EMT-B: Preparatory
Module 1 Review

Sign In to Your Account
Create an Account

• Print This Course
• Preview / Take the Test
• Look for Other Courses
• Help / FAQs

By Sean Hannon, BS, EMT-P

Joyce Boghosian, MS, RRT, Perinatal/Pediatric Specialist

LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

• Explain the role and responsibilities of the EMS medical director
• Describe the use of body substance isolation (BSI) gear for protecting self, patient, and fellow workers
• Identify the steps to approaching a hazardous material situation
• Describe proper techniques for lifting and moving a patient
• Discuss the types, causes, and treatment of stress encountered by EMTs
• Compare the types of patient consent for treatment, including patient refusal and Do Not Resuscitate orders
• Describe the management and assessment of suspected abuse or neglect patients

The field of prehospital emergency medical care is an evolving profession in which the reality of life and death is confronted at a moment’s notice. EMT-Basics work side by side with other healthcare professionals to help deliver professional prehospital care. This course will help the EMT-Basic refresh previously learned material while gaining new knowledge, skills, and attitudes necessary to be a competent, productive, and valuable member of the emergency medical services (EMS) team.

MEDICAL DIRECTION

Each state sets up its own emergency medical services (EMS) system. These systems are based on standards recommended by the National Highway Traffic Safety Administration (NHTSA). Some of these standards concern medical direction, or the process by which physicians oversee patient care. Under this system, the physician determines the proper medical response in a given emergency and delegates that action under standard medical orders (SMOs) to EMTs, paramedics, and other emergency medical personnel.

Laws and regulations covering medical direction vary from state to state, but all states mandate medical direction for EMS personnel.

Oversight of Care

The medical director is specifically responsible for the clinical oversight of care provided by EMS personnel. The director is also responsible for providing updated continuing education and training in response to the needs of the EMS personnel and the community served.

The care you provide to your patients is an extension of the medical director’s authority. It includes the following:

• On-line direction: Every ambulance, public or private, must have radio or telephone communication that enables the physician or other medical personnel to provide you with instruction or guidance as you care for your patients in medical emergencies.
• Off-line direction: The medical director may delegate this responsibility to a nurse or physician located at the receiving hospital or other site. Such direction and guidance may also come in the form of protocols or standing orders.
• The medical director or his or her designate can also assist you with patient refusal of treatment (see also “Refusal of Care” below), either on-line or off-line.

Personal Safety

Ensuring your personal safety and protection is another responsibility of medical direction. You will read over and over again about the priority given to your safety and protection and that of all other emergency medical personnel. This is not only because the system values your safety and well-being but because it recognizes that you will be unable to provide for your patients’ needs unless your own safety is secured. Further, it is important that others in the public safety system be available to perform their roles and not be diverted or endangered by the need to come to your rescue.

Protecting your own safety includes wearing protective clothing, using safe practices (such as seat belts), and taking care on the road and in your vehicle. It also requires that you follow appropriate direction from police, fire, and utility company personnel.

Quality Improvement

The medical director is responsible for providing the public with the highest quality of prehospital emergency care. Toward that end, the medical director requires documentation and audits. This enables the director to measure the success of the EMS system and plan for improvements where needed.

The medical director creates a system in which each call is documented. The data collected allows for careful review of equipment, protocols and procedures, and personnel infractions. In this way, the EMS system can remedy problems by revising protocols or procedures, reviewing EMS personnel infractions, and providing remedial testing or training. The data can also be useful for research purposes and for determining the need for particular continuing education programs.

BODY SUBSTANCE ISOLATION (BSI)

You must first protect yourself in a hazardous situation so that you can protect your fellow responders and the public. This is often a difficult concept for individuals who are accustomed to putting others first. However, there is no possibility of helping others if you yourself are overcome by a hazard.

Sean and Jen began their shift, as they do every workday, with an equipment inventory. The body substance isolation (BSI) standard requires that proper equipment be utilized:

1. When responding to any incident, and
2. Before patient contact is made.

Not all states follow OSHA regulations for body substance isolation. Follow your state and local regulations and your agency protocols. Always follow Universal Precautions.

When they arrived at the patients’ residence, Sean and Jen were already wearing protective gloves. They carried a quick-response bag containing BSI supplies and an oxygen D-tank. After the initial assessment, Sean and Jen quickly donned the appropriate additional BSI gear. Although BSI gear does not provide sufficient protection in a Hazmat situation, the incident reminded them of the reason its use is required of all care providers.

Gloves

Jen and Sean are both wearing their gloves as they initiate patient care. Gloves are required when there is a possibility that you might come in contact with blood or bodily fluids. They can be made of vinyl or latex. (Be aware that some people have sensitivities or are allergic to latex.)

Removing soiled gloves.
Step 1: Grasp the outside edge of the glove near the wrist; peel it away from the hand, turning the glove inside out; hold the glove in the opposite gloved hand.
Step 2: Slide the ungloved finger under the wrist of the remaining glove; peel it off from the inside, creating a bag for both gloves; discard the gloves. (Source: CDC, 2004.)

When the glove on Jen’s right hand tore while she was administering care to the patients, she removed it, disinfected her hands, and replaced the torn glove with a new one. If a glove tears while you are administering patient care, immediately (or as soon as it is safe to do so) remove it following agency guidelines, disinfect your hands, and replace the torn glove with a new glove.

Sean and Jen discard their gloves after completion of patient contact and put on a new pair when they prepare to see their next patients. They are careful to prevent the exposed gloves from touching anything and to dispose of the gloves safely. Never reuse gloves. Gloves are to be changed each time you see a new patient.

Upon completion of patient contact, remove your gloves and wash or disinfect your hands. This is extremely important in preventing the spread of infection. When in the process of treating a patient and it is necessary to change your gloves, use a liquid disinfecting agent that requires no water. After transferring your patient to hospital personnel, remove your gloves and scrub your hands vigorously, making sure to wash with soap and thoroughly dry your hands, wrists, and forearms.

Utility gloves may be used only for cleaning vehicles and equipment.

Eye Protection

Eye protection must be worn in highly contaminated situations. Upon arrival at the scene, the crews of Ambulances 5 and 30 joined Sean and Jen in using various methods to protect their eyes from splashing blood or other bodily fluids. Jen, who wears prescription glasses, attached removable side shields to them. Sean put on form-fitting goggles; although they are not required, they afford extra protection.

Masks

During their initial assessment, Jen and Sean considered the possibility that their patients might have an airborne infectious disease, so they put on masks. They also placed masks on their patients. If you suspect that the patient may have an airborne infectious disease, including tuberculosis, wear a high-efficiency particulate air (HEPA) or N-95 respirator. First, place one on yourself; then, place one on your patient. If weather permits, open the windows to ventilate the ambulance while transporting patients who may have airborne infections.

To don: First, select a fit-tested respirator. Place it over the nose, mouth, and chin; fit the flexible nose piece over the bridge of the nose; secure the elastic around the head; adjust to fit; perform a fit check by inhaling (respirator should collapse) and exhaling (check for leakage around the face).
To remove: First, lift the bottom elastic over your head; then, lift off the top elastic; finally, discard. (Source: CDC, 2004.)

Jen and Sean put on surgical-type (disposable) face masks for protection from blood or other bodily fluids that could come into contact with their nose or mouth. Care providers’ masks and patients’ disposable masks are discarded upon completion of patient contact. Dispose of masks in bags labeled with the biohazard symbol.

Donning a disposable mask. Place the mask over nose, mouth, and chin; fit the flexible nose-piece over the bridge of the nose; secure the mask to the head with ties or elastic; adjust to fit. (Source: CDC, 2004.)

Gowns

Gowns are available for additional protection of EMS personnel in highly contaminated situations. Gowns are worn where there may be bodily fluid exposure such as might be encountered in childbirth or major trauma scenes. Gowns are removed and disposed of upon completion of patient contact. Disposable gowns are preferred, and they are never reused.

Even where you wear a gown, it is still possible that bodily fluids will contaminate your uniform. It is recommended to carry a second uniform in case of such a situation.

Notification and Testing of an Exposure

When Jen removed her torn glove during the course of patient care, she noticed blood on her hand. Jen immediately cleansed her hand with a liquid disinfecting agent. After Jen and Sean transferred their patients to hospital personnel, they remained at the hospital, where Jen was promptly treated for this exposure.

Jen notified her supervisor and prepared formal written documentation of the exposure for her department and for the hospital. She delivered a copy of the formal notification to her department. If you are exposed, document the exposure, notify your supervisor and the hospital, and promptly obtain the appropriate treatment and tests in the local hospital. It is advisable to keep a copy of all documentation for your personal records.

SCENE ASSESSMENT AND SAFETY PRECAUTIONS

Upon arriving on the scene, your instinct may be to make a quick response. Instead, you must utilize self-control in order to correctly identify and reduce potentially life-threatening situations. Use extreme caution when approaching any situation involving the following dangers:

• Electricity
• Fire
• Explosion
• Motor vehicle accidents
• Hazardous materials incidents

Always be prepared to identify hazards when arriving on the scene.When possible, use binoculars to do so from a distance.

Call for specialized assistance from the utility company, the fire department, police, hazardous materials team, or other appropriate agencies to assist in dangerous situations.

Hazardous Materials

Always approach a potential hazardous materials incident from upwind. Become familiar with the system of identifying hazardous materials. In your emergency vehicle, carry a current copy of the Emergency Response Guidebook, which is published by the United States Department of Transportation.

Hazardous materials incidents are controlled by specialized teams. Hazardous materials (Hazmat) teams should be called to the scene whenever you suspect such material may be present. The Hazmat team will bring the patient(s) to the EMTs after they have been decontaminated. Only then do the EMTs provide patient care. Under no circumstances should the EMT go into the hazard area (or “hot zone”), even after the patient has been decontaminated.

Be aware that low levels of carbon monoxide (CO) poisoning can be confused with flu symptoms, food poisoning, and even depression. High levels of carbon monoxide can cause death within a few minutes of inhalation. It is strongly recommended that all ambulances be equipped with handheld carbon monoxide detectors that attach to the hand with a finger probe.

Emergency medical personnel are well served to locate a hazardous materials awareness class in their area. Such a class will alert the EMT to common precautions, including the necessity of having binoculars available in the ambulance, carrying an emergency response guidebook (for first responders during the initial phase of a dangerous goods/hazardous materials incident), as well as stocking other useful equipment. Such training is generally available in continuing education programs to all levels of emergency medical care providers.

Violence

A violent or potentially violent scene should be controlled by law enforcement before the EMT provides patient care. Perpetrators of the crime may still be on the scene. Bystanders and family members who are agitated, angry, or upset may intentionally or unintentionally interfere with patient care. Use extreme caution.

Domestic disturbances are potentially the most dangerous for the EMT or other care provider. You may not be aware until your arrival that you have been called to a scene of domestic violence. Such situations are characterized by irrational and unpredictable behaviors that can readily turn violent. Police presence is a necessary component for ensuring the safety of the care provider and the patient. Be prepared to retreat if you are faced with imminent danger or a threat to your personal safety.

LIFTING AND MOVING PATIENTS

In the course of patient care, you will be required to lift, carry, reach, push, and pull. The circumstances will often be less than ideal. In responding to a call, you may find yourself in countless circumstances that will require you to use your physical strength, power, stability, and flexibility to serve the needs of your patient as well as the other rescuers. Examples include:

• Dwellings with multiple stories without elevators or with elevators that are out of service
• Stairways that are steep, poorly lit, and not well maintained
• Slick surfaces and inclement weather
• Obese or otherwise-compromised patients

It is essential that you keep your body fit, paying special attention to maintaining strength in your core muscles. This will enable you to avoid some injuries and will limit the severity of injuries that do occur. It is also important to call for additional resources or backup and to share the load; these are important methods of avoiding or limiting the risk of injury to you and your patient.

Learn and practice the principles of good body mechanics. Keeping fit and using proper techniques for lifting, carrying, reaching, pulling, pushing, and all other functional movements will significantly reduce your risk of on-the-job injuries. Review the general guidelines that follow with your own individual strengths and weaknesses in mind.

Consult your doctor before beginning any strenuous training program. Work with a fitness trainer or physical therapist who will understand the physical demands of your job. The trainer or therapist can direct your training based on an evaluation of your strength, cardio-endurance, and flexibility. These professionals are trained to assess any past injuries as well as your genetic predispositions.

Lifting Techniques

It is important to know the limits of your own physical strength as well as those of your partner. Don’t proceed with lifting until you have assessed a patient’s weight and determined whether additional human resources or equipment are needed. When you do use additional rescuers, try to achieve balance with them as you lift the patient.

• Use your core muscles (quadriceps, hamstrings, gluteus, and abdominal muscles) to assist you when moving a heavy person or object.
• Tighten your abdominal and other core muscles when lifting.
• Exhale when you lift.
• Limit the stress on your lower back by keeping the weight of the object or person as close to your body as possible.
• Avoid twisting your body when possible.
• Tell your patient not to shift their weight.
• Give the patient something to hold, or ask the patient to place both hands on straps, to prevent the patient from reaching out toward you and putting you both off balance.
• Use stretchers or stair chairs as a conveying device when moving the patient.

Take the time to learn the proper form for the power-lift, or squat-lift, technique. If you feel that it may be necessary to utilize lifting maneuvers, strongly consider calling for additional aid.

In the power-lift position, your feet are a comfortable distance (shoulder-width) apart. Tighten your core muscles and lock your back in a position with a slight inward curve. Straddle the object. Bend your knees slightly. Distribute the weight to the balls of your feet. Stand, while keeping the back locked.

Use a power grip to get maximum strength from your hands. The palm and fingers should come into complete contact with the person or object being lifted, and all fingers should be bent at the same angle. Hands should be shoulder-width apart.

When lowering a cot or stretcher, reverse the power steps. Always avoid bending at the waist.

Carrying

Again, it is important to learn proper body mechanics and to maintain your fitness, strength, stability, and flexibility to avoid or limit the risk of injury. Whenever possible, transport patients on devices that can be rolled. Guidelines for carrying include:

• Assess the patient’s weight before lifting.
• Know the limitations of the crew’s abilities.
• Work in a coordinated manner and communicate with partners.
• Keep the weight as close to the body as possible.
• Refrain from twisting when possible.
• Do not bend at the waist; bend slightly at the knees.
• Do not hyperextend the back (do not lean back from the waist).

Reaching

As in the case of the other functional movements, maintain fitness and practice proper body mechanics. Guidelines for reaching include:

• Reposition the object or person so it is closer to you.
• Keep core muscles tight and knees slightly bent.
• When reaching overhead, avoid a hyperextended position.
• Avoid twisting the back while reaching.
• Avoid reaching more than 15 to 20 inches in front of the body.
• Call in additional help to avoid situations where prolonged (more than a minute) strenuous effort is needed.

Pushing and Pulling

Pushing and pulling guidelines include the following:

• Push, rather than pull, whenever possible.
• Keep core muscles tight and knees slightly bent.
• Keep weight close to the body.
• Push from the area between the waist and the shoulder.
• If weight is below waist level, use a kneeling position.
• Avoid pushing or pulling from an overhead position if possible.
• Keep elbows bent, with your arms close to your sides.

STRESS MANAGEMENT

EMS caregivers, as well as patients and bystanders, are subject to severe stress responses due to the many traumatic situations they may encounter on the job. Examples include:

• Death or injury of a co-worker or other public safety personnel
• Infant and child trauma
• Amputations
• Infant, child, elder, or spousal abuse
• Mass casualty events

Warning Signs of Stress

To manage stress, you must recognize the warning signs. They may apply to you or your partner. Warning signs include:

• Irritability or confrontational behavior toward patients, co-workers, family, and friends
• Inability to concentrate, mental exhaustion
• Difficulty sleeping or nightmares
• Anxiety
• Indecisiveness
• Guilt
• Loss of appetite
• Loss of interest in sexual activities
• Isolation and reduced self-esteem
• Loss of interest in work
• Increased cynicism about your job, yourself, and others

Some warning signs may also signal depression, which can include suicidal thoughts.

Actions to Manage Stress

Emergency personnel must recognize and acknowledge that stressful situations occur every day on the job. You must also understand that it takes time and attention to learn to adjust and cope with stress. Failure to allow yourself this time and opportunity can result in self-destructive behavior and a chronic inability to take care of yourself. This inability may be expressed in drinking excessively, smoking, gambling, and a host of other inappropriate coping mechanisms. It is essential that you become your own loving caretaker.

Actions that can enhance well-being include achieving a better balance between your work and personal life. Make sure to provide a space in your life for individual and personal activities, including recreation, health needs, hobbies, and other areas of interest.

Stress Among Family and Friends

Your family and friends may also suffer stress as a result of your job. Some of this may be due to the following:

• They may lack knowledge and understanding of the demands your job.
• They may be distressed by your long hours away from them and feel unimportant and ignored.
• They may fear of the dangers of your work.
• They may be frustrated by the inability to plan activities.
• They may be frustrated in their desire to support you if you find it difficult to talk about incidents that happened at work.

From a practical standpoint, it may be difficult to effect changes in your work environment that will address all the concerns of friends and family. If able to do so, you could:

• Request time off occasionally specifically for family and friends
• Request a rotation or duty assignment to a less busy area
• Take breaks during your shift for a workout or a brisk walk to reduce your own stress
• Encourage, and assist in providing, an atmosphere of support for your co-workers

Seeking Help

Often you will not have the freedom or flexibility to change your schedule or duty hours. Sometimes you may need to request a temporary medical leave. At other times, you may want to seek independent professional assistance in dealing with the extraordinary tensions connected to your work.

Establish a relationship with a trusted psychologist who can help you to gain self-knowledge so that you can anticipate periods of increased stress and avoid some of the destructive behaviors associated with the stress response. Such a relationship will then be available when unanticipated traumatic events occur. Doing this may also assist you in career advancement and educational choices.

EMPLOYEE ASSISTANCE

Your employer may have an employee assistance program or provide options for mental health services. Utilizing these services on a regular basis, in advance of severe stress reactions, can greatly benefit you, your family, your co-workers, and your patients.

Managers must be encouraged to provide maintenance programs to assist EMS personnel with stress management. An effective employee assistance program requires:

• Complete confidentiality
• Unconditional support from management
• Quality leadership from the mental health field (psychiatrists and psychologists)
• Development of the program to meet the growing and changing needs of EMS personnel
• Education and outreach programs that teach the techniques of self-care

CRITICAL INCIDENT STRESS DEBRIEFING

Critical incident stress debriefing (CISD) is a process in which a team of peer counselors and mental health professionals help EMS personnel to deal with the phases of stress that may occur because of a critical incident. A CISD includes:

• Pre-incident stress education
• One-on-one support (with psychologists trained in EMS-related stress)
• Disaster support services
• Diffusing emotions
• Follow-up services
• Spouse/family support
• Community outreach programs
• Other programs, such as a wellness program

A CISD includes any caregivers who were involved in an incident—for example, law enforcement, firefighters, and EMS or hospital emergency personnel. The meeting should occur as soon as possible following the event. Sometimes it may be delayed, however, and occur as late as 72 hours after the critical incident. The meeting proceeds through seven steps, which include:

• Reassurance of confidentiality (that nothing said will have an impact on job status)
• Review of the facts
• Exploration of the feelings of the participants about what happened
• Exploration of any physical, mental, or emotional symptoms of the participants
• Assistance of skilled professionals in looking closely at these feelings
• Assistance in overcoming the stress and planning for the participants’ return to the job
• Follow-up meeting several weeks later to review and resolve lingering issues

Ask your employer about—or otherwise make yourself aware of—the availability of CISD through your EMS system.

MEDICAL, ETHICAL, AND LEGAL ISSUES

Ethical Issues

In the above scenario, Jen and Sean may have conflicted feelings, caught between a desire to render aid to the offender and feelings of anger or disgust toward the offender. As an EMS care provider, you may experience ethical dilemmas about:

• The obligation to treat the offender when you are concerned about your own safety (i.e., the potential for violence to erupt from the bystanders)
• The possibility that you may have to protect the patient-offender
• The obligation to treat the offender when there are family members and bystanders who may also need care

The EMS care provider must be keenly aware of the impact of procedural details: placing a tarp over the vehicle to cover the deceased couple, towing the vehicle with the bodies still in it, preserving the crime scene tape, limiting photos, and other details.

You must decide how and where to treat the offender, which may include walking or carrying the offender to the ambulance in a highly charged environment of grief and violence. For example, you may have to drive the ambulance a few blocks to a safer location and treat the patient there. (Always notify the police of any relocation.)

Patient Consent

The above scenario illustrates some of the issues of patient consent and refusal of treatment. A patient has the right to accept or refuse medical treatment, but the matter of consent can be ambiguous and complicated.

EXPRESSED AND IMPLIED CONSENT

Expressed consent is required before any conscious, mentally competent adult may be treated. The patient must be of legal age, capable of making a rational decision, and fully informed of the procedure you will be performing and of all of the risks of that procedure. Then the patient may consent verbally or with an affirmative gesture such as a nod of the head.

Implied consent refers to the assumption that an unconscious or disoriented patient, were they able to make a rational decision, would consent to life-saving emergency intervention. If the patient is not conscious and rationale and there is no family member to consult, you may assume implied consent for treatment.

CHILDREN AND MENTALLY INCOMPETENT ADULTS

What if your patient is a child or a mentally incompetent adult? Consent for treatment of a child or mentally incompetent adult must be obtained from a parent or guardian unless:

• The child is emancipated according to state law. The term emancipated may include a child who is not of legal age but is married, pregnant, or already a parent; is a member of the armed forces; or is financially independent and living away from the parents’ home.
• A life-threatening situation exists and the parent or legal guardian is not available for consent. In those cases, implied consent may be assumed and emergency treatment rendered.

Keep in mind that when you transport a minor to the hospital, you must release the minor to the custody of the emergency department. Be certain to record the name of the ED staff member to whom you release the minor and keep thorough documentation of the transfer of custody as well as the incident.

Refusal of Care

A competent adult has the right to refuse treatment. Competence means that the adult is capable of making an informed decision. The refusal of care may be verbal or it may be indicated by the patient shaking the head or pushing or gesturing you away, or some similar action.

Just as in the case of consent, a patient who wishes to refuse treatment must be fully informed about the risks and benefits of the treatment as well as the risks and consequences of refusing the treatment. The patient may withdraw from treatment at any time. For example, an unconscious patient who regains consciousness may refuse further treatment and transport to the hospital.

A PATIENT’S DECISION-MAKING CAPACITY

In some areas, competency can only be established by the legal system. On the scene, you need to focus on the patient’s decision-making capacity. Any care provider can form a judgment about this. When you inform patients of your medical concerns and spell out the medical risks they may incur by refusing care, you are providing them with information on which they can base an informed decision.

It is important to ask patients why they want to refuse this care. Even if you don’t agree with a patient’s reason (“I can’t afford it” or “I have to pick up my kids from school”), when their response demonstrates a decision-making capacity and they voice an understanding of the risks involved, the patient is probably competent to refuse care. If their answer makes no sense (“Because it rained today” or “Because the voices told me to”), they are not demonstrating decision-making capacity are likely not competent to refuse care.

You may also seek the assistance of medical direction to determine whether treatment may be justified on the basis that the patient is not currently competent to refuse.

RELEASE FROM LIABILITY

The patient who refuses treatment must be presented with and asked to sign a “release from liability” form (sometimes referred to as an “against medical advice,” or AMA, form). The form states that the patient has been advised to accept medical treatment, informed of the consequences of not receiving the treatment, refuses to accept the treatment, and releases the city or ambulance service of liability for any consequences of the patient’s refusal. If the patient refuses to sign, you may ask a police officer or other family member to sign that they have witnessed the patient’s refusal.

It is tempting to think that having a patient sign an AMA form is the most convenient way to deal with difficult patients, but this is a dangerous trap. These patients are far more likely to suffer a bad outcome, and they or their relatives are more likely to seek legal investigation into the reason care was not provided.

To protect yourself from legal repercussions, it is important to thoroughly document your reasons for believing that the patient demonstrated decision-making capacity and to include the patient’s stated reason for refusal.

Confidentiality

Laws pertaining to confidentiality vary from state to state and may have been changed (and expanded) significantly in recent years. Best practice is to obtain updated information on the status of confidentiality constraints in your jurisdiction from your EMS system advisor or from a recognized continuing education program in your jurisdiction.

In general, your patient interview, assessment and findings, and treatment are all confidential information. You are not permitted to release confidential information unless you obtain a written release form signed by the patient, or, if the patient is an unemancipated child or a mentally incompetent adult, from the parent or guardian. A release may not be required when:

• Other healthcare providers need to know information to continue care
• State law requires reporting incidents such as rape, abuse, or gunshot wounds
• Third-party payment billing forms require the information
• A valid subpoena has been served

Do Not Resuscitate (DNR)

Do Not Resuscitate (DNR) orders arise most often in cases of terminally ill patients. A patient (or the family) may have an advance directive, or written instructions that have been prepared in advance, to document and clarify their refusal of resuscitative efforts. The written instructions may come in the form of a DNR order, a living will, or a healthcare proxy. Become familiar with the documents that may be used for this purpose in your jurisdiction. Be aware of the specific language they must contain in order to be effective.

The DNR order is in writing and signed by the physician. The physician’s instructions must be clear and unambiguous. In general, check for the required signatures and the effective and/or expiration dates.

Learn your EMS system protocols concerning DNR advance directives. Keep yourself knowledgeable about any updates of the protocols. If you have any doubt concerning the meaning or effectiveness of the order, begin resuscitation efforts and consult medical direction immediately. Remember, you must see the actual DNR order.

Also keep in mind that DNR does not mean “do not care.” Provide supportive care that decreases patient suffering. Explain hospice care and its availability to patients and their families.

Domestic Violence, Abuse, and Neglect

Physical abuse occurs when improper or excessive actions injure or cause harm. Neglect occurs when someone who has a claim to attention (such as a child or elder) receives inadequate attention or respect. Abuse of elders can be physical, mental, or emotional in nature. Both children and elders may be victims of abuse (physical, emotional, or sexual) or neglect. Domestic violence is the emotional or physical abuse of one household member by another.

The EMT-Basic must be aware of the most common signs of abuse and neglect. Be alert to the following:

• Multiple bruises, abrasions, lacerations, and broken bones in various stages of healing
• Defensive wounds, such as bruises on the back of the arms (especially seen in victims of domestic violence)
• Injury on both the front and back of the patient
• Injuries that are inconsistent with the description of what happened or conflicting stories of how the injuries occurred
• Unusual wounds, including cigarette and other burns
• A fearful patient
• Injuries to the genitals
• Injuries to the brain or spinal cord, such as may occur when an infant is violently shaken (shaken baby syndrome)
• Repeated calls to the same address
• Delay in reporting injuries
• Caregiver seems excessively concerned, guards the patient, and refuses to leave the patient’s side (typically in domestic abuse and violence situations)
• Lack of supervision by the caregiver
• Malnourished-appearing child
• Unsafe living environment
• Signs of violence in the house (broken plates, furniture)

Always request police assistance when you suspect abuse or neglect.

Be aware that scenes of possible abuse may arouse your emotions. Use self-restraint. Be objective and reserve judgment. Avoid acting in an accusatory or confrontational manner as this may escalate an already tense situation, putting you and the abuse victim at greater risk.

Make an accurate and detailed report of the injuries and the history as well as your findings concerning the home environment, the conduct of the caregivers, and the victim’s injury patterns and locations. Your documentation will assist the hospital physician in reaching the appropriate conclusions regarding the possible abuse.

SEPARATING VICTIMS FROM ABUSERS

Although it is nearly impossible to separate the victim from the abuser in the residence, it is important that you attempt to do so. If you are unable to separate them, interview patients when you are alone together in the ambulance.

Remember that patients may not view themselves as battered victims. Ask direct questions and avoid the words battered and abused (“Are you afraid of someone in your household?” “Has anyone hurt or threatened you?”). Do not name the suspected abuser (“Did your husband/wife do this to you?”), as this may cause the victim to feel the need to take sides.

Discourage the abuser from accompanying you and the victim in the ambulance during transport to the hospital. You might tell them:

• “There isn’t enough room in the ambulance.”
• “It may be more convenient to have your own vehicle at the hospital.”
• “Rules prohibit us from allowing family members to accompany the patient to the hospital.”
• “The law requires me to provide a safe environment for the patient.”

REPORTING REQUIRED BY STATE LAW

Make yourself aware of the laws in your jurisdiction concerning who is required to report suspected abuse or neglect. Keep yourself updated on the procedures and protocols of your EMS system about reporting requirements when abuse or neglect is suspected. Make sure that you understand how your EMS system approaches the requirements of confidentiality and balances them with the legal reporting requirements in cases of suspected abuse or neglect.

CONCLUSION

Understanding the basics of patient assessment and care in the field is imperative for safe practice. Appreciating the legal aspects of scene assessment prevents the EMT from liability and risk of injury. Understanding this material will allow you to be a competent, productive, and valuable member of the EMS team.