Intoxicated refusals w/ trauma

[WyMedic]

I suppose that's a good point. Sometimes I wonder how the physicians feel about taking that responsibility. I think that if I were in medical controls shoes, i would be a) pretty agitated that the liability for a refusal, of a patient j never saw came back on me and b) want to be very thorough with knowing the exact circumstances around that refusal.

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[luke_31]

Heck I've had strange cases where patients who wanted to refuse were told they couldn't refuse and needed to come in, even with nothing wrong with them. Other than being in a crappy situation that wasn't even their fault. Then other times where I thought the patient does need to go in and the doctor was like whatever if they don't want to go, just have them report to sick call in the morning and they can deal with it.

 

[PassionMedic]

In addition to your standard questions to assess if a patient is alert and oriented x4 (not recalling the bar would make him a 3, or *maybe* 4 with confusion, leading to me not likely doing a refusal unless it was 'my friends picked it I've never been here before') I also ask how many quarters in a dollar or some semblance and 'is Mickey Mouse a cat or a dog?' To gain a little more insight into cognitive processing and pt mental status. I've also head of crews asking to recall a specific set of 3-5 unrelated words 5 mins later for memory recall.

Document the heck out of it, even if it seems repetitive.

In your case, I probably would have transported him. Explaining that due to his injuries and his confusion that he needs to be seen by a doctor. If he continues to refuse I would contact the doc to remove the onus from me.


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[WyMedic]

In addition to your standard questions to assess if a patient is alert and oriented x4 (not recalling the bar would make him a 3, or *maybe* 4 with confusion, leading to me not likely doing a refusal unless it was 'my friends picked it I've never been here before') I also ask how many quarters in a dollar or some semblance and 'is Mickey Mouse a cat or a dog?' To gain a little more insight into cognitive processing and pt mental status. I've also head of crews asking to recall a specific set of 3-5 unrelated words 5 mins later for memory recall.

Document the heck out of it, even if it seems repetitive.

In your case, I probably would have transported him. Explaining that due to his injuries and his confusion that he needs to be seen by a doctor. If he continues to refuse I would contact the doc to remove the onus from me.


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Well and that's what finally happened after much convincing. What got me about it was the second they got him in the ED the nurse signed him out ama without a second thought. So I know my partner really had sone second thoughts about it. Maybe I'm wrong but frankly, I think the ED should have held him until he was evaluated by the physician at least.

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[PassionMedic]

A lot of EDs are over worked and overwhelmed and this is not uncommon. I don't agree with it, but I try and give the clearest picture I can to my receiving RN, and express my concerns directly. I know some hospitals just 'metabolize to discharge' but there is only so much we can do unfortunately.


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[BobBarker]

Heck I've had strange cases where patients who wanted to refuse were told they couldn't refuse and needed to come in, even with nothing wrong with them.

And you know that doctor who "forced" them to come in when they didn't want/need to sure isn't picking up their bill!

 

[luke_31]

Nope, no bill. Where I work only active duty can be forced to go.

 

[TransportJockey]

In my area, PD probably would have arrested him for PI and taken him to get evaluated before he went to jail. But otherwise I would have been decently ok with a refusal if he could continue to answer my questions and talk w/out repetitive questioning. I'd do my best to convince him to go, but if he's A&O and absolutely against the idea of transport to the ED... Not much I can do. And We don't call medcon for refusals, since if the doc orders me to bring in a completely A&O person against their will, that's an order I have to refuse and it causes a problem.

 

[DrParasite]

@WyMedic Passing on the liability football is exactly what we are doing and thats the whole point. I work under my medical directors license and have an approved scope of practice/protocols. When I get to the edge of those protocols or scope of practice I call medical control to document it and it's no different with refusals. I want medical control to have the responsibility of the refusal. My job is to accurately explain the patients condition, mental status, my exam findings, and the patients ability to refuse care.

there are two problems with this concept.

1) so if the medical director says the patient needs to go, then what? forcibly kidnap him and transport him to the hospital against his will?

2) if something goes wrong, what is stopping your medical control (especially if you have a rotating group of online medical control people) from saying, when the lawsuit is served and his license is on the line, that because the paramedic didn't paint a clear enough picture, he shouldn't be responsible for any negative outcomes? You might be even more surprised to know that there are still large EMS agencies that don't record their medical control conversations.

Ya know, I was going to jump in and state my case on how dangerous I believe refusals to be ... but I realized that if you don't seem to think refusals are a big deal, nothing I'm going to say is going to change your mind.

But maybe this will: One study found that in 85 cases where paramedics felt ED transport was unnecessary, 27 (32%) met criteria for ED treatment, including 15 (18%) who were admitted and five (6%) who were admitted to an ICU

http://gatheringofeagles.us/2010/Presentations/Eckstein - Mandatory Transport.pdf

That's the study, I thought it was San Francisco and couldn't find the report. And it was focused on Los Angeles, which does have a great reputation for having a stellar EMS system....

Using the first example provided, what did the paramedics do wrong? They supported his decision to refuse, and offered an alternative hypothesis as to what was wrong. For the second example, who refused for the incarcerated patient? sounds like the lawsuit should be against the jailers, rather than the paramedics. And yes, I did have a patient (with a finger injury) who wanted to go to the hospital, but he was in jail, and the officer made it every clear that I was to clean up the very minor injury, and the offer would refuse transport for the patient. Jail calls and person under arrest can be a little tricky, because the patient doesn't always have the right to make their own decisions.

Although, I am curious as to what criteria was used for the following:

One study found that in 85 cases where paramedics felt ED transport was unnecessary, 27 (32%) met criteria for ED treatment, including 15 (18%) who were admitted and five (6%) who were admitted to an ICU

Criteria for admission could be abnormal labs, followup observation, or some other non-acute issue. I once had a patient take a train an hour (from one city to another), and then call 911 two blocks from the hospital saying she felt sick. She seemed fine, so we took her to the ER and left her in triage. The next day the attending pulled me aside, advising me the patient had been admitted for some abnormal lab value (it was years ago, I don't remember what).

@NomadicMedic I think you said you used to work in a flycar system..... if you were working in such a system, and you released a patient to BLS (found nothing acutely wrong with them, so no need for your services), and the patient ended up admitted to the hospital, have you failed as a paramedic?

Want a simpler solution? every patient refusal is an AMA, and documented as such. I don't think OLMC helps, unless you need advice on how to handle a situation or don't know what to do. The simple truth is, patients (for the most part) have the right to make stupid choices regarding their health, and just because they refuse to be transported doesn't necessarily mean the paramedic failed at their job.

I learned many years ago that it is easier to spend 10 minutes transporting the patient than spending 20 minutes working out a refusal. If they want to go to the ER by ambulance, lets walk to the ambulance and off we go, regardless of whether I feel they need it or not. But if they don't want to go, and they understand that everything can get worse and lead to death, why should I drag them kicking and screaming to a hospital that they don't want to go to?

 

[epipusher]

Anxious to read how nomad and others will violate a patients 4th amendment rights.

 

[captaindepth]

there are two problems with this concept.

1) so if the medical director says the patient needs to go, then what? forcibly kidnap him and transport him to the hospital against his will?

2) if something goes wrong, what is stopping your medical control (especially if you have a rotating group of online medical control people) from saying, when the lawsuit is served and his license is on the line, that because the paramedic didn't paint a clear enough picture, he shouldn't be responsible for any negative outcomes? You might be even more surprised to know that there are still large EMS agencies that don't record their medical control conversations.

I have noticed a few different folks in this thread mention something along the lines of "what if medical control says they have to go? What are you going to do, kidnap them?" If the pt is sober, competent, has decision making capacity and is making an informed decision than there is nothing the online medical control can do to force us (EMS) to take the patient against their will. When I call base for a refusal, I clearly state "I am calling to document a refusal" I'm not calling for permission. Like I said earlier, the physician on the other end of the line can huff and puff all they want, I even get them to talk to the patient directly on the recorded line sometimes, but if the patient is capable to refuse than there is nothing the physician can do to force them to go.

Luckily all of our "Biophone" or base contact/medical control lines are recorded and we frequently get to listen to good and bad biophone reports as a learning tool. Again being able to do an accurate and full assessment is critical in the refusal process, so is relaying that information to the physician.

 

[DrParasite]

When I call base for a refusal, I clearly state "I am calling to document a refusal" I'm not calling for permission. Like I said earlier, the physician on the other end of the line can huff and puff all they want, I even get them to talk to the patient directly on the recorded line sometimes, but if the patient is capable to refuse than there is nothing the physician can do to force them to go.

Maybe I am missing something here.,,, what is the purpose of the call to the doc? I mean, couldn't you call your mother on a recorded line, and it would document just as well? How is it "passing some liability" to the doctor, since you aren't asking for permission, and nothing the doc says will affect the patient's right to refuse? And if your not asking for permission, and it's just documentation and notification, wouldn't a field supervisor be a better person to speak to?

Sure, maybe the doctor knows the magic words to convince the person to go, but I haven't seen many cases where a paramedic couldn't convince the person to go, yet a talk with an unknown voice on the other end of the phone causes the person to change their mind (even if they should got to the ER).

And I'm not saying med control calls shouldn't be recorded, I'm just saying that not all are.

 

[SpecialK]

In my jurisdiction, ambulance personnel cannot be sued, in fact really nobody can be, so there's that dropped from consideration.

With that in mind, and regardless, there is a professional and moral duty to do what is right by the patient, while respecting their ability make informed decisions about their healthcare, provided of course they are deemed "competent" to do so. What your flavour of "competency" will look like is obviously different from place to place.

I doubt there is anywhere on earth which doesn't enshrine in law that patients have certain rights when using healthcare services and that those include both the right to make informed decisions and the right to decline treatment. Doesn't actually matter what is wrong with the patient, unless their condition makes them not competent, they have the same right to refuse regardless yes?

There was a case ages ago of a patient who walked out of ED after being whacked over the noggin with a bit of lumber, he was proven competent at the time by the clinical staff, and later died of a brain bleed. There was a bit of discourse about "how could they let him do that?: et al ... but he was deemed competent so couldn't stop him!

What is wrong the patient is largely irrelevant unless it produces non-competency (for example severe TBI or psychiatric illness or hypoxia) however the condition doesn't change how their legal rights are affected. I'd bet most places are pretty similar.

 

[joshrunkle35]

Well, in most places EMS cannot truly make a decision that a patient is intoxicated, as a breatholizer or blood draw have not been performed. A patient might exhibit signs of intoxication, but I cannot say whether or not they are drunk.

If I am in this situation, I have police pink slip them and then they don't have a choice about continuing care with me. Or, I take them, as I believe they are not in a state to provide informed consent for themselves, and I document what the circumstances were that I believed that they could not provide informed consent.

The situation which you describe is one where the person, no matter how much they understand the situation, does not sound as if they are legally able to make decisions for themselves regarding their own medical care.


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[WyMedic]

Well, in most places EMS cannot truly make a decision that a patient is intoxicated, as a breatholizer or blood draw have not been performed. A patient might exhibit signs of intoxication, but I cannot say whether or not they are drunk.

If I am in this situation, I have police pink slip them and then they don't have a choice about continuing care with me. Or, I take them, as I believe they are not in a state to provide informed consent for themselves, and I document what the circumstances were that I believed that they could not provide informed consent.

The situation which you describe is one where the person, no matter how much they understand the situation, does not sound as if they are legally able to make decisions for themselves regarding their own medical care.


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What do you mean that you have the police "pink slip" them?

 

[joshrunkle35]

What do you mean that you have the police "pink slip" them?

Sorry, that may be an Ohio-specific thing.

http://mha.ohio.gov/Portals/0/asset...-conf-followup/Emergency-Hospitalization.pptx


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[captaindepth]

Maybe I am missing something here.,,, what is the purpose of the call to the doc? I mean, couldn't you call your mother on a recorded line, and it would document just as well? How is it "passing some liability" to the doctor, since you aren't asking for permission, and nothing the doc says will affect the patient's right to refuse? And if your not asking for permission, and it's just documentation and notification, wouldn't a field supervisor be a better person to speak to?

Sure, maybe the doctor knows the magic words to convince the person to go, but I haven't seen many cases where a paramedic couldn't convince the person to go, yet a talk with an unknown voice on the other end of the phone causes the person to change their mind (even if they should got to the ER).

And I'm not saying med control calls shouldn't be recorded, I'm just saying that not all are.

Sorry maybe I'm missing something here too, what point are you trying to make exactly? That we shouldn't be making base contact to document higher risk refusals? My whole point was that refusals require good and thorough documentation to protect ourselves and documenting the refusal with the base physician only further supports our documentation. Not sure how a field supervisor or my mother would help with documenting a refusal. I'm not sure where what else you are trying to get at.

Well, in most places EMS cannot truly make a decision that a patient is intoxicated, as a breatholizer or blood draw have not been performed. A patient might exhibit signs of intoxication, but I cannot say whether or not they are drunk.

If I am in this situation, I have police pink slip them and then they don't have a choice about continuing care with me. Or, I take them, as I believe they are not in a state to provide informed consent for themselves, and I document what the circumstances were that I believed that they could not provide informed consent.

The situation which you describe is one where the person, no matter how much they understand the situation, does not sound as if they are legally able to make decisions for themselves regarding their own medical care.


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I agree that the patient in the OP does not have the mental capacity to refuse care and can be treated/transported under implied consent.

I looked at that Pink Slip slide show and it's similar to an M1 hold we have here in Colorado. In the description of the Pink Slip it specifically sates it is appropriate for mental health hospitalization and treatment but "is not appropriate if principal focus of treatment is a medical issue." I don't think the patient in the OP is an appropriate candidate for a mental health hold. IMO, he shouldn't be placed on a 72 hour hold for getting drunk and getting his a** whooped.

 

[joshrunkle35]

Sorry maybe I'm missing something here too, what point are you trying to make exactly? That we shouldn't be making base contact to document higher risk refusals? My whole point was that refusals require good and thorough documentation to protect ourselves and documenting the refusal with the base physician only further supports our documentation. Not sure how a field supervisor or my mother would help with documenting a refusal. I'm not sure where what else you are trying to get at.





I agree that the patient in the OP does not have the mental capacity to refuse care and can be treated/transported under implied consent.

I looked at that Pink Slip slide show and it's similar to an M1 hold we have here in Colorado. In the description of the Pink Slip it specifically sates it is appropriate for mental health hospitalization and treatment but "is not appropriate if principal focus of treatment is a medical issue." I don't think the patient in the OP is an appropriate candidate for a mental health hold. IMO, he shouldn't be placed on a 72 hour hold for getting drunk and getting his a** whooped.

The pink slip is for the mental incapacitation due to intoxication, not due to trauma.


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[DrParasite]

Sorry maybe I'm missing something here too, what point are you trying to make exactly? That we shouldn't be making base contact to document higher risk refusals? My whole point was that refusals require good and thorough documentation to protect ourselves and documenting the refusal with the base physician only further supports our documentation. Not sure how a field supervisor or my mother would help with documenting a refusal. I'm not sure where what else you are trying to get at.

I think you are. HOW does contacting the base physician support your documentation? you aren't asking for permission, you are just telling him what you are doing. That is the part that I seem to be missing. If you aren't asking for his permission to allow the refusal (and you stated you weren't), than what purpose does speaking to this person who went to medical school serve?

The comment about contacting your mother or a field supervisor was because I didn't know if the call being recorded was the actual documentation you were referring to. As in, it doesn't matter who you speak to, as long as it's on a recorded line (supports your documentation).

Let me try this another way.... pretend for a moment, that I know nothing about EMS. Nothing about healthcare. lets say i'm a law student, or an engineer, or an IT professional. Explain to me how telling someone over the phone that the patient is refusing to be transported transfers some liability from you to them. While you are at it, why don't you explain exactly what part of the conversation helps support the documentation, and why do you need to tell a doctor who isn't there that the patient doesn't want to go? remember, you aren't asking permission (despite the fact that you are working under he license), you are just telling him what is going on.

 

[captaindepth]

I think you are. HOW does contacting the base physician support your documentation? you aren't asking for permission, you are just telling him what you are doing. That is the part that I seem to be missing. If you aren't asking for his permission to allow the refusal (and you stated you weren't), than what purpose does speaking to this person who went to medical school serve?

The comment about contacting your mother or a field supervisor was because I didn't know if the call being recorded was the actual documentation you were referring to. As in, it doesn't matter who you speak to, as long as it's on a recorded line (supports your documentation).

Let me try this another way.... pretend for a moment, that I know nothing about EMS. Nothing about healthcare. lets say i'm a law student, or an engineer, or an IT professional. Explain to me how telling someone over the phone that the patient is refusing to be transported transfers some liability from you to them. While you are at it, why don't you explain exactly what part of the conversation helps support the documentation, and why do you need to tell a doctor who isn't there that the patient doesn't want to go? remember, you aren't asking permission (despite the fact that you are working under he license), you are just telling him what is going on.

So it seems like you are really getting hung up on this "not asking for permission" statement. When I say I am not "asking for permission," i'm not saying I call and act like an a**hole or tell the Doc what to do. I simply relaying my situation in the field, assessment and exam findings, the risks vs. benefits speech, and the patients ability to refuse the care I offered to provide. I'm not calling to ask IF the patient can refuse (we have already made that determination in the field), im calling to state the patient IS refusing care. The reason to call is to inform the physician of the refusal, document my explanation of risks to the patient (on the recorded line as well as in my PCR), and sometimes the physician will speak to the patient (also on the recorded line) in an attempt to convince them to be treated/transported by EMS. The only time we contact base for refusals is higher risk refusals when it is truly AMA, and these are the times when documentation needs to be at its best, and speaking with the medical control only helps support my documentation.

I'm not sure how this concept can be so upsetting, but I have a feeling no matter what answer I give it will not be satisfy what you are looking for.