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Therapeutic Communications; Compassion, Death & Dying; MAD Condell Medical Center EMS System October 2010 CE Site Code # 107200-E-1210 Objectives by: Debbie.

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Presentation on theme: "Therapeutic Communications; Compassion, Death & Dying; MAD Condell Medical Center EMS System October 2010 CE Site Code # 107200-E-1210 Objectives by: Debbie."— Presentation transcript:

1 Therapeutic Communications; Compassion, Death & Dying; MAD Condell Medical Center EMS System October 2010 CE Site Code # E-1210 Objectives by: Debbie Semenek, RN, EMS System Coordinator Packet prepared by: Sharon Hopkins, RN, BSN, EMT-Paramedic

2 Objectives Upon successful completion of this module, the EMS provider will be able to: Upon successful completion of this module, the EMS provider will be able to: 1. Define the communication process. 1. Define the communication process. 2. List components of the communication process. 2. List components of the communication process. 3. List obstructions to the communication process. 3. List obstructions to the communication process. 4. Identify strategies for developing trust and 4. Identify strategies for developing trust and rapport with patients. rapport with patients. 5. Define interpersonal zones. 5. Define interpersonal zones. 6. Identify strategies used during the interview 6. Identify strategies used during the interview process with patients. process with patients.

3 Objectives cont’d 7. Describe elements of patient caring. 8. Describe the unique challenges for EMS 8. Describe the unique challenges for EMS personnel in dealing with themselves, adults, personnel in dealing with themselves, adults, children and special populations related to death children and special populations related to death and dying. and dying. 9. List the 5 predictable stages of loss by 9. List the 5 predictable stages of loss by Elizabeth Kubler Ross. Elizabeth Kubler Ross. 10. State the components of the State of Illinois 10. State the components of the State of Illinois Advanced Directives. Advanced Directives.

4 Objectives cont’d 11. Review the Region X SOP “Withdrawing 11. Review the Region X SOP “Withdrawing Resuscitative Effort”. Resuscitative Effort”. 12. Review the MAD usage. 12. Review the MAD usage. 13. Review documentation components for 13. Review documentation components for discussed conditions. discussed conditions. 14. Actively participate in case scenario 14. Actively participate in case scenario discussions. discussions. 15. Successfully complete the post quiz with a 15. Successfully complete the post quiz with a score of 80% or better. score of 80% or better. 16. Given the equipment, demonstrate use of 16. Given the equipment, demonstrate use of the MAD device. the MAD device.

5 Communication Just an exchange of symbols: Just an exchange of symbols: Written, spoken, gestured Written, spoken, gestured

6 Components of Communication A sender – creates the message A sender – creates the message The message is sent The message is sent A receiver – interprets the message sent A receiver – interprets the message sent Feedback – response is given to the message received Feedback – response is given to the message received

7 Failed Communications Prejudice – toward patient or situation Prejudice – toward patient or situation Lack of empathy – identifying with and understanding another’s situation, feelings, motives Lack of empathy – identifying with and understanding another’s situation, feelings, motives Lack of privacy – may inhibit responses Lack of privacy – may inhibit responses External distractions – TV, traffic, crowds External distractions – TV, traffic, crowds Internal distractions – thinking about other things Internal distractions – thinking about other things

8 Key Point Improve communication skills with: Improve communication skills with: PATIENCE PATIENCE FLEXIBILITY FLEXIBILITY RESPECTFULNESS RESPECTFULNESS EVIDENCE OF COMPASSION EVIDENCE OF COMPASSION Once trust is established, rapport follows Once trust is established, rapport follows Avoid false promises – they violate your patient’s trust Avoid false promises – they violate your patient’s trust

9 Building Trust & Rapport Use the patient’s name Use the patient’s name Breaks down some barriers Breaks down some barriers Ask the patient how they want to be addressed Ask the patient how they want to be addressed To remember names: To remember names: Say the name out loud three times in the 1 st minute Say the name out loud three times in the 1 st minute “See” the name in your head “See” the name in your head “Feel” yourself writing the name in your imagination “Feel” yourself writing the name in your imagination

10 Trust and Rapport Voice Voice Watch your volume, speak quietly in low tones Watch your volume, speak quietly in low tones Check your pitch – high voices are harder to hear Check your pitch – high voices are harder to hear Watch your rate of speaking Watch your rate of speaking Use a professional, compassionate tone Use a professional, compassionate tone Avoid sarcasm, irritation, anger Avoid sarcasm, irritation, anger

11 Trust & Rapport Explanations Explanations Explain what you are doing Explain what you are doing Explain why you must do something Explain why you must do something Eases patient’s anxiety Eases patient’s anxiety Often best to give a short explanation immediately prior to the procedure Often best to give a short explanation immediately prior to the procedure Less time for the patient to dwell on what will be done Less time for the patient to dwell on what will be done Less time for the imagination to roam Less time for the imagination to roam

12 Trust & Rapport Facial expressions Facial expressions Keep a kind, calm facial expression Keep a kind, calm facial expression Keep a “poker” face Keep a “poker” face Convinces the patient you can handle the situation Convinces the patient you can handle the situation Smiling when speaking puts a more pleasant tone in your voice Smiling when speaking puts a more pleasant tone in your voice

13 Interpersonal Zones Intimate zone – 0 – 1.5 feet Intimate zone – 0 – 1.5 feet Visual distortions Visual distortions Best for assessing breath & body odors Best for assessing breath & body odors Personal space – 1.5 – 4 feet Personal space – 1.5 – 4 feet Used for much of patient interview and assessment Used for much of patient interview and assessment No visual distortion No visual distortion Voice is moderate Voice is moderate Social distance – 4 – 12 feet Social distance – 4 – 12 feet Impersonal business transactions Impersonal business transactions Personal interview in dangerous situations Personal interview in dangerous situations

14 Interviewing Techniques Goal: Goal: Identify chief complaint Identify chief complaint Determine circumstances causing the emergency Determine circumstances causing the emergency Determine the patient’s condition Determine the patient’s condition Achieving the goal: Achieving the goal: Asking questions Asking questions Observational skills Observational skills Effective listening skills Effective listening skills

15 Interviewing Techniques Open-ended questions Open-ended questions Questions that permit unguided, spontaneous answers Questions that permit unguided, spontaneous answers “ What happened that you needed to call 911?” “ What happened that you needed to call 911?” “What seems to be the problem?” “What seems to be the problem?” Benefit Benefit Patient responds in an unguided way Patient responds in an unguided way May include information that indicates additional assessment of patient May include information that indicates additional assessment of patient Chief complaint can drive direction of rest of the interview Chief complaint can drive direction of rest of the interview

16 Interviewing Techniques Leading questions Leading questions Question framed to guide the direction of the patient’s answer Question framed to guide the direction of the patient’s answer “Are you having chest pain?” “Are you having chest pain?” Problem – Problem – Could miss a serious problem by refocusing the patient away from their true chief complaint Could miss a serious problem by refocusing the patient away from their true chief complaint

17 Interviewing Techniques Direct or closed questions Direct or closed questions Requests specific information Requests specific information “Are you nauseated?” “Are you nauseated?” Answers fill in information generated from open-ended questions Answers fill in information generated from open-ended questions Answers crucial questions when time is limited Answers crucial questions when time is limited Helps control overly talkative patients Helps control overly talkative patients

18 Interviewing Techniques Ask one question at a time Ask one question at a time Allows patient to finish answering one question and to complete their thought Allows patient to finish answering one question and to complete their thought Designate one person to ask questions Designate one person to ask questions Confuses patient when multiple people ask questions Confuses patient when multiple people ask questions May not be clear which person/which question the patient is responding to May not be clear which person/which question the patient is responding to Listen to the responses Listen to the responses Do not interrupt Do not interrupt

19 Interviewing Techniques Use of language Use of language Use words the patient understands Use words the patient understands “pee” instead of “urinate” “pee” instead of “urinate” Avoid slang or jargon Avoid slang or jargon May need to phrase the words multiple ways for the patient to understand the question May need to phrase the words multiple ways for the patient to understand the question Remember that children are literal, concrete minded Remember that children are literal, concrete minded You say “I’m taking your blood pressure” and the child wonders where you are taking it to You say “I’m taking your blood pressure” and the child wonders where you are taking it to

20 Patient Caring “People will seldom remember what you did or what you said. But they will almost always remember how you made them feel.” Cab Driver, Boston

21 What EMS does… We fix problems We fix problems Technical stuff Technical stuff Splint Splint Bandage Bandage IV’s IV’s Drugs Drugs Etc. Etc.

22 What else we do…. We fix people We fix people Family concerns Family concerns Non-medical needs Non-medical needs Emotions Emotions Comfort Comfort Being a friend / advocate Being a friend / advocate

23 EM“S ” Service Service Must have a natural ability to like people Must have a natural ability to like people We encounter people at their worst – they are in crisis We encounter people at their worst – they are in crisis If you don’t want to be there and you don’t want to take care of them…they will sense that, so… If you don’t want to be there and you don’t want to take care of them…they will sense that, so… …consider a different profession!

24 Remember, an emergency is defined by its owner – not by us Remember, an emergency is defined by its owner – not by us Don’t underestimate the patient Don’t underestimate the patient People are easily overwhelmed People are easily overwhelmed They don’t know where to turn, so they turn to us They don’t know where to turn, so they turn to us It does not make them stupid It does not make them stupid It is not a waste of our time… It is not a waste of our time…

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26 Who Do We Serve? Define who all of our customers are Define who all of our customers are In-house, department members In-house, department members Vendors supplying the department Vendors supplying the department Other village/city/governmental departments Other village/city/governmental departments Hospital staff Hospital staff Our patients Our patients Our patient’s families Our patient’s families Who else??? Who else???

27 What’s the message???  Regard everyone as a customer.

28 Be Effective To be effective with your technical skills you must: To be effective with your technical skills you must: See the patient as more than the problem, complaint, that they present See the patient as more than the problem, complaint, that they present They are customers that reach out to you in the worst moment of their lives They are customers that reach out to you in the worst moment of their lives

29 Be Effective Explain every phase of treatment to your patient Explain every phase of treatment to your patient Let them know what to expect Let them know what to expect Ask permission before a procedure Ask permission before a procedure When you can accept a ‘yes’ or ‘no’ answer When you can accept a ‘yes’ or ‘no’ answer When there shouldn’t be a choice (ie: necessary IV), avoid phrases like “Can I start this IV” When there shouldn’t be a choice (ie: necessary IV), avoid phrases like “Can I start this IV” Give the choice, instead, possibly to the IV site Give the choice, instead, possibly to the IV site Give them an opportunity to report changes Give them an opportunity to report changes

30 Patients are highly aware of a caregiver’s attitude – whether positive or negative. If you show honest concern, the patient will sense it.

31 Caring… We must be people who can enjoy serving others for 30 years and sell them the real deal We must be people who can enjoy serving others for 30 years and sell them the real deal Not every call is dramatic Not every call is dramatic Burnout is a possibility Burnout is a possibility What are your expectations? What are your expectations? Our role in a patient’s life is more than just a moment Our role in a patient’s life is more than just a moment

32 Caring… Habitually use peoples’ names Habitually use peoples’ names Hi. What is your name? Hi. What is your name? Introduce yourself Introduce yourself Ask how the patient wants to be addressed Ask how the patient wants to be addressed Connect with the person – not the problem Connect with the person – not the problem Smile Smile Be respectful Be respectful Maintain eye contact Maintain eye contact Immediately puts you in touch with their emotional state and mental status Immediately puts you in touch with their emotional state and mental status

33 Caring… Remember people have families / significant others Remember people have families / significant others Families are important to us Families are important to us Healing Healing Informative Informative Supportive Supportive DO NOT toss a family member/significant others aside so we can do our work DO NOT toss a family member/significant others aside so we can do our work May be the last time the patient is seen in a comfortable setting May be the last time the patient is seen in a comfortable setting

34 Understand that physical comfort, fear and embarrassment are important to our patient Understand that physical comfort, fear and embarrassment are important to our patient Need to be vigorously addressed Need to be vigorously addressed Pain control Pain control Keeping a patient warm / cool Keeping a patient warm / cool Providing emotional comfort Providing emotional comfort Maintaining modesty / dignity Maintaining modesty / dignity

35 Families and Death The reality of death is: The reality of death is: It’s traumatic It’s traumatic It’s stressful It’s stressful For us, too For us, too It’s a situation that is permanently imprinted It’s a situation that is permanently imprinted Everything that is heard and seen and will be remembered Everything that is heard and seen and will be remembered

36 Delivering the News of Death EMS often in the position to have to deliver news of a death EMS often in the position to have to deliver news of a death No script can cover all situations No script can cover all situations Each scene must be assessed as well as the persons involved Each scene must be assessed as well as the persons involved Then determine safest and most compassionate way to deliver sad news Then determine safest and most compassionate way to deliver sad news Provide a private area for sharing information Provide a private area for sharing information

37 Deaths – Phrases to avoid… “I know how you feel” “I know how you feel” “I understand” “I understand” “You’re so strong” “You’re so strong” “Get on with your life” “Get on with your life” “It was God’s will” “It was God’s will” “They led a good life” “They led a good life” “It could have been worse” “It could have been worse”

38 The high road The high road Compassionate Compassionate To each other To each other Conveying caring / offering condolences Conveying caring / offering condolences Explaining actions / inactions Explaining actions / inactions Giving permission to grieve Giving permission to grieve Denial, anger, bargaining, depression, acceptance Denial, anger, bargaining, depression, acceptance Offering continuing support Offering continuing support Clergy Clergy CISM (CISD # ) CISM (CISD # ) Counselors Counselors Friends Friends Caring… Two roads to take

39 The low road… Tough / abrasive Tough / abrasive Don’t talk to anyone, keeping them away Don’t talk to anyone, keeping them away “Death does not phase me” attitude “Death does not phase me” attitude Being cold Being cold Being distant Being distant Tough is not professional Tough is not professional

40 Dealing with the difficult situation Dealing with the difficult situation Families who are able to spend time with the body or dying person do better emotionally in the long run Families who are able to spend time with the body or dying person do better emotionally in the long run “There is an image of the loved one looking worse than they really are when the body can’t be seen.” If the image is bad, give family the option If the image is bad, give family the option

41 What to say & do… It’s OK to share that it’s hard for you It’s OK to share that it’s hard for you Let touch convey caring Let touch convey caring “I wish so much you had them back” “I wish so much you had them back” “I see how painful this is for you” “I see how painful this is for you” Ask to hear about their loved one Ask to hear about their loved one Be a good listener Be a good listener

42 Stages of Loss Experienced in any loss Experienced in any loss Death Death Relationships Relationships Jobs Jobs EMS is exposed to a multitude of emotional responses EMS is exposed to a multitude of emotional responses We don’t always see people at their best is why we always need to function at our best We don’t always see people at their best is why we always need to function at our best

43 Stages of Loss 5 predictable stages 5 predictable stages Denial – “not me” Denial – “not me” Anger – “why me” Anger – “why me” Bargaining – “okay, but first” Bargaining – “okay, but first” Depression – “okay, but I haven’t” Depression – “okay, but I haven’t” Acceptance – “okay, I’m not afraid” Acceptance – “okay, I’m not afraid” Stages can progress in any order and time frame for each is individualized Stages can progress in any order and time frame for each is individualized

44 Denial Inability or refusal to believe the reality of the event Inability or refusal to believe the reality of the event Used as a defense mechanism Used as a defense mechanism Person can put off dealing with the inevitable Person can put off dealing with the inevitable If death is discussed, use the terms “dying, died, death, dead” If death is discussed, use the terms “dying, died, death, dead” Use of “passed on, left us, gone away” can be misinterpreted Use of “passed on, left us, gone away” can be misinterpreted Avoid statement’s of “God’s way” or relief of pain or other subjective assumptions Avoid statement’s of “God’s way” or relief of pain or other subjective assumptions

45 Anger Really a frustration over inability to control situation Really a frustration over inability to control situation Anger can be focused on anyone or anything in their pathway Anger can be focused on anyone or anything in their pathway Watch for safety issues Watch for safety issues

46 Bargaining Patients may try to “make deals” to put off or change the inevitable Patients may try to “make deals” to put off or change the inevitable “I promise to …(go to church, be kinder, donate my money…) if…(the diagnosis is wrong, the disease isn’t so bad, it was mistaken identity) “I promise to …(go to church, be kinder, donate my money…) if…(the diagnosis is wrong, the disease isn’t so bad, it was mistaken identity)

47 Depression Patient experiences a variety of feelings Patient experiences a variety of feelings Sadness Sadness Mourning Mourning Retreats into self/private world Retreats into self/private world May lose interest in self care May lose interest in self care Bathing issues Bathing issues Non-compliance with medical care Non-compliance with medical care

48 Acceptance Patient may or may not reach this stage Patient may or may not reach this stage May achieve a reasonable level of comfort with situation May achieve a reasonable level of comfort with situation Family may need more support at this point in time Family may need more support at this point in time

49 EMS and Patient Resources Department peers Department peers Department chaplain Department chaplain Family members Family members Religious affiliation Religious affiliation Hospital services patient is connected to Hospital services patient is connected to Hospice if patient is enrolled Hospice if patient is enrolled Others? Others?

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51 Components of a Valid DNR IDPH Uniform DNR Order form which has not been revoked IDPH Uniform DNR Order form which has not been revoked Name of the patient Name of the patient Name and signature of the attending physician Name and signature of the attending physician Effective date Effective date The words “DO NOT RESUSCITATE” The words “DO NOT RESUSCITATE” Evidence of consent: Evidence of consent: Signature of the patient or their legal guardian Signature of the patient or their legal guardian Signature of durable power of attorney for Health Care Agent Signature of durable power of attorney for Health Care Agent Signature of surrogate decision maker Signature of surrogate decision maker

52 State of Illinois DNR Form Did you know? Did you know? Form is acceptable reproduced in any color Form is acceptable reproduced in any color Acceptable components must be present Acceptable components must be present State of Illinois is only State form acceptable State of Illinois is only State form acceptable If patient presents an out of State form, CPR must be initiated If patient presents an out of State form, CPR must be initiated Call Medical Control ASAP to request termination of CPR based on presence of out of State DNR form Call Medical Control ASAP to request termination of CPR based on presence of out of State DNR form

53 IDPH DNR Form Gives an individual the additional freedom to decide what medical treatment fits his or her beliefs and wishes Gives an individual the additional freedom to decide what medical treatment fits his or her beliefs and wishes Differentiates between “full cardiopulmonary arrest” and a “pre-arrest emergency” Differentiates between “full cardiopulmonary arrest” and a “pre-arrest emergency”

54 Pre-arrest Emergency When breathing is labored or stopped but the heart is still beating When breathing is labored or stopped but the heart is still beating 2 options to choose from: 2 options to choose from: “Do Attempt Cardiopulmonary Resuscitation” “Do Attempt Cardiopulmonary Resuscitation” “Do Not Attempt Cardiopulmonary Resuscitation” “Do Not Attempt Cardiopulmonary Resuscitation” There is also a space available for an individual to give “other instructions” regarding application of the DNR Order under certain circumstances: There is also a space available for an individual to give “other instructions” regarding application of the DNR Order under certain circumstances: Accidents Accidents Surgery Surgery Choking Choking

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57 IDPH DNR Form The order is still considered valid if the back of the form has not been completed. The order is still considered valid if the back of the form has not been completed. The order can be revoked The order can be revoked Writing “VOID” in large letters across the front of the form revokes the form Writing “VOID” in large letters across the front of the form revokes the form Form can be torn/shredded/destroyed Form can be torn/shredded/destroyed Can be revoked by the individual or their legal representative Can be revoked by the individual or their legal representative

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59 Durable Power of Attorney for Healthcare (DPOA) Written record (multiple pages) Written record (multiple pages) Allows patient to choose an agent who will make healthcare treatment decisions when the patient cannot Allows patient to choose an agent who will make healthcare treatment decisions when the patient cannot Applies whenever the patient can no longer make treatment decisions for themselves Applies whenever the patient can no longer make treatment decisions for themselves Provides “agent” with power to provide consents and refusal for any type of medical care or treatment Provides “agent” with power to provide consents and refusal for any type of medical care or treatment

60 DPOA Form Completed by any adult with sound mind Completed by any adult with sound mind Must be witnessed Must be witnessed Agent’s signature is not mandatory Agent’s signature is not mandatory Can be revoked at any time Can be revoked at any time Downside for EMS Downside for EMS Less familiar to EMS than the DNR form Less familiar to EMS than the DNR form Lengthy document to review in critical situation Lengthy document to review in critical situation

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63 Living Will Written record Written record Expresses care patient would choose during a terminal injury or illness Expresses care patient would choose during a terminal injury or illness Specifies care patient would want / not want Specifies care patient would want / not want Cannot be used if the patient is capable of making decisions Cannot be used if the patient is capable of making decisions Is not recognized by EMS Is not recognized by EMS If presented by a Living Will document, begin appropriate care and contact Medical Control If presented by a Living Will document, begin appropriate care and contact Medical Control

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65 Region X SOP Withdrawing Resuscitative Efforts Contact Medical Control while continuing patient care ⇓ Report events of the call including estimated duration of cardiac arrest and treatments rendered. ⇓

66 Reaffirm the following: Patient is normothermic adult Patient experienced an unwitnessed arrest Advanced airway secured and IV/IO placement confirmed Patient remains in arrest despite aggressive BLS and ALS treatment modalities following appropriate SOPs At least two full medication rounds have been administered ⇓ ⇓

67 SOP cont’d ⇓ If the Physician orders termination of efforts, note the time of death and the physician’s name on the run report. Notify Coroner or Medical Examiner. NOTE: Only a physician may make the determination to withdraw resuscitative efforts ⇓

68 Review - MAD Mucosal atomization device Mucosal atomization device Tool to deliver medications via nasal route Tool to deliver medications via nasal route Medication atomized into tiny particles Medication atomized into tiny particles Nasal mucosa highly vascular Nasal mucosa highly vascular Immediate absorption into bloodstream Immediate absorption into bloodstream No delay in gaining access No delay in gaining access

69 MAD Syringe can be filled as needed Syringe can be filled as needed Tips are removable Tips are removable Deliver medication in divided doses Deliver medication in divided doses Maximum of 1 ml per nares Maximum of 1 ml per nares

70 MAD Insert device into nostril and make firm seal Insert device into nostril and make firm seal Hold head steady Hold head steady Aim tip of MAD towards same side ear Aim tip of MAD towards same side ear As quick as possible deliver medication As quick as possible deliver medication Divide dose volume equally into both nostrils Divide dose volume equally into both nostrils Max volume 1 ml per nares Max volume 1 ml per nares

71 Documentation MAD Document in the usual manner for medication administration Document in the usual manner for medication administration Dose route indicated is “inh” Dose route indicated is “inh” Example: Example: Narcan - 2mg - inh Narcan - 2mg - inh Include response to intervention in comments Include response to intervention in comments

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73 Case Scenario #1 EMS is called to a location for a person with shortness of breath EMS is called to a location for a person with shortness of breath Upon arrival Upon arrival Patient conscious, in respiratory distress laying in a hospital bed Patient conscious, in respiratory distress laying in a hospital bed History lung cancer, in hospice History lung cancer, in hospice Family states the patient has a valid DNR and produces form Family states the patient has a valid DNR and produces form Family requests transport but no other care Family requests transport but no other care What are you going to do?

74 Discussion Case Scenario #1 1. Who speaks for the patient at this time? 1. Who speaks for the patient at this time? Patient is conscious Patient is conscious Patient has a valid DNR Patient has a valid DNR Patient speaks for themselves Patient speaks for themselves 2. Is it appropriate to withhold care because the patient is in hospice? 2. Is it appropriate to withhold care because the patient is in hospice? What is the purpose of the DNR? What is the purpose of the DNR? When does the DNR become “active”? When does the DNR become “active”?

75 REMEMBER… DNR means DNR means “Do Not Resurrect” “Do Not Resurrect” Doesn’t mean “Do Not Treat” Doesn’t mean “Do Not Treat” Provide care based on signs, symptoms and general impression Provide care based on signs, symptoms and general impression Provide oxygenation, pain control, medication, etc Provide oxygenation, pain control, medication, etc If it were your family member, how would you want them to be treated? If it were your family member, how would you want them to be treated?

76 Case Scenario #2 EMS arrives on the scene and the patient is triple 0 (0-0-0) EMS arrives on the scene and the patient is triple 0 (0-0-0) No evidence of foul play or trauma No evidence of foul play or trauma The patient was found by the family just prior to the call The patient was found by the family just prior to the call The family states the patient has a DNR; the patient would not want to be “worked” The family states the patient has a DNR; the patient would not want to be “worked”

77 Discussion Case Scenario #2 What should be your first approach at the scene? What should be your first approach at the scene? Assess the patient (ABC’s) Assess the patient (ABC’s) Request to see the DNR form Request to see the DNR form If the DNR is not presented, how do you proceed? If the DNR is not presented, how do you proceed? CPR must be initiated until a valid DNR is produced CPR must be initiated until a valid DNR is produced Once a valid DNR is produced, contact Medical Control Once a valid DNR is produced, contact Medical Control Give report Give report Be specific and ask for what you want Be specific and ask for what you want With the valid DNR form in hand, “can we stop CPR?” With the valid DNR form in hand, “can we stop CPR?”

78 Discussion Case Scenario #2 Once CPR is started, when can EMS stop CPR? Once CPR is started, when can EMS stop CPR? When patient is resuscitated When patient is resuscitated When a physician directs you to stop When a physician directs you to stop When there is someone to take over When there is someone to take over When you are exhausted and there is no one to relieve you When you are exhausted and there is no one to relieve you Document name of physician ordering CPR to be stopped Document name of physician ordering CPR to be stopped Document time CPR was stopped Document time CPR was stopped

79 Case Scenario #3 You are called to the scene for a 27 year-old patient who is unresponsive at work You are called to the scene for a 27 year-old patient who is unresponsive at work No history of trauma No history of trauma Last seen 3 hours ago Last seen 3 hours ago 102/56; P – 86; R – 4; pupils constricted 102/56; P – 86; R – 4; pupils constricted AVPU – responds to painful stimuli (purposeful) AVPU – responds to painful stimuli (purposeful) GCS – 2/2/5 – 9 GCS – 2/2/5 – 9 Describe further assessment needed and describe interventions taken

80 Discussion Case Scenario #3 Immediate problem is airway What techniques could be used to open this airway? What techniques could be used to open this airway? In absence of trauma, head tilt - jaw thrust In absence of trauma, head tilt - jaw thrust In presence of trauma – modified jaw thrust In presence of trauma – modified jaw thrust What interventions could be used to maintain an open airway? What interventions could be used to maintain an open airway? Oropharyngeal in the absence of a gag reflex Oropharyngeal in the absence of a gag reflex Nasopharyngeal with or without a gag reflex Nasopharyngeal with or without a gag reflex Intubation with conscious sedation Intubation with conscious sedation

81 Discussion Case Scenario #3 How do you address the breathing problem? (respiratory rate 4 per minute) How do you address the breathing problem? (respiratory rate 4 per minute) Maintain an open airway Maintain an open airway Augment the respiratory rate to ventilate the patient once every seconds (has spontaneous heart beat) Augment the respiratory rate to ventilate the patient once every seconds (has spontaneous heart beat) Use BVM Use BVM Have suction available and ready Have suction available and ready Now trouble shoot why the respiratory rate is a problem Now trouble shoot why the respiratory rate is a problem

82 Discussion Case Scenario #3 Further assessment detail: Further assessment detail: Blood sugar level - 86 Blood sugar level - 86 EKG monitor EKG monitor Sinus rhythm Sinus rhythm Consider need for 12 lead EKG based on data Consider need for 12 lead EKG based on data Patient assessment Patient assessment Lead II rhythm strip Lead II rhythm strip General impression General impression Physical assessment Physical assessment No signs of trauma No signs of trauma No evidence of drug paraphernalia No evidence of drug paraphernalia

83 Discussion Case Scenario #3 Why does this patient have an altered level of consciousness? Why does this patient have an altered level of consciousness? Think: Think: A – acidosis, alcohol A – acidosis, alcohol E – Epilepsy E – Epilepsy I – Infection (brain, sepsis) I – Infection (brain, sepsis) O – Overdose O – Overdose U – Uremia (kidney failure) U – Uremia (kidney failure) T – Trauma, tumor, toxins T – Trauma, tumor, toxins I – Insulin – hypo or hyperglycemia I – Insulin – hypo or hyperglycemia P – Psychosis, poison P – Psychosis, poison S – Stroke, seizure S – Stroke, seizure

84 Discussion Case Scenario #3 Possible drug overdose Possible drug overdose Altered level of consciousness Altered level of consciousness Pinpoint pupils Pinpoint pupils Depressed respirations Depressed respirations Intervention Intervention Support airway (BVM in this case) Support airway (BVM in this case) Administer Narcan Administer Narcan Obtain blood glucose level Obtain blood glucose level Be prepared for vomiting Be prepared for vomiting

85 Discussion Case Scenario #3 Narcan Narcan Narcotic antagonist Narcotic antagonist Dose 2 mg IVP Dose 2 mg IVP Repeated every 5 minutes as needed to achieve desired effect Repeated every 5 minutes as needed to achieve desired effect Maximum dose total 10 mg Maximum dose total 10 mg Routes Routes IVP/IO IVP/IO Inhalation (Inh) Inhalation (Inh)

86 Discussion Case Scenario #3 What is maximum volume for each nostril using the MAD? What is maximum volume for each nostril using the MAD? 1 ml 1 ml Divide total volume between each nostril Divide total volume between each nostril Increases absorption surface area Increases absorption surface area What are “desired” effects of Narcan? What are “desired” effects of Narcan? Improvement in level of consciousness Improvement in level of consciousness Improvement in ventilation rate and depth Improvement in ventilation rate and depth

87 Narcan Does the patient have to be awake and talking? Does the patient have to be awake and talking? Is that the “desired” effect? Is that the “desired” effect? NO!!!! NO!!!! For combative patients, why would you want them totally awake? For combative patients, why would you want them totally awake? Goal is to improve ventilations Goal is to improve ventilations

88 Narcan cont’d Remember with narcotics and Narcan Remember with narcotics and Narcan Narcan is short acting Narcan is short acting Once patient improves ventilations, the narcotic influence may depress ventilations again when Narcan wears off Once patient improves ventilations, the narcotic influence may depress ventilations again when Narcan wears off

89 Case Scenario #4 Altered perceptions Altered perceptions Have one member wear distorted glasses Have one member wear distorted glasses Have second member review the release form or other document and ask the “patient” to review and sign Have second member review the release form or other document and ask the “patient” to review and sign Discuss as a group the distorted perception experienced Discuss as a group the distorted perception experienced

90 Case Scenario #5 Altered perceptions Altered perceptions Have one member of the group muffle their hearing Have one member of the group muffle their hearing Have a second member talk to the “patient” and give the “patient” commands to follow Have a second member talk to the “patient” and give the “patient” commands to follow Discuss as a group the distorted perception experience Discuss as a group the distorted perception experience

91 Final Comments….  Consider how and what you are doing looks to others.  …and what you say! you say!

92 Some more to think about  Treat all patients with gentleness  Provide a smooth ride  Always tell the truth  Count your blessings  Always be nice – treat everyone with respect, kindness, patience, and consideration.

93 Bibliography Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices. Prentice Hall Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices. Prentice Hall IDPH Uniform DNR Order Form. PO M. 5/05. IDPH Uniform DNR Order Form. PO M. 5/05. Region X SOP, March 2007; amended January 1, Region X SOP, March 2007; amended January 1, Steingart, J. Chief, Countryside Fire Protection District. Patient Caring Steingart, J. Chief, Countryside Fire Protection District. Patient Caring


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