Emergency Medical Responder, First on Scene [11 ed.] 2018041388, 9780134988467, 0134988469
301 35 4MB
English Pages [68] Year 2018
Recommend Papers
![Emergency Medical Responder Your First Respons Orthopaedic Surgeons [7 ed.]
2020039682, 9781284225914](https://ebin.pub/img/200x200/emergency-medical-responder-your-first-respons-orthopaedic-surgeons-7nbsped-2020039682-9781284225914.jpg)
![SEC501.4: First Responder [A12_02 ed.]](https://ebin.pub/img/200x200/sec5014-first-responder-a1202nbsped.jpg)
![Emergency Medical Responder, First on Scene [11 ed.]
2018041388, 9780134988467, 0134988469](https://ebin.pub/img/200x200/emergency-medical-responder-first-on-scene-11nbsped-2018041388-9780134988467-0134988469.jpg)
- Author / Uploaded
- Chris Le Baudour
- David Bergeron
- Keith Wesley
File loading please wait...
Citation preview
Get Complete eBook Download by email at [email protected] Le Baudour Bergeron
EMERGENCY MEDICAL RESPONDER
People. Trust. Innovation. www.bradybooks.com
FIRST ON THE SCENE www.pearson.com ISBN-13: 978-0-13-498846-7 ISBN-10: 0-13-498846-9
Eleventh Edition
Le Baudour • Bergeron
Eleventh Edition
EMERGENCY MEDICAL RESPONDER FIRST ON THE SCENE
Medical Editor Keith Wesley, MD
EAN
Get Complete eBook Download by email at [email protected]
11th Edition
EMERGENCY MEDICAL RESPONDER
FIRST ON SCENE
Christopher J. Le Baudour Medical Reviewer: Keith Wesley, MD Legacy Authors: J. David Bergeron, Gloria Bizjak
Get Complete eBook Download by email at [email protected]
Library of Congress Cataloging-in-Publication Data Names: Le Baudour, Chris, author. Title: Emergency medical responder : first on scene / Christopher J. Le Baudour; medical reviewer, Keith Wesley; legacy authors, J. David Bergeron, Gloria Bizjak. Description: 11th edition. | Hoboken, NJ : Pearson Education, Inc., [2019] | Includes bibliographical references and index. Identifiers: LCCN 2018041388 | ISBN 9780134988467 | ISBN 0134988469 Subjects: | MESH: Emergency Medical Services | Emergencies | Emergency Responders | Emergency Medical Technicians | Emergency Treatment Classification: LCC RC86.7 | NLM WX 215 | DDC 616.02/5--dc23 LC record available at https://lccn.loc.gov/2018041388
Senior Vice President, Portfolio Management: Adam Jaworski Director, Portfolio Management: Marlene McHugh Pratt Portfolio Manager: Derril Trakalo Development Editor: Jill Rembetski, iD8-TripleSSS Media Development, LLC Portfolio Management Assistant: Cara Schaurer Vice President, Content Production and Digital Studio: Paul DeLuca Managing Producer, Health Science: Melissa Bashe Content Producer: Faye Gemmellaro Operations Specialist: Maura Zaldivar-Garcia Creative Digital Lead: Mary Siener Director, Digital Production: Amy Peltier Digital Studio Producer, REVEL and e-text 2.0: Ellen Viganola Digital Content Team Lead: Brian Prybella Digital Content Project Lead: Lisa Rinaldi Vice President, Product Marketing: Brad Parkins Executive Product Marketing Manager: Rachele Strober Sr. Field Marketing Manager: Brian Hoehl Full-Service Project Management and Composition: Pearson CSC Full-Service Project Manager: Pearson CSC, Dan Knott Inventory Manager: Vatche Demirdjian Manager, Rights & Permissions: Gina Cheselka Interior Design: Pearson CSC Cover Design: Pearson CSC Cover Art: © Ed Effron Printer/Binder: LSC Communications, Inc. Cover Printer: Phoenix Color/Hagerstown
Notice on Care Procedures It is the intent of the authors and publisher that this textbook be used as part of a formal Emergency Medical Responder education program taught by qualified instructors and supervised by a licensed physician. The procedures described in this textbook are based on consultation with first responder and medical authorities. The authors and publisher have taken care to make certain that these procedures reflect currently accepted clinical practice; however, they cannot be considered absolute recommendations. The material in this textbook contains the most current information available at the time of publication. However, federal, state, and local guidelines concerning clinical practices, including, without limitation, those governing infection control and universal precautions, change rapidly. The reader should note, therefore, that new regulations may require changes in some procedures. It is the responsibility of the reader to familiarize himself or herself with the policies and procedures set by federal, state, and local agencies as well as the institution or agency where the reader is employed. The authors and the publisher of this textbook and the supplements written to accompany it disclaim any liability, loss, or risk resulting directly or indirectly from the suggested procedures and theories, from any undetected errors, or from the reader’s responsibility to stay informed of any new changes or recommendations made by any federal, state, or local agency as well as by his or her employing institution or agency.
Copyright © 2019, 2016, 2011 by Pearson Education, Inc. or its affiliates. All Rights Reserved. Printed in the United States of America. This publication is protected by copyright, and permission should be obtained from the publisher prior to any prohibited reproduction, storage in a retrieval system, or transmission in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise. For information regarding permissions, request forms and the appropriate contacts within the Pearson Education Global Rights & Permissions department, please visit www.pearsoned.com/permissions/. 1 19
ISBN-10: 0-13-498846-9 ISBN-13: 978-0-13-498846-7
Get Complete eBook Download by email at [email protected]
DEDICATION To the selfless and dedicated EMTs, Paramedics, and Nurses of Falck Northern California Ambulance service who worked day and night through the devastating wildfires in Sonoma, Mendocino, and Napa Counties in October of 2017. They participated in the evacuation of two large acute care hospitals and more than a dozen sub-acute facilities, keeping hundreds of bedbound patients out of harm’s way. Their work was instrumental in allowing the dedicated 911 resources to remain available for more emergent responses. I am proud to call these professionals my colleagues.
Get Complete eBook Download by email at [email protected]
This page intentionally left blank
A01_THOM6233_05_SE_WALK.indd 9
1/13/17 6:50 PM
Get Complete eBook Download by email at [email protected]
CONTENTS Photo Scans xiii Skills Videos xv Letter to Students xvii Preface xix Acknowledgments xxiii About the Author xxvii American Safety & Health Institute xxix Walk Through xxxi MyLab BRADY with Pearson eText xxxiii
CHAPTER 1
Refusal of Care 24 Documenting a Refusal of Care 24 Advance Directives 25 Do Not Resuscitate (DNR) Order 25 Negligence 25 Abandonment 27 Confidentiality 28 Reportable Events 29 Special Situations 29 Organ Donors 29
Introduction to EMS Systems 1
Medical Identification Devices 29
Education Standards • Competencies • Chapter Overview • Objectives 1 The EMS System 2 EMS Models 6 Scope of Practice 7 Activating the EMS System 7
CHAPTER 3
Wellness and Safety of the Emergency Medical Responder 33 Education Standards • Competencies • Chapter Overview • Objectives 33
Medical Direction 8
Personal Well-Being 34 Immunizations 34
Roles and Responsibilities 9
Standard Precautions 35
Traits 11
Body Substance Isolation (BSI) Precautions 35
Skills 13 Equipment, Tools, and Supplies 14 Continuous Quality Improvement 14 The Role of the Public Health System 14 Disaster Assistance 14 The Role of Research in EMS 15 Advances in Technology 15 Review 16
Legal and Ethical Principles of Emergency Care 18 Education Standards • Competencies • Chapter Overview • Objectives 18 Legal Duties 19 Standard of Care 19
Routes of Exposure 36 Managing Risk 37 Bloodborne and Airborne Pathogens 38 Employee Responsibilities 41 Following an Exposure 41 Scene Safety 42 Hazardous Materials Incidents 42 Rescue Operations 43 Crime Scenes and Acts of Violence 43 Emotional Aspects of Emergency Medical Care 43 Emergency Medical Responders and Stress 43 Another Side of Personal Safety 44 Causes of Stress 44
Scope of Practice 20
Burnout 45
Ethical Responsibilities 20
Signs and Symptoms of Stress 45
Consent 21 Capacity 21
Death and Dying 46 Dealing with Stress 47
Competence 21
Lifestyle Changes 47
Expressed and Informed Consent 22
Critical Incident Stress Management 48
Implied Consent 23 Emancipated Minor 23
Review 31
In-Hospital Care System 8 The Emergency Medical Responder 9
CHAPTER 2
Crime Scenes 30
Review 49
v
Get Complete eBook Download by email at [email protected] CHAPTER 4
Body Mechanics 96
Introduction to Medical Terminology, Human Anatomy, and Lifespan Development 51
Emergent Moves 98
Education Standards • Competencies • Chapter Overview • Objectives 51
Standard Moves 99
When to Move a Patient 98 Drags 99
Medical Terminology 52
Direct Ground Lift 100
Positional and Directional Terms 55
Extremity Lift 101
Overview of the Human Body 56
Direct Carry Method 102
Regions of the Body 56
Draw Sheet Method 102
Body Cavities 57
Equipment For Transporting Patients 104
Abdominal Quadrants 59
Patient Positioning 109 Recovery Position 109
Body Systems 60 Cardiovascular System 63
Fowler’s and Semi-Fowler’s Positions 109
Musculoskeletal System 63
Shock Position 109
Nervous System 67
Log Roll 110
The Respiratory System 61
Lift-and-Slide Technique 112
Digestive System 71
Restraining Patients 113
Reproductive System 71 The Urinary System 75
Types of Restraints 113
Integumentary System 75
Patient Restraint 113
Endocrine System 75
Positional Asphyxia 114 Restraint Injuries 114
Lifespan Development 77
Review 115
Developmental Characteristics 79 Review 83
CHAPTER 5
CHAPTER 7
Introduction to Pathophysiology 85
Education Standards • Competencies • Chapter Overview • Objectives 117
Education Standards • Competencies • Chapter Overview • Objectives 85
What is Communication? 118
Understanding Pathophysiology 86
Types of Communication 118
Cardiopulmonary System and Perfusion 86
The Communication Process 119 Transmitting the Message 119
Hypoperfusion and Shock 86
Barriers to Communication 119
Aerobic and Anaerobic Metabolism 87
Strategies for Effective Communication 120
The Respiratory System 88 Respiratory System Dysfunction 89
Interpersonal Communication 121
Respiratory System Compensation 89
Therapeutic Communication 121
The Blood 90
Strategies for Successful Interviewing 121
Blood Vessels 90
Cultural Considerations 123
The Heart 91
Translation Services 123
The Cardiovascular System 90
Patients with Disabilities 123
Cardiovascular System Compensation 92
Transfer of Care 124
Pediatric Compensation 92
Radio Communications 125
Review 93
CHAPTER 6
Principles of Lifting, Moving, and Positioning of Patients 95 Education Standards • Competencies • Chapter Overview • Objectives 95 Principles of Moving Patients Safely 96
vi
Principles of Effective Communication 117
www.bradybooks.com
Review 127
CHAPTER 8
Principles of Effective Documentation 129 Education Standards • Competencies • Chapter Overview • Objectives 129
Get Complete eBook Download by email at [email protected] Patient Care Reports 130 Elements of the PCR 132 Minimum Data Set 133 The Narrative 133 Correcting Errors 134 Methods of Documentation 134 Review 136
CHAPTER 9
Principles of Airway Management and Ventilation 138 Education Standards • Competencies • Chapter Overview • Objectives 138 Breathing and Ventilation 139 How Breathing Works 139 How We Breathe 140 Respiratory System Anatomy 141 Ventilation Cycle 141 An Open and Clear Airway 142 Signs of Normal Breathing 143 Signs of Abnormal Breathing 143 Rescue Breathing 144 Opening the Airway 144 Repositioning the Head 144 Head-Tilt/Chin-Lift Maneuver 144 Jaw-Thrust Maneuver 145 Barrier Devices 145 Mouth-to-Mask Ventilation 146 Mouth-to-Shield Ventilation 147 Special Patients 148 Infants and Children 148 Terminally Ill Patients 149 Stomas 149 Trauma Patients 150 Air in the Stomach and Vomiting 150 Airway Obstruction 151 Causes of Airway Obstruction 151 Signs of Partial Airway Obstruction 151 Signs of Complete Airway Obstruction 151 Clearing a Foreign Body Airway Obstruction 152 Obese and Pregnant Patients 154 Finger Sweeps 156 Aids to Airway Management 156 Oropharyngeal Airways 157 Nasopharyngeal Airways 158 Bag-Mask Ventilation 160 Two-Rescuer Bag-Mask Ventilation 162
One-Rescuer Bag-Mask Ventilation 163 Suction Devices 163 General Guidelines for Suctioning 163 Measuring a Suction Catheter 164 Suctioning Techniques 165 Review 167
CHAPTER 10 Principles of Oxygen Therapy 170
Education Standards • Competencies • Chapter Overview • Objectives 170 Importance of Oxygen 171 Oxygen Saturation 171 Hazards of Oxygen Cylinders 172 Oxygen Therapy Equipment 172 Oxygen Cylinders 172 Oxygen System Safety 174 Oxygen Regulators 174 Oxygen Delivery Devices 176 Administering Oxygen 178 Administration of Oxygen to a Nonbreathing Patient 178 General Guidelines for Oxygen Therapy 181 Review 183
CHAPTER 11 Principles of Resuscitation 185 Education Standards • Competencies • Chapter Overview • Objectives 185 The Chain of Survival 186 Circulation and CPR 186 Cardiopulmonary Resuscitation 187 CPR—How It Works 188 When to Begin CPR 188 Locating the CPR Compression Site 190 External Chest Compressions 191 Providing Rescue Breaths During CPR 192 Rates and Ratios of Compressions and Ventilations 192 Effective CPR 193 Adult and Child CPR 193 One-Rescuer CPR 194 Two-Rescuer CPR 196 Infant and Neonatal CPR 198 Positioning the Infant 198 Opening the Airway 198
Contents
vii
Get Complete eBook Download by email at [email protected] Assessing Breathing 198 Checking for a Pulse 198
The General Impression 246
Infant CPR Techniques 198
Mental Status 247
Possible Complications 200
Airway and Breathing 247
Special CPR Situations 200
Circulation 248
Moving the Patient 200
Patient Priority 249
Trauma 200
Special Considerations for Infants and Children 249
Hypothermia 200 Stopping CPR 200 Automated External Defibrillation 201
Alerting Dispatch 250 Secondary Assessment 250
External Defibrillation 201
The Trauma Patient 251
Using AEDs 202
The Medical Patient 254
Potential Problems 205
Patient History 254
Quality Assurance 205
Vital Signs 257
Review 207
CHAPTER 12 Obtaining a Medical History and Vital Signs 210
Education Standards • Competencies • Chapter Overview • Objectives 210 Obtaining a Medical History 211 Interviewing Your Patient 211 Additional Sources of Information 215 Vital Signs 216 An Overview 216 Mental Status 217 Respirations 218 Pulse 220 Blood Pressure 221 Skin Signs 227 Capillary Refill 228 Pupils 229 Review 231
CHAPTER 13 Principles of Patient Assessment 233
Education Standards • Competencies • Chapter Overview • Objectives 233 Patient Assessment 234
The Physical Exam 258 Reassessment 264 Review 266
CHAPTER 14 Caring for Cardiac
Emergencies 269 Education Standards • Competencies • Chapter Overview • Objectives 269 Normal Heart Function 270 Cardiac Compromise 271 Angina Pectoris 271 Myocardial Infarction 272 Heart Failure 273 Emergency Care for Cardiac Compromise 275 Assessment 275 Oxygen Saturation 276 Emergency Care 277 Medications 277 Review 280
CHAPTER 15 Caring for Respiratory Emergencies 282
Education Standards • Competencies • Chapter Overview • Objectives 282
Scene Safety 236
Overview of Respiratory Anatomy 283
Immediate Life Threats 236
Respiratory Compromise 284
Scene Size-Up 240
Respiratory Distress 285
BSI Precautions 241
Adequate Breathing 285
Scene Safety 241
Inadequate (Abnormal) Breathing 286
Mechanism of Injury or Nature of Illness 242
Signs and Symptoms of Respiratory Compromise 287
Number of Patients and Need for Additional Resources 242
Emergency Care for Respiratory Compromise 292
Arrival at the Patient’s Side 243
viii
Primary Assessment 244
www.bradybooks.com
Review 295
Get Complete eBook Download by email at [email protected] CHAPTER 16 Caring for Common Medical Emergencies 297
Education Standards • Competencies • Chapter Overview • Objectives 297 Medical Emergencies 298
Snakebites 336 Jellyfish Stings 337 Water-Related Incidents 337 Reaching the Victim 338 Care for the Patient 338 Submersion Injuries 341
Signs and Symptoms of a General Medical Complaint 298
Ice-Related Incidents 342
Assessment 299
Review 344
Altered Mental Status 299 Evaluating Mental Status 299 Glasgow Coma Scale 300 Signs and Symptoms of Altered Mental Status 300 Assessing the Patient with an Altered Mental Status 301 Poisoning and Overdose 309 Routes of Exposure 309 Poison Control Centers 309
CHAPTER 18 Caring for Soft Tissue Injuries and Bleeding 347
Education Standards • Competencies • Chapter Overview • Objectives 347 Heart, Blood, and Blood Vessels 348 The Heart 348 Blood 348 Blood Vessels 349 Bleeding 350
Ingested Poisons 310
External Bleeding 350
Inhaled Poisons 311
Evaluating External Bleeding 351
Absorbed Poisons 312
Controlling External Bleeding 351
Injected Poisons 312
Internal Bleeding 356
Alcohol Intoxication/Abuse 313 Drug Abuse/Overdose 314
Multisystem Trauma 358 Soft Tissue Injuries 359
Generalized Infections (Sepsis) 316
Types of Injuries 359
Allergic Reactions 317
Emergency Care of Open Wounds 362
Kidney (Renal) Failure 317 Behavioral Emergencies 318 Assessment and Emergency Care 319 Assessing the Potential for Violence 320 Restraining Patients 320 Review 322
CHAPTER 17 Caring for Environmental Emergencies 325
Education Standards • Competencies • Chapter Overview • Objectives 325 Temperature and the Body 326 Heat Emergencies 327 Heat Cramps 328
Emergency Care of Specific Injuries 363 Avulsions and Amputations 363 Burns 371 Classification of Burns 371 Severity of Burns 372 Emergency Care of Burns 373 Thermal Burns 374 Chemical Burns 374 Electrical Burns 377 Infants and Children 377 Review 378
CHAPTER 19 Recognition and Care of
Heat Exhaustion 329
Shock 381
Heat Stroke 329
Education Standards • Competencies • Chapter Overview • Objectives 381
Cold Emergencies 330 Hypothermia 330 Localized Cold Injury 332 Bites and Stings 334
Perfusion and Shock 382 Categories of Shock 382 Types of Shock 386
Assessment of and Emergency Care for Bites and Stings 335
The Body’s Response During Shock 386
Anaphylactic Shock 335
Signs and Symptoms of Shock 388
Contents
ix
Get Complete eBook Download by email at [email protected] Mechanism of Injury and Shock 389 Caring for Shock 389 Fainting (Syncope) 389 Review 390
CHAPTER 20 Caring for Muscle and Bone Injuries 392
Education Standards • Competencies • Chapter Overview • Objectives 392
Review 443
CHAPTER 22 Caring for Chest and Abdominal Emergencies 445
Education Standards • Competencies • Chapter Overview • Objectives 445 Anatomy of the Chest 446 Chest Injuries 446
The Musculoskeletal System 393
Closed Chest Injuries 447
Appendicular Skeleton 395
Open Chest Injuries 449
Causes of Extremity Injuries 397 Types of Injuries 398 Signs and Symptoms of Extremity Injuries 398 Patient Assessment 401 Managing Skeletal Injuries 402 Splinting 402 Why Splint? 403 General Rules for Splinting 403 Manual Stabilization 405 Managing Angulated Injuries 405 Types of Splints 406 Management of Specific Extremity Injuries 409 Upper Extremity Injuries 409 Lower Extremity Injuries 415 Review 421
CHAPTER 21 Caring for Head and Spinal Injuries 424
Education Standards • Competencies • Chapter Overview • Objectives 424 Anatomy of the Head and Spine 425 Mechanisms of Injury 426 Injuries to the Head and Face 428
Abdominal Emergencies 452 Anatomy of the Abdomen and Pelvis 452 Generalized Abdominal Pain 453 Signs and Symptoms of Acute Abdominal Pain 453 Assessing the Patient with Acute Abdominal Pain 454 Abdominal Injuries 454 Caring for a Closed Abdominal Injury 455 Open Abdominal Injuries 455 Abdominal Evisceration 455 Review 458
CHAPTER 23 Care During Pregnancy and Childbirth 460
Education Standards • Competencies • Chapter Overview • Objectives 460 Understanding Childbirth 461 Anatomy of Pregnancy 462 Stages of Labor 463 Supplies and Materials 464 Delivery 465 Preparing for Delivery 465
Injuries to the Head 428
Normal Delivery 468
Injuries to the Face 428
Caring for the Baby 471
Signs and Symptoms of Head (Brain) Injury 429
Caring for the Mother 475 Complications and Emergencies 476
Caring for Head Injuries 430
Predelivery Emergencies 476
Caring for Injuries to the Face 430
Complications During Delivery 478
Injuries to the Spine 431 Signs and Symptoms of Spinal Injury 431 Caring for a Suspected Spinal Injury 433 Manual Stabilization 435
x
Helmet Removal 439
Other Emergencies 481 Review 484
CHAPTER 24 Caring for Infants and Children 487
Rules for Care of Spinal Injury 435
Education Standards • Competencies • Chapter Overview • Objectives 487
Cervical Collars 436
Caring for the Pediatric Patient 488
www.bradybooks.com
Get Complete eBook Download by email at [email protected] Your Approach to Infants and Children 488
Assessment of Geriatric Patients 523 Scene Size-up 523
Age, Size, and Response 490
Primary Assessment 523
Special Considerations 490
Obtaining a History 523
Assessment of Infants and Children 494 Scene Size-up 494 Primary Assessment 495
The Physical Exam 524 Common Medical Problems of Geriatric Patients 524
Secondary Assessment 498
Illnesses 524
Physical Exam 498
Injuries 524
Reassessment 499
Elder Abuse and Neglect 525
Managing Specific Medical Emergencies 499 Respiratory Emergencies 499 Altered Mental Status 502 Shock 502 Diarrhea and Vomiting 503
Advocate for the Older Adult Population 526 Review 527
CHAPTER 26 Introduction to EMS Operations and Hazardous Response 529
Hypothermia 504
Education Standards • Competencies • Chapter Overview • Objectives 529
Poisoning 504
Safety First 530
Drowning 504
The Call 531
Fever 503
Phase 1: Preparation 531
Sudden Unexplained Infant Death (SUID) and Sudden Infant Death Syndrome (SIDS) 505
Phase 2: The Dispatch 532
Managing Trauma Emergencies 505
Phase 4: At the Scene 533
General Care of the Child Trauma Patient 505 Burns 506
Phase 3: En Route to the Scene 533 Phase 5: Transfer of Care 533 Phase 6: Postcall Preparation 533 Motor Vehicle Collisions 534
Suspected Abuse and Neglect 506
Upright Vehicle 535
Safety Seats 510
Overturned Vehicle 535
Review 514
CHAPTER 25 Special Considerations for the Geriatric Patient 516
Education Standards • Competencies • Chapter Overview • Objectives 516 Understanding Geriatric Patients 517 Characteristics of Geriatric Patients 517 Multiple Illnesses 518 Multiple Medications 518 Mobility 518 Difficulties with Communication 519 Incontinence 519 Confusion or Altered Mental Status 519 Age-Related Physical Changes 520 Respiratory System 520 Cardiovascular System 521 Nervous System 521
Vehicle on Its Side 535 Patients Pinned Beneath Vehicles 539 Patients Trapped in Wreckage 540 Electric/Hybrid Vehicles 540 Building Access 541 Hazards 541 Fire 541 Natural Gas 542 Electrical Wires and Aboveground Transformers 543 Hazardous Materials 543 Radiation Incidents 547 Review 549
CHAPTER 27 Introduction to Multiple-
Casualty Incidents, the Incident C ommand System, and Triage 552
Musculoskeletal System 522
Education Standards • Competencies • Chapter Overview • Objectives 552
Integumentary System (Skin) 522
Multiple-Casualty Incidents 553
Contents
xi
Get Complete eBook Download by email at [email protected] Incident Command System 554 National Incident Management System 554 The Medical Branch 555
Epinephrine Autoinjectors 577 Nerve Agent Autoinjectors 580
Medical Staging 556
Education Standards • Competencies • Overview • Objectives 581
Triage 556 Triage Priorities 557
Crew Configurations 582
Triage Process 557
Air Medical Resources 582
START Triage System 557
Rotor-Wing Resources 582
JumpSTART Pediatric Triage System 560
Fixed-Wing Resources 583 Requesting Air Medical Resources 583
Alternative Triage Systems 562 Review 564
APPENDICES
The Landing Zone 584
Education Standards • Competencies • Overview • Objectives 566
Selecting an Appropriate Landing Zone 584
Cardiac Monitor 567
Safety Around the Aircraft 585
Glucometer 569 End-Tidal Carbon Dioxide Detector 570 Limitations of Monitoring Devices 570 Appendix 2 Principles of Pharmacology 571 Education Standards • Competencies • Overview • Objectives 571 Medications 572 Indications, Contraindications, Actions, and Side Effects 572
Appendix 4 Introduction to Terrorism Response and Weapons of Mass Destruction 586 Education Standards • Competencies • Overview • Objectives 586 Incidents Involving Nuclear/Radiological Agents 587 Incidents Involving Biological Agents 587 Incidents Involving Chemical Agents 588 Nerve agents 588 Vesicant Agents 588
Rules for Administering Medications 572
Cyanogens 588
Routes for Administering Medications 572
Riot-Control Agents 588
Medications Carried on the Emergency Medical Responder Unit 574 Activated Charcoal 574 Oral Glucose 574 Oxygen 575 Prescription Medications 575 Metered-Dose Inhalers 575 Naloxone (Narcan) 575 Nitroglycerin 575
xii
What Happens After a Request Is Made? 584
Appendix 1 Patient Monitoring Devices 566
Pulse Oximeter 568
Appendix 3 Air Medical Transport Operations 581
www.bradybooks.com
Pulmonary Agents 588 Role of the Emergency Medical Responder 589 Decontamination 589
ANSWER KEY 590 GLOSSARY 596 INDEX 605
Get Complete eBook Download by email at [email protected]
PHOTO SCANS 1.1
The EMS System 5
10.2
Administering Oxygen 180
1.2
Emergency Medical Responders 10
11.1
1.3
Patient-Related Duties 12
ocating CPR Compression Site on Adult and L Child 190
3.1
Proper Removal of Gloves 39
11.2
One-Rescuer CPR for the Adult or Child 195
4.1
Major Body Organs 60
11.3
Two-Rescuer CPR for the Adult or Child 197
4.2
The Respiratory System 62
11.4
Operating an AED 204
4.3
The Cardiovascular System 64
12.1
Blood Pressure by Auscultation 225
4.4
The Skeletal System 66
12.2
Blood Pressure by Palpation 226
4.5
The Muscular System 68
13.1
4.6
The Nervous System 70
Focused Secondary Assessment– Responsive/Stable Medical Patient 237
4.7
The Digestive System 72
13.2
4.8
he Male Reproductive System and the T Female Reproductive System 73
Rapid Secondary Assessment–Unresponsive/ Unstable Medical Patient 238
13.3
4.9
The Urinary System 76
Focused Secondary Assessment–Trauma Patient with No Significant Mechanism of Injury 239
4.10
The Integumentary System 77
13.4
4.11
The Endocrine System 78
6.1
Power Lift 97
Rapid Secondary Assessment–Trauma Patient with a Significant Mechanism of Injury 240
6.2
Emergent Moves–One-Rescuer Drags 100
13.5
Scene Size-up 241
6.3
Direct Ground Lift 101
13.6
6.4
Extremity Lift 102
rimary Assessment–Trauma Patient with No P Significant MOI 244
6.5
Direct Carry 103
13.7
Primary Assessment–Medical Patient 245
6.6
Wheeled Stretchers 105
13.8
6.7
Stretchers 106
Primary Assessment–Unresponsive Patient (Medical or Trauma) 246
6.8
Backboards 107
13.9
Focused Secondary Assessment–Trauma with No Significant MOI 252
6.9
lacing the Patient in the Recovery P Position 110
13.10
Rapid Secondary Assessment–Significant MOI or Unstable Medical Patient 253
6.10
Log Roll of a Patient 111
13.11
6.11
Lift-and-Slide onto Long Board 112
Focused Secondary Assessment–Stable Medical Patient 255
9.1
Abdominal Thrusts 153
14.1
Nitroglycerin
9.2
are for the Unresponsive Choking C Infant 155
14.2
Aspirin 279
15.1
Respiratory Compromise 284
9.3
Inserting an Oropharyngeal Airway 159
15.2
Metered-Dose Inhaler 291
9.4
Inserting a Nasopharyngeal Airway 161
16.1
9.5
Two-Rescuer Bag-Mask Ventilation 162
ltered Mental Status–Stroke: A Cerebrovascular Accident 304
9.6
One-Rescuer Bag-Mask Ventilation 164
16.2
Diabetic Emergencies 307
9.7
Types of Suction Devices 165
17.1
Heat-Related Emergencies 328
9.8
Suctioning 166
17.2
Cold-Related Emergencies 333
10.1
dministering Oxygen: Preparing the A Oxygen Delivery System 179
17.3
Water Rescue 340
18.1
Controlling External Bleeding 352
278
xiii
Get Complete eBook Download by email at [email protected] 18.2
Examples of Dressing and Bandaging 357
21.4
Verifying the Fit of a Cervical Collar 437
18.3
Impaled Object 366
21.5
18.4
remoistened Commercial Burn P Dressings 374
pplying a Cervical Collar to a Seated A Patient 438
21.6
pplying a Cervical Collar to a Supine A Patient 439
18.5
Assessment and Care of Thermal Burns 375
19.1
Four Categories of Shock 383
21.7
Helmet Removal 441
19.2
Progression of Shock 387
22.1
Dressing an Abdominal Evisceration 456
20.1
Select Mechanisms of Extremity Injury 399
23.1
Normal Delivery 469
20.2
Splinting an Upper Extremity 404
24.1
20.3
Sling and Swathe 407
apid Extrication from a Car Safety R Seat 512
20.4
Examples of SAM® Splint Applications 408
26.1
Unlocking Vehicle Doors 537
20.5
Examples of Upper Extremity Splints 410
26.2
20.6
Immobilizing a Bent Elbow 413
Gaining Access Through a Vehicle Window 539
20.7
Immobilizing a Forearm 414
20.8
pplication of the SAM Sling® Pelvic A Splint 416
Appendices
20.9
Immobilizing a Bent Knee 418
A2.1
Activated Charcoal 573
20.10
Immobilizing the Lower Leg 419
A2.2
Oral Glucose 574
21.1
Mechanisms of Spine Injury 427
A2.3
Metered-Dose Inhaler 576
21.2
ssessing the Patient with a Suspected A Spinal Injury 432
A2.4
Naloxone (Narcan) 577
A2.5
Nitroglycerin 578
Manual Stabilization of Head and Neck 434
A2.6
Epinephrine Autoinjector 579
21.3
xiv
www.bradybooks.com
Get Complete eBook Download by email at [email protected]
SKILLS VIDEOS available in MyLab Brady Airway (18 skills) Head-Tilt Chin-Lift Jaw-Thrust Jaw-Thrust with Mask: Mouth-to-Mask with Suspected Spinal Injury Ventilation: Mouth-to-Mask Mouth-to-Shield Ventilation for a Nonbreathing Patient with a Pulse Recovery Position or Lateral Recumbent Position Oropharyngeal Airway: Measuring and Insertion in Adults Oropharyngeal Airway: Measuring and Insertion for Infants and Children Nasopharyngeal Airway: Measuring and Insertion for Adults Nasopharyngeal Airway: Measuring and Insertion for Infants and Children One Rescuer Bag-Valve-Mask Ventilation Two Rescuer Bag-Valve-Mask Ventilation Oral Suction: Electric Nasal Suction: Electric Oxygen Tank Set Up Oxygen Administration: Nasal Cannula Oxygen Administration: Nonrebreather Mask Complete Ventilation Sequence for a Nonbreathing Patient with a Pulse
Assessment (10 skills) Counting Respirations Locating Radial, Carotid, Brachial, and Pedal Pulses Stethoscope Use Blood Pressure: Placement of Cuff and Obtaining Reading Pupils: With and Without Light Source Primary Assessment Secondary Assessment: Medical Secondary Assessment: Trauma Secondary Assessment: Anatomical with Medical and Trauma Examination Reassessment
Medical (12 skills) Automated External Defibrillator Naloxone Administration
Inhaler Use With and Without Holding Chamber Complete Cardiac Arrest Management Sequence Small-Volume Nebulizer Continuous Positive Airway Pressure Equipment and Application Blood Glucose Monitor Stroke Assessment: Cincinnati Prehospital Stroke Scale (CPSS) Stroke Assessment: Los Angeles Prehospital Stroke Screen (LAPSS) Stroke Assessment: Miami Emergency Neurologic Deficit (MEND) Stroke Assessment: Rapid Arterial Occlusion Evaluation (RACE)
Trauma (9 skills) Bleeding Control: Direct Pressure Bleeding Control: Tourniquet Bleeding Control with Hemostatic Agent Shock Management Assessment for Spinal Injury: Ambulatory Patient Spine Motion Restriction: Ambulatory Patient Spine Motion Restriction: Self Extrication Cervical Collar: Sizing and Application Log Roll: Three Person with Spine Motion Restriction
Other (12 skills) Removal of Gloves Obtaining a Medical History Epinephrine Auto Injector Nitroglycerin Administration Applying 12-Lead Electrodes Oral Glucose Administration Splinting Joints Splinting a Long Bone Arm Sling Neonatal Resuscitation Routine Care of the Newborn Clamping and Cutting an Umbilical Cord
xv
Get Complete eBook Download by email at [email protected]
This page intentionally left blank
A01_THOM6233_05_SE_WALK.indd 9
1/13/17 6:50 PM
Get Complete eBook Download by email at [email protected]
LETTER TO STUDENTS As the lead author of this textbook, I want to personally congratulate you on your decision to become an Emergency Medical Responder. Your decision to serve others, especially in times of great need, is one of the most rewarding opportunities anyone can experience. This textbook has been an important component of thousands of training programs over the past 30 years and has contributed to the success of hundreds of thousands of students just like you. The new 11th edition retains many of the features found to be successful in previous editions and includes some new topics and concepts that have recently become part of most Emergency Medical Responder programs. The foundation of this text is the National Emergency Medical Services Education Standards for Emergency Medical Responders and includes the 2017 Focused Updates from the American Heart Association Guidelines for Cardiopulmonary Resuscitation and First Aid. Unique among Emergency Medical Responder textbooks, this edition again includes references to some of the most current medical literature. Your decision to become an Emergency Medical Responder is significant. I believe strongly that being able to assess and care for patients requires much more than just technical skills. It requires you to be a good leader, and good leaders demonstrate characteristics such as integrity, compassion, accountability, respect, and empathy. My team and I have enhanced components in the 11th edition that we believe will help you become the best Emergency Medical Responder you can be; one such component is the “First on Scene” scenarios woven throughout each chapter. In these scenarios, we throw you right in the middle of a real-life emergency and offer you a perspective that you will not get with any other training resource. You will see firsthand how individuals just like you make decisions when faced with an emergency situation. You will feel the fear and anxiety that is such a normal part of being a new Emergency Medical Responder. Not everyone you meet will make the best decisions, so we want you to consider each scenario carefully and discuss it with your classmates and instructor. At the end of each chapter is the “First on Scene Run Review.” Here you will have a chance to answer specific critical-thinking questions relating to the First on Scene scenario and consider how you might have done things differently. This edition places a stronger focus on the language of inclusiveness, recognizing that Emergency Medical Responders and our patients come from a variety of cultures, socioeconomic backgrounds, and experiences. To emphasize this, unless the gender of a person is relevant to the content, I use both “he and she” throughout the text. Becoming an Emergency Medical Responder is just the first step in what is likely to be a lifetime of service. Just a warning to you: The feeling you get when you are able to help those in need is contagious. I encounter students all across the country who have discovered that their passion is helping others. I hope that we can be part of helping you discover your passion. I welcome you to EMS and a life of service! Improving patient care, one student at a time. Chris Le Baudour
xvii
Get Complete eBook Download by email at [email protected]
This page intentionally left blank
A01_THOM6233_05_SE_WALK.indd 9
1/13/17 6:50 PM
Get Complete eBook Download by email at [email protected]
PREFACE The publication of the 11th edition of Emergency Medical Responder marks the 36th anniversary of the publication of the first edition back in 1982. This new edition is driven by the National Emergency Medical Services Education Standards. These standards represent the work of leading EMS educators across the nation as well as internationally. The majority of the changes are the result of evidence-based research conducted by many individuals and o rganizations. The contents of the 11th edition are summarized below, followed by notes on what’s new to each chapter. Note that, within each chapter, the cognitive objectives are updated and reorganized to more effectively match the flow of chapter content, and the Quick Quizzes were revised to better assess the cognitive objectives. The chapters also include a number of new photos.
Chapters 1–5 The first few chapters set the foundation for all that follow by introducing the basic concepts, information, and framework for someone entering the profession. The EMS system and the role of the Emergency Medical Responder within the system are introduced. Legal and ethical principles of emergency care are covered, as well as basic anatomy, physiology, and medical terminology.
What’s New? • Chapter 1, Introduction to EMS Systems, includes updates to the EMS timeline. • Chapter 2, Legal and Ethical Principles of Emergency Care, includes an expanded definition of durable power of attorney and clarification of documenting a patient’s refusal of care. • Chapter 3, Wellness and Safety of the Emergency Medical Responder, now includes Zika and Ebola as emerging pathogens, discusses the new Hepatitis B vaccine for adults, and provides recommendations to health care providers to receive the meningitis vaccination. The chapter also introduces the concept of hospice care for patients with terminal illnesses. • Chapter 4, Introduction to Medical Terminology, Human Anatomy, and Lifespan Development, includes updates to positional terms, blood flow through the heart, the musculoskeletal and male reproductive systems, and human development. It also introduces the term zygote in the section on embryonic development. • Chapter 5, Introduction to Pathophysiology, includes updated statistics related to diabetes; the chapter also contains expanded coverage of blood vessel structure, cardiac output, and tidal volume.
Chapters 6–8 These three chapters introduce many of the fundamental skills necessary to be an effective Emergency Medical Responder, covering the proper techniques for lifting, moving, and positioning ill and injured patients. They also address important principles related to proper verbal and written communication and documentation.
What’s New? • Chapter 6, Principles of Lifting, Moving, and Positioning of Patients, offers updated information on situations that require a standard move, clarification of performing a direct ground lift, and differentiates the shock and Trendelenburg positions. New information includes bariatric stretchers, the use of patient restraints, and the ergonomic stance for lifting. Scans that describe emergent moves, direct ground lifts, direct carry, and using stretchers and backboards now include many new photos to show updated concepts. • Chapter 7, Principles of Effective Communication, provides updated information on communication barriers, expanded information on the topics of cultural differences, translation services, establishing patient rapport, and communication with patients with hearing loss, cognitive disabilities, or who require a service animal. • Chapter 8, Principles of Effective Documentation, now includes information on patient health information privacy as it relates to HIPAA, correcting errors on both an electronic and paper PCR, an expanded description of subjective patient information, and the use of smart phone apps for patient documentation.
Chapters 9–11 Chapters 9 and 10 may be considered the most important. No patient will survive without an open and clear airway. Basic airway management techniques are covered in detail, as is proper ventilation and oxygen administration. Chapter 11 contains all of the most recent updates related to cardiopulmonary resuscitation (CPR) and the use of the automated external defibrillator (AED).
What’s New? • Chapter 9, Principles of Airway Management and Ventilation, includes updates on the following: care instructions for a witnessed cardiac arrest, respiratory system anatomy, ventilations for a patient with a
xix
Get Complete eBook Download by email at [email protected] stoma, and management of an unconscious patient with a gag reflex. Also added is information on the causes for vomiting during rescue breathing, the possible consequences of a poorly fitting airway adjunct, and content related to respiratory failure. • Chapter 10, Principles of Oxygen Therapy, explains the importance of hydrostatically testing oxygen cylinders, contains an improved explanation of the oxygen concentration of room air, clarifies situations in which a patient might require supplemental oxygen, and updates information on the use of a bag-mask device with two rescuers. • Chapter 11, Principles of Resuscitation, retains the newest information on CPR as well as the use of the automated external defibrillator according to the American Heart Association’s guidelines and recommendations. Updates to the chapter include information on the proper duration of rescue breaths, an explanation of the recommendations for performing CPR in unwitnessed pediatric cardiac arrest, and information on locating the proper CPR hand position on female patients.
Chapters 12–13 These two chapters are all about patient assessment, the foundation for the care Emergency Medical Responders will provide.
tions of some erectile dysfunction medications and the use of nitroglycerin. • Chapter 15, Caring for Respiratory Emergencies, includes new content on trauma-related respiratory compromise, pulmonary edema, pneumonia, and agonal respirations. It also contains updates related to the use of positive pressure ventilations for inadequate breathing and the common signs and symptoms of emphysema. • Chapter 16, Caring for Common Medical Emergencies, introduces the “last known normal” and the FAST assessment tool for patients experiencing stroke. It also includes examples of common street drugs, the risk of exposure to potent drugs for the rescuer, and additional strategies for calming a patient experiencing a behavioral emergency. It also introduces the use of Naloxone as a treatment for narcotic overdose. • Chapter 17, Caring for Environmental Emergencies, now includes updated information on rewarming a local cold injury, heat cramps, and the amount of air to provide during rescue breaths. It also differentiates between submersion injury and injuries caused by diving into shallow water.
Chapters 18–22 These chapters address many of the more common emergencies related to trauma and bleeding.
What’s New?
What’s New?
• Chapter 12, Obtaining a Medical History and Vital Signs, includes new blood pressure guidelines from the American Hospital Association along with updated information on vital signs in fit athletes, obtaining blood pressure, observing and counting respirations, and obtaining skin temperature manually. • Chapter 13, Principles of Patient Assessment, offers expanded information on multi-system trauma, significant versus non-significant mechanism of injury, and rapid trauma assessment. It also provides updated AVPU descriptions and introduces the term “kill zone” and its relationship to the trauma assessment.
• Chapter 18, Caring for Soft Tissue Injuries and Bleeding, includes updated information on the following topics: tourniquet and roller bandage applications, hemostatic dressing use, signs and symptoms of internal bleeding, impaled object removal, open chest wound care, and burn treatment based on affected body surface area. • Chapter 19, Recognition and Care of Shock, now includes additional examples of distributive shock, updated information on signs and symptoms of shock, and more detailed definitions of septic shock, hypoperfusion, and shock. • Chapter 20, Caring for Muscle and Bone Injuries, offers updated information on immobilization of an elbow injury as well as determining treatment priorities. • Chapter 21, Caring for Head and Spinal Injuries, now includes updated information on the assessment of distal extremities, cerebral contusion, and sizing a cervical collar. It also includes new information on abnormal vital signs for head injury and spinal motion restriction (SMR). • Chapter 22, Caring for Chest and Abdominal Emergencies, now offers an expanded section on
Chapters 14–17 These chapters cover many of the most common medical emergencies encountered in the field and the most up-todate recommendations for patient care.
What’s New? • Chapter 14, Caring for Cardiac Emergencies, expands the discussion of congestive heart failure, includes a new Scan on aspirin, and discusses the contraindica-
xx
www.bradybooks.com
Get Complete eBook Download by email at [email protected] management of open chest injuries along with updates on treatment of patients with a flail chest, the care of open chest wounds, spontaneous pneumothorax, and the management of evisceration.
Chapter 23 This chapter covers normal pregnancy and childbirth. It also discusses many of the common emergencies related to pregnancy and childbirth.
What’s New? • Chapter 23, Care During Pregnancy and Childbirth, retains all the most up-to-date information regarding Emergency Medical Responder care of the mother and child before, during, and after delivery. Updates include an explanation of bloody show, ways to suction a newborn, and how to perform chest compressions on an infant.
Chapters 24 and 25 Chapters 24 and 25 cover the unique differences in the special populations of pediatric and geriatric patients. They also introduce specific assessment strategies for each group.
mechanical falls, and an expanded discussion on multiple medications and side effects of some common medications.
Chapters 26 and 27 These two chapters cover many of the topics related to EMS operations, such as the phases of an emergency response, responding to a hazardous materials incident, and responding to multiple-casualty incidents. The principles of the incident management system (IMS) and triage are also addressed. Both chapters retain information important to the roles of Emergency Medical Responders during hazardous materials and multiple-casualty responses.
What’s New? • Chapter 26, Introduction to EMS Operations and Hazardous Response, includes an update on managing patients who are contaminated along with new information on safety awareness related to working around electric and hybrid vehicles. • Chapter 27, Introduction to Multiple-Casualty Incidents, the Incident Command System, and Triage, includes information about online FEMA training, the SALT triage system, and the use of colored ribbon to replace triage tags.
What’s New? • Chapter 24, Caring for Infants and Children, offers updates in relation to definitions of newborn and infant decompensated shock, plus new content on Apparent Life Threatening Event (ALTE) and a reorganization of the content on shock and dehydration. • Chapter 25, Special Considerations for the Geriatric Patient, provides updated statistics on the aging population along with discussions of suicide in older adults, the causes of pressure sores, definitions of
Appendices There are four appendices in this new edition: “Patient Monitoring Devices;” “Principles of Pharmacology,” including an all-new photo scan for administration of Naloxone; “Air Medical Transport Operations;” and an “Introduction to Terrorism Response and Weapons of Mass Destruction.” Each includes an overview of its topic relevant to the role of the Emergency Medical Responder.
Preface
xxi
Get Complete eBook Download by email at [email protected]
This page intentionally left blank
A01_THOM6233_05_SE_WALK.indd 9
1/13/17 6:50 PM
Get Complete eBook Download by email at [email protected]
ACKNOWLEDGMENTS I constantly remind my students that responding effectively to the needs of others during an emergency requires a team effort. It takes the efforts of many to render care efficiently and appropriately when the stress is on. Assembling a project such as this is no exception. Without the coordinated efforts of many people spread throughout the United States, this project could not have been possible. I’d like to acknowledge the key players who helped create the end product that you see before you. I’d like to begin with Audrey Le Baudour, my personal assistant, copy editor, travel coordinator, and, last but not least, my wife. She is the one who keeps me organized, focused, and most importantly on schedule. I’d like to extend a special thank you to our photographer, Michal Heron, who has single-handedly raised the bar for the way EMS is depicted in textbooks across this country. Michal, you bring something no other artist brings when shooting for these books. Your work is clearly head and shoulders above the rest, and you really challenge authors to do it better. A very special thank you is in order for my team at Pearson, Derril Trakalo, Faye Gemmellero, Jill Rembetski, and Erin Hernandez. I simply could not ask for a more professional and passionate team to be working with. A special thanks to the entire sales team at Pearson Education, who provide the support and infrastructure to make these projects happen and get them to those who need them. The skill and teamwork it takes to choreograph a project such as this is truly amazing. A special shout-out to Shawna Whooley for her work in helping make certain this edition of Emergency Medical Responder is as complete and accurate as possible. I greatly appreciate all the long hours you put in behind the scenes and the passion you are adding. Finally I want to recognize my dear friend and colleague Paramedic Larry Thompson. Larry gave this project many hours of his time to ensure the photos we shot for this edition were the most current and accurate as possible. Larry is one of the most passionate and caring EMS professinals I have had the pleasure to work with.
Medical Director Keith Wesley, MD, FACEP Our special thanks to Dr. Keith Wesley. His reviews were carefully prepared, and we appreciate the thoughtful advice and keen insight offered. Dr. Keith Wesley is board certified in emergency medicine with subspecialty board certification in emergency medical services. Dr. Wesley is the EMS medical director for HealthEast Medical Transportation in St. Paul, Minnesota. He has served as the state EMS medical director for both Minnesota and Wisconsin and chair of the National Council of State EMS Medical Directors. Dr. Wesley is the author of many articles and EMS textbooks and a frequent speaker at EMS conferences across the nation.
Contributors to the previous editions We would like to extend our sincere appreciation and thanks to the following individuals who contributed to the completion of the 10th edition, as well as previous editions. Thank you for your ideas, feedback, and contributions. Lorenzo J. Alviso, CHT, NREMT; Instructional Assistant, Santa Rosa Junior College EMT Program, Santa Rosa, CA
xxiii
Get Complete eBook Download by email at [email protected] Lt. John L. Beckman, AA, BS, FF/EMT-P; Fire Science Instructor, Technology Center of Dupage, Addison, IL Brian Bricker, EMT; Director of Integrated Services, Falck Northern California, Petaluma, CA Ted Williams, NREMT-P; Faculty, Santa Rosa Junior College, Santa Rosa, CA Janssen Todd, NREMT; Falck Northern California, Petaluma, CA
Reviewers We wish to thank the following EMS professionals who reviewed material for the 11th edition of Emergency Medical Responder. The quality of their reviews has been outstanding, and their assistance is deeply appreciated. Blance Bankston, NRP; LSU Fire and Emergency Training Institute, Baton Rouge, LA Andrew Haynes, NRP; Southwest Virginia Community College, Cedar Bluff, VA Rebecca Smith, M.Ed, NREMT; Keeping Safety Smart, LLC Folsom, LA Delilah McFadden, NREMTP; Southwest Virginia Community College, Richlands, VA Mark Chapman, Rowan College at Gloucester County Deptford Township, NJ Maggie Haynes, BS, NRP; Southwest Virginia Community College Cedar Bluff, VA Levan Doucet, NRP; Acadian Companies, Lafayette, LA Bernard Falgoust, NREMT; RIPs Safety & Training Consulting, LLC, Vacherie, LA Gretchen Medel, EMT Program Director, Los Medanos College, Pittsburg, CA; Contra Costa College, San Pablo, CA; Dozier Libbey Medical High School, Antioch, CA Hudson Garrett, PhD, MSN, MPH, FNP-BC, CSRN, VA-BC, DON-CLTC, C-NAC; University of Louisville, Louisville, KY Shawna Renga, Paramedic Instructor, United States Coast Guard Kenneth Kirkland, RN, BSN, NRP; Calhoun Community College, Decatur, AL Andrew Appleby, RN; Western Wyoming Community College, Rock Springs, WY
xxiv
www.bradybooks.com
Get Complete eBook Download by email at [email protected] Photo Acknowledgments All photographs not credited adjacent to the photograph were photographed on assignment by Michal Heron for Pearson Education, Inc.
Organizations We wish to thank the following organizations for their assistance in creating the photo program for this edition: Windsor Fire Department, Windsor, California, Chief Doug Williams Falck Northern California, Gary Tennyson—CEO, and Sean Sullivan—COO Santa Rosa Junior College–Public Safety Training Center, April Chapman—Dean Sonoma County Regional Parks, Mark Norman—Park Ranger/EMT, Sabrina Spear—Lifeguard/EMT, John Menth—Lifeguard/EMT Sonoma County Search and Rescue Team, Steve Freitas—Sheriff
Photo Coordinators/Subject Matter Experts Thanks to Paramedic Ted Williams for his valuable assistance directing the medical accuracy of the shoots and coordinating models, props, and locations for our photo shoots.
Models Thanks to the following people who portrayed patients and EMS providers in our photographs: Rachel Abravaya Joseph Armbruster Veronique Asti Amanda Baker Michael Baker Kevin Beans Breanne Benward Irene Calzada-Bickham Andrea Bordignon Rebecca Calleja Breanna Cheatham Don Chigazola Jesus Diaz Mark Diaz Jason Freyer
Jacob Garrison Brandon Hefele Mark Hubenette Melissa Keck Mina Kiani Nathan Koman Misty Landeros Katy Le Baudour Matt Marshall John “JR” Maricich John Martin Mike McDonald Addison Meints Casey Meints Kayla Meints
John Menth Molly Muldoon Mark Norman Ryan Opiekun Fredrick Presler James Renegar Tyler Reynolds Sabrina Spear Morgan Stameroff Lana Trapp Cody Whitmore Steve Whitmore Bradley Williams Ted Williams
Photo Assistants/Digital Postproduction Maria Lyle
Acknowledgments
xxv
Get Complete eBook Download by email at [email protected]
This page intentionally left blank
A01_THOM6233_05_SE_WALK.indd 9
1/13/17 6:50 PM
Get Complete eBook Download by email at [email protected]
ABOUT THE AUTHOR Chris Le Baudour Chris Le Baudour has been working in the EMS field since 1978. In 1984, Chris began his teaching career in the Department of Public Safety—EMS Division at Santa Rosa Junior College in Santa Rosa, California. Chris holds a Bachelor’s Degree in Communications and a Master’s Degree in Education with an emphasis in online teaching and learning as well as numerous EMS and instructional certifications. Chris has spent the past 30 years mastering the art of experiential learning in EMS and is well known for his innovative classroom techniques and his passion for both teaching and learning in both traditional and online classrooms. Chris is very involved in EMS education at the national level, served six years as a board member of the National Association of EMS Educators, and advises many organizations throughout the country. Chris is a frequent presenter at both state and national conferences and a prolific EMS writer. Along with numerous articles, he is the author of Emergency Care for First Responders, and coauthor of EMT Complete: A Basic Worktext, and the Active Learning Manual for the EMT-Basic. Chris and his wife, Audrey, have two children and reside in northern California.
xxvii
Get Complete eBook Download by email at [email protected]
This page intentionally left blank
A01_THOM6233_05_SE_WALK.indd 9
1/13/17 6:50 PM
Get Complete eBook Download by email at [email protected]
AMERICAN SAFETY & HEALTH INSTITUTE Emergency Medical Response Certification Program American Safety & Health Institute (ASHI) is a member of the Health & Safety Institute (HSI) family of brands. HSI’s mission is Making the Workplace and Community Safer.™. ASHI authorizes qualified individuals to offer Emergency Medical Response training and certification programs for corporate America, government agencies, and emergency responders. Emergency Medical Responder: First on Scene, is the required textbook of the ASHI Emergency Medical Response training program. To learn more about ASHI, visit https://emergencycare.hsi.com/ In the early 1970s, officials at the U.S. Department of Transportation National Highway Traffic Safety Administration (NHTSA) recognized a gap between basic first aid training and the training of Emergency Medical Technicians (EMTs). Their solution was to create “Crash Injury Management: Emergency Medical Services for Traffic Law Enforcement Officers,” an emergency medical care course for “patrolling law enforcement officers.” As it evolved, the course expanded to include other “First Responders”—public and private safety and service personnel who, in the course of performing other duties, are likely to respond to emergencies (firefighters, highway department personnel, etc.). The Crash Injury Management course provided the basic knowledge and skills necessary to perform lifesaving interventions while waiting for EMTs to arrive. The original program was never intended for training EMS personnel. Because the Crash Injury Management course was designed to fill the gap between basic first aid training and EMT, it was considered “advanced first aid training.” In 1978, the Crash Injury Management course was renamed Emergency Medical Services First Responder Training Course and was specifically targeted at “public service law enforcement, fire, and EMS rescue agencies that did not necessarily have the ability to transport patients or carry sophisticated medical equipment.” Then, in 1995, the course went through a major revision and its name was changed to First Responder: National Standard Curriculum. At that time, the First Responder was described as “an integral part of the Emergency Medical Services System.” Later, in 2006, a FEMA EMS Working Group recommended a new job title for first responders working within the EMS system—the Emergency Medical Responder (EMR). This title is meant to specify a state-
licensed and credentialed individual responding within an EMS-providing entity, organization, or agency. Specifically, the use of the word “medical” in the EMR title is intended to help distinguish those persons who have successfully completed a state-approved EMR program from other first responders such as law enforcement officers, public health workers, and search & rescue personnel (to name a few).
ASHI Emergency Medical Response for Non-EMS Personnel The gap between basic first aid training and the training of EMS professionals that was recognized more than 30 years ago remains. There is still a need for an “advanced first aid course” for the original “first responder” target audience—non-EMS providers who, in the course of performing other duties, are likely (or expected) to respond to emergencies. These individuals, including law enforcement officers, fire fighters, and other public and private safety and service personnel, are indeed an integral part of the overall EMS System. That is to say, they are part of a network of resources—people, communications, and equipment— prepared to provide emergency care to victims of sudden illness or injury. On the other hand, these individuals are not, and in most cases do not wish to be, state-licensed and credentialed EMS professionals. The original first responder program was intended to provide these “pre-EMS” responders with the basic knowledge and skills necessary for lifesaving interventions while waiting for the EMS professionals to arrive. That original intent–filling the knowledge and skill gap between basic first aid training and EMS—is the intent of ASHI’s Emergency Medical Response for Non-EMS Personnel program. Additionally, because this program uses the same textbooks and related instructional tools as those used to train EMRs, it serves to encourage a continuum in care for the ill or injured person as he or she is transitioned from care provided by the first responder to care provided by the EMS professional.
Certification In ASHI Emergency Medical Response Evaluation of knowledge and skill competence is required for certification in ASHI Emergency Medical Response. The learner must successfully complete the ASHI Emergency Medical Response for Non-EMS Personnel
xxix
Get Complete eBook Download by email at [email protected] Exam and demonstrate the ability to work as a lead first responder in a scenario-based team setting, adequately directing the initial assessment and care of a responsive and unresponsive medical and trauma patient.
disability, and save lives, ASHI encourages this international expansion, particularly in areas with emerging but undeveloped EMS systems. However, as in the United States, the scope of practice for medically trained persons is often subject to federal, state, provincial, or regional laws and regulations. It is not the intent of ASHI’s Emergency Medical Response program to cross the EMS (or medical) scope of practice threshold in any country.
Health & Safety Institute (HSI) State Licensure and Credentialing State EMS agencies have the legal authority and responsibility to license, regulate, and determine the scope of practice of EMS providers within the state EMS system. ASHI’s Emergency Medical Response program is designed to allow properly qualified and authorized ASHI instructors to train and certify individuals as first responders consistent with the National EMS Education Standards and Instructional Guidelines. It is not the intent of ASHI’s Emergency Medical Response program to cross the EMS scope of practice threshold. An individual that has been trained and certified in ASHI Emergency Medical Response is NOT licensed and credentialed to practice emergency medical care as an EMS provider within an organized state EMS system. EMS provider licensing and credentialing are legal activities performed by the state, not ASHI. Individuals who require or desire licensure and credentialing within the state EMS system must complete specific requirements established by the regulating authority.
International Use of ASHI Emergency Medical Response for Non-EMS Personnel
The Health and Safety Institute (HSI) is a family of wellknown and respected brands in the Environmental, Health and Safety (EH&S) space. Our brands span the broad range of needs in EH&S–from emergency care training to facilitating workplace safety training, tracking, and reporting, to the management of chemical inventories. HSI’s emergency care training and emergency medical service (EMS) continuing education programs are currently accepted, approved, or recognized as meeting the requirements of more than 5000 state regulatory agencies, occupational licensing boards, national associations, commissions, and councils in more than 550 occupations and professions. Since 1978, ASHI and MEDIC First Aid authorized instructors have certified nearly 33 million emergency care providers in the US and more than 100 countries throughout the world. HSI is an accredited organization of the Commission on Accreditation of Pre-Hospital Continuing Education (CAPCE), the national accreditation body for Emergency Medical Service Continuing Education programs and a member of the American National Standards Institute and ASTM International, two of the largest voluntary standards development and conformity assessment organizations in the world.
Given the current state of globalization and the increasing international reach of ASHI-authorized instructors, the ASHI Emergency Medical Response program has expanded outside of the United States. As appropriate actions by first responders alleviate suffering, prevent
American Safety & Health Institute 1450 Westec Drive, Eugene, OR 97402. PHONE 800-447-3177 FAX 541-344-7429
xxx
www.bradybooks.com
Get Complete eBook Download by email at [email protected]
WALK THROUGH Education Standards and Competencies
6
Provides standards and competencies that are addressed in each chapter.
Principles of Lifting, Moving, and Positioning of Patients Education Standards: Competencies: Chapter Overview:
• Preparatory—Workforce Safety and Wellness • Uses simple knowledge of the EMS system, safety/well-being of the Emergency Medical Responder, medical/legal issues at the scene of an emergency while awaiting a higher level of care. Many Emergency Medical Responders are injured every year because they attempt to lift or move a patient or piece of equipment improperly. The International Association of Fire Fighters’ annual Death and Injury Survey shows that back injuries account for approximately 50% of all line-of-duty injury retirements each year.1 One of the most important things that you can do for yourself, your co-workers, and your patients is to learn how to lift and move patients and objects using proper body mechanics.
Chapter Overview
Just as critical as knowing how to move patients properly is knowing when they should be moved. There are many factors that you must consider before moving a patient, such as the safety of the scene, the patient’s condition, and the number of rescuers available to assist.
A brief preview of the chapter’s highlights.
This chapter discusses common situations in which an Emergency Medical Responder may be required to move or reposition a patient. It also describes some simple lifting and moving techniques that use proper body mechanics to make it possible for you to be a safe and healthy Emergency Medical Responder for many years to come. 3. Explain the importance of using proper body mechanics. (p. 98) Explain the hazards of not using proper body mechanics when lifting and moving patients. (p. 98) Explain the importance of active communication during patient lifts and moves. (p. 98) Differentiate between an emergent move and a standard move, and state when each should be used. (p. 101) Identify the common devices used for transporting patients. (p. 106) Explain the purpose of the “recovery position,” and state when it should be used. (p. 111) Describe the following patient positions, and state when each should be used: Fowler’s, semi-Fowler’s, and shock. (p. 111) Explain the criteria for using patient restraints. (p. 114) Identify the various types of patient restraints. (p. 114) Explain the technique for the proper restraint of a patient. (p. 115)
4. COGNITIVE 1. Define the following terms: a. blanket drag (p. 101) 5. b. body mechanics (p. 98) c. clothing drag (p. 101) 6. d. direct carry (p. 104) e. direct ground lift (p. 102) f. draw sheet method (p. 104) 7. g. emergent move (p. 100) h. extremity lift (p. 103) 8. i. Fowler’s position (p. 111) j. log roll (p. 112) 9. k. positional asphyxia (p. 116) one-third the depth • Like the chain of EMS resources, the chain of survival is also l. power lift (p. 98)of the infant’s chest or about one and one-half inches. a linked system of patient-care events. These events include m. recovery position (p. 111) 10. • n.After 30 compressions, provide two rescue breaths over immediate recognition and activation of EMS, early CPR, restraint (p. 114) one second each and begin compressions again. Do not rapid defibrillation, effective advanced life support (ALS), and o. semi-Fowler’s position (p. 111) stop CPR for more than 10 seconds other than to move11. integrated post–cardiac arrest care. p. shock position (p. 111) the patient because of danger at the scene. Continue • The survival of the brain is dependent on the activities of q. standard move (p. CPR until the patient 101) regains a pulse and/or breathing breathing and circulation. When the heart stops beating, a 12. or until the youcharacteristics are relieved by of anproper equallybody or more highly patient is in cardiac arrest and cannot circulate oxygenated 2. Describe trained individual, care for the patient is accepted by a blood to the brain. The major signs of cardiac arrest are unremechanics. (p. 98) physician, or until you can no longer continue because sponsiveness, no breathing, and no pulse. of exhaustion. • If a patient is unresponsive, check for signs of breathing. If the • Automated external defibrillators (AEDs) are lifesaving patient is not breathing or has only gasping breaths, call 911 units used by Emergency Medical Responders and available and check for a pulse. If the patient has no pulse, begin chest in many public areas. AEDs are electrical devices that can compressions immediately. convert certain lethal heart rhythms to a normal cardiac • If you are alone and caring for a pediatric patient, provide rhythm and must be used with caution and according to two minutes of CPR before leaving the child to activate EMS. specific protocols. • To provide proper CPR, you will place the patient in a supine M06_LEBA8467_11_SE_C06.indd 95 • The general steps for the use of a typical AED are as position on a hard surface. If the patient is unresponsive, check follows: for signs of breathing. If he or she is not breathing or showing • Confirm the patient is unresponsive and has no breathing only gasping breaths, begin compressions: or pulse. • For an adult or child, provide compressions at a rate of • Turn on the AED, expose the patient’s chest, and securely 100 to 120 per minute and a depth of two inches but no attach the pads. Wipe dry or shave hair if necessary. more than 2.4 inches. Compressions that are too deep may Follow prompts to defibrillate and check breathdamage organs. “Chris!” Maria screams• and dropsthe to AED’s her knees next to “What do you think, Chris?” Mariainternal Andrews, security maningyou and pulse. Follow AED prompts to check a pulse or • For an infant (up to is one year of age), compressions him, shaking his shoulders. “Are okay?” ager for Western Legends Hotel and Casino, examining a provide start if there is no pulse. at a rate of 100 to 120 per minute and compress the chest There is no response, and hisCPR eyes, partially hidden CCTV video screen closely. “Chris?” She turns to see why
11 REVIEW
Summary
Chapter Objectives
OBJECTIVES
Upon successful completion of this chapter, the student should be able to:
A list of the Cognitive, Psychomotor, and Affective goals for you to master following completion of a chapter. Each Cognitive objective includes the page number where it is covered in the chapter as a quick KEY POINT reference. While childbirth is a beautiful event, it is often messy. Appropriate BSI includes gloves, gown, mask, and eye protection. When the membrane ruptures, amniotic fluid can easily shower you. In addition, it is not uncommon for the woman to unexpectedly urinate and defecate. Be respectful of how embarrassing this all can be for both the mother and those helping her.
9/14/18 5:05 PM
First on Scene and First on Scene Run Review
FIRST ON SCENE
You will experience a new medical emergency at the start of each chapter as you follow the actions of an Emergency Medical Responder who is first on the scene, then follow the EMR and his or her patients throughout the chapter as the case develops. Finally, you’ll have a chance to debrief at (OB) kit. All items are disposable. the end of theobstetric chapter as you respond to Run Review questions, thinking about the steps the EMR took and is not the time to find supplies. The items you what might have gone differently.
behind half-closed lids, stare vacantly at her. the hotel’s lead security agent hasn’t answered her. “Okay,” Maria says to herself. “Okay, calm down. First Chris sits several feet from her, both hands on his chest. thing’s first.” Maria searches her memory for the proceHis face is ghostly pale. “What’s wrong, Chris? Chris?” dures that she learned in last spring’s Emergency Medical Maria stands quickly, sending her chair crashing into a Responder course. She takes a deep breath,and rollslocations Chris onto bookshelf. Chris looks up at her, his bulging eyes reflecting LOCAL RESOURCES following agencies to ask if they have AEDs availhis back, and checks for any breathing. the wall of video monitors next to him. He tries to speak ablesigns in theofevent of a cardiac arrest. Also ask which employees As more and more people become trained, AEDs are becoming several times, and then collapses into a heap on the floor. are trained in their use. more widely available. It is quite common to find AEDs available • Large shopping malls. Often it is the security staff that carfor public access in airports, shopping malls, amusement parks, ries the AED and is trained in its use. and any place that attracts the public in large numbers. In fact, • Large employers. Many large employers have employee volthere are probably several businesses in your own town or city continued Figure 23.4 Contents of a commercial unteers who are trained to respond to medical emergencies. that have an AED and personnel trained in its use. OBJECTIVE She then•drops theagencies. radio onto thejurisdictions floor next to heralland “Sydney, do you copy?” Maria grabs the portable radio after Police Some have police vehicles begins chestequipped compressions. Chris is not at breathing and doesn’t have that a have 3. Explain the componentsconfirming of For this that activity, identify leastchain three public locations withsystem. If AEDs. Chapter 1 describes the of human resources and services in the EMS each countsvenues. out loud, she fairgrounds, focuses on the hallway pulse. the adult “chain of survival. ”AEDs available. You will have to make some calls or talk to peo- As Maria Public Often race tracks, zoos, and link in the chain works quickly and efficiently, the EMS•system can provide effective to see when Sydney coming with the AED. “Yeah, go ahead,” comes a reply withwish a strong ple who work in different locations. You may to contactmonitor the amusement parksishave AEDs available. at the patient’s home, but during delivery prehospital emergency The American Heart adult chain of survival is chain of survival ▶ the five to facialcare. injuries when you findAssociation’s any of Australian accent. will need include the following: critical components (links) that another linked system of patient-care events that specifically addresses patients in cardiac you to get an ambulance here and bring an AED the following signs: affect the likelihood for survival“I need arrest. For a patient to have the best chance of survival following a cardiac arrest, each to the security office right now! Chris is in cardiac arrest!”
Take Action
FIRST ON SCENE
The Chain of Survival
from a cardiac arrest. The • Personal protective equipment such as protective gloves, face masks, eye shields, link in the chain survival mustairway be strong. Theor links are: • of Blood in the (nose mouth) links are early recognition and gowns access to EMS, early CPR, early Deformities or depression of any of emergency response • Immediate• recognition of cardiac arrest and activation defibrillation, early advanced • AED Towels, 2. Was it the correct decision for Sydney to put the on sheets, and blankets for draping the mother, for placement under the Recall thesystem events of the “First scenario in this chapter, part on ofScene” the face (911). life support, and integrated Chris? What are the criteria for someone who gets anmother, AED? and answer the following questions, which are related to the call. and for drying and wrapping the baby post–cardiac arrest care. • Early CPR• with an emphasis on chest compressions. Swelling or discoloration aroundThe sooner chest compressions
First on Scene Run Review
and
Two-Rescuer CPR
Rationales are offeredAll in the Answer Key atshould the backlearn of theand book. EMS personnel remain proficient inbrain bothand oneand two-rescuer are initiated, the sooner circulation can be restored to3.the patient’s vital What information should Maria give the CPR EMTs•when they pads for wiping mucus from the baby’s mouth Gauze trained rescuers is more efficient and less tiring • Rubber bulb syringe for suctioning the baby’s airway arrive? •forSwelling orwhen discoloration any of an the • floor? What should you look for determining ifof your both rescuers (Figure Two-rescuer CPR minimizes Defibrillation is11.9). the application electric shock the to atransition time between Rapid defibrillation. ing normally after birth chest compressions ▶ rapid, patientpatient’s is breathing? part the ventilations and face compressions and therefore maximizes theone. effectiveness of both. For the heart in anofattempt to convert a lethal rhythm into a normal The
the eyesCPR that is performed by two cardiac arrest ▶ the heart stops 1. Did Maria respondtechniques. appropriately following Chris’s collapse to organs. pumping blood.
IS IT SAFE
and nose only if the baby is not breath-
?
deep, regular compressions patient, the compression-ventilation 30:2. When time from•adult cardiac arrest to defibrillation is an essential factorremains in the survival rate ofperforming two- • Clamps and ties for use on the umbilical cord before cutting Poor function of or inability to ratio on the center of the chest in an • Sterile scissors or a single-edged razor for cutting the cord rescuer CPR a child, the compression-ventilation ratio collapse changes and to 15:2. out-of-hospital cardiac-arrest patients. The shorter the time between Each rescuer attempt to circulate blood to theshould use move theonjaw Chapter 11 Principles of Resuscitation 207 Usebetter. of an AED is also more efficient with two rescuers. One rescuer can begin to set • Sanitary pads or bulky dressings for vaginal bleeding or her own barrierdefibrillation, the brain, lungs, andhis heart.
• Teeth that are loose or have been
up the AED attach the padslife to support the patient while the other rescuer begins a primary device with one-way • Effective advanced life and support. Advanced (ALS) is the care provided
defibrillation ▶ the application knocked out/broken dentures valve and HEPA filterby more highly assessment the patient. If you on scene Emergency and find that an AED is being used, ensure trainedofEMS personnel sucharrive as Advanced Medical of an electric shock to a patient’s insert to perform two-Technicians that the individuals are performing the steps properly and taking the necessary safety pre(AEMTs) and Paramedics. In addition to using defibrillators, they heart in an attempt to convert a rescuer CPR safely. provide other cautions. Offer tosuch assistasthem and support actions. access You also need to relieve or interventions, advanced airways,their intravenous for may fluids, lethal rhythm to a normal one.
Key Point
Is it Safe?
• A basin and plastic bags for collecting and transporting the placenta • Red, plastic biohazard bags for storing and disposing of soiled linens and dressings
Signs and Symptoms of guide someone who is unsure of the procedure. and medications. (Brain) Injury IntegratedHead post–cardiac arrest care. A more formal and organized approach to post– KEY POINT
These stop-and-think boxes reinforce the idea that the Appearing throughout the chapters, safety—of the patient, the these boxes highlight important or Emergency Medical Responder, critical conceptsareas,that are important such as airports, shopping malls, stadiums, and other public gathering places. chest compressions. Monitor his or her effectiveness and provide any necessary coaching much, could put If Emergency Medical Responders in your jurisdiction are permitted towhich use AEDs, your best immediate indicators is the to the ensure good-quality compressions. Figure 21.5 Open head injuries are characterized by of by-standers, or others—is of pressure on the brain if instructor or medical provide the appropriate training. from your reading. mental statuswill ofthe the injured individIf adirector member of EMS system is performing CPR when you arrive, begin two-rescuerDelivery a break intake-aways the skin and the underlying skull. the patient sustained CPR.An To help make a smooth from one-rescuer to has two-rescuer CPR, follow ual. individual who istransition alert and The deliveryparamount of a baby is one of the most exciting calls for any EMS provider. Knowing what a significant skull fracture. these steps: importance when oriented following Circulation and CPRa head injury is to expect and being properly prepared will go a long way for making this a successful event. At thewho centerisofunresponsive the circulatory system the When the heart beats, it acts likely to have less damage than an individual or oneis who 1. heart. If,experienced upon arriving on the scene, youas seea apump. rescuer performing Blood from the body flows into the heart and is sent to the lungs. In the lungs, the blood releases r esponding to the scene. CPR, identify yourself. Then, if not already done, activate a brief period of unconsciousness. OBJECTIVE carbon dioxide gathered while circulating through the body and exchanges it for oxygen. This Your primary and secondary assessments will help you determine if the mother is ready 9/10/18 8:29 PM to deliver. If birth appears likely before a transport unit can get her to the hospital, place • Changing OneTwo-Rescuer CPR many situations, a bystander may startsupplies so they are within your reach during the delivery process. Don your personal cardiac arrest care occurs when thetopatient is delivered to aIn definitive care hospital Injuries tofrom the head can range from When controlling the CPRneurological, before Emergency Medical Responders arrive. arrival, assess theprotective equipment. Then prepare the mother for delivery. It may be helpful to ask the with expertone-rescuer cardiovascular, and intensive care capabilities. TheseUpon include minor tothethe and bleeding ofCPR a scalp cardiac catheterization facilities performance of therapeutic hypothermia. patient’slacerations pulse beforeand taking overscalp and performing two-rescuer withwound your partner. mother if she has been receiving prenatal care. This is the regular care and monitoring of faceIftoyousevere skull fractures and sig- Responder with direct pressure, arrive as a sole Emergency Medical and determine that a bystander’s Each link in the chain of survival isthe essential toorimproving survival. In recent years, CPR techniques are incorrect, take over one-rescuer CPR. If the bystanderthe fetus by a healthcare provider throughout the pregnancy. A woman who has been be careful to apply only nificant injury toinadequate brain. While itpatient defibrillator technology has improved to the pointdevice that anand automated external defibrillator receiving regular prenatal care will be more informed if there are any expected complicais CPR trained but has no barrier is reluctant to ventilate a stranger, perform pressure to stop is difficult knowtraining. the true extent of can beenough (AED) can be operated withto minimal Today, found in many the ventilations yourself with your ownAEDs pocket face Have thepublic bystander themask. bleeding but not too take overtions with the delivery. damage when the brain is injured, one
M11_LEBA8467_11_SE_C11.indd 207
advanced life support (ALS) ▶ prehospital emergency care that involves the use of intravenous fluids, drug infusions, cardiac monitoring, defibrillation, intubation, and other advanced procedures.
automated external defibrillator (AED) ▶ an electrical device that, when applied to the chest, can detect certain abnormal heart rhythms and deliver a (© Edward T. Dickinson, shock MD) to the patient’s heart. This shock may allow the heart to resume a normal pattern of beating.
The following is a list of common signs and symptoms of a head injury:the EMS system. • • • • • • • • • •
IS IT SAFE
?
The delivery of an infant in the field setting presents a significant risk of exposure to blood and other potentially infectious materials to the Emergency Medical Responder. This is one of the rare occasions when you would take full BSI precautions, including gloves, face mask, and gown.
OBJECTIVE
oxygen-rich blood is then returned to the 2. heart, where it is rescuer pumped outthe to two the body. 7. Describe signs and get in posiWhile the first isback delivering breaths, Due to the nature of childbirth, it is important for you to wear appropriate face and eye 6. Explain the steps for preparsymptoms tion next to the patient’s chest. of a head injury. ing for a field delivery. 3. After the two breaths, resume chest compressions. The firstprotection and a gown, in addition to protective gloves, to minimize your exposure to rescuer should then resume ventilations, providing two ven-the mother’s body fluids during delivery. Make sure that an EMS transport unit has been tilations after every 30 of your compressions. activated. Let the mother know that you have called for additional assistance and that 4. Provide compressions at the rate of 100 to 120 per minute with a pause after every 30 compressions to allow for two ventilations. Chapter 23 Care During Pregnancy and Childbirth 465 5. After two minutes or approximately five cycles 9/10/18 of 8:29 PM 30 compressions and two ventilations, both you and the other rescuer change positions.
Significant mechanism of injury Bleeding186 of thewww.bradybooks.com scalp Deformity of the cranium Altered mental status Nausea and vomiting Convulsions M11_LEBA8467_11_SE_C11.indd Abnormal vital signs 186 Abnormal breathing patterns Combative behavior Repetitive questionsFigure 11.9 During two-rescuer CPR, compressions
Preparing for Delivery
prenatal care ▶ the routine medical care provided to a mother during her pregnancy.
should be paused to allow for the delivery of ventilations.
If the Emergency Medical Responder is equipped with an AED and arrives on the scene to see CPR being performed, he
xxxi
Always position yourself appropriately to manage the patient’s airway and monitor his or her mental status. Place the patient in the recovery position at the first sign of a decreased level of responsiveness.
OBJECTIVE
Get Complete eBook Download by email at [email protected] Fowler’s and Semi-Fowler’s Positions
Many patients may be placed in either a position of comfort or specific positions that allow for more effective care of particular conditions. These may include patients with medical complaints such as chest pain, nausea, or difficulty breathing. For example, someone with difficulty breathing can be aided by placing them in either a Fowler’s position (full sitting) or a semi-Fowler’s position (semi-sitting). This will make it easier for them to breathe. A trauma patient with no significant signs of spinal injury may be allowed to remain in a semi-Fowler’s position and transported on the stretcher with a cervical collar in place as a precaution.
Key Terms in the Margins
9. Describe the following patient positions, and state when each should be used: Fowler’s, semi-Fowler’s, and shock.
Geriatric Focus 11 REVIEW
Fowler’s position ▶ a position in which a patient is placed fully upright in a seated position, creating a 90-degree angle.
Definitions of new, unfamiliar, or important vocabulary 2. A second rescuer should kneel at the patient’sterms side oppositeappear the direction the head is Shock Position IS IT SAFE? facing. Quickly arms to ensure there arefor no the obvious Raise The assess the patient’s is an option that may be helpful patientinjuries. you think could be in in and the margins of the pages where extend the patient’s arm that is opposite theexhibiting head is facing. shock. This position should be used the onlydirection for patients signs ofPosition shock but who The most important indithat arm straight upevidence above the head. This rolling and provides support have no of injury. Thisallows positionfor is easy achieved by placing the patient in a supine vidual involved in perfor theappear headposition during and thein roll. This especially if the youshock mustposition, do the log alone.legs are forming a log roll is the raising theislegs 6 to 12 helpful inches. In theroll patient’s they bold. bent at the hips and the torso remains flat. Raising the legs helps promote venous blood individual at the head. He
Appearing throughout theofchapters, these boxesDeliver relate • provide ventilations at a ratio two breaths for every 30 compressions. each breath over one second. care concepts to the specific needs of older adult Summary • avoid interrupting compressions for longer than 10 seconds once you have begun CPR. Interrupt compressions only for ventilations or for moving the patients. one-third the depth of the infant’s chest or about one and • Like the chain of EMS resources, the chain of survival is also patient.
semi-Fowler’s position ▶ semiseated position in which the patient reclines at a 45-degree angle. shock position ▶ elevation of the feet of a supine patient 6 to 12 inches—recommended for shock that is not caused by injury.
shock position
6
3. A third rescuer should kneel at the patient’s hips. returngrasp to thethe heart. or she must think ahead 4. Rescuers should patient’s shoulders, hips, knees, and ankles. If only one Theretomay times when he a patient in shockgrasp and one more parts of these are and position his or her rescuer is available rollbethe patient, or sheisshould theorheavy ofpositions the not recommended, such as a patient with a significant head or chest injury. Always follow hands in anticipation of torso—the shoulders and hips. local protocols when positioning patients. the movement of the 5. The rescuer at the patient’s head should signal and give directions: “On three, slowly patient from face down roll. One, two, three.” All rescuers should slowly roll the patient toward the rescuers to face up. Positioning Chapter 6 Principles of Lifting, Moving, and Positioning of Patients 109 in a coordinated move, keeping the spine in a neutral, in-line position. It is important the hands incorrectly to note that the rescuer holding the head should not initially try to turn the head will result in an awkward with the body. Because the head is already facing sideways, allow the body to come hand and body position into alignment with the head. Once the body and head are aligned, approximately of the rescuer and may halfway through the roll, the rescuer at the head will then move it with the body, result in excessive moveM06_LEBA8467_11_SE_C06.indd 109 9/14/18 ment of the patient’s keeping the head and body aligned until the patient is in the supine position.
•
•
Scans
These are the key skills the Emergency Sometimes the patient is already supine but must be placed on a blanket or spine board. If this is the case, perform steps 1–5 above. Without removing their hands, the Medical Responder performs when rescuers continue with the following: 1. The rescuer at the head should the patient’s assisting apatient’s patient atcontinue the stabilization sceneofof an head and neck until other rescuers position a blanket or long spine board (backboard) behind the patient. emergency.
• 5:05 PM
•
neck.
First on Scene Run Review requiring crews to carry and use a metronome to ensure an accurate rate. You may also
hum specific songs in your head that maintain an approximate 100 beat per minute rate. As previously, these questions give you a One such song is “Stayin’ Alive” by the Bee Gees. Takedescribed Action chance to think through the events actions that LOCAL RESOURCES following agenciesand and locations to ask if they have AEDs availEffective CPR able in the event of a cardiac arrest. Also ask which employees As more and more people become trained, AEDs are becoming trained in their use. You becommon performing correctly occurred in the chapter caseif:arestudy and evaluate what more widely available. Itwill is quite to find CPR AEDs available • Large shopping malls. Often it is the security staff that carfor public access in airports, shopping malls, amusement parks, riesover the AED is trained in use.sternum. • your in the center of thewhat chest theand lower half work, ofitsthe and any place that attracts thehands public are inwent large numbers. In fact, happened, what well, needed and • two Largeinches employers. Many large employers have there are probably several in your ownthe town or city • youbusinesses are compressing chest at least hard and fast at a rate ofemployee volunteers who are trained to respond to medical emergencies. that have an AED and personnel trained in its use. 100 to 120 per minute. how you•might have responded if you were • Policedifferently agencies. Some jurisdictions have all police vehicles you arethree releasing all pressure off the chest between compressions. For this activity, identify at least public locations that have equipped with AEDs. AEDs available. You•will have to make some calls talkfall to peoPublic venues. fairgrounds, race tracks, zoos, and you see theMedical chest riseorand during•ventilations. the Emergency Responder inOftenthat situation. ple who work in different locations. You may wish to contact the amusement parks have AEDs available.
SCAN 6.10 6.10.2 Kneel at the patient’s side opposite the
board. Reach across the patient and position your hands. Inspect the patient’s back.
you place the board parallel to the patient. Maintain manual stabilization throughout the roll.
6.10.3 On command from the rescuer at the head, roll the patient toward you. Then move the spine board into place.
LOG ROLL OF A PATIENT
6.10.1 Manually stabilize the patient’s head and neck as
one-half inches. a linked system of patient-care events. These events include • After 30 compressions, provide two rescue breaths over immediate recognition and activation of EMS, early CPR, one second each and begin compressions again. Do not rapid defibrillation, effective advanced life support (ALS), and stop CPR for more than 10 seconds other than to move integrated post–cardiac arrest care. GERIATRIC FOCUS the patient because of danger at the scene. Continue The survival of the brain is dependent on the activities of until the patient regains a pulse and/or much breathing breathing and circulation. the of heart stops beating, a Due to When the loss calcium in the bones of CPR the older adult, their ribs can become or until you are relieved by an equally or more highly patient is in cardiac arrest and cannot circulate oxygenated less flexible and therefore allow far less chest wall movement during breathing. As you trained individual, care for the patient is accepted by a blood to the brain. The major signs of cardiac arrest are unrecheck for in older adults, you can might not see as much or until you no longer continue because sponsiveness, no breathing, andbreathing no pulse. or provide ventilations physician, chest rise and fall as in a younger when you assess breathing or provide exhaustion. If a patient is unresponsive, check for signs of breathing. If the patient.ofSo, Automated external You defibrillators are fall lifesaving patient is not breathing or has only gasping the breaths, call 911for •signs ventilations, observe abdomen of movement. may see(AEDs) a rise and of units used by Emergency Medical Responders and available and check for a pulse. If the patient has no pulse, begin chest the abdomen much like you would of the chest. Of course, a lack of movement is never in many public areas. AEDs are electrical devices that can compressions immediately. good, and you must consider the possibility of a total airway obstruction and provide care convert certain lethal heart rhythms to a normal cardiac If you are alone and caring for a pediatric patient, provide rhythm and must be used with caution and according to two minutes of CPR before leaving the child to activate EMS. accordingly. specific protocols. To provide proper CPR, you will place the patient in a supine • The general steps for the use of a typical AED are as position on a hard surface. If the patient is unresponsive, check follows: for signs of breathing. If he or she is not breathing or showing • Confirm the patient is unresponsive and has no breathing only gasping breaths, begin compressions: The rate forcompressions chest compressions the speed rather than the number of comor pulse. • For an adult or child, provide at a rate of refers to thearescuer Because rescuers must interrupt com• Turn on the AED, expose the patient’s chest,chest and securely 100 to 120 pressions per minute and depth of delivers two inchesin butone no minute. attach the pads. Wipe dry or shave will hair if be necessary. more than 2.4 inches. Compressions thatbreaths, are too deepthe mayactual number pressions to deliver of compressions less than • Follow the AED’s prompts to defibrillate and check breathdamage internal organs. 100 per minute. To be sure you provide compressions at the proper rate of 100 to ing and pulse. Follow AED prompts to check a pulse or • For an infant (up to one year of age), provide compressions 120 per minute, out loud as you deliver compressions. Many EMS systems are start CPR if there is no pulse. at a rate of 100 to 120 per minute count and compress the chest
If you are performing CPR correctly, you may notice the patient’s skin color improve,
but this doesReview not always occur. Sometimes the patient may try to swallow, gasp, or move First on Scene Run
his or her limbs. Those actions do not necessarily mean that he or she is recovering. How2. Was the correct for Sydney put and the AED on Recall the events of the “First Scene” scenario this chapter, ever, suchonmovements arein signs of life and doitmean that decision you should stop to CPR check Chris? What are the criteria for someone who gets an AED? and answer the following which are relatedand to the call. for thequestions, return of breathing pulse. Rationales are offered in the Answer Key at the back of the book. Whatbreathing, information stop shouldcompressions Maria give the EMTs when they If the patient regains a pulse but is3. not and continue 1. Did Maria respond following collapse to withappropriately ventilations only.Chris’s Rescue breaths forarrive? an adult should be delivered at a rate of one the floor? What should you look for when determining if your breath every five to six seconds or about 10 to 12 breaths per minute. If there is no pulse, patient is breathing? continue CPR. Patients will usually require defibrillation and possibly other special medical procedures before they regain heart function. CPR only delays the onset of biological death Chapter 11 Principles of Resuscitation 207 until special medical procedures can be provided.
Adult and Child CPR Quick Quiz The following is a step-by-step procedure for performing one- and two-rescuer CPR. The
the command of the rescuer at the head. Center the patient on the board.
M11_LEBA8467_11_SE_C11.indd 207
Principles of Lifting, Moving, and Positioning of Patients
A bullet list of the key points from the chapter. REVIEW
9/10/18 procedures follow the American Heart Association (AHA) recommendations. The exten-
9/14/18 5:05 PM
16
1. You are caring for a patient who you suspect has a spinal M11_LEBA8467_11_SE_C11.indd 193 injury. Which of the following should you do FIRST? a. b. c. d.
sweating, abnormal pulse and/or breathing, unresponsiveness, pain when breathing or swallowing, dilated or constricted pupils, and weakness or dizziness. • Patients experiencing carbon monoxide poisoning may present with headaches, dizziness, confusion, seizures, and even coma. If a patient presents with these signs and symptoms and he or she has been near any sort of combustion (fire, automobile, heater, etc.), you should suspect carbon monoxide poisoning. • Caring for the poisoning or overdose patient is primarily about protecting the patient’s airway, administering oxygen (if allowed), activating the EMS system, and monitoring the ABCs. • A local, regional, or national poison control center should be contacted (per local protocols) once you have established that the patient has been exposed to poison and you have determined the type of poison encountered. • A patient who already has either a serious infection or a suppressed immune system can develop a generalized infection called sepsis. Sepsis is an infection that spreads through the patient’s bloodstream to become a systemwide problem. Fever, chills, confusion, unresponsiveness, rapid breathing, rapid heart rate, and low blood pressure are all common signs and symptoms of sepsis. • Septic patients must be treated at a hospital as soon as possible. The Emergency Medical Responder should ensure activation of the EMS system, provide oxygen (if allowed), and monitor the patient’s ABCs closely while awaiting advanced care. • Anaphylaxis is a life-threatening allergic reaction characterized by altered mental status, difficulty breathing, and swelling of the throat. Support the ABCs and assist with the prescribed autoinjector (per local protocols), if available. • Renal failure occurs when the kidneys no longer function normally. Dialysis is the process of artificially filtering the blood and removing excess water and waste products. • Any time a patient is behaving in a manner that is dangerous to him- or herself, their family, or the community, he or she is said to be having a behavioral emergency. Emergency Medical Responders should first and foremost ensure their own safety and the safety of others near the patient. Following that, they should clearly and calmly identify themselves to the patient, ensure that the EMS system is activated, and engage the patient with clear, effective communication until assistance arrives.
Assessing a medical patient, especially one with an altered mental status, can be very challenging—especially if the patient is unable to provide any clues to what may be going on. Getting some practice with asking questions when you do not know what is wrong will be very helpful when you encounter your first real live patient. Pair up with another student in your class. One of you will serve as the patient and use this chapter as a reference while
322
xxxii
Assess for circulation, sensation, and movement. Apply a rigid cervical collar. Transport the patient to the nearest trauma center. Manually stabilize the patient’s head and neck.
2. Which one of the following mechanisms of injury would cause you to suspect a spinal injury? a. b. c. d.
Circular-saw amputation of fingers Fall from an anchored speedboat Bicycle crash Self-inflicted gunshot wound to the hip
3. Your patient is unresponsive, lying prone on the floor after falling off a high ladder. Appropriate care for this patient includes: a. completing your assessment with the patient in the prone position. b. using the log-roll maneuver to roll the patient into the supine position. c. placing the patient in the recovery position to protect the airway. d. immobilizing the patient in the prone position. 4. Your patient is unresponsive following a motorcycle crash. Several attempts to open his or her airway with the jaw-thrust maneuver are not successful. You should: a. b. c. d.
maintain manual stabilization and wait for EMS to arrive. attempt the head-tilt/chin-lift maneuver. attempt to ventilate the patient anyway. begin chest compressions.
5. Combative behavior, abnormal breathing patterns, and repetitive questions are all signs of a(n): a. b. c. d.
cervical-spine injury. unresponsive individual. peripheral nervous system trauma. head injury.
Principles of Resuscitation
6. You witness a low-speed ATV collision that knocks both riders from their vehicles. Neither of the men is wearing a helmet, but both quickly get back to their feet. You notice one of them is walking oddly as he retrieves his vehicle. You ask if he is okay, and he tells you his legs “are tingling.” You should suspect: a. b. c. d.
7. The central nervous system is comprised of the: a. b. c. d.
peripheral and central nerves. discs and vertebrae. brain and spinal cord. spine and nerves.
8. You are caring for a motorcycle rider who was ejected from his vehicle. Your physical exam reveals no crepitus or instability, however the patient complains of a headache. He asks repeatedly “what happened?” You suspect: a. b. c. d.
an open head injury. spinal trauma. a closed head injury. an ischemic stroke.
9. Your main priority when caring for a patient with a suspected head injury is to: a. b. c. d.
completely immobilize the head and neck. obtain a detailed medical history. monitor vital signs. assess and manage airway, breathing, and circulation.
10. You are caring for a patient with a suspected open skull injury. When attempting to control the bleeding, you should: a. b. c. d.
1. Joshua B. Brown, Paul E. Bankey, Ayodele T. Sangosanya, et al. “Prehospital Spinal Immobilization Does Not Appear to be Beneficial and May Complicate Care Following Gunshot Injury to the Torso.” The Journal of TRAUMA, Vol. 67, No. 4 (October 4, 2009): pp. 774–778. 2. Nicholas Theodore, Mark Hadley, Bizhan Aarabi, et al. “Prehospital Cervical Spinal Immobilization After Trauma,” Neurosurgery.Vol. 72, Suppl. 3 (March 1, 2013): pp. 22–34. 3. Mark Dixon, Joseph O’Halloran, and Niamh M. Cummins, “Biomechanical Analysis of Spinal Immobilisation During Prehospital Extrication: A Proof of Concept Study,”
the other one asks the questions. Use this chapter to select a specific medical problem such as stroke or hyperglycemia. As the individual playing the role of the patient, take a few minutes to refer to the specific signs and symptoms of the complaint. When you are ready, instruct the individual acting as the Emergency Medical Responder to begin asking questions. The goal is to identify the specific medical condition in as few questions as possible.
apply firm fingertip pressure on the open wound. use only enough pressure to slow or stop the bleeding. tightly wrap a pressure bandage around the skull. keep the patient in a head-down position while holding pressure.
Prehospital Emergency Care, Vol. 17, No. 1 (June 28, 2013): p. 106. 4. James F. Morrissey, Elsie R. Kusel & Karl A. Sporer (2014) “Spinal Motion Restriction: An Educational and Implementation Program to Redefine Prehospital Spinal Assessment and Care,” Prehospital Emergency Care, Vol. 18, No. 3 (2014): pp. 429–432, DOI: 10.3109/10903127.2013.869643. 5. Bryan P. Conrad, Gianluca Del Rossi, Mary Beth Horodyski, Mark L. Prasarn, Yara Alemi, and Glenn R. Rechtine, “Eliminating Log Rolling as a Spine Trauma Order,” Surgical Neurology International, 3, Suppl. S3 (2012): pp. 188–197.
Hands-on activities that give you an opportunity to practice some of the skills and concepts you learned in a chapter.
www.bradybooks.com
444
www.bradybooks.com
www.bradybooks.com
M16_LEBA8467_11_SE_C16.indd 322
9/10/18 8:34 PM
M21_LEBA8467_11_SE_C21.indd 444
19
9/1
head injury. internal bleeding. spinal injury. hip dislocation.
Endnotes
Take Action
Take Action 20 QUESTIONS
Chapter 11
Quick Quiz To check your understanding of the chapter, answer the following questions. Then compare your answers to those in the Answer Key at the back of the book.
Summary • Medical emergencies are those conditions that threaten an individual’s life and are caused by some type of illness. One of the most common signs of a medical emergency is an altered mental status. • Several conditions can cause a patient to experience an altered mental status, including seizures, strokes, diabetic emergencies, poisonings, breathing problems, and cardiac events. • Altered mental status can present with a wide range of signs and symptoms, from confusion and dizziness to seizures and even syncope (fainting). • The assessment and care of a patient with an altered mental status is dependent on the Emergency Medical Responder observing the patient’s environment and asking questions. • A sudden loss of consciousness and convulsions characterize a generalized seizure. It is most important to protect the patient from harm while waiting for the seizure to subside. • Following a generalized seizure, the patient will be unresponsive. This is referred to as the postictal stage. Monitor the patient’s airway and breathing status closely until he or she regains consciousness. • A stroke occurs when there is a disruption in blood flow to the brain by either a clot or a ruptured artery. • Common signs and symptoms of a stroke include headache, altered mental status, confusion, difficulty speaking or swallowing, and weakness (paresis) on one side of the body. • Stroke patients should be closely monitored since they may experience airway compromise, breathing difficulty, or even cardiac arrest. • Diabetes occurs when a patient’s pancreas no longer produces adequate amounts of the hormone insulin or when the body cannot properly process insulin. • Diabetic emergencies can present with altered mental status, abnormal breathing, abdominal pain, seizures, extreme thirst, fruity breath odor, and even unresponsiveness. • When the Emergency Medical Responder cannot determine if the diabetic emergency is caused by hypo- or hyperglycemia, the care for both should be the same. Administer oral glucose (if appropriate), provide oxygen, and activate the EMS system. Monitor the patient’s ABCs and place him or her in the recovery position if they are unresponsive. • Common signs and symptoms of a patient who has been poisoned are altered mental status, vomiting, abdominal pain,
8:29 PM
sive research done by the AHA has found them check to be most your efficient in saving the lives of These multiple choice questions patients in cardiac arrest. Also, remember that the following steps are a part of the primary assessment. (See 11.1 for a summary ofcontent. CPR techniques.) understanding ofTable the chapter’s
111
Summary M06_LEBA8467_11_SE_C06.indd 111
7. Explain the importance of minimizing interruptions during CPR.
• you interrupt compressions as little as possible.
6.10.4 Lower the patient onto the spine board at
Chapter 6
OBJECTIVE
9/14/18 5:11 PM
Get Complete eBook Download by email at [email protected]
MYLAB BRADY WITH PEARSON ETEXT What Is MyLab BRADY with Pearson eText ? MyLab BRADY is a comprehensive online program that gives you—the student—the opportunity to test your understanding of information and concepts to see how well you know the material. The added benefit of the embedded Pearson eText for Emergency Medical Responder: First on Scene, 11th edition, gives you access to your textbook anytime, anywhere, on the device of your choice—even offline! With MyLab BRADY for Emergency Medical Responder, you can track your own progress through your entire emergency medical responder course.
How Do Students Benefit? Here’s how MyLab BRADY for Emergency Medical Responder helps you: • Keep up and get unstuck by providing immediate feedback on homework. • Apply your knowledge with case studies of situations you may encounter in the field. • Review videos of key skills so you can be ready anywhere, anytime. • Use the mobile eText to help you learn on your terms, wherever you are.
Key Features of MyLab BRADY for Emergency Medical Responder, 4th Edition • Chapter Audio Review from expert author, Chris Le Baudour, points you in the direction of the chapter’s key concepts. • Homework covers all chapter objectives and consists of multiple-choice questions with study aids to assist when you are uncertain. • Animations help you visualize difficult concepts for greater understanding. • Case Studies with questions help with application of knowledge and retention for situations you may encounter in the field. • Skills Videos of more than 50 critical skills allow you to watch and review at a moment’s notice. • MultiMedia Library gathers all of media items in one searchable location so you don’t ever have to struggle finding what you need.
How Do Instructors Benefit? • Keep students with different learning styles engaged through a variety of interactive components. • Track student progress and understanding of course content through Homework and Case Studies. • Save time through auto-grading. • Enliven classroom presentations by working through a case study or displaying an animation or skill video. • Deliver tests/exams online with auto-grading so you can eliminate the time to tabulate results. • MyLab BRADY can be fully integrated into the majority of commercially available Learning Management Systems, so the experience can be completely seamless. Ask for details.
xxxiii
Get Complete eBook Download by email at [email protected] Pearson eText The Pearson eText provides a fully-integrated electronic experience so users can read, study, and take notes anytime, anywhere on the device of their choice—even offline.
How Do Students Benefit? Standard Pearson eText features include the ability to highlight, take notes, bookmark pages, and search. In addition, the eText for Emergency Medical Responder, 11th edition includes interactivity and multimedia that enhances the learning experience: • Audio Intros and Insights • Video Lecture Captures • Animations • Skills Videos • End-of-chapter self-study review questions • Application review questions included as part of the “First on Scene” scenarios
How Do Instructors Benefit? Instructors can push notes and highlights directly to students so they can provide embellishment or focus on key concepts within the text.
xxxiv www.bradybooks.com
Get Complete eBook Download by email at [email protected]
1 Introduction to EMS Systems
Education Standards: • Preparatory—EMS Systems, Research, Public Health Competencies: • Uses simple knowledge of the EMS system, safety/well-being of the Emergency Medical Responder, and medical/legal issues at the scene of an emergency while awaiting a higher level of care.
• Demonstrates an awareness of local public health resources and the role EMS personnel play in public health emergencies.
Chapter Overview:
You have made a great choice in deciding to become a member of the EMS team and become trained as an Emergency Medical Responder. An estimated 240 million calls are made to 911 in the United States each year,1 and many of those calls are responded to by individuals such as yourself who are trained to the Emergency Medical Responder level. Thousands of people become ill or are injured every day, and many of them are far from a hospital at the time of their emergency. Emergency medical services (EMS) systems have been developed for this very reason. Their purpose is to get trained medical personnel to the patient as quickly as possible and to provide emergency care at the scene of the emergency. Emergency Medical Responders are an essential part of a community and the EMS team. Realizing that people will depend on you to provide assistance during an emergency can be overwhelming. To gain confidence in your knowledge and skills, it is very important that you learn and understand what is expected of you in this new role. When you do, you can act more quickly to provide efficient and effective emergency care.
Upon successful completion of this chapter, the student should be able to: COGNITIVE 1. Define the following terms: a. Advanced Emergency Medical Technician (AEMT) (p. 7) b. continuous quality improvement (CQI) (p. 14) c. Disaster Medical Assistance Team (DMAT) (p. 14) d. emergency care (p. 2) e. Emergency Medical Dispatcher (EMD) (p. 7) f. Emergency Medical Responder (EMR) (p. 6) g. emergency medical services (EMS) system (p. 4) h. Emergency Medical Technician (EMT) (p. 7) i. evidence-based practice (p. 4)
j. medical director (p. 4) k. medical oversight (p. 4) l. National EMS Education Standards (p. 6) m. off-line medical direction (p. 8) n. on-line medical direction (p. 8) o. Paramedic (p. 7) p. protocols (p. 8) q. public health system (p. 14) r. public safety answering point (PSAP) (p. 7) s. research (p. 15) t. scope of practice (p. 7) u. Scope of Practice Model (p. 6) v. specialty hospital (p. 8) w. standing order (p. 8)
2. Explain the role of the National Highway Traffic Safety Administration (NHTSA) and its relationship to EMS. (p. 4)
OBJECTIVES
This chapter will introduce you to the EMS system, its components, and how they work together to deliver care to the ill and injured. We will also discuss the roles and responsibilities you will be expected to embrace as an Emergency Medical Responder.
Get Complete eBook Download by email at [email protected] 3. Differentiate the various attributes of an EMS system and describe the function of each. (p. 4) 4. Explain the roles that the National EMS Education Standards and the National Scope of Practice Model play in shaping the EMS system around the United States. (p. 6) 5. Differentiate the four nationally recognized levels of EMS provider. (p. 6) 6. Differentiate the roles and responsibilities of the Emergency Medical Responder from those of other EMS providers. (p. 6) 7. Differentiate the various EMS models in practice around the United States. (p. 6) 8. Explain the roles that state and local EMS offices, medical oversight, and local credentialing play in an EMS system. (p. 6) 9. Explain the various methods used to access the EMS system. (p. 7) 10. Explain how state and local statutes and regulations affect how an Emergency Medical Responder might function. (p. 7) 11. Explain the various types of medical direction and how the Emergency Medical Responder might interact with each. (p. 8) 12. Describe the characteristics of professionalism as they relate to the Emergency Medical Responder. (p. 13) 13. Explain the role of the Emergency Medical Responder with regard to continuous quality improvement (CQI). (p. 14)
14. Explain the role of public health systems and their relationship to EMS, disease surveillance, and injury prevention. (p. 14) 15. Explain the role that Disaster Medical Assistance Teams (DMAT) play and how they integrate with EMS systems. (p. 14) 16. Explain the role that research plays in the EMS system and the ways that an Emergency Medical Responder might seek out and support research. (p. 15) PSYCHOMOTOR 17. Participate in simple research activities facilitated by the instructor. AFFECTIVE 18. Value the importance of accepting and upholding the responsibilities of an Emergency Medical Responder. 19. Support the rationale for always maintaining a high degree of professionalism when performing the duties of an Emergency Medical Responder. 20. Value the importance of providing the best possible care for all patients regardless of culture, gender, age, or socioeconomic status. 21. Model a desire for continuous quality improvement (CQI) both personally and professionally. 22. Value the importance of quality research and its connection to good patient care.
FIRST ON SCENE It’s a bright, sunny spring day and you have just left what you feel was one of your best interviews yet. All that time invested in becoming an Eagle Scout is starting to pay off. If all goes well, you will soon be working as a senior camp counselor for the largest summer camp in the state. Things are looking up, and there is a noticeable bounce in your step as you descend the stairs to the visitor parking lot. Just as you reach the sidewalk, you hear a yell for help from across the lot. You hesitate for a moment and look around to see if anyone else hears what you hear. Again, you hear a female voice yelling for help, but you cannot see anyone. You decide to investigate and go toward the direction of the call.
The EMS System emergency care ▶ the prehospital assessment and basic care for the ill or injured patient.
2
www.bradybooks.com
Two rows over, you see a middle-aged woman leaning over a young boy on the ground. He appears to be shaking and a white, foamy substance is coming from his mouth. The woman sees you and yells in a panicked voice for you to go call an ambulance. “Yes, okay," you respond as you reach for your cell phone but realize you left it in the car before going into the interview. “I’ll go back to the lobby and call for help. I’ll be right back!” You make it back to the lobby in record time and, in short bursts of words, advise the receptionist that someone is down in the parking lot and to call 911. She makes the call and alerts the building’s Medical Emergency Response Team as well. With some hesitation, you return to the scene in the parking lot.
It is likely that people have been providing emergency care for one another since humans first walked the Earth. Many of those early treatments would seem primitive by today’s standards, but the awareness that some kind of care is often needed at the scene of the emergency has not changed. A formal system for responding to emergencies has existed for only a relatively short time (Table 1.1). During the American Civil War, the Union Army began
Get Complete eBook Download by email at [email protected] TABLE 1.1 | EMS Time Line 1790s
Napoleon’s chief physician, Dominique Jean Larrey, develops a system designed to triage and transport injured soldiers from the battlefield to established aid stations.
1805–1815
Dominique Jean Larrey formed the Ambulance Volante (flying ambulance). It consisted of a covered horsedrawn cart designed to bring medical care closer to the injured on the battlefields of Europe.
1861–1865
Clara Barton coordinates the care of sick and injured soldiers during the American Civil War.
1869
New York City Health Department Ambulance Service begins operation out of what was then known as the Free Hospital of New York, now Bellevue Hospital.
1915
First recorded air medical transport occurs during the retreat of the Serbian army from Albania.
1928
The concept of “on-scene care” is first initiated, when Julian Stanley Wise started the Roanoke Life Saving and First Aid Crew in Roanoke, Virginia.
1950–1973
The first use of helicopters to evacuate injured soldiers and deliver them to waiting field hospitals occurs in the Korean and Vietnam wars.
1966
The report entitled “Accidental Death and Disability: The Neglected Disease of Modern Society,” commonly referred to as the “White Paper,” is published. The study concludes that many of the deaths occurring every day were unnecessary and could be prevented through better prehospital treatments. The report resulted in Congress’s passing the National Highway Safety Act.
1968
On February 16, 1968, Senator Rankin Fite completed the first 9-1-1 call made in the United States in Haleyville, Alabama. The serving telephone company was then Alabama Telephone Company. This Haleyville 9-1-1 system is still in operation today. On February 22, 1968, Nome, Alaska implemented 9-1-1 service.
1973
Congress passes the Emergency Medical Services Act, which provides funding for a series of projects related to trauma care.
1988
The National Highway Traffic and Safety Administration (NHTSA) defines elements necessary for all EMS systems.
1990
The Trauma Care Systems Planning and Development Act of 1990 encourages development of improved trauma systems.
1995
An update to the EMT Basic and First Responder National Standard curricula is released.
1996
The EMS Agenda for the Future outlines the most important directions for the future of EMS development.
1998
An update to the EMT Paramedic National Standard Curriculum is released.
1999
An update to the EMT Intermediate National Standard Curriculum is released.
2000
NHTSA publishes “EMS Education Agenda for the Future: A Systems Approach.”
2005
NHTSA publishes the National EMS Core Content.
2007
NHTSA publishes the National EMS Scope of Practice Model, redefining the four levels of EMS certification and licensure.
2009
NHTSA publishes the new EMS Education Standards.
training soldiers to provide first aid to the wounded on the battlefield. These corpsmen, as they were known, were trained to provide care for the most immediate of life threats, such as bleeding. After their initial care, the injured were transported by horse-drawn carriage to awaiting physicians (Figure 1.1). Thus, the first formal ambulance system in the United States had begun. The first civilian ambulance services began in the late 1800s with the sole purpose of transporting injured and ill patients to the hospital for care. It was not until 1928 that the concept of civilian on-scene care was first implemented, with the organization of the Roanoke Life Saving and First Aid Crew in Roanoke, Virginia.
Chapter 1 Introduction to EMS Systems 3
Get Complete eBook Download by email at [email protected]
Figure 1.1 Examples of early ambulances used to transport ill and injured patients. (© Associated Press) OBJECTIVES 2. Explain the role of the National Highway Traffic Safety Administration (NHTSA) and its relationship to EMS. 3. Differentiate the various attributes of an EMS system and describe the function of each. emergency medical services (EMS) system ▶ the chain of human resources and services linked together to provide continuous emergency care at the scene and during transport to a medical facility. evidence-based practice ▶ integrating clinical expertise with the best available clinical evidence from systematic research.
medical director ▶ a physician who assumes the ultimate responsibility for medical oversight of the patient care aspects of the EMS system. medical oversight ▶ the supervision related to patient care provided for an EMS system or one of its components by a licensed physician.
4
www.bradybooks.com
In 1966, the National Academy of Sciences released a report called “Accidental Death and Disability: The Neglected Disease of Modern Society.” That report revealed for the first time the inadequacies of prehospital care. It also provided suggestions for the development of formal EMS systems. Fortunately, it has become possible to extend lifesaving care through a chain of resources known as the emergency medical services (EMS) system (Scan 1.1). Once the EMS system is activated, care begins at the emergency scene and continues during transport to a medical facility. At the hospital, a formal transfer of care to the emergency department staff ensures a smooth continuation of care. (Note that the emergency department may still be referred to as the emergency room or ER in some areas.) The National Highway Traffic Safety Administration (NHTSA) has identified 14 key attributes of an integrated EMS system and assists states in developing and assessing those components.2 They are:
• Integration of health services. Historically, EMS has always focused on only the care provided in the prehospital setting. By integrating with other health system components, EMS can improve health care for the entire community. The future of EMS includes EMTs and Paramedics working closely with public health departments and health care networks to identify non-emergent health needs in the community and to assist in providing for those needs. • EMS research. EMS has evolved relatively fast over the past 50 years despite the slow progress of EMS-related research. Only in recent years has the importance of EMS-related research gained the attention of the federal government. The National Institutes of Health are more committed than ever to funding EMS research. EMS systems are placing a greater emphasis on evidence-based practice when developing policies and protocols. • Legislation and regulation. To provide a quality, effective system of emergency medical care, each state must have legislation and regulations that identify and support a lead EMS agency. This agency has the authority to plan and implement an effective EMS system. It can also create appropriate rules and regulations for each recognized component of the EMS system. • System finance. Emergency medical services systems must be financially stable to provide services for the community and continue to improve those services. EMS systems must develop new and creative relationships with health care insurance companies and other health care providers to become more financially efficient and sustainable. • Human resources. The ability to provide high-quality EMS care depends heavily on the availability of qualified, competent, and compassionate personnel. To attract and retain these personnel, EMS must strive to develop a strong career ladder like other health care professions. • Medical direction. Each state must ensure that physicians are involved in all aspects of the EMS system. The role of the state EMS medical director must be clearly defined. It should have legislative authority and responsibility for EMS system standards, protocols, and evaluation of patient care. Medical oversight for all EMS providers must be used to evaluate medical care as it relates to patient outcomes, training programs, and medical direction. • Education systems. Quality training and education of the EMS workforce is the foundation of excellent patient care. The future of EMS education must maximize the use of technology. Technology will allow those in rural areas more convenient access to quality EMS education resources. • Public education. EMS can play an important role in the education of the community on topics, such as system function, access, bystander care, and prevention.
Get Complete eBook Download by email at [email protected] SCAN 1.1
An effective EMS system depends on both trained and untrained resources.
1.1.2 A witness to the incident calls 911.
1.1.3 The Emergency Medical Dispatcher sends the
1.1.4 Emergency Medical Responders arrive to assist
1.1.5 EMTs and Paramedics continue care and transport
1.1.6 Once at the hospital, care is transferred to the
appropriate resources.
the patient to the hospital.
THE EMS SYSTEM
1.1.1 An individual becomes injured in a vehicle collision.
the patient.
emergency department personnel.
Chapter 1 Introduction to EMS Systems 5
Get Complete eBook Download by email at [email protected] OBJECTIVES 4. Explain the role that the National EMS Education Standards and the National Scope of Practice Model play in shaping EMS around the country. 5. Differentiate the four nationally recognized levels of EMS provider. 6. Differentiate the roles and responsibilities of the Emergency Medical Responder from other EMS providers. 7. Differentiate the various EMS models in practice around the United States. 8. Explain the roles that state and local EMS offices, medical oversight, and local credentialing play in an EMS system.
Scope of Practice Model ▶ a national model that defines the scope of care for the four nationally recognized levels of EMS provider. National EMS Education Standards ▶ the education and training standards developed by the National Highway Traffic Safety Administration (NHTSA) for the four nationally recognized levels of EMS training. Emergency Medical Responder (EMR) ▶ a member of the EMS system who has been trained to render first-aid care for a patient and to assist higher-level providers at the emergency scene.
6
www.bradybooks.com
• Prevention. In addition to education about injury prevention, EMS systems can collect data to identify trends related to illness and injury rates in a community. Education programs and other systems can then be developed to target those prevention needs. • Public access. The 911 number has been in service since 1968 and today serves approximately 96 percent of the population of the United States.3 Barriers to accessing prompt EMS care still exist in many areas in the United States. EMS systems must continue to expand the reach of the 911 system in the communities they serve. • Communication systems. As you are well aware, effective and efficient communication is an essential component of any high-performing system or process. As more and more agencies and institutions become integrated in an overall health care delivery model, the need for efficient communications becomes more important. All components of the health care system must be able to communicate and share information to ensure the best patient care possible. • Clinical care. The care provided by EMS professionals has evolved significantly over the past 40 years and must continue to do so. The care the EMS professionals provide must continue to be driven by evidence and maximize the use of technology and advances in science. • Information systems. The federal government has mandated that EMS systems collect data on many aspects of their performance within the communities they serve. The ability to collect, link, and analyze this data will allow EMS systems to respond more appropriately to the needs of the community. • Evaluation. Each state EMS system is responsible for evaluating the effectiveness of its services. A uniform, statewide data-collection system must exist to capture the minimum data necessary to measure compliance with standards. It also must ensure that all EMS providers consistently and routinely provide data to the lead agency. The lead agency performs routine analysis of that data. Your participation in the evaluation process will help drive the improvement of the EMS system and the care that patients receive. The events that occurred on September 11, 2001, as well as the many subsequent terrorist attacks and natural disasters that have occurred in recent years, have increased public awareness of our EMS systems. These events have also brought to the public’s attention rescue personnel who are called first responders. The public did not always understand the difference between a rescuer who appears first on scene and an EMS first responder, a trained medical care provider. The National Highway Traffic Safety Administration (NHTSA) is the lead-coordinating agency for EMS on a national level and defines all levels of EMS providers. These definitions are included in two documents called the Scope of Practice Model and the National EMS Education Standards. In support of the definitions established in these two documents, this text addresses the level of training known as Emergency Medical Responder (EMR). Refer to Table 1.2 to see the levels of training and compare their roles and responsibilities. All are based on NHTSA’s National Scope of Practice Model but may vary slightly from state to state and region to region. Your instructor will explain variations in your area. The framework for this text and all EMS education and training is guided by the National EMS Education Standards. These standards are the culmination of many years of work and will serve as the basis for EMS education at all levels for many years to come.
EMS Models Emergency medical services are delivered in a variety of “models” throughout the United States. One model is called the fire-based EMS model. In a fire-based system, much of the EMS service and infrastructure are operated by a local fire department or group of organized fire departments within a city or region. A second model is referred to as the “third-service” or “public utility” model, which is typically operated by non-fire-based government entities within cities or counties. In this model, the EMS agency reports directly to governmental authorities. A third common system around the country is the hospital-based EMS system. Typically, it is operated by a large hospital or group of hospitals serving a particular region. A fourth model is the private EMS model and consists of the delivery of EMS services by a
Get Complete eBook Download by email at [email protected] IS IT SAFE
Emergency Medical Responder (EMR). This level of EMS education and training is designed specifically for the individual who is often first to arrive at the scene. Many police officers, firefighters, industrial workers, and other public service providers are trained as Emergency Medical Responders. This training emphasizes scene safety and how to provide immediate care for life-threatening injuries and illnesses as well as how to assist ambulance personnel when they arrive.
Many people are injured and even killed each year when they rush into an unsafe scene to help an injured victim. Take the time to stop and observe the scene before rushing in. Do your best to identify any obvious hazards that could endanger you or others arriving at the scene.
Emergency Medical Technician (EMT). In most areas of the United States, an EMT is considered the minimum level of education and certification for ambulance personnel. The training emphasizes assessment, care, and transportation of the ill or injured patient. The EMT may also assist with the administration of certain common medications. (This was previously called the EMT-Basic level of training.) Advanced Emergency Medical Technician (AEMT). An Advanced EMT is a basic-level EMT who has received additional education and training in specific areas, allowing a minimal level of advanced life support. Some of the additional skills an Advanced EMT may be able to perform are starting IV (intravenous) lines, inserting certain advanced airways, and administering certain medications. (This was previously called the EMT-Intermediate level of training.) Paramedic. Paramedics are trained to perform what is commonly referred to as advanced life support care, such as inserting advanced airways and starting IV lines. They also administer a large list of medications, interpret electrocardiograms, monitor cardiac rhythms, and perform cardiac defibrillation. (This was previously called the EMT-Paramedic level of training.)
privately owned company. The private entity often contracts with a municipality to provide services for a specific area. Many of these models overlap and can operate together within a given EMS system. Regardless of the model, all EMS systems are designed to deliver the best care possible in the most efficient manner possible.
Scope of Practice The term scope of practice identifies the duties and skills an EMS provider is legally allowed to perform. Quite often, the scope of practice is defined by state and/or regional statutes and regulations. Those statutes and regulations will also define any related licensing, credentialing, and certification that may be required. While a scope of practice typically is defined at the state level, local counties and/or EMS agencies may further define the scope of practice based on local needs. Most EMS providers are licensed or certified by a state or local EMS agency to practice in the EMS system.
Activating the EMS System Once someone at the scene recognizes an emergency, it is necessary to activate the EMS system. Most citizens activate it by way of a 911 phone call to an emergency dispatcher, who then sends available responders—Emergency Medical Responders (EMRs), Emergency Medical Technicians (EMTs), Advanced Emergency Medical Technicians (AEMTs), and Paramedics—to the scene. Some areas of the country may not have a 911 system. In those areas, the caller may need to dial a seven-digit number for ambulance, fire, police, or rescue personnel. Most 911 calls are automatically directed to a designated public safety answering point (PSAP). Most primary PSAPs are operated by city or county agencies with specially trained dispatchers. Many 911 dispatch centers are staffed with Emergency Medical Dispatchers (EMDs), who receive special training. In addition to taking the call and dispatching appropriate resources, EMDs provide prearrival instructions to callers, thereby helping to initiate lifesaving care before EMS personnel arrive. Once the EMS system is activated, resources such as personnel and vehicles are dispatched. EMS personnel will provide care at the scene and during transport. They also deliver the patient to the most appropriate medical facility.
?
TABLE 1.2 | Levels of EMS Education
OBJECTIVES 9. Explain the various methods used to access the EMS system. 10. Explain how state and local statutes and regulations affect how an Emergency Medical Responder might function. scope of practice ▶ the care that an Emergency Medical Responder, an Emergency Medical Technician, or Paramedic is allowed and supposed to provide according to local, state, or regional regulations or statutes. Also called scope of care. Emergency Medical Technician (EMT) ▶ a member of the EMS system whose training emphasizes assessment, care, and transportation of the ill or injured patient. Depending on the level of training, emergency care may include starting IV (intravenous) lines, inserting certain advanced airways, and administering some medications. Advanced Emergency Medical Technician (AEMT) ▶ a member of the EMS system whose training includes basic-level EMT training plus responsibility for a minimal level of advanced life support. Additional skills include starting IV (intravenous) lines, inserting certain advanced airways, and administering certain medications.
Chapter 1 Introduction to EMS Systems 7
Get Complete eBook Download by email at [email protected] Paramedic ▶ a member of the EMS system whose training includes advanced life support care, such as inserting advanced airways and starting IV lines. Paramedics also administer medications, interpret electrocardiograms, monitor cardiac rhythms, and perform cardiac defibrillation. public safety answering point (PSAP) ▶ a designated 911 emergency dispatch center. Emergency Medical Dispatcher (EMD) ▶ a member of the EMS system who provides prearrival instructions to callers, thereby helping to initiate lifesaving care before EMS personnel arrive. specialty hospital ▶ a hospital that is capable of providing specialized services, such as trauma care, pediatric care, cardiac care, stroke care, or burn care. OBJECTIVE 11. Explain the various types of medical direction and how the Emergency Medical Responder might interact with each.
The most desirable 911 activation service is referred to as an enhanced 911 (E911) system. An enhanced 911 system enables the call to be selectively routed to the most appropriate dispatch center (PSAP) for the caller’s location. In addition, the E911 system enables the communications center to automatically receive caller information, such as phone number and address, making it easier to confirm location and reconnect should the call be dropped. As of June 2017, it is estimated that nearly 51 percent of all U.S. households currently rely on cellular service as their primary telephone service.4 The widespread use of cellular phones has had a huge impact on how people access the 911 system. Recent developments in technology and wireless communications have required that 911 systems be enhanced to accommodate cellular access. The Federal Communications Commission (FCC) has developed a two-phase plan for how E911 systems must accommodate cellular phone users: Phase I requires that wireless carriers deliver the phone number of the cellular caller and the location of the cell site/sector receiving the 911 call to the appropriate PSAP. In addition to the requirements for phase I, phase II requires that wireless providers deliver the latitude and longitude of the caller.
In-Hospital Care System Most patients who are seen by EMS are taken to a hospital emergency department. Hospital personnel stabilize all immediate life threats and provide the appropriate care before the patient is discharged. If necessary, the patient may be transferred to the most appropriate in-hospital resources, such as the medical/surgical or intensive care units, or the patient is transferred to a more specialized hospital for more advanced care. Some hospitals handle all routine and emergency cases and have a medical specialty that sets them apart from other hospitals. One type of specialty hospital is a trauma center. A trauma center is where specific trauma services and surgery teams are available 24 hours a day. Some hospitals specialize in the care of certain conditions, such as burns (Burn Center), cardiac problems (Cardiac [STEMI] Receiving Hospital), or strokes (Stroke Receiving Hospital). Other hospitals may specialize in a particular type of patient, such as pediatric and neonatal patients.
FIRST ON SCENE By the time you return to the scene, you can tell that the young boy has stopped shaking. Within seconds, two women arrive and introduce themselves as Christine and Jessica, members of the company’s Medical Emergency
protocols ▶ written guidelines that direct the care EMS personnel provide for patients. standing orders ▶ a component of a protocol that allows the EMS personnel to provide specific interventions to a patient. off-line medical direction ▶ an EMS system’s written standing orders and protocols, which authorize personnel to perform particular skills in certain situations without actually speaking to the medical director or their designated agent. Also called indirect medical direction.
8
www.bradybooks.com
Response Team. They have equipment with them and seem to know what they are doing. Christine kneels beside the patient and appears to be listening for something. Jessica takes the woman aside and asks questions about the boy.
Medical Direction Each EMS system has a medical director. He or she is a licensed physician who assumes the ultimate responsibility for direction and oversight of all patient care delivered by personnel in an EMS system. The medical director also oversees training and assists in the development of treatment protocols. Protocols are clearly defined, written guidance that describe how to manage the most common types of conditions, such as chest pain, cardiac arrest, difficulty breathing, and severe allergic reactions. Some protocols contain standing orders. Standing orders give the EMS provider permission to administer specific interventions, such as oxygen and medications. Protocols and standing orders are a type of medical direction known as off-line medical direction (or indirect medical direction). While quite rare for the EMR, procedures not covered by protocols or standing orders require EMS personnel to contact medical direction by radio or telephone prior to performing a particular skill or intervention. Orders from medical direction given in this manner— by radio or phone—are called on-line medical direction (or direct medical direction). The primary role of medical direction is to ensure that the quality of care is standardized and consistent throughout the local EMS system.
Get Complete eBook Download by email at [email protected] As an Emergency Medical Responder at the scene of an emergency, you may have limited access to the medical director. It will be necessary for you to adhere to the training you receive or to follow the orders of on-scene EMS providers who have a higher level of training or certification. Like all EMS personnel, you must only provide the care that is within your scope of practice. The scope of practice is defined as the care an Emergency Medical Responder is allowed and expected to provide according to local, state, or regional regulations or statutes. The scope of practice is outlined in protocols and guidelines approved by your medical director. The scope of practice may vary from state to state and region to region. Your instructor will inform you of any local protocols and policies that may define your scope of practice. Always follow your local protocols.
on-line medical direction ▶ orders to perform a skill or administer care from the on-duty physician given to the rescuer in person by radio or by phone. Also called direct medical direction.
The Emergency Medical Responder
The lack of people with enough training to provide care before more highly skilled EMS providers arrive at a scene is the weakest link in the chain of any EMS system. Training Emergency Medical Responders will help overcome this challenge. Emergency Medical Responders are trained to reach patients, find out what is wrong, and provide emergency care while at the scene. They are also trained to move patients when necessary and without causing further injury (Scan 1.2, p. 10). They are usually the first medically trained personnel to reach the patient. In all cases, an Emergency Medical Responder has successfully completed an Emergency Medical Responder course. Many police officers and firefighters are trained to this level. Many companies have trained employees as Emergency Medical Responders as well. The more individuals who become trained as Emergency Medical Responders, the stronger the EMS system becomes.
FIRST ON SCENE Within minutes, the sirens of responding emergency vehicles can be heard. By now there are five members of the Medical Emergency Response Team caring for the young boy. The team of responders places the boy on his side,
clears out his mouth with a suction device, and gives him oxygen. That must be what he needed because after they clear his mouth, he begins to cough and wakes up.
Roles and Responsibilities Personal Safety Your primary concern as an Emergency Medical Responder at an emergency scene is your own personal safety. The desire to help those in need of care may tempt you to ignore the hazards at the scene. You must make certain that you can safely reach the patient and that you will remain safe while providing care. Part of an Emergency Medical Responder’s concern for personal safety must include the proper protection from infectious diseases. All Emergency Medical Responders who assess or provide care for patients must take steps to avoid direct contact with blood and other bodily fluids. Personal protective equipment (PPE) that minimizes contact with infectious material includes the following: • • • •
Disposable gloves Barrier devices, such as face masks with one-way valves Protective eyewear, such as goggles or face shields Specialized face masks (HEPA, N95, N100) with filters that minimize contact with airborne microorganisms • Gowns or aprons that minimize contact of splashed blood and other bodily fluids
Typically, you will need only protective gloves and eye protection for most patient care situations. However, all the items listed above should be on hand so you can protect yourself and provide care safely when needed. We will talk more about infectious diseases and personal protection in Chapter 3.
Chapter 1 Introduction to EMS Systems 9
Get Complete eBook Download by email at [email protected] SCAN 1.2 EMERGENCY MEDICAL RESPONDERS
1.2.1 Emergency Medical Responders
1.2.2 Emergency Medical Responders
1.2.3 Many law enforcement person-
1.2.4 Emergency Medical Responders
working as part of a search-andrescue team.
nel receive Emergency Medical Responder training.
1.2.5 Emergency Medical Responders are often used to support large events, such as NASCAR.
10
www.bradybooks.com
serving as lifeguards at a recreational area.
also serve on industrial Medical Emergency Response Teams.
1.2.6 Emergency Medical Responders also
serve on specialized response teams, such as hazmat and rescue teams.
Get Complete eBook Download by email at [email protected] Keep in mind that Emergency Medical Responders who are in law enforcement, the fire service, or industry, may be required to carry out their specific job tasks before they provide patient care (such as controlling traffic, stabilizing vehicles, or shutting down machinery). If this applies to you, always follow department or company standard operating procedures. Patient-Related Duties Prior to receiving care, the ill or injured individual may be referred to as a victim. Once you start to carry out your duties as an Emergency Medical Responder, the victim becomes your patient. Your presence at the scene means that the EMS system has begun its first phase of care (Scan 1.3, p. 12). True, the patient may need the skills of a physician at the hospital to survive, but the patient’s chances of reaching the hospital alive are greatly improved because of your training as an Emergency Medical Responder. As an Emergency Medical Responder, you have six main patient-related duties to carry out at the emergency scene: • Size up the scene. Scene safety is your first concern, even before patient care. Before rendering care, evaluate how to protect yourself, those helping you, bystanders, and the patient. You must also try to determine what caused the patient’s illness or injury, the number of patients, and what kind of assistance you will need. You must remain alert for changing conditions at the scene to protect yourself and the patients and to minimize additional injuries. • Determine the patient’s chief complaint. Gather information from the patient, from the scene, and from bystanders. Using the supplies you have, provide emergency care to the level of your training. Remember, emergency care deals with both illness and injury. It can be as simple as providing emotional support to someone who is frightened because of a crash or mishap. Or it can be more complex, requiring you to deal with life-threatening emergencies, such as providing basic life-support measures for an individual experiencing a heart attack. In later chapters, you will learn how to provide a combination of emotional support and physical care skills to help the patient until more highly trained personnel arrive. • Lift, move, or reposition the patient when it is necessary. You need to judge when safety or care requires you to move or reposition patients. When you must move a patient, use techniques that minimize the chance of injuring yourself or the patient. • Transfer the patient and patient information. Provide for an orderly transfer of the patient and all patient-related information to more highly trained personnel. You may also be asked to assist such personnel and work under their direction. • Protect the patient’s privacy and maintain confidentiality. You have a responsibility both morally and legally to protect the privacy of your patient. You may not share any information relating to the patient or the situation unless it is with other EMS professionals who are taking over care of the patient. • Be the patient’s advocate. You must be willing to be an advocate for the patient and do what is best for him or her as long as it is safe to do so.
KEY POINT Besides proper handwashing and the use of personal protective equipment to prevent being exposed to infectious agents, an additional and often overlooked precaution is to be vaccinated against some of the more common agents you may encounter. Blood has the potential of exposing you to hepatitis B and C, while an individual with a fever may expose you to pneumonia, meningitis, and influenza (the flu). There are vaccines for meningitis, pneumonia, and influenza. The influenza vaccine is released yearly based on assumptions of what type of flu will be most prevalent. Being vaccinated against those agents provides you with one more layer of protection. In addition, being vaccinated may help you stay healthy during flu season when exposure may occur outside of your Emergency Medical Responder duties. Many EMS systems are requiring field personnel to become vaccinated with the seasonal flu vaccine.
Traits To be an Emergency Medical Responder, you must be willing to take on certain duties and responsibilities. It takes hard work and study to be an Emergency Medical Responder. Since you must keep your emergency care skills sharp and current (Figure 1.2, p. 12), you may also be required to obtain continuing education and to recertify or relicense periodically. It is becoming quite common today for a state or local EMS authority to require criminal background checks for anyone seeking certification or licensing to practice. Those processes are designed to protect the patient and ensure the quality of patient care delivered within an EMS system. You must also be willing to deal with difficult situations and people. Individuals who are ill or injured are not at their best. You must be able to overlook rude behavior and unreasonable demands, realizing that patients may act this way because of fear, uncertainty, or pain. Dealing with patient reactions is often the hardest part of the job. You have a responsibility to remain professional and compassionate even when it is difficult to do so.
Chapter 1 Introduction to EMS Systems 11
Get Complete eBook Download by email at [email protected] SCAN 1.3 PATIENT-RELATED DUTIES
1.3.1 One of the duties of an Emergency Medical Responder is to safely gain access to the patient.
1.3.3 Emergency Medical Responders must learn to safely lift and move patients when necessary.
1.3.2 The Emergency Medical Responders must act quickly to find out what is wrong with the patient.
1.3.4 The Emergency Medical Responder will often assist EMTs and other transport personnel at the scene of an emergency.
All patients have the same right to the very best of care. Your respect for others and acceptance of their rights are essential parts of the total patient care that you provide as an Emergency Medical Responder. You must not modify the care you provide or discriminate based on your view of another individual’s religious beliefs, cultural expression, age, gender, sexual orientation, social behavior, socioeconomic background, or geographic origin. Every patient is unique and deserves to have his or her needs met by a consistent standard of care. To be an Emergency Medical Responder, you must be honest and realistic. When helping patients, you cannot tell them they are okay if they are truly sick or hurt. You cannot tell them that everything is all right when they know that something is wrong. Telling someone not to worry is not realistic. When an emergency occurs, there is truly something to worry about. Your conversations with patients can help them relax, if you are honest. By telling patients that you are trained in emergency care and that you will help them, you ease their fears and gain their confidence. Letting patients know that additional aid is on the way also will help them relax. As an Emergency Medical Responder, you may have limits on what you can say to a patient or a patient’s loved ones. Telling a patient that a loved one is dead may not be appropriate if you are still providing care for the patient. In such circumstances, it is necFigure 1.2 Frequent training promotes a high standard of essary for you to be tactful. You also don’t want to provide false care for your patients. 12
www.bradybooks.com
Get Complete eBook Download by email at [email protected] hope by telling a family member that a loved one is fine when they are really not. Remember, people under the stress of illness or injury often do not tolerate additional stress well. Being an Emergency Medical Responder requires that you control your feelings at the emergency scene. You must learn how to care for patients while controlling your emotional reactions to their illnesses or injuries. Patients do not need sympathy and tears. They need your professional care, compassion, and empathy. As an Emergency Medical Responder, you are required to be a highly disciplined professional at the emergency scene. You must not make inappropriate comments about patients or the horror of the incident. You must maintain your focus on the patient and avoid unnecessary distractions. Providing appropriate care requires you to admit that the stress of responding to emergency scenes will affect you. You may have to speak with a respected peer, counselor, other EMS professionals, or a specialist within the EMS system to resolve the stress and emotional challenges caused by responding to emergencies. No one can demand that you change your lifestyle to be an Emergency Medical Responder. However, first impressions are very important and your appearance alone can earn a patient’s confidence. So, keep your uniform neat and clean at all times. Also, how you approach the patient and the respect you show are very important. Refer to the patient in a manner that is appropriate for his or her age. All adults should be referred to as Mr., Mrs., or Ms. In contrast, children respond well to their first names. The significance of how you refer to a patient can greatly affect the willingness of the patient to share information and feel comfortable in your care.
OBJECTIVE 12. Describe the characteristics of professionalism as they relate to the Emergency Medical Responder.
Skills In addition to learning the knowledge that is the foundation of emergency care, you will be required to perform certain skills as part of your Emergency Medical Responder training. Those skills vary from course to course. The list below is an example of the skills learned by the typical Emergency Medical Responder. Read it and check off each skill as you learn it in your course. As an Emergency Medical Responder, you should be able to: • • • • • • • • • • • • • • • • • • • • • • • • • •
Assess for and manage potential hazards at the scene Gain access to patients in vehicles, buildings, and outdoor settings Evaluate the possible cause of an illness or injury Properly use all items of personal safety Evaluate and manage a patient’s airway and breathing status Conduct an appropriate patient assessment Obtain and record accurate vital signs Properly document assessment findings Relate signs and symptoms to illnesses and injuries Perform cardiopulmonary resuscitation (CPR) for adults, children, and infants Operate an automated external defibrillator (AED) Control all types of bleeding Assess and manage the patient who is showing signs of shock Perform basic dressing and bandaging techniques Assess and care for injuries to bones and joints Assess and care for possible head and face injuries Assess and care for possible injuries to the neck and spine Assess and care for possible heart attacks, strokes, seizures, and diabetic emergencies Identify and care for poisonings Assess and care for burns Assess and care for heat- and cold-related emergencies Assist a woman in delivering her baby Provide initial care for the newborn Identify and care for patients who are experiencing drug- or alcohol-related emergencies Perform standard and emergent patient moves when required Perform triage at a multiple-patient emergency scene Chapter 1 Introduction to EMS Systems 13
Get Complete eBook Download by email at [email protected] OBJECTIVES 13. Explain the role of the Emergency Medical Responder with regard to continuous quality improvement (CQI). 14. Explain the role of public health systems and their relationship to EMS, disease surveillance, and injury prevention.
• Work under the direction of an Incident Commander in an incident command system (ICS) or incident management system (IMS) operation • Work under the direction of more highly trained personnel to help them provide patient care, doing what you have been trained to do at your level of care as an Emergency Medical Responder In some systems, Emergency Medical Responders may be required to perform some or all of the following: • • • • •
Administer oxygen Apply specialized splints Apply cervical collars Assist with the application of specialized extrication devices Assist in securing a patient to a long spine board (backboard) or other device used to immobilize a patient’s spine
Equipment, Tools, and Supplies Most Emergency Medical Responders carry very few pieces of equipment, tools, and supplies. Some may carry specialized kits for trauma emergencies, medical emergencies, and childbirth. If you are assigned to a special event, such as a concert, sporting event, or carnival, you may want to include items that will meet the needs of that event in addition to the standard dressings and bandages. For instance, if you were providing medical support for a football game, it would be appropriate to have cervical collars and a backboard handy, given the likelihood of a significant mechanism of injury.
Continuous Quality Improvement continuous quality improvement (CQI) ▶ a continuous improvement in the quality of the product or service being delivered.
public health system ▶ local resources dedicated to promoting optimal health and quality of life for the people and communities they serve. OBJECTIVE 15. Explain the role that Disaster Medical Assistance Teams (DMAT) play and how they integrate with EMS systems. Disaster Medical Assistance Team (DMAT) ▶ specialized teams designed to provide medical care following a disaster.
14
www.bradybooks.com
One of the goals of the evaluation component of an EMS system is a concept known as continuous quality improvement (CQI). CQI is exactly what the name implies—a continuous improvement in the quality of the product or service being delivered. In the case of EMS, that product is patient care. As a trained Emergency Medical Responder working within an EMS system, you will be accountable for and expected to participate in the CQI process. If designed properly, a CQI program is based on the philosophy that every component within a system can be improved. It is a process that expects and allows everyone in the system to participate and contribute to its improvement. It should focus more on the systems and processes and less on the people within the system. As an Emergency Medical Responder, you will be an important component of the CQI system and will be expected to submit accurate and complete patient care reports that will be audited by trained individuals. Those audits are meant to reveal many characteristics of the care being provided including, but not limited to, types of illnesses and injuries, ages of patients, geographic location of calls, and many other factors. You may be asked to participate in training or serve on a quality committee as part of the CQI process. Whatever your role or level of participation, everyone in the system plays an important part in the CQI process.
The Role of the Public Health System
Each county, region, and state has people and resources that serve as part of the public health system. Those resources are dedicated to promoting optimal health and quality of
life for the communities they serve. Public health systems help ensure the quality of life by monitoring the health of the population, providing health care, and educating the community about disease and injury prevention. They also serve to advance population-based health programs and policies.
Disaster Assistance
Each state has identified specific individuals already working in its EMS systems to participate in specialized teams designed to provide medical care following a disaster. This type of team is called a Disaster Medical Assistance Team (DMAT). The individuals who make
Get Complete eBook Download by email at [email protected] up DMATs are highly experienced, trained EMS personnel. They can be deployed on a moment’s notice should a disaster strike anywhere in the United States. For example, DMATs from across the nation descended on Northern California during the wildfires that devastated several counties in 2017. DMATs arrive in an area during and after a disaster and are quickly integrated into the local EMS resources.
The Role of Research in EMS
OBJECTIVE 16. Explain the role that research plays in EMS and the ways that an Emergency Medical Responder might seek out and support research. research ▶ the systematic investigation to establish facts.
Research is the systematic investigation to establish facts
(Figure 1.3). Each year, more and more new research is being conducted and old research is being challenged. Several organizations around the globe have spent years gathering and verifying research that is defining how EMS providers practice emergency care. Approximately every five years, the American Heart Association and the International Liaison Committee on Resuscitation (ILCOR) release new guidelines that define how EMS providers should perform resuscitation and emergency care.5 The military is constantly conducting research that is influencing how EMS providers care for those who are ill or injured in the civilian world. This book includes many of the changes in emergency care that are being recommended as a result of this new research. Be sure to play an active role in searching for, reading, and evaluating research that affects your job as an Emergency Medical Responder.
Figure 1.3 Staying current with the latest research is an important aspect of being a good Emergency Medical Responder.
Advances in Technology
In recent years, several advances in technology have made the job of the EMS team more effective and efficient. One of the most important of those advances is the introduction of the global positioning system (GPS) to the civilian marketplace (Figure 1.4). GPS is a standard tool in all types of public safety vehicles, such as police cars, fire engines, and ambulances. The use of GPS technology allows emergency personnel to more easily navigate to the location of the emergency, thus reducing response time. It also gives dispatch personnel the ability to track the location of emergency vehicles and to use resources more efficiently.
Figure 1.4 A typical device with GPS capability installed in an emergency vehicle.
FIRST ON SCENE Wrap-up It looks like the cavalry is arriving; there are so many vehicles with lights and sirens. First, there are two fire trucks. Then, an ambulance shows up and behind that is another SUV-type vehicle, painted just like the ambulance. Before you know it, nearly a dozen people are hovering over the young boy. You stick around to observe the excitement and even forget for a minute why you are actually there. You hear
Christine give a report to the ambulance team about the boy and that she thinks he might have had a seizure. Wow, what an exciting day! You can’t stop thinking about the poor boy and how he must have felt when he awoke to see so many people hovering over him. The woman with the boy turns out to be his mother and she takes the time to thank you for making sure the call to 911 was made quickly.
Chapter 1 Introduction to EMS Systems 15
Get Complete eBook Download by email at [email protected]
1 REVIEW
Summary The emergency medical services (EMS) system is a chain of resources established to provide care to the patient at the scene of an emergency and during transport to the hospital emergency department. Review these key concepts related to working within an EMS system: • There are four levels of nationally recognized EMS education and training: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced Emergency Medical Technician (AEMT), and Paramedic. • EMS personnel are dispatched to the scene of an emergency when a dispatcher receives an emergency call. Dispatchers may be specially trained as Emergency Medical Dispatchers (EMDs) who offer prearrival care instructions to bystanders at the scene. • Every EMS system is required to designate a medical director—a physician who assumes the ultimate responsibility for medical oversight of the patient care aspects of the EMS system. • The Emergency Medical Responder’s primary responsibility is personal safety. No one should enter or approach an emergency scene until it is safe to do so.
• An Emergency Medical Responder’s main duties are scene safety, gaining access to the patient, assessing the patient and providing emergency care, moving patients (when necessary), and transferring care to more highly trained personnel. • You must be mindful of your patient’s privacy and any cultural differences that may affect the care you provide. • Patient confidentiality is an important concept and you may not discuss details of the call or the patient with those not directly involved in the care of the patient. • Being a patient advocate means putting the patient’s needs before your own. • Emergency Medical Responders have a duty to maintain skills, keep up to date with the latest trends and research, and maintain a professional demeanor at all times. • As an Emergency Medical Responder, you play an important part in the quality of the system you will be working in and may participate in specific duties related to the CQI process. • More than ever before, research is defining the way that EMS personnel deliver care to patients. As an Emergency Medical Responder, you have a duty to stay informed about the latest research findings.
Take Action KNOW YOUR SYSTEM No two EMS systems are exactly the same. To provide the best care possible, you must know what resources are available within your system. Find someone who is currently working with EMS and ask him or her the following questions: • Where are 911 calls answered? • Does the system use an enhanced 911 system? • Which of the four levels of EMS providers are recognized by your local EMS system? • What are the levels of providers that are utilized in your EMS system?
• What types of EMS models exist in your area or region: firebased, third-service, or hospital-based? • Are there any specialty hospitals in your system? • Are there helicopter resources operating in your local system? If possible, try to arrange a tour of a 911 dispatch center. A good place to begin is by asking your instructor. Most dispatch centers allow people to sit in and observe during certain times. This experience will give you a good appreciation for how the dispatch side of things works.
First on Scene Run Review Recall the events of the “First on Scene” scenario in this chapter and answer the following questions which are related to the call. Rationales are offered in the Answer Key at the back of the book. 1. Prior to calling 911, what important information should you have obtained from the woman who was with the boy? And why?
16
www.bradybooks.com
2. What equipment should the company’s Medical Emergency Response Team have with them when responding to a call? 3. When caring for this patient, how would each of the six patientrelated duties apply? 4. How would protocols and standing orders apply to this call?
Get Complete eBook Download by email at [email protected] Quick Quiz To check your understanding of the chapter, answer the following questions. Then compare your answers to those in the Answer Key at the back of the book. 1. Which one of the following is NOT an attribute of an integrated EMS system? a. b. c. d.
EMS Research Medical Direction Health insurance companies Education systems
2. The licensed physician who assumes the ultimate responsibility for the oversight of all patient care is called the: a. medical director. b. fire chief.
c. ambulance supervisor. d. nursing supervisor.
3. Which one of the following BEST describes the role of the Emergency Medical Responder in an EMS system? a. Decontaminates hazardous materials b. Cares for immediate life threats and assists EMTs c. Serves as an Incident Commander and directs other personnel d. Assists Paramedics with advanced skills 4. Emergency Medical Dispatchers receive training that allows them to: a. b. c. d.
control the scene via the radio. triage patients via the radio. declare a mass-casualty incident. provide prearrival care instructions.
5. Which one of the following receives the highest level of training in an EMS system? a. b. c. d.
6. Clearly defined, written guidance that describe how to manage the most common types of conditions are called: a. dispatches. b. protocols.
c. on-line direction. d. prescriptions.
7. Specialized teams of experienced EMS personnel who respond on short notice during disasters are called: a. b. c. d.
Rapid Response Work Groups. Disaster Medical Assistance Teams. Disaster Care Response Teams. Rapid Response Task Force.
8. Protocols and standing orders are forms of: a. b. c. d.
off-line medical direction. on-line medical direction. prearrival instructions. stand-by guidelines.
9. The care that an Emergency Medical Responder is allowed and supposed to provide according to local, state, or regional regulations or statutes is known as: a. b. c. d.
scope of practice. standard of care. national standard curricula. Emergency Medical Responder care.
10. Protocols and patient care decisions should be based on: a. b. c. d.
current EMS research. which options are cheapest. the opinion of EMRs. traditions and historical practice.
Emergency Medical Responder Emergency Medical Technician Advanced Emergency Medical Technician Paramedic
Endnotes 1. “9-1-1 Statistics,” National Emergency Number Association website, n.d. Accessed December 10, 2017, at https://www .nena.org/?page=911Statistics 2. “Emergency Medical Services: Agenda for the Future,” National Highway Traffic Safety Administration website, August 1996. Accessed July 2, 2014, at http://www.ems.gov/ pdf/2010/EMSAgendaWeb_7-06-10.pdf 3. “9-1-1 Statistics,” National Emergency Number Association Web site, n.d. Accessed December 10, 2017, at https://www .nena.org/?page=911Statistics
4. https://www.npr.org/sections/alltechconsidered/2015/12/03 /458225197/the-daredevils-without-landlines-and-whyhealth-experts-are-tracking-them 5. American Heart Association, “2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations,” Circulation, 2015;132:S1, originally published October 14, 2015. This citation refers to nearly the whole issue of the journal, which includes all 12 parts of the recommendations.
Chapter 1 Introduction to EMS Systems 17
Get Complete eBook Download by email at [email protected]
2 Legal and Ethical Principles of Emergency Care Education Standards: • Preparatory—Medical/Legal and Ethics Competencies: • Uses simple knowledge of the EMS system, safety and well-being of the Emergency Medical Responder, and medical/legal issues at the scene of an emergency.
Chapter Overview:
One of the most common reasons someone would be hesitant to stop and render aid at the scene of an emergency is the fear of being held liable for doing something wrong. The reality is that lawsuits are relatively rare in EMS and the likelihood of doing something wrong can be greatly reduced with good training. As an Emergency Medical Responder, you must make many decisions when responding to an emergency and while caring for patients. For example, should you, as an off-duty Emergency Medical Responder, stop to aid victims of an automobile crash? Should you release information about your patient to an attorney over the telephone? May a child with a suspected broken arm be treated, even if a parent is not present? What should you do if a patient who needs emergency medical care refuses it? Understanding the legal and ethical issues related to some of your decisions and actions will help you make the best choices possible for the patient.
OBJECTIVES
This chapter will provide you with an overview of the legal and ethical aspects of being an Emergency Medical Responder.
Upon successful completion of this chapter, the student should be able to: COGNITIVE 1. Define the following terms: a. abandonment (p. 27) b. advance directive (p. 25) c. battery (p. 24) d. capacity (p. 21) e. competence (p. 21) f. confidentiality (p. 28) g. consent (p. 21) h. criminal law (p. 24) i. duty (p. 19) j. duty to act (p. 26) k. emancipated minor (p. 23) l. ethics (p. 20) m. expressed consent (p. 22) n. Good Samaritan law (p. 27) o. Health Insurance Portability and Accountability Act (HIPAA) (p. 28) p. implied consent (p. 23) q. informed consent (p. 22) r. mandated reporter (p. 29) s. negligence (p. 25) t. standard of care (p. 19) u. unresponsive (p. 23) v. values (p. 21)
2. Differentiate the terms scope of practice and standard of care. (p. 19) 3. Explain the term ethics and how it relates to the Emergency Medical Responder. (p. 20) 4. Differentiate the various types of consent used by the Emergency Medical Responder. (p. 21) 5. Explain the role of the Emergency Medical Responder for patients who refuse care. (p. 24) 6. Differentiate civil (tort) versus criminal litigation. (p. 24) 7. Explain the common elements of an advance directive. (p. 25) 8. Explain the role of the Emergency Medical Responder when confronted with an advance directive. (p. 25) 9. Explain the concepts of duty and breach of duty as they relate to the Emergency Medical Responder. (p. 25) 10. Explain the term Good Samaritan law and how these laws relate to the Emergency Medical Responder. (p. 27)
Get Complete eBook Download by email at [email protected] 11. Explain the role of the Emergency Medical Responder with regard to patient confidentiality. (p. 28) 12. Explain the term mandated reporter and how it relates to the Emergency Medical Responder. (p. 29) 13. Explain the role of the Emergency Medical Responder with respect to evidence preservation when working in or around an actual or potential crime scene. (p. 30) PSYCHOMOTOR There are no psychomotor objectives identified for this chapter.
AFFECTIVE 14. Consistently model ethical behavior in all aspects of Emergency Medical Responder training and job performance. 15. Demonstrate compassion and empathy toward all classmates, coworkers, and simulated patients. 16. Participate willingly as a team member in all class/ training activities. 17. Value the importance of maintaining patient confidentiality. 18. Demonstrate a desire to always do what is right for the patient.
FIRST ON SCENE They’re moving fast on the open road when Anthony yells, “Hold on!” and she feels his body tense under the smooth leather jacket. The motorcycle leans far to the right and then quickly back to the left, causing the tires to squeal and wobble as the bike comes to a clumsy stop. Sara looks over Anthony’s shoulder and feels her stomach grow cold. Two deep gouges scar the asphalt all the way to the far side of the road where a small sports car is overturned and partially wrapped around a tree. Behind her, amazingly close
to the black skid marks left by the motorcycle, a man is lying in a heap on the road. In a matter of seconds, the entire Emergency Medical Responder class that Sara took two months ago flashes through her head. “Stop,” she says, quickly pulling her wind-whipped hair back into a ponytail. “That guy in the road needs help right now!”
Legal Duties
Most of us have heard stories about people being sued because of something they did or did not do when they stopped to help someone at the scene of an emergency. Successful suits of this type are not very common. Most states have established Good Samaritan laws that minimize exposure to liability and encourage passersby to provide emergency care to those in need.1 Most of these laws require the individual who is providing care to be doing so without compensation and to remain within a specified standard of care. Depending on the specific role you play as an Emergency Medical Responder, you may have a legal and/or ethical duty to assist those in need. Duty is a legal term that simply means that one is morally or legally obligated to provide care. An Emergency Medical Responder who works normal shifts or is on call as a volunteer and is expected to respond to dispatches has a legal duty to respond and provide care to those who are ill or injured. In addition to the duty to respond, you also have a duty, or obligation, to provide care as you have been trained and to the expected standard in your area, region, or state.
OBJECTIVE 2. Differentiate the terms scope of practice and standard of care.
duty ▶ the legal obligation to provide care.
Standard of Care The term standard of care is somewhat subjective and deals with questions such as, “Did you do the right thing, at the right time, and for the right reasons?” It is defined by several factors, such as your level of training, common practice, current research, and sometimes juries. Standard of care can and does vary from county to county, state to state, and region to region (Figure 2.1). Another way of describing standard of care is to ask, “What would a similarly trained individual do, given the same or similar circumstances?” A standard of care allows you to be judged based on what is expected of someone with your training and experience working under similar conditions. Your Emergency Medical Responder course follows guidelines developed by the U.S. Department of Transportation as well as other authorities that have studied what is needed to provide the most appropriate standard of care required at your level in your region. You will be trained so you can provide this standard of care. As we discussed in the previous chapter, each agency that provides care
standard of care ▶ the care that should be provided for any level of training based on local laws, administrative orders, and guidelines and protocols established by the local EMS system.
Chapter 2 Legal and Ethical Principles of Emergency Care 19
Get Complete eBook Download by email at [email protected] Figure 2.1 Different emergency personnel may be assisting during an emergency, including police, firefighters, and EMTs. Each must practice the standard of care expected of his or her own level of training.
within an EMS system receives direction and guidance from a physician medical director. The standard of care that your agency provides is largely defined by your medical director. While it is relatively uncommon for the EMR to interact directly with medical direction from the field, you will be expected to follow approved standing orders or protocols developed by your medical director for your EMS system. It is always a good practice to keep written notes of what you do at the emergency scene. You may be called on to provide this information at a later date. If your EMS system requires you to complete forms, submit reports, or sign patient transfer forms, complete these forms thoroughly and in a timely manner. Your documentation must be able to show that you provided an appropriate standard of care.
Scope of Practice
ethics ▶ the moral principles that define behavior as right, good, and proper. OBJECTIVE 3. Explain the term ethics and how it relates to the Emergency Medical Responder.
20
www.bradybooks.com
Recall from Chapter 1 that the term scope of practice refers to what is legally permitted to be done by some or all individuals trained or licensed at a particular level, such as an Emergency Medical Responder, Emergency Medical Technician, or Paramedic. The scope of practice, however, does not define what must be done for a given patient or in a particular situation. That is more often defined by the standard of care. The scope of practice for a layperson might be based on nothing more than common sense or an eight-hour first-aid class taken many years ago. However, the scope of practice for Emergency Medical Responders and other EMS personnel is based in part on the U.S. Department of Transportation’s education standards for EMS and, in most cases, is more clearly defined by local and state statutes and regulations. In short, scope of practice is what one is allowed to do by training and/or statute, and standard of care is what one is supposed to do for any given situation based on more local standards and expectations.
Ethical Responsibilities Ethics can be defined as the moral principles that guide our behavior. However, it is not
just any behavior, but behavior that is right, good, and proper. As an Emergency Medical Responder, you have an ethical obligation to behave in a way that puts your patient’s needs before your own, so long as it is safe to do so. You have a responsibility to see that your patient receives the most appropriate medical care possible, even when he or she does not think they need any care.
Get Complete eBook Download by email at [email protected] As an Emergency Medical Responder, you will be caring for people of all social, economic, and cultural backgrounds. You must maintain an open mind and develop an understanding of those differences. You have an ethical responsibility to treat all people equally and provide the highest standard of care for your patients. Another ethical responsibility as a member of the EMS team is to maintain your skills and continue to grow your knowledge related to your duties as an EMR. This includes keeping abreast of current research by reading professional publications and attending conferences when practical. It means practicing your skills in order to maintain confidence and an appropriate level of competency. You must also attend continuing education and refresher programs to keep yourself ready to perform at all times. Remember, every patient deserves the best care possible. It is also important for you to be honest in reporting the care you provided to a patient, even if a mistake was made. While all EMS providers should provide the appropriate care at all times, mistakes do happen. Errors should be reported immediately so corrective steps, if needed, may be taken as soon as possible. Your behavior (ethics) is always being influenced by your personal core values. Values are core beliefs that you hold to be true. Doing the right thing is not always easy and can cause you internal struggles. Many groups and professions have a common set of shared values. Those values serve as a moral compass and help guide an individual’s and organization’s decision-making processes. Because EMS personnel are frequently faced with making difficult decisions, several EMS groups, agencies, and institutions have adopted the following set of core values for the EMS profession2: • • • • •
Integrity Compassion Accountability Respect Empathy
Consent
Consent is a legal term that means to give formal permission for something to happen. In
the case of the Emergency Medical Responder, you must receive permission from each and every patient before you can legally provide care. The individual providing consent must have the legal capacity to do so as well as be competent to make rational decisions about his or her own healthcare. Consent may come in several different forms, depending on the situation.
Capacity The term capacity refers to a patient’s legal rights and ability to give consent for his or her own care.3 In the United States, most individuals under the age of 18 do not have the legal capacity to provide consent for care. In these instances, a parent or legal guardian provides consent for treatment based on a legal concept called “implied consent” which will be discussed more below. The capacity of an individual to legally grant consent for treatment may be affected by such things as incarceration and mental illness. For instance, an incarcerated prisoner or an individual with a severe mental illness may not have the legal capacity to grant or deny consent because his or her rights have been taken away or assumed by the state in which he or she lives.
Competence A discussion about consent would not be complete without a clear definition of the word competence. Competence is the patient’s ability to understand what is going on around him or her, your questions, and the implications of the decisions he or she is making. For an Emergency Medical Responder to obtain consent or accept a refusal of care, he or she should establish that the patient is competent to make such decisions.
values ▶ the personal beliefs that determine how an individual actually behaves.
OBJECTIVE 4. Differentiate the various types of consent used by the Emergency Medical Responder. consent ▶ the legal term that means to give formal permission for something to happen.
capacity ▶ refers to a patient’s legal rights and ability to make decisions concerning his or her medical care.
competence ▶ refers to the patient’s mental ability to comprehend the situation and make rational decisions regarding his or her medical care.
Chapter 2 Legal and Ethical Principles of Emergency Care 21
Get Complete eBook Download by email at [email protected] GERIATRIC FOCUS According to the Alzheimer’s Association, as of 2017 there are approximately 5.5 million Americans living with some degree of dementia.4 Dementia is the deterioration of specific mental capacities such as memory, concentration, and judgment. One of the most common causes of dementia is Alzheimer’s disease. An older adult patient with dementia may not fully comprehend the seriousness of his or her situation and may not want you to provide care. In other words, the older adult patient with dementia may not be competent to make decisions regarding his or her own medical care. When presented with an older adult patient who is showing signs of disorientation, a short attention span, confusion, or hallucinations, obtain a detailed history from family members or caregivers. It will be important to determine if the patient’s mental status is normal for him or her or if it has gotten worse since you arrived on the scene. Do not allow patients who are showing signs of dementia to refuse care without further investigation into their normal state of mind. In most cases, you will want to wait for the EMTs to arrive and take over care before you leave the scene.
A patient may not be competent to make medical decisions in certain cases, such as intoxication, drug ingestion, serious injury, or mental illness. To determine competency, the Emergency Medical Responder may begin by asking questions that a competent individual should be able to answer, such as where the patient is at the time, what day or month it is, and what has happened.
Expressed and Informed Consent expressed consent ▶ a competent adult’s decision to accept emergency care. informed consent ▶ consent granted by a patient after he has been appropriately informed of the care being suggested and associated consequences.
An adult patient of legal age, when alert and competent, can give you consent to provide care. In an emergency situation, a patient’s consent is usually oral and commonly referred to as expressed consent. Another type of consent common to medicine is known as informed consent. To qualify as informed consent, the patient must be given enough information to make an informed decision regarding the care that is being offered (Figure 2.2). Informed consent is most often used in hospitals prior to a significant procedure, such as surgery. For a patient to make an informed decision, you need to advise the patient of the following: • • • •
A
Your level of training Why you think care may be necessary What care you plan to provide Any consequences related to providing that care or the refusal of care
B
Figure 2.2 (A) Once the scene is safe, you must obtain consent to care for the patient. (B) Always show respect when obtaining consent.
22
www.bradybooks.com
Get Complete eBook Download by email at [email protected] You must receive consent before caring for any patient. A simple way to gain this consent may be by stating something like, “Hi, my name is Chris. I am an Emergency Medical Responder. May I help you?” A patient who is responsive may answer verbally or simply allow you to continue your care. Expressed consent does not need to be verbal. By not pulling away or stopping you and by allowing you to initiate care, the patient is providing expressed consent. There are occasions when a child refuses care. By law, only a parent or guardian of the child may give consent or refuse care. Of course, gaining the child’s confidence and easing any fears should be a part of your care.
Implied Consent In emergency situations in which a patient is unresponsive, confused, or so severely ill or injured that expressed consent cannot be given, you may legally provide care based on the concept of implied consent. It can be implied that the patient would want to receive care and treatment if he or she was aware of the situation and able to respond appropriately. Since children are not legally allowed to grant consent or to refuse medical care, a form of implied consent is used in most states when parents or guardians are not on the scene and cannot be reached quickly. The law assumes that the parents would want care to be provided for their child (Figure 2.3). The same holds true in cases involving the individuals with a developmental disability and individuals with mental illness. It is assumed that the patient’s parents or legal guardians would give consent for treatment if they knew of the emergency situation.
unresponsive ▶ having no reaction to verbal or painful stimuli; also referred to as unconscious. implied consent ▶ a legal form of consent that assumes that a patient who lacks the capacity or competency to provide his or her own consent would consent to receiving emergency care if he or she were able. This form of consent may apply in situations where the patient is a minor, unresponsive, or lacks capacity.
Emancipated Minor Not all those under the age of 18 are considered minors in the traditional sense. Some individuals have become legally emancipated and have been released from the control of their parents or legal guardians. Emancipated minors are legally allowed to make their own decisions regarding medical care. Minors may become legally emancipated if they are married, pregnant, a parent, a member of the armed forces, or financially independent and living away from home. It is not common for an Emergency Medical Responder to encounter an emancipated minor. Should this situation occur, simply provide care as you would an adult patient in the same situation. You may not have any real way of verifying if the patient is indeed emancipated; you may have to go on faith. If in doubt, allow someone of higher authority to decide.
emancipated minor ▶ a minor whose parents have entirely surrendered the right to the care, custody, and earnings and no longer are under any duty to support the minor.
Figure 2.3 Implied consent is used when the patient is a minor.
Chapter 2 Legal and Ethical Principles of Emergency Care 23
Get Complete eBook Download by email at [email protected] OBJECTIVES
Refusal of Care
5. Explain the role of the Emergency Medical Responder for patients who refuse care.
Alert and competent adults have the right to refuse care. Their refusal may be based on a variety of reasons, including their economic situation or religious views. They may even base it on a lack of trust. In fact, they may have reasons that you find senseless. For whatever reason, competent adults may refuse care. You may not force care on competent adults, nor may you restrain them against their wishes. Restraining or threatening to restrain a patient against his or her wishes could result in a violation of criminal law and result in a charge of assault and/or battery. Your only course of action is to try to gain a patient’s confidence and trust through conversation. If this fails and you feel the patient is at risk, you may have to call in law enforcement. A patient does not have to speak to refuse your care. If the patient shakes his or her head to signal “no” or if he or she holds up their hand to signal you to stop, the patient has refused your help. Should the patient pull away from you, that also may be viewed as refusal of care. It is important for you to understand the laws that govern patient refusal in your area. In many jurisdictions, an Emergency Medical Responder may not leave a patient who is refusing care until someone with higher training has arrived and taken over care. When your care is refused:
6. Differentiate civil (tort) versus criminal litigation. criminal law ▶ the body of law dealing with crimes and punishment. battery ▶ unlawful physical contact.
• Stay calm and professional, and do your best to explain the situation to the patient. • Inform him or her of the potential dangers of refusal. • Do your best to identify his or her reasons for refusal. • Use the aid of someone the patient trusts to try to convince him or her to accept care. • Carefully document the refusal of care.
Documenting a Refusal of Care
KEY POINT When providing care to the ill and injured, you are more likely to be sued for what you DON’T DO rather than for what you DO. For this reason, refusal of care is the source of highest liability for an Emergency Medical Responder. Your medical director and service director should provide you guidelines and protocols to follow in these circumstances.
Situations that involve a refusal of care can be some of the riskiest from a legal standpoint. There may be an accusation of negligence if the patient becomes worse or dies following your contact, despite a refusal of care. Carefully document your offer of help, your explanation of your level of training, why you think care is needed, the consequences of not accepting care, and the patient’s refusal to accept your care. Also document the names of anyone who witnessed your efforts to assist the patient. If your EMS system provides you with release forms, ask the patient to please read and sign the form. Make certain that you ask the patient if he or she understands what he or she has read before signing the form. Whenever possible, have someone such as the patient’s spouse or a member of another agency sign as a witness to the refusal of care. A parent or legal guardian can refuse to let you care for a child. If the reason is fear or lack of confidence, simple conversation may change the individual’s mind. In cases involving children, if the adult takes the child from the scene before EMTs arrive, you must report the incident to the EMTs or to the police. All states have special laws protecting the welfare of children. Know the laws in your state and jurisdiction regarding reporting such events. In all cases, know and follow local protocols.
FIRST ON SCENE continued Sara approaches the man lying in the road and finds him unresponsive. With each raspy breath, blood pours from his mouth and collects on the pavement in a shining pool. Unsure exactly what to do, she walks over to the overturned car where she finds a woman, clad in a bright tank top and
24
www.bradybooks.com
shorts, pinned between the passenger door and the tree. “Hello?” Sara says. “Are you okay?” The woman moans softly, but her eyes remain closed. Anthony is now off the motorcycle and staring at the man in the road. “Come on!” he shouts to Sara. “My cell phone has no signal. Give your phone a try!”
Get Complete eBook Download by email at [email protected]
Advance Directives
There have been many high-profile medical cases over the years that involve the right to die and end-of-life decisions. These decisions are often left up to the surviving family members who do not always agree on the most appropriate action. Many of these cases can enter the court system and take years to resolve. One solution to the dilemma of end-of-life decisions is a legal document referred to as an advance directive. An advance directive allows a patient to define in advance what his or her wishes are should he or she become incapacitated due to a medical illness or severe injury. Advance directives are relatively simple documents that allow an individual to define their wishes or appoint another individual to make decisions on their behalf. Advance directives commonly address such issues as: • Designation of an agent or health care representative (a spouse, family member, or friend) to make decisions on the patient’s behalf • Choice to prolong or not prolong life • Pain relief • Donation of organs
OBJECTIVES 7. Explain the common elements of an advance directive. 8. Explain the role of the Emergency Medical Responder when confronted with an advance directive.
advance directive ▶ a document that allows a patient to define in advance what his wishes are should he become incapacitated due to a medical illness or severe injury.
Do Not Resuscitate (DNR) Order At some time, you will come upon a patient who has a do not resuscitate (DNR) order. It is typically in the form of a written document, usually signed by the patient and his or her health care provider. It often states that, due to specific medical reasons, the patient does not wish to prolong life through resuscitative efforts. A DNR order is written and signed in advance of any event where resuscitation may be undertaken (Figure 2.4). It is more than the expressed wishes of the patient or family. It may be in the form of a document or, in some cases, the patient will be wearing a piece of medical identification jewelry containing a DNR order. The presence of a DNR order does not mean “do not provide care.” As an Emergency Medical Responder, you have a duty to provide appropriate comfort and care within the bounds of the DNR. It is also within the patient’s rights and those of the person holding Power of Attorney to withdraw the DNR order at any time. Many states also have laws governing living wills. These are the patient’s signed statements about the use of long-term life support and comfort measures such as respirators, intravenous feedings, and pain medications. Another form of advanced directive is known as a POLST or Physician’s Orders for Life-Sustaining Treatment. A POLST form is used for a seriously ill patient who is near the end of life. It does not replace an advance directive but can sometimes accompany one. The POLST provides specific instructions regarding the immediate care of a patient of any age. The two types of documents may be described as follows:
KEY POINT Be sure to understand the laws in your state regarding living wills and DNR documents so you can provide the patient with the most appropriate and compassionate care. If in doubt as to whether the documents presented to you are valid or pertain to the patient’s condition, it is better to err on the side of treating him or her until those with a higher level of certification arrive.
Advance directive • Used for anyone 18 and older • Provides instructions for future treatment • Appoints a health care representative • Does not guide EMS personnel POLST and DNR • Used for those who have a serious illness, at any age • Provides medical orders for current treatment • Guides actions by EMS personnel
Negligence
OBJECTIVE
The basis for many civil (tort) lawsuits involving prehospital emergency care is the concept of negligence. Tort law involves a wrongful act, whether intentional or unintentional, that causes an injury. Negligence is a term often used to indicate either that a care provider did not do
9. Explain the concepts of duty and breach of duty as they relate to the Emergency Medical Responder. negligence ▶ a failure to provide the expected standard of care.
Chapter 2 Legal and Ethical Principles of Emergency Care 25
Get Complete eBook Download by email at [email protected] PREHOSPITAL DO NOT RESUSCITATE ORDERS ATTENDING PHYSICIAN In completing this prehospital DNR form, please check part A if no intervention by prehospital personnel is indicated. Please check Part A and options from Part B if specific interventions by prehospital personnel are indicated. To give a valid prehospital DNR order, this form must be completed by the patient's attending physician and must be provided to prehospital personnel. A) ______________Do Not Resuscitate (DNR): No Cardiopulmonary Resuscitation or Advanced Cardiac Life Support be performed by prehospital personnel B) ______________Modified Support: Prehospital personnel administer the following checked options: _____________Oxygen administration _____________Full airway support: intubation, airways, bag/valve/mask _____________Venipuncture: IV crystalloids and/or blood draw _____________External cardiac pacing _____________Cardiopulmonary resuscitation _____________Cardiac defibrillator _____________Pneumatic anti-shock garment _____________Ventilator _____________ACLS meds _____________Other interventions/medications (physician specify) _____________________________________________________________________________ Prehospital personnel are informed that (print patient name)_____________________________________ should receive no resuscitation (DNR) or should receive Modified Support as indicated. This directive is medically appropriate and is further documented by a physician's order and a progress note on the patient's permanent medical record. Informed consent from the capacitated patient or the incapacitated patient's legitimate surrogate is documented on the patient's permanent medical record. The DNR order is in full force and effect as of the date indicated below. ______________________________________________ Attending Physician's Signature
____________________________________________
______________________________________________ Print Attending Physician's Name
____________________________________________ Print Patient's Name and Location (Home Address or Health Care Facility)
______________________________________________ Attending Physician's Telephone ______________________________________________ Date
____________________________________________ Expiration Date (6 Mos from Signature)
Figure 2.4 A DNR order is one example of an advance directive. Other examples include POLSTs and living wills.
what was expected or did something carelessly. For a lawsuit alleging negligence to be successful, the following four elements must be established:
duty to act ▶ a requirement that Emergency Medical Responders, at least while on duty, must provide care according to a set standard.
26
www.bradybooks.com
• Duty to act. The Emergency Medical Responder had a legal duty to provide care. • Breach of duty. Care for the patient was not provided to an acceptable standard of care. • Damages. The patient was injured (damaged) in some way as a result of improper or lack of care. • Causation. A direct link can be established between the damages to the patient and the breach of duty on the part of the Emergency Medical Responder. In many cases, Emergency Medical Responders have a legal duty to act. Those functioning as part of a fire service, rescue squad, police agency, or formal response team
Get Complete eBook Download by email at [email protected] may be legally obliged to respond and render care. This means they are required, at least while on duty, to provide care according to their agency’s standard operating procedures. In some localities, this duty to act also may apply to paid Emergency Medical Responders when they are off duty. The concept of a duty to act can be less clear in the case of Emergency Medical Responders working in a business office or industrial environment. When in doubt, it is best to provide care and call for help. Since the laws governing the duty to act vary from state to state, your instructor can inform you about the specifics in your state or region. In most cases, an Emergency Medical Responder is considered to have a duty to act once he or she begins caring for a patient. If care is offered and accepted by the patient, a legal duty to act has been established, and the Emergency Medical Responder must remain at the scene until someone of equal or higher training takes over. After a duty to act has been established, the second condition for negligence would be applicable if the care provided was substandard. The same would apply if the care rendered was beyond the scope of the Emergency Medical Responder. Finally, if there was a duty to act and the standard of care was not met, a suit for negligence may be successful if the patient was injured (damaged) in some way due directly to the inappropriate actions of the Emergency Medical Responder. This is a complex legal concept, made more difficult by the fact that the damage may be physical, emotional, or psychological. Physical damage is the easiest to understand. For example, if an Emergency Medical Responder moved a patient’s injured leg before applying a splint and the standard of care states that the Emergency Medical Responder should have suspected a fracture and placed a splint on the limb, then the responder may be negligent if this action worsened the existing injury. The same case becomes much more involved when the patient claims that the Emergency Medical Responder’s inappropriate action caused emotional or psychological problems. The court could decide that the patient has been damaged and establish the third requirement for negligence. Inappropriate care does not always involve splinting, bandaging, or some other physical skill. As a general rule, you should always advise a patient to seek treatment by EMTs and to go to the hospital. If you tell an ill or injured patient that he or she does not need to be seen by more highly trained personnel, you could be negligent if you had a duty to act and the patient accepted your care, but: • The standard of care stated that you should have alerted or had someone activate the EMS system to request an EMS response, and you failed to do so. • An avoidable delay in providing care led to additional injury. As stated above, a requirement for proof of negligence is the failure of the Emergency Medical Responder to provide care to a recognized and acceptable standard of care. There is no guarantee that you will not be sued, but a successful suit is unlikely if you provide care to an acceptable standard. If your state has Good Samaritan laws, you may be protected from civil liability if you act in good faith to provide care to the level of your training and to the best of your ability. You will be trained to deliver the standard of care expected of Emergency Medical Responders in your area. Your instructor will explain the laws specific to your locality.
Abandonment
Once you begin to help someone who is sick or injured, you have established a legal duty and must continue to provide care until you transfer patient care to someone of equal or higher training (such as an EMT, paramedic, or physician). If you leave the scene before more highly trained personnel arrive, you may be guilty of abandoning the patient and may be subject to legal action under specific civil (tort) laws of abandonment (Figure 2.5). If the
OBJECTIVE 10. Explain the term Good Samaritan law and how these laws relate to the Emergency Medical Responder.
IS IT SAFE
?
One of the most common places abandonment is likely to occur is at an emergency scene, before EMTs or Paramedics arrive. This can occur if the Emergency Medical Responder leaves the patient and the scene before providing an appropriate hand-off to EMTs.
Good Samaritan laws ▶ state laws designed to protect certain care providers if they deliver the standard of care in good faith, to the level of their training, and to the best of their abilities. abandonment ▶ to leave a sick or injured patient before equal or more highly trained personnel can assume responsibility for care.
Chapter 2 Legal and Ethical Principles of Emergency Care 27
Get Complete eBook Download by email at [email protected]
Figure 2.5 Once care is initiated, the Emergency Medical Responder assumes responsibility for the patient until relieved by more highly trained personnel.
IS IT SAFE
?
One of your legal and ethical obligations is patient confidentiality. Discuss with your instructor just what you can talk about and with whom before you accidentally share something that you should not. It is better to be safe than sorry. If in doubt, don’t share! OBJECTIVE 11. Explain the role of the Emergency Medical Responder with regard to patient confidentiality. confidentiality ▶ refers to the treatment of information that an individual has disclosed in a relationship of trust and with the expectation that it will not be divulged to others. Health Insurance Portability and Accountability Act (HIPAA) ▶ a law that dictates the extent to which protected health information can be shared.
28
www.bradybooks.com
scene becomes unsafe and you must leave the patient to ensure your own safety, it is unlikely that you will be accused of abandonment. Because you are not trained in medical diagnosis or how to predict the stability of a patient, you should avoid leaving a patient even if someone with training equal to your own arrives at the scene. The patient may develop more serious problems that would be better handled by two Emergency Medical Responders. Some legal authorities consider abandonment to include the failure to turn over patient information during the transfer of the patient to more highly trained personnel. You must inform those providers of the facts you gathered, the assessment made, and the care rendered.
Confidentiality
Confidentiality is an important concept for those who deal with and care for patients. As an Emergency Medical Responder, you should not speak to your friends, family, and other members of the public (including the press and media) about the details of care you have provided to a patient. You should not name the individuals who received your care. If you speak of the emergency, you should not relate specifics about what a patient may have said, any unusual aspects of behavior, or any descriptions of personal appearance. To do so may violate the confidentiality of the patient. Your state may not have specific laws stating the above, but most individuals in emergency care feel very strongly about protecting the patient’s right to privacy. Information about an emergency and patient care should be released only if the patient has authorized you to do so in writing or if you receive an appropriate request from a court or law enforcement agency. In all other cases, refer requests for patient information to your supervisor or other appropriate individual within your agency or institution. Authorization is not required for you to pass on patient information to other health care providers who are a part of the continued care of the patient (Figure 2.6). This sharing of information with those involved in the care of the patient is a necessary and important part of good patient care (Figure 2.7). There are laws, such as the Health Insurance Portability and Accountability Act (HIPAA) that went into effect in 1996, that dictate the extent to which protected health information may be shared. HIPAA gives patients more control over their own healthcare information and limits the way that information is stored and shared with others. It also establishes strong accountability for the protection, use, and sharing of patient information, and provides significant fines for violating these regulations. A good rule of thumb regarding the sharing of patient information is, when in doubt, don’t. Your instructor will explain in detail what types of information may be shared and in what situations. Figure 2.6 To maintain patient confidentiality, discuss your patient with only those who will be continuing patient care.
Get Complete eBook Download by email at [email protected] Figure 2.7 You must provide an accurate report to the EMS team who will be taking over care of the patient.
Reportable Events
All 50 states have laws that define mandated reporters and what types of events they must report.5 What differs from state to state is who is considered a mandated reporter. For example, all Emergency Medical Responders must report certain events or conditions that they know or suspect have occurred. These events may include such things as exposures to certain infectious diseases, injuries that result from a crime, child and elder abuse, domestic violence, and rape. Check with your instructor, service director, or state and federal agencies to learn which incidents are reportable in your area and to whom or to which agency you should report them.
KEY POINT Patient confidentiality does not apply if you are required by law to report certain incidents (such as rape, abuse, or neglect), if you are asked to provide information to the police, or if you receive a subpoena to testify in court. Maintain notes about each incident to which you respond, and keep a copy of any official documents filled out by you or responding EMTs.
OBJECTIVE 12. Explain the term mandated reporter and how it relates to the Emergency Medical Responder.
FIRST ON SCENE continued Sara realizes that she can’t safely reach the woman pinned by the car and decides to try to help the man in the road. She shakes off her backpack, rummages through it, and pulls out two large beach towels. “Help me roll him onto his side,” she says to Anthony. “Slow and careful!” They are able to get the man onto his side and clear much of the blood from his mouth and nose. “Hey, here comes a car,” Anthony says as he holds the man’s head
still. “Let’s have them stay here with these people while we go get help.” “I’ve already started helping them,” Sara says and grabs one of her oversized beach towels to flag down the oncoming car. “I can’t leave now.” The approaching car slows to a stop, and the windows are suddenly filled with round, curious faces. Sara runs to the driver’s side. “Listen, these people are really hurt. I need you to find a phone and call 911!”
Special Situations Organ Donors You may respond to a call where a critically injured patient is near death and has been identified as an organ donor. An organ donor is a patient who has completed a legal document that allows for donation of the patient’s organs and tissues in the event of his or her death. A family member may give you this information, or you may find an organ donor card in a patient’s personal effects. Sometimes this information is indicated on the patient’s driver’s license. Emergency care of a patient who is an organ donor must not differ in any way from the care of a patient who is not a donor.
mandated reporter ▶ any individual required by law to report (or cause a report to be made) whenever financial, physical, sexual, or other types of abuse or neglect have been observed or are suspected.
Medical Identification Devices Another special situation involves the patient who wears a medical identification device (Figure 2.8). This device—a card, necklace, or wrist or ankle bracelet—is meant to alert
Chapter 2 Legal and Ethical Principles of Emergency Care 29
Get Complete eBook Download by email at [email protected] EMS personnel that the patient has a particular medical condition, such as a heart problem, allergies, diabetes, or epilepsy. If the patient is unresponsive or unable to answer questions, this device may provide important medical information. In some areas of the country, the Vial of Life program is currently in use. This program includes a special vial where important medical information is stored and a window sticker that alerts EMS personnel to the presence of the vial. The vial is kept in the patient’s refrigerator, where it can be found easily by rescuers.
Crime Scenes A crime scene is defined as the location where a crime has been committed or any place where evidence relating to a crime Figure 2.8 The MedicAlert bracelet is one example of a may be found. Many crime scenes involve injuries to people medical identification device. and therefore require the assistance of EMS personnel. If you suspect a crime has been committed, do not enter the scene OBJECTIVE until it is safe to do so or you are instructed to by law enforcement personnel. 13. Explain the role of the When an Emergency Medical Responder is providing care at a crime scene, certain Emergency Medical actions should be taken to preserve evidence. Make as little impact on the scene as possible, Responder with respect moving items only as necessary for patient care. Take special care to note the position of to evidence preservation the patient and preserve any clothing you may remove or damage. Try not to cut through when working in or around holes in clothing from gunshot wounds or stabbings. Remember to report any items you an actual or potential crime move or touch. scene.
FIRST ON SCENE Wrap-up About 15 minutes later, just when Sara is beginning to think that the people in the car might have just kept on driving, she hears sirens approaching. What a comforting sound! she thinks. Within moments, the scene is filled with firefighters in bulky yellow coats and pants, carrying multicolored bags and shouting orders to each other. The man on the road is quickly loaded into an ambulance, which rushes away with sirens blaring. Sara turns and
30
www.bradybooks.com
walks over to see what they are doing to help the trapped woman. The firefighters have peeled most of the car away using large, noisy power tools. Once the woman is finally freed, Sara sees that the woman’s left leg is nearly severed at about mid-thigh. With a sigh, Sara makes her way past the blood and bent pieces of the small car and finds Anthony over by the motorcycle. She hugs him and they both watch silently as the second ambulance pulls away and disappears around the same bend.
Get Complete eBook Download by email at [email protected]
2 REVIEW
Summary As an Emergency Medical Responder, you must become well informed regarding the legal and ethical responsibilities that come with your new role. Here is a summary of some of these key principles: • You may have a legal duty to provide care and must do so within your scope of practice. • You must understand the difference between your scope of practice and the expected standard of care for your area, region, or state. • You must maintain a high degree of integrity as well as ethical and moral standards when caring for patients. • You have a responsibility to keep both your knowledge and skills up to date.
• You must obtain consent from each and every victim you enco unter and be able to apply the principles of expressed and implied consent appropriately. • It is especially important to properly manage and document all patients who refuse care and enlist the assistance of EMS personnel and/or law enforcement when necessary. • You could be accused of negligence if you do not provide an acceptable level of care or if you abandon your patient. • You must respect the privacy and confidentiality of all patients and refrain from sharing information about patients unless legally allowed or required to do so.
Take Action MY WISHES
COMPANY VALUES
Most states have a standard advance directive form that can be found online. Download this form and study it so you can be familiar with what it looks like and what it contains. Take it one step further and complete the form with your own information. Going through the steps of deciding your own end-of-life choices is a good exercise for all EMS professionals. Share your wishes with family members, and ask them to share theirs as well.
Ethics and values were briefly discussed in this chapter. Consider doing some research to determine if the company or agency you work or volunteer for has a common set of shared values. If so, what are they, and do you feel you can embrace them? Perhaps they have a code of ethics. Find out what it says, and ask yourself how such a document may have been developed. Compare these values with your own. Do they complement or perhaps conflict with one another? For a fun activity that allows you to identify your own personal core values, go to www.icarevalues.org.
First on Scene Run Review Recall the events of the “First on Scene” scenario in this chapter, and answer the following questions, which are related to the call. Rationales are offered in the Answer Key at the back of the book. 1. Why do you think Anthony wanted to leave the scene so quickly?
2. Out of the patients listed, who is your first priority and why? 3. Should you leave the scene after you start treatment? 4. What information will you want to give the ambulance crew when they arrive on scene?
Quick Quiz To check your understanding of the chapter, answer the following questions. Then compare your answers to those in the Answer Key at the back of the book. 1. The actions that a similarly trained individual would do, given the same or similar circumstances, are referred to as the: a. standard of care. b. scope of practice.
c. duty. d. negligence.
2. A document that allows a patient to define in advance what his or her wishes are should he or she become incapacitated is called a(n): a. power of attorney. b. advance directive.
c. individual protocol. d. doctor’s directive.
3. What type of consent is necessary to obtain from responsive, competent adult patients? a. b. c. d.
Implied Applied Absentee Expressed
4. Which one of the following is NOT true about expressed consent? a. b. c. d.
The patient may withdraw it at any time. It may be given via nonverbal communication. It can be given by parents of minors on their behalf. It requires a signed form to be valid.
Chapter 2 Legal and Ethical Principles of Emergency Care 31
Get Complete eBook Download by email at [email protected] 5. You are caring for an overdose patient who is unresponsive. You are legally allowed to provide care based on what type of consent? a. b. c. d.
Implied Expressed Assumed Informed
6. Which one of the following patients may legally refuse care at the scene of an emergency? a. 11-year-old boy who was hit by a car while riding his bicycle b. 26-year-old unresponsive overdose patient c. 46-year-old intoxicated driver of a vehicle involved in a collision d. 68-year-old alert woman having chest pain 7. Which one of the following is NOT an element required for a claim of negligence? a. b. c. d.
Duty Abandonment Damages Causation
8. Most states require Emergency Medical Responders and other EMS personnel to report incidents involving known or suspected: a. seizure activity. b. accidental overdose.
c. abuse or neglect. d. pregnancy.
9. When caring for a patient at a crime scene, you should: a. allow the patient to shower prior to transport if they wish. b. avoid moving objects at the scene when possible. c. question the patient about the crime and report information to law enforcement. d. refuse to enter without an armed police escort. 10. An Emergency Medical Responder fails to protect patient privacy when he or she: a. provides detailed information about the patient to the nurse in the emergency department. b. returns to the station and shares the patient’s name with colleagues. c. shares details of the patient’s condition with the EMTs who are taking over care. d. provides details about the emergency after being subpoenaed to court.
Endnotes 1. Eboni Morris, “Liability under ‘Good Samaritan’ Laws,” AAOS Now website, Vol. 8, No. 1 (January 2014). Accessed July 3, 2014, at http://www.aaos.org/news/aaosnow/jan14/ managing3.asp 2. Heather Caspi, “ICARE Revisited,” EMS World Web site, October 18, 2013. Accessed July 2, 2014, at http://www .emsworld.com/article/11186188/ems-customer-servicecompassion-care 3. Marc Tunzi, “Can the Patient Decide? Evaluating Patient Capacity in Practice,” American Family Physician, Vol. 64, No. 2 (July 15, 2001): pp. 299–308.
32
www.bradybooks.com
4. Alzheimer’s Association, “2018 Alzheimer’s Disease Facts and Figures,” Alzheimer’s Association, 201. Accessed March 2018 at https://www.alz.org/facts/. 5. Child Welfare Information Gateway, “Mandatory Reporters of Child Abuse and Neglect,” U.S. Department of Health and Human Services Children’s Bureau Web site, 2014. Accessed July 3, 2014, at https://www.childwelfare.gov/ topics/systemwide/laws-policies/statutes/manda/
Get eBook Payment Instant Download Link below https://browsegrades.net/documents /286751/ebook-payment-link-forinstant-download-after-payment