Rules For Documentation
- must be accurate-fill in everything
- must be objective- don’t assume/judge
- must be specific- describe findings
- must be legible
- must be timely
- be thorough-if you didn’t write it down, you didn’t do it
Scene Survey
- PPE
- SPERM
- Bystander Interview
- General Impression
Head-To-Toe
- Head-chest: DCAP-BLS-TIC, ausultate chest, assess equal fall and rise of chest
- Abdomen: DCAP-BLS, Distention, Rigidity, Tnederness, do they guard, pulsating mass
- Pelvis: DCAP-BLS-TIC, push into and down on pelvis to check for stability
- Lower Extremities: DCAP-BLS-TIC, CMS (circulation, motor function, sensation), pedal pulse
- Upper Extremities: DCAP-BLS-TIC, CMS, radial pulse
- Back: DCAP-BLS-TIC
Health Information Act
The legislative act that allows EMS to share information with other health care professionals.
Steps To Take In An Emergency
- PPE
- Scene Safety
- Primary Survey
- Secondary Survey
- Ongoing Survey
Primary Survey
- introduce yourself and ask if you may help them(even if they seem to be unconscious)
- assess LOC
- assess cervical spine
- assess airway and breathing
- assess circulation (pulse and skin check)
- distinguish between trauma and medical assessment
Six Major Responsibilities
- ensure safety for yourself and any bystanders
- gain access to the patient
- determine any threats to the patients life
- obtain more advanced medical care as needed
- provide needed care for the patient
- assist more advanced medical personnel
Secondary Responsibilities
- controlling or directing bystanders or asking them for help
- taking additional steps, if necessary, to protect bystanders from dangers such as traffic or fire
- recording what you saw, heard, and did at the scene
- reassuring the patient’s family or friends
Emergency Medical Personnel Characteristics
- maintaining a caring and professional attitude
- controlling your fears
- presenting a clean and professional appearance
- keeping your skills and knowledge up to date
- staying fit with daily exercise and a healthy diet
- maintaining a safe and healthy lifestyle
Duty To Act
A legal responsibility of some in individuals to provide a reasonable standard of emergency care;
May be required by caselaw, statute, or job description.
Scope of practice
Responders scope of practice is defined as the range of duties and skills he is allowed expected to perform when necessary to his level of training and reasonable care and skill. The responder it’s governed by legal, ethical, and medical standards.
Ethical responsibilities
As a responder, you have an ethical obligation to carry out your duties and responsibilities in a professional manner. This includes showing compassion and dealing with a patient’s physical and mental needs and communicating sensitively and willingly at all times.
Be honest when reporting actions and events that occurred at a scene.
Consent
An individual has a basic right to decide what can and cannot be done with their body. Therefore, to provide care for a patient, you must first obtain that person’s consent.
To obtain consent, you must; •identify yourself to the person •state your level of training •explain what’s you think may be wrong •explain what you plan to do
The person can now decide whether or not to grand their informed consent.
A person who is unconscious, confused, or seriously ill or injured may not be able to grant informed consent. In these cases, the law assumes that the person would grant consent for care if they were able to do so.
Consent: special circumstances
Unless an illness or injury is life threatening, a parent or guardian must be present and give consent for minors before care can be given.
If a parent or guardian refuses to allow you to provide care, if the situation is life threatening, a law enforcement officer can help obtain the necessary legal authority to provide care.
In some situations, a persons religion or cultural beliefs may prevent that person from receiving care or being cared for by strangers or members of the opposite sex.
Always respect the person’s wishes.
