1. AEMT Critical Care
Introduction to Advanced
Prehospital Care

2. Topics
 Roles and Responsibilities
 Medical Direction
 Well-Being of the AEMT
 Illness and Injury Prevention
 Medical/Legal Issues
 Ethics

3. Roles and
Responsibilities
of the AEMT-CC

4. Topics
 Introduction
 Review of EMS Systems
 Education
 Continuing Education
 Professional Attitudes
 Primary Responsibilities

5. EMS System
 A comprehensive network of
personnel, equipment, and
resources established to deliver
aid and emergency medical care
to the community.

6. OUT-OF-HOSPITAL COMPONENTS OF AN
MEMBERS OF
THE COMMUNITY
COMMUNICATION
S SYSTEM
EMS PROVIDERS
PUBLIC
UTILITIES
POISON CONTROL
CENTERS
FIRE
RESCUE
HAZMAT
EMS SYSTEM

7. OUT-OF-HOSPITAL COMPONENTS OF AN
EMERGENCY
NURSES
EMS SYSTEM
EMERGENCY AND
SPECIALTY
PHYSICIANS
ANCILLARY
SERVICES
REHABILITATION
SERVICES

8. NYS EMS System
 State EMS Council
SEMAC
 Regional EMS Council
WEREMS, Big Lakes REMS CO
 Regional Medical Advisory
Committee
WREMAC
 County EMS Coordinator
 Medical Director

9. Personal and Professional
Development
 Personal and professional
development is your responsibility.
 Keep updated with journals,
seminars, computer newsgroups,
and other learning experiences.
 Explore alternative or non-traditional
career paths.

10. Education and
Certification
 Two kinds of EMS education are
initial and continuing education.
Initial education is the original training
course for prehospital providers.
Continuing education programs include
refresher courses for recertification and
periodic in-service training sessions.

11. Initial Education
 Based on the EMT-Paramedic:
National Standard Curriculum
published by the U.S. D.O.T.
establishes the minimum content for the
course
divided into 3 specific learning domains:
• Cognitive
• Affective
• Psychomotor

12. Once the initial education is
completed, the paramedic
will become either certified
or licensed.

13. Certification vs. Licensure
 Certification is the process by which
an agency grants recognition to an
individual who has met its
qualifications.
 Licensure is the process of
occupational regulation.

14. National Registry of EMTs
(NREMT)
 Prepares and administers
standardized tests for the First
Responder, EMT-Basic, EMT-Intermediate,
and EMT-Paramedic.
 Establishes the qualifications for
registration and re-registration, and
for establishing a minimal standard
of competency.

15. Belonging to a
Professional
Organization is a good
way to keep informed
about the latest
technology.

16. Professional Organizations
Include:
 National Association of EMTs
 National Association of Search and Rescue
 National Association of State EMS
Directors
 National Association of EMS Physicians
 National Flight Paramedics Association
 National Council of State EMS Training
Coordinators

17. A variety of journals are
available to keep the paramedic
aware of the latest changes in
this ever-changing industry.

18. These Professional
Journals Include:
 Annals of Emergency Medicine
 Emergency Medical Services
 Emergency
 Journal of Emergency Medical
Services
 Journal of Emergency Medicine

19. Continuing Education
The paramedic must always strive
to stay abreast of changes in EMS.

20. Research (1 of 2)
 Research programs are essential for
moral, educational, medical,
financial, and practical reasons.
 Future EMS research must address
the following issues:
Which interventions actually reduce morbidity
and mortality?
Are the benefits of a procedure worth the risk?
What is the cost-benefit ratio?

21. Research (2 of 2)
 Has your organization
participated in research?

22. The Components of a
Research Program: (1 of 2)
 Identify a problem.
 Identify the body of knowledge
on the subject.
 Select the best design for the
study.
 Begin the study and collect raw
data.

23. The Components of a
Research Program: (2 of 2)
 Analyze the data.
 Assess and evaluate the results.
 Write a concise, comprehensive
description of the study for
publication in a medical journal.

25. Professionalism
Professionalism is the conduct or
qualities that characterize an
expert practitioner in a particular
field or occupation.

26. Professional Attributes
 Leadership
 Integrity
 Empathy
 Self-motivation
 Professional
appearance and
hygiene
 Communication
skills
 Time management
skills
 Diplomacy in
teamwork
 Respect
 Patient advocacy
 Careful delivery of
service

27. Professional Attitudes
True professionals establish
excellence as their goal
and never allow themselves
to become complacent about
their performance.

28. As the leader of the EMS team, the
paramedic must interact with
patients, bystanders, and other
rescue personnel in a professional
manner.

29. Primary Responsibilities of the
Paramedic
 Preparation
 Response
 Scene size-up
 Patient
assessment
 Treatment and
management
 Disposition and
transfer
 Documentation
 Clean-up,
maintenance,
and review

30. Preparation
The paramedic must be physically, mentally,
and emotionally able to meet job demands.

31. Response
Safety is the number one priority!
 Wear seatbelts.
 Obey posted speed limits.
 Monitor roadway for potential
hazards.

32. Scene Size-up
 Scene safety.
 Identify the number of patients.
 Identify the mechanism or nature of
illness.

33. Patient Assessment
 Initial assessment.
 Physical examination.
 Patient history.
 Ongoing assessment.
Fig. 4-3

34. Recognition of Illness or
Injury
 First aspect of patient
prioritization.
 Usually based on the urgency
for transport.

35. Patient Management
 Protocols ensure consistent
patient care.
 Communication with medical
direction.
 Movement of the patient from
one location to another.

36. Appropriate Disposition
 Transportation type.
 Receiving facility.
 Treat and release.

37. Patient Transfer
 While moving the patient from one
facility to another the first priority
is patient care.
 Request a verbal report from
primary-care provider.
 At destination provide a report to
receiving care provider.

38. Documentation
 Complete a patient care report as
soon as possible after emergency
care has been provided.
 Necessary to ensure continuity of
care.
 Be complete, neat, and legible.

39. Accurate and complete
documentation is extremely
important.
Fig. 4-4

40. Returning to Service
Prepare the unit to return to service
 Clean and decontaminate.
 Restock.
 Refuel.
 Review the call with crew members.
 Be aware of signs of critical incident
stress.

41. Patient Advocacy
 An EMT is an advocate for patients,
defending them, protecting them,
and acting in their best interest.
Except when your safety is
threatened, you should always
place the needs of your patient
above your own.

42. Additional
Responsibilities
 Community involvement.
 Support for primary care.
 Citizen involvement in EMS.
 Personal and professional
development.

43. Community Involvement
Help the public:
 Recognize an emergency;
 Know how to provide BLS;
 Know how to properly access
the EMS system.

44. Support For Primary
Care
 Help develop services that decrease
the need for EMS.
 Establish protocols that specify the
mode of transportation for non-emergency
patients.
 Team up with hospitals to provide
an alternative to the emergency
department.

45. Medical Direction

46. Medical Direction
 A medical director is a
physician who is legally
responsible for all clinical
aspects of the system.
 EMT-Critical Care Technicians
operate as “physician extension”

47. Medical Direction
 The medical director’s role in a
system is to:
educate and train personnel
participate in equipment and personnel selection
develop clinical protocols
participate in problem resolution and quality
improvement
provide direct input into patient care
interface with the EMS system
advocate within the medical community
serve as the “medical conscience” of the
EMS system

48. The Medical
Director can
provide on-line
guidance
to EMS
personnel in
the field.
This is
known as
on-line
medical
direction.

49. Off-line medical
direction refers to
medical policies,
procedures, and
practices that
medical direction
has set up in
advance of a call,
such as standard
protocols or
standing orders.

50. Protocols are the policies
and procedures for all
elements of an EMS system.

51. Protocols are designed around
the four “T’s” of emergency care.
 Triage
 Treatment
 Transport
 Transfer

52. On-scene Physician
 Be currently licensed in NYS
 Assume responsibility for the
patient’s care
 Realize EMS providers will not
comply with orders that exceed
their scope of practice
 Accompany patient to hospital if
requested

53. KEY POINT
MC is ultimately
responsible for
the actions of the
EMS provider and
must be
contacted.

54. Special Note:
T h e o n - s c e n e
p h y s i c i a n
mus t
d o c ume n t h i s
i n t e r v e n t i o n s

55. Quality Assurance and
Improvement
 Quality Assurance is designed to
maintain continuous monitoring and
measurement of the quality of
clinical care.
 Continuous Quality Improvement
(CQI) is designed to refine and
improve an EMS system,
emphasizing customer satisfaction.

56. CQI – A Dynamic
Pocess  Identify Problems
 Elaborate on the cause
 Develop remedies
 Lay out plan to correct problems
 Enforce the plan
 Reexamine the problem

57. An EMS system must be
designed to meet the
needs of the patient.
Therefore, the only
acceptable quality of an
EMS system is
EXCELLENCE!

58. Customer satisfaction
can be created or
destroyed with a simple
word or deed.

59. The well-being of
the AEMT

60. Topics
 Wellness of the AEMT
 Impact of Shift Work on the
AEMT
 Proper Body Mechanics
 Managing Hostile Situations

61. Introduction
 Well-being is a fundamental
aspect of top-notch performance
in EMS. It includes:
Physical well-being
Mental and emotional well-being
Safe lifting
 Seize the information about safe
practice and apply it to your life.

62. Basic Physical Fitness
 The benefits of
physical fitness
are well known:
Decreased resting heart
rate and blood pressure
Increased oxygen-carrying
capacity
Increased muscle mass
and metabolism
Increased resistance to
illness and injury
Enhanced quality of life

63. Core Components of
Physical Fitness
 Muscular
Strength
 Cardiovascular
Endurance
 Flexibility

64. Muscular Strength
 Achieved with
regular
exercise
 Exercises may
be isometric
and isotonic
 ISOMETRIC exercise
is active exercise
performed against
stable resistance.
 ISOTONIC exercise
is active exercise
during which
muscles are worked
through their range
of motion.

65. Cardiovascular
Endurance
 Is a result of exercising at
least three days a week
vigorously enough to raise your
pulse to its target heart rate.

66. Flexibility…the Forgotten
Element of Fitness
 To achieve or
regain flexibility,
stretch main
muscle groups
regularly.
 Stretch daily.
 Never bounce
when stretching.
 Hold a stretch
for at least 60
seconds.

67. It’s a Tough Job…

68. Nutrition
 It is a myth that people in EMS
cannot maintain an adequate
diet.
 The most difficult part is
changing bad habits.
 Good nutrition is fundamental
to well-being.

69. Learn the major food groups and
eat a variety of foods from them
daily.
6 to 11 servings
3 to 5 servings
2 to 4 servings
2 to 3 servings 2 to 3 servings

70. Avoid or minimize intake of fat,
salt, sugar, cholesterol, &
caffeine.

71. Check food
labels for
information
about the
nutritional
content of
the food you
eat.

72. Good sense says…
 Eating on the run can be less
detrimental if you plan ahead –
Avoid fast foods.
Carry a small cooler filled with whole-grain
sandwiches, fruits, and vegetables.
Monitor your fluid intake. Drink plenty of
water.

73. Habits and
Addictions
 Many in high-stress jobs abuse
substances such as nicotine
and caffeine. Those in EMS are
no exception.

74. Habits & Addictions
(cont)
 Choose a
healthier life
and avoid
overindulging
in harmful
substances.

75. Habits & Addictions
(cont)
 Consider substance abuse
programs, nicotine patches,
or a 12-step program.

76. Habits & Addictions
(cont)
 Whatever
it takes:
Get free
of addictions.

77. Back Safety
 EMS is a physically demanding
career.
 Lifting and moving patients
is frequently required.
 To avoid back injury, you must
keep your back fit for the work
you do.

78. Correct
Posture
Will
Minimize
the Risk of
Back
Injury

79. Correct Sitting Posture

80. Important Lifting
Principles (1 of 2)
 Move a load only if you can handle it.
 Ask for help if you need it.
 Position load close to your body.
 Keep your palms up—when possible.
 Do not hurry.
 Bend with your knees.
 “Lock-in” the spine.

81. Important Lifting
Principles (2 of 2)
 Always avoid twisting and turning.
 Let the leg muscles do the work.
 Exhale during lifting.
 Given a choice, push. Do not pull.
 Look where you are going.
 Only one person should be in
charge of verbal commands.

82. Personal Protection from
Disease
 There’s a lot you can do to
minimize the risk of infection.
 Begin by developing a habit of
doing the things promoted in
this chapter.

83. Body Substance Isolation
 A strict form of infection control
that is based on the assumption
that all blood and other body
fluids are infectious.
Take BSI precautions with every patient.

84. BSI is achieved through the
use of PPE.
 Appropriate personal
protective equipment
should be available in
every emergency
vehicle.
Protective gloves
Masks and protective
eyewear
HEPA and N-95
respirators
Disposable resuscitation
equipment

85. High
Efficiency
Particulate
Air
Respirator
(HEPA
Mask)

86. An N-95 Respirator

87. To Remove Gloves, Hook the
Gloved Fingers of One Hand
Under the Cuff of the Other
Glove.

88. Then Slide the Fingers of the
Ungloved Hand Under the
Remaining Glove’s Cuff.

89. Perhaps the Most
Important Infection-
Control Practice Is...
HANDWASHING

90. To Wash Your Hands Properly,
Lather Well and Scrub Under
Your Nails.

91. When You Rinse Your Hands,
Point Them Downward So That
Soap and Water Run Off Away
From Your Body.

92. Important:
 Dispose of
Biohazardous
Waste in a
Properly
Marked Bag.

93. Also Very Important:
 Discard
Needles and
Other Sharp
Objects in a
Properly
Labeled,
Puncture-proof
Container.

94. Contaminated
Non-disposable Equipment
Must Be Cleaned,
Disinfected, or Sterilized.

95. …Cleaned, Disinfected, or
Sterilized
 Cleaning refers to washing an object
with soap and water.
 Disinfecting is cleaning with an agent
that can kill some microorganisms on
an object
 Sterilizing is the use of a chemical
or steam to kill all microorganisms
on an object.

96. Post-Exposure
Procedures
 In most areas, an EMS provider who
has had an exposure should:
Immediately wash the affected area.
Get a medical evaluation.
Take the immunization boosters.
Notify the agency’s infection control liaison.
Document the event.

97. EX
P
OS
URE
P
R
OCE
DURES

98. Infectious Disease
 Caused by pathogens, such as
bacteria or viruses.
 May be spread from person to
person.
 For example, infection by way of
bloodborne pathogens can occur
when the blood of an infected
person comes in contact with
another person’s broken skin.

99. Common Infectious
Diseases

100. Hepatitis
 Inflammatory condition caused by:
Infectious agents
Toxins
Drugs
Metabolic aberration
Hypersensitivity or immune mechanism

101. Hepatitis
 Types of Hepatitis
Hepatitis A, (HAB, infectious hepatitis)
Hepatitis B, (HBV, serum hepatitis)
Hepatitis C, (HCV, virus)
Hepatitis D, (HDV, delta agent virus)
Hepatitis E, (HEV, hepatitis E virus)
Non A-Non B Hepatitis (NANB, unknown
virus

102. Hepatitis
 Signs and Symptoms
Fever
Weakness
Loss of appetite
Nausea
Abdominal pain
Jaundice
Dark colored urine
Light colored urine

103. Hepatitis
 Incubation period
 Mode of transmission

104. Hepatitis
 Management Precautions
Use disposable gloves and wash hands following
contact
Sterilization of all equipment used
Red bag and label any specimens and linen
Follow-up if protective measures were not used
 (a) file exposure report
 (b) Immunization with ISG (Immune serum Globulin)

105. Tuberculosis
 Infectious disease caused by tubercule
bacillus
 Signs and Symptoms
Cough
Fever
Night sweats
Weight loss
Fatigue
Hemoptysis

106. Tuberculosis
 Incubation period 4-6 weeks
 Mode of transmission

107. Tuberculosis
 Management Precautions
Mask and gloves
Avoid prolonged contact
Fresh air (well ventilated patient
compartment)
Avoid contact with sputum
Regular PPD skin test
Chest x-ray as needed, per CDC
recommendations

108. Meningitis
 Inflammation of the membranes of
the spinal cord or brain
 Signs and Symptoms
Fever
Headache
Nausea and vomiting
Stiff neck
Rash

109. Meningitis
Incubation period 2-10 days
Management Precautions
(1) Mask (on you or patient)
(2) Gloves and wash hands after contact

110. Acquired Immune Deficiency Syndrome
(AIDS)
 Signs and Symptoms
Fever with profuse night sweats
Weight loss (10 - 20 lbs. per month
Red/purple skin lesions
Pneumonia

111. AIDS
 Incubation period from 2 months to
2 years or more
Mode of transmission
Blood contact
Contact with other bodily secretions
Sexual contact

112. AIDS
 Management Precautions
Ware disposable gloves when in contact
with blood or body fluids
Wash hands following care of the patient

113. Stress and Stress
Management (1 of 2)
 A stimulus that causes stress is
known as a stressor.

114. Stress and Stress Management
(2 of 2)
 Adapting to stress is a dynamic,
evolving process:
Defensive strategies
Coping skills
Problem-solving skills

115. Your job in managing stress is
to learn these things:
 Your personal stressors.
 Amount of stress you can take
before it becomes a problem.
 Stress management strategies
that work for you.

118. To manage stress:
 Use controlled breathing…focus
attention on your breathing.
 Use reframing…mentally reframe
interfering thoughts.
 Attend to the medical needs of the
patient…even if you know them.

119. Shift Work Is Inherently
Stressful Due to the
Disruption of Circadian
Rhythms and Sleep
Deprivation.

120. Shift Work Disruption
 IF YOU HAVE TO SLEEP IN THE
DAYTIME:
 Sleep in a cool, dark place.
 Stick to a common sleeping time and
pattern.
 Unwind appropriately after a shift in
order to rest.
 Post a “day sleeper” sign on your front
door, turn off the phone’s ringer and
lower the volume of the answering
machine.

121. Critical Incident Stress
Management (CISM)
 an adaptive short term helping
process that focuses solely on an
immediate and identifiable problem to
enable the individual(s) affected to
return to their daily routine(s) more
quickly and with a lessened likelihood
of experiencing post-traumatic stress
disorder.

122. Incidents when CISM may be
helpful
 Line of duty deaths
 Suicide of a colleague
 Serious work related injury
 Multi-casualty / disaster / terrorism incidents
 Events with a high degree of threat to the personnel
 Significant events involving children
 Events in which the victim is known to the personnel
 Events with excessive media interest
 Events that are prolonged and end with a negative
outcome
 Any significantly powerful, overwhelming distressing
event

123. Death and Dying
 Situations involving death and
dying are the most personally
uncomfortable for most AEMTs.
 Each person faces a death situation
based on his or her prior experience
of loss, coping skills, religious
convictions, and other personal
background.

124. Loss, Grief, and Mourning

125. Know and Understand the
5 Stages of Loss
 Denial
 Anger
 Bargaining
 Depression
 Acceptance

126. ILLNESS AND
INJURY
PREVENTION

127. Topics
 Impact of Unintentional
Injuries
 Community Hazards and
Crime Areas
 Community Resources
 Illness and Injury Prevention

128. Introduction
 Injury is one of our nation’s
most important health problems.
 Injuries result from interaction
with potential hazards in the
environment, which means that
they may be predictable and
preventable.

129. Facts About Injury…
 Injury is the 3rd leading cause of death.
 Unintentional injuries result in 70,000
deaths annually.
 The estimated lifetime cost of injuries
will exceed $144 billion.
 For every death caused by injury,
there are an estimated 19
hospitalizations.

130. Epidemiology
 The study of the factors that
influence the frequency,
distribution, and cause of injury,
disease, and other health-related
events in a population.

131. Injury (1 of 2)
 Intentional or unintentional
damage to a person resulting
from acute exposure to thermal,
mechanical, electrical, or
chemical energy or from the
absence of such essentials as
heat and oxygen.

132. Injury (2 of 2)
 Unintentional injury is an
accident.
 Intentional injury is
purposefully inflicted on a
person, i.e., homicide.

133. As medical
professionals, EMS
providers should assess
every scene and
situation for injury risk.

134. Prevention (1 of 2)
 EMS providers can focus on primary
prevention, or keeping an injury from ever
occurring.
 Such prevention can occur as teachable
moments that occur shortly after an
injury when the patient and observers
remain acutely aware of what has
happened and may be receptive to
learning how to prevent a similar incident
in the future.

135. Prevention (2 of 2)
 Secondary prevention occurs
during medical care.
 Tertiary prevention occurs
during rehabilitation activities.

136. Prevention within EMS
 Few experience the aftermath of trauma
more directly than EMS providers.
 EMTs and paramedics are widely
distributed in the population and are
often role models for the community.
 Paramedics have become prime
candidates to be advocates of injury
prevention.

137. The more than 600,000 EMS
providers
in the United States comprise a
great arsenal in the war to prevent
injury
and disease.

138. Organizational
commitment is vital to
the development of any
prevention activities.

139. Primary responsibilities
include:
 Protection of EMS Providers
 Education of EMS Providers
 Data Collection
 Financial Support
 Empowerment of EMS
Providers

140. When appropriate, specific EMS
education and training in specialized
safety procedures should be
available
to you.

141. Funding for illness/injury
campaigns may be contributed by
corporations and advertising
agencies, as well as non-profit
agencies.

142. Data should be collected and
incorporated into patient
documentation.

143. EMS Provider
Commitment  Body Substance Isolation (BSI)
Precautions.
 Physical Fitness.
 Stress Management.
 Seeking Professional Care.
 Driving Safety.
 Scene Safety.

144. BSI equipment, such as
protective gloves and eyewear,
is one of a provider’s basic
lines of defense.

145. Keep your safety equipment in
good condition and readily
available in your emergency
vehicle.

146. Prevention in the
Community
 EMS has a responsibility not only
to prevent injury and illness among
workers, but also to promote
prevention among the members
of the public.
 EMS providers can be an
appropriate and effective means of
prevention in several situations.

147. Areas in Need of
Prevention Activities (1 of 2)
 Low birth weight in newborns.
 Unrestrained children in motor
vehicles.
 Bicycle-related injuries.
 Household fire and burn
injuries.
 Unintentional firearms injuries.

148. Areas in Need of Prevention
Activities (2 of 2)
 Alcohol-related motor vehicle
collisions.
 Fall injuries in the elderly.
 Workplace injuries.
 Sports and recreation injuries.
 Misuse or mishandling of
medication.
 Early discharge of patients

149. Implementation of
Prevention Strategies
 Preserve the safety of the response
team.
 Recognize scene hazards.
 Document findings.
 Engage in on-scene education.
 Know your community resources.
 Conduct a community needs
assessment.

150. Summary
 Impact of Unintentional Injuries
 Community Hazards and Crime
Areas
 Community Resources
 Illness and Injury Prevention

151. ETHICS IN
ADVANCED
PREHOSPITAL
CARE

152. Topics
 Ethics
 Morals
 Law
 Advanced Directives

153. Introduction (1 of 2)
 In one survey, almost 15% of ALS
calls in an urban system generated
ethical conflict.
 In another survey, EMS providers
reported frequent ethical problems
related to patient refusals, hospital
destinations, and advance directives.

154. Introduction (2 of 2)
 Other aspects include patient
confidentiality, consent, the
obligation to provide care, and
research.

155. Ethics VS. Morals
 Ethics and morals are closely related
concepts but distinctly separate.
 Morals are the social, religious, or
personal standards of right and
wrong.
 Ethics are the rules or standards
that govern the conduct of members
of a particular group or profession.

156. Relationship of Ethical
and Legal Issues with
Medicine

157. Approaches to Making
Ethical Decisions (1 of 2)
 Ethical relativism suggests that
each person must decide how
to behave and whatever
decision that person makes
is okay.
 Some say, “Just do what is
right.”

158. Approaches to Making Ethical
Decisions (2 of 2)
 The deontological method
suggests that people should
simply follow their duties.
 Followers of consequentialism
believe that actions can only be
judged after we know the
consequences.

159. Code of Ethics
 Many organizations have developed
a code of ethics over the years for
their members.
 Most codes of ethics address broad
humanitarian concerns and
professional etiquette.
 Very few provide solid guidance on
the kind of ethical problems
commonly faced by practitioners.

160. To gain and maintain the
respect of their colleagues and
their patients, it is vital that
individual paramedics exemplify
the principles and values of
their profession.

161. The single most important
question a paramedic has to
answer when faced with an
ethical challenge is:
WHAT IS IN THE PATIENT’S BEST
INTEREST?

162. 4 Principles to Resolve
Ethical Problems
 Beneficence is the principle of doing
good for the patient.
 Nonmaleficence is the obligation not
to harm the patient. Primum non
nocere, “first, do no harm”
 Autonomy is a competent adult
patient’s right to determine what
happens to his or her own body.
 Justice refers to the obligation to
treat all patients fairly.

163. An
approach
to ethical
decision-making.

164. Quick Ways to Test
Ethics  Impartiality test---asks whether you
would be willing to undergo this
procedure or action if you were in the
patient’s place.
 Universalizability test---asks whether you
would want this action performed in all
relevantly similar circumstances.
 Interpersonal justifiability test---asks
whether you can defend or justify your
actions to others.

166. Ethical Issues in Contemporary
Paramedic Practice
 Resuscitation Attempts
 Confidentiality
 Consent
 Allocation of Resources
 Obligation to Provide Care
 Teaching
 Professional Relations
 Research

167. Resuscitation Attempts
 Learn the local laws regarding
do not resuscitate (DNR) orders.
 Understand your local policy.
 “When in doubt, resuscitate.”

168. Confidentiality
 Your obligation to every patient is
to maintain as confidential the
information you obtained as a result
of your participation in the medical
situation.
 Reporting certain information such
as child neglect or elder abuse are
exceptions.

169. Consent (1 of 2)
 Patients of legal age have the
right to decide what healthcare
they will receive.
 Implied consent may apply in
cases where the patient is
incapacitated or unable to
communicate.

170. Consent (2 of 2)
 Patients are generally able to
consent or refuse care if they are
alert and oriented, aware of their
surroundings, and making sound
judgments.
 When leaving the patient, he or she
must understand the issues at hand
and be able to make an informed
decision.

171. Allocation of Resources
 Several approaches to consider…
All patients could receive the same amount of
attention.
Patients could receive resources based on
need.
Patients could receive what someone has
determined they’ve earned.
 Triage is a common field activity
that demonstrates one method of
allocating scarce resources.

172. Obligation to Provide Care
 A paramedic…
Has a responsibility to help others.
Is obligated to provide care
without regard to the ability to
pay or other criteria.
Has a strong ethical obligation to
help others even while off-duty.

173. Teaching
 Two possible ethical questions are
raised when a student is caring for
patients:
Whether or not patients should be
informed that a student is working on them
How many attempts a student should be
allowed to have in performing an
intervention.

174. To avoid problems…
 Clearly identify students as such.
 The preceptor should, when
appropriate, inform the patient of the
student’s presence and obtain the
patient’s consent.
 Take the student’s experience and
skill level into account and have a
pre-determined limit identified for the
number of attempts at a procedure.

175. Professional
Relations
 A paramedic answers to the
patient, the physician medical
director, and to his employer.
 Sometimes conflict arises
out of such relationships.
 Know your policies…and
communicate.

176. Research
 EMS research is only in its infancy
but is essential to the advancement
of EMS.
 Strict rules and guidelines must be
followed when conducting patient
care-related studies.
 Gaining the patient’s consent is
paramount.

177. Summary
 Ethics
 Morals
 Law
 Advance Directives

178. Medical/Legal
Aspects of Advanced
Prehospital Care

179. Topics
 Legal Duties and Ethical Responsibilities.
 The Legal System.
 Laws Affecting EMS and the AEMT.
 Legal Accountability of the AEMT.
 AEMT-Patient Relationships.
 Resuscitation Issues.
 Crime and Accident Scenes.
 Documentation.

180. Best Protection
 Your best protection from
liability is to perform systematic
assessments, provide
appropriate medical care, and
maintain accurate and complete
documentation.

181. Legal Duties and Ethical
Responsibilities (1 of 2)
 Promptly respond to the needs of
every patient.
 Treat all patients and their families
with respect.
 Maintain your skills and medical
knowledge.
 Participate in continuing education.

182. Legal Duties and Ethical
Responsibilities (2 of 2)
 Critically review your performance,
and constantly seek improvement.
 Report honestly and with respect for
patient confidentiality.
 Work cooperatively and with respect
for other emergency professionals.

183. Each EMS response has the
potential of involving EMS
personnel in the legal system.

184. Sources of Law (1 of 2)
 Constitutional—based on the
U.S. Constitution.
 Common—also called case law
derived from society’s
acceptance of customs and norms.

185. Sources of Law (2 of 2)
 Legislative—created by law-making
bodies such as
Congress and state assemblies.
 Administrative—enacted by
governmental agencies at either
federal or state levels.

186. Categories of Law
(1 of 3)
 Criminal—division of the
legal
system that deals with
wrongs
committed against society or
its members.

187. Categories of Law
(2 of 3)
 Civil—division of the legal
system that deals with non-criminal
issues and conflicts
between two or more parties.

188. Categories of Law
(3 of 3)
 Tort—a civil wrong
committed
by one individual against
another.

189. Components of a Civil
Lawsuit
 Incident
 Investigation
 Filing of
complaint
 Answering
complaint
 Discovery
 Trial
 Decision
 Appeal
 Settlement

190. Laws Affecting
EMS and the
AEMT

191. Scope of Practice
 Range of duties and skills
AEMTs are allowed and
expected to perform.

192. You may function as
a AEMT only under the direct
supervision of a licensed
physician through a delegation
of authority.

193. Possessing and administering controlled
substances
 Public Health Law Article 30
 Public Health Law Article 33
 State EMS Code Part 800
 New York State Rules and
Regulations Part 80
 NYS-EMS Policy Statements

194. Licensure and
Certification
 Certification refers to the
recognition granted to an individual
who has met predetermined
qualifications to participate in a
certain activity.
 Licensure is a process used to
regulate occupations generally
granted by a governmental body to
engage in a profession or
occupation.

195. Motor Vehicle Laws
 New York State Vehicle and
Traffic Law
§ 114-b Emergency Operations
§ 101 Definition of Authorized
Emergency Vehicles
§ 1104 Privileges and Responsibilities of
Authorized Emergency Vehicles

196. Motor Vehicle Laws
 Driver is not relieved from the duty to
drive with Due Regard for the
 safety of all persons
 Driver is not protected from the
consequences of his/her reckless
 disregard for the safety of other
 NYS-EMS Policy Statement on use of
lights and siren

197. Mandatory Reporting
Requirements
 Spouse abuse
 Child abuse and neglect
 Elder abuse
 Sexual assault
 Gunshot and stab wounds
 Animal bites
 Communicable diseases

198. Abuse and Neglect
 Abuse is improper or excessive
action so as to cause harm
 Neglect is giving insufficient
attention or respect to someone
who has a claim to that attention

199. Signs and Symptoms of
Abuse
 Multiple bruises in various stages of healing
 Injury inconsistent with the mechanism
described
 Repeated calls to the same address
 Fresh burns
 Parent or guardian seem inappropriately
unconcerned
 Conflicting stories
 Fear on the part of the patient to discuss how
the injury occured

200. Signs and Symptoms of
Neglect
 Lack of adult supervision
 Malnourished appearing child
 Unsafe living environment
 Untreated chronic illness (for
example an asthmatic with no
medications

201. Domestic Violence
Definition – a pattern of coercive
behavior of one individual by
another in order to establish and
maintain power and control

202. Forms of abuse
either by Commission or Omission
 Physical
 Emotional
 Psychological
 Environmental
 Sexual
 Economic

203. Physical Abuse
Inflicting or attempting to inflict
physical pain and withholding
access to medication and medical
care

204. Emotional Abuse
constant criticism, bellitling
someone’s abilities and competency,
name-calling and other attempts to
undermine someone’s self-image
and sense of worth

205. Psychological Abuse
controlling access to friends,
family, school or work; forced
isolation, intimidation, threats and
blackmail

206. Environmental Abuse
withholding appropriate climate
control, lighting, or clothing for the
environmental conditions

207. Sexual Abuse
any exploitive or coercive, non-consensual
sexual contact including
marital, and aquaintance rape;
attacks on the sexual parts of the
body and treating someone in a
sexually derogatory manner.

208. Economic Abuse
attempts to make a person
completely dependant on the abuser
for money and economic survival

209. Phases of Abuse
Phase 1 - arguing and verbal abuse
Phase 2 - physical and sexual abuse
Phase 3 - Honeymoon; denial and
apologies
Intervention is best accomplished in
phase 1 and 2. Cycle repeats without
intervention, increasing in frequency and
severity

210. Relationships which may lead to
Domestic Violence
 Child
 Spousal
 Elders (parents and others)
 Siblings
 Living companion
 Dating Partners
 Health care provider or attendant

211. Role of EMS Provider
 Assess and treat the patient
 Report observation to hospital staff
and police officers
Conditions at scene
Reactions of patient
Reactions of household member

212. Conditions at the
Scene  Environment
 Temperature and light
 Foul odors
 isolation

213. Reactions of patient
 Hesitant when questioned
 Fearful of those present
 Hygiene/clothing/cleanliness

214. Reactions of household
member
 Angry
 Indifferent
 Refusing necessary assistance
 Obstructing and questioning care

215. Information Gathering
 Out of hearing and sight of the possible
abuser
 Stress confidentiality
 Does the patient feel safe
At the scene
In the ambulance
 Be direct; non-threatening and
empathetic
 Listen to what children have to say

216. Information Gathering
 Conflicting accounts of the
incident
 Physical findings
 History of calls to the same
location or patient
 History, circumstances, setting,
condition or environment
inconsistent with injury or illness

217. Physical Findings
 Old bruises
 Sores and ulcers
 Topical infections – neglected injuries
 Injuries in uncommon places
Back of legs
Soles of feet
 Patterned injuries – hand, belt buckle or
other imprints
 Thermal injuries – burns and cold

218. The severity of an injury is not
necessarily a good indicator of the
severity of the situation

219. Documentation
 Be factual and specific – not
judgmental
 Include
Patient condition
Conditions found at the scene
Interaction with those at the scene
History
Patient states “…”
“reported to …”

220. Other Issues
 Provider safety
 Maintain a professional attitude
 Consider emotions of the provider
Consider Critical Incident Stress
Management

221. KEY POINT
Do not accuse in
the field.
Accusation and
confrontation
delays
transportation

222. www.nysmandatedreporter.
org

223. Legal Protection for the AEMT
 Immunity—exemption from liability
granted to governmental agencies.
 Good Samaritan Laws—provide immunity
to certain people who assist at the scene
of a medical emergency.
 Ryan White CARE Act—requires
notification and assistance to AEMTs
who have been exposed to certain
diseases.
 Local laws and regulations.

224. Local laws and regulations.
 Assault in the second degree (Penal
Law, § 120.05 and120.08); Assault of an
EMT-Critical Care Technician while
performing duties
 Obstructing governmental
administration in the second degree
(Penal Law § 195.05); Obstruction of EMT-Critical
Care Technician in the
performance of his/her duty

225. Legal Accountability
of the AEMT

226. Negligence
 Deviation from accepted
standards of care recognized by
law for the protection of others
against the unreasonable risk of
harm.

227. Always exercise the degree
of care, skill, and judgment
expected under like
circumstances by a similarly
trained, reasonable AEMT in
the same community.

228. Components of a
Negligence Claim
 Duty to act.
 Breach of duty.
 Actual damages.
 Proximate cause.

229. Duty to Act
 …is a formal contractual or
informal legal obligation to
provide care.

230. Duties Include
 Duty to respond and render care
 Duty to obey laws and regulations
 Duty to operate emergency vehicle reasonably
and prudently
 Duty to provide care and transportation to the
expected standard
 Duty to provide care and transportation consistent
with the scope of practice and local medical
protocols
 Duty to continue care and transportation through
to its appropriate conclusion

231. Breach of Duty
 …is an action or inaction that
violates the standard of care
expected from a AEMT.

232. Standard of Care
 Standard of care is established by court
testimony and reference to published
codes, standards, criteria and
guidelines applicable to the situation
Public Health Law Article 30
State EMS Code (Part 800)
Standardized Curriculum
Regional Protocols

233. Breaches of Duty
 Malfeasance—performance of a
wrongful or unlawful act by a
AEMT.
 Misfeasance—performance of a legal
act in a harmful or injurious manner.
 Nonfeasance—failure to perform a
required act or duty.

234. In some cases, negligence may be
so obvious that it does not require
extensive proof
Res ipsa loquitur - the injury could only have
been caused by negligence
Negligence per se - negligence is shown by the
fact that a statute was violated and injury
resulted

235. Actual Damages
 …refers to compensable
physical, psychological, or
financial harm.

236. An action or inaction
that immediately caused
or worsened the damage is
called proximate cause.

237. Defenses to negligence
 Good Samaritan laws
Do not generally protect providers from acts of
gross negligence, reckless disregard, or willful
or wanton conduct
Do not generally prohibit the filing of a lawsuit
May provide coverage for paid or volunteer
providers
Varies from state to state

238. Defenses to negligence
 Governmental immunity
Trend is toward limiting protection
May only protect governmental agency, not
provider
Varies from state to state

239. Defenses to negligence
 Statute of limitations
Limit the number of years after an incident
during which a lawsuit can be filed
Set by law and may differ for cases involving
adults and children
Varies from state to state

240. Defenses to negligence
Contributory negligence
Plaintiff may be found to have contributed to
his or her own injury
Damages awarded may be reduced or
eliminated based on the plaintiff's contribution
to his or her injury

241. Special Liability
Concerns

242. Medical Direction (1 of
2)
 A AEMT’s medical director and
on-line physician may be sued if:
 Medically incorrect orders were
given to the AEMT;
 There was a refusal to authorize the
administration of a necessary
medication;

243. Medical Direction (2 of
2)
 A AEMT’s medical director and on-line
physician may be sued if:
 The AEMT was directed to take
the patient to an inappropriate
facility;
 Negligent supervision of a
AEMT is proven.

244. Borrowed Servant
Doctrine
 While supervising an EMT-I or
EMT-B, a AEMT may be liable
for any negligent act that
person commits.

245. Civil Rights
 If medical care is withheld due to any discriminatory reason, a AEMT may be sued.
Examples:
 Race
 Creed
 Color
 Gender
 National origin
 Ability to pay (in some cases)

246. Off-Duty AEMTs
 Performing procedures that
require delegation from a
physician while off-duty may
constitute practicing medicine
without a license.

247. AEMT-Patient
Relationships

248. Legal Principles (1 of 5)
 Confidentiality is the principle
of law that prohibits the release
of medical or other personal
information about a patient
without the patient’s consent.

249. Legal Principles (2 of 5)
 Defamation is an intentional
false communication that
injures another person’s
reputation or good name.

250. Legal Principles (3 of 5)
 Libel is the act of injuring a
person’s character, name, or
reputation by false statements
made in writing or through the
mass media with malicious
intent or reckless disregard for
the falsity of those statements.

251. Legal Principles (4 of 5)
 Slander is the act of injuring a
person’s character, name, or
reputation by false or malicious
statements spoken with
malicious intent or reckless
disregard for the falsity of those
statements.

252. Legal Principles (5 of 5)
 A AEMT may be accused of
invasion of privacy for the release
of confidential information, without
legal justification, regarding a
patient’s private life, which might
reasonably expose the patient to
ridicule, notoriety, or
embarrassment.

253. The fact that the information
released is true is not a
defense to an action for
invasion of privacy.

254. Consent
 The granting of permission to
treat a patient.
 You must have consent before
treating a patient.
 Patient must be competent to
give or withhold consent.

255. Informed Consent
 Consent based on full disclosure of the
nature, risks, and benefits of a procedure.
 Must be obtained from every competent
adult before treatment may be initiated.
 In most states a patient must be 18 years
of age or older to give or withhold
consent.
 In general, a parent or guardian must give
consent for children.

256. Expressed Consent
 Verbal, non-verbal, or written
communication by a patient who
wishes to receive treatment.
 The act of calling for EMS is
generally considered an expression
of the desire to receive treatment.
 You must obtain consent for each
treatment provided.

257. Implied Consent
 Consent for treatment that is
presumed for a patient who is
mentally, physically, or emotionally
unable to give consent.
 It is assumed that a patient would
want life-saving treatment if able to
give consent.
 Also called emergency doctrine.

258. Involuntary Consent
 Consent for treatment granted by a
court order.
 Most commonly encountered with
patients who must be held for mental-health
evaluation or as directed by law
enforcement personnel who have the
patient under arrest.
 May be used on patients whose
disease threatens a community at
large.

259. Special Consent Situations (1 of
2)
 Minors
Usually a person under 18 years of age.
Consent must be obtained from a parent
or legal guardian.
 Mentally incompetent adult
Consent must be obtained from the legal
guardian.

260. Special Consent Situations (2 of
2)
 For Minors & Mentally
incompetent adults…
If a parent or legal guardian cannot be
found, treatment may be rendered under
the doctrine of implied consent.

261. Emancipated Minors
 Person under 18 years of age who is:
Married
Pregnant
A parent
A member of the armed forces
Financially independent living away from home
Emancipated minors may give
informed consent.

262. Withdrawal of Consent
 A patient may withdraw consent
for treatment at any time, but it
must be an informed refusal of
treatment.

263. An example of a
“release-from-liability form.”

264. Refusal of Service
 Not every EMS run results in
the transportation of the patient
to the hospital.
 Emergency care must always
be offered to the patient, no
matter how minor the injury or
illness.

265. If a Patient Refuses
(1 of 4)
 Is the patient legally permitted
to refuse care?
 Make multiple, sincere attempts
to convince the patient to
accept care.

266. If a Patient Refuses
(2 of 4)
 Make sure the patient is
informed in his or her decision.
 Consult with on-line medical
direction.

267. If a Patient Refuses
(3 of 4)
 Have the patient and a
disinterested witness sign a
release-from-liability form.
 Advise the patient he or she
may call again for help.

268. If a Patient Refuses
(4 of 4)
 Attempt to get someone to stay
with the patient.
 Document the entire situation
thoroughly.

269. Some EMS systems have checklists for
procedures to follow when a patient refuses
care.

270. Legal Complications
Related to Consent

271. Legal Complications
Related to Consent (1 of 4)
 Abandonment is the termination
of the AEMT-patient
relationship without assurance
that an equal or greater level of
care will continue.

272. Legal Complications
Related to Consent (2 of 4)
 Assault is an act of unlawfully
placing a person in apprehension
of immediate bodily harm without
his or her consent.
 Battery is the unlawful touching
of another person without his or
her consent.

273. Legal Complications
Related to Consent (3 of 4)
 False imprisonment is the
intentional and unjustifiable
detention of a person without
his or her consent or other legal
authority.

274. Legal Complications Related
to Consent (4 of 4)
 Reasonable force is the minimal
amount of force necessary to
ensure that an unruly or violent
person does not cause injury to
himself, herself, or others.
Involve law enforcement, if
possible.

275. Patient Transportation
 Maintain the same level of care
as was initiated at the scene.
 Know the closest, most
appropriate facility.
 Respect the patient’s choice of
facility without putting patient
care in jeopardy.

276. Resuscitation Issues

277. Advance Directives
 A document created to ensure
that certain treatment choices
are honored when a patient is
unconscious or otherwise
unable to express his or her
choice of treatment.

278. A Living
Will allows
a person to
specify
what kinds
of medical
treatment
he or she
should
receive.
Fig. 6-4

279. Do Not
Resuscitate
Order (DNR)
indicates which,
if any, life-sustaining
measures should
be taken when
the patient’s
heart and
respiratory
functions have
ceased.

280. Some
systems
have
developed
protocols
that address
organ
viability after
a patient’s
death.

281. A death in the field must be
appropriately dealt with and
documented by following
local protocol.

282. Crime and Accident
Scenes
(1 of 3)
 If you believe a crime has been
committed, involve law
enforcement.
 Protect yourself and other EMS
personnel.

283. Crime and Accident
Scenes
(2 of 3)
 Initiate patient care only when
the scene is safe.

284. Crime and Accident
Scenes (3 of 3)
 Preserve the scene as much as
possible:
Observe and document anything moved;
Leave gunshot or stabbing holes intact if
possible;
If something must be moved, notify
investigating officers and document your
actions.

285. Documentation
 Complete promptly after patient
contact.
 Be thorough.
 Be objective.
 Be accurate.
 Maintain patient confidentiality.
 Never alter a patient care record.

286. Summary
 Legal duties and ethical responsibilities.
 The legal system.
 Laws affecting EMS and the AEMT.
 Legal accountability of the AEMT.
 AEMT-patient relationships.
 Resuscitation issues.
 Crime and accident scenes.
 Documentation.