Disclaimer

1
Disclaimer

• This is an informational slide for instructors
  and not intended to be shown.
• Every attempt has been made to ensure the
  accuracy of these materials. However, statutes
  and regulations do change and the person using
  these slides should be familiar with Alaskas
  statutes and regulations related to emergency
  medical care. In the event that discrepancies
  are found, the statutes and regulations published
  by the State of Alaska have primacy.
• Users are encouraged to customize these slides to
  make them more aesthetic and useful for
  particular audiences. Again, care must be taken
  to ensure consistency with the statutes and
  regulations.

2
Medicolegal Issues
Prepared by the Section of Community Health and
Emergency Medical Services Division of Public
Health Department of Health and Social
Services Juneau, Alaska
3
Definitions

• Medicine The science and art of diagnosing,
  treating, and preventing disease.
• Law A system that provides for rights between
  parties.
• Civil Law concerns disputes among private parties
  (individuals, businesses, corporations).
• Criminal law concerns enforcement of societal
  rules against individuals.

4
Sources of Law

• Constitution
• Statutory
• Common
• Administrative

5
Areas of Vulnerability

• Emergency Vehicle Operations
• Confrontation, Lack of Rapport
• Patients Who Refuse Treatment

6
Liability Litigation (1987 - 1992)

• National Retrospective Computer Study
• 76 cases met inclusion criteria
• Half of cases involved ambulance collisions
• Half of cases involved patient care
• In almost half of cases, EMT was named as
  codefendant
• Average of 1 claim per 25,000 patient encounters

7
Ambulance Collision Cases

• Plaintiffs
• Motor Vehicle Operator (30)
• EMS Patient (5)
• Other (3)
• Settlements
• 0 - 39.5
• 1 - 10,000 - 26.3
• 10,001 - 100,000 - 21.1
• 100,001 - 1,000,000 - 10.5
• 1,000,000 - 2,000,000 2.6

8
Patient Care Cases

• Allegations of Negligence
• Arrival Delay
• Inadequate Assessment
• Inadequate Treatment
• Patient Transport Delay
• No Transport Provided

9
Patient Care Cases

• Settlements
• 0 - 42.1
• 1 - 10,000 - 0
• 10,001 - 100,000 - 15.8
• 100,001 - 1,000,000 - 31.6
• 1,000,000 - 2,000,000 - 10.5

10
Protection Against Litigation

• Good Patient Care
• Rapport With Patient and Family
• Comprehensive and Factual Written Reports
• Compliance with Standing Orders and Safety
  Requirements
• Safe Emergency Vehicle Operations

11
Standard of Care

• How a reasonable, prudent, properly trained EMT
  at the same level of training would perform under
  the same, or similar circumstances.

12
General Standards

• Provide Medically Correct Treatment Consistent
  with Scope of Practice
• Ensure Vehicle is Appropriately Stocked
  Supplied
• Ensure Equipment is in Good Working Order
• Operate Vehicle and Park in a Safe Manner

13
Consent

• Informed Consent
• Expressed Consent
• Implied Consent
• Special Circumstances
• Minors
• Patients with Impaired Mentation

14
Battery (Tort)

• Physical contact with a person without his
  consent and without legal justification.
• The plaintiff may recover monetary damages for
  battery without proving the elements of
  negligence.

15
Consent to Treat Minors

• The age of majority is 18 or when the individual
  becomes married.
• Minors can give consent for medical treatment
  when
• the minor is living apart from parent or guardian
  and manages own finances or
• the parent or guardian cannot be contacted or is
  unwilling to either grant or withhold care

AS 09.65.100
16
Consent to Treat Minors (Continued)

• A minor parent can give consent for childs care
• Consent is valid if EMS personnel relied in good
  faith on assertion of minor that he or she could
  give consent under this statute

AS 09.65.100
17
Refusal of Care

• Mentally competent adult patients have the right
  to refuse medical treatment
• Mentally competent parents have the right to
  refuse treatment for their children
• Patient should sign refusal form
• Ensure that all actions and the patient's
  condition are well documented, particularly LOC
  and assessment findings. The patient should be
  encouraged to seek medical care.

18
Negligence - Definitions

• Tort is a legal wrong for which damages can be
  awarded in court.
• Tort law is primarily common law, defined and
  evolving as courts decide cases.
• Statute of Limitations defines the period in
  which the lawsuit must be initiated. In Alaska,
  the complaint must be filed within two years of
  discovery of the alleged negligence in a tort
  action. The statute of limitations for contracts
  is 6 years..

19
Typical Causes of Negligence

• Not performing required skills
• Performing skills incorrectly
• Performing unauthorized skills

20
Requirements to Prove Negligence

• The EMT had a duty to act
• The EMTs act or omission did not conform to the
  standard of care
• Injuries occurred to the plaintiff
• The acts or omissions were the proximate cause of
  the injuries
• The injuries are of a kind for which damages can
  be awarded

21
Vicarious Liability

• Also known as respondeat superior
• Occurs when employer held responsible for
  negligence of employee or someone under
  employers control

22
Abandonment

• Defined as Terminating medical care without
  legal justification or turning the patient over
  to less qualified personnel resulting in injury
  to the patient

23
Duty to Act

• Generally, an EMT has a duty to act when he or
  she is on duty with an organization which is
  responsible for providing emergency care.
• Duty can be defined more broadly to mean an
  obligation to conform to a particular standard of
  care.
• Duties occur before, during, and after a run.

24
Anatomy of a Civil Lawsuit

• Suspicious Incident
• Investigation
• Filing of Lawsuit Within Statute of Limitations
• Service of Complaint
• Legal Representation Obtained and Answer Filed

25
Anatomy of a Civil Lawsuit (Continued)

• Discovery
• Interrogatories (written)
• Depositions (sworn, in person, and recorded)
• Trial
• Appeal
• Settlement (Possible at any time)

26
Determination of Damages

• Compensatory
• Special Damages
• General Damages
• Punitive

27
If Youre Involved in a Suit

• Always notify employer and medical director
• Always make sure that complaint is answered

28
Principles of Confidentiality

• Establishment of Physician-Patient Relationship
• Legal Requirements to Maintain Confidentiality of
  Information
• Increase in Legal Risks if Information is Misused

29
Alaska Statutes and Regulations

• Statutes
• Created by Legislature
• Example AS 18.08.080
• Regulations
• Created by Administrative Agency
• Example 7 AAC 26.030

30
Specific Alaska Statutes and Regulations

• These laws define many of the EMTs
  responsibilities and should be clearly
  understood.
• Most of the statutes related specifically to EMS
  can be found in AS 18.08.010 - AS 18.08.090.

31
Good Samaritan Law

• Encourages people to render care by decreasing
  risks of liability.
• Typically does not cover those with a duty to
  act.
• Does not cover gross negligence or reckless or
  intentional misconduct

AS 09.65.090
32
Requirements to be Certified

• Individuals must be certified in order to claim
  to be state certified as an EMT-I.
• Individuals must be certified and under medical
  direction in order to provide advanced life
  support.
• Agencies must be certified and under medical
  direction in order to provide advanced life
  support.

AS 18.08.084
33
Authority of EMTs

• Statute requires that EMTs exercising this
  authority
• must respond to an emergency with an ambulance
  service or first responder service and
• must have a current emergency medical technician
  identification card in his or her possession.

AS 18.08.075
34
Authority of EMTs (Continued)

• An EMT under this statute may
• control and direct activities at the accident
  site or emergency until the arrival of law
  enforcement personnel
• order a person other than the owner to leave a
  building or place in the vicinity of the accident
  or other emergency for the purpose of protecting
  the person from injury
• temporarily block a public highway, street, or
  private right-of-way while at the scene of an
  accident, illness, or emergency

35
Authority of EMTs (Continued)

• trespass upon property at or near the scene of an
  accident, illness, or emergency at any time of
  day or night
• enter a building, including a private dwelling,
  or premises where a report of an injury or
  illness has taken place or where there is a
  reasonable cause to believe an individual has
  been injured or is ill to render emergency
  medical care and
• direct the removal or destruction of a motor
  vehicle or other thing that the emergency medical
  technician determines is necessary to prevent
  further harm to injured or ill individuals.

36
Authority of EMTs (Continued)

• A person who knowingly refuses to comply with an
  order of an emergency medical technician
  authorized under (a) of this section is, upon
  conviction, guilty of a class B misdemeanor. In
  this subsection, "knowingly" has the meaning
  given in AS 11.81.900(a)

37
Immunity From Liability for EMTs

• Covers certified persons and agencies
• Covers physicians arranging transfer of patients
• Covers emergency medical dispatchers and
  instructors
• Does not cover gross negligence or intentional
  misconduct

AS 18.08.086
38
Reporting Requirements

• EMTs are required to report certain injuries or
  suspicions
• EMS agencies usually have standard operating
  procedures and forms for reporting
• There may be a criminal penalty for refusing to
  report
• Usually, there is immunity from liability for
  reports made in good faith

39
Duty to Report Certain Injuries

• 2nd or 3rd degree burns gt 5 or more of body
• Burns to upper airway, laryngeal edema from
  super-heated air
• Bullet wounds, powder burns or injuries
  apparently caused by firearms

AS 08.64.369
40
Duty to Report Certain Injuries (Continued)

• Injuries apparently caused by a knife, axe, or
  other sharp object, unless injuries were clearly
  accidental
• Non-accidental injuries likely to cause the death
  of patient

AS 08.64.369
41
Duty to Report Certain Injuries (Continued)

• Oral reports must be made promptly to the
  Department of Public Safety, or local law
  enforcement personnel.
• Written reports must be made within 3 working
  days of treating the patient.

AS 08.64.369
42
Child Abuse and Neglect

• Reports must be made to AK Dept. of Health and
  Social Services, Division of Family and Youth
  Services
• 465-1650 (Juneau)
• [phone]
• If child is in immediate danger, reports should
  be made to law enforcement personnel
• Reports to supervisor or medical director do not
  fulfill the reporting requirement

AS 47.17.020
43
Protection of Vulnerable Adults

• A vulnerable adult means a person 18 years of
  age or older who, because of physical or mental
  impairment, is unable to meet the persons own
  needs or to seek help without assistance. (AS
  47.24.900)
• Emergency Medical Technicians and Paramedics are
  required by statute to report suspicions of
  abandonment, exploitation, abuse, neglect, or
  self neglect must report within 24 hours after
  first having cause for the belief.

AS 47.24.010
44
Protection of Vulnerable Adults

• Reports should be made to the Division of Senior
  Service of the Department of Administration.
• 269-3669 (Anchorage)
• 1-800-478-9996
• Law enforcement personnel should be contacted if
  the adult in in danger.
• A person who knowingly fails or refuses to make
  report may be charged with a crime.
• Immunity from liability extended for reports made
  in good faith.

45
Organ Donors

• Requires that law enforcement and medical
  personnel make a reasonable search for a
  document of gift or other information identifying
  the bearer as a an organ donor or as an
  individual who has refused to make an anatomical
  gift

AS 13.50.016
46
Emergency Vehicle Operations

• This is a major source of liability for EMS
  Agencies
• EMS personnel should know and comply with state
  and local laws regarding emergency vehicle
  operations

47
Emergency Vehicle Operations

• Lighting requirements for emergency vehicles are
  specified in 13 AAC 04.090.
• Emergency vehicles may disregard laws regarding
  operation, parking, standing, and stopping
  vehicles when displaying the required lights and
  using the siren in response to an emergency.

48
Emergency Vehicle Operations

• All operators of emergency vehicles must operate
  in a safe manner.
• Studies have shown that
• In most cases, a lights and siren response saves
  little time and
• lights and sirens are used on more calls than is
  warranted by the patients condition.

49
Blue Light Laws

• Authorization issued by DPS Commissioner or
  designee
• Amended (6/97) regulations allow police chief,
  fire chief, or EMS chief to authorize if
  designated by DPS Commissioner
• The flashing blue light used by EMS personnel may
  not be illuminated except when the driver of the
  vehicle is properly certified to render emergency
  lifesaving or medical services and his vehicle
  displays the "star of life" symbol.

13 AAC 04.100
50
Blue Light Laws (Continued)

• A flashing blue light that must be visible from
  the front and sides for a distance of 300 feet in
  normal sunlight.
• The flashing blue light authorized by this
  subsection may be illuminated only when the
  driver of the vehicle is a member of a fire or a
  police department responding to an emergency, and
  the vehicle must display a sign or plate that
  indicates the department membership and the name
  of the municipality or organization in which the
  driver is a member

51
Blue Light Laws (Continued)

• Individual must provide verification that
• the person's motor vehicle complies with the
  equipment standards set out in 13 AAC 04
• the person holds a valid Alaska driver's license
  that has not been suspended, revoked, cancelled,
  or limited within the three years before the form
  is returned and
• the person has read and understands the
  regulations for emergency vehicle operation set
  out in 13 AAC 02.140 , 13 AAC 02.517 and 13 AAC
  04.100

52
Blue Light Laws (Continued)

• if requested by the commissioner or the
  commissioner's designee, the person must provide
  a certified copy of the person's driving record.

53
Blue Light Laws (Continued)

• Driver of vehicle with authorized blue light may
• park vehicle near scene in violation of traffic
  laws
• exceed the speed limit if it does not endanger
  life or property
• disregard regulations and ordinances regarding
  direction, movement, or turning, if done at
  speeds lower than posted.

13 AAC 02.517
54
Blue Light Laws (Continued)

• These privileges only exist while responding, not
  returning.
• A vehicle displaying a blue light must yield the
  right of way to an authorized emergency vehicle
  responding to an emergency.

13 AAC 02.517
55
Blue Light Laws (Continued)
The provisions of this chapter do not relieve
the driver of an authorized emergency vehicle or
a vehicle displaying a flashing blue light from
the duty to drive with regard for the safety of
all persons, nor do the provisions of this
section allow the driver of a vehicle displaying
a flashing blue light to proceed past a stop sign
or red signal without first stopping
13 AAC 02.517
56
Blue Light Laws (Continued)

• Alaska EMS Section recommends that EMTs using
  blue lights
• Drive no faster than posted speed limit and
• Obey all traffic laws.

57
Summary

• EMTs should provide good patient care while
  maintaining patient rapport
• EMTs should develop and practice good
  documentation and reporting skills
• EMTS should understand the reporting requirements
  found in Alaska statutes and regulations

58
Declaration of Death

• Allows EMTs, Mobile Intensive Care Paramedics and
  Physician Assistants to Pronounce death in
  certain circumstances.
• Amends statutes AS 09.68.120 DEFINITION OF DEATH
  and AS 18.08.098 AUTHORITY TO PRONOUNCE DEATH.

59
EMT/MICP Qualifications

• EMTs and Mobile Intensive Care Paramedics must
• be members of an EMS agency certified by the
  state and
• be unable to communicate immediately with a
  physician by radio or telephone.

60
Post Mortem Lividity

• A red or purple skin discoloration resulting from
  pooling of blood to dependent parts of the body
  after death.
• Usually discernible clearly 1 hour after death.
• Increasing in color for 6 - 10 hours after death.
  
• May be mimicked by hypothermia.
• Heat hastens the speed with which it develops,
  cold slows.

61
Rigor Mortis

• Stiffening of body and limbs.
• Discernible approximately 1 hour after death.
• Stiffening increasing for 6 - 10 hours after
  death.
• May be mimicked by profound hypothermia.
• Heat hastens the speed with which it develops,
  cold slows.

62
Hypothermia

• Cold core temperature which causes or complicates
  cardiac arrest.
• Dead bodies cool at a rate of approximately 2
  degrees per hour at room temperature.
• EMS personnel must be able to distinguish between
  hypothermia and normal cooling effects.

63
Withholding Resuscitation

• The EMT, MICP, or PA may withhold resuscitation
  efforts when the patient has injuries
  incompatible with life, including cardiac arrest
  accompanied by
• incineration
• decapitation
• open head injury with loss of brain matter or
• detruncation.

64
Withholding Resuscitation (Cont.)

• cardiac arrest accompanied by rigor mortis
• cardiac arrest accompanied by the presence of
  post mortem lividity or
• advanced life support is not available, the
  patient is not hypothermic, proper CPR has been
  performed for at least 30 minutes and the patient
  has not developed spontaneous respiration or
  pulse.

65
Terminating Resuscitation

• The patient may be pronounced dead when
• Advanced life support is not available, the
  patient is not hypothermic, proper CPR has been
  performed for at least 30 minutes and the patient
  has not developed spontaneous respiration or
  pulse
• Advanced life support has been properly provided
  for at least 30 minutes without the patient
  developing spontaneous respiration or pulse or

66
Terminating Resuscitation (Cont.)

• The patient is hypothermic and the patient has
  received at least 60 minutes of properly
  performed cardiopulmonary resuscitation in
  conjunction with rewarming techniques as
  described in the current State of Alaska
  Hypothermia and Cold Water Near Drowning
  Guidelines without the patient developing
  spontaneous respiration or pulse.

67
Resuscitation and Hypothermia

• Although the law allows CPR to be terminated or
  not started when 30 minutes of properly performed
  ALS has been performed, even on the hypothermic
  patient, the Alaska EMS Section recommends that
  resuscitation be continued for at least an hour.
• This will allow rewarming to be more effective
  and your unit to have a better chance of
  contacting a physician for additional orders and
  advice.

68
Points to Remember

• Attempt to contact physician medical control
  before pronouncing patient dead.
• Document all findings and actions carefully.
• When in doubt, resuscitate!
• If possible, have someone attend to needs of
  family during resuscitation efforts.

69
After Pronouncing a Patient Dead

• Leave IVs and Tubes in Place.
• Do not disturb jewelry, clothing, pockets, and
  other personal effects.
• Cover patient.
• Minimize Number of Personnel at Scene.

70
After Pronouncing a Patient Dead

• If death was pronounced en route
• Reattempt radio communications with physician
  medical director or hospital.
• Transport deceased in accordance with standing
  orders or contact the law enforcement agency with
  jurisdiction for additional guidance.

71
After Pronouncing a Patient Dead

• If death was pronounced on-scene
• Notify coroner and law enforcement personnel.
• Treat the scene as if it were a crime scene.
• Protect scene until coroner and/or law
  enforcement personnel arrive.
• Personnel exiting the scene should retrace steps.

72
After Pronouncing a Patient Dead (Cont.)

• If in a residence or building
• Remember what you've touched and entrance route.
• Avoid touching objects.
• Avoid using the residence telephone.
• Be prepared to describe the condition of scene,
  e.g. placement of objects, etc., when you arrived
  at the scene.

73
Notification of Patient Death

• Historically done by hospital or law enforcement
  personnel.
• This legislation will increase the frequency with
  which EMS personnel notify survivors.
• Notify survivors as early as is practicable,
  dont let suspense build.

74
Notification of Death (Cont.)

• Introduce yourself and your role.
• Use appropriate body language.
• Find quiet place, if possible.
• Take cues from survivors.
• Use the patients name.

75
Notification of Death (Cont.)

• Use simple, non-medical, clear terms
• heart attack instead of AMI.
• dead instead of no longer with us.
• Answer any questions you can.
• Allow silence.
• Ask them if they have any questions.

76
Notification of Death (Cont.)

• Touching may be appropriate.
• Dont be afraid to show your emotions.
• Ask if there is someone you can call for them,
  e.g. clergy, friend, family member, etc.
• Try to prepare survivors for what is next.

77
Notification of Death (Cont.)

• Notifying people that a loved one has died is one
  of the most stressful challenges an EMT or MICP
  may face.
• Make sure you recognize signs of stress in
  yourself and colleagues.

78
Notification of Death (Cont.)

• Reassure survivors that you did everything
  medically possible.
• If possible, reassure the survivors that there
  was nothing else they could do.
• If it is true, tell them the patient did not
  suffer.
• Arrange for support for survivors after you leave.

79
Notification of Death (Cont.)

• If it will be possible for the survivors to view
  the body, and they wish to do so, prepare them
  for how it will look.
• AS 13.50.016 requires medical and law enforcement
  personnel to make a reasonable attempt to
  determine whether patient wished his or her
  organs and/or tissues donated. If the patient
  was a donor, notify nearest medical facility.

80
Documentation

• The pronouncement of death must be certified by a
  physician within 24 hours after the pronouncement
  made by the EMT or MICP.
• Run sheets should be completed in accordance with
  local protocols.
• A copy of the run sheet should be given to the
  person completing the death certificate if
  allowed by local protocol.

81
Documentation (Cont.)

• The EMT or MICP must provide to the person
  signing the death certificate, the following
  information
• name of the deceased
• the presence of a contagious disease, if known
• date and time of death.

82
Summary

• Pronouncing death is an important responsibility
  and EMTs and MICPs must understand the law well.
• Reattempt to contact medical control before
  pronouncing death.
• When in doubt, resuscitate.
• Be responsive to your psychological needs, as
  well as those of, survivors, and other rescuers.
• Ensure activities and findings are documented
  appropriately.