Have you seen movies or TV shows that highlight a dog tracking a person? The attention is on the dog, but in reality the K9 works closely with its handler. So, what does it take to become a K9 handler for a search and rescue dog?
Besides training the dog and having it certified by an appropriate agency through a rigorous evaluation process, a K9 handler should be certified in search and rescue by the National Association of Search and Rescue (NASAR – www.nasar.org). There is a comprehensive list of knowledge and skills required to be a search and rescue technician. SAR Technician III is the first level and is an introduction to search and rescue training. SAR Technician II is the fundamentals of search and rescue which includes much more knowledge and skill in the field. SAR Technician I is an advanced level for people who may function as Crew Leader. Each level requires a written and practical exam, much like EMS training.
Those of us on the Northstar SAR team are required to be SAR Technician II. The newbies like me just completed a course over two weekends that ended with the written exam – and we all passed! We practiced the required skills which included land navigation by compass, tracking footsteps, evidence detection on a route and in an area, and rope tying plus creating a harness from webbing. The practical skills test will be held as soon as the snow is gone.
Anyone who claims to be on a search and rescue team should have NASAR certification. If they don’t – and there are plenty of teams out there who have no training at all – then they are not adequately trained and will be lucky to find their way out of the woods.
One of the most important rules in search and rescue is to be prepared for anything during a search, such as an overnight or bad weather or getting hurt. We are responsible for our own safety first, even over that of the victim. That should sound familiar to EMS personnel! Another requirement we have is to gather the supplies for a 24-hour period and pack them into a backpack which we will then carry during the practical skills test. Our instructor’s pack was 70 pounds! Guess what the heaviest item is – water. We need at least 2 x 1 quart containers for a short search, and overnights need a couple gallons – more if it’s extreme weather. Of course, K9 handlers also need to carry water for their dog, which increases the load.
Northstar SAR holds high standards for members of the team, and that means we have a lot of learning and practice and review to do, not just for the exam but for real searches. I can hardly wait until I’m certified and going out to support my team on searches!
Informed Consent
- The patient must be provided with sufficient information about their medical condition.
- In terms of treatment, the patient must be informed about the consequences of action and non-action.
- The patient, using the information provided, must have the opportunity to make a decision based on their own personal values and beliefs.
- The patient must be able to communicate their choices with regards to their medical treatment.
- The patient must be able to make their decision free from the influence of medical professionals, family, friends, or other parties.
During an emergency situation when a patient is incapacitated and it is not possible to get informed consent before commencing treatment, care can still be given. In this situation, EMS may provide lifesaving treatment under the assumption that a normal individual would consent to this type of care. This type of permission is known as implied consent.
Competency and Capacity
A problem can arise, however, when EMS providers encounter an emancipated minor. Typically, a parent or guardian is responsible for the well-being of minor until they reach the age of maturity, usually 18 or 19 (except in Puerto Rico where it is 21). For children under this age, it is the parent or guardian who will decide what medical care they will receive.
When a minor is emancipated, they can function as an adult in society and provide informed consent. There are several ways that a minor can become emancipated. A minor can gain emancipation by getting married, joining the military, or obtaining the permission of a court. The major problem for EMS providers is that the emancipatory status is dictated at the state level rather than the national level. Therefore, it is important that EMS professional know their state’s laws in order to provide the most informed care.
Capacity should be evaluated once competency has been established and, unlike competency, capacity can vary day by day and hour by hour. A person has decision-making capacity when they are able to understand the risks and benefits of both receiving treatment and not receiving treatment. Determining the capacity of a patient goes beyond testing them to make sure that they are alert and oriented although, if they are not, they cannot have capacity. Types of patents who do not have capacity include those who are psychotic, suicidal, or homicidal.
Capacity can also be altered by medical conditions. For example, someone with a very low blood glucose level might be unable to think clearly about their current medical situation and therefore would not have capacity. A patient who has suffered a severe head injury and has a Glasgow Coma Scale of 12 likewise would not have decision-making capacity as would someone with a high blood alcohol level. In each of these situations, if the medical condition is corrected, these individuals will regain their capacity.
Establishing whether or not a patient has capacity can be challenging for even experienced EMS workers. The choice to allow a patient who would benefit from EMS assistance to refuse treatment or transport can be extremely difficult so it is important that we have a good framework for verifying patient capacity.
Here are five questions that you can ask a patient that can help you determine if they have decision-making capacity:
- Have you decided what you want to do?
- What are the risks of the different options we discussed?
- What could happen if you decide to do nothing at this time?
- Why do you think that is the best option for you at this time?
- Why have you chosen the option that you did?
If the patient is able to provide clear answers to these questions, even if they are not answers that you agree with, this would be a strong indication that they have capacity. Conversely, if the patient is unable or unwilling to answer these questions, this should increase your suspicion that they may lack capacity.
Avoiding Patient Refusal
- Establish good patient relationships: There are many factors that can play into someone decision to refuse EMS treatment or transport. The people that need our help the most are frequently scared, stressed, confused, or in pain. None of these factors does anything to enhance good decision making. Also, they may have previous negative interactions with EMS workers, hospitals, or insurance companies and these issues might be the real driving force behind their unwillingness to be treated. Displaying a friendly face and showing the patient respect could make all the difference when you are trying to convince them that, for their own good, they need to go to a hospital. In your conversations with the patient, try to find a balance between what is best for them physically and what they will agree to mentally.
- Risks and rewards of non-treatment and treatment: Make sure that your patient knows what the consequences might be if they refuse care. This is not intended to be an opportunity for you to frighten them into doing what you want, but make sure they are aware of the consequences of their actions. Conversely, you should also make them aware of the inherent risks involved in treatment. Beyond being what is ethically demanded of you as a health care professional, this honest and open approach can also serve to increase your credibility with the patient and may make them more likely to listen to your advice.
- Contact medical direction: Despite the fact that you are an exceptionally trained and capable medical provider, there is still something about the social authority that a doctor can speak with that can prompt people to accept medical treatment. It has been proven that talking to a physician has the power to change some patients’ minds.
If despite your best efforts the patient still refuses treatment or transport, you should complete a patient refusal form and have them sign it. Make sure that you also document your medical opinion with regards to the patient’s condition, the steps you took to try and convince them to get care, and the reasoning behind their refusal. Finally, encourage the patient to call or seek medical aid if they change their mind or if their condition worsens. Give them a list of symptoms that they should watch for with instructions to call EMS or go to a hospital if any of those symptoms appear.
Sources & More Information
JEMS, “Know When and How Your Patient Can Legally Refuse Care” https://www.jems.com/articles/print/volume-40/issue-3/features/know-when-and-how-your-patient-can-legal.html
JEMS, “Patient Refusal: What to do when medical treatment and transport are rejected” https://www.jems.com/articles/1969/12/patient-refusal-what-do-when-m.html
