Ok, my answer is, whether or not EMTs were to administer glucagon, and whether or not some people see danger in paramedics agreeing to refusals after administering glucagon, the same procedures in place for refusals of any nature would apply to refusals after glucagon is given. What's so special about executing a refusal post glucagon?
Glucagon then a Refusal?
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Ok, my answer is, whether or not EMTs were to administer glucagon, and whether or not some people see danger in paramedics agreeing to refusals after administering glucagon, the same procedures in place for refusals of any nature would apply to refusals after glucagon is given. What's so special about executing a refusal post glucagon?
NomadicMedic
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I’ve seen several brittle diabetics with home glucagon injector kits. Hypoglycemia is a process that’s corrected with sugar. It doesn’t matter if he patient gets IV dextrose, glucagon or a glass of orange juice. Once they are normalized, they can refuse care. In cases of frequent hypoglycemia, most patients know the drill well enough that they’re on the phone making an appointment with their endocrine doc before we leave or they realize their sliding insulin dose needs to be slid down a bit.
Honestly, taking these now awake and stable patients to the ED is a waste of resources. “Eat a sandwich and follow up with your doc. Sign here.”
Honestly, taking these now awake and stable patients to the ED is a waste of resources. “Eat a sandwich and follow up with your doc. Sign here.”
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1. Glucagon has systemic side effects that dextrose does not, and they are potentially serious.
2. There is likely a perception - right or wrong - that patients who require glucagon (vs. dextrose) are less healthy in general and less compliant, and therefore a little riskier to sign-off.
3. Glucagon is less frequently used in general, so people are just less familiar and less comfortable with it.
Taken these points together, you can see how policymakers and protocol writers might view runs involving glucagon administration differently than than they view giving some dextrose.
When I was a street medic, glucagon administration was pretty rare. I only remember using once, maybe twice. And diabetic sign-offs weren't all that common - we did them, just not all the time. Now, it's been about 17 years since I regularly worked as a street medic, so this all may have changed quite a bit, especially with the significant increase in the incidence in obesity and diabetes during the past couple of decades. But you can see how someone of my vintage or older - I'm probably in a similar age / experience bracket as many of your medical directors and program directors - might view a wakeup using glucagon as just a little different than one using sugar water.
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Diabetic treat and release is very common in my area. We have a protocol for it. In fact, the way the protocol reads, it almost expects it (however I always leave that to be determined after having a good discussion with the post-treatment patient.)
I'm in a rural area and people here don't have a lot of extra money and are rather independent people who live off in the woods for a reason. They'd rather not go to the ER, which is fine.
Is the perception of Glucagon being a more "advanced" medication because people are giving it after dextrose was ineffective? I've only ever administered Glucagon in patients that probably would've responded to dextrose, but that I couldn't get safe IV access in. And by safe, I mean either the patient was combative, or I wasn't confident pushing D50 through a 22g in the hand.
I'm in a rural area and people here don't have a lot of extra money and are rather independent people who live off in the woods for a reason. They'd rather not go to the ER, which is fine.
Is the perception of Glucagon being a more "advanced" medication because people are giving it after dextrose was ineffective? I've only ever administered Glucagon in patients that probably would've responded to dextrose, but that I couldn't get safe IV access in. And by safe, I mean either the patient was combative, or I wasn't confident pushing D50 through a 22g in the hand.
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In post # 21 you asked "What's so special about executing a refusal post glucagon"? I gave a couple examples of why it might be viewed as special. I agree about not needing a specific post-glucagon refusal protocol. I've never heard of that.
Isn't that what you were asking?
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No. But you completely missed the point.
My question wasn't "are we allowed to do this" but should we be more wary about allowing this.
The problem isn't of forcing people to go to the hospital, but making sure the patient is properly informed before refusing.
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Simply saying "sign this understanding that you might die" isnt enough.
My father in law is a personal injury lawyer and him and I have had many discussions about proper medical-legal documentation and what's saved people's careers or ended them. If you get up on the stand, and can't describe what you warned the patient about, you could be in a lot of trouble.
Obviously, this is an extreme example. But I like to understand the risks. Not just about Glucagon, but everything. It helps with documentation and being a professional medical provider, rather than "just a paramedic."
DrParasite
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I'm pretty sure your father in law also told you that a good attorney can make any provider look like a fool in front of a jury right? You could do everything right, document perfectly, but they can bring up some random medical fact, that no paramedic knows, and make you look like an incompetent buffoon.
Plus, his JOB is to make medical providers look like idiots (I'm assuming he goes after the providers), especially when they screw up. Medical malpractice attorneys are even better (go watch Scrubs season 4, episodes 9 & 10 for reference). You can do everything right, and still make you look bad.
Since you brought it up, have you ever discussed with your FIL instances where the medical provider screwed up, but because it was documented so well, it saved the provider's career and he lost the case? or when the provider didn't screw up, but the documentation was lacking, so your FIL cost the provider his career?
If you screw up, and you have poor documentation, your going to lose. that's just how it is. and if you don't screw up, and you have great documentation, your not going to lose. that's just how it is. it's those other two examples where it's a very gray area, often coming down to how good or not good an attorney is
Documentation (which is a VERY subjective bar as to what is enough) is important, and many people don't document well. But a person still has the right to refuse care anytime during their treatment, regardless of how risky it is, and you can't just say "well, because you receive XYZ, you are now unable to refuse transport." It just doesn't work that way. And yes, people still have the right to make stupid choices over their healthcare, and if they make the wrong one, you can be sued over it.... but that doesn't mean you were wrong, nor will they win.
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I agree with everything you've said. I know a good lawyer will test you apart but having good documentation helps. I've seen some reports that make me cringe.
He did in fact tell me about a case where a situation went bad, but it was well documented. He represented my former employer is a huge multi-million dollar negligence lawsuit. Everyone there knows the case. The PD lost and paid dearly for it. The ambulance company was cleared. The paramedic covered himself with good documentation, and he told me exactly what the paramedic did to protect himself.
So, just to make sure I'm not missing any points, are you now taking this thread beyond glucagon, into the realm of refusals in general? If so, I agree with what you said about understanding risks, documentation and lawyers. However, if this is still going to be about glucagon, I've changed my mind and feel glucagon should be banned, like thalidomide.
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No. I'm not making this thread about other things. Just that like with other things, I like to be fully aware of potential harms with giving a medication, especially if the patient is going to sign a refusal.
This thread is/was specifically about the effects of Glucagon that you might want to be aware of when a patient is signing a refusal. That answer has been more or less delivered.
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This post touches on a couple points that have always been of interest to me.
The first is that even though documentation is important, it's probably is not as helpful to us as we think it is, because a decent attorney and the right set of circumstances will get you roasted no matter how right you were and no matter how well you documented. Frankly, I think there is way too much emphasis in EMS on "documenting EVERYTHING". In areas of healthcare outside of EMS, "documentation by exception" is much more commonly used. This means that only unusual findings or events are documented; if it wasn't written, the finding or action was routine and unremarkable. Writing as much as possible doesn't do much to protect to, and when trying to document everything, it is entirely possible to write something that can later be used against you. Quality is much more important than quantity.
The second is the idea of informed consent. To be completely honest, I don't think it's our job to try to ensure that a patient is "informed". Laypeople are rarely truly "informed". How can they be? It took us a lot of education to get to where we understand this stuff. And now we're supposed to impart all that understanding in a 10 minute conversation? Doesn't work. Should we explain the basic risks as we see them? Try to talk patients into going when we really think it's in their best interest? Of course we should. But both morally and legally, I don't think we should be held accountable for a patients understanding, or lack thereof. Patients have the responsibility to seek out the information they need to make a decision.
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I agree with this 100%.
Perhaps it is my background in law enforcement, but I write reports completely differently than every other provider I've ever met. I write them in the fashion you describe, and in my (admittedly short-ish) career, now going into year #6, I've never been called into court or even been subpoenaed over one of my patients. Now, I've only treated around 1,700 patients during this time, so it's not some crazy-high number.
I've gotten flak for my narratives at my last job, and I flat-out told the billing (!) woman who was questioning me to have me fired if she had a problem with my reports, and my "style" of report writing wasn't changing. Her issue was she wanted the reports written for the benefit of the insurance company; I am far more concerned with my reports providing a clear picture of what happened during my interaction with the patient. I don't necessarily care if the insurance company has issues with the reports (although I do understand that my agency needs to be paid in order for my paychecks to continue coming).