Transcript Legal and Nasal Medications PowerPoint ALS-ILS-BLS

Silver Cross EMS System
November CME
3rd Trimester 2012
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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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Don’t forget to join our email list! You will
find sign-up information at
www.silvercrossems.com
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.
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Your best protection from liability is to
perform systematic assessments, provide
appropriate medical care, and maintain
accurate and complete documentation.
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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.
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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.
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Constitutional
◦ Based on the U.S. Constitution
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Common
◦ Derived from society’s acceptance of customs and
norms
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Legislative
◦ Created by lawmaking bodies such as Congress and
state assemblies
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Administrative
◦ Enacted by governmental agencies at either federal
or state levels
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Criminal
◦ Division of the legal system that deals with wrongs
committed against society or its members
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Civil
◦ Division of the legal system that deals with noncriminal issues and conflicts between two or more
parties
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Tort
◦ A civil wrong committed by one individual against
another
Incident
 Investigation
 Filing of
complaint
 Answering
complaint
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Discovery
 Trial
 Decision
 Appeal
 Settlement
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Range of duties and skills EMT-B’s and
Paramedics are allowed and expected to
perform
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Certification
◦ The recognition granted to an individual who has
met predetermined qualifications to participate in a
certain activity
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Licensure
◦ The process by which a governmental agency
grants permission to engage in a given occupation
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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)
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Spousal abuse (IL Domestic Violence Act - 750 ILCS 60/)
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Abused & Neglected Child Reporting Act (325 ILCS 5/)
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Elder Abuse & Neglect Act (320 ILCS 20/)
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Abused and Neglected Long Term Care Facility Residents
Reporting Act (210 ILCS 30/)
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Sexual assault (720 ILCS 5/12-13, 14, 14.1, 15, 16)
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Gunshot and stab wounds
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Animal bites
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Communicable diseases
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Immunity
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Good Samaritan laws
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Ryan White CARE Act
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Local laws and regulations
◦ Exemption from liability granted to
governmental agencies
◦ Provide immunity to certain people who
assist at the scene of a medical emergency
◦ Requires notification and assistance to EMS
workers who have been exposed to certain
diseases (has since been changed/worse for EMS)
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Deviation from accepted standards of care
recognized by law for the protection of others
against the unreasonable risk of harm
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Duty to act
Breach of duty
Actual damages
Proximate cause
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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
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Malfeasance
◦ Performance of a wrongful or unlawful act by a
Paramedic
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Misfeasance
◦ Performance of a legal act in a harmful or injurious
manner
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Nonfeasance
◦ Failure to perform a required act or duty
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Refers to compensable physical,
psychological, or financial harm
Proximate Cause
An action or inaction that
immediately caused or worsened
the damage
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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
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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
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While supervising an EMT-B or EMT-I, a
Paramedic may be liable for any negligent act
that person commits.
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If medical care is withheld due to any
discriminatory reason, a Paramedic
or EMT may be sued.
◦ Examples:
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Race
Creed
Color
Gender
Sexual orientation
National origin
Ability to pay (in some cases)
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Performing procedures that require
delegation from a physician, while off-duty,
may constitute practicing medicine without a
license.
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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)
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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.
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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.
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Defamation
◦ An intentional false communication that injures
another person’s reputation or good name
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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
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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
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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.
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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.
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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.
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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.
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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
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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.
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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
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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.
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Person under 18 years of age who is:
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Married
Pregnant
A parent
A member of the armed forces
Financially independent living away from home
Emancipated minors may give informed consent.
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A patient may withdraw consent for treatment
at any time, but it must be an informed
refusal of treatment.
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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.
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Is the patient legally permitted to refuse care?
Make multiple, sincere attempts to convince
the patient to accept care.
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Make sure the patient is informed in his or
her decision.
Consult with on-line medical direction.
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Have the patient and a disinterested witness
sign a release-from-liability form.
Advise the patient he or she may call again
for help.
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Attempt to get someone to stay with the
patient.
Document the entire situation thoroughly.
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Violent
Victim of drug overdose
Intoxicated
Ill or injured minor with no adult to provide
consent for treatment
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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…
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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…
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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.
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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.
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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”.
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A petition is a paper form.
◦ States someone feels someone else is danger to
self or others and requires involuntary treatment.
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A petition does not “commit” someone.
◦ Just allows ER docs to move on to next step,
seeking involuntary admission to psych facility.
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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.
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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.
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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.
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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.
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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
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Otherwise, once the patient gets to the ER,
docs will have to let the patient go, unless ER
staff witness the behavior as well.
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Is patient willing to go voluntarily with a little
persuasion?
◦ Bring them in. Problem solved.
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Is patient alert, oriented and appears to pose no
harm to self or others?
◦ Call medical control to authorize a release.
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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.
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Abandonment
◦ The termination of the EMS-patient relationship
without assurance that an equal or greater level of
care will continue
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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)
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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)
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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)
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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
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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.
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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.
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In Illinois, EMS personnel cannot honor Living
Wills in the field
◦ Only DNR’s
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If you ever have a question, contact medical
control
Do Not
Resuscitate Order
(DNR) indicates
which, if any, lifesustaining
measures should
be taken when the
patient’s heart
and respiratory
functions have
ceased.
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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.
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If you believe a crime has been committed,
involve law enforcement.
Protect yourself and other EMS personnel.
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Initiate patient care only when the scene is
safe.
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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.
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Complete promptly after patient contact.
Be thorough.
Be objective.
Be accurate.
Maintain patient confidentiality.
Never alter a patient care record.
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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
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For suspected opiate overdose
◦ Heroin, vicodin, morphine, etc.
◦ S/S include pinpoint pupils, altered mental status,
respiratory depression
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Narcan is an opiate “antagonist”, does not
allow opiates to bind properly with receptors
in the central nervous system.
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Remove MAD tip from syringe.
Draw up Narcan 2ml (1mg/ml) and replace
the tip.
◦ Or put tip on luer-lock prefilled syringe
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Tilt patient’s head back if possible
Put atomizer in nostril, advance until sealed
against opening.
Depress plunger briskly
◦ 1ml in each nostril
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For low blood sugar (under 60) when IV not
available for glucose.
◦ For BLS providers when patient cannot take oral
glucose.
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Glucagon causes the liver to convert stored
glycogen into glucose.
Comes in powder that must be mixed with
saline.
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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
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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
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Results from a rapid reentry circuit
◦ 250-350 beats per minute
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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
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Common causes are:
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Mitral or tricuspid valve disorder
Rarely occurs as result of an AMI
Atrial enlargement or dilation
Pulmonary embolus
Hypoxia
Quinidine toxicity
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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
USEFUL TRICK…
USUALLY 2:1 CONDUCTION
=150 BPM
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Atrial flutter
with
2:1 conduction
Atrial flutter
with
4:1 conduction
Mosby items and derived items © 2011,
2006 by Mosby, Inc., an affiliate of
Elsevier Inc.
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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
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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
[email protected] with questions.
Or call 815-300-7425 with questions!