2233445577__0000__FFMM--pp0000ii--xxxxvviiiiii..iinndddd ii 1111//1188//0099 44::1144::5500 AAMM Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 2233445577__0000__FFMM--pp0000ii--xxxxvviiiiii..iinndddd ii 1111//1188//0099 44::1144::5500 AAMM This is an electronic version of the print textbook. Due to electronic rights restrictions, some third party content may be suppressed. Editorial review has deemed that any suppressed content does not materially a ffect the overall learning experience. 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Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 5522660099__0000__ffmm__ppii--ppxxxxvvii..iinndddd iiii 22//11//1100 1111::3377::4433 PPMM Australia • Brazil • Japan • Korea • Mexico • Singapore • Spain • United Kingdom • United States Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 2233445577__0000__FFMM--pp0000ii--xxxxvviiiiii..iinndddd iiiiii 1111//1188//0099 44::1144::5511 AAMM Professional Paramedic: Foundations of © 2010 Delmar, Cengage Learning Paramedic Care Richard Beebe and Jeffrey Myers, DO ALL RIGHTS RESERVED. No part of this work covered by the copyright herein may be reproduced, transmitted, stored, or used in any form or by any means graphic, Vice President, Career and Professional electronic, or mechanical, including but not limited to photocopying, recording, Editorial: Dave Garza scanning, digitizing, taping, Web distribution, information networks, or information storage and retrieval systems, except as permitted under Section 107 or 108 of Director of Learning Solutions: Sandy Clark the 1976 United States Copyright Act, without the prior written permission of the Product Development Manager: publisher. Janet Maker Managing Editor: Larry Main For product information and technology assistance, contact us at Senior Product Manager: Jennifer A. Starr Cengage Learning Customer & Sales Support, 1-800-354-9706 Editorial Assistant: Amy Wetsel For permission to use material from this text or product, submit all requests Vice President, Career and Professional online at www.cengage.com/permissions. Further permissions questions Marketing: Jennifer Baker can be emailed to [email protected] Executive Marketing Manager: Deborah S. 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NOTICE TO THE READER Publisher does not warrant or guarantee any of the products described herein or perform any independent analysis in connection with any of the product informa- tion contained herein. Publisher does not assume, and expressly disclaims, any obligation to obtain and include information other than that provided to it by the manufacturer. The reader is expressly warned to consider and adopt all safety pre- cautions that might be indicated by the activities described herein and to avoid all potential hazards. By following the instructions contained herein, the reader will- ingly assumes all risks in connection with such instructions. The publisher makes no representations or warranties of any kind, including but not limited to, the war- ranties of fitness for particular purpose or merchantability, nor are any such repre- sentations implied with respect to the material set forth herein, and the publisher takes no responsibility with respect to such material. The publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or part, from the readers’ use of, or reliance upon, this material. Printed in the United States of America 1 2 3 4 5 XX 11 10 09 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 2233445577__0000__FFMM--pp0000ii--xxxxvviiiiii..iinndddd iivv 1111//1188//0099 88::1100::4400 AAMM Dedicated to the memory of John Pryor: Paramedic, surgeon, father, husband, brother, and son. On Christmas Day, 2008, while serving his country in Iraq, Dr. Pryor was tragically killed in the line of duty. Dr. Pryor felt compelled to join the U.S. Army Reserve after witnessing the effects of September 11, 2001, from the rubble pile at Ground Zero. As a member of the U.S. Forward Army Surgical Unit, Dr. Pryor volunteered for not one, but two tours of duty in Iraq, believing that he needed to be there to help others, especially his fellow soldiers. Dr. Pryor’s history as a volunteer in medical service started at age 17 with the Clifton Park–Halfmoon Volunteer Ambulance Corp., where he became an Emergency Medical Technician and later a Paramedic. These early beginnings in EMS may have led Dr. Pryor to a career as a widely respected trauma surgeon in Philadelphia. Dr. Pryor often wrote eloquently about his view of the human condition, whether he observed it in war–torn Iraq or the streets of Philadelphia. In one letter he wrote to the family of a mortally wounded Marine, he described his struggle to save the soldier. He expressed that he, his fellow physicians, and especially the Paramedics and EMTs who had the honor of serving with the dead Marine “more than anyone else, know he was a true American hero.” The life of service, love for others, and spirit of devotion of Dr. John Pryor is an example for us all. We, his fellow Paramedics, more than almost anyone else, know he was a true American hero. Dedication v Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 2233445577__0000__FFMM--pp0000ii--xxxxvviiiiii..iinndddd vv 1111//1188//0099 44::1144::5533 AAMM Foreword ........................................................xvi Architecture of EMS Systems ....................................28 Information Systems .................................................30 Preface .........................................................xviii Integration of Health Services ...................................30 SECTION I: FRAMEWORK FOR Medical Direction .....................................................31 Finance Systems .......................................................31 PARAMEDIC PRACTICE National Healthcare Systems ............................32 1. Roles and Responsibilities of 3. Workforce Safety the Professional Paramedic 2 and Wellness 38 What Is Paramedicine? .......................................4 Wellness ..........................................................40 Hallmarks of a Profession ..................................5 Benefits of Wellness .................................................40 Education Systems .............................................6 Methods Used to Achieve Wellness ............................40 Commission on Accreditation of Allied Health Stress ..............................................................41 Education Programs .................................................6 Symptoms of Stress ...................................................42 National Registry of Emergency Medical The Crisis Process ....................................................43 Technicians .............................................................6 Stress Management ...................................................43 National Association of Emergency Medical Specific Stressful Situations ......................................43 Technicians .............................................................6 Personal Injury Prevention ...............................45 National Institute of Medicine Report ..........................7 Back Injury ...............................................................46 Core Values .......................................................7 Risk Management .....................................................46 Roles of a Paramedic .........................................8 Safety .......................................................................46 Healer .........................................................................8 Infection Control .............................................49 Clinician .....................................................................8 Infectious Disease Exposure ......................................51 Researcher ................................................................10 Teacher .....................................................................10 4. research and ems 56 Patient Advocate .......................................................11 Paramedics as Physician Extenders ............................11 Practice, Protocols, and Procedures .................58 2. Introduction to Emergency Evidence-Based Practice ..................................58 Medical Service Systems 16 Performing a Literature Search ..................................59 Reviewing the Literature ...........................................59 The Evolution of EMS .....................................18 Types of Research ............................................60 Historical Evolution of American Health Care ...........18 Descriptive Studies ...................................................60 Observational Studies ...............................................60 The History of Emergency Medical Service ......20 Experimental Studies ................................................61 Emergence of Civilian EMS ......................................21 Prehospital Research .................................................61 Changing Paradigms .................................................21 Economic Research ...................................................62 The White Paper .......................................................22 Absence of Research .................................................63 Prehospital Coronary Care ........................................22 Emergency Hits TV Screens ......................................23 SECTION II: ETHICS AND LAW EMS Act of 1973 ......................................................23 IN EMS Federal EMS Efforts in the 1980s ..............................23 EMS Agenda for the Future ..............................25 5. Ethics and the Paramedic 70 National EMS Education Agenda for the Future .........26 Mission of the EMS System .............................27 Ethics Defined .................................................72 Legislation and Regulation ........................................28 Public Access ............................................................28 Medical Ethics .................................................72 Communication Systems ...........................................28 Foundations for Value Judgments ..............................73 vi Table of Contents Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 2233445577__0000__FFMM--pp0000ii--xxxxvviiiiii..iinndddd vvii 1111//1188//0099 44::1155::0055 AAMM Foundations of Bioethics ...........................................74 Limited Disclosure ....................................................98 EMS Code of Ethics ..................................................76 Health Insurance Portability and Accountability Act ...98 Moral Rules and Particular Circumstances ........76 Disclosure to Law Enforcement .................................98 Ethical Obligation .....................................................76 Employment Law .............................................98 Allocation of Scarce Medical Resources ....................76 Americans with Disabilities Act ................................98 Ethics and EMS Research ..........................................77 Title VII....................................................................99 End-of-Life Decisions ...............................................77 Ethics Committees ....................................................78 SECTION III: EMS AND PUBLIC HEALTH 6. The Law and Paramedics 82 7. Public Health Origin of Law ..................................................84 and the Paramedic 106 Criminal Law versus Civil Law ........................84 Criminal Law ............................................................84 What Is Public Health? ..................................108 Civil Law ..................................................................85 Elements of a Tort Action .................................85 Public Health in History .................................108 Duty to Act ...............................................................85 Traditional Public Health Missions ..........................109 Good Samaritan Act ..................................................86 Public Health Organization .....................................109 Breach of Duty .........................................................86 Public Health Management .............................110 Damages ...................................................................87 International ...........................................................110 Proximate Causation .................................................87 The American Public Health Movement ...................111 Borrowed Servant Doctrine ..............................87 Public Health and EMS ..................................112 The Process of a Civil Lawsuit .........................87 Healthcare Access ...................................................112 Pretrial Discovery .....................................................88 Disaster Response ...................................................113 Quality Assurance and Discoverability ......................88 8. Illness and Injury Prevention 118 Immunity and Defense ..............................................88 Motions in Court .......................................................89 Patient Consent ................................................89 Public Health .................................................120 Disclosure.................................................................89 Impact of Public Health Prevention Programs ..........120 Understanding ...........................................................90 Public Health Prevention Initiatives .........................120 Voluntariness ............................................................90 Injury Surveillance .................................................120 Permission ................................................................90 EMS and Injury Prevention ............................121 BARNACLE .............................................................90 Injury Prevention Theory and the Emergency Exception ................................................90 Haddon Matrix ...................................................121 Therapeutic Privilege ................................................91 Injury Countermeasures ..........................................122 Waiver of the Right to Consent ..................................91 Injury Prevention Strategies ....................................123 Advantages of Consent ..............................................91 Assessment .............................................................123 Types of Consent.......................................................91 Implementation .......................................................124 Medical Restraint .............................................92 Teaching Injury Prevention ............................124 Positional Asphyxia ...................................................93 EMS Injury Prevention Programs ............................124 Refusal of Medical Assistance ..........................94 Outcomes ................................................................125 Against Medical Advice ............................................94 SECTION IV: SCIENTIFIC Destination ......................................................94 PRINCIPLES Advanced Directives ........................................96 Case of Karen Ann Quinlan .......................................96 Case of Nancy Cruzan ...............................................96 9. Lifespan Development 130 Principles of Advanced Directives .............................96 Patient Self-Determination Act of 1990 .....................97 Types of Advanced Directives ....................................97 Personal Development ....................................132 Do-Not-Resuscitate Orders ........................................97 Theories of Personal Development .................132 Physician’s Order of Life-Sustaining Treatment .........97 Theories of Psychosocial Development ....................132 Confidentiality ................................................97 Topics in Human Development .......................133 Breaches of Patient Confidentiality ...........................98 Table of Contents vii Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 2233445577__0000__FFMM--pp0000ii--xxxxvviiiiii..iinndddd vviiii 1111//1188//0099 88::1111::2233 AAMM Conception to Childbirth ................................133 Stress and the Endocrine System .............................166 Genetics and Human Development ..........................133 Stress and the Immune System ................................167 Pregnancy ...............................................................134 Cellular Adaptation ........................................167 Childbirth ...............................................................135 Atrophy ..................................................................167 The Newly Born.............................................135 Hypertrophy ............................................................167 Cell Replacement ....................................................167 The Infant ......................................................135 Dysplasia ................................................................167 Physical Development .............................................135 Apoptosis ...............................................................168 Cognitive Development ...........................................138 Psychosocial Development ......................................138 Parent–Child Relationships .....................................138 Preschool Children: Early Childhood ..............139 11. Principles of Physical Development .............................................139 Pathophysiology 174 Cognitive Development ...........................................140 Psychosocial Development ......................................140 Pathophysiology Defined ...............................176 School-Aged Children: Disease: Defined ...........................................176 Middle Childhood ....................................141 Physical Development .............................................141 Etiologies of Disease .....................................176 Cognitive Development ...........................................141 Known Causes of Disease........................................176 Psychosocial Development ......................................141 Risk Factors ............................................................177 Adolescence ..................................................142 Prognosis ................................................................178 Physical Development .............................................142 Iatrogenic Disease ..........................................178 Adolescent Health Concerns....................................143 Disease as a Process.......................................178 Cognitive Development ...........................................143 Psychosocial Development ......................................143 Morbidity and Mortality .................................179 Early Adulthood .............................................144 Chemical Causes of Cell Injury ......................179 Physical Development .............................................145 Hypoxic Injury ........................................................179 Cognitive Development ...........................................145 Reperfusion Injury and Free Radicals ......................180 Psychosocial Development ......................................145 Toxins .....................................................................180 Middle Adulthood ..........................................146 Physical Causes of Cellular Injury ..................181 Physical Development .............................................146 Mechanical Injury ...................................................181 Cognitive Development ...........................................146 Heat or Cold Injury .................................................181 Psychosocial Development ......................................146 Burn Injury .............................................................182 Late Adulthood ..............................................147 Barotrauma .............................................................183 Life Expectancy ......................................................147 Metabolic Disorders .......................................184 Physical Development .............................................147 Cognitive Development ...........................................147 Genetic Disorders ..........................................184 Psychosocial Development ......................................148 Infection ........................................................184 Death and Dying .....................................................148 Immune Reactions .........................................185 10. Basic Human Physiology 156 Effect: Systemic Defense ...............................185 Nonspecific Defenses..............................................186 Physiology .....................................................158 Inflammatory Response ...........................................186 Cellular Milieu ..............................................158 Immune Response ...................................................189 Homeostasis ..................................................158 Outcomes: Shock Syndrome ...........................190 Cellular Physiology ........................................158 Classifications of Shock ..........................................190 Sodium Potassium Pump .........................................159 Pathophysiology of Shock .......................................190 Glucose Storage ......................................................159 Organs in Shock ......................................................190 Shock: Vital Organs ................................................191 Fluid Balance ................................................160 Decompensated Shock.............................................192 Temperature Regulation .................................162 Axioms of Shock Treatment ....................................192 Temperature and the Oxyhemoglobin Curve .............163 Pathological Cell Injury .................................193 Stress ............................................................163 Patterns of Necrosis .......................................193 Stress and Cellular Response ...................................163 Stress and the Autonomic Nervous System ..............164 Death .............................................................193 viii Table of Contents Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 2233445577__0000__FFMM--pp0000ii--xxxxvviiiiii..iinndddd SSeecc11::vviiiiii 1111//1188//0099 44::1155::5544 AAMM