# Combative patient.



## andyrad (Feb 25, 2009)

I'm currently taking my emt and a scenario we had last monday went like this.

20 year old female was "not making any sense" to security so they called an ambulance. Upon arrival she was very non compliant and kept shoving us away and kept refusing treatment. She was very weak and had an altered LOC. At first I suspected stroke as she was slurring her words and had the arm drift. 

Any time I suggested she needed help, she refused. I guess my question is, can you be more assertive because they're obviously in need of help? Is the refusal of help an issue or should you just proceed taking in to consideration that they're clearly in an altered state of mind?! Maybe I answered my own question and am just mulling over a scenario that didn't go too well in my own mind.


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## Aidey (Feb 25, 2009)

Just an bit of info before I answer your question. While not unheard of 20 is pretty young for a stroke, so you should also be thinking drug intoxication, hypoglycemia and head trauma. All of which can mimic strokes. 

How was she altered? Did she know who she was and where she was and what was going on? If she did, technically she can refuse, although it probably wouldn't be a good idea. If she wasn't alert and oriented to person, place, time and events then you can ignore what she is saying and treat her under implied consent. The idea is that if she was AOx4 she would consent to treatment.


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## DT4EMS (Feb 25, 2009)

Well........ a woman in her 20's showing signs of a stroke.......... How about a history of smoking and contraceptive use? She very well could have had a stroke.

Now, this is NOT a combative patient. This would be an "uncooperative patient". A person who does not want you to touch them is not combative by my definition. 

A person actively trying to touch you could be classified as combative/assaultive.

Now in this scenario........ talk, talk, talk......... try to almost beg for her allowance of treatment. If she refuses........ and she is mentally competent......... let her go. Treat her after she loses consciousness, or she gives informed consent........ that's about it.

Moving in and forcing treatment on her without consent is bad ju-ju..........


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## BossyCow (Feb 25, 2009)

I have a friend who suffered a stroke at age 16. It happens. Not common, but it does happen. DT4 is correct. This is a sales job. Try to gain the woman's trust. Touch her hand, try to maintain eye contact. Be sincere, caring and concerned. Pulling out the authoritative, standing over the pt, "I'm in charge" posture that works with some pts probably won't do it with this one. Common sales practice is getting the pt to answer questions that are yes answers. 
"So...  you want us to leave you alone?"
"yes"
"You want me to go away?"
"Yes"
"Well, I don't want to make you do anything you don't want to do, but if you let me do a quick assessment, I can tell these cops/bystanders/family members that you are fine and then you and I can both go on with our day.. Okay?"

I've had a few that were right with me, saying yes and right at the last minute pulled back and I had to start over. These can be painfull slow processes. But I'd rather take the time to convince someone than deal with the issues resulting from trying to force them.


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## DT4EMS (Feb 25, 2009)

BossyCow said:


> I have a friend who suffered a stroke at age 16. It happens. Not common, but it does happen. DT4 is correct. This is a sales job. Try to gain the woman's trust. Touch her hand, try to maintain eye contact. Be sincere, caring and concerned. Pulling out the authoritative, standing over the pt, "I'm in charge" posture that works with some pts probably won't do it with this one. Common sales practice is getting the pt to answer questions that are yes answers.
> "So...  you want us to leave you alone?"
> "yes"
> "You want me to go away?"
> ...



See Bossy has proven my point..........

There are so many "lectures" or "how to talk to patients" classes for EMS that are just out to make a buck.......... many EMS providers are already GREAT communicators.

Now before you go telling me about how many are not........ well most of those don't need to be in the profession anyway


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## andyrad (Feb 26, 2009)

She was not alert and oriented to anything. She kept swearing at me and shoving (weakly) me away.


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## TomB (Feb 26, 2009)

It was a violent patient! Run away! Oops, sorry wrong thread.


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## Sasha (Feb 26, 2009)

> Is the refusal of help an issue or should you just proceed taking in to consideration that they're clearly in an altered state of mind?!



A patient can refuse if they are a competent adult. Because she was AMS she is no longer competent and cannot refuse. 

And no, I'm not for the habit of kidnapping drunks, but you can not determine ETOH until you've done a full assesment and ruled out hypoglycemia, head injury, etc.



> It was a violent patient! Run away! Oops, sorry wrong thread.


Scream and run away, live to treat another day!


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## BossyCow (Feb 26, 2009)

andyrad said:


> She was not alert and oriented to anything. She kept swearing at me and shoving (weakly) me away.



Sometimes the pt who won't talk to you will love your partner or someone else on scene. Use that! Your frustration level with her behavior has to be less important than her care.


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## dtermnd (Mar 1, 2009)

I agree with the other's, just keep attempting to get her to allow you to assess her, then get a D-stick right away.  If nothing else, tell her if she lets you check her sugar, then you can consider leaving her alone.  But the BGL should be done right away, to rule things out.


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## downunderwunda (Mar 1, 2009)

Sasha said:


> And no, I'm not for the habit of kidnapping drunks, but you can not determine ETOH until you've done a full assesment and ruled out hypoglycemia, head injury, etc.



Does this mean drunks, or should I say those under the influence of ETOH are fully competent & capable of making an informed decision to refuse treatment?


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## Aidey (Mar 1, 2009)

My previous protocols stated that even if someone was under the influence of ETOH, if they were oriented to person, place, time and events (AOx4) they could refuse treatment and transport.


Bossy/DT I didn't say she couldn't have had a stroke, just that it was unlikely.


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## reaper (Mar 1, 2009)

downunderwunda said:


> Does this mean drunks, or should I say those under the influence of ETOH are fully competent & capable of making an informed decision to refuse treatment?



That is a case by case situation. You could drink two beers and not be compatent to make a decision. I could drink ten beers and still be compatent enough to make that decision.

You can not throw all etoh pt's into a group. You need to evaluate each one and decide on your own!


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## JPINFV (Mar 1, 2009)

reaper said:


> That is a case by case situation. You could drink two beers and not be compatent to make a decision. I could drink ten beers and still be compatent enough to make that decision.
> 
> You can not throw all etoh pt's into a group. You need to evaluate each one and decide on your own!



Wow, welcome to a JEMS Connect thread where I've been saying this for a while. 


A/Ox4 is a God aweful way to determine capacity. Yes, a patient who isn't A/Ox4 (or 3 depend on the system) lacks capacity (provided the provider isn't being a butt hole on the entire time thing. Who hasn't lost track of time or days at some point in their life?), BUT a patient that is A/Ox4 doesn't necessarily have capacity. How many psychiatric patients are transported under a temporary hold or conservatorship every day that is A/Ox4?


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## downunderwunda (Mar 2, 2009)

reaper said:


> That is a case by case situation. You could drink two beers and not be compatent to make a decision. I could drink ten beers and still be compatent enough to make that decision.
> 
> You can not throw all etoh pt's into a group. You need to evaluate each one and decide on your own!



I agree completely. 

However, what you need to consider now is that, under World Health Organisation (WHO) guidelines, anyone who has consumed alcohol, and "makes a decision that would not be considered appropriate bya right minded person" is recommended to be detained, not criminally, but under a mental health order, until they sober up. This can also apply to a person who is say having a hypoglycaemic attack, or even in severe pain.

This is really discretionary, however reaper, as you can see, while tryin to ridicule my question, there is proven data to show that while you may think you are capable, after 10 beers, you may not be truly capable of those decisions. 

Is the decision to drive a vehicle after those 10 beers a rational decision?


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## reaper (Mar 2, 2009)

downunderwunda said:


> I agree completely.
> 
> However, what you need to consider now is that, under World Health Organisation (WHO) guidelines, anyone who has consumed alcohol, and "makes a decision that would not be considered appropriate bya right minded person" is recommended to be detained, not criminally, but under a mental health order, until they sober up. This can also apply to a person who is say having a hypoglycaemic attack, or even in severe pain.
> 
> ...



First, I was not trying to ridicule your question. I was answering it!

Second, I don't follow WHO guidelines!


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## downunderwunda (Mar 3, 2009)

reaper said:


> I don't follow WHO guidelines!



Then what do you follow? Protocols? Where do they base their information?

The world Health Oranisation actually provides good data & information. To say what you have said shows complete ignorance. 

Here is some useful infor I have lifted from their web site, maybe you will realise the importance of this oranizatin in relation to prehospital care.



> WHO is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends.
> 
> In the 21st century, health is a shared responsibility, involving equitable access to essential care and collective defence against transnational threats.
> 
> ...




Maybe you should look at what they study today to see how you will be working in the future.


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## reaper (Mar 3, 2009)

downunderwunda said:


> Then what do you follow? Protocols? Where do they base their information?
> 
> The world Health Oranisation actually provides good data & information. To say what you have said shows complete ignorance.
> 
> ...



We are talking about a Pt's right to decide, based on competency. I do not follow WHO or the united Nations guidelines for this basis. We have different laws and freedoms, then most of the nations in the UN. So yes, I follow what our laws dictate. That is the difference in this debate!


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## downunderwunda (Mar 3, 2009)

reaper said:


> We are talking about a Pt's right to decide, based on competency. I do not follow WHO or the united Nations guidelines for this basis. We have different laws and freedoms, then most of the nations in the UN. So yes, I follow what our laws dictate. That is the difference in this debate!




The questin is not about a patients right to decide, it is about when they forego that right. If a person has a blatant open head wound, with brain matter visible (this is a real case) & they say it is OK they dont want to go to hospital, it isobvious they are incapable of an informed decision, therefore their rights have to be overridden. In the case of a person under the influence of alcohol, the decision should be based around a duty of care. Can they, or the people they are with provide a duty of care that will ensure that person will get home safely, if not, then their 'right (rights mean responsibility) MUST be violated. You state you have different laws & freedoms, but what happens when, even though that person has not broken the law, but is impinging on someone elses freedom? What about their rights & freedom? Are they not entitled to the same consideration?

Is the most appropriate place for them a prison cell - no, they are not criminals, but it is also not a hospital bed. 

Like it or not, the information you provide on your PHCR will end up with WHO as a statistical number somewhere along the line. Like it or not, this information is used to modify laws to further protect your rights & freedoms, as well as the rights & freedoms of others.

Stop being ignorant reaper. Open your eyes & look at the world from a third party perspective. It does exist outside the USA & exists surprisingly well.


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## ffemt8978 (Mar 4, 2009)

Play nice or go find somewhere else to play.


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## mycrofft (Mar 5, 2009)

*I'm with Bossy, although I'm not as good. But LE is needed.*

If the pt is not competent and is on the street, then she is "danger to self and others" and needs a "5150" determination as well call 'em here. If the pt gets aggressive you need someone else to be the "hands-on" bad guy and assist you. If the pt loses consciousness, implied consent is in order, but will they wake up in your unit?

Also...even if unilateral CNS signs present (yes, even in a kid), and you cannot communicate with the pt, how can you be sure they are not a longstanding affect from a birth defect, old CVA or brain injury, etc.?

In my practice, many pts are incompetent because they are ignorant. Once they understand then accept the rationale for care or it's witholding, then many are at least compliant and can be worked with. Some folks just never CAN understand...


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