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Medico Legal Aspects Of Prehospital Care


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Medico Legal Aspects Of Prehospital Care

  1. 1. Medical/Legal Aspects of Prehospital Care Dr. Ashendu Pandey
  2. 2. Easy Way
  3. 3. ? Stop Medical Practice !!!
  4. 7. Equipment
  5. 8. Equipment
  6. 9. Medicine !
  7. 10. Staff
  8. 12. Monitor
  9. 13. Beware Of Dogs
  10. 14. Advocate Ambulance -Chaser
  11. 15. Topics to Discuss <ul><li>Legal vs. Ethical vs. Moral Responsibilities </li></ul><ul><li>Review of the Legal System </li></ul><ul><li>Specific Laws Applicable to EMS </li></ul><ul><li>Accountability & Malpractice </li></ul><ul><li>Specific Paramedic-Patient Issues </li></ul><ul><li>Operational Issues </li></ul><ul><li>Documentation </li></ul>
  12. 16. Legal vs. Ethical vs. Moral Responsibilities <ul><li>What are the differences? </li></ul><ul><ul><li>Legal Responsibilities </li></ul></ul><ul><ul><li>Ethical Standards </li></ul></ul><ul><ul><li>Morality </li></ul></ul>
  13. 17. Legal vs. Ethical vs. Moral Responsibilities <ul><li>Legal Responsibilities </li></ul><ul><ul><li>Established by the law-making bodies of government </li></ul></ul><ul><li>Ethical Standards </li></ul><ul><ul><li>Principles of conduct identified by members of a group or profession </li></ul></ul><ul><li>Morality </li></ul><ul><ul><li>Individual’s assessment of right and wrong </li></ul></ul>
  14. 18. The Legal System <ul><li>Sources of Law </li></ul><ul><ul><li>Constitutional </li></ul></ul><ul><ul><li>Administrative </li></ul></ul><ul><li>Legislative and Administrative are often the focus of EMS Providers </li></ul>
  15. 19. The Legal System <ul><li>Central Vs State law </li></ul><ul><li>Categories of Law </li></ul><ul><ul><li>Criminal Law </li></ul></ul><ul><ul><li>Civil Law </li></ul></ul><ul><ul><ul><li>Tort Law </li></ul></ul></ul>What are examples of how each of these may affect the paramedic?
  16. 20. The Legal System <ul><li>Terminology </li></ul><ul><ul><li>Plaintiff </li></ul></ul><ul><ul><li>Defendant </li></ul></ul><ul><ul><li>Discovery phase </li></ul></ul><ul><ul><ul><li>Deposition </li></ul></ul></ul><ul><ul><ul><li>Interrogation </li></ul></ul></ul><ul><ul><ul><li>Documentation </li></ul></ul></ul><ul><ul><li>Appeal </li></ul></ul>
  17. 21. Laws Affecting EMS <ul><li>Scope of Practice </li></ul><ul><ul><li>Paramedic Vs MBBS Vs Specialist </li></ul></ul><ul><li>Ability to Practice </li></ul><ul><ul><li>Certification or Licensure </li></ul></ul><ul><ul><li>Authorization to Practice </li></ul></ul>
  18. 22. Laws Affecting EMS <ul><li>Motor Vehicle Laws </li></ul><ul><li>Infectious Disease Exposure </li></ul><ul><li>Assault against Public Safety Officer </li></ul><ul><li>Obstruction of Duty </li></ul><ul><li>Good Samaritan Law </li></ul>
  19. 23. Laws Affecting EMS <ul><li>Mandatory Reporting </li></ul><ul><ul><li>Criminal Acts </li></ul></ul><ul><ul><li>MLC </li></ul></ul><ul><ul><li>Animal Bites </li></ul></ul><ul><ul><li>Communicable Diseases </li></ul></ul><ul><ul><li>Out of hospital deaths </li></ul></ul><ul><ul><li>Possession of Controlled Substances </li></ul></ul>
  20. 24. Accountability & Malpractice Issues <ul><li>Standard of Care </li></ul><ul><li>Negligence </li></ul><ul><li>Liability when off-duty </li></ul>
  21. 25. Accountability & Malpractice <ul><li>Standard of Care </li></ul><ul><ul><li>The expected care, skill, & judgment under similar circumstances by a similarly trained, reasonable paramedic </li></ul></ul><ul><li>Negligence </li></ul><ul><ul><li>Deviation from accepted or expected standards of care expected to protect from unreasonable risk of harm </li></ul></ul>What are the required components for proof of a negligence claim in EMS?
  22. 26. Accountability & Malpractice <ul><li>Elements Required to prove Negligence </li></ul><ul><ul><li>Duty to Act </li></ul></ul><ul><ul><li>Breach of duty </li></ul></ul><ul><ul><li>Actual damage or harm </li></ul></ul><ul><ul><li>Proximate cause </li></ul></ul>
  23. 27. Accountability & Malpractice <ul><li>Civil Cases </li></ul><ul><ul><li>Proof of guilt required by a “preponderance of evidence” </li></ul></ul><ul><ul><li>“res ipsa loquitur” </li></ul></ul><ul><ul><ul><li>Burden of proof shifts to the defendant </li></ul></ul></ul><ul><li>Simple vs. Gross Negligence </li></ul>
  24. 28. Defenses <ul><li>Good Samaritan Law </li></ul><ul><li>Government Immunity </li></ul><ul><li>Statue of Limitations </li></ul><ul><li>Contributory Negligence </li></ul>
  25. 29. Specific Paramedic-Patient Issues <ul><li>Issues Surrounding Consent </li></ul><ul><li>Refusals </li></ul><ul><li>Restraint </li></ul><ul><li>Abandonment </li></ul><ul><li>Transfer of Patient Care </li></ul><ul><li>Out of Hospital Death </li></ul><ul><li>Confidentiality & Privacy </li></ul>
  26. 30. Specific Paramedic-Patient Issues <ul><li>Issues Surrounding Consent </li></ul><ul><ul><li>Patient has legal & mental capacity </li></ul></ul><ul><ul><li>Patient understands consequences </li></ul></ul><ul><ul><li>Types of Consent </li></ul></ul><ul><ul><ul><li>Informed </li></ul></ul></ul><ul><ul><ul><li>Expressed </li></ul></ul></ul><ul><ul><ul><li>Implied </li></ul></ul></ul><ul><ul><ul><li>Involuntary </li></ul></ul></ul>
  27. 31. Specific Paramedic-Patient Issues <ul><li>Issues Surrounding Consent </li></ul><ul><ul><li>Specific Consent Issues </li></ul></ul><ul><ul><ul><li>Minors </li></ul></ul></ul><ul><ul><ul><li>Prisoners </li></ul></ul></ul>
  28. 32. Specific Paramedic-Patient Issues <ul><li>Refusals </li></ul><ul><ul><li>Consent for Transport vs. Treatment </li></ul></ul><ul><ul><li>Withdrawing Consent </li></ul></ul><ul><ul><li>Refusal of Service </li></ul></ul><ul><ul><ul><li>Has legal & mental capacity </li></ul></ul></ul><ul><ul><ul><li>Is informed of risks & benefits </li></ul></ul></ul><ul><ul><ul><li>Offer alternatives </li></ul></ul></ul><ul><ul><ul><li>All of the above are well documented & witnessed </li></ul></ul></ul>
  29. 33. Specific Paramedic-Patient Issues <ul><li>Refusals </li></ul><ul><ul><li>Incompetent Persons </li></ul></ul><ul><ul><ul><li>Unable to understand the nature & consequences of his/her injury/illness </li></ul></ul></ul><ul><ul><ul><li>Unable to make rational decisions regarding medical care due to physical or mental conditions </li></ul></ul></ul><ul><ul><ul><li>Do not assume incompetence unless obvious </li></ul></ul></ul>
  30. 34. Specific Paramedic-Patient Issues <ul><li>Restraint </li></ul><ul><ul><li>In Custody of Law Enforcement or Corrections </li></ul></ul><ul><ul><li>Patient is not competent to refuse & requires care </li></ul></ul><ul><ul><li>Patient is a danger to self or others (involve law enforcement) </li></ul></ul><ul><ul><li>Does not provide authorization to harm! </li></ul></ul>
  31. 35. Specific Paramedic-Patient Issues <ul><li>Restraint </li></ul><ul><ul><li>Involve Law Enforcement Early </li></ul></ul><ul><ul><li>Have a plan of action </li></ul></ul><ul><ul><li>Ensure safety of all </li></ul></ul><ul><ul><li>Reasonable force </li></ul></ul><ul><ul><li>Physical restraints </li></ul></ul><ul><ul><li>Chemical restraints </li></ul></ul><ul><ul><li>Document well </li></ul></ul>
  32. 36. Specific Paramedic-Patient Issues <ul><li>Patient Abandonment </li></ul><ul><ul><li>Unilateral termination of the patient-provider relationship </li></ul></ul><ul><ul><ul><li>Still needed and desired </li></ul></ul></ul><ul><ul><li>Exceptions </li></ul></ul><ul><ul><ul><li>MCI </li></ul></ul></ul><ul><ul><ul><li>Risks to well-being </li></ul></ul></ul>
  33. 37. Specific Paramedic-Patient Issues <ul><li>Transfer of Patient Care </li></ul><ul><ul><li>Transfer of Care to other Providers </li></ul></ul><ul><ul><li>Transfer of Care at the ED </li></ul></ul>
  34. 38. Specific Paramedic-Patient Issues <ul><li>Out of Hospital Death </li></ul><ul><ul><li>Can EMT declare a patient dead?? </li></ul></ul><ul><ul><li>SOP for out f hospital death </li></ul></ul>
  35. 39. Specific Paramedic-Patient Issues <ul><li>Patient Confidentiality & Privacy </li></ul><ul><ul><li>“Medical information about a patient will not be shared with a third party without consent, statute, or court order” </li></ul></ul>
  36. 40. Specific Paramedic-Patient Issues <ul><li>Patient Confidentiality & Privacy </li></ul><ul><ul><li>Colleague & Station Talk </li></ul></ul><ul><ul><ul><li>Must not identify the patient </li></ul></ul></ul><ul><ul><ul><li>Maintains confidentiality of specific medical info </li></ul></ul></ul><ul><ul><li>Scene or Patient Photographs </li></ul></ul><ul><ul><li>EMS Radio Dispatch & Discussions </li></ul></ul><ul><ul><li>“Need to Know” Basis </li></ul></ul>
  37. 41. Operational Issues <ul><li>Equipment failure </li></ul><ul><li>Interaction with Law Enforcement </li></ul><ul><ul><li>Crime Scenes </li></ul></ul><ul><ul><li>Preservation of Evidence </li></ul></ul><ul><li>Vehicle Operation </li></ul><ul><li>Medical Control </li></ul><ul><li>Instructor Liability </li></ul><ul><li>Hospital Selection </li></ul><ul><li>Dispatch </li></ul><ul><li>Interfacility Transfers </li></ul>
  38. 42. Operational Issues <ul><li>Equipment Failure </li></ul><ul><ul><li>Product Liability </li></ul></ul><ul><ul><ul><li>Design flaw in ventilator </li></ul></ul></ul><ul><ul><li>Failure on part of owner/operator </li></ul></ul><ul><ul><ul><li>No backup battery for defibrillator </li></ul></ul></ul>
  39. 43. Operational Issues <ul><li>Interaction with Law Enforcement </li></ul><ul><ul><li>Crime Scenes </li></ul></ul><ul><ul><ul><li>Request law enforcement </li></ul></ul></ul><ul><ul><ul><li>Await law enforcement arrival if possible </li></ul></ul></ul><ul><ul><ul><li>Minimize areas of travel and contact with scene </li></ul></ul></ul><ul><ul><ul><li>Document any alterations to the scene created by EMS personnel </li></ul></ul></ul><ul><ul><ul><li>Minimize personnel within scene if possible </li></ul></ul></ul><ul><ul><ul><li>Document pertinent observations </li></ul></ul></ul>
  40. 44. Operational Issues <ul><li>Interaction with Law Enforcement </li></ul><ul><ul><li>Evidence Preservation </li></ul></ul><ul><ul><ul><li>Avoid cutting through penetrations in the clothing </li></ul></ul></ul><ul><ul><ul><li>Save everything – clothing of assault victim, items found on person, etc </li></ul></ul></ul><ul><ul><ul><li>Prevent sexual assault victim from washing </li></ul></ul></ul><ul><ul><ul><li>Follow sound chain of evidence procedures </li></ul></ul></ul>
  41. 45. Operational Issues <ul><li>Vehicle Operation </li></ul><ul><ul><li>It is 3:00 am. While responding to a MVC, a driver fails to yield the right of way at an intersection. The driver’s traffic signal is green. You attempt to stop but are unable to do so. Witnesses state your emergency lights were on but do not recall hearing your siren. The driver is injured. (cont’d) </li></ul></ul>
  42. 46. Operational Issues <ul><li>Vehicle Operation </li></ul><ul><ul><li>What issues might the driver’s attorney consider? </li></ul></ul><ul><ul><ul><li>Were all of your emergency lights really operational? Are daily inspections performed? </li></ul></ul></ul><ul><ul><ul><li>Why was the siren not working? </li></ul></ul></ul><ul><ul><ul><li>Were poorly maintained brakes responsible for your inability to stop? What type of PM is performed on your ambulance? </li></ul></ul></ul><ul><ul><ul><li>Did you exercise due regard for the safety of others? </li></ul></ul></ul>
  43. 47. Operational Issues <ul><li>Medical Control Issues </li></ul><ul><ul><li>Failure to follow med contr direction </li></ul></ul><ul><ul><li>Following obviously harmful direction </li></ul></ul><ul><ul><li>Implementing therapies without prior authorization </li></ul></ul><ul><ul><li>Following direction of an unauthorized person </li></ul></ul><ul><ul><li>Med Contr directs EMS to an inappropriate hospital </li></ul></ul><ul><ul><li>The paramedic exceeds the scope of his training or medical authorization </li></ul></ul>
  44. 48. Operational Issues <ul><li>Instructor Liability </li></ul><ul><ul><li>Student discrimination </li></ul></ul><ul><ul><li>Sexual harassment </li></ul></ul><ul><ul><li>Student injury during laboratory </li></ul></ul><ul><ul><li>Patient claim re. Failure to properly train graduate or supervise student </li></ul></ul><ul><ul><li>Instructors – Follow curriculum, document student attendance & competency </li></ul></ul>
  45. 49. Operational Issues <ul><li>Hospital Selection </li></ul><ul><ul><li>Paramedic & Medical Control decision </li></ul></ul><ul><ul><li>Closest & Appropriate Facility </li></ul></ul><ul><ul><li>Written policies or guidelines </li></ul></ul>What is the closest & most appropriate facility? What does this mean?
  46. 50. Operational Issues <ul><li>Dispatch Issues </li></ul><ul><ul><li>Untimely dispatch </li></ul></ul><ul><ul><li>Failure to provide responding units with adequate directions (incorrect address) </li></ul></ul><ul><ul><li>Dispatch of inadequate level of care </li></ul></ul><ul><ul><li>Failure to provide pre-arrival instructions </li></ul></ul><ul><ul><li>Inadequate recordkeeping </li></ul></ul>
  47. 51. Operational Issues <ul><li>Interfacility Transfer Issues </li></ul><ul><ul><li>Do you have the necessary equipment & training? </li></ul></ul><ul><ul><li>Should any specialized providers accompany you? </li></ul></ul><ul><ul><li>Do you have a patient report including history? </li></ul></ul><ul><ul><li>Is the patient “stable”? What are the potential complications? </li></ul></ul><ul><ul><li>Are there any specific physician orders? </li></ul></ul><ul><ul><li>Has the patient been accepted? Who are the transferring & accepting physicians? </li></ul></ul>
  48. 52. Documentation <ul><li>Patient Confidentiality </li></ul><ul><li>Securing/Sharing/Requests for Information </li></ul><ul><li>Quality & Effectiveness </li></ul>
  49. 53. Documentation <ul><li>Patient Confidentiality </li></ul><ul><ul><li>Written report only intended for those with a need to know </li></ul></ul><ul><ul><li>Personal identifiers may be removed for QA/QI uses </li></ul></ul><ul><ul><li>Patient radio reports should not contain personal identifiers </li></ul></ul>
  50. 54. Documentation <ul><li>Securing/Sharing/Requests for Information </li></ul><ul><ul><li>Where are completed patient reports stored? </li></ul></ul><ul><ul><li>Who received the report at the ED? </li></ul></ul><ul><ul><li>Requests for copies should be routed through an accepted policy or an attorney </li></ul></ul><ul><ul><li>Does the requestor have a need to know? </li></ul></ul>
  51. 55. Documentation <ul><li>Quality & Effectiveness </li></ul><ul><ul><li>Complete soon after the patient contact </li></ul></ul><ul><ul><li>Be thorough and accurate </li></ul></ul><ul><ul><li>Be honest, objective and factual </li></ul></ul><ul><ul><li>Caution with abbreviations </li></ul></ul><ul><ul><li>Maintain confidentiality </li></ul></ul><ul><ul><li>Do not alter </li></ul></ul>
  52. 56. Documentation <ul><li>Quality & Effectiveness </li></ul><ul><ul><li>Does your report relay to future healthcare providers the information you obtained regarding this patient? </li></ul></ul><ul><ul><li>Is the information clear and concise? </li></ul></ul><ul><ul><li>Will the report help you recall this incident if necessary 3 years from now? </li></ul></ul><ul><ul><li>Are you willing to sit in court with only this document? </li></ul></ul>
  53. 57. Eyes of Relatives
  54. 58. Serious Disease Major Surgery Old Age Emergency
  55. 60. Young Patient
  56. 61. <ul><li>Poor Communication. </li></ul>
  57. 62. Minor Ailment
  58. 64. Consent
  59. 65. Medical Record
  60. 67. Defences
  61. 68. Emergency:
  62. 69. Accident: I.V. may go out.
  63. 70. Circumstances:
  64. 71. Accepted Practice:
  65. 72. Error of Judgment
  66. 73. Delegate
  67. 74. Difference of Opinion
  68. 75. Compromise
  69. 76. Insurance
  70. 77. Thank You