The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
Office of Emergency Medical Services
ARGCOPAULCELLUCCI 56 Roland Street, Suite 100
Governor Boston , MA 02129
JANE SWIFT
Lieutenant Governor
WILLIAM D. O’LEARY
Secretary
HOWARD K. KOH. MD, MPH
Comm ivsioner
August 21, 2000
OEMS ADVISORY
Out-of Hospital Treatment of Minors
Introduction to Issue
In Massachusetts a minor is someone under the age of eighteen (18), with a few exceptions explained below. EMTs encounter problems when called to treat minors, where there is no one legally authorized to consent to treatment or to refuse treatment. This particular problem is found most often at the scene of a motor vehicle crash involving 16 and 17 year olds, who do not want to be treated or transported. The following is a guideline to assist EMTs in handling such situations. While the guideline should assist in evaluating and handling such issues, it will not resolve every situation and decisions vary based on the specific facts in each instance. The EMT should share the decision-making responsibility with other EMTs, supervisory personnel, and/or medical control physician. Services should review specific questions with their own legal counsel and meet with local police to work out cooperative solutions. Documentation is critical throughout the analysis.
H. Guideline
1. Assess whether there is an emergency. Apply Doctrine of Implied Consent:
a. EMTs are required to treat and transport any minor who clearly has an emergency condition. See, 105 CMR 170.255 (A).
b. Emergency is when: the injury or illness is a threat to life; the failure to treat would cause irreversible injury; or the delay in treatment would adversely endanger the life, limb, or mental well-being of the patient. In assessing whether there is an emergency, particularly with regard to motor vehicle crashes, EMTs should include the mechanism of injury in their analysis. Including the mechanism of injury in the analysis may result in an injury that might not otherwise be considered an emergency to be classified as an emergency, allowing transport without actual consent, relying on implied consent.
c. As a matter of public policy, consent is implied by law in an emergency because inaction may result in harm to the patient. Therefore, in an emergency, it is not necessary to obtain explicit consent to treat and transport, since consent is implied.
d. Determining the conditions that actually constitute an emergency in any given situation is a determination left to the EMT based on the assessment of the patient, including mechanism of injury. If there is any question whether or not an emergent condition exists, the EMT should (if possible) consult other EMTs at the scene, EMS supervisory personnel, and/or a medical control physician.
e. EMTs must fully document all factors leading to the conclusion that the injury or illness constitutes an emergency, including the names of individuals with whom the EMT consulted.
2. Assess whether there is an injury or illness:
a. 105 CMR 170.255 (A) provides that an EMT has a responsibility to treat and transport patients who have a critical or unknown illness or injury (including mechanism of injury).
b. After assessment, if there is no illness or injury, there is no obligation to transport. Remember to include the mechanism of injury in the analysis.
c. Document the assessment and basis for the decision not to transport.
3. If there is an injury or illness, but no emergency, assess the age and legal status of the individual:
a. M.G.L. c. 231, § 85P provides that age 18 is the age of majority in the Commonwealth.
b. M.G.L. c. 112, § 12F defines individuals under 18 as emancipated minors if they are (I) married, widowed or divorced; (ii) the parent of a child; (iii) a member of the armed forces; (iv) pregnant or believes herself to be pregnant; (v) living separate and apart from a parent/legal guardian and managing his or her own financial affairs; or (vi) under the reasonable belief that he or she is suffering from or has come into contact with a disease defined as dangerous to the public health.
c. If the individual is 18 or the EMT can determine that he or she is an emancipated minor, the individual can make decisions as to his or her treatment or decline treatment. Several of the emancipated minor categories will be difficult, if not impossible, to determine in the field.
d. The EMT must clearly document in the trip record how the EMT derived the age or emancipation status of the patient.
4. If the individual is under 18 or not emancipated, attempt to obtain consent if the patient refuses to be transported:
a. Consent is most often an issue when patients are refusing to be transported. Although minors also cannot legally consent to transport, if all parties are in agreement that the minor should be transported, there is likely to be no issue. Successful cases alleging battery are rare. EMTS should carefully consider all factors presented and use their best judgment in making decisions and document clearly all decisions.
b. If feasible, contact the parent or guardian or school officials if they are responsible for the minor.
c. If possible, contact other family members or responsible party to obtain consent, if parent or guardian is unavailable. Police, if on scene may assist in making calls. The increased presence of cell phones may ease this task.
d. Fully inform the minor of the full extent of the injury, the mechanism of injury, the potential outcomes, the need for evaluation by a physician and encourage transport;
e. Contact medical control for further instruction or discussion with the minor;
f. Document all attempts to obtain consent and document oral consent, if provided over the phone.
g. Contact supervisory personnel of ambulance service.
a. Options may depend on the nature of the injury, whether law enforcement is present and is working cooperatively with EMTs, and such other factors as the urgency to return the ambulance to service.
b. The police may place individuals in protective custody if they are deemed to be a danger to themselves or others.
c. Police could transport the minor to station to await parent or guardian.
6. EMT must evaluate the situation, use discretion, and document all aspects of decision.
a. If there is any question, EMTs should err toward treatment and transport. Successful lack-of-consent and battery cases against EMTs are rare.
7. Develop service policies:
a. Review guidelines within each ambulance service and with legal counsel for the service. Most issues related to minor consent involve concerns regarding liability. These issues should be fully evaluated with ambulance service counsel.
b. Meet with public safety agencies to develop cooperative guidelines including, but not limited to the transport of minors.
The IC must be familiar with various Massachusetts laws or statutes that are related to or affect Emergency Medical Service operations. The information in Section 8 must be presented to the EMT-Basic students during the course of EMT training. Complete copies of the Massachusetts General Laws are available in most public libraries. EMTs are subject to federal and state laws.and it is not possible to cover all laws and regulations governing EMS in the EMT-Basic course.
In addition to laws, there are two sets of regulations promulgated under the authority of the EMS law. Copies of these, EMS (105 CMR 170.000) and First Responder (105 CMR 17 1.000) regulations may be obtained from the State House Bookstore, Room 116, State House, Boston, MA 02113. Telephone (617) 727-2834 for current price information.
8.1 - VEHICLE OPERATION
Chapter 89, Section 7 EMERGENCY VEHICLE RIGHT OF WAY
The members and apparatus of a fire department while going to a fire or responding to an alann, police patrol vehicles and ambulances and ambulances on a call for the purposes of hospitalizing a sick or injured person shall have the right of way through any street, way, lane, or alley. Whoever willfully obstructs or retards the passage of any of the foregoing in the exercise of such right shall be punished by a fine of not more than fifty dollars or imprisonment for not more than three months.
Chapter 89, Section 7A YIELD TO APPROACHING EMERGENCY VEHICLES
Upon the approach of any fire apparatus, police vehicle, ambulance, or disaster vehicle which is going to a fire or responding to call, alarm or emergency situation, eveiy person driving a vehicle on a way shall inunediately drive said vehicle as far as possible toward the right-hand curb or side of said way and shall keep the same at a standstill until such fire apparatus, police vehicle, ambulance or disaster vehicle has passed. No person shall drive a vehicle over a hose of a fire department without the consent of a member of such department. No person shall drive a vehicle within three hundred feet of any fire apparatus going to a fire or responding to an alarm, nor drive said vehicle, or park or leave the same unattended, within eight hundred feet of a fire or within the fire lines established by the fire department, or upon or beside any traveled way, whether public or private, leading to the scene of a fire, in such a manner as to obstruct the approach to the fire of any fire apparatus or any ambulance, safety or police vehicle, or of any vehicle bearing an official fire or police department designation. No person shall operate a motor vehicle behind any such fire apparatus, ambulance, safety or police vehicle, or any vehicle bearing an official fire or police designation which is operating with emergency systems on, for a distance of three hundred feet. Violation of any provision of this section shall be punished by a fine of not more than one hundred dollars. (Amended June 6,
Chapter 89. Section 7B EMERGENCY VEHICLE SPEED & STOP SIGN/LIGHTS
The driver of a vehicle of a fire, police or recognized protective department and the driver of an ambulance shall be
subject to the provisions of any statute, rule, regulation, ordinance or by-law relating to the operation or parking of vehicles, except that a driver of a fire apparatus while going to a fire or responding to an alarm, or the driver of a vehicle of a police or recognized protective department or the driver of an ambulance, in an emergency and while in performance of a public duty or while transporting a sick or injured person to a hospital or other destination where professional medical services are available, may drive such vehicle at a speed in excess of the applicab
under the circumstances for the safety of persons and property, and r contraiy to any traffic signs or signals regulating traffic at such inter then proceeds with caution and due regard for the safety of persons a officer regulating traffic at such intersection. The driver of any such provisions of section fourteen of chapter ninety when approaching a
Chapter 90, Section 7E ; EMERGENCY WARNING LIGHTS (excerpts)
No motor vehicle....other than fire apparatus, ambulances, school buses, vehicles specified in section 7D...and vehicles specified in section 71 shall mount or display a flashing, rotating or oscillating red light in any direction, except as herein provided; provided, however, that nothing in this section shall prohibit an official police vehicle from displaying a flashing, rotating or oscillating red light in the opposite direction in which the vehicle is proceeding or prohibit fire apparatus from displaying a flashing, rotating or oscillating blue light in the opposite direction in which the vehicle is proceeding.
A vehicle owned and operated by a....chief or deputy chief of a municipal fire department, a chaplain of a municipal fire department, a member of a fire department of a town or a call member of a fire department or a member or a call member of an emergency medical service may have mounted thereon flashing, rotating or oscillating red lights. Such lights shall only be displayed when such owner or operator is proceeding to a fire or in response to an alarm and when the official duty of such owner or operator requires him to proceed to said fire or to respond to said alarm, and at no other time.
No such red light shall be mounted or displayed on such vehicle until proper application has been made to the registrar by the head of the fire department and a written permit has been issued and delivered to the owner and operator.
Any person operating a vehicle upon which flashing, rotating or oscillating red lights herein authorized are mounted shall have the permit for said lights upon his person or in the vehicle in some easily accessible place
. ..Nothing in this section shall authorize any owner or operator to disregard or violate any statute, ordinance, by-law, rule or regulation regarding motor vehicles or their use on ways of the commonwealth
(underline and bold added)
Any person who violates any provision of this section for which a penalty is not otherwise provided shall be subject to a fine of not less than one hundred dollars, nor more than three hundred dollars.
Chapter 90, Section 13 (excerpt) CHOCK VEHICLES
Whenever...a truck weighing, unloaded, more than four thousand pounds...shall be parked on a way, on a grade sufficient to cause such vehicle to move of its own momentum, and is left unattended by the operator, one pair of adequate wheel safety chock blocks shall be securely placed against the rear wheels of such vehicle so as to prevent movement thereof.
Chapter 90. Section 14 (excerpt) STOP FOR SCHOOL BUS
When approaching a vehicle which displays a sign bearing the words “SCHOOL BUS” and which is equipped with front and rear alternating flashing red signal lamps which are flashing as provided in section 7B, and which has been stopped to allow pupils to alight from or board the same, a person operating a motor vehicle shall, except when approaching from the opposite direction on a divided highway, bring his vehicle to a full stop not less than fifteen feet from said school bus and shall not thereafter proceed until the warning signals are deactivated, unless directed to the contraiy by a police officer duly authorized to control the movement of traffic. Any person who violates the provisions of the preceding sentence shall be punished by a fine of not more than one hundred dollars.
(Note: This excerpt from the school bus law is included so that EMT students can be reminded that ambulances are subject to its provisions even when they are responding to an emergency.)
Chapter 90. Section 16 (excerpt) USE OF SIREN
No siren shall be mounted upon any motor vehicle except fire apparatus, ambulances, vehicles used in official line of duty by any member of the police or fire fighting forces of the commonwealth or any agency or political subdivision thereof, and vehicles owned by call firefighters or by persons with police powers and operated in official line of duty, unless authorized by the registrar. No person shall use on or in connection with any motor vehicle a spot light, so called, the rays from which shine no more than two feet above the road at a distance of thirty feet from the vehicle, except that such a spot light may be used for the purpose of reading signs, and as an auxiliary light in cases of necessity when the other lights required by law fail to operate.
No person operating a motor vehicle on any way shall run it at a rate of speed greater than is reasonable and proper, having regard to traffic and the use of the way and the safety of the public. Unless a way is otherwise posted in accordance with the provisions of section eighteen, it shall be prima facie evidence of a rate of speed greater than is reasonable and proper as aforesaid (1) ii a motor vehicle is operated on a divided highway outside a thickly settled or business district at a rate of speed exceeding fifty miles per hour for a distance of a quarter of a mile, or (2) on any other way outside a thickly settled or business district at a rate of speed exceeding forty miles per hour for a distance of a quarter of a mile, or (3) inside a thickly settled or business district at a rate of speed exceeding thirty miles per hour for a distance of one eighth of a mile, or (4) within a school zone established in conformance with the standards of the department of public works at a rate of speed exceeding twenty miles per hour.
If a speed limit has been duly established upon any way, in accordance with the provisions of said section, operation of a motor vehicle at a rate of speeding excess of such limit shall be prima facie evidence that such speed is greater than is reasonable and proper; but, notwithstanding such establishment of a speed limit, every person operating a motor vehicle shall decrease the speed of the same when a special hazard exists with respect to pedestrians or other traffic, or by reason of weather or highway conditions. No person shall operate a school bus at a rate of speed exceeding forty miles per hour, while actually engaged in carrying school children.
N.B. This law applies to ambulances
Chapter 11 1C, Section 14 (of EMS law)
No emergency medical technician certified under the provisions of this chapter and no police officer or firefighter, who in the performance of his duties and in good faith renders emergency first aid or transportation to an injured person or to a person incapacitated by illness shall be personally in any way liable as a result of rendering such aid or as a result of transporting such person to a hospital or other safe place, nor shall he be made liable to a hospital for its expenses, if under emergency conditions, he causes the admission of such person to said hospital.
Chapter 112, Section 12V (CPR rendered by any citizen)
Any person who is currently certified by the American National Red Cross or the American Heart Association in cardiopulmonary resuscitation, or any person who has successfully met the training requirements of a course in basic emergency care of the unwitnessed cardiac arrest, conducted according to the standards established by the American Heart Association, who in good faith and without compensation renders emergency cardiopulmonary resuscitation in accordance with his training, other than in the course of his regular professional or business activity, to any person who apparently requires cardiopulmonary resuscitation, shall not be liable for acts or omissions, other than gross negligence or willful or wanton misconduct, resulting from the rendering of such emergency cardiopulmonary resuscitation.
Chapter 123. Section 12 EMERGENCY RESTRAiNT OF DANGEROUS PERSONS;... (excerpts)
(a) Any physician who is licensed...after examining a person has reason to believe that failure to hospitalize such person would create a likelihood of serious harm by reason of mental illness may restrain or authorize the restraint of such person and apply for the hospitalization of such person for a ten day period at a public facility or at a private facility authorized for such purposes by the department.
...In an emergency situation if a physician or qualified psychologist is not available, a police officer, who believes that failure to hospitalize a person would create a likelihood of serious harm by reason of mental illness may restrain such person and apply for the hospitalization...
...An application for hospitalization shall state the reasons for the restraint of such person and any other relevant information
...Whenever practicable, prior to transporting such person, the applicant shall telephone or otherwise communicate with a facility to describe the circumstances and known clinical history and to determine whether the facility is the proper facility to receive such person and also to give notice of any restraint to be used and to determine whether such restraint is necessary.
Chapter 123, Section 21 TRANSPORTATION OF MENTALLY ILL PERSONS; RESTRAINT (excerpts)
Any person who transports a mentally ill person to or from a facility for any purpose authorized under this chapter shall not use any restraint which is unnecessary for the safety of the person being transported or other persons likely to come in contact with him.
In the case of persons being hospitalized under the provisions of section 6, the applicant* shall authorize practicable and safe means of transport, including where appropriate, departlnental** or police transport.
Restraint of a mentally ill patient may only be used in cases of emergency, such as the occurrence of, or serious threat of, extreme violence, personal injury or attempted suicide; provided, however, that written authorization for such restraint is given by the superintendent or director of the facility or by a physician designated by him for this purpose who is present at the time of the emergency or if the ... superintendent or director or designated physician is not present at the time of the emergency, non-chemical means of restraint may be used for a period of one hour provided that within one hour the person in restraint shall be examined by the superintendent, director or designated physician.
...Any minor child placed in restraint shall be examined within 15 minutes of the order for restraint by a physician or, by a registered nurse or a certified physician’s assistant,
* (“applicant” refers to the authority, physician etc., who committed the patient)
** (“departmental” refers to Department of Mental Health)
Chapter 123, Section 21 (cont. )
No person shall be kept in restraint without a person in attendance specially trained to understand, assist and afford therapy to the person in restraint.
in emergency situations, when a person specially trained is not available, an adult, may be kept in restraint unattended for a period not to exceed two hours. In that event, the person kept in restraints must be observed at least every five minutes, provided, further, that the superintendent, director or designated physician shall attach to the restraint form a written report as to why the specially trained attendant was not available.
...No “P.R.N.” or “as required” authorization of restraint may be written.
.No later than 24 hours after the period of restraint, a copy of the restraint form shall be delivered to the person who was in restraint.
...A copy of the restraint form and any such attachments shall become part of the chart of the patient.
Chapter 123, Section 22 CIVIL LIABILITY
Physicians, qualified psychologists and police officers shall be immune from civil suits for damages for restraining, transporting, applying for the admission of or admitting any person to a facility or the Bridgewater State Hospital, providing said physician, qualified psychologist or police officer acts pursuant to the provisions of this chapter.
No person shall: (1) establish or maintain an ambulance service without a valid license or in violation of the terms of a valid license; (2) operate, maintain, or otherwise use any aircraft, boat, motor vehicle, or other means of transportation as an ambulance without a valid certificate of inspection; (3) operate an ambulance or to serve as an attendant thereon or impersonate, hold oneself out as, or use the title of emergency medical technician or the acronym, EMT in violation of section-six; (4) obstruct, bar, or otherwise interfere with an inspection undertaken under authority of this chapter; (5) knowingly to make an omission of a material fact or a false statement in any application or other. document filed with the department; or (6) violate or fail to observe any requirement of this chapter, or of any rule, regulation or order under this chapter, which the requirement the department has made subject to this section by regulation.
Whoever engages in, aids, abets, causes, or permits any act prohibited under the section shall be punished by a fine of not less than one hundred dollars and not more than five hundred dollars for each offense. A separate and distinct offense shall be deemed to have been committed on each day during which any prohibited act continues after written notice by the department to the offender. The commissioner shall report each suspected offense to the attorney general for investigation and, if appropriate, prosecution in the courts of the commonwealth.
Chapter 119, Section 5 1A CHILD ABUSEINEGLECT MANDATED REPORTER
Any physician, medical intern, hospital personnel engaged in the examination, care or treatment of persons, medical
ambulance attendant, while said technician, operator or attendant is treating or transporting, in the line of duty, a person, shall be punished by imprisonment in the house of correction for not less than ninety days nor more than two and one-half years, or by a fine of not less than five hundred not more than five thousand dollars, or both.
Chapter 266, Section 69 INSIGNIA USE
Whoever, not being a member of a society, association or labor union, for the purpose of representing that he is a member thereof, willfully wears or uses the insignia, ribbon, badge, rosette, button or emblem thereof, if it has been registered in the office of the state secretary, shall be punished by a fine of not more than twenty dollars or by imprisonment for not more than one month or both.
(NOTE: Both the state and National Registry emblems are so protected. The “Star of Life” emblem is protected under the federal trademark act.)
Chapter 111. Section 201 - FIRST RESPONDER LAW
Members of police and fire departments, members of the state participating in highway patrol, persons appointed
Chapter 19A, Section 15 ELDERLY ABUSE, MANDATED REPORTERS (excerpt)
Any physician, a medical intern, dentist, nurse, family counselor, probation officer, social worker, policeman, firefighter, emergency medical technician , licensed psychologist, coroner, registered physical therapist, registered occupational therapist, osteopath, podiatrist, executive director of a licensed home health agency, or executive director of a homemaker service agency who has reasonable cause to believe that an elderly person is suffering from or has died as a result of abuse, shall immediately make a verbal report of such information or cause a report to be made to the department or its designated agency and shall within forty-eight hours make a written report to the department or its designated agency.
(underline added)
(the term ‘department’ in the excerpt refers to the Massachusetts Department of Elder Affairs which is a department of the state government)
Call 1-800-922-2275 to report neglect/abuse of the elderly.
Call Dept. of Elder Affairs at (617) 727-7009 for reporting form and information.
Chapter 111. Section 11 1C REPORTING OF INFECTIOUS DISEASES DANGEROUS TO THE PUBLIC HEALTH
Any person, including without limitation, a police officer, fire fighter, emergency medical technician , corrections officer, ambulance operator or attendant who, while acting in his or her professional capacity, attends, assists, or transports a person to a health care facility licensed under section 51 of chapter 111, and who sustains an unprotected exposure capable of transmitting an infectious disease dangerous to the public health, shall immediately, upon arrival at such facility, provide to the admitting agent or other appropriate employee of the said facility a standardized trip form. The department shall prepare and distribute said standardized trip form. which shall include , but need not be limited to the names of tersons who believe they have had such unprotected exposure, and the manner in which such exposure occurred .
“Infectious diseases dangerous to the public health” shall be defined by department regulations which shall be promulgated pursuant to this section.
“Unprotected exposure capable of transmitting an infectious disease dangerous to the public health” shall be defined in regulations promulgated by the department and shall include, but not be limited to, instances of direct mouth-to-mouth resuscitation, or co-mingling of the blood of the patient and the person who has transported the patient to the health care facility.
Any health care facility licensed under section 51 of chapter 111 which, after receiving a transported individual. diagnoses the individual as having an infectious disease dangerous to the public health as defined pursuant to the provisions of this section shall notify orally within 48 hours after making such a diagnosis, and in writing within 72 hours of such diagnosis, any individual listed on the trip report who has sustained an unprotected exposure which , in the opinion of the health care facility is capable of transmitting such disease . Such response shall include, but not be limited to, the appropriate medical precautions and treatments which should be taken by the party who has sustained the unprotected ~“\. exposure; provided, however, that the identity of the patient suspected of having such disease shall not be released in such response, and shall be kept confidential in accordance with the provisions of section 70. The department shall determine the method by which the response to the trip report is conveyed, and shall assure the patient is informed of those individuals who have been notified of his her disease pursuant to this section, and that the response is directed only to those parties who have sustained an unprotected exposure to an infectious disease.
Chapter 111. Section 111 C REPORTING OF iNFECTIOUS DISEASES DANGEROUS TO THE
PUBLIC HEALTH (continued)
Notwithstanding the provisions of any general law or special law to the contrary, no hospital, or agent, employee, administrator, doctor, official, or other representative of said reporting institution shall be held jointly or severally liable either as an institution, or personally, for reporting pursuant to the requirements of this section, if such report was made in good faith. All such parties, provided they have operated in good faith, shall otherwise be afforded total immunity from civil or criminal liability as a result of fulfilling the provisions of this section or the regulations promulgated in accordance with this section.
(underline added)
(the term ‘department’ in the law refers to the Massachusetts Department of Public Health which is a department of the state government)
Please see also the regulations, 105 CMR 172.000 et seq, which are available from the State House Bookstore.
unapter II IL , section 1UA ~trom tne state I~MS law)An injured or sick child who is to be transported to a hospital or other medical treatment facility by an ambulance or other emergency vehicle shall be accompanied by a parent upon such parent’s request, unless the emergency medical technician or other person in charge determines that the medical situation is life threatening or that the presence of a parent would create a potential risk to such child. Such determination shall be noted in the written report of said emergency medical technician and a copy of such report shall be sent to such parent within thirty days of such determination.
(underline added)
Effective October 10, 1989