sanders: mosby's paramedic textbook, revised 3 edition...
TRANSCRIPT
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Chapter 4Chapter 4Medical/Legal IssuesMedical/Legal Issues
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ObjectivesObjectivesDescribe structure of legal systemDescribe structure of legal system
Relate how laws affect paramedic practiceRelate how laws affect paramedic practice
List situations paramedic must reportList situations paramedic must report
List four elements of negligenceList four elements of negligence
Describe how paramedics can protect themselves Describe how paramedics can protect themselves from claims of negligencefrom claims of negligence
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ObjectivesObjectivesDefine the paramedicDefine the paramedic’’s responsibility to protect s responsibility to protect patient confidentiality responsibilitiespatient confidentiality responsibilities
Outline the process for obtaining consentOutline the process for obtaining consent
Describe legal complications related to consentDescribe legal complications related to consent
Describe actions in refusal of care situationDescribe actions in refusal of care situation
Describe legal considerations regarding patient Describe legal considerations regarding patient transportationtransportation
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Sanders: Mosby's Paramedic Textbook, Revised 3rd Edition PowerPoint Lecture Notes
Chapter 4: Medical/Legal Issues
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ObjectivesObjectivesOutline legal issues related to resuscitationOutline legal issues related to resuscitation
List measures to preserve evidenceList measures to preserve evidence
Detail the components of narrative Detail the components of narrative documentationdocumentation
Define medicalDefine medical--legal terms related to EMSlegal terms related to EMS
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ScenarioScenario
Your preceptor doesnYour preceptor doesn’’t flinch when the alert t flinch when the alert patient with chest pain says he doesnpatient with chest pain says he doesn’’t want t want to go to the hospital. He tells him, to go to the hospital. He tells him, ““You have You have no choice,no choice,”” and then forcibly transports him. and then forcibly transports him. During the struggle, the patientDuring the struggle, the patient’’s condition s condition worsens and he suffers a serious heart worsens and he suffers a serious heart attack.attack.
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DiscussionDiscussionDoes this call meet any of the elements needed to prove Does this call meet any of the elements needed to prove negligence?negligence?
What type of consent should have been obtained on this What type of consent should have been obtained on this call?call?
Should this patient have been transported against his Should this patient have been transported against his wishes?wishes?
What criminal or civil laws may relate to this situation?What criminal or civil laws may relate to this situation?
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ParamedicParamedic’’s Legal Dutiess Legal DutiesPatientPatient
EmployerEmployer
Medical directorMedical director
PublicPublic
Statutes and regulationsStatutes and regulations
Accepted medical standardsAccepted medical standards
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Ethical ResponsibilitiesEthical ResponsibilitiesRespect for patientRespect for patient’’s physical and emotional needss physical and emotional needsMastery of skillsMastery of skillsContinuing educationContinuing educationReviewing performance Reviewing performance Reporting honestlyReporting honestlyRespecting confidentialityRespecting confidentialityWorking cooperatively with other professionalsWorking cooperatively with other professionalsStaying current with new concepts and modalitiesStaying current with new concepts and modalities
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Legal and Ethical ResponsibilitiesLegal and Ethical Responsibilities
Civil or criminal liabilityCivil or criminal liability
Best legal protection:Best legal protection:Appropriate assessment and careAppropriate assessment and careAccurate and complete documentationAccurate and complete documentation
Laws differ from state to stateLaws differ from state to stateGet competent legal adviceGet competent legal advice
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Types of LawTypes of LawLegislative lawLegislative law
Administrative lawAdministrative law
Common lawCommon law
Criminal lawCriminal law
Civil lawCivil law
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Legislative LawLegislative Law
Made by legislative branches of governmentMade by legislative branches of government
Statutes, constitutionsStatutes, constitutionsCity councilsCity councilsDistrict boardsDistrict boardsGeneral assembliesGeneral assembliesU.S. CongressU.S. Congress
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Administrative LawAdministrative Law
Regulations developed by a governmental Regulations developed by a governmental agency to provide details about the function agency to provide details about the function and process of the lawand process of the law
General requirements for paramedic licensureGeneral requirements for paramedic licensure
Regulatory agencies may revoke or suspend Regulatory agencies may revoke or suspend licenselicense
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Common LawCommon LawCase or judgeCase or judge--made lawmade law
Derived from customs or norms over timeDerived from customs or norms over time
Based on decisions of state/federal judicial systemsBased on decisions of state/federal judicial systems
Court decisions may defineCourt decisions may defineAcceptable conductAcceptable conductNegligenceNegligenceInterpretation of EMS statutes and regulationsInterpretation of EMS statutes and regulations
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Criminal LawCriminal LawGovernment prosecutes person for violating Government prosecutes person for violating laws designed to protect societylaws designed to protect society
Public complaintPublic complaint
Punishment by fine, imprisonment, or bothPunishment by fine, imprisonment, or both
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Civil (Tort) LawCivil (Tort) Law
Private complaints brought against a Private complaints brought against a defendant for illegal act/wrongdoing defendant for illegal act/wrongdoing
Plaintiff requests court to award damagesPlaintiff requests court to award damages
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How Laws Affect the ParamedicHow Laws Affect the ParamedicScope of practiceScope of practice
Duties/skills paramedic is allowed to performDuties/skills paramedic is allowed to performDictated by state law or regulationDictated by state law or regulation
Medical directionMedical directionOnOn--line or offline or off--lineline
Medical practice actMedical practice actLegislation governing practiceLegislation governing practice
Licensure/certificationLicensure/certification
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Motor Vehicle LawsMotor Vehicle LawsStandards for equipping and operating Standards for equipping and operating emergency vehiclesemergency vehicles
Vary by stateVary by state
State codes regardingState codes regardingReckless drivingReckless drivingExcessive speedsExcessive speedsFailure to consider road and weather conditionsFailure to consider road and weather conditionsInappropriate use/nonuse of sirens and lightsInappropriate use/nonuse of sirens and lights
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Mandatory Reporting RequirementsMandatory Reporting RequirementsChild abuse and neglectChild abuse and neglectElder abuseElder abuseSpouse abuseSpouse abuseSexual assaultSexual assaultGunshot and stab woundsGunshot and stab woundsAnimal bitesAnimal bitesSome communicable diseasesSome communicable diseases
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Protection for the ParamedicProtection for the ParamedicInfectious disease exposure notificationInfectious disease exposure notification
Ryan White Comprehensive AIDS Resources Ryan White Comprehensive AIDS Resources Emergency Act of 1990Emergency Act of 1990
Immunity statutesImmunity statutesGovernmental immunityGovernmental immunityGood Samaritan lawsGood Samaritan laws
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Protection for the ParamedicProtection for the ParamedicIn some areasIn some areas
Illegal to harm EMS providers or obstruct careIllegal to harm EMS providers or obstruct care
Best to avoid unsafe scenesBest to avoid unsafe scenes
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Anatomy of an Injury LawsuitAnatomy of an Injury Lawsuit
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Anatomy of an Injury LawsuitAnatomy of an Injury Lawsuit
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Legal AccountabilityLegal Accountability——ParamedicParamedic
Act in reasonable and prudent mannerAct in reasonable and prudent manner
Provide level of care consistent with Provide level of care consistent with education and local protocoleducation and local protocol
Failure to meet these responsibilities can Failure to meet these responsibilities can result in legal liabilityresult in legal liability
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NegligenceNegligence
The failure to act as a reasonable, prudent The failure to act as a reasonable, prudent paramedic would act in similar paramedic would act in similar
circumstancescircumstances
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Components of NegligenceComponents of Negligence
Four elements needed to prove negligence Four elements needed to prove negligence exists:exists:
Duty to actDuty to actBreach of dutyBreach of dutyDamagesDamagesProximate cause Proximate cause
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Defenses to Negligence ClaimsDefenses to Negligence Claims
TrainingTrainingCompetent patient care skillsCompetent patient care skillsThorough documentation of patient care Thorough documentation of patient care Good Samaritan lawsGood Samaritan laws
Limited protection for EMSLimited protection for EMS
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Defenses to Negligence ClaimsDefenses to Negligence Claims
Governmental immunityGovernmental immunityVariableVariable
Statute of limitationsStatute of limitationsDifferent for adults/childrenDifferent for adults/children
Contributory negligenceContributory negligenceMay affect size of awardMay affect size of award
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Liability InsuranceLiability InsuranceCovers legal defense and judgmentsCovers legal defense and judgments
Primary policyPrimary policy
Umbrella policyUmbrella policy
Individual coverageIndividual coverage
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Special Liability ConcernsSpecial Liability ConcernsMedical directorMedical director
OnOn--linelineOffOff--lineline
Liability for Liability for ““borrowed servantsborrowed servants””
Considerations for issues relating to civil Considerations for issues relating to civil rightsrights
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Civil RightsCivil RightsCOBRA/EMTALA 1986: May not discriminate by COBRA/EMTALA 1986: May not discriminate by reason of race, color, gender, national origin, or, reason of race, color, gender, national origin, or, in some cases, ability to payin some cases, ability to pay
Rehabilitation Act of 1973: May not discriminate Rehabilitation Act of 1973: May not discriminate based on a handicap based on a handicap
Title II of the Americans with Disabilities Act: Title II of the Americans with Disabilities Act: Guarantees equal accessibilityGuarantees equal accessibility
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Protection Against Negligence ClaimsProtection Against Negligence Claims
Education/training/CE and skill retentionEducation/training/CE and skill retention
Appropriate quality improvementAppropriate quality improvement
Appropriate medical directionAppropriate medical direction
Accurate, thorough documentationAccurate, thorough documentation
Professional attitude and demeanorProfessional attitude and demeanor
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ConfidentialityConfidentiality——HIPAAHIPAAConfidential informationConfidential information
Patient historyPatient historyAssessment findingsAssessment findingsTreatment renderedTreatment rendered
Information may be used forInformation may be used forTreatmentTreatmentPaymentPaymentOperationsOperations
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ConfidentialityConfidentialityRelease of informationRelease of information
Requires written permissionRequires written permission
Legal exceptionsLegal exceptions
Improper release of information or release of Improper release of information or release of inaccurate information can result in liabilityinaccurate information can result in liability
Invasion of privacyInvasion of privacyDefamationDefamation
•• LibelLibel•• SlanderSlander
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ConsentConsent
Conscious, competent patients have the right Conscious, competent patients have the right to decide what medical care and to decide what medical care and transportation to accepttransportation to accept
Must be of legal age Must be of legal age
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ConsentConsentMust inform patient ofMust inform patient of
Nature of illness or injuryNature of illness or injuryTreatment recommendedTreatment recommendedRisks and dangers of treatmentRisks and dangers of treatmentAlternative treatments possibleAlternative treatments possibleDangers of refusing treatment/transportDangers of refusing treatment/transport
Conscious, competent patient can revoke Conscious, competent patient can revoke consent at any time consent at any time
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ConsentConsentInformed consentInformed consent
Based on full information disclosureBased on full information disclosure
Expressed consentExpressed consentWritten or verbalWritten or verbal
Implied consentImplied consentPresumed due to conditionPresumed due to condition
Involuntary consentInvoluntary consentBy authority of lawBy authority of law
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Special Consent SituationsSpecial Consent Situations
MinorsMinors
Mentally incompetent adultsMentally incompetent adults
Prisoners or arresteesPrisoners or arrestees
Refusal of care or transportRefusal of care or transport
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MinorsMinors
Usually 18, unless emancipatedUsually 18, unless emancipated
Unemancipated minors canUnemancipated minors can’’t give or withhold t give or withhold consentconsent
Consent by parent, legal guardian, or courtConsent by parent, legal guardian, or court--appointed custodian appointed custodian Emergency doctrine applies when parent or Emergency doctrine applies when parent or guardian cannot be contactedguardian cannot be contacted
•• Thoroughly document nature of emergencyThoroughly document nature of emergency
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Mentally Incompetent AdultsMentally Incompetent Adults
Legal guardian may give or withhold consentLegal guardian may give or withhold consent
Emergency doctrine is used if legal guardian Emergency doctrine is used if legal guardian cancan’’t be contactedt be contacted
Contact medical directionContact medical direction
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Prisoners or ArresteesPrisoners or Arrestees
As a rule, incarceration does not deny a As a rule, incarceration does not deny a personperson’’s right to decide about medical s right to decide about medical treatment.treatment.
If limbIf limb-- or lifeor life--threatening injury present, court threatening injury present, court or police who have custody may authorize or police who have custody may authorize emergency treatment (in some cases)emergency treatment (in some cases)
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Refusal of Care or TransportRefusal of Care or Transport
Must be able to make a reasonable decisionMust be able to make a reasonable decision
Make multiple attempts to have patient Make multiple attempts to have patient accept careaccept care
Have others try to convince patientHave others try to convince patient
Make risks of refusal clearMake risks of refusal clear
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Advise that patient may call againAdvise that patient may call again
Try to get someone to stay with patientTry to get someone to stay with patient
Consult medical directionConsult medical direction
Document thoroughlyDocument thoroughly
““Release from liability" formRelease from liability" form
Refusal of Care or TransportRefusal of Care or Transport
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Legal Complications Related to ConsentLegal Complications Related to Consent
AbandonmentAbandonment
False imprisonmentFalse imprisonment
Assault Assault
BatteryBattery
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AbandonmentAbandonment
Terminating care needed by patient without Terminating care needed by patient without ensuring that care is provided by another ensuring that care is provided by another qualified providerqualified provider
May occur in the field or when a patient is May occur in the field or when a patient is delivered to emergency departmentdelivered to emergency department
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False ImprisonmentFalse Imprisonment
Intentional or unjustifiable detention of a Intentional or unjustifiable detention of a personperson
Transport without consentTransport without consentRestraint without proper cause or authorityRestraint without proper cause or authority
May be a civil or criminal violationMay be a civil or criminal violation
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Assault/BatteryAssault/Battery
AssaultAssaultThreatening, attempting, or causing fear of Threatening, attempting, or causing fear of offensive physical contact offensive physical contact
BatteryBatteryUnlawful touching without consentUnlawful touching without consent
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Use of ForceUse of ForceUse of restraints or Use of restraints or ““reasonablereasonable”” forceforce
Unruly or violent patientsUnruly or violent patients
Involve law enforcement if possibleInvolve law enforcement if possible
Be humane Be humane
Never punitive in natureNever punitive in nature
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Transportation of PatientsTransportation of Patients
Care must be continued untilCare must be continued untilPatient is transferred to appropriate personnelPatient is transferred to appropriate personnelPatient no longer requires carePatient no longer requires carePatient terminates relationshipPatient terminates relationship
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Emergency Vehicle Operating PrivilegesEmergency Vehicle Operating Privileges
““RightRight--ofof--wayway”” privilegesprivilegesTravel slightly faster than the posted speed limit Travel slightly faster than the posted speed limit (usually no more than 10 mph)(usually no more than 10 mph)Move safely from one lane into opposing trafficMove safely from one lane into opposing trafficSafely travel through redSafely travel through red--light intersectionslight intersectionsAppropriately use audible and visual warning Appropriately use audible and visual warning devicesdevicesPark in unauthorized areasPark in unauthorized areas
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Choice of Patient DestinationChoice of Patient DestinationBased on patient needs and hospital Based on patient needs and hospital capabilitycapability
Protocols for hospital selectionProtocols for hospital selection
Involve medical direction when patientInvolve medical direction when patient’’s s choice cannot be honoredchoice cannot be honored
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Payer ProtocolsPayer ProtocolsParamedics need basic understanding of Paramedics need basic understanding of reimbursement programs to help patients reimbursement programs to help patients determine what services are likely to be determine what services are likely to be covered by their insurance policiescovered by their insurance policies
In lifeIn life--threatening emergencies, payer threatening emergencies, payer protocols should not be a factorprotocols should not be a factor
Document patient care thoroughlyDocument patient care thoroughly
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Resuscitation IssuesResuscitation IssuesWithholding or stopping resuscitationWithholding or stopping resuscitation
Obvious signs of irreversible death Obvious signs of irreversible death Resuscitation would place the EMS provider at Resuscitation would place the EMS provider at risk of personal injuryrisk of personal injuryPatient or surrogate has indicated resuscitation is Patient or surrogate has indicated resuscitation is not desirednot desiredEstablished by local protocolsEstablished by local protocolsRole of medical direction should be clearly Role of medical direction should be clearly delineateddelineated
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Resuscitation TerminationResuscitation Termination
When patient cannot be resuscitated after When patient cannot be resuscitated after adequate trial of BLS and ACLS:adequate trial of BLS and ACLS:
Airway successfully securedAirway successfully securedIV access establishedIV access establishedAppropriate drugs and shocks givenAppropriate drugs and shocks givenPersistent asystole or agonal rhythmPersistent asystole or agonal rhythmNo reversible cause identifiedNo reversible cause identified
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Advance DirectivesAdvance DirectivesPatient SelfPatient Self--Determination ActDetermination Act
State laws and local protocolsState laws and local protocols
Written patient statementsWritten patient statementsLiving willLiving willDurable power of attorney for health Durable power of attorney for health carecareDo not resuscitate (DNR) ordersDo not resuscitate (DNR) orders
Medical direction policies Medical direction policies
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Potential Organ DonationPotential Organ DonationIdentify potential donorIdentify potential donor
Notify medical directionNotify medical direction
Care to help maintain viable organsCare to help maintain viable organsAirway managementAirway managementFluid resuscitation to maintain perfusionFluid resuscitation to maintain perfusionEye careEye care
Careful documentationCareful documentation
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Death in the FieldDeath in the FieldDetermined byDetermined by
No spontaneous cardiac electrical activity (confirmed No spontaneous cardiac electrical activity (confirmed by ECG in two leads)by ECG in two leads)No spontaneous respirationsNo spontaneous respirationsAbsent cough and gag reflexAbsent cough and gag reflexNo spontaneous movementNo spontaneous movementNo response to painful stimuliNo response to painful stimuliFixed and midpoint pupilsFixed and midpoint pupilsDependent lividityDependent lividityRigor mortisRigor mortis
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Death in the FieldDeath in the FieldParamedic shouldParamedic should
Contact medical direction for guidanceContact medical direction for guidanceFollow protocolsFollow protocolsDocument observations or unusual findingsDocument observations or unusual findingsNotify appropriate authorities Notify appropriate authorities Disturb the scene as little as possibleDisturb the scene as little as possibleProvide emotional supportProvide emotional support
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Crime Scene ResponsibilitiesCrime Scene ResponsibilitiesProtect self and other EMS personnelProtect self and other EMS personnel
Patient carePatient care
Notify law enforcement Notify law enforcement
Document unusual findingsDocument unusual findings
Protect potential evidenceProtect potential evidence
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DocumentationDocumentation
If it is not written down, it was not doneIf it is not written down, it was not done
Memory is fallibleMemory is fallible•• Claims may not be filed until years after an Claims may not be filed until years after an
eventevent
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Effective Patient Care ReportEffective Patient Care ReportCompletedCompleted
PromptlyPromptlyThoroughlyThoroughlyObjectivelyObjectivelyAccuratelyAccurately
Confidentiality maintainedConfidentiality maintained
Copy is part of patient's hospital recordCopy is part of patient's hospital record
Maintain for extent of statute of limitationsMaintain for extent of statute of limitations
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ConclusionConclusion
To safeguard against litigation, the To safeguard against litigation, the paramedic must be knowledgeable about paramedic must be knowledgeable about
legal issues and the effects they may have.legal issues and the effects they may have.
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Questions?Questions?
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