Med legal and airway equipment Flashcards
The ambulance act
to work as a paramedic you must have AEMCA, a graduate of a PCP program or equivalent w/ 70%, paramedic service operator can employ new PCPs for 210 days while waiting for AEMCA certification, six or more demerit points under highway traffic act, three years before employment date started be prohibited from driving a motor vehicle under the criminal code, free from all communicable diseases, immunization signed by physician, no conviction involving moral turpitude that has not been pardoned
What entities govern paramedic practice
MOH- provincial exam with over 70% to pass
BHP- certifies the medic to perform delegated “controlled medical acts”
EHS (employers)- hire medics and apply for certification with regional base hospital and MOH for our emergency health services card
Medical directive
written order approved by a physician pertaining to any patient who meets the criteria. Provides authority to carry out treatments/ procedures/ interventions as specified in the directive if pt has certain conditions/ circumstances present
Direct order
instructions to another health care provider or group and the order is for one pt and to initiate a specific intervention/ treatment for a specific time that can be verbal or written
Delegated acts
BLS/ALS PCS dictates what we can/ cant do
Auxiliary medical directive
additional skills to be delegated through use of the auxiliary medical directives that can be introduces after consultation and mutual agreement between RBH and service
10-4
acknowledge transmission
10-7
out of service- arrived at scene
10-8
in service- mobile to a location
10-19
return to station
10-20
what is your location
10-200
need police
10-2000
need police immediately- urgent request
Who governs radio equipment standards for EMS
MOH
Code 1
deferrable- any non-emergent call
Code 3
prompt call, non life threatening, lights and sirens optional
Code 2
scheduled call
Code 4
urgent/ life threatening, warning systems are mandatory
Code 5
obviously dead w/o physician present
Code 6
legally dead- pronounced by physician
Code 7
unstaffed at station
Code 8
standby at location
Code 9
unit in for servicing
Code 19
non-essential call
Deceased pt codes
5 and 6, CTAS 0
How many CTASs during a call
3 minimum- on pt contact, on departure, arrival at destination and possible change on route
CTAS Rule one
a minimum of two scores applied to each pt- arrival CTAS and departure CTAS
CTAS Rule 2
the CTAS level reported to the receiving institution is the CTAS at departure or if condition deteriorates after transport is initiated
CTAS Rule 3
when the CTAS level changes due to pts reaction to treatment, it cannot be greater than two levels below pre-treatment acuity (arrival CTAS)
CTAS Rule 4
a pt VSA on arrival and is resuscitated must stay as a CTAS 1
CTAS Rule 5
if a TOR is received while managing a pt, the CTAS level documented on ACR is based on status of pt on arrival/ departure
CTAS Rule 6
when pt is obviously dead, on arrival, no CTAS level is assigned and documented as 0
Level 1
nearest/ closest most appropriate receiving facility
Level 2
nearest/ closest most appropriate receiving facility based on communication b/w medics, dispatch, and receiving facility
Level 3,4,5
most available receiving facility based on communication of dispatch and facility, final destination may also take into consideration patient’s wishes
CEDIS categories
cardiovascular, ENT, environmental, gastrointestinal, genitourinary, mental health, neurologic, obstetrics/gynecology, ophthalmology, orthopedic, pediatric, respiratory, skin, substance misuse, trauma, general and minor
First order modifiers
applied once complaint is determined and applied in two steps. Group 1 is dependent on ABCs and deficits like resp distress, hemodynamic stability, LOC, temp. Group 2 is related to specific conditions like pain, bleeding disorders, MOI
Second order modifiers
more complaint specific, applied after CC, not used to downgrade CTAS. Blood glucose level, hypertension, dehydration, obstetrics, mental health
Pediatric assessment triangle
Appearance- tone, interactiveness, consolability, look/gaze, speech\
Work of breathing- breath sounds, positioning, retractions, flaring, apnea/gasping
Circulation- pallor, mottling, cyanosis
5 most common presenting complaints in pediatric pts
fever, respiratory difficulties, injuries, changes in behaviour, vomiting and/or diarrhea
Transport ACR
an ACR will be completed for each ambulance service request where a pt was assessed regardless if care was provided or pt was transported by ambulance or emergency response vehicle
Refusal of transport ACR
crew seeks pt/ substitute decision maker to complete and sign the appropriate areas of the refusal of service portion of call report. The crew requests witnesses to complete appropriate area of the report and document the request on ambulance call report incase witness refuses to sign the report
Where do ACRS go and where are they kept
Original copy is left at the receiving hospital/ coroner who is taking over responsibility
Billing copy is distributed to the department/ office responsible for billing
Base hospital copy is distributed to base hospital
Ambulance service copy is retained by service operator for records for a minimum of 5 years
How many pts can an ambulance carry and how to document
can carry two patients and determine who is primary by labelling patient 1/2 and sequence 1/2 based on degree of injuries
How are communicable diseases spread
blood borne: blood, semen, vaginal secretions, cerebral spinal fluid
Airborne: singing, coughing, sneezing, shouting, talking, aerosols
Infectious droplets: virus on hands and touching your nose, mouth, eyes with unwashed hands, inhaled, poor ventilation locations
Fecal oral, direct contact
Who is responsible for PPE
Employer- provides equipment and training, MSDS documents
Worker- follows PPE practice
Informed consent
tell pt nature of treatment, expected benefits, material risks, material side effects, alternatives, likely consequences if not done, chances to ask questions and get answers
Implied consent
consent is presumed for a pt who is mentally, physically, or emotionally unable to give consent. It is assumed the pt would want lifesaving treatment if able to give consent. Also called emergency doctrine
Expressed consent
verbal/ nonverbal/ written communication by a pt who wants treatment, the act of calling EMS is generally considered an expression of the desire to receive treatment, must obtain consent for each treatment provided
Consent for minors (under 18)
must be given by parents or guardians but under special circumstances an individual at 16 can have the capacity to make health care decisions- emancipated
Emancipated minors
a person under 18 who is married, pregnant, a parent, member of the armed forces, financially independent living away from home
Valid consent
valid informed consent must have 3 components- disclosure: you tell them everything, capacity in your opinion is present, voluntariness: pt is not refusing
Involuntary consent
is consent for a treatment granted by a court order
Abandonment
termination of the paramedic patient relationship without assurance that an equal/ greater level of care will continue
Assault
an act of unlawfully placing a person in apprehension of immediate bodily harm without consent
Health care consent act
did he consent to the treatment, was the consent informed, was the consent obtained voluntarily, did you misinterpret the treatment to give consent
Power of attorney
authorization of the person(s) to make decisions concerning granters personal care
When is a person incapable of personal care
if the person is unable to understand information relevant to decision making concerning health care, nutrition, shelter, clothing, hygiene, or safety or is not able to appreciate the foreseeable consequences of a decision/ lack of.
When would you contact PD
Abuse and neglect situations, WSIB (workplace injuries)
Can paramedics medically clear someone
Paramedics cannot medically clear someone, so we need to properly assess and offer transport to the ED
What should you do if not granted access to a crime scene
Express the need to medically assess for code 5 status, make all attempts to not disturb the scene, if still not allowed in call dispatch and supervisors
Who can you order to transport a dead body
The police
What is legal death and when does it occur to paramedics
Legal death is a death pronouncement from a physician, pronounced by base hospital physician through certified ALS provider
Ex. TOR, Withhold of resuscitation
What is the role of a coroner
Responsible for determining the cause/circumstances of death surrounding unexpected, unnatural, unexplained deaths
Responsible for identifying deceased and time of death
Conduct investigations or inquests
What is the purpose of a coroner’s inquest
To answer the questions of who the deceased was, how the deceased died, when the deceased died, where the deceased died, and by what means the deceased came to die.
Mandatory coroners’ inquests (required by law)
Jail deaths, death in police custody, death at a construction project, death of a psychiatric patient while being physically restrained and detained in a facility, death of a child because of the criminal act of the person with custody where other circumstances are met
Discretionary coroners’ inquests
All other inquests conducted at the discretion of the coroner
What power does a coroner have
They can access information at will and investigate areas a death occurred without warrants, and request documentation without subpoena
what makes a DNR valid
A DNR is valid if it has a pre-printed serial number, first/last name, a check box identifying the professional designation of MD, RPN, RN, or RN (EC), check box stating a current plan of treatment exists saying pts capable/ decision maker when pt is incapable, printed name and signature of MD, RPN, RN, RN (EC), and date that precedes date of request for an ambulance
What do you do when given a DNR
Obtain the physical copy, ensure its validity, ensure it’s for the right patient
Withold of resuscitation
Order given by BHP to a medic to not initiate resuscitation measures
TOR
An order given by BHP to a medic to stop resuscitation measures
Trauma: >16, VSA, no shocks delivered, no heart rate or ER is >30min away
Medical: >18, cardiac arrest not witnessed, no defibrillations delivered, no ROSC, and cardiac arrest has to be medical in nature. Final decision is made after 3rd analysis
Mental health act
The mental health act is a law that describes what should happen when someone who is living with a mental illness needs treatment and protection for themselves/others
Regulates the assessment, admission, and treatment of a person with a mental disorder in a psychiatric facility and defines the rights of patients in psychiatric facilities
How do paramedics restrain people
Supine, cloth restraints are preferred, use respect and dignity, restrain with one arm above the head/ one at waist/ and feet in spread eagle position.
Can paramedics use restraints
Only if directed by a physician or police officer or an unescorted patient becomes violent en route
Chemical restraints
Ketamine: excited delirium/ severe violent psychosis
Midazolam
Doesn’t always work and can have neg side effects like resp depression, ketamine reemergence syndrome, and cardiac arrest
How many people are needed to restrain someone
5- one on each limb and someone controlling the head
Form 1
The subject of an application for assessment signed by a physician. It is used to declare that the individual is at risk of harming themself or others due to a suspected mental disorder.
Lasts 7 days
Form 2
The subject of an order for examination signed by a justice of peace. It is used to authorize the detention of a person long enough for a doctor to make an initial examination to decide if form 1 is appropriate.
Lasts 7 days
What are the acts used to help children in need
Child in need of protection standard, child, youth and family services act, duty to report, the criminal code
What agency/society helps children in need
CAS- children’s aid society
PHIPA- protects personal health information
What is a child in need of protection- paediatric
Pediatric injuries: submersion injury, burns, accidental ingestion/poisoning, other types of home injuries (falls)
what scene observations can be made for a child in need of protection
house/siblings dirty, unkempt, disarray, evidence of violence, animal abuse, evidence of substance abuse
what physical injuries indicate a child in need
gross/multiple deformities that are incompatible with incident history, multiple new/old unreported bruises, distinctive marks or burns, bruises in unusual areas, signs of long-lasting physical neglect, signs of malnutrition, signs of shaking syndrome.
Special consent situtaions
Usually persons under 18- consent given from parent/guardian, mentally incompetent adult
In Ontario situationally a 16-year-old may be considered to have the capacity to make healthcare decisions for themself
Emancipated minors
A person under 18 who is married, pregnant, military personnel, financially independent living away from home
May give informed consent
Ontario laws on emancipation
No laws on emancipation: age of majority is 18, 16 year old can apply to courts and withdrawal from parenteral control, 16 year old may give medical consent without SDM in some cases
Health Care Consent Act 1996
To facilitate treatment, admission to care facilities, and personal assistance services for pts lacking the capacity to make decisions about such matters
No treatment without consent
Health practitioners who propose treatment shall not administer treatment and shall take reasonable steps to ensure it is not administered unless they believe that the pt is capable concerning treatment and pt has given consent or they believe that pt is incapable concerning treatment and pts substitute decision-maker has given consent on pts behalf
Emergency treatment- health care consent act
The treatment administered to a pt with consent that the health practitioner believes is on reasonable grounds and in good faith to be sufficient of the act, the health practitioner is not liable for administering the treatment without consent.
Can be applying or withholding treatment
Types of investigations
Service, NOH- ESH branch, coroners inquest, base hospital investigation, civil/ criminal court, police inquiry/ investigation, lawyer/ insurance/ private investigator
Service investigations
Occur due to complaints from family members, patients, base hospital, policy and procedure violation, internal chart audits
How long are incident reports kept on file
5 years
Base hospital investigation
Develop from audits, self-reports, complaints
The base hospital has control over your certification, you represent yourself, and if you’re not certified you’re not an employee
Police authority inquiry
Police act
Request for information with no regard to a police investigation should be in writing or accompanied by a subpoena
Ambulance call reports, incident reports, personal notes (uncommon)
Lawyer/ insurance/ private investigator
Requests accompanied by a subpoena or duly authorized release order, requests of this type are routed through a manager or emergency health services branch investigators
Paramedics are not covered/ protected personally in the following contexts of healthcare
911 emergency calls, alternate destinations, clinical settings, community paramedics, freelance/ subcontractor work, hospital settings, interfacility transfers, long-term care settings, mental wellness response teams, patient discharge, remote communities, special events, special operations
Form 3
Certificate of involuntary admission by a psychiatric facility
Form filled when a person meets the criteria for involuntary admission
Lasts 2 weeks
Form 4
Certificate of involuntary admission by a psychiatric facility
A form issued when a patient continues to meet criteria for an involuntary admission when form 3 expires
The first lasts 1 month, the second lasts 2 months, the third lasts 3 months
Form 8 & 9
Admission and return to psychiatric facilities
BLS standard mental health
In situations with an emotional disturbance, the medic shall: consider underlying organic disorders, give particular attention to personal safety,in incases of pts with known/suspected suicide/self-harm assume attempts are serious and ask the patient directly if they have ideation/intent of self-harm
Medical conditions that mimic a psychological condition
Hypoglycemia, head injury, stroke, brain tumor, drug overdose
BLS aggressive pt
Consider organic disorders, give attention to personal safety, request police assistance on the scene, wait for police assistance, active shooter scenario, direct evidence of ongoing violence, uncooperative pt- use others on the scene for information to determine if illness/injury/alcohol/drugs triggered behaviour, history of violence, alert for behavioural signs of impending violence, in confronted seek safe egress and attempt to withdraw, is safe withdraw is not feasible attempt to speak and calm patient
BLS escorts and restraints
Recognize the need for escorts if: pt is violent, pt is in custody under the court or Ontario review board disposition, concerning restraints: only restrain a patient if directed by a physician or police officer, unescorted pt becomes violent en route,
Restrained patients
Dont leave alone, do not leave on a stretcher in loading heights, obtain vitals every 5-10min, manage and treat all injuries as needed, have police search for weapons
Restrained pt documentation
Indicate on ACR: reason for restraints, person ordering restraints, method of restraint used, pt position during restraints, consequences of restraint if any
Excited delirium
Extreme agitation and aggression in a patient with an altered mental status: 1/10 lead to cardiac arrest.
Two main triggers: acute drug use and psychiatric illness
10 signs of excited delirium
Inappropriate clothing, attraction to glass, failure to respond to police presence, constant/ near-constant physical activity, not tiring despite heavy exertion, unexpected/ unusual strength, unaffected by pain, very rapid breathing, excessive heat/ hot to touch, excessive sweating
Minimum 6 required for diagnosis
Behavioural signs of impending violence
Pacing; approach/ avoidance pattern, tense posture, lout/ strident/ accusatory/ challenging speech, reflex actions; startle response out of proportion to minor stimulus, open threats
Prone restraints
Impairs patient assessment/ monitoring abilities, increased risk of death especially if arms tied behind back, violent struggling combined with obesity/ full stomach/ drugs/ alcohol/ exhaustion can compromise diaphragm and lung function- increased cardiac irritability causing sudden death
Physical abuse- child in need of protection
Results from a parent or person in charge causing physical injury to a child, failing to supervise a child adequately, or from a pattern of neglect.
Ex. beating, slapping, hitting, pushing, throwing, shaking, or burning
Sexual abuse- child in need of protection
Parent or other person in charge sexually molests, uses a child for sexual purposes, or knowingly fails to protect a child from sexual abuse
Ex. any sexual act between adult and child, fondling, exposing a child to adult sexual activity, sexual exploitation through child prostitution, or child pornography
Emotional abuse- child in need of protection
Parent or person in charge causes emotional harm or fails to protect a child from emotional harm that results from verbal abuse, mental abuse, and psychological abuse.
Ex. yelling, screaming, threatening, frightening, bullying, humiliation, name-calling, negative comparisons to others, showing little/ no physical affection or words of affection, withdrawing attention, confining a child to a dark room, tying a child to a chair for long periods of time, allowing a child to be present during violent behaviour of others
Child in need of protection
Child who is/ appears to be suffering from abuse and/or neglect. Section 72 od child and family act details circumstances for concern
Duty to report
Requirement to promptly report any reasonable suspicion that a child is or may require protection directly to a child’s aid society (CAS)
Types of pediatric calls noteworthy of attention- child in need of protection
Near-drowning, all burns, accidental ingestion/poisoning, and other types of in-home injuries
Physical signs- child in need of protection
gross/ multiple deformities incompatible with incident history, multiple new/old bruises which have not been reported, distinctive burn marks (belt, hand, cigarette), bruises in unusual areas (chest, abdomen, genitals, buttocks), burns in unusual areas (buttocks, genitals, soles of feet), signs of long-standing physical neglect, signs of malnutrition, signs of shaking syndrome
Signs of shaking syndrome
Hemorrhages over whites of eyes, hand/ fingerprints on the neck/ upper arms/ shoulders, signs of head injury unrelated to the incident history
Child in need of protection standard
Ensure the child is not left alone, and request police assistance at the scene when it is believed the patient is at imminent risk
Legal death
Pronounced by a physician and BHP through trained/certified ALS provider: TOR Withhold of resuscitation order
Gross rigor mortis
Stiff limbs and body, cold posturing limbs/body, lividity, complete/partial corneal opacification
Hypothermia slows metabolism but prolongs viability
High voltage electric shock
Exceptions to rules: electrocutions/ lightning strikes
S&S: fixed dilated pupils, pt may appear dead
Death during transport with DNR
Keep assessing until death is confirmed- very elderly can have apneic episodes lasting 3 min
Transport code 5
Request for notification to receiving facility of death
Dont transport deceased pt to morgue/ funeral home/ private residence/ code 6 on ACR
Physician delegate
RN, RPN, other medical professional who has been delegated this responsibility by physician
