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    Default A rare serious issue from me.........

    We were dispatched for a pick-up truck vs. Amish buggy...ejection w/ serious injuries. Upon arrival we found an OBVIOUSLY critically injured, elderly female laying in a ditch. We maintained an airway and started c-spine immobilization prior to ALS arrival. An Amish crowd had gathered and became instantly intrusive onto our scene at the mention of a helicopter on our radios. They insisted that she was not to be flown as it was against their belief system. Generally flight time to the nearest Level One Trauma Center is twenty minutes as compared to a 1 hour and twenty minute drive by ambulance. She was semi-conscious, but not coherent enough to make her own decision. The medic, our Chaplain and myself plead our case as we worked to package her and start IV lines. Still they balked. The patient was transported via ambulance to the nearest ER and the chopper was diverted there. Upon arrival, the patient was loaded into the helicopter and flown to Level One Trauma Center. Her husband was flown there later on with internal injuries. Unfortunately, later that night she passed away.

    This was the first time I've have ever dealt with such an issue in the field. I was always under the impression that if the adult patient could not voice their own request...the standard protocol of care should be rendered, regardless of other's demands or wishes.




    (sidebar) We have flown other Amish patients will no difficulty before, but as they are self-insured, we have heard it is more of a financial issue rather than beliefs issue.


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    I understand that the Amish have concerns about technology, hence the horses and buggies. Being otherwise unfamiliar with Amish doctrine, it strikes me odd that they objected to the helicopter, yet had no apparent problem with being transported in a squad.

    Generally, if the patient is unable to refuse care due to being unresponsive or otherwise unable to refuse, implied consent pretty much rules. This is in spite of what unrelated bystanders might say. They ain't got a nickle in that dime, so it doesn't much matter what "they" think.

    We've loaded patients into the aircraft at a site remote from the crowd in the past, but the crowd that we were avoiding had a history of a little greater level of violence than I've ever heard from the Amish. It was actually a near riot, and several shots had been fired. I doubt that this would have been a concern in your case though.

    It may be an issue that you might want to address with the Amish leadership, your medical director, and possibly your Chaplain to address some of the concerns and answer questions on both side prior to another incident.
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    Stayback,
    I have not been "On the job" as long as others.
    But I have been taught to follow OUR standerd protocol,not the familys or faiths,DNR order or not.

    I have been taught by COJ's DNR orders,family wishes or beliefs mean nothing to us in the field and thats a matter for the doctors and familys when they arrive at the hospital.



    IMO you were right and did the right thing.
    Last edited by stm4710; 08-04-2004 at 11:33 PM.
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    sometimes ya just gotta punt ........good job Stayback....!
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    I have been taught by COJ's DNR orders,family wishes or beliefs mean nothing to us in the field and thats a matter for the doctors and familys when they arrive at the hospital.
    You better double check with somebody that knows for sure about that one.

    If you're given written DNR orders in the field in Ohio, you have to comply. That's not got anything to do with protocols...it's law. I know it's the same way in a lot of other states as well.
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    In my first responder class a person asked "If we come upon a victim and they or family present us DNR orders what should we do" We were told by the instructor and two FF concured with the statement"They dont mean anything to us the field".

    The Mass laws read.

    Comfort Care/ DNR Order Verification Protocol

    INTRODUCTION
    Emergency medical services (EMS) personnel (refers collectively to Emergency Medical Technicians - EMTs and First Responders) are required to provide emergency care and to transport patients to appropriate medical facilities. EMS personnel are further required to provide treatment to the fullest extent possible, subject to their level of training. However, more and more patients, where it is medically appropriate, are opting not to be resuscitated. Many patients arrange with their physician, nurse practitioner or physician assistant for a Do Not Resuscitate (DNR) order; an order directing that the individual not be resuscitated in the event of cardiac or respiratory arrest. However, since there is currently no uniform mechanism to enable EMS personnel to recognize DNR orders in out-of-hospital settings, EMS personnel have been obligated to perform full resuscitative measures when encountering a patient unable to convey directions regarding medical treatment.

    While it is clear within the emergency medical services' community that a patient has the authority to determine his/her medical treatment, EMS personnel have been unable to consider a patient's wishes regarding resuscitation in the out-of-hospital setting where the patient is either not conscious or not competent, due to the difficulty of ascertaining the validity of these wishes in the field under emergency conditions. Usually there is no ongoing relationship between the emergency medical services personnel and the patient. Emergency conditions require an immediate response and accurate identification. Authentication of individuals and documents is difficult, if not impossible, under emergency field conditions.

    This Comfort Care / DNR ("CC/DNR") Order Verification Protocol is designed to allow EMS personnel to honor a DNR order in an out-of-hospital setting. To date, there are no standardized documents by which EMS personnel can verify a DNR order in the field, under emergency conditions. This protocol provides for a state-wide, uniform DNR order verification, approved by the Department of Public Health (DPH), that EMS personnel can instantly recognize as an acceptable verification of an existing DNR order; thus, allowing EMS personnel to honor the patient's request for no resuscitation and to provide the patient with palliative care in conformance with the Comfort Care protocol.

    PURPOSE

    The purpose of this protocol is to: (1) provide a verification/authentication of DNR orders to enable EMS personnel to honor DNR orders in out-of-hospital settings; (2) clarify the role and responsibilities of EMS personnel at the scene and/or during transport of patients who have a current, valid CC/DNR Order Verification; (3) avoid resuscitation of patients who have a current, valid CC/DNR Order Verification; and (4) provide palliative/comfort care measures for patients with a current, valid CC/DNR Order Verification. This protocol is not intended to alter the standard of practice in issuing DNR orders in any way, but only to provide a standardized mechanism for the verification of the DNR order so that it may be recognized in out-of-hospital settings.

    DEFINITIONS

    For purposes of this protocol, the following are defined:

    1. Attending Physician: A physician, licensed pursuant to M.G.L. c.112 2, selected by or assigned to a patient, who is responsible for the treatment and care of the patient, in whatever setting medical diagnosis or treatment is rendered. Where more than one physician shares such responsibility, any such physician may act as the attending physician for purposes of this protocol.

    2. Authorized Nurse Practitioner ("Authorized NP"): A registered nurse in the Commonwealth with advanced nursing knowledge and clinical skills as required by M.G.L. c. 112, 80B and 244 CMR 4.00 et seq. A nurse practitioner may write a DNR order, where this activity is agreed upon by the nurse practitioner and the collaborating physician in written practice guidelines (244 CMR 4.22 (1)). It is the obligation of the nurse practitioner, the collaborating physician, and the institution where the nurse practitioner is practicing at the time the CC/DNR is issued to ensure that the nurse practitioner is authorized under his/her written practice guidelines to write a DNR Order and by extension to sign the Comfort Care Verification form.

    3. Authorized Physician Assistant ("Authorized PA"): A person who meets the requirements for registration set forth in M.G.L. c. 112, 9I, and who may provide medical services appropriate to his or her training, experience and skills under the supervision of a registered physician. The Board of Registration provides that a physician assistant may write DNR orders if : (1) his/her supervising physician determines that issuing a DNR order is within the competence of the physician assistant given the physician assistant's level of training and expertise (263 CMR 5.04 (1)), and (2) with regard to initial DNR orders, the physician assistant must consult with his/her supervising physician prior to issuance. A physician assistant may properly review and renew a preexisting DNR order without prior consultation with his/her supervising physician. Since the Comfort Care/Do Not Resuscitate Order Verification is a verification of an existing valid DNR order, the signing of the verification is comparable to the renewal of a preexisting DNR order. It is the obligation of the physician assistant, his/her supervising physician, and the institution where the physician assistant is practicing at the time the CC/DNR is issued to ensure that the physician assistant is authorized under his/her practice guidelines to write a DNR order and by extension to sign the Comfort Care Verification form.

    4. Cardiopulmonary Resuscitation ("CPR"): Includes for purposes of this protocol, cardiac compression, artificial ventilation, oropharyngeal airway (OPA) insertion, advanced airway management such as endotracheal intubation, cardiac resuscitation drugs, defibrillation and related procedures.

    5. Comfort Care / DNR Order Verification Bracelet ("bracelet"): A bracelet modeled after a hospital identification bracelet, which shall include the patient's name; date of birth; gender; date of expiration, if any, of the underlying DNR order; and the signature and telephone number of an attending physician, authorized nurse practitioner, or authorized physician assistant. The bracelet can only be issued to someone who has a valid CC/DNR Order Verification Form and must be issued by an attending physician, authorized nurse practitioner, or authorized physician assistant. Wearing the bracelet is voluntary; however, it is strongly recommended for individuals who remain mobile.

    6. Comfort Care / DNR Order Verification Form ("form"): A standardized state-wide form for verification of DNR orders in the out-of-hospital setting, approved by the Department of Public Health. The CC/DNR Order Verification Form shall include the patient's name; date of birth; gender; address; date of issuance and date of expiration, if any, of the underlying DNR order; the signature and telephone number of an attending physician, authorized nurse practitioner, or authorized physician assistant; and the signature of the patient, guardian or health care agent. The CC/DNR Order Verification Form is the only DNR document that EMS personnel will be instructed to honor and can only be issued by an attending physician, authorized nurse practitioner, or authorized physician assistant.

    7. Comfort Care / DNR Order Verification Protocol: A standardized state-wide patient care protocol to be followed by EMS personnel (EMTs and First Responders) when encountering a patient with a current, valid CC/DNR Order Verification Form and/or Bracelet. The protocol provides that the patient in respiratory or cardiac distress will receive palliative, comfort care consistent with the scope of the EMT's training and certification, but no resuscitative measures. The protocol applies to all emergency medical services personnel (Basic, Intermediate and Paramedic EMTs and First Responders) operating in an out-of-hospital setting and requires that they perform patient assessment and treatment in accordance with this protocol.

    8. Emergency Medical Services Personnel: Any EMT certified pursuant to 105 CMR 170.000 et seq. and any First Responder as defined in 105 CMR 171.050.

    9. Guardian: An individual appointed by the court, pursuant to M.G.L. c. 201, 6, 6A, or 6B, to make decisions for a person who is mentally ill, mentally retarded or unable to make or communicate informed decisions due to physical incapacity or illness, provided that the appointment as guardian includes the right to make health care decisions; or, a parent or other individual who is legally entitled to make decisions about the care and management of a child during his/her minority.

    10. Health Care Agent: An individual authorized by a health care proxy to make health care decisions on behalf of the principal, pursuant to M.G.L. c. 201D. The authority of the health care agent becomes effective only upon a written determination of the attending physician, pursuant to M.G.L. c. 201D, 6, that the principal lacks the capacity to make or to communicate health care decisions.

    11. Life-sustaining procedure: Cardiopulmonary resuscitation, as defined in number 4 above. Life-sustaining procedures shall not include any medical procedure or intervention considered necessary by the health care provider, EMS personnel, or the medical control physician to provide comfort care or to alleviate pain.

    12. Medical Control Physician: A physician designated within the EMS system to provide on-line and off-line medical direction to EMS personnel.

    13. Palliative care: Comfort care that eases or relieves symptoms without correcting the underlying cause or disease.

    14. Out-of-hospital: Any setting outside a hospital where EMS personnel may be called and may encounter patients with CC/DNR Order Verifications including, but not limited to, long-term care, hospice, assisted living, private homes, schools, inter-facility transport, and other public areas.

    AUTHORITY

    It is well settled in Massachusetts that individuals, while competent, have the right to determine the course of their medical treatment, including the right to refuse medical treatment and to make end of life decisions. Norwood Hospital v. Munoz, 409 Mass. 116, 564 N.E.2d 1017 (1991); Brophy v. New England Sinai Hospital, 398 Mass. 417, 497 N.E.2d 626 (1986); Lane v. Candura, 6 Mass. App. Ct. 377, 376 N.E.2d 1232 (1978); and Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728, 370 N.E.2d 417 (1977). Similarly, it is recognized that incompetent individuals have the same right to determine the course of their medical treatment as well as to refuse medical treatment. Brophy v. New England Sinai Hospital, supra; Saikewicz, supra; Matter of Spring, 380 Mass. 629, 405 N.E.2d 115 (1980). See also, Matter of Dinnerstein, 6 Mass. App. Ct. 466, 380 N.E.2d 134 (1978); and Care and Protection of Beth, 412 Mass. 188, 587 N.E.2d 1377 (1992).

    As an extension of the health profession into the field, the emergency medical system has the same obligation to recognize an individual's right to refuse medical treatment in an out-of-hospital setting, where the authenticity of the documentation can be validated.

    Further authority: M.G.L. c. 111C and 105 CMR 170.000 et seq.; M.G.L. c. 111 201 and 105 CMR 171.000 et seq.

    IMPLEMENTATION PROCEDURES

    Eligibility: Anyone with a current valid DNR order is eligible for a CC/DNR Order Verification (Form and/or Bracelet), including minors.

    A DNR order is an order, executed by a physician, authorized nurse practitioner, or authorized physician assistant, issued according to the current standard of care. The standard for issuing the DNR order is neither defined nor changed by this protocol. This protocol simply serves to verify, for EMS personnel, a DNR Order issued according to the current standard of care.

    Validity: To assure that a DNR order is recognized in any out-of-hospital setting, an attending physician, authorized nurse practitioner, or authorized physician assistant must provide a patient, who has a current DNR order, with a fully executed CC/DNR Order Verification. Pursuant to this protocol, EMS personnel will be instructed to honor a current valid CC/DNR Order Verification Form or CC/DNR Order Verification Bracelet. Patients without CC/DNR Order Verification Form or Bracelet will be resuscitated by EMS personnel in accordance with standard EMS protocols.

    Content: The CC/DNR Order Verification Form shall include:

    the name, date of birth, gender, and address of the patient;
    the name of the guardian or health care agent, if any;
    the signature of the patient or of the guardian or health care agent;
    verification by the attending physician, authorized nurse practitioner, or authorized physician assistant, of the existence of a current valid DNR order;
    the signature and telephone number of the attending physician, authorized nurse practitioner, or authorized physician assistant. If the signature is of an authorized nurse practitioner or authorized physician assistant, the name (signature not required) of the collaborating or supervising physician shall also be included;
    the issuance date and expiration date, if any, of the DNR order; and,
    authorization of EMS personnel to act pursuant to the Comfort Care protocol.
    The CC/DNR Order Verification Bracelet shall include:

    the name, date of birth, and gender of the patient;
    the expiration date of the DNR order, if any; and,
    the printed name, signature and telephone number of the attending physician, authorized nurse practitioner, or authorized physician assistant. If the signature is of an authorized nurse practitioner or authorized physician assistant, the name (signature not required) of the collaborating or supervising physician shall also be included
    Expiration: To the extent that the underlying DNR order has an expiration date, the CC/DNR Order Verification Form and CC/DNR Order Verification Bracelet, if issued, shall have an identical expiration date. This protocol does not prescribe an expiration date, but rather leaves the expiration date up to the physician, authorized nurse practitioner, or authorized physician assistant who issued the underlying DNR order. If the DNR order is revoked by the physician, authorized nurse practitioner, or authorized physician assistant, patient, guardian or authorized health care agent, the CC/DNR Order Verification Form and CC/DNR Order Verification Bracelet, if any, shall be similarly revoked.

    Access: This protocol is accessed solely through physicians. Only physicians can request and receive forms from the Department of Public Health; however, a physician may distribute forms to an authorized nurse practitioner or an authorized physician assistant for whom the physician is a collaborating or supervising physician.

    This protocol is activated when EMS personnel encounter a CC/DNR Order Verification Form or Bracelet. EMS personnel must:

    confirm the identity of the individual with the CC/DNR Order Verification Form or Bracelet; and,
    confirm that the CC/DNR Order Verification Form is an original and is current and valid, or that the patient is wearing a current and valid CC/DNR Order Verification Bracelet.
    If there is a CC/DNR Order Verification Form and/or a Bracelet, and either indicates a revocation or expiration of the CC/DNR Order Verification, EMS personnel shall resuscitate.

    Patient Care: Upon confirmation of a current, valid CC/DNR Order Verification Form or Bracelet, EMS personnel shall follow the following procedures:

    If the patient is not in respiratory or cardiac arrest and the patient's heart beat and breathing are adequate, but there is some other emergency illness or injury, the EMS personnel shall provide full treatment and transport, as appropriate, within the scope of their training and level of certification.
    If the patient is in full respiratory or cardiac arrest, the EMS personnel shall not resuscitate, which means:
    do not initiate CPR;
    do not insert an oropharyngeal airway (OPA);
    do not provide ventilatory assistance;
    do not artificially ventilate the patient (mouth-to-mouth, bag valve mask, positive pressure, etc.);
    do not administer chest compressions;
    do not initiate advanced airway measures such as endotracheal intubation;
    do not administer cardiac resuscitation drugs; and,
    do not defibrillate.
    If the patient is not in full respiratory or cardiac arrest, but the patient's heart beat or breathing is inadequate, EMS personnel shall not resuscitate but shall provide, within the scope of their training and level of certification, full palliative care and transport, as appropriate, including:
    emotional support;
    suction airway;
    administer oxygen;
    application of cardiac monitor;
    control bleeding;
    splint;
    position for comfort;
    initiate IV line; and,
    contact Medical Control, if appropriate, for further orders, including necessary medications.
    If EMS personnel have any question regarding the applicability of the CC/DNR Order Verification with regard to any specific individual, the EMS personnel shall:
    verify with the patient, if the patient is able to respond;
    provide full treatment; or,
    contact Medical Control for further orders.
    If efforts are initiated prior to confirmation of the valid CC/DNR Order Verification, discontinue the following resuscitative measures upon verification:
    CPR;
    ventilatory assistance;
    cardiac medications; and,
    advanced airway measures.
    Established IV lines and advanced airways should remain in place.


    Documentation: When a CC/DNR Order Verification Form and/or Bracelet is encountered by EMS personnel, it shall be documented. EMS personnel must also document palliative care provided to the patient and that the CC/DNR Order Verification Form or Bracelet is current and valid. Ambulance service personnel must document the presence of the CC/DNR Order Verification on the ambulance trip record.

    Revocation: EMS personnel are not to honor any DNR request where the CC/DNR Order Verification Form or Bracelet, if present, is void or not intact. If there is a CC/DNR Order Verification Form and Bracelet, and either indicates a revocation, EMS personnel shall resuscitate.

    The CC/DNR Order Verification may be revoked by the patient at any time, regardless of mental or physical condition, by the destruction or affirmative revocation of the CC/DNR Order Verification, or by his or her direction that the CC/DNR Order Verification not be followed by out-of-hospital providers or be destroyed. Patients shall be instructed, upon revocation, to destroy the CC/DNR Order Verification From, CC/DNR Order Verification Bracelet, if issued, and the underlying DNR order.
    If an individual identifying him/herself as the health care agent or guardian revokes the CC/DNR Order Verification, EMS personnel shall resuscitate, as this raises an issue of doubt as to the validity of the CC/DNR Order Verification.
    EMS personnel, upon witnessing or verifying a revocation, shall communicate that revocation in writing to the hospital to insure its inclusion in the patient's medical record. Ambulance service personnel shall document the revocation on the ambulance trip record.

    In any situation where EMS personnel have a good faith basis to doubt the continued validity of the CC/DNR Order Verification, EMS personnel shall resuscitate.

    I belive the last paragraph was what said instructor meant for us as at the time we were only explorers and if treating would only be in good faith....and we would not have the training to tell a valid from invalid DNR order. Thanks steamer putting that doubt thier and makeing me look. I guess I took his statement wrong

    http://www.mass.gov/dph/oems/comfort/ccprot2a.htm
    Last edited by stm4710; 08-05-2004 at 12:15 AM.
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    A DNR order is a DNR order is a DNR order ...... NO MATTER WHAT ..... if you are handed one IN the field you had damn well better act according to the wishes of the pt or your *** is on the line. Are you saying Jesse, that if a pt has a valid, signed DNR which is presented to you in the field that you DISREGARD it and start interventions anyway "because your protocol says so"....... who made you or the authors of your protocols GOD???? A DNR order is a patients right to have a FINAL say in their care when they may not be able to verbally have that say, if they don't want any heroic measures then ya don't go down that road, simple.

    Here's a little food for thought........ My Mom passed away in June, she had a DNR order (she'd had that for quite some time). She just quit breathing, NO ONE decided that her DNR order was no good, they abided by it and left her to rest in peace. I can say one thing for sure, had ANYONE laid hands on her to perform heroic measures they'd have had a fight on their hands as my Father, myself and my brother were well aware of her wishes ....... I myself had just gone through her DNR in the Spring to make sure all the t's were crossed and the i's dotted ...... so yeah Jesse, when it comes to DNR's the wishes of the patient DO matter.
    Last edited by PFire23; 08-05-2004 at 12:13 AM.
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    Originally posted by stm4710any situation where EMS personnel have a good faith basis to doubt the continued validity of the CC/DNR Order Verification, EMS personnel shall resuscitate


    Jesse what this means is .. if you are presented with a DNR in the field that you have VALID concerns regarding it's validity and can back up your concerns with a logical explanation, ie: it wasn't signed, it appeared to be a photocopy, it wasn't signed by a MD, etc. THEN, AND ONLY THEN do you take heroic measures and interventions.
    Last edited by PFire23; 08-05-2004 at 12:27 AM.
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    [QUOTE]Originally posted by PFire23
    Originally posted by stm4710any situation where EMS personnel have a good faith basis to doubt the continued validity of the CC/DNR Order Verification, EMS personnel shall resuscitate

    Jesse what this means is .. if you are presented with a DNR in the field that you have VALID concerns regarding it's validity and can back up your concerns with a logical explanation, ie: it wasn't signed, it appeared to be a photocopy, it wasn't signed by a MD, etc. THEN, AND ONLY THEN do you take heroic measures and interventions.
    Yes Jenn
    I understand that now,my previous thought was that since we were not trained in checking validity(haveing never seen one)then we in "good faith" would resuscitate, I was wrong.
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    As long as it's on a medical form (in Canada they are on specific forms don't know about there), are signed and dated by a Medical Doctor in ink and is not a photocopy then it is deemed valid. Sometimes it comes down to a judgement call, you have to look at it and make a decision as to whether or not it appears valid. The only time I ever accept a photocopy is when we are transporting pt's between facilities for procedures, then we WITNESS the RN make the photocopy and we take that with us so the original remains in the pt's file. Upon returning them to said facility the photocopy is returned with them.
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    I was taught in my 'legality in ems" class that if there is a legal form of a DNR that the family has handed to you, you can not do anything to bring them back after they code. If the DNR can not be produced, then work the code. The piece of paper must be present.
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    Stayback,

    There are different sects of Amish just as there are different sects of other religions and churches.

    There may have been a valid objection based on their belief's but you definitely handled it well.

    I grew up about two hundred miles east of your location and although we were not in the heart of Amish country, we did have a few families around.

    Some had telephones but not in the house. They were in a box mounted on a pole out in the yard. Other would use pay phones or go to a non Amish neighbor to make phone calls. They always insisted on paying for the use of the phone.

    There was also a sect that we called the "Black Bumper Amish". They owned vehicles that were painted black includung the chrome.

    Sometimes you just have to make your best call in the field. There are groups other than Amish that could give you problems. They do not believe in medical treatment other than prayer.

    I won't get into the DNR debate other than to say we are bound by law in this state to honor them. I have been presented with them several times and have complied including one that was written out of state. The family was here visiting relatives and the Pt was a terminal cancer Pt.

    Stay Safe
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    Default We Have Amish here in Upstate NY

    I would never second guess anyones decision unless it was so far out of normal proceedure has to cause greater harm..sound like you made a good call to go to the nearest ER and fly from there. If the patient can't speak for themself and is not a minor then you do what's proper for the patient and not the family.....and like steamer said "Generally, if the patient is unable to refuse care due to being unresponsive or otherwise unable to refuse, implied consent pretty much rules. This is in spite of what unrelated bystanders might say. They ain't got a nickle in that dime, so it doesn't much matter what "they" think." Good Call
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    thank you Jenny for the MAJOR pee-ppe spankin of another misguided post by Jesse.
    IACOJ both divisions and PROUD OF IT !
    Pardon me sir.. .....but I believe we are all over here !
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    LETHA' FOREVA' ! 010607
    I'm sorry, I haven't been paying much attention for the last 3 hours.....what were we discussing?
    "but I guarentee you I will FF your arse off" from>
    http://www.firehouse.com/forums/show...60#post1137060post 115

  15. #15
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    Time for my advice......

    First:

    But I have been taught to follow OUR standerd protocol,not the familys or faiths,DNR order or not.
    This is in spite of what unrelated bystanders might say. They ain't got a nickle in that dime, so it doesn't much matter what "they" think.
    No but just because the protocols (which is a GUIDELINE) says to do it, they do not fit every situation. You may need to fly someone, but if the crowd makes it hostile for you, you obviously don't do it in front of them. You do as Stayback did, transport towards the ED, have the chopper meet you and load the patient there. It is a safety issue, and you also do not spend time arguing on scene over it - very unprofessional to do so.

    Cookbook medicine has no place in this job. As I said, Protocols are guidelines for treatment. Just because the yutzes at Mass. OEMS say you have to do this, doesn't mean it gets done. If I have to start an IV because of protocol says so and my patient doesn't want it, you know what - they aren't gettting it. That does not mean that I will not inform them as to the whats and whys of the procedure, but if they still do not want it, they aren't getting it. That is called Battery, and I am not going to jail for it.

    From the information we have I think they did the right thing, transport by truck, diffuse the situation, and as far as these folks are concerned their wishes were obliged and the doctor made the call to fly patient, not EMS.

    I agree though, a meeting with the Amish leaders in the area is very much in order. See if a compromise may be reached or if they can be brought to think along the same lines as EMS. It is for the well being of a person, not personal motivations other than that. THis is why we wanted to fly the person.

    As for DNRs:

    In Massachusetts the DNR order has to be completed on an official Mass. Comfort Care / DNR form (CC/DNR). If it is not on this form then it does not get honored. No ifs, ands, or buts. I have had discussions with nurses and physicians over this when they tell me it is written in the patient's chart that they are a DNR. I Tell them I don't care, show me the form and / or bracelet (the forms have a bracelet the patient may wear as well). No form we do our job.

    That being said, I always look for a reason not work them. Any hint of lividity, rigor, or other obvious signs of death, I don't work 'em.

    The same goes on at a residence or out in the streets. If the patient or family does not have a valid DNR order handy, they get worked, regardless of what the family wants (in most situations). That is the law. Again, I am not going to jail so I will do my duty.

    I have been taught by COJ's DNR orders,family wishes or beliefs mean nothing to us in the field and thats a matter for the doctors and familys when they arrive at the hospital.
    I will go with this. We were always trained to cover our butts. If there is a doubt to the validity of the order, work 'em, bring 'em to the ED, and let the doc sort it out. He makes 6 or 7 times my pay and pays a lot more in malpractice to make those decisions.
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    Only until recently (under certain circumstances) are EMTs and paramedics allowed to HONOR DNRs in the field in Indiana...protocol and law stated that all attempts must be made to save the pts. life...
    the argument/suppsed law suits were that at the family could change their mind at the last minute..and agencies were getting sued because they let "gramma' die..

    The law and protocol changed a few years ago...now it is only certain rigid circumstances are we still allowed to honor DNRs in the field

    I know it sounds ridiculous..but thats the way it was..

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    Sometimes you just gotta do what you gotta do. Ever done CPR essentially "for the family" when it would ordinarily be contraindicated? or to keep an angry mob from taking their anger out on your crew? scoop and run in the face of an agitated crowd?

    I'd say you took the best available option this time. Good call.

    I like the idea of "preplanning" with church and community leaders. If this a widespread issue that is likely to come up again in your (and other) communities, can your state EMS board provide guidance?
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    Default back to the original topic

    Stayback, if I had been in your shoes, that chopper would have landed and taken the woman from the scene to the hospital. if she is unable to make her own decisions, then implied consent takes over. as for the cost thing, just imagine how much it costs for an ALS transport if you are not insured. and besides, cost shouldn't be a factor when you are treating someone. It's more of a belief (and amish aren't the only ones) that nothing should be injected, anti-biotics shouldn't be taken, and moderm medicine has no place in society. their faith will heal the sick and injured.

    I know I would definately sleep better knowing I did all I could to save a patient's life, followed all my local protocol and state laws, then if I had listened to bystanders of the same religion of her and she ended up passing away.
    If my basic HazMat training has taught me nothing else, it's that if you see a glowing green monkey running away from something, follow that monkey!

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    There was no DNR...just the wishes of a few Amish at the scene. I've been rolling it around in my head and I still think we made a decent choice. The ambulance that took her to the ER had established ALS care and the bird was waiting for them when they got there.
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    You may need to fly someone, but if the crowd makes it hostile for you, you obviously don't do it in front of them.
    They're called police officers; use them.

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    I had a call recently where there was an elderly gentleman who had gone into cardiac arrest. The daughter claimed that she did not want CPR/other care performed on him, she claimed power of attorney. I tried (while bagging the pt. while others were performing compressions) to explain that without a DNR, we had to act. There was an uproar from the family, but we scooped him up and got him out to the ambo to meet the medics. It didn't matter what the other members of her community or family want, implied consent is applicable.

  22. #22
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    They're called police officers; use them.
    Depends on how many of them you have and how big the crowd is. There are other things a police officer needs to worry about as well. Everything is situationally dependent, and that is what I make my decisions and judgements on.
    "Too many people spend money they haven't earned, to buy things they don't want, to impress people they don't like." Will Rogers

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    "As Americans we must always remember that we all have a common enemy, an enemy that is dangerous, powerful and relentless. I refer, of course, to the federal government." - Dave Barry

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    Firstly I will agree with Pfire on the administration of a DNR in Canada. It has to be an original and be made available to the first arrived unit and must travel with the pt.

    We do not under any circumstance accept "verbal" instructions from family or by-standers; at that time full emergency protocols go into effect.

    That being said - I do believe that Jesse was only posting what he was given as a text book answer from his class. The language was pretty "Legalese" to me.

    On the position of SB, I have something of a local anecdote from 4 or 5 yrs ago. There was a report of a serious MVA, involving a Jehova (sp?) Witness (elderly) couple. Both were very badly injured, and one of them (I do not remember which) eventually died of sustained injuried because as most of us know, persons of that faith can not accept blood transfusions. In this case, there was nothing that could be done as representatives of the Church were present and refused to allow the transfusion.

    In his situation, I think SB and his dept did the best they could with the situation they had.
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    1) Regarding the Amish situation...
    From what I've always read on them, I wouldn't see the helicopter being against their religion. Maybe this was a particularly ultra-conservative sect, but I suspect it was more a conservative feeling of those there that they shouldn't have her flown without first checking with a Bishop if that would be acceptable.

    Things can get stressful, and transporting a short distance to a modified scene may be the best way to defuse a situation.

    There are other things we do in EMS that are meant for feelings more than anything (i.e. our protocols to transport SIDS even when mortality is obvious so the parent's aren't left sitting in the house with a cop waiting for the funeral home to show up).

    2) Regarding DNRs
    Two situations come to mind.
    One, I've been presented with a valid Massachusetts DNR form on a CPR call.
    Only one small problem...we're in Connecticut. Tried to get medical control permission to discontinue resuscitation...they ordered her transported ALS...grrrrr.

    Second, in Connecticut the decision whether a DNR is valid doesn't rest with the EMTs. We can only follow a written DNR presented to us by the staff of a licensed medical care facility (i.e. the Nurse at the Nursing Home hands it to us and states the patient is DNR.) or the patient outside of a licensed facility is wearing a special orange "DNR" wristlet. There is no recognition under EMS protocols of a written DNR outside of institutions -- it's bracelet only, and if the bracelet isn't properly on the patient (on the floor, nightstand, torn, carried on a necklace, etc) you resuscitate. We rely on either the staff handing us an order they state is valid, or we rely on the existence of the bracelet. Otherwise we gotta pump.
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    Interesting comment on the bracelet. During my last re-cert that question was raised. Currently in Canada, we do not use any form of physical identification, other than a written document to indicate that a DNR is in effect.
    If you don't do it RIGHT today, when will you have time to do it over? (Hall of Fame basketball player/coach John Wooden)

    "I may be slow, but my work is poor." Chief Dave Balding, MVFD

    "Its not Rocket Science. Just use a LITTLE imagination." (Me)

    Get it up. Get it on. Get it done!

    impossible solved cotidie. miracles postulo viginti - quattuor hora animadverto

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