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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
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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
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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
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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
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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
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