1. Copyright 2008 Seattle/King County EMS CBT/OTEP 935 Street Medicine – Special Situations

2. Copyright 2008 Seattle/King County EMS Introduction This course is intended to provide general guidance to EMS providers in unique situations. Follow your local protocols when they vary from the recommendations in this course. This course is intended to provide general guidance to EMS providers in unique situations. Follow your local protocols when they vary from the recommendations in this course. This course will address special problems encountered by EMS providers in the field including refusal of care, violence, forced restraint, and other situations.

3. Copyright 2008 Seattle/King County EMS New Terms compelling reasons – Circumstances that permit EMS personnel to withhold resuscitation from a patient in cardiac arrest. excited delirium – A term used to describe out- of-control behavior in people usually under the influence of stimulants. In some cases, a severely agitated person can go into cardiac arrest.

4. Copyright 2008 Seattle/King County EMS New Terms, continued legal capacity – In EMS, this concept mostly concerns whether or not a person is a minor. mental competence – A person’s ability to understand information about their condition and weigh the risks and benefits of not receiving care. reasonable force – The force needed to keep a patient from injury or from injuring others.

5. Copyright 2008 Seattle/King County EMS Refusal of Care Competent person has a right to refuse treatment Must assure he is of sound mind and legally able to Mental competence Legal capacity

6. Copyright 2008 Seattle/King County EMS Mental Competence A person’s ability to understand information about his or her condition and weigh the risks and benefits of not receiving care

7. Copyright 2008 Seattle/King County EMS Legal Capacity Is the patient a minor? In most states, under age 18 considered a minor Parent or guardian generally must give permission for medical treatment

8. Copyright 2008 Seattle/King County EMS Case Study – MVA 28-year-old male – motor scooter/auto collision at a busy intersection. Patient refuses care. He says he doesn’t have heath insurance and thinks he will be fine. He hit the curb at about 5 mph and fell over with the bike as it came to a stop. He’s alert and oriented X 3.

9. Copyright 2008 Seattle/King County EMS Case Study – MVA, continued Is this patient mentally competent? Does he have legal capacity?

10. Copyright 2008 Seattle/King County EMS Case Study – Alcohol Intoxication Man in his 40’s at local tavern – fall from bar stool. Has been drinking for 2+ hours. Speech is slurred. He refuses care. He says feels fine. Friend says he hit his head when he fell. Alert and oriented to person and place (but not time).

11. Copyright 2008 Seattle/King County EMS Case Study – Alcohol, continued Is this patient mentally competent? You are concerned that he might have a head injury or hypoglycemia. What strategies can you employ to allow for treatment?

12. Copyright 2008 Seattle/King County EMS Safety and Violent Behavior Look for hazards before approaching Plan an escape route Approach in a calm and non-threatening manner Do not try to intervene in a fight or argument Ask if there are weapons Do not get separated from your partner Consider additional resources early

13. Copyright 2008 Seattle/King County EMS Safety and Violent Behavior If a scene suddenly becomes dangerous, do not hesitate to back out and call for help!

14. Copyright 2008 Seattle/King County EMS Attempted Suicide Rescuer and patient safety high priority Calm patient Treat injuries, if possible Manage family anxiety Clear onlookers from scene

15. Copyright 2008 Seattle/King County EMS Case Study – Attempted Suicide 24-year-old female, said to be “suicidal.” Threatening to kill herself with a straight razor. She is sitting on the bathroom floor next to the bathtub, without clothing. There is blood on the floor. She is emotionally distraught and crying. Friend says “I can’t deal with her any more.”

16. Copyright 2008 Seattle/King County EMS Case Study – Suicide, continued What will be your initial steps in approaching and dealing with this patient?

17. Copyright 2008 Seattle/King County EMS Forced Restraint Use forced restraint only to protect a patient, yourself, or others from harm

18. Copyright 2008 Seattle/King County EMS Reasonable Force Use only enough force to keep patient from injury or from hurting others Size and strength of patient Type of abnormal behavior Sex of patient Mental state of patient Method of restraint

19. Copyright 2008 Seattle/King County EMS Restraints Use commercial, soft restraints or use a towel and two-inch tape Secure restraint to backboard or stretcher

20. Copyright 2008 Seattle/King County EMS Seek Patient Cooperation Be calm, patient, and reassuring Do not belittle or threaten Do not argue or shout Encourage patient to speak openly Suggest appropriate steps for pt to take Treat with respect Avoid forced restraint unless absolutely necessary!

21. Copyright 2008 Seattle/King County EMS Guidelines for Forced Restraint Have sufficient personnel Consult medical direction, if possible Have a clear plan of action Once decision is made, act quickly Use reasonable force Assign one rescuer to each limb Reassess breathing and circulation frequently Document reasons for restraining

22. Copyright 2008 Seattle/King County EMS Case Study – Violent Behavior 25-year-old male – bizarre, violent, and combative behavior, on meth. Patient sitting in street with no shirt or shoes on, abrasions on his hands and knees. Patient threatens police and EMS responders. Police attempt to arrest him. Puts up impressive struggle. Eventually, they subdue him down and two officers kneel atop him. He is grunting and moaning, but then stops and doesn’t resist.

23. Copyright 2008 Seattle/King County EMS Case Study – Violent, continued As you move closer to the patient, you notice that he remains completely still and is not making a sound. What actions should you take next? You see no chest rise and you quickly determine he is not breathing. What is your best guess as to what happened?

24. Copyright 2008 Seattle/King County EMS TASER Dart Removal Assure scene safe and pt under control Don gloves and eye protection Break or cut wires before removing darts Grasp dart firmly with one hand and pull to remove Dispose of darts in sharps container Bandage wounds Document assessment and care provided

25. Copyright 2008 Seattle/King County EMS TASER Dart Removal DO NOT remove a dart if: Patient is not under control Eye, face, neck, breast, or groin are involved

26. Copyright 2008 Seattle/King County EMS Compelling Reasons Permits EMS personnel to withhold resuscitation from patient in cardiac arrest when two criteria are BOTH present: End stage of a terminal condition Written or verbal information from family or patient stating that patient did not want resuscitation

27. Copyright 2008 Seattle/King County EMS Compelling Reasons, continued If both criteria not met, initiate resuscitation If both criteria are met, withhold resuscitation If resuscitation already started, stop If there is disagreement among family, initiate resuscitation

28. Copyright 2008 Seattle/King County EMS Palliative Care No CPR does not mean "no treatment" or "no caring" Comfort measures (oxygen, suctioning) Request medics if you feel that ALS care (e.g., pain management) is needed Support and assistance family

29. Copyright 2008 Seattle/King County EMS Case Study – No DNR Orders 82-year-old female, difficulty breathing. She has end-stage lung cancer. Patient is unconscious, unresponsive, and pulseless. Daughter and son both say their mother did not want CPR. There is no advance directive.

30. Copyright 2008 Seattle/King County EMS Case Study – No DNR, continued Do compelling reasons apply in this case? Why? What would you do if there the daughter and son disagreed about whether or not to begin resuscitation? What will you do to care for this patient?

31. Copyright 2008 Seattle/King County EMS Expanding Role of EMS Providing information to patients: Disease intervention Controlling costs End of life decisions

32. Copyright 2008 Seattle/King County EMS Importance of Documentation Health record for your patient Research tool Quality improvement tool Legal document that protects you

33. Copyright 2008 Seattle/King County EMS Summary Mental competence is a person’s ability to understand information about his or her condition and weigh risks and benefits of not receiving care In EMS, legal capacity mostly concerns whether or not a person is a minor

34. Copyright 2008 Seattle/King County EMS Summary, continued Safety precautions for violent patient: Look for hazards before approaching Plan escape route Approach in calm and non-threatening manner Do not try to intervene in a fight or argument Ask if there are weapons Do not get separated from your partner Consider additional resources early

35. Copyright 2008 Seattle/King County EMS Summary, continued Guidelines for forced restraint: Have sufficient personnel Consult medical direction, if possible Have clear plan of action Once decision is made, act quickly Use reasonable force Assign one rescuer to each limb Reassess circulation frequently Document reasons for restraint

36. Copyright 2008 Seattle/King County EMS Summary, continued Remove TASER dart by pulling it out Do not remove dart if eye, face, neck, breast, or groin are involved

37. Copyright 2008 Seattle/King County EMS Summary, continued Compelling reasons permit you to withhold resuscitation when two criteria are present: End stage of terminal condition Written or verbal information from family or patient stating that patient did not want resuscitation