77 Questions
What is the first step in the approach to disruptive behavior described in the text?
Requesting back-up
Which of the following is NOT a medical cause of disruptive behavior mentioned in the text?
Diabetes
What is the recommended dose of haloperidol for patients over 65 years old?
2.5 mg IM/IV
What is the preferable approach in terms of medications for subduing geriatric patients?
Administering the minimum medications necessary
If a patient under 65 years old requires further sedation after maximum doses of midazolam, what action should be considered?
Contacting OLMC for additional options
What assessments are recommended to be obtained if possible in the described approach to disruptive behavior?
12-lead ECG, SpO2, and ETCO2
What is the maximum recommended total dose of midazolam for a patient under 65 years old?
20 mg SIVP/IO or IM
What is the recommended maximum total dose of haloperidol for a patient under 65 years old?
10 mg IM
If a patient under 65 requires further sedation after maximum doses of midazolam and haloperidol, which of the following is NOT recommended in the text?
Increase the dose of midazolam beyond 20 mg
Based on the information provided, which of the following statements is correct regarding the recommended approach for geriatric patients?
Administer lower initial doses of haloperidol compared to younger patients
Which of the following medical conditions is NOT listed as a potential cause of disruptive behavior in the text?
Delirium
According to the information provided, what is the maximum recommended total dose of ketamine for a patient under 65 years old?
There is no specific maximum dose mentioned
If a patient under 65 years old has received the maximum doses of midazolam and haloperidol but remains inadequately controlled, what additional medication should be considered?
Call for further sedation options from OLMC
What is the recommended maximum total dose of ketamine for a patient under 65 years old?
There is no specific maximum total dose mentioned
If a patient over 65 years old requires additional sedation after the initial dose of haloperidol and midazolam, which medication should be administered next?
Haloperidol 2.5 mg IM/IV and midazolam 2.5 mg SIVP/IO
Which of the following medical conditions is listed as a potential cause of disruptive behavior?
Seizures
For a patient under 65 years old, what is the maximum recommended total dose of midazolam administered intramuscularly (IM)?
20 mg
Based on the information provided, which of the following statements is correct regarding the use of ketamine in patients over 65 years old?
The text does not provide any specific recommendations for the use of ketamine in patients over 65
For a patient under 65 years old exhibiting disruptive behavior, what is the recommended initial dose and route of administration for midazolam?
5 mg SIVP/IO every 5 minutes to a maximum of 20 mg
If a patient under 65 years old requires additional sedation after reaching the maximum doses of midazolam and haloperidol, which medication is NOT recommended in the text?
Continuing to administer additional doses of midazolam or haloperidol
Based on the information provided, which of the following statements about the use of ketamine in patients over 65 years old is correct?
Ketamine should be administered at a dose of 0.5 mg/kg SIVP/IO every 15 minutes to a maximum of 5 mg.
According to the information provided, what is the maximum recommended total dose of haloperidol for a patient under 65 years old exhibiting disruptive behavior?
10 mg
Which of the following medical conditions is NOT listed as a potential cause of disruptive behavior in the provided text?
Hyperthyroidism
Based on the information provided, which of the following statements regarding the recommended approach for geriatric patients (over 65 years old) is correct?
The minimum medications necessary to subdue the patient are preferable.
What is the purpose of this operational protocol?
To provide guidelines for managing patient care situations where a patient refuses EMS care and/or transport.
What is the difference between non-conveyance and patient refusal?
Non-conveyance via an ATR algorithm is different than patient refusal, as it involves shared decision-making among healthcare providers.
What happens in a patient refusal situation?
The patient is assessed, but refuses care and/or transport against recommended treatment.
What is the patient's right in a patient refusal situation?
The patient has the right to refuse treatment, as long as they understand and accept the risks.
What is the goal of the ATR algorithm?
To identify patients that are low risk for medical deterioration and/or can have their health needs met without ambulance transport.
What is the outcome of patient refusal?
The patient is at higher risk for adverse outcomes.
Who can refuse EMS care and/or transport?
Adults over the age of 18 years, mature minors, parents or legal representatives of minors, and legal representatives/guardians of dependent adults
What determines a patient's capacity to refuse care?
Their ability to understand the nature, risks, and benefits of treatment or transport
What should EMS practitioners do when a patient refuses care and/or transport?
Formally assess the patient's capacity and document the conversation
What is the purpose of a Form 10 issued by a peace officer?
To authorize a peace officer to detain and convey the patient
What should EMS practitioners do when a patient is uncooperative or attempting to flee?
Involve AHS Protective Services or Police for assistance
What is the purpose of a Patient Medical Release?
To obtain the patient's signature for refusal of care
When can EMS practitioners treat and transport patients without their consent?
When the patient lacks capacity and requires emergency medical care
Who can issue a Form 1?
A physician
What should EMS practitioners do when a patient refuses care and/or transport?
Document the patient's capacity assessment and risks of refusal
What is the purpose of Goals of Care Designation Order?
To inform EMS practitioners about the patient's treatment preferences
What is the primary responsibility of the practitioner in providing patient care?
To provide the patient with the opportunity to ask questions and make informed decisions
What should a practitioner do when a patient refuses care and/or transport and demonstrates capacity?
Attempt to perform a thorough assessment, explain benefits and risks, and discuss alternatives
What is a high-risk criterion that may require Mandatory Online Medical Consultation (OLMC) during patient assessment?
Chest pain
What should a practitioner document in the Patient Care Record when a patient refuses care and/or transport?
The clinical assessment, discussion of risks and benefits, and alternatives
What should a practitioner do when a patient refuses care and/or transport and demonstrates lack of capacity?
Contact OLMC for further consultation and advice
What should a practitioner provide to the patient when they refuse care and/or transport?
The Patient Information Booklet for Patients Remaining on Scene
Why is it important to document the patient's refusal of care and/or transport?
To prove that the patient was informed of the risks and benefits
What is the purpose of contacting OLMC during patient assessment?
To obtain further consultation and advice on the patient's care
What should a practitioner do when a patient has a history of significant submersion injury?
Contact OLMC for further consultation and advice
What should a practitioner document in the EMS Refusal of Care and/or Transport Record?
The patient's refusal of care and/or transport, including their signature
What are the three conditions that must be met under the Mental Health Act of Alberta to allow for involuntary detention, transport, and treatment of a person?
Mental disorder, likely to cause harm to self or others, and unsuitable for voluntary admission
What form does a law enforcement officer complete when detaining a person for a mental health assessment?
Form 10
Who can authorize EMS to treat or transport non-consenting patients?
Physician or law enforcement officer
What is a characteristic of a mental disorder?
A substantial disorder of thought, mood, perception, orientation, or memory that significantly impairs judgement, behaviour, the capacity to recognize reality, or the ability to complete usual daily activities
What should EMS practitioners do if a patient refuses transport?
Call OLMC
What is a consideration when assessing a patient with altered mental status?
The patient's level of consciousness, attention, memory, cognitive ability, affect and mood, and probable cause of their present condition
What is a potential underlying medical cause of acute anxiety and other disorders?
Either A or B
Which of the following is a criterion for determining a patient's competence to make decisions about their own care?
If they are cognitively impaired
What is an indication that a patient's agitation and anxiety may be caused by an underlying medical condition?
Low EtCO2 levels
What medication is considered for acute anxiety in the text?
Lorazepam
What is the primary goal of the treatment approach in the text?
Establish safety of staff and patient
What is the role of hospital security personnel in the treatment approach?
To assume responsibility for the patient
What is the purpose of referring to the Adult Combative Behaviour MCP in the text?
To manage combative behavior
Which of the following is a differential diagnosis for a patient presenting with dyspnea and hyperventilation?
Metabolic disorders, acute coronary syndrome, arrhythmia, heart failure, pulmonary embolism, pneumothorax, asthma exacerbation, chronic obstructive pulmonary disease exacerbation, seizure disorder, and hyperthyroidism
When can a patient refuse treatment or transport?
If they are competent and have the capacity to make informed decisions about their own care
What is a consideration when evaluating a patient's ability to make informed decisions about their own care?
Their mental status, their ability to communicate, and their ability to understand the consequences of their decisions
What is the first priority in managing a patient with disruptive behavior?
Establishing safety of staff and patient
What medication regimen is recommended for acute anxiety in a patient with disruptive behavior?
Lorazepam 1 mg SL every 15 min to a max of 4 mg
What is the recommended course of action if a patient refuses transport?
Call OLMC for guidance
What additional monitoring is recommended for a patient with disruptive behavior?
Monitoring the 4-lead ECG
What protocol should be referred to if the patient is aggressive or requires restraint?
Adult Combative Behaviour MCP
What is the condition under which an off-duty EMS practitioner can assume responsibility for patient care?
If they can provide a level of care above that of the Attending EMS Crew
What must be reviewed with the off-duty EMS practitioner if they assume responsibility for patient care?
The 'Healthcare Professional on Scene Card'
What should be done if the off-duty EMS practitioner's treatment plans do not comply with MCPs?
Contact OLMC
Who is responsible for documenting the off-duty EMS practitioner's orders?
The Attending EMS Crew
What is the purpose of the 'Healthcare Professional on Scene Card'?
To review treatment plans with the off-duty EMS practitioner
What should be done if disagreements arise between the off-duty EMS practitioner and the Attending EMS Crew?
Contact OLMC
Study Notes
Patient Refusal of EMS Care and/or Transport
- This operational protocol outlines guidelines for managing patient care situations where the patient or legal representative refuses EMS care and/or transport.
Who Can Refuse Care and/or Transport
- Adults over the age of 18 years
- Mature Minors
- Parents or legal representatives of minors
- Legal Representatives/Guardians of dependent adults
- Patients who demonstrate the capacity to refuse care
Determination of Capacity
- Patients have capacity when they understand the nature, risks, and benefits of treatment or transport and the consequences of consent or refusal
- Adults are presumed to have capacity until evidence suggests otherwise
- Capacity can be affected by mental illness, physical illness, injury, or intoxication due to drugs or alcohol
Capacity Assessment and Refusal of Care
- Competent patients can refuse treatment and/or transport after being informed of potential risks and consequences
- Assessment of capacity and discussion regarding risks and consequences must be well-documented
- Patients should be informed how to access follow-up care and sign the Patient Medical Release
Care of Patients Refusing Care and/or Transport
- Practitioners must not coerce patients to refuse care and/or transport
- Practitioners will formally assess the patient's capacity in all cases of refusal
- Patients have the right to access care provided in hospital Emergency Departments or alternative recognized healthcare resources via EMS transport
Mandatory Online Medical Consultation (OLMC)
- OLMC criteria include:
- History of significant submersion injury
- Recent, partial or complete foreign body airway obstruction
- Apparent life-threatening event (ALTE)/brief resolved unexplained event (BRUE) in a neonate or child less than 2 years old
- Refusal of care and/or transport after medication administration
Documentation and Refusal of Care Records
- Document the clinical assessment, discussion of risks, benefits, and alternatives with the patient in the Patient Care Record
- Complete the "Response Outcome" field of the Patient Care Record as "Patient Refused Care and/or Transport"
- Document the patient's refusal of care on the EMS Refusal of Care and/or Transport Record, including their signature
- Leave the Patient Information Booklet for Patients Remaining on Scene with the patient
Etiology of Mental Disorders
- A mental disorder is characterized by a substantial disorder of thought, mood, perception, orientation, or memory that significantly impairs judgment, behavior, the capacity to recognize reality, or the ability to complete usual daily activities.
- Patients with disorders such as depression, schizophrenia, bipolar disorder, or a situational crisis may experience an acute psychiatric crisis.
- Acute anxiety and other disorders can be caused by other medical conditions (e.g., acute coronary syndrome, hypoxemia, trauma).
Differential Diagnosis
- Metabolic disorders (ketoacidosis, less frequently hypoglycemia or hypocalcemia)
- Acute coronary syndrome
- Arrhythmia
- Heart failure
- Pulmonary embolism
- Pneumothorax
- Asthma exacerbation
- Chronic obstructive pulmonary disease exacerbation
- Seizure disorder
- Hyperthyroidism
Assessment of Patients with Altered Mental Status
- Level of consciousness
- Attention
- Memory
- Cognitive ability
- Affect and mood
- Probable cause of present condition
- Low EtCO2 may be correlated with metabolic acidosis, indicating the possibility of an underlying medical cause for agitation and anxiety
Consent and Competency
- Competent patients can refuse treatment or transport if they are able to:
- Answer questions about their identity, location, and date
- Are not a harm to themselves or others
- Are not significantly disabled due to acute illness or injury
- Are not intoxicated due to alcohol or drugs
- The Mental Health Act of Alberta allows for the involuntary detention, transport, and treatment of persons with mental disorders if they meet all three conditions:
- Mental disorder
- Likely to cause harm to self or others
- Unsuitable for voluntary admission
Treatment and Interventions
- Establish safety of staff and patient
- Verbally attempt to diffuse the situation
- Search for and treat possible medical causes
- Consider lorazepam 1 mg SL every 15 min as needed to a max of 4 mg or midazolam 2.5 mg IV every 15 min as needed to a max of 5 mg for acute anxiety
- Consider monitoring the 4-lead ECG
Treatment of Aggressive Patient
- Establish safety of staff and patient as the primary concern
- Attempt to verbally diffuse the situation to prevent escalation
- Investigate and treat possible underlying medical causes of the behavior
Pharmacological Intervention
- Consider administering lorazepam 1 mg SL every 15 minutes as needed, up to a maximum of 4 mg, for acute anxiety
- Alternatively, consider midazolam 2.5 mg IV every 15 minutes as needed, up to a maximum of 5 mg
Monitoring and Referral
- Monitor the 4-lead ECG to ensure patient's cardiac stability
- Refer to the Disruptive Behavior Management of Combative Patients (MCP) protocol if the patient requires restraint or is aggressive
- Refer to the Adult Combative Behavior MCP protocol for further guidance
- If the patient refuses transport, it is mandatory to call OLMC for further instruction
Off Duty EMS Practitioner on Scene
- Off-duty EMS healthcare professionals with active practice permits can assist with patient care if they comply with Medical Control Protocols (MCPs) and do not exceed the Transporting EMS Crew's Scope of Practice.
- Participation is at the discretion of the Attending EMS Crew, and if disagreements arise, contact OLMC (Online Medical Control).
Assuming Responsibility for Patient Care
- If an off-duty EMS practitioner can provide a level of care above that of the Attending EMS Crew, they can assume responsibility for patient care.
- In this case, one member of the Attending EMS Crew must review the "Healthcare Professional on Scene Card" with the off-duty EMS practitioner within the electronic patient care record form.
- Contact OLMC if:
- Treatment does not comply with MCPs
- Disagreements arise
- Treatment is outside the Scope of Practice of the Transporting EMS Crew, and the off-duty EMS practitioner declines to accompany the patient to the Transport Destination
Documentation
- Document the off-duty EMS healthcare professional's orders and ensure they sign the Patient Care Record (PCR)
Test your knowledge on how to handle disruptive behavior in a medical setting. Learn about requesting back-up, ensuring law enforcement attendance, diffusing the situation verbally, and more.
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