Introduction to advanced prehospital care

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  • From Article 30 of the NYS Public Health Law The State EMS Council consists of representative fro the 18 Regional councils and assists the NYS DOH Bureau of EMS in developing rules and regulations and general guidelines for operations in EMS. The Stet Emergency Medical Advisory Committee (SEMAC) is a subcommittee of the State EMS Council and is responsible for minimum standards for medical control, treatment, triage, transport protocols and use of equipment and drugs. The Regional Medical Advisory Committees (REMAC) develop policies, procedures and triage treatment and tx protocols which are consistent with SEMAC which address specific local conditions. There are currently 14 REMACS WREMS – Wyoming Erie Regional EMS Council WREMS Big Lakes – Niagara, Orleans, Genesee
  • Ruling out C-Spine in the field
  • What qualities can you list?
  • Patient Advocate
  • It’s designed to help people deal with their trauma one incident at a time by allowing the individual to talk about the incident when it happens without judgment or criticism. The program is peer-driven and the people giving the treatment may come from all walks of life, but most are first responders or work in the mental health field. All interventions are strictly confidential. EAP may be helpful. A number of studies have shown that CISM has little effect, or that it actually worsens the trauma symptoms
  • Denial – not me Anger – why me Bargaining – okay but first let me Depression – okay but I haven’t Acceptance - Okay I’m not afraid
  • Can anyone think of a way we can help promote injury and illness prevention in the community. WHALE
  • Laws describe what is wrong in the eyes of society while ethics goes beyond this and examines what is right or good.
  • You must utilize reason and exclude emotion while making decisions.
  • Physical abuse includes withholding medication and medical care
  • Introduction to advanced prehospital care

    1. 1. AEMT Critical Care:Division 1 – Introduction toAdvanced Prehospital Care
    2. 2. Topics Roles and Responsibilities Medical Direction Well-Being of the AEMT Illness and Injury Prevention Medical/Legal Issues Ethics
    3. 3. Roles and Responsibilities of the AEMT-CC
    4. 4. Topics Introduction Review of EMS Systems Education Continuing Education Professional Attitudes Primary Responsibilities
    5. 5. EMS System A comprehensive network of personnel, equipment, and resources established to deliver aid and emergency medical care to the community.
    6. 6. OUT-OF-HOSPITAL COMPONENTS OF AN EMS SYSTEMMEMBERS OF COMMUNICATIONS EMS THE SYSTEM PROVIDERSCOMMUNITY POISON CONTROL FIRE PUBLIC CENTERS RESCUE UTILITIES HAZMAT
    7. 7. OUT-OF-HOSPITAL COMPONENTS OF AN EMS SYSTEM EMERGENCY EMERGENCY AND NURSES SPECIALTY PHYSICIANS ANCILLARY REHABILITATION SERVICES SERVICES
    8. 8. NYS EMS System State EMS Council  SEMAC Regional EMS Council  WEREMS, Big Lakes REMS CO Regional Medical Advisory Committee  WREMAC County EMS Coordinator Medical Director
    9. 9. Personal and Professional Development Personal and professional development is your responsibility. Keep updated with journals, seminars, computer newsgroups, and other learning experiences. Explore alternative or non-traditional career paths.
    10. 10. Education and Certification Two kinds of EMS education are initial and continuing education.  Initial education is the original training course for prehospital providers.  Continuing education programs include refresher courses for recertification and periodic in-service training sessions.
    11. 11. Initial Education Based on the EMT-Paramedic: National Standard Curriculum published by the U.S. D.O.T.  establishes the minimum content for the course  divided into 3 specific learning domains: • Cognitive • Affective • Psychomotor
    12. 12. Once the initial education iscompleted, the paramedic will become either certified or licensed.
    13. 13. Certification vs. Licensure Certification is the process by which an agency grants recognition to an individual who has met its qualifications. Licensure is the process of occupational regulation.
    14. 14. National Registry of EMTs (NREMT) Prepares and administers standardized tests for the First Responder, EMT-Basic, EMT- Intermediate, and EMT-Paramedic. Establishes the qualifications for registration and re-registration, and for establishing a minimal standard of competency.
    15. 15. Belonging to a ProfessionalOrganization is a good wayto keep informed about the latest technology.
    16. 16. Professional Organizations Include: National Association of EMTs National Association of Search and Rescue National Association of State EMS Directors National Association of EMS Physicians National Flight Paramedics Association National Council of State EMS Training Coordinators
    17. 17. A variety of journals are available tokeep the paramedic aware of the latestchanges in this ever-changing industry.
    18. 18. These Professional Journals Include: Annals of Emergency Medicine Emergency Medical Services Emergency Journal of Emergency Medical Services Journal of Emergency Medicine
    19. 19. Continuing EducationThe paramedic must always strive to stay abreast of changes in EMS.
    20. 20. Research (1 of 2) Research programs are essential for moral, educational, medical, financial, and practical reasons. Future EMS research must address the following issues:  Which interventions actually reduce morbidity and mortality?  Are the benefits of a procedure worth the risk?  What is the cost-benefit ratio?
    21. 21. Research (2 of 2) Has your organization participated in research?
    22. 22. The Components of a Research Program: (1 of 2) Identify a problem. Identify the body of knowledge on the subject. Select the best design for the study. Begin the study and collect raw data.
    23. 23. The Components of a Research Program: (2 of 2) Analyze the data. Assess and evaluate the results. Write a concise, comprehensive description of the study for publication in a medical journal.
    24. 24. ProfessionalismProfessionalism is the conduct or qualities that characterize an expert practitioner in a particular field or occupation.
    25. 25. Professional Attributes Leadership  Time management Integrity skills Empathy  Diplomacy in Self-motivation teamwork Professional  Respect appearance and  Patient advocacy hygiene Communication  Careful delivery of skills service
    26. 26. Professional Attitudes True professionals establish excellence as their goal and never allow themselvesto become complacent about their performance.
    27. 27. As the leader of the EMS team, the paramedic must interact with patients,bystanders, and other rescue personnel in a professional manner.
    28. 28. Primary Responsibilities of the Paramedic Preparation  Disposition and Response transfer Scene size-up  Documentation Patient  Clean-up, assessment maintenance, Treatment and and review management
    29. 29. PreparationThe paramedic must be physically, mentally, and emotionally able to meet job demands.
    30. 30. Response Safety is the number one priority! Wear seatbelts. Obey posted speed limits. Monitor roadway for potential hazards.
    31. 31. Scene Size-up Scene safety. Identify the number of patients. Identify the mechanism or nature of illness.
    32. 32. Patient Assessment Initial assessment. Physical examination. Patient history. Fig. 4-3 Ongoing assessment.
    33. 33. Recognition of Illness or Injury First aspect of patient prioritization. Usually based on the urgency for transport.
    34. 34. Patient Management Protocols ensure consistent patient care. Communication with medical direction. Movement of the patient from one location to another.
    35. 35. Appropriate Disposition Transportation type. Receiving facility. Treat and release.
    36. 36. Patient Transfer While moving the patient from one facility to another the first priority is patient care. Request a verbal report from primary-care provider. At destination provide a report to receiving care provider.
    37. 37. Documentation Complete a patient care report as soon as possible after emergency care has been provided. Necessary to ensure continuity of care. Be complete, neat, and legible.
    38. 38. Accurate and complete documentation is extremely important. Fig. 4-4
    39. 39. Returning to ServicePrepare the unit to return to service Clean and decontaminate. Restock. Refuel. Review the call with crew members. Be aware of signs of critical incident stress.
    40. 40. Patient Advocacy An EMT is an advocate for patients, defending them, protecting them, and acting in their best interest. Except when your safety is threatened, you should always place the needs of your patient above your own.
    41. 41. Additional Responsibilities Community involvement. Support for primary care. Citizen involvement in EMS. Personal and professional development.
    42. 42. Community InvolvementHelp the public: Recognize an emergency; Know how to provide BLS; Know how to properly access the EMS system.
    43. 43. Support For Primary Care Help develop services that decrease the need for EMS. Establish protocols that specify the mode of transportation for non- emergency patients. Team up with hospitals to provide an alternative to the emergency department.
    44. 44. Medical Direction
    45. 45. Medical Direction A medical director is a physician who is legally responsible for all clinical aspects of the system. EMT-Critical Care Technicians operate as “physician extension”
    46. 46. Medical Direction The medical director’s role in a system is to:  educate and train personnel  participate in equipment and personnel selection  develop clinical protocols  participate in problem resolution and quality improvement  provide direct input into patient care  interface with the EMS system  advocate within the medical community  serve as the “medical conscience” of the EMS system
    47. 47. The Medical Director canprovide on-line guidance toEMS personnel in the field. This is known as on-line medical direction.
    48. 48. Off-line medical direction refers to medical policies, procedures, andpractices that medicaldirection has set up in advance of a call, such as standardprotocols or standing orders.
    49. 49. Protocols are the policies andprocedures for all elements of an EMS system.
    50. 50. Protocols are designed around the four “T’s” of emergency care. Triage Treatment Transport Transfer
    51. 51. On-scene Physician Be currently licensed in NYS Assume responsibility for the patient’s care Realize EMS providers will not comply with orders that exceed their scope of practice Accompany patient to hospital if requested
    52. 52. KEY POINTMC is ultimatelyresponsible forthe actions of theEMS provider andmust becontacted.
    53. 53. Special Note: n-s ceneT he o ust sicianmphy his cum ent do ions in ter vent
    54. 54. Quality Assurance and Improvement Quality Assurance is designed to maintain continuous monitoring and measurement of the quality of clinical care. Continuous Quality Improvement (CQI) is designed to refine and improve an EMS system, emphasizing customer satisfaction.
    55. 55. CQI – A Dynamic Pocess Identify Problems Elaborate on the cause Develop remedies Lay out plan to correct problems Enforce the plan Reexamine the problem
    56. 56. An EMS system must bedesigned to meet the needs of the patient. Therefore,the only acceptable quality of an EMS system is EXCELLENCE!
    57. 57. Customer satisfactioncan be created or destroyedwith a simple word or deed.
    58. 58. The well-being of the AEMT
    59. 59. Topics Wellness of the AEMT Impact of Shift Work on the AEMT Proper Body Mechanics Managing Hostile Situations
    60. 60. Introduction Well-being is a fundamental aspect of top-notch performance in EMS. It includes:  Physical well-being  Mental and emotional well-being  Safe lifting Seize the information about safe practice and apply it to your life.
    61. 61. Basic Physical Fitness  The benefits of physical fitness are well known:  Decreased resting heart rate and blood pressure  Increased oxygen- carrying capacity  Increased muscle mass and metabolism  Increased resistance to illness and injury  Enhanced quality of life
    62. 62. Core Components of Physical Fitness Muscular Strength Cardiovascular Endurance Flexibility
    63. 63. Muscular Strength Achieved with  ISOMETRIC exercise is regular active exercise exercise Exercises may performed against be isometric stable and isotonic resistance.  ISOTONIC exercise is active exercise
    64. 64. Cardiovascular Endurance Is a result of exercising at least three days a week vigorously enough to raise your pulse to its target heart rate.
    65. 65. Flexibility…the Forgotten Element of Fitness To achieve or  Stretch daily. regain  Never bounce flexibility, when stretching. stretch main  Hold a stretch muscle groups for at least 60 regularly. seconds.
    66. 66. It’s a Tough Job…
    67. 67. Nutrition It is a myth that people in EMS cannot maintain an adequate diet. The most difficult part is changing bad habits. Good nutrition is fundamental to well-being.
    68. 68. Learn the major food groups and eat a variety of foods from them daily. 3 to 5 servings6 to 11 servings 2 to 4 servings 2 to 3 servings 2 to 3 servings
    69. 69. Avoid or minimize intake of fat, salt, sugar, cholesterol, & caffeine.
    70. 70. Check food labels for information about the nutritionalcontent of thefood you eat.
    71. 71. Good sense says… Eating on the run can be less detrimental if you plan ahead –  Avoid fast foods.  Carry a small cooler filled with whole- grain sandwiches, fruits, and vegetables.  Monitor your fluid intake. Drink plenty of water.
    72. 72. Habits and Addictions Many in high-stress jobs abuse substances such as nicotine and caffeine. Those in EMS are no exception.
    73. 73. Habits & Addictions (cont) Choose a healthier life and avoid overindulging in harmful substances.
    74. 74. Habits & Addictions (cont) Consider substance abuse programs, nicotine patches, or a 12-step program.
    75. 75. Habits & Addictions (cont) Whatever it takes: Get free of addictions.
    76. 76. Back Safety EMS is a physically demanding career. Lifting and moving patients is frequently required. To avoid back injury, you must keep your back fit for the work you do.
    77. 77. CorrectPosture Will Minimize the Risk ofBack Injury
    78. 78. Correct Sitting Posture
    79. 79. Important Lifting Principles (1 of 2) Move a load only if you can handle it. Ask for help if you need it. Position load close to your body. Keep your palms up—when possible. Do not hurry. Bend with your knees. “Lock-in” the spine.
    80. 80. Important Lifting Principles (2 of 2) Always avoid twisting and turning. Let the leg muscles do the work. Exhale during lifting. Given a choice, push. Do not pull. Look where you are going. Only one person should be in charge of verbal commands.
    81. 81. Personal Protection from Disease There’s a lot you can do to minimize the risk of infection. Begin by developing a habit of doing the things promoted in this chapter.
    82. 82. Body Substance Isolation A strict form of infection control that is based on the assumption that all blood and other body fluids are infectious.  Take BSI precautions with every patient.
    83. 83. BSI is achieved through the use of PPE. Appropriate personal protective equipment should be available in every emergency vehicle.  Protective gloves  Masks and protective eyewear  HEPA and N-95 respirators  Disposable resuscitation equipment
    84. 84. HighEfficiencyParticulate Air Respirator (HEPA Mask)
    85. 85. An N-95 Respirator
    86. 86. To Remove Gloves, Hook theGloved Fingers of One Hand Under the Cuff of the Other Glove.
    87. 87. Then Slide the Fingers of the Ungloved Hand Under the Remaining Glove’s Cuff.
    88. 88. Perhaps the Most ImportantInfection-Control Practice Is... HANDWASHING
    89. 89. To Wash Your Hands Properly, Lather Well and Scrub Under Your Nails.
    90. 90. When You Rinse Your Hands, Point Them Downward So That Soap andWater Run Off Away From Your Body.
    91. 91. Important:  Dispose of Biohazardous Waste in a Properly Marked Bag.
    92. 92. Also Very Important: Discard Needles and Other Sharp Objects in a Properly Labeled, Puncture-proof Container.
    93. 93. ContaminatedNon-disposable Equipment Must Be Cleaned,Disinfected, or Sterilized.
    94. 94. …Cleaned, Disinfected, or Sterilized Cleaning refers to washing an object with soap and water. Disinfecting is cleaning with an agent that can kill some microorganisms on an object Sterilizing is the use of a chemical or steam to kill all microorganisms on an object.
    95. 95. Post-Exposure Procedures In most areas, an EMS provider who has had an exposure should:  Immediately wash the affected area.  Get a medical evaluation.  Take the immunization boosters.  Notify the agency’s infection control liaison.  Document the event.
    96. 96. EX PP RO OS CU ER DE U R E S
    97. 97. Infectious Disease Caused by pathogens, such as bacteria or viruses. May be spread from person to person. For example, infection by way of bloodborne pathogens can occur when the blood of an infected person comes in contact with another person’s broken skin.
    98. 98. Common Infectious Diseases
    99. 99. Hepatitis Inflammatory condition caused by:  Infectious agents  Toxins  Drugs  Metabolic aberration  Hypersensitivity or immune mechanism
    100. 100. Hepatitis Types of Hepatitis  Hepatitis A, (HAB, infectious hepatitis)  Hepatitis B, (HBV, serum hepatitis)  Hepatitis C, (HCV, virus)  Hepatitis D, (HDV, delta agent virus)  Hepatitis E, (HEV, hepatitis E virus)  Non A-Non B Hepatitis (NANB, unknown virus
    101. 101. Hepatitis Signs and Symptoms  Fever  Weakness  Loss of appetite  Nausea  Abdominal pain  Jaundice  Dark colored urine  Light colored urine
    102. 102. Hepatitis Incubation period Mode of transmission
    103. 103. Hepatitis Management Precautions  Use disposable gloves and wash hands following contact  Sterilization of all equipment used  Red bag and label any specimens and linen  Follow-up if protective measures were not used  (a) file exposure report  (b) Immunization with ISG (Immune serum Globulin)
    104. 104. Tuberculosis Infectious disease caused by tubercule bacillus Signs and Symptoms  Cough  Fever  Night sweats  Weight loss  Fatigue  Hemoptysis
    105. 105. Tuberculosis Incubation period 4-6 weeks Mode of transmission
    106. 106. Tuberculosis Management Precautions  Mask and gloves  Avoid prolonged contact  Fresh air (well ventilated patient compartment)  Avoid contact with sputum  Regular PPD skin test  Chest x-ray as needed, per CDC recommendations
    107. 107. Meningitis Inflammation of the membranes of the spinal cord or brain Signs and Symptoms  Fever  Headache  Nausea and vomiting  Stiff neck  Rash
    108. 108. Meningitis Incubation period 2-10 days Management Precautions  (1) Mask (on you or patient)  (2) Gloves and wash hands after contact
    109. 109. Acquired Immune Deficiency Syndrome (AIDS) Signs and Symptoms  Fever with profuse night sweats  Weight loss (10 - 20 lbs. per month  Red/purple skin lesions  Pneumonia
    110. 110. AIDS Incubation period from 2 months to 2 years or more  Mode of transmission  Blood contact  Contact with other bodily secretions  Sexual contact
    111. 111. AIDS Management Precautions  Ware disposable gloves when in contact with blood or body fluids  Wash hands following care of the patient
    112. 112. Stress and Stress Management (1 of 2) A stimulus that causes stress is known as a stressor.
    113. 113. Stress and Stress Management (2 of 2) Adapting to stress is a dynamic, evolving process:  Defensive strategies  Coping skills  Problem-solving skills
    114. 114. Your job in managing stress is to learn these things: Your personal stressors. Amount of stress you can take before it becomes a problem. Stress management strategies that work for you.
    115. 115. To manage stress: Use controlled breathing…focus attention on your breathing. Use reframing…mentally reframe interfering thoughts. Attend to the medical needs of the patient…even if you know them.
    116. 116. Shift Work Is InherentlyStressful Due to the Disruption of Circadian Rhythms and Sleep Deprivation.
    117. 117. Shift Work Disruption IF YOU HAVE TO SLEEP IN THE DAYTIME:  Sleep in a cool, dark place.  Stick to a common sleeping time and pattern.  Unwind appropriately after a shift in order to rest.  Post a “day sleeper” sign on your front door, turn off the phone’s ringer and lower the volume of the answering machine.
    118. 118. Critical Incident Stress Management (CISM) an adaptive short term helping process that focuses solely on an immediate and identifiable problem to enable the individual(s) affected to return to their daily routine(s) more quickly and with a lessened likelihood of experiencing post- traumatic stress disorder.
    119. 119. Incidents when CISM may be helpful Line of duty deaths Suicide of a colleague Serious work related injury Multi-casualty / disaster / terrorism incidents Events with a high degree of threat to the personnel Significant events involving children Events in which the victim is known to the personnel Events with excessive media interest Events that are prolonged and end with a negative outcome Any significantly powerful, overwhelming distressing event
    120. 120. Death and Dying Situations involving death and dying are the most personally uncomfortable for most AEMTs. Each person faces a death situation based on his or her prior experience of loss, coping skills, religious convictions, and other personal background.
    121. 121. Loss, Grief, and Mourning
    122. 122. Know and Understand the 5 Stages of Loss Denial Anger Bargaining Depression Acceptance
    123. 123. ILLNESS AND INJURY PREVENTION
    124. 124. Topics Impact of Unintentional Injuries Community Hazards and Crime Areas Community Resources Illness and Injury Prevention
    125. 125. Introduction Injury is one of our nation’s most important health problems. Injuries result from interaction with potential hazards in the environment, which means that they may be predictable and preventable.
    126. 126. Facts About Injury… Injury is the 3rd leading cause of death. Unintentional injuries result in 70,000 deaths annually. The estimated lifetime cost of injuries will exceed $144 billion. For every death caused by injury, there are an estimated 19 hospitalizations.
    127. 127. Epidemiology The study of the factors that influence the frequency, distribution, and cause of injury, disease, and other health- related events in a population.
    128. 128. Injury (1 of 2) Intentional or unintentional damage to a person resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essentials as heat and oxygen.
    129. 129. Injury (2 of 2) Unintentional injury is an accident. Intentional injury is purposefully inflicted on a person, i.e., homicide.
    130. 130. As medical professionals,EMS providers should assessevery scene and situation for injury risk.
    131. 131. Prevention (1 of 2) EMS providers can focus on primary prevention, or keeping an injury from ever occurring. Such prevention can occur as teachable moments that occur shortly after an injury when the patient and observers remain acutely aware of what has happened and may be receptive to learning how to prevent a similar incident in the future.
    132. 132. Prevention (2 of 2) Secondary prevention occurs during medical care. Tertiary prevention occurs during rehabilitation activities.
    133. 133. Prevention within EMS Few experience the aftermath of trauma more directly than EMS providers. EMTs and paramedics are widely distributed in the population and are often role models for the community. Paramedics have become prime candidates to be advocates of injury prevention.
    134. 134. The more than 600,000 EMS providers in the United States comprise a great arsenal in the war to prevent injury and disease.
    135. 135. Organizational commitmentis vital to the development of any prevention activities.
    136. 136. Primary responsibilities include: Protection of EMS Providers Education of EMS Providers Data Collection Financial Support Empowerment of EMS Providers
    137. 137. When appropriate, specific EMS education and training in specializedsafety procedures should be available to you.
    138. 138. Funding for illness/injury campaignsmay be contributed by corporations and advertising agencies, as well as non- profit agencies.
    139. 139. Data should be collected and incorporated into patient documentation.
    140. 140. EMS Provider Commitment Body Substance Isolation (BSI) Precautions. Physical Fitness. Stress Management. Seeking Professional Care. Driving Safety. Scene Safety.
    141. 141. BSI equipment, such as protective gloves and eyewear, is one of aprovider’s basic lines of defense.
    142. 142. Keep your safety equipment in good condition and readily available in your emergency vehicle.
    143. 143. Prevention in the Community EMS has a responsibility not only to prevent injury and illness among workers, but also to promote prevention among the members of the public. EMS providers can be an appropriate and effective means of prevention in several situations.
    144. 144. Areas in Need of Prevention Activities (1 of 2) Low birth weight in newborns. Unrestrained children in motor vehicles. Bicycle-related injuries. Household fire and burn injuries. Unintentional firearms injuries.
    145. 145. Areas in Need of Prevention Activities (2 of 2) Alcohol-related motor vehicle collisions. Fall injuries in the elderly. Workplace injuries. Sports and recreation injuries. Misuse or mishandling of medication. Early discharge of patients
    146. 146. Implementation of Prevention Strategies Preserve the safety of the response team. Recognize scene hazards. Document findings. Engage in on-scene education. Know your community resources. Conduct a community needs assessment.
    147. 147. Summary Impact of Unintentional Injuries Community Hazards and Crime Areas Community Resources Illness and Injury Prevention
    148. 148. ETHICS IN ADVANCEDPREHOSPITAL CARE
    149. 149. Topics Ethics Morals Law Advanced Directives
    150. 150. Introduction (1 of 2) In one survey, almost 15% of ALS calls in an urban system generated ethical conflict. In another survey, EMS providers reported frequent ethical problems related to patient refusals, hospital destinations, and advance directives.
    151. 151. Introduction (2 of 2) Other aspects include patient confidentiality, consent, the obligation to provide care, and research.
    152. 152. Ethics VS. Morals Ethics and morals are closely related concepts but distinctly separate. Morals are the social, religious, or personal standards of right and wrong. Ethics are the rules or standards that govern the conduct of members of a particular group or profession.
    153. 153. Relationship of Ethical andLegal Issues with Medicine
    154. 154. Approaches to Making Ethical Decisions (1 of 2) Ethical relativism suggests that each person must decide how to behave and whatever decision that person makes is okay. Some say, “Just do what is right.”
    155. 155. Approaches to Making Ethical Decisions (2 of 2) The deontological method suggests that people should simply follow their duties. Followers of consequentialism believe that actions can only be judged after we know the consequences.
    156. 156. Code of Ethics Many organizations have developed a code of ethics over the years for their members. Most codes of ethics address broad humanitarian concerns and professional etiquette. Very few provide solid guidance on the kind of ethical problems commonly faced by practitioners.
    157. 157. To gain and maintain therespect of their colleagues and their patients, it is vital thatindividual paramedics exemplify the principles and values of their profession.
    158. 158. The single most important question a paramedic has to answer when faced with an ethical challenge is: WHAT IS IN THE PATIENT’S BEST INTEREST?
    159. 159. 4 Principles to Resolve Ethical Problems Beneficence is the principle of doing good for the patient. Nonmaleficence is the obligation not to harm the patient. Primum non nocere, “first, do no harm” Autonomy is a competent adult patient’s right to determine what happens to his or her own body. Justice refers to the obligation to treat all patients fairly.
    160. 160. Anapproachto ethical decision- making.
    161. 161. Quick Ways to Test Ethics Impartiality test---asks whether you would be willing to undergo this procedure or action if you were in the patient’s place. Universalizability test---asks whether you would want this action performed in all relevantly similar circumstances. Interpersonal justifiability test---asks whether you can defend or justify your actions to others.
    162. 162. Ethical Issues in Contemporary Paramedic Practice Resuscitation Attempts Confidentiality Consent Allocation of Resources Obligation to Provide Care Teaching Professional Relations Research
    163. 163. Resuscitation Attempts Learn the local laws regarding do not resuscitate (DNR) orders. Understand your local policy. “When in doubt, resuscitate.”
    164. 164. Confidentiality Your obligation to every patient is to maintain as confidential the information you obtained as a result of your participation in the medical situation. Reporting certain information such as child neglect or elder abuse are exceptions.
    165. 165. Consent (1 of 2) Patients of legal age have the right to decide what healthcare they will receive. Implied consent may apply in cases where the patient is incapacitated or unable to communicate.
    166. 166. Consent (2 of 2) Patients are generally able to consent or refuse care if they are alert and oriented, aware of their surroundings, and making sound judgments. When leaving the patient, he or she must understand the issues at hand and be able to make an informed decision.
    167. 167. Allocation of Resources Several approaches to consider…  All patients could receive the same amount of attention.  Patients could receive resources based on need.  Patients could receive what someone has determined they’ve earned. Triage is a common field activity that demonstrates one method of allocating scarce resources.
    168. 168. Obligation to Provide Care A paramedic…  Has a responsibility to help others.  Is obligated to provide care without regard to the ability to pay or other criteria.  Has a strong ethical obligation to help others even while off-duty.
    169. 169. Teaching Two possible ethical questions are raised when a student is caring for patients:  Whether or not patients should be informed that a student is working on them  How many attempts a student should be allowed to have in performing an intervention.
    170. 170. To avoid problems… Clearly identify students as such. The preceptor should, when appropriate, inform the patient of the student’s presence and obtain the patient’s consent. Take the student’s experience and skill level into account and have a pre-determined limit identified for the number of attempts at a procedure.
    171. 171. Professional Relations A paramedic answers to the patient, the physician medical director, and to his employer. Sometimes conflict arises out of such relationships. Know your policies…and communicate.
    172. 172. Research EMS research is only in its infancy but is essential to the advancement of EMS. Strict rules and guidelines must be followed when conducting patient care-related studies. Gaining the patient’s consent is paramount.
    173. 173. Summary Ethics Morals Law Advance Directives
    174. 174. Medical/Legal Aspectsof Advanced Prehospital Care
    175. 175. Topics Legal Duties and Ethical Responsibilities. The Legal System. Laws Affecting EMS and the AEMT. Legal Accountability of the AEMT. AEMT-Patient Relationships. Resuscitation Issues. Crime and Accident Scenes. Documentation.
    176. 176. Best Protection Your best protection from liability is to perform systematic assessments, provide appropriate medical care, and maintain accurate and complete documentation.
    177. 177. Legal Duties and Ethical Responsibilities (1 of 2) 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.
    178. 178. Legal Duties and Ethical Responsibilities (2 of 2) 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.
    179. 179. Each EMS response has the potential of involving EMS personnel in the legal system.
    180. 180. Sources of Law (1 of 2) Constitutional—based on the U.S. Constitution. Common—also called case law derived from society’s acceptance of customs and norms.
    181. 181. Sources of Law (2 of 2) Legislative—created by law- making bodies such as Congress and state assemblies. Administrative—enacted by governmental agencies at either federal or state levels.
    182. 182. Categories of Law (1 of 3) Criminal—division of the legal system that deals with wrongs committed against society or its members.
    183. 183. Categories of Law (2 of 3) Civil—division of the legal system that deals with non- criminal issues and conflicts between two or more parties.
    184. 184. Categories of Law (3 of 3) Tort—a civil wrong committed by one individual against another.
    185. 185. Components of a Civil Lawsuit Incident  Discovery Investigation  Trial Filing of  Decision complaint  Appeal Answering  Settlement complaint
    186. 186. Laws Affecting EMS and the AEMT
    187. 187. Scope of Practice Range of duties and skills AEMTs are allowed and expected to perform.
    188. 188. You may function asa AEMT only under the direct supervision of a licensedphysician through a delegation of authority.
    189. 189. Possessing and administering controlled substances Public Health Law Article 30 Public Health Law Article 33 State EMS Code Part 800 New York State Rules and Regulations Part 80 NYS-EMS Policy Statements
    190. 190. Licensure and Certification Certification refers to the recognition granted to an individual who has met predetermined qualifications to participate in a certain activity. Licensure is a process used to regulate occupations generally granted by a governmental body to engage in a profession or occupation.
    191. 191. Motor Vehicle Laws New York State Vehicle and Traffic Law  § 114-b Emergency Operations  § 101 Definition of Authorized Emergency Vehicles  § 1104 Privileges and Responsibilities of Authorized Emergency Vehicles
    192. 192. Motor Vehicle Laws Driver is not relieved from the duty to drive with Due Regard for the safety of all persons Driver is not protected from the consequences of his/her reckless disregard for the safety of other NYS-EMS Policy Statement on use of lights and siren
    193. 193. Mandatory Reporting Requirements Spouse abuse Child abuse and neglect Elder abuse Sexual assault Gunshot and stab wounds Animal bites Communicable diseases
    194. 194. Abuse and Neglect Abuse is improper or excessive action so as to cause harm Neglect is giving insufficient attention or respect to someone who has a claim to that attention
    195. 195. Signs and Symptoms of Abuse Multiple bruises in various stages of healing Injury inconsistent with the mechanism described Repeated calls to the same address Fresh burns Parent or guardian seem inappropriately unconcerned Conflicting stories Fear on the part of the patient to discuss how the injury occured
    196. 196. Signs and Symptoms of Neglect Lack of adult supervision Malnourished appearing child Unsafe living environment Untreated chronic illness (for example an asthmatic with no medications
    197. 197. Domestic ViolenceDefinition – a pattern of coercivebehavior of one individual byanother in order to establish andmaintain power and control
    198. 198. Forms of abuse either by Commission or Omission Physical Emotional Psychological Environmental Sexual Economic
    199. 199. Physical AbuseInflicting or attempting to inflictphysical pain and withholdingaccess to medication and medicalcare
    200. 200. Emotional Abuseconstant criticism, bellitlingsomeone’s abilities andcompetency, name-calling andother attempts to underminesomeone’s self-image and sense ofworth
    201. 201. Psychological Abusecontrolling access to friends,family, school or work; forcedisolation, intimidation, threats andblackmail
    202. 202. Environmental Abusewithholding appropriate climatecontrol, lighting, or clothing for theenvironmental conditions
    203. 203. Sexual Abuseany exploitive or coercive, non-consensual sexual contactincluding marital, and aquaintancerape; attacks on the sexual parts ofthe body and treating someone in asexually derogatory manner.
    204. 204. Economic Abuseattempts to make a personcompletely dependant on theabuser for money and economicsurvival
    205. 205. Phases of Abuse Phase 1 - arguing and verbal abuse Phase 2 - physical and sexual abuse Phase 3 - Honeymoon; denial and apologies Intervention is best accomplished in phase 1 and 2. Cycle repeats without intervention, increasing in frequency and severity
    206. 206. Relationships which may lead to Domestic Violence Child Spousal Elders (parents and others) Siblings Living companion Dating Partners Health care provider or attendant
    207. 207. Role of EMS Provider Assess and treat the patient Report observation to hospital staff and police officers  Conditions at scene  Reactions of patient  Reactions of household member
    208. 208. Conditions at the Scene Environment Temperature and light Foul odors isolation
    209. 209. Reactions of patient Hesitant when questioned Fearful of those present Hygiene/clothing/cleanliness
    210. 210. Reactions of household member Angry Indifferent Refusing necessary assistance Obstructing and questioning care
    211. 211. Information Gathering Out of hearing and sight of the possible abuser Stress confidentiality Does the patient feel safe  At the scene  In the ambulance Be direct; non-threatening and empathetic Listen to what children have to say
    212. 212. Information Gathering Conflicting accounts of the incident Physical findings History of calls to the same location or patient History, circumstances, setting, condition or environment inconsistent with injury or illness
    213. 213. Physical Findings Old bruises Sores and ulcers Topical infections – neglected injuries Injuries in uncommon places  Back of legs  Soles of feet Patterned injuries – hand, belt buckle or other imprints Thermal injuries – burns and cold
    214. 214. The severity of an injury is notnecessarily a good indicator of the severity of the situation
    215. 215. Documentation Be factual and specific – not judgmental Include  Patient condition  Conditions found at the scene  Interaction with those at the scene  History  Patient states “…”  “reported to …”
    216. 216. Other Issues Provider safety Maintain a professional attitude Consider emotions of the provider  Consider Critical Incident Stress Management
    217. 217. KEY POINTDo not accuse inthe field.Accusation andconfrontationdelaystransportation
    218. 218. Legal Protection for the AEMT 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 AEMTs who have been exposed to certain diseases. Local laws and regulations.
    219. 219. Local laws and regulations. Assault in the second degree (Penal Law, § 120.05 and120.08); Assault of an EMT-Critical Care Technician while performing duties Obstructing governmental administration in the second degree (Penal Law § 195.05); Obstruction of EMT-Critical Care Technician in the performance of his/her duty
    220. 220. Legal Accountability of the AEMT
    221. 221. Negligence Deviation from accepted standards of care recognized by law for the protection of others against the unreasonable risk of harm.
    222. 222. Always exercise the degree ofcare, skill, and judgment expected under like circumstances by a similarly trained, reasonable AEMT in the same community.
    223. 223. Components of a Negligence Claim Duty to act. Breach of duty. Actual damages. Proximate cause.
    224. 224. Duty to Act …is a formal contractual or informal legal obligation to provide care.
    225. 225. Duties Include Duty to respond and render care Duty to obey laws and regulations Duty to operate emergency vehicle reasonably and prudently Duty to provide care and transportation to the expected standard Duty to provide care and transportation consistent with the scope of practice and local medical protocols Duty to continue care and transportation through to its appropriate conclusion
    226. 226. Breach of Duty …is an action or inaction that violates the standard of care expected from a AEMT.
    227. 227. Standard of Care Standard of care is established by court testimony and reference to published codes, standards, criteria and guidelines applicable to the situation  Public Health Law Article 30  State EMS Code (Part 800)  Standardized Curriculum  Regional Protocols
    228. 228. Breaches of Duty Malfeasance—performance of a wrongful or unlawful act by a AEMT. Misfeasance—performance of a legal act in a harmful or injurious manner. Nonfeasance—failure to perform a required act or duty.
    229. 229. In some cases, negligence may be soobvious that it does not requireextensive proof  Res ipsa loquitur - the injury could only have been caused by negligence  Negligence per se - negligence is shown by the fact that a statute was violated and injury resulted
    230. 230. Actual Damages …refers to compensable physical, psychological, or financial harm.
    231. 231. An action or inaction that immediately causedor worsened the damage is called proximate cause.
    232. 232. Defenses to negligence Good Samaritan laws  Do not generally protect providers from acts of gross negligence, reckless disregard, or willful or wanton conduct  Do not generally prohibit the filing of a lawsuit  May provide coverage for paid or volunteer providers  Varies from state to state
    233. 233. Defenses to negligence Governmental immunity  Trend is toward limiting protection  May only protect governmental agency, not provider  Varies from state to state
    234. 234. Defenses to negligence Statute of limitations  Limit the number of years after an incident during which a lawsuit can be filed  Set by law and may differ for cases involving adults and children  Varies from state to state
    235. 235. Defenses to negligence Contributory negligence  Plaintiff may be found to have contributed to his or her own injury  Damages awarded may be reduced or eliminated based on the plaintiffs contribution to his or her injury
    236. 236. Special Liability Concerns
    237. 237. Medical Direction (1 of 2) A AEMT’s medical director and on-line physician may be sued if:  Medically incorrect orders were given to the AEMT;  There was a refusal to authorize the administration of a necessary medication;
    238. 238. Medical Direction (2 of 2) A AEMT’s medical director and on-line physician may be sued if:  The AEMT was directed to take the patient to an inappropriate facility;  Negligent supervision of a AEMT is proven.
    239. 239. Borrowed Servant Doctrine While supervising an EMT-I or EMT-B, a AEMT may be liable for any negligent act that person commits.
    240. 240. Civil Rights If medical care is withheld due to any discriminatory reason, a AEMT may be sued.  Examples:  Race  Creed  Color  Gender  National origin  Ability to pay (in some cases)
    241. 241. Off-Duty AEMTs Performing procedures that require delegation from a physician while off-duty may constitute practicing medicine without a license.
    242. 242. AEMT-PatientRelationships
    243. 243. Legal Principles (1 of 5) Confidentiality is the principle of law that prohibits the release of medical or other personal information about a patient without the patient’s consent.
    244. 244. Legal Principles (2 of 5) Defamation is an intentional false communication that injures another person’s reputation or good name.
    245. 245. Legal Principles (3 of 5) Libel is 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.
    246. 246. Legal Principles (4 of 5) Slander is 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.
    247. 247. Legal Principles (5 of 5) A AEMT may be accused of invasion of privacy for the release of confidential information, without legal justification, regarding a patient’s private life, which might reasonably expose the patient to ridicule, notoriety, or embarrassment.
    248. 248. The fact that the information released is true is not a defense to an action for invasion of privacy.
    249. 249. Consent 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.
    250. 250. Informed 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 of age or older to give or withhold consent. In general, a parent or guardian must give consent for children.
    251. 251. Expressed Consent Verbal, non-verbal, 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.
    252. 252. Implied Consent Consent for treatment that is presumed for a patient who is mentally, physically, or emotionally unable to give consent. It is assumed that a patient would want life-saving treatment if able to give consent. Also called emergency doctrine.
    253. 253. Involuntary Consent Consent for treatment granted by a court order. Most commonly encountered with 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.
    254. 254. Special Consent Situations (1 of 2) Minors  Usually a person under 18 years of age.  Consent must be obtained from a parent or legal guardian. Mentally incompetent adult  Consent must be obtained from the legal guardian.
    255. 255. Special Consent Situations (2 of 2) For Minors & Mentally incompetent adults…  If a parent or legal guardian cannot be found, treatment may be rendered under the doctrine of implied consent.
    256. 256. Emancipated Minors 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.
    257. 257. Withdrawal of Consent A patient may withdraw consent for treatment at any time, but it must be an informed refusal of treatment.
    258. 258. An example of a“release-from-liability form.”
    259. 259. Refusal of Service 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.
    260. 260. If a Patient Refuses (1 of 4) Is the patient legally permitted to refuse care? Make multiple, sincere attempts to convince the patient to accept care.
    261. 261. If a Patient Refuses (2 of 4) Make sure the patient is informed in his or her decision. Consult with on-line medical direction.
    262. 262. If a Patient Refuses (3 of 4) Have the patient and a disinterested witness sign a release-from-liability form. Advise the patient he or she may call again for help.
    263. 263. If a Patient Refuses (4 of 4) Attempt to get someone to stay with the patient. Document the entire situation thoroughly.
    264. 264. Some EMS systems have checklists for procedures to follow when a patient refuses care.
    265. 265. Legal Complications Related to Consent
    266. 266. Legal Complications Related to Consent (1 of 4) Abandonment is the termination of the AEMT-patient relationship without assurance that an equal or greater level of care will continue.
    267. 267. Legal Complications Related to Consent (2 of 4) Assault is an act of unlawfully placing a person in apprehension of immediate bodily harm without his or her consent. Battery is the unlawful touching of another person without his or her consent.
    268. 268. Legal Complications Related to Consent (3 of 4) False imprisonment is the intentional and unjustifiable detention of a person without his or her consent or other legal authority.
    269. 269. Legal Complications Related to Consent (4 of 4) Reasonable force is the minimal amount of force necessary to ensure that an unruly or violent person does not cause injury to himself, herself, or others. Involve law enforcement, if possible.
    270. 270. Patient Transportation 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.
    271. 271. Resuscitation Issues
    272. 272. Advance Directives 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.
    273. 273. A LivingWill allowsa person to specifywhat kindsof medical Fig. 6-4 treatment he or she should receive.
    274. 274. Do Not Resuscitate Order (DNR)indicates which, ifany, life-sustainingmeasures should be taken when thepatient’s heart and respiratory functions have ceased.
    275. 275. Some systems have developed protocols that address organviability after a patient’s death.
    276. 276. A death in the field must be appropriately dealt with anddocumented by following local protocol.
    277. 277. Crime and Accident Scenes (1 of 3) If you believe a crime has been committed, involve law enforcement. Protect yourself and other EMS personnel.
    278. 278. Crime and Accident Scenes (2 of 3) Initiate patient care only when the scene is safe.
    279. 279. Crime and Accident Scenes (3 of 3) 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 investigating officers and document your actions.
    280. 280. Documentation Complete promptly after patient contact. Be thorough. Be objective. Be accurate. Maintain patient confidentiality. Never alter a patient care record.
    281. 281. Summary Legal duties and ethical responsibilities. The legal system. Laws affecting EMS and the AEMT. Legal accountability of the AEMT. AEMT-patient relationships. Resuscitation issues. Crime and accident scenes. Documentation.

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