Friday, April 29, 2016

EMT keypoints of respitory distress

How may respitory distress key points can you remember? Here is a refresher to remind you of some important information at a scene.

It is important to recognize the signs and symptoms of respitory emergencies. Complete a thorough assessment, and provide immediate intervention.

A patient who was initially breathing adequately may deteriorate to a point where breathing is inadequate and insufficient to sustain life.

The EMT must remain acutely aware of a patients idiosyncrasies at the extremes of age. This being pediatric patients and geriatric patients.

Because respiratory distress can rapidly deteriorate into respiratory failure prompt intervention and transport is critical for the infant or child. Same rules apply for geriatric patients.

An agitated or confused facial expression may indicate inadequate breathing, hypoxia, or hypercarbia.

Because a patient with difficulty in breathing is considered a priority patient, consider advance life support back up and expeditious transport.

Thursday, April 21, 2016

Emergency Medical Technician we have SOAP, A CHART and someone CHEATED!

I hope as an EMT and Paramedic, you have soap. soap is an important thing. It must be used constantly....oh wait...were not talking about hygiene here. There are actually three ways to record call information while working. As you can tell from the title one is SOAP, CHART, and CHEATED. So what does each one include?

S (Subjective) The information that the patient tells you.
O (Objective) Examination through inspection, palpation, and auscultation
A (Assessment) Field assessment
P (Plan) Emergency Care provided to the patient

C (Chief Complaint) 
H (History of Patient) Medical history of patient
A (Assessment)
R (Rx) Treatment given to the patient
T (Transport)

C (Chief Complaint)
H(History of Patient)
E(Exam) Physical Exam of patient
A (Assessment)
T (Treatment of Patient)
E (Evaluation) Is patient improving or deteriorating with treatment
D (Transfer of medical care)

The CDRFC of a PCR

What is a CDRFC of a PCR. I wonder how many EMT and Paramedics out there can guess? Let's see did you get it right. My topic for this post is the confidentiality, allowed distribution of information, the documentation of refusal of treatment, falsification of a report, and correction of errors on the Prehospital Care Report.


  • PCR is confidential
  • Do not show form or discuss info with unauthorized personell
  • Remember HIPAA 
  • Follow state and local protocols
  • Distribute to heal care provider, police, third party billing, and court if there is a legal subpoena

Refusal of treatment
  • Perform as much assessment as possible
  • Make sure patient is rational and not suicidal
  • Make one last effort of persuation
  • Inform patient of why care is needed
  • Discuss possible consequences
  • Confirm that patient understands
  • Discuss situation with medical directive
  • Have patient sign refusal of treatment, family member, Police Officer or a bystandard
  • Suggest alternative ways to getting to care.

  • If its not done, don't write it down
  • If you don't write it down its not done.

I think falsification is clear enough. If you didn't do something, don't write it down to cover your behind on the clock. If you did do something, make sure that you write it down.

Correction of errors
Never delete or erase something. Simply put a line through it and continue with the right information on your report.

Objective and Subjective Information?

When an EMT is dealing with a Prehospital Care Report they are going to come across the patients narrative. If you remember from my previous EMT Refresher Training post I discussed that a patients narrative included patients chief complaint, patient history, signs, symptoms, Objective information and subjective information. What exactly are these last two items on the PCR?

Objective Information
Measurable or verifiable information. A sign or symptom of an illness.

Subjective Information
Individuals perception or interpretation of a medical illness.

I for one don't understand why an EMT would need Subjective Information. I feel that the Objective information would be more helpful in the care of the patient. But perhaps the subjective information can give more insight to what is really going on with the patient if certain signs and symptoms are not showing.

The different parts of a Prehospital Care Report

Are you ready for another day of Emergency Medical Technician classes? In the last refresher and training post, I talked about the different parts of a Prehospital Care Report. The report is not going to have five empty spaces. The Department of Transportation and other facilities are going to need to know pertinent information from those in contact with the patient. 

If you remember there are five different areas on the Prehospital Care Report. They are Patient Information, Administrative Information, Administrative, Patient Demographics, Vital Signs, and Patient Chief Complaint in their own words. What does an EMT have to include in each section?

Patient Information

  • Chief complaint
  • Level of responsiveness
  • Blood pressure for patients over 3 years old
  • Skin Perfusion (Capillary refill) for patients less than 6 years old
  • Skin color, temperature, and condition of skin
  • Pulse rate
  • Respiratory rate and effort of breathing

Administrative Information

  • Time the incident was reported
  • Time the unit was notified
  • Time of arrival at the patient
  • Time the unit left the scene
  • Time the unit arrived at its destination
  • Time of transfer care.


  • EMS Unit Number
  • Names of crew members and level of certification
  • Address of patient
Patient Demographics
  • Legal name, age, sex, race, and birth date
  • Home address
  • Insurance or billing information
  • Care given before EMT arrived
Vital Signs
  • Two complete sets of vital signs
  • Record of what position the patient was in

Patient Narrative
  • Patients chief complaint in patients own words
  • Patient history
  • Objective and subjective information
  • Symptoms based on chief complaint
In the next post I plan to include all the abbreviations that an EMT or Paramedic has to deal with. In the future I will also be discussing Objective information, Subjective information, Confidentiality of the PCR, distribution of information, documenting refusal of treatment, falsification of the PCR, and correction of errors on the Prehospital Care Report. 

Purpose of a Prehospital Care Report

What is the purpose of a Prehospital Care Report? The purpose of a PCR is to record the care given to a patient. It is then used to check quality of care and perform the highest quality of patient care. These reports help ensure a continuity of care. The PCR becomes part of the patients' permanent hospital records and can be used as a legal document in court. 

Other uses for a Prehospital Care Report are to educate other Emergency Medical Technicians and be used for research. Many Ambulance companies will use it to evaluate their medics and their services. Many use the reports to make continuous improvement in the services that they provide.

The Department of Transportation has made an effort to standardize the information needed on a Prehospital Care Report. This is in hopes to provide better patient care and EMS efficiency. 

What is on the Prehospital Care Report?
  • Patient Information
  • Administration Information
  • Patient Demographics
  • Care that was given 
  • Vital Signs 
  • Health complaint is patients own words

Wednesday, April 20, 2016

I don't want your help EMT!

Here is the scenario. The Emergency Medical Technicians have arrived on scene. They have explained everything to the patient. The patient does not want to receive treatment. What does the EMT do now? This type of scenario for an EMT can bring on a headache. The EMT knows that the patient needs to receive medical treatment but they are still saying “NO!”

Try to persuade the patient to accept medical treatment or transport to the hospital. At times just by showing the patient their vitals, they will agree to go to the hospital.

Make sure that the patient is competent and rational

Document what was explained to the patient, explain the possible risks, record his response and have the patient sign a release form.

Encourage the patient to seek medical attention if more symptoms occur or they get worse.

If unsure, contact the medical directive.

Don't Touch Me EMT!

Each time an EMT arrives on scene they must obtain consent from the patient, family member or legal guardian of the patient. There are five different types of consent that EMS deals with. Informed, Expressed, Implied, Minor, and Involuntary consent are the five different types of consent.

Informed- Procedures are explained to patient and explicit permission is given by the patient.

Expressed – Patient is informed of assessment, procedures, and related risks

Implied – This is also known as Emergency Doctrine. This consent is used when the patient is unresponsive or incompetent and would consent to emergency care if they could.

Minor – The EMT must obtain consent from a parent or legal guardian. If there is no one present then Implied consent comes into play.

I don't want to breathe EMT!

An EMT may come across a DNR. What exactly is a DNR order for a patient? DNR “Do Not Resuscitate” is an order that states that an EMT should not perform CPR or provide oxygen to a patient. An EMT must follow a DNR if one is written, present, and up to date. If in question contact the medical directive.

Other reports EMT and Paramedics deal with

There are situations where an EMT may be mandated to make a report such as suspected abuse, crimes, and infectious diseases. So when does an EMT make a report?

Child abuse, Elderly abuse, Spousal abuse. Such statures frequently grant EMS from lawsuits of libel, slander or defamation of character when reporting such crimes.

Many states require EMS to report an injury resulting from a crime. Gunshot wounds, knife wounds, suspicious burns, poisonings or sexual assault.

Drug related injuries
Some states require you to report drug related injuries or patients that are under the influence or narcotics.

Miscellaneous injuries

Infectious diseases, use of patient restraints, mental incompetent, Intoxication, suicides and dog bites.

EMT at a crime scene

Eventually as an EMT, you will be called to a scene that is a crime scene. So what do you do to keep yourself safe? What can you do to preserve the crime scene? My first crime scene was a mess. I had moved something that I wasn’t supposed to move. It was by accident because I was trying to get a response out of the patient but I was still at fault.

A crime scene requires a high index of suspicion. A potential crime scene is any scene that may require police report.

Be sure to take one way in or out. Touch only what you need to touch and inform Police. Move only what you need to move to protect the patient, inform Police of what you moved. Do not use crime scene telephone unless you have permission from Police. In absence of Police permission, move the patient only if patient is in danger. Observe and document everything. Do not cut through holes in clothing that may be caused by staffing or gun shots. Do not cut through a rope or tie not. Do not cover patient with sheet. 

If crime is rape, do not allow the patient to wash, change clothes, use the bathroom or take anything by mouth.

The reason why you do not want the patient to take anything by mouth is in case of injury to the mouth due to abuse, rape, or forced oral sex.

Dealing with Law Enforcement and Medical Examiners/Coroners Office as an EMT

There are going to be moments in an Emergency Medical Technicians career where the local Police, Medical Examiners Officer or Coroners Office will be involved. I’m happy to say that I’ve worked with the local Police Department for two years. Trust me, if you are professional, you will build a professional bond with both of these departments.  The men and women in blue should be called:

  • Homicide
  • Suicide
  • Violent Death
  • Crash Related Deaths
  • Sudden Infant Death (SIDS)
  • Dead on Arrival.

Most of the time, the Police Department will already be on scene. There are times when the local Fire Department will have to bust down a door and one of these types of scenes will be called.

As an EMT, I had often wondered why the Police Department might be called out to a death of an infant. Then I imagined what the scene could be like. The parents are distraught and may become angry. There is also the chance that the child was not taken care of correctly and placed in bed the wrong way.

Unfortunately my dealings with local Police have been due to use of drugs on the premises. 

What if the patient is a potential organ donor?

As an EMT or Paramedic you do not have the final say on if a patient is an organ donor or not. Most patients who are potential organ donors will have a signed donor card. This is considered a legal document. Remember that the patient is a patient first and then an organ donor. The Hospital staff and patients family will have the final say if there is no donor card available.  Be sure to communicate with your medical directive.

A word of warning about potential organ donors, please do not mention or discuss this in front of a crowd and family members. Remember as an EMT or Paramedic, you are responsible for this patient’s confidentiality. Information like such should not get out to the press.

Also a family member may not know that the patient has decided to be an organ donor. Or they may not agree with the patient’s decision. If a family member is there, as the EMT you will want to keep the scene as calm as possible. This kind of information could cause the family member to become upset and act out on their emotions. As someone who has experienced caring for a patient and also having to deal with a family member at the same time, it’s not a pretty sight as an EMT.

As an EMT am I legally unprotected?

Legally, being an EMT can be a scary job. Was the patient hurt by our actions? Did we do all the right things? Thankfully there are things that an EMT or Paramedic can do to protect themselves during transport and transfer situations.

Do not bypass a medical facility that is able to treat the patient, unless directed by medical direction, patient or predetermined protocol. Our patients are taken to the local hospital because they are the best in emergency medicine. Sometimes I questioned that because there is actually a hospital closer. I decided to sit down and discuss it with a fellow EMT that works transport.  It seems that this particular hospital deals with a lot of cases due to the COBRA laws.

Another way to protect you as a medical professional is to get a full and clear report about the patient’s condition. Not only will this allow you to provide the best medical treatment but you will also be able to pass this information onto the receiving medical facility.

Be sure that you are able to provide the level of care necessary during the transport and it is within your scope of education. Call for Advance Life Support if you are unable to provide the level of care necessary to the patient.
  • Obtain the informed consent form signed by the patient or legal guardian
  • Obtain the written certification of transfer that includes the transferring physicians name and address, facility receiving the patient and the reason for the transfer.
  • Know where you are going and take the quickest possible route.

Patient confidentiality

An EMT comes on scene and there is a crowd forming. Is the patient a circus act? Or do you have certain responsibilities other than providing medical care to the patient?

This is a topic that grinds a nerve with me. I get a lot of heat at work because I don’t like other clients looking at a client that might have a medical illness or physical trauma. I also can’t stand it when other co-workers tell clients what is wrong with another client. If that person is not a family member or legal guardian then it’s none of their business.

As an EMT, you also have the responsibility to take care of that patient’s confidentiality and privacy. So how do EMT and Paramedics keep a patients confidentiality and privacy while providing medical care? Confidentiality deals with emergency care, patient history, and physical assessment and treatment. Therefore do not give out this information out to other than the legal guardian or family member of the patient.  Releasing confidential information requires a written release form signed by the patient or a legal guardian.

What if it’s a major accident and the press is all over the place? Do not speak to the press, your family, friends or other members of the public about the details of the emergency care. This can be really difficult to achieve. I have to catch myself at times. Sometimes I’ll have explained what a scene was like to a family member but in no way to I give the patients name or the location of the scene. 

Tuesday, April 19, 2016

Sue happy EMT patients

There's going to come a time in your EMT career where you accidentally break someones ribs. Or there was no intent to do harm but it happened anyway. That's when criminal liability, civil liability, and negligence comes into play. An EMT had a duty to act, the EMT breached that duty to act, a patient suffered an injury or harm, those injuries were the result of the breach of the duty.

Criminal liability cases happen when the government brings legal action against an EMT for the public.

Civil liability cases happen when a single individual comes against an EMT. Most EMT and Paramedics will have suits against them due to negligence.

Negligence is a tort where there was no intent to do any harm but in which a breach in duty occurred. 

Monday, April 18, 2016

Is the directive at hand? Can the document be found?

What happens if an EMT, Paramedic, or Firefighter comes to a scene and the claim is that there is a directive that needs to be followed? Given the scenario that a patient has an advance directive and it can not be found or the patient refuses care. What appropriate actions are to be taken?

  • Consider initiating treatment immediately
  • Contact your medical directive for instructions on how to proceed
  • Continue treatment until the problem has be resolved

A competent adult who can prove orientation to "Person, Place, and Time" can deny treatment. Be sure to inform patient of all potential risks and the possibility of death.

What if the patient still refuses?

  • Try to persuade the patient to accept treatment or transport to the hospital
  • Clearly document what was told to the patient, their response, and have them sign a refusal form.
  • Before you leave the scene, encourage patient to seek help if symptoms occur.
  • If unsure about patient the contact your medical directive.

How many directives are there for an EMT?

Compare the types of directives that an EMT, Paramedic, and Firefighter deals with.

An Advance directive are instructions written in advance. There are four types of directives. They are:

  • DNR Order
  • Living Will
  • Health care durable power of attorney
  • Physicians orders for life sustaining treatment (POLST)

A DNR Order is a directive to Do Not Resuscitate. A legal document or order that covers resuscitating issues only.

A living will covers DNR but also includes more general health care issues including to use life support or not.

A health care durable power of attorney is also known as a health care proxy. It is a legal document that empowers some to make decisions if the patient is unable to make the choice for themselves. These usually pertain to in-hospital or long term care facilities.

A (POLST) Physicians orders for life sustaining treatment pertains if the patient is not expected to live more than a year. This allows the patient to express the level of care in case their health worsens before resuscitation is needed.

Involuntary Consent

What is an Involuntary Consent?

Involuntary Consent is consent from a mentally incompetent adult or an individual in custody of law enforcement or the court. You will need a third party such as legal guardian, LEO , or Officer of the Court to deem the patient incompetent. This type of consent is also for those that are legally deemed to be unable to take care of themselves.

This is the type of consent that I'm uncomfortable with. This gives a lot of power over the patient to a family member or legal guardian. Thankfully if you have concerns always look to your supervisor on duty or the medical directive on duty.

Minor Consent

What happens if an EMT is called to a scene and the crew find that the patient is a minor. The EMT or Paramedic would need a Minor Consent. This is why it is important for a guardian of the child to have a note stating that the parents give consent to the guardian. 

It's important that the EMT obtain parent or legal guardian consent. If no parent or guardian is available then the concept of implied consent or emergency doctrine is use. What is an emergency doctrine? 

principle that allows individuals to take action in the face of a sudden or urgent need for aid, without being subject to normal standards of reasonable care. Also called imminent peril doctrine, or sudden peril doctrine.

Signs of adequate breathing in a patient

Name the signs of adequate breathing in a patient

Rate of breathing is 8-24 respiration per minute for adult. 15-20 respiration per minute for a child and 25-50 respiration per minute for an infant. 20 respiration per minute for elderly. Rhythm will be regular. Quality of breath sounds will be equal. Depth (tidal volume) is good. The chest will rise fully with each inhalation.

Adequate and Inadequate breathing

Outline the assessment techniques you would use to determine if the Pt breathing is adequate or inadequate.

The two important things to determine if a Pt has adequate or inadequate breathing is the rate a patient is breathing and how deeply a patient is breathing. This is the minute volume and the tidal volume of a Patient. 

Other EMT information you might enjoy:

Sunday, April 17, 2016

EMT and airway junctions

Name the two airway adjuncts that can be inserted to assist in establishing and maintaining an open airway, and explain the circumstances in which each should be used.

The two airway adjuncts that can be inserted are the Oropharyngeal Airway and the Nasopharyngeal Airway.  A Nasopharyngeal Airway should be used if the Pt is responsive, has a gag reflex, clenched teeth, biting, or a Pt that has injuries to their face. 

Of course this question doesn't go into detail on which Oropharyngeal or Nasopharyngeal an EMT should use. It also doesn't discuss how to insert either of these tools to help a patient breath. 

EMT methods of opening airways

Describe the two manual methods an EMT shoud use to open an airway, and explain the circumstances in which each should be used.

The two manual ways of opening an airway is the head tilt, chin lift maneuver or the Jaw thrust maneuver.  Either maneuver can be used if no spinal injury is suspected with an adult. With Children, the head tilt, chin life maneuver is preferred. 

I know this is a short answer but I promise to include pictures of what a chin lift maneuver and a Jaw thrust maneuver should look like. In the future I will describe step by step what should be done. I plan on including pictures for this EMT lesson.

It's important to know both ways of opening an airway out in the field. As an EMT you will never know what the scene is going to be like and what you will come against. 

Save the puppy Arlington FD!

So you called EMS for a congestion

I have another story while in uniform for you. I'm just surprised that in one weekend EMT, Paramedics, Fort Worth Fire Department, and Fort Worth Police Department got involved in trivial things. It's the night of the storm. I'm already stressed because Tarrant County is under Tornado watch. I have five partners to work with and over 600 clients to keep safe and sound.

A homeless man comes up to the front door saying that his camp got flooded out on Hulen and could he come in. I informed him that we did not have any beds left in the mens dorm and that our policy is that you had to be a Police or Hospital drop off. It seems the guy had selective hearing and only wanted to hear Hospital drop off.

"Will you call the Police?"
"No we don't have an issue that the Police need to handle"
"Will you call the ambulance?"
"Do you have a medical emergency?"
"Yes, I'm having trouble breathing."
"Sigh, You can use the pay phone."

He had spent the past fifteen minutes arguing with me about letting him into the building. There was no way in hell that I was going to call 911 unless I personally saw signs of breathing distress.

Here comes the Fort Worth Fire Department Truck #2 with sirens blaring and lights flashing. Medstar unit follow closely behind "Code Red". I'm all happy because these are my guys and I love seeing them in action but I'm so sorry they had to get out of bed at midnight for something like this.

The man had a congestion....

Let's just say that I was such a bad girl. I tore into this guy. So bad that I had to apologize to the Paramedics for my raised voice. You just don't call my guys out of their beds and away from their lunches because you wanted them to persuade me to let you in the building. These Firefighters and Paramedics could have been at another scene saving a life.