Medical-Legal Considerations for Paramedics

Medical-Legal Considerations

• Review the presentation "Medical-Legal Considerations" on Brightspace.
• Read textbook chapters 2 (pp.18-20) and 3 (pp.37-48). Note that these chapters, while UK-specific, cover mirrored concepts in Canadian law.

Objectives

• Identify regulations under the Food and Drug Act and Food and Drug Regulations applicable to paramedics.
• Identify laws under which paramedics carry and dispense medications.
• Identify special regulations for storage, transport, documentation, and administration of controlled substances under the Controlled Substances Act.
• Discuss forms of medical delegation.
• Explain how physicians may delegate to paramedics.
• Discuss the structure of a medical directive or standing order.

Canadian Regulations and Legislation

• Canadian legislation began in 1875.
• Two acts of Parliament (Food and Drug Act [1941] and Controlled Drugs and Substances Act [1996]) form the basis of drug laws.
• The Department of National Health and Welfare is responsible for drug control in Canada.

Canadian Regulations and Legislation (Specific Acts)

• Food and Drug Act: Protects consumers from contaminated, adulterated or unsafe food and drugs; addresses falsely labelled or misleading products; and regulates drug manufacture & sale.
• Food and Drug Regulation: An annex to the Food and Drug Act, explicitly defining terms used in the Act, and covering importing, preparing, treating, processing, labeling, advertising, and selling of food, drugs, cosmetics, natural health products (including herbal products), and medical devices.
• Controlled Drugs and Substances Act (CDSA): Addresses drug possession, sale, manufacture, distribution, production, import, and export of controlled drugs, their precursors, and other controlled substances; and describes drug record keeping, documentation, and dispensing procedures.

CDSA Classification

• CDSA classifies drugs into 8 categories based on safety risk, potential for dependence, and medical use.
• Schedule V & VI: Precursors required to produce controlled substances.
• Schedule VII & VIII: Repealed.
• Schedule IX: Pill making equipment.
• (See Table I, Schedules of Controlled Substances within the CSA for specific details on each schedule and examples.)*

CDSA Exemptions for Paramedics

• Ontario paramedics (Primary Care, Advanced Care, and Critical Care) employed by certified ambulance services are exempted from some CDSA regulations, effective May 16, 2019 (subsect. 56(1)).
• Exemptions pertain to possession of certain controlled substances (fentanyl, hydromorphone, ketamine, morphine, pethidine).
• Also, exemptions regarding controlled substance selling, giving, transfer, etc. (diazepam, fentanyl, hydromorphone, ketamine, lorazepam, midazolam, morphine, pethidine).
• Benzodiazepine possession also exempted (diazepam, lorazepam, midazolam).

Medical Delegation

• Only physicians can prescribe medications in a clinical setting.
• Paramedics are delegated the ability to administer certain medications, with specific medical criteria.
• Administering medication outside their scope is considered practicing medicine without a license; MDSO's (Medical directives and standing orders) are crucial in such cases.

General Structure of a Medical Directive (MDSO)

• Provides guidelines for when a paramedic may administer a medication.
• Outlines conditions under which medication may be administered and specific clinical requirements.
• Medical directives will indicate if/when a patch to online medical control is required.

Acute Coronary Syndrome (ACS) / Nitroglycerin Administration

• For ACS, specific conditions must be met before initiating Nitroglycerin administration (e.g., patient age, MAP, heart rate, alertness),
• Specific contraindications exist (e.g., nitrate allergy, use of phosphodiesterase-5 inhibitors within 48 hours).

Cardiac Ischemia Protocol (ALS PCS)

• Protocol outlines conditions and considerations for treatment of cardiac ischemia, including potential use of ASA and nitroglycerin. Key considerations include age requirements, vital signs, and potential contraindications.

Responsibilities of the Paramedic

• Maintain up-to-date information on medications and side effects.
• Assess patient needs accurately and appropriately manage medication.
• Employ appropriate interventions based on assessment.
• Ensure accurate medication administration and maintain proper documentation.

Medical Delegation Case Studies

• Case 1: Paramedic is asked to administer NTG, but patient does not meet MDSO criteria. Legal implications are discussed.
• Case 2: Paramedic is asked for advice on a sick child. Legal responsibility is discussed.
• Case 3: Paramedic tasked with escorting a patient with complex medical needs to a destination. Legal requirements are discussed.
• Case 4: Paramedic called for an elderly patient with DNR. Patient refusing transport and wishes to die at home. Legal implications are discussed.

Consent for Treatment

• Paramedics must obtain consent prior to treating a patient, except in emergency situations. Informed or implied consent is acceptable.
• Informed consent includes disclosing treatment nature, expected benefits, potential risks/side effects, alternatives, possible consequences of refusing treatment, and responding to patient questions/requests for further information.
• Emergency situations allow for treatment without consent when the delay would prolong suffering/risk/bodily harm. Delay of treatment and ability to give consent should also be considered.

Determining Competence

• Valid consent requires a patient's capacity to provide consent.
• A patient is considered competent if able to understand relevant information, make decisions, and appreciate the consequences of their decisions/lack thereof.

Care Outside of Scope

• Paramedics cannot provide care that exceeds their authorized skill set. Knowledge of technology/medication is assumed once it's verified the patient or caregiver has the corresponding training. Exceeding paramedic scope of practice must be communicated, and further direction requested of a higher medical authority.

Additional Notes

• Information is based on the provided images.
• Specific dosages, conditions, and examples are included where applicable.