Advice on a call

[Kuhnz350]

Hello everyone. First post here so if this is the wrong section or I am not allowed to post topics like this please let me know! I want some advice on a call that's been bothering me. I am an EMT on an ALS truck from a 911 company in Pennsylvania. The other day we responded to a MVA with rescue. Upon arriving we found a single vehicle into a tree. The patient had already self extricated. The vehicle was obviously totaled, major damage to its front end and debris all over the road. The patient had some blood on his face from a nosebleed following the accident which had stopped prior to our arrival. He was complaining of no pain or any injuries for that matter. He said he was fine and didn't want to go to the hospital.

All of his vitals looked good, he was fully alert and oriented and able to answer all questions. He said he was driving at about 35 MPH when he lost control and went off the road. He told me he was wearing his seat belt however we later found out from his brother that he lied. He said the vehicle did not roll however it showed signs of at least rolling onto its side (scratches on the right doors and roof pillar).

Anyway. I asked him if he had been drinking, he answers no. He was slurring his speech at times. I asked his brother if that is regular for him and his brother said he was in an accident 3 years ago and his injury causes that so it is regular. I'm filling out refusal paperwork as a state trooper enters the truck and gets information. The trooper suspects him of drinking. He asks me:
"Are you taking him to the hospital?"
I said we are still figuring it out but he says he isn't hurt and doesn't want to go, the trooper replies
"Well make a decision because he is either coming with me to the hospital or he is coming with me to the station, but either way he is coming with me."

The trooper says he needed to ask the patient more questions outside the truck so I told him feel free to do so while I write up a refusal. After completing the refusal I find the patient on the other side of the accident scene. Before I can even talk to him again he is thrown into handcuffs and put in the back of the police car. I ended up with a signature on the refusal from the arresting officer.

The biggest thing getting me nervous is that we didn't contact medical command for this refusal. My medic on the truck said he can be released as a police matter but I'm still iffy. Technically he must have been drinking despite him telling me he had nothing. He was able to walk straight lines and answer questions appropriately which led me to believe he had capacity to refuse. At what point does having a drink become to intoxicated to have capacity, one of the gray areas I can't stand. Another thing was the was basically taken out of our care by police. Without even informing us they cuffed him and drove him away so who has higher authority, medical command or police investigating a crime.

I'm just nervous over this call and wanted to share my story on here to see if others have been through similar situations or if any of you would have done anything differently. Feel free to ask any questions for clarification.

 

[FLMedic311]

Hi and Welcome! First I would look and make sure that you know and understand your state laws and local protocol regarding this, that would be your best and most reliable source for information. That being said when in comes to the pt who I have suspected of being "under the influence" I assess the pt as if they were not, I look for signs that would lead me to believe that their functional capacity is what I might normally expect. Based on your presentation of this person it sounds like you did that and checked the boxes.. A/O x4, GCS-15, Steady Gait, and Answering more complicated questions appropriately. The one question about his speech was accounted for by his brother, so with all that sounds like an appropriate AMA, minus the d*** trooper..

 

[hometownmedic5]

So first, keep in mind that an adult patient with a significant and obvious injury or illness that maintains capacity retains the right to refuse treatment and transport; even if it means permanent disability or death. Part of capacity is understanding the consequences of their actions. If they have the capacity to understand their decision, they are good to go.

Second, depending on your state laws and protocols, ETOH by itself does not nullify capacity. You can be under the influence of alcohol and still maintain capacity to refuse. In Ma, these are high risk refusals(meaning contact OLMC), but that may not be the case where you live. Check your protocols.

Third, no matter what other circumstances are at play, a person in custody of law enforcement can only be transported with the consent(and usually presence) of a sworn jurisdictional officer. This is mainly a practical concern i.e. how do you get a prisoner away from a police officer.

So, as to your call, you were ready to let them sign off AMA. You got a signature from the police officer at the scene(and if you were smart, his badge/unit number also). You are in the clear.

Establishing capacity: The patient must be alert; oriented to person place time and event; they must be informed about their potential injuries and the potential consequences of those injuries if left untreated or treatment is delayed; they must be able to express understanding of the above; and they must be willing to accept those consequences.

If all of those qualifications are met, they maintain capacity and have the right to refuse. Their arm could be twelve feet from their body. They could be impaled with a foreign object. They could have 5mm Inferior ST elevation. It doesn't matter. If they have capacity, they have the right to refuse. In cases where you have a high index of suspicion that this patients injury or illness will result in permanent disability or death, OLMC is the correct choice.

 

[NysEms2117]

What hometown said is right. Your narrative may have been off, or maybe im just not reading it right. The way it reads to me is a trooper showed up, and without contacting the person at all, not doing a FST said that he's going to be taken into custody?
1. you have to remember your the EMT, if he is your patient advocate for him, if not get him to sign the RMA when he knows anything can happen up to and including sudden death(if you search on this site i wrote my RMA with a State prosecutor it may help you a bit). Get the LEO to sign it as follows: Name, Troop unit(state troopers usually go A-K or something along those lines), and Badge number. All LEO's have to give that information, don't let any of them tell you otherwise(myself included).
2. Especially if your a newer EMT, call and ask regardless. Let them be cranky, i'll take people being annoyed at me for a day then losing my job over a call.

If he is a patient, he is going to the hospital. The cop/trooper/parole officer/whatever can(and will provided they are in custody) ride in the ambulance with you to the hospital, and remain with the suspect/your patient, until 1 of 2 things happen. 1. discharge 2. relief comes for the LEO. Again if your on the fence that an LEO is not doing what should be done, call a doctor and let the doctor and the leo duke it out.

Intoxication goes along the same lines of any other non alert patient(DKA or what have you). If they a/ox4 GCS15 chances are somethings wrong and they don't have the capacity for decisions. This decision should be made in my opinion by the highest level provider on scene.

 

[zzyzx]

Sounds like an awfully complicated situation, so I sympathize with you

Regarding that gray area of how intoxicated you can be and still refuse treatment, ask yourself "Is this person truly competent to be making decisions." If you think they are, document the heck out of what things indicate that they in fact are. (Don't say that they are competent, but rather show objective evidence that they appear to be.) Most importantly indicate that they fully understand the consequences of their refusal.

One point I strongly disagree with is your partner saying that since the cop took the pt into custody, you are in the clear. This is an area where many medics have been burned. If anything happens to the patient and you don't have an airtight refusal, you are just as much liable as the police department.

 

[Grozler]

How involved was the medic in this process? His/her name should be on that paperwork as the higher medical authority. At least in my neck of the woods.