# Refusal to backboard



## joeboo (Dec 10, 2012)

Here is the hypothetical scenario:unsure:


Crew dispatched to independent living facility for possible lumbar injury.

On scene patient lying supine in bed. Pt is roughly 90 years old.

Pt is confused, cannot tell you what year it is, but can tell you her name and where she is. she know's the president is Barak Obama. Basically Alert and oreinted x 2(out of 4).

Pt has possible spinal injury to the lumbar region and claims pain of 5 out of 10. 

The fall occurred 2 days ago and she has been up and about at various times since. They finally called the ambulance when they saw the pain was not getting better.

Upon telling the patient that she would be needing to be placed on a backboard, the pt refused, and just wanted to be transported on the stretcher.

Here is the question:

*At what point can a patient's mental capacity be overridden to where they lose their rights to refuse treatment?*


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## NYMedic828 (Dec 10, 2012)

At the point that the crew is not correct in attempting to restrain a 90 year old woman to an uncomfortable board for a fall that happened 2 days in the past.

The lumbar is the thickest strongest portion of the spine. Most "lumbar" injuries are muscular strains/sprains to the lower back. I doubt she herniated a disc doing deadlifts or squats.

The only place I have for backboards outside of blatantly fitting every aspect of the criteria, is as a carrying device.


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## VFlutter (Dec 10, 2012)

joeboo said:


> Here is the hypothetical scenario:unsure:
> 
> 
> Crew dispatched to independent living facility for possible lumbar injury.
> ...



Since your question is specifically asking about mental capacity I will try to refrain from derailing the thread about why you want to backboard a patient who has been ambulatory for 2 days after a fall. 

What do you mean by confused? Not knowing the year alone does not really concern me if she can tell you who she is, where she is, and who the president is. Did you ask her what month it was? 

When it comes to refusing treatment you need to make sure that the patient understands what you are trying to do and the consequences of not doing it. Did she tell you why she did not want to be back-boarded?  

If you explain that the patient may experience permanent loss of sensation, paralysis, and etc and they can verbalize understanding then IMO they can refuse treatment.


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## firecoins (Dec 10, 2012)

No reason to backboard here.


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## Medic Tim (Dec 10, 2012)

pt would be transported in position of least discomfort from me


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## joeboo (Dec 10, 2012)

Thanks for the insight everyone


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## Clare (Dec 10, 2012)

Lumbar pain is not a sign of cervical spine injury.  A 90 year old who has been up and about for 2 days and complains no focal neurological deficit, altered sensation etc does not seed their cervical spine immobilised.  

I'd either extricate her in the stair chair, or more than likely, directly onto the stretcher.

Remember also that a competent patient has the right to decline treatment; I do not know how you assess competency but here as long as the patient can explain back to you what you want to do and can show they understand what you are telling them and why they do not want it consistently they are competent regardless of outside circumstances.


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## MSDeltaFlt (Dec 10, 2012)

Chase said:


> Since your question is specifically asking about mental capacity I will try to refrain from derailing the thread about why you want to backboard a patient who has been ambulatory for 2 days after a fall.
> 
> What do you mean by confused? Not knowing the year alone does not really concern me if she can tell you who she is, where she is, and who the president is. Did you ask her what month it was?
> 
> ...



Exactly.  Your time assessment could have been more accurate.  Bare in mind she's NINETY FREAKING YEARS OLD in a nursing home where she doesn't get to go out and about like you and I.  Which makes time to become skewed.  So she knew who she was, where she was, and why she was.  And since she knew some of the current events going on around her, I would argue she knew essentially when she was.  Add to that the fact she was aware of the spine board lucidly refused the spine board I would bet she could tell you of possible consequences of refusing making her essentially C-A-O X 4 and verbally appropriate.

Now to derail the thread.

Two questions for you.

1. What clinical presentations were present prompting you to want to board a 2 day post fall?

2. Why would NOT want to board a 90yo geriatric?


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## mycrofft (Dec 10, 2012)

Medic Tim said:


> pt would be transported in position of least discomfort from me.



LHS *





(like he said)

PS: I know, you're asking about field determination about mental competence. The easy answer is check your protocols (and if you have one share it!), but your considerations are these: 
1. Is this going to lead to a screaming and /or thrashing patient?
2. IS the treatment really necessary? (Call Medical Control...)
3. If the solution is not immediately dire, can you contact a family member, friend or conservator/lawyer or maybe case manager or medical caregiver and advise them what's going on.
4. If the situation is dire, maybe calling law enforcement to at least witness the procedure is a good idea, because stepping over that line (treatment against wishes presuming mental incompetence) can make you a hero, or a lawsuit magnet. Even if you possibly save the pt.


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## Handsome Robb (Dec 10, 2012)

I won't beat the dead horse about the backboard. 

If she can reiterate what is going on and is acting appropriately I'd say she's oriented.


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## zmedic (Dec 10, 2012)

You can never go wrong with calling medical control.

"Hi, I have this 90 year old patient who fell 2 days ago, her lower back hurts but she is refusing backboarding which my protocols are directing me to do. I am requesting permission to transport the patient without backboarding her, she has no neuro deficits, and is able to understand the risks of not being backboarded."

Document the MD you talked to. And you are all set.


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## mycrofft (Dec 11, 2012)

LHS too.


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## Chris07 (Dec 11, 2012)

zmedic said:


> You can never go wrong with calling medical control.
> 
> "Hi, I have this 90 year old patient who fell 2 days ago, her lower back hurts but she is refusing backboarding which my protocols are directing me to do. I am requesting permission to transport the patient without backboarding her, she has no neuro deficits, and is able to understand the risks of not being backboarded."
> 
> Document the MD you talked to. And you are all set.



Assuming as a BLS provider you even have access to medical control. BLS out my way doesn't have that luxury. 
Either way this is a no brainer...no board needed. I'd only use the board if I needed a carry device, but I would certainly not use a collar.


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## STXmedic (Dec 11, 2012)

Chris07 said:


> Assuming as a BLS provider you even have access to medical control. BLS out my way doesn't have that luxury.


Uhh... Seriously? :unsure:


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## Chris07 (Dec 11, 2012)

If this was a 911 call (which it probably wouldn't be) the responding medics would obviously have access to online medical control (base contact). If this was a private non-emergency call, the responding BLS crew would not have any sort of access to online control.

Besides...We follow the holy ems trinity here at both the BLS and ALS levels. Backboard, O2, and L&S. 

Yet another example of why ya'll need to move to Southern California <_<


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## Christopher (Dec 11, 2012)

joeboo said:


> Pt has possible spinal injury to the lumbar region and claims pain of 5 out of 10.



Not quite. There could be an injury to the cauda equina, but that manifests itself in a different manner than a true SCI. Backboards and c-collars do not immobilize the lumbar region, thus they are never indicated for this purpose.



joeboo said:


> The fall occurred 2 days ago and she has been up and about at various times since. They finally called the ambulance when they saw the pain was not getting better.



If she was ambulatory in the interim 2 days....I'm willing to wager her injury is stable. If she can walk with it, she can ride on a stretcher.

Again, no indication for a backboard and C-collar yet.



joeboo said:


> Upon telling the patient that she would be needing to be placed on a backboard, the pt refused, and just wanted to be transported on the stretcher.



Sounds good, don't assault a 90 year old 



joeboo said:


> Here is the question:
> 
> *At what point can a patient's mental capacity be overridden to where they lose their rights to refuse treatment?*



You have to have an indication for the treatment before you seek to use implied consent for a confused patient.


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## Brandon O (Dec 11, 2012)

zmedic said:


> You can never go wrong with calling medical control.
> 
> "Hi, I have this 90 year old patient who fell 2 days ago, her lower back hurts but she is refusing backboarding which my protocols are directing me to do. I am requesting permission to transport the patient without backboarding her, she has no neuro deficits, and is able to understand the risks of not being backboarded."
> 
> Document the MD you talked to. And you are all set.



In most cases I would expect the answer to this to be "no," unless you were very good at selling it. It falls under "you wouldn't be asking me this if you knew what you're doing."


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## Brandon O (Dec 11, 2012)

Also, more prosaically, this is exactly how calling medical control can "go wrong" -- you end up putting your doc into a position where he feels obliged to force you to do something that's not in the patient's interest.

Remember that even the best med control physician is not standing where you are, so he's making decisions from a different perspective -- one in which "err on the side of caution" may figure prominently.

View making that CYA call like any treatment: it has potential benefits and potential harms, and you should have a sense of both so you can weigh them in each situation.


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## Handsome Robb (Dec 11, 2012)

If you're truly that worried about it have her sign a refusal of c-spine. 

We've got signatures for freaking everything. RMA, AMA, Witness, Privacy, Refusal of C-Spine, Refusal of Trauma Center.


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## usalsfyre (Dec 12, 2012)

Chris07 said:


> If this was a private non-emergency call, the responding BLS crew would not have any sort of access to online control.



What kind of malarkey is this?


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## Sublime (Dec 13, 2012)

joeboo said:


> Pt is confused, cannot tell you what year it is, but can tell you her name and where she is. she know's the president is Barak Obama. Basically Alert and oreinted x 2(out of 4).



Shouldn't that be AO x 3? She is alert and oriented to Person, Place, and Event. Only thing she failed is time. That's pretty good for a 90 year old nursing home patient. If I was in a nursing home I probably wouldn't know the day/month either.


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## firecoins (Dec 13, 2012)

Sublime said:


> Shouldn't that be AO x 3? She is alert and oriented to Person, Place, and Event. Only thing she failed is time. That's pretty good for a 90 year old nursing home patient. If I was in a nursing home I probably wouldn't know the day/month either.



a/ox4 is person, place, time & event


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## Sublime (Dec 13, 2012)

firecoins said:


> a/ox4 is person, place, time & event



Right... he said she knows her name, where she is, and that the president is barack obama. Thats person, place, and event.

She didn't know the month... which would be time.

EDIT: Correction. It was the year she did not know. But same concept.


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## JPINFV (Dec 13, 2012)

PoeticInjustice said:


> Uhh... Seriously? :unsure:





usalsfyre said:


> What kind of malarkey is this?




When there's a hospital within 15 minutes in most places and a paramedic crew within 5-8, there really isn't need for online control at the EMT level. If an EMT needs online control, then the patient needs paramedics or a hospital, not online control to tell the EMT to take the patient to the hospital or call paramedics.


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## martor (Dec 13, 2012)

JPINFV said:


> When there's a hospital within 15 minutes in most places and a paramedic crew within 5-8, there really isn't need for online control at the EMT level. If an EMT needs online control, then the patient needs paramedics or a hospital, not online control to tell the EMT to take the patient to the hospital or call paramedics.



Well this call would be a waste of time for an ALS unit. If patient is A&Ox2 but is able to understand the risk with no spinal precautions then I would as Pt to sign. It is similar to an AMA. If they understand what is going on and is coherent enough to talk to you about the situation than transport in POC.

I work for a small private and when I need medical control I use the same radio that I use to let ED know that we are coming. I have NEVER heard of a BLS crew with no radio to contact base hospital.


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## Aidey (Dec 13, 2012)

JPINFV said:


> When there's a hospital within 15 minutes in most places and a paramedic crew within 5-8, there really isn't need for online control at the EMT level. If an EMT needs online control, then the patient needs paramedics or a hospital, not online control to tell the EMT to take the patient to the hospital or call paramedics.



But technically, online control is still available right?


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## JPINFV (Dec 13, 2012)

martor said:


> Well this call would be a waste of time for an ALS unit. If patient is A&Ox2 but is able to understand the risk with no spinal precautions then I would as Pt to sign. It is similar to an AMA. If they understand what is going on and is coherent enough to talk to you about the situation than transport in POC.



I agree, but why do you need medical control for that?


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## JPINFV (Dec 13, 2012)

Aidey said:


> But technically, online control is still available right?




Nope. The non-911 units (in Orange County) don't even have the standard radio setup that paramedics use to contact medical control. There' the MCI radio which can be used as a backup radio for medical control, but it's not the standard medical control radio.


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## Handsome Robb (Dec 13, 2012)

I'm still failing to see how spinal motion restriction is indicated for this patient. 

I agree with Socal, she's A&Ox3 which by my protocols is competent. If her back didn't hurt already it sure will after she bumps down the road on a hard spine board and lays in the ER for God knows how long before she's cleared off the board. 

Lumbar spine pain doesn't indicate spinal motion restriction. With focal neuro deficits absolutely but other than that...no. Thoracic or Cervical pain does though.


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## Aidey (Dec 13, 2012)

JPINFV said:


> Nope. The non-911 units (in Orange County) don't  even have the standard radio setup that paramedics use to contact  medical control. There' the MCI radio which can be used as a backup  radio for medical control, but it's not the standard medical control  radio.



How on earth is that legal? I would think that all ambulances would be required to have some way to contact medical control.


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## EMT11KDL (Dec 14, 2012)

I work both for a 911 agency and a IFT Agency, we always have some sort of medical control on both units.  If we are picking up a patient to take them somewhere else, there has to be a Doctor their at that facility 99% of the time, or one at the facility we are currently at.  Also, you can always call the ER and speak to a Physician there, and get online medical control from them.  Or call your own medical director.


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## JPINFV (Dec 14, 2012)

Aidey said:


> How on earth is that legal? I would think that all ambulances would be required to have some way to contact medical control.


 
Where's the law that says every ambulance has to have access to online control... period? The scenario where an IFT EMT level ambulance needs online medical control and nothing else is extremely extremely rare. If an EMT is thinking that they need to divert, then the answer is going to be to divert and not waste time on the radio talking to someone who's going to tell you to divert. This is espeically true since most of the time the radio call is going to take about the same time as simply transporting to the closest ED.


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## Brandon O (Dec 15, 2012)

While in practice you're right (in areas like SoCal, anyway), in principle I would think that most areas would mandate the ability to access online medical control as a fundamental and inextricable component of an EMS system.


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## zmedic (Dec 15, 2012)

JPINFV; said:
			
		

> Where's the law that says every ambulance has to have access to online control... period? The scenario where an IFT EMT level ambulance needs online medical control and nothing else is extremely extremely rare. If an EMT is thinking that they need to divert, then the answer is going to be to divert and not waste time on the radio talking to someone who's going to tell you to divert. This is espeically true since most of the time the radio call is going to take about the same time as simply transporting to the closest ED.



For new york state protocols I found this:

Obviously, significant indirect (off-line) medical control has been assumed in the development of these protocols. It was also assumed that appropriate local direct (on-line) medical control at both the basic life support (BLS) and advanced life support (ALS) level will be provided.

http://www.health.ny.gov/professionals/ems/pdf/2008-11-19_bls_protocols


Many places that do transfers are also providing EMS, if you get called to a nursing home to transfer a septic patient to the hospital, you are going to be expected to provide care that complies with the state protocols. At the very least you are going to be acting under the license of the medical director for the service, and have written protocols. I think most medical directors give their crews some way to contact them or another doctor if they have a question. It's less an issue of if BLS crews need medical control that often, and more an issue of if your license is on the line, you are going to give your crews a chance to talk to someone before they do something stupid. 

I'm pretty sure all the big companies (AMR, rural metro etc) that do IFT have a number for their EMTs to call for medical control.


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## JPINFV (Dec 15, 2012)

zmedic said:


> For new york state protocols I found this:
> 
> Obviously, significant indirect (off-line) medical control has been assumed in the development of these protocols. It was also assumed that appropriate local direct (on-line) medical control at both the basic life support (BLS) and advanced life support (ALS) level will be provided.
> 
> http://www.health.ny.gov/professionals/ems/pdf/2008-11-19_bls_protocols


So everyone has to follow NYS protocols now?



> Many places that do transfers are also providing EMS, if you get called to a nursing home to transfer a septic patient to the hospital, you are going to be expected to provide care that complies with the state protocols. At the very least you are going to be acting under the license of the medical director for the service, and have written protocols. I think most medical directors give their crews some way to contact them or another doctor if they have a question. It's less an issue of if BLS crews need medical control that often, and more an issue of if your license is on the line, you are going to give your crews a chance to talk to someone before they do something stupid.
> 
> I'm pretty sure all the big companies (AMR, rural metro etc) that do IFT have a number for their EMTs to call for medical control.



Assuming it's not gross negligence, what stupid things are you expecting EMTs to do with they're huge scope of oxygen and oral glucose? 

Also, do you think that the medical director's medical license is on the line for what paramedics do? Um, I'd love to see the story where a physician lost his medical license for something a crew did on offline protocols.


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## Handsome Robb (Dec 15, 2012)

JPINFV said:


> Also, do you think that the medical director's medical license is on the line for what paramedics do? Um, I'd love to see the story where a physician lost his medical license for something a crew did on offline protocols.



Kinda off topic but if I remember correctly the physician that talked those two Jersey medics through the field c-section a while back had to take a one or two day remediation class about being an on-line med control doc while the two medics lost their certs. I may be wrong though. 

It's odd to me that BLS crews down there don't have access to online medical control. From what I hear it's different elsewhere, especially California, but I rarely call OLMD. Only really call for termination orders. I'd be willing to bet that a BLS crew could get OLMD if they _really_ needed it with a cellphone call to the charge desk of the hospital or worst case scenario to the front desk and asking for a transfer, but like JP said, by the time you jumped through those hoops you'd more than likely be at a hospital or already committed to transport to the original facility.


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## crazycajun (Dec 15, 2012)

JPINFV said:


> Also, do you think that the medical director's medical license is on the line for what paramedics do? Um, I'd love to see the story where a physician lost his medical license for something a crew did on offline protocols.



So would I. If the information given to me by a family attorney is correct, the person (in this case medic/emt) performing the procedure holds the liability. It would be the same as calling for orders for morphine and the online doctor telling you to admin 50mg morphine IV push. It is our job to ensure the orders are correct and question an order we know is a mistake. Should you push the morphine and the PT die I do not believe a judge and jury would understand your explanation of "The doc told me to do it"


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