copyright 2008 seattle/king county ems cbt/otep 935 street medicine – special situations

Copyright 2008 Seattle/King County EMS

CBT/OTEP 935Street Medicine – Special

Situations


Introduction

This course is intended to provide This course is intended to provide general guidance to EMS providers in general guidance to EMS providers in

unique situations. unique situations.

Follow your local protocols when Follow your local protocols when they vary from the recommendations they vary from the recommendations

in this course.in this course.

This course is intended to provide This course is intended to provide general guidance to EMS providers in general guidance to EMS providers in

unique situations. unique situations.

Follow your local protocols when Follow your local protocols when they vary from the recommendations they vary from the recommendations

in this course.in this course.

This course will address special problems encountered by EMS providers in the field including refusal of care, violence, forced restraint, and other situations.


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 out-of-control behavior in people usually under the influence of stimulants. In some cases, a severely agitated person can go into cardiac arrest.


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.


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


Mental Competence

A person’s ability to understand information about his or her condition and weigh the risks and benefits of not receiving care


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


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.


Case Study – MVA, continued

Is this patient mentally competent?

Does he have legal capacity?


Case Study – Alcohol IntoxicationMan 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).


Case Study – Alcohol, continuedIs 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?


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


Safety and Violent Behavior

If a scene suddenly becomes dangerous, do not hesitate to

back out and call for help!


Attempted Suicide

• Rescuer and patient safety high priority

• Calm patient• Treat injuries, if possible• Manage family anxiety• Clear onlookers from scene


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.”


Case Study – Suicide, continued

What will be your initial steps in approaching and dealing with this patient?


Forced Restraint

Use forced restraint only to protect a patient, yourself, or others from

harm


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


Restraints

• Use commercial, soft restraints or use a towel and two-inch tape

• Secure restraint to backboard or stretcher


Seek Patient Cooperation

• 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!


Guidelines for Forced Restraint • 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


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.


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?


TASER Dart Removal

• 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


TASER Dart Removal

DO NOT remove a dart if:• Patient is not under control• Eye, face, neck, breast, or groin are

involved


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


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


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


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.


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?


Expanding Role of EMS

Providing information to patients: • Disease intervention • Controlling costs• End of life decisions


Importance of Documentation• Health record for your patient• Research tool• Quality improvement tool• Legal document that protects you


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


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


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


Summary, continued

• Remove TASER dart by pulling it out• Do not remove dart if eye, face, neck,

breast, or groin are involved


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 cbt/otep 935 street medicine – special situations

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