(a “no load”) When in doubt, it is usually safest to transport the patient Language barriers can be an important factor in accurately assessing a patient and situation, and it is important to address how to approach language incompatibilities ahead of time There are numerous resources for telephone-based interpreters available (at a cost), but these are difficult to access unless the EMS service already has an existing account with a translation service (such as Language Line) Using telephone interpreters is cumbersome in the EMS setting due to the need for privacy and mobility, but at times it is the only option It may also be useful to have printed medical translation cards specific to the demographics of the EMS service area All healthcare providers must understand their duties to provide care Questions often arise concerning issues of consent, especially when children are involved The doctrine of implied consent permits the treatment of minors without parental consent when a medical emergency exists In general, any minor with a condition that threatens “life and limb” is considered an emergency and should be treated and transported This is typically true even in the difficult situation when a parent refuses EMS for a patient who appears to be emergent Minor patients cannot refuse treatment and transport in an emergency situation The same is true when parents are incapable of understanding the risks of refusing care because of cognitive impairment from intoxication or injury The use of online medical command can help evaluate and resolve a situation where there may be disagreement at the scene regarding the need for transport Patient refusals for EMS transport are a large source of patient care liability for EMS providers If parents/guardians refuse care for their ill or injured child, and the EMS provider deems the child’s condition to be serious or feels that the parent is not acting in the child’s best interest, the EMS provider is warranted in escalating to medical control as well as calling the police when indicated The parents must be informed of the risk of not transporting a sick or injured pediatric patient, which typically may include death or permanent disability Regardless of religious beliefs or parental desires, a child must be treated and transported if there is a life-threatening emergency or if providers suspect child abuse, even if parents refuse Medical control should be involved early, and law enforcement may be necessary to ensure that the patient receives the necessary emergency stabilization and transport All EMTs, regardless of certification level, have a duty to report suspected child abuse at all times and in all patients Even if the ED says that they will report a suspected case later on, it is important to immediately report to the authorities to protect the EMS provider In some states, failure to report suspected child abuse is treated as a felony, and providers and medical directors should know the law in the state where they practice The EMSC program in Colorado and pediatric specialists at the University of Colorado offer an online training module to assist EMS providers recognize signs of child abuse, which can be found at https://www.identifychildabuse.org Many states have an EMS not resuscitate (DNR) protocol to limit resuscitative efforts for those who have made that decision with their physician These are under the authority of the parent/guardian, not the physician, and they can be revoked at any time if the parent changes his or her mind, something common in pediatric medical emergencies Providers and medical oversight physicians must be familiar with the specific documents required for an EMS DNR to be in effect, commonly a patient wristband as well as accompanying paperwork When in doubt, EMS providers must resuscitate a patient and transport them to the ED A challenging situation for EMS providers is when a clinician unknown to the EMS service stops at an emergency scene and wishes to participate in and/or direct the medical care This is a precarious situation for both the provider and clinician, since it is difficult to verify the qualifications of the bystander Wherever possible, this situation should be guided by a protocol, and at no time should the clinician be allowed to endanger the patient or providers ACEP has produced a policy statement that outlines the issues involved in having a bystander clinician involved in the care of the EMS patient Because of the liabilities involved in having an unknown bystander take a role in an established system of providing prehospital care, this is a circumstance where online medical control should be contacted to determine the ways in which the bystander may assist Options may range from providing an extra set of hands to having the clinician assume control for the patient and accompanying them to the ED It is strongly encouraged that EMS systems draft an information card or document to give to on-scene providers to explain how this will work for a specific service This should be written in conjunction with the EMS service’s medical director REGIONALIZATION Based on protocol and/or the online medical control, a decision is made regarding the receiving hospital, or point of entry (POE) The POE selection is based on various factors: patient condition, the capabilities of the receiving