NEED HELP/ADVICE on a call!

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Gheed

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I'm and EMT on a BLS rig who was called out to SNF in San Diego for a patient who was having disturbance in their behavior.

We get on scene and make patient contact, my partner gets the run down for the RN and I begin my assessment on the patient

He was 67 y/o male about 130lbs standing in his room looking out the slider door into the dark, tracking spontaneously, ABC intact, AAOX1 (Baseline due to dementia), no c/c, kept asking me "HU?" to most of my questions and unable to hold a conversation more than a sentence or so. Vitals were stable

The story from staff was that the patient had got aggressive with a staff member 2 days before, swung and struck her, he has been refusing to take his medication only eating crackers, becoming increasingly paranoid, wandering into other patients rooms and having visual hallucinations of his deceased brother. They called the cops the day after the aggressive act and they refused to place a hold since the patient was currently not a danger to himself, others and not in their eyes as gravely disabled.

As I mention to him that we need him to come with us to the hospital so they can evaluate him and place him in a better suited facility he starts raising his voice, repeating he doesn't need to go etc. He hurries down the hall and enters another patients room, the staff has to use force to bring him back to his room and we shut the door so he doesn't get out.

P.D. is called to see for myself if they really can't/won't place him on a hold so we can restrain him under paperwork and not deal with any legal issues.

I call up the direct power of attorney over him and after explaining the situation she decides she wants him to be seen at the ER.

P.D. refused the hold and says something about how he is under the care of the SNF and that voids the gravely disabled indication of a hold. The RN can't get a doc (either unavailable of refused, its 1 am) to put a hold on him.

So at this point we have no hold, pt AAOx1 uncooperative, a facility not equipped to care for the patient which seems like enough for the gravely disabled portion of a hold to be in effect but if someone can clarify this?) the responsible parties authorization to transport and a patient who will require force to be restrained.

SD protocol says for altered neurological function to restrain the patient if needed and under behavioral emergencies to restrain if necessary to prevent injury.

The staff, me and my partner ended up carrying the pt to the gurney and restraining him, no acts of violence towards us occurred and PD stood and could only step in if he did get violent due to their protocol.

I would like to know your thoughts on this situation and feedback on whether there was a better way to go about this and if everything was justified legally. Thanks!!
 
The only thing I can think of doing differently would be to call your supervisor if you were unsure about restraints in this situation, but otherwise sounds like you did the best you could for a tough call (uncooperative patients are never fun)
 
I am not familiar with what your protocols are, but is calling medical control to get a hold an option?
 
Tigger said:
I am not familiar with what your protocols are, but is calling medical control to get a hold an option?
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Not for a BLS crew in San Diego. Everything is off of standing orders and only a medic will contact base.
For the OP, I don't think you handled it poorly, obviously you got him to the hospital and nothing you've said so far leads me to believe you lost your job.
He's obviously altered, the facility and his power of attorney would like him to be seen at the ER, and he's not currently competent to object. I would have had law enforcement on scene, even if they won't write a hold, just as a precaution while we restrain him. If/when he becomes a problem and starts to get physical, law enforcement can step in. More often than not if I simply explain to the patient that I have no choice, I'll lose my job if I don't take them, and my rules say I have to put these uncomfortable things on your wrists and ankles until we get to the hospital, they'll respond positively. PD just adds another level of faux intimidation to the matter.
But if you're not sure, get a higher level of care (ALS) and a supervisor on scene. As a BLS IFT car in SD, that means Fire and R/M. Once they arrive, you've taken that monkey off your back and put it on there's. He's not in extremis, there's nothing that you need to do for him this minute, and it's a complicated decision. Leave it to someone with more experience, more education, more authority, and more money to pay for an attorney :D
I don't really think there's anything you should have done differently though. It worked out, take it as a learning experience, and you'll be better equipped to handle something like that the next time it happens.
I'd really like to educate that facility though. "Let's just have the bambalance come kidnap this guy cuz he's causing problems." Because having the doctor write a hold at some point in past 2 days this has been a problem, well that's just way too logical.
 
Apparently the facility was in the process of finding a lock-down facility for him but they weren't having luck with any openings then the weekend rolled by.
But okay, gotcha, could have called supervisor and or ALS. Thanks for taking the time to read and the replies!

To be honest though, since much of SD county BlS is inter-facility transports I now enjoy these calls, they're thought provoking and require some critical thinking which is a nice opportunity to gain experience for down the road!
 
Gheed said:
inter-facility transports I now enjoy these calls
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We'll see if you have that same mindset come 6-12 months from now ;)
 
Why do you need a hold? The DPOA wanted transport, the patient is demented, altered at their baseline and unable to make sound decisions for themselves...you don't need a hold, by the DPOA consenting to transport that's all you need....why are you so set on needing a legal hold placed? Don't take this the wrong way but you need to learn more about the different forms of consent and how DPOAs work. Again, don't take this the wrong way but you kinda wasted LE's time calling them out, no real reason for them to be there.

If it takes an excessive amount of force to get him to the gurney get an ALS crew coming to you so they can sedate him and transport him in a way that doesn't risk harm to him or the providers around him. I don't totally understand the hesitation of many providers to sedate patients. I always hear the argument "if you sedate them the doctor can't assess them well." That's why you gather a good history of present illness and a physical assessment. If he's off his meds a couple milligrams of versed or Ativan aren't going to magically make his signs and symptoms disappear when the medications wear off.

Don't fight with old demented patients. 1) THEYRE stronger than they look. 2) they can be easily injured, especially if they have osteoporosis or some similar disease process. 3) It's not nearly as traumatic for the patient even if they potentially may not remember the entire event in a few hours. 4) It's safer for everyone involved.
 
Gheed said:
I'm and EMT on a BLS rig who was called out to SNF in San Diego for a patient who was having disturbance in their behavior.

We get on scene and make patient contact, my partner gets the run down for the RN and I begin my assessment on the patient

He was 67 y/o male about 130lbs standing in his room looking out the slider door into the dark, tracking spontaneously, ABC intact, AAOX1 (Baseline due to dementia), no c/c, kept asking me "HU?" to most of my questions and unable to hold a conversation more than a sentence or so. Vitals were stable

The story from staff was that the patient had got aggressive with a staff member 2 days before, swung and struck her, he has been refusing to take his medication only eating crackers, becoming increasingly paranoid, wandering into other patients rooms and having visual hallucinations of his deceased brother. They called the cops the day after the aggressive act and they refused to place a hold since the patient was currently not a danger to himself, others and not in their eyes as gravely disabled.

As I mention to him that we need him to come with us to the hospital so they can evaluate him and place him in a better suited facility he starts raising his voice, repeating he doesn't need to go etc. He hurries down the hall and enters another patients room, the staff has to use force to bring him back to his room and we shut the door so he doesn't get out.

P.D. is called to see for myself if they really can't/won't place him on a hold so we can restrain him under paperwork and not deal with any legal issues.

I call up the direct power of attorney over him and after explaining the situation she decides she wants him to be seen at the ER.

P.D. refused the hold and says something about how he is under the care of the SNF and that voids the gravely disabled indication of a hold. The RN can't get a doc (either unavailable of refused, its 1 am) to put a hold on him.

So at this point we have no hold, pt AAOx1 uncooperative, a facility not equipped to care for the patient which seems like enough for the gravely disabled portion of a hold to be in effect but if someone can clarify this?) the responsible parties authorization to transport and a patient who will require force to be restrained.

SD protocol says for altered neurological function to restrain the patient if needed and under behavioral emergencies to restrain if necessary to prevent injury.

The staff, me and my partner ended up carrying the pt to the gurney and restraining him, no acts of violence towards us occurred and PD stood and could only step in if he did get violent due to their protocol.

I would like to know your thoughts on this situation and feedback on whether there was a better way to go about this and if everything was justified legally. Thanks!!
Click to expand...
I think you did what was appropriate, I am also curious as to which company you work for
 
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