# Question about Refusing Care



## newEMT (Dec 28, 2008)

I'm a new EMT, and I was wondering what to do in the following scenario. 

Dispatched for vehicle accident. When arrive, there is 1 patient in the vehicle with no apparent injuries. Patient states that they want to refuse care. Do you have to stabilize their C-spine while you're checking to see if they are competent to refuse care?


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## Ridryder911 (Dec 28, 2008)

Okay, they refuse to be treated, and your doing what? Remember, before you are to touch someone (if they are awake) you ask to help them (consent?) If they refuse treatment ask the simple questions to obtain they are competent and orientated enough to make decisions. Advise, risk, alternatives, and sign refusal, get witness if possible.. then by-by to another call. 

R/r 911


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## NJN (Dec 28, 2008)

Textbook side of me says yes, always suspect c-spine until you rule it out, even if they are going to RMA. I would hold c-spine until you have completed your assessment and they are competent and understand risks of RMA-ing, and once they officially refuse care then i would let go.

Real world side of me says that it depends on what your scene size up is, how is the car damaged, what appeared to have happened, was the driver wearing a seat belt and did they appear to hit their head on anything. If its a small fender bender, minimal damage, and they aren't complaining of any pain and are competent to refuse, then most likely wouldn't.

This is all done if they consent to be at least assessed.


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## newEMT (Dec 28, 2008)

I would have to get vital signs though according to our protocol. How would you deal with a patient who didn't want you to even take their pulse or BP? Sorry, these are really basic questions but we never really talked about these issues in EMT class and I don't want to screw up.


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## MMiz (Dec 28, 2008)

First, welcome to EMTLife!

An alert, oriented, and informed patient has the right to refuse care.  I usually initiated patient care with:

"My name is Matt, I'm an EMT with xxx, I'm going to...".  If the patient refuses care or contact, I would:
1.  Confirm that they were AOX3 (or x4 depending on service)
2.  Check for obvious head injury
3.  Check to see if I see any drugs or smell drug/alcohol use
4.  Inform patient of possible consequences of not receiving care, and how to receive care should in the future if needed.

If a patient was clear that they didn't want treatment prior to c-spine, then I would not initiate any further treatment.


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## NJN (Dec 28, 2008)

newEMT said:


> I would have to get vital signs though according to our protocol. How would you deal with a patient who didn't want you to even take their pulse or BP? Sorry, these are really basic questions but we never really talked about these issues in EMT class and I don't want to screw up.



These are things that really should have been covered in your class. RMA by action is when their actions clearly state they do not want to be treated by you, ex: getting violent or running away. It would be a RMA by action if they refuse to let you near them even though you informed them that it is necessary to obtain vitals for a proper refusal. You would document this to your best abilities.


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## MMiz (Dec 28, 2008)

newEMT said:


> I would have to get vital signs though according to our protocol. How would you deal with a patient who didn't want you to even take their pulse or BP? Sorry, these are really basic questions but we never really talked about these issues in EMT class and I don't want to screw up.


That can't be true.  You can not force an assessment on a patient.  I would ask that patient if they wouldn't mind me taking their vital signs so that I could put the information on my refusal form.  If they refused, I'd note their respirations, pupils as best I could, skin condition, and any other apparent vital.


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## ffemt8978 (Dec 28, 2008)

If they're CAO and competent to refuse care, you can NOT touch them, even for vital signs, without their consent.  You need to explain to them what you want to do, but if they continue to refuse, then that's it.  Sign here, press hard, multiple copies and be on your way.  To CYA, you can always call medical control and explain the situation to them, and they may or may not be able to convince the patient to change their mind.

Even taking a blood pressure without consent can be construed as assault, if they want to press the issue.


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## vquintessence (Dec 28, 2008)

newEMT said:


> I'm a new EMT, and I was wondering what to do in the following scenario.
> 
> Dispatched for vehicle accident. When arrive, there is 1 patient in the vehicle with no apparent injuries. Patient states that they want to refuse care. Do you have to stabilize their C-spine while you're checking to see if they are competent to refuse care?



In a test... yes?  Real world?  No (assuming it's a minor MVC and the pt refusing isn't altered from medical/trauma issues --- even in pts who do want transport... usually c-spine is forgone unless it's a serious mechanism of injury or suspicion).

Just document to CYA.  MVA's are the biggest pain in the explitive; most of the time the pt is pissed off and wont want to seek medical attention.  To protect yourself: Mention the extent and location of damage to vehicle (INCLUDING if glass is intact or not), that pt denies complaints _(pertinent negatives are crucial [ex: -LOC, neck pain, -N/V, -pain])_ pt refused physical exam, mention airbags deploying/not, seat belts used/not, try to get vitals and if pt refuses, state that as well.  It's all about pertinent negatives and findings in this instances.

_On an off note, pay attention to whether or not the pt has a "bad headache."  Our medical director has been beating his shoe on the podium lately on this issue (pt refusals involving MVC's and headaches).  We had a refusal for a decent MVC that came back and bit one of the EMTs on the explitive.  The person signed a refusal and the paperwork was very lack on the EMT's part... but the EMT mentioned a headache.  Well, the person was picked up hours later for altered LOC (pt was in 20's).  Turns out the poor fella had sustained a subarachnoid bleed, supposedly after the MVC.  Well now the EMT's are under state investigation.  No lawsuits mentioned yet._  Just my $0.02.


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## daedalus (Dec 28, 2008)

NJNewbie196 said:


> Textbook side of me says yes, always suspect c-spine until you rule it out, even if they are going to RMA. I would hold c-spine until you have completed your assessment and they are competent and understand risks of RMA-ing, and once they officially refuse care then i would let go.
> 
> Real world side of me says that it depends on what your scene size up is, how is the car damaged, what appeared to have happened, was the driver wearing a seat belt and did they appear to hit their head on anything. If its a small fender bender, minimal damage, and they aren't complaining of any pain and are competent to refuse, then most likely wouldn't.
> 
> This is all done if they consent to be at least assessed.


A. Thats assault with battery
B. Holding C-spine is a myth
C. Your going to hold it only to later let go?


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## NJN (Dec 28, 2008)

daedalus said:


> A. Thats assault with battery
> B. Holding C-spine is a myth
> C. Your going to hold it only to later let go?



A. Read my last line, only if they consent to at least being assessed
B. I learned to hold C-Spine in class, the state tells me to, so i do, myth or not.
C. And i never said i would, that is just what i would do if i were to follow my poorly written protocols to the letter. 

That conclusion was based upon ONLY what was discussed in my EMT class. Which just shows that the EMT-B should be eliminated or the class should be expanded. The real street is a lot different than class and i recognize that.


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## rescuepoppy (Dec 28, 2008)

*Refusal*



newEMT said:


> I would have to get vital signs though according to our protocol. How would you deal with a patient who didn't want you to even take their pulse or BP? Sorry, these are really basic questions but we never really talked about these issues in EMT class and I don't want to screw up.


  Protocols are made to be followed, they are there partly to cya, but if the patient refuses treatment that also means assesment. If the patient won.t let you check vitals it doesnt matter what your protocols say. They are there for you to follow not rules for the patient. In this case be sure to explain to your patient about the possible risks of refusing treatment. Then make sure eveything is documented. If they refuse all treatment that is all you can do.


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## KEVD18 (Dec 28, 2008)

lay one finger on a person wihtou there consent and you have assualted them. i assualt my patients about as often as i kidnap them, and i never kidnap patients.


the first lesson you need to learn is that you cant save everyone. as soon as you get that one, your career will instantly become easier.


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## Code 3 (Dec 28, 2008)

KEVD18 said:


> lay one finger on a person wihtou there consent and you have assualted them.



That's actually battery. Assault is only the intent or threat of inflicting harm.


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## daedalus (Dec 28, 2008)

The clever lawyer-folk can make easy arguments for both assault and battery. They can pretty much make you fit into any category of crime. I have heard that they even like to pretend children are adults to get bigger sentences. 

I meant no offense by the way to NJNewbie. My post was really directed at the futility of this discussion.


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## KEVD18 (Dec 28, 2008)

Code 3 said:


> That's actually battery. Assault is only the intent or threat of inflicting harm.


 
great, you've bested me in the legaleese but my point is still valid.


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## Shishkabob (Dec 28, 2008)

Code 3 said:


> That's actually battery. Assault is only the intent or threat of inflicting harm.



Depends on the state actually.

In Michigan, assault is the threat of, while battery is the commission.

In Texas, assault is everything from verbal to sexual to physical.


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## Code 3 (Dec 28, 2008)

KEVD18 said:


> great, you've bested me in the legaleese but my point is still valid.



I was merely making a simple correction. I think it's particularly important to relay accurate information regarding assault vs battery since it's discussed in the beginning chapters of a lot of text books. This site is used as a resource and citing correct terms should be a priority.


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## Shishkabob (Dec 28, 2008)

Code 3 said:


> I was merely making a simple correction. I think it's particularly important to relay accurate information regarding assault vs battery since it's discussed in the beginning chapters of a lot of text books. This site is used as a resource and citing correct terms should be a priority.





Which you still got wrong depending on peoples location... sooo.....


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## Code 3 (Dec 28, 2008)

Linuss said:


> Which you still got half wrong... sooo.....



Maybe I can't read, but BRADY states that assault is considered placing a person in fear of or immediate bodily harm, while battery is touching unlawfully.


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## Shishkabob (Dec 28, 2008)

Code 3 said:


> Maybe I can't read, but BRADY states that assault is considered placing a person in fear of or immediate bodily harm, while battery is touching unlawfully.





Text book definition =/= law.

Each state uses different phrases, as I showed with Michigan and Texas.


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## traumateam1 (Dec 29, 2008)

If the patient says "don't touch me" before I touch them, than I don't. I'll ask them if they are alright, if they know where they are, what happened, the date, and if they have been drinking. If they check out fine: A&O x3 / GCS:15 than I don't touch them. I explain what could/might happen by refusing medical attention, and then refer them to other medical aid like a hospital. I get them to sign the dotted line, get a witness and be on my way.

If I have already started "treating" the patient and then they turn around and say "f*** off!" and they are, again, A&O x3 / GCS:15 than I stop what I am doing, and explain what could/might happen by refusing further medical attention, and then refer them to other medical aid, like a hospital. And again, get them to sign the dotted line, get a witness and be on my way.

Like others have said, by continuing medical attention by doing C-Spine or treating the patient or whatever when they are in the right frame of mind to make the decision, than you could be sued and charged. There's gonna be a lot of times someone who definitely needs your help will refuse it, sadly we can't save them all, and some will just want us to be on our way.


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## BossyCow (Dec 29, 2008)

I hate to break up the nitpickers meeting, but I'm going to attempt to address the concerns raised by the OP. 

In class, you were I hope taught how to approach a pt. You need to identify yourself, your level of certification and in some places, your agency affiliation. After that, you request permission to treat. If permission is withheld, then you need to determine if the criteria for informed consent have been met. Is the pt a legally competent adult? If they are, and they do not want to be treated.. you may not touch them without being possibly charged with a crime. (in my state it's Assault IV)

That is the text book factual rendition. However in real life, if we believe that based on the mechanism of injury that there's a high likelihood of severe injury that adrenalin or chemicals are keeping hidden from the pt, then I'm going to do my level best to get them to allow at least a basic assessment of their injuries. If I believe based on the damage to the car or other evidence that a c-spine injury may be present, I'm going to be very graphic and direct with the pt regarding the potential problems.

This is a fine line, if you scare them too much, they can panic and refuse treatment. If you don't scare them enough, you haven't sold them on the need for treatment.  I generally use the approach of.. "How about if I just take a quick look to rule out any serious injury.. just to be sure.. it will only take a minute"  Most people will allow it if they believe that this exam is going to prove that they are right and you are wrong.


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## aussieemt1980 (Dec 29, 2008)

It seems that the issue of consent keeps reappearing despite it being part of the training. But on that note, the more you ask about it, the more you know.

Maybe any trainers could do a course on the issue of consent and deliver it? (Actually, that does give me an idea....)

If a patient is conscious and breathing, and refuses consent for treatment or transport, that is it. The patient has said no.

You do not need to physically touch a patient to do a mental status assessment. A few questions can very quickly determine if the patient is capable of making the decision, and you have to be very careful in making this decision to overturn the patients wishes. Remember, you may have to explain to a judge why you felt the patient was psychologically unfit at that point.

There are ways of talking the patient around. A common phrase that I use is "I am here now, and it does not take much to make sure you are ok...."

Surprisingly, the issue of consent does not come up that often. 99.999999999999999% of the time, I work under implied consent (I am hurt, can you have a look.....and give me a bandaid) and very rarely do people refuse consent initially. Some may refuse transport, and this is after assessment.

Yes, there are occassions where the pt cannot refuse consent. I am not sure of the laws in the US, but over here in Australia, a pt who has been admitted under the mental health acts cannot refuse consent to treatment. There is also the grey area of "not mentally fit to make that decision at that point" in cases of severe life threatening injury or illness. 

In some areas where I work, a patient may not be able refuse an assessment. In saying that, they have full right to refuse to be assessed, but then they cannot continue with the motorsport event until they are medically cleared. So the pt has that little "incentive".

What I have been taught at uni:

1. If the patient refuses consent to treatment, and you touch them, it is assault under common law;

2. If a patient refuses consent, and you place them in a room (or ambulance with the doors closed), it is false imprisonment under common law;

3. It is up to you to prove that you took the right course of action at that point when in court.

I do know of a medic from a private company that placed a woman at a car accident in his vehicle and closed the doors AFTER she refused consent. He did have some answering to do as he locked her in the car as she was wanting to leave the scene, and did not realise that he had in fact assaulted her by doing so.

This is my 10 cents worth about this topic, and judging by the number of replies, quite a few of our medic brothers and sisters have said much the same, so there is probably not much I could add to this topic after all.


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## BossyCow (Dec 29, 2008)

I have a frequent flier who enjoys the occasional gallon of wine with her dinner. She does have health issues so we can't always assume that her call to us was due to her drinking. 

An example of informed consent and mental competence arose with her not long ago. Our rule is the pt has to be alert and oriented x3. When asking the pt (What's your name Lucy? J/K) these questions ,she responded to "What day is it, with "I have no idea" I asked.. do you know what year it is.. she responded... "of course I know that.. its 1988.."... when I told her that was incorrect..she got very irritated and retorted.. "Okay then... '89.. close enough!" Which meant I could not leave her home alone and she could no longer determine her own medical care.


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## JPINFV (Dec 29, 2008)

Code 3 said:


> Maybe I can't read, but BRADY states that assault is considered placing a person in fear of or immediate bodily harm, while battery is touching unlawfully.



Brady puts out a book on the law now? Just because that's the general definition doesn't mean that the statute in every state is the same. Assuming it isn't a Brady Law Text, I'm going to bet that it doesn't actually include, say, a citation of the legal code in all 50 states plus the District of Colombia.


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## JPINFV (Dec 29, 2008)

BossyCow said:


> In class, you were I hope taught how to approach a pt. You need to identify yourself, your level of certification and in some places, your agency affiliation. After that, you request permission to treat. If permission is withheld, then you need to determine if the criteria for informed consent have been met. Is the pt a legally competent adult? If they are, and they do not want to be treated.. you may not touch them without being possibly charged with a crime. (in my state it's Assault IV)



The devil is always in the details.



> *How much do emergency healthcare workers know about capacity and consent?
> *
> Aim: To assess knowledge of capacity and consent among emergency healthcare workers.
> 
> ...



http://emj.bmj.com/cgi/content/abstract/24/6/391


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## frogtat2 (Dec 30, 2008)

*Consent*

Ah the joy of being a newbie, all excited about life and out to save everyone in it.  I remember when i was that way.  Then reality came into the picture.  

When you roll on scene, always do a good assessment of the vehicle involved so you have a good idea of what injuries to expect/look for.  Adrenaline in the patient will mask pain.  You can get a good idea of gcs just by asking some questions without having to touch the patient.  

Work with your crew.  If you aren't getting anywhere with the patient, trade off and see if your partner has any better luck.  The area I work has a large elderly population.  Little old ladies respond far better to male crew members than to me.  On the flip side, little old men respond better to me than male crew.  Play on what works best.  If a patient responds better to someone else, don't take it personally.  There will be times when YOU make the connection when someone else can't.

At the end of the day, if the patient is A+O x 3 or 4 (whatever your protocol says) and you have explained the dangers of not seeking medical help, have them sign a refusal form in front of a witness and go on your way.  

As much as we'd like to, not everyone will want or accept our help.  We do the best we can in explaining the dangers of not getting medical help and then go on our way.  Don't let that dim your excitement or enthusiasm about what you are doing.  It's just all part of a days work.


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## downunderwunda (Feb 7, 2009)

aussieemt1980 said:


> Yes, there are occassions where the pt cannot refuse consent. I am not sure of the laws in the US, but over here in Australia, a pt who has been admitted under the mental health acts cannot refuse consent to treatment. There is also the grey area of "not mentally fit to make that decision at that point" in cases of severe life threatening injury or illness.



You might want to look at the Mental Health Act more closley. It is pretty specific about when a person can be declared incompetent. 

In essence it states that a person can be declared incopmpetent if they are incapable of makeing a decision that would be made by a normal thinking person. This includes people under the influence of alcohol & drugs. 

Having said that, the easiest way to upset a drunk is to threaten to have them locked up on a Mental Health Shedule.

The area is not as grey as you think, however it is a discretionary call for officers. Since the implementation last year, I have had call to use a mechanical restraint once, & a Mental Health Schedule once.


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## aussieemt1980 (Feb 8, 2009)

downunderwunda said:


> Having said that, the easiest way to upset a drunk is to threaten to have them locked up on a Mental Health Shedule.



*Mental Health Act 2007 (NSW), S16, 1K

A person is not a mentally ill person or a mentally disordered person merely because of any one or more of the following: 

....
k. the person takes or has taken alcohol or any other drug,
....
an acutely intoxicated person cannot be scheduled under the mental health act 2007.

MHA 2007 (NSW) S16 Part 2:

(2) Nothing in this Part prevents, in relation to a person who takes or has taken alcohol or any other drug, the serious or permanent physiological, biochemical or psychological effects of drug taking from being regarded as an indication that a person is suffering from mental illness or other condition of disability of mind. 

In relation to intoxicated persons, this covers Alcohol Related Dementia and Korsakoffs Psychosis as long term abusers of alcohol present with. In the hospital setting, I have dealt with a few of these patients, who have paranoia and dementia symptoms. This is due to a Vitamin B12 deficiency from ETOH abuse.*



downunderwunda said:


> Since the implementation last year, I have had call to use a mechanical restraint once, & a Mental Health Schedule once.



MHA 2007 (NSW) S20:

*20 Detention on information of ambulance officer

    (1) An ambulance officer who provides ambulance services in relation to a person may take the person to a declared mental health facility if the officer believes on reasonable grounds that the person appears to be mentally ill or mentally disturbed and that it would be beneficial to the person’s welfare to be dealt with in accordance with this Act. 

    (2) An ambulance officer may request police assistance if of the opinion that there are serious concerns relating to the safety of the person or other persons if the person is taken to a mental health facility without the assistance of a police officer. 
*

This allows ASNSW to take a person to a declared mental health facility if the officer has concerns in relation to the patient. It does not mean that the officer is actually scheduling the patient. This can only be done by an authorised officer:

*18 When a person may be detained in mental health facility

    (1) A person may be detained in a declared mental health facility in the following circumstances:

        (a) on a mental health certificate given by a medical practitioner or accredited person (see section 19), 

        (b) after being brought to the facility by an ambulance officer (see section 20), 

        (c) after being apprehended by a police officer (see section 22), 

        (d) after an order for an examination and an examination or observation by a medical practitioner or accredited person (see section 23), 

        (e) on the order of a Magistrate or bail officer (see section 24), 

        (f) after a transfer from another health facility (see section 25), 

        (g) on a written request made to the authorised medical officer by a primary carer, relative or friend of the person (see section 26). 

    (2) A person may be detained, under a provision of this Part, in a health facility that is not a declared mental health facility if it is necessary to do so to provide medical treatment or care to the person for a condition or illness other than a mental illness or other mental condition. 

    (3) In this Act, a reference to taking to and detaining in a mental health facility includes, in relation to a person who is at a mental health facility, but not detained in the mental health facility in accordance with this Act, the detaining of the person in the mental health facility. 

    Note: A person taken to and detained in a mental health facility must be provided with certain information, including a statement of the person’s rights (see section 74). *



downunderwunda said:


> In essence it states that a person can be declared incopmpetent if they are incapable of makeing a decision that would be made by a normal thinking person. This includes people under the influence of alcohol & drugs.



The MHA 2007 (NSW) is very clear in defining those who are mentally ill.

http://www.austlii.edu.au/au/legis/nsw/consol_act/mha2007128/s4.html#mental_illness

"mental illness" means a condition that seriously impairs, either temporarily or permanently, the mental functioning of a person and is characterised by the presence in the person of any one or more of the following symptoms:

    (a) delusions, 

    (b) hallucinations, 

    (c) serious disorder of thought form, 

    (d) a severe disturbance of mood, 

    (e) sustained or repeated irrational behaviour indicating the presence of any one or more of the symptoms referred to in paragraphs (a)-(d). 

* MHA 2007 S14:
14 Mentally ill persons

(cf 1990 Act, s 9)

    (1) A person is a mentally ill person if the person is suffering from mental illness and, owing to that illness, there are reasonable grounds for believing that care, treatment or control of the person is necessary:

        (a) for the person’s own protection from serious harm, or 

        (b) for the protection of others from serious harm. 

    (2) In considering whether a person is a mentally ill person, the continuing condition of the person, including any likely deterioration in the person’s condition and the likely effects of any such deterioration, are to be taken into account. *

You may be able to have a schedule under S15 of the Act:

*15 Mentally disordered persons

(cf 1990 Act, s 10)
A person (whether or not the person is suffering from mental illness) is a mentally disordered person if the person’s behaviour for the time being is so irrational as to justify a conclusion on reasonable grounds that temporary care, treatment or control of the person is necessary:

    (a) for the person’s own protection from serious physical harm, or 

    (b) for the protection of others from serious physical harm. 

*

Also, S16 1k of the Act mentions that people under the influence of alcohol or drugs is not a mentally ill or mentally disturbed person. Also, diagnosis of mental health conditions have to meet certain criteria under DSM IV (Diagnostic and Statistical Manual IV) - Yes, I have seen this book and used it to understand certain mental health conditions.

Admittedly, when I wrote this post, I had not begun to study the Mental Health Act and was relying solely on the nursing training on the issues of consent and refusal of consent within the health system. However, I am now doing my mental health training.


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## Aidey (Feb 8, 2009)

For me, it's all about what the patient says. If they say "Don't $^%@^* touch me!" that is different from "I don't want to go to the hospital". I've found the majority of the patients in the first category are drunk/intoxicated anyway, and they usually get the option of coming with me, or going with the police (guess who they pick). The second category tend do be pretty good with allowing an assessment/vitals once you explain. 

I have a bit of a spiel that I give, and once I explain that they don't have to go to the hospital if they don't want to, but it would be incredibly helpful if I could at least take a pulse and blood pressure most people usually allow it.



On a slight tangent, do any of the services you guys work for allow intoxicated patients to refuse treatment?


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## emtwacker710 (Feb 12, 2009)

IF the pt. is CAOx3 (Concious, alert, and orientated to 3 simple questions) then they can refuse care and you cannot touch them. At least thats what they taught in my EMT class here in NYS.


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## Juxel (Feb 12, 2009)

Aidey said:


> On a slight tangent, do any of the services you guys work for allow intoxicated patients to refuse treatment?



Absolutely.  Being intoxicated is not reason enough to drag someone to the hospital.  Quite frequently we will get called to a residence because someone got too drunk and is now bowing to the porcelain god.

Police can elect to sign a transportation hold on the patient, but that's very ill advised.  

On an aside, my wife is an attorney and has won more than a couple settlements in cases where the police signed a hold on someone simply because they were intoxicated (usually in their own home).  Those cities are much more reluctant to place someone on a hold than they used to be.


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## Aidey (Feb 12, 2009)

What about someone who was intoxicated and *NOT *AOx3 (or 4 depending on the system you use).


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## tydek07 (Feb 12, 2009)

If the pt is *NOT* A&Ox3 and have consumed ETOH..... ok, well, it all depends on the situation 

I always call Med. Control if the pt should go into the ER for his/her own good, and they are still refusing. That way it is up to the doctor, if he feels it necassary to place a medical hold on the pt or not.

Medical Control is your friend  

Its really hard to say, because each situation is completely different.


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## emtfarva (Feb 12, 2009)

Ok, here is what I would do. 1) Is the person A+O x4 (Person, Place, Time (Year, month, date, or whatever you would like to use) and Events leading up to the MVC and what happened during the MVC)? Yes, Ok, does the Pt have a head injury that you can see? Does the Pt have any head, neck, back pain? Does the Pt seem agitated? Does the Pt take any anticoagulants? How is the Pt's resp. rate (take it a couple of times. you don't need to touch the Pt to do that.), it irregular? Do you feel that the Pt needs to be seen by an doc? If you answered yes to any of these questions you need to try and convince this person to go to the Hosp. I don't mean to kidnap the person. I mean try to tell the person what will happen if they don't go to the Hosp. My rule of thumb is if the car is towed then the Pt goes. I will go as far as telling the cop not take the person home if the car gets towed. If the person calls a friend or family member, I will try to convince them into trying to convince the Pt to go. If they still refuse, I will tell them that they could die from their injuries if they do not seek a medical evaluation or worst paralysis. Not many people will want to here that they may not to be able to move their legs or arms ever again. If that doesn't work, then you are s**t out of luck, no only kidding. I would call Medical Control. If that doesn't work, Sign here...

Of course this was all done after I have introduced myself. Oh, to answer your question I would not hold C-spine unless they gave me their permission. Make sure you document everything you did and observed.

If you suspect drugs or etoh, you can get the police involved. They will help sometimes. Most of the time it's go with us or go to jail.


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## CAOX3 (Feb 13, 2009)

Cancelled by fire.  Back to bed....


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## Sapphyre (Feb 13, 2009)

Sounds like someone works in LA.  But, can't be, we transport most of our ETOH only pts...


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## CAOX3 (Feb 13, 2009)

ETOH alone is not a medical emergency, hence there is no need for an ambulance. Its legal and the desired affect is to become altered. 

However in conjunction with a suspected injury.  I have seen drunks jump out third floor windows and then walk half a mile on a open leg fracture.


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## Sasha (Feb 13, 2009)

> ETOH alone is not a medical emergency



but can mimic true medical emergencies and should always be assesed to rule out true medical emergencies.


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## VentMedic (Feb 13, 2009)

Sasha said:


> but can mimic true medical emergencies and should always be assesed to rule out true medical emergencies.


 
Exactly. Many costly mistakes for both the patient and the EMS providers have been made over assuming alcohol.

*Detained California Stroke Victim Sues Paramedics, Police*

Friday, December 19, 2008
http://www.emsresponder.com/web/onl...-Stroke-Victim-Sues-Paramedics--Police/1$8708



> Dec. 16--A Bakersfield surgeon handcuffed and forced to wait more than an hour for treatment after suffering a massive stroke last year is suing the Bakersfield Police Department, Hall Ambulance, the county of Kern and others.
> 
> The case could cost taxpayers millions in damages.
> 
> ...


 
And who can now forget the infamous Washington D.C. alcohol mishap?

*Four D.C. Firefighter/EMTs Face Internal Charges*
http://www.emsresponder.com/article/article.jsp?siteSection=1&id=3643


*The Death of David Rosenbaum*

By Colbert I. King
Saturday, February 25, 2006; 

http://www.washingtonpost.com/wp-dyn/content/article/2006/02/24/AR2006022401676.html


Florida also has separate statutes for addressing how to legally detain someone with drugs and alcohol vs those with psych problems.


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## emtfarva (Feb 13, 2009)

CAOX3 said:


> ETOH alone is not a medical emergency, hence there is no need for an ambulance. Its legal and the desired affect is to become altered.
> 
> However in conjunction with a suspected injury. I have seen drunks jump out third floor windows and then walk half a mile on a open leg fracture.


It is in Mass. When can transport a Pt with just a cc of Etoh. We call AMS, even though we know it is Etoh. Too many drunks in our state. Also MA accepts alcoholism as disease.


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## CAOX3 (Feb 14, 2009)

Competent vs. incompetent assesment.


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## emtfarva (Feb 14, 2009)

CAOX3 said:


> Competent vs. incompetent assesment.


What do you mean?


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## CAOX3 (Feb 14, 2009)

Do you think adequate assesments were done on these pts?  Incompetent providers make up 99% of EMS litigation.  I should say competent providers acting incompetent.


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## BossyCow (Feb 14, 2009)

We treat the sick and injured. Some of them are drunk. Some are not. The same rules apply in drunk and sober patients. We need to determine their ability to give informed consent. The ETOH is secondary to their physical condition. It can complicate our ability to determine their symptoms but it is still secondary. 

Some drunks have other health issues. We have one who has been hospitalized for a cerebral bleed. You can't rule out other issues and you sometimes can't determine if what you are seeing is related to the drunkeness or something else. It's a very tricky situation. Drunks love to find some other reason for their problems than their alcohol abuse. They weren't drunk.. they were sick..... and it's your fault they didn't get the treatment they deserved.. not the fact that they haven't drawn sober breath in years. I'm very careful with patients that have been drinking. I don't want to be made the pawn in their denial game.


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## EMTDON970 (Feb 17, 2009)

I dont argue with them, want to refuse go ahead...


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## firefighter170 (Feb 17, 2009)

have them sign it, then go back home


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## Nycxice13 (Feb 19, 2009)

newEMT said:


> I would have to get vital signs though according to our protocol. How would you deal with a patient who didn't want you to even take their pulse or BP? Sorry, these are really basic questions but we never really talked about these issues in EMT class and I don't want to screw up.



93 refuse all...


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## karaya (Feb 19, 2009)

CAOX3 said:


> Incompetent providers make up 99% of EMS litigation.


 
Could you please cite this?  There's too many medics out here spewing a plethora of stats and nothing to back them up.


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## JPINFV (Feb 19, 2009)

Don't you know that 35% of all statistics are made up on the spot?


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## Shishkabob (Feb 19, 2009)

Don't YOU know that 63.214% of of that 35% are actually true?


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## medic417 (Feb 19, 2009)

Linuss said:


> Don't YOU know that 63.214% of of that 35% are actually true?




But actualy 27.96345% are an alternative reality.


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## CAOX3 (Feb 19, 2009)

karaya said:


> Could you please cite this?  There's too many medics out here spewing a plethora of stats and nothing to back them up.[/QUOTE
> 
> As I stated in the second part of my post.  Most are competent providers acting incompetent.
> 
> Read the newspapers.


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## karaya (Feb 19, 2009)

I do read the newspapers and newspapers are hardly a credible source for statistics unless of course the paper cites it's sources.

You made the statement that "Incompetent providers make up 99% of EMS litigation" and I asked if you could cite this statistic.

It appears you cannot.


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## CAOX3 (Feb 19, 2009)

Here you go, draw your own conclusions. 

http://www.emsnetwork.org/artman2/publish/criminal.shtml


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## karaya (Feb 19, 2009)

CAOX3 said:


> Here you go, draw your own conclusions.
> 
> http://www.emsnetwork.org/artman2/publish/criminal.shtml


 
Nope, that is hardly a statistic.  Furthermore, none of those ten articles had anything to do with direct patient care.

I didn't ask for articles to draw a conclusion upon.  I just simply asked if you could provide a credible citation to support your claim, "Incompetent providers make up 99% of EMS litigation."


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## CAOX3 (Feb 19, 2009)

What else would it be besides incompetence.   

Read some case files where litigation was brought against EMS providers.


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## medic417 (Feb 19, 2009)

karaya said:


> Nope, that is hardly a statistic.  Furthermore, none of those ten articles had anything to do with direct patient care.
> 
> I didn't ask for articles to draw a conclusion upon.  I just simply asked if you could provide a credible citation to support your claim, "Incompetent providers make up 99% of EMS litigation."



One could argue just the oposite that the majority of EMS litigation is money grubbing bogus law suits.  But I can not back that but I would believe that before 99% are because of incompetent providors.


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## karaya (Feb 19, 2009)

CAOX3 said:


> What else would it be besides incompetence.
> 
> Read some case files where litigation was brought against EMS providers.


 
Okay, it's pretty clear by now that you cannot come up with a credible citation that supports your statement, "Incompetent providers make up 99% of EMS litigation."

Your statement leaves one to the belief that EMS litigation is brought upon 99% of the time by incompetent providers, which in itself suggests incompetency in providing patient care. 

Clearly the 99% is strictly from _your_ point of view and in no way an accurate statistic as to what the percentage of EMS litigation is in relation to incompetency.

So, this ad hoc stat was arrived by your parsing a few newspaper articles.  What about EMS litigation that never made the papers?  Seems that would skew you stat a bit?


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## CAOX3 (Feb 19, 2009)

Ok maybe I should have stated in my opinion.  

I think the majority of cases our do to incompetency in providing pt care.

Ok what other derivitive could possibly be the cause of litigation besides incompetency.

Actually there our quite a few sites where you can review litigation cases against EMS providers.

Are you looking for a case study? All cases once closed are made public and are not that difficult to find.

Review some of them.  Im sure you will come to the same conclusion. Maybe not.


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## medic417 (Feb 19, 2009)

CAOX3 said:


> Ok maybe I should have stated in my opinion.
> 
> I think the majority of cases our do to incompetency in providing pt care.
> 
> ...




If I were to review I would find large number of settlements because most cases the companys and insurance providors settle rather than risk losing.  So the fact that the plantif got money does not prove guilt.  People sue all the time because they know that odds are they will never have to go to court to prove anything.


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## CAOX3 (Feb 20, 2009)

I had a link here, I cant find it,  I wrote a paper on not this exact topic, a few years back for school.

To read some of the case files it was astonishing some of the things people were sued for,  pt refusals headed the list.  Some of the others ones were unbelievable

If I find it i will post it.  It was really interesting.


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## BossyCow (Feb 20, 2009)

CAOX3 said:


> Ok maybe I should have stated in my opinion.
> 
> 
> 
> ...


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## CAOX3 (Feb 20, 2009)

Oh attack of Webster and I was an english major.  How unfortunate,  at least I have you to translate.

Maybe I could explain the word derivative for you, or you could do your own homework.  Let me help "not original, secondary to"  hence a derivative would be another cause.  Thank you anyway though.

Settlements and judgements *ARE* two diffrent things.


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## BossyCow (Feb 20, 2009)

CAOX3 said:


> Oh attack of Webster and I was an english major.  How unfortunate,  at least I have you to translate.
> 
> Maybe I could explain the word derivative for you, or you could do your own homework.  Let me help "not original, secondary to"  hence a derivative would be another cause.  Thank you anyway though.
> 
> Settlements and judgements *ARE* two diffrent things.



Its important if you want to be taken seriously to be articulate.

I understand that a settlement and a judgement are two different things. You stated that once a case is closed, it is made public.. this is inaccurate. A case can be closed for many reasons, because a settlement has been reached, a judgement has been made, either or both parties ended the litigation or failed to file documents with the court in a timely fashion etc. 

Incompetence would not be a derivative in the context you presented. Incompetence can be derived from a lack of education, a poor work ethic.. but Incompetence would not be a derivative causing an action. In the example you cite in your reply to me, justifying your use of the word, you are using the adjective form of the word to defend your use of it as a noun... English Major? I doubt it! 

I certainly hope you are a bit more concise in your language on your reports.


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## DevilDuckie (Feb 21, 2009)

If weren't not supposed to diagnose, wouldn't refusing care be diagnosing them in some way?


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## HasTy (Feb 21, 2009)

Ridryder911 said:


> Okay, they refuse to be treated, and your doing what? Remember, before you are to touch someone (if they are awake) you ask to help them (consent?) If they refuse treatment ask the simple questions to obtain they are competent and orientated enough to make decisions. Advise, risk, alternatives, and sign refusal, get witness if possible.. then by-by to another call.
> 
> R/r 911



IMHO that is best thing to do...the way I was taught in CA if you lay hands on a patient without there consent then you are in effect assaulting them...


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## medic417 (Feb 21, 2009)

DevilDuckie said:


> If weren't not supposed to diagnose, wouldn't refusing care be diagnosing them in some way?




You have to diagnose to treat, why could an properly educated Paramedic not also diagnose that they are not in need of an ambulance and say no.  We do it all the time.  There is no law in any state that says we can not deny, only some local protocols and policys.


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## exodus (Feb 21, 2009)

Why not just transport? I am sure if you refuse to transport they will have A LOT more paperwork to do, than if you just transported. All I see this is a way for a huge liability gap to come into place.


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## medic417 (Feb 21, 2009)

exodus said:


> Why not just transport? I am sure if you refuse to transport they will have A LOT more paperwork to do, than if you just transported. All I see this is a way for a huge liability gap to come into place.



Why not educate people by saying no then in the long run it saves time?


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## exodus (Feb 21, 2009)

medic417 said:


> Why not educate people by saying no then in the long run it saves time?



I doubt telling someone, "You don't need an ambulance for this, and it will be much cheaper for you to just take a cab if you want to go." will really help very much. If they call already, they have made up their mind most of the time and that is what they are going to do.

Sure maybe 2 out of 10 people may actually listen and take it to heart, but I doubt the majority would.


Not working yet, but from my impression of what I read here, is most bs calls are psychiatric, so with that, telling them that they don't need an ambulance won't help them at all.


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## VentMedic (Feb 21, 2009)

medic417 said:


> Why not educate people by saying no then in the long run it saves time?


 See below.


exodus said:


> I doubt telling someone, "You don't need an ambulance for this, and it will be much cheaper for you to just take a cab if you want to go." will really help very much. If they call already, they have made up their mind most of the time and that is what they are going to do..


This can also back fire for discrimination. They may perceive what you say as indicating their inability to pay and not worthy of your ambulance. 



exodus said:


> Sure maybe 2 out of 10 people may actually listen and take it to heart, but I doubt the majority would.


 
Those that listen to all the the education about when not to call an ambulance will be someone who may actually need one. It will give those who are high risk for heart attacks a few extra arguments for fueling their denial especially if the call was may by a friend or family member who witnessed symptoms and do have concerns. If you are called and have not witnessed the symptoms that family and friends did, you may tend to side with the patient who is in denial about their own health.



exodus said:


> Not working yet, but from my impression of what I read here, is most bs calls are psychiatric, so with that, telling them that they don't need an ambulance won't help them at all.


 
Does this mean psychiatric patients don't need medical care? Do you know that some psychiatric patients must have regular cardiac screenings because of the meds they are on and the systemic symptoms they can cause while controlling the psych problems?


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## medic417 (Feb 21, 2009)

exodus said:


> I doubt telling someone, "You don't need an ambulance for this, and it will be much cheaper for you to just take a cab if you want to go." will really help very much. If they call already, they have made up their mind most of the time and that is what they are going to do.
> 
> Sure maybe 2 out of 10 people may actually listen and take it to heart, but I doubt the majority would.
> 
> ...



I disagree with that.  Many people call for the ambulance because they have been taught that abuse will not have consequences and they will get to where they want for free.  There are some with mental issues but most that do not need the ambulance in my experience are more sane than you or I and have been educated to save money by taking the free ambulance. Free as they will not pay.  

By doing a proper exam then informing them they are not going by ambulance then leaving they have no choice but becoming educated to find another ride.


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## exodus (Feb 21, 2009)

VentMedic said:


> See below.
> 
> This can also back fire for discrimination. They may perceive what you say as indicating their inability to pay and not worthy of your ambulance.
> 
> ...



I'm against telling people they don't need an ambulance and would much rather just transport everyone, takes a lot of stress off of my shoulders worrying about someone I denied transport to, and having something happen to them later that day.



medic417 said:


> I disagree with that.  Many people call for the ambulance because they have been taught that abuse will not have consequences and they will get to where they want for free.  There are some with mental issues but most that do not need the ambulance in my experience are more sane than you or I and have been educated to save money by taking the free ambulance. Free as they will not pay.
> 
> By doing a proper exam then informing them they are not going by ambulance then leaving they have no choice but becoming educated to find another ride.



You do not know the patients history 100%, they could be lieing about something, but just because you don't find anything in your exams does not mean that there "isn't" something there.

 How is it going to hurt "you" to just transport them? 99.9% of the time there will be another ambulance to take care of another call when it comes in. So by doing this, you are going to have no liability at all for mis-diagnosis because you are not the one judging them. You don't show your training, but I am pretty sure you are a paramedic / rn, which is about 7 years / 5 years respectively, short of being a doctor in terms of education. As a paramedic / RN , you do not have the proper education to say someone does not need an ambulance 100%.


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## AJ Hidell (Feb 21, 2009)

exodus said:


> I'm against telling people they don't need an ambulance and would much rather just transport everyone, takes a lot of stress off of my shoulders worrying about someone I denied transport to, and having something happen to them later that day.


The whole point here is that, if the provider is properly educated, he is likely to be comfortable with his assessment, relieving him of any stress or worry associated with the decision process.  Obviously, when in doubt, transport.  However, there are a lot of undeniably black-and-white scenarios where it is clear that EMS transportation is neither indicated nor warranted.  And a properly educated medical professional should have the ability to make that call.


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## VentMedic (Feb 21, 2009)

medic417 said:


> I disagree with that. Many people call for the ambulance because they have been taught that abuse will not have consequences and they will get to where they want for free. There are some with mental issues but most that do not need the ambulance in my experience are more sane than you or I and have been educated to save money by taking the free ambulance. Free as they will not pay.
> 
> By doing a proper exam then informing them they are not going by ambulance then leaving they have no choice but becoming educated to find another ride.


 
Before making a blanket statement, I would have to look at the complaint. A broken finger is one thing but medical problems are much more difficult to pinpoint. If is hard to tell if a patient's sodium is a little off that is causing their abnormal "psych" issues. Or, if they have been compliant or maybe their medication dosage needs adjusting or it could even be at toxic level. Maybe another organ such as the kidneys or liver is starting to show signs of failure from long term psych med use. Can you check the BUN and Creatine? Can you check the lytes? Liver enzymes? Lactate? Lipid panel? ANA? Do you take a temp on every patient? Assess lymph nodes? 

Also, the public information messages have involved "see a doctor" and don't wait if "A, B or C" symptoms appear.
If the patient takes the paramedic for his/her word that there is nothing serious, they may take your assessment at the same value as that of a doctor and delay going to a clinic. 

Do you know how many patients have entered the ED with "general malaise" and left the hospital with a diagnosis of some cancer? 

How about the young drug user who gets written off because his symptoms are not specific but later gets the diagnosis of ALS? I saw two patients like that last month who are only in their 20s. I will continue to see them because their disease is advancing so quickly they will probably die within the next few months on a ventilator in the sub-acute part of our hospital system. The ED doctors at our hospital also almost wrote them off also but decided to check a couple more things that the other doctors didn't bother to do.


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## medic417 (Feb 21, 2009)

exodus said:


> How is it going to hurt "you" to just transport them? 99.9% of the time there will be another ambulance to take care of another call when it comes in. So by doing this, you are going to have no liability at all for mis-diagnosis because you are not the one judging them. You don't show your training, but I am pretty sure you are a paramedic / rn, which is about 7 years / 5 years respectively, short of being a doctor in terms of education. As a paramedic / RN , you do not have the proper education to say someone does not need an ambulance 100%.



Heck doctors can not be 100% sure a patient does not need an ambulance.  Its in the news way to often someone sent home after seeing the doctor just to die.  Life is not 100%.  

As to my liability by doing a consistant exam I can determine with reasonable certainity whether they have a real life threatening emergency in need of ambulance transport or could be treated by their regular doctor w/o the use of an ambulance.  

"99.9% of the time there will be another ambulance to take care of another call when it comes in."

Wow I want to live in your dream world.  Or should I ask you to pass what ever you are smoking?   Sorry even in big citys calls start stacking frequently, yes eventually an ambulance will come but might be hours rather than minutes.  In my area if I take a patient to the hospital the community has to wait an hour for mutual aid if they are available.  

As to paperwork I would rather do paper work than continue to be used as a horizontal taxi.  I am a medical professional not an ambulance driver.


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## medic417 (Feb 21, 2009)

VentMedic said:


> Before making a blanket statement, I would have to look at the complaint. A broken finger is one thing but medical problems are much more difficult to pinpoint. If is hard to tell if a patient's sodium is a little off that is causing their abnormal "psych" issues. Or, if they have been compliant or maybe their medication dosage needs adjusting or it could even be at toxic level. Maybe another organ such as the kidneys or liver is starting to show signs of failure from long term psych med use. Can you check the BUN and Creatine? Can you check the lytes? Liver enzymes? Lactate? Lipid panel? ANA? Do you take a temp on every patient? Assess lymph nodes?
> 
> Also, the public information messages have involved "see a doctor" and don't wait if "A, B or C" symptoms appear.
> If the patient takes the paramedic for his/her word that there is nothing serious, they may take your assessment at the same value as that of a doctor and delay going to a clinic.
> ...




Vent if there is any doubt about mental condition patients are transported.  Mental illness is not something we joke around with.  Many patients physical S/S turn out to be related to mental conditions.  

As to the general weakness calls often those do turn out to be the most critical.  It is surprising how many of those actually are in the downward spiral of decompensated shock of one form or the other.  

We do not ever tell them that it is not serious but that it does not need an ambulance.  We do explain to them where the should go such as ER right now and we call ahead, or to their doctor and we will call their doctor so they will get worked in.  

We do not abandon patients.  I always love this discussion because so many freak out that we are just saying no to everyone when in reality it is not used but on a small number of calls.


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## AJ Hidell (Feb 21, 2009)

This all comes down to one simple question:

Does this patient require medical care, assessment, or observation enroute to immediate definitive care?

Yes = Transport
No = No transport

Even Medicare addresses this in their reimbursement, so this is not a new concept of screening.  Simply being ill or injured does not necessarily mean that you need EMS care and/or transportation.  A great many people call 911 not because they believe they need -- or even want -- EMS care or transportation, but simply because they believe that is what they have to do to get seen in an ER.  Those people are quite happy to make alternative arrangements when they are educated about the process.

Of course, this is all a very theoretical discussion.  The number of medics (and certainly no EMTs) in this country educated and experienced enough to competently make these sorts of decisions intelligently, and consistently without error, is so microscopic as to be statistically insignificant.  So this discussion is not so much about what we should be doing, but what EMS should be doing in the future. We can't continue to forever keep doing things this way simply because it's the way we've always done it.  That is a recipe for professional failure.


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## medic417 (Feb 21, 2009)

AJ Hidell said:


> This all comes down to one simple question:
> 
> Does this patient require medical care, assessment, or observation enroute to immediate definitive care?
> 
> ...




Enjoyed the post.  Many say if we don't transport we won't get paid.  Well facts are unless fraud is committed many Medicare/Medicaid/Insurance patients are denied reimbursement as they even determine that the patient could go safely by other means.  So if the Insurance says no most patients will just file the bill you send them in the trash and in 911 service not really anything you can do to them.  Some services try and do the bill collecting thing but unless they get the patient into a payment contract nothing can be done.


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## BossyCow (Feb 21, 2009)

You gotta love these guys~ If you get a chance to attend one of their many seminars.. do it. 
http://www.pwwemslaw.com/cms/uploads/file/%5C04.24.03%20-%20PWW%20Refusal%20Form%20With%20NPP%20Acknowledgment%20and%20Diversion%20Info.pdf


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## medic417 (Feb 21, 2009)

BossyCow said:


> You gotta love these guys~ If you get a chance to attend one of their many seminars.. do it.
> http://www.pwwemslaw.com/cms/uploads/file/%5C04.24.03%20-%20PWW%20Refusal%20Form%20With%20NPP%20Acknowledgment%20and%20Diversion%20Info.pdf




Good post.  Proper documentation will almost benefit you better than being a good providor, at least in a law suit.


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