explain patient can’t be transported involuntarily if no

one will admit witnessing suicidal/dangerous behavior.

Abandonment◦ The termination of the EMS-patient relationship

without assurance that an equal or greater level of care will continue

1. Assault 720 ILCS 5/12-1: A person commits an assault when,

without lawful authority, he engages in conduct which places another in reasonable apprehension of receiving a battery. (Class C Misdemeanor)

2. Battery 720 ILCS 5/12-3: A person commits battery if he

intentionally or knowingly without legal justification and by any means, (1) causes bodily harm to an individual or (2) makes physical contact of an insulting or provoking nature with an individual. (Class A Misdemeanor)

False imprisonment ◦ The intentional and unjustifiable detention of a

person without his or her consent or other legal authority

(IL – Unlawful Restraint – 720 ILCS 5/10-3)

Reasonable force◦ The minimal amount of force necessary to ensure

that an unruly or violent person does not cause injury to himself, herself, or others

Maintain the same level of care as was initiated at the scene.

Know the closest, most appropriate facility. Respect the patient’s choice of facility

without putting patient care in jeopardy.

A document created to ensure that certain treatment choices are honored when a patient is unconscious or otherwise unable to express his or her choice of treatment

A Living Will allows a person to specify what kinds of medical treatment he or she should receive.

In Illinois, EMS personnel cannot honor Living Wills in the field◦ Only DNR’s

If you ever have a question, contact medical control

Do Not Resuscitate Order (DNR) indicates

which, if any, life-sustaining

measures should be taken when the patient’s

heart and respiratory

functions have ceased.

In Illinois, a photocopy of a DNR is valid as long as it is a full copy.

The DNR must travel with the patient.◦ The family or nursing home staff must give the

DNR or a copy to you before transport.

Some systems have developed protocols that address organ viability after a patient’s

death.

A death in the field must be appropriately dealt with and documented by following local

protocol.

If you believe a crime has been committed, involve law enforcement.

Protect yourself and other EMS personnel.

Initiate patient care only when the scene is safe.

Preserve the scene as much as possible.◦ Observe and document anything moved.◦ Leave gunshot or stabbing holes intact if

possible.◦ If something must be moved, notify police on

scene and document your actions.

Complete promptly after patient contact. Be thorough. Be objective. Be accurate. Maintain patient confidentiality. Never alter a patient care record.

Both ALS and BLS providers are allowed to administer Glucagon and Narcan intranasally.◦ Mucous membranes in the nose are well suited for

quickly absorbing these medications.◦ Does not require IV/IO access or injections.◦ Quick and easy to give

For suspected opiate overdose◦ Heroin, vicodin, morphine, etc.◦ S/S include pinpoint pupils, altered mental status,

respiratory depression Narcan is an opiate “antagonist”, does not

allow opiates to bind properly with receptors in the central nervous system.

Remove MAD tip from syringe. Draw up Narcan 2ml (1mg/ml) and replace

the tip.◦ Or put tip on luer-lock prefilled syringe

Tilt patient’s head back if possible Put atomizer in nostril, advance until sealed

against opening. Depress plunger briskly

◦ 1ml in each nostril

For low blood sugar (under 60) when IV not available for glucose.◦ For BLS providers when patient cannot take oral

glucose. Glucagon causes the liver to convert stored

glycogen into glucose. Comes in powder that must be mixed with

saline.

Reconstitute Glucagon 1mg in 1ml sterile water.

Remove MAD tip from syringe Draw up reconstituted Glucagon (1mg/ml)

and replace tip back on syringe. Tilt patient’s head back if possible Put atomizer in nostril and advance until

sealed against opening Depress plunger briskly.

◦ 0.5 ml in each nostril

Firefighter/paramedic Matt Bozicevich, one of our Silver Cross instructors, will now demonstrate the use of the nasal atomizer.

If you are watching live, the sound will come from your speakers, not your phone.

If you are watching the pre-recorded version, the video should be included. ◦ If not, or if you are attending an in-person

presentation, check out the youtube link at:◦ http://youtu.be/oNABe93SN1g

Results from a rapid reentry circuit◦ 250-350 beats per minute

AV node blocks conduction in a regular fashion

Electrical stimulation slower than AFib AV blocking is usually in a fixed ratio (ie. 2:1

or 3:1) Well tolerated arrhythmia if controlled rate Often in conjunction with AFib

Atrial Flutter

Common causes are:◦ Mitral or tricuspid valve disorder◦ Rarely occurs as result of an AMI◦ Atrial enlargement or dilation◦ Pulmonary embolus◦ Hypoxia◦ Quinidine toxicity

Rhythm analysis◦ More P waves than QRS complexes◦ Rhythm is regular with atrial rate faster but in

direct proportion to the ventricles◦ P waves resembles “sawtooth” pattern and are

called F waves or Flutter waves◦ QRS is <.12 seconds

Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of

Elsevier Inc.

Atrial flutter with 2:1 conduction

Atrial flutter with 4:1 conduction

USEFUL TRICK…

USUALLY 2:1 CONDUCTION=150 BPM

Treatment:◦ Some patients don’t have symptoms related to

their flutter.◦ So treat the patient, not the monitor.◦ If a 2:1 flutter, will look identical to SVT

So treat accordingly, like any other SVT Vagal maneuvers and adenocard if stable Sedation and cardioversion if unstable

Questions? If you are watching the live presentation, feel free to type questions in the text box to the right.

If you are watching the pre-recorded version or the Powerpoint, email afinkel@silvercross.org with questions.

Or call 815-300-7425 with questions!