Partner not backing me up.....

[medic417]

My thoughts are we are getting only one side. The OP recalls the vitals and the story in such a way that makes them seem right. Perhaps they had heard their partner wrong when they said the vitals. There are to many possible reasons for me to list.

I am disgusted so many jumped to kick them out of EMS or start class over with out getting both sides. Are you all actually children claiming to be adults? Adults know there's your side, my side, and then there's the truth.

 

[Veneficus]

Showing my age

Back in the days when I worked on a rig in the later part of my career, we had not only a pt refusal, but the paramedic could assess and refuse transport.

There was so much procedure (all pt refusals required a call to med control to make sure the party wasn't talked out if it and somewhere there is a stuy most patients will not refuse after speaking with a physician) and paperwork involved with both that it was actually less work to work them up and transport them.

My first instructor told me advice I still follow today.

"Always ask yourself how this is going to look on the evening news."

The court of public opinion can wreck your agency and career just as quickly and totally as a jury of your peers. (Ask the lady from the dept of agriculture here in the US that has been all over the news recently)

I agree with 417, both sides should be told before a judgement.

 

[Aidey]

She was A&O but quite intox. No c/o pain. ECG NSR, BGL WNL, neuros intact.....Intox pts cannot refuse, since the ETOH may mask certain S/Sx. They are also presumed to lack decisional capacity if it was more than a drink or two.

How do you justify that in court if the patient is AOx4 with a GCS of 15? I can understand if they aren't, but if they are wouldn't that legally still be kidnapping ?


Back on topic, I'm starting to think that a requirement for BLS crews to do patient refusals should be contacting med control.

 

[Outbac1]

Both sides need to be heard on why they recommeded what they did. They both need to talk about and come to some consensus about how to treat this type of pt.

A 56yo male feeling dizzy and lethargic, clammy skin, kinda tired, pupils were sluggish, and his BP was 192/110. No HX of HTN or Diabetes. This pt definitely needs a more detailed assessment. This HTN could be a one off event or could be the first time HTN was noticed. To develop a hx of HTN it first has to be noticed. Unless he gets his b/p taken at somewhat of a regular interval he wouldn't know if he had HTN or not. Same for DM.
Just to throw out another thought. How hot and humid has it been in New Jersey lately? What was the work enviroment like? Hot, sticky, poor airflow, cool A/C? Just some other things to think about.

 

[exodus]

Ummmmmm. Am I the only one thinking that the lethargia and dizziness are from the tissues not perfusing properly? If the pressure is constantly that high, when are the capillaries able to perfuse efficiently?

 

[46Young]

How do you justify that in court if the patient is AOx4 with a GCS of 15? I can understand if they aren't, but if they are wouldn't that legally still be kidnapping ?


Back on topic, I'm starting to think that a requirement for BLS crews to do patient refusals should be contacting med control.

Well, for starters, we use the ePCR. We have a refusal form on there that we have the pt sign. It goes on to say things like we're not doctors, and our care is not a substitute for that of a doctor. At the bottom, right above the "accept" checkbox that sends the pt to the signature page, the form says a line about the pt refusing treatment and transport, and it says "and I do so unimpaired by drugs or alcohol." Furthermore, our OMD and our protocol manual both point out that the pt must demonstrate acceptable decisional capacity as well as being A&O4. The manual states that impairment by ETOH and/or drugs affects the pt's judgment and decisional capacity. I wouldn't count two drinks as impairment, but I would certainly question their decisional capacity if they're inebriated enough where they're showing signs of intox, such as slurred speech, ataxia, nystagmus, irrational behavior, sleepiness, etc. Matter of fact, in NY we responded to a lot of drunks on the street, dispatched as unconscious (asleep, typically). Should we get a refusal from them and then they get hit by a car, it's our jobs.

Regarding devisional capacity, the pt has to fully understand the risks/consequences of their refusal, the differentials regarding their presentation, etc. Repeating " I don't wanna go to the hospital" without a good reason why isn't good enough for me, and shows that they don't understand their situation fully. Now, even though we would most likely be covered by the decisional capacity clause, I will still punt and get the EMS Capt involved, the med director if available, and/or the local Magistrate for an emergency detention order. That way, I'm covering my crew and the pt, and I've also succeeded in shifting any liability onto others. If we're to accept the refusal, it will be by order from a higher authority, thus protecting us legally.

Now, for 46 Young's street tip: If you have an intox, possibly belligerent, and you're sure it's in fact ETOH and not some other underlying cause, they may wish to refuse. You can find a tactful way to let them know that if they just up and leave the scene, you can't follow them and detain them. You just advise and document that the pt refused treatment, refused to speak with and be evaluated by EMS, and left the scene by foot. In NYC it's called a 10-93 refused all. It's quite common, actually.

 

[jjesusfreak01]

Who reads the text for the refusal in the ePCR software? In my short experience where I have witnessed both systems used, people seem to be more likely to read it when its their signature in real ink on real paper.

 

[Aidey]

State law always wins out over protocol, so I would still love to know how that is legal.

 

[46Young]

Who reads the text for the refusal in the ePCR software? In my short experience where I have witnessed both systems used, people seem to be more likely to read it when its their signature in real ink on real paper.

I make it a point to read the refusal aloud in it's entirety, in the prescence of a witness, preferably LE or a family member. I'll document that the refusal was witnessed by that person(s), along with a badge #, etc. It's a bit of a pain, but one moment of laziness could potentially cost you your career, or more.

 

[Shishkabob]

Eh, if they are AOx4, GCS 15, and refusing, I get on phone with med control and have the liability of any possible kidnapping claim lay on them, with the call being recorded on the voice line.



I HAVE, actually just the other night, told a lady she had no choice in the matter of what hospital she was going to, that I deemed her unable to make the decision, and by law had the ability to force her to go. I also had a LEO standing next to me saying he'd arrest her if I wanted him to.


She complied. h34r:





As for refusals, I have one of their friends/family in with us, I explain that I wanted them to go but they are refusing, what can happen (and make death my final point) and tell them what to watch out for, and if they see any of the signs I explain, that they need to call 911. I then have BOTH the patient AND their friend/family sign. I'm not losing my cert because some punk thinks he's too tough for drug induced seizures...

 

[Aidey]

Eh, if they are AOx4, GCS 15, and refusing, I get on phone with med control and have the liability of any possible kidnapping claim lay on them, with the call being recorded on the voice line.

Our med control has told me in the past that if the pt is AOx4, GCS 15 that there is nothing they can do. They can't order us to kidnap someone. I've had med control talk to the person on the phone before, but even our MC concedes that a refusal is a refusal.

If we feel the patient (or parent/caregiver) is not making a decision in their best interest we can call the police, make our case to them, and they can decide if protective custody is warranted. However, if we did that for someone who was drunk with out any serious medical issues, PD would not be happy at all.

 

[JPINFV]

Ok, here is the deal with HTN and the ER. It has been found that it is better for high BP to be lowered slowly unless it is severely symptomatic. Going to the ER for high BP will get you a referral to see your GP and possibly 10 day RX of the anti-hypertensive of the month.

I'm not 100% sure I can agree with this. Yes, HTN is lowered slowly, regardless. However, how many EMT courses cover the difference between urgency and emergency and short of the obvious (i.e. head ache, SOB, other pain, gross neuro deficits), how many signs and symptoms indicating end organ or vasicular damage can an EMT pick up. An EMT (or even medics in most cases and systems, to be honest) isn't going to pick up, for example, papilledema.

 

[JPINFV]

In my opinion, if you were not in charge you shouldn't have been making recommendations to the patient.

So if you see your partner making gross errors in either technique or judgment, if it isn't 'your patient' you aren't going to step in? I don't if I could justify sitting back and watching my partner give erroneous recommendations based on an erroneous conclusion. This isn't to say that there isn't tactful ways about approaching the subject, but saying, "I was driving" isn't going to cover for an AMA followed by an adverse event where the official opinion of the crew, as communicated to the patient, was "nothing to see here." If the only way to provide correct information is to directly contradict my partner, then so be it. My obligation to provide quality care to my patient (regardless of if I'm assisting or leading the encounter) is more important than an obligation to back up my partner, regardless of if my partner is right or wrong.

 

[CAOX3]

Eh, if they are AOx4, GCS 15, and refusing, I get on phone with med control and have the liability of any possible kidnapping claim lay on them, with the call being recorded on the voice line..

No med control doctor I know is going to request I drag a AOX4 patient to the ER regardless of complaint.

Medical care is a choice, they have the right to refuse it.

 

[JPINFV]

How do you justify that in court if the patient is AOx4 with a GCS of 15? I can understand if they aren't, but if they are wouldn't that legally still be kidnapping ?

GCS of 15 and A/Ox4 does not indicate the presence or absence of capacity to give consent on its own. Have you never transported a patient who lacked capacity based on psychological illness who was A/Ox4 with a GCS of 15?

 

[JPINFV]

Who reads the text for the refusal in the ePCR software? In my short experience where I have witnessed both systems used, people seem to be more likely to read it when its their signature in real ink on real paper.

I think that any text written on a form is irrelevant at the time of signature and that patients should be verbally advised of the situation much like a suspect is advised of their constitutional rights at the time of arrest. After all, the rights involved in a Miranda advisement are all written down in the US Bill of Rights. If suspects are granted a quick civics lesson at time of arrest, I think it's only prudent to grant a quick lesson of what EMS providers can and cant do and provide informed consent for AMAs.

 

[Veneficus]

GCS of 15 and A/Ox4 does not indicate the presence or absence of capacity to give consent on its own. Have you never transported a patient who lacked capacity based on psychological illness who was A/Ox4 with a GCS of 15?

Had your ethics class yet?

These comments not directed at you but to the gallery.

What about a patient who doesn't have the understanding of the language, the education, or the mental capacity?

What protects you if you tell a patient what could happen to them in medical language that would make Greek and Latin Scholars jealous and they refused?


Many patients and students if asked if they understand something will reply that they do. (even when they don't)

I'll bet I could convince almost any patient to go to the hospital.

It doesn't take much skill as a provider to talk somebody out of a procedure.

 

[46Young]

I'm not 100% sure I can agree with this. Yes, HTN is lowered slowly, regardless. However, how many EMT courses cover the difference between urgency and emergency and short of the obvious (i.e. head ache, SOB, other pain, gross neuro deficits), how many signs and symptoms indicating end organ or vasicular damage can an EMT pick up. An EMT (or even medics in most cases and systems, to be honest) isn't going to pick up, for example, papilledema.

I'll be honest, I just googled papilledema. I figured just by the nomenclature that it had to do with eye swelling, but I didn't know much past that.

 

[JPINFV]

As for refusals, I have one of their friends/family in with us, I explain that I wanted them to go but they are refusing, what can happen (and make death my final point) and tell them what to watch out for, and if they see any of the signs I explain, that they need to call 911. I then have BOTH the patient AND their friend/family sign. I'm not losing my cert because some punk thinks he's too tough for drug induced seizures...

I'm sure that you get consent before discussing a patient's condition with a non-medical provider besides the patient, correct?

 

[Shishkabob]

No med control doctor I know is going to request I drag a AOX4 patient to the ER regardless of complaint.

Medical care is a choice, they have the right to refuse it.

Except AOx4 is not the only determining factor when it comes to deciding if someone is capable of making their own decisions or not.