# Chest Pain - BLS - No Meds - Pt Refusing Care



## jhopper (Dec 1, 2010)

50 y/o male complains of chest pain on exertion. Hx of hypertrophy and mitral valve regurgitation. Pt takes medication to controll b/p.

V/S BP: 170/80 HR: 90 RR: 18 Skin: PCD

We are a stand by service providing BLS care.

Pt found sitting in lawn chair complaining of 2 in severity of pain. After assessment my partner suggests pt call ambulance. PT refuses. Pt was noticably anxious, in pain. Partner suggest that pt seek help at urgent care facility. Pt refuses. Partner suggest pt seek care at ED to have ECG performed. Pt refuses. 

I suggest 02. Pt refuses. Pt contact time now > 5 minutes. Pain increasing. Listen to lung sounds - clear in all fields. No pain upon inspiration. We have no meds beyond 02.

I inform pt that his "pain is caused from ischemia. If it were angina it should abate after rest. Because the pain will not abate this is cause for concern. Your heart is starving for oxygen." Pt chose to drive to ed where he received a stent.

Did I handle this correctly; what more could I have done?


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## Handsome Robb (Dec 1, 2010)

In a situation like that there isn't a whole lot more that you could have done. As long as the Pt is A&O he has the right to refuse care. I would be cautious about diagnosing something in the field. Better off to just explain potential things that could be going on, which you basically did, I would have worded it differently, personally. With AMAs I have always been taught to inform the pt of risks of denying care up to and including death. It can come off a little gruff/extreme but it covers your *** and could end up saving your pt's life.


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## SanDiegoEmt7 (Dec 1, 2010)

If he's competent to refuse care, that's his right.

It's your job to inform him of all the risks (how did you deduce ischemia from the host of differentials merely based those vitals?), and treat at his discretion.  I would have had him sign an AMA as well, and documented extremely well.


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## jhopper (Dec 1, 2010)

.
.
.


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## JPINFV (Dec 1, 2010)

jhopper said:


> Did I handle this correctly; what more could I have done?



You could have called paramedics anyways if he didn't fairly quickly transport himself. No one can force him to be seen, treated, or transported, but you can offer better on scene care. The paramedics should be able to run a 12 lead EKG and, if the patient was suffering from a STEMI, diagnosis it on scene. Unless you think the patient is incompetent (which no evidence was provided to say he was), there's nothing you can do to compel evaluation and treatment, just facilitate it and hope he eventually accepts.


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## DrParasite (Dec 1, 2010)

you know, who makes a diagnosis on chest pain without a cardiac monitor and without enzyme tests is probably asking for trouble, especially when your diagnosis is that the pain isn't life threatening. If he has chest pain, say he has chest pain, and it should be evaluated by a doctor to confirm that it isn't a cardiac issue, because if it is, it can lead to events up to and including death.

Anyone who doesn't want to go, as long as they are AOx3, can refuse care, regardless of if it's the smart thing to do.


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## JPINFV (Dec 1, 2010)

NVRob said:


> I would be cautious about diagnosing something in the field.



Why? I'm not sure given the diagnostic capabilities of an EMT that a forceful "Your heart is ischemic and dying" is appropriate, but a "One of the likely causes of your pain given your medical history and how you are describing it is that you are having a heart attack and I am unable to appropriate evaluate you to rule it out. I can call the paramedics and have them evaluate you here just in case." would be appropriate. Not all chest pain is cardiac and not all cardiac chest pain is an infarct, however an infarct needs to be ruled out in most cases of chest pain.


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## JPINFV (Dec 1, 2010)

DrParasite said:


> you know, who makes a diagnosis on chest pain without a cardiac monitor and without enzyme tests is probably asking for trouble, especially when your diagnosis is that the pain isn't life threatening.


Who said that the working diagnosis given wasn't life threatening? He effectively ruled out angina based on the history of present illness. He ruled out a non-emergent cardiac diagnosis in favor of going with an emergent working diagnosis. 





> Anyone who doesn't want to go, as long as they are AOx3, can refuse care, regardless of if it's the smart thing to do.


So your psych patients who are on a hold, but are A/Ox3 or 4 (system dependent) are free to sign AMA? Alternatively, does competence go past a simple a simple A/O x ____?


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## DrParasite (Dec 1, 2010)

JPINFV said:


> Who said that the working diagnosis given wasn't life threatening? He effectively ruled out angina based on the history of present illness. He ruled out a non-emergent cardiac diagnosis in favor of going with an emergent working diagnosis.


you did.  I made the general statement about making diagnosis without having all the proper tests ran.  Maybe if I had put the  non-life threatening part in parenthesis, it would be clearer for you to understand





JPINFV said:


> So your psych patients who are on a hold, but are A/Ox3 or 4 (system dependent) are free to sign AMA? Alternatively, does competence go past a simple a simple A/O x ____?


ok, now you are giving facts not in evidence.  yes, i admit, if the chest pain patient is on a psych hold, even if AOx3, they can't refuse.  similarly, if they are under 18 and not emancipated, they can't refuse.  and I am also guessing the patient has no 

based on the fact that the OP let the guy drive himself to the hospital, I am guessing he wasn't on a psych hold.

but what do I know, I'm just a dumb EMT


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## JPINFV (Dec 1, 2010)

DrParasite said:


> you did.


Please tell me you aren't talking about paramedics ruling out a STEMI. If so, I don't think you understand what the "ST-elevation" part of a STEMI is, or why its differentiated from a NSTEMIs. There's a reason I didn't address NSTEMIs, and I hope that anyone who actually runs a 12 lead knows that differentiation. 



> based on the fact that the OP let the guy drive himself to the hospital, I am guessing he wasn't on a psych hold.
> 
> but what do I know, I'm just a dumb EMT


I think you failed to see that I was getting at the fact that a simple A/Ox4=competent is bad medical care.


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## SanDiegoEmt7 (Dec 1, 2010)

JPINFV said:


> So your psych patients who are on a hold, but are A/Ox3 or 4 (system dependent) are free to sign AMA? Alternatively, does competence go past a simple a simple A/O x ____?



In your own words, they are on a hold.  They have lost their right to refuse care for 72 hours (5150 in CA), 14 days (5250 in CA) or indefinitely (conservatorship)


For patients who are not on a hold, absolutely.  But it depends on the c/c.  Many a suicidal patient is a/ox3, do we cut them loose?  For a cardiac patient that is A/Ox3, there's not much you can do if they don't want to go.  BUT I do agree with what you said above, and I would have activated ALS regardless if the patient had said "I don't want to go"  what if after the "5 minutes" of debate they did decide to go, now ALS is 5 minutes behind.  Would have called ALS (people tend to trust anyone who shows up in an ambulance with a fire truck more :unsure

This EMT would have been better off, activating 911 while he talked to this gentlemen.  If the guy let you get lung sounds and other vitals, its likely he would have allowed an EKG, not to mention if he had coded they would have been there earlier to start ACLS. 

If after all this and a confirmed by EKG cardiac issue, he still refused, let ALS handle the AMA, and wash your hands of the call.  Its not your job to be cutting loose ALS level calls anyway.  Activate your 911 backup, if he leaves before they arrive, cancel them.


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## Handsome Robb (Dec 1, 2010)

JPINFV said:


> Why? I'm not sure given the diagnostic capabilities of an EMT that a forceful "Your heart is ischemic and dying" is appropriate, but a "One of the likely causes of your pain given your medical history and how you are describing it is that you are having a heart attack and I am unable to appropriate evaluate you to rule it out. I can call the paramedics and have them evaluate you here just in case." would be appropriate. Not all chest pain is cardiac and not all cardiac chest pain is an infarct, however an infarct needs to be ruled out in most cases of chest pain.



You just agreed with me....you just actually spelled it out where I said I would word it differently.



			
				NVRob said:
			
		

> Better off to just explain potential things that could be going on


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## JPINFV (Dec 1, 2010)

SanDiegoEmt7 said:


> For patients who are not on a hold, absolutely.  But it depends on the c/c.


There's a disconnect here. If the only thing that determines competence is the fact that the patient can remember when, where, why, and who, then why should the complaint matter? Unless it's about the totality of the situation and not a simple A/Ox4. If a patient can remember who/when/where/why, but can't explain back in their own words what refusing care means, and the risks of refusing care, can they still sign out against medical advice?


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## SanDiegoEmt7 (Dec 1, 2010)

JPINFV said:


> There's a disconnect here. If the only thing that determines competence is the fact that the patient can remember when, where, why, and who, then why should the complaint matter? Unless it's about the totality of the situation and not a simple A/Ox4. If a patient can remember who/when/where/why, but can't explain back in their own words what refusing care means, and the risks of refusing care, can they still sign out against medical advice?



I apologize for the brevity (read: laziness) in my "A/Ox3" answer. I meant all the criteria for AMA have been met.  For different counties this means different things.

Here are the criteria for an AMA in my service, and what I meant when I repeated the A/Ox3 classification used throughout the thread.

-Is the patient 18 years of age?
-Does the patient have a GCS of 15?
-Are there no barriers to communication with the patient?
-Is the patient not under the influence of alcohol/drugs?
-Is the patient not exhibiting signs of behavioral emergency?
-Is the patient competent (understand condition, treatment options, risks)?
-Are there no family and/or bystanders expressing concern about patient's decision?

Many of these questions were left unanswered by the OP, and everyone assumed they were answered in the affirmative.

Perhaps since he did not mention an AMA process, he doesn't have one or understand his.  My recommendation still stands to let ALS handle the call.


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## Melclin (Dec 1, 2010)

I think you did well OP. What exactly are you worried about?

I don't really think just laying out the dry facts, removing yourself from the decision completely and then accepting their decision is enough. You've gotta push a little. 

Also, ask why they don't want to go to hospital. I've had people flat out refuse even when told they were basically going to die if they didn't. Then when you ask why they can't leave, its because: 
-someone has to feed the dog.
-they've called a family member and they can't leave before that family member arrives.
-don't want to worry the neighbours by being taken away in an ambulance.
(three examples from my admittedly limited experience)

Trouble shoot their problem and your task of convincing them to go to hospital may get a whole lot easier. (Asked the a friend who was there to feed the dog. Rang the family member and had them meet us at the hospital instead. For some reason the patient felt being taken out in the wheel chair was acceptable to neighbours while the stretcher was a deal breaker...sigh)

I don't have any issues at all with being firm, even forceful in my explanation of the possible outcomes.* I reckon advocating for your patients means protecting them, to some extent, from their own stupidity/denial.* In a general sense, I'm all for the idea of being free to make the wrong decision rather than being forced to make the right one, but since we've got some time before the rise of INGSOC and our annexation by Oceania, I feel there is a little wiggle room.


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## jhopper (Dec 1, 2010)

Why do I bring this scenario up; what is my concern? Because I want to learn to communicate better in situations like this.


I do agree that calling ALS would have been appropriate; however I was not in charge. Furthermore I understand telling the pt "your heart is suffering from ischemia" may have been a diagnosis that lacked objective data, but my partner was not communicating the risk of denying care effectively. I suppose I explained to the pt what _was_ happening when I should have explained what _could have _been happening.


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## usalsfyre (Dec 1, 2010)

jhopper said:


> I do agree that calling ALS would have been appropriate; however I was not in charge.



If you were doing the paperwork, you were in charge. Furthermore is your partner of the same or lower level is not able to adaquately provide care (for any number of reasons), you have an ethical obligation to step in.


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## MrBrown (Dec 1, 2010)

jhopper said:


> I inform pt that his "pain is caused from ischemia. If it were angina it should abate after rest. Because the pain will not abate this is cause for concern. Your heart is starving for oxygen."



Are you a doctor or a diagnostician? (for that matter, avert your eyes from the odd fellow in the orange getup with "DOCTOR" written on it for he too may not be a doctor!) 

The best thing to tell this guy is that his chest pain is a serious concern and that in your medical judgement he needs to be seen by a physician.  You are obliged to tell him that he has evey right to refuse your recommendation but that he is displaying several classic symptoms of having an infarct (well, just say heart attack) and that he needs to go get checked out.


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## JPINFV (Dec 1, 2010)

MrBrown said:


> Are you a doctor or a *diagnostician*?


Emphasis added.
I would argue yes, as what are you treating if you aren't developing a working diagnosis from a set of differential diagnoses?


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## brentoli (Dec 1, 2010)

Do your protocols address "special" sor situations? I believe mine (ill have to double check, switching to new ones has 2 sets on the brain) state ALS must be requested for any SORs on a chest pain patient. 
Not trying to take away from your independent thought, just something to consider.


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## jhopper (Dec 1, 2010)

No such SOR protocol


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## Sandog (Dec 1, 2010)

JPINFV said:


> Emphasis added.
> I would argue yes, as what are you treating if you aren't developing a working diagnosis from a set of differential diagnoses?



You made a believer out of me JP. I read your article, I liked it, and I agree.


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## 18G (Dec 1, 2010)

To the OP... it sounds to me like you and your crew members handled the call appropriately. Sometimes patients are just butt heads and refuse to listen to reason. You guys informed the patient of his current condition and what the risks of refusing care and transport were. As long as the patient was conscious, alert, and oriented, and he was enabled to make his decision an informed one, there wasn't anything else you could have done. 

And in telling the patient that you thought his pain was from ischemia.... I think that was totally a-ok. It's not hard to get a good general sense of ischemic pain from non-ischemic pain even without a ECG and labs. This guy's history and presentation rings very loudly of ischemia. Sometimes you need to use scare tactics and be very blunt with patients to get them to understand and accept the seriousness of their condition.... I'm not saying lie to them... but choose words that emphasize the immediacy of the situation. 

The patient got lucky this time and hopefully he learned his lesson. If you encounter the same patient again or similar cases handle it the same. As someone else suggested you could request ALS even though the patient says he refuses. Perhaps a change in the scene dynamics can persuade the patient to accept transport in a unit that he can see in front of his house and it will show that you tried every thing in your power to get the patient a level of care they needed.


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## CodyHolt83 (Dec 17, 2010)

I agree with JPINFIV


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## zmedic (Dec 17, 2010)

If you were on an ambulance, on duty I would call your on line medical control and have the doc speak to the patient, that can really help. Also covers your butt with the refusal "pt continued to refuse care even after speaking to online medical control Dr. X." 

You should be really explicit in explaining the risks to the patient and document as such:

"Pt was told that his chest pain could be due to a life threatening condition including heart attack, pulmonary embolism, or damage to his aorta. Pt was told that proper evaluation should happen at a hospital and refusal of care or delay in treatment could lead to serious consequences including disability, cardiac arrest and death. Pt verbalized understanding of risks and that he could call 911 if he changed his mind, signed refusal form and ambulated away without assistance."


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## CodyHolt83 (Dec 18, 2010)

zmedic said:


> "Pt was told that his chest pain could be due to a life threatening condition including heart attack, pulmonary embolism, or damage to his aorta. Pt was told that proper evaluation should happen at a hospital and refusal of care or delay in treatment could lead to serious consequences including disability, cardiac arrest and death. Pt verbalized understanding of risks and that he could call 911 if he changed his mind, signed refusal form and ambulated away without assistance."




That is awesome!  As a new EMT, this statement is perfect for me!  Thanks for posting.


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## Sasha (Dec 18, 2010)

> "pain is caused from ischemia. If it were angina it should abate after rest. Because the pain will not abate this is cause for concern. Your heart is starving for oxygen.



Not to be nit picky, but I hate when people try to use big words like ischemia and angina when talking to patients. In your report, that's fine, but a lot of people don't know these words, and it can be kind of intimidating and confusing for them, which is not going to win them over to your side.


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## jjesusfreak01 (Dec 19, 2010)

I would call for an ALS response, and let them try to convince him to at least go for a 12-lead before he left, reminding him that he doesn't get billed unless we transport. Do your best to get them checked out, and if they still leave, thats not your problem.


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