Medical Legal and Ethical Issues in EMS

so welcome to chapter four medical legal and ethical issues now we have a lot of chapters that are really good and they're all important in their own right however I love talking legal Concepts when it comes to EMS just because to operate in this industry you have to know the laws federally locally and what medical Direction sets forth for you and how you should operate to keep yourself out of trouble and remember by trouble I mean you can be held criminally and snivily liable for certain offenses so this chapter is going to go over the scope of practice what you can do a patient consent and refusal and how to handle those situations and other legal issues so let's talk about the scope of practice we've previously mentioned this term and it's a super important term and basically what your scope of practice is is simply put is what you're allowed to do all right and this is going to be defined by the dot right and what they've said that an EMT can and can't do by National Standard uh the state level will have a hand in certain States saying this is what we expect our EMTs to and to not do and then most importantly the standards of any agency or department is set forth by the medical director so you have federal state and local levels of determining what you are allowed to do and and point is at the National Registry level we take a generalized approach it's kind of right down the middle so one example is for a severe allergic reaction which we call anaphylaxis and EMT can give epinephrine well at the in our EMT level you are just assisting the patient with their own EpiPen you're not carrying it but through Texas law all be a less and above trucks are required to have protocols for anaphylaxis and carry an EpiPen or a replacement device just like pure Epi that you draw up so it just goes to show you that certain things at the national level will be different at the state level and each agency will govern that scope of practice differently as well whereas careflight EMTs are allowed to start IVs in the presence of paramedics which is not a common scope of practice across the industry and then we have the standard of care so if the scope of practice is what you can do your standard of care is how you should do it and we should never violate either of these things never do something that you are not trained or qualified or given permissions to do by medical Direction and then when you do a procedure or intervention you have to do it up to the standard of care per your training any violation of this you can cause harm to the patient and will get into negligence later prior to treating a patient you're going to need to have consent from them so that is basically permission to treat them now a patient who is alert and oriented and let's talk about that before we get into expressing implied a person who's alert oriented let's talk about what that is well there are four factors to orientation alert or awake just means your eyes are open you're looking around but oriented means you're you're familiar with your surroundings and we use we prove orientation by four Concepts and that's person place time and event do you know who you are do you know what day it is do you know where you're currently at and are you familiar with the situation that's going on if the answer to that question is no then the patient is considered confused okay and this is when they're awake if they're unresponsive or anything like that that totally goes out the window so when the patient can speak for themselves they're alert and rain at times for they give us express consent you can or cannot touch me okay then we get into implied consent which is an assumption so this is for people who are disoriented and no matter why they're disoriented if we will assume that the patient if they were an O times four would want us to touch them now there are other cases in which we will use implied consent uh for the patient like minors with significant injuries where we can't get a hold of their parents we'll use implied consent or patients who are suicidal in almost all 50 states a patient who is suicidal cannot refuse EMS care now they may not come willingly we may have to get PD involved but we have to use implied consent to think that they were if they were of sound body in mind they'd want to come you also have to give consideration and follow your local protocol for things like intoxication or under the influence of drugs are they able to actually make their own decisions make rational decisions to dictate the care they received so expressed I told you implied I assume with children though we're using applied consent if they have a major injury we can't get a hold of anybody but oftentimes if the parent is not available to give us to consent remember a minor is anyone below the age of 18 please remember that uh if they're not available to us uh and the child doesn't have a major injury then we can use in loco parentis that's Latin for the absence of the parents so this could be a school administrator a school teacher a friend of the family who is watching the child like if the parents dropped them off at a babysitter the babysitter can speak for the child this could be a sibling or Aunt uncle or grandparent above the age of 18 okay these are all people that in loco parentis applies to in almost all 50 states also they can get a hold of them if you're missing that then often law oftentimes law enforcement's a great way to come assume custody of the child if they're not injured don't need to go to the hospital but there's no one there to take custody of them okay um in addition to you may come across people who are what we call emancipated or no longer with their parents and this can be a legal emancipation or someone who is legally kind of divorced their parents that can be hard to prove but we can use things like bills if they have like a water bill or an electric bill or a rent bill in their name that proves they live at their own residence and on their own uh oftentimes people won't lie about that they won't know that well unless it's ever happened anyone who's seven in the state of Texas this is a specific law so it's a little different than these slides so anyone serving in the armed forces 17 and older so it only gives you about a year extension miners who have children is not absolutely true in Texas in Texas it's pregnant minors as soon as the minor has the child she goes back to being a minor she does have guardianship over her child the parent the grandparents do not have guardianship over the child she does but she goes back to being a minor and that's referred to as medical emancipation so pregnant females have medical emancipation and actually uh married people have emancipation okay and don't forget about uh any kind of time you see life-threatening injuries you can use applied consent for the kiddos police familiarize yourself with the laws you can find these by typing in Texas administrative code 157 in Google so consent oftentimes you may have a court order we call it a pal where we have involuntary Transportation this has to do with things like suicide attempts patients who are ruled and mentally incompetent and they may have APS Protective Services out at their residence with a court order saying there to go by EMS oftentimes if you have an a pal a police officer needs to go with you because they are in custody just ensure that when a patient has to be handcuffed or put into restraint by PD that the PD officer the law enforcement officer needs to be in the back of the truck with you because you may need access to that patient if they have a life-threatening emergency which may involve removing handcuffs and restraining devices so honestly you need to have a police officer with you oftentimes they'll try to follow you tell them that's unacceptable they'll have to ride with you all right always monitor people very closely that are in Restraint remember someone who has proclivity to want to hurt themselves could have a proclivity to hurt you not that those teens absolutely go hand in hand but it has to be a thought in the back of your head so when can my patient refuse care and we'll call that against medical advice or AMA so when can a patient go AMA well they have to be able to consent that means they have to be above the age of 18. and they have to be alert oriented times four and then they have to be informed of that risk before signing a release so let's break that all down so we've just been talking about legal age of consent is 18 we can get a hold of the parents by phone or in loco parentis someone there who can speak for the child who is an adult then we'll ask the ano times four questions to make sure they're oriented do you know who you are do you know where you are do you know what day it is or or gear or whatever and what's been going on that's pretty easy to establish okay once you establish that they're above the age of 18 they're already times four you need to make sure they are fully informed meaning this is the risk of refusal that you have fully assessed them remember assessment's the foundation of our care you've checked Vital Signs you've used every diagnostic you can checking blood sugar on diabetics if ALS is there and it's cardiac patient doing EKGs and hook them up to the cardiac monitor make sure they're not having heart attacks do everything you can to assess the patient and let them know of your findings and using careful wordage to not try to dissuade the patient from going but making it their choice once they've made the choice to not go you inform them of the risk of refuse they'll be blank with them if you believe something they need to go and it's harmful you would say something like listen you're having chest pain you could be having a heart attack and you could die from a heart attack today are you aware yes cool if they're aware of that then you're good and you document the heck out of it and you check vitals multiple times and make sure you fully assess that patient before you walk out now after you assure the patient is fully informed they know what's going on they know the risk of them refusing they are aware they can call us back at any time you need to have them sign a release form and that release form is something specific to your agency that says hey we are not doctors we do not have all the diagnostic materials in education needed to fully diagnose you we always recommend you go to the hospital you're taking this liability on yourself you're a sound body of mine to make this decision however you're doing it against our EMS crew's wishes so make sure you're careful on your wording you should always read that aloud and ensure the patient understands it because you can always be recorded by PD or home camera or something like that I had a mentor of mine lost a job over something like that he was in a jail cell and he said he read a refusal for him and he did not and it was recorded So be careful don't lie do the right thing not out of your convenience and you're here to transport people and sometimes that sucks on a busy day but don't get yourself in legal trouble by being lazy um oftentimes you're going to require a witness for this form uh great Witnesses uh patient family patient friends bystanders First Responders PD law enforcement of any kind I really don't want your partner signing it it's not illegal but it looks like coercion uh when it's YouTube signing it versus an outside party who is agreeing with you all that the refusal was done correctly so get a witness get everything filled out the correct way don't shortchange anything because it'll shortchange your career real quick about 80 to 85 percent of EMS lawsuits are centered around the AMA so it's pretty high risk stuff so you want to try and convince them to go to the hospital in the end so spend time speaking with them sometimes we're going to be delayed on scene make sure it's clear they understand that risk of refusal aka the consequences of not going and make a clear statement to them and document the statement you made because in EMS we have a saying is if you didn't document it it did not happen all right if it's a high risk refusal where you really feel like someone needed to go and they could really truly die get medical director on the phone see if you can't get them to speak with the patient the patient to speak with an actual doctor they may have more trust for a physician than us in addition if you feel like they have a significant you can get family on the phone friends and even utilize PD now sometimes law enforcement can't make someone go but they can try to encourage it now there are times when they feel like the patient's a threat to themselves even though they haven't made a clear suicidal threat they can sometimes get them but that's a real Shaky Ground oftentimes as long as patient hasn't been a threat they won't and I've done some silly no rides before where I had a patient having a heart attack and he absolutely refused and PD couldn't help me get him to go either and I left a guy there I never knew what happened to him but I had no doubt he was having a heart attack um and he wasn't suicidal he just hated hospitals that much that he rather just died home uh families often though the best resources in all honesty sometimes you get family in there and they'll really help you out a lot um one thing you have to remember is the power of attorney and the power of attorney is a person who can speak for the patient this is often common with patients with long-term health issues going cancer hospice patients and patients with dementia people who may go altered and unable to make a sound decision for themselves assign a power of attorney here's the deal the power of attorney has the right to say whether or not the patient does or don't does not go but only when the patient is disoriented if the patient can speak for themselves they're really no times fourth and the patient makes that decision in the power of attorney is void but if 10 seconds later while you're having them sign they start acting confused then whatever the power of attorney says will help you so what are the risks of beginning treatment or transport without consent from the patient congratulations you just committed an act of assault and battery absolutely transporting a patient against their will is kidnapping touching people against their will is assault and battery at any kind even if your your overall desire to do good was there you still touched someone who didn't want it and likewise threatening patients with patient care like some paramedics have been known to say if you don't knock us off I'm going to put a bigger IV in you that's assault you just threatened to assault someone so please don't do things like that okay treat people like people and how you would want to be treated remember to previous chapters it's always the your mama test treat patients like your mom and you're probably doing the right thing so what would you do if the patient refuses to sign the refusal form well you got to make sure they're alert and oriented times for before they can make any decision as long as you verbalize the risk then you're going to document try to get a witness there this is a great time for law enforcement or the First Responders Society or even enough had family members like I'm sorry they're being a jerk I'll Witness it is never okay to have someone sign for the patient as the patient's name they sign if it's a power of attorney they're signing their personal name all right for the patient because they have the right to do so and they should have some paperwork to back up the power of attorney claim but other than that you know you'll have husbands and wives that want to sign for each other that's unacceptable and this could be like a Parkinson's patient who's unable to write because they don't have any coordination and you know they're alert and Orient sounds for they don't want to go so if the wife you'll have the wife's side but she'll sign her name not his name sign it and you'll put y in the narrative and just like that you would document everything in that area the patient was refusing care EMS established a patient's alert Marine Sims 4 the patient refused to allow us to check vital signs or answer any questions EMS made the patient aware that we were called for a medical emergency and we had concerns that we without an assessment we do not know what's going on with the patient they told us to get off their property puberty was called and unable to assist EMS patient refused to sign a waiver form or EMS obtained a witness signature from a family member member due to the multiple attempts and so forth and so on right you document right if you didn't document it it didn't happen so it's simply put if they refused to sign and they're alert and right and just being rude then by all means just document what happened all right you fill out the refusal form you sign where the crew is supposed to sign you try to get a witness assigned to back your claim up and that's where it gets sketchy if you it looked real fishy if you're saying they refuse to sign it it was you and your partner signing and oftentimes you can't help it you're not going to have a witness because there's no one else there it's not a bad idea to get medical control on the phone to back up back you up and that's really the key to everything we talk about when you are at a point where you don't know how to treat your patient or you have some kind of medical or legal issue with the patient that's what medical control's for that's what online medical directions for is to back us up as that are their designated agent hey you don't know what's going on call me I'm a physician I probably have your answer we can figure it out together at the end of the day the medical director will give you will take the burden Off of You by that and remember when we talked to Medical direction we want to always document the order they gave us repeat it back to them and get their name and the time the order was given remember you're not always going to be talking to your medical director maybe an agent of your medical doctor or fellow physician it's absolutely okay for someone to change their mind they have the right to call 9-1-1 back and they should be made aware of that this does not mean you can't call back this just means for the hearing and now try to get someone to take and see if they'll go with someone else some people are apprehensive don't want to pay the bill see if we can't get someone to take them or stay with them oftentimes you know one time I had a parent refused let me take their kid and I was not comfortable and they're going down two miles of the roof down the road to the hospital and it was on the way back to my station I said I'm following y'all I said so go because they absolutely refused let me take them and I did I just followed them to the hospital at a safe thing they got there just fine and walked in but it made me very uncomfortable when I documented my you know all my findings so then we get into what we call Advanced directives now Advanced directives are legal documents and statements that basically tell us what we should do if the patient experiences thing like death and people have certain wishes some people do not want to be intubated or be on a ventilator or in a medical induced coma so they have these orders Advanced directives these could be a living will and most commonly an out of Hospital DNR in Texas and out of hospital dnro hdnr will have that symbol of taxes or Texas state symbol on the top and it should be signed by a physician a patient and a witness if it is not correctly signed you cannot honor it if if you have any kind of advance directive your protocol doesn't cover you can't honor it it's best to always start CPR because you can always stop it looks real bad if you didn't start CPR and after five minutes of figuring out you realize you should be starting CPR all right uh in some states like Texas a immediate family member can revoke the DNR which is kind of crappy but it's happened before so if you're there and spouse is saying please start CPR you don't look at them go they have a DNR we're not doing it go ahead and start CPR and make everyone aware of the situation um anytime you have a question about a DNR you know you're going to follow the family's guidelines what was their wishes do you have a DNR no matter what their wishes were or what the families wishes are you have to start CPR without proper documentation okay they can revoke a DNR but they cannot enact a DNR where my wife would be really wanting to get some of that insurance money you should keep a the actual copy not a copy but the original DNR needs to come with you uh here at careflight we have the ability to attach that to our chart and hand it over uh if we need to we shouldn't we shouldn't you know be transporting patients with DNR uh but sometimes we have critical patients uh hospice patients things like that that are going to have dnrs we need that original one certain uh departments and companies may like allow for like living wills and certain things that careflight were pretty strict we wanted we want our DNR and again if there's any question of the paperwork you're looking at go ahead and call medical control and clarify what kind of issue you're facing so you know get yourself in any illegal trouble so let's talk about negligence important word this is when something we have done has caused harms of the patient and the number one rule approving negligence against the EMT is to prove the ENT did harm by not acting or failing to act in an appropriate way okay and we refer to that act as the duty to act so when do you think you have a duty to act I can tell you this when you're in service and on your ambulance you have a duty to in your service area you have a duty to act when you're going home from shift in uniform and you got an EMS sticker on the back of your truck you do not have a duty to act in this state you can put EMT 9-1-1 license plate and carefied or Farmer's Branch fire department whatever you want to put all over that vehicle if it is not a response vehicle you are not on the clock you are not in Duty and you do not have a duty to act now we would hope you would help people who need you and we'll get into the good Samaritan's law about protecting us when we do want to help people on the off duty at a later slide but the duty to act is very narrow now what about Mutual aiding and stuff like that if you're going through Dallas from a transfer and then you see a car just wrecks out in front of you yes you won't get legally sued for that but you should stop and help them outside of the duty act there's a breach in the duty so the you know the duty to act is the the ability to perform care and then we get into standard to care how we did it so we had some kind of false uh action like uh uh we you know mistakenly did an intervention or we did it in an intervention we weren't qualified to do or we didn't do anything for the patient you know these all equal uh negligent actions especially when we can call prove harm now that's when we get into a very important word start Circle it highlighted if you're following on notes which is called approximate causation an approximate causation is where we can prove that the emt's action caused harm to the patient this can also be an inaction a failure of the duty to act right not acting at all and with the negligence can come civil and criminal penalty so you could face a heavy fine loss of certification termination from your job be sued by the patient and de credentialed wow just for laziness I don't defend negligence because quite frankly you have to go out of your way to commit it you can be personally sued most likely it's going to be your agency because that's going to give them the most money but your agency can also list you in the state of Texas as an RTP or a responsible third party and deflect some of that fine to you for falsification and it's a high likelihood that if they prove negligence that the state of Texas May revoke your licensure and it would be a minimum of two years before you could appeal that or not appeal but try to research that you have a you have like 14 days after legal after mail-in notice to appeal I believe it is in this state but uh most likely if they approve negligence in the court of law you're done and some of these laws will show blatant your lawyers like uh we need to just settle saddle saddle saddle saddle all right and that's called the RIS ipsa liquid I took Latin for four years so nailed it uh that just means the thing speaks for itself in Latin and I added these below that the feces all right and this often can go back to what we call in law malfi since misfeasance and non-feason said I want you to break these words down think Mal malpractice doing something you're not qualified to do think Miss mistake I can I had a failure in the standard of care and then non-feasons non no doing nothing that's abandonment which we'll get into in a second or a failure of the duty to act right you just can't walk off a scene because you don't like the patient you don't like the way they're talking to you that's considered an active abandonment you just can't leave the patient at the yard without a report or hand off and care that's an active abandonment so this is your obligation your legal obligation moral and ethical obligation to provide care so some states may have some differences I don't really know this I do know ours forwards and backwards you have to be on duty uh typically you have to be in your jurisdiction I don't believe you can get sued if you're passing by a wreck like here in Houston Texas dropping someone off and you pass by or wreck and you're ambulance I don't believe you legally have to stop uh but we would really be pissed off if you didn't a care fight so until we clarify that in class please always stop and render Aid when you're in your Ambience as long as there's not a patient in the pack okay there's a patient in the back we need to continue patient care roll down your window says we already have a patient on board who were taken to the hospital we have called this wreck in and we call this the First Responders help is on the way it's always you know like morals and ethics you know morals are something personal to you and ethics is more how Society or a system dictates what you should and should not do so abandonment is considered once care being initiated and the men discontinued before we hand off care to equal or greater training and that's what we've been talking about in every chapter so far we always hand off care to equal or greater levels of Provider so nurses and Physicians paramedics things like that so if we don't do that we just leave the scene where there's patience there we've committed an act of Abandonment this can happen at the hospital especially during covid where sometimes we're holding the wall or waiting to get our patient onto a hospital bed for hours you can't just leave the patient in a waiting room without proper permission signature and a handoff of care or you could be hit with abandonment charges there's another thing in the state of Texas that can constitute abandonment that's not mentioned in these slides and that is walking off an in-service ambulance without proper relief or notification so if I got mad at my you know Regional director and I you know custom out hung up the phone and jumped off the truck that call comes out and no one can get there because I I walk off the truck that the set of Texas has known to suspend someone for abandonment of post I'm real big on that too I can't stand someone you know let someone know listen I'm done I need to go ahead and quit I need you to make you aware that I am quitting at this point in time this is my resignation uh you are going to need to get someone here or simply notifying someone hey I have a family emergency I have to go all right letting dispatch know hey we're down I have a family emergency I'm out of service okay be careful you just remember how it feel to be you if it was your kid at the house and you call the local 911 system they're going to be 15 minutes delayed because some EMT decided to get mad and walk off a truck all right use your brain don't put your pride again before patient care okay you are servant to the community and the citizens we serve you got to act as such good Samaritan's laws are really interesting because people have a lot of misconceptions about them and again this is one of those things where nationally everyone has their own laws but they're pretty really close in nature and I'm going to talk to you more related to Texas law so the Good Samaritans laws aren't there to force you to act they are protect to protect you from the liability of acting so as long as you are not negligent in a situation the Good Samaritan laws can protect you in another situation uh the Good Samaritan law won't protect you if you are actually involved in the incident in the state of Texas there's a good case from someone up north I don't believe this was in Texas we're a nurse stop to render Aid on a motor vehicle accident she did an emergency jerk because the vehicle was feeling full of smoke or hit electrical lines or something and she pulls a lady out of the car emergency jerk wiser remember that's appropriate because the scene's not safe right and she drags her away well the woman wound up having like a broke neck or back or something and she takes the nurse to court saying if she wouldn't have moved her so aggressively she probably caused her injury one which we all know that most likely the injury was caused by the wreck not that she didn't hurt it but she's not negligent because of the situation calls for an emergency move so it last I followed up I believe that she had won the case uh good Samaritan's Law High protector and it was an appropriate action so you arrive on scene of a patient in Cardiac Arrest the family says she has a DNR but doesn't know where it is how should you handle this start CPR okay you start CPR and while you're starting say listen we have to start CPR legally we could get in a lot of trouble because we have to have paperwork so we're going to start CPR and we're going to start the whole thing and if you can go find that uh documentation for us once you find it we can talk with medical Direction and stop if the families like we can't find it you'll have to explain them we'll have to transport okay if they get nasty with you then just get on the phone with PD and medical Direction and see if we can't find Happy ground but start CPR please so you are off duty and arrive on scene of a vehicle crash police and EMS have not yet arrived are you legally obligators to stop and render Aid again this will be state by state basis but in the state of Texas no you are not you are not on duty you do not have the duty to act now morally or ethically should you act maybe I would say more morally that your own personal morals do you feel like you should act and help people also depends on where you're at are you in a bad neighborhood are there suspicious people out are people shouting at each other right you'll have to make those decisions based on scene safety and that goes for whether you're on duty or not keep yourself safe especially when it's free now we have confidentiality as well so not only do we have to take care of patients physically and psychologically we also have to consider their personal health care information or Phi and this is information that's very important to their identity so they don't get identity theft is on the rise right in the digital world driver's license social security cards birth records insurance card and Medicare cards face sheet and information on the hospital reports old Run Forms everything so much you got to think how important a medical records number is on the hospital charts all right so remember anything that can identify your patient as the patient is Phi and you are required to protect it and when you're done documenting get it under lock-in key immediately at the station the only people who can view the Phi that particular patient on that particular call are the people that have been involved in care meaning you have a first responder there paramedic first responder at EMT first responder like hey can we get the patient's name for our chart that's absolutely okay you get to registration at the hospital you arrive at the ER and they want the patient's name social home birthday that's absolutely okay you got a nurse you know walking generator walks by and goes hey what's going on with your patient it's not their business they're not involved in patient care and I'm not trying to insult the janitors but if you're not involved in patient care then don't say anything say well that's we can't discuss that I'll let the nursing staff talk to you about that blow them off right and this all came out because the federal act HIPAA the health insurance portability and accountability act right to protect American uh Americans who go to the hospital or have medical care if you have any sort of Medical Care in this country whether it's at a doctor's office an Outpatient Surgical and emergency department or even like an obstetrical facility having a baby you're gonna have to sign something regarding your rights to the billing and your rights for protection of personal health care information and our private Health Care information and HIPAA everyone has signed one of these at some point in time you can hear it careflight on the back of our little abbreviated short forms that we give out kind of like notes that we give the nurse until our documentation is gone we have a Peak form that advises the patient of their rights and even when the patient's unresponsive I'll often put it in the room with them or near the nurse because they'll sign for it often and the patient can't sign for themselves or with the oriented patients I tell them Hey listen this is the form I promise to give you and it's going in your back to View later all right now who has rights to that document well police officers do not have right if the police officers want to see it even if the patient's committed a crime you have to they have to subpoena that record from whoever the custodian of record is for that particular agency a carefight it's Martha Goddard who works under corporate compliance at the maybe training center all of y'all have probably seen Miss Martha so that's who the elevators for outside of our classroom so miss Martha controls those subpoenas and things like that and gets records to people after they pay certain fees which is normal at every service and Department uh the patient may want to see their record they have a right to that however they have to go through Martha again at no point in time do you give a chart to anyone but the receiving facility period That's the only people you give that chart to all right there's no other law or anything that's in place to protect that just remember the patient may have identifiers on them as well typically it's more generalized stuff but here is a medical alert ID and this is great for assessment so in case you can't figure out why your patients aren't responsive they a lot of patients with long-term health issues use things I think the most common uh two diseases you'll see that are on these medical ID bracelets would be epilepsy a seizure disorder and diabetes because these are often common reasons why someone is sometimes acutely altered with their mentation so that's why they wear it so my wife will talk about her a lot in this class she is a type 1 diabetic has been since the age of three and she is 40 years old so she's coming up on year 37 quick um I believe in January or February is actually technically our 37th year uh so uh that she wears a medical ID tag always and in addition to the medical ID text she has a tattoo below it and it's the diabetes ribbon and it says she's a diabetic so I think it's real cool like her date her first like the day she was diagnosed so look for tattoos you know that's real cool that because people have those kind of things so just viewing other things that could be on the medical ID band um you know heart conditions patients who haven't planted devices like ventricular assist devices which we'll learn about later uh pacemakers defibrillators and different kinds of like uh implanted devices such as artificial heart valves significant allergies like peanuts things like that and this could be bracelets could be a card in their wallet uh so you just kind of got to do a good body assessment especially if they're altered to where you look in their wallet get their name address emergency contacts this is going to also be gained through medical apps on phones uh in contact some people have their ice number put like I do and that stands for in case of emergency some people put in their phone ice and that's to help fire departments and EMS Personnel identify the emergency contacts real cool thing they used to do but almost all smart watches and stuff people have the health app they give them their blood type medications medical problems and their emergency contacts and allergies they have so you got to kind of think broadly when you're dealing with sponsor Folk what about organ donors well that's seen in Texas on IDs I have a philosophy with organ donors I'm not trying to down you if you're not an organ donor but you do not have the right in my opinion to accept an organ if you're not willing to give an organ I think actually it's pretty damn disgusting so I would keep it to yourself not that I'd ever do anything to any of y'all I love everyone the same but keep it to yourself please because I have a big problem with people who won't donate the organs because the you will definitely aren't going to do anything with them at your time of death so uh family members may be able to identify that they may have a donor card and here in Texas again the driver's license a big thing uh this may dictate whether or not we do CPR a little longer than we normally would because we want to save those organs if possible all right um you know the hospital no receiving that's why you're working them it's because of that because if they can get them going we can want to harvest those organs while they can and save a whole bunch more lives so that life was never in vain here's some other things uh Safe Haven laws those are really cool this ensures that patients aren't uh or I'm sorry newborn babies aren't dumped and dumpsters um and and murdered and things like that uh by you know mothers who feel like they cannot uh you know maintain or keep that child in a stable home uh instead of giving them up the right way they sometimes panic and we've established Safe Haven baby sites across the country to ensure that we can limit that if we save one child per year which they do a lot more than that then it's well worth it if you didn't know QT all has these safe uh Haven baby signs that you see up there that you saw animatedly pop up in the in the presentation uh EMS stations and fire stations especially in Texas I don't know about other states if it's federal or local but I know in Texas EMS and fire stations and release stations are all considered safe haven baby sites as are churches why uh so we can save as many children as possible and not get them abandoned into bad situations one of the key things I worked for when the safe haven laws started coming out I was in EMS and my previous medical director and clinical team said hey if you ever have a safe haven baby dropped off to you by a family member don't ask any questions because we don't want to have them flee so basically what they meant is get the baby in your hands before you ask any questions the thought process in that if you start asking questions their defense mechanism goes off they run off for the kid and now you don't have them so get the baby in your hands and as they're walking away at most go hey is there anything we need to know about this child's health and safety that is our health you say any health quite frankly I don't care we can figure that out I'll let them just walk and say thank you for doing the right I would tell them thank you for doing the right thing just in case if they're ever faced with that situation again that they'll do the same damn thing okay what about crime scenes think about the specialty situation what's important not to disturb evidence now there's lots of different crime scenes you're going to be on the scenes and most commonly of domestic violence you gotta remember if someone's been attacked most likely it's by someone they know and domestic violence seems like it's on the rise or just the populations getting more noticeable and there's a just a greater awareness through the media about it so uh scene safety is your top priority so do not get on scenes uh that are crime scenes without law enforcement there I didn't say fire department I said law enforcement okay the fire department wants to be silly and jump the scene before it's safe that's their business do not put yourself in unsafe situation remember this is what we refer to as staging setting up a great distance from the call but available to only that call until PD has made it uh safe a residence we want to Stage a minimum of a block down and a block over where we're out of you and typically I want to Stage typically I like about a quarter to a half a mile away I just want to be good and out of sight of whatever is happening always ensure that you park and stay in your vehicle that you are uh not in a place where you can get hit or be attacked okay oftentimes if you know where the fire department's staging it's best to stage with them because many uh apparatus and bodies make it a less chance for you to get attacked okay deactivate your lights and Sirens while you're sitting there most of the times most companies and agencies are not going to have you activated priority when you're going to Stage for a possible crime scene okay when you are cleared to enter by PD they're confirmed on scene you get on scene monitor turn off your lights and if they have their lights on you may turn your lights off on but if their lights are off keep your lights off because we don't want to alarm this and get people's guard up as you're walking in be mindful of where you step and where you walk let's take one line in one eye line out to not disturb any evidence however this could be a multi-faceted thing if the patient's deceased and you're not going to work them because they have an injury incompatible with life say a gunshot wound in their head or something you know there's not much angst going on because the patient's dead you're not working them but oftentimes on the crime scene the patient may still be alive a sexual assault being really common so what do you do well just FYI your safety always comes first then the patient's life threats all right we do want to preserve seen evidence but not at the cost of treating our patients so do what you can to protect the patient take one line and one eye out don't disturb evidence on scene but be mindful that the patient's needs are a priority over evidence we'll get into rape and things like that and how we handle it and what kind of facility we should go to at a later time but it's often important to remember what you touched if the patient was assaulted in any way or sexually assaulted in any way we want to keep the clothing they have have and bag it put it in the ambulance we prefer paper over plastic we want to document everything we have to PD we want to get a good statement from PD and we want to discourage the patient from using the restroom or showering because they have evidence on their body well again we'll get real heavy into that later as far as special reporting goes just remember that any kind of abuse and neglect is required to be told to Texas Department of Family Services protective family services again you can call the number provided on previous slides and previous presentations I can get you that number if you ever call me or you just simply type that into Google and you follow the directions and set up an account I would suggest if you're going to work in healthcare you just go ahead and set up account and do everything via online human trafficking if you have an issue of human trafficking I haven't had that call yet but it is on the rise any kind of violence involving weapons typically PD better be there already uh and that likely goes with sexual assault or rape um you have to report these things okay now after again when PD's on scene that's different with cases of abuse and neglect where oftentimes you don't may not know until it ends that's when you would report it oftentimes you're going to report to the adult side on patients who are living at home elderly patients and unable to take care of themselves and it sucks to take away their independence but it's for their own good some states may require that if you have an intoxicated person whose cause injuries or is injured themselves in this state it's only if we have an intoxicated person whose cause like other damage and injuries we have one alert PD and again most wrecks you're going to have an officer come out there to do a report mentally incompetent people with injuries these people could have long-term mental incompetency or be child uh oftentimes we can use implied consent with mental and competent people just like we can with the children okay if they are truly injured uh again oftentimes when we're confused we just need to consult with medical Direction and law enforcement work together to make sure the patient has the best possible outcome and we're operating morally ethically and legally and speaking of that it's kind of set us up morality right your morals that's the personal opinions but your ethics is more of like a standard of behavior for oppression or a profession or how Society views you okay so there's certain ethical Behavior an EMT should have and then you should have your own morals to kind of dictate and we all have different morals and oftentimes it's a product of your raising right and what I find to be moral and what you find to be moral right and we need to find a happy medium ground not to be too controversial we don't need to give off our own political or religious views our views on race or anything like that we need to be right down the line and we need to be bipartisan on everything so you need to respect people to make their own rights don't talk down to people even when they're altered ovaries operate fairly and justly with patient advocacy at the Forefront of your mind right behind scene safety right remember that you are a representation of not only care flight but of me and our entire profession never take that lightly okay people judge you by your performance and if you're a good person and you operate morally and ethically you're probably viewed as a good EMT the last slide of this presentation is a slide I added looks all cool and stuff it's important to me and I find that your book lacks in the law as far as I know I may have not just caught it because I haven't read it from cover to cover I just kind of eye through it and it's referred as the entaila law or the emergency medical treatment Act of Labor Act this is known as the federal anti-dumping law and this keeps people from dumping patients off at the wrong facility not necessarily us because we have a lot of power when it comes to that but ensuring that hospitals don't refer patients to inappropriate hospitals because they don't want them at theirs or you know trying to send a patient out ALS or BLS when they should be ALS just for the sake of getting them out faster right so this prevents hospitals also from denying care from people there's the 250 yard Rule and that means when we're within 250 yards of that ER entrance that that patient is now legally there so don't think you can just go under an ER Bay and the patient goes where are we at he said we're at Sunnyvale remember it said I was taking you all decided I want to go somewhere else you have to tell I'm sorry there's a a law that prevents me from doing that once I'm within 250 yards of this uh facility I have to be here the only exception to the 250 yard rule is helicopter lz's these hospitals all have licensed lz's that are appropriately lighted in safety standards to ensure that helicopter Crews get the land and take off in the safest area possible so uh oftentimes when we have seen responses and we need to utilize aircraft we'll land them in a field or on a highway well that's not inappropriate and it puts a lot greater Danger on the helicopter crew and in like places that careflight we can't land a helicopter if there's not a ground contact whether that's First Responders or the MS crew Landing them so uh if we're tied up in patient care that makes it really hard to land them right so why not just travel to a local hospital and land them there so that's just a verbal agreement you do not have to have a written agreement on that so what like one we use a lot is Texas Health Kaufman and Baylor Scott and White Forney and there's one's down south as well this is just the area I'm familiar with we'll call them on their patient care line like where we're going to give a report and say hey this is unit 9412 we're not to your facility we have a patient we're going to fly off of your LZ we just wanted to know if you could send an alert get everything activated and we don't need y'all we're just going to use the LZ if that's cool they'll say you're right on we have it thank you for letting us know giving us a heads up they do that so they can make an announcement to anyone who's partner there also make sure their maintenance people know to activate lights and make sure the scene is safe so it offers an extra level of protection by giving them a heads up as well and so they're not wondering why there's an ambulance sitting out in their Bay uh also uh you know like I told you it ensures that there is accountability between transferring facilities that's because hospitals used to dictate hey we don't want this patient or that patient because they can't pay now if you're an ER you have to receive all patience all right um one case that we see with this is that when you go to transfer patients when you learn how to do that in the academy you're going to receive a whole bunch of paperwork from the transferring facility it's something it's called an mot and that's a memorandum of transfer so basically you have to have three Physicians involved in the transfer of a patient this is where it gets crazy so you're going to have the patient the main physician who is treating the patient at that local ER Hospital right and then they call around and get acceptance uh the nursing staff does from another hospital that can handle that capability so then that receiving physician has to accept the patient then you have nursing supervisors who have to sign paperwork and inside of the patient is consent to release and transfer and all these signatures have to happen in agreement between the two facilities this can take hours to days at times depending on what type of facility you want to go to all right and and sometimes we're having to go to Long Distance facilities because that's the only one that would accept that patient and has the capabilities the patient needs so when you take a patient to a facility that can't handle them know that it's not just a oh we'll get them out to the trauma center quickly no it could take forever depending on who's accepting especially after covid where there's not enough staff in in hospital beds that go around it seems and now we talked about the two doctors where's that third one come into play I want you to think about that I told you there were three doctors involved so on the MLT we have the transferring and we have the receiving who do you think's the Third doctor is involved in this and they're not their name's not signed anywhere anything you ready for that you're a medical director because now you're involved because it's your job to go pick up that BLS patient as an EMT and take them to that next facility so now that you're providing care your medical director oversees you so that's kind of intricate no one really ever thinks an Impala that way but just remember the patient has an illegal obligation to treat the patient as you arrive once you're at their facility they cannot refuse you do not let them lie to you you are protected under the Impala laws well I hope you found this to be informative y'all almost every slide of this presentation is super informative about how you should act morally ethically and legally throughout your career please understand that these are involved on every dang call remember what consent is we can get Express consent to patients they know times four and they're telling us what they want they're not impaired by drugs or alcohol they're not making any threat against their life if they are or they're disoriented we'll use implied consent because we will imply they'd want to go if they're of sound body in mind this also pertains to children with injury or significant illness we can imply that the parents would want them to go otherwise we're going to try to get consent from the parents or in loco parentis in the absence of the parents a representative of the child maybe a family friend who's watching the kid a babysitter a school administrator or a sibling above the age of 18. our goal and refusal is to try to convince the patient to go at all costs making them aware of the risk of refusal and fully informing them please ensure that you have assigned a witnessed refusal statement to protect yourself legally and if you did not document it it did not happen remember that negligence is failing to act properly when you have a duty to act or having a malpractice or misstep in your standard of care that and induces a negative outcome and remember anytime that negligence is found and with proximate causation it's hard to win those kinds of cases it's often best just to settle out of court remember that abandonment is leaving your patient before handing off to equal or higher level of care this can be on scene when you have multiple patients this can be at a hospital you cannot get into with a patient on scene and then leave you can go stage if you feel unsafe but you are still involved on that call confidentiality is right behind patient care protecting your patient at all costs when it's a trauma mechanism a medical nature of illness scene safety we have to protect confidentiality okay ensure that you have all the documents they gave you and you hand them over document what you have in the back of your truck ensure you know that you have a custodian of record per Medicare that's supposed to handle patient requests care requests and they have to be subpoenaed the patient can simply call in and request a record for a fee and we'll give it to them you cannot give them a copy of their chart you cannot give the First Responders a coffee chart the only person you can hand over a copy of that chart to is the Receiving Hospital okay he was receiving care and instead of Texas you have 24 hours to ensure that your electronic record has been submitted in fact to the receiving facility not many services are using paper so we're going to call it an electronic PCR mm-hmm remember you can be held criminally and civilly liable for any damages you cause in this industry protect crime scenes make sure you walk the same way out that you walked in remember patient care dictate safety dictates all then patient care then worrying about the crime scene now we can do everything simultaneously for intelligent ents but I never want you to put protecting evidence ahead of good patient care in your own personal safety all right it's all common sense yo you got to go out of your way and violate your morals and ethics to be negligent okay that's why I have no pity for anybody who commits these acts all right protect your patients information use the your mama test if you how would you feel if someone leaked your private information or your mother's social security number because they were careless and having speaking on that I want to give you one last bit of information social media and HIPAA reporting patient outcomes on social media will get you quickly in a world of trouble I have had to terminate people for this in the past please do not share patient outcomes or identifiers even the scene of a call anything that's remotely don't talk about work on social media it's just not a good idea and I find it to be very immature when you ask what you've got out of this lecture I want you to know can you define the scope of practice negligence Duty direct abandonment and confidentiality if not you need to be reading okay I think it made it very clear so think about though what steps must you take when your patient refuses care or Transportation well let's ensure that they can or of legal age to consent or decline make sure they're alert and oriented and then make sure they're informed at the very end they need to sign a refusal statement and it needs to be witnessed by someone other than your crew so what are some steps you're going to do to prevent serve evidence well bag it make the police aware of it discourage showering and rape victims ensure we put things in paper bags and ensure we just limit overall touching and disturbance of the crime scene okay if you wind up on a crime scene where there is no PD that may be a time where you consider to go and Retreat the scene and Stage until PD has made it safe the last critical thinking question is you respond to a motor vehicle crash and find a seriously injured patient he has no pulse and you're about to begin CPR when someone says don't do that he's got cancer in the DNR no one has the DNR on scene you start CPR and transport the patient and that is an absolute yes unfortunately you have to have some sort of paperwork if people are getting nasty then you're gonna have to get police involved but unfortunately if they do not have the paperwork available the key is you have to transport them okay um quite frankly I'm going to be honest with you here if I find a DNR patient who is pulseless on the scene of a crash and has a significant injury I don't know if I'm going to work them so this is not the best story I didn't write this one uh but yeah we would uh we can always call medical control too and see what they say but you have to start CPR otherwise what kind of move would you get to you utilize to get the access to the patient though going back to chapter three for those of you who picked emergent you picked correct remember the patients of the CPR or need CPR you got to get them out of the vehicle quick well that's it I will see y'all on chapter five

so welcome to chapter four medical legal and ethical issues now we have a lot of chapters that are really good and they&#39;re all important in their own right however I love talking legal Concepts when it comes to EMS just because to operate in this industry you have to know the laws federally locally and what medical Direction sets forth for you and how you should operate to keep yourself out of trouble and remember by trouble I mean you can be held criminally and snivily liable for certain offenses so this chapter is going to go over the scope of practice what you can do a patient consent and refusal and how to handle those situations and other legal issues so let&#39;s talk about the scope of practice we&#39;ve previously mentioned this term and it&#39;s a super important term and basically what your scope of practice is is simply put is what you&#39;re allowed to do all right and this is going to be defined by the dot right and what they&#39;ve said that an EMT can and can&#39;t do by National Standard uh the state level will have a hand in certain States saying this is what we expect our EMTs to and to not do and then most importantly the standards of any agency or department is set forth by the medical director so you have federal state and local levels of determining what you are allowed to do and and point is at the National Registry level we take a generalized approach it&#39;s kind of right down the middle so one example is for a severe allergic reaction which we call anaphylaxis and EMT can give epinephrine well at the in our EMT level you are just assisting the patient with their own EpiPen you&#39;re not carrying it but through Texas law all be a less and above trucks are required to have protocols for anaphylaxis and carry an EpiPen or a replacement device just like pure Epi that you draw up so it just goes to show you that certain things at the national level will be different at the state level and each agency will govern that scope of practice differently as well whereas careflight EMTs are allowed to start IVs in the presence of paramedics which is not a common scope of practice across the industry and then we have the standard of care so if the scope of practice is what you can do your standard of care is how you should do it and we should never violate either of these things never do something that you are not trained or qualified or given permissions to do by medical Direction and then when you do a procedure or intervention you have to do it up to the standard of care per your training any violation of this you can cause harm to the patient and will get into negligence later prior to treating a patient you&#39;re going to need to have consent from them so that is basically permission to treat them now a patient who is alert and oriented and let&#39;s talk about that before we get into expressing implied a person who&#39;s alert oriented let&#39;s talk about what that is well there are four factors to orientation alert or awake just means your eyes are open you&#39;re looking around but oriented means you&#39;re you&#39;re familiar with your surroundings and we use we prove orientation by four Concepts and that&#39;s person place time and event do you know who you are do you know what day it is do you know where you&#39;re currently at and are you familiar with the situation that&#39;s going on if the answer to that question is no then the patient is considered confused okay and this is when they&#39;re awake if they&#39;re unresponsive or anything like that that totally goes out the window so when the patient can speak for themselves they&#39;re alert and rain at times for they give us express consent you can or cannot touch me okay then we get into implied consent which is an assumption so this is for people who are disoriented and no matter why they&#39;re disoriented if we will assume that the patient if they were an O times four would want us to touch them now there are other cases in which we will use implied consent uh for the patient like minors with significant injuries where we can&#39;t get a hold of their parents we&#39;ll use implied consent or patients who are suicidal in almost all 50 states a patient who is suicidal cannot refuse EMS care now they may not come willingly we may have to get PD involved but we have to use implied consent to think that they were if they were of sound body in mind they&#39;d want to come you also have to give consideration and follow your local protocol for things like intoxication or under the influence of drugs are they able to actually make their own decisions make rational decisions to dictate the care they received so expressed I told you implied I assume with children though we&#39;re using applied consent if they have a major injury we can&#39;t get a hold of anybody but oftentimes if the parent is not available to give us to consent remember a minor is anyone below the age of 18 please remember that uh if they&#39;re not available to us uh and the child doesn&#39;t have a major injury then we can use in loco parentis that&#39;s Latin for the absence of the parents so this could be a school administrator a school teacher a friend of the family who is watching the child like if the parents dropped them off at a babysitter the babysitter can speak for the child this could be a sibling or Aunt uncle or grandparent above the age of 18 okay these are all people that in loco parentis applies to in almost all 50 states also they can get a hold of them if you&#39;re missing that then often law oftentimes law enforcement&#39;s a great way to come assume custody of the child if they&#39;re not injured don&#39;t need to go to the hospital but there&#39;s no one there to take custody of them okay um in addition to you may come across people who are what we call emancipated or no longer with their parents and this can be a legal emancipation or someone who is legally kind of divorced their parents that can be hard to prove but we can use things like bills if they have like a water bill or an electric bill or a rent bill in their name that proves they live at their own residence and on their own uh oftentimes people won&#39;t lie about that they won&#39;t know that well unless it&#39;s ever happened anyone who&#39;s seven in the state of Texas this is a specific law so it&#39;s a little different than these slides so anyone serving in the armed forces 17 and older so it only gives you about a year extension miners who have children is not absolutely true in Texas in Texas it&#39;s pregnant minors as soon as the minor has the child she goes back to being a minor she does have guardianship over her child the parent the grandparents do not have guardianship over the child she does but she goes back to being a minor and that&#39;s referred to as medical emancipation so pregnant females have medical emancipation and actually uh married people have emancipation okay and don&#39;t forget about uh any kind of time you see life-threatening injuries you can use applied consent for the kiddos police familiarize yourself with the laws you can find these by typing in Texas administrative code 157 in Google so consent oftentimes you may have a court order we call it a pal where we have involuntary Transportation this has to do with things like suicide attempts patients who are ruled and mentally incompetent and they may have APS Protective Services out at their residence with a court order saying there to go by EMS oftentimes if you have an a pal a police officer needs to go with you because they are in custody just ensure that when a patient has to be handcuffed or put into restraint by PD that the PD officer the law enforcement officer needs to be in the back of the truck with you because you may need access to that patient if they have a life-threatening emergency which may involve removing handcuffs and restraining devices so honestly you need to have a police officer with you oftentimes they&#39;ll try to follow you tell them that&#39;s unacceptable they&#39;ll have to ride with you all right always monitor people very closely that are in Restraint remember someone who has proclivity to want to hurt themselves could have a proclivity to hurt you not that those teens absolutely go hand in hand but it has to be a thought in the back of your head so when can my patient refuse care and we&#39;ll call that against medical advice or AMA so when can a patient go AMA well they have to be able to consent that means they have to be above the age of 18. and they have to be alert oriented times four and then they have to be informed of that risk before signing a release so let&#39;s break that all down so we&#39;ve just been talking about legal age of consent is 18 we can get a hold of the parents by phone or in loco parentis someone there who can speak for the child who is an adult then we&#39;ll ask the ano times four questions to make sure they&#39;re oriented do you know who you are do you know where you are do you know what day it is or or gear or whatever and what&#39;s been going on that&#39;s pretty easy to establish okay once you establish that they&#39;re above the age of 18 they&#39;re already times four you need to make sure they are fully informed meaning this is the risk of refusal that you have fully assessed them remember assessment&#39;s the foundation of our care you&#39;ve checked Vital Signs you&#39;ve used every diagnostic you can checking blood sugar on diabetics if ALS is there and it&#39;s cardiac patient doing EKGs and hook them up to the cardiac monitor make sure they&#39;re not having heart attacks do everything you can to assess the patient and let them know of your findings and using careful wordage to not try to dissuade the patient from going but making it their choice once they&#39;ve made the choice to not go you inform them of the risk of refuse they&#39;ll be blank with them if you believe something they need to go and it&#39;s harmful you would say something like listen you&#39;re having chest pain you could be having a heart attack and you could die from a heart attack today are you aware yes cool if they&#39;re aware of that then you&#39;re good and you document the heck out of it and you check vitals multiple times and make sure you fully assess that patient before you walk out now after you assure the patient is fully informed they know what&#39;s going on they know the risk of them refusing they are aware they can call us back at any time you need to have them sign a release form and that release form is something specific to your agency that says hey we are not doctors we do not have all the diagnostic materials in education needed to fully diagnose you we always recommend you go to the hospital you&#39;re taking this liability on yourself you&#39;re a sound body of mine to make this decision however you&#39;re doing it against our EMS crew&#39;s wishes so make sure you&#39;re careful on your wording you should always read that aloud and ensure the patient understands it because you can always be recorded by PD or home camera or something like that I had a mentor of mine lost a job over something like that he was in a jail cell and he said he read a refusal for him and he did not and it was recorded So be careful don&#39;t lie do the right thing not out of your convenience and you&#39;re here to transport people and sometimes that sucks on a busy day but don&#39;t get yourself in legal trouble by being lazy um oftentimes you&#39;re going to require a witness for this form uh great Witnesses uh patient family patient friends bystanders First Responders PD law enforcement of any kind I really don&#39;t want your partner signing it it&#39;s not illegal but it looks like coercion uh when it&#39;s YouTube signing it versus an outside party who is agreeing with you all that the refusal was done correctly so get a witness get everything filled out the correct way don&#39;t shortchange anything because it&#39;ll shortchange your career real quick about 80 to 85 percent of EMS lawsuits are centered around the AMA so it&#39;s pretty high risk stuff so you want to try and convince them to go to the hospital in the end so spend time speaking with them sometimes we&#39;re going to be delayed on scene make sure it&#39;s clear they understand that risk of refusal aka the consequences of not going and make a clear statement to them and document the statement you made because in EMS we have a saying is if you didn&#39;t document it it did not happen all right if it&#39;s a high risk refusal where you really feel like someone needed to go and they could really truly die get medical director on the phone see if you can&#39;t get them to speak with the patient the patient to speak with an actual doctor they may have more trust for a physician than us in addition if you feel like they have a significant you can get family on the phone friends and even utilize PD now sometimes law enforcement can&#39;t make someone go but they can try to encourage it now there are times when they feel like the patient&#39;s a threat to themselves even though they haven&#39;t made a clear suicidal threat they can sometimes get them but that&#39;s a real Shaky Ground oftentimes as long as patient hasn&#39;t been a threat they won&#39;t and I&#39;ve done some silly no rides before where I had a patient having a heart attack and he absolutely refused and PD couldn&#39;t help me get him to go either and I left a guy there I never knew what happened to him but I had no doubt he was having a heart attack um and he wasn&#39;t suicidal he just hated hospitals that much that he rather just died home uh families often though the best resources in all honesty sometimes you get family in there and they&#39;ll really help you out a lot um one thing you have to remember is the power of attorney and the power of attorney is a person who can speak for the patient this is often common with patients with long-term health issues going cancer hospice patients and patients with dementia people who may go altered and unable to make a sound decision for themselves assign a power of attorney here&#39;s the deal the power of attorney has the right to say whether or not the patient does or don&#39;t does not go but only when the patient is disoriented if the patient can speak for themselves they&#39;re really no times fourth and the patient makes that decision in the power of attorney is void but if 10 seconds later while you&#39;re having them sign they start acting confused then whatever the power of attorney says will help you so what are the risks of beginning treatment or transport without consent from the patient congratulations you just committed an act of assault and battery absolutely transporting a patient against their will is kidnapping touching people against their will is assault and battery at any kind even if your your overall desire to do good was there you still touched someone who didn&#39;t want it and likewise threatening patients with patient care like some paramedics have been known to say if you don&#39;t knock us off I&#39;m going to put a bigger IV in you that&#39;s assault you just threatened to assault someone so please don&#39;t do things like that okay treat people like people and how you would want to be treated remember to previous chapters it&#39;s always the your mama test treat patients like your mom and you&#39;re probably doing the right thing so what would you do if the patient refuses to sign the refusal form well you got to make sure they&#39;re alert and oriented times for before they can make any decision as long as you verbalize the risk then you&#39;re going to document try to get a witness there this is a great time for law enforcement or the First Responders Society or even enough had family members like I&#39;m sorry they&#39;re being a jerk I&#39;ll Witness it is never okay to have someone sign for the patient as the patient&#39;s name they sign if it&#39;s a power of attorney they&#39;re signing their personal name all right for the patient because they have the right to do so and they should have some paperwork to back up the power of attorney claim but other than that you know you&#39;ll have husbands and wives that want to sign for each other that&#39;s unacceptable and this could be like a Parkinson&#39;s patient who&#39;s unable to write because they don&#39;t have any coordination and you know they&#39;re alert and Orient sounds for they don&#39;t want to go so if the wife you&#39;ll have the wife&#39;s side but she&#39;ll sign her name not his name sign it and you&#39;ll put y in the narrative and just like that you would document everything in that area the patient was refusing care EMS established a patient&#39;s alert Marine Sims 4 the patient refused to allow us to check vital signs or answer any questions EMS made the patient aware that we were called for a medical emergency and we had concerns that we without an assessment we do not know what&#39;s going on with the patient they told us to get off their property puberty was called and unable to assist EMS patient refused to sign a waiver form or EMS obtained a witness signature from a family member member due to the multiple attempts and so forth and so on right you document right if you didn&#39;t document it it didn&#39;t happen so it&#39;s simply put if they refused to sign and they&#39;re alert and right and just being rude then by all means just document what happened all right you fill out the refusal form you sign where the crew is supposed to sign you try to get a witness assigned to back your claim up and that&#39;s where it gets sketchy if you it looked real fishy if you&#39;re saying they refuse to sign it it was you and your partner signing and oftentimes you can&#39;t help it you&#39;re not going to have a witness because there&#39;s no one else there it&#39;s not a bad idea to get medical control on the phone to back up back you up and that&#39;s really the key to everything we talk about when you are at a point where you don&#39;t know how to treat your patient or you have some kind of medical or legal issue with the patient that&#39;s what medical control&#39;s for that&#39;s what online medical directions for is to back us up as that are their designated agent hey you don&#39;t know what&#39;s going on call me I&#39;m a physician I probably have your answer we can figure it out together at the end of the day the medical director will give you will take the burden Off of You by that and remember when we talked to Medical direction we want to always document the order they gave us repeat it back to them and get their name and the time the order was given remember you&#39;re not always going to be talking to your medical director maybe an agent of your medical doctor or fellow physician it&#39;s absolutely okay for someone to change their mind they have the right to call 9-1-1 back and they should be made aware of that this does not mean you can&#39;t call back this just means for the hearing and now try to get someone to take and see if they&#39;ll go with someone else some people are apprehensive don&#39;t want to pay the bill see if we can&#39;t get someone to take them or stay with them oftentimes you know one time I had a parent refused let me take their kid and I was not comfortable and they&#39;re going down two miles of the roof down the road to the hospital and it was on the way back to my station I said I&#39;m following y&#39;all I said so go because they absolutely refused let me take them and I did I just followed them to the hospital at a safe thing they got there just fine and walked in but it made me very uncomfortable when I documented my you know all my findings so then we get into what we call Advanced directives now Advanced directives are legal documents and statements that basically tell us what we should do if the patient experiences thing like death and people have certain wishes some people do not want to be intubated or be on a ventilator or in a medical induced coma so they have these orders Advanced directives these could be a living will and most commonly an out of Hospital DNR in Texas and out of hospital dnro hdnr will have that symbol of taxes or Texas state symbol on the top and it should be signed by a physician a patient and a witness if it is not correctly signed you cannot honor it if if you have any kind of advance directive your protocol doesn&#39;t cover you can&#39;t honor it it&#39;s best to always start CPR because you can always stop it looks real bad if you didn&#39;t start CPR and after five minutes of figuring out you realize you should be starting CPR all right uh in some states like Texas a immediate family member can revoke the DNR which is kind of crappy but it&#39;s happened before so if you&#39;re there and spouse is saying please start CPR you don&#39;t look at them go they have a DNR we&#39;re not doing it go ahead and start CPR and make everyone aware of the situation um anytime you have a question about a DNR you know you&#39;re going to follow the family&#39;s guidelines what was their wishes do you have a DNR no matter what their wishes were or what the families wishes are you have to start CPR without proper documentation okay they can revoke a DNR but they cannot enact a DNR where my wife would be really wanting to get some of that insurance money you should keep a the actual copy not a copy but the original DNR needs to come with you uh here at careflight we have the ability to attach that to our chart and hand it over uh if we need to we shouldn&#39;t we shouldn&#39;t you know be transporting patients with DNR uh but sometimes we have critical patients uh hospice patients things like that that are going to have dnrs we need that original one certain uh departments and companies may like allow for like living wills and certain things that careflight were pretty strict we wanted we want our DNR and again if there&#39;s any question of the paperwork you&#39;re looking at go ahead and call medical control and clarify what kind of issue you&#39;re facing so you know get yourself in any illegal trouble so let&#39;s talk about negligence important word this is when something we have done has caused harms of the patient and the number one rule approving negligence against the EMT is to prove the ENT did harm by not acting or failing to act in an appropriate way okay and we refer to that act as the duty to act so when do you think you have a duty to act I can tell you this when you&#39;re in service and on your ambulance you have a duty to in your service area you have a duty to act when you&#39;re going home from shift in uniform and you got an EMS sticker on the back of your truck you do not have a duty to act in this state you can put EMT 9-1-1 license plate and carefied or Farmer&#39;s Branch fire department whatever you want to put all over that vehicle if it is not a response vehicle you are not on the clock you are not in Duty and you do not have a duty to act now we would hope you would help people who need you and we&#39;ll get into the good Samaritan&#39;s law about protecting us when we do want to help people on the off duty at a later slide but the duty to act is very narrow now what about Mutual aiding and stuff like that if you&#39;re going through Dallas from a transfer and then you see a car just wrecks out in front of you yes you won&#39;t get legally sued for that but you should stop and help them outside of the duty act there&#39;s a breach in the duty so the you know the duty to act is the the ability to perform care and then we get into standard to care how we did it so we had some kind of false uh action like uh uh we you know mistakenly did an intervention or we did it in an intervention we weren&#39;t qualified to do or we didn&#39;t do anything for the patient you know these all equal uh negligent actions especially when we can call prove harm now that&#39;s when we get into a very important word start Circle it highlighted if you&#39;re following on notes which is called approximate causation an approximate causation is where we can prove that the emt&#39;s action caused harm to the patient this can also be an inaction a failure of the duty to act right not acting at all and with the negligence can come civil and criminal penalty so you could face a heavy fine loss of certification termination from your job be sued by the patient and de credentialed wow just for laziness I don&#39;t defend negligence because quite frankly you have to go out of your way to commit it you can be personally sued most likely it&#39;s going to be your agency because that&#39;s going to give them the most money but your agency can also list you in the state of Texas as an RTP or a responsible third party and deflect some of that fine to you for falsification and it&#39;s a high likelihood that if they prove negligence that the state of Texas May revoke your licensure and it would be a minimum of two years before you could appeal that or not appeal but try to research that you have a you have like 14 days after legal after mail-in notice to appeal I believe it is in this state but uh most likely if they approve negligence in the court of law you&#39;re done and some of these laws will show blatant your lawyers like uh we need to just settle saddle saddle saddle saddle all right and that&#39;s called the RIS ipsa liquid I took Latin for four years so nailed it uh that just means the thing speaks for itself in Latin and I added these below that the feces all right and this often can go back to what we call in law malfi since misfeasance and non-feason said I want you to break these words down think Mal malpractice doing something you&#39;re not qualified to do think Miss mistake I can I had a failure in the standard of care and then non-feasons non no doing nothing that&#39;s abandonment which we&#39;ll get into in a second or a failure of the duty to act right you just can&#39;t walk off a scene because you don&#39;t like the patient you don&#39;t like the way they&#39;re talking to you that&#39;s considered an active abandonment you just can&#39;t leave the patient at the yard without a report or hand off and care that&#39;s an active abandonment so this is your obligation your legal obligation moral and ethical obligation to provide care so some states may have some differences I don&#39;t really know this I do know ours forwards and backwards you have to be on duty uh typically you have to be in your jurisdiction I don&#39;t believe you can get sued if you&#39;re passing by a wreck like here in Houston Texas dropping someone off and you pass by or wreck and you&#39;re ambulance I don&#39;t believe you legally have to stop uh but we would really be pissed off if you didn&#39;t a care fight so until we clarify that in class please always stop and render Aid when you&#39;re in your Ambience as long as there&#39;s not a patient in the pack okay there&#39;s a patient in the back we need to continue patient care roll down your window says we already have a patient on board who were taken to the hospital we have called this wreck in and we call this the First Responders help is on the way it&#39;s always you know like morals and ethics you know morals are something personal to you and ethics is more how Society or a system dictates what you should and should not do so abandonment is considered once care being initiated and the men discontinued before we hand off care to equal or greater training and that&#39;s what we&#39;ve been talking about in every chapter so far we always hand off care to equal or greater levels of Provider so nurses and Physicians paramedics things like that so if we don&#39;t do that we just leave the scene where there&#39;s patience there we&#39;ve committed an act of Abandonment this can happen at the hospital especially during covid where sometimes we&#39;re holding the wall or waiting to get our patient onto a hospital bed for hours you can&#39;t just leave the patient in a waiting room without proper permission signature and a handoff of care or you could be hit with abandonment charges there&#39;s another thing in the state of Texas that can constitute abandonment that&#39;s not mentioned in these slides and that is walking off an in-service ambulance without proper relief or notification so if I got mad at my you know Regional director and I you know custom out hung up the phone and jumped off the truck that call comes out and no one can get there because I I walk off the truck that the set of Texas has known to suspend someone for abandonment of post I&#39;m real big on that too I can&#39;t stand someone you know let someone know listen I&#39;m done I need to go ahead and quit I need you to make you aware that I am quitting at this point in time this is my resignation uh you are going to need to get someone here or simply notifying someone hey I have a family emergency I have to go all right letting dispatch know hey we&#39;re down I have a family emergency I&#39;m out of service okay be careful you just remember how it feel to be you if it was your kid at the house and you call the local 911 system they&#39;re going to be 15 minutes delayed because some EMT decided to get mad and walk off a truck all right use your brain don&#39;t put your pride again before patient care okay you are servant to the community and the citizens we serve you got to act as such good Samaritan&#39;s laws are really interesting because people have a lot of misconceptions about them and again this is one of those things where nationally everyone has their own laws but they&#39;re pretty really close in nature and I&#39;m going to talk to you more related to Texas law so the Good Samaritans laws aren&#39;t there to force you to act they are protect to protect you from the liability of acting so as long as you are not negligent in a situation the Good Samaritan laws can protect you in another situation uh the Good Samaritan law won&#39;t protect you if you are actually involved in the incident in the state of Texas there&#39;s a good case from someone up north I don&#39;t believe this was in Texas we&#39;re a nurse stop to render Aid on a motor vehicle accident she did an emergency jerk because the vehicle was feeling full of smoke or hit electrical lines or something and she pulls a lady out of the car emergency jerk wiser remember that&#39;s appropriate because the scene&#39;s not safe right and she drags her away well the woman wound up having like a broke neck or back or something and she takes the nurse to court saying if she wouldn&#39;t have moved her so aggressively she probably caused her injury one which we all know that most likely the injury was caused by the wreck not that she didn&#39;t hurt it but she&#39;s not negligent because of the situation calls for an emergency move so it last I followed up I believe that she had won the case uh good Samaritan&#39;s Law High protector and it was an appropriate action so you arrive on scene of a patient in Cardiac Arrest the family says she has a DNR but doesn&#39;t know where it is how should you handle this start CPR okay you start CPR and while you&#39;re starting say listen we have to start CPR legally we could get in a lot of trouble because we have to have paperwork so we&#39;re going to start CPR and we&#39;re going to start the whole thing and if you can go find that uh documentation for us once you find it we can talk with medical Direction and stop if the families like we can&#39;t find it you&#39;ll have to explain them we&#39;ll have to transport okay if they get nasty with you then just get on the phone with PD and medical Direction and see if we can&#39;t find Happy ground but start CPR please so you are off duty and arrive on scene of a vehicle crash police and EMS have not yet arrived are you legally obligators to stop and render Aid again this will be state by state basis but in the state of Texas no you are not you are not on duty you do not have the duty to act now morally or ethically should you act maybe I would say more morally that your own personal morals do you feel like you should act and help people also depends on where you&#39;re at are you in a bad neighborhood are there suspicious people out are people shouting at each other right you&#39;ll have to make those decisions based on scene safety and that goes for whether you&#39;re on duty or not keep yourself safe especially when it&#39;s free now we have confidentiality as well so not only do we have to take care of patients physically and psychologically we also have to consider their personal health care information or Phi and this is information that&#39;s very important to their identity so they don&#39;t get identity theft is on the rise right in the digital world driver&#39;s license social security cards birth records insurance card and Medicare cards face sheet and information on the hospital reports old Run Forms everything so much you got to think how important a medical records number is on the hospital charts all right so remember anything that can identify your patient as the patient is Phi and you are required to protect it and when you&#39;re done documenting get it under lock-in key immediately at the station the only people who can view the Phi that particular patient on that particular call are the people that have been involved in care meaning you have a first responder there paramedic first responder at EMT first responder like hey can we get the patient&#39;s name for our chart that&#39;s absolutely okay you get to registration at the hospital you arrive at the ER and they want the patient&#39;s name social home birthday that&#39;s absolutely okay you got a nurse you know walking generator walks by and goes hey what&#39;s going on with your patient it&#39;s not their business they&#39;re not involved in patient care and I&#39;m not trying to insult the janitors but if you&#39;re not involved in patient care then don&#39;t say anything say well that&#39;s we can&#39;t discuss that I&#39;ll let the nursing staff talk to you about that blow them off right and this all came out because the federal act HIPAA the health insurance portability and accountability act right to protect American uh Americans who go to the hospital or have medical care if you have any sort of Medical Care in this country whether it&#39;s at a doctor&#39;s office an Outpatient Surgical and emergency department or even like an obstetrical facility having a baby you&#39;re gonna have to sign something regarding your rights to the billing and your rights for protection of personal health care information and our private Health Care information and HIPAA everyone has signed one of these at some point in time you can hear it careflight on the back of our little abbreviated short forms that we give out kind of like notes that we give the nurse until our documentation is gone we have a Peak form that advises the patient of their rights and even when the patient&#39;s unresponsive I&#39;ll often put it in the room with them or near the nurse because they&#39;ll sign for it often and the patient can&#39;t sign for themselves or with the oriented patients I tell them Hey listen this is the form I promise to give you and it&#39;s going in your back to View later all right now who has rights to that document well police officers do not have right if the police officers want to see it even if the patient&#39;s committed a crime you have to they have to subpoena that record from whoever the custodian of record is for that particular agency a carefight it&#39;s Martha Goddard who works under corporate compliance at the maybe training center all of y&#39;all have probably seen Miss Martha so that&#39;s who the elevators for outside of our classroom so miss Martha controls those subpoenas and things like that and gets records to people after they pay certain fees which is normal at every service and Department uh the patient may want to see their record they have a right to that however they have to go through Martha again at no point in time do you give a chart to anyone but the receiving facility period That&#39;s the only people you give that chart to all right there&#39;s no other law or anything that&#39;s in place to protect that just remember the patient may have identifiers on them as well typically it&#39;s more generalized stuff but here is a medical alert ID and this is great for assessment so in case you can&#39;t figure out why your patients aren&#39;t responsive they a lot of patients with long-term health issues use things I think the most common uh two diseases you&#39;ll see that are on these medical ID bracelets would be epilepsy a seizure disorder and diabetes because these are often common reasons why someone is sometimes acutely altered with their mentation so that&#39;s why they wear it so my wife will talk about her a lot in this class she is a type 1 diabetic has been since the age of three and she is 40 years old so she&#39;s coming up on year 37 quick um I believe in January or February is actually technically our 37th year uh so uh that she wears a medical ID tag always and in addition to the medical ID text she has a tattoo below it and it&#39;s the diabetes ribbon and it says she&#39;s a diabetic so I think it&#39;s real cool like her date her first like the day she was diagnosed so look for tattoos you know that&#39;s real cool that because people have those kind of things so just viewing other things that could be on the medical ID band um you know heart conditions patients who haven&#39;t planted devices like ventricular assist devices which we&#39;ll learn about later uh pacemakers defibrillators and different kinds of like uh implanted devices such as artificial heart valves significant allergies like peanuts things like that and this could be bracelets could be a card in their wallet uh so you just kind of got to do a good body assessment especially if they&#39;re altered to where you look in their wallet get their name address emergency contacts this is going to also be gained through medical apps on phones uh in contact some people have their ice number put like I do and that stands for in case of emergency some people put in their phone ice and that&#39;s to help fire departments and EMS Personnel identify the emergency contacts real cool thing they used to do but almost all smart watches and stuff people have the health app they give them their blood type medications medical problems and their emergency contacts and allergies they have so you got to kind of think broadly when you&#39;re dealing with sponsor Folk what about organ donors well that&#39;s seen in Texas on IDs I have a philosophy with organ donors I&#39;m not trying to down you if you&#39;re not an organ donor but you do not have the right in my opinion to accept an organ if you&#39;re not willing to give an organ I think actually it&#39;s pretty damn disgusting so I would keep it to yourself not that I&#39;d ever do anything to any of y&#39;all I love everyone the same but keep it to yourself please because I have a big problem with people who won&#39;t donate the organs because the you will definitely aren&#39;t going to do anything with them at your time of death so uh family members may be able to identify that they may have a donor card and here in Texas again the driver&#39;s license a big thing uh this may dictate whether or not we do CPR a little longer than we normally would because we want to save those organs if possible all right um you know the hospital no receiving that&#39;s why you&#39;re working them it&#39;s because of that because if they can get them going we can want to harvest those organs while they can and save a whole bunch more lives so that life was never in vain here&#39;s some other things uh Safe Haven laws those are really cool this ensures that patients aren&#39;t uh or I&#39;m sorry newborn babies aren&#39;t dumped and dumpsters um and and murdered and things like that uh by you know mothers who feel like they cannot uh you know maintain or keep that child in a stable home uh instead of giving them up the right way they sometimes panic and we&#39;ve established Safe Haven baby sites across the country to ensure that we can limit that if we save one child per year which they do a lot more than that then it&#39;s well worth it if you didn&#39;t know QT all has these safe uh Haven baby signs that you see up there that you saw animatedly pop up in the in the presentation uh EMS stations and fire stations especially in Texas I don&#39;t know about other states if it&#39;s federal or local but I know in Texas EMS and fire stations and release stations are all considered safe haven baby sites as are churches why uh so we can save as many children as possible and not get them abandoned into bad situations one of the key things I worked for when the safe haven laws started coming out I was in EMS and my previous medical director and clinical team said hey if you ever have a safe haven baby dropped off to you by a family member don&#39;t ask any questions because we don&#39;t want to have them flee so basically what they meant is get the baby in your hands before you ask any questions the thought process in that if you start asking questions their defense mechanism goes off they run off for the kid and now you don&#39;t have them so get the baby in your hands and as they&#39;re walking away at most go hey is there anything we need to know about this child&#39;s health and safety that is our health you say any health quite frankly I don&#39;t care we can figure that out I&#39;ll let them just walk and say thank you for doing the right I would tell them thank you for doing the right thing just in case if they&#39;re ever faced with that situation again that they&#39;ll do the same damn thing okay what about crime scenes think about the specialty situation what&#39;s important not to disturb evidence now there&#39;s lots of different crime scenes you&#39;re going to be on the scenes and most commonly of domestic violence you gotta remember if someone&#39;s been attacked most likely it&#39;s by someone they know and domestic violence seems like it&#39;s on the rise or just the populations getting more noticeable and there&#39;s a just a greater awareness through the media about it so uh scene safety is your top priority so do not get on scenes uh that are crime scenes without law enforcement there I didn&#39;t say fire department I said law enforcement okay the fire department wants to be silly and jump the scene before it&#39;s safe that&#39;s their business do not put yourself in unsafe situation remember this is what we refer to as staging setting up a great distance from the call but available to only that call until PD has made it uh safe a residence we want to Stage a minimum of a block down and a block over where we&#39;re out of you and typically I want to Stage typically I like about a quarter to a half a mile away I just want to be good and out of sight of whatever is happening always ensure that you park and stay in your vehicle that you are uh not in a place where you can get hit or be attacked okay oftentimes if you know where the fire department&#39;s staging it&#39;s best to stage with them because many uh apparatus and bodies make it a less chance for you to get attacked okay deactivate your lights and Sirens while you&#39;re sitting there most of the times most companies and agencies are not going to have you activated priority when you&#39;re going to Stage for a possible crime scene okay when you are cleared to enter by PD they&#39;re confirmed on scene you get on scene monitor turn off your lights and if they have their lights on you may turn your lights off on but if their lights are off keep your lights off because we don&#39;t want to alarm this and get people&#39;s guard up as you&#39;re walking in be mindful of where you step and where you walk let&#39;s take one line in one eye line out to not disturb any evidence however this could be a multi-faceted thing if the patient&#39;s deceased and you&#39;re not going to work them because they have an injury incompatible with life say a gunshot wound in their head or something you know there&#39;s not much angst going on because the patient&#39;s dead you&#39;re not working them but oftentimes on the crime scene the patient may still be alive a sexual assault being really common so what do you do well just FYI your safety always comes first then the patient&#39;s life threats all right we do want to preserve seen evidence but not at the cost of treating our patients so do what you can to protect the patient take one line and one eye out don&#39;t disturb evidence on scene but be mindful that the patient&#39;s needs are a priority over evidence we&#39;ll get into rape and things like that and how we handle it and what kind of facility we should go to at a later time but it&#39;s often important to remember what you touched if the patient was assaulted in any way or sexually assaulted in any way we want to keep the clothing they have have and bag it put it in the ambulance we prefer paper over plastic we want to document everything we have to PD we want to get a good statement from PD and we want to discourage the patient from using the restroom or showering because they have evidence on their body well again we&#39;ll get real heavy into that later as far as special reporting goes just remember that any kind of abuse and neglect is required to be told to Texas Department of Family Services protective family services again you can call the number provided on previous slides and previous presentations I can get you that number if you ever call me or you just simply type that into Google and you follow the directions and set up an account I would suggest if you&#39;re going to work in healthcare you just go ahead and set up account and do everything via online human trafficking if you have an issue of human trafficking I haven&#39;t had that call yet but it is on the rise any kind of violence involving weapons typically PD better be there already uh and that likely goes with sexual assault or rape um you have to report these things okay now after again when PD&#39;s on scene that&#39;s different with cases of abuse and neglect where oftentimes you don&#39;t may not know until it ends that&#39;s when you would report it oftentimes you&#39;re going to report to the adult side on patients who are living at home elderly patients and unable to take care of themselves and it sucks to take away their independence but it&#39;s for their own good some states may require that if you have an intoxicated person whose cause injuries or is injured themselves in this state it&#39;s only if we have an intoxicated person whose cause like other damage and injuries we have one alert PD and again most wrecks you&#39;re going to have an officer come out there to do a report mentally incompetent people with injuries these people could have long-term mental incompetency or be child uh oftentimes we can use implied consent with mental and competent people just like we can with the children okay if they are truly injured uh again oftentimes when we&#39;re confused we just need to consult with medical Direction and law enforcement work together to make sure the patient has the best possible outcome and we&#39;re operating morally ethically and legally and speaking of that it&#39;s kind of set us up morality right your morals that&#39;s the personal opinions but your ethics is more of like a standard of behavior for oppression or a profession or how Society views you okay so there&#39;s certain ethical Behavior an EMT should have and then you should have your own morals to kind of dictate and we all have different morals and oftentimes it&#39;s a product of your raising right and what I find to be moral and what you find to be moral right and we need to find a happy medium ground not to be too controversial we don&#39;t need to give off our own political or religious views our views on race or anything like that we need to be right down the line and we need to be bipartisan on everything so you need to respect people to make their own rights don&#39;t talk down to people even when they&#39;re altered ovaries operate fairly and justly with patient advocacy at the Forefront of your mind right behind scene safety right remember that you are a representation of not only care flight but of me and our entire profession never take that lightly okay people judge you by your performance and if you&#39;re a good person and you operate morally and ethically you&#39;re probably viewed as a good EMT the last slide of this presentation is a slide I added looks all cool and stuff it&#39;s important to me and I find that your book lacks in the law as far as I know I may have not just caught it because I haven&#39;t read it from cover to cover I just kind of eye through it and it&#39;s referred as the entaila law or the emergency medical treatment Act of Labor Act this is known as the federal anti-dumping law and this keeps people from dumping patients off at the wrong facility not necessarily us because we have a lot of power when it comes to that but ensuring that hospitals don&#39;t refer patients to inappropriate hospitals because they don&#39;t want them at theirs or you know trying to send a patient out ALS or BLS when they should be ALS just for the sake of getting them out faster right so this prevents hospitals also from denying care from people there&#39;s the 250 yard Rule and that means when we&#39;re within 250 yards of that ER entrance that that patient is now legally there so don&#39;t think you can just go under an ER Bay and the patient goes where are we at he said we&#39;re at Sunnyvale remember it said I was taking you all decided I want to go somewhere else you have to tell I&#39;m sorry there&#39;s a a law that prevents me from doing that once I&#39;m within 250 yards of this uh facility I have to be here the only exception to the 250 yard rule is helicopter lz&#39;s these hospitals all have licensed lz&#39;s that are appropriately lighted in safety standards to ensure that helicopter Crews get the land and take off in the safest area possible so uh oftentimes when we have seen responses and we need to utilize aircraft we&#39;ll land them in a field or on a highway well that&#39;s not inappropriate and it puts a lot greater Danger on the helicopter crew and in like places that careflight we can&#39;t land a helicopter if there&#39;s not a ground contact whether that&#39;s First Responders or the MS crew Landing them so uh if we&#39;re tied up in patient care that makes it really hard to land them right so why not just travel to a local hospital and land them there so that&#39;s just a verbal agreement you do not have to have a written agreement on that so what like one we use a lot is Texas Health Kaufman and Baylor Scott and White Forney and there&#39;s one&#39;s down south as well this is just the area I&#39;m familiar with we&#39;ll call them on their patient care line like where we&#39;re going to give a report and say hey this is unit 9412 we&#39;re not to your facility we have a patient we&#39;re going to fly off of your LZ we just wanted to know if you could send an alert get everything activated and we don&#39;t need y&#39;all we&#39;re just going to use the LZ if that&#39;s cool they&#39;ll say you&#39;re right on we have it thank you for letting us know giving us a heads up they do that so they can make an announcement to anyone who&#39;s partner there also make sure their maintenance people know to activate lights and make sure the scene is safe so it offers an extra level of protection by giving them a heads up as well and so they&#39;re not wondering why there&#39;s an ambulance sitting out in their Bay uh also uh you know like I told you it ensures that there is accountability between transferring facilities that&#39;s because hospitals used to dictate hey we don&#39;t want this patient or that patient because they can&#39;t pay now if you&#39;re an ER you have to receive all patience all right um one case that we see with this is that when you go to transfer patients when you learn how to do that in the academy you&#39;re going to receive a whole bunch of paperwork from the transferring facility it&#39;s something it&#39;s called an mot and that&#39;s a memorandum of transfer so basically you have to have three Physicians involved in the transfer of a patient this is where it gets crazy so you&#39;re going to have the patient the main physician who is treating the patient at that local ER Hospital right and then they call around and get acceptance uh the nursing staff does from another hospital that can handle that capability so then that receiving physician has to accept the patient then you have nursing supervisors who have to sign paperwork and inside of the patient is consent to release and transfer and all these signatures have to happen in agreement between the two facilities this can take hours to days at times depending on what type of facility you want to go to all right and and sometimes we&#39;re having to go to Long Distance facilities because that&#39;s the only one that would accept that patient and has the capabilities the patient needs so when you take a patient to a facility that can&#39;t handle them know that it&#39;s not just a oh we&#39;ll get them out to the trauma center quickly no it could take forever depending on who&#39;s accepting especially after covid where there&#39;s not enough staff in in hospital beds that go around it seems and now we talked about the two doctors where&#39;s that third one come into play I want you to think about that I told you there were three doctors involved so on the MLT we have the transferring and we have the receiving who do you think&#39;s the Third doctor is involved in this and they&#39;re not their name&#39;s not signed anywhere anything you ready for that you&#39;re a medical director because now you&#39;re involved because it&#39;s your job to go pick up that BLS patient as an EMT and take them to that next facility so now that you&#39;re providing care your medical director oversees you so that&#39;s kind of intricate no one really ever thinks an Impala that way but just remember the patient has an illegal obligation to treat the patient as you arrive once you&#39;re at their facility they cannot refuse you do not let them lie to you you are protected under the Impala laws well I hope you found this to be informative y&#39;all almost every slide of this presentation is super informative about how you should act morally ethically and legally throughout your career please understand that these are involved on every dang call remember what consent is we can get Express consent to patients they know times four and they&#39;re telling us what they want they&#39;re not impaired by drugs or alcohol they&#39;re not making any threat against their life if they are or they&#39;re disoriented we&#39;ll use implied consent because we will imply they&#39;d want to go if they&#39;re of sound body in mind this also pertains to children with injury or significant illness we can imply that the parents would want them to go otherwise we&#39;re going to try to get consent from the parents or in loco parentis in the absence of the parents a representative of the child maybe a family friend who&#39;s watching the kid a babysitter a school administrator or a sibling above the age of 18. our goal and refusal is to try to convince the patient to go at all costs making them aware of the risk of refusal and fully informing them please ensure that you have assigned a witnessed refusal statement to protect yourself legally and if you did not document it it did not happen remember that negligence is failing to act properly when you have a duty to act or having a malpractice or misstep in your standard of care that and induces a negative outcome and remember anytime that negligence is found and with proximate causation it&#39;s hard to win those kinds of cases it&#39;s often best just to settle out of court remember that abandonment is leaving your patient before handing off to equal or higher level of care this can be on scene when you have multiple patients this can be at a hospital you cannot get into with a patient on scene and then leave you can go stage if you feel unsafe but you are still involved on that call confidentiality is right behind patient care protecting your patient at all costs when it&#39;s a trauma mechanism a medical nature of illness scene safety we have to protect confidentiality okay ensure that you have all the documents they gave you and you hand them over document what you have in the back of your truck ensure you know that you have a custodian of record per Medicare that&#39;s supposed to handle patient requests care requests and they have to be subpoenaed the patient can simply call in and request a record for a fee and we&#39;ll give it to them you cannot give them a copy of their chart you cannot give the First Responders a coffee chart the only person you can hand over a copy of that chart to is the Receiving Hospital okay he was receiving care and instead of Texas you have 24 hours to ensure that your electronic record has been submitted in fact to the receiving facility not many services are using paper so we&#39;re going to call it an electronic PCR mm-hmm remember you can be held criminally and civilly liable for any damages you cause in this industry protect crime scenes make sure you walk the same way out that you walked in remember patient care dictate safety dictates all then patient care then worrying about the crime scene now we can do everything simultaneously for intelligent ents but I never want you to put protecting evidence ahead of good patient care in your own personal safety all right it&#39;s all common sense yo you got to go out of your way and violate your morals and ethics to be negligent okay that&#39;s why I have no pity for anybody who commits these acts all right protect your patients information use the your mama test if you how would you feel if someone leaked your private information or your mother&#39;s social security number because they were careless and having speaking on that I want to give you one last bit of information social media and HIPAA reporting patient outcomes on social media will get you quickly in a world of trouble I have had to terminate people for this in the past please do not share patient outcomes or identifiers even the scene of a call anything that&#39;s remotely don&#39;t talk about work on social media it&#39;s just not a good idea and I find it to be very immature when you ask what you&#39;ve got out of this lecture I want you to know can you define the scope of practice negligence Duty direct abandonment and confidentiality if not you need to be reading okay I think it made it very clear so think about though what steps must you take when your patient refuses care or Transportation well let&#39;s ensure that they can or of legal age to consent or decline make sure they&#39;re alert and oriented and then make sure they&#39;re informed at the very end they need to sign a refusal statement and it needs to be witnessed by someone other than your crew so what are some steps you&#39;re going to do to prevent serve evidence well bag it make the police aware of it discourage showering and rape victims ensure we put things in paper bags and ensure we just limit overall touching and disturbance of the crime scene okay if you wind up on a crime scene where there is no PD that may be a time where you consider to go and Retreat the scene and Stage until PD has made it safe the last critical thinking question is you respond to a motor vehicle crash and find a seriously injured patient he has no pulse and you&#39;re about to begin CPR when someone says don&#39;t do that he&#39;s got cancer in the DNR no one has the DNR on scene you start CPR and transport the patient and that is an absolute yes unfortunately you have to have some sort of paperwork if people are getting nasty then you&#39;re gonna have to get police involved but unfortunately if they do not have the paperwork available the key is you have to transport them okay um quite frankly I&#39;m going to be honest with you here if I find a DNR patient who is pulseless on the scene of a crash and has a significant injury I don&#39;t know if I&#39;m going to work them so this is not the best story I didn&#39;t write this one uh but yeah we would uh we can always call medical control too and see what they say but you have to start CPR otherwise what kind of move would you get to you utilize to get the access to the patient though going back to chapter three for those of you who picked emergent you picked correct remember the patients of the CPR or need CPR you got to get them out of the vehicle quick well that&#39;s it I will see y&#39;all on chapter five

Transcript for:Medical Legal and Ethical Issues in EMS

Transcript for:
Medical Legal and Ethical Issues in EMS