# Uncooperative Patients



## Anonymous (Aug 20, 2012)

I had a patient the other day who called 911 for arm pain and because he wanted his medications refilled. Patient was alert and oriented, ABCs and Vitals WNL. He was sent BLS to a hospital with a long wall time. As we are holding the wall the patient quickly becomes bored with sitting on the gurney, first he wants to use the restroom, then starts hitting on every female in sight, then he wants a cigarette. The hospital is a smoke free campus and I deny him a cigarette. He then gets off the gurney and walks outside, refuses to stay on the gurney or in the ER. He then starts to roll a cigarette, lights it up and tells me to buzz off, but not in that nice of language. He won't go back inside when I ask him to and won't put out the cigarette. 

The thing is the patient wants care but refuses to cooperate with me. However, I cannot transfer care until there is a bed available for him and I cannot have patient's sign AMA. Feel like I am kind of in a bind. Do I let security deal with it? The charge nurse? How would you deal with him?


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## DrankTheKoolaid (Aug 20, 2012)

Anonymous said:


> I had a patient the other day who called 911 for arm pain and because he wanted his medications refilled. Patient was alert and oriented, ABCs and Vitals WNL. He was sent BLS to a hospital with a long wall time. As we are holding the wall the patient quickly becomes bored with sitting on the gurney, first he wants to use the restroom, then starts hitting on every female in sight, then he wants a cigarette. The hospital is a smoke free campus and I deny him a cigarette. He then gets off the gurney and walks outside, refuses to stay on the gurney or in the ER. He then starts to roll a cigarette, lights it up and tells me to buzz off, but not in that nice of language. He won't go back inside when I ask him to and won't put out the cigarette.
> 
> The thing is the patient wants care but refuses to cooperate with me. However, I cannot transfer care until there is a bed available for him and I cannot have patient's sign AMA. Feel like I am kind of in a bind. Do I let security deal with it? The charge nurse? How would you deal with him?



Sounds like he eloped to me.  Document patient broke chain of care and move on.  Unless 5150, the minute they decide to get off the gurney and go outside I am done with them.  They can sign the AMA or i will document an elopment with refusal.  Have ED staff co-sign and be on your way


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## Anonymous (Aug 20, 2012)

Corky said:


> Sounds like he eloped to me.  Document patient broke chain of care and move on.  Unless 5150, the minute they decide to get off the gurney and go outside I am done with them.  They can sign the AMA *or i will document an elopment with refusal*.  Have ED staff co-sign and be on your way



Perfect. That is exactly what I was not sure if I could do. I told him if he walked out of the door then he was no longer my patient, and if he wanted through the ER the only way he was getting a bed was as my patient. otherwise he could wait in the lobby with everyone else to see a doctor. Just was not sure if I could wash my hands of him at that point or if that would be considered abandonment.


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## medicdan (Aug 20, 2012)

At that point, its the Hospitals problem... and lies in EMTALA. The patient presented within 200 feet requesting care... involve public safety and move on.


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## JPINFV (Aug 20, 2012)

Patient eloped. Document what happened, let the triage nurse know what happened, reset the gurney, and clear up for another run. Even the hospital can't hold someone with capacity against their will until they sign an AMA form.


However, why couldn't you have the patient sign AMA?


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## Anonymous (Aug 20, 2012)

JPINFV said:


> However, why couldn't you have the patient sign AMA?



I do not have AMA forms, I know the hospital does but I am pretty sure he would not have signed it anyway and I was not able to get much assistance from the nurses. He still wanted to be seen by a doctor, just didn't want to play by the rules in the mean time.


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## Handsome Robb (Aug 20, 2012)

You guys don't put those patients in triage?

Here he would have gone out to triage, I would help register him, give the triage RN a brief report and be on my way.

I agree, document he was uncooperative and walked away and be done with it.


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## STXmedic (Aug 20, 2012)

He wouldn't have gone to the hospital in the first place. If he was nice and truly had no means of transportation, then maybe a taxi voucher.


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## Aidey (Aug 20, 2012)

You guys don't have AMA forms?


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## Anonymous (Aug 21, 2012)

NVRob said:


> You guys don't put those patients in triage?



The patients are triaged when they first arrive to the ER but they remain on our gurney until they are assigned a bed and nurse and report is given to that nurse as well. Until then they are ours. This is for runs that are sent BLS. ALS runs usually receive a bed immediately. 




Aidey said:


> You guys don't have AMA forms?



No the medics have them but they don't accompany us on runs that are sent BLS.


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## Aidey (Aug 21, 2012)

1. Someone is courting disaster at that hospital. If they've been triaged by a staff member they are that hospitals responsibility. On the rare occasion we get stuck boarding a patient in the hall on our gurney the hospital staff want ZERO info on them. As soon as someone takes report, or traiges the patient, care has been transferred. 

2. Only the medics have AMA forms? You need to do something about that ASAP. If you transport patients without medics present you also need to have forms. Period.


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## JPINFV (Aug 21, 2012)

Aidey said:


> 2. Only the medics have AMA forms? You need to do something about that ASAP. If you transport patients without medics present you also need to have forms. Period.



I think a better alternative is that if the company only wants paramedics processing AMAs, then request paramedics every time someone wants to AMA. I think stupid rules like that should be complied with to the maximum amount possible, otherwise they won't be changed.


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## Anonymous (Aug 21, 2012)

Aidey said:


> 1. Someone is courting disaster at that hospital. If they've been triaged by a staff member they are that hospitals responsibility. On the rare occasion we get stuck boarding a patient in the hall on our gurney the hospital staff want ZERO info on them. As soon as someone takes report, or traiges the patient, care has been transferred.
> 
> 2. Only the medics have AMA forms? You need to do something about that ASAP. If you transport patients without medics present you also need to have forms. Period.



Actually that is how the majority of the hospitals operate around here. Thought that was the norm. They are triaged when we first arrive at the ED, then we hold the wall until a bed is available, then we give report to the nurse and transfer care. Not uncommon for my company to have multiple units holding the wall for several hours at a hospital. 



JPINFV said:


> I think a better alternative is that if the company only wants paramedics processing AMAs, then request paramedics every time someone wants to AMA. I think stupid rules like that should be complied with to the maximum amount possible, otherwise they won't be changed.



Currently its either AMA on scene or at the hospital after i have transferred care. If a patient absolutely refuses during transport then I notify operations. I think its worth noting i work for a private BLS company who has the 911 contract for county so we may operate a little differently?


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## JPINFV (Aug 21, 2012)

Anonymous said:


> Currently its either AMA on scene or at the hospital after i have transferred care.




So what do you do if the patient wants to leave after arriving, but before care is transferred? Is this an eloped vs AMA distinction? Are you prepared to use force to keep the patient there until care is transferred?

At least with during transport I definitely see the safety issue (no, you can't sign AMA and get out in the middle of the freeway...).


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## Aidey (Aug 21, 2012)

Can you explain exactly what you mean by triage?


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## Anonymous (Aug 21, 2012)

JPINFV said:


> So what do you do if the patient wants to leave after arriving, but before care is transferred? Is this an eloped vs AMA distinction? Are you prepared to use force to keep the patient there until care is transferred?
> 
> At least with during transport I definitely see the safety issue (no, you can't sign AMA and get out in the middle of the freeway...).



If they want to leave and are competent then I just document what happened. Patient left private auto stating they did not wish to wait to be seen etc etc. Not going to hold then against their will if they are of sound mind. 



Aidey said:


> Can you explain exactly what you mean by triage?




Ya im thinking perhaps my idea of triage is not the same. What i mean is i walk into the ED. Nurse asks what we have. Report is given and put in the computer. C/C history allergies, meds, interventions, vitals etc and the nurse either gives us a bed right away or we hold the wall until one is available and based on priority of the patient relative to others who may be waiting.


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## med51fl (Aug 21, 2012)

Anonymous said:


> Ya im thinking perhaps my idea of triage is not the same. What i mean is i walk into the ED. Nurse asks what we have. Report is given and put in the computer. C/C history allergies, meds, interventions, vitals etc and the nurse either gives us a bed right away or we hold the wall until one is available and based on priority of the patient relative to others who may be waiting.



That patient is the hospitals problem.  As soon as the ED "triages" them, they can do as they see fit with them so long as they are not on my gurney.  I will usually give them 15 minutes of my time to find a bed if they want otherwise they sit in the waiting area with the other BLS patients.  What the ED is doing is called "patient parking" and I believe there was a directive from CMS (Center for Medicaid/Medicare Services) that this is not allowed.


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## mycrofft (Aug 21, 2012)

Anonymous said:


> The thing is the patient wants care but refuses to cooperate with me. However, I cannot transfer care until there is a bed available for him and I cannot have patient's sign AMA. Feel like I am kind of in a bind. Do I let security deal with it? The charge nurse? How would you deal with him?


Do yo mean you are not allowed to get an AMA signed, you can't get the patient to sign one, or you aren't allowed to do a witnessed two-party AMA?

Technically he is eloped, even if he is sitting three feet away, by stating he refuses care and moving away from the litter or you. Different if he refuse to stay on litter because it makes him uncomfortable, that's not an elopement unless he then evades. An example of wisdom of getting billing info first


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## Shishkabob (Aug 21, 2012)

Write the report stating patient refused to cooperate, radio dispatch saying patient went AMA without signing and go on your way.


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## nocoderob (Aug 21, 2012)

He is there voluntarily and can come and go just the same. If he walked on me, I would have told the charge nurse he bailed then gotten in the bus and left.

If necessary, call your sup and/or base. Documentation is key here to avoid further issue.


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## Aidey (Aug 21, 2012)

Anonymous said:


> If they want to leave and are competent then I just document what happened. Patient left private auto stating they did not wish to wait to be seen etc etc. Not going to hold then against their will if they are of sound mind.
> 
> 
> 
> ...



No, your idea of triage is what I was imagining. Here that is considered taking over care of the patient. I would be totally within my right to leave the pt sitting in a chair and walk out of the building. As I said before, if we get stuck boarding a patient in the hall we say nothing to the ED staff about the patient. The pt is not put into the computer. No report is given. We continue to administer treatment and monitor vitals if needed. I would honestly be surprised if the way the hospital there is doing it is legal.


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## Anonymous (Aug 21, 2012)

med51fl said:


> What the ED is doing is called "patient parking" and I believe there was a directive from CMS (Center for Medicaid/Medicare Services) that this is not allowed.



I looked it up and you are right about the directive. However, there seems to be some confusion/controversy surrounding it so I will be doing some more homework and maybe talking to my managers regarding the directives interpretation. 



mycrofft said:


> Do yo mean you are not allowed to get an AMA signed, you can't get the patient to sign one, or you aren't allowed to do a witnessed two-party AMA?



I do not have any AMA form for anyone to sign. It is not really an option for me other than documenting AMA in my report as suggested. 



Linuss said:


> Write the report stating patient refused to cooperate, radio dispatch saying patient went AMA without signing and go on your way.






nocoderob said:


> He is there voluntarily and can come and go just the same. If he walked on me, I would have told the charge nurse he bailed then gotten in the bus and left.
> 
> If necessary, call your sup and/or base. Documentation is key here to avoid further issue.



Thank you. That is what I wanted to do but was not sure if this was abandonment because in my mind I had not transferred care yet, which it seems I was wrong about. 



Aidey said:


> No, your idea of triage is what I was imagining. Here that is considered taking over care of the patient. I would be totally within my right to leave the pt sitting in a chair and walk out of the building. As I said before, if we get stuck boarding a patient in the hall we say nothing to the ED staff about the patient. The pt is not put into the computer. No report is given. We continue to administer treatment and monitor vitals if needed. I would honestly be surprised if the way the hospital there is doing it is legal.



 Got it.


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## mycrofft (Aug 21, 2012)

Spineboard everybody and that walking away thing gets less frequenth34r:


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## JPINFV (Aug 21, 2012)

mycrofft said:


> Spineboard everybody and that walking away thing gets less frequenth34r:




For that comment, I hate you so much that flames... flames on the side of my face....


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## Aidey (Aug 22, 2012)

I LOVE that movie. Just watched it last night in fact. 

I'm so proud I got one of your references without having to look it up


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## mycrofft (Aug 22, 2012)

Sorry I'm CLUELESS........


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## JPINFV (Aug 22, 2012)

mycrofft said:


> Sorry I'm CLUELESS........




:huh::unsure::huh::unsure:


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## DrParasite (Aug 22, 2012)

Anonymous said:


> Not uncommon for my company to have multiple units holding the wall for several hours at a hospital.


several hours???? I'm sorry, but this still blow my mind.  esp if you are a 911 truck babysitting a stable patient for hours due to poor staffing in the ER.





Anonymous said:


> Currently its either AMA on scene or at the hospital after i have transferred care. If a patient absolutely refuses during transport then I notify operations. I think its worth noting i work for a private BLS company who has the 911 contract for county so we may operate a little differently?


We have RMA (sign here) RMA-AMA (sign here,we really don't think you should, but ok), RMA-AMA w/Sup (sign here,we really don't think you should, the supervisor tried to convince you, but you have the right to do something stupid) and RMA by action (pt says "Go F$*k yourself, I don't want an ambulance, get out of here" or walks away from the EMS crew, no signature is needed).

I agree with what everyone else said, if he hops off your cot so he can go out and smoke and you told him not to, he eloped, and let security deal with it.  if you want to be technical, and say he was still under your care, call local law enforcement and let them get involved.

But based on what you said, he either eloped from the hospital (making it security and the ER's issue), or he RMA by action, making it not your problem.  either way, pack up your things and go on the next job; once he is done with his cigarette, he will just have to have to wait in the triage room with all the other walkins.


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## JPINFV (Aug 22, 2012)

DrParasite said:


> I agree with what everyone else said, if he hops off your cot so he can go out and smoke and you told him not to, he eloped, and let security deal with it.  if you want to be technical, and say he was still under your care, call local law enforcement and let them get involved.



What are you expecting law enforcement to do with a patient who has capacity who eloped?


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## DrParasite (Aug 22, 2012)

JPINFV said:


> What are you expecting law enforcement to do with a patient who has capacity who eloped?


not a damned thing.  just another person who will say "yep, he eloped," and file a reporting stating jus that.

 but if you think he should be brought back against his will, typically it's a law enforcement call, (or a LE decision to enforce your decision) since security has no authority outside of the hospital.


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## mycrofft (Aug 23, 2012)

Shoot  them


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## martor (Sep 10, 2012)

I had a patient that had a c/c of SOB. She was on 15 LPM. En route she tried lighting a cigarette. As soon as we got to the Hospital she unbuckled herself and jumped off thee gurney. Had a nearby nurse sign that patient went AWOL. So far didnt get any heat for that.


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