CBT/OTEP 935
Street Medicine – Special Situations
Copyright 2008 Seattle/King County EMS
Introduction
This course will address special problems
encountered by EMS providers in the field
including refusal of care, violence, forced
restraint, and other situations.
This course is intended to provide general
guidance to EMS providers in unique
situations.
Follow your local protocols when they
vary from the recommendations in this
course.
Copyright 2008 Seattle/King County EMS
New Terms
compelling reasons – Circumstances that
permit EMS personnel to withhold resuscitation
from a patient in cardiac arrest.
excited delirium – A term used to describe outof-control behavior in people usually under the
influence of stimulants. In some cases, a
severely agitated person can go into cardiac
arrest.
Copyright 2008 Seattle/King County EMS
New Terms, continued
legal capacity – In EMS, this concept mostly
concerns whether or not a person is a minor.
mental competence – A person’s ability to
understand information about their condition
and weigh the risks and benefits of not
receiving care.
reasonable force – The force needed to keep a
patient from injury or from injuring others.
Copyright 2008 Seattle/King County EMS
Refusal of Care
• Competent person has a right to refuse
treatment
• Must assure he is of sound mind and legally
able to
• Mental competence
• Legal capacity
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Mental Competence
A person’s ability to understand information
about his or her condition and weigh the risks
and benefits of not receiving care
Copyright 2008 Seattle/King County EMS
Legal Capacity
• Is the patient a minor?
• In most states, under age 18 considered a
minor
• Parent or guardian generally must give
permission for medical treatment
Copyright 2008 Seattle/King County EMS
Case Study – MVA
28-year-old male – motor scooter/auto
collision at a busy intersection.
Patient refuses care. He says he doesn’t have
heath insurance and thinks he will be fine.
He hit the curb at about 5 mph and fell over
with the bike as it came to a stop.
He’s alert and oriented X 3.
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Case Study – MVA, continued
Is this patient mentally competent?
Does he have legal capacity?
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Case Study – Alcohol Intoxication
Man in his 40’s at local tavern – fall from bar
stool. Has been drinking for 2+ hours.
Speech is slurred.
He refuses care. He says feels fine.
Friend says he hit his head when he fell.
Alert and oriented to person and place (but
not time).
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Case Study – Alcohol, continued
Is this patient mentally competent?
You are concerned that he might have a
head injury or hypoglycemia. What strategies
can you employ to allow for treatment?
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Safety and Violent Behavior
• Look for hazards before approaching
• Plan an escape route
• Approach in a calm and non-threatening
manner
• Do not try to intervene in a fight or
argument
• Ask if there are weapons
• Do not get separated from your partner
• Consider additional resources early
Copyright 2008 Seattle/King County EMS
Safety and Violent Behavior
If a scene suddenly becomes
dangerous, do not hesitate to back
out and call for help!
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Attempted Suicide
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Rescuer and patient safety high priority
Calm patient
Treat injuries, if possible
Manage family anxiety
Clear onlookers from scene
Copyright 2008 Seattle/King County EMS
Case Study – Attempted Suicide
24-year-old female, said to be “suicidal.”
Threatening to kill herself with a straight
razor.
She is sitting on the bathroom floor next to
the bathtub, without clothing. There is blood
on the floor. She is emotionally distraught
and crying.
Friend says “I can’t deal with her any more.”
Copyright 2008 Seattle/King County EMS
Case Study – Suicide,
continued
What will be your initial steps in approaching
and dealing with this patient?
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Forced Restraint
Use forced restraint only to protect a
patient, yourself, or others from harm
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Reasonable Force
• Use only enough force to keep patient
from injury or from hurting others
• Size and strength of patient
• Type of abnormal behavior
• Sex of patient
• Mental state of patient
• Method of restraint
Copyright 2008 Seattle/King County EMS
Restraints
• Use commercial, soft restraints or use a
towel and two-inch tape
• Secure restraint to backboard or stretcher
Copyright 2008 Seattle/King County EMS
Seek Patient Cooperation
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Be calm, patient, and reassuring
Do not belittle or threaten
Do not argue or shout
Encourage patient to speak openly
Suggest appropriate steps for pt to take
Treat with respect
Avoid forced restraint unless
absolutely necessary!
Copyright 2008 Seattle/King County EMS
Guidelines for Forced Restraint
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Have sufficient personnel
Consult medical direction, if possible
Have a clear plan of action
Once decision is made, act quickly
Use reasonable force
Assign one rescuer to each limb
Reassess breathing and circulation
frequently
• Document reasons for restraining
Copyright 2008 Seattle/King County EMS
Case Study – Violent Behavior
25-year-old male – bizarre, violent, and
combative behavior, on meth. Patient sitting in
street with no shirt or shoes on, abrasions on
his hands and knees.
Patient threatens police and EMS responders.
Police attempt to arrest him. Puts up impressive
struggle.
Eventually, they subdue him down and two
officers kneel atop him. He is grunting and
moaning, but then stops and doesn’t resist.
Copyright 2008 Seattle/King County EMS
Case Study – Violent,
continued
As you move closer to the patient, you notice
that he remains completely still and is not
making a sound. What actions should you
take next?
You see no chest rise and you quickly
determine he is not breathing. What is your
best guess as to what happened?
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TASER Dart Removal
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Assure scene safe and pt under control
Don gloves and eye protection
Break or cut wires before removing darts
Grasp dart firmly with one hand and pull
to remove
• Dispose of darts in sharps container
• Bandage wounds
• Document assessment and care provided
Copyright 2008 Seattle/King County EMS
TASER Dart Removal
DO NOT remove a dart if:
• Patient is not under control
• Eye, face, neck, breast, or groin are
involved
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Compelling Reasons
Permits EMS personnel to withhold
resuscitation from patient in cardiac arrest
when two criteria are BOTH present:
• End stage of a terminal condition
• Written or verbal information from family
or patient stating that patient did not
want resuscitation
Copyright 2008 Seattle/King County EMS
Compelling Reasons,
continued
• If both criteria not met, initiate
resuscitation
• If both criteria are met, withhold
resuscitation
• If resuscitation already started, stop
• If there is disagreement among family,
initiate resuscitation
Copyright 2008 Seattle/King County EMS
Palliative Care
• No CPR does not mean "no treatment" or
"no caring"
• Comfort measures (oxygen, suctioning)
• Request medics if you feel that ALS care
(e.g., pain management) is needed
• Support and assistance family
Copyright 2008 Seattle/King County EMS
Case Study – No DNR Orders
82-year-old female, difficulty breathing. She
has end-stage lung cancer.
Patient is unconscious, unresponsive, and
pulseless.
Daughter and son both say their mother did
not want CPR. There is no advance directive.
Copyright 2008 Seattle/King County EMS
Case Study – No DNR,
continued
Do compelling reasons apply in this case?
Why?
What would you do if there the daughter and
son disagreed about whether or not to begin
resuscitation?
What will you do to care for this patient?
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Expanding Role of EMS
Providing information to patients:
• Disease intervention
• Controlling costs
• End of life decisions
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Importance of Documentation
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Health record for your patient
Research tool
Quality improvement tool
Legal document that protects you
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Summary
• Mental competence is a person’s ability to
understand information about his or her
condition and weigh risks and benefits of not
receiving care
• In EMS, legal capacity mostly concerns
whether or not a person is a minor
Copyright 2008 Seattle/King County EMS
Summary,
continued
Safety precautions for violent patient:
• Look for hazards before approaching
• Plan escape route
• Approach in calm and non-threatening
manner
• Do not try to intervene in a fight or argument
• Ask if there are weapons
• Do not get separated from your partner
• Consider additional resources early
Copyright 2008 Seattle/King County EMS
Summary,
continued
Guidelines for forced restraint:
• Have sufficient personnel
• Consult medical direction, if possible
• Have clear plan of action
• Once decision is made, act quickly
• Use reasonable force
• Assign one rescuer to each limb
• Reassess circulation frequently
• Document reasons for restraint
Copyright 2008 Seattle/King County EMS
Summary,
continued
• Remove TASER dart by pulling it out
• Do not remove dart if eye, face, neck,
breast, or groin are involved
Copyright 2008 Seattle/King County EMS
Summary,
continued
Compelling reasons permit you to withhold
resuscitation when two criteria are present:
• End stage of terminal condition
• Written or verbal information from family or
patient stating that patient did not want
resuscitation
Copyright 2008 Seattle/King County EMS