# Refusal after Narcan administration



## PNWmedic767 (Aug 7, 2019)

Hey yall,

Recently I have had to review a case where a patient was reported to be UC/UR possible OD. Patient was given 1mg IN Narcan by a bystander and "CPR" was initiated. PD beat the ambulance to the scene and administered a second dose of 1mg IN, EMS arrives on scene patient is still not very responsive. Loaded onto gurney and halfway through the first set of vitals she wakes up. She presents irate and inconsolable, starts removing all vitals equipment and is considered A/Ox4 by the Medic on scene. Patient then willfully signs a refusal and walks her way home, only to be found by PD a few hours later and EMS was re-dispatched. 

Excluding the second ambulance being dispatched. First question: Did the Medic do the right thing by getting a refusal since the patient was A/O x4 and answering all questions appropriately? She obviously responded to the Narcan, so it somewhat proves more than disproves a narcotic overdose. Second question, if he did not do the right thing what legal justification did he have to "force" her to go. She did not stated whether she was trying to kill herself or not, Medic stated she did not seem intoxicated, and seemed to understand the extent of what was going on and why she was in the ambulance.  In many ways in our area we can justify forceful transportation to the ER if the patient is suicidal, intoxicated, or not able to understand the extent of risks of refusal of transport. 

Forceful transportation means we call PD explain the situation the situation is further explained to the patient. PD either agrees they are suicidal, intoxicated or unable to understand the risks of refusal of transport. If PD agrees the patient is advised they either come willingly with ambulance or they will be put in "protective" custody and still brought to the ER.


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## hometownmedic5 (Aug 7, 2019)

In my state, that would be a high risk refusal and require OLMC. Without it, that medics actions would be indefensible, here based on our regulations. YMMV


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## Peak (Aug 7, 2019)

Unfortunately competent adults have the right to make stupid decisions. If the patient was competent and was recreationally using drugs (rather than as a self harm attempt) I doubt there is any real ground for a medical or mental health hold. I would absolutely be getting an online refusal from a doc though, the situation reeks of liability. 

Did the medic do the right thing? Realistically this patient would probably go home and use narcotics again whether the patient refused in the ambulance or refused/was discharged from the ED shortly after. The ambulance trip is very unlikely to change their pattern of behavior.

You don't even know why the patient was unconscious on the second call. The patient could have easily used drugs again. I've found no shortage of people smoking heroin and shooting up meth in the waiting room bathrooms. Sometimes they even shut down the ED when they set off the sprinkler system trying to smoke their meth.


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## DrParasite (Aug 7, 2019)

Many/most drug ODs are not suicidal; they just wanted to get high.

She's AOx4.  you want to kidnap her?  even if you speak to the doc, than what?  People have the right to make stupid decisions regarding their healthcare.  She understands the risks, you've done your part, if she ODs an hour later that's her choice


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## mgr22 (Aug 7, 2019)

I agree with the other comments about a patient's right to refuse. Judging a patient competent to understand the risks of refusal also involves risk, particularly in a case like the OP's, so I'd use whatever means my system prescribed to get a doc's approval.


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## PotatoMedic (Aug 7, 2019)

hometownmedic5 said:


> In my state, that would be a high risk refusal and require OLMC. Without it, that medics actions would be indefensible, here based on our regulations. YMMV


Why?  You have an alert and oriented adult who is no longer altered and is aware of their actions and the consequents of them.  What would you do if the doc said bring them in and the patient said no and started to walk away.  Would you then kidnap them?  

Now I get it that your protocols require you to call olmc but what is their reasoning of that?  Because even if the doc said bring them in, you are literally kidnapping them and in a whole lot more risk of a lawsuit.  I guess I'm wondering what is the reasoning for needing to contact olmc?

Sorry... That was rambling.


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## CCCSD (Aug 7, 2019)

How is someone who is still inder the influence of an Opioid , a lethal amount since they had to be revived with a medication, considered A&Ox4 and able to be allowed to walk away? In 15-20 minutes the Narcan will wear off and they will OD again.


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## PotatoMedic (Aug 7, 2019)

CCCSD said:


> How is someone who is still inder the influence of an Opioid , a lethal amount since they had to be revived with a medication, considered A&Ox4 and able to be allowed to walk away? In 15-20 minutes the Narcan will wear off and they will OD again.


Because at that moment they are alert and oriented and able to understand what is going on.  And legally that is all that matters.  If you don't give them narcan you can take them to the hospital without the legal issues.


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## Phillyrube (Aug 7, 2019)

Capnography.  If the numbers are ok, why narcan?   Finally got the local cops to go easy on narcan, so refusals were few.


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## CCCSD (Aug 7, 2019)

PotatoMedic said:


> Because at that moment they are alert and oriented and able to understand what is going on.  And legally that is all that matters.  If you don't give them narcan you can take them to the hospital without the legal issues.



So you would allow them to drive off. Nice. Hope you have DEEP pockets.
Danger to Self. Danger to others. Fits the criteria right there.


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## ffemt8978 (Aug 7, 2019)

CCCSD said:


> So you would allow them to drive off. Nice. Hope you have DEEP pockets.
> Danger to Self. Danger to others. Fits the criteria right there.


And if you kidnap them against their will you will not only need deep pockets but a criminal defense attorney as well.


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## Jim37F (Aug 7, 2019)

Dont forget laws tend to vary in different jurisdictions, one state may say "Yes the patient is now competent and can Refuse Medical Attention", a different state may say the presence of opioids means the patient is not competent regardless of their ability to answer A&O questions


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## ffemt8978 (Aug 7, 2019)

Jim37F said:


> Dont forget laws tend to vary in different jurisdictions, one state may say "Yes the patient is now competent and can Refuse Medical Attention", a different state may say the presence of opioids means the patient is not competent regardless of their ability to answer A&O questions


Excellent point that often gets lost in a forum with members from across the globe.


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## captaindepth (Aug 7, 2019)

PNWmedic767 said:


> Hey yall,
> 
> Recently I have had to review a case where a patient was reported to be UC/UR possible OD. Patient was given 1mg IN Narcan by a bystander and "CPR" was initiated. PD beat the ambulance to the scene and administered a second dose of 1mg IN, EMS arrives on scene patient is still not very responsive. Loaded onto gurney and halfway through the first set of vitals she wakes up. She presents irate and inconsolable, starts removing all vitals equipment and is considered A/Ox4 by the Medic on scene. Patient then willfully signs a refusal and walks her way home, only to be found by PD a few hours later and EMS was re-dispatched.
> 
> ...



This call would have gone so much smoother if the patient hadn't received the IN Narcan prior to EMS arrival. The fact that they did is of no fault of the medic but the subsequent care is their responsibility. There is NO WAY I would let this patient refuse. First of all the pt is altered/minimally responsive upon arrival and placed on the stretcher, then "halfway through the first set of vitals she wakes up. She presents irate and inconsolable, starts removing all vitals equipment..." this is not the way someone who is sober with decision making capacity behaves. From this description there is no way this patient can rationally appreciate the scenario/risks/benefits of transport/and understand informed consent. Does this patient present with the four components of decision making capacity? 

"Informed consent involves providing patients with accurate and adequate information about the risks, benefits, and alternatives of a treatment in a manner that is free from coercion. It also requires that patients have medical decision-making capacity. Medical decision-making capacity has four key elements. Patients must be able to (1) demonstrate understanding of the benefits and risks of, and the alternatives to, a proposed treatment or intervention (including no treatment); (2) demonstrate appreciation of those benefits, risks, and alternatives; (3) show reasoning in making a decision; and (4) communicate their choice.1,2"

Irate and Inconsolable makes me think the patient was possibly mixing a stimulant with her opiate and now that the opiate is gone you are dealing with a sympathomimetic overdose. I have a real hard time imagining this patient being able to sit through the "refusal speech" and truly appreciating the information. I was once told that if I act in the BEST INTEREST of my patient, than 99 times out of 100 it will protect me from "getting in trouble." I think monitoring, treating, and transporting this patient is 100% in their best interest and that would be my decision.


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## Carlos Danger (Aug 8, 2019)

CCCSD said:


> How is someone who is still inder the influence of an Opioid , a lethal amount since they had to be revived with a medication, considered A&Ox4 and able to be allowed to walk away? *In 15-20 minutes the Narcan will wear off and they will OD again.*



No, that isn’t how it works. Once the opioid is reversed, they no longer are under the influence of it.

Narcan lasts at least an hour (up to 4 hours depending on which source you are looking at), which is longer than the most toxic effects of most opioids that are abused recreationally.

Of course if it possible that the opioid could last longer than the narcan, but if the peak effects of the initial dose weren’t enough to cause apnea, it’s even less likely to do so after the drug has been given well over an hour to be eliminated.


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## StCEMT (Aug 8, 2019)

SI overdose? Sure. A recreational drug user? Not forcing that.

People have the right to make stupid choices. If they want to get high, then it's not my place to force them to go to the hospital. I'm not about to go around kidnapping someone.


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## johnrsemt (Aug 9, 2019)

Lets change it up a little;

You get to the scene of an unconscious person:  as you do your patient evaluation and talk to family you find his Blood Glucose is 25.  You start a line and give D50.  He wakes up and refuses transport.   Are you going to force him to go to the hospital against his will because he was unconscious when you 1st got to the patient?  No, you can't.  if you call the hospital and the doctor says to bring him in, and patient still refuses same problem.  95/100 areas you won't even have an officer respond so you won't have that option, but most officers would laugh at you if you asked them to arrest an awake and alert patient.

What if the patient was seizing when you get to them.  Then he stops and over 15 minutes his postictal period wears off:  he doesn't want to go, because this is the 10 time he has seized this month.  Are you going to force him to go?  Most ED doctors would laugh at you if you tried to get them to talk to the patient to get the patient to go to the hospital.

Document the run in great detail; including that the patient refused all contact as soon as he woke up (be it low sugar, seizure or OD); and either pt. signed refusal or refused to sign.  Remember to document a refusal better than a transport.  and walk away from it.  
  Which one gets you into more trouble?  The OD who dies 3 hours later on the next OD where no one is there to give them Narcan, after they didn't go to the hospital with you?  Or the one that you committed assault and battery on by forcing them into the ambulance and then kidnapped them by forcing them to go to the hospital against their will?  When they get to the hospital and start screaming that the hospital will let them go in a few minutes and the ambulance chaser will hear it and help them sue you and your company.
    You will lose that case.


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## hometownmedic5 (Aug 9, 2019)

johnrsemt said:


> Lets change it up a little;
> 
> You get to the scene of an unconscious person:  as you do your patient evaluation and talk to family you find his Blood Glucose is 25.  You start a line and give D50.  He wakes up and refuses transport.   Are you going to force him to go to the hospital against his will because he was unconscious when you 1st got to the patient?  No, you can't.  if you call the hospital and the doctor says to bring him in, and patient still refuses same problem.  95/100 areas you won't even have an officer respond so you won't have that option, but most officers would laugh at you if you asked them to arrest an awake and alert patient.
> 
> ...



That would also be a high risk refusal in Ma, perhaps even the original. So I would wake them up, wait till their sugar was good, and call the doc. If the person is stable and able to care for themself, I have never not gotten orders to release them on scene; but if they’re unable to care for themselves, then they are usually going.

I did this exact call for a nearly bed bound diabetic once. They could technically ambulate around their house, but it was a “500 steps a day, choose wisely” kind of situation. The caretaker had gone out erranding, called to check in and when they didnt get an answer, called 911 as they were a ways away. The patient didnt want to go after D50, but since they couldn’t care for themselves independently, the doc said bring them in. I just got back from the post office, no letter revoking my license again today, maybe tomorrow. Will advise.

I guess the point I’m trying to make is that there are a million variables, a million systems, at least 50 sets of rules in this country and like 206 other countries out there, so what will “definitely land you in jail” in one place maybe be a Tuesday afternoon special three states away.


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## Phillyrube (Aug 9, 2019)

We used to have a very brittle diabetic in our first due area..everyone knew the address. Guy weighed maybe 160 lbs soaking wet, but could throw us all over the place.   We used to work with him and try to give oral glucose to bring him around, but after quite a few of these calls.  Our OMD finally nixed that. said to transport him each time.  That always led to full fledged battle AFTER we got him back.  Finally he got his MD to order D50, IV bags, Glucagon, so we could use his supplies instead of ours.  His wife graciously padded the hearth in living room so no one would get hurt and had our PPCR 3/4 filled out.  Guy was really nice, did a big cookout for the fire department and donated big to the rescue squad.  Sadly he passed a couple years later.

Love ya, Jack.


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## captaindepth (Aug 9, 2019)

johnrsemt said:


> Lets change it up a little;
> 
> You get to the scene of an unconscious person:  as you do your patient evaluation and talk to family you find his Blood Glucose is 25.  You start a line and give D50.  He wakes up and refuses transport.   Are you going to force him to go to the hospital against his will because he was unconscious when you 1st got to the patient?  No, you can't.  if you call the hospital and the doctor says to bring him in, and patient still refuses same problem.  95/100 areas you won't even have an officer respond so you won't have that option, but most officers would laugh at you if you asked them to arrest an awake and alert patient.
> 
> ...



These are invalid comparisons and lead to more questions than answers. The argument isn't whether or not someone can refuse care/transport following narcan administration, the argument is whether or not the patient in the OPs post is capable of refusing. It states the patient is AAOx 4 but that does not equate to decision making capacity.

In the scenarios you provided there are a lot of questions about those scenarios that would influence the decision to transport or not. Diabetic wake-ups are some of the best calls in EMS IMO, do I treat and release on a regular basis... absolutely, BUT the pt must have decision making capacity to refuse following treatment.

If I arrive to find a seizing patient, I am treating the seizure and transporting the  patient. If I arrive to find a postictal patient, than assessment and scenario will dictate whether or not that patient needs transport (i.e. are they alone? do they have a hx of seizures? is there trauma associated with the event? ). 

I want to practice in a way that I am proud to defend. Letting someone who just overdosed, wake up screaming and yelling, verbally and physically escalating,  ripping off equipment, and "willfully signed a refusal form," is not a call I would be proud of or comfortable defending. The pt needed continued evaluation and treatment and IMO does not have the decision making capacity to refuse care.


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## DrParasite (Aug 9, 2019)

Phillyrube said:


> Our OMD finally nixed that. said to transport him each time.  That always led to full fledged battle AFTER we got him back.


So you have a patient who is alert and oriented, and doesn't want to go to the hospital.  he is refusing to be transported.  He knows and acknowledges the risk.  

What did you do, drag him kicking and screaming to the ER, and when you made it to the ER doors, he signed out AMA?  Or did he begrudgingly consent to be transported?

Serious question, because even if the MD says he should go, and it's in his best interest to go, people still have the right to make stupid decisions about their healthcare, decisions that the medical professionals don't agree with.


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## FiremanMike (Aug 10, 2019)

captaindepth said:


> These are invalid comparisons and lead to more questions than answers. The argument isn't whether or not someone can refuse care/transport following narcan administration, the argument is whether or not the patient in the OPs post is capable of refusing. It states the patient is AAOx 4 but that does not equate to decision making capacity.
> 
> In the scenarios you provided there are a lot of questions about those scenarios that would influence the decision to transport or not. Diabetic wake-ups are some of the best calls in EMS IMO, do I treat and release on a regular basis... absolutely, BUT the pt must have decision making capacity to refuse following treatment.
> 
> ...



I’m curious, can you articulate why it is that you feel the patient doesn’t have the decision making capacity to refuse care?  Think about the action of Narcan.. 

Here’s the thing, and I’m just restating what other folks have said in this thread.. At the point of the discussion of refusal, provided they can repeat back to you they understand the risks, they are not intoxicated and they have the basic human right to not be told what to do.  Moral high grounds and what-ifs do not allow any of us to override that, and frankly the same goes with the diabetic that we just got back.. 

It’s been my experience with overdoses that when they’re high, it’s obvious, and when they’re not high, it’s also pretty obvious (I.e. s/p Narcan).  While we don’t have a high number of overdose refusals, they happen and they are well documented.  I know one person mentioned going back on a re-overdose, anyone else? We’ve never seen one here..

Tl:dr - people are allowed to make their own decisions, even if we think they’re bad..


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## hometownmedic5 (Aug 10, 2019)

FiremanMike said:


> I’m curious, can you articulate why it is that you feel the patient doesn’t have the decision making capacity to refuse care?  Think about the action of Narcan..
> 
> Here’s the thing, and I’m just restating what other folks have said in this thread.. At the point of the discussion of refusal, provided they can repeat back to you they understand the risks, they are not intoxicated and they have the basic human right to not be told what to do.  Moral high grounds and what-ifs do not allow any of us to override that, and frankly the same goes with the diabetic that we just got back..
> 
> ...



I have treated the same person more than one time in a day, in short order, for opiate overdoses; but I can't really say I've ever gone back for someone right after the narcan I gave them wore off.


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## FiremanMike (Aug 10, 2019)

hometownmedic5 said:


> I have treated the same person more than one time in a day, in short order, for opiate overdoses; but I can't really say I've ever gone back for someone right after the narcan I gave them wore off.



Any idea if it was from the same use of opiate or if he/she consumed more after you left?  I'm just curious what the actual rate of "re-overdose" is.. We know the half life of opiates is longer than narcan, but is that ever really an issue?


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## Phillyrube (Aug 10, 2019)

DrParasite said:


> So you have a patient who is alert and oriented, and doesn't want to go to the hospital.  he is refusing to be transported.  He knows and acknowledges the risk.
> 
> What did you do, drag him kicking and screaming to the ER, and when you made it to the ER doors, he signed out AMA?  Or did he begrudgingly consent to be transported?
> 
> Serious question, because even if the MD says he should go, and it's in his best interest to go, people still have the right to make stupid decisions about their healthcare, decisions that the medical professionals don't agree with.



No, he went with us and then AMAed.   This led to the home supplies.


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## hometownmedic5 (Aug 10, 2019)

FiremanMike said:


> Any idea if it was from the same use of opiate or if he/she consumed more after you left?  I'm just curious what the actual rate of "re-overdose" is.. We know the half life of opiates is longer than narcan, but is that ever really an issue?



I don’t know one way or the other to be certain. For the sake of conversation, lets say I first contacted this person at 10 am. Narcan, transport, AMA, find the guy with the dope(which in my town is like trying to find a car salesman Memorial Day weekend. Stand in one place long enough, one will find you), shove off on a park bench or gas station bathroom, wait for a passerby to call me brings us to about noon that day. Probably not the same dope as the first time, but it has happened and is a concern.


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## jgmedic (Aug 10, 2019)

If they are combative and refusing, but AOx4, why take the risk on your own? Call OLMC, and get a doc, tell them the story and go from there. Ive had plenty of these calls, and most of the time base asked us to involve LE, which usually resulted in an officer telling us there's nothing we can do. Then, once they have done that, and I relayed this to base, the doc would usually say we've exhausted all options and the pt could sign out, all recorded, documented the hell out of everything by me and no one got kidnapped.


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## captaindepth (Aug 10, 2019)

FiremanMike said:


> I’m curious, can you articulate why it is that you feel the patient doesn’t have the decision making capacity to refuse care?  Think about the action of Narcan..
> 
> Here’s the thing, and I’m just restating what other folks have said in this thread.. At the point of the discussion of refusal, provided they can repeat back to you they understand the risks, they are not intoxicated and they have the basic human right to not be told what to do.  Moral high grounds and what-ifs do not allow any of us to override that, and frankly the same goes with the diabetic that we just got back..
> 
> ...



 Reading the OPs description of the patient and the scene I have hard time believing this patient be capable of rational thought. How can the provider complete a thorough assessment to obtain the necessary information needed to inform the patient of the risks WHILE the pt s actively fighting? How can the providers get the necessary vital signs while the patient is "irate, inconsolable, and removing all vitals equipment?" The patient must be able to process all of the information with rational thought in order to make an informed decision. From the description provided I do not think this patient can meet that aspect. Being able to answer questions does not equate to the patient being able to making rational decisions.


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## Underoath87 (Aug 10, 2019)

I would probably be fired for taking that refusal, especially without consulting med control. Our protocols specifically state that "patients presenting with AMS, who respond to narcan, are not candidates for informed refusal. Due to the relatively short half-life of Narcan, these patients are medically incapacitated, and should be transported, regardless of the presence of an apparently normal mental status. If needed, contact LE and/or med control for assistance with patient transport". 
This is in Orange County, Florida.


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## silver (Aug 11, 2019)

Underoath87 said:


> I would probably be fired for taking that refusal, especially without consulting med control. Our protocols specifically state that "patients presenting with AMS, who respond to narcan, are not candidates for informed refusal. Due to the relatively short half-life of Narcan, these patients are medically incapacitated, and should be transported, regardless of the presence of an apparently normal mental status. If needed, contact LE and/or med control for assistance with patient transport".
> This is in Orange County, Florida.



Do you document a capacity assessment? Unless you demonstrate that the patient lacks capacity at that given moment to make that decision its a matter of time until you or a colleague will get burned.


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## Underoath87 (Aug 11, 2019)

silver said:


> Do you document a capacity assessment? Unless you demonstrate that the patient lacks capacity at that given moment to make that decision its a matter of time until you or a colleague will get burned.



Of course I record their LOC and mentation before and after the Narcan.
But as the protocol states, someone who is only responsive due to Narcan is considered to be lacking capacity. So any liability would fall to our medical director. Florida gives first responders a good amount of protection when forcing people to go the the ER. The hospital will usually let them leave AMA, but the medical directors just don't want that liability.
Whether I agree with it or not, that's how things are done in central Florida. I have never heard of anyone getting in trouble for this particular issue. It's the high risk refusals that usually get people fired/sued.


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## Tigger (Aug 11, 2019)

Underoath87 said:


> Of course I record their LOC and mentation before and after the Narcan.
> But as the protocol states, someone who is only responsive due to Narcan is considered to be lacking capacity. So any liability would fall to our medical director. Florida gives first responders a good amount of protection when forcing people to go the the ER. The hospital will usually let them leave AMA, but the medical directors just don't want that liability.
> Whether I agree with it or not, that's how things are done in central Florida. I have never heard of anyone getting in trouble for this particular issue. It's the high risk refusals that usually get people fired/sued.


Why do they lack capacity?


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## GMCmedic (Aug 11, 2019)

Situations like this I refer to my own personal algorithm. 

Can I talk them into going?
If yes they go, if not....

Will PD force them to go?
If yes they go, if not....

Am I going to get throat punch if I force them to go?
If yes they stay home, if no they probably still stay home. 

Either way document document document. 

There are really only two types of patients, those that are going to go to the hospital, and those that are going to fight you. Fighting isnt my job.


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## Tigger (Aug 12, 2019)

GMCmedic said:


> There are really only two types of patients, those that are going to go to the hospital, and those that are going to fight you. Fighting isnt my job.


Yup. I don't have to put my personal safety at risk to force someone to go to the hospital. For any patient.


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## FiremanMike (Aug 12, 2019)

Well I don’t think it’s quite that simple.  Some combative patients need to go to the hospital - that’s why we give out ketamine like it’s going out of style..

However, a revived heroin overdose who’s being a jerk but is otherwise lucid is not on my list of people to fight.


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## Underoath87 (Aug 12, 2019)

Tigger said:


> Why do they lack capacity?



Again, this doesn't necessarily align with my opinion. I just quoted it straight out of my protocol in my first post in this thread. The rationale was explained, even if many here do not agree with it.


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## DrParasite (Aug 12, 2019)

Underoath87 said:


> The hospital will usually let them leave AMA, but the medical directors just don't want that liability.


So your medical director is directing you to take the person kicking and screaming, and once you get to the ER, they can just AMA out of the ER?  sounds like a waste of an ambulance trip.





Underoath87 said:


> It's the high risk refusals that usually get people fired/sued.


With all due respect, no it's not.  It's the inappropriate high risk refusals that get people fired or sued.  Such was when protocols don't get followed, or paramedics fail to do their jobs.

In your case, no one is suggesting you go against your medical director; that is a good way to end up getting fired.  But knowing why you are calling your medical director, and realizing that if you do get sued, most of the time the suit will be against the paramedic and the agency.  if disciplinary action is taken, it's usually taken against the paramedic, and rarely against online medical control (especially if that person isn't the full time medical director).  

So they might tell you something, but there have been cases where medical control tells a paramedic to do something that is questionable, and later found to be wrong.  The paramedic usually takes all the heat for it, and the doc on the other end gets at most a slap on the wrist.

BTW, just because someone "accidentally" takes too much narcotic, and needs to be revived with narcan, doesn't mean they lack capacity.  Once they are awake, alert, and understand the risk of their actions, they are AOx3.  I'm pretty sure I could convince a lawsuit that forcing an AOx3 to go to the hospital against their will is wrongful imprisonment and kidnapping.  maybe even battery too, if force was used. Might even be able to file criminal charges against you for your actions.  And those would all be directed at your personally; your medical director and agency might be named for the deep pockets in a civil case only.



captaindepth said:


> Reading the OPs description of the patient and the scene I have hard time believing this patient be capable of rational thought. How can the provider complete a thorough assessment to obtain the necessary information needed to inform the patient of the risks WHILE the pt s actively fighting? How can the providers get the necessary vital signs while the patient is "irate, inconsolable, and removing all vitals equipment?" The patient must be able to process all of the information with rational thought in order to make an informed decision. From the description provided I do not think this patient can meet that aspect. Being able to answer questions does not equate to the patient being able to making rational decisions.


So your going to forcibly restrain the patient, prevent them from leaving, the ambulance, and, against their will, reassess their vitals?  maybe even chemically sedate/restrain them?

If a patient gets irate and say "get the F off me, get all these things off me" they have made their intentions and desires very clear.  I have no problems calling the cops and letting them wrestle with the patient (they are on more solid legal ground than I am), but forcing my treatments on an patient who obviously does not want them is stretching my job description a bit.  Esp one whose alert enough to convey the message that they don't want me help.

That being said, have I wrestled with my fair share of drunks, and restrained people in crisis?  sure.  but a simply overdose patient, especially a violent one who has conveyed that he doesn't want my help?  the cynic inside me says he's going to OD again.  maybe them time he will only get enough narcan to get him breating, not enough to wake him up.


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## Tigger (Aug 12, 2019)

Underoath87 said:


> Again, this doesn't necessarily align with my opinion. I just quoted it straight out of my protocol in my first post in this thread. The rationale was explained, even if many here do not agree with it.


I understand, I just don't get how even the system can make that argument in such a black and white manner. It also unfortunate that the best we can do sometimes is say "well it's protocol."



FiremanMike said:


> Well I don’t think it’s quite that simple.  Some combative patients need to go to the hospital - that’s why we give out ketamine like it’s going out of style..
> 
> However, a revived heroin overdose who’s being a jerk but is otherwise lucid is not on my list of people to fight.


There are times when providing sedation is not safe. I've been stuck in several situations with law enforcement stating that they want the patient transported but are not willing to go hands on. If they aren't going to help facilitate safely sedating these individuals, I'm not going in there by myself.


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## FiremanMike (Aug 12, 2019)

Tigger said:


> There are times when providing sedation is not safe. I've been stuck in several situations with law enforcement stating that they want the patient transported but are not willing to go hands on. If they aren't going to help facilitate safely sedating these individuals, I'm not going in there by myself.



Well obviously I agree with that, I was merely responding to the notion of "well if he's gunna fight, I'm not going to transport him" statement..


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## captaindepth (Aug 12, 2019)

DrParasite said:


> So your going to forcibly restrain the patient, prevent them from leaving, the ambulance, and, against their will, reassess their vitals?  maybe even chemically sedate/restrain them?
> 
> If a patient gets irate and say "get the F off me, get all these things off me" they have made their intentions and desires very clear.  I have no problems calling the cops and letting them wrestle with the patient (they are on more solid legal ground than I am), but forcing my treatments on an patient who obviously does not want them is stretching my job description a bit.  Esp one whose alert enough to convey the message that they don't want me help.
> 
> That being said, have I wrestled with my fair share of drunks, and restrained people in crisis?  sure.  but a simply overdose patient, especially a violent one who has conveyed that he doesn't want my help?  the cynic inside me says he's going to OD again.  maybe them time he will only get enough narcan to get him breating, not enough to wake him up.


Safety is everyones responsibility. Think about the original scenario ("EMS arrives on scene patient is still not very responsive. Loaded onto gurney and halfway through the first set of vitals she wakes up. She presents irate and inconsolable, starts removing all vitals equipment") this is a suspected narcotic OD but initially the patient had not yet responded to the Narcan and was altered upon EMS arrival so other medical causes for the patients presentation MUST be considered at this point. This patient should be initially assessed, searched for weapons/needles, loaded onto the stretcher, secured AND restrained. Restrained not because they are in custody or in "trouble" but because they are "not very responsive" and needed to have their limbs controlled. Once the pt wakes up "irate and inconsolable" and is actively trying to "remove all vitals equipment" (or fight against restraints) and is not able to reasonably communicate or allow a complete and thorough assessment than they should be sedated. 

We have all determined this is in fact a "patient" and I have shared why I believe this patient does not have capacity to refuse care. So now I have a patient, that I am responsible for, on my stretcher who does not have the decision making capacity to refuse care. I am not going to allow someone to scream and fight in the back of the ambulance, they are going to be sedated.

It sucks waking up a narcotic OD patient and having to re-sedate them, I've done it and I am always bummed the call went that way but safety is paramount. Like I said earlier, its a lot easier when the pt doesn't receive Narcan prior to EMS arrival and can be treated with small doses of Narcan JUST enough to improve their respiratory effort but not enough to remove all of the effects of the opioid. 

Also can anyone share a case study or article written about when an EMT/Paramedic has successfully been prosecuted for treating/transporting a patient against their will when the patients decision making capacity was in question? It seems like most litigation against EMS personnel is when the DO NOT treat/transport the pt appropriately (think about that case in N.C earlier this year).

Here is an article written by a co-worker regarding assessing a patients decision making capacity.









						Evaluating Patients’ Decision-Making Capacity
					






					www.emsworld.com


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## FiremanMike (Aug 12, 2019)

captaindepth said:


> Safety is everyones responsibility. Think about the original scenario ("EMS arrives on scene patient is still not very responsive. Loaded onto gurney and halfway through the first set of vitals she wakes up. She presents irate and inconsolable, starts removing all vitals equipment") this is a suspected narcotic OD but initially the patient had not yet responded to the Narcan and was altered upon EMS arrival so other medical causes for the patients presentation MUST be considered at this point. This patient should be initially assessed, searched for weapons/needles, loaded onto the stretcher, secured AND restrained. Restrained not because they are in custody or in "trouble" but because they are "not very responsive" and needed to have their limbs controlled. Once the pt wakes up "irate and inconsolable" and is actively trying to "remove all vitals equipment" (or fight against restraints) and is not able to reasonably communicate or allow a complete and thorough assessment than they should be sedated.
> 
> We have all determined this is in fact a "patient" and I have shared why I believe this patient does not have capacity to refuse care. So now I have a patient, that I am responsible for, on my stretcher who does not have the decision making capacity to refuse care. I am not going to allow someone to scream and fight in the back of the ambulance, they are going to be sedated.
> 
> ...



There's a nuance here that you may be forgetting.  There is a difference between being a violent jerk because the patient is still altered (can't refuse) and the patient being a violent jerk because they're just a jerk (can refuse).  Most of us can tell the difference pretty quickly and we weren't sitting in front of the patient described in the OP.  

Honestly, it's this nuance that's critical to the entire conversation.

Frankly - it's been my experience that the overwhelming majority of patients who receive narcan wake up completely and are subsequently completely lucid and oriented.


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## DrParasite (Aug 12, 2019)

captaindepth said:


> Also can anyone share a case study or article written about when an EMT/Paramedic has successfully been prosecuted for treating/transporting a patient against their will when the patients decision making capacity was in question? It seems like most litigation against EMS personnel is when the DO NOT treat


No, but if you check out https://www.emsworld.com/article/1223025/pinnacle-ems-case-law-are-you-protected one important takeway from Major liability areas that arose during [Paramedic Attorney] Streger’s search included the following statement:


> Use of force and false imprisonment. What we’re not seeing, Streger said, are refusal-of-care charges, which runs counter to what’s typically stressed in education. “Don’t take patients against their will,” he stressed.


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## ffemt8978 (Aug 12, 2019)

captaindepth said:


> and is not able to reasonably communicate or allow a complete and thorough assessment than they should be sedated.


Since  when does someone who is AOx4 have to allow a thorough assessment ... Especially under the threat of sedation if they don't?

"If you don't  allow me to do this then I'm going  do that and then  do this anyway, no matter what you want" is  necessarily a good idea in EMS.


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## captaindepth (Aug 12, 2019)

ffemt8978 said:


> Since  when does someone who is AOx4 have to allow a thorough assessment ... Especially under the threat of sedation if they don't?
> 
> "If you don't  allow me to do this then I'm going  do that and then  do this anyway, no matter what you want" is  necessarily a good idea in EMS.



Being alert and orientated person, place, time, and event does NOT equate to having decision making capacity. I have stated why I believe the patient described in the original scenario does not have decision making capacity. The patient was initially found to be minimally responsive, moved to the ambulance for further assessment, and became combative. If the patient cannot be assessed safely, the patient is "inconsolable," is unable to reason, and is a danger to themselves or others, I am sedating the patient for safety reasons. Again, this is not the optimal way I'd like for this call to go but I am comfortable defending my actions and believe it is in the best interest of the patient.


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## ffemt8978 (Aug 12, 2019)

@captaindepth I understand that, but what do you use to determine if a patient has "decision making capacity"?

Seems like your determination of that ability is the foundation you use to justify the rest of your actions.  (Which if they don't have that capacity, I have no issues with the treatment plan you described.)

Is there another objective, repeatable, and documentable method besides AOx4 that you use?


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## captaindepth (Aug 12, 2019)

ffemt8978 said:


> @captaindepth I understand that, but what do you use to determine if a patient has "decision making capacity"?
> 
> Seems like your determination of that ability is the foundation you use to justify the rest of your actions.  (Which if they don't have that capacity, I have no issues with the treatment plan you described.)
> 
> Is there another objective, repeatable, and documentable method besides AOx4 that you use?



Below is the link to the same article I listed earlier, it is the basis of my argument written by a coworker whom I very much trust and agree with.









						Evaluating Patients’ Decision-Making Capacity
					






					www.emsworld.com
				





*0030 GENERAL GUIDELINES: CONSENT *

General Principles: Adults

A. An adult in the State of Colorado is 18 years of age or older.
B. Every adult is presumed capable of making medical treatment decisions. This includes the right to make "bad" decisions that the prehospital provider believes are not in the best interests of the patient.
C. A person is deemed to have decision-making capacity if he/she has the ability to provide informed consent, i.e., the patient:
            1. Understands the nature of the illness/injury or risk of injury/illness.
            2. Understands the possible consequences of delaying treatment and/or refusing transport.
            3. Not intoxicated with drugs and/or alcohol
            4. Given the risks and options, the patient voluntarily refuses or accepts treatment and/or transport.
D. A call to 9-1-1 itself does not prevent a patient from refusing treatment. A patient may refuse medical treatment (IVs, oxygen, medications), but you should try to inform the patient of the need for therapies, offer again, and treat to the extent possible.
E. The odor of alcohol on a patient’s breath does not, by itself, prevent a patient from refusing treatment.
F. Implied Consent: An unconscious adult is presumed to consent to treatment for life-threatening injuries/illnesses.
G. Involuntary Consent: a person other than the patient in rare circumstances may authorize Consent. This may include a court order (guardianship), authorization by a law enforcement officer for prisoners in custody or detention, or for persons under a mental health hold or commitment who are a danger to themselves or others or are gravely disabled.


This is directly from out protocols which can be found online. Note that no where in the description above does it reference "alert and orientated" questions. I believe patient in the original scenario is unable to meet the criteria listed above as having capacity to refuse treatment. Especially when the patient presents as irate and inconsolable, how can a provider obtain and discuss, in detail, the necessary information to inform this irate patient? 

When picturing this scenario in my mind and the experiences I have had with similar calls, I can not imagine a way to argue that this patient does in fact have the decision making capacity to refuse care.


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## FiremanMike (Aug 13, 2019)

captaindepth said:


> Below is the link to the same article I listed earlier, it is the basis of my argument written by a coworker whom I very much trust and agree with.
> 
> 
> 
> ...



I just went and reread the OP to make sure I didn’t miss anything, and I didn’t.

Frankly there’s not enough information in the OP to make the determination as to whether the patient is still altered, “irate and inconsolable” really doesn’t tell us much.

The bottom line is that you can’t universally say that someone who has been revived with Narcan is incapable of refusal of transport.


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## CWATT (Aug 15, 2019)

Remi said:


> No, that isn’t how it works. Once the opioid is reversed, they no longer are under the influence of it.



Katzung, Basic & Clinical Pharmacology 14 ed., p.571:

”_It is very important that the relatively short duration of action of naloxone be borne in mind, because a severely depressed patient may recover after a single dose of naloxone and appear normal, only to relapse into a coma after 1-2hrs.”_

Naloxone is a competitive antagonist, meaning the rate and probability of relapse is dependent on the relative half-life the of opiate ingested.  For example, Fenanyl has a half-life of 7hrs compared to 1.24hrs for 0.4mg IV or 1.85hrs for 2mg IN or 2.04hrs for 4mg IN (DrugBank.ca).  Therefore, opiate reversal may be achieved once a sufficient quantity naloxone is administered to out-compete the opiate, however as naloxone is metabolized the effects of the opiate may return.  



PNWmedic767 said:


> Did the Medic do the right thing by getting a refusal since the patient was A/O x4 and answering all questions appropriately?



Where I currently practice, paramedics have their own license granted by our regulating body (the College of Paramedics).  Though every service continues to use ‘protocols’ approved by a medical director, we technically don’t need either and it is the College’s expectation that members be familiar with the pharmacodynamic and pharmacokinetic profile of each medication within our scope (as you can imagine, this has a high degree of variability, hence the continued use of protocols).  Nevertheless, it would be ‘expected’ that the Medic in your scenario understand the half-life of 1MG IN Naloxone be approximately 45-60minutes and the risks include a return of sedation and possible apnea.  Thus, allowing a patient to sign a ‘refusal of care’ form would be allowing the patient to become a risk to themselves (criteria to be ‘formed’) and could also count as ’abandonment of care’ and ’gross negligence’.


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## mgr22 (Aug 15, 2019)

CWATT said:


> Nevertheless, it would be ‘expected’ that the Medic in your scenario understand the half-life of 1MG IN Naloxone be approximately 45-60minutes and the risks include a return of sedation and possible apnea.  Thus, allowing a patient to sign a ‘refusal of care’ form would be allowing the patient to become a risk to themselves (criteria to be ‘formed’) and could also count as ’abandonment of care’ and ’gross negligence’.



Are you saying that in your system, paramedics are expected to transport competent, asymptomatic patients because they may become obtunded later? If so, how do you enforce that?


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## CWATT (Aug 15, 2019)

There are two separate entities here — the professional regulator (the College of Paramedics) who set-forth the expectations of members (described in my first post), and your employer who establish the operational standards (protocols) as per the regional legislature.  The employer ‘refusal of care’ protocol here disallows a patient to refuse care if they “...present a danger to themselves...” which they would if they discontinued care (as outlined in my original post).

Also, another criteria is ‘intoxication due to alcohol ingestion or drug use‘.   Even if you administer a drug (e.g., Naloxone) which is capable of blocking the undesired effects of the opiates (i.e., respiratory depression), they are still in a toxic state (overdose).  Naloxone does not metabolize opiates, thus it is still present and active in the patient’s system, independent to whether or not the patient is symptomatic.


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## silver (Aug 15, 2019)

CWATT said:


> Katzung, Basic & Clinical Pharmacology 14 ed., p.571:
> 
> ”_It is very important that the relatively short duration of action of naloxone be borne in mind, because a severely depressed patient may recover after a single dose of naloxone and appear normal, only to relapse into a coma after 1-2hrs.”_
> 
> ...



It’s important to note that the half life here is generally not relevant as drugs like fentanyl have such a large volume of distribution that the duration of action is much shorter, like closer to 15-20 mins. Though re dosing of naloxone does exist but more likely to be when for instance a patient has been on a fentanyl drip for days (and you some how now need to avoid the effects) or high dose long acting like methadone. 

Chances are most patients that get redosed end up having been underdosed to start or are digesting and absorbing more PO dosing. 

...Also you are questioning a guy named “remi” on opioids.


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## Carlos Danger (Aug 15, 2019)

CWATT said:


> Katzung, Basic & Clinical Pharmacology 14 ed., p.571:
> 
> ”_It is very important that the relatively short duration of action of naloxone be borne in mind, because a severely depressed patient may recover after a single dose of naloxone and appear normal, only to relapse into a coma after 1-2hrs.”_
> 
> Naloxone is a competitive antagonist, meaning the rate and probability of relapse is dependent on the relative half-life the of opiate ingested.  For example, Fenanyl has a half-life of 7hrs compared to 1.24hrs for 0.4mg IV or 1.85hrs for 2mg IN or 2.04hrs for 4mg IN (DrugBank.ca).  Therefore, opiate reversal may be achieved once a sufficient quantity naloxone is administered to out-compete the opiate, however as naloxone is metabolized the effects of the opiate may return.



OK.

First, yes there is a definite possibility of re-narcotization, especially with very large doses of opioids. However, re-narcotization is not what I was referring to in my text that you quoted.  I was referring to the actual effects of the opioid, which can be completely non-existent following reversal with naloxone.

Next,* you guys really need to stop referring to the "half life" of these drugs.* The half life of a drug tells you almost nothing about the duration of the drug's clinical effects, which is all we are concerned about for this discussion. For instance, propofol has a half life of 5 hours, but effects of a singe bolus peak at 60 seconds and are almost completely gone at 5 minutes. Heroin has a half life of minutes, but a duration of action of about an hour. The clinical effects of a normal dose of valium last 8 hours or so, but the half-life is 36 hours. There are many pharmacokinetic and pharmacodynamic factors that determine the onset, peak, and duration of clinical effects, but of all those factors, the plasma half-life has probably the least influence.

Finally, While recurrence of severe respiratory depression after giving narcan is certainly possible, it is pretty unlikely with most commonly abused opioids. First, as a _competitive _antagonist, narcan has significantly greater affinity for the Mu2 receptor than the opioids that it displaces. This means that you can see a return of the sedative effects of the narcotic (kappa receptors), while not seeing significant ventilatory depression (mediated primarily by the Mu2 subtype).

Also, when talking about serious respiratory depression, it isn't the duration of the reversed drug that matters as much as the response curve (peak effect duration). Morphine's respiratory depressant effects mirror it's overall clinical effects on the dose-response curve, and the clinical effects peak at 45 minutes and are waning by 90 minutes. Narcan lasts from 45-90 minutes. Assuming that a dose of narcan administered by EMS isn't given until 15-30 minutes or so after the morphine was self-administered, you now only have 60 minutes before you are firmly on the downslope of the effect-site concentration. Re-narcotization is possible, but recurrence of severe respiratory depression is pretty unlikely, unless a very large dose of the opioid were consumed, but you would have a clue about that from the amount of narcan you had to use to wake them up.

Personally, I would be uneasy about taking a refusal after a narcan wakeup unless the person were left in the presence of a reasonably trustworthy third party. They could take another dose of whatever after you leave and be found dead a few hours later. How would your refusal then look then to jury?


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## mgr22 (Aug 16, 2019)

CWATT said:


> Also, another criteria is ‘intoxication due to alcohol ingestion or drug use‘.   Even if you administer a drug (e.g., Naloxone) which is capable of blocking the undesired effects of the opiates (i.e., respiratory depression), they are still in a toxic state (overdose).  Naloxone does not metabolize opiates, thus it is still present and active in the patient’s system, independent to whether or not the patient is symptomatic.



So while they're in that asymptomatic but toxic state, how do you enforce transport if a patient wants to refuse?


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## DrParasite (Aug 16, 2019)

Great post @Remi however, I disgree with this part





Remi said:


> They could take another dose of whatever after you leave and be found dead a few hours later. How would your refusal then look then to jury?


probably as good as taking a refusal from a ped struck with minor injuries, who a few hours later gets hit by another car and dies.  or a person who has an asthma attack, panics and calls 911 then puts on their CPAP with inline neb and feels better, so EMS gets there, patient is breathing fine, so they give a another treatment and then sign a refusal, and then call 911 again when their breathing flares up again.  Or you get dispatched for the 3rd party call for a person in cardiac arrest on the lawn, and when Fire/EMS arrive, they find someone taking a nap; 4 hours later, the person shoots themselves in the head.  how do those look to a jury?

A jury (and an attorney, supervisor, regulating body investigating committee, etc) has the benefit of hindsight.  That doesn't mean the provider was wrong, because most don't have a fully functional crystal ball that allows them to know the future.  Could the OD patient re-overdose and die?  absolutely. They could also get hit by a bus crossing the street.  Or a tree could fall on them.  It can happen; but that doesn't mean they lose their right to make stupid decisions regarding their health, and we, as EMS providers, need to force treatments on them and take away their rights to refuse care.

99% of the ODs we go to aren't suicidal; they just want to get high.  and 90% of the drug users we take to the ER are going to get discharged and are going to try to get high once they get out.  Maybe I'm a little jaded from being on a first name basis with several frequent fliers, but the drug abuse problem is not one EMS can solve.  We can help those in need, give narcan to get them breathing, and transport them to the ER or even wake them up and they can sign a refusal; but we aren't going to stop them from using, and using the argument of "how will it look like to a jury" is an overused scare tactic, and an overused one that is used to justify doing something to someone else because of "whatif."

Of course It will look bad, especially with hindsight being 20/20.... but the threat of potential civil litigation against the provider doesn't justify depriving an alert and oriented person (or the criteria you use to allow an RMA) of their rights to refuse treatment or transport, or criminal charges of battery, kidnapping, and false imprisonment for taking said person against their will to a hospital they don't want to go to, and to receive a treatment they have clearly and competently told you they don't want.


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## Carlos Danger (Aug 16, 2019)

DrParasite said:


> Great post @Remi however, I disgree with this partprobably as good as taking a refusal from a ped struck with minor injuries, who a few hours later gets hit by another car and dies.  or a person who has an asthma attack, panics and calls 911 then puts on their CPAP with inline neb and feels better, so EMS gets there, patient is breathing fine, so they give a another treatment and then sign a refusal, and then call 911 again when their breathing flares up again.  Or you get dispatched for the 3rd party call for a person in cardiac arrest on the lawn, and when Fire/EMS arrive, they find someone taking a nap; 4 hours later, the person shoots themselves in the head.  how do those look to a jury?



No. I was referring to a scenario where you wake someone up with narcan and a few hours later they are found dead. The real reason they died was because they did another big hit, but no one knows that. So the presumption is they died from the original dose that you reversed.

There's no way come out of that looking good


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## Underoath87 (Aug 17, 2019)

mgr22 said:


> So while they're in that asymptomatic but toxic state, how do you enforce transport if a patient wants to refuse?



If I may, since this is my protocol as well: we explain to them that since they OD'd and are only awake because of the Narcan, our doc would have our asses if we don't take them to the hospital. Once there, they can leave AMA if they want.
I never get sent to an OD without a 4-man engine/tower and a handful of cops for backup.  I've only had 1 OD patient not comply (because the engine medic had slammed 2mg of Narcan IV on her and she was irate and hitting the cops with her purse), but handcuffs and 5mg of Haldol changed that.


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## mgr22 (Aug 17, 2019)

Underoath87 said:


> If I may, since this is my protocol as well: we explain to them that since they OD'd and are only awake because of the Narcan, our doc would have our asses if we don't take them to the hospital. Once there, they can leave AMA if they want.
> I never get sent to an OD without a 4-man engine/tower and a handful of cops for backup.  I've only had 1 OD patient not comply (because the engine medic had slammed 2mg of Narcan IV on her and she was irate and hitting the cops with her purse), but handcuffs and 5mg of Haldol changed that.



Sure sounds different from anyplace I've worked, but good to know.


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## coolidge (Aug 17, 2019)

*In national first, N.J. program will let paramedics administer ...*


https://www.statnews.com/2019/06/.../new-jersey-paramedics-buprenorphi...

Cached
Jun 26, 2019 - In a nationwide first, _*New Jersey*_ authorizes _*paramedics*_ to start ... _*approved*_ to treat opioid use disorder, _*buprenorphine*_ has become a ...
*NJ paramedics first in US authorized to administer buprenorphine*


https://www.ems1.com/.../394211048-NJ-paramedics-first-in-US-authorize...

Cached
Jun 26, 2019 - _*New Jersey paramedics*_ will begin _*administering buprenorphine*_ to revived overdose patients in a _*new*_ two-prong approach towards providing improved long-term treatment to patients with drug addictions. According to Stat News, _*New Jersey’s*_ Health Commissioner Dr. Shereef Elnahal ...


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## Carlos Danger (Aug 17, 2019)

coolidge said:


> *In national first, N.J. program will let paramedics administer ...*
> https://www.statnews.com/2019/06/.../new-jersey-paramedics-buprenorphi...
> 
> Cached
> ...


I do not understand why anyone would want to use buprenorphine in the field.

All over social media everyone is remarking on what a "progressive" protocol this is, yet I have yet to see someone even explain the rationale behind it, never mind why it is progressive.


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## Peak (Aug 17, 2019)

Remi said:


> I do not understand why anyone would want to use buprenorphine in the field.
> 
> All over social media everyone is remarking on what a "progressive" protocol this is, yet I have yet to see someone even explain the rationale behind it, never mind why it is progressive.


It's the whole new tools versus actually knowing how to use what you already have.


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