Resuscitation And RefusalsResuscitation And RefusalsECRN Review ECRN Review

Presence Regional EMSPresence Regional EMS

Spring 2014Spring 2014

ObjectivesObjectives

Define the term “advanced directives” as it applies Define the term “advanced directives” as it applies to EMSto EMS

Discuss the recognition and honoring of a Do Not Discuss the recognition and honoring of a Do Not Resuscitate order in the pre-hospital settingResuscitate order in the pre-hospital setting

List the criteria required for field termination of List the criteria required for field termination of resuscitationresuscitation

Discuss the assessments and documentation Discuss the assessments and documentation required for patients meeting Triple Zero criteriarequired for patients meeting Triple Zero criteria

Describe situations in which the criteria for Field Describe situations in which the criteria for Field Death Declaration is applicableDeath Declaration is applicable

Review the criteria for refusal of treatment and/or Review the criteria for refusal of treatment and/or transporttransport

Describe situations that require contact with Describe situations that require contact with Medical ControlMedical Control

Right to Die PeacefullyRight to Die Peacefully

All patients have the right to make decisions All patients have the right to make decisions in advance about the circumstances of their in advance about the circumstances of their death. More and more individuals are death. More and more individuals are making these decisions. Health Care making these decisions. Health Care providers including EMS must be well aware providers including EMS must be well aware of patient/family rights in these difficult of patient/family rights in these difficult situations. situations.

Protocols and PoliciesProtocols and Policies

Refer to Refer to Region 6 Protocols for:Region 6 Protocols for:– Do Not Resuscitate Do Not Resuscitate Medical/Legal Policies Section C P. 7-9Medical/Legal Policies Section C P. 7-9

Physician Orders for Life-Sustaining Treatment Physician Orders for Life-Sustaining Treatment (POLST)(POLST)

– Termination of Resuscitation Termination of Resuscitation P. H09P. H09

– Triple Zero Triple Zero P. H10P. H10

– Field Death Declaration Field Death Declaration P. C14P. C14

Advanced DirectivesAdvanced Directives

Legal papers put in place before an Legal papers put in place before an emergency arises outlining individuals who emergency arises outlining individuals who are designated to make medical decisions are designated to make medical decisions for the patient, if the patient is no longer able for the patient, if the patient is no longer able to make decisions.to make decisions.– Durable Power of Attorney for Health CareDurable Power of Attorney for Health Care– Surrogate Decision MakerSurrogate Decision Maker– Living WillLiving Will

Living WillLiving Will

A witnessed written documents voluntarily A witnessed written documents voluntarily executed by a person with the proper executed by a person with the proper formalities instructing the person’s physician formalities instructing the person’s physician to withhold or withdraw death delaying to withhold or withdraw death delaying procedures in the event that the person is procedures in the event that the person is diagnosed as having a terminal event.diagnosed as having a terminal event.

EMS providers EMS providers will not be held will not be held responsible responsible for determining the validity of a for determining the validity of a Durable Power of Attorney, Surrogate Durable Power of Attorney, Surrogate Decision Maker or Living Will.Decision Maker or Living Will.

A Durable Power of Attorney, Surrogate A Durable Power of Attorney, Surrogate Decision Maker or Living Will alone Decision Maker or Living Will alone cannot cannot be accepted as the means to halt be accepted as the means to halt resuscitation by EMS providersresuscitation by EMS providers

If a patient is found in cardiopulmonary If a patient is found in cardiopulmonary arrest and EMS providers are presented arrest and EMS providers are presented with a Durable Power of Attorney, Surrogate with a Durable Power of Attorney, Surrogate Decision Maker or Living Will, CPR must be Decision Maker or Living Will, CPR must be started and Medical Control contacted started and Medical Control contacted immediately for direction. immediately for direction.

Whose orders does EMS follow?Whose orders does EMS follow?

EMS providers follow the orders of a EMS providers follow the orders of a physician, not legal paperwork.physician, not legal paperwork.

Medical Control mayMedical Control may

determine that the determine that the

legal paperwork islegal paperwork is

sufficient to halt sufficient to halt

resuscitative measuresresuscitative measures

Do Not ResuscitateDo Not Resuscitate

Do not resuscitate orders ( DNR) orders are Do not resuscitate orders ( DNR) orders are physician orders physician orders which advise nursing and which advise nursing and EMS providers that if a patient suffers a EMS providers that if a patient suffers a cardiopulmonary arrest, the patient does not cardiopulmonary arrest, the patient does not wish to be resuscitated.wish to be resuscitated.

DNRDNR

Because a DNR is an order from a Because a DNR is an order from a physician, a valid DNR can be honored by physician, a valid DNR can be honored by EMS providers.EMS providers.

2013 IDPH Form2013 IDPH Form

To find a copy of the form go toTo find a copy of the form go to– www.idph.state.il.us– Click on A to Z Click on A to Z – Look up Do Not Resuscitate formLook up Do Not Resuscitate form

2013 IDPH Form Basics2013 IDPH Form Basics

Uniform Do-Not Resuscitate Advance Uniform Do-Not Resuscitate Advance DirectiveDirective– Part A Attempt Resuscitation/CPRPart A Attempt Resuscitation/CPR– Yes/NoYes/No– Includes intubation and mechanical ventilationIncludes intubation and mechanical ventilation

Physician Orders for Life Sustaining Physician Orders for Life Sustaining Treatment Part B If a patient has a pulse Treatment Part B If a patient has a pulse and/or is breathingand/or is breathing– Comfort measures only Comfort measures only – Limited additional interventionsLimited additional interventions– Intubation and mechanical interventionsIntubation and mechanical interventions

Part C: Artificially administered nutritionPart C: Artificially administered nutrition– Feeding tube yes/noFeeding tube yes/no

Part D: Documentation of discussionPart D: Documentation of discussion– Signatures of patient, family and witnessSignatures of patient, family and witness

Part E: Signature of attending physicianPart E: Signature of attending physician

A Valid DNRA Valid DNR

A DNR is valid if it is on the appropriate A DNR is valid if it is on the appropriate IDPH formIDPH form– It must be signed by the patient’s physicianIt must be signed by the patient’s physician– It must be signed by the patient or their durable It must be signed by the patient or their durable

power of attorney/surrogate decision maker.power of attorney/surrogate decision maker.

Please notePlease note

– THE DNR DOES NOT HAVE TO BE THE DNR DOES NOT HAVE TO BE RESIGNED WITHIN A PARTICULAR AMOUNT RESIGNED WITHIN A PARTICULAR AMOUNT OF TIME IN ORDER TO REMAIN VALIDOF TIME IN ORDER TO REMAIN VALID

– THE DNR DOES NOT HAVE TO BE ON ANY THE DNR DOES NOT HAVE TO BE ON ANY PARTICULART COLOR OF PAPERPARTICULART COLOR OF PAPER

Revoking a DNRRevoking a DNR

A DNR may be revoked ifA DNR may be revoked if– It is physically destroyed or rescinded by the It is physically destroyed or rescinded by the

physician who wrote the order.physician who wrote the order.– It is physically destroyed or rescinded by the It is physically destroyed or rescinded by the

person who gave consent to the written orderperson who gave consent to the written order

When presented with a DNRWhen presented with a DNR

EMS makes a reasonable attempt to verify EMS makes a reasonable attempt to verify the identity of the patient named in the DNR.the identity of the patient named in the DNR.

If the validity of the DNR is unclear EMS If the validity of the DNR is unclear EMS begins CPR and call Medical Controlbegins CPR and call Medical Control

IF the patient is in cardiopulmonary IF the patient is in cardiopulmonary arrest andarrest and

No valid DNR order is producedNo valid DNR order is produced No agreement by the family on the DNRNo agreement by the family on the DNR Family is very upsetFamily is very upset

EMS providers complete an assessment of EMS providers complete an assessment of the patient begin CPR and call Medical the patient begin CPR and call Medical Control. Control.

Medical Control (ED Physician with ECRN) Medical Control (ED Physician with ECRN) determine if the patient is resuscitated or determine if the patient is resuscitated or not.not.

DNR does not mean Do Not CareDNR does not mean Do Not Care

Resuscitation ** isResuscitation ** is– CPRCPR– Electrical defibrillationElectrical defibrillation– Tracheal intubationTracheal intubation– Manually assisted ventilationManually assisted ventilation** Part A** Part A

Resuscitation is not **Resuscitation is not **– IV fluidsIV fluids– Dextrose IVDextrose IV These are Physician OrdersThese are Physician Orders– SuctioningSuctioning for life-sustaining treatmentfor life-sustaining treatment– Oxygen administrationOxygen administration** Part B and Part C** Part B and Part C

Whenever a patient with a DNRWhenever a patient with a DNR Suffers cardiopulmonary arrest, EMS calls Suffers cardiopulmonary arrest, EMS calls

Medical Control for direction if:Medical Control for direction if:– The patient is being transported to and from homeThe patient is being transported to and from home– The patient is at a long term care facilityThe patient is at a long term care facility– The patient is on an inter-hospital transferThe patient is on an inter-hospital transfer– The patient is a HospiceThe patient is a Hospice– EMT needs clarification and confirmation of actionsEMT needs clarification and confirmation of actions

All Patients with Valid DNR All Patients with Valid DNR PaperworkPaperwork

Call Medical Control to document incident Call Medical Control to document incident on a recorded line.on a recorded line.

Whenever a patient with a DNRWhenever a patient with a DNR

Is not in cardiac arrestIs not in cardiac arrest Treatment is started according to applicable Treatment is started according to applicable

protocolprotocol

Termination of ResuscitationTermination of Resuscitation

Resuscitation may be halted without a Do Not Resuscitation may be halted without a Do Not Resuscitate order if:Resuscitate order if:– Patient is Patient is found in asystolefound in asystole– Unwitnessed arrest with no bystander CPR before Unwitnessed arrest with no bystander CPR before

arrival of EMSarrival of EMS– Patient remains in asystole despite the treatment of the Patient remains in asystole despite the treatment of the

Asystole protocolAsystole protocol CPRCPR Airway securedAirway secured Vascular accessVascular access Epinephrine 1 mgEpinephrine 1 mg

Termination of ResuscitationTermination of Resuscitation

In order to Terminate Resuscitative efforts In order to Terminate Resuscitative efforts for the previous criteriafor the previous criteria– EMS must call Medical Control for permission to EMS must call Medical Control for permission to

terminate resuscitation and put incident on the terminate resuscitation and put incident on the recorded linerecorded line

– The family must be in agreement with the The family must be in agreement with the terminationtermination

– EMS must call the local coronerEMS must call the local coroner

““Before the wheels roll. . .”Before the wheels roll. . .”

The decision to terminate resuscitation must The decision to terminate resuscitation must be made before the wheels of the be made before the wheels of the ambulance roll to transport a patient to the ambulance roll to transport a patient to the hospital.hospital.

No way to “register” a dead person.No way to “register” a dead person.

Triple ZeroTriple Zero

A patient who is not viable and for whom A patient who is not viable and for whom resuscitation efforts would be fruitlessresuscitation efforts would be fruitless– UnconsciousUnconscious– No pulseNo pulse– No respirationNo respiration

Triple Zero Signs of Long Term Triple Zero Signs of Long Term DeathDeath

The patient must exhibit one or more of the The patient must exhibit one or more of the following signsfollowing signs– Rigor mortis – Rigor mortis – stiffness of the limbsstiffness of the limbs

– Lividity – Lividity – pooling of blood in dependent parts of the bodypooling of blood in dependent parts of the body

– DecompositionDecomposition– MummificationMummification– DecapitationDecapitation– No resuscitative efforts for at least 20 minutesNo resuscitative efforts for at least 20 minutes– No palpable pulses.No palpable pulses.– Asystole in 3 chest leads (Lead I, II, III)Asystole in 3 chest leads (Lead I, II, III)

Contact Medical Control Contact Medical Control – Document findingsDocument findings– Time Triple Zero confirmedTime Triple Zero confirmed– Physician on the radioPhysician on the radio– On recorded lineOn recorded line

– The confirmation of TripleThe confirmation of Triple

Zero does not constituteZero does not constitute

a pronouncement of death.a pronouncement of death.

RememberRemember

EMS must call the local coronerEMS must call the local coroner EMS must stay with the patient until relieved EMS must stay with the patient until relieved

by coroner or local law enforcementby coroner or local law enforcement

If any doubt exists, If any doubt exists,

Whether patient meets criteria for Triple ZeroWhether patient meets criteria for Triple Zero

RESUSCITATERESUSCITATE

Especially if:Especially if:

suspected hypothermiasuspected hypothermia

drowning/near drowningdrowning/near drowning

uncertain down timeuncertain down time

EXCEPTIONEXCEPTION

ALL INFANTS WHO ARE ALL INFANTS WHO ARE VICTIMS OF SIDS ARE VICTIMS OF SIDS ARE BROUGHT IN TO THE ED BROUGHT IN TO THE ED WITH RESUSCITATION WITH RESUSCITATION ATTEMPTS!!!ATTEMPTS!!!

Field Death DeclarationField Death Declaration

Chance of survival from traumatic cardiac Chance of survival from traumatic cardiac arrest at the scene is minimalarrest at the scene is minimal

Must make the best use of time, personnel Must make the best use of time, personnel and resourcesand resources

Protocol approved for all levels of EMS Protocol approved for all levels of EMS providers (FR-D, Basic, Intermediate, providers (FR-D, Basic, Intermediate, Paramedic)Paramedic)

Criteria for Field Death Declaration Criteria for Field Death Declaration

> 14 years old> 14 years old Significant mechanism of injurySignificant mechanism of injury Pulseless and not breathing on EMS arrivalPulseless and not breathing on EMS arrival No active electrical activity on the monitorNo active electrical activity on the monitor

or “No Shock Indicated” on AEDor “No Shock Indicated” on AED

Asystole or Idioventricular RhythmAsystole or Idioventricular Rhythm

MAY BE WARM WITHOUT RIGOR OR MAY BE WARM WITHOUT RIGOR OR LIVIDITYLIVIDITY

So what if?So what if?

EMS is called to the scene of a 27 year-old EMS is called to the scene of a 27 year-old male in a motor vehicle crash. The vehicle male in a motor vehicle crash. The vehicle was traveling at a high rate of speed and was traveling at a high rate of speed and rolled over sustaining heavy damage. The rolled over sustaining heavy damage. The patient was ejected and is found face down patient was ejected and is found face down 20 feet from the vehicle. On initial 20 feet from the vehicle. On initial assessment EMS finds the patient pulseless assessment EMS finds the patient pulseless and apneic. and apneic.

How should EMS to proceed?How should EMS to proceed?

PatientPatient

Is an adult ( over the age of 14)Is an adult ( over the age of 14) Trauma resulted in significant mechanism of Trauma resulted in significant mechanism of

injuryinjury Patient was pulseless and not breathing on Patient was pulseless and not breathing on

initial assessmentinitial assessment Major trauma to the body found on Major trauma to the body found on

assessmentassessment

On the monitor the patient does not have a On the monitor the patient does not have a viable rhythmviable rhythm

Important PointImportant Point

Medical Control MUST BE Medical Control MUST BE CONTACTED on a CONTACTED on a recorded line for all Field recorded line for all Field Death Declaration Death Declaration questions/decisionsquestions/decisions

RememberRemember

EMS must call the local coronerEMS must call the local coroner EMS must stay with the patient until relieved EMS must stay with the patient until relieved

by coroner or local law enforcementby coroner or local law enforcement

Review of Refusal CriteriaReview of Refusal Criteria

Refusal of treatment/transport should be Refusal of treatment/transport should be initiated by the patient.initiated by the patient.

At At NONO time should any EMS provider time should any EMS provider suggest or initiate a patient refusal.suggest or initiate a patient refusal.

Upon refusal of treatment and/or transport, Upon refusal of treatment and/or transport, the EMS provider should evaluate the the EMS provider should evaluate the patient.patient.

Evaluation - Mental StatusEvaluation - Mental Status

Is the patient alert and oriented to person, Is the patient alert and oriented to person, place, time and event?place, time and event?

Is the patient free of the influence of drugs Is the patient free of the influence of drugs or alcohol?or alcohol?

Evaluation - Vital SignsEvaluation - Vital Signs

Evaluate airway, breathing and circulation.Evaluate airway, breathing and circulation. A complete set of vital signs should be A complete set of vital signs should be

obtained.obtained. If patient refuses to have vital signs taken, If patient refuses to have vital signs taken,

the EMS provider should use a visual and the EMS provider should use a visual and verbal assessment to determine if vital signs verbal assessment to determine if vital signs are altered.are altered.

Evaluation - MOI / NOIEvaluation - MOI / NOI

Is the scene free of significant mechanism of Is the scene free of significant mechanism of injury?injury?

Does the patient have a life-threatening Does the patient have a life-threatening chief complaint or evidence of significant chief complaint or evidence of significant signs and/or symptoms?signs and/or symptoms?

Is the patient free of “pertinent” medical Is the patient free of “pertinent” medical history?history?

Evaluation - CompetenceEvaluation - Competence

– Is the patient Is the patient ≥≥ 18 years of age? 18 years of age?

– If the patient is not the appropriate age:If the patient is not the appropriate age: Does the patient proof of emancipation?Does the patient proof of emancipation? Is accompanied by parent or legal guardian?Is accompanied by parent or legal guardian?

Review of Refusal CriteriaReview of Refusal Criteria

EMS must explain possible risks and EMS must explain possible risks and complications that may occur if treatment complications that may occur if treatment and/or transport are not provided.and/or transport are not provided.

This may include “death or reduction in This may include “death or reduction in quality of life” if the patient’s condition is quality of life” if the patient’s condition is considered life threatening by the EMS considered life threatening by the EMS provider or Medical Control.provider or Medical Control.

Refusal Form DocumentationRefusal Form Documentation

EMS providers complete the PREMSS EMS providers complete the PREMSS Refusal form by answering all questions in Refusal form by answering all questions in the upper portion of the form. the upper portion of the form.

Document scene and assessment findings Document scene and assessment findings in the space labeled “Notes/Comments”.in the space labeled “Notes/Comments”.

Document vital signs in the space provided.Document vital signs in the space provided.

Medical ControlMedical Control

Medical Control must be contacted when:Medical Control must be contacted when:– Any question in the upper portion of the refusal Any question in the upper portion of the refusal

form has been answered “NO”form has been answered “NO”– If a patient refuses transport after EMS treatment If a patient refuses transport after EMS treatment

has been initiatedhas been initiated– All AMA refusalsAll AMA refusals

When Medical Control is contacted, check the When Medical Control is contacted, check the box next to the hospital contacted and print box next to the hospital contacted and print the physician’s name on the line indicatedthe physician’s name on the line indicated

Medical ControlMedical Control

By calling Medical Control, EMS is not By calling Medical Control, EMS is not looking for “approval” of the refusal.looking for “approval” of the refusal.

Medical Control is confirming the efforts of Medical Control is confirming the efforts of EMS in assuring that the patient is safe and EMS in assuring that the patient is safe and competent to refuse treatment.competent to refuse treatment.

EMS is documenting the questionable EMS is documenting the questionable refusal on a recorded radio/phone line for refusal on a recorded radio/phone line for legal purposes.legal purposes.

SummarySummary

Know the policies and protocols regarding Know the policies and protocols regarding end of life/ resuscitation decisions and end of life/ resuscitation decisions and refusal of care.refusal of care.

EMS must always notify Medical Control for EMS must always notify Medical Control for documentation on a recorded line and documentation on a recorded line and guidance.guidance.

EMS must call the coroner in the cases of EMS must call the coroner in the cases of death outside the hospital.death outside the hospital.

ReviewReview Consider the following 12 ScenariosConsider the following 12 Scenarios Answer all the questions for each scenario Answer all the questions for each scenario .. Please e-mail your answers to:Please e-mail your answers to:

– Mary.butzow@presencehealth.org– ““ECRN CE” in subject box.ECRN CE” in subject box.

You will receive an e-mail confirmation with the You will receive an e-mail confirmation with the correct answers. Print this confirmation for your correct answers. Print this confirmation for your records.records.

Scenario 1Scenario 1

EMS Providers are called to a motor vehicle EMS Providers are called to a motor vehicle crash. The driver of one car is pulseless crash. The driver of one car is pulseless and not breathing. He has massive damage and not breathing. He has massive damage to both lower extremities and a mushy area to both lower extremities and a mushy area on his scalp. He is in asystole on the on his scalp. He is in asystole on the monitor. Does this patient meet Field Death monitor. Does this patient meet Field Death Declaration criteria? What should EMS do?Declaration criteria? What should EMS do?

Scenario 2Scenario 2

EMTs have been called to the house by neighbors EMTs have been called to the house by neighbors concerned that they have not seen Floyd all day. concerned that they have not seen Floyd all day. Floyd usually takes his dog out for walks at least Floyd usually takes his dog out for walks at least twice a day, but no one has seen him since twice a day, but no one has seen him since yesterday. Police find Floyd in his recliner, yesterday. Police find Floyd in his recliner, pulseless and not breathing. He has purple pulseless and not breathing. He has purple discoloration of his dependent parts and is very discoloration of his dependent parts and is very stiff. The monitor shows asystole in all leads. stiff. The monitor shows asystole in all leads. Does Floyd meet Triple Zero criteria? What should Does Floyd meet Triple Zero criteria? What should EMS do?EMS do?

Scenario 3Scenario 3

Mary Jane’s mother has cardiac arrested. Mary Jane’s mother has cardiac arrested. Mary Jane thinks her mom has a living will, Mary Jane thinks her mom has a living will, but she can’t find it. She has never heard of but she can’t find it. She has never heard of a durable power of attorney. What should a durable power of attorney. What should you advise EMS to do? you advise EMS to do?

Scenario 4Scenario 4

Susan is lying in her back yard. It is early Susan is lying in her back yard. It is early April, railing and about 50 degrees out. She April, railing and about 50 degrees out. She is not moving, stiff and cold to touch. EMS is not moving, stiff and cold to touch. EMS cannot find any pulses on her and she does cannot find any pulses on her and she does not appear to be breathing. Does she meet not appear to be breathing. Does she meet criteria for Triple Zero? Why or why not?criteria for Triple Zero? Why or why not?

Scenario 5Scenario 5

Mr. Blue has a signed Do Not Resuscitate Mr. Blue has a signed Do Not Resuscitate order for his mother who is 90 years old with order for his mother who is 90 years old with cancer. Now that she is pulseless and not cancer. Now that she is pulseless and not breathing he has changed his mind and breathing he has changed his mind and wants everything done. What should you wants everything done. What should you advise EMS Providers to do?advise EMS Providers to do?

Scenario 6Scenario 6

Mrs. Green is dying of cancer. She has a Mrs. Green is dying of cancer. She has a DNR. Mrs. Green has suffered a cardiac DNR. Mrs. Green has suffered a cardiac arrest and the local fire department has arrest and the local fire department has started CPR. The paramedic with the started CPR. The paramedic with the transport agency has called for guidance as transport agency has called for guidance as to what to do now. What do you want to to what to do now. What do you want to advise him to do?advise him to do?

Scenario 7Scenario 7

Mrs. Schmidt has suffered a cardiac arrest. Mrs. Schmidt has suffered a cardiac arrest. Responding EMS Providers have started Responding EMS Providers have started CPR. She is entubated, given epinephrine CPR. She is entubated, given epinephrine and remains in asystole. CPR continues, and remains in asystole. CPR continues, she is given additional epinephrine. The she is given additional epinephrine. The family is crying “please let her go”. What family is crying “please let her go”. What should you advise EMS do? What protocol should you advise EMS do? What protocol does this follow?does this follow?

Scenario 8Scenario 8

It is snowing and the EMS transport unit can only It is snowing and the EMS transport unit can only go about 20 miles an hour on the highway. On go about 20 miles an hour on the highway. On board they have a 6- year-old boy who was hit by board they have a 6- year-old boy who was hit by a car in a rural community. The child is critical and a car in a rural community. The child is critical and had a pulse at the scene but about 10 minutes ago had a pulse at the scene but about 10 minutes ago he went into cardiac arrest. EMS has done CPR, he went into cardiac arrest. EMS has done CPR, intubated him, and started IV fluids. They have intubated him, and started IV fluids. They have given Epinephrine according to protocol. He is given Epinephrine according to protocol. He is asystole and EMS is still 8 miles from the hospital. asystole and EMS is still 8 miles from the hospital.

Does this child meet Field Death Does this child meet Field Death Declaration? Why or Why not?Declaration? Why or Why not?

Does this child meet the Termination of Does this child meet the Termination of Resuscitation Protocol? Why or Why not?Resuscitation Protocol? Why or Why not?

Scenario 9Scenario 9

Eric’s mom is in the Hospice program for Eric’s mom is in the Hospice program for emphysema. She has a valid DNR signed emphysema. She has a valid DNR signed by her, her doctor and Eric. Eric’s mom is in by her, her doctor and Eric. Eric’s mom is in cardiac arrest. Eric wants to honor the DNR cardiac arrest. Eric wants to honor the DNR but his sister just got here from Florida and but his sister just got here from Florida and she is screaming “save my mother!!”. What she is screaming “save my mother!!”. What should you advise EMS to do?should you advise EMS to do?

Scenario 10Scenario 10

EMS is dispatched for a 32 year old male patient EMS is dispatched for a 32 year old male patient with a diabetic problem. Upon arrival they find with a diabetic problem. Upon arrival they find Tony lying in bed. He is unresponsive but Tony lying in bed. He is unresponsive but breathing. His skin is pale, cool and clammy. His breathing. His skin is pale, cool and clammy. His blood sugar is 40 mg/dl.blood sugar is 40 mg/dl.

Providers obtain vascular access and administer Providers obtain vascular access and administer

25g of 50% dextrose25g of 50% dextrose

After administration of the dextrose, Tony wakesAfter administration of the dextrose, Tony wakes

up. He is a little slow to respond but is alert andup. He is a little slow to respond but is alert and

oriented x4. He wants to refuse transport to the oriented x4. He wants to refuse transport to the

hospital. hospital.

Can Tony refuse transport? Can Tony refuse transport?

The EMS providers call Medical Control, how will The EMS providers call Medical Control, how will advise them to proceed?advise them to proceed?

Scenario 11Scenario 11

Patty was on her way home from work and has Patty was on her way home from work and has been involved in a minor vehicle accident. There been involved in a minor vehicle accident. There is minimal damage to the front end of her car. She is minimal damage to the front end of her car. She has a small bump on her forehead. has a small bump on her forehead.

Patty is 32 years oldPatty is 32 years old Patty is alert and oriented x4. She denies any loss Patty is alert and oriented x4. She denies any loss

of consciousness. Her vital signs are within of consciousness. Her vital signs are within normal limits. She states she doesn’t want to be normal limits. She states she doesn’t want to be transported to the hospital. transported to the hospital.

Can Patty refuse transport?Can Patty refuse transport?

Does EMS need to contact Medical Control?Does EMS need to contact Medical Control?

How should EMS proceed?How should EMS proceed?

How would this scenario change if Patty had How would this scenario change if Patty had alcohol on her breath and tells EMS she has alcohol on her breath and tells EMS she has had 3 glasses of wine?had 3 glasses of wine?

Scenario 12Scenario 12

Katie is a 22-year old woman. Neighbors Katie is a 22-year old woman. Neighbors had called the ambulance because of a had called the ambulance because of a domestic disturbance. Police has not been domestic disturbance. Police has not been dispatched at this point. Katie has an dispatched at this point. Katie has an obviously deformed jaw, with an abrasion on obviously deformed jaw, with an abrasion on her chin and pain opening and closing her her chin and pain opening and closing her mouth. mouth.

Katie’s husband states that she is fine and Katie’s husband states that she is fine and does not need to go to the hospital. Katie does not need to go to the hospital. Katie has a flat affect and is not communicating has a flat affect and is not communicating with EMS providers. She does not make with EMS providers. She does not make eye contact.eye contact.

EMS has called you for direction. Can Katie EMS has called you for direction. Can Katie refuse treatment at this point? refuse treatment at this point?

What do you want to advise EMS to do?What do you want to advise EMS to do?