Transcript Legal Implications - Advocate Health Care

LEGAL IMPLICATIONS
PSYCHIATRIC
CONSIDERATIONS
EBOLA
Mod IV 2014 ECRN CE
Condell Medical Center EMS System
Site Code #107200E-1214
Prepared by: Sharon Hopkins, RN, EMT-P, BSN
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OBJECTIVES
Upon successful completion of this module, the ECRN will
be able to:
1. Define Munchausen by proxy syndrome, anorexia, bulimia
2. Describe situations when it is appropriate to obtain consent for medical care
from emancipated minors versus pregnant minor versus minor parent
3. Describe characteristics and EMS interventions for a variety of behavioral
emergencies.
4. Describe the difference between voluntary and involuntary committal and
EMS responsibilities.
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OBJECTIVES CONT’D
5. Describe the assessment and field care of the patient that has been
Tasered.
6. Describe the restraining of a patient via physical and chemical
methods when in the field.
7. Review a variety of advanced directives.
8. Describe the State of Illinois revised POLST form and
implications for EMS.
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OBJECTIVES CONT’D
9. Describe the implications of the Ebola virus and EMS care of the patient
10. Review the case scenarios presented.
11. Review selected Region X SOP’s included in the module.
12. Evaluate and review a variety of EKG rhythms and 12 lead EKG’s.
13. Successfully complete the post quiz with a score of 80% or better.
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SCENE SAFETY
• First step in any patient approach
• You do everything possible to make the environment safe
• For yourself
• For your team/peers
• For other responding personnel
• For the patient
• For others around
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SCENE SAFETY
• Establish a safe perimeter
• Evaluate the safety of the environment before entering
• Call for help as necessary
• EMS may need to stage which could delay patient contact
• EMS to document any delays
• The reason for staging
• Interventions taken to make the environment safe
• When you made patient contact
• FYI -This information also applies to ED staff
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SCENE SAFETY
• Never let your guard down
• Use those eyes in the back of your head
• If it doesn’t feel right, do not enter an area
• Keep yourself closest to the means of exit
• Never let yourself be cut off from egress
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MUNCHAUSEN SYNDROME
• A mental disorder
• Sufferer causes or pretends to have physical or
psychological symptoms
• Typical patient is an adult 20-40 years old
• Thought to be motivated by a desire to be seen as ill versus
other benefit
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MUNCHAUSEN SYNDROME BY PROXY
• Considered a mental illness of factitious disorders
• Considered a relatively rare form of child abuse
• Caretaker fakes or causes symptoms in a child
• Often caretaker has familiarity with medical knowledge
• Affected persons usually under 4 years old
• Most of the time the mothers are the perpetrators
• Often more than one child victimized per household
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EMS ROLE IN MUNCHAUSEN’S
• Be objective in report and documentation
• Need to site source of information provided (“_____ states…”)
• May take years to prove the presence of this mental illness
so EMS and ED staff may not have knowledge of this diagnosis
• Caregiver must admit to the abuse and be willing to seek
psychological treatment
• Psychological and physical damage to victim could lead to poor
long-term prognosis
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ANOREXIA
• An eating disorder that is a real, treatable medical illness
• Has distorted body image of self; typically female
• Has an intense fear of gaining weight
• Thinks about food a lot but limits intake
• Uses starvation to feel more in control of life
• Uses starvation to ease tension, anger, anxiety
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FACE OF ANOREXIA
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ANOREXIA
• Body slows down due to lack of source of energy to continue
to function
• Patient suffers impairments
Brain function
Infertility
Dental decay
Kidney failure
Cardiac arrest
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BULIMIA
• Serious, potentially life-threatening eating disorder
• Preoccupied with body shape and weight
• Patients usually secretly binge and purge
• Binge – eat large amounts of food
• Purge – self-induce vomiting or misuse of laxatives, diuretics
or enemas after binging or fast
• Can follow a strict diet or participates in excessive exercise
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BULIMIA
• Serious and life-threatening complications
Dehydration
Heart problems
Severe tooth decay and gum disease
Absence of periods in females
Digestive problems; possible dependence on laxatives
Anxiety and depression
Drug and alcohol abuse
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CYCLE OF BULIMIA
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COMPLICATIONS OF EATING DISORDERS
• Self-induced vomiting – oral complications
• Erosion of tooth enamel from exposure to gastric acid
• Sensitivity to hot/cold foods
• Oral swelling or soreness
• GI tract complications especially with bulimia
• Ulcers, ruptures, strictures of esophagus from repeated
vomiting
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COMPLICATIONS CONT’D
• Infertility due to lack of periods
• Continual use of laxatives – colon function problems
• Loss of normal function
• Electrolyte imbalance with misuse of diuretics and laxatives
• Fetal harm if pregnant
• Low birth weight, premature labor, post-partum depression
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THE DESTRUCTION FROM ANOREXIA
• Body and muscles are being starved
• Heart muscle atrophies; high risk for heart failure
• Drop in sodium, zinc, potassium and calcium put the patient at
increased risk for abnormal heart rhythms (SVT, VT, bradycardia)
• Kidney failure can develop due to dehydration
• Sudden cardiac death often due to dysrhythmias due to electrolyte
imbalance and mineral disturbance
• Common presentations: orthostatic hypotension, shock, CHF, sudden
death
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TREATMENT FOR EATING DISORDERS
• Counseling is a must for psychotherapy
• Antidepressants may help
• Works with a nutritionist for an eating plan
• Hospitalization may be necessary
• Slightly higher recovery rate and better long-term prognosis
for bulimia than anorexia
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IMPLICATIONS FOR EMS & ED
• Maintain heightened awareness for the situation
• Overall low body weight
• Poor dentition
• From repeated vomiting and poor nutritional state
• Incomplete/inaccurate history provided by patient
• Denial of any problems by patient
• Note: Cardiac monitoring should be considered due to potential for
electrolyte imbalance and resulting cardiac dysrhythmias
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DEFINITIONS
• Emancipated minor – minor of any age who is or has been
married or minor over 16 and under 18 who by court order
has been freed from care, custody, and control of parents
• Did you know - Emancipation does NOT extend to specific
constitutional and statutory age requirements regarding
voting, use of alcoholic beverages, possession of firearms
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CONSENT FOR MEDICAL CARE
• May be obtained from
Any person 18 and older
Emancipated minor
Minor who is married
Minor who is pregnant
Minor who is a parent
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OBTAINING CONSENT FROM MINOR
• Healthcare professionals shall not incur civil or criminal liability for
failure to obtain valid consent when they relied in good faith on the
representation made by the minor
• This means you can take consent at face value when the minor
states they have the authority to provide consent
They are emancipated from parental care
They are or have been married
They are pregnant
They are a parent with custody of their child (extends to the
mother and the father if they are a custodial parent)
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IMPLIED CONSENT
• Emergency exception rule based on the assumption that a reasonable
person would consent to emergency care if able to do so
• Medical professional may presume consent and proceed with
appropriate treatment:
• Child is suffering from emergent condition and life or health is in danger
• Legal guardian unavailable or unable to provide consent
• Treatment or transport cannot be safely delayed waiting for consent
• Treatment rendered limited for emergent conditions that are posing an
immediate threat to child
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EMS AND CONSENT
• Burden of proof falls on medical professional when treating minor without
proper consent
• Need to justify and document that emergency actions were necessary to
prevent imminent and significant harm to child
• Generally considered as emergent conditions includes treatment of fractures,
infections, pain control
• Always act in best interest of patient
• Clearly document nature of emergency and reason minor required
immediate treatment and/or transportation and efforts made to contact legal
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guardian
INFORMED CONSENT AND LANGUAGE
BARRIER DURING EMS CARE
• Interpretation can be performed in person, via videoconferencing or
by telephone
• Certified medical interpreter preferred
• Using family members should be avoided unless absolutely necessary
• Translation may not be accurate
• Document use of interpreter
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IN LOCO PARENTIS
• A Latin term meaning in place of or instead of the parent
• Relationship is similar to that of a parent and a child, but with
limitations
• Original intent was for the care, supervision, and discipline of a child
• Parent, guardian, or person in loco parentis can consent to emergent
medical treatment
• Generally inferred most commonly onto teachers but also could
include babysitter
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SITUATIONS OKAY TO OBTAIN CONSENT
FROM A MINOR
• Emancipated minor by court order
• Married minor
• Pregnant minor
• Minor (mother and/or father) who is a custodial parent
• For treatment of a sexually transmitted disease (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 outpatient mental health treatment (12 years or older)
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PUBLIC ASSUMPTIONS
• The paramedic is medically trained so they must know what
they are talking about;
• “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
swayed that nothing is wrong and transport is not warranted
• Transport can be expensive; some paramedics may
capitalize on the patient’s financial fears
• EMS needs to consider: Do you want to be responsible for
the one call you talked down who had a bad outcome???
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CASE REPORTS
• The following 3 cases are real events
• They DID NOT happen in this area
• Be open to learn lessons from other’s mistakes
• Decide how you would have handled the call if EMS had
contacted you for directions
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CASE REPORT #1
• EMS was called for an adult patient with chest pain past few hours
• EKG showed sinus rhythm
• Vital signs were stable
• Lung sounds were clear
• The patient was convinced by EMS it was acid reflux
• A release was obtained
Was this call handled appropriately?
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OUTCOME CASE REPORT #1
• Hopefully, EMS would do a cardiac work-up and transport this
patient
Outcome report:
• The responding paramedic’s general impression was that the
patient had acid reflux, suggested antacids and left the scene
after the patient signed AMA
• The patient took the antacids
• The patient died 3 hours after being evaluated by EMS
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CASE REPORT #2
• EMS was called for a 4 year-old child having an asthma attack
• Bilateral wheezes were auscultated
• EMS convinced the mother the patient was only suffering from croup
• The mother was instructed to put the child in the bathroom and run the
shower for the steam
• A release was obtained
Was this call handled appropriately?
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OUTCOME CASE REPORT #2
• The mother followed instructions and placed the child in a
steamy bathroom
• The child “fell asleep”; “breathing wasn’t a struggle”
• The mother assumed her child was more relaxed
• The child died due to a severe asthma attack
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CASE REPORT #3
• EMS summoned by police to respond to a reported suicide attempt
• Dispatch states they received a call from the patient's friend who stated
they were threatening to commit suicide by overdose
• EMS assesses the patient who has stable vital signs
• Patient states they were just venting to their friend and didn’t really
take any pills
• Pill bottles offered were checked and levels seemed appropriate
• EMS obtained a release
Was this call handled appropriately?
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OUTCOME CASE #3
• Boy, this one is TOUGH!!!
• This paramedic did not talk patient out of going to the
hospital but neither did they encourage her to go
• Patient was left at home alone
• The patient was found dead the next morning
• Should EMS have involved Medical Control in dialogue???
• Hopefully, yes. Doesn’t mean the outcome would have been
different
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RELEASES/REFUSALS
• EMS to respond to each call assuming every one will be a transport
• EMS to work harder at convincing them to be transported than accepting them
as a refusal/release
• Patients are aware of your attitude – show yours as positive
• EMS to contact Medical Control for all controversial or questionable
releases/refusals
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OBTAINING A RELEASE
• Patient must demonstrate decisional capacity in order to give consent
for a release or refusal
• A patient who is decisional, awake & oriented and understands the
risks and benefits has the right to refuse consent (even when you feel
the decision made is not in their best interest)
• Police do not have the right to make the person in custody receive
medical assistance if they refuse it (i.e.: laceration, pain)
• Just because a person has had alcohol does not make them
non-decisional
• Every case needs to be evaluated on its own
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EMS AND REFUSALS
• Medical Control cannot “order” a patient to receive care and/or be
transported if they have decisional capacity and are refusing
• Transporting a patient with decisional capacity against their will could
be kidnapping
• People have the right to make poor decisions
• The medical team must make sure we have explained the risks and
benefits to the patient and this is documented
• We all have horror stories of the patient who refused
care/transportation and then had a negative outcome but it is the
patient’s right to refuse IF they are decisional
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CHARACTERISTICS OF BEHAVIORAL
EMERGENCIES
• A call involving interaction with a patient whose behavior is
Unusual
Bizarre
Threatening
Dangerous
• Behavior not generally accepted by society
• Requires intervention from medical personnel
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OBJECTIVE INDICATIONS OF BEHAVIORAL
ISSUE
• Actions or situations that:
• Interfere with activities of daily living (dressing, eating
sleeping, maintaining housing)
• Pose a threat to the life or well-being of the patient or others
• Significant deviation from society’s expectations or norms
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AVOID TUNNEL VISION
• Always keep in mind medical conditions that may be
presenting as a behavioral issue
Diabetes
Trauma
Brain disorder / neurological condition
Medication influence
Recreational drug use
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DELIRIUM
• Relatively rapid, acute onset (hours to days)of widespread
disorganized thought
• May be reversible
• Patient has inattentiveness
• Memory impairment
• Disorientation
• Clouding of consciousness
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DEMENTIA
• Irreversible process that develops slowly over months
• Consists of memory impairment and cognitive disturbance
• Many common causes
• Alzheimer’s disease
• Vascular problems
• AIDS
• Head trauma
• Parkinson’s disease
• Substance abuse
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SCHIZOPHRENIA
• A significant change in behavior and loss of contact with
reality
• Common signs, symptoms, types
• Hallucinations
• Delusions
• Depression
• Flat affect
• Paranoid
• Disorganized behavior, dress, speech
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EXCITED DELIRIUM
• Sudden onset of unexplained aggressive behavior
• Often accompanied by profuse sweating, high body temp, and delusional
behavior
• Often linked to a history of chronic cocaine abuse
• Cocaine abuse contributes to development of coronary artery disease and
damage to the heart muscle
• Aggressive chemical sedation required
• Continued physical struggle increases catecholamine surge and metabolic
acidosis; sedation at this point can be life-saving
• Per Region X SOP’s for sedation, EMS will administer Versed 2 mg IN
• Can repeat every 2 minutes up to 10 mg
• For additional sedation, Valium is given; IV or IM
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CASCADE OF EVENTS OF EXCITED DELIRIUM
• Patient is agitated
• There is a struggle with the patient
• Increased O2 demand; if compromised airway cannot increase O2 supply
• Energy stores (i.e.: glucose) are quickly depleted
• There is an adrenalin overdose from the increased & aggressive activity
• Excessive lactic acid created as a by-product
• Heart is stressed from the exertion and adrenalin rush
• Respiratory muscles will begin to fail
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RHABDOMYOLYSIS –
RESULTS FROM THE STRUGGLE
• Breakdown of myoglobin – a by-product in muscles
• Causes myoglobinemia – the protein myoglobin released into
blood
• Intramuscular acidosis develops
• Kidneys try to filter the dead muscle cells, eventually clog and
then begin to fail
• Patient presents with muscle weakness or flaccidity
• May present with nausea and vomiting
• Vomiting increases the risk of aspiration
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FIELD TREATMENT RHABDOMYOLYSIS
Urine sample due to
rhabdomyolysis
• Fluid hydration
• 200 ml increments; repeated as necessary
• Watch for fluid overload
• Monitor breath sounds
• Monitor cardiac rhythm
• Watch for dysrhythmias induced by acidosis and electrolyte
imbalance
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EMS APPROACH FOR COGNITIVE
DISORDERS
• Patient suffers from significant impaired social or
occupational functioning
• Approach in the field is supportive
• Additionally assess and manage for medical conditions
• Don’t get tunnel vision or distracted
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TYPES OF PSYCHIATRIC COMMITTAL
• Informal voluntary admission
• Patient can terminate stay after 240
• Formal voluntary admission
• Patient signs self in and agrees to stay until MD discharges them
• Patient has right to request discharge at any time
• Involuntary admission
• Admitted against patient’s will for a minimum of 720 and then must be
examined and then can be kept or must be discharged
• If suicidal, homicidal, psychotic, unable to care for self, MD must arrange
court hearing within 5 days for a judge to keep or discharge patient
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INVOLUNTARY COMMITTAL LAW
• Allows placement of any individual in treatment that because of the
nature of their illness, is unable to understand their need for treatment
and who, if not treated, is at risk of suffering or continuing to suffer
mental deterioration or emotional deterioration, or both, to the point
that the person is at risk of engaging in dangerous conduct
• Involuntary commitment can be made by family members, mental
health professionals, and police officers
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COMMITTAL PAPERWORK
• ED practice is to transfer patients to psych facilities with involuntary
paperwork completed
• This prevents the “voluntary “ patient from getting to the in-patient facility
and then “changing their mind” about admission
• The person directly witnessing the behavior or hearing the comments
must be involved in completing the documentation
• Hearsay is not valid or allowable in these situations
• EMS will complete their own patient care run report
• To keep information objective and descriptive
• May be asked to complete witness observations only if EMS was direct
witness to behavior/language and ED staff is not
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PETITION FOR INVOLUNTARY/JUDICIAL
ADMISSION
• Witness to state in detail signs and symptoms of mental illness
displayed
• Can include prior diagnosis, treatment and hospitalizations
• Objectively describe any threats, behavior or pattern of behavior
which supports the complaint
• Can include personal observations that lead to your belief for
involuntary admission
• The address and phone number on commitment papers can be given
as your work information
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TRANSPORTS OF PSYCH PATIENTS
• When EMS does not witness the “psych” behavior
• These cases are VERY difficult
• They often pin one person against another
• They sometimes come down to a “he said/she said” struggle
• Always act in the best interest of the patient
• EMS should involve Medical Control for these unclear calls
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FIELD CARE OF PATIENT TASED
• EMS to evaluate depth of skin penetration
• Darts NOT removed if patient is not under control
• Darts NOT removed but stabilized and patient transported if:
• Dart in lid/globe of eye
• Dart in face or neck
• Dart in genitalia
• Dart in bony prominence
• Dart in spinal column
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REMOVAL OF DARTS
• Taser cartridge removed from gun or wires cut
• One hand placed on patient next to embedded dart to stabilize
surrounding skin
• Probe firmly grasped with other hand
• Dart removed by gently pulling straight out
• Dart is inspected to assure it is intact; take sharps precautions
• Darts returned to law enforcement or disposed of as a sharps
• Wound cleansed with saline
• Site covered with a dry dressing (i.e.: band aid)
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RESTRAINTS
• High risk, low volume task
• Use of restraints puts the provider and organization at risk
legally AND in the court of public opinion
• Remember:
• You are treating a patient, not a criminal
• Combative issues are symptoms of the illness or injury
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PRINCIPLES OF USE OF RESTRAINTS
• Restraints used only after verbal de-escalation attempted
• Situations exist where immediate use of restraints is required
• Restraints should be individualized
• Make reasonable attempts to protect patient’s privacy and dignity
• Method used should be least restrictive necessary for protection
of patient and others
• Need to be trained in use and application and monitoring of
patient
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PRINCIPLES CONSIDERED WHEN USING
RESTRAINTS
• Medical and legal issues
• Medical ethics
• Scene safety and assessment
• Patient assessment
• Psychological causes of
combative patients
• Proper team patient-restraining
techniques
• Knowledge of chemical-restraint
pharmacology
• Airway control
• Reassessment
• Documentation
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CONSIDERATIONS
• Once a patient is restrained, providers must take full
responsibility for the patient’s welfare
• Frequent reassessment of airway and breathing
• Frequent reassessment of distal movement, sensation, and
circulation of extremities
• The same standard of care that would have been provided
for the unrestrained patient would still need to be performed
• Clear documentation is required if any expected care was withheld62
RESTRAINT PRINCIPLES
• Objective and detailed reasons need to be documented
indicating need of restraints
• Document alternative methods attempted to avoid restraints
• i.e.: verbal de-escalation
• Document type of restraint applied
• Document periodic assessment/reassessment of patient
• Include assessment of airway status and distal circulation of
restrained extremities
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ADVANCED DIRECTIVES
• Legal documents
• Spells out your wishes for end-of-life care
• Several types/forms available
• Living will – describes care when dying or unconscious
• Cannot be honored by pre-hospital providers
• Durable Power of Attorney for Healthcare
• Allows patient to name health care proxy
• Proxy can speak up only when patient is unconscious or unable to make
medical decisions
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POLST
• Physician Orders for Life-Sustaining Treatment
• A signed medical order that travels with patient
• In Illinois, POLST is the revision of the IDPH Uniform DNR
Advanced Directive
• Allows patient to create medical orders reflecting treatment
wishes at end-of-life
• Helps health professionals know and honor wishes of patient
• Allows emergency personnel to facilitate patient wishes
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POLST
• Does not take place of Power of Attorney for Healthcare form
• Used in addition to that form
• Without a POLST or IDPH Uniform DNR Advanced Directive, EMS
must do what they can to attempt to save a person’s life
• EMS cannot accept the word of the family regarding what the
wishes of the patient would have been
• EMS must begin resuscitation as they contact Medical Control
• POLST photocopies are acceptable
• 2nd page of POLST form does not have to be completed; can be
left blank
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COMPLETING POLST FORMS
• Signed by patient or representative
• As a physician order, signed by a physician
• Effective date is noted
• Witness signature is obtained
• On page #1, section A, B, C, D, and/or E must be completed
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FOLLOWING POLST/DNR GUIDELINES
• Healthcare professional or healthcare provider may presume
a DNR is valid
• …who in good faith complies with a DNR order is not subject
to any criminal or civil liability except for willful or wanton
misconduct and may not be found to have committed an act
of unprofessional conduct
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• Subsection (d) of Section 65 HealthCare Surrogate Act, 755 ILCS 40/65
CASE SCENARIOS
• Review the following cases
• Prepare to discuss how YOU would respond to EMS in
that situation if they contacted Medical Control
• Be prepared to support your decisions/orders to EMS
• Region X SOP’s
• Standard of Care
• By what is just the right thing to do
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CASE #1
• EMS was called to the scene for a 32 year old
female with dizziness who passed out
• Patient appears very thin, warm and pale
• Is awake, answering all questions, cooperative
• What’s your general impression?
• What is the treatment of choice?
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CASE #1 – WHAT’S THE RHYTHM???
• Sinus bradycardia
• What would make you consider that the patient is
symptomatic, in need of intervention?
• Decreased level of consciousness, blood pressure <90 systolic
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CASE #1
• What is the treatment for unstable sinus bradycardia per
Region X SOP’s?
• Atropine 0.5 mg rapid IVP/IO
• Prepare for TCP
• If atropine is ineffective, administer sedation with Valium 2mg
IVP/IO over 2 minutes
• Begin TCP
• Rate 80/minute, sensitivity auto/demand
• Start mA at 0 and increase until capture is confirmed
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CASE #1
• What could be used as listed in the Region X SOP’s for discomfort
caused during the use of the TCP?
• Valium 2 mg IVP/IO over 2 minutes
• This takes the edge off and relaxes patient
• May be repeated every 2 minutes as needed to a max of 10 mg
• What would be used for management of pain per Region X SOP’s?
• Fentanyl 1 mcg/kg IVP/IO/IN
• May repeat same dose in 5 minutes
• Max total is 200 mcg
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CASE #1
• Patient’s rhythm changes and patient loses consciousness
• Now what is the rhythm?
• Polymorphic VT / Torsades de pointes
• What determines which treatment to follow?
• If patient has a pulse or not; if patient is relatively stable or unstable
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CASE #1
• Patient is pulseless and apneic with polymorphic VT
• What is the treatment plan now per Region X SOP’s?
• Immediate defibrillation
• Followed by rapid initiation of CPR (30:2)
• Establishment of IV access
• Epinephrine 1:10,000 1 mg IVP/IO
• Repeated every 3-5 minutes
• Amiodarone 300 mg IVP/IO 1st dose
• 150 mg for 2nd dose in 3-5 minutes
• Antidysrhythmic alternated with the vasopressor used
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CASE #1
• If the patient with polymorphic VT had a pulse and was
relatively stable (talking to you, had a palpable radial pulse
(therefore a B/P), what would EMS do per Region X SOP’s?
• Amiodarone 150 mg
• Diluted in 100 ml D5W
• Administered IVPB over a minimum of 10 minutes
• If patient was unstable, what would EMS do?
• Synchronized cardioversion with sedation (if time to give)
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CASE #1 – UNSTABLE VT
• Consider sedation if time to administer
• Versed 2 mg IVP/IO every 2 minutes titrated to max of 10 mg
• Begin electrical therapy
• Synchronized cardioversion 100 joules
• Antidysrhythmic medication to begin – to give time to be effective
• Amiodarone 150 mg diluted in 100 ml D5W IVPB
• Run over at least 10 minutes
• Watch for hypotension – slow rate down if occurs
• Continue cardioversion attempts at 200 j, then 300 j, then 360 j
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CASE #2
• EMS is on the scene for a 72 year-old patient who “stopped
breathing”
• Upon arrival family is present; patient last seen a few minutes ago
• Family states the patient has a DNR (but not present)
• Patient confirmed 0-0-0
• What should EMS do?
• Ask to see the DNR
• EMS needs to begin CPR in absence of DNR paperwork
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CASE #2
• What would EMS do if the family could not produce the DNR form?
• EMS needs to begin CPR and then contact Medical Control for orders
• What information would be important to provide to Medical Control?
• Circumstance of how patient found
• Patient history
• Family verbalizing that there is a DNR but unable to produce
• Fact that CPR has been begun
• Initial rhythm on the monitor
• EMS should be specific and request permission to withdraw CPR
efforts if that is what they want
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CASE #2 – WITHDRAWING RESUSCITATION
SOP
• EMS to include in report to Medical Control
• Patient is normothermic
• If arrest was witnessed or unwitnessed
• How airway is secured and if IV access is established
• That rhythm remains asystole
• Any interventions performed up to that point
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CASE #2
• EMS documentation of withdrawing resuscitation
• Note time of withdrawal of efforts
• Document name of physician on run report
• Document notification of coroner or Medical Examiner
• EMS does not need to remain at the scene if scene turned
over to police
• If leaving the body at the scene is a problem, EMS is to
contact the hospital to inform of transport to get the patient
off the scene
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CASE #2
• What if EMS is ordered to work the call???
• What is the rhythm?
Asystole
• What does EMS (and in general, medical personnel) do for
asystole?
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CASE #2 - ASYSTOLE
• Lots of CPR; 10 second pauses every 2 minutes to reevaluate the
rhythm
• NO PULSE CHECKS
• Unless a rhythm is produced that should provide a pulse!
• Consider possible causes – the H’s and T’s
• 200 ml fluid challenge if breath sounds clear
• Repeat as needed
• A vasopressor is the only med intervention
• Epinephrine 1:10,000 – 1 mg IVP/IO
• May be substituted with Vasopressin 40 units one time 1st or 2nd round dose
• Region X EMS does not carry Vasopressin – FYI: some Regions do
• Every 3- 5 minutes for the duration
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CASE #3
• EMS responds to a bar for an injured patron
• Patron tripped and fell
• Received laceration to palm; bleeding controlled
• Admits to having 2 beers
• Patron does not want your care
• Now what should EMS do???
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CASE #3
• EMS needs to determine the decisional capacity of the patron
• Does the patient have the ability to understand and appreciate the nature
and consequences of refusing assessment and care?
• EMS assessment for decisional capacity
• Affect – behavior appropriate for the environment?
• Behavior –patient remains in control?
• Cognition / judgment – can patient understand the information?
• Patient insight – does patient appreciate the implications of
situation?
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CASE #3 – THOROUGH DOCUMENTATION
• Decisional capacity
• Assessment performed
• Understanding of EMS impression and attempts by EMS to
convince patient to accept treatment and/or transportation
• Any EMS concerns about accepting a refusal
• Risks and benefits provided to the patient
• Involvement of Medical Control
• Instructions to patient to seek medical care if condition
changes
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CASE #4
• EMS is called to the scene of a MVC – category III trauma
(non-I and non-II category trauma)
• EMS has a 17 year-old patient who is refusing transportation
• The patient states she is 3 months pregnant
• EMS has the 17 year-old boyfriend also refusing
transportation
• Can these patients sign refusals?
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CASE #4
• Who can sign a refusal in this scenario?
• A pregnant minor can sign a refusal
• A custodial parent who is a minor can grant permission for
themselves and their child
• The boyfriend cannot sign a refusal unless he becomes a
custodial parent of his child
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CASE #5
• EMS is called for a 16 year-old female patient and her
4 month-old child
• They were involved in a minor MVC
• The patient is refusing transportation for herself and her
child
• How would you handle this call from EMS?
• A minor who is a custodial parent of their child has the right to
refuse medial care for themselves and their child
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CASE #6
• EMS is called to the scene for a patient who is threatening to
hurt themselves
• The threats were witnessed by family and police; not by EMS
• What should EMS do if the patient refuses transport?
• Can this patient refuse transport?
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CASE #6
• This patient made threats witnessed by police and family
• Therefore, patient not allowed to sign a refusal
• EMS CANNOT be the one to complete an involuntary petition
• Only those persons who have first hand knowledge as
witnesses can complete the involuntary documentation of the
behavior
• The police or family would be involved in completing the
form with hospital staff
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ADDITIONAL REMINDERS OF LEGAL
IMPLICATIONS AND EMS
• Hospital on by-pass
• Must still accept all critical/unstable patients in life threatening
conditions
• May need to clarify in report what the patient’s condition is
• Of course, this is usually the worst time for ED to receive another
patient
• But these patients need to be transported to the closest appropriate
hospital
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ADDITIONAL RADIO ETIQUETTE
• Focus attention on the report being provided
• Formulate clarifying questions on what is NOT said in report
• ECRN should appropriately activate codes (per ED policies/procedures)
(i.e.: trauma, cardiac, stroke) based on EMS report
• Know the radio calls are recorded – keep them professional
• Complete the Radio Log Report – they are periodically pulled and
reviewed as apart of case review
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THE EBOLA VIRUS
• Important to understand…
• Information continues to be shared and is generally generated
by CDC and IDPH
• As information is received at the EMS Resource Hospitals, it is
disseminated as soon as feasible to EMS
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GOALS OF DISSEMINATING INFORMATION
• Educate/inform to increase detection of possible
Ebola cases
• Protect healthcare workers and general public
• Provide guidelines directing appropriate response
for caring of patients
• Imperative to keep up to date with revised material
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EBOLA VIRUS DISEASE/
EBOLA HEMORRHAGIC FEVER
• A rare, deadly disease caused by infection with the virus strain
• 4 of 5 strains can cause disease in humans
• Virus found in several countries in West Africa
• First discovered in 1976
• Unknown who the natural host site is but most likely animal borne
• Bats the most likely reservoir
• 2 – 21 day incubation period (average 8-10 days) after contact
with Ebola patient
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EBOLA TRANSMISSION
• Direct contact with broken skin or via mucous membranes
(eyes, nose, mouth) with contaminated blood or body fluids
• Ebola is NOT spread via casual contact
• Contact with contaminated objects
• Contact with infected animals
• NOT spread via air, water, or general food
• In Africa, could be spread after handling bushmeat or
contact with infected bats
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STANDARD PRECAUTIONS FOR EVERY CALL
• Taking blood and body fluid precautions
• Reduces risk of transmission of bloodborne pathogens
• Need to apply these principles to ALL patients you care for
• Appropriate PPE’s need to be available AND used
• The process of removing protective gear is just as important
as donning them
• Remember the simplest standard precaution which is often
the most neglected…
• HANDWASHING
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EBOLA SCREENING
SIGNS & SYMPTOMS
ANY OR ALL MAY BE PRESENT
• Fever
> 38.60C or 101.50F
• Diarrhea
• Severe headache
• Abdominal pain
• Muscle/joint pain
• Hemorrhage – bleeding
or bruising
• Weakness/fatigue
• Vomiting
• Lack of appetite
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EBOLA SCREENING QUESTIONS
• After/while screening for signs and symptoms, inquire about
travel
• West Africa (Guinea, Liberia, Sierra Leone, Senegal, Nigeria,
or other countries where Ebola transmission has been
reported by WHO
• Travel would have been within past 21 days/3 weeks of
symptom onset
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EBOLA QUESTIONS FOR EVERY PATIENT
CALL
• ED’s and EMS being requested to ask screening questions
• Yes/no to presence of any signs or symptoms
• Yes/no to travel history in past 3 weeks out of the country by
patient or close family members
• Also question regarding the history of a cough
• Remember, there are still other diseases we need to be vigilant
about like TB
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ISOLATION FOR SUSPECTED CASES OF
EBOLA
• If patient has positive signs and symptoms AND travel within
past 21 days, then isolate patient
• Standard precautions
• Performed for every patient contact
• Handwashing still very important
• Contact isolation – fluid impermeable gown and gloves
• Add shoe covers in certain situations
• Eye and face masks/shields
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ISOLATION CONT’D
• Droplet precautions
• Particles are heavy and do not stay suspended in air for long
• Transmission via talking, coughing, sneezing
• 6 feet is safer distance than 3 feet
• In general droplet precautions, can wear surgical mask if
within 6 feet of patient
• If Ebola virus suspected, must wear N95 mask
• Not just if providing aerosol-generating procedures
• Nebulizer treatments
• Suctioning, intubation
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HAND HYGIENE
• Remains extremely important
• If hands not visibly soiled, can use 60-95% alcohol based
hand sanitizer
• Use soap and water for 15 seconds
• When hands visibly soiled
Did you remember hand washing over hand sanitizer for:
For contact with clostridium (infection in colon)
For contact with norovirus (inflammation of stomach &/or
intestines)
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TREATMENT OF EBOLA
• No approved specific treatments currently available
• Clinical management focused on supportive care of complications
Hypovolemia
Electrolyte abnormality
Bleeding disorders and hemorrhage
Shock
Hypoxia
Multi-organ failure
DIC
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CLEANING EQUIPMENT
• Need to reinforce cleaning procedures that should be
carried out following the care and transport of each and
every patient
• For possible Ebola infection, bleach and Cavicide wipes to
be used
• Reminder: bleach based product required for use following
care of patient with diarrhea
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DISCUSSION OF PPE PRODUCTS
• Minimum use of PPE products for suspected Ebola patient:
• Gloves – double gloving recommended
• Face mask with eye shield or goggles
• Gown – impermeable especially in presence of body fluids
• Booties – especially in presence of body fluids
• Linen contaminated with body fluids to be double bagged and remain
with patient in their room
• Hospital to make notification to the Health Department
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HOSPITAL ISOLATION
• Hospitals have established set procedures internally to
accept patients suspected of Ebola virus
• Need to direct EMS to the selected room
• Best to minimize travel through patient care areas
• Know what your facility policy is and if you are transferring
patient out what that process is
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BIBLIOGRAPHY
• Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices,
4th edition. Brady. 2013.
• Region X SOP’s; IDPH Approved April 10, 2014.
• Steingart, J. EMS…Caring. Article 2014
• http://thelegalguardian.com/resources/ems-case-law/
• http://www.idph.state.il.us/public/books/UniformDNRAdanceDirectives.pdf
• http://www.mayoclinic.org/diseases-conditions/bulimia/basics/definition/CON20033050?p=1
• http://www.womenshealth.gov/publications/our-publications/fact-sheet/anorexianervosa.html
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BIBLIOGRAPHY CONT’D
• http://kidshealth.org/parent/general/sick/munchausen.html
• http://www.jems.com/article/training/proper-restraint-technique-sta
• http://www.acep.org/Clinical---Practice-Management/Use-of-Patient-Restraints/
• http://www.emsmdc.com/pdf/prehospital-restraint-final.pdf
• http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1539&ChapterID=35
• http://www.legis.state.il.us/
• 410 ILCS 210/ - Consent by Minors to Medical Procedures Act
• http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/qa.html
• http://www.ilga.gov/legislation/ilcs/ilcs4.asp?DocName=040500050HCh%2E+III&Ac
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