4/14/2016. Take ownership of the care - This is my patient!

Transcription

1 Guidelines and Training in how to be a Emergency Health Professional NAVIGATOR 2016 Paul Stiegler MD FACEP Medical Director EMD Dane County PSCC Onstar LLC Take ownership of the care - This is my patient! - In order to help -you need to understand what is going on! - From the moment you pick up that call, you have established : - A Patient-caregiver relationship. Duty to treat. "Duty to treat" implies that the licensed health care professional (HCP) agrees to practice medicine and accepts a patient for the purposes of medical treatment. In doing so, HCP-patient relationship is established and a contract to provide care exists. The HCP owes each patient the duty to possess and to bring to bear on the patient's behalf that degree of knowledge, skill, and care usually exercised by reasonable and careful practitioners under similar circumstances, given the current medical knowledge and the available resources. 1

2 You are there to take control of the situation and provide the appropriate help. You have the training to determine when EMD is needed the caller may not know that they need EMD. This training is intended to give you the support to start thinking like an emergency health professional. Treat the patient as if you are their doctor. Doctors usually don t ask patients if they want to take the medicine Doctors don t usually ask if they want treatment Doctors don t thank them for answering their questions Your job is to get the callers the help they need while telling them what they need to do. Callers assume you know how to do that. That is the service they expect when they pick up the phone to call 911. This is probably the first time this caller has ever called 911. At the end of the call they want to make sure they ve done everything to help their loved one/friend/bystander They need your support as you gather critical information The protocol is there so you don t miss anything like a pilot s check list. However, at the same time, it helps to have situational awareness of what is actually going on. This is the PRACTICE of medicine and being a health care giver. It takes active practice and study. There is more to EMD than the protocol. Situation awareness (SA) is the perception of environmental elements with respect to time or space, the comprehension of their meaning, and the projection of their status after some variable has changed, such as time, or some other variable, such as a predetermined event. 2

3 It is also a field of study concerned with understanding of the environment critical to decision-makers in complex, dynamic areas from, power plant operations, military command and control, and emergency services such as emergency dispatch, fire fightingand policing; to more ordinary but nevertheless complex tasks such as driving an automobile or riding a bicycle. Situation awareness involves being aware of what is happening in the vicinity to understand how information, events, and one's own actions will impact goals and objectives, both immediately and in the near future. One with an adept sense of situation awareness generally has a high degree of knowledge with respect to inputs and outputs of a system, an innate "feel" for situations, people, and events that play out because of variables the subject can control. Lacking or inadequate situation awareness has been identified as one of the primary factors in accidents attributed tohuman error. [1] Thus, situation awareness is especially important in work domains where the information flow can be quite high and poor decisions may lead to serious consequences (such aspiloting an airplane, functioning as a soldier, or treating critically ill or injured patients). 3

4 We have script to help us be consistent in obtaining data, giving instructions and using as a check list. What we don t have is guidelines on how to picture the scene and understand what is actually going on with the patient, especially when things CHANGE..and how to adapt to every new situation. This is the ART and PRACTICE of medicine. The ability to learn how to do this can come naturally, or it may need a lot of hard work, time, and experience. We are all different in this. But being able to be situationally aware definitely helps take care of patients and can guide us naturally in the right direction when times are tough. Just before answering the next call, prepare yourself. Be ready mentally for anything might happen. Realize that for the person on the other end of the phone, this may be the only time they call an emergency line. Try to imagine what they are feeling, seeing, touching, and hearing. If you ask their name, be sure to use it after that. The question Tell me exactly what happened? is critically important to understand before going on. That is the first time to picture the scene. It s absolutely OK, recommended, and needed, to ask clarifying questions if the EMD cannot answer that question. Obviously asking the question a second time would be the first option, but then after that clarifying if needed. 4

5 Every key question should add detail to the picture the EMD imagines in their head. It should done at the same time as getting through the script. Study and learn the pre-question qualifiers! Know when you might see these. So many times the EMD either reads them or doesn t see them and reads the wrong question. Understand that the post-dispatch instructions script can be alteredto fit the situation. They are not always needed to be read as written depending on the situation. Read them as if you are the caller listening to them. They should make sense. For example, no need to say if he is still seizing,., If you know and the caller know they are still seizing. No need to say don t move him unless he is in danger if you know patient is not breathing effectively and you will need to open their airway. Once the EMD knows if the caller is with the patient, don t ask it again later when going into PAIs better to ask where exactly are you and where is the patient? This helps you help them where to go. At any point during the call, the EMD should be able to answer the theoretical question describe what you see right now? They should be able to describe the scene as if they are drawing a picture of it. Part of that description should include the true status of consciousness and breathing of the patient. If the EMD doesn t know, then it should be asked and clarified as often as needed 5

6 During pre-arrival instructions, always understand the condition of the patient. When given information that the patient s condition may have changed, be sure to go straight to asking about status of consciousness and breathing to re-verify Always feel comfortable alerting the caller to what you may need them to do as a pre-script. This will actually help them help the patient more easily and effectively. Examples are: We need to do a breathing test., Get out of the car, if safe, go around to their side hit the latch on the seat, His breathing is critical we need to get him out of the car to do cpr Case Entry-No Gaps! First time to show you care and find out who is your patient..and first time to find out if any need for life saving DLS. If more than one symptom, OK to clarify i.e. what was the main symptom that caused you to call 911? Ok to ask what do you mean by.? Assume your patient is breathing ineffectively until proven untrue. Act with empathetic urgency.not speed, to show caller you care. Abdominal pain hurts as does all pain empathize. Callers are afraid it s the worst (heart attack, stroke, poisoned, severe infection, fatal choking, appendicitis ). Callers may be unsure about bothering you. Reassure them Callers assume you know what to do..havean answer prepared for any question they might ask why the safety pin? Anxious/angry/hostile/hysterical patients are still YOUR patients. There are many reasons for these emotions, many may be medical. You need to be their advocate. Patients don t care about your feelings 6

7 What is the one thing a caller wants?... AN AMBULANCE.ok to tell them one is coming at any time sooner the better. Do not stop PAIs until 1 st Responder physically present and taking over! Don t abandon them to lower level of care Tell caller what to do, don t ask if they can It s only a matter of time..ineffective breathing, severe bleeding. Act with urgency until you are sure they are stable. State of being where the patient has a complete or near complete lack of responsiveness to people and all other stimuli. They are typically asleep and cannot raise any part of their body on their own. Their breathing may be normal or labored depending if they can control their airway reflexes. Remember it is a spectrum. Only full unconscious pts need to be layeddown and airway stabilized. Unconscious Semi-conscious LOOK AT HER/HIM VERY CLOSELY AND TELL ME WHAT YOU SEE AND HEAR HER/HIM DOING 7

8 Therefore: Unconsciousness/semi-conscious/not alert are a spectrum. Being aware of the scene and taking care of your patient involves constant assessment and reassessment, including visualizing the scene. The concept that a patient is having such a hard time breathing, that they are not getting enough oxygen to the brain to stay awake and oxygen level will continue to drop until they expire. EVERYTHING ELSE IS SEVERE RESPIRATORY DISTRESS OR LESS.AND THEY ARE STABLE FOR NOW Remember: Just because the patient may qualify as ineffective breathing for coding purposes in case entry, yes, but barely!.doesn t mean they actually are breathing ineffectively. You have to prove it in key questions and definitely before you pick the appropriate DLS link. 8

9 Requires you understand the situations when to use it. Is for UNCONSCIOUS patients where you as the EMD are UNSURE if they are breathing effectively Seizures After the twitching/jerking has stopped to verify effective breathing, or to make sure it wasn t a cardiac arrest disguised as a seizure. Unconscious patients When answer to key question #1 Is her/his breathing completely normal? is NO During Airway/Arrest PAI Check breathing (panel 3) -When answer to Is s/he breathing normally? is NO If a non-breathing patient starts breathing again ANYTIME the EMD is concerned the unconscious patient may be changing and/or breathing is worsening. Patient is NOT breathing (go to PAIs) Patient is conscious Patient is awake and talking or just talking Patient is up and moving around Patient is combative Patient is too far away to assess properly Patient still somewhat awake with severe respiratory distress Sorry to hear that Never say, it will be OK When asked Is this a heart attack? say something like, it s one of the possibilities, that s why we are getting you help Never say, Hope everything turns out all right Don t use technical language, ( ineffective breathing, agonal breathing, stroke diagnostic ) 9

10 ARE YOU AN AWARE HEALTH CARE PROVIDER NOW? 10