Diabetic Emergency...and a subsequent complaint. Your opinions, please?

A patient with a BGL of 2.8 mmol/l would, by any reasonable clinical person, be presumed to have a condition making them incompetent to make informed decisions about their medical treatment. I would attempt to treat him either with oral glucose, IM glucagon or IV glucose 10%. Probably easiest to give him some IM glucagon because you don't have to put in an IV.

Unless he can understand, repeat and explain the implications of the information given to him on refusing care then he is deemed not to be competent and can be treated against his will.

There was a patient probably 10 to 15 years ago who got belted around the head with a bit of wood and walked out of ED. He later died of a cerebral haemorrhage. At the time it was questioned why he was not held against his well for not being competent. The clinical information showed he was able to repeat and explain the information provided to him regarding leaving ED included potentially dying, which is exactly what happened. He made an informed choice and proved he was competent.
 
We've been dealing with the state on this one, because of the complaint. Everybody involved told the story the exact same way--except for the family. Turns out, he DID eat something shortly thereafter, and was fine. I appreciate the responses. The state guy says he doesn't see where we did anything wrong, and that if necessary there would be a follow-up. So far, so good.
 
Here's the thing, given the facts of the OP, no lawyer is going to get a judge to buy into the notion that a person suffering acute hypoglycemia is anywhere near mentally competent to refuse treatment. Nor is any Medical Doctor going to testify that such a person was mentally competent, either. Hence, this is really a non-issue in terms of how you handle it. Remember, The family has no legal authority to sign a refusal, unless they have a POA or the patient is a non-emancipated minor, and the situation clearly doesn't yet rise to the level of even remotely being covered by a DNR.

Hence, if anything, this is where you contact medical control, get their take on things, and contact LE to witness a refusal if medical control insists that the patient is competent (which is a virtually zero percent chance) Assuming that LE doesn't decide to use a psych hold to get the job done (which is your most likely scenario, depending upon the patient's behavior in the presence of LE.)
 
bakertaylor28 said:
Hence, if anything, this is where you contact medical control, get their take on things, and contact LE to witness a refusal if medical control insists that the patient is competent (which is a virtually zero percent chance) Assuming that LE doesn't decide to use a psych hold to get the job done (which is your most likely scenario, depending upon the patient's behavior in the presence of LE.)
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Why would LE place a hypoglycemic AMS patient on a psych hold? A large component of a psych hold relies on the fact that a person is having a psychiatric emergency, and needs to be stopped from harming themselves or others. Would LE show up to put a stroke AMS patient on a psych hold?
 
MonkeyArrow said:
Why would LE place a hypoglycemic AMS patient on a psych hold? A large component of a psych hold relies on the fact that a person is having a psychiatric emergency, and needs to be stopped from harming themselves or others. Would LE show up to put a stroke AMS patient on a psych hold?
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The thing is that sooner than latter this kind of patient will either threaten self harm or threaten harm against another person (which will probably be either you or LE- and hence you can then easily articulate justification for a psych hold or an arrest either one depending upon what position one wishes to take with respect to the argument on the patient's mental state. ) I've seen it more than once. Extreme hypoglycemia actually cause full blown psychosis if left to its own devices and the sugar levels don't pass the threshold of just simply dropping the patient cold.
 
bakertaylor28 said:
The thing is that sooner than latter this kind of patient will either threaten self harm or threaten harm against another person (which will probably be either you or LE- and hence you can then easily articulate justification for a psych hold or an arrest either one depending upon what position one wishes to take with respect to the argument on the patient's mental state. ) I've seen it more than once. Extreme hypoglycemia actually cause full blown psychosis if left to its own devices and the sugar levels don't pass the threshold of just simply dropping the patient cold.
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bakertaylor28 said:
The thing is that sooner than latter this kind of patient will either threaten self harm or threaten harm against another person (which will probably be either you or LE- and hence you can then easily articulate justification for a psych hold or an arrest either one depending upon what position one wishes to take with respect to the argument on the patient's mental state. ) I've seen it more than once. Extreme hypoglycemia actually cause full blown psychosis if left to its own devices and the sugar levels don't pass the threshold of just simply dropping the patient cold.
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How high are you?


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Handsome Robb said:
How high are you?


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Perhaps you aren't familiar with the effects of Hypoglycemia on mental health, particularly with psychosis? Its relatively rare, but it has well been documented that extreme hypoglycemia can cause psychosis. Also can cause seizures and hence a severely altered mental state of sorts that some might classify as a psychosis when being overly pedantic.
 
bakertaylor28 said:
Perhaps you aren't familiar with the effects of Hypoglycemia on mental health, particularly with psychosis? Its relatively rare, but it has well been documented that extreme hypoglycemia can cause psychosis. Also can cause seizures and hence a severely altered mental state of sorts that some might classify as a psychosis when being overly pedantic.
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I think we all know how hypoglycemia effects the body. Psych holds are NOT for medical patients. They're for patients with mental illnesses, for them to get to an appropriate facility to provide them the psychiatric help they need. What the hell is a psychiatrist going to do with hypoglycemia? I realize they're often seen in the ED first, but that is not what an emergency detention is for. Hell, many even explicitly state that a mental illness must be present, and the consumer does not have other disqualifying medical issues (like hypoglycemia).

I really hope you're trolling.
 
bakertaylor28 said:
Perhaps you aren't familiar with the effects of Hypoglycemia on mental health, particularly with psychosis? Its relatively rare, but it has well been documented that extreme hypoglycemia can cause psychosis. Also can cause seizures and hence a severely altered mental state of sorts that some might classify as a psychosis when being overly pedantic.
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Do you have any sort of medical education?

These posts lead me to think you are in way over your head.

Are you able to articulate what a mental status exam is? That is what makes someone capable, not a blood sugar.
 
Tigger said:
Do you have any sort of medical education?

These posts lead me to think you are in way over your head.
.
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Supposedly in Medical School which I can only assume is in the Carribean. Or Doctor of Chiropractic. Can't decide which is more likely
 
Late to the game, but here is my input on a similar call, and maybe you can extract something for it.

Similar response, for an altered female, reported to be diabetic and combative. Upon arrival I approached the patient who was apparently alert, but very agitated. I started a basic assessment by talking to her and determined her to in fact be alert, but significantly disoriented. In addition to being altered she was combative and angry. She refused to allow me to check her blood sugar, so unfortunately we had to hold her down to check it. It was 20mg/dl. It was about 1 in the afternoon, and she was still in bed. I found she also had an insulin pump which was still delivering insulin. BLS fire arrives and I explain the situation. We dress her, move her to the gurney and restrain her. Patient was given glucagon IM because even restrained an IV was going to be cumbersome, and she wouldn't cooperate with the oral glucose. About 2 minutes after the glucagon she starts to calm down and starts answering questions appropriately. About 1-2 minutes after that, she's A/Ox4 refusing transport (albeit angrily.)

BGL is now 25, A/Ox4.

I release the restraints and she continues to become more calm as her BGL improves. I explained calmly that now that she's oriented, I would not force her to go to the hospital, but that I wanted to keep her in the ambulance until her sugar comes up to an acceptable level. I've found great success in proposing these kinds of compromises to patients either for assessments of AMA patients or other uncooperatives.

I made base contact and explained. They had no objection to the patient signing AMA following glucagon and returning to her baseline.

Patient eventually gets her sugar up to 56 and we take her in side. She is now completely calm and apologetic. A total 180 from her while she was altered.

A lot of how a call goes, can be attributed to how you (or your partner) presents themselves and interacts with the patient and their family. I wasn't there, but you mention that this was an early morning call, right before you got off duty, which leads me to believe that since you mentioned it, the fact that you were there at an inconvenient time may have at least subconsciously effected the demeanor of either your or your partner. We all do it sometimes.

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bakertaylor28 said:
Perhaps you aren't familiar with the effects of Hypoglycemia on mental health, particularly with psychosis? Its relatively rare, but it has well been documented that extreme hypoglycemia can cause psychosis. Also can cause seizures and hence a severely altered mental state of sorts that some might classify as a psychosis when being overly pedantic.
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Agitation does not equal psychosis. Also, this patient is not "severely hypoglycemic". He's hypoglycemic but hardly severe.


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bakertaylor28 said:
The thing is that sooner than latter this kind of patient will either threaten self harm or threaten harm against another person (which will probably be either you or LE- and hence you can then easily articulate justification for a psych hold or an arrest either one depending upon what position one wishes to take with respect to the argument on the patient's mental state. ) I've seen it more than once. Extreme hypoglycemia actually cause full blown psychosis if left to its own devices and the sugar levels don't pass the threshold of just simply dropping the patient cold.
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You. Are. An. Idiot.

Please go away.
 
According to the NREMT text, anyone A/Ox4 with the GCS of 15 has the right to refuse treatment and transport, whether that results in their death or not. Calling Medical Command would be wise to divert liability over to the physician's insurance policy and is wise. To provide treatment and/or transport could be deemed assault, battery, and/or be deemed "kidnapping". The pt could have a viable lawsuit on their hands.

The reality is with hypoglycemia, this can quickly be corrected with just about any sugar, containing food or liquid. EMS can't give this by mouth, but himself or his family can with recommendation from EMS. If he refuses care and transport being A/O x 4, than he has that right to refuse and it must be honored. EMS should encourage the pt, but if he ultimately refuses than that all must be honored and thoroughly documented.

As for the refusal form, someone has to sign it. whether that be the patient, a family member, a by standard or a police officer. If the guy started getting hostile and the scene became unsafe, PD should be dispatched to the location.

Regarding the refusing of the signing of the refusal form. If no one will sign, and no police officer is not around to sign, I honestly don't know what one would do. It'd be interesting to hear people comment on that part.
 
Just document that the patient refused to sign the refusal form
 
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