# "She's not acting right."



## abckidsmom (Dec 9, 2011)

Scenario:  At 0130, you are called for an 18 yo female with an altered mental status.  The additional on dispatch is just "caller states that the patient is not acting right, and she's 5 months pregnant."  You have a 15 minute response time.

During the response, the dispatcher adds that the patient herself called in and asked to cancel the ambulance, but that her speech was slurred, and given the history on the address in the CAD there is a potential for drugs or alcohol to be involved, and they have you continue in.

When you arrive on scene, you are met at the door by a young man who identifies himself as the patient's fiance.  He leads you through a cluttered but not terribly unkept double wide trailer to a bedroom, where the patient is lying on a bare mattress, covered completely by a dirty comforter except for her head.  She says, in a slurred voice, "I told them not to send you, you aren't going to touch me, and you can go ahead and leave."

She looks very pale and it looks like a lot of effort for her when she moves around in bed.  She has dark circles under her eyes.  Getting the demographic info, you determine she's A&Ox4, and adamently refuses to be evaluated, does not give a reason other than, "I'm OK, just leave me alone!"

She has had issues with hypoglycemia, and was treated and released by EMS for the same 10 days prior to this event.  She has a history of Crohn's disease, but has had that well under control with a medical regimen. She's G2A1P0, 21 weeks gestation with a baby boy.  She reports that she has had regular prenatal care, but can't name her doctor or the name of the practice.  

She refuses any physical exam, include all vital signs and blood glucose monitoring.

A deputy arrives and is willing to do whatever you think is right.  

What do you do?  How comfortable are you with your decision?  Will you lose sleep over this girl?


----------



## Aidey (Dec 9, 2011)

What does the fiance think and want you to do? Is he the father of the baby?


----------



## abckidsmom (Dec 9, 2011)

Aidey said:


> What does the fiance think and want you to do? Is he the father of the baby?



The fiance is the father, and isn't sure what the right thing to do is.  He really doesn't want to piss her off any more than she already is.


----------



## usafmedic45 (Dec 9, 2011)

> A deputy arrives and is willing to do whatever you think is right.


Tell them to make her drink something and then eat something.  If that fixes the slurred speech and if she's A/O x 4 and there's nothing else to indicate she's not unable to refuse, it's time for my three favorite non-vulgar words in the English language:  "not my problem".


----------



## Aidey (Dec 9, 2011)

I would take the fiance into another room and speak with him. Find out  if she has and any drugs, alcohol, illicit meds etc and when she ate  last. I would also ask if this is similar to what happened when her  blood sugar was low before. Like USAF I would very likely have them make her eat something. 

If there are drugs/alcohol on board it gets a little stickier. The lowest cut off any of our hospitals have for a viable baby is 21 weeks, 3 days and she is right around that.


----------



## usafmedic45 (Dec 9, 2011)

> If there are drugs/alcohol on board it gets a little stickier. The lowest cut off any of our hospitals have for a viable baby is 21 weeks, 3 days and she is right around that.



Eh....the kid isn't even a factor in this equation for me at once I rule out the pregnancy having something to do with the matter at hand.

That said....at 21 weeks, calling a fetus "viable" is kind of optimistic. LOL


----------



## mycrofft (Dec 9, 2011)

*Enlist the boyfriend.*

Quietly but firmly explain the stakes involved and suggest he get her to eat something with sugar in it first. Have law enforcement please wait outside and ask the boyfriend (as a co-inhabitor he can say yes) to allow you to look at the medicine cabinet. 
 Bring in the deputy and make sure the female understands the refusal deal one article at a time, (draw a little line by each paragraph, initial it yourself as she initials it herself) and if at any time she exhibits a failure to understand plain speech in her fluent tongue, you probably have inability to  competently refuse.

I wonder if in some states the presence of a fetus would subject you to bad things legally should the mother refuse and then she aborts or they both die. Recently some state defeated a measure that made it to a vote to abolish *all* abortion due to the fetus being a human life; this would extend the concept of an unlawful taking of a life to letting Mom refuse tx and either die, or abort.


----------



## usafmedic45 (Dec 9, 2011)

> I wonder if in some states the presence of a fetus would subject you to bad things legally should the mother refuse and then she aborts or they both die.



If she refuses and is competent to do so, you're on pretty good legal ground so long as you document the :censored::censored::censored::censored: out of the run.  Even if something bad happens and one of those asinine attempts at laws were applied, it would be applied to the mother because it was her actions (or inaction rather) that were the proximate cause of the death of the fetus.



> Quietly but firmly explain the stakes involved



You mean the fact that evolution is trying to work its magic and eliminate the weakest genes from the collective pool?


----------



## mycrofft (Dec 9, 2011)

*Ah, being sardonic are we?*

You'll confuse the kiddies!

Agreed. In fact, I bet if you barged in and did something that worked you could still come out smelling OK. It can be surprising how far outcome can overwhelm questions of process...thank heavens (sometimes).


----------



## Veneficus (Dec 9, 2011)

*a radical idea*

Thank Roscoe P Coltrane for coming and let him be on his way.

Ask the girl if you can evaluate her and remind her she doesn't have to go to the hospital if she doesn't want. Explain to her the purpose of each question or test and ask specifically for permission for each part.

Remind her she can refuse or stop the exam at any moment once it has begun. 

Explain to her that even after you begin treatment, she has the right to stop and refuse transport.

Ask the boyfriend if you can talk to her privately. 

Rather an all or nothing approach, why not go with some baby steps?


----------



## usafmedic45 (Dec 9, 2011)

> Ah, being sardonic are we?



Actually, I am not.  I seriously view trying to force this woman to seek care as interfering with one of the basic tenets of evolution.  To quote George Carlin: "The kid who eats too many marbles, doesn't grow up to have kids of his own."



> It can be surprising how far outcome can overwhelm questions of process...thank heavens (sometimes).



I'd take my chances with the dead trailer trash and fetus.  A lawsuit based on violation of the patient's basic right to autonomy is far more likely to succeed.


----------



## mycrofft (Dec 9, 2011)

*Sardonic is ok.*

I like Carlin's take on things. He was supposedly actually a softy in many ways, especially after his first heart attack.

If a judge was given the choice to prosecute someone for saving a fetus and mom against the mom's wishes, versus letting the EMT off go, (or finding guilty and sentencing to a one year suspended sentence and no fine), I bet she or he would tend to ream out the EMT but let it go. If it failed  and the patient(s) died, and the tort was committed, then ...off to the guillotine.


----------



## usafmedic45 (Dec 9, 2011)

> He was supposedly actually a softy in many ways, especially after his first heart attack.



I had the pleasure of meeting him once when I was a young man.  He was polite, kind and soft-spoken.


----------



## usafmedic45 (Dec 9, 2011)

> If a judge was given the choice to prosecute someone for saving a fetus and mom against the mom's wishes, versus letting the EMT off go


The thing is the judge doesn't get to make such decisions based on that.  The decision is made based on clear cut legal standing just as with any other claim of malpractice.  Remember, we're talking a civil case here not a criminal one as there is no criminal offense implicit in anything being discussed here.


----------



## Veneficus (Dec 9, 2011)

I agree with USAF on this one.

The woman has a basic right of self determination. If the step approach doesn't work, she has met all criteria to refuse so far.

No matter what you do, there is going to be a pile of paperwork.

If you think she is so serious and the boyfriend agrees he wants her checked out, just call in service on location and wait for her mental status to circle the drain.


----------



## Aidey (Dec 9, 2011)

usafmedic45 said:


> Eh....the kid isn't even a factor in this equation for me at once I rule out the pregnancy having something to do with the matter at hand.
> 
> That said....at 21 weeks, calling a fetus "viable" is kind of optimistic. LOL



It is what the hospital has set. Anything before 21 weeks, 3 days is considered non-viable and they will not attempt to treat even if the fetus is delivered breathing. After that they will treat. I personally think it is low given the abysmal survival statistics, but I'm not the NICU director. 

I see it as a one patent/two patient issue. If we are past the date of viability and she is refusing, but the father is concerned about the welfare of the child I've got grounds to do something. If we're before that date, or he isn't worried then I don't. As heartless as it sounds if she is before the cut off it doesn't matter what she is doing to herself because the fetus is considered non-viable no matter what happens. 

It is one of those we've gotta draw the lines somewhere issues.


----------



## usafmedic45 (Dec 9, 2011)

> but the father is concerned about the welfare of the child I've got grounds to do something.



No, you don't.  At least so far as I am aware, the father's wishes are immaterial when they conflict with a patient's right to self-determination.   



> As heartless as it sounds if she is before the cut off it doesn't matter what she is doing to herself because the fetus is considered non-viable no matter what happens.



I don't care if she's nine months along.  It's her call if she wants to endanger herself and her fetus.


----------



## Veneficus (Dec 9, 2011)

Aidey said:


> It is what the hospital has set. Anything before 21 weeks, 3 days is considered non-viable and they will not attempt to treat even if the fetus is delivered breathing. After that they will treat. I personally think it is low given the abysmal survival statistics, but I'm not the NICU director.
> 
> I see it as a one patent/two patient issue. If we are past the date of viability and she is refusing, but the father is concerned about the welfare of the child I've got grounds to do something. If we're before that date, or he isn't worried then I don't. As heartless as it sounds if she is before the cut off it doesn't matter what she is doing to herself because the fetus is considered non-viable no matter what happens.
> 
> It is one of those we've gotta draw the lines somewhere issues.



I think there is too much grey area here.

We have only her word this is before 21 weeks. Based on what?

Then, the viability is based on the practicioner who is going to treat. I have seen kids as young as 19 weeks treated and ultimately discharged. I have heard of a 17 week second hand, but i strongly suspect that one was improperly dated.

When you start removing rights based on unborn fetuses, you are really getting into some tricky territory there and that is not a can of worms I want to open.

What if the fetus has some diagnosed genetic defect and she has chosen to carry to the possibility of spontaneous abortion?

What if she now or retrospectively decides to claim medical intervention is against her religion?

What if there is an abusive relationship going on here and the girl really is hoping for a miscarriage?

Just my opinion, but I would want to keep this as simple as possible.


----------



## firecoins (Dec 9, 2011)

I am sorry but the fetus plays no role here. The mother has the choice of being treated or not being treated unless she is altered.  The fetus is not my concern. 

She signs the RMA, the cop acts as a witness and we bounce.


----------



## abckidsmom (Dec 10, 2011)

Veneficus said:


> Thank Roscoe P Coltrane for coming and let him be on his way.
> 
> Ask the girl if you can evaluate her and remind her she doesn't have to go to the hospital if she doesn't want. Explain to her the purpose of each question or test and ask specifically for permission for each part.
> 
> ...



 She refuses every slick attempt at the step approach, including the slick "I'm on your team" kneeling by the side of the bed trick.  "Get back from me, don't touch me!  You know you can't touch me if I tell you not to.!"

She refuses to eat or drink.  

She's just a shining ray of sunshine in the night!

Private conversation with the boyfriend reveals that she is in charge of the house, and he's thinking he's in major trouble for calling at all.  He says he will not be calling again unless she's unconscious.  You take a minute to educate him on what to do if he thinks her sugar is low.

Private conversation with her reveals nothing.  She's not talking.

Boyfriend says there are no drugs or alcohol in the house (even before Roscoe arrived.)


----------



## abckidsmom (Dec 10, 2011)

firecoins said:


> I am sorry but the fetus plays no role here. The mother has the choice of being treated or not being treated unless she is altered.  The fetus is not my concern.



I totally agree.  The fetus is not in play.


----------



## Veneficus (Dec 10, 2011)

abckidsmom said:


> She refuses every slick attempt at the step approach, including the slick "I'm on your team" kneeling by the side of the bed trick.  "Get back from me, don't touch me!  You know you can't touch me if I tell you not to.!"
> 
> She refuses to eat or drink.
> 
> ...




Then there is no patient and no reason to stay.


----------



## abckidsmom (Dec 10, 2011)

Veneficus said:


> Then there is no patient and no reason to stay.



While I know this, and am comfortable with that decision, I still feel a little doubt when I'm in a situation like this.  My point with this scenario was to see if other experienced medics have any of that.

Would you (the collective you) give this chick a second thought after you left?


----------



## NomadicMedic (Dec 10, 2011)

abckidsmom said:


> Would you (the collective you) give this chick a second thought after you left?



Nope. At least, not until we were dispatched again for "unconscious diabetic".


----------



## mycrofft (Dec 10, 2011)

*Sure I'd think about it.*

There are calls I think about thirty years later.

There is the possibility that the boyfriend DID pull the red lever too fast, also.


----------



## Veneficus (Dec 10, 2011)

abckidsmom said:


> While I know this, and am comfortable with that decision, I still feel a little doubt when I'm in a situation like this.  My point with this scenario was to see if other experienced medics have any of that.
> 
> Would you (the collective you) give this chick a second thought after you left?



probably more than I should


----------



## EMSrush (Dec 10, 2011)

abckidsmom said:


> While I know this, and am comfortable with that decision, I still feel a little doubt when I'm in a situation like this.



Did you consider calling MedCon, to see if the Pt might be willing to speak to him/her? Even if the Pt refused to speak on the phone, it's another good way to document your attempt, and CYA.


----------



## abckidsmom (Dec 10, 2011)

EMSrush said:


> Did you consider calling MedCon, to see if the Pt might be willing to speak to him/her? Even if the Pt refused to speak on the phone, it's another good way to document your attempt, and CYA.



I have called medical control on refusals where I truly believed the patient would die if they stayed home, but this was not one of those times.

I feel comfortable with documenting the attempt to convince her with just the deputy there as a witness.  Calling medical control is nothing more than having one more knee-jerk reaction in the thing, IMO.  They never say anything more than "you are going to die if you don't go to the hospital!"  

The last time I called, for the guy in anaphylaxis who was refusing, the resident was more uncomfortable with his refusal than I was.  We had arrived on scene and given him epi immediately, then after he could breathe he was refusing transport.  We ended up giving him 50 mg Benadryl, a liter of saline and solumedrol before we left him on the scene.  It was not one of my happiest moments, but given his absolute refusal to be transported, I figured we did alright by him.  The resident dictated the paragraph he wanted included in my report.  It had a lot of direct quotations in it.


----------



## Seaglass (Dec 10, 2011)

I'm not as experienced as most people here, and I'm not a medic, but I would've thought about it after the fact. I usually forget about calls pretty quickly, but sometimes they'll stick with me. I'll try to figure out why. 

In this case, I'd try talking to the patient alone first. I can usually talk them into letting me evaluate. The pregnancy isn't a factor for me, though I'd try using it to persuade the patient to let me evaluate her. 

If that doesn't work, I'd take the boyfriend aside, tell him what he can do and when he really needs to call, and probably take my time getting back to the station. Then I'd document the hell out of it.


----------



## Veneficus (Dec 10, 2011)

EMSrush said:


> Did you consider calling MedCon, to see if the Pt might be willing to speak to him/her? Even if the Pt refused to speak on the phone, it's another good way to document your attempt, and CYA.



There was actually an EM study about 7 years ago (I read a lot of studies, some 4-6 a day so I don't always have the link handy) that showed patients were less likely to refuse when speaking to a doctor, even on the phone, than with EMS persons.

BUt if the person is (like in this case) doesn't want anything to do with help, then I wouldn't be too inclined to pull a doc away from whatever she was doing to listen to an argument between me and the patient over the phone.

In this case, the patient seems really anxious about accepting help. Perhaps from a fear or negative experience in the past. (like a self righteous provider that threatened her or made her afraid of calling for hellp.)


----------



## usafmedic45 (Dec 10, 2011)

> She refuses every slick attempt at the step approach, including the slick "I'm on your team" kneeling by the side of the bed trick. "Get back from me, don't touch me! You know you can't touch me if I tell you not to.!"
> 
> She refuses to eat or drink.
> 
> She's just a shining ray of sunshine in the night!



Then her shuffling off her mortal coil and taking her spawn with her would be no great loss to the world now would it?



> Would you (the collective you) give this chick a second thought after you left?



You mean beyond hoping that somehow her uterus becomes so polluted from whatever drugs she uses and VD she's picked up that she can't breed anymore?  No, not really. 



> I have called medical control on refusals where I truly believed the patient would die if they stayed home, but this was not one of those times.
> 
> I feel comfortable with documenting the attempt to convince her with just the deputy there as a witness. Calling medical control is nothing more than having one more knee-jerk reaction in the thing, IMO. They never say anything more than "you are going to die if you don't go to the hospital!"



CYA.  The doc is a much more lucrative and attractive target for the malpractice lawyers than an EMS provider.  



> Nope. At least, not until we were dispatched again for "unconscious diabetic".



Hopefully, the "father" would get distracted enough by his XBox or the NASCAR race that he wouldn't notice until it was well beyond that point. 



> In this case, the patient seems really anxious about accepting help. Perhaps from a fear or negative experience in the past. (like a self righteous provider that threatened her or made her afraid of calling for hellp.)



More than likely just good ol' fashioned stupidity.


----------



## Veneficus (Dec 11, 2011)

usafmedic45 said:


> More than likely just good ol' fashioned stupidity.



I disagree, more than likely is afraid of the bill that is going to come with going to the hospital.


----------

