AMA Altered and Postictal

[LACoGurneyjockey]

I have a question about a call earlier today, and so far every time I bring a question here I get just the answers I need.
So I work on a Medic/EMT truck, dispatched for a seizure. Find the patient sitting on the curb with superficial cuts to his hands and face. Can tell us his name, and has a hard time answering anything more complicated. Refuses any treatment, refuses to be transported, saying if he goes to the hospital no one will be able to take care of his mother who's there with him, and he has no way of getting back from the hospital. All V/S check out ok, and he is very slowly becoming more oriented and able to answer questions. We spend a good 10-15 minutes on scene assessing him and "waiting for him to come out of it" in the words of my paramedic partner.
After about 15 minutes he can tell us his DOB, address, where he's at, but all with a delay of several seconds and is still obviously not completely alert and oriented.
End up having him sign AMA and he walks approx a mile back home with his mom.

I'm a bit conflicted on this one, he has seizures regularly when he isn't taking his meds, and doesn't want to be hospitalized every time a bystander sees him seize and calls. But at the same time, he's clearly altered and has sustained some facial trauma, albeit it very minor. Even after 15 minutes of waiting around on scene he still only had minor improvement in mental status.
If this had been a BLS truck and my call to make, I'd have transported him and involved PD if he continued to refuse. But working with a Medic I can't go against his judgement and make that call. At the same time, I'm on scene and am more than capable of assessing the patient.
How responsible am I for the decisions made by my partner as the highest medical authority? Is there any way a poor or reckless decision by the Paramedic could fall back onto me? What can I do when I have such a disagreement with the treatment decisions of a partner I see as burned out and tired of their job, particularly when patient care appears to suffer?
Basically, how could I have better handled this situation as I have a feeling it will come up again with this partner, and what is my responsibility as an EMT in decisions made by the Paramedic?

 

[VFlutter]

So what exactly are you or the hospital going to do for this patient? He has a know seizure disorder with a known cause, medical non compliance. What are you going to accomplish by involving PD and forcibly taking him to the ER against his will?

 

[Akulahawk]

All the hospital's going to do with this guy, since he's not actively seizing, has a known seizure disorder, and is off his meds, is just watch him for a little while until he's alert & oriented, and send him on his way, along with a bill. In essence, they're going to do exactly the same thing you guys did, babysit him for a few minutes until he was aware enough to care for himself and go home with his mother.

I get a bit more leery about dealing with post-ictal patients that still aren't waking up after a few minutes. They're likely to get a ride and closer observation.

 

[TransportJockey]

If he's got a hx of seizures, and this has happened to him before, then I don't see a problem waiting for him to come to a little more. I have done similar things with our frequent seizure patients

 

[mycrofft]

Only teaching people to "get the AMA signed" is negligent.

The standard is that they understand what you are saying and can understand the consequences of their actions so they do not pose an foreseeable immediate threat to themselves or others. Not that they can hold a pen and scribble.

Need a protocol for those sorts of calls. Many more altered state cases where they are intoxicated.

 

[LACoGurneyjockey]

Great, thanks for the responses.
Chase, I wouldn't have enjoyed taking him against his will, but I was more saying Id have been bound by protocols to transport him.
My other question then is can the EMT be held responsible for patient care decisions made by the Medic?

 

[Handsome Robb]

We AMA seizure patients all the time. They have to prove to me they're with it though. In your case he was also with someone, his mother. What was she like? Was she disabled either physically or mentally? Or was she elderly but still capable? If the latter I'm even more comfortable letting him go with her. He's with someone who can watch him, is probably more familiar with him and his postictal states than you are, and if something changes for the worse can call 911 back.

Like someone else said, the hospital isn't going to do anything for this man beside watch him, if he seizes again he might ER a dose of IV meds prophylactically then they will send him on his way. Patients with seizure disorders have seizures from time to time, even if they take their meds. Some don't have one for years. If they're changing meds or doses they may have more frequent seizures and are often told by the neurologist in charge of their care not to go to the emergency room unless the have prolonged seizure activity or multiple seizures without periods of lucidity in between them.

To answer your question, if your partner did something grossly negligent that you had knowledge of and you didn't intervene you may be able to be included in the suit but in a situation like this where your partner is the higher medical authority and is attending the patient I don't think that you'd be held accountable.

 

[TheLocalMedic]

Ditto on what everyone has said about not transporting resolving postictal patients with known seizure disorders. If they are oriented and refusing care, that's fine, and the hospital won't do anything for them.

If they're still "not right" or slow to respond after waiting a while or they don't have a seizure history, then I'll generally err on the side of caution and try to get them in.

Did your partner do something wrong? I don't think so, but I wasn't there to truly see how this patient was acting. Sounds a little borderline, but I wouldn't stress about it. 99% chance this guy would have been perfectly back to normal had you spent another 5 minutes with him.


As to whether or not you are responsible as an EMT for something your paramedic partner does, that depends on the situation. If they do something grossly negligent that you know full well should have been done differently, then yeah, you can be held accountable for not speaking up to change the situation (think abandonment or something similar). But if it's a less significant clinical issue then you should generally defer to your partner's judgement and leave it be.

However, if you feel strongly enough that your partner may be making a mistake, then your best bet is to ask them (please, not in front of the patient or other responders, be smart enough to pull them aside and not look like an a-hole) what they are doing and explain your disagreement. They may have a good reason for doing/saying what they are, and that may resolve the issue in your mind. On the other hand, you may have seen something your partner missed and didn't realize. God knows we aren't perfect and I've had EMT partners save my bacon a couple of times.

Hopefully you have a good enough working relationship with your partner that you feel comfortable approaching them when you have an issue. But don't be one of those people that take issue with their partners and don't address them directly. If you have a problem, say something. Nobody likes people who talk behind their backs!

 

[M1ke10191]

Also, if push comes to shove about making the decision, medical control is your friend.

 

[unleashedfury]

Your patient was CAOx3 after shaking off the Postictal state, Has a known history of seizures, or epilepsy. Patient admits to being noncompliant with his medications. I have no problem with allowing the patient to be released to family or friends.

Same situation. Pt. is a Known Diabetic and has been non compliant, you give them the good old liquid snickers, they come to admit that they have not eaten or complied with medication properly. Does not wanna go to the hospital. Treat and street.

A little history, I was in a car accident, which resulted in a severe concussion and a skull fracture, I was monitored and 12 hours later had a seizure, which subsided on its own without intervention. when your body experiences a grand mal seizure its literally exhausting. When I came to it took me a few minutes to gather my bearings before being able to answer simple questions appropriately.

 

[mycrofft]

Your patient was CAOx3 after shaking off the Postictal state, Has a known history of seizures, or epilepsy. Patient admits to being noncompliant with his medications. I have no problem with allowing the patient to be released to family or friends.

Same situation. Pt. is a Known Diabetic and has been non compliant, you give them the good old liquid snickers, they come to admit that they have not eaten or complied with medication properly. Does not wanna go to the hospital. Treat and street.

A little history, I was in a car accident, which resulted in a severe concussion and a skull fracture, I was monitored and 12 hours later had a seizure, which subsided on its own without intervention. when your body experiences a grand mal seizure its literally exhausting. When I came to it took me a few minutes to gather my bearings before being able to answer simple questions appropriately.

1. Hope you're ok! Yikes!
2. Diabetes is another matter. "A slug of sugar then off with you" is not enough, the sugar will foreseeably wear of soon and rapidly. THey need someone responsible to get them to a hamburger or PBJ or medical help.
My experience is that when you have someone who is or foreseeably and shortly may hereafter become a threat to self or others , then law enforcement may be required. They may give the pt a ride, they may require you to transport to a medical facility. But you can't stand up a diabetic with some sugar (or a heroin OD with just enough narcan) then take their word they'll be ok.