# No minors refuse....



## CAOX3 (Feb 7, 2010)

http://www.examiner.com/x-17800-Ral...h-of-Chapel-Hill-football-player-Atlas-Fraley

With this kids complaints, history and recent activities(football paractise in the heat), how do you not transport this patient.

History of asthma and exhibiting signs of heat stroke.

Whats your policy in allowing a minor to refuse medical treatment?


----------



## MMiz (Feb 7, 2010)

To add to it:

Orange County's internal investigation found the Paramedic failed to:
*  Take Fraley's vital signs while he was both sitting and standing.
*  Take his temperature.
* Transport him for hyperthermia treatment.
*  Tell him how soon to see a doctor.
* Contact his parents.
*  Seek a doctor's opinion.
* Completely document his examination.


----------



## xgpt (Feb 7, 2010)

Is a minor even allowed to sign one of those forms?

Isn't that like a contract or something? I'm just starting off in this arena...so I really don't know...

But if it is like a contract, can a minor even _legally_ sign it?


----------



## MrBrown (Feb 7, 2010)

We can only recommend treatment and/or transport, Ambulance Officers can also decline transport and are not legally obligated to transport a patient.



> Whenever personnel are called to a patient they must make three decisions:
> 1. Is treatment required?
> 2. Is transport to a medical facility required?
> 3. If transport is required, what form of transport is most appropriate?
> ...


----------



## CAOX3 (Feb 7, 2010)

Recommend transport?  

Im guessing he talked this kid out of going to the hospital and inturn signed his death certificate.


----------



## MrBrown (Feb 7, 2010)

CAOX3 said:


> Recommend transport?



Last time I checked, kidnapping was not in my scope of practice


----------



## 18G (Feb 7, 2010)

This is a sad case... around here a minor is not allowed to refuse unless they are emancipated. Emancipated being currently pregnant, has a child, or living on their own outside of their parents home. 

In all other cases involving minors, if a parent is not present or cannot be contacted, the minor gets transported. Even if just to sit in the waiting room at the ED. Legally, we cannot accept a refusal from a minor. The legal council of my one station advised it is legal to get consent from a parent or guardian verbally over the phone if they cannot be physically present onscene. 

I think too many ppl take refusals lightly. I always follow strict procedure when obtaining a refusal and  document it thoroughly.


----------



## MMiz (Feb 7, 2010)

MrBrown said:


> Last time I checked, kidnapping was not in my scope of practice


It may be that the legal system is different in New Zealand and you aren't subject to as many lawsuits.  

I found that if I transport I'm subject to a parent angry over an expensive and "unnecessary" ambulance bill.  I follow protocol for refusal, including assessing, informing, and all that jazz, and I potentially will be sued for neglecting a little snowflake.  I call online medical control, and few doctors or nurses are willing to  allow a child to refuse treatment/transport.

I can only remember one case where a minor refused treatment, and we didn't transport without leaving him in the care of his parent.  In that case I spoke to the parent on the phone and an adult family member picked up the teenager.

We always followed protocol:
1.  Explained the condition/symptoms/injury.
2.  Explained when those conditions would be considered an emergency to call 911 again.  When in doubt, call.
3.  Explained what could happen if not treated/transported.
4.  Contacted medical control (on a case-by-case basis, depended)
5.  Fill out the paperwork and get signatures, including adult witnesses.


----------



## CAOX3 (Feb 7, 2010)

MrBrown said:


> Last time I checked, kidnapping was not in my scope of practice



Kidnapping?   

Thats why we transport minors because they dont know whats in their best interest especially in a medical emergency.  

If your an adult and you want to refuse have at it.

This kid was asking for an IV on the phone I doubt he was refusing transportation.


----------



## 18G (Feb 7, 2010)

Sounds like the kid knew more of what he needed than the Paramedic.


----------



## MMiz (Feb 7, 2010)

CAOX3 said:


> Kidnapping?
> 
> Thats why we transport minors because they dont know whats in their best interest especially in a medical emergency.
> 
> ...


In most U.S. states in an _emergency _EMS operates under Implied Consent.  The idea is that without a parent or legal guardian, In the absence of a parent or legal emergency treatment and/or transport of a minor may be initiated without consent, because it is in the best interest of the minor.

Here is more information.


----------



## JPINFV (Feb 7, 2010)

CAOX3 said:


> Kidnapping?
> 
> Thats why we transport minors because they dont know whats in their best interest especially in a medical emergency.
> 
> ...



I'd buy that argument if he was 12. He's 17. His birthday could have been the next day. While legally the age of consent is a hard line set at what ever age the state wants, in reality the closer you get to that date the muddier the waters get. I don't agree with the sentiment of the parents that he was "just a child." Nope... sorry. He's a young adult on the verge of being in full charge of his fate. He's not "just a child."

However, given the exam findings that were released and the fact that the "child" knew just how big of trouble he was in (seriously, a high school football player calling 911 because of cramps? Think about *that* one for a minute), I would love to be on a wall during this call. I normally try to see it from the providers view point, however in this case I can't see how the young adult would call 911 and then decline treatment.


----------



## VentMedic (Feb 7, 2010)

MrBrown said:


> Last time I checked, kidnapping was not in my scope of practice


 
The 17 y/o was at home and *he called EMS* because he felt something was wrong. I doubt if there was ever an issue of this kid not wanting treatment. The kid thought he needed an IV so all one had to say is come into my ambulance if you want your IV. Of course some in EMS also don't like the patients telling them what they think is wrong or the treatment. 

This was discussed after it first happened. It made the rounds on the EMS forums because this agency had recently added a "refuse transport" protocol to cover the Paramedics' decisions. 

http://www.emtlife.com/showthread.php?t=12274&highlight=minor+refuse

As Venificus pointed out a 12-Lead would have been nice but the problem with cook book medicine is that per this agency's protocols only complaints of heart trouble, fainting, an antidepressant overdose, difficulty breathing or electrical shock get a 12-lead. For this kid, "dehydration" appeared to be the issue and that wasn't on the list.


----------



## JPINFV (Feb 7, 2010)

MMiz said:


> In most U.S. states in an _emergency _EMS operates under Implied Consent.  The idea is that without a parent or legal guardian, In the absence of a parent or legal emergency treatment and/or transport of a minor may be initiated without consent, because it is in the best interest of the minor.
> 
> Here is more information.



Actually, the doctrine that allows treatment of pediatric patients is "minor consent"


----------



## MrBrown (Feb 7, 2010)

MMiz said:


> It may be that the legal system is different in New Zealand and you aren't subject to as many lawsuits.



To the best of my knowledge, ambo has never been sued; the complaint rate is just under two per thousand patients.

Legally a patients is being kidnapped unless they agree to accompany the ambos or they are deemed to be under the rule of implied consent for patients who do not expressly consent  (e.g. an unconscious patient hit by a car)

In this particular case, the patient is over 16 so if he fits our competency critera (outlined above) then he can refuse all day long and there's not a thing the Ambulance Officers can do.


----------



## CAOX3 (Feb 7, 2010)

JPINFV said:


> I'd buy that argument if he was 12. He's 17. His birthday could have been the next day. While legally the age of consent is a hard line set at what ever age the state wants, in reality the closer you get to that date the muddier the waters get. I don't agree with the sentiment of the parents that he was "just a child." Nope... sorry. He's a young adult on the verge of being in full charge of his fate. He's not "just a child."
> 
> However, given the exam findings that were released and the fact that the "child" knew just how big of trouble he was in (seriously, a high school football player calling 911 because of cramps? Think about *that* one for a minute), I would love to be on a wall during this call. I normally try to see it from the providers view point, however in this case I can't see how the young adult would call 911 and then decline treatment.



Thats why we use the eighteenth birthday its a line in the sand one he hadnt reached.

Almost an adult?  We cant almost send him to war, he cant almost vote and in my area he cant almost refuse treatment.  He goes, and its late but I dont recall anywhere where he stated he was refusing treatment.  

Unfortunatley he will never get a chance to be in "full charge of his fate." 

The parent referring to him as a child may be emotional.

And I agree with you how a provider can dismiss these symptoms as BS is beyond me, this is any easy one, there are plenty of difficult decisions to be made this doesnt seem to be one of them with his age, symptoms, history and complaint he goes.


----------



## JPINFV (Feb 7, 2010)

CAOX3 said:


> Thats why we use the eighteenth birthday its a line in the sand one he hadnt reached.
> 
> Almost an adult?  We cant almost send him to war, he cant almost vote and in my area he cant almost refuse treatment.  He goes, and its late but I dont recall anywhere where he stated he was refusing treatment.



So you're dispatched to a minor motor vehicle collision and one car has a 16 year old occupant with a hematoma on her shoulder where she hit the door. She asks for an ice pack. Do you give her an ice pack, and if so, do you still transport over her objections since she "can't refuse?" Based on your assessment so far, the hematoma is her only complaint and she if fully alert and orientated.

There are situations where reality is more nuanced than the class room. At what point is the patient with a psychiatric disorder unable to consent and is instead treated under informed consent. I'd definitely argue that A/Ox4 isn't the end all, be all of determining competence. What about elderly patients who are slowly losing their mental abilities due to progressive neurological disorders? How about when said patient's wishes clashes with their nurses wishes when in a long term care facility or a family members. These aren't easy questions to answer in reality and not one which can necessarily be run through medical control a lot of little details are going to fall through the cracks in a radio conversation.


----------



## CAOX3 (Feb 7, 2010)

MrBrown said:


> To the best of my knowledge, ambo has never been sued; the complaint rate is just under two per thousand patients.
> 
> Legally a patients is being kidnapped unless they agree to accompany the ambos or they are deemed to be under the rule of implied consent for patients who do not expressly consent  (e.g. an unconscious patient hit by a car)
> 
> In this particular case, the patient is over 16 so if he fits our competency critera (outlined above) then he can refuse all day long and there's not a thing the Ambulance Officers can do.



Ok in your area, in the US everyone gets sued.  

If in fact he did refuse, simply having a signed patient refusal in hand that any second year law student can have thrown out of court in about two seconds is useless, decisions made under duress dont hold much water in a US court of law, and any decision made in the presence of a medical emergency (duress)  will be a point argued by any lawyer with a pulse.  

Im going with the medic talked him out of going.


----------



## CAOX3 (Feb 7, 2010)

JPINFV said:


> So you're dispatched to a minor motor vehicle collision and one car has a 16 year old occupant with a hematoma on her shoulder where she hit the door. She asks for an ice pack. Do you give her an ice pack, and if so, do you still transport over her objections since she "can't refuse?" Based on your assessment so far, the hematoma is her only complaint and she if fully alert and orientated.
> 
> There are situations where reality is more nuanced than the class room. At what point is the patient with a psychiatric disorder unable to consent and is instead treated under informed consent. I'd definitely argue that A/Ox4 isn't the end all, be all of determining competence. What about elderly patients who are slowly losing their mental abilities due to progressive neurological disorders? How about when said patient's wishes clashes with their nurses wishes when in a long term care facility or a family members. These aren't easy questions to answer in reality and not one which can necessarily be run through medical control a lot of little details are going to fall through the cracks in a radio conversation.



I agree with all your point however not in the case of minors, in my system under eighteen gets you a ride to the ER no matter the complaint and I agree with it, unless I can speak with your parents, we allow speaking to the parents over the phone but I dont neccesarily agree with that, I like the parents to be present, they know their child better then I do.

It has nothing to do with getting sued.  I dont do my job in fear of litigation, it has more to do with a child or young adult not being forthcoming with information or leaving out some details they dont think are neccesary like the MVA, the injured shoulder I can see and treat but the dull abdominal pain they may not admit or even think is pertinent. Thats what I worry about.


----------



## JPINFV (Feb 7, 2010)

So would you transport a 16 y/o driver in a TC even is she was without complaint out of fear of some injury that she has but isn't complaining about?


----------



## CAOX3 (Feb 7, 2010)

JPINFV said:


> So would you transport a 16 y/o driver in a TC even is she was without complaint out of fear of some injury that she has but isn't complaining about?




TC? 

In my system I dont have a choice unless a parent or adult is present or I can speak with them.  

I dont have a problem transporting a minor without complaint, they lie, they are scared and they just wrecked daddys Benz.  

There are a whole list of reasons why they wouldnt be honest with me, their not where their supposed to be, their not with the people their supposed to be with, their hiding their dope in the glove compartment, whatever.

Why not err on the side of caution?  Unaccompanied minors make up a very small percentage of our calls.


----------



## exodus (Feb 7, 2010)

JPINFV said:


> So would you transport a 16 y/o driver in a TC even is she was without complaint out of fear of some injury that she has but isn't complaining about?



I would.

She's not liable for herself, and I would imply that her parents would want her to get a full medical assessment by a doctor before being totally cleared, rather than be sent home. If the collision is strong enough for her to be bruised on her shoulder, it was strong enough for her to hit her head and bruise it.


----------



## JPINFV (Feb 7, 2010)

TC=Traffic collision. I'd argue that not everyone in a traffic collision is a patient and I don't have to get a refusal from a non-patient. 

For starters, money. If I ever have a child transported when they lack a complaint, then I'm not paying for services not requested. 

Inconvenience to everyone involved (the hospital now has to baby sit. The parents now have to come to the hospital when the vehicle might be in drivable condition. List goes on).

In the case of a patient without complaint, the fact that there is no complaint. 


Exodus, there are a lot of things that can cause bruises. I guess football players should be required to go to the hospital if they're parents weren't at the game since if an impact is hard enough to leave a bruise, then it was hard enough to bruise their head.


----------



## EMSLaw (Feb 7, 2010)

JPINFV said:


> So would you transport a 16 y/o driver in a TC even is she was without complaint out of fear of some injury that she has but isn't complaining about?



You can transport a minor to the ER under the doctrine of implied consent for a life-threatening medical emergency.  The idea being that an reasonable parent would want their child treated in a life-or-death situation.

In the case of minor injuries, though, things get a bit foggier.  You really need to contact the parents if possible, and obtain their consent for treatment and/or transport.  If you can't contact the parents, then you have to get the police involved so they can assume temporary custody of the child (and probably tell you to take him or her to the hospital).


----------



## 18G (Feb 7, 2010)

JPINFV makes a valid point. Not everyone involved in an MVC is considered a patient. We had this specifically addressed in my region. Unless the occupants requested EMS themselves, have a complaint, or have visible injuries, they are not considered a patient and do not require a refusal. This gets documented as a "no patient found", non-injury, or good intent call regardless if minor or adult. 

I think some common sense needs to prevail and you need to show that you acted in the best interest of the individual in question.


----------



## JPINFV (Feb 7, 2010)

A few quick final comments because I don't want this to go around in circles, which I fear it is heading in.

"Always" and "never" are almost always not the correct answer on multiple choice tests and this is one test strategy that applies to real life. 

Absolutes like zero tolerance always comes with unintended consequences. 

"Can" and "should" are two different questions. 

Just because you can doesn't mean you should. 

Sometimes just because you "should" doesn't mean you should (see comment about absolutes).

The road to hell is paved with good intentions.


----------



## CAOX3 (Feb 7, 2010)

I agree we did get a little off track.

As far as the article, in my opinion it seems this was a slam dunk transport the medic failed his patient.

Refusals policies are put in place for these such occasions, we cant control decisions made by all providers, so we institute policies to prevent these situations from occuring.  

So yes I agree we may transport some minors that may not even require transportation and yes it may be a pain in the butt for everyone involved.  Im fine with that if it prevents some knucklehead provider from leaving a kid on scene to die.


----------



## Aidey (Feb 8, 2010)

JPINFV said:


> So you're dispatched to a minor motor vehicle collision and one car has a 16 year old occupant with a hematoma on her shoulder where she hit the door. She asks for an ice pack. Do you give her an ice pack, and if so, do you still transport over her objections since she "can't refuse?" Based on your assessment so far, the hematoma is her only complaint and she if fully alert and orientated.
> 
> There are situations where reality is more nuanced than the class room. At what point is the patient with a psychiatric disorder unable to consent and is instead treated under informed consent. I'd definitely argue that A/Ox4 isn't the end all, be all of determining competence. What about elderly patients who are slowly losing their mental abilities due to progressive neurological disorders? How about when said patient's wishes clashes with their nurses wishes when in a long term care facility or a family members. These aren't easy questions to answer in reality and not one which can necessarily be run through medical control a lot of little details are going to fall through the cracks in a radio conversation.



This isn't about classroom medicine vs real world medicine. It is about what is legal or not to do. Whether we agree with the laws or not, we still have to follow them. I also work in a system where someone under the age of 18 who is not emancipated legally can not refuse transport. Period. End of discussion. We (EMS) have no control over this. State law states anyone under the age of 18 is not capable of refusing care. 

If we arrive on scene and assess a minor to be uninjured and we can't contact their parents we can call med control and request permission to not transport. Unless it is an emergency, I attempt to contact all parents prior to transporting to let them know, get any history the kid may be forgetting, and to find out what hospital the patient should be taken to. 

Like was mentioned above, most MDs won't go for under 18 refusals. Maybe, maybe they would with someone who is 17, nearly 18 and they were not the one who requested EMS; but when I call I expect the MD to always tell me to transport. 

In the other examples you used it's hard to say what I would do without a scenario since there is a large spectrum of patients that fall under those categories. If we have a patient that is technically AOx4 and turns to me and says "you really need to shut the ambulance door before the carnivorous pink polka-dot bunnies get in" chances are they are going to the hospital even if they don't want to.


----------



## Outbac1 (Feb 8, 2010)

Here a pt can refuse at age 16. If we have any doubt as to the pts condition we very strongly encourage them to go. If they still refuse I then call online for a second opinion. If the DR. thinks they should go they usually say something along the lines of " I think they should go if they continue to refuse be sure they know they could DIE from this and have them sign a refusal." Sometimes if the pt hears the Dr. say they could "Die"  they change their mind. 

 In this case its hard to say what really happened and was said. But it raises concerns about an inadequate assessment and a one person responding truck. A second medic may have had a different opinion as to the pts condition. Also we don't know the level of the attending persons medical training. Were they really qualified to do a thourough assessment?


----------



## Outbac1 (Feb 8, 2010)

MrBrown said:


> We can only recommend treatment and/or transport, Ambulance Officers can also *decline* transport and are *not legally obligated to transport *a patient.



There are times this would be nice to have. (Bold highlights mine)


----------



## MrBrown (Feb 8, 2010)

Aidey said:


> This isn't about classroom medicine vs real world medicine. It is about what is legal or not to do. Whether we agree with the laws or not, we still have to follow them.



Good point 



Aidey said:


> If we have a patient that is technically AOx4 and turns to me and says "you really need to shut the ambulance door before the carnivorous pink polka-dot bunnies get in" chances are they are going to the hospital even if they don't want to.



Here, that would fall under the bit that says ambos can transport and/or treat an incompetent patient if it is in thier best interest.



Outbac1 said:


> There are times this would be nice to have. (Bold highlights mine)



I am suprised Canada doesn't have something like we do here, you Canuckistanaians seem darn clever


----------



## Outbac1 (Feb 9, 2010)

MrBrown;207632
I am suprised Canada doesn't have something like we do here said:
			
		

> Now thats a mouthfull! Glad I was sober when I read that.
> 
> When someone calls, we HAVE to transport. No matter how ridiculas the pt complaint. Now that doesn't mean they get baby sat at the hosp. I've marched a good many in the front door to wait their turn in the waiting room with all the walk ins.  If a person becomes a frequent flyer for non life threatening calls then we can have them investigated and their future 911 calls will go to a triage Dr. who decides if they get picked up. Documatation is imp., if they are calling to say they are SOB and we continually document that they are not. It definantly goes against them.


----------



## firecoins (Feb 9, 2010)

I really have not read the thread but several things about the article stick out.



> Medic2 was given the duty to assist the emergency call.  Medic2 only had one responder, James Griffin.  Griffin arrived at 1:54 p.m. and left 16 minutes later at 2:10 p.m. on August 12, 2008.  One responder at just 16 minutes, a questionable evaluation


The ;ength of time it takes to do an assessment seems odd.  I can do a full assessment in less than 16 including an ECG and orthostatics.  We do not take exact temperatures since nobody carries thermometers. Most ALS providers I know can do this and be quite thorough. 



> Atlas Fraley rated his cramp pains at 7 on a scale from 1 to 10 with 10 being aggressively severe.  Atlas explained muscle pains in arms, legs, and abdomen.  Fraley's pains were so bad he could not sit still nor stand still.  Fraley was noted as asking for an IV and when the pain would subside.  Fraley's blood pressure was 134/102 with 92 beats per minute while standing as noted by Griffin.


Based on this the pt should be going to the ER. 




> Griffin's report reflects Orthostatics were not performed along with no ECG, and no temperature taken.


ECG shpuld have been done.  We don't take temperatures. We feel the patient's skin. They are hot, cold or inbetween but a hx of events should have set something off here.  Does anyone else take temperature?


----------



## Aidey (Feb 10, 2010)

I thought it was strange too that they were going on about "just 16 minutes". I sure as heck hope I can take full vitals, orthos, and an EKG in 16 minutes...


----------



## NC_EMT (Feb 10, 2010)

This was not too far from where I live.  I was under the impression that minors could not sign a refusal and must be transported as implied consent.  At least thats what I was taught in school.


----------



## firecoins (Feb 10, 2010)

In 16 minutes you should be on the way to the ER.


----------

