Emergency Care Textbook Professional Responders-part-1 PDF

Introduction As a responder, you are a key part of the pre-hospital care system, also known as the emergency medical system. The pre-hospital care system is a network of professional responders with an integrated approach to providing care in an emergency situation. Your level of expertise may provi...

Introduction As a responder, you are a key part of the pre-hospital care system, also known as the emergency medical system. The pre-hospital care system is a network of professional responders with an integrated approach to providing care in an emergency situation. Your level of expertise may provide a link between the first actions of bystanders and more advanced medical care. A professional responder is a person who, in a paid or volunteer capacity, is often summoned to provide initial care during an emergency. As the first trained professional on the scene, you perform critical actions and may have a significant effect on the patient’s outcome. Emergency Medical Responders (EMRs) According to the Paramedic Association of Canada (PAC), first responders may be included within the emergency medical responder (EMR) level, although in many settings, first responders do not transport patients. Key Content Professional Responder Training Levels..................... Preceptorship.......................... Medical Oversight................... Communicating with the Medical Director............... The Professional Responder... Responsibilities..................... Interpersonal Communication.................... Self-Care.................................. Critical Incident Stress and Post-Traumatic Stress Disorder............................. Legal and Ethical Issues.......... Duty to Act........................... Scope of Practice.................. Abuse and Neglect............... Consent................................. Refusal of Care..................... Transfer of Care.................... Documentation.................... Communication...................... Medical Terminology.............. 10 10 11 11 12 13 14 15 16 17 17 17 18 19 21 21 22 23 24 THE PROFESSIONAL RESPONDER 1 The Professional Responder 7 According to PAC, the EMR “has successfully completed a recognized training program in emergency patient care and transportation.” As part of the foundation of the Canadian emergency systems, EMRs are often linked with volunteer emergency services organizations in rural and remote areas and, in some communities, they may be the sole provider of emergency services. Responders across the country have different roles to perform, including primary and secondary assessments, the provision of safe and prudent care, effective oral and written communication, and the transport of a patient to the most appropriate healthcare facility. Responders must also learn to recognize the signs of high levels of stress in themselves and their co-workers. Throughout your course, you will gain the knowledge, skills, and confidence to provide appropriate care and assistance when you are called to help someone who has become injured or suddenly ill. You will learn how to assess a patient’s condition and how to recognize and care for life-threatening emergencies. You will also learn how to minimize a patient’s discomfort and prevent further complications until you can obtain more advanced medical care. Finally, you will learn the importance of understanding how stress can affect you as a professional responder and learn some techniques to manage stress. THE PROFESSIONAL RESPONDER Patient (Injury/ Illness) 8 Public Response EMS Activation Figure 1–1: The components of an emergency response. Components of a Pre-Hospital Care System The pre-hospital care system, which contains Emergency Medical Services (EMS), is a network of community resources and medical personnel that provides emergency care to patients with injuries or sudden illnesses (Figure 1–1). When people recognize an emergency and take action, they activate this system. Care is provided by more highly trained professionals in succession until a patient receives the level of care required. An effective pre-hospital care system includes the following components: Communications Transportation Facilities Medical control Trauma systems Public information and education Human resources, training, and continuing education Resource management Regulation and policy Evaluation Paramedicine in Canada PARAMEDIC ASSOCIATION OF CANADA (PAC) EMS systems throughout Canada vary by region and, in many cases, by city. In 2001, with the support of Human Resources Development Canada (now Human Resources and Skills Development Canada) and the Canadian Medical Association, Responder Care Advanced Pre-Hospital Care Rehabilitation PAC established the National Occupational Competency Profile (NOCP) to promote national consistency in paramedic training and practice. Paramedic Regulators (COPR) received letters of support from all provincial jurisdictions, and these authorities provide the funding for COPR. Since 1988, PAC (originally The Canadian Society of Ambulance Personnel) has been the national association for paramedics. Its mandate includes the following: Promotion of paramedic self-regulation Promotion of a national examination Promotion of a national registry for paramedics Advocacy for paramedics to be included in the Canada Health Act Support for paramedic research through the Canadian Emergency Health Services Research Consortium Stewardship of the National Occupational Competency Profile for paramedics The regulators’ initial success with meeting the AIT labour mobility requirements resulted in the acknowledgement that a national organization would benefit a number of initiatives, including, but not limited to, labour mobility. PARAMEDIC CHIEFS OF CANADA The Paramedic Chiefs of Canada is a national forum for information gathering, policy development, and coordinated action by the leadership of Canada’s EMS systems. This group works under the operating mission “To advance and align EMS leadership in Canada.”1 CANADIAN ORGANIZATION OF PARAMEDIC REGULATORS (COPR) Established in 2009, COPR represents a national viewpoint on: Education. Operations. Regulation. Professional practice in paramedicine. In 2008, paramedic regulators from across Canada began working together informally “to discuss ways to ensure compliance with the new labour mobility requirements of the Agreement on Internal Trade (AIT) that came in to effect on April 1, 2009.”2 These regulators agreed on a statement of intent that identified a strategy to achieve AIT compliance in the short term. When it was formed, the Canadian Organization of The Agreement on Internal Trade is an intergovernmental trade agreement, signed by Canadian first ministers, that came into force in 1995. Its purpose is to reduce and eliminate, to the extent possible, barriers to free movement of persons, goods, services, and investment within Canada and to establish an open, efficient, and stable domestic market. In early 2010, regulators established COPR as a formal organization. “In addition, federal government and provincial labour mobility coordinators recognized the group’s innovation and willingness to adapt practices to succeed with labour mobility.”3 This support—coupled with the group’s desire to build upon its initial successes—led regulators to successfully apply for federal government funding to further their labour mobility work. Also, COPR submitted a set of bylaws to the federal government as part of the process for incorporation. SOCIETY FOR PREHOSPITAL EDUCATORS IN CANADA (SPEC) The Society for Prehospital Educators in Canada (SPEC; rebranded in 2006 from the former Canadian Society of Prehospital Care Educators) is a national group of paramedic educators that “has demonstrated a keen desire to represent paramedic education on a national basis.”4 The concept of labour mobility is the freedom of workers to practise their occupation wherever opportunities exist. In 2008, with the help of Human Resources and Skills Development Canada, several provincial regulators established a national THE PROFESSIONAL RESPONDER Though PAC was the first, other national paramedic stakeholder groups have arisen that also share several aspects of PAC’s mandate. AGREEMENT ON INTERNAL TRADE (AIT) 9 body of paramedic regulators, whose purpose is “to address national standards within the context of labour mobility.”5 In 2009, the Canadian Organization of Paramedic Regulators was established. As a result, there is now a national perspective on education, regulation, operations, and professional practice. PROFESSIONAL RESPONDER TRAINING LEVELS A pre-hospital care system may utilize emergency care providers with many different levels of training. A first responder may or may not be trained as an emergency medical responder (EMR). EMRs are often considered first responders, but other groups may be considered first responders as well. PAC has developed occupational competency profiles at four levels of pre-hospital care training: THE PROFESSIONAL RESPONDER Emergency Medical Responder (EMR) The EMR has successfully completed a recognized training program in emergency patient care and transportation. Historically, EMRs have been the medical first responder in rural and remote communities. They are often associated with volunteer emergency services organizations, and may be the sole provider of emergency medical services in some communities. EMRs may be responsible for initial assessments, the provision of safe and prudent care, and the transport of a patient to the most appropriate healthcare facility. 10 Primary Care Paramedic (PCP) The PCP has successfully completed a recognized education program in paramedicine at the primary care paramedic level. PCPs may be volunteer or career paramedics associated with remote, rural, suburban, urban, industrial, air ambulance, and military services. PCPs constitute the largest group of paramedics in Canada. Controlled or delegated medical acts in the PCP competency profile include intravenous cannulation and the administration of certain medications. Advanced Care Paramedic (ACP) The ACP has successfully completed a recognized education program in paramedicine at the advanced care paramedic level. ACP education builds upon the PCP competencies, and ACPs apply their added knowledge and skills to provide enhanced levels of assessment and care. ACPs are often employed in rural, suburban, urban, industrial, and air ambulance services. Controlled or delegated medical acts in the ACP competency profile include advanced techniques to manage life-threatening problems affecting patient airway, breathing, and circulation. ACPs may implement treatment measures that are invasive and/or pharmacological in nature. Critical Care Paramedic (CCP) The CCP has successfully completed a recognized education program in paramedicine at the critical care paramedic level. This is currently the highest level of paramedic certification available. CCPs are often employed in suburban, urban, and air ambulance services. CCP education builds upon the ACP competencies, and CCPs apply their added knowledge and skills to provide enhanced levels of assessment and care. Controlled or delegated medical acts in the CCP competency profile include advanced techniques, such as using invasive hemodynamic monitoring devices to manage life-threatening problems. CCPs may implement treatment measures that are invasive and/or pharmacological in nature. PRECEPTORSHIP Preceptorship is a relationship between an experienced responder (the preceptor) and a new responder. The preceptor serves as a coach and mentor, providing support, guidance, and assessment in the field. Preceptorship is a teaching method that is widely used by a number of healthcare professionals within the EMS system. In some cases, the preceptor evaluates the new responder’s individual skills, confirming that he or she is demonstrating the required competencies. By ensuring that new responders are meeting standardized minimum competency profiles, EMS providers can create consistency throughout the country, which in turn allows for portability and an appropriate standard of professional care for every patient. Helping  to alleviate repetitive emergency department visits and hospital readmissions due to gaps in care between hospital and outpatient primary care or specialty management. Creating the capacity for short-notice home visits, especially during off hours. Alleviating primary care shortages in underserved areas. MEDICAL OVERSIGHT The pre-hospital care system is continuing to evolve as the needs of workplaces, communities, and medical systems change. For example, many businesses are seeing the benefits of establishing workplace response teams. These response teams are composed of specially trained workplace advanced first aid attendants who are responsible for attending to injuries or illnesses of employees. COMMUNITY PARAMEDICINE The increased demand on the medical system has also highlighted the benefits of Community Paramedics (CPs). Community paramedicine is the delivery of healthcare services by paramedics in communitybased, non-emergency-care roles. Community Paramedic programs have been successfully implemented across Canada and in countries such as the United States, the United Kingdom, New Zealand, and Australia. CP programs provide targeted solutions for many communities, including: Helping to relieve overuse of the EMS system for social or psychological problems. Providing alternative means to manage patients who do not require transport to a general acute care hospital emergency department. Medical oversight may present in various forms depending on an organization’s operational, administrative, or training requirements. Physicians are the primary body providing oversight. Medical Director Medical direction is a formal relationship between pre-hospital care (EMS) providers and a physician who is responsible for out-of-hospital emergency medical care. This physician is known as the medical director, and is legally responsible for the clinical and patient-care aspects of the pre-hospital (EMS) system. The medical director provides guidance and medical oversight for all emergency care provided by EMS personnel. The medical director can also be responsible for reviewing and determining the scope of practice in a pre-hospital care (EMS) system, though in some cases this is determined by regulations or legislation. The medical director may oversee the organization’s training and quality assurance, and the development of standing orders or protocols. COMMUNICATING WITH THE MEDICAL DIRECTOR In some systems, there is a physician on call at all times who can be consulted when additional treatment is required or a patient refuses treatment and/or transport. Contact him or her whenever you have questions about a patient’s condition that cannot be resolved by protocols. Since the physician may not be at the emergency scene, it is up to you to present all the relevant THE PROFESSIONAL RESPONDER WORKPLACE RESPONSE TEAMS 11 information clearly and concisely. Prepare yourself ahead of the call so that you are ready to provide the following information during your conversation: Your name, unit identifier, the fact that you are a responder, and the level of your training The patient’s age, sex, and chief complaint A brief, pertinent history of the events leading to the injury or illness Results of the patient’s assessments, including vital signs Any care provided to the patient and his or her response to that care The reason you are calling This information is what you would relay to any other healthcare provider when giving a verbal report. If the physician gives you orders for patient care, repeat the orders back to verify them. Make sure that you understand all of the orders and advice that the physician provides. If you have any questions, ask the physician for clarification. Professional responders should be aware that it is possible to contact a physician from an airplane at any time, regardless of the location. THE PROFESSIONAL RESPONDER Direct or Online Medical Control 12 A professional pre-hospital care provider may be required to perform some skills that can only be delegated by a physician. Physicians provide medical direction within a pre-hospital care (EMS) system through a process called direct medical control. Usually, a medical director, who assumes responsibility for the care given through delegated medical acts, does this monitoring. This process allows a physician to direct the care given to patients by pre-hospital care professionals and may include direct communication with crews at the scene of a medical incident. Procedures that are not covered by standing orders require the responder to speak directly with the physician (via mobile or landline telephone or radio). Indirect or Offline Medical Control Since it is impossible for the medical director to be present at every medical incident outside the hospital, he or she can direct care through predetermined standing orders or medical control protocols (MCPs). Standing orders or MCPs allow responders to provide certain types of care and treatments without consulting with the physician. This type of medical control is called indirect or offline and includes education, protocol review, and continuous improvement in the quality of care and treatments. For a first responder or emergency medical responder, certification is not a licence to perform all the skills in the Emergency Care for Professional Responders text. Some skills should be performed only by a responder who has been delegated these responsibilities by a physician. EMERGENCY RESPONSE SUPPORTING THE PREHOSPITAL CARE SYSTEM The efficiency of the pre-hospital care system depends on the people involved performing their roles correctly and promptly. When each component of the system works effectively, this enhances the patient’s chances for a positive prognosis and recovery. In a serious injury or illness, survival and recovery are not a matter of chance. Survival is the result of a carefully orchestrated series of procedures in which all participants fulfill their roles. The EMS system can make the difference between life and death or a positive and negative recovery. As a professional responder, you play a critical role in this system and the outcomes of patients. THE PROFESSIONAL RESPONDER Professional responders are made up of a wide variety of individuals who are tasked with providing medical interventions in the course of their duties. They respond to emergencies on a professional basis and have an obligation to respond to emergencies while they are on duty or when called upon. As a professional responder, you have a duty to respond quickly and safely to the scene of an emergency incident. Your duties include: Assessing the patient’s condition and providing necessary care within your professional practice designation. Acting as the patient’s advocate. Ensuring that additional assistance has been summoned. Assisting any additional medical personnel at the scene. Documenting your actions. Responsibilities As a Professional Responder who interacts with the public, you must be willing to take on additional responsibilities beyond providing care. These responsibilities require you to demonstrate certain additional characteristics. MAINTAIN A CARING AND PROFESSIONAL ATTITUDE Be compassionate to your patients; try to understand their concerns and fears. Realize that any anger a patient may show is often the result of fear. Someone who helps at the emergency may also be afraid. Try to be reassuring. Even though a bystander may not have done everything perfectly, be sure to thank him or her for taking action and providing assistance. Recognition and praise can help affirm a person’s willingness to act. Also, be careful about what you say. Do not give distressing news about the emergency to the patient or the patient’s family or friends. WORK COLLABORATIVELY WITH OTHER PROFESSIONALS As a professional responder, you are part of a network of professionals working towards a common goal. You have a responsibility to work collaboratively and professionally with your colleagues, whether they are team members or staff of other agencies. Without effective communication and mutual respect between responders, patient care can be negatively impacted and your professionalism can be compromised in the eyes of those around you. MANAGE YOUR FEARS Try not to reveal your anxieties to patients or bystanders. The presence of blood, vomit, unpleasant odours, or torn or burned skin is disturbing to most people. In some cases, you may need to take a moment to compose yourself. Focus on the patient’s needs and remember that your role is to provide professional care. PRESENT A CLEAN AND PROFESSIONAL APPEARANCE A clean and professional appearance can help to instill confidence in patients. Representing yourself as part of a professional system will reinforce to patients that you are competent and ready to help. KEEP YOUR SKILLS AND KNOWLEDGE UP TO DATE Take part in continuing education such as reading professional journals and completing refresher training. PARTICIPATE IN QUALITY ASSURANCE AND ENHANCEMENT PROGRAMS Each organization will participate in quality assurance and enhancement programs such as internal audits, independent reviews, ongoing professional development programs, and post-call analysis. Ensure that you are aware of your role in these important processes, as they support the effective functioning of your organization. These processes ensure that the required standards of care are achieved or surpassed, and also help to support crucial considerations such as patient confidentiality and legislative compliance. THE PROFESSIONAL RESPONDER When a person dials 9-1-1 or the local EMS number, he or she will request public safety personnel (i.e., police, fire, or ambulance personnel). However, responders do not necessarily work in public safety agencies. Any of the following may be considered professional responders if they are called to help in the event of a medical emergency: Industrial rescue or safety personnel Workplace first aid attendants Disaster response team members Emergency management personnel Ski patrol members Athletic therapists Lifeguards 13 Primary Responsibilities Since you will often be the first trained professional responder to arrive on scene at emergency incidents, your primary responsibilities focus on safety and early emergency care. Your seven major responsibilities are to: 1. ENSURE YOUR OWN SAFETY. Your first responsibility is to not make the situation worse by getting hurt yourself. By making sure the scene is safe as you approach it, you can avoid unnecessary injuries. 2. ENSURE SAFETY FOR ANY BYSTANDERS. So long as it does not put your safety at risk, you should also prevent any harm from coming to bystanders at the scene. Keep people away from hazards, and encourage them to stay at a safe distance from the scene. 3. GAIN ACCESS TO THE PATIENT.  Carefully approach the patient unless the scene is too dangerous to handle without help. Electrical hazards, unsafe structures, and other dangers may make it difficult to reach the patient. Recognize when a rescue requires additional specially trained emergency personnel and know how to activate this response. 4. DETERMINE ANY THREATS TO THE PATIENT’S LIFE. Assess the patient for life-threatening injuries or conditions, such as airway, breathing, or circulation emergencies. THE PROFESSIONAL RESPONDER 5. REQUEST MORE ADVANCED MEDICAL CARE AS NEEDED. 14 Your assessment of the patient may reveal the need for more advanced medical care. Request additional support as required. You may also need to transport the patient to a medical facility (if you have the training and resources to do so). 6. PROVIDE THE NECESSARY CARE FOR THE PATIENT. Provide appropriate care for the patient within the scope of your licence and training until you are relieved or transfer care to another person with the same or a higher level of qualification. 7. ASSIST MORE ADVANCED MEDICAL PERSONNEL. Transfer your information about the patient and the emergency to more advanced personnel. Tell them how you found the patient, any problems or conditions you found, and the care you provided. Assist them as needed and help provide care for any other patients at the scene. When possible, try to anticipate the needs of those who are providing care. In addition to these primary responsibilities, you have secondary responsibilities that include: Directing bystanders. Documenting in detail what you saw, heard, and did at the scene. Maintaining the confidentiality of information about the incident, the patient(s) and bystanders, and any responders at the scene. Reassuring the patient’s family or friends without disclosing confidential information. Interpersonal Communication Medical emergencies can be frightening to people. Be sure to speak slowly and clearly when communicating with the patient and family. Avoid technical terms that will confuse and possibly frighten them. Use language they can understand. Communicating effectively means providing information, listening actively, establishing trust, and helping the patient feel as comfortable as possible. One way to put patients at ease is to address them by name whenever possible, but you should not address an older adult by his or her first name unless invited to do so. NONVERBAL COMMUNICATION When speaking to patients, think about the message your body language sends. Try to put yourself at patients’ eye level rather than standing over them. Make eye contact. LISTENING Listen carefully to what the patient tells you. Provide reassurance if someone appears reluctant to speak about a topic. Tell the patient that any information he or she may have about the problem is important, even if it is upsetting to talk about, and remind him or her that you will keep everything you hear confidential. Listen to what bystanders tell you. They may have seen or heard something that will help you determine how you will treat the patient. Many times, people will want to stay with the patient or watch to see what is going on. Be firm but reasonable with bystanders. Ask them to move away for the safety and comfort of everyone involved. Consider allowing a parent of a child or an immediate family member to stay, although this is not always possible. You can also learn a lot about physical problems just by observing the patient while he or she talks. Be observant. Nonverbal communication (or body language) can convey a great deal of information. For example, if the patient can only speak a few words before needing to take a breath, he or she may be having a breathing emergency. If the patient is holding his or her stomach or clutching the chest without being aware of it, this might give an indication about the patient’s condition. A person who winces should be questioned about any pain. From the patient’s perspective, nothing is more annoying than being ignored or not having focus on their complaint. Consider the last time you had to repeat information to someone several times; it is not a pleasant experience. Listening to patients allows them to realize that they are important. If you ask someone a question, listen for the answer. If necessary, make notes so you do not forget what the patient said. Sometimes, the patient may stop answering your questions altogether if he or she feels ignored. LANGUAGE BARRIERS If you are called to care for someone who does not speak a language that you understand, call for someone who can translate. For example, a family member or neighbour may be able to speak both your language and the patient’s language. This is true for sign language as well. There may also be translation resources available through dispatch centres to assist you. CULTURAL AND RELIGIOUS CONSIDERATIONS Be respectful and sensitive of cultural and religious traditions specific to each patient. In some cultures or religions, for example, it may be inappropriate to make eye contact or for someone of a different gender to help the patient. Respect your patient’s wishes and do what you can to help. Ask for help with cultural translation if necessary when providing care for patients with obviously different cultural backgrounds. Some communities have specialized response groups that provide emergency care for particular ethnic, cultural, or religious groups. These response groups may be separate from the EMS system, or they may be fully integrated. Be familiar with specialized response groups in the community, and do your best to accommodate their participation. SELF-CARE Given the nature of the work that responders do, they are exposed to vicarious and traumatic stress. Self-care is an important part of staying healthy— both physically and mentally. The Canadian Red Cross offers programs that help professional responders develop self-care plans in support of their psychosocial health. Elements of self-care include: Maintaining a healthy diet by eating sensibly and regularly. Getting adequate sleep. Engaging in regular exercise. Participating in activities outside of work (hobbies). THE PROFESSIONAL RESPONDER Observe the patient when he or she speaks. Use body language that shows you are listening and open to what people are saying. For example, avoid crossing your arms or putting your hands in your pockets. 15 Paying attention to your stress level, and taking precautions against exceeding your own limits. Understanding how you react to stressful situations and having a self-care plan outlining protective systems that you can rely on when in distress. If you can, try to diversify your own tasks at work. A change can make a difference in both personal engagement and stress management. Some general things you can do to maintain self-care at work include: Taking breaks during your workday. Taking vacation days. Using relaxation techniques (e.g., deep breathing). Talking with colleagues about how your work affects you. Seeking or establishing a professional support group. Setting limits with patients and colleagues. Job stresses can adversely affect your health. Exercise and diet can help you manage physical, mental, and emotional stress. Developing a fitness plan and having regular checkups with your physician will help you maintain the physical and mental capabilities necessary for your duties. You should also identify the risk factors in your life so that you can take steps to mitigate them. THE PROFESSIONAL RESPONDER Self-care is important at all stages of your career as a professional responder. Ignoring self-care can put you at greater risk of developing a serious occupational stress injury such as post-traumatic stress disorder (PTSD). Self-care is specific to each individual. What works for another person may not work for you. 16 the feelings of others. Remember that reactions to death and dying can be dramatically different from person to person and from situation to situation. Critical Incident Stress and PostTraumatic Stress Disorder For years, researchers have recognized that individuals who provide emergency care can experience high levels of stress. Incidents involving multiple patients, rescues, children, failed resuscitation attempts, serious injury to co-workers, or death may cause more stress than most other incidents. Any emergency response, regardless of the circumstances, can cause an adverse stress reaction such as critical incident stress (CIS). Occupational stress injuries can happen to anyone involved in responding to an emergency (Figure 1–2). They could be characterized as acute and chronic versions of a similar condition: Signs and symptoms of CIS usually appear soon after the event, but may not last long. PTSD usually occurs later and can be much more long-lasting. From the time you begin to establish a rapport with a patient, you become involved in that person’s pain and stress. To some degree, you share the thoughts and emotions of that person. As a result, the emotional impact of a situation may be too great for you to handle alone. You may need the help of professional mental health services in order to deal with the stress. Death and Dying You may be summoned to an emergency in which one or more people have died or are dying. Although your responses will vary according to the situation, you must recognize that death will have an emotional impact on you, as well as on others who are involved. Be prepared to interpret your feelings responsibly and be considerate of Figure 1–2: Watch for the signs of CIS and PTSD. PTSD is a serious anxiety disorder. Trauma is a natural emotional reaction to disturbing experiences that involve actual or threatened serious harm to oneself or others. However, for some people, the thoughts or memories of these events seriously affect their lives long after any real danger has passed. PTSD usually appears within 3 months of the event, but sometimes symptoms may not appear for years. Common symptoms include reliving the event, avoiding reminders of the event, and a constant feeling of dread. PTSD can also present with physical symptoms such as difficulties concentrating and/or sleeping, sudden attacks of dizziness, rapid heartbeat, and shortness of breath. In addition to being alert to your own mental and emotional states, you should watch for the signs and symptoms of distress in your colleagues. People can recover from PTSD, but the recovery time varies greatly from person to person. All treatment approaches should follow the stages of the trauma therapy model and can include a combination of counselling, therapy, and medication. Some people think that participating in counselling is an admission of weakness, but it takes more strength to face something than to hide from it. The most important thing you can do to minimize the effect that an emergency will have on you is to know your protective factors and have a self-care plan. Ensure that you are aware of the resources that are available through your organization. LEGAL AND ETHICAL ISSUES Many people are concerned about lawsuits. However, lawsuits against those who give care at the scene of an emergency are highly unusual and rarely successful. By being aware of some basic legal principles, you can protect yourself against litigation. In general terms, the following sections address the legal principles that concern emergency care. Laws and regulations can vary from region to region or from role to role: You must ensure that you are aware of the legislation and regulations that apply to you. Legal issues are constantly evolving. The information presented here is intended as an overview of the important concepts, but you must always confirm the specific laws that apply to your situation. Duty to Act Either by case law, statute, or job description, most responders have a duty to act at the scene of an emergency. This duty applies to public safety officers, government employees, licensed and certified professionals, and paraprofessionals while on duty. For instance, members of a volunteer fire department have a duty to act based on their agreement to participate in the fire department. An athletic therapist has a duty to give care to an injured athlete. Failure to adhere to these agreements could result in legal action. Scope of Practice A responder’s scope of practice is the range of duties and skills he or she is allowed and expected to perform. Using reasonable care and skill, a responder performs these duties according to his or her level of training. The responder is governed by legal, ethical, regulatory, and medical standards. These standards establish the scope and limits of care that the responder provides and ensure that all patients receive appropriate care from qualified personnel. THE PROFESSIONAL RESPONDER CIS can cause a number of signs and symptoms, including the following: Confusion Lowered attention span Poor concentration Denial Guilt Depression Anger Change in interactions with others Increased or decreased appetite Uncharacteristic, excessive humour or silence Unusual behaviour 17 Since standards may differ by region, responders must be aware of the variations existing for their level of training and licensing in their region. Be aware that when you practise a medical act, you may be doing so as an extension of your medical director. 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 when dealing with a patient’s physical and mental needs, and communicating sensitively and willingly at all times. You should never become satisfied with meeting minimum training requirements but rather strive to develop your professional skills to surpass the standards for your region. Doing so includes not only practising and mastering the skills you acquired in your initial training but also seeking further training and information through workshops, continuing medical education, conferences, and supplemental or advanced educational programs. In addition, be honest in reporting your actions and the events that occurred at a scene or when you responded to an emergency. You have a legal and ethical responsibility to document events accurately. Make it a personal goal to be a person whom others trust and can depend on to provide accurate reports as well as effective care. You should address your responsibilities to the patient at each and every emergency. Periodically, you must reflect on your professional practice. This may help you improve any weaknesses and skills (e.g., providing care to the patient, communication with the patient, and documentation). THE PROFESSIONAL RESPONDER Patient Advocacy 18 Patient advocacy refers to the practice of hearing and representing a patient’s concerns, respecting his or her rights, and making every effort to ensure that your patient receives effective care that is in accordance with his or her wishes. Patient advocacy includes basic practices such as treating each patient with dignity and getting consent before providing care, but it can also include elements such as expressing a patient’s wishes to other healthcare practitioners (if you know what those wishes are and the patient is unable to express them). Abuse and Neglect Professional responders may respond to a situation where they suspect abuse or neglect. Abuse is any behaviour or action that is used to scare, harm, threaten, control, exploit, or intimidate another person. It can come in different forms: physical, emotional, verbal, sexual, or financial. Neglect is a failure to provide the necessary care, aid, or guidance to dependent adults or children by those responsible for their care. Abuse and neglect can happen to anyone, so be mindful of any stereotypes that you might already have. A professional responder’s responsibility is not to judge but to provide appropriate care, document the situation, and notify the authorities when necessary. As a professional responder, you not only have a duty to act, you also have a duty to report. In the case of children, this ethical duty is also a legal responsibility. You must be aware of the referral and reporting systems used by your organization and understand how and when to use them. Because of the potential for criminal investigation in these cases, it is important to document everything you observe that could be relevant to investigators. Follow your local protocols. CHILD ABUSE Child abuse refers to the physical, psychological, or sexual assault of a child, resulting in injuries and/or emotional trauma. Children of all ages and backgrounds can be victimized. The child abuser can come from any geographic, ethnic, religious, occupational, or socio-economic background. The abuser is often a person that the child or family knows and trusts. The signs of child abuse include: Unexplained physical trauma in a child less than 2 years of age (e.g., fractures). Signs of shaken baby syndrome. Injuries in various stages of healing, especially bruises and burns. Unusual extent or number of injuries. Injuries located in suspect parts of the body. An injury that does not fit the description of what caused it. In all provinces and most territories in Canada, suspected child abuse must be reported to the appropriate provincial/territorial child protection agency. Protocols may require you to make a report to law enforcement personnel as well. When in doubt, ask your local police department or child protection agency for advice. As a followup, accurately complete an incident report, noting in detail anything you were told and any injuries you noted when you first examined the child. Also ensure that you record any instructions provided by the police or child protection agency. ELDER ABUSE Elder abuse is a growing problem in our society. Elder abuse involves any of four types of abuse: the infliction of pain or injury (physical abuse), mental anguish or suffering (psychological abuse), financial or material abuse, or unnecessary confinement or willful deprivation (neglect) by an older adult’s caretaker. Typically, but not always, the abuser is a relative and lives with the abused elder. The signs and symptoms of elder abuse generally include any unexplained injury or any physical situation in which older adults seem to be neglected. Provincial/territorial laws may require the reporting of such abuse if suspected, so follow your local protocol. Consent An individual has a basic right to decide what can and cannot be done with his or her body. Therefore, to provide care for a patient, you must first obtain that person’s consent. Usually, the person needs to tell you clearly that you have permission to provide care. To obtain consent, you must: 1. Identify yourself to the person. 2. State your level of training. 3. Explain what you think may be wrong. 4. Explain what you plan to do. After you have provided this information, the person can decide whether to grant his or her informed (or actual) consent. Gaining consent is not limited to getting permission just once. A person can withdraw consent for care at any time or for any part of treatment. To ensure that the patient is giving informed consent, it is important for the professional responder to tell the patient what he or she plans to do, the intended outcome or purpose, and the possible risks and consequences. There is no specific age at which one is old enough to either consent to or reject first aid treatment. You must judge for yourself whether the patient is capable of giving or refusing informed consent. In general, the person receiving the treatment must be mature enough to understand the circumstances that he or she is in, the nature of the treatment to be provided, and the consequences of refusal. A person who is unresponsive, confused, 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 he or she were able to do so. This is called implied consent. The legal issues regarding consent are complex and constantly evolving. It is critical that you remain aware of specific legislation that pertains to you and remain informed of any changes that could affect the care that you provide. PEDIATRIC PATIENTS If you encounter a young child who requires care, you must get consent from his or her parent or guardian before care can be given. If a child requires urgent care and his or her parent or guardian is not available, provide the care that is necessary. If a child’s parent or guardian refuses to let you provide care, try to explain the consequences that may occur if care is not given to the ill or injured child. Use terms that the parent or guardian will THE PROFESSIONAL RESPONDER An abused child may be frightened, hysterical, or withdrawn. He or she may be unwilling to talk about the incident in an attempt to protect the abuser. As you provide care for any injuries, attempt to reassure the child and listen calmly and openly to what he or she tells you. Do not interrogate the child or make any accusations. Instead, explain your concerns to responding law enforcement or EMS personnel and follow organizational policies regarding making a report of child abuse. 19 understand. Do not argue with the patient’s parent or guardian. If necessary, you can request a law enforcement officer for assistance in establishing the legal authority to provide care. If the person is an adult who is under a legal guardian’s care, you must also get the guardian’s consent to provide care. COMPETENCE Competence refers to a person’s ability to understand the responder’s questions and understand the implications of decisions. Before providing any care to a competent person, you must obtain the person’s consent. Before receiving consent or refusal of care, the responder should determine whether the patient is competent. A person may not be competent to make rational decisions if he or she is intoxicated or on drugs, has a serious injury that might affect his or her judgment, or has a mental illness or disability. In such cases, call appropriate personnel to evaluate the person. A law enforcement officer may need to be present to obtain the necessary legal authority so that care can be provided. Advance Directives THE PROFESSIONAL RESPONDER Advance directives are documented instructions from a competent person, signed by a medical authority, which capture the person’s wishes concerning healthcare decisions that could arise in the future (either what those decisions should be or who should make them on the person’s behalf). If the person becomes incompetent with regard to these decisions, advance directives may specify what his or her wishes are. For example, an advance directive may specify that the patient refuses specific interventions, such as CPR, if the patient is not able to express these wishes. Advance directives are legal documents. 20 There are two distinct types of advance directive: instructional directives and proxy directives. Instructional directives specify the healthcare decisions that a patient wishes to be made if he or she becomes unable to express those wishes. Proxy directives specify a person or persons who will make decisions on the patient’s behalf if the patient is unable to make the decisions. Proxy directives are sometimes called durable powers of attorney for healthcare. Advance directives may differ by province, territory, and region. You must be aware of the proper legislation and protocols in relation to these orders. In any emergency medical incident, professional responders are to follow their governing protocols with respect to any advance directive(s) that may be in place. Negligence Negligence is the failure to follow a reasonable standard of care, thereby causing injury or damage to another. A person could be negligent by either acting incorrectly or failing to act at all. Acting reasonably means performing to the standard of care expected of a person with your training and working in your position. If a responder fails to act or to live up to the established standard of care, and this failure causes damage to another person, the responder could be vulnerable to legal action. To help avoid lawsuits, responders must do only what they have been trained and authorized to do and stay within their standard of care. Responders are governed and regulated by legal, ethical, and medical standards. These standards establish the scope of practice for the responder. Four components must be present for a negligence lawsuit to be successful: 1. The responder had a duty of care. 2. That duty was breached. 3. Damage was caused. 4. This damage resulted from something the responder did or failed to do. Good Samaritan Laws Most provinces and territories have enacted laws to protect people who provide emergency care voluntarily. When you have a duty to respond, these laws are usually not applicable. These laws, which differ across Canada, are often called Good Samaritan laws. They will generally protect you from legal liability as a responder as long as you: 1. Act in good faith. 2. Are not negligent. 3. Act with reasonable care and skill. 4. Act within the scope of your training. Some people, even those who desperately need care, may refuse the care you offer. Even though the person may be seriously injured, you should honour a refusal of care. Emphasize the need for care but do not argue with him or her. Repeat your offer of help at least once. If a patient is not competent or has an altered mental state, or if you believe that the patient poses a threat to him- or herself or to others, he or she cannot legally refuse care. You may need to request law enforcement personnel to assist you. If you have exhausted the options available to you through your response organization or regulatory body to encourage the patient to co-operate with your request for assessment or an assessment by a physician, you must make it clear that you did not abandon the person. Many EMS systems have a Refusal of Care or release from responsibility form that you can use in these situations. This is a legal document, so ensure that it is filled out carefully and completely, including any necessary signatures. You will often have to read the required legal documentation to the competent patient. Completely explain the patient refusal process and ensure the required number of legal witnesses are present. All parties, including the patient and witnesses, must sign the applicable document. As always, refer to your organization’s legal guidance and follow local protocol. HOSTILE PATIENTS If a patient who requires care is hostile toward you, try to explain calmly who you are and that you are there to help. A patient’s anger or hostility may be caused by the injury or illness, or by fear. Remember that you cannot give care without the patient’s consent. If the patient accepts your offer to help, keep talking to him or her as you assess the condition. When the patient realizes that you are not a threat, the hostility will usually disappear. If the patient refuses your care or threatens you, withdraw from the scene. Never try to restrain or argue with a patient, or to provide care without consent. If a patient does not let you provide care, call for additional help. Sometimes a friend or a family member will be able to calm a hostile patient and convince him or her to accept your care. Abandonment Once you have started providing care, you are legally obligated to continue until either you transfer the patient to someone with equal or higher qualification or the patient formally refuses additional care. Usually, your obligation ends when you transfer the patient’s care to more advanced personnel. Cessation of patient care prior to this transfer can leave you legally responsible for the abandonment of a patient in need and subject to applicable laws and professional discipline by a regulatory body. If a person’s condition improves and additional care is unnecessary, you must have the patient sign a legal document indicating that he or she is refusing additional care. Confidentiality While providing patient care, you may acquire information about the patient that is private and/or confidential. Information such as a patient’s previous medical problems, physical problems, and medications is personal to the individual. Respect the patient’s privacy by maintaining confidentiality, including any documentation you may create. Do not discuss confidential or private information with anyone, including lawyers or members of the media who approach you. Never discuss the patient or the care you provided with anyone except law enforcement personnel with a direct interest in the patient, or other personnel caring for the individual. Once transfer of care has taken place, your responsibilities for data gathering are terminated unless you are asked to act further. Any information gathered up to that point must be documented. Transfer of Care At some point during the response, professional responders may need to transfer a patient’s care to another medical professional. This transfer of care may become necessary at the scene, during transport, or at the receiving medical care facility. THE PROFESSIONAL RESPONDER Refusal of Care 21 This involves transferring care to another practising medical professional (e.g., a paramedic, nurse, or physician). The receiving medical professional will need a brief, concise report detailing what you observed while the patient was in your care, what treatment has been provided, and any changes in the patient’s condition that you are aware of (Figure 1–3). Your Patient Care Report should include: Patient information (e.g., name, age). The patient’s chief complaint. A brief history of what happened. Relevant patient history (e.g., past medical history, medications, allergies). The treatment provided. Any changes in patient condition as a result of that treatment. Patient vitals, including relevant changes in vital signs. Documentation THE PROFESSIONAL RESPONDER Documenting the care that you provide is as important as the care itself. Your documentation will help healthcare professionals assess and continue to care for the patient. As a patient’s condition may change before he or she arrives at the hospital, delivering a record of the condition immediately after the emergency will provide useful information for healthcare providers (Figure 1-4). They can compare the current condition with information you documented earlier. 22 Figure 1–3: Provide a Patient Care Report when transferring care of a patient. As a legal document, your record will be important if legal action occurs. Should you be called to court for any reason, your record will support what you saw, heard, and did at the scene of the emergency. It is important to write the record as soon as possible after the emergency, while all the facts are fresh in your memory. Many systems have electronic forms for responders to use, while others use printed forms. REASONS FOR DOCUMENTATION There are four main reasons for documentation: 1. Medical: To document the care that you provided 2. Legal: To defend against lawsuits, as well as possibly serve as evidence in court proceedings (e.g., if an act of violence was involved) 3. Administrative: To transfer information about the individual from one person to another 4. Research: To improve your EMS system PAC lists several competencies for paramedics under the area of professional responsibilities. Those that pertain to written reports can be summarized as follows: Record organized, accurate, and relevant patient information. ◆ Organize patient information for the purposes of a written report. ◆ Communicate accurate, organized, and relevant documentation.6 Figure 1–4: Provide a brief, concise report when transferring care of a patient. ELEMENTS OF GOOD DOCUMENTATION Each EMS system has a different Patient Care Report that is filled out for every emergency call. Responders should keep in mind the following record-keeping characteristics: Completeness and accuracy Objectivity Absence of alterations (If an error is made, never use liquid paper. Cross out the error with a straight line through the word or comment and initial the change.) Legibility (see Appendix A: Abbreviations for Documentation) Timeliness If the form you are using is multi-layered, press firmly to ensure transfer. Note that when using multi-layered forms, you need to ensure that you are not transferring ink (and confidential information) to the wrong paper/surface. Documentation should include the following: Administrative information: names of responders, unit number, call number, and address to which the responders were sent Patient’s information: name, age, sex, birth date, address, and any care given prior to the responder’s arrival Patient’s vital signs Patient’s chief complaint History and assessment findings (see Chapter 5) Care provided Local protocols often dictate the specific details that are to be included in a report, as well as the format that the information is to be documented in. There are some situations when other documentation, or variances in the usual documentation, may be required. Such situations may include: Caring for injuries to responders. Multiple-casualty incidents. Infectious disease exposure. It may be necessary to provide a verbal report about the patient to another healthcare provider. Report the facts about what you found and what you have done up to that point. ELECTRONIC PATIENT CARE REPORT (E-PCR) Electronic Patient Care Reports (e-PCRs) are becoming more popular in Canada. They are tablet-style devices that allow data to be rapidly entered, collected, and analyzed. Confidential information entered into an e-PCR is kept secure but can be transmitted electronically to predetermined receiving agencies, such as hospitals, or between crews when care is transferred (maintaining the continuity of patient care information). E-PCRs may also be integrated with computer-aided dispatching systems, helping to centralize information gathered by responders. E-PCRs also increase the legibility of documentation and allow for data management and analysis. They may allow access to specific protocols. Specific training is required for responders to become proficient in using e-PCRs. COMMUNICATION You must make every reasonable attempt through interviewing and assessing the patient to determine the patient’s chief complaint, obtain his or her past and present medical history, and properly reassure and comfort the patient. These responsibilities are just as important as updating incoming EMS units on the patient’s status or requesting help from dispatch. Both types of communication require training and experience, and they depend on your skills as a good communicator. You may communicate with other EMS personnel by radio or telephone, or in person. It is important THE PROFESSIONAL RESPONDER Include  all pertinent and required information on reports and medical records. ◆ Organize  information for documentation. ◆ Apply  principles of correct documentation. ◆ Acknowledge  the importance of appropriate documentation. ◆ Demonstrate  proper documentation.7 23 for you to speak slowly, accurately, and clearly. Clear communication is crucial for providing accurate, complete information. Ineffective communication could result in harm to the patient in your care. Radio Communication Radios operate on specific frequencies that are regulated and licensed by Industry Canada’s Spectrum Management and Telecommunications. Unauthorized people do not have access to these frequencies, so they cannot disrupt emergency radio traffic. THE PROFESSIONAL RESPONDER A radio system is made up of several components (Figure 1–5) that usually include: A base station: The base system is the stationary radio located in a dispatch centre, station, or hospital. Mobile radios: These radios are mounted inside vehicles. Portable radios: These are hand-held radios that may be carried on your belt or in your pocket. Repeaters: Repeaters are devices that receive a low-power radio transmission and rebroadcast it with increased power. Mobile phones: Mobile phones are useful for contacting the medical director or the dispatcher where radio coverage is unavailable. Satellite phones: These are mobile phones that connect to orbiting satellites and are found in many remote communities or environments. 24 During an emergency call, you will need to keep the dispatcher aware of your activities, assuming that your EMS system has a dispatch centre and radios. You should inform dispatch whenever you: Are en route to a call. Arrive at the scene of a call. Require additional assistance or specialized personnel. Are transporting a patient. Return to service and are available for the next call. You will also use the radio to update incoming responder units or to speak with the medical director. During training, it is important for the Figure 1–5: A radio communication system in an emergency vehicle. professional responder to become familiar with the use of a radio so that he or she understands how to use it during an emergency. The professional responder needs to be familiar with the different types of communication used in their EMS system. There are many different types of radios, including portable and permanently mounted, or base, units. Follow the manufacturer’s recommendations for the unit you are using. When using the radio, keep your transmissions brief; others may be waiting to use the frequency. Listen before you transmit so that you don’t disrupt another conversation. Remember to speak slowly and clearly. Assume that anything you say over the radio can be overheard by others, even outside your organization. People with scanners can listen to emergency frequencies. Never say anything personal or confidential, even a patient’s name, on the radio. The public nature of radio transmission also means you should always be aware of your language and maintain a professional tone of voice. MEDICAL TERMINOLOGY In order to communicate accurately about patients with other professionals, you must have a common language that is clear and universally understood. Using this language requires a basic understanding of medical terminology. One of the key elements to understanding medical terminology is the ability to break down the terms into their parts. Medical terms are often made up of a combining form (a root word plus a combining vowel; Table 1–1) that contains the core meaning of the term, along with a suffix (a word ending) and/or a prefix (a word beginning) that qualifies the combining form (Table 1–2). For example, the medical term endotracheal is made up of the following language elements: The combining form trache-, which means trachea The prefix endo-, which means within The suffix -al, which means pertaining to By understanding the parts of the word, you can deduce that the term endotracheal means pertaining to something within the trachea. You can then also guess that an endotracheal tube describes a type of tube used within the trachea. TABLE 1–1: COMMON COMBINING FORMS COMBINING FORM MEANING Cardi/o- Heart, cardiac Neur/o- Nerve, neural Oro- Mouth Arteri/o- Artery, arterial Hem/o- Blood Therm/o- Heat Vas/o- Duct, vessel, vascular TABLE 1–2: COMMON PREFIXES COMBINING FORM MEANING A- Without, no Hyper- Excessive, above, over, beyond Hypo- Less than normal, under Tachy- Fast, swift, rapid, accelerated Brady- Slow, dull The easiest way to learn medical combining forms, their prefixes, and their suffixes is to memorize them. A few of the more common suffixes are -emic (pertaining to the blood), -emia (condition of the blood), and -a or -ia (condition). THE PROFESSIONAL RESPONDER A list of common medical word elements can be found in Appendix D: Medical Terminology. 25 SUMMARY Professional Responsibilities As a professional responder, you must: Maintain a caring and professional attitude. Have an up-to-date self-care plan to help manage distress. Present a clean and professional appearance. Keep your skills and knowledge up to date. Maintain a safe and healthy lifestyle. Primary Responsibilities 1. 2. 3. 4. 5. 6. 7. Ensure your own safety. Ensure safety for any bystanders. Gain access to the patient. Determine any threats to the patient’s life. Request more advanced medical care as needed. Provide the necessary care for the patient. Assist more advanced medical personnel. THE PROFESSIONAL RESPONDER Elements of Good Documentation 26 Administrative information: names of responders, unit number, call number, and address Patient’s information: name, age, sex, birth date, address, and any care given prior to responder’s arrival Patient’s vital signs Patient’s chief complaint History and assessment findings Care provided