Legal Implications Psychiatric considerations ebola

1. Legal Implications Psychiatric considerationsebola Mod IV 2014 ECRN CE Condell Medical Center EMS System Site Code #107200E-1214 Prepared by: Sharon Hopkins, RN, EMT-P, BSN

2. Objectives Upon successful completion of this module, the ECRN will be able to: 1. Define Munchausen by proxy syndrome, anorexia, bulimia 2. Describe situations when it is appropriate to obtain consent for medical care from emancipated minors versus pregnant minor versus minor parent 3. Describe characteristics and EMS interventions for a variety of behavioral emergencies. 4. Describe the difference between voluntary and involuntary committal and EMS responsibilities.

3. Objectives cont’d 5. Describe the assessment and field care of the patient that has been Tasered. 6. Describe the restraining of a patient via physical and chemical methods when in the field. 7. Review a variety of advanced directives. 8. Describe the State of Illinois revised POLST form and implications for EMS.

4. Objectives cont’d 9. Describe the implications of the Ebola virus and EMS care of the patient 10. Review the case scenarios presented. 11. Review selected Region X SOP’s included in the module. 12. Evaluate and review a variety of EKG rhythms and 12 lead EKG’s. 13. Successfully complete the post quiz with a score of 80% or better.

5. Scene Safety • First step in any patient approach • You do everything possible to make the environment safe • For yourself • For your team/peers • For other responding personnel • For the patient • For others around

6. Scene safety • Establish a safe perimeter • Evaluate the safety of the environment before entering • Call for help as necessary • EMS may need to stage which could delay patient contact • EMS to document any delays • The reason for staging • Interventions taken to make the environment safe • When you made patient contact • FYI -This information also applies to ED staff

7. Scene safety • Never let your guard down • Use those eyes in the back of your head • If it doesn’t feel right, do not enter an area • Keep yourself closest to the means of exit • Never let yourself be cut off from egress

8. Munchausen Syndrome • A mental disorder • Sufferer causes or pretends to have physical or psychological symptoms • Typical patient is an adult 20-40 years old • Thought to be motivated by a desire to be seen as ill versus other benefit

9. Munchausen Syndrome by Proxy • Considered a mental illness of factitious disorders • Considered a relatively rare form of child abuse • Caretaker fakes or causes symptoms in a child • Often caretaker has familiarity with medical knowledge • Affected persons usually under 4 years old • Most of the time the mothers are the perpetrators • Often more than one child victimized per household

10. Ems role in Munchausen’s • Be objective in report and documentation • Need to site source of information provided (“_____ states…”) • May take years to prove the presence of this mental illness so EMS and ED staff may not have knowledge of this diagnosis • Caregiver must admit to the abuse and be willing to seek psychological treatment • Psychological and physical damage to victim could lead to poor long-term prognosis

11. anorexia • An eating disorder that is a real, treatable medical illness • Has distorted body image of self; typically female • Has an intense fear of gaining weight • Thinks about food a lot but limits intake • Uses starvation to feel more in control of life • Uses starvation to ease tension, anger, anxiety

12. Face of Anorexia

13. anorexia • Body slows down due to lack of source of energy to continue to function • Patient suffers impairments • Brain function • Infertility • Dental decay • Kidney failure • Cardiac arrest

14. Bulimia • Serious, potentially life-threatening eating disorder • Preoccupied with body shape and weight • Patients usually secretly binge and purge • Binge – eat large amounts of food • Purge – self-induce vomiting or misuse of laxatives, diuretics or enemas after binging or fast • Can follow a strict diet or participates in excessive exercise

15. bulimia • Serious and life-threatening complications • Dehydration • Heart problems • Severe tooth decay and gum disease • Absence of periods in females • Digestive problems; possible dependence on laxatives • Anxiety and depression • Drug and alcohol abuse

16. cycle of bulimia

17. Complications of eating disorders • Self-induced vomiting – oral complications • Erosion of tooth enamel from exposure to gastric acid • Sensitivity to hot/cold foods • Oral swelling or soreness • GI tract complications especially with bulimia • Ulcers, ruptures, strictures of esophagus from repeated vomiting

18. Complications cont’d • Infertility due to lack of periods • Continual use of laxatives – colon function problems • Loss of normal function • Electrolyte imbalance with misuse of diuretics and laxatives • Fetal harm if pregnant • Low birth weight, premature labor, post-partum depression

19. The Destruction from Anorexia • Body and muscles are being starved • Heart muscle atrophies; high risk for heart failure • Drop in sodium, zinc, potassium and calcium put the patient at increased risk for abnormal heart rhythms (SVT, VT, bradycardia) • Kidney failure can develop due to dehydration • Sudden cardiac death often due to dysrhythmias due to electrolyte imbalance and mineral disturbance • Common presentations: orthostatic hypotension, shock, CHF, sudden death

20. Treatment for eating disorders • Counseling is a must for psychotherapy • Antidepressants may help • Works with a nutritionist for an eating plan • Hospitalization may be necessary • Slightly higher recovery rate and better long-term prognosis for bulimia than anorexia

21. Implications for EMS & ED • Maintain heightened awareness for the situation • Overall low body weight • Poor dentition • From repeated vomiting and poor nutritional state • Incomplete/inaccurate history provided by patient • Denial of any problems by patient • Note: Cardiac monitoring should be considered due to potential for electrolyte imbalance and resulting cardiac dysrhythmias

22. Definitions • Emancipated minor – minor of any age who is or has been married or minor over 16 and under 18 who by court order has been freed from care, custody, and control of parents • Did you know - Emancipation does NOT extend to specific constitutional and statutory age requirements regarding voting, use of alcoholic beverages, possession of firearms

23. Consent for medical care • May be obtained from • Any person 18 and older • Emancipated minor • Minor who is married • Minor who is pregnant • Minor who is a parent

24. obtaining Consent from minor • Healthcare professionals shall not incur civil or criminal liability for failure to obtain valid consent when they relied in good faith on the representation made by the minor • This means you can take consent at face value when the minor states they have the authority to provide consent • They are emancipated from parental care • They are or have been married • They are pregnant • They are a parent with custody of their child (extends to the mother and the father if they are a custodial parent)

25. Implied Consent • Emergency exception rule based on the assumption that a reasonable person would consent to emergency care if able to do so • Medical professional may presume consent and proceed with appropriate treatment: • Child is suffering from emergent condition and life or health is in danger • Legal guardian unavailable or unable to provide consent • Treatment or transport cannot be safely delayed waiting for consent • Treatment rendered limited for emergent conditions that are posing an immediate threat to child

26. EMS and Consent • Burden of proof falls on medical professional when treating minor without proper consent • Need to justify and document that emergency actions were necessary to prevent imminent and significant harm to child • Generally considered as emergent conditions includes treatment of fractures, infections, pain control • Always act in best interest of patient • Clearly document nature of emergency and reason minor required immediate treatment and/or transportation and efforts made to contact legal guardian

27. Informed consent and language barrier During EMS care • Interpretation can be performed in person, via videoconferencing or by telephone • Certified medical interpreter preferred • Using family members should be avoided unless absolutely necessary • Translation may not be accurate • Document use of interpreter

28. In loco parentis • A Latin term meaning in place of or instead of the parent • Relationship is similar to that of a parent and a child, but with limitations • Original intent was for the care, supervision, and discipline of a child • Parent, guardian, or person in loco parentis can consent to emergent medical treatment • Generally inferred most commonly onto teachers but also could include babysitter

29. Situations okay to obtain consent from a Minor • Emancipated minor by court order • Married minor • Pregnant minor • Minor (mother and/or father) who is a custodial parent • For treatment of a sexually transmitted disease (12 years or older) • For treatment of alcohol or substance abuse (12 years or older) • For psychiatric admission and treatment (16 years or older) • For outpatient mental health treatment (12 years or older)

30. Public assumptions • The paramedic is medically trained so they must know what they are talking about; • “if they say I don’t have to go to the hospital, then I’m okay” • Patients want to believe nothing is wrong so will easily be swayed that nothing is wrong and transport is not warranted • Transport can be expensive; some paramedics may capitalize on the patient’s financial fears • EMS needs to consider: Do you want to be responsible for the one call you talked down who had a bad outcome???

31. Case Reports • The following 3 cases are real events • They DID NOT happen in this area • Be open to learn lessons from other’s mistakes • Decide how you would have handled the call if EMS had contacted you for directions

32. Case report #1 • EMS was called for an adult patient with chest pain past few hours • EKG showed sinus rhythm • Vital signs were stable • Lung sounds were clear • The patient was convinced by EMS it was acid reflux • A release was obtained Was this call handled appropriately?

33. Outcome Case report #1 • Hopefully, EMS would do a cardiac work-up and transport this patient Outcome report: • The responding paramedic’s general impression was that the patient had acid reflux, suggested antacids and left the scene after the patient signed AMA • The patient took the antacids • The patient died 3 hours after being evaluated by EMS

34. Case report #2 • EMS was called for a 4 year-old child having an asthma attack • Bilateral wheezes were auscultated • EMS convinced the mother the patient was only suffering from croup • The mother was instructed to put the child in the bathroom and run the shower for the steam • A release was obtained Was this call handled appropriately?

35. Outcome Case report #2 • The mother followed instructions and placed the child in a steamy bathroom • The child “fell asleep”; “breathing wasn’t a struggle” • The mother assumed her child was more relaxed • The child died due to a severe asthma attack

36. Case report #3 • EMS summoned by police to respond to a reported suicide attempt • Dispatch states they received a call from the patient's friend who stated they were threatening to commit suicide by overdose • EMS assesses the patient who has stable vital signs • Patient states they were just venting to their friend and didn’t really take any pills • Pill bottles offered were checked and levels seemed appropriate • EMS obtained a release Was this call handled appropriately?

37. Outcome case #3 • Boy, this one is TOUGH!!! • This paramedic did not talk patient out of going to the hospital but neither did they encourage her to go • Patient was left at home alone • The patient was found dead the next morning • Should EMS have involved Medical Control in dialogue??? • Hopefully, yes. Doesn’t mean the outcome would have been different

38. Releases/refusals • EMS to respond to each call assuming every one will be a transport • EMS to work harder at convincing them to be transported than accepting them as a refusal/release • Patients are aware of your attitude – show yours as positive • EMS to contact Medical Control for all controversial or questionable releases/refusals

39. Obtaining a Release • Patient must demonstrate decisional capacity in order to give consent for a release or refusal • A patient who is decisional, awake & oriented and understands the risks and benefits has the right to refuse consent (even when you feel the decision made is not in their best interest) • Police do not have the right to make the person in custody receive medical assistance if they refuse it (i.e.: laceration, pain) • Just because a person has had alcohol does not make them non-decisional • Every case needs to be evaluated on its own

40. Ems and refusals • Medical Control cannot “order” a patient to receive care and/or be transported if they have decisional capacity and are refusing • Transporting a patient with decisional capacity against their will could be kidnapping • People have the right to make poor decisions • The medical team must make sure we have explained the risks and benefits to the patient and this is documented • We all have horror stories of the patient who refused care/transportation and then had a negative outcome but it is the patient’s right to refuse IF they are decisional

41. Characteristics of behavioral emergencies • A call involving interaction with a patient whose behavior is • Unusual • Bizarre • Threatening • Dangerous • Behavior not generally accepted by society • Requires intervention from medical personnel

42. Objective indications of behavioral issue • Actions or situations that: • Interfere with activities of daily living (dressing, eating sleeping, maintaining housing) • Pose a threat to the life or well-being of the patient or others • Significant deviation from society’s expectations or norms

43. Avoid tunnel vision • Always keep in mind medical conditions that may be presenting as a behavioral issue • Diabetes • Trauma • Brain disorder / neurological condition • Medication influence • Recreational drug use

44. delirium • Relatively rapid, acute onset (hours to days)of widespread disorganized thought • May be reversible • Patient has inattentiveness • Memory impairment • Disorientation • Clouding of consciousness

45. dementia • Irreversible process that develops slowly over months • Consists of memory impairment and cognitive disturbance • Many common causes • Alzheimer’s disease • Vascular problems • AIDS • Head trauma • Parkinson’s disease • Substance abuse

46. schizophrenia • A significant change in behavior and loss of contact with reality • Common signs, symptoms, types • Hallucinations • Delusions • Depression • Flat affect • Paranoid • Disorganized behavior, dress, speech

47. Excited delirium • Sudden onset of unexplained aggressive behavior • Often accompanied by profuse sweating, high body temp, and delusional behavior • Often linked to a history of chronic cocaine abuse • Cocaine abuse contributes to development of coronary artery disease and damage to the heart muscle • Aggressive chemical sedation required • Continued physical struggle increases catecholamine surge and metabolic acidosis; sedation at this point can be life-saving • Per Region X SOP’s for sedation, EMS will administer Versed 2 mg IN • Can repeat every 2 minutes up to 10 mg • For additional sedation, Valium is given; IV or IM

48. Cascade of Events of Excited Delirium • Patient is agitated • There is a struggle with the patient • Increased O2 demand; if compromised airway cannot increase O2 supply • Energy stores (i.e.: glucose) are quickly depleted • There is an adrenalin overdose from the increased & aggressive activity • Excessive lactic acid created as a by-product • Heart is stressed from the exertion and adrenalin rush • Respiratory muscles will begin to fail

49. Rhabdomyolysis – Results from the struggle • Breakdown of myoglobin – a by-product in muscles • Causes myoglobinemia – the protein myoglobin released into blood • Intramuscular acidosis develops • Kidneys try to filter the dead muscle cells, eventually clog and then begin to fail • Patient presents with muscle weakness or flaccidity • May present with nausea and vomiting • Vomiting increases the risk of aspiration

50. Field Treatment rhabdomyolysis Urine sample due to rhabdomyolysis • Fluid hydration • 200 ml increments; repeated as necessary • Watch for fluid overload • Monitor breath sounds • Monitor cardiac rhythm • Watch for dysrhythmias induced by acidosis and electrolyte imbalance