Diabetic Emergency...and a subsequent complaint. Your opinions, please?

[jteeters]

A couple weeks ago now, my partner and I (I was still a Basic on the truck at this time) responded to a call (at 0630 in the morning on my offgoing day), for a diabetic emergency. Report was that the PT was unresponsive, with a FSBS of 23. BLS Fire beat us on scene, and advised from the get-go that the PT has a history of becoming very combative, sometimes to the point that law enforcement is necessary.

We are met in the yard by a family member, who advises that the PT is now awake, and has a FSBS of 40. We make contact with the PT, who is awake, and seemingly alert just based on general impression. He allows my partner and I to take another blood glucose reading with our glucometer. It reads 48 mg/dL. He is A/Ox4. My partner advises him that he would like to give him some oral glucose to bring the sugar up just a little bit more. The PT then became very agitated (as expected), and said, "No, you're not doing a g*ddamn thing to me, I'm not going to the hospital, I don't want any sugar, get the hell out of my house".

After some pleading from the family, he tells them "I just don't want them messing with me." At this time, he gets up and starts pacing the floor, so we back out. He refuses to sign a refusal, and medical direction was NOT called. We remained on scene only a short time after, with one more attempt at a refusal, or transport to no avail. Come to find out, the family has now complained to the state (mainly because they didn't want to pay the bill).

My question is: What could we have done differently? I'm not approaching this as an "Oh my god we messed up", but more as a "we could have done better." Your thoughts?

 

[STXmedic]

Called Medical Direction to at least get them in the loop. It's not clear from your post if the patient was competent to refuse care, and medical direction could've helped you with that.

Obtain a refusal from the family (and ideally PD also) as witnesses that patient is refusing but also refusing to sign.

Also, verbal judo and patience can also be pretty effective. Practice that if you're not good at it.

 

[jteeters]

Thank you. He answered every A/O question, knew his name and his social, his address and phone number. I'll remember to call medical control (I start as a Paramedic tomorrow).

 

[STXmedic]

Ability to answer typical A&O questions does not necessarily mean they are competent to refuse care (not saying that your patient wasn't competent).

 

[Underoath87]

Ask him what he plans to do, should you leave. If he tells you that he's going to have a soda and eat some food, that's reassuring and shows competence. If he says pretty much anything else, he isn't competent as he isn't mentating properly and I'd get med control and LEO involved.

Also, it sucks for you guys that your service bills for refusals. We don't bill unless we transport, so people don't try to sue us to get out of the refusal bill.

 

[jteeters]

Thank you. I have voiced my displeasure more than once about billing for refusals, but unfortunately, I know nothing, apparently. It is what it is. I'm interested to see where the complaint goes, honestly. If I have to run on him in the future, I'll make sure that I have LE with me.

 

[Gurby]

Instead of oral glucose, maybe you would have had more success just convincing him to have a snack, drink some orange juice or soda, etc?

 

[jteeters]

Instead of oral glucose, maybe you would have had more success just convincing him to have a snack, drink some orange juice or soda, etc?

We tried that too. He said he would, but he didn't need us to tell him.

 

[luke_31]

Sometimes you are damned if you do and damned if you don't. Sounds like one of those cases where documentation of what was going in with Med Control would have helped. From what you describe I don't think you did anything wrong. I just hope your documentation reflects what you did.

 

[Tigger]

Ability to answer typical A&O questions does not necessarily mean they are competent to refuse care (not saying that your patient wasn't competent).

Mhhmmmm! Mental Status Examination, it's a thing.

If he is competent to refuse that's fine, just make sure to be clear in your documentation and get some witnesses. A medical control call in might not be a bad idea either.

 

[ERDoc]

I don't like the answer of passing the buck but I think this is a case where it would be appropriate. Let the doc know what is going on. In residency we used to have to take the RMA calls from the field. It's interesting how many people change their mind when a doc on the phone says, "you need to go." I don't know if that would have happened in this case (I doubt it from the sounds of it). As others have said you need to prove that the have the capacity to make their own decisions. He has to understand what is wrong, what is needed to fix it and what could happen if it doesn't get fixed. This is different from competence. Competence is a legal issue determined by a court. Medical providers determine capacity. Sometimes it pays to be an ***. Tell him that you are willing to leave but you have to see him eat something first and then sit on the couch.

 

[SpecialK]

So his BGL was about 2.5 mmol/l.

Hmm. if he didn't want ambulance personnel to touch him then see if he'd be agreeable to getting the family to give him either some glucose paste, or some sugar water or other glucose-containing food.

If he really put up a fight I'd see if we could get a couple family members to distract or subdue him so I could get some glucagon into him. It is often the case for hypoglycaemia patients who are a bit too trashy to get an IV into you can give them some glucagon.

Audio can be recorded in ePRF so if he doesn't want to sign a refusal he doesn't have to, he can just record it.

 

[MonkeyArrow]

If he really put up a fight I'd see if we could get a couple family members to distract or subdue him so I could get some glucagon into him. It is often the case for hypoglycaemia patients who are a bit too trashy to get an IV into you can give them some glucagon.

So let me get this straight. You would willingly plan to restrain or distract someone who has clearly stated that they don't want your treatment to give them said treatment. Jail time for you!

 

[SpecialK]

So let me get this straight. You would willingly plan to restrain or distract someone who has clearly stated that they don't want your treatment to give them said treatment. Jail time for you!

I dno mate, his blood sugar is 2.8 mmol/l ... that's like half of normal. Considering he is displaying signs consistent with symptomatic hypoglycaemia, I would have a good go at getting some glucose or glucagon into him. I would attempt to treat him "in his best interest" as a patient who was not competent to make decisions as a reasonable practitioner who believes his agitation is caused by his hypoglycaemia; that doesn't mean not treat him as a human being with kindness and dignity, it means attempt to give him what, based upon my diagnosis, is best for him.

The family are often bloody ace in these situations as is the "you want us to go? fine, have this sugar and we'll bugger off" method of cajoling somebody into having some glucose paste or a sugary cuppa.

To "pass" the test to be competent he has to be able to understand, repeat and explain the implications of the information given to him. If he can do all that and doesn't want it still then fine, he can either sign or record a refusal in ePRF and I'm leaving, but not before I tell the family to sneak some sugar into his next drink and call us back if he gets worse.

 

[MonkeyArrow]

To "pass" the test to be competent he has to be able to understand, repeat and explain the implications of the information given to him. If he can do all that and doesn't want it still then fine, he can either sign or record a refusal in ePRF and I'm leaving, but not before I tell the family to sneak some sugar into his next drink and call us back if he gets worse.

That's still unethical. In your hypothetical, you stated that you've determined the patient to be competent and able to refuse. Thus, you don't get to dictate care if the patient doesn't want it. If he wants to die of hypoglycemia and he understands that he might, then be it. It is not our place to force treatments onto people who do not want it or try to turn the patient's family against him. Would you actively recommend for a family to override a patient's DNR in a code situation and try to coerce them into getting their family member treated even though it is against their wishes?

 

[Underoath87]

That's still unethical. In your hypothetical, you stated that you've determined the patient to be competent and able to refuse. Thus, you don't get to dictate care if the patient doesn't want it. If he wants to die of hypoglycemia and he understands that he might, then be it. It is not our place to force treatments onto people who do not want it or try to turn the patient's family against him. Would you actively recommend for a family to override a patient's DNR in a code situation and try to coerce them into getting their family member treated even though it is against their wishes?

Gotta disagree here. Hypoglycemia is a special case and different than a DNR situation or even a STEMI, because it can mess with your emotions (it makes you obstinate and irritable as hell), even if you are still relatively oriented. Reversing hypoglycemia is a quick fix that costs very little and is painless, so only someone who is irrational due to hypoglycemia or OD'd on insulin as a suicide attempt would attempt to refuse sugar.

Additionally, someone who is in an agitated hypoglycemic state could easily be considered a danger to himself or others, so there is a good reason to not leave him alone and to request help from LE.

 

[MonkeyArrow]

Gotta disagree here. Hypoglycemia is a special case and different than a DNR situation or even a STEMI, because it can mess with your emotions (it makes you obstinate and irritable as hell), even if you are still relatively oriented. Reversing hypoglycemia is a quick fix that costs very little and is painless, so only someone who is irrational due to hypoglycemia or OD'd on insulin as a suicide attempt would attempt to refuse sugar.

Additionally, someone who is in an agitated hypoglycemic state could easily be considered a danger to himself or others, so there is a good reason to not leave him alone and to request help from LE.

But does irrational equal (mentally) incompetent? Also, don't you think trying to hold him for psych reasons is a bit of a stretch...

 

[STXmedic]

But does irrational equal (mentally) incompetent? Also, don't you think trying to hold him for psych reasons is a bit of a stretch...

If they aren't thinking rationally, can they understand the risks of refusing care? Especially in this patient's current context. Do you trust them to competently care for themselves? If you leave him and he crashes, how do you think it would look if you put in your report that you obtained a report from this now brain-dead individual despite him having "irrational thought"? I'm certainly no lawyer and my knowledge of the law is limited at best, but I'd personally rather be brought to court for having the patient's best interest in mind, than defending getting a refusal from an irrational or incompetent patient who suffered damages.

 

[MonkeyArrow]

If they aren't thinking rationally, can they understand the risks of refusing care? Especially in this patient's current context. Do you trust them to competently care for themselves? If you leave him and he crashes, how do you think it would look if you put in your report that you obtained a report from this now brain-dead individual despite him having "irrational thought"? I'm certainly no lawyer and my knowledge of the law is limited at best, but I'd personally rather be brought to court for having the patient's best interest in mind, than defending getting a refusal from an irrational or incompetent patient who suffered damages.

Well I think the term "irrational thought" is being misconstrued. In this hypothetical context, the patient is able to understand and read back the risks of refusing. I think SpecialK initially only referred to the specific action of refusing treatment as an irrational action, not a part of a longer string of irrational thinking that led them to it.

 

[Gurby]

That's still unethical. In your hypothetical, you stated that you've determined the patient to be competent and able to refuse. Thus, you don't get to dictate care if the patient doesn't want it. If he wants to die of hypoglycemia and he understands that he might, then be it. It is not our place to force treatments onto people who do not want it or try to turn the patient's family against him. Would you actively recommend for a family to override a patient's DNR in a code situation and try to coerce them into getting their family member treated even though it is against their wishes?

In his hypothetical, SpecialK put the word "pass" in quotations. He is implying that patient is not really truly mentally competent, but patient is alert+oriented enough that he can make it sound on the documentation like patient IS competent to refuse. Thus he has covered his arse if something bad should happen. Although that's a high risk refusal that should really involve medical control.

Something bad probably will happen, though, if someone doesn't intervene. If patient lived alone, you would never allow him to refuse here. If family can sneak some sugar into him, then everyone wins. If not, he gets worse, family calls 911 again and you hold him down to give glucagon or D50, which is going to be a lot more unpleasant for everyone involved.