Notes on Ch.1,2,3, 4 PDF

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Emergency Care and Transportation of the Sick and Injured 11th Edition...

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Chapter 1 EMS Systems A) Course Description a) Emergency Medical Services is a system – consists of a team of health care professionals, who in each area or jurisdiction, are responsible for and provide emergency care and transportation to the sick and injured b) Certification – used to ensure all health care providers have at least the same basic level of knowledge and skill c) Licensure – the process by which states ensure applicant competency in an examination setting d) Four Training and Licensure Levels: i) Emergency medical responder • Very basic training and provides care before ambulance arrives ii) Emergency medical technician • Has training in basic life support (BLS) including automated external defibrillation (AED), use of airway adjuncts, and assisting with certain medication iii) Advanced EMT • Trained in some advanced life support: IVs and administration of emergency medicine iv) Paramedic • Extensive training in ALS, including endotracheal intubation, emergency pharmacology, cardiac monitoring, and other advanced assessment and treatment skills e) Most state’s requirements follow or exceed guidelines recommended by current National Highway Traffic Safety Administration B) EMT Training: Focus and Requirements a) Scene Size-up i) Involves awareness of scene safety and a big-picture awareness of overall situation. Primary job is to ensure it is as safe as possible. b) Patient assessment i) It is the foundation of every EMS call, must determine what is wrong with the patient c) Treatment i) EMTs can provide oxygenation and medication therapies. Control bleeding and assist in childbirth d) Packaging i) Will learn how to transport patients with a wide variety of illnesses and injuries e) EMS as a career i) Important to learn how to take care of yourself C) Licensure Requirements a) Usually include: i) High school diploma

ii) Proof of immunization iii) Completion of background check and drug screening iv) Driver’s license v) Completion of BLS and CPR course vi) Completion of state-approved EMT course vii) Completion of state-recognized certification exam viii) Completion of state-recognized practical certification exam ix) Demonstrate mental and physical ability necessary to perform b) States have requirements prohibiting people with certain legal infractions from becoming EMS providers D) History of EMS a) Volunteer ambulances were organized during WWI b) In WWII, military trained special corpsmen to provide care in the field and bring casualties to aid stations c) In the 1960s/70s, states had no standards to uphold. Emergency care could have been provided by first aid modern ambulances, funeral homes, police or fire department, etc. d) Only large urban cities hospitals had an emergency department e) 1966 publication i) Accidental Death and Disability: The Neglected Disease of Modern Society ii) Known more commonly as The White Paper iii) Prepared by the Committees on Trauma and Shock of the National Academy of Sciences / National Research Council iv) Revealed the inadequacy of prehospital emergency care v) Because of this, Congress mandated that two federal agencies address this issue: • NHTSA of the DOT – Highway Safety Act of 1966 • Department of Health, Education, and Welfare (today the Dept. of Health and Human Services) – Emergency Medical Services Development Act of 1973 f) In 1970s, DOT made first curriculum as guideline for EMT training: The Orange Book g) In 1980s, many areas enhanced the EMT national standard curriculum h) In 1990s, NHTSA made the EMS Agenda for the Future to standardize the levels of EMS education throughout the country E) Medical Direction a) Medical director – a physician who authorizes the EMTs in the service to provide medical care in the field i) The appropriate care is described in a set of written standing orders and protocols ii) Determine the continuing education and training that are required of each EMT b) Medical control – provided either offline (indirect) or online (direct) as authorized by the medical director i) Online: direction given over the phone or radio directly from the medical director, a live person. ii) Offline: consists of standing orders, training, and supervision authorized by the medical director. iii) Standing Order: Not required to consult a doctor, specific protocol for specific conditions.

F) Mobile Integrated Healthcare (MIH) a) This is a new method of delivering health care that utilizes the prehospital spectrum i) Has evolved because of the Patient Protection and Affordable Care Act b) Continuity of care: pass off patient to equal or higher level of care. Must have legal documentation. G) Evaluation a) Quality Control – ensuring all staff members who are involved in caring for patients meet appropriate medical care standards on each call i) Maintained by the medical director ii) Done by reviewing PCRs, audit administrative records, and survey patients b) Continuous Quality Improvement – a circular system of continuous internal and external reviews and audits of all aspects of an EMS system i) Periodic run review meetings are held with those involved in patient care to review the run reports and then discuss any areas of care that appear to need change or improvement ii) Also determine ways to limit or eliminate human error iii) Three types of errors: • Rules-based failure – practicing outside scope of practice • Knowledge-based failure – occurs if EMT does not know all pertinent information • Skills-based failure – operating equipment improperly H) Professional Attributes of EMTs a) Integrity – honest behavior b) Empathy c) Self-motivation d) Appearance e) Self-confidence – a state of being where you know what you know AND know what you do not know; able to ask for help f) Time management g) Communications h) Teamwork and diplomacy i) Respect j) Patient advocacy k) Careful delivery of care

Chapter 2 Workforce Safety and Wellness A) General Health and Wellness a) Your health and the health of the patient are intertwined b) Wellness is a state of complete mental, physical, and social well-being

B) Management of Acute Stress a) Stress is defined as any event, thought, or action perceived as a threat b) No matter how stressful a situation is, you must focus on the following: i) Personal safety ii) Scene safety, including safety of others iii) Patient care c) Stress management refers to the tactics that have been shown to alleviate or eliminate stress reactions d) Stress is all about how the individual reacts to the event C) Infectious and Communicable Diseases a) Infectious disease – a medical condition caused by the growth and spread of small, harmful organisms within the body b) Communicable disease – a disease that can be spread from one person or species to another c) Pathogen – a microorganism that is capable of causing disease in a susceptible host d) Contamination – the presence of infectious organisms or foreign bodies on or into objects such as dressings, water, food, needles, wounds, or a patient’s body e) Exposure – a situation in which a person has had contact with blood, body fluids, tissues, or airborne particles in a manner that may allow disease transmission to occur f) Personal Protective Equipment (PPE) – protective equipment that individuals wear to prevent exposure to a pathogen or a hazardous material D) Routes of Transmission a) This is the way an infectious disease is spread b) Contact transmission: movement of an organism through physical touch (two types): i) Direct contact – organism moves through touching without any intermediary • Hepatitis in bloodborne pathogens and HIV transferred through sex ii) Indirect contact – involves the spread of infection through an inanimate object • The object that transmits the infection is called a fomite • Needle sticks • Sneezing can be both direct and airborne E) Risk Reduction and Prevention for Infectious and Communicable Diseases a) The Occupational Safety and Health Administration (OSHA) develops and publishes guidelines concerning reducing hazards in the workplace b) Centers for Disease Control and Prevention (CDC) developed a set of standard precautions for health care workers i) Standard precautions – protective measures designed to prevent health care workers from coming into contact with objects, blood, body fluids and other potential risks that could lead to exposure to germs c) If you suspect a patient has tuberculosis, place a surgical mask on the patient and a particulate air respirator on yourself

F) Scene Hazards a) Placards are used on transportation vehicles and buildings b) Labels are used on individual packages containing hazardous materials c) Electricity i) Power lines • Do not touch downed power lines • The safety zone is the span of one power pole’s distance ii) Lightning • Can be threatening in two ways: (a) Direct hit (b) Ground current (i) Stay away from drainage ditches, moist areas, small depressions, and wet ropes d) Fire i) Fire consumes oxygen, making it difficult to breath ii) Carbon monoxide: a colorless, odorless gas that is responsible for more fire deaths each year than any other by-product of combustion • Combines with the hemoglobin in your red blood cells • It blocks the ability of the hemoglobin to transport oxygen to your body tissues iii) Cyanide • Prevents cells from using oxygen iv) Turnout gear is a fire service term for protective clothing used in structural firefighting situations e) A fall zone is an area where you are likely to encounter falling objects G) Techniques for Communicating with the Critical Patient a) Avoid sad and grim comments b) Orient the patient c) Be honest d) Initial refusal of care e) Allow for hope H) The Grieving Process (DABDA) a) Denial i) Refusing to accept diagnosis or care, unrealistic demands for miracles, or persistent failure to understand why there is no improvement b) Anger i) Projecting bad news onto the environment and commonly in all directions, at time almost random. The person lashes out. Someone must be blamed, and those who are responsible must be punished. This is usually an ugly phase, and may even be inappropriately directed toward an EMT c) Bargaining i) Attempting to secure a prize for good behavior or promising to change

d) Depression i) Internalizing anger, hopelessness, and the desire to die. It rarely involves suicidal threats, complete withdrawal, or giving up long before the illness seems terminal. The patient is usually silent e) Acceptance i) Accepting the impending death of the patient, or accepting the death of a loved one I) Stress Management on the Job a) Stress is the impact of stressors on your physical and mental well-being b) General Adaptation Syndrome i) Alarm response ii) Reaction and resistance iii) Recovery or exhaustion c) Physiologic manifestations: i) Increased respiration, heart rate, blood pressure, and blood glucose levels ii) Dilated vessels (causes cool clammy skin) iii) Dilated pupils iv) Tensed muscles v) Perspiration vi) Decreased blood flow to GI tract d) Acute – during a stressful situation e) Delayed – manifest after the stressful event f) Cumulative – after the event is over, are you able to recover and shake it off? i) Occurs when exposed to prolonged or excessive stress g) Critical incident stress management (CISM) – developed to address acute stress situations and potentially decrease the occurrence of PTSD i) Used to confront responses and defuse them J) Factors that Influence Stress a) Socioeconomic background b) Fear of medical personnel c) Alcohol or substance abuse d) History of chronic disease e) Mental disorders f) Reaction to medication g) Age h) Nutritional status i) Feelings of guilt j) Past experience with illness or injury K) Maintain Chain of Evidence a) Do not disturb scene b) Do not cut shirt of patient if it has been affected by weapon

c) Do not move weapons or body L) Sexual Harassment a) Any unwelcome sexual advance, request for sexual favors, or other verbal or physical conduct of sexual nature b) Two types: i) Quid pro quo– the harasser requests sexual favors in exchange for something else like a promotion ii) Hostile work environment – jokes, touching, leering, requests for a date, talking about body parts Chapter 3 Medical, Legal, and Ethical Issues A) Introduction a) Basic principle of emergency care is to do no further harm b) EMTs may be the first link in the chain of prehospital care c) It is important to take into account both legal aspects of emergency medical care as well as ethical issues B) Consent a) Consent (permission) is required for every conscious adult before care can be started i) An adult who is conscious, rational, and capable of making informed decisions has a legal right to refuse care b) The foundation of consent is decision-making capacity: the ability of a patient to understand the information you are providing, coupled with the ability to process that information and make an informed choice regarding medical care i) There is a difference between decision-making capacity and competence • Competence is generally regarded as a legal term and determinations regarding competence are typically made by a court of law, whereas decision-making capacity is more commonly used in health care to determine whether a patient is capable of making health care decisions c) Patient autonomy: the right of a patient to make decisions concerning his or her health d) Determining a patient’s decision-making capacity: i) Is their intellectual capacity impaired by mental limitation or dementia? ii) Is patient of legal age (18)? iii) Is patient impaired by alcohol or drug intoxication? iv) Does patient appear to be experiencing significant pain? v) Does patient have a significant injury that could distract him from a more serious injury? vi) Are there any apparent visual or hearing problems? vii) Is a language barrier present? viii) Does patient appear to understand what you are saying?

C) Types of Consent a) Expressed Consent i) Is also known as actual consent, is given when the patient verbally or otherwise acknowledges that he or she wants you to provide care or transport ii) May be nonverbal iii) The consent the patient provides must be informed consent • This means that you explained the nature of the treatment being offered, along with potential risks, benefits, and alternatives to treatment, as well as potential consequences of refusing treatment b) Implied Consent i) When a person is unconscious or otherwise incapable of making a rational, informed decision about care, and unable to give consent, the law assumes the patient would consent to care and transport to a medical facility if he or she were able to do so ii) Patients intoxicated by drugs or alcohol, mentally impaired, or suffering from certain conditions such as a head injury may fall under this category iii) Only applies when a serious medical condition exists and should never be used unless there is a threat to life or limb iv) The principle of implied consent is known as emergency doctrine • Important to make every effort to gain consent from a relative, but do not delay treatment if life is at stake • If a patient is being treated and regains consciousness and appears capable of making an informed decision, the doctrine of implied consent would no longer apply • Often occurs with calls dealing with diabetic emergencies, overdoses, syncope (fainting), and seizures c) Involuntary Consent i) Deals with assisting patients who are mentally ill, developmentally delayed, or are in behavioral crisis ii) These patients are typically not able to give informed consent iii) Many states have protective custody statutes allowing such a person to be taken, under law enforcement authority, to a medical facility d) Minors and Consent i) Minors might not have the wisdom, maturity, or judgment to give consent ii) Because of this, the law requires that a legal guardian give consent when available iii) In every state, if a parent cannot be reached, health care providers are allowed to give emergency care to a child iv) Emancipated minors: are people who despite being under the legal age, can be legally treated as adults based on certain circumstances • There is a lot of confusion around this issue • Minors are considered emancipated if they are married, members of the armed forces, parents, or living away from and no longer relying on parents for support • A minor who is a parent may also give consent for his or her child

v) If a minor is injured and requires treatment in a school or camp setting, teachers may act in loco parentis  this means in position of the parent vi) You must never withhold lifesaving care for a minor because a person authorized to provide consent is not available D) Forcible Restraint a) Sometimes necessary if a patient requires treatment but is combative and presents a significant physical risk of danger to themselves, rescuers, or others b) Consult medical control for authorization to restrain or contact law enforcement personnel who have the authority to restrain people i) In some states only a police officer may restrain people c) Restraints should only be considered if the patient has a medical condition that appears serious or if he or she suffers from an apparent behavioral disorder that poses a risk to the patient or others i) Remember if they are conscious and the situation is not urgent that consent is still required d) *Make sure airway is protected E) The Right to Refuse Treatment a) Adults who are conscious, alert, and appear to have decision making capacity have the right to refuse treatment, even if it may result in death or injury b) A patient’s decision to accept or refuse treatment should be based on information that you provide i) This information should include your assessment of what might be wrong, a description of the treatment you believe is necessary, any risks of treatment, the availability of alternative treatments, and possible consequences of refusing treatment c) Refusal patients can often result in litigation, be sure to follow procedure and have the patient sign a refusal form before you leave (also have a witness) d) We also may face a situation which the parent refuses to permit treatment of an ill or injured child i) Consider the emotional impact of the emergency on the parent’s judgment, usually can resolve the situation with patience and calm persuasion e) MCI – mass casualty incident f) AAOx3 = Awake Alert Oriented x person x place x time/event i) Can you tell me your name? Who is this person? ii) Do you know where you are? What is your address? iii) What day is it? What month? Can you tell me who the president is? iv) If all these are met they have NMS = normal mental status v) -1 = altered mental status F) Confidentiality a) Communication between you and the patient is considered confidential and cannot be disclosed without permission from the patient or court order

i) This includes patient history, assessment findings, and treatment provided b) HIPAA: Health Insurance Portability and Accountability Act of 1996 i) The aim of the patient privacy section is to strengthen laws for the protection and privacy of health care information and to safeguard patient confidentiality ii) Provides guidance on what type of information is protected, the responsibility of health care providers regarding that protection, and the penalties for breaching that protection iii) Includes not only protected health information, which is information obtained in the course of providing medical treatment to the patient, but also any information that can be used to identify the patient G) Advance Directives a) These are valid, written documents that specify medical treatment for a competent patient, should they become unable to make decisions i) Do not resuscitate (DNR) also known as do not attempt to resuscitate ii) An advance directive is often referred to as a living will but may also be called a health care directive iii) DNR orders must have: • Clear statement of patient’s medical problem • Signature of patient or legal guardian • Signature of one or more physicians or other licensed health care provider • Some states have a DNR expiration date b) May also encounter Physician Orders for Life Sustaining Treatment i) These describe acceptable interventions for the patient in the ...