# Simple assault, EtOH use, altered mental state or competent to refuse?



## thatJeffguy (Dec 4, 2009)

At approximately 2340 the unit I've been riding with was called to an assault at a local bar, ambulance requested by on-scene officer.  Upon arrival, one white male, moderate bleeding from left eye on the lower eye lid was talking with an officer and stating that he was going to refuse medical treatment.  Examined patients eye and saw ~3cm laceration under the eye on the lid, split ~.5cm open at widest point.  Patient admitted to drinking, smelled of alcohol, but was alert and oriented.  No visible signs of intoxication.  Patient again insisted he did not want to go to the hospital due to his lack of medical insurance.  Obtained permission and proceeded to clean surrounding area with wet 4x4 gauze.  EMT's advised pt that the wound could possibly be infected and is in close enough proximity to the eyeball to merit a look by a M.D.  Pt acknowledged the information and was able to sign the waiver, with a EMT signing as "Witness".

The physical examination of patient was only examination completed. 

Based on this information *alone*, would you have allowed them to refuse medical care?

What other information might you seek before making that decision?

Thanks again!


FWIW, I currently have no training in the EMS field.  I'm only reporting the events that I see and asking questions, not being judgmental or armchair quarterbacking.


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## medicdan (Dec 4, 2009)

I work in two systems. In one it would be acceptable to get a refusal with additional assessment, in the other not. 
I work on a college campus, where we need to weigh what is in the best interest of our patients-- utimately whether they should just go home, sleep it off, and get it checked out in the morning, or they need an ALS ride and ER visit. 
Ultimately, though, I need a lot more information before accepting a refusal on a patient like this.  Information such as:
--Quantity of ETOH intake
--When patient began drinking? When did they stop? (Keeping in mind BAC levels continue to rise 45-60 minutes after last consumption
--When did they last eat?
--Any N/V? 
--Meds? Prescribed or otherwise? SSRIs? Interactions with ETOH
--PMH
--Allergies
--A GOOD SET OF VITALS-- when I walk away, it is my only quantifiable measure of patient condition. 
--Falls? Hit head? LOC?
--How did injury happen? Punched? What do bystanders say?
A Good Physical Exam:
--Can the patient manage their own airway? Speak clearly?
--How well are they giving their history? Reliable?
--Pupils?
--Can the patient ambulate without assistance? Can they make it home aided? Unaided? Is there someone at home who can monitor?

I would be wary, in this case, to accept a refusal. I would need a really reliable history from patient and bystanders, little intoxication, and a wound that can be safely left until the morning.


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## JPINFV (Dec 4, 2009)

thatJeffguy said:


> Based on this information *alone*, would you have allowed them to refuse medical care?


There's not enough information to allow an AMA or compel transport. What's needed is a complete assessment as much as the patient would allow.


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## thatJeffguy (Dec 4, 2009)

JPINFV said:


> There's not enough information to allow an AMA or compel transport. What's needed is a complete assessment as much as the patient would allow.



That was my lay assessment of the situation as well.

Physical attack?  Check.

Alcohol involved?  Check.

Head trauma?  Check.

Probably needs a bit more checking into, *in my lay opinion*.  

What specific assessments would you want to perform?


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## JPINFV (Dec 4, 2009)

Well... a better idea of LOC. The fact that the patient is A/Ox4 just means that the patient knows his/her name, where he/she is, a general idea about time, why he/she's at that location. There are plenty of people who lack capacity (psych, neuro, or development disorders, for example) who clearly lack competence. Similarly, just because someone had alcohol doesn't mean that they lack capacity (this is dependent on the person, the amount of alcohol, and the time frame).


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## flhtci01 (Dec 4, 2009)

All systems vary with SOPs.  Our's requires Medical Control to be contacted if we have a refusal with suspected ETOH onboard.  Refusal is still possible with ETOH onboard if all our other requirements are met.


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## mycrofft (Dec 4, 2009)

*Alert oriented and informed=AMA OK*

We don't "allow" an AMA, they _allow *us*_ to provide care...unless they are either unable to due to LOC or psychiatric impairment, or pose danger for others. LE should be involved whenever the pt is resistive to provide safety and to settle any later issues of false arrest, battery, or kidnapping.
Sometimes the best thing is to establish A/O, explain the AMA  and potential effects, then stand up and walk off. If the pt doesn't change their mind then, they may take a non-punitive/challenging message to heart and go in later when the pain starts or the bleeding won't stop.


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## trevor1189 (Dec 4, 2009)

Depends on what your medical director approves.

Here, ETOH, Syncope, CP, Head Injury, BP Sys <100 or >200, Pulse <60 or >100 are all supposed to be approved by med command.

However, it ultimately comes down to if the patient doesn't want to go, then they don't go.

Based on the info provided above, my phone call to med command would be

"On scene with an adult male. Involved in an assault at a bar, laceration with moderate bleeding to the left eye. Pt is alert and oriented and does not wish to be evalutated or transported via ambulance due to lack of health insurance." Get the ok from the doctor and get the OFFICER ON SCENE to sign the witness spot on the refusal.

Always best to have someone other than medical personel on scene to witness if there is only one spot. With ours, I usually sign one noting my emt number and get PD or a family member/friend to witness if possible.

As for futher questions to ask see emt.dan's post above.


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## reaper (Dec 4, 2009)

Exactly. Obtaining an AMA refusal is a privilege, not a right.

A pt can walk away from you at any time and there is nothing you can do about it. They do no need to sign a refusal and sometimes will refuse to sign. You document and walk away.

Any thing beyond that is up to LEO to handle.


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## firetender (Dec 4, 2009)

Location of injury could indicate head injury. If the pt. refuses, he refuses, Period, unless there's grounds for 5150 or equivalent. Other than that the only thing I'd do is thoroughly document as extensive an exam as the pt. will allow.


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## VentMedic (Dec 4, 2009)

firetender said:


> Location of injury could indicate head injury. If the pt. refuses, he refuses, Period, unless there's grounds for 5150 or equivalent. Other than that the only thing I'd do is thoroughly document as extensive an exam as the pt. will allow.


 

If a head injury is suspected, a 5150 is not the appropriate detainment since this patient would need an acute medical ED and not a psych facility for a 72 hour hold.   The exception would be if the injury was done intentionally by himself. The patient can then be placed with the 5150 after medical clearance.   However if his behavior is possibly altered due to the head  injury then you provide whatever means possible to get him the appropriate treatment.


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## guardian528 (Dec 4, 2009)

in our protocols, there is a difference between consuming alcohol and being intoxicated. if they are intoxicated, they can't refuse, however if they had "1 or 2" and are A&Ox4 they can refuse.


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## Lifeguards For Life (Dec 4, 2009)

we have a statute that allows for examining and treatment of a patient WITHOUT informed consent if all of the following 3 condidions are met.

     1. the patient has an emergency medical condition(EMC) as defined as the likelihood that the patient has a condition that may cause loss of life, limb, or bodily function; or the patient is in labor, or the patient has sever pain and,

     2. the patient is unreasonable and,

     3. the person is considered to be incapacitated either by 
          a. drugs, alcohol or other substance
          b. trauma (i.e head trauma)
          c. medical condition (i.e hypoglycemia, hypoxia)
          d. psychiatric condition

If ALL 3 conditions are met we are empowered to take the person against their will for further examination and treatment of the EMC, and may use "reasonable force". Reasonable force includes LE


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## DT4EMS (Dec 6, 2009)

Lifeguards For Life said:


> we have a statute that allows for examining and treatment of a patient WITHOUT informed consent if all of the following 3 condidions are met.
> 
> 1. the patient has an emergency medical condition(EMC) as defined as the likelihood that the patient has a condition that may cause loss of life, limb, or bodily function; or the patient is in labor, or the patient has sever pain and,
> 
> ...



Wow....... you have a statute that "empowers" you to use "reasonable force". That scares me..... on the behalf of the EMS providers in your area. I think you are painted into a corner with that one.

The wording of part 3 states "the person is considered to be incapacitated"
Who makes that determination? What training is provided to staff to recognize the the different levels of an intoxication to state when a person is "incapacitated"?

What training is then provided on "reasonable force" if you decide to take this person against their will?


So, you are called to a rural home for a "fall" when you get there you find it is a 255 pound "biker". He has a cut on his forehead and is bleeding. He tells you he didn't call....the neighbor must have........ You can smell ETOH about his person. He tells you and your partner to pound sand. Now what? 

Statutes like the one you have need to be read carefully (in my I am no lawyer advice)
I am totally on your side on his one..... but we must be very careful and not cross the line as to when we don't "allow" a person to refuse. 

So the most important question I pose is...... what would you consider "reasonable force" if you decided to use it?


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## Lifeguards For Life (Dec 6, 2009)

DT4EMS said:


> Wow....... you have a statute that "empowers" you to use "reasonable force". That scares me..... on the behalf of the EMS providers in your area. I think you are painted into a corner with that one.
> 
> The wording of part 3 states "the person is considered to be incapacitated"
> Who makes that determination? What training is provided to staff to recognize the the different levels of an intoxication to state when a person is "incapacitated"?
> ...



It's an actual statute. Florida Statute 401.445. In our paramedic class, we have one day set aside every so often where we get to meet with our medical director, and this was the main topic for one of those meetings. We all agreed that this leaves alot of gray area, alot of room for interpretation. In my opinion, any "reasonable force" used is going to come from law enforcement. I have no business in physically forcing a patient to do anything. 

As for the scenario you posted, I would say the patient meets the 3rd criteria to make him accept transport, but does he meet the first and second criteria?  

the statute is not really designed to allow us to "kidnap" patients. 

Florida Statute 401.445 also reads 
"No recovery shall be allowed in any court in this state against any emergency medical technician, paramedic or physician as defined in this chapter, or any person acting under the direct medical supervision of a physician, in an action brought for examining or treating a patient without his or her informed consent if"
The statute then goes on to list the 3 conditions i had in my previous post

The statute is to protect us. There have been many succesfull suits for not treating patients when we should have. In almost twenty years since this statute has been in effect, there have been no succesfull suits for treating a patient without informed consent under the guidelines of the statutes


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## reaper (Dec 6, 2009)

If you are referring to the "Baker Act". That does not give EMS any authority.

Only LEO or Dr's can enact it. You are only being used as a transport service. There has been many challenges to it, over the years. It is less likely to be used, as it once was. Too many problems arise from it.

You also have the "March man act". This is used more for ETOH and drug related cases, where the person is a risk to themselves or someone else. This is not used very often either. This act can also be used by family, to petition the courts, for forced rehab.

Neither of these acts empower EMS do to anything.


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## Lifeguards For Life (Dec 6, 2009)

reaper said:


> If you are referring to the "Baker Act". That does not give EMS any authority.
> 
> Only LEO or Dr's can enact it. You are only being used as a transport service. There has been many challenges to it, over the years. It is less likely to be used, as it once was. Too many problems arise from it.
> 
> ...


No. i am not reffering to a baker act. I believe it is called the florida incapacitated act.


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## reaper (Dec 6, 2009)

But, for LEO to use that act, they must be under direct medical supervision by a Dr.

EMT's and Paramedics cannot direct LEO to use this act.

In a case like this, The Marchman Act would be more likely. If they could prove that the pt was a harm to themselves. This was a simple assault and unless proven that he has life threatening injuries, it would not be wise.

Here is a great explanation of 401.445 http://myfloridalegal.com/ago.nsf/Opinions/31BAF9D2A385C66A852562A7005D02E6


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## Lifeguards For Life (Dec 6, 2009)

reaper said:


> But, for LEO to use that act, they must be under direct medical supervision by a Dr.
> 
> EMT's and Paramedics cannot direct LEO to use this act.
> 
> ...



Reasonable force includes the use of law enforcement.


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