Condell Medical Center EMS System Continuing Education August, 2004

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Condell Medical Center EMS System Continuing
EducationAugust, 2004

• System Operating Guidelines
• Review of Patient Care
• Case Studies

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System Operating Guidelines

• Administrative Policy 7
• Request for Clarification
• available to any System participant
• used to request an explanation of a specific
  situation
• deviation from SOPs
• questionable orders from medical control
• misunderstanding between provider and other party
• EMS Coordinator to investigate and share results
• Information protected (Medical Studies Act)

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SOG Review

• Administrative Policy 7
• Incident Report
• Used to report occurrence not consistent with
  routine practice or standard of care
• Used to report initiate investigation of an
  incident of serious nature
• Confidential document
• Completed by person involved or witnessing
  incident before leaving the hospital
• Routed to EMS Coordinator
• Coordinator to investigate report findings
• Appropriate action to be determined acted upon

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SOG Review

• Infield Policy 12
• Management of Emotionally Disturbed Pt/Behavioral
  Emergency
• If EMS is called to the scene and patient is
  requesting transport, transport completed to
  closest hospital honoring patient request when
  possible
• Competent emotionally disturbed persons have same
  rights of refusal as others
• Patient to be transported if they are harm to
  self or others or competency questionable

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Behavioral Emergencies Contd

• Petition for Involuntary Admission
• completed by person(s) witnessing behavior
• if petition not completed and exam in ED is
  normal, patient cannot be held
• petition may be completed by family if they are
  the only witness to the behavior
• the transporting authority acting in good faith
  and without negligence shall incur no liability,
  civil or criminal, due to the transport
• petitions available in the ED

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CISD/CISMCritical Incident Stress
Debriefing/Management

• Critical Incident
• a critical incident is any situation faced by
  emergency personnel that causes them to
  experience unusually strong emotional reactions
  which have the potential to interfere with their
  ability to function normally either at the scene
  or later

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CISD/CISM

• Purpose of CISD/CISM
• to accelerate normal recovery for normal people
  having normal reactions to abnormal events
• Goal of CISD/CISM
• provide methods to help emergency workers cope
  with stressful experiences, learn to build stress
  management behaviors while the emergency
  responder continues in their productive careers

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CISD/CISM

• When to call
• anytime emergency personnel have experienced an
  incident that causes an unusually strong
  emotional reaction. The closer to the time of
  the incident is preferred.
• Who can call
• anyone can initiate the call
• How to call
• 1-800-225-2473

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Case Review 1

• 79 year old male complains of feeling weak,
  lightheaded, and dizzy. He has vague complaints
  of chest pressure 7/10 with mild shortness of
  breath.
• Vital signs B/P 116/60 P - 120 R - 24
• Skin pale, cool, slightly moist
• Allergies sulfa drugs
• Meds Dyazide, Potassium, Lipitor
• What else would you assess and what care would
  you provide?

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Case Review 1

• Assess breath sounds - moist bilaterally
• Routine medical care O2, EKG (rhythm 12-lead),
  IV, pulse ox
• Monitor shows

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Case Review 1

• Monitor interpretation
• Sinus tachycardia (most likely due to
• response of heart to situation treat pts
• symptoms which should reduce the heart
  rate)
• Impression
• Acute coronary syndrome

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Case Review 1

• Interventions necessary
• ASA (aspirin) 324 mg chewed- inhibits
• platelet clumping
• NTG (nitroglycerin) 0.4mg every 5 min-
• vasodilator (reduces work load of
  heart)
• MS (morphine) 2 mg every 3 min- ?
• anxiety, vasodilator

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Case Review 1

• Understanding pathophysiology
• If patient is having an MI, heart could lose
  effectiveness of contractions (pale, cool, moist
  skin). Blood does not move forward effectively so
  backs up (moist breath sounds). Treatment for
  acute coronary syndrome (ACS) aimed at reducing
  workload of heart (NTG) and preventing further
  clot formation (ASA). Want to reduce stress
  level work load of patient their heart (MS).

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Case Review 2

• 82 year old female presents with complaint of
  feeling weak, tired, and has no energy. She
  feels like she will pass out when she stands up
  to walk.
• Assessment
• vitals B/P 98/56 P - 46 R - 18
• skin cool, dry
• allergies penicillin, adhesive tape
• meds ASA, lopressor, zantac, nitro
• Intervention Routine medical care,
  IV-O2-monitor-pulse ox

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Case Review 2

• Monitor shows

• Sinus Bradycardia

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Case Review 2

• Treatment intervention decision
• is the patient stable or unstable? (98/56, P -
  46, weak)
  
  

• Atropine 0.5 mg IV rapid (blocks vagal nerve
  ? rate of discharge at SA node ? degree of block
  at AV node) repeat in 2-5 minutes as needed
• 2nd dose if needed is Atropine 1 mg rapid IV
• 3rd dose if needed is Atropine 0.5 mg every 2-3
  min (max 3mg)
• To support B/P, Dopamine drip starting at 5
  mcg/kg/min (take pts weight in pounds, take 1st
  two numbers and subtract 2 to get drips per
  minute

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Case Review 3

• You arrive on the scene of a 28 year old
  conscious and alert male who appears agitated.
  You were called to the scene for threats of harm
  to self made by the patient. While you assessing
  the patient, he tells you that he has nothing to
  live for and wants to end it all. He agrees to
  transport. As you start to walk him to the
  ambulance, this patient now refuses transport.
• What do you do?

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Case Review 3

• Is there evidence that this patient is a threat
  to himself or others?
• Who witnessed the action or statement?
• How should this information be documented on the
  run report?
• Is there anywhere else this information needs to
  be documented?

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Case Review 3

• Is there evidence that this patient is a threat
  to himself or others?
• This patient made statements that he has nothing
  to live for and wants to end it all.
• Who witnessed the action or statement?
• Statements were heard by EMS crew

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Case Review 3

• How should this information be documented on the
  run report?
• Document objectively, put statements in quotation
  marks, fill in checkboxes
• Is there anywhere else this information needs to
  be documented?
• The witness to statements or actions must be the
  one to complete the Petition for Involuntary
  Admission - without the witnesses statement the
  patient cannot be held if exam is normal

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Case 4

• You have assessed your patient and found the
  following rhythm
• The patient is symptomatic and you have decided
  that medication is required because they are
  stable

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Case 4

• You have drawn up and delivered 1 mg of Atropine
  to the above patient
• The vital signs remain unchanged
• There is no response from the patient to the
  medication
• As you review your actions, what is your critique
  of the situation?

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Case 4

• The patient was deemed to be in supraventricular
  tachydardia (most likely atrial tachycardia)
• The patient was symptomatic and stable
• What drug would have been appropriate to give?

• Adenosine 6 mg rapid IVP followed immediately by
  a 20 ml saline flush
• Repeat dose after 1-2 minutes of 12 mg again
  rapid IVP with a 20 ml saline flush

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Case 4

• How would you handle this situation of a drug
  error?

• Report facts to medical control with a current
  status report of the patient
• Give face-to-face report to RN upon ED arrival
• Document facts on the patient care run report
• Upon arrival to the ED, complete an incident
  report, attach a copy of the completed run
  report, and route to the EMS coordinator in a
  confidential envelope

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• Questions?