EMS AND
LEGAL IMPLICATIONS
PSYCHIATRIC SITUATIONS
EBOLA
October 2014 CE
Condell Medical Center EMS System
Site Code #107200E-1214
Prepared by: Sharon Hopkins, RN, EMT-P, BSN
Revised 10.30.14
1
OBJECTIVES
Upon successful completion of this module, the EMS
provider will be able to:
1. Review scene safety as the first step in every call.
2. Define Munchausen by proxy syndrome, anorexia, bulimia
3. Describe situations when it is appropriate to obtain consent for medical care
from emancipated minors versus pregnant minor versus minor parent
4. Describe characteristics and EMS interventions for a variety of behavioral
emergencies.
5. Describe the difference between voluntary and involuntary committal and
2
EMS responsibilities.
OBJECTIVES CONT’D
6. Describe the assessment and care of the patient that has been Tasered.
7. Describe the restraining of a patient via physical and chemical
methods.
8. Describe documentation of the patient that has been physically
restrained.
9. Review a variety of advanced directives.
10. Describe the State of Illinois revised POLST form and implications for
EMS.
3
OBJECTIVES CONT’D
11. Describe the implications of the Ebola virus and EMS care of the patient
12. Actively participate in case scenario discussion.
13. Actively participate in review of selected Region X SOP’s.
14. Actively participate in review of a variety of EKG rhythms and 12 lead
EKG’s.
15. Successfully complete the post quiz with a score of 80% or better.
4
SCENE SAFETY
• First step in any patient approach
• You do everything possible to make the environment safe
• For yourself
• For your crew
• For other responding personnel
• For the patient
• For others around
5
SCENE SAFETY
• Establish a safe perimeter
• Evaluate the safety of the environment
• Call for help as necessary
• If you need to stage, document
• The reason for staging
• Interventions taken to make the environment safe
• When you made patient contact
6
SCENE SAFETY
• Never let your guard down
• Use those eyes in the back of your head
• If it doesn’t feel right, do not enter
• Keep yourself closest to the means of exit
• Never let yourself be cut off from egress
7
MUNCHAUSEN SYNDROME
• A mental disorder
• Sufferer causes or pretends to have physical or
psychological symptoms
• Typical patient is an adult 20-40 years old
• Thought to be motivated by a desire to be seen as ill versus
other benefit
8
MUNCHAUSEN SYNDROME BY PROXY
• Considered a mental illness of factitious disorders
• Considered a relatively rare form of child abuse
• Caretaker fakes or causes symptoms in a child
• Often caretaker has familiarity with medical knowledge
• Affected persons usually under 4 years old
• Most of the time the mothers are the perpetrators
• Often more than one child victimized per household
9
EMS ROLE IN MUNCHAUSEN’S
• Be objective in documentation
• Site source of information provided (“_____ states…”)
• May take years to prove the presence of this mental illness
so EMS may not have knowledge of this diagnosis
• Caregiver must admit to the abuse and be willing to seek
psychological treatment
• Psychological and physical damage to victim could lead to
poor long-term prognosis
10
ANOREXIA
• An eating disorder that is a real, treatable medical illness
• Has distorted body image of self; typically female
• An intense fear of gaining weight
• Thinks about food a lot but limits intake
• Uses starvation to feel more in control of life
• Uses starvation to ease tension, anger, anxiety
11
FACE OF ANOREXIA
12
ANOREXIA
• Body slows down due to lack of source of energy to continue
to function
• Patient suffers impairments
Brain function
Infertility
Dental decay
Kidney failure
Cardiac arrest
13
BULIMIA
• Serious, potentially life-threatening eating disorder
• Preoccupied with body shape and weight
• Patients usually secretly binge and purge
• Binge – eat large amounts of food
• Purge – self-induce vomiting or misuse laxatives, diuretics or
enemas after binging or fast, follows a strict diet or
participates in excessive exercise
14
BULIMIA
• Serious and life-threatening complications
Dehydration
Heart problems
Severe tooth decay and gum disease
Absence of periods in females
Digestive problems; possible dependence on laxatives
Anxiety and depression
Drug and alcohol abuse
15
CYCLE OF BULIMIA
16
COMPLICATIONS OF EATING DISORDERS
• Self-induced vomiting – oral complications
• Erosion of tooth enamel from exposure to gastric acid
• Sensitivity to hot/cold foods
• Oral swelling or soreness
• GI tract complications especially with bulimia
• Ulcers, ruptures, strictures of esophagus from repeated
vomiting
17
COMPLICATIONS CONT’D
• Infertility due to lack of periods
• Continual use of laxatives – colon function problems
• Loss of normal function
• Electrolyte imbalance with misuse of diuretics and laxatives
• Fetal harm
• Low birth weight, premature labor, post-partum depression
18
THE DESTRUCTION FROM ANOREXIA
• Body and muscles are being starved
• Heart muscle atrophies; high risk for heart failure
• Drop in sodium, zinc, potassium and calcium put the patient at
increased risk for abnormal heart rhythms (SVT, VT, bradycardia)
• Kidney failure can develop due to dehydration
• Sudden cardiac death often due to dysrhythmias due to electrolyte
imbalance and mineral disturbance
• Common presentations: orthostatic hypotension, shock, CHF, sudden
death
19
TREATMENT FOR EATING DISORDERS
• Counseling is a must for psychotherapy
• Antidepressants may help
• Work with a nutritionist for an eating plan
• Hospitalization may be necessary
• Slightly higher recovery rate and better long-term prognosis
for bulimia than anorexia
20
IMPLICATIONS FOR EMS
• Maintain heightened awareness for the situation
• Overall low body weight
• Poor dentition
• From repeated vomiting and poor nutritional state
• Incomplete/inaccurate history provided by patient
• Denial of any problems by patient
• Note: Cardiac monitoring essential due to potential for electrolyte
imbalance and resulting cardiac dysrhythmias
21
DEFINITIONS
• Emancipated minor – minor of any age who is or has been
married or minor over 16 and under 18 who by court order
has been freed from care, custody, and control of parents
• Did you know - Emancipation does NOT extend to specific
constitutional and statutory age requirements regarding
voting, use of alcoholic beverages, possession of firearms
22
CONSENT FOR MEDICAL CARE
• May be obtained from
Any person 18 and older
Emancipated minor
Minor who is married
Minor who is pregnant
Minor who is a parent
23
OBTAINING CONSENT FROM MINOR
• Healthcare professionals shall not incur civil or criminal liability for
failure to obtain valid consent when they relied in good faith on the
representation made by the minor
• This means you can take consent at face value when the minor
states they have the authority to provide consent
They are emancipated from parental care
They are or have been married
They are pregnant
They are a parent with custody of their child
24
IMPLIED CONSENT
• Emergency exception rule based on the assumption that a reasonable
person would consent to emergency care is able to do so
• Medical professional may presume consent and proceed with
appropriate treatment:
• Child is suffering from emergent condition and life or health is in danger
• Legal guardian unavailable or unable to provide consent
• Treatment or transport cannot be safely delayed waiting for consent
• Treatment rendered limited for emergent condition posing immediate
threat to child
25
EMS AND CONSENT
• Burden of proof falls on medical professional when treating minor without
proper consent
• Need to justify and document that emergency actions were necessary to
prevent imminent and significant harm to child
• Generally considered as emergent conditions includes treatment of fractures,
infections, pain control
• Always act in best interest of patient
• Clearly document nature of emergency and reason minor required
immediate treatment and/or transportation and efforts made to contact legal
26
guardian
INFORMED CONSENT AND LANGUAGE
BARRIER
• Interpretation can be performed in person, via videoconferencing or
by telephone
• Certified medical interpreter preferred
• Using family members should be avoided unless absolutely necessary
• Translation may not be accurate
• Document use of interpreter
27
IN LOCO PARENTIS
• A Latin term meaning in place of or instead of the parent
• Relationship is similar to that of a parent and a child, but with
limitations
• Original intent was for the care, supervision, and discipline of a child
• Parent, guardian, or person in loco parentis can consent to emergent
medical treatment
• Generally inferred most commonly onto teachers but also could
include babysitter
28
CONSENT FROM A MINOR
• Emancipated minor by court order
• Married minor
• Pregnant minor
• Parent of a minor child
• For treatment of a sexually transmitted disease (12 years or older)
• For treatment of alcohol or substance abuse (12 years or older)
• For psychiatric admission and treatment (16 years or older)
• For outpatient mental health treatment (12 years or older)
29
PUBLIC ASSUMPTIONS
• The paramedic is medically trained so they know what they
are talking about;
• “if they say I don’t have to go to the hospital, then I’m okay”
• Patients want to believe nothing is wrong so will easily be
swayed that nothing is wrong and transport is not warranted
• This transport is going to be expensive; some paramedics
may capitalize on the patient’s financial fears
• Do you want to be responsible for the one call you talked
down who had a bad outcome???
30
CASE REPORT #1
• EMS called for an adult patient with chest pain past few hours
• EKG showed sinus rhythm
• Vital signs were stable
• Lung sounds were clear
• The patient was convinced by EMS it was acid reflux
• A release was obtained
How would you have handled this call?
31
OUTCOME CASE REPORT #1
• Hopefully, you’ve done a cardiac work-up and transported this
patient
• The responding paramedic’s general impression was that the
patient had acid reflux, suggested antacids and left the scene
after the patient signed AMA
• The patient took the antacids
• The patient died 3 hours after being evaluated
32
CASE REPORT #2
• EMS was called for a 4 year-old child having an asthma attack
• Bilateral wheezes auscultated
• EMS convinced the mother the patient was only suffering from croup
• The mother was instructed to put the child in the bathroom and run the
shower for the steam
• A release was obtained
How would you have handled this call?
33
OUTCOME CASE REPORT #2
• The mother followed instructions and placed the child in a
steamy bathroom
• The child “fell asleep”; “breathing wasn’t a struggle”
• The mother assumed her child was more relaxed
• The child died from a severe asthma attack
34
CASE REPORT #3
• EMS summoned by police to respond to a reported suicide attempt
• Dispatch states they received a call from the patient's friend who stated
they were threatening to commit suicide by overdose
• EMS assesses the patient who has stable vital signs
• Patient states they were just venting to their friend and didn’t really
take any pills
• Pill bottles offered were checked and levels seemed appropriate
• EMS obtained a release
How would you have handled this call?
35
OUTCOME CASE #3
• Boy, this one is TOUGH!!!
• This paramedic did not talk patient out of going to the
hospital but neither did they encourage her to go
• Patient was left at home alone
• The patient was found dead the next morning
• Would you have involved Medical Control in dialogue???
• Hopefully, yes
36
TALKING PEOPLE OUT OF TRANSPORT
• Which person are you:
• Every call you take is with the assumption that you will be transporting a
patient
OR
• You work harder at convincing someone not to go to the hospital than to
be transported
• Accepting refusals increases the risk of contribution to a preventable
tragedy
• There is a right way and wrong way to get a refusal
37
RELEASES/REFUSALS
• Respond to each call assuming every one will be a transport
• Work harder at convincing them to be transported than accepting them as a
refusal/release
• Patients are aware of your attitude – show yours as positive
• If someone called you, they usually are expecting transport
• So, just take them
• Of all calls, make these the most detailed and complete documentation
• Show what patient looked like when you arrived and then again when you left
• Contact Medical Control for all controversial or questionable
releases/refusals
38
CHARACTERISTICS OF BEHAVIORAL
EMERGENCIES
• A call involving interaction with a patient whose behavior is
Unusual
Bizarre
Threatening
Dangerous
• Behavior not generally accepted by society
• Requires intervention from medical personnel
39
OBJECTIVE INDICATIONS OF BEHAVIORAL
ISSUE
• Actions or situations that:
• Interfere with activities of daily living (dressing, eating
sleeping, maintaining housing)
• Pose a threat to the life or well-being of the patient or others
• Significant deviation from society’s expectations or norms
40
AVOID TUNNEL VISION
• Always keep in mind medical conditions that may be
presenting as a behavioral issue
Diabetes
Trauma
Brain disorder
Medication influence
Recreational drug use
41
DELIRIUM
• Relatively rapid, acute onset (hours to days)of widespread
disorganized thought
• May be reversible
• Patient has inattentiveness
• Memory impairment
• Disorientation
• Clouding of consciousness
42
DEMENTIA
• Irreversible process that develops slowly over months
• Consists of memory impairment and cognitive disturbance
• Many common causes
• Alzheimer’s disease
• Vascular problems
• AIDS
• Head trauma
• Parkinson’s disease
• Substance abuse
43
SCHIZOPHRENIA
• A significant change in behavior and loss of contact with
reality
• Common signs, symptoms, types
• Hallucinations
• Delusions
• Depression
• Flat affect
• Paranoid
• Disorganized behavior, dress, speech
44
EXCITED DELIRIUM
• Sudden onset of unexplained aggressive behavior
• Often accompanied by profuse sweating, high body temp, and delusional
behavior
• Often linked to a history of chronic cocaine abuse
• Cocaine abuse contributed to development of coronary artery disease
and damage to the heart muscle
• Aggressive chemical sedation required
• Continued physical struggle increases catecholamine surge and
metabolic acidosis
45
CASCADE OF EVENTS OF EXCITED DELIRIUM
• Patient is agitated
• There is a struggle with the patient
• Increased O2 demand; if compromised airway cannot increase O2 supply
• Energy stores (i.e.: glucose) are quickly depleted
• There is an adrenalin overdose from the increased & aggressive activity
• Excessive lactic acid created as a by-product
• Heart is stressed from the exertion and adrenalin rush
• Respiratory muscles will begin to fail
46
RHABDOMYOLYSIS –
RESULTS FROM THE STRUGGLE
• Breakdown of myoglobin – a by-product in muscles
• Causes myoglobinemia – the protein myoglobin released into
blood
• Intramuscular acidosis develops
• Kidneys try to filter the dead muscle cells, eventually clog and
then begin to fail
• Patient presents with muscle weakness or flaccidity
• May present with nausea and vomiting
• Vomiting increases the risk of aspiration
47
TREATMENT RHABDOMYOLYSIS
• Fluid hydration
Urine sample due to
rhabdomyolysis
• 200 ml increments; repeated as necessary
• Watch for fluid overload
• Monitor breath sounds
• Monitor cardiac rhythm
• Watch for dysrhythmias induced by acidosis and electrolyte
imbalance
48
EMS APPROACH FOR COGNITIVE
DISORDERS
• Patient suffers from significant impaired social or
occupational functioning
• Approach in the field is supportive
• Additionally assess and manage for medical conditions
• Don’t get tunnel vision or distracted
49
TYPES OF PSYCHIATRIC COMMITTAL
• Informal voluntary admission
• Patient can terminate stay after 240
• Formal voluntary admission
• Patient signs self in and agrees to stay until MD discharges them
• Patient has right to request discharge at any time
• Involuntary admission
• Admitted against your will for a minimum of 720 and then must be
examined and keep or discharge patient
• If suicidal, homicidal, psychotic, unable to care for self, MD must arrange
court hearing within 5 days for a judge to keep or discharge patient
50
INVOLUNTARY COMMITTAL LAW
• Allows placement of any individual in treatment that because of the
nature of their illness, is unable to understand their need for treatment
and who, if not treated, is at risk of suffering or continuing to suffer
mental deterioration or emotional deterioration, or both, to the point
that the person is at risk of engaging in dangerous conduct
• Involuntary commitment can be made by family members, mental
health professionals, and police officers
51
COMMITTAL PAPERWORK
• ED practice is to transfer patients to psych facilities with involuntary
paperwork completed
• This prevents the “voluntary “ patient from getting to the in-patient facility
and then “changing their mind” about admission
• The person directly witnessing the behavior or hearing the comments
must be involved in completing the documentation
• Hearsay is not valid or allowable in these situations
• EMS will complete their own patient care run report
• Keep information objective and descriptive
52
PETITION FOR INVOLUNTARY/JUDICIAL
ADMISSION
• EMS to state in detail signs and symptoms of mental illness displayed
• Can include prior diagnosis, treatment and hospitalizations
• Describe any threats, behavior or pattern of behavior which support
your complaint
• Include personal observations that lead to your belief for involuntary
admission
• Your address and phone number on commitment papers can be given
as your work information
53
TRANSPORTS OF PSYCH PATIENTS
• When EMS does not witness the “psych” behavior
• These cases are VERY difficult
• They sometimes come down to a “he said/she said”
struggle
• Always act in the best interest of the patient
• Involve Medical Control for these unclear calls
54
CARE OF PATIENT TASED
• Evaluate depth of skin penetration
• DO NOT remove darts if patient is not under control
• DO NOT remove darts but stabilize and transport
• Dart in lid/globe of eye
• Dart in face or neck
• Dart in genitalia
• Dart in bony prominence
• Dart in spinal column
55
REMOVAL OF DARTS
• Remove Taser cartridge from gun or cut wires
• Place one hand on patient next to embedded dart to stabilize
surrounding skin
• Firmly grasp probe with other hand
• Remove dart by gently pulling straight out
• Assure dart is intact; take sharps precautions
• Return darts to law enforcement or dispose of sharps
• Cleanse wound with saline
• Cover with a dry dressing (i.e.: band aid)
56
RESTRAINTS
• High risk, low volume task
• Use of restraints puts the provider and organization at risk
legally AND in the court of public opinion
• Remember:
• You are treating a patient, not a criminal
• Combative issues are symptom of the illness or injury
57
PRINCIPLES OF USE OF RESTRAINTS
• Restraints used only after verbal de-escalation attempted
• Situations exist where immediate use of restraints is required
• Restraints should be individualized
• Make reasonable attempts to protect patient’s privacy and dignity
• Method used should be least restrictive necessary for protection
of patient and others
• Need to be trained in use and application and monitoring of
patient
58
PRINCIPLES CONSIDERED WHEN USING
RESTRAINTS
• Medical and legal issues
• Medical ethics
• Scene safety and assessment
• Patient assessment
• Psychological causes of
combative patients
• Proper team patient-restraining
techniques
• Knowledge of chemical-restraint
pharmacology
• Airway control
• Reassessment
• Documentation
59
CONSIDERATIONS
• Once a patient is restrained, providers must take full
responsibility for the patient’s welfare
• Frequent reassessment of airway and breathing
• Frequent reassessment of distal movement, sensation, and
circulation of extremities
• The same standard of care that would have been provided
for the unrestrained patient would still need to be performed
• Clear documentation is required if any expected care was withheld60
RESTRAINT DOCUMENTATION
• Objective reasons for need of restraints
• Detailed description of the situation
• Alternatives attempted to avoid restraints
• i.e.: verbal de-escalation
• Type of restraints applied
• Periodic assessment/reassessment of patient
• Include assessment of airway status and distal circulation of
restrained extremities
61
ADVANCED DIRECTIVES
• Legal documents
• Spells out your wishes for end-of-life care
• Several types/forms available
• Living will – describes care when dying or unconscious
• Cannot be honored by pre-hospital providers
• Durable Power of Attorney for Healthcare
• Allows patient to name health care proxy
• Proxy can speak up only when patient is unconscious or unable to make
medical decisions
62
POLST
• Physician Orders for Life-Sustaining Treatment
• A signed medical order that travels with patient
• In Illinois, POLST is the revision of the IDPH Uniform DNR
Advanced Directive
• Allows patient to create medical orders reflecting treatment
wishes at end-of-life
• Helps health professionals know and honor wishes of patient
• Allows emergency personnel to facilitate patient wishes
63
POLST
• Does not take place of Power of Attorney for Healthcare form
• Used in addition to that form
• Without a POLST or IDPH Uniform DNR Advanced Directive,
EMS must do what they can to attempt to save a person’s life
• EMS cannot accept the word of the family regarding what the
wishes of the patient would have been
• POLST photocopies are acceptable
• 2nd page of POLST form does not have to be completed; can
be left blank
64
COMPLETING POLST FORMS
• Signed by patient or representative
• As a physician order, signed by a physician
• Effective date is noted
• Witness signature is obtained
• On page #1, section A, B, C, D, and/or E must be completed
65
FOLLOWING POLST/DNR GUIDELINES
• Healthcare professional or healthcare provider may presume
a DNR is valid
• …who in good faith complies with a DNR order is not subject
to any criminal or civil liability except for willful or wanton
misconduct and may not be found to have committed an act
of unprofessional conduct
66
• Subsection (d) of Section 65 HealthCare Surrogate Act, 755 ILCS 40/65
CASE SCENARIOS
• Review the following cases
• Prepare to discuss how YOU and your crew would handle
the situation
• Be prepared to support your decisions
• Region X SOP’s
• Standard of Care
• By what is just the right thing to do
67
CASE #1
• EMS called to the scene for a 32 year old female
with dizziness who passed out
• Patient appears very thin, warm and pale
• Is awake, answering all questions, cooperative
• Take this call
• Decide general impression
• Determine choice of treatment
68
CASE #1 – WHAT’S THE RHYTHM???
• Sinus bradycardia
• What would make you consider that the patient is
symptomatic, in need of intervention?
• Decreased level of consciousness, blood pressure <90 systolic
69
CASE #1
• What is the treatment for unstable sinus bradycardia?
• Atropine 0.5 mg rapid IVP/IO
• Prepare for TCP
• If atropine is ineffective, administer sedation with Valium 2mg
IVP/IO over 2 minutes
• Begin TCP
• Rate 80/minute, sensitivity auto/demand
• Start mA at 0 and increase until capture is confirmed
70
CASE #1
• What could be used for discomfort caused by use of the TCP?
• Valium 2 mg IVP/IO over 2 minutes
• This takes the edge off and relaxes patient
• May repeat every 2 minutes as needed to a max of 10 mg
• What would be used for management of pain?
• Fentanyl 1 mcg/kg IVP/IO/IN
• May repeat same dose in 5 minutes
• Max total is 200 mcg
71
CASE #1
• Patient’s rhythm changes and patient loses consciousness
• Now what is the rhythm?
• Polymorphic VT / Torsades de pointes
• What determines which treatment to follow?
• If patient has a pulse or not; if patient is relatively stable or unstable
72
CASE #1
• Patient is pulseless and apneic with polymorphic VT
• What is the treatment plan now?
• Immediate defibrillation
• Followed by rapid initiation of CPR (30:2)
• Establishment of IV access
• Epinephrine 1:10,000 1 mg IVP/IO
• Repealed every 3-5 minutes
• Amiodarone 300 mg IVP/IO 1st dose
• 150 mg for 2nd dose
• Antidysrhythmic alternated with the vasopressor used
73
CASE #1
• If the patient with polymorphic VT had a pulse and was
relatively stable (talking to you, had a palpable radial pulse
(therefore a B/P), what would you do?
• Amiodarone 150 mg
• Diluted in 100 ml D5W
• Administered IVPB over a minimum of 10 minutes
• If patient was unstable, what would you do?
• Synchronized cardioversion with sedation if time to give
74
CASE #1 – UNSTABLE VT
• Consider sedation
• Versed 2 mg IVP/IO every 2 minutes titrated to max of 10 mg
• Begin electrical therapy
• Synchronized cardioversion 100 joules
• Antidysrhythmic medication to begin – to give time to be effective
• Amiodarone 150 mg diluted in 100 ml D5W IVPB
• Run over at least 10 minutes
• Watch for hypotension – slow rate down if occurs
• Continue cardioversion attempts at 200 j, then 300 j, then 360 j
75
CASE #2
• EMS is on the scene for a 72 year-old patient who “stopped
breathing”
• Upon arrival family is present; patient last seen a few minutes ago
• Family states the patient has a DNR
• Patient confirmed 0-0-0
• What would you do?
• Ask to see the DNR
• You need to begin CPR as you contact Medical Control
76
CASE #2
• What would you do if the family could not produce the DNR form?
• You need to begin CPR and contact Medical Control for orders
• What information would be important to provide to Medical Control?
• Circumstance of how patient found
• Patient history
• Family verbalizing that there is a DNR but unable to produce
• Fact that CPR has been begun
• Initial rhythm on the monitor
• Be specific and request permission to withdraw CPR efforts if that is77
your impression
CASE #2 – WITHDRAWING RESUSCITATION
• Include in report to Medical Control
• Patient is normothermic
• If arrest was witnessed or unwitnessed
• How airway is secured and if IV access is established
• That rhythm remains asystole
• Any interventions performed up to that point
78
CASE #2
• Documentation of withdrawing resuscitation
• Note time of withdrawal of efforts
• Document name of physician on run report
• Document notification of coroner or Medical Examiner
• EMS does not need to remain at the scene if scene turned
over to police
• If leaving the body at the scene is a problem contact the
hospital to inform of transport to get the patient off the scene
79
CASE #2
• What if ordered to work the call???
• What is the rhythm?
Asystole
• What do you do for asystole?
80
CASE #2 - ASYSTOLE
• Lots of CPR; 10 second pauses every 2 minutes to reevaluate the
rhythm
• NO PULSE CHECKS
• Unless a rhythm is produced that should provide a pulse!
• Consider possible causes – the H’s and T’s
• 200 ml fluid challenge if breath sounds clear
• Repeat as needed
• A vasopressor is the only med intervention
• Epinephrine 1:10,000 – 1 mg IVP/IO
• Every 3- 5 minutes for the duration
81
CASE #3
• EMS responds to a bar for an injured patron
• Patron tripped and fell
• Received laceration to palm; bleeding controlled
• Admits to having 2 beers
• Patron does not want your care
• Now what do you do???
82
CASE #3
• EMS needs to determine the decisional capacity of the patron
• Does the patient have the ability to understand and appreciate the nature
and consequences of refusing assessment and care?
• EMS assessment for decisional capacity
• Affect – behavior appropriate for the environment?
• Behavior –patient remains in control?
• Cognition / judgment – can patient understand the information?
• Patient insight – does patient appreciate the implications of
situation?
83
CASE #3 – THOROUGH DOCUMENTATION
• Decisional capacity
• Assessment performed
• Understanding of EMS impression and attempts by EMS to
convince patient to accept treatment and/or transportation
• Any EMS concerns about accepting a refusal risks and
benefits provided to the patient
• Involvement of Medical Control
• Instructions to patient to seek medical care if condition
changes
84
CASE #4
• EMS is called to the scene of a MVC – category III trauma (non-I
and non-II category trauma)
• You have a 17 year-old patient who is refusing transportation
• Your patient states she is 3 months pregnant
• You have the 17 year-old boyfriend also refusing transportation
• Can these patients sign refusals?
85
CASE #4
• Who can sign a refusal in this scenario?
• A pregnant minor can sign a refusal
• A parent who is a minor can grant permission for themselves
and their child
• The boyfriend cannot sign a refusal until he becomes a parent
with custody of his child
86
CASE #5
• EMS is called for a 16 year-old female patient and her
4 month-old child
• They were involved in a minor MVC
• The patient is refusing transportation for herself and her
child
• How would you handle this call?
• A minor who is a parent with custody of their child has the
right to refuse medial care for themselves and their child
87
CASE #6
• EMS is called to the scene for a patient who is threatening to
hurt themselves
• The threats were witnessed by family and police; not by EMS
• What would you do if the patient refuses transport?
• Can this patient refuse transport?
88
CASE #6
• This patient made threats witnessed by police and family
• Therefore, patient not allowed to sign a refusal
• EMS CANNOT be the one to complete an involuntary petition
• Only those persons who have first hand knowledge as
witnesses can complete the involuntary documentation of the
behavior
• The police or family would be involved in completing the
form with hospital staff
89
THE EBOLA VIRUS
• Important to understand…
• Information is coming out on a daily basis and often multiple
times per day
• Information is coming from the CDC and IDPH
• As information is received at the EMS Resource Hospitals, it
will be disseminated as soon as feasible
• The goal from the CMC EMS office is to date and time each
memo to help in determining most current memo
90
GOALS OF DISSEMINATING INFORMATION
• Educate/inform to increase detection of possible
Ebola cases
• Protect healthcare workers and general public
• Provide guidelines directing appropriate response
for caring of patients
• Imperative to keep up to date with revised material
91
EBOLA VIRUS DISEASE/
EBOLA HEMORRHAGIC FEVER
• A rare, deadly disease caused by infection with the virus strain
• 4 of 5 strains can cause disease in humans
• Virus found in several countries in West Africa
• First discovered in 1976
• Unknown who the natural host site is but most likely animal borne
• Bats the most likely reservoir
• 2 – 21 day incubation period (average 8-10 days) after contact
with Ebola patient
92
EBOLA TRANSMISSION
• Direct contact with broken skin or via mucous membranes
(eyes, nose, mouth) with contaminated blood or body fluids
• Ebola is NOT spread via casual contact
• Contact with contaminated objects
• Contact with infected animals
• NOT spread via air, water, or general food
• In Africa, could be spread after handling bushmeat or
contact with infected bats
93
STANDARD PRECAUTIONS FOR EVERY CALL
• Taking blood and body fluid precautions
• Reduces risk of transmission of bloodborne pathogens
• Need to apply these principles to ALL patients you care for
• Appropriate PPE’s need to be available AND used
• The process of removing protective gear is just as important
as donning them
• Remember the simplest standard precaution which is often
the most neglected…
• HANDWASHING
94
EBOLA SCREENING
SIGNS & SYMPTOMS
ANY OR ALL MAY BE PRESENT
• Fever
> 38.60C or 101.50F
• Diarrhea
• Severe headache
• Abdominal pain
• Muscle/joint pain
• Hemorrhage – bleeding
or bruising
• Weakness/fatigue
• Vomiting
• Lack of appetite
95
EBOLA SCREENING QUESTIONS
• After/while screening for signs and symptoms, inquire about
travel
• West Africa (Guinea, Liberia, Sierra Leone, Senegal, Nigeria,
or other countries where Ebola transmission has been
reported by WHO
• Travel would have been within past 21 days/3 weeks of
symptom onset
96
EBOLA QUESTIONS FOR EVERY PATIENT
CALL
• ED’s being requested and now EMS to specifically document
yes/no answers to the screening process
• Document yes/no to presence of any signs or symptoms
• Document yes/no to travel history in past 3 weeks out of the
country by patient or close family members
• Also question regarding the history of a cough
• Remember, there are still other diseases we need to be vigilant
about like TB
97
ISOLATION FOR SUSPECTED CASES OF
EBOLA
• If patient has positive signs and symptoms AND travel within
past 21 days, then isolate patient
• Standard precautions
• Performed for every patient contact
• Handwashing still very important
• Contact isolation – fluid impermeable gown and gloves
• Add shoe covers in certain situations
• Eye and face masks/shields
98
ISOLATION CONT’D
• Droplet precautions
• Particles are heavy and do not stay suspended in air for long
• Transmission via talking, coughing, sneezing
• 6 feet is safer distance than 3 feet
• In general droplet precautions, can wear surgical mask if
within 6 feet of patient
• If Ebola virus suspected, must wear N95 mask
• Not just if providing aerosol-generating procedures
• Nebulizer treatments
• Suctioning, intubation
99
HAND HYGIENE
• Remains extremely important
• If hands not visibly soiled, can use 60-95% alcohol based
hand sanitizer
• Use soap and water for 15 seconds
• When hands visibly soiled
Did you remember hand washing over hand sanitizer for:
For contact with clostridium (infection in colon)
For contact with norovirus (inflammation of stomach &/or
intestines)
100
TREATMENT OF EBOLA
• No approved specific treatments currently available
• Clinical management focused on supportive care of complications
Hypovolemia
Electrolyte abnormality
Bleeding disorders and hemorrhage
Shock
Hypoxia
Multi-organ failure
DIC
101
CLEANING EQUIPMENT
• Need to reinforce cleaning procedures that should be
carried out following the care and transport of each and
every patient
• For possible Ebola infection, use bleach and Cavicide wipes
• Reminder: bleach based product required for use following
care of patient with diarrhea
102
DISCUSSION OF PPE PRODUCTS
• At the Medical Officer meeting 10.14.14 discussed the minimum use
for suspected Ebola patient:
• Gloves – double gloving recommended
• Face mask with eye shield or goggles
• Gown – impermeable especially in presence of body fluids
• Booties – especially in presence of body fluids
• Linen contaminated with body fluids to be double bagged and remain
with patient in their room
• Hospital to make notification to the Health Department
103
BIBLIOGRAPHY
• Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices,
4th edition. Brady. 2013.
• Region X SOP’s; IDPH Approved April 10, 2014.
• Steingart, J. EMS…Caring. Article 2014
• http://thelegalguardian.com/resources/ems-case-law/
• http://www.idph.state.il.us/public/books/UniformDNRAdanceDirectives.pdf
• http://www.mayoclinic.org/diseases-conditions/bulimia/basics/definition/CON20033050?p=1
• http://www.womenshealth.gov/publications/our-publications/fact-sheet/anorexianervosa.html
104
BIBLIOGRAPHY CONT’D
• http://kidshealth.org/parent/general/sick/munchausen.html
• http://www.jems.com/article/training/proper-restraint-technique-sta
• http://www.acep.org/Clinical---Practice-Management/Use-of-Patient-Restraints/
• http://www.emsmdc.com/pdf/prehospital-restraint-final.pdf
• http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1539&ChapterID=35
• http://www.legis.state.il.us/
• 410 ILCS 210/ - Consent by Minors to Medical Procedures Act
• http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/qa.html
• http://www.ilga.gov/legislation/ilcs/ilcs4.asp?DocName=040500050HCh%2E+III&Ac
105
tID=1496&ChapterID=34&SeqStart=7400000&SeqEnd=17800000